Susilene Maria Tonelli Nardi

Spatial analysis of leprosy incidence and associated socioeconomic factors

OBJECTIVE To identify clusters of the major occurrences of leprosy and their associated socioeconomic and demographic factors. METHODS Cases of leprosy that occurred between 1998 and 2007 in São José do Rio Preto (southeastern Brazil) were geocodified and the incidence rates were calculated by census tract. A socioeconomic classification score was obtained using principal component analysis of socioeconomic variables. Thematic maps to visualize the spatial distribution of the incidence of leprosy with respect to socioeconomic levels and demographic density were constructed using geostatistics. RESULTS While the incidence rate for the entire city was 10.4 cases per 100,000 inhabitants annually between 1998 and 2007, the incidence rates of individual census tracts were heterogeneous, with values that ranged from 0 to 26.9 cases per 100,000 inhabitants per year. Areas with a high leprosy incidence were associated with lower socioeconomic levels. There were identified clusters of leprosy cases, however there was no association between disease incidence and demographic density. There was a disparity between the places where the majority of ill people lived and the location of healthcare services. CONCLUSIONS The spatial analysis techniques utilized identified the poorer neighborhoods of the city as the areas with the highest risk for the disease. These data show that health departments must prioritize politico-administrative policies to minimize the effects of social inequality and improve the standards of living, hygiene, and education of the population in order to reduce the incidence of leprosy.OBJECTIVE: To identify clusters of the major occurrences of leprosy and their associated socioeconomic and demographic factors. METHODS: Cases of leprosy that occurred between 1998 and 2007 in Sao Jose do Rio Preto (southeastern Brazil) were geocodifi ed and the incidence rates were calculated by census tract. A socioeconomic classifi cation score was obtained using principal component analysis of socioeconomic variables. Thematic maps to visualize the spatial distribution of the incidence of leprosy with respect to socioeconomic levels and demographic density were constructed using geostatistics. RESULTS: While the incidence rate for the entire city was 10.4 cases per 100,000 inhabitants annually between 1998 and 2007, the incidence rates of individual census tracts were heterogeneous, with values that ranged from 0 to 26.9 cases per 100,000 inhabitants per year. Areas with a high leprosy incidence were associated with lower socioeconomic levels. There were identifi ed clusters of leprosy cases, however there was no association between disease incidence and demographic density. There was a disparity between the places where the majority of ill people lived and the location of healthcare services. CONCLUSIONS: The spatial analysis techniques utilized identifi ed the poorer neighborhoods of the city as the areas with the highest risk for the disease. These data show that health departments must prioritize politico-administrative policies to minimize the effects of social inequality and improve the standards of living, hygiene, and education of the population in order to reduce the incidence of leprosy.

Criação de banco de dados para sustentação da pós-eliminação em hanseníase

São José do Rio Preto reached the World Health Organization goal eliminating leprosy as a Public Health problem in the year 2006, with a prevalence of 0.79/10,000 inhabitants. In order to warrant reliable information to promote management measures that keep this status, the aim of this study was to create a leprosy data bank in the city with information from 1998 to 2006. A data collection protocol was used and it contained 74 clinical-epidemiological variables that were gathered from primary and secondary sources. This work was initiated with 442 cases registered in the municipal control program database, from those 168 were excluded and 85 were inserted. There were 24 cases not notified in the National Information System (SINAN). The 74 variables collected will allow further studies about themes: epidemiological profiles, household contacts control, reactions and deficiencies, and others. The difficulties faced during the elaboration of the database were related to decoding medical files data and inconsistency in the SINAN. The frequent mistakes while entering the data weaken the information system and difficult the plan of precise actions regarding health. These facts are relevant to the quality of attention and the maintenance of the leprosy elimination status.

