Commingled crypts: Comparative health among Byzantine monastics in the Levant.

OBJECTIVES: Early Byzantine (A.D. 330-842) monastic rules stipulated that entrants relinquished familial connections, personal belongings and secular relationships to become part of the ascetic collective that continued in death, resulting in bioarchaeological marginalization, as was the case of the monastics excavated from the Chapel of Robebus at Mount Nebo, Jordan (ca. A.D. 491-640). It was hypothesized that compared to contemporary monastic groups, the Mount Nebo monastics experienced poorer health and gravitated to Mount Nebo, owing to its association with the Prophet Moses and proximity to the Dead Sea, Livias baths and Jordan River, all associated with curative benefits, especially for those suffering from leprosy. MATERIALS AND METHODS: The commingled remains of 73 adult males from Mount Nebo and the articulated skeletons (n = 27) from the Sanctuary of Agios Lot at Deir 'Ain 'Abata (Jordan) were assessed for paleopathology, then compared with a contemporary commingled group from the Monastery of Saint Euthymius at Khan-el-Ahmar (Judean Desert) (n = 117). RESULTS: No skeletal evidence of leprosy was observed among the groups. Most Mount Nebo individuals did not reach an older age, yet injuries, severe osteoarthritis, lower leg osteoperiostitis and antemortem tooth loss were common. The paleopathological profile was similar at Deir 'Ain 'Abata, but paleopathology was negligible at Khan-el-Ahmar. CONCLUSIONS: The similar paleopathological profiles of the Jordanian monastic groups suggest that the proximity to the Dead Sea may have attracted monastics to both sites, in addition to spirituality, but leprosy was not a factor based on the skeletal evidence.

A panorama of the health situation in Brazil's Federal District, 2005 to 2017. / Panorama da situação de saúde do Distrito Federal: análise do período de 2005 a 2017.

This study examines the health situation in Brazil's Federal District between 2005 and 2017. A related set of indicators were selected and compared to those for Brazil's Midwest ("Centro-Oeste") region and for the country as a whole. First, data are presented on the demographic profile and current organizational structure of the health regions and administrative areas of the Federal District. The results show that infant mortality declined from 18.3% in 2006 to 10.3% (one of the lowest in rates in Brazil) in 2016. AIDS incidence in the Federal District declined 21.3% between 2006 and 2016, a positive result when compared to data for the Midwest region and Brazil. Tuberculosis incidence and mortality rates were among the lowest in Brazil between 2006 and 2016, well below the national average, as were those for Hansen's disease, where both annual incidence and incidence of grade 2 disability decreased significantly between 2007 and 2017. Congenital syphilis in under 1 year-olds has increased in recent years in Brazil and the Midwest, and also in the Federal District, where the rate was 2.56 per 1,000 live births in 2006 and 4.7 per 1,000 live births in in 2016. These data enable managers to identify trends and challenges to be met, and inform decision-making in response to health realities in the Federal District.

Este artigo analisa a situação de saúde no Distrito Federal (DF) no período de 2005 a 2017. Um conjunto de indicadores foram selecionados e comparados aos da região Centro-Oeste (CO) e do Brasil. Inicialmente são apresentados dados sobre o perfil demográfico e a atual estrutura organizacional das regiões de saúde e áreas administrativas do DF. Os resultados mostram que o DF apresenta melhoria na taxa de mortalidade infantil, de 18,3% em 2006 para 10,3% em 2016, considerada uma das menores do país. A taxa de detecção de aids no DF apresenta tendência de queda (21,3%), entre os anos de 2006 e 2016, resultado positivo se comparado aos dados da região CO e do Brasil. Quanto à situação epidemiológica de tuberculose no DF, foi constatada, entre 2006 a 2016, um dos menores coeficientes de incidência e mortalidade do país, bem abaixo da média nacional, assim como a hanseníase com uma importante redução da taxa de detecção anual e a detecção de grau II de incapacidade, entre os anos 2007 e 2017. No caso da sífilis congênita em < de 1 ano, teve aumento nos últimos anos no Brasil, CO e no DF em 2006 apresentou uma taxa de (2,56/1.000NV) e em 2016 (4,7/1.000NV). Os dados permitem que os gestores conheçam as tendências e identifiquem os desafios para o enfrentamento e a tomada de decisão frente à realidade de saúde do DF.

