Recurrence of leprosy cases in the State of Mato Grosso, Central-West Brazil

Abstracts

OBJETIVO: Comparar as novas entradas por recidiva de hanseníase em unidades básicas de saúde (UBS) e em unidades especializadas (UE) no estado de Mato Grosso. MÉTODOS: Estudo transversal com base em todos os registros (N = 323) de recidivas de hanseníase do Sistema de Informação de Agravos de Notificação (Sinan) de 2004 a 2006, notificados no estado de Mato Grosso. Os casos diagnosticados foram comparados quanto ao sexo, idade, aspectos clínico-laboratoriais e distribuição geográfica nos municípios. Para a comparação e cálculo das proporções das variáveis utilizou-se o teste qui-quadrado ao nível de significância de 5%. RESULTADOS: Das novas entradas de recidiva, 20% foi confirmado nas UE e 80% em UBS; entretanto, a maioria dos diagnósticos em UBS tinham baciloscopia negativa (÷² =12,34; p = 0,002). O sexo masculino atingiu 71%, com idade média de 43 anos. Não foi observada diferença nos percentuais das entradas entre as unidades de saúde segundo forma clínica, classificação operacional e grau de incapacidade física. Do total de municípios do estado, 64,7% apresentou recidiva, com percentual entre 6% e 20% de todas as entradas. CONCLUSÕES: As novas entradas de casos de recidiva em Mato Grosso são influenciadas pelos diagnósticos feitos em UBS, sugerindo que há deficiência na rede de serviços de saúde em reconhecer casos de recidiva.

Hanseníase; Recidiva; Notificação de Doenças; Estudos Transversais

ORIGINAL ARTICLES

Recurrence of leprosy cases in the State of Mato Grosso, Central-West Brazil

Recurrencia de casos de hanseníasis en el estado de Mato Grosso, Centro-Oeste de Brasil, 2004-2006

Silvana Margarida Benevides Ferreira^{I, II}; Eliane Ignotti^III; Ligia Maria Senigalia^IV; Diego Ricardo Xavier Silva^V; Mônica Antar Gamba^VI

^IFaculdade de Enfermagem. Universidade de Cuiabá. Cuiabá, MT, Brasil

^IISecretaria Municipal de Saúde de Cuiabá. Cuiabá, MT, Brasil

^IIIDepartamento de Enfermagem. Universidade do Estado de Mato Grosso. Cáceres, MT, Brasil

^IVHospital Jardim Cuiabá. Cuiabá, MT, Brasil

^VInstituto de Comunicação e Informação Científica e Tecnológica em Saúde. Fundação Oswaldo Cruz. Rio de Janeiro, RJ, Brasil

^VIEscola Paulista de Enfermagem. Universidade Federal de São Paulo. São Paulo, SP, Brasil

^{Correspondence}

ABSTRACT

OBJECTIVE: To compare new registrations of recurrences of leprosy cases in primary healthcare units (PHUs) and in specialized units in the State of Mato Grosso.

METHODS: This was a cross-sectional study based on all new registrations (N = 323) of recurrences of leprosy cases within the Notifiable Disease Information System (SINAN) between 2004 and 2006 that were made in the State of Mato Grosso, Central-West Brazil. The cases diagnosed were compared regarding sex, age, clinical-laboratory characteristics and geographical distribution among the municipalities. To compare and calculate the proportions of the variables, the chi-square test at the significance level of 5% was used.

RESULTS: Among the new registrations of recurrences, 20% were confirmed at specialized units and 80% at PHUs. However, most of the diagnoses at PHUs presented negative bacilloscopy findings (c2 = 12.34; p = 0.002). Seventy-one per cent of the cases were among males; the mean age was 43 years. No differences in the percentages of registrations were observed between the healthcare units with regard to clinical form, operational classification or degree of physical incapacity. Out of the total number of municipalities in the state, 64.7% presented recurrences and these accounted for 6 to 20% of all registrations.

CONCLUSIONS: The new registrations of cases of recurrence in Mato Grosso were influenced by the diagnoses made at PHUs, thus suggesting that there is a deficiency within the healthcare services in recognizing cases of recurrence.

