SPATI AL DI STRI BUTI ON OF LEPROSY CASES I N RI BEI RÃO PRETO, BRAZI L, 2 0 0 4
Juliana Silv a Gauy1 Paula Hino2 Claudia Benedit a dos Sant os3
Gauy JS, Hino P, Sant os CB. Spat ial dist ribut ion of leprosy cases in Ribeirão Pret o, Brazil, 2004. Rev Lat ino- am Enfer m agem 2 0 0 7 m aio- j unho; 1 5 ( 3 ) : 4 6 0 - 5 .
This cross- sect ional st udy aim ed t o describe t he spat ial dist ribut ion of leprosy cases in Ribeirão Pret o in 2004. The data collection was perform ed through com pulsory notification records in the Epidem iological Surveillance Ser v ice of t he Municipal Secr et ar y of Healt h of Ribeir ão Pr et o. The dat a w er e geo- coded t hr ough t he MapI nfo program version 7.8 in order to obtain the them atic m ap. From the 37 cases found, 62% were autom atically coded, which revealed good com patibility between the database and the inform ation in the cartographic base. The rem aining 38% of t he cases were geo- coded int eract ively. The t hem at ic m ap analysis and t he geo- referenced cases revealed a concent rat ion of cases in t he Nort hern region of t he cit y, t radit ionally charact erized by poor neighborhoods.
DESCRI PTORS: lepr osy ; r esiden ce ch ar act er ist ics; epidem iologic su r v eillan ce
DI STRI BUCI ÓN ESPACI AL DE CASOS DE HANSENI ASI S
EN EL MUNI CI PI O DE RI BEI RÃO PRETO PARA EL AÑO 2 0 0 4
La present e invest igación t uvo com o obj et ivo describir la dist ribución espacial de los casos de hanseniasis en la m unicipalidad de Ribeirão Pret o, para el año 2004. Es un est udio seccional con inform aciones del año 2004 r ecolect adas con el equipo de Vigilancia Epidem iológica de la Secr et ar ia Municipal de Salud de Ribeir ão Pr et o. Fueron utilizadas las fichas de notificación com pulsoria, para la obtención del m apa tem ático; los datos fueron geo-codificados con la ayuda del program a MapI nfo, versión 7.8. Con relación a la geo- codificación, de los 37 casos encont rados, 62% fueron geo- codificados aut om át icam ent e, m ost rando una buena com pat ibilidad ent re la base de datos y las inform aciones de la base cartográfica. El resto ( 38% de casos) fueron geo- codificados de form a interactiva. Del análisis del m apa tem ático con los casos geo- referenciados se puede percibir que los casos se concentran en la región Nort e del m unicipio, com puest a por los barrios de clases sociales m as carent es de la región.
DESCRI PTORES: lepr a; dist r ibución espacial de la población; v igilancia epidem iológica
DI STRI BUI ÇÃO ESPACI AL DOS CASOS DE HANSENÍ ASE
NO MUNI CÍ PI O DE RI BEI RÃO PRETO NO ANO DE 2 0 0 4
A pr esent e invest igação t eve com o obj et ivo descr ever a dist r ibuição espacial dos casos de hanseníase no m unicípio de Ribeir ão Pr et o, no ano de 2004. Tr at a- se de est udo seccional, com infor m ações r efer ent es ao ano de 2004 colet adas j unt o à Vigilância Epidem iológica da Secr et ar ia Municipal de Saúde de Ribeir ão Pr et o. Par a t al, for am ut ilizadas as fichas de not ificação com pulsór ia, par a a obt enção do m apa t em át ico, os dados foram geocodificados com auxílio do program a MapI nfo, versão 7.8. Em relação à geocodificação dos 37 casos encont r ados, 6 2 % for am geocodificados aut om at icam ent e, m ost r ando boa com pat ibilidade ent r e o banco de dados e as infor m ações cont idas na base car t ogr áfica. Os 38% dos casos r est ant es for am geocodificados de for m a int er at iv a. Da análise do m apa t em át ico j unt am ent e com os casos geor r efenciados pôde- se apr eender q u e o s ca so s co n cen t r a r a m - se n a r eg i ã o No r t e d o m u n i cíp i o , co m p o st a p o r b a i r r o s d e cl a sses so ci a i s t r adicionalm ent e m ais car ent es da r egião.