Panorama da situação de saúde do Distrito Federal: análise do período de 2005 a 2017 / A panorama of the health situation in Brazil's Federal District, 2005 to 2017

Resumo Este artigo analisa a situação de saúde no Distrito Federal (DF) no período de 2005 a 2017. Um conjunto de indicadores foram selecionados e comparados aos da região Centro-Oeste (CO) e do Brasil. Inicialmente são apresentados dados sobre o perfil demográfico e a atual estrutura organizacional das regiões de saúde e áreas administrativas do DF. Os resultados mostram que o DF apresenta melhoria na taxa de mortalidade infantil, de 18,3% em 2006 para 10,3% em 2016, considerada uma das menores do país. A taxa de detecção de aids no DF apresenta tendência de queda (21,3%), entre os anos de 2006 e 2016, resultado positivo se comparado aos dados da região CO e do Brasil. Quanto à situação epidemiológica de tuberculose no DF, foi constatada, entre 2006 a 2016, um dos menores coeficientes de incidência e mortalidade do país, bem abaixo da média nacional, assim como a hanseníase com uma importante redução da taxa de detecção anual e a detecção de grau II de incapacidade, entre os anos 2007 e 2017. No caso da sífilis congênita em < de 1 ano, teve aumento nos últimos anos no Brasil, CO e no DF em 2006 apresentou uma taxa de (2,56/1.000NV) e em 2016 (4,7/1.000NV). Os dados permitem que os gestores conheçam as tendências e identifiquem os desafios para o enfrentamento e a tomada de decisão frente à realidade de saúde do DF.

Abstract This study examines the health situation in Brazil's Federal District between 2005 and 2017. A related set of indicators were selected and compared to those for Brazil's Midwest ("Centro-Oeste") region and for the country as a whole. First, data are presented on the demographic profile and current organizational structure of the health regions and administrative areas of the Federal District. The results show that infant mortality declined from 18.3% in 2006 to 10.3% (one of the lowest in rates in Brazil) in 2016. AIDS incidence in the Federal District declined 21.3% between 2006 and 2016, a positive result when compared to data for the Midwest region and Brazil. Tuberculosis incidence and mortality rates were among the lowest in Brazil between 2006 and 2016, well below the national average, as were those for Hansen's disease, where both annual incidence and incidence of grade 2 disability decreased significantly between 2007 and 2017. Congenital syphilis in under 1 year-olds has increased in recent years in Brazil and the Midwest, and also in the Federal District, where the rate was 2.56 per 1,000 live births in 2006 and 4.7 per 1,000 live births in in 2016. These data enable managers to identify trends and challenges to be met, and inform decision-making in response to health realities in the Federal District.

O cuidado das condições crônicas na atenção primária à saúde / The care for chronic conditions in primary health care

