Abstracts

INTRODUCTION

Leprosy is still considered a serious public health issue in developing countries. In 2011, a high detection rate of 15.88/100,000 inhabitants was registered in Brazil, according to parameters of the Ministry of Health¹1 . Ministério da Saúde. Distribuição da Hanseníase no Brasil. Brasília: Secretaria de Vigilância em Saúde; 2012.. Maranhão, in 2011, showed an overall detection rate of 56.0/100,000 inhabitants and was classified as a hyperendemic state. The prevalence reached 8.5/10,000 inhabitants, and its average detection rates exceeded the average of the Northeastern region and of Brazil as a whole²2 . Maranhão. Secretaria de Estado da Saúde. Superintendência de Epidemiologia e Controle de Doenças. Programa de Controle da Hanseníase. Relatório da Secretaria de Estado da Saúde. São Luis; 2011.. The extent of elimination of leprosy has not been easy in some regions due to the complexity of the disease³3 . Lockwood DNJ, Suneetha S. Leprosy: too complex a disease for a simple elimination. Bull World Health Organ 2005; 83(3): 230-5..

Leprosy is characterized as a chronic infectious disease, with great crippling potential, whose etiologic agent is the bacterium Mycobacterium leprae and the route of transmission is direct contact⁴4 . Brasil. Ministério da Saúde. Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Hanseníase: descrição da doença. Brasília: Ministério da Saúde; 2007.. It is characterized by dermatological and neurological symptoms, such as lesions on the skin and on peripheral nerves of the eyes and of upper and lower limbs. It presents various clinical forms that are determined according to levels of cellular immune response to Mycobacterium leprae bacteria, classified as indeterminate, tuberculoid, borderline or lepromatous⁵5 . Brasil. Ministério da Saúde. Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Área Técnica de Dermatologia Sanitária. Hanseníase: atividades de controle e manual de procedimentos. Brasília, DF; 2007..

When diagnosed and treated late, leprosy can have serious consequences, such as physical disabilities in the hands, feet and eyes resulting from involvement of the peripheral nerves. In the natural course of the disease, complications occur initially in thermal sensitivity: hyperesthesia, followed by hypoesthesia and, after some time, anesthesia. Then, progressive loss of pain sensitivity, and, finally, loss of tactile sensitivity⁶6 . Goulart IM, Penna GO, Cunha G. Imunopatologia da hanseníase: a complexidade dos mecanismos da resposta imune do hospedeiro ao Mycobacterium leprae. Rev Soc Bras Med Trop 2002; 35(4): 365-75.. In more advanced stages of the clinical manifestation, truncal neural impairment occurs, which causes repercussions such as paresthesias and muscle plegias⁷7 . Trindade MAB, Nemes MIB. Incapacidades físicas em hanseníase no momento do diagnóstico: características epidemiológicas dos casos registrados de 1983 a 1988 no Estado de São Paulo. Hansen Int 1992; 17(1/2): 8-14.. When these complications are identified early, before the presence of more severe nerve damage, disability can be avoided⁴4 . Brasil. Ministério da Saúde. Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Hanseníase: descrição da doença. Brasília: Ministério da Saúde; 2007.. The delay in diagnosis is an independent risk factor for the presence of physical disability at diagnosis⁸8 . Ferreira J. Validade do grau de incapacidades como indicador de diagnóstico tardio da hanseníase. Hansen Int 1998 (Esp): 79-84.

Physical disability affects approximately 23.0% of leprosy patients after discharge⁹9 . Gonçalves SD, Sampaio RF, Antunes CM. Fatores preditivos de incapacidades em pacientes com hanseníase. Rev Saúde Pública 2009; 43(2): 267-74.. The evaluation and monitoring of the state of the patients are essential to the preservation of the structure and function of the peripheral nerve, contributing to the early identification of neural complications and disabilities⁶6 . Goulart IM, Penna GO, Cunha G. Imunopatologia da hanseníase: a complexidade dos mecanismos da resposta imune do hospedeiro ao Mycobacterium leprae. Rev Soc Bras Med Trop 2002; 35(4): 365-75..

