Revista Adolescência e Saúde

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

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ISSN: 2177-5281 (Online)

Vol. 15 nº 4 - Oct/Dec - 2018

Original Article Imprimir 

Páginas 65 a 72


Epidemiological analysis of leprosy in children under 15 years at a reference center in region of Brazil

Análisis epidemiológico de hanseniasis en menores de 15 años en un centro de referencia en la región noreste de Brasil

Análise epidemiológica de hanseníase em menores de 15 anos em um centro de referência na região nordeste do Brasil

Autores: Erilaine de Freitas Corpes1; Natália Braga Hortêncio Jucá2; Ana Caroline Lima Vasconcelos3; Maria Araci de Andrade Pontes4; Anamaria Cavalcante e Silva5; Paulo César de Almeida6

1. Graduation in Nursing by the State University of Ceará (UECE). Fortaleza, CE, Brazil
2. Master degree in Child and Adolescent Health by the State University of Ceará (UECE). Professor of the Medicine  Course of the Christus University Center (UniChristus.). Fortaleza, CE, Brazil
3. Graduation in Nursing by the State University of Ceará (UECE). Resident in Medical Emergency and Urgency by the School of Public Health of de Ceará (ESP-CE). Fortaleza, CE, Brazil
4. Doctorate in Pharmacology by the Federal University of Ceará (UFC). Technical Director of the Dermatology Center Dona Libânia (CDERM). Fortaleza, CE, Brazil
5. Doctorate in Sciences by the São Paulo University (USP). Professor of the Medicine Course at the Christus University Center (UniChristus). Fortaleza, CE, Brazil
6. Post-doctorate in the Post-graduation Program in Nursing by the Federal University of Ceará (UFC). Professor at the State University of Ceará (UECE). Fortaleza, CE, Brazil

Erilaine de Freitas Corpes
Avenida Tenente Anderson, nº 265, apto. 102, Conjunto Esperança
Fortaleza, CE, Brasil. CEP: 60763-460
(erilainefc@gmail.com)

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Keywords: Leprosy, epidemiology, public health, child health, adolescent health.
Palabra Clave: Hanseniasis, epidemiología, salud pública, salud del niño, salud del adolescente.
Descritores: Hanseníase, epidemiologia, saúde pública, saúde da criança, saúde do adolescente.

Abstract:
OBJECTIVE: Analysis of the distribution of leprosy cases in children under 15 years, according to clinical and epidemiological characteristics.
METHODS: Analytical and retrospective study with a quantitative approach of case type series. Samples consisting of 313 records of new cases of leprosy in the period from 2009 to 2015. The data analysis included descriptive statistical tests, relative frequencies and averages, considering the value of p ≤ 0.05. To determine the association between categorical variables, the chi-square test (χ2) and Fisher-Freeman-Halton test were used.
RESULTS: In this study, the majority of the children and adolescents were male (57.7%), with ages between 10 to 14 years old (66.1%) and 77.7% were brown. The tuberculoid clinical form predominated (39.6%), followed by dimorphous (39%), undetermined form (11.7%) and virchowian (9.7%). Regarding the operational classification, 57.3% cases were paucibacillary and 42.7% multibacillary. The cases' analysis revealed that the tuberculoid clinical form as the most frequent among the age group from 1 to 9 years (52.8%), and the dimorphic from 10 to 14 years old (41.8%). These differences were statistically significant (p = 0.004). In relation to the degree of incapacity, 24 cases (7.9%) were observed, which indicates delay in diagnosis.
CONCLUSION: The prevalence of children and adolescents with leprosy is still high. To this end, it is necessary to train health professionals so that they can make an early and adequate diagnosis, as well as implement health education actions for the population.