As condições de saúde podem ser caracterizadas como circunstâncias na saúde das pessoas que se apresentam de forma mais ou menos persistentes e exigem respostas sociais reativas ou proativas, episódicas ou contínuas e fragmentadas ou integradas dos sistemas de atenção à saúde, dos profi ssionais de saúde e dos usuários. A constatação de que a tipologia clássica de doenças transmissíveis e doenças crônicas não transmissíveis não é capaz de dar suporte à organização dos sistemas de atenção à saúde levou à proposta das condições de saúde, desenvolvida no fi nal dos anos 90 por acadêmicos ligados ao modelo de atenção crônica(1,2) e, depois, acolhida pela Organização Mundial da Saúde(3). Conhecer essas condições permite conhecê-las melhor e, assim, poder prevenir os possíveis agravos através de estratégias de promoção da saúde. O recorte da tipologia de condições de saúde faz-se a partir da forma como os profi ssionais, as pessoas usuárias e os sistemas de atenção à saúde se organizam para responder socialmente às demandas colocadas, se de forma reativa, episódica e fragmentada, ou se de forma proativa, contínua e integrada. Essa tipologia está orientada, principalmente, por algumas variáveis-chaves contidas no conceito de condição de saúde: a primeira relaciona-se ao tempo de duração da condição de saúde, breve ou longo; a segunda, a forma de enfrentamento pelos profi ssionais de saúde, pelo sistema de atenção à saúde e pelas pessoas usuárias - se episódica, reativa, fragmentada e feita com foco nas doenças e na queixa-conduta, ou, se contínua, proativa, integrada e realizada com foco nas pessoas e nas famílias por meio de cuidados, mais ou menos permanentes, contidos num plano de cuidado elaborado pela equipe de saúde e pelas pessoas usuárias conjuntamente. É preciso destacar que condição crônica não é igual à doença crônica. Todas as doenças crônicas (diabetes, doenças cardiovasculares, cânceres, doenças respiratórias crônicas, doenças musculoesqueléticas crônicas e outras) são condições crônicas. Mas esse conceito envolve também as doenças infecciosas persistentes (hanseníase, tuberculose, HIV/AIDS, certas hepatites virais e outras), as condições ligadas à maternidade e ao período perinatal (acompanhamento das gestantes e atenção perinatal, às puérperas e aos recém-natos); às condições ligadas à manutenção da saúde por ciclos de vida (puericultura, hebicultura e senicultura); aos distúrbios mentais de longo prazo; às defi ciências físicas e estruturais contínuas (amputações, cegueiras, defi ciências motoras persistentes e outras); às doenças metabólicas; às doenças bucais não agudizadas; e às condições de saúde caracterizadas como enfermidades (illnesses), que se referem ao modo como as pessoas percebem o seu adoecer, ou seja, a resposta subjetiva do indivíduo e/ou de sua rede de relações frente a uma determinada situação de adoecimento(4,5). O fracasso do modelo de atenção aos eventos agudos em responder a situações de saúde dominadas por condições crônicas levou, em diferentes países e em diversas instituições, a uma busca por modelos de atenção às condições crônicas. Surgiram,então, vários modelos de atenção às condições crônicas relatados na literatura internacional(6). Os modelos mais expressivos são o modelo de atenção crônica (CCM), o modelo seminal, e o modelo da pirâmide de risco (MPR). O CCM, proposto nos Estados Unidos da América(2), encontra um ambiente melhor de desenvolvimento em sistemas de atenção à saúde públicos e universais(7), e compõe-se de seis elementos, subdivididos em dois grandes campos: o sistema de atenção à saúde e a comunidade. No sistema de atenção à saúde, as mudanças devem ser feitas na organização da atenção à saúde, no desenho do sistema de prestação de serviços, no suporte às decisões, nos sistemas de informação clínica e no autocuidado apoiado. Na comunidade, as mudanças estão centradas na articulação dos serviços de saúde com os recursos da comunidade. Esses seis elementos apresentam inter-relações que permitem desenvolver pessoas usuárias informadas e ativas, e equipe de saúde preparada e proativa para produzir melhores resultados sanitários e funcionais para a população. O segundo modelo de grande impacto internacional, o modelo da pirâmide de riscos (MPR), assenta-se na estratifi cação dos riscos da população. Isto defi ne as estratégias de intervenção em autocuidado e em cuidado profi ssional. Por sua vez, o cuidadoprofissional, em função dos riscos, define a tecnologia de gestão da clínica a ser utilizada, se gestão da condição de saúde ou se gestão de caso(8). As evidências recolhidas na literatura internacional sobre os modelos de atenção à saúde e a singularidade do Sistema Único de Saúde (SUS) fizeram com que se desenvolvesse um modelo de atenção às condições crônicas (MACC) que pudesse ser aplicado ao sistema público de saúde brasileiro(9). A base do MACC é o CCM, mas esse modelo de origem foi expandido, com a incorporação de outros dois modelos, o MPR e o modelo da determinação social da saúde(10), para se adaptar às exigências de um sistema de atenção à saúde público e universal como o SUS. O MACC está construído em três colunas: numa coluna está a população total estratificada em subpopulações por estratos de risco; noutra coluna estão os diferentes níveis de determinação social da saúde: os determinantes intermediários, proximais e individuais; e na terceira estão os cinco níveis das intervenções de saúde sobre os determinantes e suas populações: intervenções promocionais (nível 1), preventivas (nível 2) e de gestão da clínica sobre as condições crônicas estabelecidas (níveis 3, 4 e 5). Especificamente em relação à sua aplicação na atenção primária à saúde, fez-se uma pesquisa avaliativa rigorosa no município de Santo Antônio do Monte, Minas Gerais, Brasil. A intervenção ocorreu de junho de 2013 a dezembro de 2014, focando em quatro grupos-alvo: indivíduos com hipertensão arterial, indivíduos com diabetes, mulheres grávidas e crianças menores de dois anos(11). Os resultados, tanto na pesquisa quantitativa quanto na qualitativa, foram muito positivos. Outra avaliação mostrou resultados positivos do MACC na organização em rede da atenção primária à saúde e da atenção ambulatorial especializada(12). Diante dessa importante temática, o presente número da Revista Brasileira em Promoção da Saúde - RBPS - traz, para complementar esse diálogo, três artigos originais relacionados às condições crônicas em diferentes contextos da Saúde Coletiva e seu impacto na vida dos pacientes. Os principais achados dessas pesquisas dão enfoque: na atividade física como meio de reduzir o risco cardiovascular em idosos hipertensos(13), na associação da deficiência de vitamina D e suas implicações nos pacientes com diabetes tipo 1(14), e por último, os sentimentos de rejeição, tristeza e angústia oriundos de uma gravidez indesejada ao grande impacto na vida psicológica de adolescentes(15). A RBPS cumpre, assim, uma vez mais, a função de trazer aos pesquisadores e aos leitores temas de grande valia e interesse científico na promoção da saúde. (AU)

