Factors associated with delayed diagnosis of leprosy in an endemic area in Northeastern Brazil: a cross-sectional study.

This study aimed to investigate the factors related to the individual and the health system that contribute to delayed diagnosis of leprosy in an endemic area in the Northeastern Brazil. This is a cross-sectional study of 120 individuals with leprosy. Demographic and clinical data and information on the factors related to the individual and the health system that contribute to delayed diagnosis of leprosy were obtained. Delayed diagnosis in months was estimated for each participant by interviews. A multivariate Poisson's regression analysis was performed between the outcome and the independent variables. The median delay in the diagnosis of leprosy was 10.5 (4.0-24.0) months. Approximately 12.6% of participants had grade 2 disability (G2D) at the time of diagnosis. In the multivariate Poisson regression analysis, males, older age, low schooling level, residing in urban areas, multibacellar or tuberculoid leprosy, not seeking healthcare immediately after symptom onset, suspected leprosy, excessive referrals, and the need for three or more consultations to confirm the diagnosis were associated with longer diagnostic delay. This study found a significant delay in the diagnosis of leprosy in Arapiraca, Northeastern Brazil, which may explain the continuously high rate of G2D among new cases. Factors related to the individual and the health system were associated with longer diagnostic delay. Interventions to raise awareness of the disease among the general population and strengthen primary health care are urgently needed.

Factors associated with delayed diagnosis of leprosy in an endemic area in Northeastern Brazil: a cross-sectional study / Fatores associados ao atraso no diagnóstico da hanseníase em área endêmica no Nordeste do Brasil: um estudo transversal / Factores asociados con el diagnóstico tardío de la lepra en un área endémica del Nordeste de Brasil: un estudio transversal

Abstract: This study aimed to investigate the factors related to the individual and the health system that contribute to delayed diagnosis of leprosy in an endemic area in the Northeastern Brazil. This is a cross-sectional study of 120 individuals with leprosy. Demographic and clinical data and information on the factors related to the individual and the health system that contribute to delayed diagnosis of leprosy were obtained. Delayed diagnosis in months was estimated for each participant by interviews. A multivariate Poisson's regression analysis was performed between the outcome and the independent variables. The median delay in the diagnosis of leprosy was 10.5 (4.0-24.0) months. Approximately 12.6% of participants had grade 2 disability (G2D) at the time of diagnosis. In the multivariate Poisson regression analysis, males, older age, low schooling level, residing in urban areas, multibacellar or tuberculoid leprosy, not seeking healthcare immediately after symptom onset, suspected leprosy, excessive referrals, and the need for three or more consultations to confirm the diagnosis were associated with longer diagnostic delay. This study found a significant delay in the diagnosis of leprosy in Arapiraca, Northeastern Brazil, which may explain the continuously high rate of G2D among new cases. Factors related to the individual and the health system were associated with longer diagnostic delay. Interventions to raise awareness of the disease among the general population and strengthen primary health care are urgently needed.

Resumo: Neste estudo objetivou-se investigar os fatores relacionados ao indivíduo e ao sistema de saúde que contribuem para o atraso no diagnóstico da hanseníase em uma área endêmica no Nordeste do Brasil. Trata-se de um estudo transversal que incluiu 120 pacientes com hanseníase. Foram obtidos dados demográficos, clínicos e informações sobre fatores relacionados ao indivíduo e ao sistema de saúde que contribuem para o atraso no diagnóstico da hanseníase. O atraso do diagnóstico em meses foi estimado para cada participante por meio de entrevistas. Foi realizada uma análise multivariada por regressão de Poisson entre o resultado e as variáveis independentes. A mediana de atraso no diagnóstico da hanseníase foi de 10,5 (4,0-24,0) meses. Aproximadamente 12,6% dos participantes apresentavam grau de incapacidade física 2 (GIF 2) no momento do diagnóstico. Na análise multivariada por regressão de Poisson, homens, idosos, baixa escolaridade, residir em área urbana, hanseníase multibacilar, hanseníase tuberculóide, não procurar atendimento imediatamente após perceber os primeiros sintomas, suspeita de hanseníase, encaminhamentos excessivos e três ou mais consultas necessárias para confirmação diagnóstica associaram-se ao maior atraso diagnóstico. Este estudo encontrou um atraso significativo no diagnóstico da hanseníase em Arapiraca, Nordeste do Brasil, o que pode explicar a taxa continuamente alta de GIF 2 entre os casos novos. Fatores relacionados ao indivíduo e ao sistema de saúde foram associados ao maior atraso no diagnóstico. Intervenções para aumentar a conscientização sobre a doença entre a população geral e fortalecer a atenção primária à saúde são urgentemente necessárias.

Resumen: El objetivo de este estudio fue investigar los factores relacionados con el individuo y el sistema de salud que contribuyen al diagnóstico tardío de la lepra en un área endémica del Nordeste de Brasil. Se trata de un estudio transversal que incluyó a 120 pacientes con lepra. Se obtuvieron datos demográficos, clínicos e informaciones sobre los factores relacionados con el individuo y el sistema de salud que contribuyen al diagnóstico tardío de la lepra. Se estimó el retraso del diagnóstico en meses para cada participante a través de entrevistas. Se realizó un análisis multivariante por regresión de Poisson entre el resultado y las variables independientes. La mediana de retraso en el diagnóstico de lepra fue de 10,5 (4,0-24,0) meses. Aproximadamente el 12,6% de los participantes tenían grado de discapacidad física 2 (GIF 2) en el momento del diagnóstico. En el análisis multivariante por regresión de Poisson se encontró que los hombres, ancianos, la baja escolaridad, vivir en área urbana, la lepra multibacilar, la lepra tuberculoide, no buscar atención médica inmediatamente tras notar los primeros síntomas, la sospecha de lepra, las derivaciones excesivas y la necesidad de tres o más consultas para confirmar el diagnóstico se asociaron con un mayor retraso del diagnóstico. Este estudio encontró un retraso significativo en el diagnóstico de la lepra en Arapiraca, Nordeste de Brasil, lo que puede explicar la tasa continuamente alta de GIF 2 entre los nuevos casos. Factores relacionados con el individuo y el sistema de salud se asociaron con el mayor retraso del diagnóstico. Intervenciones para aumentar la concienciación sobre la enfermedad entre la población general y fortalecer la atención primaria de salud son urgentemente necesarias.