DESCRI TORES: hanseníase; dist r ibuição espacial da população; v igilância epidem iológica
1
Undergraduat e St udent , PI BI C grant holder, e- m ail: j sgauy@yahoo.com .br; 2 Doct oral St udent , Capes grant holder, e- m ail: paulahino@yahoo.com .br; 3 St at ist ician, Professor, e- m ail: cbsant os@eerp.usp.br. Universit y of São Paulo at Ribeirão Pret o, College of Nursing, WHO Collaborat ing Cent er for Nursing Research Developm ent , Brazil
I NTRODUCTI ON
Lepr osy as a public healt h pr oblem
A
m ong t he 1 1 count r ies consider ed by t he Wo r l d H e a l t h Or g a n i z a t i o n ( W H O) a s o f h i g h e rincidence of lepr osy in num ber of det ect ed cases( 1 ),
I ndia occupies t he first place, followed by Brazil. Ot her
c o u n t r i e s , s u c h a s My a n m a r, I n d o n e s i a , N e p a l ,
Ma d a g a s c a r, Et h i o p i a , Mo z a m b i q u e , D e m o c r a t i c
Re p u b l i c o f t h e Co n g o , Ta n z a n i a a n d Gu i n e a ,
geographically sit uat ed in t he t ropical belt , also present
elevat ed prevalence coefficient s of t he disease( 2). WHO
def in es t h at lepr osy is n ot a pu blic h ealt h pr oblem
w h en t h e p r ev alen ce coef f icien t is u n d er on e case
per 10,000 inhabit ant s.
Th e Mi n i s t r y o f H e a l t h ( MH ) c o n s i d e r e d
leprosy as endem ic in all Brazilian st at es and regions,
w it h v ar y in g pr ev alen ce lev els, r an gin g fr om 0 . 5 t o
1 7 cases p er 1 0 , 0 0 0 in h ab it an t s. Healt h ser v ices,
alt hough available in m ost cit ies, great ly vary in t erm s
of pr oblem solving capacit y. Likew ise, t he pr evalence
of leprosy dist ribut ion in t he count ry is very different
if we com pare m acro regions. I n 2001, t he prevalence
rat es per 10,000 inhabit ant s were: Nort h ( 9.49 cases) ;
Nort heast ( 5.19 cases) ; Sout heast ( 2.67 cases) ; Sout h
( 1. 12 cases) and Cent er East ( 11. 60 cases)( 3). Only
t w o St at es, Rio Gr an de do Su l an d San t a Cat ar in a,
hav e com plet ely elim inat ed t he disease.
According t o t he São Paulo Healt h Secret ary,
in 2002, 5,378 leprosy cases were not ified in t he St at e,
which correspond t o 1.41 cases per 10,000 inhabit ant s.
Alt h ou g h t h e p r ev alen ce lev el is con sid er ed h ig h er
t han t he goal proposed by WHO, it m ust be t aken int o
accou n t t h at sig n if ican t ad v an ces h av e b een m ad e
t ow ar ds t he elim inat ion of t he disease in com par ison
w it h pr ev alence coefficient s fr om past decades, such
as in 1986, wit h 13.01 cases per 10,000 inhabit ant s,
w hen 38,958 cases w er e r ecor ded in t he St at e.
Th e dif f icu lt ies appoin t ed in t h e pr ocess of
el i m i n at i n g l ep r o sy i n Br azi l can b e at t r i b u t ed t o
s e v e r a l f a c t o r s , s u c h a s : c o m p l e x i t y o f s o m e
ad m in ist r at iv e p r oced u r es r eg ar d in g d iag n osis an d
t r eat m ent , w hich m ak e healt h agent s see lepr osy as
a com plex and difficult disease t o t reat ; cent ralizat ion
and ver t icalizat ion of t he disease cont r ol pr ocess; no
part icipat ion of t he m anagers in t he cont rol act ions at
local lev el; infor m at ion sy st em s not t ot ally r eliable;
com m unit y ’s negat iv e per cept ion of t he disease; lat e
d iag n osis of t h e d isease. Th e lep r osy issu e is n ot
lim it ed only t o t he large num ber of cases, but also t o
it s disabling power, which can int erfere in t he pat ient ’s
w or k an d social lif e, b esid es econ om ic losses an d
psy ch ological t r au m as. Th ese disabilit ies h av e been
t h e c a u s e o f t h e s t i g m a a n d d i s c r i m i n a t i o n o f
pat ient s( 4).