Health conditions can be defined as circumstances in people's health which are more or less persistent and which require reactive or proactive, episodic or continuous and fragmented or integrated social responses from health care systems, health professionals and health care users. The finding that the classic typology of communicable diseases and noncommunicable diseases cannot support the organization of health care systems led to the proposal of health conditions, which was developed in the late 1990s by scholars linked to the chronic care model(1,2) and then adopted by the World Health Organization(3). Knowing such conditions allows to know them better and thus be able to prevent possible diseases through health promotion strategies. The study of the typology of health conditions is based on the way health professionals, health care users and health care systems are engaged to respond socially to the demands, whether in a reactive, episodic and fragmented way, or in a proactive, continuous and integrated way. Such typology is mainly based on some key variables contained in the concept of health condition: the first refers to the duration of the health condition ­ short or long; the second is the way health professionals, health care systems and health care users fight such conditions ­ an episodic, reactive and fragmented approach focused on diseases and complaints or a continuous, proactive and integrated approach focused on people and families through more or less permanent care contained in a plan of care prepared by the health team and the users together. It should be noted that chronic condition is not the same as chronic disease. All chronic diseases (diabetes, cardiovascular diseases, cancers, chronic respiratory diseases, chronic musculoskeletal diseases, and others) are chronic conditions. But this concept also encompasses persistent infectious diseases (leprosy, tuberculosis, HIV/AIDS, certain viral hepatitis, and others), maternal and perinatal conditions (follow-up of pregnant women and perinatal, postpartum and newborn care); conditions linked to the maintenance of health throughout life cycles (child care, adolescent care and older person care); long-term mental disorders; continuous physical and structural disabilities (amputations, blindness, persistent motor deficits, and others); metabolic diseases; non-acute oral diseases; and health conditions characterized as illnesses, which refer to the way people perceive their disease, that is, the subjective response of individuals and/or their network of relationships to a particular disease(4,5). The model of care for acute events has failed to respond to health situations dominated by chronic conditions, which has led different countries and several institutions to seek models of care for chronic conditions. Several models of care for chronic conditions have been reported in the international literature(6). The most significant models are the chronic care model (CCM), the seminal model, and the risk pyramid model (RPM). The CCM, proposed in the United States of America(2), works best in public and universal health care systems(7) and is composed of six elements subdivided into two main fields: the health care system and the community. In the health care system, changes must be made to the organization of health care, to the service delivery system design, to decision support, to clinical information systems and to self-management support. In the community, the changes are centered on the integration between health care services and community resources. These six elements present interrelationships that allow the development of informed and active users and a prepared and proactive health team to produce better health and functional outcomes for the population. The second major international impact model, the risk pyramid model (RPM), is based on population risk stratification. This determines self-care and professional care intervention strategies. Professional care, depending on the risks, determines the clinic management technology to be used: health condition management or case management(8). International evidence on health care models and the uniqueness of the Unified Health System (Sistema Único de Saúde ­ SUS) led to the development of a chronic condition care model (CCCM) that could be applied to the Brazilian public health system(9). The basis of the CCCM is the CCM, but this model of origin has been expanded to incorporate two other models, the RPM and the model of social determinants of health(10), to adapt to the requirements of a public and universal health care system such as the SUS. The CCCM is built on three columns: one column features the total population divided into subpopulations by risk strata; another column features the different levels of social determinants of health: intermediate, proximal and individual determinants; and the third column features the five levels of health interventions on determinants and their populations: promotional interventions (level 1), preventive interventions (level 2) and clinic management interventions on established chronic conditions (levels 3, 4 and 5). With regard to its application in primary health care, a rigorous evaluation research was carried out in the municipality of Santo Antônio do Monte, Minas Gerais, Brazil. The intervention took place from June 2013 to December 2014 and focused on four target groups: individuals with hypertension, individuals with diabetes, pregnant women and children under two years old(11). The results of both the quantitative and qualitative analyses were very positive. Another evaluation showed positive effects of CCCM on the organization of a network of primary health care and specialized outpatient care(12). Given the relevance of this subject, the present issue of the Brazilian Journal in Health Promotion (Revista Brasileira em Promoção da Saúde ­ RBPS) complements this dialog by featuring three original articles on chronic conditions in different contexts of Public Health and their impact on the life of patients. The main findings of these studies focus on: physical activity as a means of reducing cardiovascular risk in hypertensive older patients(13), the association of vitamin D deficiency and its consequences in patients with type 1 diabetes(14), and, finally, feelings of rejection, sadness and anguish arising from an unwanted pregnancy and the great impact on the psychological life of adolescents(15). RBPS fulfills, once again, the function of bringing to researchers and readers themes of great value and scientific interest in the health promotion field. (AU)

Factors associated with the delay of diagnosis of leprosy in north-eastern Colombia: a quantitative analysis.

OBJECTIVES: To determine the average time in months between the beginning of symptoms and the diagnostic confirmation of leprosy by the health system and to investigate factors associated with diagnostic delay. METHODS: A total of 249 patients older than 15 years diagnosed with leprosy between 2011 and 2015, in 20 endemic municipalities of north-eastern Colombia, provided informed consent and were interviewed face-to-face. Clinical histories from health centres or hospitals where study participants were treated for leprosy were also reviewed. RESULTS: The mean delay in diagnosis of leprosy was 33.5 months. About 14.9% of patients showed a visible deformity or damage (disability grade 2, DG2) at the time of diagnosis. In multivariable regression analysis, five or more consultancies required to confirm the diagnosis and not seeking care immediately after noticing first symptoms were associated with longer diagnostic delay. CONCLUSIONS: Our study found a significant delay in diagnosis of leprosy in north-eastern Colombia, which might explain the continuously high rate of DG2 among new cases being notified in the country. Both patient- and health system-related factors were associated with longer diagnostic delay. Interventions to increase awareness of disease among the general population and timely referral to a specialised health professional are urgently needed in our study setting.

The body mechanical: Building a caring community, crafting a functioning body.

