Ana Angélica Rêgo de Queiroz

Spatial clustering and local risk of leprosy in São Paulo, Brazil

Background Although the detection rate is decreasing, the proportion of new cases with WHO grade 2 disability (G2D) is increasing, creating concern among policy makers and the Brazilian government. This study aimed to identify spatial clustering of leprosy and classify high-risk areas in a major leprosy cluster using the SatScan method. Methods Data were obtained including all leprosy cases diagnosed between January 2006 and December 2013. In addition to the clinical variable, information was also gathered regarding the G2D of the patient at diagnosis and after treatment. The Scan Spatial statistic test, developed by Kulldorff e Nagarwalla, was used to identify spatial clustering and to measure the local risk (Relative Risk—RR) of leprosy. Maps considering these risks and their confidence intervals were constructed. Results A total of 434 cases were identified, including 188 (43.31%) borderline leprosy and 101 (23.28%) lepromatous leprosy cases. There was a predominance of males, with ages ranging from 15 to 59 years, and 51 patients (11.75%) presented G2D. Two significant spatial clusters and three significant spatial-temporal clusters were also observed. The main spatial cluster (p = 0.000) contained 90 census tracts, a population of approximately 58,438 inhabitants, detection rate of 22.6 cases per 100,000 people and RR of approximately 3.41 (95%CI = 2.721–4.267). Regarding the spatial-temporal clusters, two clusters were observed, with RR ranging between 24.35 (95%CI = 11.133–52.984) and 15.24 (95%CI = 10.114–22.919). Conclusion These findings could contribute to improvements in policies and programming, aiming for the eradication of leprosy in Brazil. The Spatial Scan statistic test was found to be an interesting resource for health managers and healthcare professionals to map the vulnerability of areas in terms of leprosy transmission risk and areas of underreporting.

The impact of social inequities on mortality due to pulmonary tuberculosis in São Luis, Maranhão, Brazil.

Introduction: Authors theorize about the relation between social inequities and death by tuberculosis. Nevertheless, the literature is restricted as to verifying the relation between these events in view of space. Therefore, the study objective was to identify areas with social inequity and its impact on the mortality rate by pulmonary tuberculosis.Methods: Ecological study, which considered deaths from pulmonary tuberculosis in the urban area of the city between 2008 and 2012, available in Mortality Information System. For the construction of the social inequity indicator, the principal component analysis was used, Multiple linear regression with the least squares method and spatial regression were used to verify the impact of inequity on mortality by TB. The spatial dependence was confirmed using Moran’s Global Index.Results: 193 deaths were identified. The social inequity was statistically associated with the mortality (R2=23.86%) in the multiple linear regression model with spatial dependence (Moran I=0.285; p<0.001), which evidenced the highest rates of mortality in the weighted areas with high and intermediate social inequity.Conclusion: Social inequity explains mortality by tuberculosis in the city investigated. To reduce the deaths by 95% until 2035, the actions the health authorities have established should not only promote better access to medical and diagnostic technologies, but also actions that promote the social development of the areas and their resident populations