A cost-effectiveness analysis of a novel algorithm to sequentially diagnose leprosy based on manufactured tests under the SUS perspective / Análise de custo-efetividade de um novo algoritmo para exame sequencial de hanseníase baseado em testes fabricados sob a perspectiva do SUS / Análisis de costo-efectividad de un nuevo algoritmo para el examen secuencial de lepra basado en pruebas fabricadas bajo la perspectiva del SUS

Abstract: Brazil has the second largest number of leprosy cases (a disease with a significant burden) in the world. Despite global and local efforts to eliminate this public health problem, inadequate or late diagnosis contribute to perpetuate its transmission, especially among household contacts. Tests such as the rapid IgM antibody detection (RT) and real-time polymerase chain reaction (RT-PCR) were developed to overcome the challenges of early diagnosis of leprosy. This study aimed to analyze the cost-effectiveness of a new diagnostic algorithm recommended by the Brazilian government to diagnose leprosy in household contacts of confirmed leprosy cases, which includes the RT and RT-PCR tests. A decision tree model was constructed and the perspective of the Brazilian Unified National Health System (SUS) and a 1-year time horizon were adopted. Only direct medical costs related to diagnostic tests were included. Effectiveness was measured as the number of avoided undiagnosed leprosy cases. Different scenarios were analyzed. The sequential use of RT, slit-skin smear (SSS) microscopy, and RT-PCR as recommended by the Brazilian Ministry of Health was compared to a base case (isolated SSS microscopy), yielding an incremental cost-effectiveness ratio of USD 616.46 per avoided undiagnosed leprosy case. Univariate sensitivity analysis showed that the prevalence of leprosy among household contacts was the variable that influenced the model the most. This is the first economic model to analyze a diagnostic algorithm of leprosy. Results may aid managers to define policies and strategies to eradicate leprosy in Brazil.

Resumo: O Brasil tem o segundo maior número de casos de hanseníase (doença com carga significativa) do mundo. Apesar dos esforços globais e locais para eliminar esse problema de saúde pública, o diagnóstico inadequado ou tardio contribui para perpetuar sua transmissão, especialmente entre contatos intradomiciliares. Exames como o teste rápido de anticorpos IgM (RT) e a reação em cadeia da polimerase em tempo real (RT-PCR) foram desenvolvidos para superar as barreiras do diagnóstico precoce da hanseníase. Este estudo teve como objetivo analisar a relação custo-efetividade de um novo algoritmo de diagnóstico recomendado pelo governo brasileiro para diagnosticar a hanseníase em contatos domiciliares de casos confirmados de hanseníase, que inclui os testes RT e RT-PCR. Foi construído um modelo de árvore de decisão e adotada a perspectiva do Sistema Único de Saúde (SUS) considerando o período de um ano. Foram incluídos apenas os custos médicos diretos relacionados aos exames diagnósticos. A efetividade foi medida considerando o número de casos evitados de hanseníase. Diferentes cenários foram analisados. O uso sequencial de RT, baciloscopia e RT-PCR, conforme recomendado pelo Ministério da Saúde, foi comparado a um caso base (baciloscopia isolada), obtendo-se uma razão de custo-efetividade incremental de USD 616,46 por caso evitado de hanseníase. A análise de sensibilidade univariada mostrou que a prevalência de hanseníase entre contatos intradomiciliares foi a variável que mais influenciou o modelo. Este é o primeiro modelo econômico a analisar um algoritmo diagnóstico da hanseníase. Os resultados poderão auxiliar os gestores na definição de políticas e estratégias para a erradicação da hanseníase no Brasil.

Resumen: Brasil tiene el segundo mayor número de casos de lepra (enfermedad con carga significativa) del mundo. A pesar de los esfuerzos globales y locales para eliminar ese problema de salud pública, el diagnóstico inadecuado o tardío contribuye a perpetuar su transmisión, sobre todo entre contactos intradomiciliarios. Los exámenes como la prueba rápida de anticuerpos IgM (RT) y la reacción en cadena de la polimerasa en tiempo real (RT-PCR) se desarrollaron para superar las barreras del diagnóstico precoz de la lepra. El objetivo de este estudio fue analizar la relación de costo-efectividad de un nuevo algoritmo de diagnóstico recomendado por el gobierno brasileño para diagnosticar la lepra en contactos domiciliarios de casos confirmados de lepra, que incluye las pruebas RT y RT-PCR. Se construyó un modelo de árbol de decisión y se adoptó la perspectiva del Sistema Único de Salud (SUS) teniendo en cuenta el periodo de un año. Solo se incluyeron los costos médicos directos relacionados con los exámenes diagnósticos. Se midió la efectividad teniendo en cuenta el número de casos de lepra evitados. Se analizaron distintos escenarios. Se comparó el uso secuencial de RT, baciloscopia y RT-PCR, conforme el Ministerio de Salud recomienda, con un caso base (baciloscopia aislada), y se obtuvo un cociente de costo-efectividad incremental de USD 616,46 por cada caso de lepra evitado. El análisis de sensibilidad univariante mostró que la prevalencia de lepra entre contactos intradomiciliarios fue la variable que más influyó el modelo. Este es el primer modelo económico que analiza un algoritmo diagnóstico de lepra. Los resultados podrán ayudar los gestores a definir políticas y estrategias para erradicar la lepra en Brasil.

Characterization of cases and epidemiological and operational indicators of leprosy: analysis of time series and spatial distribution, Piauí state, Brazil, 2007-2021 / Caracterización de casos e indicadores epidemiológicos y operativos de la lepra: análisis de series temporales y distribución espacial, Piauí, Brasil, 20072021 / Caracterização de casos e indicadores epidemiológicos e operacionais da hanseníase: análise de séries temporais e distribuição espacial, Piauí, 2007-2021

ABSTRACT Objective To analyze epidemiological characteristics, temporal trends and spatial distribution of leprosy cases and indicators in the state of Piauí, 2007-2021. Methods This was an ecological time-series study using data from the Notifiable Health Conditions Information System, describing the spatial distribution and the temporal trend of leprosy using Prais-Winsten regression. Results A total of 17,075 new cases of leprosy were reported. There was a falling trend in the overall detection rate [annual percentage change (APC) = -6.3; 95%CI -8.1;-4.5)], detection in children under 15 years of age (APC = -8,6; 95%CI -12,7;-4,3) and detection of cases with grade 2 physical disability (APC = -4,4; 95%CI -7,0;-1,8). There was a rising trend in the proportion of multibacillary cases. Spatial distribution of the average detection rate identified hyperendemic areas in the Carnaubais, Entre Rios, Vale dos Rios Piauí e Itaueiras regions. Conclusion High leprosy detection rates were found, despite the falling trend of indicators, except the proportion of multibacillary cases.