Geogr aphical space as an analy t ic cat egor y
The space, in it s classic epidem iologic concept ,
in t he at t em pt t o int egrat e t he biological and t he
non-b i o l o g i cal , i s co n si d er ed st at i c, i m m u t anon-b l e, a n o n
p ar t icip at iv e sp ect at or. Th e acceler at ion of h u m an
int ervent ion in t he nat ural space, wit h t he creat ion of
n ew p at t er n s o f sp at i al o r g an i zat i o n , o ccu r r ed so
q u ick ly t h at t h e t r eat m en t g iv en t o sp ace b ecam e
obsolet e, since t he nat ural space alm ost does not exist
anym ore. This fact point ed t o t he need t o review t he
con cep t of sp ace as a cat eg or y of an aly sis, in t h e
perspect ive of bet t er underst anding t he healt h- disease
p r o c e s s i n g r o u p s , t h r o u g h d i s t r i b u t i o n a n d
ep id em iolog ical cat eg or izat ion of t h e occu r r en ce of
e n d e m i s m i n u r b a n a r e a s( 5 ). S p a c e m u s t b e
con sider ed as a set of r elat ion s per f or m ed t h r ou gh
funct ions and in a w ay t hat t hey pr esent t hem selves
as a t est im ony of a writ t en hist ory by past and present
p r o ce sse s. Th a t i s, sp a ce i s d e f i n e d a s a se t o f
r epr esent at iv e for m s of social r elat ion fr om t he past
and t he present and t hrough a st ruct ure represent ed
by social relat ions t hat are happening in front of our
eyes and are m anifest ed by processes and funct ions( 6).
Sp ace i s, t h er ef o r e, a t r u e f i el d o f p o w er
whose accelerat ion is unequal. Thus, spat ial evolut ion
does n ot occu r iden t ically ev er y w h er e. Th e con cept
of space m ust incor por at e not only t he geogr aphical,
nat ur al and social char act er ist ics of a place, but also
“ t he life t hat fulfills and anim at es t hem , t hat is, t he
societ y in m ov em ent ”( 7). Ther efor e, t he space t heor y
g o es b ey o n d p h y si cal en v i r o n m en t i ssu es; i t al so
involv es social pr ocesses. The Wor ld Healt h St at ist ics
Quart erly affirm ed t hat t he urban space, an elaborat ed
form of space organizat ion, is and will be t he scenario
of t he m ain challenges on t he pat h t o cont rol infect ious
and non- infect ious diseases( 8 ).
Geogr aph ical I n f or m at ion Sy st em s
Geo g r a p h i ca l I n f o r m a t i o n Sy st em s ( GI S) ,
w it h t h eir in t egr at iv e capacit y, can be def in ed as a
t r ansfor m at ion, pr ocessing, analysis and pr esent at ion
of geor efer enced dat a r elat ed t o sever al fact or s, and
a r e b e c o m i n g f u n d a m e n t a l i n s t r u m e n t s f o r
environm ent al and healt h st udies. I t is a set of t ools
u sed t o d eal w it h sp at ially p r esen t ed in f or m at ion ,
per m it s m apping t he diseases and cont r ibut es t o t he
st r uct ur ing and analysis of socio- envir onm ent al r isks.
The easiness of GI S in pr ocessing and int egr at ing a
g r e a t q u a n t i t y o f d a t a a n d p r o d u ci n g m a p s i n a
d y n a m i c w a y m a k e s i t p o s s i b l e t o i m p r o v e t h e
analysis and synt heses of public healt h inform at ion( 9).
This r equir es t he geogr aphical localizat ion of
ev ent s, associat ing geogr aphical infor m at ion ( m aps)
t o alphanum er ical healt h dat a base. A geor efer enced
addr ess, defined as a pr ocess of associat ing it t o a
t er r est r ial m ap , can b e m ad e in t h r ee b asic w ay s:
associat ion t o a point , line or area( 10).
The applicat ion of t he GI S in healt h research
pr ov ides gr eat possibilit ies, w h ich allow r esear ch er s
t o apply new m et hods for t he m anagem ent of spat ial
i n f o r m at i o n , b eco m i n g a p o w er f u l t o o l t o co n n ect
healt h and env ir onm ent .