Patrón espacial y tendencia temporal de la mortalidad debido a la tuberculosis

Objetivos: describir el perfil epidemiologico de la mortalidad por tuberculosis (TB), analizar el patron espacial de estas muertes e investigar la tendencia temporal de la mortalidad por tuberculosis en el noreste de Brasil. Metodos: estudio ecologico basado en datos secundarios de mortalidad. Las muertes por TB se incluyeron en el estudio. Se calcularon las estadisticas descriptivas y se estimaron y suavizaron las tasas de mortalidad bruta mediante el Metodo Bayesiano Empirico Local. La regresion de Prais-Winsten se utilizo para analizar la tendencia temporal en los coeficientes de mortalidad por TB. La tecnica de densidad de Kernel se utilizo para analizar la distribucion espacial de la mortalidad por TB. Resultados: la tuberculosis estuvo presente en 236 muertes. El peso de muertes por tuberculosis fue mayor en hombres, personas solteras y personas de origen etnico mixto y la edad media al momento de la muerte fue de 51 anos. Las muertes por tuberculosis se agruparon en los distritos de salud del este, oeste y norte y el coeficiente de mortalidad por tuberculosis se mantuvo estable durante todo el periodo de estudio. Conclusiones: los analisis del patron espacial y la tendencia temporal de la mortalidad revelaron que ciertas areas con tasas mas altas de mortalidad por TB y, por lo tanto, deberian ser priorizadas en las intervenciones de salud publica dirigidas a esta enfermedad.ABSTRACT Objectives: To describe the epidemiological profile of mortality due to tuberculosis (TB), to analyze the spatial pattern of these deaths and to investigate the temporal trend in mortality due to tuberculosis in Northeast Brazil. Methods: An ecological study based on secondary mortality data. Deaths due to TB were included in the study. Descriptive statistics were calculated and gross mortality rates were estimated and smoothed by the Local Empirical Bayesian Method. Prais-Winsten’s regression was used to analyze the temporal trend in the TB mortality coefficients. The Kernel density technique was used to analyze the spatial distribution of TB mortality. Results: Tuberculosis was implicated in 236 deaths. The burden of tuberculosis deaths was higher amongst males, single people and people of mixed ethnicity, and the mean age at death was 51 years. TB deaths were clustered in the East, West and North health districts, and the tuberculosis mortality coefficient remained stable throughout the study period. Conclusions: Analyses of the spatial pattern and temporal trend in mortality revealed that certain areas have higher TB mortality rates, and should therefore be prioritized in public health interventions targeting the disease.

Padrão espacial e tendência temporal da mortalidade por tuberculose

Objetivos: describir el perfil epidemiologico de la mortalidad por tuberculosis (TB), analizar el patron espacial de estas muertes e investigar la tendencia temporal de la mortalidad por tuberculosis en el noreste de Brasil. Metodos: estudio ecologico basado en datos secundarios de mortalidad. Las muertes por TB se incluyeron en el estudio. Se calcularon las estadisticas descriptivas y se estimaron y suavizaron las tasas de mortalidad bruta mediante el Metodo Bayesiano Empirico Local. La regresion de Prais-Winsten se utilizo para analizar la tendencia temporal en los coeficientes de mortalidad por TB. La tecnica de densidad de Kernel se utilizo para analizar la distribucion espacial de la mortalidad por TB. Resultados: la tuberculosis estuvo presente en 236 muertes. El peso de muertes por tuberculosis fue mayor en hombres, personas solteras y personas de origen etnico mixto y la edad media al momento de la muerte fue de 51 anos. Las muertes por tuberculosis se agruparon en los distritos de salud del este, oeste y norte y el coeficiente de mortalidad por tuberculosis se mantuvo estable durante todo el periodo de estudio. Conclusiones: los analisis del patron espacial y la tendencia temporal de la mortalidad revelaron que ciertas areas con tasas mas altas de mortalidad por TB y, por lo tanto, deberian ser priorizadas en las intervenciones de salud publica dirigidas a esta enfermedad.ABSTRACT Objectives: To describe the epidemiological profile of mortality due to tuberculosis (TB), to analyze the spatial pattern of these deaths and to investigate the temporal trend in mortality due to tuberculosis in Northeast Brazil. Methods: An ecological study based on secondary mortality data. Deaths due to TB were included in the study. Descriptive statistics were calculated and gross mortality rates were estimated and smoothed by the Local Empirical Bayesian Method. Prais-Winsten’s regression was used to analyze the temporal trend in the TB mortality coefficients. The Kernel density technique was used to analyze the spatial distribution of TB mortality. Results: Tuberculosis was implicated in 236 deaths. The burden of tuberculosis deaths was higher amongst males, single people and people of mixed ethnicity, and the mean age at death was 51 years. TB deaths were clustered in the East, West and North health districts, and the tuberculosis mortality coefficient remained stable throughout the study period. Conclusions: Analyses of the spatial pattern and temporal trend in mortality revealed that certain areas have higher TB mortality rates, and should therefore be prioritized in public health interventions targeting the disease.

