Trend of leprosy detection rate in Brazil, 1990 to 2016

Anais

Brasileiros

de

Dermatologia

www.anaisdedermatologia.org.br

TROPICAL/INFECTOPARASITOLOGY

DERMATOLOGY

Trend

of

leprosy

detection

rate

in

Brazil,

1990

to

2016

夽,夽夽

Carlos

Dornels

Freire

de

Souza

_,

_Franklin

_Gerônimo

_Bispo

_Santos

_,

Thiago

Cavalcanti

Leal

_,

_João

_Paulo

_Silva

_de

_Paiva

a_{DepartmentofMedicine,UniversidadeFederaldeAlagoas,Arapiraca,AL,Brazil} b_{UniversidadeFederaldeAlagoas,Arapiraca,AL,Brazil}

Received2August2018;accepted19October2018

KEYWORDS

Epidemiology; Leprosy;

Mycobacterium leprae

Abstract Theobjectiveofthisstudywastodescribethetrendofdetectionofthedisease in Brazilfrom 1990to 2016. The joinpointregressionmodel was used.There was a

signif-icant trendofdecreased detectioninthe country (average annual percentchange −1.8%)

and in the South (average annual percent change=_−3.5%) andSoutheast regions (average

annualpercent change=−4.5%).TheNortheast(average annualpercentchange=0.2%),the Central-West(averageannualpercentchange=−1.5%),andtheNorth(averageannualpercent change=−2.6%)showedastationarytrend(p>0.05).Elevenstatesshowedadecreasingtrend. Alagoas(averageannualpercentchange=2.1%)andRioGrandedoNorte(averageannual per-cent change=1.4%)presentedsignificant increase(p<0.001).Theheterogeneouspatternof trendbetweenregionsandstatesshowsthateffortsareneededtoeliminatethedisease. ©2019PublishedbyElsevierEspa˜na,S.L.U.onbehalfofSociedadeBrasileiradeDermatologia. ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/

by/4.0/).

Leprosy is a neglected tropical disease that represents a publichealthprobleminseveraldevelopingcountries.Brazil occupies an undesirable position in the global scenario,

夽 _{Howtocitethisarticle:SouzaCDF,SantosFGB,LealTC,Paiva}

JP.TrendofleprosydetectionrateinBrazil,1990to2016.AnBras Dermatol.2019;94:603---7.

夽夽_{StudyconductedattheUniversidadeFederaldeAlagoas,}

Ara-piraca,Alagoas,Brazil.

∗_{Correspondingauthor.}

E-mail:[email protected](C.D.Souza).

being one of the 13 countries that comprised 94% of all newcasesregisteredintheworldin2014.1_In2016alone,

25,218 new patients were reported, a detection rate of 12.23/100,000inhabitants.2

The leprosy detection rate reflects the magnitude of thediseaseintheterritory.Itsrelevanceisrecognizedby theWorldHealthOrganization(WHO)asaninstrumentthat enablesthesystematicmonitoringoftheefficiencyof con-trol programs, as well the fulfillment of the established goals. In this sense, the study of the trend of detection ratesis in line withthefirst pillarofthe global initiative

https://doi.org/10.1016/j.abd.2018.10.003

0365-0596/©2019PublishedbyElsevierEspa˜na,S.L.U.onbehalfofSociedadeBrasileiradeDermatologia.Thisisanopenaccessarticle undertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

BRAZIL 40 40 45 24 19 14 9 4 0 10 8 6 4 2 35 90 80 70 60 50 40 30 20 35 30 30 25 25 20 20 15 80 70 60 50 40 30 10 15 10 5 1990 1993 1996 1999 2002 2005 2008 2011 2014 2016 1990 1993 1996 1999 2002 2005 2008 2011 2014 2016 1990 1993 1996 1999 2002 2005 2008 2011 2014 2016 1990 1993 1996 1999 2002 2005 2008 2011 2014 2016 1990 1993 1996 1999 2002 2005 2008 2011 2014 2016 Observed rate Observed rate 1990 1993 1996 1999 2002 2005 2008 2011 2014 2016 Observed rate Observed rate Observed rate Observed rate Ne w cases/100.000 inhabitants Ne w cases/100.000 inhabitants Ne w cases/100.000 inhabitants Ne w cases/100.000 inhabitants Ne w cases/100.000 inhabitants Ne w cases/100.000 inhabitants APC: 1.3 APC: -7.7 APC: 5.6 AAPC: -2.6 AAPC: 0.2 APC: 0.2 APC: -7.4∗ APC: -6.1∗ AAPC: -1.8∗ APC: 9.5∗ APC: 2.6∗ APC: 5.5∗ APC: -4.8∗ APC: -9.1∗ APC: -8.0∗ APC: -4.9∗ APC: -6.7∗ APC: -8.0 APC: 11.8 APC: 18.2 APC: -0.7 AAPC: -4.5∗ AAPC: -3.5∗ AAPC: -1.5 SOUTHEAST SOUTH CENTRAL-WEST NORTH NORTHEAST

Figure1 Trendofdetectionrateofnewleprosycasesinthegeneralpopulationper100,000inhabitants.Brazil,1990---2016.APC, annualpercentchange;AAPC,averageannualpercentchange.*_{Statisticallysignificant.}

thataimsstrengthencontrol,coordination,andpartnership withgovernment.1,2

Therefore, this work aimed to describe the temporal trendsofthedetectionratesofnewcasesofleprosyinthe generalpopulationinBrazil,anditsregionsandstates,from 1990to2016.

