Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 3 - Jul/Sep - 2018

Original Article Imprimir 

Páginas 15 a 26


Active search for hanseniasis in the schools of Cuiabá, Mato Grosso, Brazil

Búsqueda activa de hanseniasis en las escuelas de Cuiabá, Mato Grosso, Brasil

Busca ativa de hanseníase em escolas de Cuiabá, Mato Grosso, Brasil

Autores: Natricia Pilar Cardoso Blank1; Bruna Hinnah Borges Martins de Freitas2; Juliano Bortolini3

1. Graduation in Nursing by the Faculty of Nursing of the Federal University of Mato Grosso (FAEN / UFMT). Cuiabá, MT, Brazil
2. Graduation in Nursing by the Federal University of Mato Gross (UFMT), Sinop Campus. Master's Degree in Nursing by the Faculty of Nursing  (FAEN / UFMT). Teacher at FAEN / UFMT. Cuiabá, MT, Brazil
3. Graduation en in Mathematics by the Federal University of Mato Grosso  (UFMT). Master's and Doctorate in Statistics and Agricultural Experimentation by the Federal University of Lavras. Professor of the Statistics Department of the UFMT. Cuiabá, MT, Brazil

Bruna Hinnah Borges Martins de Freitas
Faculdade de Enfermagem, Universidade Federal de Mato Grosso
Av. Fernando Corrêa da Costa, nº2367- Bairro Boa Esperança
Cuiabá, MT, Brasil. CEP: 78060-900
(bruhinnah@gmail.com)

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Keywords: Leprosy, health education, adolescent health, school health services.
Palabra Clave: Hanseniasis, educación en salud, salud del adolescente, servicios de salud escolar.
Descritores: Hanseníase, educação em saúde, saúde do adolescente, serviços de saúde escolar.

Abstract:
OBJECTIVE: Determine the number of new cases of leprosy through an active search conducted with adolescents from 10 to 14 years old enrolled in public schools in Cuiabá, Mato Grosso, Brazil.
METHODS: This is a cross-sectional study in which the participant selection was made by stratified probabilistic sampling. The active search occurred through the mirror method after an educational workshop with games adapted to the general aspects of leprosy. The descriptive analysis was performed through frequency tables.
RESULTS: 31 schools were visited covering a population of 1,263 adolescents. The family income of one to two minimum wages was the most prevailed among the interviewees (40.2%). The majority (75%) stated that they had never previously participated in a health education activity on leprosy. The history of leprosy cases in the family was verified in 11% of the answers. According to the self-image record, 16.8% were considered suspects for leprosy. After all the information was validated again with the students, only 0.2% confirmed the presence of signs and symptoms of leprosy, which were referred to the reference health units of the school and no case was confirmed.
CONCLUSION: It was concluded that no new cases of leprosy were identified through active search. However, it should be emphasized that this study promoted the benefit of health education to the entire population, using games as mediators of the teaching-learning process.

Resumen:
OBJETIVO: Determinar el número de casos nuevos de hanseniasis por medio de búsqueda activa realizada con adolescentes de 10 a 14 años matriculados en escuelas públicas de Cuiabá, Mato Grosso, Brasil.
MÉTODOS: Se trata de un estudio transversal, cuya selección de participantes fue realizada por muestreo probabilístico estratificado. La búsqueda activa ocurrió por medio del método espejo después de un taller educativo con juegos adaptados para los aspectos generales de la hanseniasis. El análisis descriptivo se realizó a través de tablas de frecuencia.
RESULTADOS: Fueron visitadas 31 escuelas cubriendo una población de 1.263 adolescentes. La renta familiar de uno a dos salarios mínimos fue la que prevaleció entre los entrevistados (40,2%). La mayoría (75%) afirmó que nunca participaron anteriormente en una actividad de educación en salud sobre la hanseniasis. El historial de casos de hanseniasis en la familia se verificó en el 11% de las respuestas. De acuerdo con la ficha de autoimagen, el 16,8% fueron considerados sospechosos para la hanseniasis. Después de que toda la información se valida de nuevo con los escolares, sólo el 0,2% confirmó la presencia de signos y síntomas de hanseniasis, los cuales fueron encaminados a las unidades de salud de referencia de la escuela y no hubo confirmación de ningún caso.
CONCLUSIÓN: Se concluye que no se han identificado casos nuevos de hanseniasis a través de la búsqueda activa. Sin embargo, conviene resaltar que este estudio promovió como beneficio la educación en salud a toda la población participante, utilizando juegos como mediadores del proceso de enseñanza-aprendizaje.