Resumen:
OBJETIVO: Análisis de la distribución de los casos de hanseniasis en menores de 15 años, según las características clínicas y epidemiológicas.
MÉTODOS: Estudio analítico y retrospectivo con abordaje cuantitativo del tipo serie de casos. Muestra de 313 registros médicos de los nuevos casos de hanseniasis en el período de 2009 a 2015. El análisis incluyó pruebas descriptivas estadísticas, frecuencias relativas y medias, teniendo en cuenta el valor de p £ 0:05. Para la asociación de variables categóricas, elo test chi-cuadrado (χ2) y p Fisher-Freeman Halton.
RESULTADOS: En ese estudio, la mayoría de los niños y adolescentes eran del sexo masculino (57,7%), con edades entre 10 a 14 años (66,1%) y 77,7% eran pardos. Predominó la forma clínica tuberculoide (39,6%), seguido por dimorfa (39%), indeterminada (11,7%) y virchowiana (9,7%). En cuanto a la clasificación operacional, (57,3%) fueron paucibacilar y (42,7%) multibacilar. El análisis de los casos clínicos mostró que la forma tuberculoide fue más común entre las edades de 1 a 9 años (52,8%), y en el límite, de 10 a 14 años (41,8%). Estas diferencias fueron estadísticamente significativas (p = 0,004). En relación al grado de incapacidad, se observaron 24 casos (7,9%), lo que indica retraso en el diagnóstico.
CONCLUSIÓN: La prevalencia de niños y adolescentes con hanseniasis sigue siendo alta. Para ello, es necesario capacitar a los profesionales de salud para que éstos puedan realizar el diagnóstico precoz y adecuado, además de implementar acciones de educación en salud para la población.

Resumo:
OBJETIVO: Análise da distribuição dos casos de hanseníase em menores de 15 anos, segundo as características clínicas e epidemiológicas.
MÉTODOS: Estudo analítico e retrospectivo com abordagem quantitativa do tipo série de casos. Amostra constituída por 313 prontuários de casos novos de hanseníase no período de 2009 a 2015. A análise contemplou testes estatísticos descritivos, frequências relativas e médias, considerando o valor de p ≤ 0.05. Para a associação entre variáveis categóricas, utilizou-se o teste qui-quadrado (χ2) e o p de Fisher-Freeman-Halton.
RESULTADOS: Nesse estudo, a maioria das crianças e adolescentes eram do sexo masculino (57,7%), com idades entre 10 a 14 anos (66,1%) e 77,7% eram pardos. Predominou a forma clínica tuberculóide (39,6%), seguida pela forma dimorfa (39%), indeterminada (11,7%) e virchowiana (9,7%). Quanto à classificação operacional, (57,3%) era paucibacilar e (42,7%) multibacilar. A análise dos casos revelou que a forma clínica tuberculoide foi a mais frequente entre a faixa etária de 1 a 9 anos (52,8%), e a dimorfa, de 10 a 14 anos (41,8%). Essas diferenças foram estatisticamente significantes (p = 0,004). Em relação ao grau de incapacidade, observaram-se 24 casos (7,9%), o que sinaliza atraso no diagnóstico.
CONCLUSÃO: A prevalência de crianças e adolescentes com hanseníase ainda é alta. Para isso, é preciso capacitar os profissionais de saúde para que esses possam realizar o diagnóstico precoce e adequado, além de implementar ações de educação em saúde para a população.

INTRODUCTION

Leprosy (HANSENISIS) represents a serious public health problem that was stigmatized for a long time, causing social segregating carriers of the disease. Currently there is still much preconception to be overcome, but the advances were remarkable, mainly with the evolution of therapeutic options.

In Brazil, there is an increasing incidence of new cases related to the maintenance of social, economic and cultural vulnerability as determinants in the health-disease process. In 2015, the World Health Organization (WHO) reported 210.758 new cases of leprosy in the world, where Brazil ranks second in the ranking world, with a total of 13% of the records, second only to India, which has 60% of the cases of leprosy1.

Same prevalent among adults, children and adolescents are also susceptible to the disease because the risk of children getting sick increases in endemic areas and when there are cases in the family. In 2005, the coefficient of detection of leprosy in children under 15 in Brazil was 0.60 cases per 10,000 inhabitants. In Ceará, there are no variations in that index in the last ten years. For example, in 2013 the detection rate in this age group was 0.58 cases per 10,000 habitants in Ceará2.

In absolute numbers, there was a notification of 2.113 new cases in 2015 in children under 15 years old in the country. In Ceará of the 1.790 new cases of leprosy in the period, 93 were under 15 years old, corresponding to 5.19% of the total3.

