Epidemiological monitoring of leprosy indicators in Sergipe (2001-2015): segmented regression analysis,

AnBrasDermatol.2020;95(4):508---510

Anais

Brasileiros

de

Dermatologia

TROPICAL/INFECTOPARASITARY

DERMATOLOGY

Epidemiological

monitoring

of

leprosy

indicators

in

Sergipe

(2001---2015):

segmented

regression

analysis

夽,夽夽

Carlos

Dornels

Freire

de

Souza

_,

_Thiago

_Cavalcanti

_Leal

_,

João

Paulo

Silva

de

Paiva

_,

_Victor

_Santana

_Santos

a_{DepartmentofMedicine,CenterfortheStudyofSocialandPreventativeMedicine,UniversidadeFederaldeAlagoas,Arapiraca,}

AL,Brazil

b_{CenterforEpidemiologyandPublicHealth,UniversidadeFederaldeAlagoas,Arapiraca,AL,Brazil}

Received1April2019;accepted1July2019 Availableonline19May2020

KEYWORDS

Epidemiology; Leprosy;

Timeseriesstudies

Abstract ThisstudyanalyzedthetrendofleprosyindicatorsinSergipe,between2001and

2015. Itwas atime seriesstudy thatanalyzed the trendfor generaldetectioncoefficient, children under15yearsofage,andnew caseswithgrade 2disability. Thejoinpointmodel wasused.Two(2.6%)municipalitieshadanincreasingtrendingeneraldetectioncoefficient, five(6.6%)hadanincreasingtrendindetectionrateinchildrenunder15,and19(25.3%)had anincreasingtrendindetectioncoefficientofnewleprosycaseswithgrade2disability.The findingssuggestmaintenanceofthechainoftransmission.

©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

夽 _{Howto citethisarticle: SouzaCDF, LealTC, PaivaJPS,}

San-tosVS.EpidemiologicalmonitoringofleprosyindicatorsinSergipe (2001---2015): segmented regression analysis. An Bras Dermatol. 2020;95:508---10.

夽夽_{StudyconductedattheDepartmentofMedicine,Centerforthe}

StudyofSocialandPreventativeMedicine,UniversidadeFederalde Alagoas,Arapiraca,AL,Brazil.

∗_{Correspondingauthor.}

E-mail:carlos.freire@arapiraca.ufal.br(C.D.Souza).

1_{http://lattes.cnpq.br/6453724595999982.}

Leprosy is an infectious disease caused by Mycobac-terium leprae,1 _{which affects the skin and peripheral}

nerves,resultinginneuro-dermatologicallesionsand physi-caldisabilities.2

OnlyBrazilhasnotreachedthegoalofeliminating lep-rosyasapublichealthproblem.3_{In2017,26,875newleprosy}

caseswerediagnosedinBrazil(12.94/100,000population). Ofthese,1718werediagnosedinchildrenunder15yearsof age (3.72/100,000).The detectioncoefficient ofnew lep-rosycaseswithgrade2disabilitywas9.39/100,000.4

In 2017, Sergipe recorded a general detection coeffi-cient of15.78/100,000population,adetectioncoefficient https://doi.org/10.1016/j.abd.2019.07.015

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

EpidemiologicalmonitoringofleprosyinSergipe 509

Table1 Epidemiologicalindicatorsandmethodsselectedforthestudy.

Indicator Utility Parameters

Newleprosycasedetectionratein thegeneralpopulation/100,000 inhabitants.

Measuresthestrengthofthe disease’smorbidity,magnitude,and trend.

Hyperendemic:≥40.0/100,000inhab. Veryhigh:20.00---39.99/100,000inhab. High:10.00---19.99/100,000inhab.Medium: 2.00---9.99/100,000inhab.

Low:<2.00/100,000inhab.

Veryhigh:20.00---39.99/100,000inhab. Newleprosycasedetectionratein

thepopulationunder15 years/100,000inhabitants.

Measuresthestrengthofrecent transmissionofthediseaseandits trend.

Hyperendemic:≥10.00/100,000inhab. Veryhigh:5.00---9.99/100,000inhab. High:2.50---4.99/100,000inhab. Medium:0.50---2.49/100,000inhab. Low:<0.5/100,000inhab.

Rateofnewleprosycaseswithgrade 2physicaldisabilityatthetimeof diagnosis/100,000inhabitants.

