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foi utilizado para registrar dados sociodemogr&#225;ficos&#44; informa&#231;&#245;es sobre o tempo de atraso do paciente e atraso do PSS de todos os participantes&#46; Todos os dados obtidos foram an&#244;nimos e analisados por meio do <span class="elsevierStyleItalic">software</span> STATA vers&#227;o 12&#46;0&#46; Porcentagens foram calculadas para vari&#225;veis discretas&#44; e a mediana foi calculada para vari&#225;veis cont&#237;nuas com intervalos interquartis&#46; As vari&#225;veis que se mostraram significativas na an&#225;lise bivariada foram submetidas &#224; regress&#227;o log&#237;stica multivariada com IC95&#37;&#59; valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 foi considerado estatisticamente significativo&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Havia menos homens &#40;67&#37;&#41; entre os casos do que nos controles &#40;76&#37;&#41;&#44; e havia mais mulheres nos casos &#40;33&#37;&#41; do que nos controles &#40;24&#37;&#41;&#46; As caracter&#237;sticas sociodemogr&#225;ficas e os tipos de hansen&#237;ase s&#227;o mostrados na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46; A mediana &#40;calculada em vez do atraso m&#233;dio do paciente em raz&#227;o da assimetria dos dados&#41; do tempo de atraso do paciente&#44; atraso do PSS e atraso total em meses s&#227;o apresentados na <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#46; Fatores de risco para a deformidade no momento do diagn&#243;stico da hansen&#237;ase e o registro entre as pessoas rec&#233;m&#8208;diagnosticadas com hansen&#237;ase s&#227;o apresentadas na <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A an&#225;lise detalhada de v&#225;rios fatores de intera&#231;&#227;o mostrou que eles podem ser categorizados como fatores relacionados ao paciente ou relacionados ao PSS&#46; Neste estudo&#44; o tempo de atraso mediano do paciente foi de 18 meses nos casos e oito meses nos controles&#46; Um estudo em um hospital terci&#225;rio em Andhra Pradesh relatou que 50&#44;5&#37; dos pacientes com hansen&#237;ase demoraram mais de seis meses antes de ir ao hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Um estudo em Chhattisgarh relatou que 32&#44;5&#37; dos pacientes com GD2&#47;GD1 tiveram um atraso de mais de 12 meses no diagn&#243;stico&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Entretanto&#44; o atraso relatado neste estudo &#233; maior do que o de outras regi&#245;es geogr&#225;ficas do pa&#237;s&#46; A n&#237;vel internacional&#44; Henry et al&#46;&#44; no Brasil&#44; relataram que 34&#44;4&#37; dos pacientes com hansen&#237;ase tiveram um atraso do paciente de menos de tr&#234;s meses&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> Um estudo chin&#234;s que observou casos notificados entre 2007 e 2017 relatou um atraso m&#233;dio e mediano do paciente de 30&#44;1 meses e seis meses&#44; respectivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Nosso estudo mostrou que o atraso de mais de tr&#234;s meses do paciente representa um risco significativo para o desenvolvimento de GD2&#47;GD1 entre novos pacientes com hansen&#237;ase em Andhra Pradesh&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Embora o atraso do paciente seja o principal contribuinte para o atraso geral&#44; o atraso do PSS n&#227;o pode ser ignorado&#46; O principal motivo atribu&#237;do ao atraso no atendimento &#224; sa&#250;de &#233; a falta de profissionais de sa&#250;de qualificados para diagnosticar a doen&#231;a&#46; Como a hansen&#237;ase foi eliminada como um problema de sa&#250;de p&#250;blica na maioria dos pa&#237;ses&#44; menos import&#226;ncia &#233; dada no curr&#237;culo m&#233;dico objetivando treinar profissionais de sa&#250;de para suspeitar de hansen&#237;ase&#44; e frequentemente a doen&#231;a &#233; diagnosticada incorretamente&#46; Na &#205;ndia&#44; os profissionais de sa&#250;de do sistema p&#250;blico de sa&#250;de foram melhores no diagn&#243;stico da hansen&#237;ase em compara&#231;&#227;o com profissionais da pr&#225;tica privada&#46; Isso &#233; bastante evidente no presente estudo&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Este estudo relatou que 46&#37; dos casos procuraram primeiro um provedor de sa&#250;de privado qualificado&#44; e 52&#37; dos controles procuraram primeiro atendimento no PSS p&#250;blico&#46; V&#225;rios fatores&#44; como <span class="elsevierStyleItalic">status</span> socioecon&#244;mico&#44; n&#237;vel de escolaridade&#44; acessibilidade etc&#46; influenciam o comportamento de busca por servi&#231;os de sa&#250;de e a decis&#227;o de procurar um provedor de servi&#231;os de sa&#250;de&#46; Relatamos que quando o entrevistado visitou qualquer provedor de sa&#250;de privado qualificado mais de duas vezes antes do diagn&#243;stico&#44; a chance de GD2&#47;GD1 foi duas vezes maior do que naqueles que visitaram menos vezes ou igual a duas vezes&#46; Isso mostra que um tempo significativo de atraso ocorre com v&#225;rias visitas ao setor privado&#44; e pode servir como indicador indireto para a oportunidade perdida de diagn&#243;stico pelo setor privado&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A principal limita&#231;&#227;o do presente estudo foi sua natureza