WHO ack n ow led g es t h e GI S as a v alu ab le
m an agem en t t ool t o st r en gt h en n at ion al, st at e an d
local surveillance abilit ies. I t highlight s t hat surveillance
at local lev el can be bet t er illust r at ed and analy zed
by GI S t h an by in f or m at ion pr esen t ed in t ables. I n
t he case of lepr osy, t his sy st em can help t o m onit or
t h e ex t en si o n o f co v er ag e i n m u l t i - ch em o t h er ap y
t r e a t m e n t , p r o v i d e a g r a p h i c a l a n a l y s i s o f
epidem iological indicat or s and t he spat ial dist r ibut ion
o f t h e d i s e a s e , t h e d i s t r i b u t i o n o f c a s e s w i t h
disabilit ies, indicat ing ar eas w it h high endem ism and
ar eas needing ex t r a r esour ces( 3 ).
St u dies t h at in v olv e t h e spat ial dist r ibu t ion
of diseases hav e becom e m or e com m on, due t o t he
i n t e g r a t i o n o f e p i d e m i o l o g i c a l m e t h o d s a n d
t ech n iq u es, em p h asizin g t h eir im p or t an ce, b ecau se
t h e y p e r m i t t h e v i su a l i za t i o n o f e p i d e m i o l o g i ca l
p at t er n s of h ealt h ev en t s an d p r ocesses, an d t h e
recognit ion of t he im port ance of fact ors t hat det erm ine
such pat t erns, facilit at ing decision m aking on pot ent ial
p u b lic h ealt h act ion s. Th is in t eg r at ion can su p p or t
pr event ive pr ogr am s and cont r ibut e t o t he decline of
m o r b i d i t y a n d m o r t a l i t y ; h e l p t o i m p r o v e
ep id em iolog ical su r v eillan ce act ion s; m on it or v it al
st at ist ics and spat ial or ganizat ion of healt h ser v ices
an d h u m an r esou r ces.
Th is ar t icle pr esen t pr elim in ar y dat a of t h e
CNPq- Product ivit y Scholarship t it led “ Spat ial pat t erns
of endem ic diseases in Ribeirão Pret o”, which aim s t o
est ablish t h e spat ial dist r ibu t ion of lepr osy, den gu e
and t uberculosis in Ribeirão Pret o and t hus cont ribut e
t o t he definit ion of priorit ies in healt h act ions, allowing
for a r at ionalizat ion of r esour ces.
This work is j ust ified on t he assum pt ion t hat
t h e sp at ial d ist r ib u t ion of lep r osy occu r s u n eq u ally
am ong com m unit ies, neighborhoods, cit ies, st at es and
count ries. This process can support healt h aut horit ies
t o pr opose m or e appr opr iat e act ion s t o dim in ish or
av o i d t h e o ccu r r en ce o f h eal t h p r o b l em s, i f m o r e
pr ox im it y, int egrat ion and k now ledge of t he space in
qu est ion ar e con sider ed.
Th er efor e, t h is ar t icle aim ed t o iden t ify t h e
pr ev alen ce lev el of lepr osy an d descr ibe it s spat ial
dist r ibut ion in Ribeir ão Pr et o in 2004.
METHOD
Geogr aph ical st u dy ar ea
The city of Ribeirão Preto is located at 47º 48’24’’
W longitude and 21º 10’42’’ S latitude, in the Northeast
of t he St at e of São Paulo, ar ound 313 k m fr om t he
capit al. Th er e ar e, accor din g t o t h e Dem ogr aph ical
Census 2000, appr ox im at ely 504.923 inhabit ant s, all
living in urban conditions. I t is one of the m ain financial
centers in the country and one of the largest centers of
the state of São Paulo and of Brazil.
St udy design
This is a cr oss- sect ional st udy( 11). This k ind
of st udy com pr ehends “ inv est igat ions t hat pr oduce a
v i e w o f t h e h e a l t h s i t u a t i o n o f a p o p u l a t i o n o r
com m unit y, based on t he individual evaluat ion of t he
healt h st at e of each m em ber of a gr oup, pr oducing
global healt h indicat or s for t he st udy gr oup. I t is of
gr eat use t o r each com m unit y diagnoses of t he local
healt h sit uat ion” .