Escala salsa e grau de incapacidades da Organização Mundial de Saúde: avaliação da limitação de atividades e deficiência na hanseníase

Verificar o grau de incapacidades da OMS (GI-OMS) e a limitacao de atividades avaliada pela escala Screening of Activity Limitation and Safety Awareness (SALSA) pos-alta medicamentosa dos pacientes que tiveram hanseniase. Estudo transversal que incluiu pacientes tratados entre 2007 a 2009, em Sao Jose do Rio Preto-SP, Brasil. Utilizouse protocolo proprio para coletar dados gerais e clinicos, construido com base no Check List da Classificacao Internacional Funcionalidade, Incapacidade e Saude. A deficiencia foi medida pelo GI-OMS e a limitacao de atividades pelo SALSA que tem variacao de 10 a 80 e ponto de corte ≥25. De 84 pessoas tratadas no periodo, 54(64,3%) foram entrevistadas, sendo 31(57,4%) homens, idade 53,8(dp16,3) e 33(61,2 %) possuia ate 6 anos de educacao formal. A forma clinica dimorfa predominou 17(32,1%), 21(38,9%) considerou sua saude fisica “boa”. A analise dos escores SALSA e variaveis estudadas resultou em significância aos que relataram lesao significante (valor-p=0,04), baixa renda familiar (valor-p=0,04), baixa escolaridade (valor-p=0,00), formas clinicas multibacilares (valor-p=0,01) e deficiencias avaliadas pelo GI-OMS (valor-p=0,01). As limitacoes de atividades sao frequentes (57,4%), assim como as deficiencias medidas pelo GI-OMS (68,5%), atingem as formas multibacilares, pessoas que relataram lesao significante, de baixa renda e escolaridade.1 Terapeuta Ocupacional, Instituto de Psiquiatria do Hospital da Clinicas da Faculdade de Medicina da Universidade de Sao Paulo. 2 Terapeuta Ocupacional, Instituto Lauro de Souza Lima, Centro de Laboratorios Regionais Instituto Adolfo Lutz, Sao Jose do Rio Preto. 3 Terapeuta Ocupacional, Docente da Universidade Federal de Sao Carlos-UFSCar. 4 Centro de Laboratorios Regionais Instituto Adolfo Lutz, Sao Jose do Rio Preto. 5 Doutora, Departamento de Enfermagem e Saude Coletiva. Faculdade de Medicina de Sao Jose do Rio Preto. Verificar o grau de incapacidades da OMS (GI-OMS) e a limitacao de atividades avaliada pela escala Screening of Activity Limitation and Safety Awareness (SALSA) pos-alta medicamentosa dos pacientes que tiveram hanseniase. Estudo transversal que incluiu pacientes tratados entre 2007 a 2009, em Sao Jose do Rio Preto-SP, Brasil. Utilizouse protocolo proprio para coletar dados gerais e clinicos, construido com base no Check List da Classificacao Internacional Funcionalidade, Incapacidade e Saude. A deficiencia foi medida pelo GI-OMS e a limitacao de atividades pelo SALSA que tem variacao de 10 a 80 e ponto de corte ≥25. De 84 pessoas tratadas no periodo, 54(64,3%) foram entrevistadas, sendo 31(57,4%) homens, idade 53,8(dp16,3) e 33(61,2 %) possuia ate 6 anos de educacao formal. A forma clinica dimorfa predominou 17(32,1%), 21(38,9%) considerou sua saude fisica “boa”. A analise dos escores SALSA e variaveis estudadas resultou em significância aos que relataram lesao significante (valor-p=0,04), baixa renda familiar (valor-p=0,04), baixa escolaridade (valor-p=0,00), formas clinicas multibacilares (valor-p=0,01) e deficiencias avaliadas pelo GI-OMS (valor-p=0,01). As limitacoes de atividades sao frequentes (57,4%), assim como as deficiencias medidas pelo GI-OMS (68,5%), atingem as formas multibacilares, pessoas que relataram lesao significante, de baixa renda e escolaridade.