RESUMEN Objetivo Analizar características epidemiológicas, tendencias temporales, distribución espacial de casos y indicadores de lepra en el estado de Piauí, 2007-2021. Métodos Estudio ecológico de series temporales con datos del Sistema de Información de Enfermedades de Notificación que describen la distribución espacial y la tendencia temporal de la lepra mediante la regresión de Prais-Winsten. Resultados Se notificaron 17.075 nuevos casos de lepra. Hubo tendencia decreciente en las tasas de detección general [variación porcentual anual (VPA) = -6,3; IC95% -8,1; -4,5], detección en menores de 15 años (VPA = -8,6; IC95% -12,7; -4,3), y detección de casos con discapacidad física grado 2 (VPA = -4,4; IC95%-7,0; -1,8). Hubo una tendencia creciente en la proporción de casos multibacilares. La distribución espacial de la tasa promedio de detección identificó áreas hiperendémicas en las regiones de Carnaubais, Entre Rios, Vale dos Rios Piauí y Itaueiras. Conclusión Se observaron altas tasas de detección de lepra, a pesar de la tendencia decreciente de los indicadores, excepto la proporción de casos multibacilares

RESUMO Objetivo Analisar características epidemiológicas, tendência temporal, distribuição espacial de casos e indicadores da hanseníase no estado do Piauí, 2007-2021. Métodos Estudo ecológico de séries temporais com dados do Sistema de Informação de Agravos de Notificação, descrevendo a distribuição espacial e a tendência temporal da hanseníase pela regressão de Prais-Winsten. Resultados Foram notificados 17.075 novos casos de hanseníase. A distribuição espacial da taxa média de detecção identificou áreas hiperendêmicas nas regiões Carnaubais, Entre Rios, Vale dos Rios Piauí e Itaueiras. Verificou-se tendência decrescente nas taxas de detecção geral [variação percentual anual (VPA) = -6,3; IC95% -8,1;-4,5], de detecção em menores de 15 anos (VPA = -8,6; IC95%12,7;-4,3) e de detecção de casos com grau 2 de incapacidade física (VPA = -4,4; IC95%-7,0;1,8), e tendência crescente na proporção de casos multibacilares. Conclusão Observaram-se elevadas taxas de detecção de hanseníase, apesar da tendência decrescente dos indicadores, exceto a proporção de casos multibacilares.

Leprosy in children under fifteen years of age in the most hyperendemic municipality in Brazil / Hanseníase em menores de quinze anos no município mais hiperendêmico do Brasil

ABSTRACT Objective: To describe leprosy involvement and physical disability profiles in children and adolescents under 15 years old. Methods: Ecological time series study, based on data from the Brazilian Notifiable Diseases Information System, including new cases of leprosy residing in Palmas (TO), from 2001 to 2020. Results: A total of 471 notified cases in children and adolescents under 15 years of age were evaluated, resulting in a detection coefficient of 26.5 per 100,000 inhabitants. Of these, 52% (n=243) were women, 5% (n=24) corresponded to grade two disability, and 36% (n=168) were diagnosed through spontaneous demand. The temporal trend analysis showed a 0.5% reduction in the detection coefficient. There was a significant decrease in the diagnosis of the undetermined and tuberculoid clinical forms and a significant increase in the dimorphous form. Diagnosis through contact examination increased significantly by 13.1% and that through spontaneous demand decreased by 4.9%. The detection coefficient of cases with grade two disability reduced significantly by 7.4% while those with grade one increased by 16.8%. Conclusions: Despite the downward trend in the detection coefficient in children and adolescents under 15 years of age and in cases with grade two disability, other factors indicate failure in the adequate management of leprosy in Palmas.

RESUMO Objetivo: Descrever os perfis de acometimento de hanseníase e incapacidade física em menores de 15 anos. Métodos: Estudo ecológico de série temporal, baseado em dados do Sistema Nacional de Agravos de Notificação, incluindo casos novos de hanseníase residentes em Palmas (TO), no período de 2001 a 2020. Resultados: Foram avaliados 471 casos notificados em crianças e adolescentes menores de 15 anos, resultando em um coeficiente de detecção de 26,5 por cem mil habitantes. Destes, 52% (n=243) eram do gênero feminino, 5% (n=24) correspondiam ao grau dois de incapacidade física, e 36% (n=168) foram diagnosticados por demanda espontânea. A análise de tendência temporal mostrou queda do coeficiente de detecção em 0,5%. Houve queda significativa no diagnóstico das formas clínicas indeterminada e tuberculoide e aumento significativo da dimorfa. O diagnóstico por exame de contato teve um aumento significativo de 13,1% e o por demanda espontânea, queda significativa de 4,9%. O coeficiente de detecção de casos com grau dois de incapacidade apresentou uma queda significativa de 7,4%, enquanto o de casos com grau um, apresentou um aumento de 16,8%. Conclusões: Apesar da tendência de queda do coeficiente de detecção em menores de 15 anos e do coeficiente de detecção de casos com grau dois de incapacidade, outros fatores indicam falha no manejo adequado da hanseníase em Palmas.