Resumo:
OBJETIVO: Determinar o número de casos novos de hanseníase por meio de busca ativa realizada com adolescentes de 10 a 14 anos matriculados em escolas públicas de Cuiabá, Mato Grosso, Brasil.
MÉTODOS: Trata-se de um estudo transversal, cuja seleção de participantes foi feita por amostragem probabilística estratificada. A busca ativa ocorreu por meio do método espelho após uma oficina educativa com jogos adaptados para os aspectos gerais da hanseníase. A análise descritiva foi realizada através de tabelas de frequência.
RESULTADOS: Foram visitadas 31 escolas abrangendo uma população de 1.263 adolescentes. A renda familiar de um a dois salários mínimos foi a que prevaleceu entre os entrevistados (40,2%). A maioria (75%) afirmou que nunca participaram anteriormente de uma atividade de educação em saúde sobre a hanseníase. O histórico de casos de hanseníase na família foi verificado em 11% das respostas. De acordo com a ficha de autoimagem, 16,8% foram considerados suspeitos para hanseníase. Após todas as informações serem validadas novamente com os escolares, apenas 0,2% confirmaram presença de sinais e sintomas de hanseníase, os quais foram encaminhados para as unidades de saúde de referência da escola e não houve confirmação de nenhum caso.
CONCLUSÃO: Conclui-se que não foram identificados casos novos de hanseníase por meio da busca ativa. Contudo, convém ressaltar que este estudo promoveu como benefício a educação em saúde a toda a população participante, utilizando jogos como mediadores do processo de ensino-aprendizagem.

INTRODUCTION

Hansen's disease is a chronic and slowly developing infectious disease that manifests itself in skin cells and peripheral nerves, which can cause deformities and physical disabilities1. For many years the forms of confrontation of hanseniasis included confinement and exile, which reinforced social stigmas still evident today. Thus, even curable, hanseniasis directly interferes in social, physical and psychic aspects of the individual, culminating in feelings of less value and despair2.

Although the World Health Organization (WHO) has indicated a decline in the number of cases in the last 10 years, however, countries such as India, Brazil and Indonesia had an incidence higher than 10,000 cases in 2016. Together, the three countries represent 81% of the world notifications, in which Brazil is the second in number of new cases of hanseniasis, with 25,218 cases3.

The number of cases among children under fifteen years of age is greater in hyperendemic regions, such as Mato Grosso, and denotes the precocity of the exposure, the continuous transmission of the bacillus in the population, the difficulty of its eradication and the deficiency in surveillance and control of the disease4. Children under fifteen years of age seem to be more predisposed to the disease than other members of the family5. In addition, there is greater complexity in the diagnosis of this population, because clinical signs aren´t easily recognized in childhood, which requires a judicious clinical and epidemiological examination1.

In Brazil, since 2013 the General Coordination of Hanseniasis and diseases in elimination, together with the Ministry of Health Surveillance (SVS) and the Ministry of Health (MS) decided to adopt campaigns that identify suspected cases of hanseniasis in schoolchildren from endemic areas using the mirror method. This strategy aims to achieve one of the goals of the WHO Global Hansen Disease Strategy in four years, which emphasizes the early detection of cases before the appearance of visible disabilities, especially in children6-7.

Since 1986, the Otawa Charter has emphasized the importance of creating favorable environments for health education and holds the various sectors of society accountable, including the school. This is the place in which conceptions are constructed, destroyed or perpetuated through the construction of knowledge8. In addition, childhood and adolescence are primordial periods in the creation and solidification of attitudes and practices in health, making the school an environment conducive to the implementation of educational activities10.