Descriptors: Leprosy, epidemiology. Recurrence, prevention & control. Disease Notification. Cross-Sectional Studies.

RESUMEN

OBJETIVO: Comparar las nuevas entradas por recurrencia de hanseníasis en unidades básicas de salud (UBS) y en unidades especializadas (UE) en el estado de Mato Grosso, en Centro-Oeste de Brasil.

MÉTODOS: Estudio transversal con base en todos los registros (N=323) de recurrencias de hanseníasis del Sistema de Información de Agravios de Notificación (SINAN) de 2004 a 2006, notificados en el estado de Mato Grosso. Los casos diagnosticados fueron comparados con relación a sexo, edad, aspectos clínicos-laboratoriales y distribución geográfica en los municipios. Para la comparación y cálculo de las proporciones de las variables se utilizó la prueba de Chi-cuadrado con nivel de significancia de 5%.

RESULTADOS: De las nuevas entradas de recurrencia, 20% fueron confirmadas en las UE y 80% en UBS; mientras que la mayoría de los diagnósticos en UBS tenían baciloscopia negativa (c2 =12,34; p = 0,002). 71% eran del sexo masculino con edad promedio de 43 años. No fue observada diferencia en los porcentajes de las entradas entre las unidades de salud según forma clínica, clasificación operacional y grado de incapacidad física. Del total de municipios del estado, 64,7% presentaron recurrencias, con porcentaje entre 6% y 20% de todas las entradas.

CONCLUSIONES: Las nuevas entradas de casos de recurrencia en Mato Grosso son influenciadas por los diagnósticos hechos en UBS, sugiriendo una deficiencia en la red de servicios de salud en reconocer casos de recurrencia.

Descriptores: Lepra, epidemiología. Recurrencia, prevención & control. Notificación de Enfermedades. Estudios Transversales.

INTRODUCTION

Leprosy control began at the end of the 1940s,⁴ with the introduction of sulfones to treat the disease. After some time, given the inefficiency of this therapy, studies on resistance to sulfone monotherapy began.⁸ The existence of this resistance was proven experimentally by Pettit & Rees in 1964,¹⁵ by means of the technique of inoculation of Mycobacterium leprae, as standardized by Shepard.¹⁷ From the 1980s onwards, the World Health Organization (WHO) started to recommend the use of polychemotherapy regimens. This has resulted in treatment and cure for more than 11 million leprosy patients.^ª Polychemotherapy has been decisive in shortening the duration of treatments, thereby leading to an inversion in the flow of cases coming into and leaving the registers of active leprosy cases and a decline in the coefficient of prevalence in most endemic countries.^b

However, after discharge from polychemotherapy, some leprosy cases may present intercurrences of the disease, either because of states of leprosy reaction or because of recurrences.^3,20,21,c

Recurrences are the most important indicator of treatment effectiveness,^ª even if leprosy recurrences may be caused by strains that are monoresistant or multiresistant to chemotherapy.^4,7,12,13,15

According to the Brazilian Ministry of Health,^d the clinical criteria for diagnosing recurrence should be based on the operational classification, when the possibility of a reaction state has been ruled out. Paucibacillary patients are considered to be cases of recurrence when, after discharge because cure was achieved, they present impaired neural function, new areas with abnormal sensitivity, new lesions and/or exacerbation of previous lesions that do not respond to corticosteroid treatment within a 90-day period. For multibacillary patients, it is when they present the same dermatological-neurological abnormalities as described for paucibacillary patients, with the addition of results from bacilloscopic and/or histopathological examinations that are compatible with the active forms of the disease, and when they do not respond to treatment with corticosteroids and/or thalidomide. Confirmation of such recurrence should be discussed with specialists at reference centers, according to the criteria for diagnostic suspicion and confirmation.^c

At the start of 2007, there were 2,270 cases of recurrence around the world, of which 1,584 (69.8%) were registered in Brazil.^b According to the Brazilian Ministry of Health, the cumulative risk of recurrence after polychemotherapy was adopted was 0.7% for cases subjected to a multibacillary regimen and 1.1% for paucibacillary cases.^e