Baciloscopia para hanseníase no Sistema Único de Saúde do Brasil entre 2013 e 2022 / Bacilloscopy for leprosy in Brazil's public health system between 2013 and 2022

Objetivo: Avaliar a quantidade anual de baciloscopias para hanseníase realizadas no Sistema Único de Saúde (SUS) nos últimos dez anos. Métodos: Foi realizado um estudo ecológico, longitudinal, retrospectivo e quantitativo, utilizando dados do Sistema de InformaçõesAmbulatoriais (SIA/SUS). A quantidade de baciloscopias para hanseníase a cada 100.000 residentes foi estimada para o Brasil e suas cinco macrorregiões, avaliada entre 2013 e 2022 com nível de significância (a) de 5%. Resultados:Mais de 1,3 milhões de baciloscopias foram notificadas nos últimos dez anos no SUS. A mediana da incidência anual foi de 67 baciloscopias para hanseníase por 100.000 residentes, sendo a máxima observada em 2013 (82) e a mínima em 2022 (46). As incidências anuais nas macrorregiões Norte, Centro-oeste e Nordeste foram significativamente superiores à estimativa nacional, enquanto no Sul e Sudeste foram inferiores (p<0,05). A tendência temporal foi considerada decrescente para a estimativa nacional (p= 0,002), com variação percentualanual de -5,6% (IC95% = -3,8%; -8,2%). Entretanto, após desconsiderar os anos da pandemia de COVID-19 (2020-2022), a tendência tornou-se estacionária (p= 0,181). Além disso, a incidência durante o período pré-pandêmico foi significativamente maior quandocomparada ao terceiro ano após o advento da pandemia em todas as macrorregiões do Brasil (p<0,05). Conclusão:Foi possível concluir que o SUS realizou um número expressivo de baciloscopias para hanseníase nos últimos dez anos, mas existem disparidades macrorregionais no Brasil, bem como um impacto significativo da pandemia de COVID-19

Objective:To evaluate the annual number of skin smear microscopies for leprosy performed in the Unified Health System (SUS) in the last decade. Methods:An ecological, longitudinal, retrospective, and quantitative study was conducted using data from the Ambulatory Information System (SIA/SUS). The number of skin smear microscopies for leprosy per 100,000 residents was estimated for Brazil and its five macroregions, between 2013 and 2022, with a significance level (a) of 5%.Results:More than 1.3 million skin smear microscopies were reported in the last decade in the SUS. The median annual incidence was 67 skin smear microscopies for leprosy per 100,000 residents, with the maximum observed in 2013 (82) and the minimum in 2022 (46). Annual incidences in the North, Central-West, and Northeast macro-regions were significantly higher than the national estimate, whereas in the South and Southeast, they were lower (p <0.05). The temporal trend was considered decreasing for the national estimate (p = 0.002), with an annual percentage variation of -5.6% (95%CI = -3.8%; -8.2%). However, after disregarding the years of the COVID-19 pandemic (2020-2022), the trend became stationary (p = 0.181). Furthermore, the incidence during the pre-pandemic period was significantly higher compared with the third year after the advent of the pandemic in all macro-regions of Brazil (p<0.05).Conclusion:It was possible to conclude that the SUS performed a significant number of skin smear microscopies for leprosy in the last ten years, but there are macro-regional disparities in Brazil and a significant impact of the COVID-19 pandemic

A web-based survey to map the electromyography practice in Brazil.

BACKGROUND: Detailed information about the electromyography practice in Brazil is largely unavailable. OBJECTIVE: To evaluate where and how electromyography is performed in Brazil, as well as regional disparities and the professional and academic credentials of electromyographers. METHODS: We conducted an internet-based survey of active Brazilian electromyographers. The websites of health insurance companies, professional academies, medical cooperatives, online search engines, and social networks in each Brazilian state were screened and we evaluated the credentials of each electromyographer listed in the Brazilian Federal Medical Board (BFMB) registration website and their online curricula vitae in the Brazilian National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq, in Portuguese). We also evaluated the same parameters in a control group of non-electromyographer neurologists randomly matched by geographical distribution and gender. RESULTS: We found 469 electromyographers (384 neurologists and 85 non-neurologists), with a male predominance. In total, 81.9% were BFMB-certified neurologists, 49.9%, BFMB-certified clinical neurophysiologists, and 10.4%, BFMB-certified physiatrists. Among the non-neurologists, 48.2% were physiatrists. Most electromyographers practiced in states on the Southern and Southeastern regions of Brazil. When adjusted by population, the Federal District and the states of Mato Grosso do Sul and Goiás presented the highest of eletromyographers density. Electromyographers were not more likely to have current/past academic affiliations. CONCLUSION: In Brazil, electromyography is performed predominantly by neurologists, and half of them are BFMB-certified clinical neurophysiologists. The present study highlights regional disparities and may guide government-based initiatives, for instance, to improve the diagnosis of leprosy and the management of neuromuscular disorders within the Brazilian territory.

ANTECEDENTES: Informações detalhadas sobre a prática de eletromiografia no Brasil são em grande parte indisponíveis. OBJETIVO: Avaliar onde e como a eletromiografia é realizada no Brasil, as disparidades regionais, e as credenciais profissionais e acadêmicas dos eletromiografistas. MéTODOS: Realizamos uma enquete via internet de eletromiografistas brasileiros ativos. Foram rastreados sites de operadoras de planos de saúde, academias profissionais médicas, cooperativas médicas, ferramentas de busca online e redes sociais em cada estado brasileiro. Em seguida, avaliamos as credenciais de cada eletromiografista listado no site de registro do Conselho Federal de Medicina (CFM) e seus curricula vitae online no Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Também avaliamos os mesmos parâmetros em um grupo controle de neurologistas não eletromiografistas pareados aleatoriamente por distribuição geográfica e gênero. RESULTADOS: Encontramos 469 eletromiografistas (384 neurologistas e 85 não neurologistas), com predominância do sexo masculino. Ao todo, 81,9% eram neurologistas com certificação confirmada pelo site do CFM, 49,9%, neurofisiologistas clínicos com certificação confirmada pelo site do CFM, e 10,4%, fisiatras com certificação confirmada pelo mesmo site. Entre os não neurologistas, 48,2% eram fisiatras. A maioria dos eletromiografistas atuava nos estados do Sul e do Sudeste. Quando ajustados pela população, o Distrito Federal e os estados de Mato Grosso do Sul e Goiás apresentaram a maior densidade de eletromiografistas. Os eletromiografistas não eram mais propensos a ter vínculos acadêmicos atuais/passados. CONCLUSãO: No Brasil, a eletromiografia é realizada predominantemente por neurologistas, e metade deles são neurofisiologistas clínicos com certificação confirmada pelo site do CFM. Este estudo destacou as disparidades regionais, e pode orientar ações governamentais para, por exemplo, melhorar o diagnóstico da hanseníase e o manejo das doenças neuromusculares no território brasileiro.