The rates of detection of new cases of leprosy were analyzedinthegeneralpopulation:national,regional,and state.Fortheanalysis,asegmentedregressionmodelwas adopted.3,4 _{The annual percentage change (APC) and the}

averageannualpercentchange(AAPC)werecalculatedwith a95%confidenceinterval(95%CI)and5%significance.The trendwasclassifiedasincreasing,stationary,ordecreasing. Inaddition,theaveragerateoftheperiod(ratiobetween thesumoftheannualratesandthetotalnumberofyears intheperiodstudied)wascalculated.

There was a statistically significant reduction in the detection rate at the national level (AAPC=−1.8%; p<0.001), decreasing from 19.96 to 12.23 new cases per 100,000 inhabitants (Fig. 1). The decrease has been observednotonlyinBrazil,butalsothroughouttheworld,

as a resultof the commitment of the WHO, materialized in strategiesand actionsdirected towarddisease control, especially multidrug therapy, recommended by the WHO in the early 1980s and implemented in Brazil in 1991.1,5

Althoughtheadvancesareareality,theaveragedetection rateof theperiod(1990---2016) was22.13/100,000 inhabi-tants,classifyingthecountryashavingveryhighendemicity (Fig.2andTable1).

Intheregionalanalysis,theNorthhadthehighest aver-age rate (58.92/100,000). followed by the Central-West (55.22/100,000). In turn, the Southpresented the lowest rate (6.49/100,000). Inthe lastyear of the series,in the regionsofNorth,Northeast,andCentral-West,theendemic was classified as very severe. In addition, the Southeast and South registered average endemicity. In the analysis by the joinpoint, reduction tendencies were observed in the South (AAPC=−3.5%; p<0.001) and in the Southeast (AAPC=−4.5%;p<0.001;Figs.1and2;Table1).

Considering the Brazilian states, the highest average ratewasobservedinTocantins(85.05/100,000),increasing from 72.06/100,000 in 1990 to 88.13/100,000 in 2016. In

Detection rate of leprosy in general population per 100,000 inhabitants 1990 Regions F eder ativ e Units 2016 Average Rate N Parameters(cases/100,000) 0 a < 2.00 (Low) 2.00 a 9.99 (Medium) 10.00 a 19.99 (High) 20.00 a 39.99 (Very High) 40.00 ou + (Hyperendemic) 1000 0 1000 2000 3000 4000 km

Figure2 SpatialpatternofdetectionratesofnewleprosycasesinthegeneralpopulationofBrazil,from1990to2016.

Table1 Trendofdetectionrateofnewcasesofleprosy/100,000inhabitantsinBrazil,1990---2016.

Brazil/Regions/States Rateper100,000inhabitants AAPC 95%CI Trend

1990 2016 Average Brazil 19.96 12.23 22.13 −1.8a _{−2.3to−1.4 Decreasing} North 56.81 28.70 58.92 −2.6 −4.6to0.5 Stationary Rondônia 53.38 26.63 75.71 _−2.0a _{−3.9to0.0 Decreasing} Acre 87.63 14.20 54.30 −6.7a _{−7.9to−5.5 Decreasing} Amazonas 76.33 11.20 40.11 _−6.9a _{−7.8to−5.9 Decreasing} Roraima 49.52 16.34 54.19 −4.7a _{−7.8to−1.4 Decreasing} Pará 45.48 30.43 61.92 −1.3 −4.8to2.4 Stationary Amapá 33.43 11.50 31.57 −3.7 −11.6to4.8 Stationary Tocantins 72.06 88.13 85.05 0.5 −3.4to4.6 Stationary Northeast 19.60 19.30 28.40 0.2 −0.3to0.7 Stationary Maranhão 44.29 47.43 67.15 0.4 _−0.5to1.2 Stationary Piauí 32.18 27.64 45.78 −0.6 −1.6to0.5 Stationary Ceará 24.10 18.94 28.42 _−0.9a _{−1.5to−0.2 Decreasing}

RioGrandedoNorte 4.40 5.70 8.23 1.4a _{0.1to2.7 Increasing}

Paraíba 9.56 9.63 17.99 0.6 −1.7to2.8 Stationary

Pernambuco 26.20 19.72 33.56 −0.2 −1.5to1.0 Stationary

Alagoas 5.89 8.13 10.62 2.1a _{0.1to4.2 Increasing}

Sergipe 11.46 13.73 22.48 1.0 −1.6to3.6 Stationary

Table1 (Continued)

