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Print version ISSN 0365-0596On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.79 no.4 Rio de Janeiro July/Aug. 2004
CLINICAL, LABORATORY AND THERAPEUTIC INVESTIGATION
Epidemiologic aspects of leprosy in the city of Recife, Pernambuco state, 2002*
Sylvia Lemos HinrichsenI; Millena Raphaella Silva PinheiroII; Moacir Batista JucáII; Hévila RolimII; Guilherme José da Nóbrega DandaII; Diana Maria R. DandaII
IAdjunct Professor, Department of
Infectious and Parasitic Diseases (IPD), Health Science Center, Federal University
of Pernambuco State (UFPE). Coordinator of the Teaching, Research and Assistance
Task Force in Infectology (NEPAI), Hospital das Clinicas (HC/UFPE). Professor,
Therapy Department, Health Sciences Faculty, University of Pernambuco (UPE)
IIResearch Assistant, NEPAI, Hospital das Clínicas/UFPE
BACKGROUND: As a problem of Public Health
in Brazil, leprosy is still important due mainly to its high endemicity.
OBJECTIVES: Determine the main characteristics of this disease in the city of Recife, Pernambuco state (PE), in 2002.
METHODS: Based on data acquired from a questionnaire completed by patients, a retrospective study was carried out to analyze 100 handbooks of patients attended to in a reference center of Recife in 2002. A data base was elaborated and EPI-INFO-6 software was used for the analysis. Simple variable frequencies were obtained and a bi-varied analysis was made by studying ratio differences by means of chi-square. The cut off point was p<0.05.
RESULTS: An increase of leprosy was observed to occur with age (7.0% of cases in children and adolescents and 11.0% in adults over 65 years of age), (p<0.001). Distribution per sex showed significant differences (male 57.0%, female 43.0%), (p<0.001). The tuberculoid form had the highest prevalence in all of the age ranges studied, with 42.0% of cases (p<0.001), and its incidence was highest in females, while borderline cases predominated in males (x2=18.83; p<0.001). The paucibacillary forms (tuberculoid and indeterminate) showed only one lesion or two-to-five lesions in 55.4% and 37.5% of the cases, respectively (x2=37.04; p<0.001).
CONCLUSIONS: It was possible to demonstrate that Recife is still an endemic region due to a high incidence of the tuberculoid form, i.e. the epidemiological pointer suggestive of increased endemic diseases in the region. Only with the diagnosis and early treatment of the cases can the transmission of the illness chain be broken.
Key words: Leprosy, Mycobacterium leprae, epidemiology.
Leprosy is a chronic and curable infectious and contagious disease caused by the Hansen bacillus. It is highly infectious, but has low pathogenicity. Its immunogenic power is responsible for the disease's high incapacitating potential.1
According to Bechelli,2 the geographic distribution of leprosy would be greater where standards of living were lower. The latter are regions in which leprosy is also more endemic. In virtue of its chronicity and low lethality, endemic expansion has persisted for a long time in several regions and is characterized by non-uniform distribution. This makes epidemiologic control quite difficult.3,4,5
Given the polymorphic feature of the disease, the expression of its clinical manifestations reflects the relation between the host and the parasite. In individuals who take ill, according to the specific immunologic response to the bacillus, the infection progresses in various ways. Immune response makes up a spectrum expressing its different clinical forms.6
Its indeterminate form is often seen in regions of the world where the disease is endemic or hyperendemic.7 Almeida Neto8 referred to indeterminate forms as possibly translating the disease's initial and transitory stages. It is usually found in children whose immune response is not defined with respect to the bacillus.9
Tuberculoid leprosy affects healthy individuals. The predominance of this form in a region is an important epidemiological pointer of the growing tendencies of the disease. On the other hand, virchowian leprosy corresponds to a low resistance pole within the disease spectrum characterized by the chronic nature of its progression. Indeed, the unstable character of borderline leprosy expresses clinical alterations that range from lesions similar to those found in the virchowian pole to those present in the tuberculoid pole. The amount of lesions existing in such cases is variable.10
According to Bosq, Cordero and Maldonado,11 nodular infantile leprosy (NIL) appears to correspond to a variety of the tuberculoid type. It exclusively appears during infancy and affects children younger than five years in age. It is considered the most benign of all forms of the disease.12 The pure neural form affects less than 1% of leprosy patients.3
Brazil is a country considered to have high endemicity as it has a prevalence rate greater than 1:10,000 inhabitants.3,12,13,14 It is first in the world ranking for the number of new cases detected and holds second place for absolute number of cases.15,16 The distribution of cases occurs irregularly over Brazil's territory, which is characterized by large urban concentrations.13,17
In Pernambuco state, leprosy has acquired preoccupying proportions. Since the end of the last decade, more than 2,500 new cases of the disease have been detected per year. This is characteristic of high endemicity and shows a net expansion of the disease.18 The statewide distribution of the endemic does not show a homogenous form, which is quite characteristic of what is happening in the country overall. The greatest concentration occurs in large urban centers, but specifically on its outskirts.18 In 1996, the proportion of tuberculoid form cases in relation to indeterminate, borderline and virchowian forms corresponded to 66.3%, thereby indicating a growing endemic tendency in the region.18
Hence, with the object of studying this disease, the present paper seeks to determine the epidemiological aspects of the disease in the city of Recife, Pernambuco state (PE) during 2002.