retrospectiva&#46; Pode haver um &#8220;vi&#233;s de mem&#243;ria&#8221; introduzido at&#233; certo ponto neste estudo&#44; o que &#233; inevit&#225;vel em trabalhos de caso&#8208;controle&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Em conclus&#227;o&#44; o atraso do paciente &#233; um fator vital para a redu&#231;&#227;o das incapacidades entre os casos de hansen&#237;ase em adultos&#46; O grande tempo de atraso do paciente reflete que a comunidade n&#227;o est&#225; ciente dos sintomas e das consequ&#234;ncias da hansen&#237;ase&#59; reflete tamb&#233;m a efic&#225;cia das estrat&#233;gias de educa&#231;&#227;o e comunica&#231;&#227;o e dos mecanismos de detec&#231;&#227;o precoce de casos nos servi&#231;os p&#250;blicos de sa&#250;de&#46; Al&#233;m disso&#44; envolver o setor privado a fim de ter um sistema de refer&#234;ncia eficaz&#44; al&#233;m da redu&#231;&#227;o do atraso do paciente&#44; servir&#225; como complemento para uma estrat&#233;gia eficaz na detec&#231;&#227;o precoce e na preven&#231;&#227;o de defici&#234;ncias&#46; Os volunt&#225;rios da comunidade podem ser utilizados para preencher essa lacuna de vincula&#231;&#227;o do setor privado &#224; unidade de sa&#250;de p&#250;blica&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Suporte financeiro</span><p id="par0090" class="elsevierStylePara elsevierViewall">Esta pesquisa faz parte do estudo financiado pelo <span class="elsevierStyleItalic">Indian Council of Medical Research</span> &#40;ICMR&#41;&#46; Agradecemos ao ICMR por financiar este estudo&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Contribui&#231;&#227;o dos autores</span><p id="par0045" class="elsevierStylePara elsevierViewall">Srinivas Govindarajulu&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; an&#225;lise estat&#237;stica&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Thirumugam Muthuvel&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; planejamento do estudo&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Vivek Lal&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; planejamento do estudo&#59; obten&#231;&#227;o&#44; an&#225;lise&#44; e interpreta&#231;&#227;o dos dados&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Subha Manivannan&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Karthikeyan Pandiyambakkam Rajendran&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Sudha Seshayyan&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflito de interesses</span><p id="par0080" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Como citar este artigo&#58; Govindarajulu S&#44; Muthuvel T&#44; Lal V&#44; Manivannan S&#44; Rajendran KP&#44; Seshayyan S&#46; A case&#8208;control study to determine the risk factors for disability among the leprosy cases in Andhra Pradesh&#44; India&#46; An Bras Dermatol&#46; 2022&#59;97&#58;247&#8211;9&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Trabalho realizado nos tr&#234;s distritos &#40;Guntur&#44; Krishna&#44; e Kurnool&#41; no estado de Andhra Pradesh&#44; localizado na &#205;ndia&#46; O estudo foi realizado nas seguintes institui&#231;&#245;es&#58; District Leprosy Offices e Primary Health Centres nos tr&#234;s distritos &#40;Guntur&#44; Krishna&#44; e Kurnool&#41; de Andhra Pradesh&#44; &#205;ndia&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PB&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Atraso do paciente</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3 meses&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804; 3 meses&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#62; 1 m&#234;s&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;5 &#40;1&#44;6&#8208;4&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&#44;0 &#40;0&#44;94&#8208;4&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804; 1 m&#234;s&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75 &#40;54&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">M&#233;dico consultado pela primeira vez&#47;sa&#250;de p&#250;blica</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o qualificado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26 &#40;19&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;0 &#40;0&#44;5&#8208;2&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;4 &#40;0&#44;1&#8208;1&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M&#233;dico particular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;9 &#40;1&#44;2&#8208;4&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;2 &#40;1&#44;1&#8208;2&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PSS p&#250;blico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">49 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66 &#40;47&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Aus&#234;ncia de suspeita de hansen&#237;ase por m&#233;dicos particulares em mais de 2 consultas</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">50 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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Carta ‐ Investigação
Estudo de caso‐controle para determinar os fatores de risco para incapacidades entre os casos de hanseníase em Andhra Pradesh, Índia
Srinivas Govindarajulua,
Corresponding author
drsrini@gmail.com

Autor para correspondência.
