Epidemiologia, distribuição espacial e fatores associados à ocorrência da hanseníase e do desenvolvimento de incapacidades físicas no estado do Tocantins, 2001 a 2012

Abstract

Leprosy is considered a neglected disease with disproportionate occurrence in unfavorable socioeconomically and marginalized populations. Remains as a public health problem in many countries worldwide, including Brazil. The objectives of this study were to characterize the epidemiological patterns and temporal trends of leprosy indicators in Tocantins State from 2001 to 2012; to characterize the spatial patterns of leprosy distribution by municipality in the state of Tocantins; to identify factors associated with physical disability at diagnosis of leprosy; and to identify the socioeconomic, demographic, operational and health services patterns associated with the occurrence of leprosy in the Tocantins municipalities. Study realized with analysis of data from the Notifiable Diseases Information System (SINAN). New cases of residents in Tocantins diagnosed between 2001 and 2012 were included. The thesis was divided into four thematic areas according to each specific objective: Thematic area 1 - Calculation of operational indicators of leprosy and time trend analysis via joinpoint regression. Thematic area 2 - Descriptive Spatial analysis, Local empirical Bayesian analysis and spatial dependence through global and local Moran indices. Thematic area 3 - Identification of factors associated with physical disability at diagnosis of leprosy. Thematic area 4 - Ecological study to identify factors associated with the disease. Negative binomial log linear regression models were used to estimate the incidence rate ratios (IRR). In total, there were 14,532 new cases in the period. To the overall detection rate, 77.0% (107/139) of the municipalities were classified as hyper-endemic (> 40 cases / 100,000 population). For detection in under 15 years, 65.4% (91/139) were hyperendemic (10.0 to 19.9 cases / 100,000 inhabitants) and 26.6% (37/139) had detection with grade 2 disabilities between 5.0 and 9.9 cases / 100,000 inhabitants. There was a significant downward trend for overall detection rate in the period 2001 to 2012. The Annual Percentage Change (APC) was -3.1%, confidence interval (CI) 95%: -5.4 to - 0.8. The detection in <15 years of age was significantly increased between 2001-2008 (APC: 3.8%; 95% CI: 0.1 to 7.6) and showed significant decline between 2008-2012 (APC: -9.4 %, 95% CI: -17.2 to -0.8). The detection of cases with grade 2 (APC: 0.3; 95% CI: -4.5 to 5.4) and the proportion of cases with grade 2 (APC: 2.3; 95% CI: -2.6 to 7 4) remained stable. There was a significant increase in the proportion of cases with grade 1 (APC = 6.9%, 95% CI 4.3 to 9.6) and in the multibacillary cases (APC: 3.5%; 95% CI: 2.4 to 4, 6). The ratio of loss (grade 2) remained stable over time. Six main spatial clusters were identified, two statistically significant for the general detection indicators (global index Moran: 0.51; p <0.001), for the detection in children under 15 years (0.47; p <0.001) and for the detection with grade 2 disability (0.44; p <0.001), all with geographic coverage in the North Central and State Southwest. Factors associated with grade 2 disability at diagnosis (as a diagnostic indicator late) were males with a prevalence ratio (PR) = 2.24; 95% CI: 1.89 to 2.65), age ≥45 years (OR = 5.31, CI: 3.21 to 8, 29), illiteracy (OR = 6.70, CI: 3.75 to 11 95), diagnosed through mass campaigns (PR = 2.40; 95% CI: 1.50 to 3.85) and living in rural areas (OR = 1.28; 95% CI: 1.06 1.5). Cases with second degree disability were also more common in the presence of ≥5 skin lesions (OR = 4.42, 95% CI: 3.74 to 5.21), leprosy reactions (PR = 2.78; 95% CI: 2.31 to 3.33), multibacillary disease (OR = 7.43; 95% CI: 6.11 to 9.04), and Virchow clinical form (OR = 16.53; 95% CI: 12.10 -20.60). The ratio of incidence rate (IRR) in the multivariate analysis was significantly higher in counties with the highest concentration of immigrants with permanent residence in the last 10 years (1.31, 95% CI: 1.11 to 1.55) and with higher proportion of households with garbage collection (1.37; 95% CI: 1.11 to 1.69). There was a significant reduction in IRR with increasing coverage of family allowance program (0.98; 95% CI: 0.97-0.99). The Tocantins has regions with high transmission and late diagnosis of leprosy, pointing to expansion of heterogeneous disease in the temporal analysis. There are high risk clusters for transmission and late diagnosis of leprosy. Surveillance and control measures should be prioritized in high-risk areas identified. This study presents evidence of a greater rate of disease incidence in municipalities with low socioeconomic status and the best coverage for the family allowance program was significantly positive in reducing leprosy. Mass campaigns and community surveys can be effective means to reduce late diagnosis, so these activities should be integrated into disease control programs. The activities of control programs need to be directed to municipalities of greater social vulnerability with cross-sector investments focused on improving the living conditions of the population.