A retrospective observational study was carried out analyzing 100 patient handbooks, consisting of adults and children, who sought care at the Joaquim Cavalcanti Health Center. The patients all showed the signs and symptoms leading to a diagnostic impression of leprosy. They were submitted to clinical and bacilloscopic lesion analysis for a period of 12 months. To have access to the number of patient handbooks the medical registries of existing cases of leprosy were consulted.
Data obtained from patients filling out a specific questionnaire with information contained in the patient handbooks of the Joaquim Cavalcanti Health Center were collected. At the moment, these are the Single Health System (SUS) benchmark for treating such patients. The SUS is under the administration of the Pernambuco State Secretary of Health, and attends to some 30 leprosy patients per day, including new patients and those in therapeutic follow up.
A pre-established protocol was used for collecting information. It was elaborated according to the objectives set out by the study. Data was collected from the medical handbooks, and complemented when necessary with data from the State Secretary of Health (FUSAM) notification forms. The data base was set up by means of the EPI Info program (Version 6) and by employing the following software: Word for Windows (Version 7.0) as a word processor and for elaborating the tables and charts.
All results were statistically analyzed, which ensured a 95% reliability margin. Tests were applied according to the sample and objectives proposed.
The analysis considered 100 new cases of leprosy notified during the 12-month period to the Pernambuco State Secretary of Health.
As for distribution of cases by age range, the frequency of cases was observed to increase with age. Only 7% of cases (n=7) occurred in children, whereas 11% of cases (n=11) occurred in patients aged 65 years and older (Table 1).
The distribution of cases per sex showed significant differences, with 43 (43%) patients female and 57 (57%) male (p< 0.001).
When the sex ratio variable was analyzed according to age range, it was made clear that in lower age cases, i.e. zero-to-11 and 12-17 years of age, there was a predominance in males, with 71.4% and 55.6%, respectively, as illustrated in table 1. Yet this difference between sexes was not statistically significant (x2 = 2.68; p = 0.61).
In accordance with the clinical classification utilized, the cases were distributed in table 2 to reveal that only 13% (n=13) were virchowian and 42 (42%) showed a tuberculoid form.
When the clinical forms were analyzed according to age range, one could observe that for tuberculoid and virchowian forms, the number of cases was in a direct relation with age, except for the 65-99 year age group (Table 2).
The analysis of the cases according to the sex ratio and clinical form variables revealed that in females the tuberculoid form prevailed, which was followed by the borderline form. Meanwhile in males, the borderline form was the most frequent, with the tuberculoid form appearing in second place (Table 3). These differences in clinical form per sex were statistically significant (x2 = 18.83; p<0.001).
With respect to the amount of lesions and their clinical form, lesions were grouped together in paucibacillary (T and I) and multibacillary forms (V and B). The paucibacillary forms showed one lesion or lesions varying from two to five in number in 55.4% and 37.5%, respectively. Multibacillary forms with more than five lesions accounted for 40.9% of cases (Table 4). These differences were statistically significant (x2 = 37.04; p< 0.001).
In the patient handbooks studied, the degree of patient incapacity were recorded and assessed. Five cases (5%) were observed with some degree of incapacity (3% with degree I incapacity and 2% degree II, p<0.001). There were no cases of incapacity degree III found. And there was no record of cases with affection of the larynx, nasal collapse or facial paralysis.
Regarding clinical form, the forms determining degree I incapacities (n=3) were borderline (n=2, 66.7%) and virchowian (n-1, 33.3%). The cases presenting with degree II incapacity (n=2) were borderline (n=2, 100%) (p=0.31). All of the patients (100%) were assessed regarding incapacity at the beginning of treatment. By contrast, the patients cannot be said to have fully been diagnosed since all the cranial and peripheral nerves were not assessed.
As for bacilloscopy, all patients (100%) underwent the examination. In assessing the results of the bacilloscopy in relation to clinical forms, it was observed that among the patients with negative bacilloscopy, most showed the tuberculoid form (75%). The majority of patients with positive bacilloscopy carried the borderline and virchowian types (68.2% and 29.5%, respectively). (Table 5).
Analysis of the results obtained with respect to histopathology revealed that in 14 cases (14%), patients were registered as having undergone this procedure.
With respect to patient regularity with treatment, the majority (91%) assiduously showed up at the service. The amount of cases with irregular treatment was 9%.