Evaluatesdeformitiescausedby leprosyinthegeneralpopulationand comparesthemwithother

debilitatingdiseases.

Thereductiontrendofdetectionrate, followedbydecreasingofthisindicator, characterizesareductionoftheendemic disease’smagnitude.

inchildren under15 of2.75/100,000,anddetection coef-ficient of new leprosy cases with grade 2 disability of 16.61/100,000.4 _{Themonitoring oftheseindicatorsis}

rec-ommended by the World Health Organization (WHO),5

becauseofthecommitmentstoeliminatethediseasesigned byBrazil.

Thisstudyaimedtoanalyzethetrendofleprosy indica-torsinthestateofSergipefrom2001to2015.

For this purpose, an ecological time series study was performed, with the municipalities of Sergipe (n=75) being the units for analysis. Data were obtained from the National Information System for Notifiable Diseases (SINAN). Three indicators were analyzed: general detec-tion coefficient rate per 100,000 population; detection coefficient rate in children under 15 per 100,000 pop-ulation, and detection coefficient of new leprosy cases with grade 2 disability per 100,000 population (Table 1).

Forthetemporal analysis,the joinpointregression model was used. The annual percent change (APC) and the average annual percent change (AAPC) were calculated. A 95% confidence interval (95% CI) and an alpha of 5% were considered. Because of the use of secondary data, the approval of the Research Ethics Committee was not needed.

Inthestudyperiod,8238newleprosycaseswere identi-fied,6.25%(n=515)inchildrenunder15and7.27%(n=599) in new leprosy cases with grade 2 disability. Of the 75 municipalities,onlytwohadanincreasingtrendofthe gen-eraldetectioncoefficient:Carira(AAPC=59.2%)andMoita Bonita(AAPC=27.3%). Eight municipalities hada decreas-ingtrend(CanindédoSãoFrancisco,Cumbe,Estância,Ilha dasFlores,Japoatã,SantaLuizadoItanhy,SantanadoSão Francisco,andSantosAmarodasBrotas).Inthisgroup,the averageannualreductionwas22.56%(Fig.1).

Figure1 Spatialdistributionofaverageannualpercentchangesandclassificationofthetrendofleprosymagnitudeindicators

510 SouzaCDFetal. Regarding the detection coefficient in children under

15, five municipalities presented an increasing trend (Carira,Itabaianinha,Pacatuba,Poc¸oVerde,andSalgado), with emphasis on Carira (AAPC=56.2%). Only Aracaju (AAPC=−8.8%) and Malhada dos Bois (AAPC=−2.0%) had a decreasing trend for detection rate in children. For grade 2 disability, 19 municipalities had an increasing trend,especiallyPropriá(AAPC=50.0%)andDivinaPastora (AAPC=38.30%). No municipality presented any trend of reductioninthegrade2disabilityindicator.Thisgrouphad anaverageincreasingtrendof29.3%(Fig.1).

Although leprosy burden has declined over recent years,2,3_{recentstudieshavesuggestedthatthenumberof}

patientsregisteredinofficialinformationsystemsis substan-tiallylowerthanthenumberofindividuals withleprosyin Brazil.6_{Studiesperformedinareasconsideredlow}

endemic-ityhave evidenced underdiagnosis and, therefore, a high hiddenleprosyprevalence.7,8

The highest number of municipalities with a trend of increase in thedetection in children under 15 (n=5)and thedetectionof newleprosy caseshavinggrade2 disabil-ity(n=9)suggeststhemaintenanceofleprosytransmission inSergipe,ahiddenleprosyprevalence,underdiagnosisof leprosy, and failures of the leprosy control programs in municipalities.1,3,9 _{The mismatchbetween thethree}

indi-catorshasalreadybeenevidencedininvestigationscarried outinthestatesofBahia9 _andAlagoas,10 _whichhave

geo-graphicalboundarieswithSergipe.

Thedetectioncoefficientofnewleprosycaseswithgrade 2disabilityisoneofthemostimportantindicatorsfor eval-uatingthedisease,andsuggestsalatediagnosisofleprosy.3

In Sergipe, municipalities with a tendency of increase of thisindicatorshouldreceivespecialattentionfromthe pol-icymakers,especially throughactionsthat facilitate early diagnosis.

