Conditional Cash Transfer Program and Leprosy Incidence: Analysis of 12.9 Million Families From the 100 Million Brazilian Cohort.

Leprosy is a neglected tropical disease predominately affecting poor and marginalized populations. To test the hypothesis that poverty-alleviating policies might be associated with reduced leprosy incidence, we evaluated the association between the Brazilian Bolsa Familia (BFP) conditional cash transfer program and new leprosy case detection using linked records from 12,949,730 families in the 100 Million Brazilian Cohort (2007-2014). After propensity score matching BFP beneficiary to nonbeneficiary families, we used Mantel-Haenszel tests and Poisson regressions to estimate incidence rate ratios for new leprosy case detection and secondary endpoints related to operational classification and leprosy-associated disabilities at diagnosis. Overall, cumulative leprosy incidence was 17.4/100,000 person-years at risk (95% CI: 17.1, 17.7) and markedly higher in "priority" (high-burden) versus "nonpriority" (low-burden) municipalities (22.8/100,000 person-years at risk, 95% confidence interval (CI): 22.2, 23.3, compared with 14.3/100,000 person-years at risk, 95% CI: 14.0, 14.7). After matching, BFP participation was not associated with leprosy incidence overall (incidence rate ratio (IRR)Poisson = 0.97, 95% CI: 0.90, 1.04) but was associated with lower leprosy incidence when restricted to families living in high-burden municipalities (IRRPoisson = 0.86, 95% CI: 0.77, 0.96). In high-burden municipalities, the association was particularly pronounced for paucibacillary cases (IRRPoisson = 0.82, 95% CI: 0.68, 0.98) and cases with leprosy-associated disabilities (IRRPoisson = 0.79, 95% CI: 0.65, 0.97). These findings provide policy-relevant evidence that social policies might contribute to ongoing leprosy control efforts in high-burden communities.

Effect of a conditional cash transfer programme on leprosy treatment adherence and cure in patients from the nationwide 100 Million Brazilian Cohort: a quasi-experimental study.

BACKGROUND: Indirect financial costs and barriers to health-care access might contribute to leprosy treatment non-adherence. We estimated the association of the Brazilian conditional cash transfer programme, the Programa Bolsa Família (PBF), on leprosy treatment adherence and cure in patients in Brazil. METHODS: In this quasi-experimental study, we linked baseline demographic and socioeconomic information for individuals who entered the 100 Million Brazilian Cohort between Jan 1, 2007, and Dec 31, 2014, with the PBF payroll database and the Information System for Notifiable Diseases, which includes nationwide leprosy registries. Individuals were eligible for inclusion if they had a household member older than 15 years and had not received PBF aid or been diagnosed with leprosy before entering the 100 Million Brazilian Cohort; they were excluded if they were partial receivers of PBF benefits, had missing data, or had a monthly per-capita income greater than BRL200 (US$50). Individuals who were PBF beneficiaries before leprosy diagnosis were matched to those who were not beneficiaries through propensity-score matching (1:1) with replacement on the basis of baseline covariates, including sex, age, race or ethnicity, education, work, income, place of residence, and household characteristics. We used logistic regression to assess the average treatment effect on the treated of receipt of PBF benefits on leprosy treatment adherence (six or more multidrug therapy doses for paucibacillary cases or 12 or more doses for multibacillary cases) and cure in individuals of all ages. We stratified our analysis according to operational disease classification (paucibacillary or multibacillary). We also did a subgroup analysis of paediatric leprosy restricted to children aged up to 15 years. FINDINGS: We included 11 456 new leprosy cases, of whom 8750 (76·3%) had received PBF before diagnosis and 2706 (23·6%) had not. Overall, 9508 (83·0%) patients adhered to treatment and 10 077 (88·0%) were cured. After propensity score matching, receiving PBF before diagnosis was associated with adherence to treatment (OR 1·22, 95% CI 1·01-1·48) and cure (1·26, 1·01-1·58). PBF receipt did not significantly improve treatment adherence (1·37, 0·98-1·91) or cure (1·12, 0·75-1·67) in patients with paucibacillary leprosy. For patients with multibacillary disease, PBF beneficiaries had better treatment adherence (1·37, 1·08-1·74) and cure (1·43, 1·09-1·90) than non-beneficiaries. In the propensity score-matched analysis in 2654 children younger than 15 years with leprosy, PBF exposure was not associated with leprosy treatment adherence (1·55, 0·89-2·68) or cure (1·57, 0·83-2·97). INTERPRETATION: Our results suggest that being a beneficiary of the PBF, which facilitates cash transfers and improved access to health care, is associated with greater leprosy multidrug therapy adherence and cure in multibacillary cases. These results are especially relevant for patients with multibacillary disease, who are treated for a longer period and have lower cure rates than those with paucibacillary disease. FUNDING: CONFAP/ESRC/MRC/BBSRC/CNPq/FAPDF-Doenças Negligenciadas, the UK Medical Research Council, the Wellcome Trust, and Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-Brazil (CAPES).

