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An
Bras
Dermatol.
2020;
95(1)
:91---94
Anais
Brasileiros
de
Dermatologia
www.anaisdedermatologia.org.br
TROPICAL/INFECTOPARASITARY
DERMATOLOGY
Leprosy
in
the
elderly
population
of
an
endemic
state
in
the
Brazilian
Northeast
(2001---2017):
epidemiological
scenario

,

Carlos
Dornels
Freire
de
Souza
a
,
b
,
,
Tânia
Rita
Moreno
de
Oliveira
Fernandes
c
,
d
,
Thais
Silva
Matos
e
,
f
,
Clódis
Maria
Tavares
g
,
h
a
Fundac
̧ão
Oswaldo
Cruz,
Rio
de
Janeiro,
RJ,
Brazil
b
Medical
Program
of
Universidade
Federal
de
Alagoas,
Arapiraca,
AL,
Brazil
c
Universidade
Federal
de
São
Paulo,
São
Paulo,
SP,
Brazil
d
Medical
Program
of
Universidade
Federal
do
Vale
do
São
Francisco,
Petrolina,
PE,
Brazil
e
Program
of
Biological
Sciences
and
Health
of
Universidade
Federal
do
Vale
do
São
Francisco,
Petrolina,
PE,
Brazil
f
Dr.
Altino
Lemos
Santiago
Leprosy
Reference
Center,
Juazeiro,
BA,
Brazil
g
Universidade
de
São
Paulo,
São
Paulo,
SP,
Brazil
h
School
of
Nursery
and
Pharmacy,
Universidade
Federal
de
Alagoas,
Maceió,
AL,
Brazil
Received
25
July
2018;
accepted
13
January
2019
Available
online
18
December
2019
KEYWORDS
Aging;
Leprosy;
Mycobacterium
leprae
Abstract
This
ecological
study
aims
to
analyze
both
the
tendency
and
the
characteristics
of
leprosy
in
the
elderly
population
in
the
state
of
Bahia,
2001---2017.
The
tendency
was
analyzed
through
joinpoint
regression.
Epidemiological
variables
were
also
included
in
the
study.
The
average
detection
rate
was
38.73/100,000,
with
prevalence
of
men
(45.19/100,000).
A
down-
ward
trend
occurred
in
both
genders,
from
2004,
with
a
greater
magnitude
in
women
(annual
percent
change
[APC]
=
3.4%).
Men
presented
higher
proportions
of
the
multibacillary
forms
and
physical
disabilities.
The
epidemiological
scenario
indicates
the
need
of
implementation
of
actions
that
stimulate
early
diagnosis
and
treatment
of
the
elderly
population.
©
2019
Sociedade
Brasileira
de
Dermatologia.
Published
by
Elsevier
Espa
̃
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY
license
(
http://creativecommons.org/licenses/by/4.0/
).

How
to
cite
this
article:
Souza
CDF,
Fernandes
TRMO,
Matos
TS,
Tavares
CM.
Leprosy
in
the
elderly
population
in
an
endemic
state
in
the
Brazilian
Northeast
(2001---2017):
epidemiological
scenario.
An
Bras
Dermatol.
2020;95:91---4.

Study
conducted
at
the
Universidade
Federal
de
Alagoas,
AL,
Brazil.
Corresponding
author.
E-mail:
carlos.freire@arapiraca.ufal.br
(C.D.
Souza).
https://doi.org/10.1016/j.abd.2019.01.011
0365-0596/©
2019
Sociedade
Brasileira
de
Dermatologia.
Published
by
Elsevier
Espa
̃
na,
S.L.U.
This
is
an
open
access
article
under
the
CC
BY
license
(
http://creativecommons.org/licenses/by/4.0/
).
92
Souza
CDF
et
al.
