Saúde nas metrópoles – doenças infecciosas / Health in metropolises - Infectious Diseases

A urbanização é um processo irreversível em escala mundial e estima-se que o número de pessoas que vivem em cidades deverá atingir 67% da população do planeta até 2050. Os países de baixa ou média renda, por sua vez, possuem 30% a 40% da população urbana vivendo atualmente em favelas, em situação de risco para diversos agravos de saúde. No Brasil, embora 84,3% da população residissem em áreas urbanas já em 2010, não se verificam no momento ações consistentes voltadas ao enfrentamento das questões de saúde urbana. Neste artigo discute-se a situação epidemiológica de agravos infecciosos de interesse para a saúde pública (dengue, infecção por HIV/aids, leptospirose, hanseníase e tuberculose) a partir do ano 2000 nas 17 metrópoles do país, de modo a esclarecer o papel atual das doenças infecciosas no contexto da saúde urbana brasileira...

Urbanization is an irreversible global process and the number of people living in cities is estimated to reach 67% of the world population by 2050. In low- and middle-income countries, 30% to 40% of the population currently lives in slum areas, under risk of several diseases. Even though 84.3% of the Brazilian population already lived in urban areas in 2010, no consistent initiatives have been implemented to address urban health issues. We discuss here the epidemiological features of communicable diseases that are relevant to public health (dengue, HIV/aids, leptospirosis, leprosy and tuberculosis) in Brazil’s 17 metropolitan areas since 2000 to help clarify the current role of infections in the context of Brazilian urban health...

Selective Special Drive (SSD): an effective tool to promote new case detection through community participation--an experience during 2005-2010 in Mumbai slums.

As per the Guidelines of National Leprosy Eradication Programme (NLEP), Government of India, new case detection (NCD) in leprosy is to be promoted by voluntary reporting through Information, Education and Communication (IEC). Accordingly, in addition to the routine IEC activities, Maharashtra Lokahita Seva Mandal (MLSM) carried out Selective Special Drive (SSD) in slum pockets in Mumbai since 2005-06. The SSD methodology prescribed under Leprosy Elimination Action Program (LEAP) of ALERT-INDIA was adopted which included selection of slum pockets, identification and training of Community Volunteers (CVs), door-to-door focused IEC through CVs using standard IEC material and referral of voluntarily reported suspected cases to nearby Health Posts under General Health Services or to Leprosy Referral Centre (LRC) established through MLSM for diagnosis and treatment. During the years, 2005-06 to 2009-10, MLSM conducted five annual SSDs in 53 slum pockets having 187,391 house-holds with the total enumerated population of 882,114 of which 563,040 (63.8%) could be covered through house-to-house IEC by 772 trained CVs/CHVs. As a result, 108 new cases (PB - 79 and MB - 29) were detected with the NCD rate ranged between 13/100,000 and 34/100,000 which is much higher than the reported NCDR in Mumbai (i.e. 6/100,000). Of the new MB cases 6 were lepromatous leprosy cases. Voluntary reporting of new cases was also found to be enhanced during the subsequent period following SSD. SSD activity encourages intensified IEC with community participation and integrates General Health Services resulting into better voluntary reporting of new cases. It is, therefore recommended that the SSD with the methodology prescribed under LEAP may be considered for incorporation in NLEP.

Knowledge and attitude about leprosy in Delhi in post elimination phase.

UNLABELLED: Leprosy is a chronic communicable disease since age associated with stigma and suffering. India claims its elimination but in some districts it remains a public health problem. A cross sectional study was conducted and a total of 60 persons were interviewed with an objective to assess the knowledge and attitude about leprosy among sample of 30 adults each from leprosy colony dwellers and urban slum dwellers in South District of Delhi. RESULT: Knowledge about the leprosy among leprosy colony dwellers was significantly lower than the slum dwellers. Both the groups still believed that leprosy could be due to curse of God, past misdeeds, and could spontaneously occur. Respondents of leprosy colony had significantly less adverse attitude such as leprosy patient should never get married (12% vs 57%), patient should be kept in leprosy colony (0 vs 30%) and should not be allowed to enter religious places (0 vs 23%). Surprisingly 73% of them had not heard about MDT and only (68%) knew that treatment is available free of cost in all Govt. hospitals. Only about half of the respondents knew that deformities could be corrected. CONCLUSION: This study reflects the poor awareness and negative attitudes towards leprosy particularly among leprosy patients themselves, which could be one of the reasons for slow progress in Leprosy Elimination Program in Delhi.