The current global goal for reduction of the leprosy burden is defined by the "Enhanced Global Strategy for Further Reducing the Leprosy Burden: 2011 - 2015", and it defines the reduction of the number of new cases diagnosed with grade 2 disabilities per 100,000 inhabitants in, at least, 35% by the end of 2015. It will also contribute to the correct and timely diagnosis of new cases before the development of disabilities and neural complications and will work to reduce the social and economic impact on the lives of individuals affected by the disease¹⁰10 . Organização Mundial da Saúde. Estratégia global aprimorada para redução adicional da carga da hanseníase: período do plano: 2011-2015. Brasília: Organização Mundial da Saúde; 2010..

Considering the importance of the evaluation and monitoring of leprosy patients, this study aims to investigate the neural complications and the degree of physical disability in the eyes, hands and feet before and after treatment, and to identify the sociodemographic and clinical profile of patients affected by leprosy.

METHODS

This is an epidemiological longitudinal study consisting of 161 leprosy patients enrolled in a program of elimination of leprosy in São Luís (MA), Brazil. There was a loss of six subjects (3.7%), with a total final sample of 155 patients. The sample was selected by convenience from spontaneous demand, and consisted of patients diagnosed in the period from March 2010 to February 2011. Patients without treatment were included if it was a new case and if the patient was a São Luís resident. No patients with sequelae from other disabling diseases, such as neurological, trauma-orthopedic, and/or rheumatic, or other associated conditions, were included.

Patients were evaluated by nurses and occupational therapist with experience in dermatological and neurological evaluation. These professionals were trained aiming at a standardization of the technique for assessing patients, using the national protocol for simplified neurological evaluation and classification of the degree of disability according to the parameters adopted by the Brazilian Ministry of Health¹¹11 . Brasil. Ministério da Saúde. Fundação Nacional de Saúde. Centro Nacional de Epidemiologia, Coordenação Nacional de Dermatologia Sanitária. Guia de controle da hanseníase. Brasília: Ministério da Saúde; 1994. ^{, 12}12 . Rodrigues AL, Almeida-Sobrinho EF, Dias EP, Traple G, Vieth H, Oliveira IR et al. Manual de prevenção de incapacidade. Brasília: Fundação Nacional de Saúde; 1997.. Evaluations were performed before and after multidrug therapy (MDT) recommended by WHO¹¹11 . Brasil. Ministério da Saúde. Fundação Nacional de Saúde. Centro Nacional de Epidemiologia, Coordenação Nacional de Dermatologia Sanitária. Guia de controle da hanseníase. Brasília: Ministério da Saúde; 1994.. For the collection of data on sociodemographic and clinical conditions, a specific questionnaire was used, containing direct questions to be answered by the patients after they signed an informed consent approved by the Ethics Committee on Human Research of Universidade Federal do Maranhão (protocol no. 23115-003005/2009-36).

The disability of the patient was classified as:

A descriptive analysis of all variables was performed. A quantitative variable (age) was presented as mean and standard deviation for presenting normality according to the Shapiro-Wilk test. To assess the frequency of neural complications and disability at baseline and end of treatment, the Mc-Nemar test with significance level equal to or less than 0.05 and a confidence interval of 95% were applied. The statistical package used was Stata^(r) (version 10).

The research has no conflicts of interest.

RESULTS

The sample consisted of 25.7% of students in the 16-30 years age group (29.7%), with mixed skin color (58.6%) in a marital relationship (57.4%), with incomplete primary education (32.9%) and family income equal to or greater than three minimum wages (52.3%) (Table 1).

It was observed that, at the start of treatment, 51.6% of patients had complications in the eyes and, after treatment, there was a decrease in the proportion of patients with these complications (45.8%). Regarding nose, 7.1% of patients had complications at diagnosis and, at the end of treatment, there was an increase (11.0%) (Table 2).

At the beginning of treatment, 40.6% of patients had complications in their hands and, after treatment, 32.9% still showed complications. There was therefore an improvement of patients regarding complications in the hands after treatment. With respect to vascular complications, there was an improvement in the proportion of complications, since 52.3% had complications in diagnostic and, after the treatment, 47.1% (Table 2).