Socioeconomic risk markers of leprosy in high-burden countries: A systematic review and meta-analysis.

Over 200,000 new cases of leprosy are detected each year, of which approximately 7% are associated with grade-2 disabilities (G2Ds). For achieving leprosy elimination, one of the main challenges will be targeting higher risk groups within endemic communities. Nevertheless, the socioeconomic risk markers of leprosy remain poorly understood. To address this gap we systematically reviewed MEDLINE/PubMed, Embase, LILACS and Web of Science for original articles investigating the social determinants of leprosy in countries with > 1000 cases/year in at least five years between 2006 and 2016. Cohort, case-control, cross-sectional, and ecological studies were eligible for inclusion; qualitative studies, case reports, and reviews were excluded. Out of 1,534 non-duplicate records, 96 full-text articles were reviewed, and 39 met inclusion criteria. 17 were included in random-effects meta-analyses for sex, occupation, food shortage, household contact, crowding, and lack of clean (i.e., treated) water. The majority of studies were conducted in Brazil, India, or Bangladesh while none were undertaken in low-income countries. Descriptive synthesis indicated that increased age, poor sanitary and socioeconomic conditions, lower level of education, and food-insecurity are risk markers for leprosy. Additionally, in pooled estimates, leprosy was associated with being male (RR = 1.33, 95% CI = 1.06-1.67), performing manual labor (RR = 2.15, 95% CI = 0.97-4.74), suffering from food shortage in the past (RR = 1.39, 95% CI = 1.05-1.85), being a household contact of a leprosy patient (RR = 3.40, 95% CI = 2.24-5.18), and living in a crowded household (≥5 per household) (RR = 1.38, 95% CI = 1.14-1.67). Lack of clean water did not appear to be a risk marker of leprosy (RR = 0.94, 95% CI = 0.65-1.35). Additionally, ecological studies provided evidence that lower inequality, better human development, increased healthcare coverage, and cash transfer programs are linked with lower leprosy risks. These findings point to a consistent relationship between leprosy and unfavorable economic circumstances and, thereby, underscore the pressing need of leprosy control policies to target socially vulnerable groups in high-burden countries.

Leprosy: current situation, clinical and laboratory aspects, treatment history and perspective of the uniform multidrug therapy for all patients

Abstract: In this review, the most relevant and current epidemiological data, the main clinical, laboratory and therapeutical aspects of leprosy are presented. Detailed discussion of the main drugs used for leprosy treatment, their most relevant adverse effects, evolution of the therapeutic regimen, from dapsone as a monotherapy to the proposed polychemotherapy by World Health Organization (WHO) can be found in this CME. We specifically highlight the drug acceptability, reduction in treatment duration and the most recent proposal of a single therapeutic regimen, with a fixed six months duration, for all clinical presentations, regardless of their classification.

Leprosy: current situation, clinical and laboratory aspects, treatment history and perspective of the uniform multidrug therapy for all patients.

In this review, the most relevant and current epidemiological data, the main clinical, laboratory and therapeutical aspects of leprosy are presented. Detailed discussion of the main drugs used for leprosy treatment, their most relevant adverse effects, evolution of the therapeutic regimen, from dapsone as a monotherapy to the proposed polychemotherapy by World Health Organization (WHO) can be found in this CME. We specifically highlight the drug acceptability, reduction in treatment duration and the most recent proposal of a single therapeutic regimen, with a fixed six months duration, for all clinical presentations, regardless of their classification.

Anti-PGL-1 Positivity as a Risk Marker for the Development of Leprosy among Contacts of Leprosy Cases: Systematic Review and Meta-analysis.

