Leprosy in the elderly population of Alagoas

1 Universidade Federal de Alagoas, Programa de graduação em Enfermagem. Maceió, Alagoas, Brasil. 2 Universidade de São Paulo, Programa de pós-graduação em Ciências. São Paulo, São Paulo, Brasil. 3 Universidade Federal de Alagoas, Programa de graduação em Enfermagem. Maceió, Alagoas, Brasil. 4 Universidade Estadual de Ciências da Saúde de Alagoas, Programa de residência multiprofissional em Saúde da Família. Maceió, Alagoas, Brasil. 5 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Programa de pós-graduação em Enfermagem. Ribeirão Preto, São Paulo, Brasil. 6 Universidade Federal do Ceará, Programa de pós-graduação em Enfermagem. Fortaleza, Ceará, Brasil.


INTRODUCTION
The process of population aging is a global reality that brings with it biopsychosocial challenges, as the demographic increase of elderly people influences the organization of the health services and requires a rethink of public policies in order to confer equality and access of health care to these populations 1,2 .
It is estimated that in 2025 Brazil will have the world's sixth oldest population 3 .Long-lived persons often suffer functional loss, which can be accelerated by certain diseases, such as leprosy 2 .This is a chronic infectious contagious disease that, if not diagnosed, may evolve into the tuberculoid, dimorphic or Virchowian forms.Late diagnosis is related to neural impairment with physical disability, since the course and manifestations of the disease depend on the response of the immune system to the bacillus and symptoms may take up to 20 years to appear 4,5 .
An analysis of all leprosy cases reported from 2012 to 2016 in Brazil revealed that the mean detection rate was approximately eight times higher in the male population aged 60 years and over than in those aged under 15 6 .
In this context, it is known that leprosy has a greater impact on the elderly, as Hansen's bacillus features incapacitating vectors, resulting in an impairment of the dynamics of the life of the individual, especially in those where functional capacity is already affected by the natural course of the health-disease process, in addition to affecting personal relationships and the support network 7 .
The study of leprosy in the elderly is therefore pertinent, as this group tends to experience more complex profiles of the disease and it is important to increase our knowledge of the profile of the population of elderly people affected by leprosy.The aim of the present study was therefore to describe the epidemiological profile of elderly people with leprosy in the state of Alagoas.

METHOD
A descriptive epidemiological study of leprosy cases reported in elderly people in Alagoas from 2005 to 2015 was carried out.The data were extracted from the Disease Notification Information System (SINAN) together with the Alagoas State Health Department.
After the data were collected, the information was classified and tabulated according to the research objectives and analyzed descriptively.
Simple descriptive analyzes were performed with the aim of characterizing the study population.The study consisted of sociodemographic (age, gender, race, level of schooling and occupation) and clinical variables (clinical form, operational classification, smear microscopy results, physical disability grade at diagnosis and discharge, number of skin lesions and detection rate).As the study used secondary data it was not submitted to the Ethics Research Committee.

RESULTS
A total of 896 cases of leprosy were reported in elderly persons between 2005 and 2015, 60.5% of whom were in the 60-69 age group and 50.5% of whom were male.
In terms of operational classification, a prevalence of multibacillary cases of over ten years was observed.
Regarding the evaluation of physical disabilities caused by leprosy in the diagnosis, grade 0 disability was prevalent (370-41.3%).However, a considerable percentage (277 -42.1%) had grade I or II disability.The categories 'not evaluated' and 'ignored' are noteworthy as they represent 149 cases (16.6%).In terms of the assessment of grade of physical disability at discharge, the data show that grade 0 was predominant (280 -31.2%), but the 'not evaluated' and 'ignored' variables represented approximately half the cases (398 -44.4%).A detection rate of over 20 cases per 100,000 inhabitants was observed, with a mean of 29.48 cases between 2005 and 2015.This data reflects a hyperendemic epidemiological situation in the state, according to the parameters of the Ministry of Health 8 .High rates in 2008 and 2012 (36.20 and 40.19, respectively) were noted, followed by a sharp drop in subsequent years.