, Thirumugam Muthuvelb, Vivek Lalc, Subha Manivannand, Karthikeyan Pandiyambakkam Rajendrana, Sudha Seshayyane
a Departamento de Epidemiologia, The Tamil Nadu Dr. M. G. R Medical University, Chennai, Índia
b Pesquisador Independente, Hyderabad, Índia
c Sasakawa‐India Leprosy Foundation (S‐ILF), Nova Deli, Índia
d JIPMER, Pondicherry, Índia
e The Tamil Nadu Dr. M.G.R. Medical University, Chennai, Índia
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A &#205;ndia relata 60&#37; dos novos casos de hansen&#237;ase no mundo todos os anos&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Ap&#243;s a elimina&#231;&#227;o da hansen&#237;ase como um problema de sa&#250;de p&#250;blica em 2005&#44; o Programa Nacional de Erradica&#231;&#227;o da Hansen&#237;ase &#40;NLEP&#44; <span class="elsevierStyleItalic">National Leprosy Eradication Program</span>&#41; foi integrado ao Provedor de Servi&#231;os de Sa&#250;de &#40;PSS&#41; existente para o diagn&#243;stico e tratamento precoces da hansen&#237;ase&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Apesar de todos os esfor&#231;os&#44; o pa&#237;s relata um n&#250;mero significativo de novos casos de hansen&#237;ase com incapacidades a cada ano&#46; A &#205;ndia sozinha contribui com 37&#37; dos casos mundiais de defici&#234;ncia de grau 2 &#40;DG2&#41; e 65&#37; da regi&#227;o do Sudeste Asi&#225;tico&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> A propor&#231;&#227;o de casos de DG2 entre novos casos de hansen&#237;ase no ano de 2017 a 2018&#44; como relatado em Andhra Pradesh&#44; &#233; de 4&#44;86&#37; e 4&#44;71&#37;&#44; respectivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> A apresenta&#231;&#227;o tardia &#233; um fator de risco reconhecido para incapacidade&#44; e o presente estudo foi realizado para avaliar os fatores de risco para incapacidades entre os casos de hansen&#237;ase em adultos e medir sua for&#231;a de associa&#231;&#227;o&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Um estudo de caso&#8208;controle foi realizado em Andhra Pradesh&#44; &#205;ndia&#44; entre agosto de 2014 e julho de 2016&#46; Casos e controles foram selecionados a partir dos registros de tratamento do NLEP de tr&#234;s distritos selecionados aleatoriamente&#58; Guntur&#44; Krishna e Kurnool&#46; Os casos foram definidos como pacientes adultos com hansen&#237;ase&#44; com 18 anos ou mais na &#233;poca e registrados para tratamento no NLEP com GD2 ou GD1<span class="elsevierStyleHsp" style=""></span>da OMS&#46; Os controles foram definidos como pacientes adultos com hansen&#237;ase&#44; com 18 anos ou mais na &#233;poca e registrados para tratamento no NLEP com incapacidade de grau 0<span class="elsevierStyleHsp" style=""></span>da OMS &#40;DG0&#41;&#46; A avalia&#231;&#227;o segundo o sistema de gradua&#231;&#227;o da hansen&#237;ase em grau 0&#44; grau 1 e grau 2<span class="elsevierStyleHsp" style=""></span>da OMS foi realizada pela equipe do NLEP &#40;supervisor de hansen&#237;ase e oficial m&#233;dico distrital de hansen&#237;ase&#41; avaliando os olhos&#44; as m&#227;os e os p&#233;s dos pacientes&#46; Os pacientes do registro de tratamento do NLEP foram selecionados como casos e controles&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> O c&#225;lculo do tamanho da amostra e a metodologia s&#227;o descritos em outro artigo&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Um question&#225;rio pr&#233;&#8208;testado no idioma local &#40;t&#233;lugo&#41; foi utilizado para registrar dados sociodemogr&#225;ficos&#44; informa&#231;&#245;es sobre o tempo de atraso do paciente e atraso do PSS de todos os participantes&#46; Todos os dados obtidos foram an&#244;nimos e analisados por meio do <span class="elsevierStyleItalic">software</span> STATA vers&#227;o 12&#46;0&#46; Porcentagens foram calculadas para vari&#225;veis discretas&#44; e a mediana foi calculada para vari&#225;veis cont&#237;nuas com intervalos interquartis&#46; As vari&#225;veis que se mostraram significativas na an&#225;lise bivariada foram submetidas &#224; regress&#227;o log&#237;stica multivariada com IC95&#37;&#59; valor de p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 