At beginning of treatment, patients had complications in the nerves, with 18.7% in the radial, 9.7% in the median, 11.0% in the ulnar, 16.8% in the fibular and 14.8% in the tibial. There was a decrease in the proportion of complications in the ulnar (1.3%) and tibial (3.8%) nerves, and an increase in the proportion of patients with complications in the radial (11%), medium (3.9%) and fibular (0.6%) nerves at the end of treatment. There was statistical significance (p = 0.005) only for the complications observed in the radial nerve, when we compared the proportions of complications in the beginning (18.7%) and in the end (29.7%) of treatment (Table 3).

At diagnosis, patients experienced grade 1 or 2 disability, 11.0% being in the hands, 12.3% in the eyes and 25.8% in the feet. At the end of treatment, a decrease was observed in the proportion of disability in the eyes (0.7%) and hands (2.0%) and an increase of 2.6% in the proportion of patients with disability in the feet (Table 4).

DISCUSSION

The present study showed that a higher rate of leprosy patients were female. This finding agrees with Figueiredo and Silva¹³13 . Figueiredo IA, Silva AAM. Aumento na detecção de casos de Hanseníase em São Luis, Maranhão, Brasil, de 1993 a 1998. A endemia está em expansão? Cad. Saúde Pública 2003; 19(2): 439-45., who evaluated the spread of leprosy in São Luís (MA) in the period from 1993 to 1998. Another study, conducted in the city of Buriticupu (MA), also reported a higher rate of female leprosy patients¹⁴14 . Leite KKC, Costa JML, Barral A, Caldas AJM, Corrêa RGCF, Aquino DMC. Perfil epidemiológico dos contatos de casos de hanseníase em área hiperendêmica na Amazônia do Maranhão. Cad Saude Coletiva 2009; 17: 235-49.. However, there are studies¹⁵15 . Silva AR, Matos WB, Silva CCB, Gonçalves EGR. Hanseníase no município de Buriticupu, Estado do Maranhão: busca ativa de casos na população adulta. Rev Soc Bras Med Trop 2010; 43(6): 691-4. ^{, 16}16 . Oliveira FFL, Macedo LC. Perfil epidemiológico dos portadores de hanseníase em um município da região centro-oeste do Paraná. SaBios: Rev. Saúde e Biol 2012; 7(1): 45-51. that found a higher percentage of males. It has been suggested that the biggest concern with body image and specific policies for the female population would justify the predominance of females¹⁴14 . Leite KKC, Costa JML, Barral A, Caldas AJM, Corrêa RGCF, Aquino DMC. Perfil epidemiológico dos contatos de casos de hanseníase em área hiperendêmica na Amazônia do Maranhão. Cad Saude Coletiva 2009; 17: 235-49..

A higher frequency of individuals in their economically productive years, from 16 to 30 years of age, was observed. A similar result was observed in the study by Oliveira et al.¹⁶16 . Oliveira FFL, Macedo LC. Perfil epidemiológico dos portadores de hanseníase em um município da região centro-oeste do Paraná. SaBios: Rev. Saúde e Biol 2012; 7(1): 45-51., in a municipality in the Midwest region of Paraná. The greater affection of people in their economically productive years have social and economic importance, since leprosy has a high disabling potential, interfering in the work and social life of the patient, causing economic loss and psychological trauma¹⁷17 . Aquino DMC, Caldas AJM, Silva AAM, Costa JML. Perfil dos pacientes com hanseníase em área hiperendêmica da Amazônia do Maranhão, Brasil. Rev Soc Bras Med Trop 2003; 36(1): 54-64.. In relation to patients under 15 years of age, there was a rate of 12.2% of affection by the disease in this age group, results superior to those recommended by the Ministry of Health, suggesting that the infection is recent and active in the studied municipality⁴4 . Brasil. Ministério da Saúde. Secretaria de Políticas de Saúde. Departamento de Atenção Básica. Hanseníase: descrição da doença. Brasília: Ministério da Saúde; 2007..