Deficiências após a alta medicamentosa da hanseníase: prevalência e distribuição espacial

OBJECTIVE To estimate the frequency of people with leprosy-related physical disabilities after release from multidrug treatment and to analyze their spatial distribution. METHODS Descriptive cross-sectional study with 232 leprosy patients treated between 1998 and 2006. Physical disabilities were assessed using the World Health Organization disability grading and the eye-hand-foot (EHF) sum score. The residential address of patients and rehabilitation centers were geocoded. It was estimated the overall frequency of physical disability and frequency by disability grade (grade 0, grade 1, and grade 2) according to the WHO disability grading taking into consideration clinical and sociodemographic variables in the descriptive analysis. Students t-test, chi-square test (χ2), and Fishers test were used as appropriate at a 5% significance level. RESULTS Of the patients studied, 51.6% were female, mean age 54 years old (SD 15.7), 30.5% had less than 2 years of formal education, 43.5% were employed, and 26.9% were retired. Borderline leprosy was the most prevalent form of leprosy (39.9%). A total of 32% of these patients had disabilities according to the WHO disability grading and the EHF score. Disabilities increased with age (p = 0.029), they were more common in patients with multibacillary leprosy (p = 0.005) and poor self-rated physical health (p < 0.001). Those who required prevention/rehabilitation care traveled on average 5.5 km to the rehabilitation center. People with physical disabilities lived scattered across the city but they were mostly concentrated in the most densely populated and socioeconomically deprived area. CONCLUSIONS There is a high frequency of people with leprosy-related disabilities after release from multidrug therapy. Prevention and rehabilitation actions should target uneducated and older patients, those who had multibacillary forms of leprosy and poor self-rated physical health. The travel distance to rehabilitation centers calls for reorganization of local care networks.OBJETIVO: Estimar la frecuencia de las deficiencias fisicas, en pacientes tratados por hanseniasis, posteriores a alta medicamentosa y analizar su distribucion espacial METODOS: Estudio descriptivo transversal con 232 personas tratadas por hanseniasis de 1998 a 2006. Las deficiencias fisicas fueron evaluadas por el Grado de Incapacidades de la Organizacion Mundial de Salud (GI/OMS) y por el Eyes-Hand-Feet (EHF). Los ex -pacientes fueron geocodificados por la direccion de residencia y los servicios de rehabilitacion por la direccion de su sede. Se presentaron las frecuencias para el total y para los grupos grado 0, grado 1 y grado 2 del GI-OMS, considerandose las variables clinicas y sociodemograficas en el analisis descriptivo. Se utilizaron las pruebas t de Student, Chi-cuadrado (?2) o de Fisher, conforme apropiado, considerandose significativos p= 0,05. RESULTADOS: Cerca de 51,6% eran del sexo femenino, con promedio de edad de 54 anos (de 15,7); 30,5% tenian menos de dos anos de educacion formal; 43,5% trabajaban y 26,9% estaban jubilados; la forma dimorfa predomino (39,9%). Las deficiencias evaluadas por el GI-OMS y por el EHF alcanzaron 32% de los ex -pacientes La presencia de deficiencias fue mayor con el aumento de la edad (p=0,029), en casos multibacilares (p=0,005) y con diagnostico equivocado del paciente sobre su salud fisica (p?0,001). Los que necesitaban de prevencion/rehabilitacion recorrieron distancia promedio de 5,5km hasta el servicio de rehabilitacion. Las personas con deficiencia fisica estaban distribuidas en todo el municipio, pero se concentraban en el area mas populosa y de mayor carencia socioeconomica. CONCLUSIONES: La frecuencia de deficiencias es elevada posterior al alta medicamentosa. Los ex -pacientes mas viejos, los que tuvieron formas multibacilares de la enfermedad, los de baja escolaridad y los que presentaron diagnostico equivocado de la propia salud fisica merecen atencion especial para la prevencion y rehabilitacion de deficiencias. La distancia entre los servicios de rehabilitacion y las residencias de los pacientes requiere reorganizacion de la red de atencion en el municipio.