Dat a Collect ion
I nfor m at ion r egar ding 2004 w as collect ed in
t h e Ep i d e m i o l o g i c a l Su r v e i l l a n c e Se r v i c e o f t h e
Mu n i ci p a l Hea l t h Secr et a r y i n Ri b ei r ã o Pr et o, SP,
t hrough leprosy com pulsory not ificat ion files cont ained
in t he Br azilian Nat ional Disease Not ificat ion Sy st em
Dat a an aly sis
To obt ain t h e t h em at ic m ap, t h e dat a w er e
geocodified according t o t he not ified pat ient s’ address,
wit h t he help of MapI nfo version 7.8. I nit ially, aut om at ic
geocodificat ion w as used, w hile t he int er act iv e for m
w as u sed w h en n eed ed . I n t h is p h ase, p at t er n s of
ev ent point s w er e cr eat ed.
The not ificat ion addr esses w er e disposed t o
obt ain a connect ion wit h t he digit al cart ographic base.
Th is p r oced u r e d em an d ed a lot of w or k an d t im e,
due t o som e incom plet e addr esses and also because
t he char act er ist ics of t he st r eet or ganizat ion did not
allow for t he aut om at ic r ealizat ion of t his st age. The
addr esses w er e m anually ident ified in phone book s,
cit y st r eet gu ides an d an an alogical m ap t o per m it
t his t r ansfor m at ion.
Et h ical pr ocedu r es
The pr oj ect w as pr ev iously subm it t ed t o t he
ap p r o v al o f t h e I n st i t u t i o n al Rev i ew Bo ar d at t h e
Universit y of São Paulo College of Nursing. Since t his
st u d y u se d i n f o r m a t i o n e x cl u si v e l y f r o m l e p r o sy
com pulsory not ificat ion files and did not involve pat ient
iden t ificat ion , w e r equ est ed clear an ce fr om t h e u se
of t h e f r ee an d in f or m ed con sen t t er m , as secr ecy
w as gu ar an t eed.
RESULTS AND DI SCUSSI ON
I n 2004, Ribeir ão Pr et o pr esent ed a t ot al of
3 7 n ot if ied lepr osy cases, all r esidin g in t h e u r ban
ar ea. At t he t im e, t he populat ion consist ed of about
5 3 4 , 9 4 4 in h abit an t s, cor r espon din g t o a pr ev alen ce
coef f icien t of 6 . 9 p er 1 0 , 0 0 0 in h ab it an t s, w h ich is
a b o v e t h e St a t e av e r a g e . Re g a r d i n g t h e g e n d e r,
56.8% of t he leprosy cases were m en. As t o t he clinical
form , 37.8% present ed t he Virchowian form , followed
by t uber culoid ( 35. 1% ) ; undet er m ined ( 21. 6% ) and
dim or ph ( 5. 4) .
Undet er m ined lepr osy is consider ed t he fir st
clinical m anifest at ion of t he disease and, aft er a period
of t im e, w hich var ies fr om few m ont hs t o year s, t he
disease eit her ev olv es t o cur e or som e ot her clinical
form . I n t he t uberculoid form , t here is also a possibilit y
of spont aneous cure. However, t he orient at ion is t hat
t hese cases m ust be t r eat ed t o dim inish t he t im e of
t he disease ev olut ion and r isk of neur al dam age.
The st udy show ed t hat m ost cases displayed
t he Vir chow ian for m , w hich pr esent s highly posit iv e
s p u t u m s m e a r s a n d r e p r e s e n t s v i r g i n c a s e s o f
t r eat m ent , w hich ar e an im por t ant focus of infect ion
or disease reservoir, and also indicat es lat e diagnosis.
Anot her w or r isom e aspect is t he hidden pr ev alence,
w h ich ar e n ew ex p ect ed cases t h at ar e n ot b ein g
diagnosed or w ill be t ar dily.
I t is im p or t an t t o em p h asize t h e n eed f or
i n t e r v e n t i o n s b y t h e Le p r o s y Co n t r o l Pr o g r a m ,
including pr ocedur es t o super v ise cont act s of people
w it h Han sen ’s Bacillu s, as w ell as in t er v en t ion s in
endem ic ar eas( 12).
