Leprosy in Brazil in the 21st century: analysis of epidemiological and operational indicators using inflection point regression,

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Anais

Brasileiros

de

Dermatologia

www.anaisdedermatologia.org.br

TROPICAL/INFECTOPARASITARY

DERMATOLOGY

Leprosy

in

Brazil

in

the

21st

century:

analysis

of

epidemiological

and

operational

indicators

using

inﬂection

point

regression

夽,夽夽

Carlos

Dornels

Freire

de

Souza

∗

,

João

Paulo

Silva

de

Paiva

,

Thiago

Cavalcanti

Leal

,

Gabriel

da

Silva

Urashima

DepartmentofMedicine,UniversidadeFederaldeAlagoas,CampusArapiraca,Arapiraca,AL,Brazil

Received3April2019;accepted17September2019 Availableonline18September2020

KEYWORDS

Leprosy; Mycobacterium leprae;

Timeseriesstudies

Abstract Theobjectiveofthisstudywastoanalyzethetrendofepidemiologicaland oper-ational indicators of leprosy in Brazil, from 2001 to 2017. This was a time series study involvingnineindicators.Theinﬂectionpoint regressionmodelwasused.Decreasingtrends wereobservedforthefollowing:generaldetection(_−4.8%),childrenunder15(_−3.7%), preva-lence (−7.0%), andgrade 2/millioninhabitants (−3.5%). Theproportion ofindividualswith grade2disabilityshowedanupwardtrend(2.0%)from2001aswellascontactsexaminedfrom 2003(5.0%).Theproportionsofcureandofindividualswithadegreeofdisabilityassessedat thetimeofthediagnosisandthecureshowed astationarybehavior.Althoughadvancesare noted,therearestillchallengestobeovercome.

Leprosyisaneglectedtropicaldiseasecausedby Mycobac-terium leprae.1 _Over _the_past _three_decades,_the _number

夽 _How_to_cite_this_article:_Souza_CDF,_Paiva_JPS,_Leal_TC,_Urashima

GS.LeprosyinBrazilinthe21stcentury:analysisofepidemiological andoperationalindicatorsusinginﬂectionpointregression.AnBras Dermatol.2020;95:743---747.

夽夽_Study_conducted_at_the_Center_for_the_Study_of_Social_and

Pre-ventativeMedicine,DepartmentofMedicine,UniversidadeFederal deAlagoas,CampusArapiraca,Arapiraca,AL,Brazil.

∗_{Corresponding}_author.

E-mail:[email protected](C.D.F.Souza).

ofcasesofthediseasehasbeen progressivelydecreasing. In2017alone,150countriesreported210,671newcasesof thedisease;80.2%ofthesewerereportedbyBrazil,India, andIndonesia.Thatsameyear,Brazilaccountedfor26,875 (92.3%)ofthenewcasesregisteredintheAmericas.2

Due to this unfavorable epidemiological scenario, the

World Health Organization (WHO) launched the Global

Strategy2016---2020, basedonthreepillars:i) strengthen-inggovernmentcontrol,coordination,andpartnership; ii) ﬁghting leprosy and its complications; iii) combating dis-crimination and promoting inclusion.3 _In _this _sense, _the

monitoringofepidemiologicalindicatorsis ofspecial

rele-https://doi.org/10.1016/j.abd.2019.09.031

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Table1 Epidemiologicalandoperationalindicatorsselectedforthestudy.

Indicator Usefulness Parameters

Detectionrateofnewleprosycases inthegeneralpopulation/100,000 inhabitants.

Measurethestrengthoftheendemic morbidity,magnitude,andtendency.

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

inpersonsunder15years/100,000 inhabitants.

Measurethestrengthoftherecent transmissionoftheendemicandits tendency.

Hyperendemic:_{≥10.00/100,000} inhab.

Veryhigh:5.00---9.99/100,000inhab. High2.50---4.99/100,000inhab. Medium:0.50---2.49/100,000inhab. Low:<0.5/100,000inhab.

Annualleprosyprevalence rate/10,000inhabitants.

Measurethemagnitudeofthe endemic.

Hyperendemic:≥20.0/10,000inhab. Veryhigh:10.0---19.9/10,000inhab. High5.0---9.9/10,000inhab. Medium:1.0---4.9/10,000inhab. Low:<1.0/10,000inhab. Rateofnewleprosycaseswithgrade

2physicaldisabilityatthetimeof diagnosis/1millioninhabitants

Assessthedeformitiescausedby leprosyinthegeneralpopulationand comparethemwithotherdisabling diseases.

Thetendencytoreducethe detectionrate,accompaniedbya reductioninthisindicator, characterizesareductioninthe magnitudeoftheendemicdisease. Proportionofleprosycaseswith

grade2physicaldisabilityatthetime ofdiagnosisamongthenewcases detectedandevaluatedintheyear.

Evaluatetheeffectivenessoftimely and/orearlycasedetection activities.