When Hansen's disease became treatable in Taiwan in the mid-20th century, a group of Hansen's disease patients lost their sick role despite still having lingering symptoms that continued to evolve. While sociologists have explored in-depth situations in which the social role of the sick is ambiguous, few studies have investigated body experiences under liminality that requires sick people to find a new sick role. Living with lingering symptoms in a post-Hansen's disease world, the Hansen's disease patients I have studied face the conundrum of having to find an alternative sick role. Ethnographic fieldwork demonstrates how patients develop a specific set of body techniques that shape and are shaped by their membership in a patient community. Exploring the reinforcing projects of re-embodiment and sociality around Hansen's disease, I argue that patients are able both to legitimate each other's feelings of sickness and to use those feelings to manage their illness and, as such, to collectively acquire an alternative sick role. Adding to existing discussions of active patients, this article identifies the body mechanical as a way of practicing active patienthood organized around fixing, trials, mending and functionality.

Evaluation of the Bifactor Nominal Response Model Analysis of a Health Efficacy Measure.

The bifactor nominal response item response theory (IRT) model, proposed by Cai, Yang and Hansen (2011), provides an extension of Bock's (1972, 1997) unidimensional nominal response model to multidimensional IRT. This model has not been utilized in any published studies since its original development. In this study, the model was applied to data from a sample of college students (N = 799) to evaluate the psychometric properties of a health efficacy measure. The nominal response model has the unique capability to estimate the functioning of each single response category, and higher response categories were found to have better functioning in this study. Poor-functioning categories were identified and combined into their adjacent categories. Items with revised response format showed improved functioning. The bifactor nominal response model is a useful tool for evaluation of bifactor scales with ordered while non-equivalently functioning categories.

Socio-Economic and Health Status of Leprosy Affected Person: A Study in Jharkhand.

The study has been conducted in the Potka Block of East Singhbhum district of the state of Jharkhand. The district is mainly dominated by indigenous tribes, such as, Santhal, Munda, Ho, Bhumiz, Kharia, and Sabar. The unit of analysis of the study was an individual. The objectives were to: a) Understand the socio-economic and health status of LAP, b) Know the health seeking behavior and problems faced by the LAP, c) Assess the utilization of the programs related to Leprosy eradication in the study area and d), Suggest various measures for improving the socio-economic and health status of LAP. Fifty Leprosy affected persons (LAP) from the Potka block; comprising of 20% of LAP of that area have been selected as the study sample by using the method of Multi-Stage Random Sampling, with equal representation of men and women. The LAPs included leprosy patients, leprosy treated people and their family members. 39/50 (78%) of the respondents are illiterates and only 3/11 (6%) among the literate population have crossed matriculation and above. This seems to have resulted in the respondent's low level of awareness about the disease, resulting in delayed treatment. 14/25 (56%) percent of female and 13/25 (52%) of male respondents are considered untouchable by their natal families, thus forced to stay in congested leprosy colonies resulting in other social and health related issues. It was observed that leprosy cured children,and also children of LAP are being denied admission iany school, due to the social stigma attached to it. 27/50 (54%)of leprosy patients and leprosy cured people (mostly with visible deformities) were found to practice begging as their sole means of livelihood. Many LAPs are also engaged in cultivation and small scale business particularly among the rural population. An amount of gender disparity was also observed in the employment pattern among the LAPs. Among the, respondents 15/25 (60%) of the females are beggars as compared to 12/25 (48%) of the male respondents, 5/25 (25%) of males are each engaged in cultivation and small scale businesses in comparison to 1/25 (4%) of female and 6/25 (24%) of the female respondents are unemployed as compared to 2/25 (8%) of male respondents. It was observed that only 30% of the respondents were satisfied with the government treatment, 26% partially satisfied and rest were not satisfied with the government leprosy care system. Most of them wanted to seek treatment from the private health care providers. Overall this study reflects the poor socio-economic conditions of the LAPs. Though results of this exploratory study cannot be extrapolated to country or region or state without studying the situation in detail, it highlights the need for more in-depth studies and of government intervention in the form of encouraging awareness activities in the communities, engaging NGOs im case detection and after care service provision and rehabilitation of the LAPs.

Leprosy and its dental management guidelines.

OBJECTIVES: Leprosy is a chronic, non-fatal disease caused by Mycobacterium leprae. It can cause cutaneous lesions, peripheral nerve lesions and orofacial manifestations, including destruction of the alveolar premaxillary process associated with loss of the maxillary incisors. The aims of this study were to assess orofacial manifestations of disease in patients attending the Bombay Leprosy Project clinics and develop clinical guidelines for dentists. MATERIALS AND METHODS: A cross-sectional questionnaire based study was administered to 43 diagnosed leprosy patients. This included questions on perceived oral health status and oral hygiene habits. An extra-oral and intra-oral examination was also performed. RESULTS: Eighty-four per cent of patients were male with a mean age of 35.9 years. Forty-nine per cent had extra-oral cutaneous lesions. Twenty-eight per cent had intra-oral lesions including hyperpigmented patches. Twenty-one per cent had cranial nerve involvement and the trigeminal nerve was most commonly affected. CONCLUSIONS: From this data a clinical dental pathway protocol for managing patients with leprosy was developed. It highlights dental issues when managing leprosy patients. Nerve involvement may mean patients are unable to give an accurate account of their symptoms. Special tests should include cranial nerve examination and swabs of intra-oral ulcers. Low rates of infectivity means that normal infection control measures can be taken when treating these patients.