Regarding marital status, most of the patients had a partner, similar to that reported by Aquino et al.¹⁷17 . Aquino DMC, Caldas AJM, Silva AAM, Costa JML. Perfil dos pacientes com hanseníase em área hiperendêmica da Amazônia do Maranhão, Brasil. Rev Soc Bras Med Trop 2003; 36(1): 54-64., when studying leprosy patients in Buriticupu/Amazon of Maranhão.

With regard to education, there was a predominance of subjects who completed high school, but the frequency of patients without schooling and with only primary education is noteworthy. Disagreeing with the present study, data found in Brazil, in 2009, showed that 67.5% of registered leprosy patients had incomplete primary education and 11.7% were illiterate¹⁸18 . Brasil. Ministério da Saúde. Portaria nº 3.125, de 7 de outubro de 2010. Aprova as Diretrizes para Vigilância, Atenção e Controle da Hanseníase. Diário Oficial [da] República Federativa do Brasil. Disponível em http://www.brasilsus.com.br/legislacoes/gm/105834-3125.html (Acessado em 20 de outubro de 2012).
http://www.brasilsus.com.br/legislacoes/... . As similar to the study by Morais¹⁹19 . Morais SG. Avaliação das ações de controle de hanseníase no município de Governador Valadares, Minas Gerais, Brasil, no período de 2001 a 2006 (dissertação de mestrado). Minas Gerais: Universidade Vale do Rio Doce, Governador Valadares; 2010., held in the city of Governador Valadares (MG), when it was observed that 55.1% of individuals with leprosy had primary education and 11.6% were illiterate. It is known that low educational level is associated with low family income, which was an important risk factor to health.

With regard to occupation, most people with leprosy in this study were students, and 18.7% were salaried and were employed and working at the moment of diagnosis, unlike the data obtained in a study by Costa²⁰20 . Costa MD. Avaliação da qualidade de vida de pacientes em surto reacional de hanseníase identificadas em Centro de Referência de Belo Horizonte, MG, no período de 2007 e 2008 (dissertação de mestrado). Minas Gerais: Santa Casa de Misericórdia de Belo Horizonte; 2009., in which 53.0% were retired or on sick leave. However, this author evaluated patients with leprosy during reaction episodes, while in the present study, new cases were evaluated.

With regard to family income, the highest percentage of the population studied had a family income between 1 and 2 minimum wages, unlike the findings of Aquino et al.¹⁷17 . Aquino DMC, Caldas AJM, Silva AAM, Costa JML. Perfil dos pacientes com hanseníase em área hiperendêmica da Amazônia do Maranhão, Brasil. Rev Soc Bras Med Trop 2003; 36(1): 54-64., where most of the population had a household income of less than one minimum wage. This increase in minimum wages may be due to the increase in income in Brazil, resulting from the implementation of public policies in Brazil that are favoring a higher socioeconomic status for the underprivileged population.

Most individuals of the population studied reported proper disposal of waste, but there was a significant rate in the use of cesspools by the patients (35.5%). Leite et al.¹⁴14 . Leite KKC, Costa JML, Barral A, Caldas AJM, Corrêa RGCF, Aquino DMC. Perfil epidemiológico dos contatos de casos de hanseníase em área hiperendêmica na Amazônia do Maranhão. Cad Saude Coletiva 2009; 17: 235-49., in a study of contacts made in Buriticupu (MA), found different results, in which only 4.1% had proper disposal of waste and 58.9% disposed waste directly into cesspools.

The clinical multibacillary form (borderline or lepromatous) was the most frequent among the patients studied. The study by Lima et al.²¹21 . Lima LS, Jadão FRS, Fonseca RNM, Silva Junior GF, Barros Neto RC. Caracterização clínica-epidemiológica dos pacientes diagnosticados com hanseníase no município de Caxias, MA. Rev Bras Clin Med 2009; 7: 74-83. also found a higher frequency of clinical borderline, followed by tuberculoid, indeterminate and lepromatous forms. Similar results were observed in the study by Corrêa et al.²²22 . Corrêa RGCF, Aquino DMC, Caldas AJM, Amaral DKCR, França FS, Mesquita ERRBP. Epidemiological, clinical, and operational aspects of leprosy patients assisted at a referral service in the state of Maranhão, Brazil. Rev Soc Bras Med Trop 2012; 45(1): 89-94., also conducted at the leprosy elimination program of Hospital Universitário Presidente Dutra (MA) between 2008 and 2009, in which 42.3% of patients presented the clinical lepromatous form, which demonstrates that the diagnosis of leprosy was performed later, with a higher likelihood of disease transmission, and the development of neural complications and disability in the patient.