According t o t he MH, t he m ain obst acle in t he
process of elim inat ing leprosy in Brazil is t he exist ence
of a considerable part of t he populat ion wit hout access
t o diagnosis and t reat m ent of t he disease in it s init ial
phase. Dat a show t hat , not so long ago, m or e t han
2000 new cases were diagnosed wit h severe physical
d i sa b i l i t y, r e p r e se n t i n g a t a r d y d i a g n o si s o f t h e
d i sease.
Of t h e 3 7 lep r osy cases f ou n d , 6 2 % w er e
au t o m at i cal l y g eo d eco d ed an d t h e r em ai n d er w as
int er act iv ely geocoded. The r esult of t he int er act iv e
geodecodificat ion show ed good com pat ibilit y bet w een
t he dat a base and t he infor m at ion con t ained in t h e
c a r t o g r a p h i c b a s e . Fi g u r e 1 p r e s e n t s c a s e s o f
geocoded lepr osy accor ding t o t he hom e addr ess for
t he cit y of Ribeirão Pret o in 2004.
Fig u r e 1 – Geocod ed lep r osy cases f or t h e cit y of
Th e an aly sis of t h e t h em at ic m ap an d t h e
g eor ef er en ce cases sh ow ed t h at lep r osy cases ar e
concent r at ed in t he Nor t h ( 2 0 cases) , com posed by
t radit ionally poor neighborhoods. St udies show a st rong
relat ion bet ween leprosy and socioeconom ic condit ions
in Brazil and t he world( 13- 14), in com binat ion wit h fast
populat ion gr ow t h, populat ion m ov em ent s fr om r ur al
ar eas t o cit ies, shant y t ow ns, am ong ot her s.
Th e an al y si s o f t h e sp at i al d i st r i b u t i o n o f
leprosy in t he st at e of São Paulo, in t he period from
1991 t o 2002, showed high levels of det ect ion in t he
West , suggest ing it s cont ribut ion t o new cases in t he
Cent er East r egions of t he count r y. I n t he Nor t hw est
of t he St at e, high r at es w er e also obser ved( 15).
An ecological st udy per for m ed in Recife, PE,
Br a zi l a p p o i n t ed , t h r o u g h t h e a n a l y si s o f l ep r o sy
dist r ibu t ion , t h r ee ar eas w h er e n eigh bor h oods w it h
high levels of disease det ect ion and low levels of living
co n d i t i o n s w er e co n cen t r at ed . Th e st u d y f i n d i n g s
confir m ed t hat Recife can be consider ed an ar ea of
high endem icit y for leprosy, w it h an annual det ect ion
c o e f f i c i e n t o f m o r e t h a n 4 . 0 c a s e s p e r 1 0 , 0 0 0
inhabit ant s( 16). Anot her st udy perform ed in Olinda, PE
indicat es t hat t he het er ogeneous spat ial dist r ibut ion
o f t h e d i sease i n t h e m u n i ci p al i t y i s n o t r an d o m .
I n st e a d , t h e a g g r e g a t i o n p a t t e r n i n t h e sp a ce i s
associat ed t o t h e popu lat ion ’s liv in g con dit ion s an d
expressed by a povert y indicat or. Thus, t he inst rum ent
used t o st r at ify t he cit y in r isk ar eas w as useful t o
d ef i n e p r i o r i t i es o f h eal t h act i o n s, su p p o r t i n g t h e
plan n in g of differ en t st r at egies adequ at e t o specific
sit uat ions( 17).
Br a zi l o ccu p i es t h e u n co m f o r t a b l e seco n d
posit ion in t he list of endem ic count ries in t he world,
pr eceded on ly by I n dia. Con t r ol act ion s of en dem ic
l e p r o s y, b a s e d o n i n d i v i d u a l m e a s u r e s o f e a r l y
diagnosis and case t reat m ent , are absolut ely incapable
of con t ain in g t h e t r an sm ission pr ocess. Th er e is n o
change in t he populat ion’s living condit ions. Therefore,
t h e i n f ect i o u s ag en t r ap i d l y r eco v er s i t s p r ev i o u s
st r engt h w hen t he int ensit y of applicat ion of cont r ol
m easu r es is d im in ish ed . I n t h is case, t h e d isease
pot ent ial has not been r educed, but sim ply par t ially
neut r alized by t he pr esence of healt h ser vices. Thus,
in or der t o elim in at e lepr osy in ar eas t h at ar e st ill
con sider ed en dem ic, lik e in t h e case of Br azil, it is
i m p o r t an t t o u n d er st an d t h e ep i d em i o l o g y o f t h i s
disease in cou n t r ies t h at h av e alr eady m an aged t o
elim inat e it , and well as t o precisely sit uat e t he crit ical
ar eas r equ ir in g special t r eat m en t , t h at is, t o st u dy
t h e cit ies t h at h av e n ot m an ag ed t o elim in at e t h e
disease, per m it t ing it s elim inat ion.