High:_≥10%. Medium:5%−9.9%. Low:<5%. Proportionofnewleprosycaseswith

anydegreeofphysicaldisability assessedatdiagnosis.

Measurethequalityofcareinhealth services.

Good:≥90%. Fair:_{≥75%−89.9%.} Poor:<75%. Proportionofnewleprosycaseswith

anydegreeofphysicaldisability assessedatthetimeofcure.

Measurethequalityofcareinhealth services.

Good:_≥90%. Fair:≥75%−89.9%. Poor:<75%. Proportionofexaminedcontactsof

newleprosycasesdiagnosedinthe yearsofthecohorts.

Measuretheservices’capacityto carryoutsurveillanceofcontactsof newcasesofleprosy,increasingthe timelydetectionofnewcases.

Good:≥90.0%. Fair:≥75.0%−89.9%. Poor:<75.0%. Proportionofleprosycureamongnew

casesdiagnosedintheyearsofthe cohorts.

Assessthequalityofcareand follow-upofnewlydiagnosedcases untiltreatmentiscomplete.

Good:_≥90%. Fair:≥75%−89.9%. Poor:<75%.

Source:WorldHealthOrganization,2017.3

vance for the control of leprosy and the success of the

strategiesdeveloped.

This study aimedto analyzethe temporalevolution of

theepidemiologicalandoperationalindicatorsofleprosyin Brazil,from2001to2017.

This was an ecological time series study. Nine

epi-demiologicaland operational leprosy indicators in Brazil,

obtained from Datasus (http://datasus.saude.gov.br/),

were included in the study (Table 1).4,5 _After _collection,

theinflectionpointregressionmodelwasusedfortemporal analysis.Theannualpercentchange(APC)wascalculated. Thetrendswereclassifiedasincreasing,decreasing,or sta-tionary.A95% confidenceintervalanda significancelevel of 5% were considered. As this study used data in public domain,theneedforapprovalfromaresearchethics

com-mitteewaswaived.

Between 2001 and 2017, 652,764 new cases of

lep-rosy were reported in Brazil. Of these, 41,191 (6.31%)

were in individuals under 15 years of age. Since 2013,

thedetectionratesinthegeneralpopulationandinthose

under15yearsshowedadownwardtrend(APC=−5.9%and

−5.0%;respectively).When thecompleteperiodwas

con-sidered,thepercentagesofreductionweresmaller(−4.8%

and −3.7%, respectively). Despite the advances, in 2017

the endemic was classiﬁed as high in the general

popu-lation (12.94/100,000)and in children under15 yearsold (3.72/100,000).The prevalencerate,inturn,hasshown a lineartrendofreductionsince2001(APC=−7.0%), decreas-ingfrom3.99to1.35/10,000inhabitants(Fig.1andTable2). Amongtheindicatorsrelatedtothepresenceofphysical disability,therateofnewleprosycaseswithgrade2physical

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Table2 TrendofleprosyepidemiologicalandoperationalindicatorsinBrazil,2001---2017.

Indicator Period APC(95%CI) p-value Trend

Detectionrateofnewleprosycasesinthegeneral population/100,000inhabitants 2001−2003 3.8(−8.8to 18.1) 0.5 Stationary 2003₋₂₀₁₇ _−5.9(_−6.5 to−5.4) <0.001 Descending 2001₋₂₀₁₇ _−4.8(_−6.2 to−3.3) <0.001 Descending Detectionrateofnewleprosycasesinpersonsunder15

years/100,000inhabitants 2001₋₂₀₀₃ 5.5(_−12.1 to26.7) 0.5 Stationary 2003−2017 −5.0(−5.8 to−4.2) <0.001 Descending 2001−2017 −3.7(−5.8 to_−1.6) <0.001 Descending Annualleprosyprevalencerate/10,000inhabitants 2001−2017 −7.0%(−9.7

to_−4.2)

<0.001 Descending Rateofnewleprosycaseswithgrade2physical

disabilityatthetimeofdiagnosis/1millioninhabitants

2001−2017 −3.5(−4.5 to−2.5)

<0.001 Descending Proportionofleprosycaseswithgrade2physical

disabilityatthetimeofdiagnosisamongthenewcases detectedandevaluatedintheyear

2001−2017 2.0 (0.8---3.3)