Intervención sanitaria y desarrollo local: el ejemplo histórico de las enfermedades de la miseria y la pobreza / No disponible

El trabajo pretende trasladar el debate historiográfico al tiempo presente, y ofrecer, desde la experiencia histórica, elementos de reflexión que ayuden a cuestionar los enfoques de carácter asistencialista que suelen mostrar en la actualidad muchas de las intervenciones sanitarias en materia de cooperación para el desarrollo. A partir del marco conceptual y metodológico que ofrecía la salud comunitaria que se fue configurando a lo largo de la primera mitad del siglo XX, se aborda la problemática que acompañaba a las enfermedades de la miseria y la pobreza y los factores que las condicionaban, tal como ocurría con la malnutrición, así como la acción sanitaria de carácter preventivo que buscaba intervenir sobre dichos determinantes y mejorar las condiciones de vida de la población. En primer lugar, a partir de la consideración contemporánea del hambre y la desnutrición como una calamidad social y como expresión biológica del subdesarrollo, y por lo tanto como consecuencia de las desigualdades sociales, se analiza el reto que suponía afrontar aquel intolerable, y la oportunidad que ofrecía para salir del subdesarrollo y de la pobreza que estaban y continúan estando detrás de dicha realidad. En segundo lugar, se expone la experiencia histórica española de lucha contra el tracoma [http://asclepio.revistas. csic.es/index.php/asclepio/article/view/503/505], como un ejemplo que permite reafirmar la validez de aquellas estrategias que sostienen que para poder acabar con el problema de salud que representa la enfermedad tracomatosa en las zonas menos desarrolladas y pobres del planeta, no basta con actuar sobre los factores más inmediatos, a través de los recursos terapéuticos, por el contrario, es necesario mejorar las condiciones higiénicas y los factores medioambientales que explican su prevalencia, a través de una intervención horizontal sobre el ámbito familiar y comunitario, que sea capaz de superar el síndrome de miseria y atraso que acompaña a todo un conjunto de enfermedades que la OMS definía en noviembre de 2010 como enfermedades tropicales desatendidas u olvidadas (AU)

No disponible

Primeiro relatório da OMS sobre doenças tropicais negligenciadas: Avanços para superar o impacto global de doenças tropicais negligenciadas / First WHO report on neglected tropical diseases: working to overcome the global impact of neglected tropical diseases

[Resumo Executivo]. Doenças tropicais negligenciadas (DTN) afligem a vida de um bilhão de pessoas em todo o mundo e ameaçam a saúde de outros milhões. Essas companheiras antigas da pobreza enfraquecem populações já empobrecidas, frustram a realização dos Objetivos de Desenvolvimento do Milênio e prejudicam os resultados do desenvolvimento global. Uma avaliação mais confiável de sua importância para a saúde pública e para as economias convenceu governos, doadores, indústria farmacêutica e outras agências – entre as quais organizações não governamentais (ONGs) – a investirem na prevenção e no controle desse grupo diversificado de doenças. Os esforços globais para controlar doenças “ocultas” – tais como dracunculíase (infecção pelo verme da Guiné), lepra, esquistossomose, filariose linfática e bouba – resultaram em ganhos progressivos na área da saúde, incluindo a erradicação iminente da dracunculíase. Desde 1989 – quando a maioria dos países endêmicos passou a relatar mensalmente a situação de cada localidade infectada – o número de novos casos de dracunculíase caiu de 892.055, em 12 países endêmicos, para 3.190, em quatro países, em 2009: uma redução de mais de 99%. A Organização Mundial da Saúde (OMS) recomenda cinco estratégias de saúde pública para a prevenção e o controle das DTN: medicação preventiva; intensificação da gestão de casos; controle de vetores; provimento de água limpa, saneamento e higiene; e saúde pública animal – isso é, aplicação da ciência veterinária para garantir a saúde e o bem-estar de seres humanos. Embora uma abordagem possa predominar no controle de uma doença específica ou de um grupo de doenças, as evidências sugerem que são melhores os resultados no controle quando as cinco abordagens são associadas e aplicadas localmente... Este relatório identifica também os desafios que precisarão ser enfrentados para que sejam mantidas e ampliadas as atuais conquistas na prevenção e controle das DTN. Apesar das restrições econômicas globais, será preciso manter o apoio da Espanha, dos Estados Unidos, do Reino Unido e de outros países, agências e ONGs. Esses compromissos devem estimular outros agentes a aumentar seu apoio para o desenvolvimento dos serviços necessários para a superação das DTN.