Th e u s e o f m a p s a l l o w s f o r t h e e a s y
v i su a l i za t i o n o f r i sk si t u a t i o n s, co h e r e n t w i t h a n
epidem iological concept of space sur v eillance, based
on t he possibilit y of im port ant int eract ions, highlight ing
t h e i m p o r t a n c e o f i n t e r - s e t o r i a l a c t i o n s i n t h e
im pr ov em ent of t he qualit y of infor m at ion collect ion,
r egist r y an d av ailabilit y w h ich can be u sef u l in t h e
planning and m onit or ing of healt h act ions.
CONCLUSI ON
The obt ained r esult s cont r ibut e t o k now ledge
abou t t h e spat ial dist r ibu t ion of lepr osy in Ribeir ão
Pr et o i n 2 0 0 4 , h i g h l i g h t i n g t h e i m p or t an ce of t h e
sp ace cat eg or y as a m et h od olog ical alt er n at iv e in
t h e plan n in g, m on it or in g an d assessm en t of h ealt h
act ions, dir ect ing int er v ent ions t o decr ease inequit ies.
Th e n o n - h o m o g e n e o u s d i st r i b u t i o n o f l e p r o sy i n
Ribeir ão Pr et o suggest s an associat ion w it h pov er t y,
a v ar iable t hat is st r ongly r elat ed w it h t he occur r ence
of t h e disease.
Th e u se of t h e GI S, d u e t o it s in t eg r at iv e
capacit y, allowed for t he visualizat ion of leprosy cases
in t he ur ban space of Ribeir ão Pr et o, cont r ibut ing t o
t he process of planning act ions t o elim inat e t he disease
in priorit y areas of t he cit y, as well as t o m onit or and
evaluat e t he act ivit ies per for m ed. This obser vat ion is
i n a g r e e m e n t w i t h W H O a n d MH o r i e n t a t i o n s t o
e l i m i n a t e l e p r o s y a s a p u b l i c h e a l t h p r o b l e m ,
em p h asizin g t h e im p or t an ce of each cit y an aly zin g
it s ow n dat a, plan n in g an d dev elopin g act ion s t h at
are appropriat e and adj ust ed t o it s own epidem iological
r ealit y.
We believe t hat t he decision m aking pr ocess
in healt h can be im plem ent ed t hr ough t he gr aphical
r efer encing of dat a, because it per m it s t he det ect ion
of specif icit ies r elat ed t o t h e localizat ion of ev en t s,
a n d t h u s co n t r i b u t e s t o t h e f o r m u l a t i o n o f m o r e
e f f e ct i v e i n t e r v e n t i o n p r o p o sa l s. Fr o m t h i s p o i n t
onw ar ds, a gr adual pr ocess can st ar t t o incor por at e
and int ensify t he use of t his m et hodology, useful for
t he qualit at iv e adv ancem ent of healt h ser v ices.
I n view of t he current cont ext , t he im port ance
of dissem in at in g r esear ch r esu lt s in t h e k n ow ledge
l ast d ecad e, t h er e h as b een a co n cer n ab o u t t h e
r educed num ber of st udies on lepr osy( 2). Ther e is a
n e e d t o i n v e s t i n b a s i c a n d o p e r a t i o n a l
-epidem iological knowledge t hat allow for t he reduct ion
o f e n d e m i ci t y, w i t h a v i e w t o t h e e r a d i ca t i o n o f
infect ions by M. lepr ae.
ACKNOW LEDGMENTS
We t h an k t h e Ep id em iolog ical Su r v eillan ce
S e r v i c e o f t h e Ri b e i r ã o Pr e t o Mu n i c i p a l H e a l t h
Secr et ar y for t h e su pply of dat a, an d CNPq for t h e
funding provided t hrough t he Scient ific I nit iat ion grant .
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