Hanseníase em territórios das regiões norte e nordeste do Brasil: contextos epidemiológicos e operacionais de controle

Abstract

Leprosy is a chronic infectious disease with a high morbidity and mortality burden. By affecting peripheral nerves, it has the potential to generate physical incapacity, with direct and/or indirect consequences on the affected persons, family groups or communities where they belong. The disease presents a focal pattern of occurrence, concentrating on clusters of high-risk. In Brazil, these areas are responsible for approximately 50,0% of the cases registered in the country. The North and Northeast regions are answerable for the most endemic states of the country. Objectives: To characterize the epidemiological and operational patterns of leprosy, including the spatial distribution, spatial clusters, and temporal trend in the North and Northeast regions, with analysis of the associated factors. Methods: This is a population-based mixed ecological study with spatial and temporal approach, using national morbidity and mortality data on leprosy. The 2,244 municipalities of the two regions were used as units of analysis, including all new cases residing from 2001 to 2017. The mortality data refer to deaths in which leprosy was mentioned as the underlying or associated cause. Results: A total of 396,987 new cases were reported in the study period, 36,587 (9.2%) were in children under 15 years of age and 21,701 (5.5%) with Grade 2 Disability (G2D). We verified a reduction of the temporal trend for epidemiological indicators, but the Northeast showed a sustained trend of G2D (mean annual percentage change [AAPC] -1.7 confidence interval [CI] 95% -3.4 to 0.1). All States presented a reduction trend for detection in total cases and in cases under 15 years-old; however for both regions there were States presenting maintenance in the G2D rates. We identified areas of high endemicity in the states of Pará, Tocantins, Maranhão, Bahia, and Rondônia, areas with recurrence in temporal analysis, and confirmed by cluster analysis. The integrated analysis of operational indicators by the IntegraHans operational score (IHOS) indicates maintenance in the general trend (AAPC -0.2; CI 95% -0.6 to 0.0), with a reduction in this score for the Northeast region (AAPC -0.3*; 95% CI -0.6 to -0.1). The spatial analysis indicates that in some areas of high-rates, the best IHOS were verified. For the mortality analysis, a total of 4,907 deaths were identified (0.41/100,000 inhabitants, 95% CI 0.36 to 0.45). The trend was increased (AAPC 1.2*; 95% CI 0.0 to 2.4), with more relevance in the Northeast region (AAPC 1.5 * 95% CI 0.1 to 2.9), identified areas with death concentration in the same areas with high endemicity. Epidemiological indicators show a positive correlation with the social determinants of health (SDH), highlighting the municipality urbanization, household density, sex ratio, and average per capita income. Conclusions: Leprosy remains a public health problem still to be overcome in the study regions. Physical disabilities are a reality, as are the poor performance of health services and elements of social vulnerability. In addition to the qualification of the control actions, the need to improve the socioeconomic conditions of the population and reduce inequities is emphasized. Together, they can be strategies for effective coping with endemic diseases in the municipalities of the Northeast and in the North of the country.