Identification of Urban Leprosy Clusters

Overpopulation of urban areas results from constant migrations that cause disordered urban growth, constituting clusters defined as sets of people or activities concentrated in relatively small physical spaces that often involve precarious conditions. Aim. Using residential grouping, the aim was to identify possible clusters of individuals in São José do Rio Preto, Sao Paulo, Brazil, who have or have had leprosy. Methods. A population-based, descriptive, ecological study using the MapInfo and CrimeStat techniques, geoprocessing, and space-time analysis evaluated the location of 425 people treated for leprosy between 1998 and 2010. Clusters were defined as concentrations of at least 8 people with leprosy; a distance of up to 300 meters between residences was adopted. Additionally, the year of starting treatment and the clinical forms of the disease were analyzed. Results. Ninety-eight (23.1%) of 425 geocoded cases were located within one of ten clusters identified in this study, and 129 cases (30.3%) were in the region of a second-order cluster, an area considered of high risk for the disease. Conclusion. This study identified ten clusters of leprosy cases in the city and identified an area of high risk for the appearance of new cases of the disease.

Leprosy-related disabilities after release from multidrug treatment: prevalence and spatial distribution

OBJECTIVE To estimate the frequency of people with leprosy-related physical disabilities after release from multidrug treatment and to analyze their spatial distribution. METHODS Descriptive cross-sectional study with 232 leprosy patients treated between 1998 and 2006. Physical disabilities were assessed using the World Health Organization disability grading and the eye-hand-foot (EHF) sum score. The residential address of patients and rehabilitation centers were geocoded. It was estimated the overall frequency of physical disability and frequency by disability grade (grade 0, grade 1, and grade 2) according to the WHO disability grading taking into consideration clinical and sociodemographic variables in the descriptive analysis. Students t-test, chi-square test (χ2), and Fishers test were used as appropriate at a 5% significance level. RESULTS Of the patients studied, 51.6% were female, mean age 54 years old (SD 15.7), 30.5% had less than 2 years of formal education, 43.5% were employed, and 26.9% were retired. Borderline leprosy was the most prevalent form of leprosy (39.9%). A total of 32% of these patients had disabilities according to the WHO disability grading and the EHF score. Disabilities increased with age (p = 0.029), they were more common in patients with multibacillary leprosy (p = 0.005) and poor self-rated physical health (p < 0.001). Those who required prevention/rehabilitation care traveled on average 5.5 km to the rehabilitation center. People with physical disabilities lived scattered across the city but they were mostly concentrated in the most densely populated and socioeconomically deprived area. CONCLUSIONS There is a high frequency of people with leprosy-related disabilities after release from multidrug therapy. Prevention and rehabilitation actions should target uneducated and older patients, those who had multibacillary forms of leprosy and poor self-rated physical health. The travel distance to rehabilitation centers calls for reorganization of local care networks.OBJETIVO: Estimar la frecuencia de las deficiencias fisicas, en pacientes tratados por hanseniasis, posteriores a alta medicamentosa y analizar su distribucion espacial METODOS: Estudio descriptivo transversal con 232 personas tratadas por hanseniasis de 1998 a 2006. Las deficiencias fisicas fueron evaluadas por el Grado de Incapacidades de la Organizacion Mundial de Salud (GI/OMS) y por el Eyes-Hand-Feet (EHF). Los ex -pacientes fueron geocodificados por la direccion de residencia y los servicios de rehabilitacion por la direccion de su sede. Se presentaron las frecuencias para el total y para los grupos grado 0, grado 1 y grado 2 del GI-OMS, considerandose las variables clinicas y sociodemograficas en el analisis descriptivo. Se utilizaron las pruebas t de Student, Chi-cuadrado (?2) o de Fisher, conforme apropiado, considerandose significativos p= 0,05. RESULTADOS: Cerca de 51,6% eran del sexo femenino, con promedio de edad de 54 anos (de 15,7); 30,5% tenian menos de dos anos de educacion formal; 43,5% trabajaban y 26,9% estaban jubilados; la forma dimorfa predomino (39,9%). Las deficiencias evaluadas por el GI-OMS y por el EHF alcanzaron 32% de los ex -pacientes La presencia de deficiencias fue mayor con el aumento de la edad (p=0,029), en casos multibacilares (p=0,005) y con diagnostico equivocado del paciente sobre su salud fisica (p?0,001). Los que necesitaban de prevencion/rehabilitacion recorrieron distancia promedio de 5,5km hasta el servicio de rehabilitacion. Las personas con deficiencia fisica estaban distribuidas en todo el municipio, pero se concentraban en el area mas populosa y de mayor carencia socioeconomica. CONCLUSIONES: La frecuencia de deficiencias es elevada posterior al alta medicamentosa. Los ex -pacientes mas viejos, los que tuvieron formas multibacilares de la enfermedad, los de baja escolaridad y los que presentaron diagnostico equivocado de la propia salud fisica merecen atencion especial para la prevencion y rehabilitacion de deficiencias. La distancia entre los servicios de rehabilitacion y las residencias de los pacientes requiere reorganizacion de la red de atencion en el municipio.