Furthermore, there are important differences in the records of recurrence in Brazilian regions where there is high prevalence of the disease, such as the borders of the Statutory Amazon Region. The states of Mato Grosso, Acre, Amazonas, São Paulo, Paraná and Santa Catarina register the highest rates in Brazil: between 4% and 8% of the cases of recurrence among all the registrations in 2006.^f

Studies that identify factors relating to recurrence are essential for better accuracy to be obtained in relation to the clinical, epidemiological and therapeutic diagnoses, thereby avoiding increased morbidity, persistence of bacteria, resistance to medications and physical incapacity. Through these high numbers of recorded cases of recurrence in Mato Grosso, the present study had the objective of comparing the records of leprosy cases diagnosed at primary healthcare units and specialized units in the state of Mato Grosso.

METHODS

This was a cross-sectional study using the registrations caused by leprosy recurrence that were notified in the state of Mato Grosso, Central-West Brazil, between 2004 and 2006. These were obtained from the notifiable diseases information system (SINAN/MT). The cases selected were patients living in the municipalities of Cuiabá, Cáceres, Diamantino, Rondonópolis or Várzea Grande, between 2004 and 2006. These municipalities were selected because they had diagnostic and leprosy study support units: polyclinics, medical specialty centers and the medium and high complexity reference center (CERMAC). These municipalities have 1,032,523 inhabitants, i.e. 36.2% of the total population of the state, which is estimated to be 2,854,462 inhabitants.^g The comparative analysis included the cases diagnosed as recurrence at specialized units, the individuals living in the five municipalities selected and those diagnosed in primary healthcare units in the other municipalities of the state. The cases were compared with regard to sex, age, clinical-laboratory characteristics and geographical distribution among the municipalities of the state.

All registrations of recurrence (n = 344) were included according to the municipality of residence. From this total, 21 registrations were excluded because of diagnostic error, double data entries and transfers to other states, and thus 323 cases registered over the study period were evaluated. To validate the data relating to the three cases of double data entry, the treatment units were consulted. For this study, the diagnostic unit and its municipality were used. In selecting the cases of recurrence, the date and year of diagnosis were used. In most cases, these coincided with the date and year of treatment. When there was disagreement or failure to fill in the date and year field in the medical records, it was sought to validate the data by means of the annotations in the medical files. The cases were classified according to the operational classification (paucibacillary or multibacillary), which was obtained through confirmation of the diagnosis of recurrence that was made at the diagnostic unit. No registrations of recurrence that presented changes in operational classification after the start of the retreatment were observed.

The following variables were selected for analysis: sex, age, municipality of residence, clinical form, operational classification, degree of physical incapacity evaluated at the start of the treatment and bacilloscopy at the time of diagnosing the recurrence.

The indicator of the percentage of leprosy recurrence corresponded to the percentage of registrations of recurrence. This was defined as the number of recurrences during the years investigated, divided by all the registrations for leprosy treatment during the same year, multiplied by 100. For the denominator, the registrations with diagnostic error, double data entries and transfers to other states were also removed. The percentage recurrence was calculated for all the municipalities, taking into consideration the operational classification of the set of registrations for each locality.

The municipalities were aggregated according to the type of healthcare unit, in order to compare the clinical-laboratory criteria used in the units for diagnosing the recurrence.

To compare the total numbers of cases of recurrence between the primary healthcare units (PHU) and the specialized units (SU), according to the operational classification, the ratio of the percentages of cases of recurrence [(PHU/SU)-1)*100] was calculated using an electronic spreadsheet.

To compare and calculate the proportions according to the relative frequencies of the variables, the chi-square test was used in Epi-Info, version 3.2.1. The geographical distribution of the records of percentage recurrence was performed by means of the Terraview software, version 3.2.0.

The present project was evaluated and approved by the Research Ethics Committee of the Hospital Universitário Júlio Muller (CEP/HUJM - procedural number 321), in April 2007.