In order to reduce cases of the disease in the world, the WHO disseminated the Global Strategy for Hanseniasis, which consists of a set of integrated actions for the prevention and control of the disease from 2016 to 2020. It also addresses the challenges faced in the control of leprosy, with emphasis on early detection to reduce disability due to the disease4.

However, Brazil is still far from achieving the objectives set by the Ministry of Health (MS), which is to achieve the prevalence of less than one case per 10.000 inhabitants 5. In this way, the prevalence of the disease is a public health problem that requires effective and efficient health actions, adapted to the local reality in the control of leprosy.

Thus, the objective of the present study was to analyze the distribution of cases of leprosy in children under 15 years of age, according to clinical and epidemiological characteristics.


METHODOLOGY

Descriptive study with quantitative approach of type of series. Descriptive epidemiology analyzes the study of the distribution of the frequency of diseases and of the grievances to collective health based on variables linked to time, space and person, thus enabling the delineation of the epidemiological profile, with a view to promoting of health. There are some advantages to monitoring known diseases, identifying emerging problems, and providing the basis for planning, organizing and evaluating health6

The sample consisted of 313 records of new cases of leprosy in children under 15 years, in the period from 2009 to 2015 in the state of Ceará, who were accompanying a national reference center in dermatology in the northeastern region of Brazil. The data collection occurred through the analysis of the files, complementing them, when necessary, with the records of the National Information System of Notification Aggravators (SINAN). The variables used were demographic (age, sex, race, education, municipality of residence, place of residence) and clinic s (number of injuries, clinical form, operative classification, smear microscopy, degree of disability at the time of diagnosis, detection mode and withdrawal rate).

The presentation of the variables demographic partner and clinics were made in the tables. The means and standard deviations of the quantitative variables were calculated. The analysis of the association between the clinical form of the leprosy and the degree of disability with the variables sex, age and number of injuries were made by the test χ 2 by Fisher Freeman-Halton. Analyzes with p <0.05 were considered statistically significant. The data was processed in SPSS 20 license Do not. 10101131007.

The study was approved by the Ethics Committee, under the verified opinions available on the Brazil Platform, number 50570015.2.0000.5534 and number 50570015.2.3001.5036, respecting the ethical and legal aspects in accordance with Resolution 466/2012 of the National Health Council7. After the project was approved by the Ethics Committee on Human Research, the research was conducted by the responsible researcher helps give two learners fellows, previously trained for data collection, which occurred in the period of April and May 2016.


RESULTS

Of the 313 children and adolescents who were part of the study, 180 (57.7%) were male, being 207 (66.1%) in the age group of 10 to 14 years. In terms of schooling, 59.4% were enrolled in the 5th-8th series of fundamental education. It is important to highlight that children who were not in the age range of schooling planned for each age were considered illiterate. Regarding the origin, there were 262 (91%) people from the urban area, with Fortaleza being the most frequent city in the study with 211 (71.3%) members of the research (Table 1).




Regarding the clinical characteristics, 251 (83.1%) patients presented up to five skin lesions, with an average of 3,8 lesions. The tuberculoid clinical form predominates (39.6%), followed by dimorph (39%), undetermined (11.7%) andvirchowiana (9.7%). The operational classification was defined by the MS, 176 (57.3%) patients were reported as paucibacillary, and 131 (42.7%) as ultibacilar. When the degree of disability for the diagnosis was evaluated, 262 (85.7%) presented zero degree.

Regarding the detection mode, 271 (88.8%) occurred through routing. As to smear, 269 (91.2%) patients were examined in the diagnostic result predominantly negative (68.8%). The rate of abandonment to treatment was 5.2% (n=14).

In Table 3, it is observed that the most frequent clinical form in men was dimorph (41.3%) and tuberculoid in the female sex (43.4%). These differences were not statistically significant (p = 0.191). However, when it is associated the form clinic with age, tuberculoid was the most found in patients from one to nine years (52.8%), and in the limit in patients 10-14 years (41.8%). These differences were also statistically significant (p=0.004).