Socio-historical representations of a disease: a study of posters from campaigns against Hansen's disease during the second half of the twentieth century. / Representações sócio-históricas de uma doença: um estudo sobre cartazes de campanhas para o combate à hanseníase na segunda metade do século XX.

This article analyzes the use of iconographic sources in the context of educational campaigns to combat Hansen's disease from a socio-historical perspective at four points in time: the 1950s, 1960s, 1980s, and 1990s. Four posters are analyzed to identify the elements (textual, visual or graphic) used to develop discourse on this disease and those it affected and transformations and permanences in this discourse, as well as to verify how they became part of a narrative of institutional memory linked to public health in the state of São Paulo. These were produced by various public health institutions and are part of the Health Campaign Poster Collection held by the Emílio Ribas Public Health Museum.

Este artigo analisa o uso de fontes iconográficas no contexto das campanhas educativas para o combate à hanseníase numa perspectiva sócio-histórica em quatro momentos: décadas de 1950, 1960, 1980 e 1990. São analisados quatro cartazes para identificar os elementos (textuais, visuais ou gráficos) utilizados para elaborar um discurso sobre a doença e os doentes; suas transformações discursivas e permanências, além de verificar como se tornaram parte de uma narrativa de memória institucional ligada à saúde pública paulista. As fontes estudadas fazem parte da coleção Cartazes de Campanhas de Saúde, cujos itens foram produzidos por diversas instituições ligadas à saúde pública e integram o acervo do Museu de Saúde Pública Emílio Ribas.

A web-based survey to map the electromyography practice in Brazil / Uma enquete via internet para mapear a prática de eletromiografia no Brasil

Abstract Background Detailed information about the electromyography practice in Brazil is largely unavailable. Objective To evaluate where and how electromyography is performed in Brazil, as well as regional disparities and the professional and academic credentials of electromyographers. Methods We conducted an internet-based survey of active Brazilian electromyographers. The websites of health insurance companies, professional academies, medical cooperatives, online search engines, and social networks in each Brazilian state were screened and we evaluated the credentials of each electromyographer listed in the Brazilian Federal Medical Board (BFMB) registration website and their online curricula vitae in the Brazilian National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq, in Portuguese). We also evaluated the same parameters in a control group of non-electromyographer neurologists randomly matched by geographical distribution and gender. Results We found 469 electromyographers (384 neurologists and 85 non-neurologists), with a male predominance. In total, 81.9% were BFMB-certified neurologists, 49.9%, BFMB-certified clinical neurophysiologists, and 10.4%, BFMB-certified physiatrists. Among the non-neurologists, 48.2% were physiatrists. Most electromyographers practiced in states on the Southern and Southeastern regions of Brazil. When adjusted by population, the Federal District and the states of Mato Grosso do Sul and Goiás presented the highest of eletromyographers density. Electromyographers were not more likely to have current/past academic affiliations. Conclusion In Brazil, electromyography is performed predominantly by neurologists, and half of them are BFMB-certified clinical neurophysiologists. The present study highlights regional disparities and may guide government-based initiatives, for instance, to improve the diagnosis of leprosy and the management of neuromuscular disorders within the Brazilian territory.

Resumo Antecedentes Informações detalhadas sobre a prática de eletromiografia no Brasil são em grande parte indisponíveis. Objetivo Avaliar onde e como a eletromiografia é realizada no Brasil, as disparidades regionais, e as credenciais profissionais e acadêmicas dos eletromiografistas. Métodos Realizamos uma enquete via internet de eletromiografistas brasileiros ativos. Foram rastreados sites de operadoras de planos de saúde, academias profissionais médicas, cooperativas médicas, ferramentas de busca online e redes sociais em cada estado brasileiro. Em seguida, avaliamos as credenciais de cada eletromiografista listado no site de registro do Conselho Federal de Medicina (CFM) e seus curricula vitae online no Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Também avaliamos os mesmos parâmetros em um grupo controle de neurologistas não eletromiografistas pareados aleatoriamente por distribuição geográfica e gênero. Resultados Encontramos 469 eletromiografistas (384 neurologistas e 85 não neurologistas), com predominância do sexo masculino. Ao todo, 81,9% eram neurologistas com certificação confirmada pelo site do CFM, 49,9%, neurofisiologistas clínicos com certificação confirmada pelo site do CFM, e 10,4%, fisiatras com certificação confirmada pelo mesmo site. Entre os não neurologistas, 48,2% eram fisiatras. A maioria dos eletromiografistas atuava nos estados do Sul e do Sudeste. Quando ajustados pela população, o Distrito Federal e os estados de Mato Grosso do Sul e Goiás apresentaram a maior densidade de eletromiografistas. Os eletromiografistas não eram mais propensos a ter vínculos acadêmicos atuais/passados. Conclusão No Brasil, a eletromiografia é realizada predominantemente por neurologistas, e metade deles são neurofisiologistas clínicos com certificação confirmada pelo site do CFM. Este estudo destacou as disparidades regionais, e pode orientar ações governamentais para, por exemplo, melhorar o diagnóstico da hanseníase e o manejo das doenças neuromusculares no território brasileiro.

[The plans of Ernesto Ottoni to Combat the "affliction of lepers:" lazarettos, treatments, and endeavors to tackle leprosy in nineteenth century São Paulo]. / Os planos de Ernesto Ottoni contra o "mal dos lázaros": lazaretos, terapêuticas e trabalho no combate à lepra em São Paulo, século XIX.

This article presents the plans for a lazaretto in the city of São Paulo in the mid-nineteenth century. It consists of the transcription and analysis of an opinion prepared by the physician Ernesto Benedicto Ottoni, addressed to the president of the province of São Paulo. The article includes an analysis of the plans for the building, bearing in mind the prevailing miasma theory; the contemporary conceptions of leprosy treatment, especially beliefs regarding the transmissibility of the disease; and the physician's idealization of the routines for the treatment, work, leisure, and recovery of patients.