Despitetheadvancesobservedinthereductionof gen-eraldetectioncoefficientandinchildrenunder15,leprosy stillrepresentsapublichealthprobleminSergipe.

Financial

support

Authors’

contributions

CarlosDornelsFreiredeSouza:Statisticalanalysis;approval of final version of the manuscript; conception and plan-ningof thestudy; draftingandediting ofthemanuscript; collection,analysis, andinterpretationof data; participa-tionindesignofthestudy;intellectualparticipationinthe propaedeutic and/or therapeutic conduct of the studied cases;criticalreviewoftheliterature.

ThiagoCavalcantiLeal:Statistical analysis;approvalof finalversionofthemanuscript;conceptionandplanningof thestudy;draftingandeditingofthemanuscript;collection, analysis,andinterpretationofdata;participationindesign

ofthestudy;intellectualparticipationinthepropaedeutic and/or therapeutic conduct of the studied cases; critical reviewoftheliterature;criticalreviewofthemanuscript.

JoãoPauloSilvadePaiva:Statisticalanalysis;approvalof finalversionofthemanuscript;conceptionandplanningof thestudy;draftingandeditingofthemanuscript;collection, analysis,andinterpretationofdata;participationindesign ofthestudy;intellectualparticipationinthepropaedeutic and/or therapeutic conduct of the studied cases; critical reviewoftheliterature;criticalreviewofthemanuscript.

Victor SantanaSantos: Statistical analysis;approval of finalversionofthemanuscript;conceptionandplanningof thestudy;draftingandeditingofthemanuscript;collection, analysis,andinterpretationofdata;participationindesign ofthestudy;intellectualparticipationinthepropaedeutic and/or therapeutic conduct of the studied cases; critical reviewoftheliterature;criticalreviewofthemanuscript.

Conflicts

of

interest

Nonedeclared.

References

1.Cruz RCDS, Bührer-Sékula S, Penna MLF, Penna GO, Talhari S.Leprosy:currentsituation,clinicalandlaboratoryaspects, treatmenthistory and perspective of the uniform multidrug therapyforallpatients.AnBrasDermatol.2017;92:761---73. 2.Lockwood DN, Suneetha S. Leprosy: too complex a disease

for asimpleelimination paradigm.Bull WorldHealth Organ. 2005;83:230---5.

3.SantosVS,deMatosAM,deOliveiraLS,deLemosLM,Gurgel RQ, ReisFP, et al.Clinical variablesassociated with disabil-ity inleprosy cases innortheast Brazil. JInfect DevCtries. 2015;9:232---8.

4.Departamento de Informática do Sistema Único de Saúde [Internet]. Casos de Hanseníase (SINAN). Available from: http://www2.datasus.gov.br/DATASUS/index.php?area=0203& id=31032752[accessed25.03.19].

5.Organizac¸ão Mundial da Saúde. Estratégia global para hanseníase 2016-2020: acelerac¸ão rumo a um mundo sem hanseníase.Genebra:OMS;2016.

6.SalgadoCG,BarretoJG,SilvaMB,GoulartIMB,BarretoJA,Nery JA,etal.Areleprosycasenumbersreliable?LancetInfectDis. 2018;18:135---7.

7.BernardesF,Filho,PaulaNA,LeiteMN,Abi-RachedTLC,Vernal S,etal.Evidenceofhiddenleprosyinasupposedlylowendemic areaofBrazil.MemInstOswaldoCruz.2017;112:822---8. 8.Ribeiro GC, Fabri ACOC, Amaral EP, Machado IE, Lana FCF.

Estimateof hidden prevalence ofleprosy in theDiamantina micro-region---MinasGerais.RevEletrEnf.2014;16:728---35. 9.SouzaCDF,SantosFGB.Prevalenceofleprosy,degreeIIof

physi-calincapacityandproportionofmultibacillarycases:aparadox that evidenceslate diagnosis and hidden prevalence? R Epi-demiolControlInfec.2019;9:1---6.

10.SouzaCDF,LealTC,PaivaJPS,AraújoEMCF,SantosFGB.Pseudo eliminationofleprosyinanortheasternBrazilianstate: analy-sisfrom regression bypointsofinflation andlocal empirical Bayesianmodel.REpidemiolControlInfec.2019;9:1---15.