An investigation with adolescents in the city of Parnamirim-RN showed that 53.37% of the adolescents included in the study already heard about hanseniasis, however they referred ignorance as to the etiology, transmission, signs and symptoms of the disease. The study also describes that after educational actions the number of adolescents who referred to know the pathology moved to 90.82%. In addition, other authors investigated about increased health education in the active search for hanseniasis, identifying new cases in the community12,13.

Considering the study carried out by Freitas, Cortela e Ferreira4, who identified the growing trend of multibacillary cases and with physical disability grade 2 in children under fifteen years of age in the State of Mato Grosso, in addition to highlighting the importance of health education and search actions active for the early detection of cases in the community, as stated above, it is essential to conduct research that intervenes in these indicators. Thus, the objective of this research was to determine the number of new cases of hanseniasis through active search conducted with adolescents aged 10 to 14 years enrolled in public schools in Cuiabá, Mato Grosso, Brazil.


METHOD

This is a descriptive cross-sectional study, carried out with adolescents aged 10 to 14 years enrolled between the 5th and 9th years, of the state public schools of the urban area of Cuiabá, Mato Grosso, contemplating all the regions of the municipality. Data from the Superintendence of Basic Education of the State Secretariat for Education of Mato Grosso (SEDUC/MT) indicate that the average student population between 2016 and 2017 is 20,306.

The schools in which the managers authorized the research and the adolescents who agreed to participate in the research with the authorization of the parents were included in the study. The data collection period was between August 2016 and August 2017.

The method chosen for the selection of the sample was stratified probabilistic sampling. The students were selected in each stratum (regions of Cuiabá) by probability proportional to the number of students enrolled in the region.

The calculation of finite population was used for the establishment of the sample, that is, when the elements don´t surpass 100,000 (one hundred thousand) components, being the following formula: n = NZ2p.q / (e2 (N-1) + Z2p .q). In this formula, "n" represented the size of the sample; "Z" is equal to the chosen confidence level, expressed in number of standard deviations, being able to assume values of 1 (one) to 3 (three). In this study we chose the value 2 (two), which represents the dispersion of the sample in two standard deviations to the left or to the right in relation to the mean; "p" represents the percentage with which the phenomenon is verified, in this case, as there is no information in the literature on the matter to base the value, 50% was adopted; "q" means the complementary percentage (100-p), being therefore 50%; "N" represents the average population size of 2016 and 2017 that was 20,306 adolescents; and "e" means the maximum permissible error admitted by the researchers, which may vary from 1% to 5%, in this case, the chosen value was 3%. The result of the calculation was n=1053, where more than 20% of the "n" was added in relation to the sample due to the possibility of losses. Therefore, totaling a sample of 1263 adolescents.

The stratification occurred through the regions of Cuiabá: Stratum 1 - South Region; Stratum 2- North Region; Stratum 3- Eastern Region and; Stratum 4 - Western Region. The calculation of the proportion of the sample (n) by stratum can be seen in Table 1.




The selection of the schools by stratum was simple random, which is, the raffle was made possible by the participation of any school of the list by region. After the definition of the school, the students were invited to participate randomly until reaching the "n" of each stratum, as the total of the sample wasn´t reached in just one school one adjustment was made with the drawing of another school aiming to maintain The size of the school shows planned by stratum.

For the data collection, a Socioeconomic, Demographic and Epidemiological Form was elaborated and a pre-test (pilot research) was carried out in August 2016, for the training of the collection team, to verify difficulties of the applicator, difficulty in understanding the issues and verify the time used for its application.

This form was applied after an educational intervention that had the purpose of promoting the knowledge about hanseniasis to the students, approaching in a creative and systematic way aspects related to the concept, fear, stigma, classification, signs and symptoms, transmission, diagnosis and treatment. Each intervention had durability of two hours, was applied to groups of six adolescents and composed of five games adapted to the theme: adjective, face, semaphore, true or false and mosaic.

At the end of the workshop and the application of the form, the Self-Report Card prepared and prepared by the MS for the adolescent was filled in at home with the parents / guardians. This contains identification data, questions about signs and symptoms of hanseniasis and cases of hanseniasis in the family. Subsequently, the file was delivered to the school.