Regarding frequency of neural complications, it was observed that more than half of the individuals had some alteration in the eyes and feet prior to treatment. In a study by Carvalho and Alvarez²³23 . Carvalho GA, Alvarez RRA. Avaliação de incapacidades físicas neuro-músculo-esqueléticas em pacientes com hanseníase. Hansen Int 2000; 25(1): 39-48., there was a high frequency of disability in the feet alone when compared with the results found in the hands. The slightest evidence of hand injuries can be justified by greater self-care and early perception of disabling problems in hands, which does not happen with the feet.

There was no statistical significance in the comparison of neural complications in the eyes, hands and feet before and after treatment. Only one reduction in the proportion of these complications was observed. According to Meima et al.²⁴24 . Meima A, Saunderson PR, Gebre S, Desta K, Habbema JD. Dynamics of impairment during and after treatment: the AMFES cohort. Lepr Rev 2001; 72(2): 158-70., neural complications occur mainly before diagnosis.

The frequency of nasal complications increased after the treatment. The study of Julio et al.²⁵25 . Julio MVRF, Nardi SMT, Pedro HSP, Paschoal VD. Evolução das lesões nasais em pacientes com hanseníase. Hansen Int 2010; 35(1): 29-35. showed that there was a worsening of 4.2% of nasal lesions in 7.0% of cases, despite the guidelines given by health professionals regarding the care needed to prevent the development of injuries. One explanation for this occurrence may be the known side effects of clofazimine, one of the drugs used in multidrug therapy that causes dryness of the skin and mucous membranes²⁶26 . Brasil. Ministério da Saúde. Guia para controle da hanseníase Brasil. Brasília, DF; 2002..

In this study, low rates of complications in upper and lower nerves at the start of treatment were found. In the study by Pimentel et al.²⁷27 . Pimentel MI, Nery JA, Borges E, Gonçalves RR, Sarno EM. Impairments in multibacillary leprosy; a study from Brasil. Lepr Rev 2004; 75(2): 143-52., it was as observed that 67.0% of patients showed nerve thickening and/or pain at the beginning of the treatment. According to Kumar et al.²⁸28 . Kumar A, Girdhar A, Girdhar BK. Nerve thickening in leprosy patients and risk of paralytic deformities: a field based study in Agra, India. Lepr Rev 2004; 75(2): 135-42., two-thirds of new cases already have some degree of nerve thickening at diagnosis. Among new patients, 62.0% had at least one thickened nerve.

Comparing the presence of thickening and/or pain in the peripheral nerves at the beginning and the end of treatment, there was a significant increase in complications only in the radial nerve. Research conducted by Orsini²⁹29 . Orsini MBP. Estudo da função dos nervos periféricos de pacientes com hanseníase acompanhados por um período médio de 18 anos após o início da poliquimioterapia (dissertação de mestrado). Belo Horizonte: Universidade Federal de Minas Gerais; 2008., which evaluated the frequency of complications in lower and upper nerves before and after discharge of patients, coincides with the findings of this study, as it also noted worsening in the nerves of the upper limbs after treatment (p = 0.03). The same author²⁹29 . Orsini MBP. Estudo da função dos nervos periféricos de pacientes com hanseníase acompanhados por um período médio de 18 anos após o início da poliquimioterapia (dissertação de mestrado). Belo Horizonte: Universidade Federal de Minas Gerais; 2008. questions whether this worsening could be related to the technical improvement of the examiner or by type of household activity (washing clothes, washing dishes), considered of high impact to the radioulnar joint, favoring the affection of the radial nerve. Importantly, in late diagnosis, reactions and trauma may increase the affection of the nerves.