60
60
65
55
55
55
50
50
50
45
45
45
35
35
35
30
30
30
25
25
20
2000 2002
Rate obser
ved
Rate obser
ved
Temporal trend 2001-2007
Men
+ Women:
Men:
Women:
APC = 13.9% 95% C
I: 4.7 to 23.9 (p<0.001)
APC = 13.5% 95% C
I: 5.1 to 22.2 (p<0.001)
APC = -3.4% 95% CI: -4.1 to
-2.6 (p<0.001)
APC = 14.5% 95% C
I: 0.5 to 30.5 (p<0.001)
AAPC = 0.2% 95% C
I: -1.4 a 1.7 (p=0.8)
AAPC = 0.7% 95% C
I: -1.7 a 3.2 (p=0.6)
AAPC = -0.4% 95% CI: -1.8 a 0.9 (p=0.5)
APC = -2.2% 95% CI: -3.5 to
-0.8 (p<0.001)
APC = -2.8% 95% CI: -3.6 to
-1.9 (p<0.001)
Rate obser
ved
2004 2006 2008 2010
Det
ection rate of leprosy in the
elderly populati
on (Men + Women)
Det
ection rate of leprosy in the
elderly populati
on (Women)
Det
ection rate of leprosy in the
elderly populati
on (Men)
Year
Year
New cases per 100,000 inhabitants
New cases per 100,000 inhabitants
New cases per 100,000 inhabitants
Year
2012 2014 2016 2018
2000
2002
2004
2006
2008
2010
2012
2014
2016
2018
2000
2002
2004
2006
2008
2010
2012
2014
2016
2018
25
40
40
40
Figure
1
Trend
of
the
detection
rates
of
new
cases
of
leprosy
in
the
elderly
population,
stratified
by
gender.
Bahia,
Brazil,
2001---2017.
APC,
annual
percent
change;
AAPC,
average
annual
percent
change;
CI,
confidence
interval.
Brazil
contributed
with
92.3%
of
new
leprosy
cases
in
the
Americas
region.
The
three
countries
(Brazil,
Indian,
and
Indonesia)
with
the
highest
burdens
accounted
for
80.2%
of
the
new
case
load
globally
in
2017.
1
In
2017,
Brazil
recorded
26,875
new
cases
of
the
disease,
2225
of
which
(8.28%)
occurred
in
Bahia’s
residents.
2
Aging
is
characterized
by
important
physical,
functional,
biological
and
psychosocial
transformations
that
increase
the
risk
of
developing
some
diseases.
3
Therefore,
the
aging
process
of
the
Brazilian
population,
a
consequence
of
the
demographic
transition,
justifies
the
need
of
understanding
how
leprosy
has
been
affecting
this
age
range.
Moreover,
the
gender-stratified
analyses,
according
to
the
World
Health
Organization
(WHO)
recommendation,
have
a
special
rele-
vance,
because
they
document
the
nuances
of
the
disease
process
in
each
population
subgroup.
1
Thus,
the
objective
was
to
analyze
epidemiological
tendency
and
characteristics
of
leprosy
in
the
elderly
popu-
lation,
from
2001---2017,
in
the
state
of
Bahia,
Brazil.
An
ecological
study
was
conducted.
The
data
related
to
the
new
cases
were
obtained
from
the
National
Sys-
tem
of
Notification
Diseases
(Sistema
Nacional
de
Agravos
de
Notificac
̧ão
[SINAN]),
and
the
population
data
from
the
Brazilian
Institute
of
Geography
and
Statistics
(Instituto
Brasileiro
de
Geografia
e
Estatística
[IBGE]),
accessed
in
March
2018.
The
first
step
consisted
of
the
analysis
of
the
tendency
of
detection
rate
of
new
cases,
stratified
according
to
gen-
der.
The
joinpoint
regression
model
was
used.
4
The
tendency
was
classified
as
increasing,
decreasing,
or
stationary.
In
addition,
the
annual
percent
change
(APC)
and
the
aver-
age
annual
percent
change
(AAPC)
were
calculated
with
95%
confidence
intervals
(95%
CI).
Authorization
by
the
Research
Ethics
Committee
was
not
required,
because
the
data
used
are
secondary.
The
second
step
consisted
of
the
epidemiological
anal-
ysis
of
the
following
variables:
gender,
age,
race/color,
schooling,
clinical
form,
operational
classification,
detec-
tion
mode,
and
degree
of
physical
incapacity
at
the
time
of
diagnosis.
There
were
8843
new
cases
of
leprosy
recorded
in
the
elderly
Bahia
population.
The
average
detection
rate
was
38.73/100,000
inhabitants,
with
greater
detection
in
men
(45.19/100,000
inhabitants)
when
compared
to
the
women
(33.54/100,000
inhabitants).
Considering
that
the
number
of
leprosy
cases
in
Brazil
has
been
contested
by
researchers,
5
the
actual
epidemiological
scenario
of
leprosy
in
the
elderly
may
be
even
more
worrying.
Leprosy
in
the
elderly
population
of
an
endemic
state
in
the
Brazilian
Northeast
93
Table
1
Sociodemographic
and
clinical
characterization
of
leprosy
cases
diagnosed
in
the
elderly
population.
Bahia,
Brazil,
2001---2017.