O trabalho a seguir objetiva apresentar o projeto de estabelecimento de um lazareto para morféticos na cidade de São Paulo em meados do século XIX. Trata-se da transcrição e análise de um parecer elaborado pelo médico Ernesto Benedicto Ottoni e endereçado ao presidente da província de São Paulo. Analisamos os planos da construção do prédio, principalmente levando em consideração a teoria dos miasmas; concepções sobre as terapêuticas da lepra na época, sobretudo quanto à transmissibilidade da doença; e, por fim, a idealização do médico acerca das rotinas de tratamento, trabalho, lazer e recuperação dos doentes.

Leprosy prevalence spatial distribution and trend in a health region in Northeast Brazil, 2008-2017: an ecological study.

MAIN RESULTS: A total of 4,029 leprosy cases were notified. Mean prevalence varied between 2.0 and 11.5 cases/10,000 inhab. Spatial distribution of the cases was heterogeneous and there was a falling prevalence trend over the years studied. IMPLICATIONS FOR SERVICES: These findings point to the need to strengthen active tracing strategies and expand health actions and services targeting leprosy, with the aim of increasing detection and early treatment of cases. PERSPECTIVES: It is important to carry out epidemiological investigations on the spatial distribution and prevalence of leprosy in other health regions in the state, in order to identify other areas with greater vulnerability to leprosy. OBJECTIVE: to analyse the spatial distribution and trend of leprosy in municipalities of a health region in a Northeast Brazilian state. METHODS: this was an ecological time-series study based on compulsory notification of leprosy cases by the municipalities covered by the Imperatriz-MA Regional Health Management Unit, between 2008 and 2017; prevalence and mean prevalence for the period were calculated; spatial analysis of the area was carried out and maps were generated using ArcGis 10.5. Prais-Winsten regression was used for trend analysis. RESULT: 4,029 cases of the disease were identified, and average prevalence ranged from 2.0 to 11.5 cases/10,000 inhabitants-year. The overall trend was downward. Governador Edson Lobão had the highest prevalence, 11.5 cases/10,000 inhabitants, and Lajeado Novo had the lowest prevalence, 2.0 cases/10,000 inhabitants. CONCLUSION: spatial distribution of leprosy cases was heterogeneous in the municipalities studied and prevalence had a falling trend.

From Passos the Indian to Doctor Chernoviz: experiments to cure leprosy in nineteenth-century Pará. / Do índio Passos ao doutor Chernoviz: experiências de cura da lepra no Pará do século XIX.

This article analyzes an experiment to cure leprosy using the assacu plant (Hura crepitans L.) conducted in Santarém, Pará, in 1847, by an Indigenous man named Antonio Vieira dos Passos. The experiment was later repeated in other Brazilian provinces and abroad. This article establishes relationships between medical practices in other parts of the country while focusing on the dialog between official and Indigenous medicine. Newspaper articles and official documents of the time show that Indigenous knowledge of medicinal plants was widely recognized and utilized by physicians wishing to incorporate it into the official therapeutic repertoire.

O artigo analisa uma experiência de cura da lepra com assacu (Hura crepitans L.), realizada em Santarém, Pará, em 1847, por um indígena chamado Antonio Vieira dos Passos. A experiência passou a ser realizada nas demais províncias do Brasil e também no exterior. Por essa razão, o artigo estabelece relações com práticas médicas realizadas em outras partes do país, tendo como foco o diálogo entre a medicina oficial e a medicina indígena. A análise de matérias de jornais e documentos oficiais revelou que os saberes indígenas sobre o uso de plantas medicinais eram amplamente reconhecidos e utilizados pelos médicos com a intenção de incorporá-los em seu repertório terapêutico.

Factors associated with multibacillary leprosy in a region of northeastern Brazil.

INTRODUCTION: The analysis of factors associated with multibacillary leprosy is important for the development of strategies to mitigate the disease, which persists as a public health problem in Brazil and the world. The objective of this study was to verify the associations between sociodemographic and clinical-epidemiological variables and multibacillary leprosy in the state of northeastern Brazil. METHODOLOGY: This is a cross-sectional, analytical, and retrospective study, with a quantitative approach, carried out in 16 municipalities in the southwest of Maranhão State, northeastern Brazil. All cases of leprosy reported between January 2008 and December 2017 were considered. Sociodemographic and clinical-epidemiological variables were analyzed using descriptive statistics. The identification of the risk factors associated with multibacillary leprosy was conducted using Poisson regression models. The prevalence ratios and respective 95% confidence intervals were estimated using regression coefficients at a 5% significance level. RESULTS: A total of 3,903 leprosy cases were analyzed. Individuals older than 15 years, males, with less than 8 years of education, with level I, II, or "not evaluated" disability, and with type 1 or 2 or both reactional states were more likely to have multibacillary leprosy. Therefore, these characteristics may be considered risk factors. No protective factors were identified. CONCLUSIONS: The investigation revealed important associations between risk factors and multibacillary leprosy. The findings can be considered during the creation of strategies to control and combat the disease.

Spatial analysis of the epidemiological risk of leprosy in the municipalities of Minas Gerais.

BACKGROUND: Leprosy remains a significant public health problem of high importance. This investigation aims to analyze the spatial distribution of the leprosy epidemiological risk in the municipalities of Minas Gerais. METHODS: This ecological study was conducted with new leprosy cases diagnosed from 2004 to 2019 in the municipalities of the state of Minas Gerais. Based on the epidemiological indicators, a composite indicator called the leprosy epidemiological risk index was estimated, classifying municipalities as high, medium, low and very low risk. For the spatial analysis, the global and local spatial autocorrelation statistics were used to identify the spatial distribution of the leprosy epidemiological risk in the periods 2004-2011 and 2012-2019 and classified as High/High, Low/Low, High/Low and Low /High. RESULTS: Although leprosy is declining in the state of Minas Gerais, the Global Moran Index confirmed the spatial dependence between municipalities for the two analyzed periods, characterizing the formation of clusters. When performing the local spatial autocorrelation, it was found that the macroregions with the highest number of municipalities with high indices, surrounded by other municipalities with high indices (high-high), were Northwest, East, South East, North, and Northeast. The low risk macroregions were Southeast, Center, South-Center and South. CONCLUSION: Leprosy has a heterogeneous spatial pattern and remains concentrated in historically endemic areas of the state. It underscores the importance of intensifying actions to combat leprosy in these municipalities and macroregions. Promote improved access to health services and combat stigma and prejudice to eliminate leprosy as a public health problem.