DISCUSSION
According to the results of the study, the predominant age group was 60-69 years, which was also observed in a survey of 60 elderly persons from two Rehabilitation Centers in São Luiz, Maranhão, of whom 53.3% were from the same age range as the present study 9 .In terms of gender, while it is known that leprosy affects men and women, some studies have indicated a prevalence among men, such as the World Health Organization's Global Leprosy Strategy 2016-2020: Accelerating Towards a World Without Leprosy, which found that only 36% of new cases in 2014 involved women 10 .
A study carried out in Colombia, a country where the prevalence of the disease has been less than 1/10000 since 1997, identified a ratio of one case in women for every 3.4 in men, with a mean age of 53 years, in which half of the patients were over 51 years old and the maximum age was 90 years 11 .
An epidemiological study that investigated cases in Brazil in 2001-2013 found that of 541,090 (99.5%) individuals, 54.8% were men and 17.5% were aged 60 years or older 12 .In Ribeirão Preto, a municipal region in the state of São Paulo, a study found that of the 434 cases of leprosy in the period 2006-2013, there was a prevalence among men, with 60.83% of the total 13 .In Araçatuba, São Paulo, an endemic municipal region in Brazil, a greater distribution was found among women, with 228 (52.5%) of 434 cases examined in 2015.However, the difference was only 22 patients, with 206 (47.5%) cases among men, which represents a reasonable difference.In terms of age group, 114 (26.3%) patients were 60 years of age or older 14 .
This situation can be seen as a reflection of years of neglect of human health among men, who have become accustomed to not using health services and, consequently, have become more vulnerable to some diseases, especially serious and chronic illnesses.It was from this perspective that the Ministry of Health launched the National Policy for Integral Care for Men's Health in 2009, with the objective of encouraging health promotion actions aimed at this population 15 .Although leprosy can affect both genders, a reluctance to seek health care and being less concerned with the health-disease process, combined with an illness with chronic characteristics and transmission through intimate and prolonged contact, may combine to cause a prevalence of cases among this gender, contributing to an increased risk of illness 16 .
The sociodemographic data of the state of Alagoas is in keeping with the global reality regarding the process of population aging and the reduction of the fertility rate.Most of the population is made up of women, who have a life expectancy ten years greater than men.The gender ratio in the year 2015 was 91.7; while in the northeast of Brazil it was 93.8 and in the country as a whole it was 94.3.Of the municipal regions of the state, 58 out of 102 are classified as extremely poor, and the population of 12 municipal regions live in so-called 'subnormal communities', with a monthly income of between ¼ and ½ minimum wage 17,18 .
In 2015 the illiteracy rate in the state was 20.0; while in the northeast it was 16.0 and in Brazil it was 8.0.This demonstrates the extent to which the state trails the national average in literacy and reflects the epidemiological indicators of the population.The unemployment rate is also above the average for the northeast and for Brazil, with a value of 15.3 for Alagoas; 10.3 for the northeast and 9.6 for the country as a whole 18 .
Health indicators based on the variables of ethnicity/skin color in cases of leprosy in Brazil reveal that the disease dominates among the black/ brown population, with 31,064 new cases detected in 2014.Of these, 21,554 cases occurred among the black population.Therefore, the Ministry of Health recommends a temporal study on this variable and the disease to understand distribution among this population group 4 .
In view of this, the present study does not contradict reality, as the occurrence of the disease was concentrated among illiterate individuals without a source of income and mixed-race individuals.As a public health problem, leprosy is strongly related to social context, reflecting the determinants and conditions of health to which the individual is submitted, which contributes significantly to an increased risk of illness, in addition to adding to the stigma and neglect of the disease, also linked to social conditions, making it difficult to tackle this public health problem 19 .
In general, leprosy can be classed as BP, which includes the indeterminate and tuberculoid clinical forms; and MB, which are the dimorphic and Virchowian forms.The operational classification is based on the number of dermatological lesions, with PB cases containing up to five lesions and MB cases having more than five lesions 20 .
The present study found a predominance of the dimorphic clinical form and, consequently, of multibacillary cases, with more than five dermatological lesions.In terms of smear microscopy, the number of ignored and unrealized cases stands out.An epidemiological study carried out in Fortaleza, Ceará, between 2007 and 2011, obtained the same findings as the present study.The prevalent clinical form was dimorphic (48.0%), followed by tuberculoid (31.4%).MB cases accounted for more than half of the cases (65.4%); while in Fortaleza smear microscopies were not performed in only 1.7% of cases 21 .Data were similar to a study from the African continent conducted between 2005-2013, since the dimorphic clinical form and the MB operational classification prevailed, in addition to more than five tegumentary lesions 22 .
Deformities and physical disabilities are the main problems of the disease, generating physical and psychological harm, linked to a feeling of exclusion, stigma and prejudice that damages the health of the individual, as well as impairing the productive and financial development of the patient and affecting their family members 23 .
As for the grade of disability, there was a great concentration of 'not assessed' and 'ignored' answers in the diagnosis, along with an increase in this situation upon discharge.This reveals the negligence of health professionals with respect to their patients, since evaluation assists prevention and planning for the promotion and continuity of health care 24 .
The problem of incomplete data has been identified in other studies, which offer strategies to minimize the situation and strengthen epidemiological surveillance: the technical training of health teams working in health services where the incidence of the disease and underreported or incomplete data of cases is most exxpressive 25 , and the allocation of people with training in health surveillance to collaborate in the investigation and follow-up of cases 26 .