RESULTS

The 323 cases of recurrence of leprosy registered in Mato Grosso between 2004 and 2006 represented a mean of 107.6 cases/year.

Table 1 presents a comparison of percentages of registrations due to recurrence that were diagnosed in the primary healthcare units and specialized units, according to the variables of sex, age, clinical form, operational classification and degree of physical incapacity at diagnosis. No statistically significant difference in percentages was seen between the healthcare units according to sex. The majority (71%, n = 229) of the patients with recurrence were male; the mean age was 42.6 years (SD = 15.8; minimum 12 years and maximum 84 years). The five children with recurrence were diagnosed in primary healthcare units. The municipality of Cuiabá presented the highest percentage (13%; n = 43). Out of all the records of recurrence, 20.1% were diagnosed in specialized units and 79.9% in primary healthcare units. In general, the dimorphous form accounted for 48% (n = 156) of the registrations; 82% (n = 266) were multibacillary and 56% (n = 182) did not have any physical incapacity. There were no differences in the percentages of registrations between the units according to the clinical form, operational classification or degree of physical incapacity.

There was a statistically significant difference in the percentage of cases of recurrence between the diagnostic units, according to the bacilloscopy results [c² = 5.86 (p = 0.053)] (Table 2). Among the cases of multibacillary recurrence, 37% (n = 76) were diagnosed with a negative bacilloscopy result in primary healthcare units [c² = 12.34 (p = 0.002)].

In Table 3, it can be seen that the difference in the percentages of diagnoses of recurrence among all the registrations for leprosy treatment, between those at primary healthcare units and those at specialized units was 116%. For the category of cases of paucibacillary recurrence, this difference reached 150%.

The Figure presents the geographical distribution of registrations of cases of leprosy recurrence according to municipality of residence, in the categories of total number of cases of recurrence (A), cases of multibacillary recurrence (B) and cases of paucibacillary recurrence (C). Out of the 141 municipalities in Mato Grosso, 139 presented notifications of leprosy cases. Among this total, 64.7% (n = 90) registered cases of recurrence, among which 14% (n = 13) presented more than five cases, with percentages of 6% to 20% of all the registrations. Multibacillary cases accounted for most of the registrations and there was no difference in this respect between geographical areas of the state. Total of more than five paucibacillary cases were registered in the municipalities of Cuiabá and Araputanga.

DISCUSSION

The results obtained showed that a larger percentage of the registrations of recurrence were diagnosed at primary healthcare units. Most of these cases were confirmed, even if the bacilloscopy results were negative. Such results suggest that there were deficiencies relating to operational factors, including the capacity of the healthcare service network to diagnose cases of recurrence.

According to the Brazilian Ministry of Health (2006),^h the criteria for certifying healthcare units as reference centers for leprosy include: a multidisciplinary team with up-to-date training for healthcare relating to leprosy; provision of healthcare at specialized level, to clarify diagnoses, recurrences and intercurrences relating to episodes of reaction and neural lesions of leprosy, among others.

The patients diagnosed in Mato Grosso presented epidemiological characteristics similar to those of patients undergoing treatment in Brazilian cities in other states.² The cases were predominantly among males, at economically productive ages, and in the multibacillary form.

Occurrences of cases among children are an important epidemiological indicator, and analysis of such cases broadens the discussion regarding operational problems within the healthcare network.^1,10 The records of cases of recurrence at primary healthcare units among the present study population corroborate this reflection, because of difficulty in differential approaches in relation to other dermatological or neurological diseases and difficulty in diagnostic management for confirming the case of recurrence.

The importance of these results justifies the recommendation to follow a protocol for diagnostic actions and follow-up of cases of recurrence in specialized units, with implementation of laboratory support and quality control on the specific tests.^3,c

Through the introduction of the basic operational standards (1996),ⁱ it was envisaged that patients' access to basic and specialized healthcare services would be improved. In Mato Grosso, specialized attendance for leprosy is concentrated in municipalities with medium and large-sized populations (Cuiabá, Cáceres, Rondonópolis and Várzea Grande). In the remaining municipalities in this state, access to diagnoses of greater accuracy for cases of recurrences is more difficult.