The cases that had spots on the skin, that were not of birth, that didn´t itch or didn´t hurt, that were dormant and with a history of hanseniasis in the family, were addressed to validate the information. For this, the adolescents were again questioned orally about the answers declared in the instruments and, then, those with suspected hanseniasis were sent to the reference health unit for diagnostic confirmation.

The variable of interest was the number of new cases of hanseniasis. The other variables used were socioeconomic and demographic variables and clinical and epidemiological variables.

The structuring of the database was done through the Epi-Info 7 software with independent double fingering. The data from both banks were compared using the Data Compare tool that identified inconsistencies, which were corrected by consulting the original collection documents. The descriptive information was made through frequency tables, and the analysis was performed in the SPSS software, version 20.0.

This study is part of a matrix research called "Health education and active search for hanseniasis in children under fifteen in Cuiabá, MT", approved by the Research Ethics Committee of the JúlioMuller University Hospital (HUJM) under the opinion 1,579. 925 and CAAE 53659616.5.000.5541 on June 08, 2016.


RESULTS

A total of 31 schools were visited between 2016 and 2017, eight from the South region, nine from North, nine from the East and five from the West, covering a population of 1,263 adolescents in the age group of 10 to 14 years. The mean age was 12.55 years (SD ± 1.23). As can be seen in Table 2, among the researchers, the majority were female (58.6%) and brown (54.9%).




The majority of adolescents stated that they live with their parents (74.3%), while 62.2% answered that the number of inhabitants in the household varies from four to six people. The parents/guardians appear mostly as employees (51.0%) and the family income of one to two minimum wages prevails (40.2%).

Regarding the history of hanseniasis, according to the students, 0.5% indicates that they have already had leprosy. The case history of hanseniasis in the family was verified in 11% of the answers, being that 4.8% are in non immediate members of the family (as great-grandparents, uncles and cousins) and not the parents, grandparents and siblings. It is observed that 1.3% of the students had two family members with the disease and 0.7% with three or more members. In addition, 3.2% recognize the case history of hanseniasis in the neighbors and 2.2% of the disease in the schoolmates (Table 3).




Regarding the number of scars of Bacillus Calmette-Guérin (BCG), 20.6% of adolescents didn´t present any marks. In addition, 75% never previously participated in an educational activity on hanseniasis.

In the research of active search for hanseniasis, among those who claimed to have spots on the skin, 22.5% declared that they were not born, 94.7% didn´t scratch, 97.5% didn´t give and 7, 8% of the spots were dormant (Table 4). Figure 1 shows the distribution of cases in terms of active search for hanseniasis, carried out after health education.




Figure 1. Flow diagram of case distribution regarding the active search for leprosy. Mato Grosso, Brazil, 2018.



Based on the responses of the adolescents in the self-image file, 16.8% of adolescents were considered suspects of hanseniasis. Consequently, all the information contained in the files of the suspects was evaluated and confirmed individually on another visit to the school. In that second visit, however, only 0.2% of the adolescents had the presence of signs and symptoms of confirmed hanseniasis, and they were sent to the reference health units of the school. After evaluation by the health service, none of the adolescents obtained confirmation of the disease. Also, no clinical characteristics were found that are consistent with possible differential diagnoses.


DISCUSSION

Active search is recognized with an important method for the early diagnosis of hanseniasis and occurs through the identification of suspected cases in the community. For its part, polychemotherapy stands out as an effective treatment for its elimination14. These actions have corroborated with the reduction of cases of the disease worldwide3.

Brazil is the second country most affected by hanseniasis in the world3. One of the surveillance strategies adopted by the country for its elimination is the National Campaign for Hanseniasis, Verminosis, Trachoma and Schistosomiasis, which seeks to identify suspected cases of hanseniasis (among others), and direct them to treatment. For this, the mirror method is used, which consists of the application of a sheet containing tracking issues and a schematic design of the human body, in which the adolescent, when looking at his body, will be able to highlight in the drawing the place where he has injuries6,15.