The rates of physical disabilities at the beginning of treatment were low, with the presence of physical disability in the feet being more common. The study by Schiapati³⁰30 . Schiapati T. Grau de incapacidade atribuído aos casos novos em hanseníase no momento de sua admissão. Hansen Int 2005; 30: 124, which verified the grade of disability attributable to new leprosy cases, showed a large majority of patients without disability at onset. Oliveira et al.³¹31 . Oliveira CR, Alencar MJ, Sena NSA, Lehman LF, Schereuder PA. Impairments and Hansen´s disease control in Rondônia state, Amazon region of Brazil. Lepr Rev 2003; 74(4): 337-48., in their cohort study, showed that about 20.0% of the patients had physical disabilities during or after treatment. Contrary to these findings, the study by Aquino et al.¹⁷17 . Aquino DMC, Caldas AJM, Silva AAM, Costa JML. Perfil dos pacientes com hanseníase em área hiperendêmica da Amazônia do Maranhão, Brasil. Rev Soc Bras Med Trop 2003; 36(1): 54-64. pointed to worrying results: high rates of disability grade 1 or 2. In both studies, the higher frequency of disability was mainly on the feet.

Possibly, this disagreement of the present study with Aquino et al.¹⁷ 17 . Aquino DMC, Caldas AJM, Silva AAM, Costa JML. Perfil dos pacientes com hanseníase em área hiperendêmica da Amazônia do Maranhão, Brasil. Rev Soc Bras Med Trop 2003; 36(1): 54-64.happened because this study was conducted in the state capital (São Luís, MA), where access to health services and actions is better. Moreover, the data observed in the state municipalities, where access to health services are scarce, show that there is a difficulty in early diagnosis and appropriate treatment, which are the best strategies to prevent disease progression.

Regarding the comparison of the disability rates at the beginning and end of treatment, no statistically significant differences were found. Ribeiro's study³²32 . Ribeiro GC. Fatores relacionados à prevalência de incapacidades físicas em Hanseníase na microrregião de Diamantina, Minas Gerais (dissertação de mestrado). Belo Horizonte: Universidade Federal de Minas Gerais; 2012. showed a decrease of 21.5% in the frequency of physical disabilities of patients after discharge. The study of Julio et al²⁵25 . Julio MVRF, Nardi SMT, Pedro HSP, Paschoal VD. Evolução das lesões nasais em pacientes com hanseníase. Hansen Int 2010; 35(1): 29-35. also showed a decrease in the frequency of physical disability throughout the treatment, and this is a significant decrease, unlike in the present study. The greater presence and increased rates of physical disabilities, particularly in the feet, can be explained by the neglect of guidelines related to self-care.

One limitation of this study was the use of the grade of disability as the method of investigation, according to the Brazilian Ministry of Health, which, despite being one of the most widely used instruments, may present a great variation in the change of the sensitivity threshold for the grades 0 - 1. The relevance of this work should be highlighted, because it is a follow-up study of subjects with leprosy during treatment. We were able to analyze the sociodemographic characteristics of 155 individuals diagnosed with leprosy, as well as the evaluation of their clinical characteristics, being able to assess the complications and disabilities that were more frequent in the beginning and the end of treatment.

CONCLUSION

It is evident that most of the subjects with leprosy had a late diagnosis, since they already had some neural alterations and grade 1 and 2 disabilities at diagnosis, which have high crippling power on the individual. Before treatment, more than half of patients had complications in the eyes and feet, and the most affected nerve was the radial. No significant changes were observed in the presence of neural complications and disability in the first approach and after treatment. It is noteworthy that the study population was composed mostly of students in an age range from 16 to 30 years old which had an income greater than or equal to three minimum wages. In this sense, public policies aimed at encouraging professionals and authorities to improve the early diagnosis of leprosy, case evaluation and follow-up and services for the prevention of neural complications and disability of patients with leprosy should be developed.

REFERENCES

Publication Dates

History