Among other factors, the weaknesses of primary healthcare units in terms of case resolution have been indicated as one of the problems for maintaining the strategy of changes to the care model,⁵ especially regarding the hierarchical flow for attendance. The lack of mechanisms for regulating the municipalities' responsibilities may explain the deficiency in the quality of care.¹⁴ Other studies^16,19 have indicated that there are higher percentages of recurrence among paucibacillary patients than among multibacillary patients, thus differing from the percentages found in this study (greater percentages for recurrence in the multibacillary cases). These results may suggest that healthcare professionals find it easier to confirm the diagnosis in multibacillary cases. Among the clinical forms, recurrences in multibacillary cases are mostly confirmed through a bacilloscopic index > 2 logs, in relation to the initial treatment, through histopathological examinations compatible with active forms of the disease, and through inoculation in a mouse's paw.^17-19,21 Although bacilloscopic index results were not analyzed in the present study, given that this indicator was not available within SINAN during the study period, the higher percentage of negative bacilloscopy results obtained at primary healthcare units also suggests that there is a greater likelihood of diagnostic errors in distinguishing between reactional states and recurrence.

Reactional states or leprosy reactions are reactions of the patient's immune system to M. leprae. The clinical signs, which are called inflammatory episodes, may affect both paucibacillary and multibacillary cases, and when they appear following chemotherapy, they may be confounded with cases of recurrence.^3,9,11,20

According to Ximenes et al (2007)²¹ and Shetty et al (2005),¹⁸ patients who present reactional episodes are more likely to be treated as cases of recurrence. This indicates that there is a need for greater attention to the differential diagnosis between these two conditions. Among paucibacillary patients, recurrence can be confounded with a late reverse reaction, considering that M. leprae cannot be isolated in these cases.⁹

According to Gallo & Oliveira,⁹ in addition to the difficulty of characterizing patients with recurrence, there is no consensus regarding established parameters that might guide healthcare services towards diagnostic confirmation. There is therefore a need to conduct studies that might direct healthcare professionals towards such confirmation, with greater precision.

The paucibacillary cases registered as recurrences in municipalities with populations of fewer than 20,000 inhabitants (Araputanga, Castanheira, Guiratinga, Nova Bandeirantes, Salto do Céu and Terra Nova do Norte) stood out. These municipalities had lower capacity for diagnosing cases of recurrence and did not have reference centers to ensure the accuracy of diagnoses.

The Brazilian National Health System (SUS)^j recommends that municipalities should organize primary healthcare service, while the State should impose standards, perform assessments, provide technical advice and reorganize the referral and counter-referral system.

Within this context, effective attendance for leprosy depends on improvement of the leprosy indicators agreed at managerial levels within SUS.^k

This study presents the limitations inherent to cross-sectional studies conducted using secondary data. It is known that healthcare professionals who are well-qualified in diagnosing and treating leprosy, with professional experience obtained because of the high prevalence of this disease, may be allocated to primary healthcare units in Mato Grosso, away from the state capital.⁶ However, the technological difficulties in meeting the diagnostic criteria for recurrence of leprosy at these units reduces the importance of the points made above regarding the limitations of the study, to some extent.

It is concluded that the numbers of new cases of recurrence registered in Mato Grosso are influenced by the diagnoses made in primary healthcare centers, thus suggesting that there are deficiencies within the healthcare services, with regard to recognizing cases of recurrence.

REFERENCES

Received: 10/26/2009

Approved: 12/18/2009

Study funded by the Research Support Foundation of the State of Mato Grosso (Fapemat; procedural number: PPSUS/275-10036).

Presented at the 11th Brazilian Congress of Leprosy Studies, in Porto Alegre, Southern Brazil, 2008.

The authors declare that there are not conflicts of interest.

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Publication Dates

• Publication in this collection
  26 July 2010
• Date of issue
  Aug 2010

History

• Received
  2009
• Accepted
  18 Dec 2009