Consequently, the files are evaluated by health professionals who identify suspicious cases and, then, they are sent to the health unit for dermatoneurological examination, for confirmation or discard of the suspicion. The Practical Guide for Operability of the Campaign defends that the mirror method empowers the child and the adolescent and involves the parents and those responsible in that process, since through the self-image card they can identify, together, the signs and symptoms of hanseniasis6.

Although no case of hanseniasis was identified in this study, Sousa et al.13 in their study of health education and active search for hanseniasis involving 532 fundamental education students from public teaching institutions, identified 55 suspected cases and the rate of prevalence of the disease 18.70 per 100 thousand inhabitants. Portal et al.12 also carried out educational activities and active search in a riparian community of Pará, in which they obtained a point prevalence of 28.9 cases per 10 thousand inhabitants.

However, the mentioned authors didn´t use the mirror method in their studies, but rather a classification of all the students, with a general realization of the dermatoneurological examination, this being a strategy that seems to detect more cases than with the use of the mirror method. They identified inconsistencies in the filling of the self-image file. These may be related to the lack of understanding about the questioning or individual filling by the students, without the presence of the parents / guardians, which insn´t guaranteed by this method, because it is filled in the home environment. These inconsistencies and mainly due to the losses of the self-image file (many of the records don´t return to school) indicate that this method presents weaknesses in the active search of new cases in children under fifteen years of age.

The proportion of individuals with a history of hanseniasis in the family identified among the respondents indicates a nine times higher risk of a healthy subject developing the disease through contact, and that risk is four times greater when the contact is with a neighbor16. Therefore, the Ministry of Health recommends the examination of contacts of all newly identified cases, because the longer the diagnosis, the greater the sequelae and deformities. Thus, the search for contacts is essential for the early diagnosis of the disease in childhood and adolescence1,17.

Contact management approaches, when well developed, provide the opportunity to apply preventive measures to reduce the incidence of the disease, and decrease transmission in endemic communities. If this contact insn´t detected with the disease, it is important to add preventive interventions, such as post-exposure prophylaxis18.

The most widespread post-exposure prophylaxis in practice is immunoprophylaxis through vaccination with BCG. It is known as a vaccine against tuberculosis and is routinely administered to children as part of the neonatal immunization scheme in many parts of the world and is also indicated for contacts of leprosy cases, without signs or symptoms of the disease1. However, in this study, it should be noted that a considerable proportion of adolescents without BCG scar was identified, which, according to Goulart et al.19, implies a 3.7 times greater risk of occurrence of hanseniasis than those whose scar it's present.

Most of the subjects interviewed stated that they had never participated in a health education activity before. In the Guidelines for surveillance, care and elimination of hanseniasis as a public health problem in 2016, in addition to the active search, the Ministry of Health considers health education as one of the main activities for the reduction of the hanseniasis burden in Brazil1.

Monteiro et al.11 affirm that health education, when understood by the public, empowers the individual with knowledge and consequently contributes to early diagnosis. In this sense, the nurse plays an important role in this process, characterizing himself as a precursor of education and health promotion actions, and for his responsibility in the integrality of care.

In this perspective, the Health in School Program (PSE) was established, which aims to offer comprehensive health care actions for students to be carried out by the Family Health Strategy (ESF) teams. Its intention is to address the vulnerabilities of children and young people in the Brazilian public education network. To guarantee the sustainability of the PSE, it would be necessary the effective participation of the managers, professionals of the ESFs and of the school and school community, which would guarantee a greater participation of the students in educational activities on hanseníase20.

In this context, even though no cases of the disease have been identified through active search, it is worth noting that this study promoted the health education of this population as a benefit, allowing the elimination of false culturally established concepts, through of the propagation of information about the general aspects of the disease in a playful way and through the use of games.


CONCLUSION

It is concluded that no new cases of hanseniasis were identified through the active search with the mirror method among the 1,263 adolescents aged 10 to 14 years investigated. However, the entire participating population received health education on leprosy by means of games adapted for the subject of hanseniasis as mediators of the teaching-learning process.


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