As already described in the literature, leprosy affects children in a lower proportion than adults.19,20,21 As with all diseases with a long incubation period, cases tend to increase with age.22 Data related to low disease frequency in minors under the age of 17, increased number of cases in the 35-64 year age group (39%), followed by those aged 18 to 34 years (34%), and the smallest number being found in those aged 65 years and above, all match the existing literature.23
Various authors have reported that regarding the sex-based characteristics of leprosy, males predominate in all age groups.19,24-28 Nevertheless, when patients are distributed according to age, the sex ratio balanced out in the 18-to-34 year group. For Igens & Skjaerven,29 cultural and sociological characteristics might explain the sex-based differences of the disease.
According to Bechelli, Dominguez & Patwary,30 there seems to exist a strong correlation between clinical form and age. During infancy, there was a predominance of tuberculosis and borderline forms, followed by the indeterminate form. These data matched the results found in the literature consulted.30,31,32 The frequency of virchowian and tuberculoid forms increased with age.30,31 In the present investigation, a predominance of tuberculoid forms was observed (42%). What is worth mentioning is that there were no cases of infantile nodular leprosy specified in the handbooks. Most likely, they were referred to as merely tuberculoid.
When analyzing the 100 cases included in this study for clinical form and sex ratio variables, statistically significant differences were confirmed to exist (x2 = 18.83; p<0.001). In the virchowian and borderline forms male patients predominated (V = 21.1%, D = 43.9%) over female patients (V = 2.3% and D = 25%). In tuberculoid forms, the highest number of cases corresponded to females, which was compatible with the study made by Livorato et al.32
Lesion quantity usually reflects an organism's resistance to the bacillus. It is inversely proportional to the number of lesions and body area affected. In that regard, the less resistance found, the higher the number of lesions. Given that most cases studied are tuberculoid in form and still show high resistance, a higher number of patients with one lesion (34%) or with variations of two to five lesions (44%) were observed.
The analysis of lesion numbers with respect to clinical forms established two groups, namely paucibacillary (T and I) and multibacillary (V and B). The difference between the two groups is significant (x2 = 37.04; p<0.001). Paucibacillary cases present one lesion or vary from two to five lesions in 55.4% and 37.5% of cases, respectively. By contrast, the multi-bacilliferous cases, considered for the most part as having low resistance (40.9%), revealed more than five lesions.
In relation to clinical form, those most presenting with reactions were borderline (66.7%) and virchowian (33.3%). This data is compatible with the literature.3,6,33
The observation that only five patients (5%) had some degree of incapacity (3% with degree I, 2% with degree II, p<0.001) might reflect inadequate practice in assessing these parameters. Indeed, when the handbooks were analyzed, it was already noted how their assessment was not complete, often failing to assess several pairs of cranial and peripheral nerves.
When correlating the bacilloscopy results obtained from the survey on clinical form, the tuberculoid and indeterminate forms proved to correspond to 75% and 14.3% of the negative bacilloscopies, respectively. The virchowian and borderline forms corresponded to 29.5% and 68.2% of the positive bacilloscopies. The six borderline patients with negative bacilloscopies were classified in the handbooks as paucibacillary and subjected to treatment with paucibacillary polychemotherapy. This went counter to the Ministry of Health's standards seeing that from the operational point of view a borderline patient may have negative bacilloscopy and even then be multibacillary. This is why the patient must then be subjected to multibacillary polychemotherapy.35
Maintaining the regularity of specific treatment is fundamental for its outcome. The patient is said to be "faulty" when not taking the monthly treatment within the supervised two week period.35 The evaluation of the regularity of leprosy patients submitted to polychemotherapy revealed that the majority (91%) showed up at the service assiduously. It is still important to remind patients and their families on the importance of maintaining the treatment's regularity, which alone can improve therapeutic adhesion.
Based on the results obtained from the study framework, the group can be concluded to have shown the following:
· the highest prevalence of leprosy was tuberculosis, accounting for 42% of cases (n=42), (p<0.001), although its endemicity is evidence of the disease's spreading;
· the frequency of leprosy cases increased with age (p<0.001) and distribution per sex showed a significant difference (male 57%, female 43%), (p<0.001);
· the form to have highest incidence in females was tuberculoid, while in males the borderline form prevailed (x2 = 18.83; p<0.001);
· paucibacillary forms presented with one lesion or a variation of two to five lesions in 55.4% and 37.5%, respectively, while multibacillary forms presented with more than five lesions in 40.9% of cases (x2 = 37.04; p<0.001);
· among paucibacillary patients, most presented with the tuberculoid form (75%), while most multibacillary patients were carriers of borderline and virchowian forms (68.2% and 29.5%, respectively) (x2 = 76.10, p<0.001);
· most patients (91%) assiduously appeared at the service (p<0.001);
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Sylvia Lemos Hinrichsen
Rua Jornalista Guerra de Holanda, 158/2601
52061-060 Casa Forte Recife PE
Tel./Fax: (81) 3268-9905
Received on September 18, 2003.
Approved by the Consultive Council and accepted for publication in March 12, 2004.
* Work carried out by the Teaching, Research and Assistance Task Force in Infectology (NEPAI) at the Hospital das Clínicas of Pernambuco Federal University.