Primeiro relatório da OMS sobre doenças tropicais negligenciadas: Avanços para superar o impacto global de doenças tropicais negligenciadas / First WHO report on neglected tropical diseases: working to overcome the global impact of neglected tropical diseases

[Resumo Executivo]. Doenças tropicais negligenciadas (DTN) afligem a vida de um bilhão de pessoas em todo o mundo e ameaçam a saúde de outros milhões. Essas companheiras antigas da pobreza enfraquecem populações já empobrecidas, frustram a realização dos Objetivos de Desenvolvimento do Milênio e prejudicam os resultados do desenvolvimento global. Uma avaliação mais confiável de sua importância para a saúde pública e para as economias convenceu governos, doadores, indústria farmacêutica e outras agências – entre as quais organizações não governamentais (ONGs) – a investirem na prevenção e no controle desse grupo diversificado de doenças. Os esforços globais para controlar doenças “ocultas” – tais como dracunculíase (infecção pelo verme da Guiné), lepra, esquistossomose, filariose linfática e bouba – resultaram em ganhos progressivos na área da saúde, incluindo a erradicação iminente da dracunculíase. Desde 1989 – quando a maioria dos países endêmicos passou a relatar mensalmente a situação de cada localidade infectada – o número de novos casos de dracunculíase caiu de 892.055, em 12 países endêmicos, para 3.190, em quatro países, em 2009: uma redução de mais de 99%. A Organização Mundial da Saúde (OMS) recomenda cinco estratégias de saúde pública para a prevenção e o controle das DTN: medicação preventiva; intensificação da gestão de casos; controle de vetores; provimento de água limpa, saneamento e higiene; e saúde pública animal – isso é, aplicação da ciência veterinária para garantir a saúde e o bem-estar de seres humanos. Embora uma abordagem possa predominar no controle de uma doença específica ou de um grupo de doenças, as evidências sugerem que são melhores os resultados no controle quando as cinco abordagens são associadas e aplicadas localmente... Este relatório identifica também os desafios que precisarão ser enfrentados para que sejam mantidas e ampliadas as atuais conquistas na prevenção e controle das DTN. Apesar das restrições econômicas globais, será preciso manter o apoio da Espanha, dos Estados Unidos, do Reino Unido e de outros países, agências e ONGs. Esses compromissos devem estimular outros agentes a aumentar seu apoio para o desenvolvimento dos serviços necessários para a superação das DTN.

Awareness and attitudes towards leprosy in urban slums of Kolkata, India.

Urban slums have proliferated in India with poor health and socio-economic status with no organized health system. They are at high risk for contracting communicable diseases including leprosy. In order to obtain reliable data on knowledge, attitudes and treatment of leprosy; a random sample cluster survey was done in Kolkata slums. House to house screening for leprosy was done in 6 representative random samples of slums, each with a population of at least 5000, using accepted methods for detection. Suspects were confirmed by medical officers. Intensive interviews were done by qualified male and female investigators. A majority had some knowledge of leprosy but hardly any knew early signs or symptoms or where to get proper diagnosis and treatment. Half the respondents felt leprosy must be treated separately from general patients but stated they had no hesitation in working with or visiting a leprosy patient. There were 11 suspects of which 9 were confirmed for leprosy and sent to nearest centre for MDT. Glaring gaps are noticed between knowledge and practice of slum population regarding leprosy. An integrated health program is needed urgently in urban slums to control leprosy and other diseases using a variety of resources including medical colleges.

[The impact of leprosy elimination strategy on an endemic municipality in Rio de Janeiro State, Brazil]. / Os indicadores da hanseníase e as estratégias de eliminação da doença, em município endêmico do Estado do Rio de Janeiro, Brasil.

Various strategies for eliminating leprosy as a public health problem have evolved in the last 20 years. In some countries, especially highly endemic ones, the WHO target rate for leprosy elimination fell far short. The current study aimed to analyze the impact of different strategies for reducing leprosy prevalence in Duque de Caxias, a highly endemic municipality in Rio de Janeiro State, Brazil. The study observed the evolution of traditional operational indicators for the disease and their trends in the last 14 years. The indicators were calculated using the National Communicable Diseases Database (SINAN). Strategies that focused on decentralization of patient care and/or localized campaigns were associated with earlier case detection, reduction in prevalence, and shorter patient time in the active registry. An increase in the annual detection rate could be related to the existence of hidden prevalence or individuals with asymptomatic infection. New complementary strategies are needed to eliminate the disease in Duque de Caxias.

Leprosy situation in the slums of Agra City--epidemiological findings.

The present article is the result of a study of the leprosy caseload in Agra City and is based on a house-to-house survey conducted during April-July 2003 in 5 areas. During the survey 198,150 persons were examined, and 287 cases were detected, giving a prevalence rate of 14.5/10,000. A majority of them (92%) were new cases, detected and diagnosed for the first time. The patient load was found to be unevenly distributed with comparatively more number of patients in areas such as Jamuna Kinara, Shah Ganj and Lohamandi. Among the 264 newly detected cases, 14.8% were of MB type. Overall deformity of grade > or = 2 was seen in 2.8% of patients--0.4% in PB and significantly high at 18% in MB leprosy. The observations reveal that leprosy is endemic in slum areas of Agra City.