Spatial pattern and temporal trend of mortality due to tuberculosis

Objetivos: describir el perfil epidemiologico de la mortalidad por tuberculosis (TB), analizar el patron espacial de estas muertes e investigar la tendencia temporal de la mortalidad por tuberculosis en el noreste de Brasil. Metodos: estudio ecologico basado en datos secundarios de mortalidad. Las muertes por TB se incluyeron en el estudio. Se calcularon las estadisticas descriptivas y se estimaron y suavizaron las tasas de mortalidad bruta mediante el Metodo Bayesiano Empirico Local. La regresion de Prais-Winsten se utilizo para analizar la tendencia temporal en los coeficientes de mortalidad por TB. La tecnica de densidad de Kernel se utilizo para analizar la distribucion espacial de la mortalidad por TB. Resultados: la tuberculosis estuvo presente en 236 muertes. El peso de muertes por tuberculosis fue mayor en hombres, personas solteras y personas de origen etnico mixto y la edad media al momento de la muerte fue de 51 anos. Las muertes por tuberculosis se agruparon en los distritos de salud del este, oeste y norte y el coeficiente de mortalidad por tuberculosis se mantuvo estable durante todo el periodo de estudio. Conclusiones: los analisis del patron espacial y la tendencia temporal de la mortalidad revelaron que ciertas areas con tasas mas altas de mortalidad por TB y, por lo tanto, deberian ser priorizadas en las intervenciones de salud publica dirigidas a esta enfermedad.ABSTRACT Objectives: To describe the epidemiological profile of mortality due to tuberculosis (TB), to analyze the spatial pattern of these deaths and to investigate the temporal trend in mortality due to tuberculosis in Northeast Brazil. Methods: An ecological study based on secondary mortality data. Deaths due to TB were included in the study. Descriptive statistics were calculated and gross mortality rates were estimated and smoothed by the Local Empirical Bayesian Method. Prais-Winsten’s regression was used to analyze the temporal trend in the TB mortality coefficients. The Kernel density technique was used to analyze the spatial distribution of TB mortality. Results: Tuberculosis was implicated in 236 deaths. The burden of tuberculosis deaths was higher amongst males, single people and people of mixed ethnicity, and the mean age at death was 51 years. TB deaths were clustered in the East, West and North health districts, and the tuberculosis mortality coefficient remained stable throughout the study period. Conclusions: Analyses of the spatial pattern and temporal trend in mortality revealed that certain areas have higher TB mortality rates, and should therefore be prioritized in public health interventions targeting the disease.

Factors associated with delay in seeking care by tuberculosis patients

OBJECTIVE To identify social, clinical and behavioral factors of tuberculosis patients that are associated with delay in the search for primary health care. METHOD This is a cross-sectional, quantitative study conducted with 56 people on treatment for pulmonary tuberculosis in the city of Natal, in the state of Rio Grande do Norte, Brazil. The data were collected through a structured instrument. The Chi-square and Fisher tests were applied to test the association between independent and dependent variables (search time). A value of p <0.05 was set as statistically significant. RESULTS No social or clinical variables were statistically associated with patient delays in the search for primary health care. Among the behavioral variables, self-medication and the first health service sought had a statistically significant association with the time for seeking care (p = 0.020, and p = 0.033, respectively). CONCLUSION Self-medication contributes to the delay in the search for primary health care by tuberculosis patients.

Social determinants, their relationship with leprosy risk and temporal trends in a tri-border region in Latin America

Background Brazil is the only country in Latin America that has adopted a national health system. This causes differences in access to health among Latin American countries and induces noticeable migration to Brazilian regions to seek healthcare. This phenomenon has led to difficulties in the control and elimination of diseases related to poverty, such as leprosy. The aim of this study was to evaluate social determinants and their relationship with the risk of leprosy, as well as to examine the temporal trend of its occurrence in a Brazilian municipality located on the tri-border area between Brazil, Paraguay and Argentina. Methods This ecological study investigated newly-diagnosed cases of leprosy between 2003 and 2015. Exploratory analysis of the data was performed through descriptive statistics. For spatial analysis, geocoding of the data was performed using spatial scan statistic techniques to obtain the Relative Risk (RR) for each census tract, with their respective 95% confidence intervals calculated. The Bivariate Moran I test, Ordinary Least Squares (OLS) and Geographically Weighted Regression (GWR) models were applied to analyze the spatial relationships of social determinants and leprosy risk. The temporal trend of the annual coefficient of new cases was obtained through the Prais-Winsten regression. A standard error of 5% was considered statistically significant (p < 0.05). Results Of the 840 new cases identified in the study, there was a predominance of females (n = 427, 50.8%), of white race/color (n = 685, 81.6%), age range 15 to 59 years (n = 624, 74.3%), and incomplete elementary education (n = 504, 60.0%). The results obtained from multivariate analysis revealed that the proportion of households with monthly nominal household income per capita greater than 1 minimum wage (β = 0.025, p = 0.036) and people of brown race (β = -0.101, p = 0.024) were statistically-significantly associated with risk of illness due to leprosy. These results also confirmed that social determinants and risk of leprosy were significantly spatially non-stationary. Regarding the temporal trend, a decrease of 4% (95% CI [-0.053, -0.033], p = 0.000) per year was observed in the rate of detection of new cases of leprosy. Conclusion The social determinants income and race/color were associated with the risk of leprosy. The study’s highlighting of these social determinants can contribute to the development of public policies directed toward the elimination of leprosy in the border region.