When the degree of disability at diagnosis and the age group was analyzed, 24 (7.9%) cases with some degree of disability were observed. Patients diagnosed with more than five skin lesions showed the highest grade I disability rates (12.2%versus 2.9%) and II (10.2% versus 2.0%) in the records of revision of medical records, these characteristics being statistically significant (p=0.001) (Table 4).




DISCUSSION

Many years ago, Brazil faces difficulties in decreasing the incidence of leprosy. This complexity is related because it is a chronic infectious disease, with a high degree of infection, slow evolution and low pathogenesis, which affects people of various ages. In children and adolescents, leprosy is more worrisome since it represents an early exposure to the causative agent.

Many authors describe the characteristics of leprosy according to sex, where there prevalence of the disease in men of all ages8. This data corroborates with the results of the present study where 180 (57,7%) of the patients with leprosy were male. Regarding age, there was a prevalence of patients in the age group of 10 to 14 years, confirming a long incubation period in the group studied.

There was a prevalence of patients, who were in the school phase, being the majority (59.4%) those who were in the 5th-8th series of fundamental education. The school phase is the moment in which the child and the adolescent are in constant learning process, but the issue of leprosy is poorly addressed in schools. The lack of information influences the understanding of the seriousness and the importance of carrying out the control of the disease, thus becoming a challenge for health9.

The prevalence of operational paucibacilar classification and in the study it is very common in children, and shows a resistance to the bacillus, as well as a possible spontaneous cure. These data corroborate a study in Juazeiro - BA, in which the paucibacilar also he prevailed in leprosy cases that occurred from 2001 to 2010 in children under 15 years in the capital10 in October. However, the qualification multibacilar was also very frequent, which indicates that many patients may have difficulties in achieving a cure.

When the clinical form of the disease is analyzed according to the age group (Table 3), it was observed that for all the groups the number of cases had a direct relationship with age. Therefore, the form tuberculoid was found more frequently in patients from 1 to 9 years (52.8%), and the dysmorphia in patients aged 10 to 14 years (41.8%). Previous studies showed a strong correlation between the clinical presentation and age, being the tuberculoid and dysmorphia the most frequent forms in childhood11. The low percentage of the indeterminate clinical form (11.7%) evidences the presence of delay in the diagnosis and in the therapeutic performance, being able to be related to a type of failure to care, strengthening the vision of leprosy as careless and stigmatizes.

The mode of detection through routing prevailed in the study, evidencing the presence of professionals more attentive to the diagnosis of leprosy in the health units. The performance of an early diagnosis is essential, since it diminishes the disabilities that are caused by hanseniasis12. This information corroborates with the data presented, since 85.7% of the patients did not have disabilities at diagnosis.

The results were positive when the correlation between the degree of incapacity for diagnosis and the number of skin lesions was analyzed. Patients with more than five injuries had higher degree disability rates I (12,2% versus 2,9%) and II (10,2% versus 2,0%) compared to the group that has up to five lesions (p=0.001) (Table 4). The epidemiological indicators proposed by the MOH consider the degree of disability II to be high when it exceeds 10%; average, if it is between 5% and 10%; and low, less than 5%13. In this study, this variable is low, since only 3.5% of the cases presented a degree of disability II, reflecting a satisfactory attendance in the early diagnosis.

However, despite the fact that most of the patients have carried out the bacilloscopy, it´s draws attention to the number of patients who do not perform this procedure (5.8%). This data is a negative reflection of the MS recommendations regarding the management of the patient under treatment for leprosy. During diagnosis, this test is essential for the differentiation of paucibacillary and multibacilar, besides helping in dimorphic cases and the duration of therapy poliquimio14.

The MS considers abandonment if the patient didn´t attend the health system in the last 12 months to receive the medication15. The number of patients who abandoned the treatment in the present study was low (5.2%), but it is evidence of a public health problem, since these active sources can spread the disease to other people with whom the patient has contact.

The search for the elimination of leprosy is a public health problem, and for that goal to be achieved, some measures are necessary, among them: the early detection of new cases, the active search for cases in the community, the treatment adequate and precocious, the reduction of the rate of abandonment of the treatment, in addition to the prevention of incapacities and the rehabilitation of the leprosy carriers.