Health concerns of Micronesian peoples.

Several states in the United States have been experiencing an influx of migrants from an area of the world that most people have only heard of when learning about the atomic bomb and World War II. This area is the former U.S. Trust Territory of Pacific Islands now called the Freely Associated States. At the end of World War II, the United States took possession of many of these islands and in 1948, the United States formally took over administration of the Marshalls, the Carolines, Palau, and the Northern Marianas islands. Collectively this area is known as Micronesia. Micronesians come from areas that have high prevalence of several communicable diseases and there is growing concern that Micronesian immigrants may enable the spread of infectious disease to the United States from Asia. Data concerning Hansen's disease and tuberculosis support this claim. According to data from the Hawai'i State Department of Health, a 5-year trend examining new cases of tuberculosis in Hawai'i identified that 65 out of 77 new cases came from the Freely Associated States of Micronesia. Presented is an overview of the health concerns and health status of the people from the Federated States of Micronesia.

Health-related quality of life, depression, and self-esteem in adolescents with leprosy-affected parents: results of a cross-sectional study in Nepal.

BACKGROUND: Leprosy is a chronic infectious disease that has an impact on the Health-Related Quality of Life (HRQOL) of sufferers as well as their children. To date, no study has investigated the effects of parental leprosy on the well-being of adolescent children. METHODS: A cross-sectional study was conducted in the Lalitpur and Kathmandu districts of Nepal. Adolescents with leprosy-affected parents (n = 102; aged 11-17 years) and those with parents unaffected by leprosy (n = 115; 11-17 years) were investigated. Self-reported data from adolescents were collected using the Kinder Lebensqualität Fragebogen (KINDLR) questionnaire to assess HRQOL, the Center for Epidemiological Studies-Depression Scale (CES-D), and the Rosenberg Self-esteem Scale (RSES). Analysis of covariance (ANCOVA) was used to compare scores between the two groups. Multiple regression analysis was conducted to explore the determinants of HRQOL for adolescents with leprosy-affected parents. RESULTS: ANCOVA revealed that the KINDLR and RSES scores were significantly lower among adolescents with leprosy-affected parents compared with unaffected parents. However, the scores of "Friends" and "School" subscales of KINDLR were similar between the two groups. The CES-D score was significantly higher among adolescents with leprosy-affected parents than for adolescents with unaffected parents. The KINDLR scores for adolescents with both parents affected (n = 41) were significantly lower than the scores for those with one parent affected (n = 61). Multiple regression analysis revealed that adolescents with leprosy-affected parents who had higher levels of depressive symptoms were more likely to have lower KINDLR scores. A similar result was seen for adolescents where both parents had leprosy. CONCLUSIONS: Adolescents with leprosy-affected parents had higher levels of depressive symptoms, lower levels of self-esteem, and lower HRQOL compared with adolescents whose parents were unaffected by leprosy. Thus, mental health support programs might be necessary for adolescents with leprosy-affected parents, particularly for adolescents where both parents are leprosy-affected. Further studies with larger sample sizes are necessary to draw decisive conclusions.

An exploration of health, family and economic experiences of leprosy patients, Iran.

This study aims to explore the life experiences of Iranian leprosy patients in health, family and economic dimensions. Mycobacterium leprae is responsible for leprosy, a type of chronic inflammatory disease that existed from ancient times, still hearing the name of leprosy creates an awful imagination of cutting the organ, blindness and isolation and it has still remained as a serious social problem. The patients are confronted with particular problems physically and mentally. The phenomenological tradition was used to gain knowledge of the leprosy patients lived experiences. Data analysis method was based on Colaizzi's approach. This is a qualitative research using purposeful sampling, interviewing the leprosy patients referring to a contagious diseases department of the Health Network of Nourabad Lorestan City. Data were collected by interviews those were analyzed in Colaizzi's Methods to extract the conceptual codes. Some concepts obtained from the analysis of data in the study such as physical, psychological, social, family, economic experiences, cultural beliefs of society, the context for tendency toward defect and disability and social stigma. These findings suggest that health care professionals should pay attention not only to leprosy patients to reduce their physical and psychological but also to the community and public culture to reduce the leprosy patients suffering from social stigma. The results of the present study can help us in a better understanding of all aspects of patients' lived experiences.

[Quality of life of leprosy patients' group in Vietnam].