How do social-economic differences in urban areas affect tuberculosis mortality in a city in the tri-border region of Brazil, Paraguay and Argentina

BackgroundThe World Health Organization (WHO) launched the “End TB Strategy”, which aims to reduce tuberculosis (TB) mortality by 95% by 2035, Brazil has made a commitment to this, however, one challenge is achieving the goal in the border region, where the TB situation is more critical. The proposal was to analyse the spatial mortality due to TB and its socio-economic determinants in the general population, around the border areas of Brazil, Paraguay and Argentina, as well as the temporal trend in this region.MethodThis ecological study considered the cases of TB deaths of residents of Foz do Iguaçu (BR), with its units of analysis being the census sectors. The standardized mortality rate was calculated for each area. Socioeconomic variables data were obtained from the 2010 Demographic Census of the Brazilian Institute of Geography and Statistics (IBGE). The scan statistic was applied to calculate the spatial relative risk (RR), considering a 95% confidence interval (CI). Spatial dependence was analysed using the Global Bivariate Moran I and Local Bivariate Moran I (LISA) to test the relationship between the socioeconomic conditions of the urban areas and mortality from TB. Analysis of the temporal trend was also performed using the Prais-Winsten test.ResultsA total of 74 cases of TB death were identified, of which 53 (71.6%) were male and 51 (68.9%) people of white skin colour. The mortality rate ranged from 0.28 to 22.75 cases per 100,000 inhabitants. A spatial relative risk area was identified, RR = 5.07 (95% CI 1.79–14.30). Mortality was associated with: proportion of people of brown skin colour (I: 0.0440, p = 0.033), income (low income I: − 0.0611, p = 0.002; high income I: − 0.0449, p = 0.026) and density of residents (3 and 4 residents, I: 0.0537, p = 0.007; 10 or more residents, I: − 0.0390, p = 0.035). There was an increase in the mortality rate in people of brown skin colour (6.1%; 95% CI = 0.029, 0.093).ConclusionDeath due to TB was associated with income, race resident density and social conditions. Although the TB mortality rate is stationary in the general population, it is increasing among people of brown skin colour.

Spatial risk of tuberculosis mortality and social vulnerability in Northeast Brazil

INTRODUCTION Tuberculosis (TB) is the most common infectious disease in the world. We aimed to analyze the spatial risk of tuberculosis mortality and to verify associations in high-risk areas with social vulnerability. METHODS This was an ecological study. The scan statistic was used to detect areas at risk, and the Bivariate Moran Index was used to verify relationships between variables. RESULTS High-risk areas of tuberculosis mortality were statistically significantly associated with domain 2 of the Social Vulnerability Index (I=0.010; p=0.001). CONCLUSIONS This study provides evidence regarding areas with high risk and that vulnerability is a determinant of TB mortality.

Factors related to the place of first choice for the diagnosis of tuberculosis

The objective of this study was to identify factors related to the place of first choice for the diagnosis and treatment of tuberculosis. A descriptive quantitative study was conducted in Natal/RN, throughout February/September 2012 with 60 individuals diagnosed with pulmonary tuberculosis that responded a questionnaire. Data were analyzed by the Chi-square and Fisher test. The factors asso- ciated to the place of first choice were: having had previous contact with the disease (p = 0.04); the persons awareness of the disease (p = 0.018) and having had previous care at the health service unit of choice (p = 0.002). It is concluded that intrinsic and extrinsic factors may influence the individuals first choice of a place for care and diagnosis of diseases. It is important that nurses promote actions related to these factors, for the enhancement of early diagnosis of tuberculosis through case finding and access to the primary care unit thereby reducing the demand for emergency services.