CONCLUSION

Leprosy is a forgotten disease, causing many stigmas in society. Despite the low lethality and mortality, it is a disease that needs to be treated early, as it can affect the future of the individual, causing physical, social and psychological problems.

The results of this investigation corroborated with those of some previous studies. The low rate of indeterminate clinical form (11.7%) and not realization of bacilloscopy in all patients in this study (5.8%) are also factors that attract attention and shows assistance defects that need to be corrected.

In this study, the need to implement actions to train professionals to correct reporting of cases is done and that can make early diagnosis, in accordance with the guidelines established by the MS is evident.

Health education promotion actions are also essential, as they can make patients and their caregivers more active in their health status, contributing to the proper performance of treatment and reducing cases of abandonment.


REFERENCES

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2. Brasil. Governo do Estado do Ceará. Secretaria de Saúde. Coordenadoria de Promoção e Proteção à Saúde / Núcleo de Vigilância Epidemiológica. Informe Epidemiológico de Hanseníase. Fortaleza, 2014, 9 p.

3. Datasus. Ministério da Saúde. Hanseníase: casos confirmados notificados no Sistema de Informação de Agravos de Notificação - Sinan Net. [acesso 2018 Jan 19]. Disponível em: <http://tabnet.datasus.gov.br/cgi/sinannet/hanseniase/hans_indicadores.htm>

4. Organização Mundial De Saúde (OMS). Estratégia Global para Hanseníase. Plano: 2016-2020. Brasil, 2016.

5. Franco MCA, Macedo GMM, Menezes BQ, Jucá Neto FOM, Franco ACA, Xavier MB. Perfil de casos e fatores de risco para hanseníase, em menores de quinze anos, em município hiperendêmico da região norte do Brasil. Revista Paraense de Medicina 2014; 28(4):29-40.

6. Rouquayrol M Z, Silva MGC. Epidemiologia & Saúde. 7. ed. Rio de Janeiro: MedBook, 2013. 709 p.

7. Brasil. Ministério da Saúde. Diretrizes e normas regulamentadoras sobre pesquisa envolvendo seres humanos. Resolução 466. Brasília: MS; 2012.

8. Pereira DL, Brito LM, Nascimento AH, Ribeiro EL, Lemos KRM, Alves JN, et al. Estudo da prevalência das formas clínicas da hanseníase na cidade de Anápolis-GO. Ensaios e Ciência: Ciências Biológicas, Agrárias e da Saúde, 2012; 16(1): 55-67.

9. Pinheiro MGC, Silva SYB, França ALM, Monteiro BR, Simpson CA. Hanseníase: uma abordagem educativa com estudantes do ensino médio. J. Res.: fundam. Care. Online [periódico na Internet]. 2014 Abr-Jun [acesso 2018 Jan 16]; 6(2): 776-784. Disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/3096/pdf_1283

10. Luna ICF, Moura LTR, Vieira MCA. Perfil clínico-epidemiológico da hanseníase em menores de 15 anos no município de Juazeiro-BA. Rev Bras Promoc Saude 2013; 26(2): 208-215.

11. Matos EVM, Ferreira AMR, Palmeira IP, Carneiro DF. Conjuntura Epidemiológica da Hanseníase em menores de quinze anos, no período de 2003 a 2013, Belém - PA. Hansen Int [acesso 2018 Jan 23]; 2015; 40(2): 17-23. Disponível em: http://www.ilsl.br/revista/detalhe_artigo.php?id=12360

12. Brasil. Ministério da Saúde (MS). Diretrizes para vigilância, atenção e eliminação da hanseníase como problema de saúde pública. Brasília: MS; 2016.

13. Brasil. Ministério da Saúde (MS). Portaria Nº 3.125, de 7 de outubro de 2010. Brasília: MS; 2010. [acesso 2018 Jan 25]. Disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2010/prt3125_07_10_2010.html

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15. Brasil. Ministério da Saúde (MS). Guia prático sobre a Hanseníase. Brasília: MS; 2017.
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