Variable
Male
n
(%)
4610
(52.13%)
Female
n
(%)
4233
(47.87%)
Total
n
(%)
8843
(100%)
Age
range
60---69
2691
(58.37%)
2426
(57.31%)
5117
(57.86%)
70---79
1423
(30.87%)
1263
(29.84%)
2686
(30.38%)
80
or
more
496
(10.76%)
544
(12.85%)
1040
(11.76%)
Ethnicity
White
965
(20.93%)
897
(21.19%)
1862
(21.06%)
Black
754
(16.36%)
646
(15.26%)
1400
(15.83%)
Yellow
25
(0.54%)
29
(0.68%)
54
(0.61%)
Mixed-race
2356
(51.11%)
2103
(49.68%)
4459
(50.42%)
Indigenous
20
(0.43%)
13
(0.31%)
33
(0.37%)
Ignored/left
blank
490
(10.63%)
545
(12.88%)
1035
(11.70%)
Schooling
Illiterate
1220
(26.46%)
1236
(29.20%)
2456
(27.77%)
Elementary
school
2073
(44.97%)
1777
(41.98%)
3850
(43.54%)
Middle
school
258
(5.60%)
236
(5.57%)
494
(5.59%)
High
school
81
(1.76%)
63
(1.49%)
144
(1.63%)
Ignored/left
blank
978
(21.21%)
921
(21.76%)
1899
(21.43%)
Clinical
type
Indeterminate
404
(8.76%)
545
(12.88%)
949
(10.73%)
Tuberculoid
676
(14.67%)
1085
(25.63%)
1761
(19.91%)
Dimorphous
1536
(33.32%)
1290
(30.47%)
2826
(31.96%)
Virchow’s
1.047
(22.71%)
502
(11.86%)
1549
(17.52%)
Ignored/left
blank
947
(20.54%)
811
(19.16%)
1758
(19.88%)
Functional
classification
Paucibacillary
1087
(23.58%)
1859
(43.92%)
2946
(33.31%)
Multibacillary
3509
(76.12%)
2352
(55.56%)
5861(66.28%)
Ignored/left
blank
14
(0.30%)
22
(0.52%)
36
(0.41%)
Method
of
detection
Referral
2431
(52.73%)
2190
(51.74%)
4621
(52.26%)
Walk-in
1652
(35.84%)
1466
(34.63%)
3118
(35.26%)
Collection-based
exam
127
(2.75%)
121
(2.86%)
248
(2.80%)
Contact-based
exam
235
(5.10%)
321
(7.58%)
556
(6.29%)
Others
117
(2.54%)
102
(2.41%)
219
(2.48%)
Ignored/left
blank
48
(1.04%)
33
(0.78%)
81
(0.92%)
Grade
of
physical
incapacitation
Grade
0
2299
(49.87%)
2491
(58.85%)
4790
(54.17%)
Grade
I
1050
(22.78%)
881
(20.81%)
1931
(21.84%)
Grade
II
507
(11.00%)
228
(5.39%)
735
(8.31%)
Ignored/left
blank
754
(16.35%)
633
(14.95%)
1387
(15.68%)
The
joinpoint
model
showed
two
distinct
temporal
trends.
The
first
indicated
growth
(2001---2004),
and
the
sec-
ond
demonstrated
reduction
(2004---2017),
with
a
greater
magnitude
of
reduction
in
women
than
men
(APC
=
3.4
and
2.2%,
respectively),
corroborating
other
studies.
3,6,7
At
the
same
time,
when
considering
the
tendency
of
the
total
period
(2001---2017),
the
observed
trend
was
stationary
(
Fig.
1
).
With
regard
to
the
epidemiological
characteristics,
a
slight
predominance
of
cases
in
the
male
population
was
detected
(52.13%,
n
=
4610),
age
between
60
and
69
years
old
(57.86%,
n
=
5117),
brown-skinned
(50.42%,
n
=
4459),
and
low
level
of
schooling,
with
27.77%
(
n
=
2456)
being
illiterate.
52.26%
(
n
=
4621)
were
diagnosed
by
means
of
referral
(
Table
1
).
Similar
results
were
evidenced
in
other
investigations.
3,8,9
In
the
gender-stratified
analyses,
men
presented
higher
proportions
of
the
multibacillary
forms
when
compared
to
the
female
population
(3509/76.12%
and
2352/55.56%,
respectively).
The
lepromatous
clinical
form
corresponded
to
22.71%
(
n
=
1047)
of
the
registered
cases
in
the
male
popu-
lation
and
only
11.86%
(
n
=
502)
of
the
registered
cases
in
the
94
Souza
CDF
et
al.
female
gender
(
Table
1
).
These
data
suggest
that
diagnosis
occurs
later
in
men,
10
possibly
due
to
two
factors:
less
access
to
health
services
and
the
effects
of
negligence
regarding
symptoms
of
the
disease.