Brazil/Regions/States Rateper100,000inhabitants AAPC 95%CI Trend

1990 2016 Average

Central-West 49.79 30.02 55.22 −1.5 −3.0to0.9 Stationary

MatoGrossodoSul 28.37 15.21 27.70 0.3 −2.3to3.0 Stationary

MatoGrosso 101.65 80.62 113.33 _{−0.5 −3.0}to2.0 Stationary

Goiás 44.34 21.69 54.07 −2.3 −5.3to0.7 Stationary

DistritoFederal 21.80 5.91 13.96 _−5.1a _{−5.8to−4.3 Decreasing}

Southeast 14.47 4.17 11.50 _−4.5a _{−5.1to−4.0 Decreasing}

MinasGerais 12.42 5.34 13.00 −4.3a _{−5.1to−3.4 Decreasing}

EspíritoSanto 36.40 10.97 33.54 0.6 −9.5to11.8 Stationary

RiodeJaneiro 21.88 4.33 17.99 −6.3a _{−9.5to−3.0 Decreasing}

SãoPaulo 10.67 3.95 6.63 −4.8a _{−5.4to−4.1 Decreasing}

South 7.25 2.84 6.49 −3.5a _{−5.7to−1.2 Decreasing}

Paraná 3.43 5.20 12.95 _−3.6a _{−6.4to−0.8 Decreasing}

SantaCatarina 6.63 2.13 3.90 −4.1a _{−7.3to−0.7 Decreasing}

RioGrandedoSul 1.82 0.92 1.77 −2.3a _{−3.2to−1.5 Decreasing}

AAPC,averageannualpercentchange.

a_{Statisticallysignificant.}

sevenotherstates,the2016rates werehigherthan those observedatthebeginningoftheperiodstudied:Maranhão, RioGrandedoNorte,Paraíba,Alagoas,Sergipe,Bahia,and Paraná.Inparallel,inthelastyearoftheseries,together withTocantins,hyperendemicconditionswererecordedin MatoGrosso(80.62/100,000)andMaranhão(47.43/100,000;

Fig.2andTable1).

There were verified reduction trends in 11 states and theFederal District:four in the North,one in the North-east,three inthe Southeast, threein theSouth, andthe Federal District in the Central-West.Amazonas presented thelargestreduction(AAPC=−6.9%;p<0.001),decreasing from76.33/100,000 in1990 to11.12/100,000in2016, for anaveragerateof40.11/100,000(Fig.2andTable1).

Alagoas and Rio Grande do Norte presented statis-tically significant growth trends. In Alagoas, the rate increased from 5.89/100,000 in 1990 to 8.13/100,000 in 2016(AAPC=2.1%;p<0.001),andinRioGrandedoNorteit increasedfrom4.40/100,000in1990to5.7/100,000in2016 (AAPC=1.4%;p<0.001).Itisworthnotingthatinthesetwo states,leprosyhasalreadyreachedthelevelofelimination (prevalence<1 case/10,000 inhabitants; Fig. 2, Table 1). Thisfindingindicatesthatthechainoftransmissioninthese statesisactive,suggestingoperationalproblemsand point-ingtoahiddenprevalence.

The asymmetries observedin the detectionof the dis-ease in Brazil signal to the complexity of the problem. Recently,researchershavealertedofthehiddenhigh preva-lenceof thedisease andunderdiagnosis in the country.6,7

Theincreasingtrends observedin Alagoasand RioGrande doNorteandthestationary patternin13federativeunits andinNorth,Northeast,andCentral-Westregionssignalthe needfor interventionsintheseareasin ordertointerrupt thetransmissionchain.

Financial

Support

Author’s

contribution

CarlosDornelsFreiredeSouza:Statisticalanalysis;approval ofthefinalversionofthemanuscript;conceptionand plan-ningofthestudy;elaborationandwritingofthemanuscript; obtaining, analyzing and interpreting the data; effective participation in research orientation; intellectual partici-pation inpropaedeuticand/or therapeutic conductof the cases studied; critical review of the literature; critical reviewofthemanuscript.

Franklin Gerônimo Bispo Santos: Approval of the final version of the manuscript; conception and planning of the study; elaboration and writing of the manuscript; critical review of the literature; critical review of the manuscript.

ThiagoCavalcantiLeal:Statisticalanalysis;approval of the final version of themanuscript; conception and plan-ningofthestudy;elaborationandwritingofthemanuscript; obtaining, analyzing and interpreting the data; effective participation in research orientation; intellectual partici-pation inpropaedeuticand/or therapeutic conductof the cases studied; critical review of the literature; critical reviewofthemanuscript.

JoãoPauloSilva dePaiva:Statistical analysis;approval ofthefinalversionofthemanuscript;conceptionand plan-ningofthestudy;elaborationandwritingofthemanuscript; obtaining, analyzing and interpreting the data; effective participation in research orientation; intellectual partici-pation inpropaedeuticand/or therapeutic conductof the cases studied; critical review of the literature; critical reviewofthemanuscript.

Conflicts

of

interest

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