Diagnosis and medical treatment of neuropathic pain in leprosy

Objetivo: identificar las dificultades de diagnosticar y tratar el dolor neuropatico causado por la lepra, asi como determinar las caracteristicas principales de esa situacion. Metodos: se examinaron 85 pacientes tratados en ambulatorio de referencia para lepra y que refirieron dolor. Se aplico el cuestionario test Douleur Neuropathic 4, y se hizo un minucioso examen neurologico a traves del cual se excluyeron 42 pacientes por no haberse comprobado dolor. Resultados: de los 37 pacientes con dolor, 22 (59,5%) tenian dolor neuropatico o mixto y, de esos, 90,8% caracterizaban ese dolor como de intensidad moderada o severa, siendo que 81,8% sufrian de el hace mas de 6 meses. Apenas 12 (54,5%) pacientes habian sido diagnosticados con dolor neuropatico y casi mitad de los casos (45,5%) estaba sin reconocimiento. En cuanto al tratamiento medicamentoso (n=12) para el dolor neuropatico, 5 (41,6%) respondieron que tuvieron mejoria; en los otros 7 (58,4%) no hubo alteracion del dolor o empeoraron cuando se comparo con el cuadro inicial. El analisis estadistico, comparando la mejoria del dolor entre los pacientes tratados (n=12) y aquellos no tratados (n=10), fue significativa (valor-p=0,020). Conclusion: se identifico dificultad en diagnosticar el dolor neuropatico en la lepra, considerando que casi la mitad de los pacientes estudiados estaban sin reconocimiento de ese cuadro. Se atribuyeron como factores asociados la no adopcion de protocolo apropiado para un efectivo diagnostico y tratamientos inadecuados que pudieron haber enmascarar el cuadro.ABSTRACT Objective: to identify the difficulties in diagnosing and treating neuropathic pain caused by leprosy and to understand the main characteristics of this situation. Methods: 85 patients were treated in outpatient units with reference to leprosy and the accompanying pain. We used a questionnaire known as the Douleur Neuropathic 4 test and we conducted detailed neurological exams. As a result, 42 patients were excluded from the study for not having proved their pain. Results: Out of the 37 patients that experienced pain, 22 (59.5%) had neuropathic pain (or a mixture of this pain and their existing pain) and of these 90.8% considered this pain to be moderate or severe. 81.8% of the sample suffered with this pain for more than 6 months. Only 12 (54.5%) of the patients had been diagnosed with neuropathic pain and in almost half of these cases, this pain had not been diagnosed. With reference to medical treatment (n=12) for neuropathic pain, 5 (41.6%) responded that they became better. For the other 7 (58.4%) there were no changes in relation to the pain or in some cases the pain worsened in comparison to their previous state. Statistical analysis comparing improvements in relation to the pain amongst the patients that were treated (n=12) and those that were not, showed significant differences (value p=0.020). Conclusion: we noted difficulties in diagnosing neuropathic pain for leprosy in that almost half of the patients that were studied had not had their pain diagnosed. We attributed this to some factors such as the non-adoption of the appropriate protocols which led to inadequate diagnosis and treatment that overlooked the true picture.