foi considerado estatisticamente significativo&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Havia menos homens &#40;67&#37;&#41; entre os casos do que nos controles &#40;76&#37;&#41;&#44; e havia mais mulheres nos casos &#40;33&#37;&#41; do que nos controles &#40;24&#37;&#41;&#46; As caracter&#237;sticas sociodemogr&#225;ficas e os tipos de hansen&#237;ase s&#227;o mostrados na <a class="elsevierStyleCrossRef" href="#tbl0005">tabela 1</a>&#46; A mediana &#40;calculada em vez do atraso m&#233;dio do paciente em raz&#227;o da assimetria dos dados&#41; do tempo de atraso do paciente&#44; atraso do PSS e atraso total em meses s&#227;o apresentados na <a class="elsevierStyleCrossRef" href="#tbl0010">tabela 2</a>&#46; Fatores de risco para a deformidade no momento do diagn&#243;stico da hansen&#237;ase e o registro entre as pessoas rec&#233;m&#8208;diagnosticadas com hansen&#237;ase s&#227;o apresentadas na <a class="elsevierStyleCrossRef" href="#tbl0015">tabela 3</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A an&#225;lise detalhada de v&#225;rios fatores de intera&#231;&#227;o mostrou que eles podem ser categorizados como fatores relacionados ao paciente ou relacionados ao PSS&#46; Neste estudo&#44; o tempo de atraso mediano do paciente foi de 18 meses nos casos e oito meses nos controles&#46; Um estudo em um hospital terci&#225;rio em Andhra Pradesh relatou que 50&#44;5&#37; dos pacientes com hansen&#237;ase demoraram mais de seis meses antes de ir ao hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Um estudo em Chhattisgarh relatou que 32&#44;5&#37; dos pacientes com GD2&#47;GD1 tiveram um atraso de mais de 12 meses no diagn&#243;stico&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> Entretanto&#44; o atraso relatado neste estudo &#233; maior do que o de outras regi&#245;es geogr&#225;ficas do pa&#237;s&#46; A n&#237;vel internacional&#44; Henry et al&#46;&#44; no Brasil&#44; relataram que 34&#44;4&#37; dos pacientes com hansen&#237;ase tiveram um atraso do paciente de menos de tr&#234;s meses&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> Um estudo chin&#234;s que observou casos notificados entre 2007 e 2017 relatou um atraso m&#233;dio e mediano do paciente de 30&#44;1 meses e seis meses&#44; respectivamente&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> Nosso estudo mostrou que o atraso de mais de tr&#234;s meses do paciente representa um risco significativo para o desenvolvimento de GD2&#47;GD1 entre novos pacientes com hansen&#237;ase em Andhra Pradesh&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Embora o atraso do paciente seja o principal contribuinte para o atraso geral&#44; o atraso do PSS n&#227;o pode ser ignorado&#46; O principal motivo atribu&#237;do ao atraso no atendimento &#224; sa&#250;de &#233; a falta de profissionais de sa&#250;de qualificados para diagnosticar a doen&#231;a&#46; Como a hansen&#237;ase foi eliminada como um problema de sa&#250;de p&#250;blica na maioria dos pa&#237;ses&#44; menos import&#226;ncia &#233; dada no curr&#237;culo m&#233;dico objetivando treinar profissionais de sa&#250;de para suspeitar de hansen&#237;ase&#44; e frequentemente a doen&#231;a &#233; diagnosticada incorretamente&#46; Na &#205;ndia&#44; os profissionais de sa&#250;de do sistema p&#250;blico de sa&#250;de foram melhores no diagn&#243;stico da hansen&#237;ase em compara&#231;&#227;o com profissionais da pr&#225;tica privada&#46; Isso &#233; bastante evidente no presente estudo&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Este estudo relatou que 46&#37; dos casos procuraram primeiro um provedor de sa&#250;de privado qualificado&#44; e 52&#37; dos controles procuraram primeiro atendimento no PSS p&#250;blico&#46; V&#225;rios fatores&#44; como <span class="elsevierStyleItalic">status</span> socioecon&#244;mico&#44; n&#237;vel de escolaridade&#44; acessibilidade etc&#46; influenciam o comportamento de busca por servi&#231;os de sa&#250;de e a decis&#227;o de procurar um provedor de servi&#231;os de sa&#250;de&#46; Relatamos que quando o entrevistado visitou qualquer provedor de sa&#250;de privado qualificado mais de duas vezes antes