CONCLUSION
It was found that an evaluation of physical disabilities caused by leprosy was carried out at diagnosis, there was a high proportion of cases with a grade 1 or II disability at the time of diagnosis, as well as a prevalence of multibacillary patients, indicating the need for improved early detection.There was a notable frequency of 'not evaluated' and 'ignored' physical disability, indicating that priority should be given to improving the notifications regarding such patients and investigating the difficulties faced by health professionals when registering such information.
Adequate and effective treatment against leprosy exists, but the required coverage of health services must be maintained, eliminating this pathology through a reduction in prevalence.Likewise, the disease can have negative implications in the lives of the elderly, with risks and harm for the social life of the individual.
It is important to understand the situation of the elderly population with leprosy in terms of their sociodemographic data.In this way, interventions to support recovery from leprosy, a disease with serious consequences if not treated early, can be made.National and international data on this theme are scarce.The present study provides information on the epidemiological profile of the elderly in Alagoas, contributing to the knowledge of the scientific community.
In conclusion, it is important to recognize the health situation of elderly persons who are carriers and ex-carriers of leprosy in the state of Alagoas, as knowing the epidemiology of the disease in this group allows the key components of health care to be identified, with the aim of minimizing the chances of the disease worsening.
In a study conducted in Aracaju, capital of the state of Sergipe, with 2,358 patients, a predominance of grade zero (1,692 -71.8%) disability was observed.A cross-sectional study conducted in Fortaleza from November to December 2010 with a sample of 51 patients obtained some sociodemographic data similar to Alagoas.In terms of disability, 25 (49.1%)patients with grade I or II disability were identified, while 14 (27.5%);11 (21.6%) and 26 (51.0%) of clients had grade zero disability 27 .According to the Ministry of Health, grade zero disability at the time of diagnosis is a national trend, revealing the importance of early diagnosis of notified cases as a leprosy control strategy 4 .
Neural impairment arises because the Hansen bacillus has a predilection for the peripheral nerves.It is therefore imperative that health professionals perform a neurofunctional evaluation, both at the time of diagnosis, halfway through treatment and at discharge, to investigate possible neurological disorders and allowing them to be treated quickly, aimed at the prevention of harm 28 .
A considerable portion of the patients in the present study were not assessed at the time of diagnosis.This fact is even more serious when it comes to the elderly, as more than half of those investigated were MB, which can result in possible neural damage in patients who are already at risk of functional deficit.
The detection rate represents new cases per 100,000 inhabitants over a certain period 29 .In 2014, 213,899 patients were diagnosed globally, with 94% of this total concentrated in 13 countries, among which Brazil ranked second.In the elderly population in Alagoas, the detection rate of the study was above 20 per 100,000 inhabitants, with an average of 29.48, considered hyperendemic according to the parameters of the Ministry of Health.

Graph 2 .
Temporal trend of the detection rate of leprosy cases among the elderly (N=896).

Table 2 .
Clinical characteristics of elderly persons diagnosed with leprosy (N=896).
Graph 1. Proportion of cases of leprosy in elderly persons according to operational classification (N=896).