Clinical and epidemiological profiles of individuals with drug-resistant tuberculosis

Drug-resistant tuberculosis (TB) is a growing global threat. Approximately 450,000 people developed multidrug-resistant TB worldwide in 2012 and an estimated 170,000 people died from the disease. This paper describes the sociodemographic, clinical-epidemiological and bacteriological aspects of TB and correlates these features with the distribution of anti-TB drug resistance. Mycobacterium tuberculosis (MT) cultures and drug susceptibility testing were performed according to the BACTEC MGIT 960 method. The results demonstrated that MT strains from individuals who received treatment for TB and people who were infected with human immunodeficiency virus were more resistant to TB drugs compared to other individuals (p < 0.05). Approximately half of the individuals received supervised treatment, but most drug-resistant cases were positive for pulmonary TB and exhibited positive acid-fast bacilli smears, which are complicating factors for TB control programs. Primary healthcare is the ideal level for early disease detection, but tertiary healthcare is the most common entry point for patients into the system. These factors require special attention from healthcare managers and professionals to effectively control and monitor the spread of TB drug-resistant cases.

Associação entre sintomas depressivos, trabalho e grau de incapacidade na hanseníase

A depressao e o transtorno psiquiatrico mais comum na hanseniase e com alto indice de sintomas depressivos. Objetivo: Verificar a frequencia dos sintomas depressivos e sua relacao com o grau de incapacidade (GI) da OMS e variaveis sociodemograficas. Metodo: Aplicou-se um questionario, contendo aspectos sociodemograficos, clinicos e o GI. Foi aplicada a escala original do BDI para identificar a frequencia dos sintomas depressivos (21 itens) e a subescala cognitiva chamada BDI-Short Form - BDI-SF (1-13 itens), recomendada para avaliar sintomas depressivos em individuos com diagnostico de alguma patologia. Foi utilizada analise estatistica descritiva, com distribuicao de frequencia para a caracterizacao da casuistica e para o cruzamento das variaveis, foi utilizado o Teste Chi-square-corrected (Yates), considerando resultados significantes valor - p < 0,05. Resultados: Foram avaliados 130 pacientes que tem ou tiveram hanseniase. A idade media dos pacientes foi de 49,64 (SD 14,04). Houve predominio do sexo masculino (64,6%), dos que vivem com familiares (87,7%), com ensino fundamental incompleto (66,2%), uniao civil estavel (61,6%), nao trabalham (75,4%) e recebem aposentadoria ou auxilio saude (63,9%). Em relacao aos aspectos clinicos, 94,5% sao multibacilares, 74,6% concluiram a poliquimioterapia e a maioria apresenta perda da sensibilidade protetora e/ou deformidades (31,5% grau 1 e 37% grau 2). Dentre os casos avaliados 43,1% apresentou sintomas depressivos de intensidade moderada a grave. Nao houve correlacao significativa entre BDI-SF e GI (valor - p = 0,950), mas, “nao trabalhar” associou-se com sintomas depressivos (BDI-SF) (valor - p = < 0,05). Preocupacao somatica foi o sintoma mais frequente (80,7%), seguido de dificuldade no trabalho (78,5%), irritabilidade (68,5%), fadiga (67,7%), auto-acusacao (62,3%) e choro facil (60%). Conclusao: Conclui-se que sintomas depressivos moderados e graves acometeram 43,1% dos casos avaliados, independentemente de ter ou nao deficiencias fisicas (GI 1 e 2). As pessoas que nao trabalhavam foram mais acometidas por sintomas depressivos em comparacao aos que exerciam alguma atividade profissional.

Physical Therapy in Leprosy

Leprosy is a public health problem worldwide, with Brazil ranking second on the world stage. The introduction of multidrug therapy provided significant changes in the control of the disease, but this treatment does not prevent the occurrence of the physical disabilities caused by the involvement of nerves. The presence of disabilities, including physical disabilities, may lead to a reduction in work potential, restricted social life, and psychological disorders, and are responsible for discrimination against patients. Some factors contribute to the appearance of these problems, such as delayed diagnosis, lack of patient adherence to treatment, and the presence of reactive episodes. Early diagnosis, proper treatment and prevention of disabilities impede the transmission of disease and reduce disabilities including psychosocial impairment. Thus, physical rehabilitation and surgery are important tools to prevent disabilities, to improve functional capacity, aesthetics, and social life, and to alleviate pain.