do diagn&#243;stico&#44; a chance de GD2&#47;GD1 foi duas vezes maior do que naqueles que visitaram menos vezes ou igual a duas vezes&#46; Isso mostra que um tempo significativo de atraso ocorre com v&#225;rias visitas ao setor privado&#44; e pode servir como indicador indireto para a oportunidade perdida de diagn&#243;stico pelo setor privado&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A principal limita&#231;&#227;o do presente estudo foi sua natureza retrospectiva&#46; Pode haver um &#8220;vi&#233;s de mem&#243;ria&#8221; introduzido at&#233; certo ponto neste estudo&#44; o que &#233; inevit&#225;vel em trabalhos de caso&#8208;controle&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Em conclus&#227;o&#44; o atraso do paciente &#233; um fator vital para a redu&#231;&#227;o das incapacidades entre os casos de hansen&#237;ase em adultos&#46; O grande tempo de atraso do paciente reflete que a comunidade n&#227;o est&#225; ciente dos sintomas e das consequ&#234;ncias da hansen&#237;ase&#59; reflete tamb&#233;m a efic&#225;cia das estrat&#233;gias de educa&#231;&#227;o e comunica&#231;&#227;o e dos mecanismos de detec&#231;&#227;o precoce de casos nos servi&#231;os p&#250;blicos de sa&#250;de&#46; Al&#233;m disso&#44; envolver o setor privado a fim de ter um sistema de refer&#234;ncia eficaz&#44; al&#233;m da redu&#231;&#227;o do atraso do paciente&#44; servir&#225; como complemento para uma estrat&#233;gia eficaz na detec&#231;&#227;o precoce e na preven&#231;&#227;o de defici&#234;ncias&#46; Os volunt&#225;rios da comunidade podem ser utilizados para preencher essa lacuna de vincula&#231;&#227;o do setor privado &#224; unidade de sa&#250;de p&#250;blica&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Suporte financeiro</span><p id="par0090" class="elsevierStylePara elsevierViewall">Esta pesquisa faz parte do estudo financiado pelo <span class="elsevierStyleItalic">Indian Council of Medical Research</span> &#40;ICMR&#41;&#46; Agradecemos ao ICMR por financiar este estudo&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Contribui&#231;&#227;o dos autores</span><p id="par0045" class="elsevierStylePara elsevierViewall">Srinivas Govindarajulu&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; concep&#231;&#227;o e planejamento do estudo&#59; an&#225;lise estat&#237;stica&#59; elabora&#231;&#227;o e reda&#231;&#227;o do manuscrito&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Thirumugam Muthuvel&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; planejamento do estudo&#59; obten&#231;&#227;o&#44; an&#225;lise e interpreta&#231;&#227;o dos dados&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Vivek Lal&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; planejamento do estudo&#59; obten&#231;&#227;o&#44; an&#225;lise&#44; e interpreta&#231;&#227;o dos dados&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; participa&#231;&#227;o efetiva na orienta&#231;&#227;o da pesquisa&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Subha Manivannan&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Karthikeyan Pandiyambakkam Rajendran&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Sudha Seshayyan&#58; Aprova&#231;&#227;o da vers&#227;o final do manuscrito&#59; an&#225;lise estat&#237;stica e interpreta&#231;&#227;o dos dados&#59; revis&#227;o cr&#237;tica da literatura&#59; revis&#227;o cr&#237;tica do manuscrito&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflito de interesses</span><p id="par0080" class="elsevierStylePara elsevierViewall">Nenhum&#46;</p></span></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804; 3 meses&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">29 &#40;21&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t  " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Atraso do PSS</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#62; 1 m&#234;s&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">91 &#40;65&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">65 &#40;46&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&#44;5 &#40;1&#44;6&#8208;4&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;0 &#40;0&#44;94&#8208;4&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8804; 1 m&#234;s&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">75 &#40;54&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">M&#233;dico consultado pela primeira vez&#47;sa&#250;de p&#250;blica</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>N&#227;o qualificado&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">38 &#40;27&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26 &#40;19&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#44;0 &#40;0&#44;5&#8208;2&#44;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#44;4 &#40;0&#44;1&#8208;1&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>M&#233;dico particular&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#44;2 &#40;1&#44;1&#8208;2&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>PSS p&#250;blico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">49 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sim&nbsp;\t\t\t\t\t\t\n
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          "pt" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Atraso do paciente&#44; atraso do PSS e fatores relacionados como fatores de risco para deformidades no momento do diagn&#243;stico da hansen&#237;ase e registro entre pessoas com hansen&#237;ase rec&#233;m&#8208;diagnosticada</p>"
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                0 => array:1 [
                  "referenciaCompleta" => "Who&#46;int &#91;Internet&#46; Global leprosy update&#44; 2017&#58; reducing the disease burden due to leprosy&#46; Weekly Epidemiological Record&#44; 31 August 2018&#44; vol&#46; 93&#44; 35&#93;&#46; Available from&#58; https&#58;&#47;&#47;www&#46;who&#46;int&#47;wer&#47;2018&#47;wer9335&#47;en&#47;&#46;&#91;cited 22&#46;04&#46;2020&#93;&#46;"
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                0 => array:1 [
                  "referenciaCompleta" => "P&#46;N&#46; Rao Global leprosy strategy 2016&#8208;2020&#58; Issues and concerns Indian J Dermatol Venereol Leprol&#46; 20217&#59;83&#58;4&#46;"
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              "identificador" => "bib0060"
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                0 => array:1 [
                  "referenciaCompleta" => "Nlep&#46;nic&#46;in &#91;Internet&#46; National Leprosy Eradication Program&#46; Report&#58; State&#8208;wise Report on Major indicators for the F&#46;Y&#46; 2017&#8208;18&#93;&#46; Available from&#58; http&#58;&#47;&#47;nlep&#46;nic&#46;in&#47;&#46;&#91;cited 21&#46;03&#46;2020&#93;&#46;"
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                      "titulo" => "WHO disability grading&#58; operational definitions"
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                          "etal" => false
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                            0 => "J&#46;W&#46; Brandsma"
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                        "link" => array:1 [
                          0 => array:2 [
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                      "titulo" => "Risk of disability among adult leprosy cases and determinants of delay in diagnosis in five states of India&#58; A case&#8208;control study"
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                          "etal" => false
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                            2 => "V&#46; Lal"
                            3 => "K&#46; Vaikundanathan"
                            4 => "E&#46;-M&#46; Schwienhorst-Stich"
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                      "titulo" => "A study of clinical profile of leprosy in post leprosy elimination era"
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                            3 => "T&#46; Vani"
                            4 => "Rammohan Ch"
                            5 => "R&#46;N&#46; Neenavathu"
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Article information
ISSN: 26662752
Original language: Portuguese
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