Vietnam has achieved WHO's leprosy elimination goal at a national level, but there are a lot ofex-leprosy patients who have severe physical disabilities in the leprosy treatment centers and resettlement villages. The purpose of this study is to analyze the quality of life (QOL) of ex-leprosy patients in Vietnam. The study was conducted in two leprosy treatment centers in Vietnam. The SF-36v2 QOL survey was used to evaluate the leprosy patients' health related conditions, and as a comparison group, SF-36v2 QOL survey was provided to a random group from the general population to measure the general groups' health related conditions. For those participants aged from 10 to 29 years old, the patients' group scored lower than the general group in each of the following categories; Role physical, Bodily pain, General health perceptions, Vitality, Social functioning, Role emotional. On the other hand, middle aged and elderly participants were found to show no significant difference between the patients' group and the general group. In comparing the two leprosy treatment centers, the score of Role physical and Role emotional were significantly higher in the leprosy treatment center where vocational training programs for leprosy patients are offered. From these results, the use of vocational training program is one of the effective methods for improving the QOL of the patients' group.

Clusters of leprosy transmission and of late diagnosis in a highly endemic area in Brazil: focus on different spatial analysis approaches.

OBJECTIVE: The Brazilian National Hansen's Disease Control Program recently identified clusters with high disease transmission. Herein, we present different spatial analytical approaches to define highly vulnerable areas in one of these clusters. METHOD: The study area included 373 municipalities in the four Brazilian states Maranhão, Pará, Tocantins and Piauí. Spatial analysis was based on municipalities as the observation unit, considering the following disease indicators: (i) rate of new cases/100,000 population, (ii) rate of cases <15 years/100,000 population, (iii) new cases with grade-2 disability/100,000 population and (iv) proportion of new cases with grade-2 disabilities. We performed descriptive spatial analysis, local empirical Bayesian analysis and spatial scan statistic. RESULTS: A total of 254 (68.0%) municipalities were classified as hyperendemic (mean annual detection rates >40 cases/100,000 inhabitants). There was a concentration of municipalities with higher detection rates in Pará and in the center of Maranhão. Spatial scan statistic identified 23 likely clusters of new leprosy case detection rates, most of them localized in these two states. These clusters included only 32% of the total population, but 55.4% of new leprosy cases. We also identified 16 significant clusters for the detection rate <15 years and 11 likely clusters of new cases with grade-2. Several clusters of new cases with grade-2/population overlap with those of new cases detection and detection of children <15 years of age. The proportion of new cases with grade-2 did not reveal any significant clusters. CONCLUSIONS: Several municipality clusters for high leprosy transmission and late diagnosis were identified in an endemic area using different statistical approaches. Spatial scan statistic is adequate to validate and confirm high-risk leprosy areas for transmission and late diagnosis, identified using descriptive spatial analysis and using local empirical Bayesian method. National and State leprosy control programs urgently need to intensify control actions in these highly vulnerable municipalities.

Study on differences and similarities in the concept and origin of leprosy stigma in relation to other health-related stigma.

While the experienced or enacted stigma may be the same for all health related stigma, in terms of isolation, discrimination and social participation restrictions of the affected persons; the concept and origin of stigma varies from one disease to another. An understanding of the cause of stigma is, therefore, essential to formulate effective strategies for its reduction/elimination. This is especially imperative in the case of leprosy where the basis of stigma is significantly different from other health related stigma. In this paper, a comparison is made between the concept and origin of leprosy stigma with that of other stigmatised diseases.

[Interpreting Brazil as afflicted by disease and by the spirit of routine: the repercussion of Arthur Neiva and Belisário Penna's medical report (1917-1935)]. / Uma interpretação do Brasil como doença e rotina: a repercussão do relatório médico de Arthur Neiva e Belisário Penna (1917-1935).

The release of a report on the Oswaldo Cruz Institute's 1912 scientific voyage to North and Northeast Brazil, led by physicians Arthur Neiva and Belisário Penna, debate that found its way to the pages of magazines of the letters and sciences. The report used the images of disease, geographic and cultural isolation, illiteracy, poverty, and a vocation for backwardness to portray the people living in interior Brazil. These images of the sertão were extensively criticized in the periodical A Informação Goiana, published by local doctors who refused to see the interior defined as 'sickly' and 'backwards'. The article analyzes the ways in which the Neiva-Penna report distinguished itself becoming a reference for intellectual controversies surrounding the national question in Brazil.

[The compulsory isolation of Hansen's disease patients: memories of the elderly]. / Isolamento compulsório de portadores de hanseníase: memória de idosos.

From 1924 to 1962, Brazil used compulsory internment of Hansen's disease patients as one of the ways of controlling the disease in the community. After this policy ended, many patients continued to live in these units. The former Asilo Pirapitingui, now the Hospital Dr. Francisco Ribeiro Arantes, is the only old-style asylum for the socially determined internment of those suffering from Hansen's disease. Through recorded and transcribed interviews of eight of those remaining, we sought to learn their history and the meaning of this isolation in their lives. The thematic analysis of the discourse enabled identification of the following analysis categories: Hansen's disease; internment day-to-day life; the institution; current health conditions; and staying in the institution after the end of compulsory internment.