Negligência no diagnóstico precoce de hanseníase na atenção primária: um relato de caso / Negligence in the early diagnosis of leprosy in primary care: a case report

A hanseníase é uma doença infecciosa, transmissível, de caráter crônico, com potencial grau de incapacidade, que ainda persiste como problema de saúde pública no Brasil. A demora e a falta de conhecimento técnico para realizar o diagnóstico resulta em inúmeros prejuízos aos pacientes acometidos pela doença, sendo que, a prevenção das incapacidades está relacionada diretamente com o diagnóstico precoce da doença. Com a finalidade de evitar a negligência diagnóstica e o desenvolvimento de incapacidades físicas, ressaltamos a importância do conhecimento técnico sobre o diagnóstico e o manejo da hanseníase por profissionais da saúde em qualquer nível de atenção à saúde ou especialidade.

Hansen is an infectious disease, transmissible, of a chronic nature, with serious potential for disability, which still persists as a public health problem in Brazil. The delay and the lack of technical knowledge to carry out the diagnosis with numerous prejudices to the patients affected by the disease, since the prevention of disabilities is directly related to the early diagnosis of the disease. In order to avoid diagnostic negligence and the development of physical disabilities, we highlight the importance of technical knowledge about the diagnosis and management of training by health professionals at any level of health care or special care.

Características sociodemográficas e epidemiológicas relacionadas ao grau de incapacidade física em hanseníase no estado da Paraíba, Brasil / Sociodemographic and epidemiological characteristics related to the degree of physical disability in leprosy in the state of Paraíba, Brazil

Objetivou-se analisar a associação entre características sociodemográficas e clínicas com o desenvolvimento dos graus de incapacidades físicas 1 ou 2 em pessoas com diagnóstico de hanseníase na Paraíba, Brasil. Estudo ecológico, de base populacional, que teve como unidades de análises os 223 municípios do estado. Os dados foram coletados no Núcleo de Doenças Crônicas e Negligenciadas/Hanseníase, pertencente à Gerência Executiva de Vigilância em Saúde da Secretaria de Saúde do estado da Paraíba em junho de 2021, após extração do Sistema de Informação Nacional de Agravos de Notificação. O banco de dados reuniu 2.468 casos novos de hanseníase registrados no período de 2016 a 2020. A chance de uma pessoa diagnosticada com hanseníase desenvolver a incapacidade física 1 ou 2 é maior nas pessoas de sexo masculino, com 15 anos ou mais, estudo formal menor ou igual a nove anos, classificação operacional multibacilar, com mais de cinco lesões e mais de um nervo afetado, além de baciloscopia positiva. Políticas de educação em saúde são fortemente recomendadas no intuito de melhorar o conhecimento dos profissionais e da comunidade. Abordagens sobre a hanseníase, diagnóstico precoce, busca ativa, vigilância e acompanhamento dos casos e de seus contatos, além das incapacidades físicas, em especial para pessoas de maior vulnerabilidade a desenvolvê-las, são fundamentais.(AU)

The objective was to analyze the association between sociodemographic and clinical characteristics with the development of physical physical disabilities of grades 1 and 2 in people diagnosed with leprosy in Paraíba, Brazil. It's an ecological study, population-based, which had the 223 municipalities at the Center of Chronic and Neglected Diseases/Leprosy belonging to the Health Surveillance Executive Management of Health Department of Paraíba State in June 2021, after extraction from the Notifiable Diseases Information System. The database gathered 2,468 new cases of leprosy registered in the period from 2016 to 2020. The probability of a person diagnosed with leprosy developing physical disability 1 or 2 is greater in males, aged 15 or over, formal education less than or equal to nine years, operational classification multibacillary, with more than five lesions and more than one affected nerve, in addition to positive bacilloscopy. Health education policies are strongly recommended in order to improve the knowledge of professionals and the community. Approaches about leprosy, early diagnosis, active search, surveillance and follow-up of cases and their contacts, in addition to physical disabilities, especially for people who are more vulnerable to develop them, are fundamental.(AU)

Evolução do grau de incapacidade física e do escore olhos, mãos e pés em casos novos de hanseníase: do diagnóstico à alta medicamentosa / Evolution of the degree of physical disability and the eye, hand and foot score in new cases of leprosy: from diagnosis to medication discharge

Este estudo tem por objetivo avaliar a evolução do grau de incapacidade física e do escore olhos, mãos e pés, do diagnóstico à alta medicamentosa, segundo as variáveis sociodemográficas e clínicas, em pacientes diagnosticados com hanseníase. Trata-se de estudo transversal, baseado na análise de 71 pacientes com diagnóstico de hanseníase, acompanhados no Hospital Eduardo de Menezes, centro de referência em Belo Horizonte, Minas Gerais, Brasil, entre janeiro de 2017 a dezembro de 2020. Foi observado predomínio do sexo feminino (53,5%), média de idade de 46 anos, sendo a maioria procedente de outros municípios do interior de Minas Gerais (54,9%). A forma clínica mais frequente foi a dimorfa (64,8%), classificação operacional multibacilar (84,5%). O grau de incapacidade física 0 foi o mais prevalente no diagnóstico (56,5%) e na alta (53,1%), e em relação ao escore olhos, mãos e pés, houve variação entre 0 e 10 no diagnóstico e entre 0 e 8 na alta. Pelo teste de McNemar foi observado que dentre os pacientes que apresentavam algum grau de incapacidade física no momento do diagnóstico, 30,8% apresentaram ausência de incapacidade na alta. Ao comparar a evolução do grau de incapacidade física de paucibacilares e multibacilares no momento do diagnóstico e da alta, houve manutenção em 59,3% e melhora em 17,2% dos pacientes. Os dados apresentados indicam que muitos pacientes foram tratados tardiamente já apresentando as formas graves e com sequelas, já que o estudo foi desenvolvido em um centro de referência, que atende casos mais complexos e com complicações já instaladas. Os dados sugerem que pacientes assistidos que realizam o tratamento com poliquimioterapia podem ter melhora das incapacidades já instaladas. O mesmo ocorreu com o escore olhos, mãos e pés, que ao final do tratamento instituído houve melhora se comparado com a admissão.(AU)