<0.001 Ascending

Proportionofnewleprosycaseswithanydegreeof physicaldisabilityassessedatdiagnosis

2001−2011 0.6 (0.3---1.0) <0.001 Ascending 2011−2017 −0.4(−1.2 to0.3) 0.2 Stationary 2001−2017 0.2(−0.1to 0.6) 0.2 Stationary Proportionofnewleprosycaseswithanydegreeof

physicaldisabilityassessedattimeofcure

2001−2007 −1.5(−2.3 to−0.6) <0.001 Descending 2007₋₂₀₁₀ 8.4 (3.1---14.0) <0.001 Ascending 2010₋₂₀₁₇ _−1.1(_−1.8 to−0.5) <0.001 Descending 2001−2017 0.5(−0.4to 1.4) 0.3 Stationary Proportionofexaminedcontactsofnewleprosycases

diagnosedintheyearsofthecohorts

2001−2003 −20.4 (−35.5to −1.7) <0.001 Descending 2003₋₂₀₁₇ 5.0 (4.0---6.1) <0.001 Ascending 2001₋₂₀₁₇ 1.4(_−1.1to 4.0) 0.3 Stationary Proportionofleprosycureamongnewcasesdiagnosed

intheyearsofthecohorts

2001−2004 −6.1(−8.8 to−3.6) <0.001 Descending 2004−2007 7.8 (2.1---13.9) 3.1 Descending 2007−2017 −0.1(−0.6 to0.3) 0.5 Stationary 2001−2017 0.1(−0.9to 1.1) 0.8 Stationary

95%CI,95%conﬁdenceinterval;APC,annualpercentchange.

2001(APC=−3.5%),decreasingfrom14.00to9.39/1million inhabitants.Inturn,theproportionofindividualsdiagnosed withgrade2showedasigniﬁcantgrowthtrend(APC=2.0%), goingfrom6.0%in2001to8.3%in2017(Fig.1andTable2). The proportions of individuals assessed at the timeof thediagnosisandthecurepresentedastationarytemporal patterninthestudiedperiod.Inallyearsofthetimeseries,

theproportionofsubjectsevaluatedwasconsideredregular (75%---89.9%)atthetimeofdiagnosisandprecarious(<75%) atthetimeofdischargeduetocure(Fig.1andTable2).

The proportionof contactsexamined showed agrowth

trendsince2003(APC=5.0%),goingfrom43.9%in2003to 78.9%in 2017,thus being consideredregular. In turn,the proportionof individuals cured showed a steady trend in

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Figure1 EpidemiologicalandoperationalindicatorsofleprosyinBrazil,2001−2017.

theperiod,with81.6%in2001and81.2%in2017,thusbeing consideredregular(Fig.1andTable2).

Even considering theadvances inthe fightagainst lep-rosy,thefindingsshowimportantchallengestobeovercome byBrazil. The first one is thehigh annual percentages of reductionin generaldetection (−4.8%), detection in

chil-dren under 15 yearsold (−3.7%), and detection of grade

2disability(−7.0%).As thisisachronic diseasewithslow evolutionanddifﬁcultcontrol,suchsharpannualreductions shouldbeviewedwithconcern.Forexample,in2005,over 49,000casesofthediseasewereregistered inthegeneral population;thefollowingyear,slightlyover43,000. Brazil-ianstudiespointtothehighhiddenprevalenceofthedisease inBrazil,whichhaspreventedtheidentiﬁcationofthereal numberof patients in the country.5 _In _the _present _study,

theincreaseintheproportionofgrade2casesatdiagnosis reinforcesthisunderdiagnosishypothesis.6,7

ThesecondBrazilianchallengeistheneedtoqualifythe surveillance system. There is a lack of outpatient clinics andqualiﬁedpersonnelforthepropermonitoringofcases, whichcompromisestheassessmentofthedegreeof disabil-ity,themonitoringofneuralfunctions,themanagementof reactions,andtheproperexaminationofcontacts, funda-mentaltoolsforinterruptingthetransmissionchainofthis disease.8---10

Basedonthepresentﬁndings,theauthorsadvocatethe

need for the developmentof plans/strategies that would

allowearlydiagnosisofthediseaseandfavorthesystematic monitoringofpatients,withemphasisonearlydiagnosisand preventionofphysicaldisabilities.

Financial

support

Nonedeclared.

Authors’

contributions

CarlosDornelsFreiredeSouza:Statisticalanalysis;approval oftheﬁnalversionofthemanuscript;conceptionand plan-ningofthestudy;elaborationandwritingofthemanuscript; obtaining, analyzing, andinterpreting the data;effective participationinresearchorientation;criticalreviewofthe literature;criticalreviewofthemanuscript.

JoãoPauloSilva dePaiva:Statistical analysis;approval oftheﬁnalversionofthemanuscript;elaborationand writ-ingofthemanuscript;obtaining,analyzing,andinterpreting thedata;criticalreviewoftheliterature;criticalreviewof themanuscript.

ThiagoCavalcantiLeal:Statisticalanalysis;approval of the ﬁnal versionof the manuscript;elaboration and writ-ingofthemanuscript;obtaining,analyzing,andinterpreting thedata;criticalreviewoftheliterature;criticalreviewof themanuscript.

GabrieldaSilvaUrashima:Statisticalanalysis;approval oftheﬁnalversionofthemanuscript;elaborationand writ-ingofthemanuscript;obtaining,analyzing,andinterpreting thedata;criticalreviewoftheliterature;criticalreviewof themanuscript.

Conﬂicts

of

interest

Nonedeclared.

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