Planning for PPM-DOTS implementation in urban slums in Kenya: knowledge, attitude and practices of private health care providers in Kibera slum, Nairobi.

SETTING: Kibera, the largest slum in Nairobi, Kenya. OBJECTIVE: To determine the tuberculosis (TB) knowledge, attitude and practices (KAP) of private health care providers (PHCPs) to identify their training needs and willingness to participate in a National Leprosy and Tuberculosis Control Programme (NLTP) guided TB control effort in the slum. DESIGN AND METHODOLOGY: A cross-sectional survey. The KAP of PHCPs was assessed using an interviewer administered questionnaire. RESULTS: Of 75 PHCPs interviewed, the majority (96.0%) were paramedics; 51 (77.1%) did not consider sputum smear microscopy crucial in patients presenting with prolonged cough or when a chest X-ray was suggestive of TB; of 29 (38.7%) who indicated familiarity with the drugs used in TB treatment, 20 (58.5%) would have chosen the NLTP-recommended regimens for the treatment of the various types of TB; 16 (21.3%) PHCPs indicated that they treated TB, six (37.5%) of whom were not familiar with anti-tuberculosis drug regimens. All the PHCPs referred TB suspects to the public sector for diagnosis. CONCLUSION: This study reveals a significant gap in TB knowledge among the PHCPs in Kibera slum. However, given appropriate training and supervision, there is potential for public-private mix for DOTS implementation in this setting.

Some epidemiological observations on leprosy in India.

This population sample survey conducted in rural and urban areas of the Agra District in India showed an active leprosy caseload of 60.1/10,000 in the rural and 39.1/10,000 in the urban areas against a targeted prevalence of < 1/10,000. The disease appeared to be widespread since almost 65% of the villages or urban pockets surveyed had at least one prevalent case of leprosy. Significantly larger numbers of leprosy patients were found among males, agricultural/manual workers, persons with no formal schooling, individuals living in unkept households with dirty surroundings, and among those living in dark and poorly ventilated houses. The epidemiological significance of this study reveals the endemic nature of leprosy in Agra and suggests the need to intensify and widen case-detection activities to achieve leprosy control.

Psychiatric morbidity in displaced leprosy patients.

One hundred confirmed leprosy patients, all of them migrated from elsewhere, were examined for psychiatric co-morbidity. Forty-six of them were from an 'ashram' and the others were from a slum area. 76% of the patients were found to be having psychiatric illness. Of these, 55% were having neurotic depression and 21% had anxiety neurosis. Single, unemployed, socio-economically backward and patients with physical deformities were suffering significantly more often with psychiatric symptoms. Psychiatric morbidity was found to be more frequent in the patients staying in slum than in those in the 'ashram' where they had some security.

Study of leprosy among slum dwellers in Pune. Part II--Disabilities.

While conducting a leprosy survey in an urban slum in Pune 45 cases of leprosy were detected in a population of 4915 and only 7 of these cases had some disability. Disability rate in the leprosy cases was 15.56 percent, and maximum number had Grade 2 disability of hands or feet. Disability was higher in the higher age groups, males, Hindus, widower/widows, unemployed and lower socio-economic classes. Majority of the cases had a very low Disability Index DI (2) between 0.10 to 0.69 which is heartening and proves the successful implementation of the National Leprosy Eradication Programme.

Study of leprosy among slum dwellers in Pune. Part-I. Prevalence.

While conducting a point prevalence total population survey in Ghorpuri slum in Pune, the overall prevalence or leprosy was 9.16 per thousand. The prevalence rate varied in different bastis with Madari basti having a very high prevalence rate of 17.31 per thousand and showing clustering. Prevalence was highest in age group 31-40 years, females, Muslims, Widower/widow, skilled workers, illiterates and primary school educated and the lower socio-economic groups. Joint families had the highest prevalence of leprosy (20.83/1,000) and also higher prevalence was seen in families with more than 7 members.

Sensitisation by mycobacteria and the effects of BCG on children attending schools in the slums of Bombay.

Quadruple skin testing with new tuberculins was used to evaluate the effects of previously administered BCG Madras in children attending schools in the slums, or living in Kopri Leprosy Colony in Bombay. There were differences between schools both in the level of sensitisation of children without BCG scars and in the effects of BCG vaccination. Results obtained at one school resembled those obtained in a previous study in Agra, where BCG was thought to be ineffective. Results from the other schools and Kopri were more like those previously reported from Ahmednagar, where BCG was considered to be much more effective. Thus within the same city groups of children of the same social status may vary widely both in their contact with mycobacteria and in their capacity to benefit from BCG vaccination.