Health assessment of free-ranging three-banded (Tolypeutes matacus) and nine-banded (Dasypus novemcinctus) armadillos in the Gran Chaco, Bolivia.

The Gran Chaco, Bolivia, has a total of seven species of armadillos with the three-banded (Tolypeutes matacus) and nine-banded (Dasypus novemcinctus) the most commonly hunted by the local Isoseño-Guarani people. Armadillos are known carriers of zoonotic pathogens, including Mycobacterium leprae, Toxoplasma gondii, and Trypanosoma cruzi; thus human handling and consumption of these species may have a significant public health impact. A health assessment that included physical examinations, hematology, plasma biochemical analyses, levels of exposure to selected infectious agents, and endoparasite and ectoparasite identification was performed on nine-banded and three-banded armadillos in the Gran Chaco, Bolivia. Based on clinical findings, the general health of these armadillos was rated as good. However, many of the nine-banded armadillos (64%) had abrasions and wounds, probably related to the capture method. The blood value results from a subset of these armadillos are presented as baseline values for free-ranging populations of both these species in Bolivia. Serologic antibody tests for M. leprae were negative in three-banded (n = 8) and nine-banded (n = 2) armadillos. Three-banded armadillos were antibody positive for Eastern equine encephalitis virus (8/8; 100%) and Saint Louis encephalitis virus (5/8; 62.5%). Two of 12 (16.7%) three-banded armadillos tested were antigen positive for Dirofilaria immitis. Nine-banded armadillos were antibody positive for T. gondii (3/9; 33.3%), Eastern equine encephalitis virus (5/8; 62.5%), and T. cruzi (2/9; 22.2%). Two of eight (25%) nine-banded armadillos were antigen positive for D. immitis. A number of endo- and ectoparasites were identified in/on both species of armadillos. Results from this study support the possibility that the handling and consumption of these species by the local Isoseño-Guarani people may have a public health impact.

Uma interpretação do Brasil como doença e rotina: a repercussão do relatório médico de Arthur Neiva e Belisário Penna (1917-1935) / Interpreting Brazil as afflicted by disease and by the spirit of routine: the repercussion of Arthur Neiva and Belisário Penna's medical report (1917-1935)

A divulgação do relatório da viagem científica promovida pelo Instituto Oswaldo Cruz em 1912 ao Norte e Nordeste do Brasil, realizada por Arthur Neiva e Belisário Penna, suscitou debates e ocupou espaço em revistas de letras e ciências. No documento, as populações do interior do país foram caracterizadas pelas imagens de doença, isolamento, geográfico e cultural, analfabetismo, pobreza e vocação para regredir. Essas imagens do sertão foram criticadas no periódico A Informação Goiana, editado por médicos que não admitiam ser o interior definido como 'doente' e 'atrasado'. Este artigo analisa as formas pelas quais o relatório Neiva-Penna se destacou e tornou-se referência para controvérsias intelectuais sobre a questão nacional no Brasil.

The release of a report on the Oswaldo Cruz Institute's 1912 scientific voyage to North and Northeast Brazil, led by physicians Arthur Neiva and Belisário Penna, debate that found its way to the pages of magazines of the letters and sciences. The report used the images of disease, geographic and cultural isolation, illiteracy, poverty, and a vocation for backwardness to portray the people living in interior Brazil. These images of the sertão were extensively criticized in the periodical A Informação Goiana, published by local doctors who refused to see the interior defined as 'sickly' and 'backwards'. The article analyzes the ways in which the Neiva-Penna report distinguished itself, becoming a reference for intellectual controversies surrounding the national question in Brazil.

Isolamento compulsório de portadores de hanseníase: memória de idosos / The compulsory isolation of Hansen's disease patients: memories of the elderly

De 1924 a 1962 o Brasil utilizou a internação compulsória de pacientes de hanseníase como controle da doença na comunidade. Com o final dessa política, muitos pacientes continuaram a viver nessas unidades. O Asilo Pirapitingui, hoje Hospital Dr. Francisco Ribeiro Arantes, é a única retaguarda asilar para internação de portadores de hanseníase por indicação social. Obtivemos o relato da história de vida de oito de seus remanescentes, que foram gravados e transcritos. A análise temática desses relatos permitiu a identificação das seguintes categorias: hanseníase; internação; vida cotidiana; a instituição; condições atuais de saúde; e permanência na instituição após a extinção da internação compulsória.

From 1924 to 1962, Brazil used compulsory internment of Hansen's disease patients as one of the ways of controlling the disease in the community. After this policy ended, many patients continued to live in these units. The former Asilo Pirapitingui, now the Hospital Dr. Francisco Ribeiro Arantes, is the only old-style asylum for the socially determined internment of those suffering from Hansen's disease. Through recorded and transcribed interviews of eight of those remaining, we sought to learn their history and the meaning of this isolation in their lives. The thematic analysis of the discourse enabled identification of the following analysis categories: Hansen's disease; internment; day-to-day life; the institution; current health conditions; and staying in the institution after the end of compulsory internment.