3,8,9
The
presence
of
physical
disabilities
was
another
element
that
was
highlighted
in
the
analyses.
Of
the
total
number
of
new
cases,
30.15%
(
n
=
2666)
already
had
some
incapac-
ity
at
the
time
of
diagnosis
and,
in
8.31%
(
n
=
735),
these
disabilities
were
permanent.
The
proportion
of
men
with
permanent
physical
incapacity
was
2.04
times
higher
than
that
of
women
(11.00%,
n
=
507
and
5.39%,
n
=
228,
respec-
tively)
(
Table
1
).
This
scenario
highlights
what
has
been
mentioned
previously,
indicating
the
severe
consequences
of
the
disease
in
the
elderly
population,
3,9
especially
in
the
male
population,
and
in
the
maintenance
of
the
chain
of
transmission
in
the
community.
5
Although
the
results
presented
are
already
capable
of
justifying
the
authors’
concern
about
leprosy
in
the
elderly
population,
the
high
proportions
of
unfilled
and/or
ignored
fields
in
the
evaluation
of
the
degree
of
physical
disability
at
the
time
of
diagnosis
reflect
not
only
on
the
operational
problems
in
disease
vigilance,
3,6,9
but
also
indicate
that
the
number
of
disabled
may
be
even
higher
than
that
presented.
Leprosy
in
the
elderly
must
be
viewed
with
concern,
since
this
population
is
stricken
by
more
multibacillary
forms
of
the
disease
and
has
an
increased
risk
of
developing
physi-
cal
disabilities.
In
addition,
the
precarious
access
to
health
services
--- which
makes
these
patients
invisible
---
keeps
the
disease’s
chain
of
transmission
active,
making
it
persistent
in
the
community.
Authors’
contributions
Carlos
Dornels
Freire
de
Souza:
Statistical
analysis;
approval
of
the
final
version
of
the
manuscript;
conception
and
planning
of
the
study;
composition
of
the
manuscript;
col-
lection,
analysis,
and
interpretation
of
data;
participation
in
the
design
of
the
study;
intellectual
participation
in
the
propaedeutic
and/or
therapeutic
conduct
in
the
studied
cases;
critical
review
of
the
literature;
critical
review
of
the
manuscript.
Tânia
Rita
Moreno
de
Oliveira
Fernandes:
Approval
of
the
final
version
of
the
manuscript;
conception
and
planning
of
the
study;
composition
of
the
manuscript;
participation
in
the
design
of
the
study;
intellectual
participation
in
the
propaedeutic
and/or
therapeutic
conduct
in
the
studied
cases;
critical
review
of
the
literature;
critical
review
of
the
manuscript.
Thais
Silva
Matos:
Statistical
analysis;
approval
of
the
final
version
of
the
manuscript;
conception
and
planning
of
the
study;
composition
of
the
manuscript;
collection,
analysis,
and
interpretation
of
the
data;
participation
in
the
design
of
the
study;
intellectual
participation
in
the
propaedeutic
and/or
therapeutic
conduct
in
the
studied
cases;
critical
review
of
the
literature;
critical
review
of
the
manuscript.
Clódis
Maria
Tavares:
Approval
of
the
final
version
of
the
manuscript;
conception
and
planning
of
the
study;
compo-
sition
of
the
manuscript;
participation
in
the
design
of
the
study;
intellectual
participation
in
the
propaedeutic
and/or
therapeutic
conduct
in
the
studied
cases;
critical
review
of
the
literature;
critical
review
of
the
manuscript.
Financial
support
None
declared.
Conflicts
of
interest
None
declared.
References
1.
Word
Health
Organization
(WHO).
Weekly
epidemiological
record.
Global
leprosy
update,
2017:
reducing
the
disease
burden
due
to
leprosy.
2018;
35:445---56.
Available
from:
https://zeroleprosy.org/who
wer/
[cited
10.01.19].
2.
Portalarquivos.saude.gov.br
Brasil.
Ministério
da
Saúde.
Sec-
retaria
de
Vigilância
em
Saúde.
Registro
ativo:
número
e
percentual,
Casos
novos
de
hanseníase:
número,
coeficiente
e
percentual,
faixa
etária,
classificac
̧ão
operacional,
sexo,
grau
de
incapacidade,
contatos
examinados,
por
estados
e
regiões,
Brasil,
2017
(atualizac
̧ão
30
maio
2018).
Available
from:
http://portalarquivos2.saude.gov.br/images/pdf/2018/julho/
13/Registro-ativo-numero-e-percentual-por-estados-e-regioes-
Brasil-2017.pdf
[cited
01.12.18].
3.
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