This study aims to evaluate the evolution of the degree of physical disability and the eye, hand and foot score, from diagnosis to medication discharge, according to sociodemographic and clinical variables, in patients diagnosed with leprosy. This is a cross-sectional study, based on the analysis of 71 patients diagnosed with leprosy, followed by Hospital Eduardo de Menezes, a reference center in Belo Horizonte, Minas Gerais, Brazil, between January 2017 and December 2020. There was a predominance of females (53.5%), average age of 46 years old, the majority coming from other municipalities in the interior of Minas Gerais (54.9%). The most frequent clinical form was borderline (64.8%), multibacillary operational classification (84.5%). Degree of physical disability 0 was the most prevalent at diagnosis (56.5%) and at discharge (53.1%); in relation to the eye, hand and foot score, there was variation between 0 and 10 at diagnosis and between 0 and 8 at discharge. By the McNemar test, it was observed that of the patients who had degree of physical disability at the time of diagnosis, 30.8% had no disability at discharge. When comparing the evolution of the GIF in paucibacillary and multibacillary patients at the time of diagnosis and discharge, there was maintenance in 59.3% and improvement in 17.2% of the patients. The presented data indicates that many patients were treated late, already presenting severe forms and with sequelae, since the study was carried out in a reference center, which treats cases with complications already installed and more complex cases. The data suggest that assisted patients undergoing treatment with multidrug therapy may experience improvement in disabilities already established. The same occurred with eye, hand and foot score, at the end of the established treatment there was an improvement compared to admission.(AU)

Self-reported clinical history of misdiagnosed leprosy cases in the State of Mato Grosso, Brzil, 2016-2019.

This study aimed to analyze the self-reported clinical history of patients misdiagnosed with leprosy in the State of Mato Grosso, Brazil. This is a cross-sectional study of new leprosy cases diagnosed in the State of Mato Grosso from 2016 to 2019, with individuals who were released from multidrug therapy due to misdiagnosis after starting treatment. Data were collected via telephone interviews. Over the study period, 354 leprosy cases were released from treatment due to misdiagnosis, of which 162 (45.8%) could be interviewed. All interviewees expressed dissatisfaction with their treatment, which prompted them to seek a reevaluation of their diagnosis before they were released due to "misdiagnosis". Among them, 35.8% received a final diagnosis of a musculoskeletal or connective tissue disease - mainly fibromyalgia and degenerative changes in the spine - followed by 13.6% with diagnoses of skin and subcutaneous tissue diseases. For 23.5% of the respondents, no alternative diagnosis was established, whereas 7.4% were later re-diagnosed with leprosy. Fibromyalgia and spinal problems were the most common alternative diagnoses for erroneous leprosy. Although the diagnosis of leprosy is usually clinical and does not require access to technical infrastructure in most cases, some more complex situations require diagnostic support via complementary tests, as well as close collaboration between primary care and reference services.

ML Flow serological test: complementary tool in leprosy.

BACKGROUND: The evaluation of household contacts of leprosy cases allows the early diagnosis of new cases. OBJECTIVE: To associate the results of the ML Flow test with the clinical characteristics of leprosy cases and to verify their positivity in household contacts, in addition to describing the epidemiological profile of both. METHODS: Prospective study with patients diagnosed over the course of one year (n = 26), without prior treatment, and their household contacts (n = 44) in six municipalities in northwestern São Paulo, Brazil. RESULTS: There was a predominance of men among the leprosy cases, of 61.5% (16/26); 77% (20/26) were over 35 years old; 86.4% (22/26) were multibacillary; 61.5% (16/26) had a positive bacilloscopy; and 65.4% (17/26) had no physical disability. The ML Flow test was positive in 53.8% (14/26) of the leprosy cases and was associated with those who had a positive bacilloscopy and were diagnosed as multibacillary (p-value <0.05). Among the household contacts, 52.3% (23/44) were women and aged over 35 years; 81.8% (36/44) had been vaccinated with BCG ‒ Bacillus Calmette-Guérin. The ML Flow test was positive in 27.3% (12/44) of household contacts, all of whom lived with multibacillary cases; seven lived with positive bacilloscopy cases and six with consanguineous cases. STUDY LIMITATIONS: Difficulty in convincing the contacts to undergo the evaluation and collection of the clinical sample. CONCLUSION: The ML Flow test, when positive in household contacts, can help the identification of cases that require more attention by the health team, as it indicates a predisposition to disease development, especially when they are household contacts of multibacillary cases, with positive bacilloscopy and consanguineous. The ML Flow test also helps in the correct clinical classification of the leprosy cases.

Assessment of neuropathic pain, functional activity limitation and quality of life of people affected by leprosy in an endemic area in Northeast Brazil: a cross-sectional study.

BACKGROUND: This study investigated the prevalence of neuropathic pain (NP) among people affected by leprosy and its effects on functional limitation and health-related quality of life (HRQoL) in an endemic area in Northeast Brazil. METHODS: This is a cross-sectional study of 122 leprosy patients. Functional limitation and HRQoL were assessed using the Screening of Activity Limitation and Safety Awareness (SALSA) and WHO Quality-of-Life (WHOQoL-BREF) scales, respectively. Participants were assessed for the presence of pain and completed the Douleur Neuropathique 4 and the Brief Pain Inventory scales. RESULTS: The prevalence of NP was 59%. Participants with NP had higher SALSA scores than those without pain (median; IQR: 42; 32-49.5 vs 27.5; 24-34; p=0.002). Increasing SALSA scores were related to decreasing WHOQoL-BREF scores in the physical (r=-0.54; p<0.001), psychological (r=-0.33; p=0.002) and environmental (r=-0.22; p=0.01) domains, but not in the social domain (r=-0.14; p=0.10). Individuals with NP had the lowest scores in all domains compared with individuals without pain. CONCLUSIONS: Appropriate tools and training of clinicians for diagnosing NP in leprosy patients are necessary for their appropriate management and better HRQoL outcomes.