BACKGROUND: There is no point of care diagnostic test for infection with M. Leprae or for leprosy, although ELISA anti PGL-1 has been considered and sometimes used as a means to identify infection. METHODS: A systematic review of all cohort studies, which classified healthy leprosy contacts, at entry, according to anti-PGL1 positivity, and had at least one year follow up. The outcome was clinical diagnosis of leprosy by an experienced physician. The meta-analysis used a fixed model to estimated OR for the association of PGL-1 positivity and clinical leprosy. A fixed model also estimated the sensibility of PGL-1 positivity and positive predictive value. RESULTS: Contacts who were anti PGL-1 positive at baseline were 3 times as likely to develop leprosy; the proportion of cases of leprosy that were PGL-1 positive at baseline varied but was always under 50%. CONCLUSIONS: Although there is a clear and consistent association between positivity to anti PGL-1 and development of leprosy in healthy contacts, selection of contacts for prophylaxis based on anti PGL1 response would miss more than half future leprosy cases. Should chemoprophylaxis of controls be incorporated into leprosy control programmes, PGL1 appears not to be a useful test in the decision of which contacts should receive chemoprophylaxis.

The additional benefit of the ML Flow test to classify leprosy patients.

The use of the skin lesion counting classification leads to both under and over diagnosis of leprosy in many instances. Thus, there is a need to complement this classification with another simple and robust test for use in the field. Data of 202 untreated leprosy patients diagnosed at FIOCRUZ, Rio de Janeiro, Brazil, was analyzed. There were 90 patients classified as PB and 112 classified as MB according to the reference standard. The BI was positive in 111 (55%) patients and the ML Flow test in 116 (57.4%) patients. The ML Flow test was positive in 95 (86%) of the patients with a positive BI. The lesion counting classification was confirmed by both BI and ML Flow tests in 65% of the 92 patients with 5 or fewer lesions, and in 76% of the 110 patients with 6 or more lesions. The combination of skin lesion counting and the ML Flow test results yielded a sensitivity of 85% and a specificity of 87% for MB classification, and correctly classified 86% of the patients when compared to the standard reference. A considerable proportion of the patients (43.5%) with discordant test results in relation to standard classification was in reaction. The use of any classification system has limitations, especially those that oversimplify a complex disease such as leprosy. In the absence of an experienced dermatologist and slit skin smear, the ML Flow test could be used to improve treatment decisions in field conditions.

[Use of an artificial neural network for detecting excess deaths due to cholera in Ceará, Brazil]. / Rede neural artificial para detecção de sobremortalidade atribuível à cólera no Ceará.

OBJECTIVE: To evaluate recurrent neural networks as a predictive technique for time-series in the health field. METHODS: The study was carried out during a cholera epidemic which took place in 1993 and 1994 in the state of Ceará, northeastern Brazil, and was based on excess deaths having 'poorly defined intestinal infections' as the underlying cause (ICD-9). The monthly number of deaths with due to this cause between 1979 and 1995 in the state of Ceará was obtained from the Ministry of Health's Mortality Information System (SIM). A network comprising two neurons in the input layer, twelve in the hidden layer, one in the output layer, and one in the memory layer was trained by backpropagation using the fist 150 observations, with 0.01 learning rate and 0.9 momentum. Training was ended after 22,000 epochs. We compare the results with those of a negative binomial regression. RESULTS: ANN forecasting was adequate. Excessive mortality (number of deaths above the upper limit of the confidence interval) was detected in December 1993 and October/November 1994. However, negative binomial regression detected excess mortality from March 1992 onwards. CONCLUSIONS: The artificial neural network showed good predictive ability, especially in the initial period, and was able to detect alterations concomitant and a subsequent to the cholera epidemic. However, it was less precise that the binomial regression model, which was more sensitive to abnormal data concomitant with cholera circulation.

Rede neural artificial para detecção de sobremortalidade atribuível à cólera no Ceará / Use of an artificial neural network for detecting excess deaths due to cholera in Ceará, Brazil

OBJETIVO: Avaliar as redes neurais recorrentes enquanto técnica preditiva para séries temporais em saúde. MÉTODOS: O estudo foi realizado durante uma epidemia de cólera ocorrida no Estado do Ceará, em 1993 e 1994, a partir da sobremortalidade tendo como causa básica as infecções intestinais mal definidas (CID-9). O número mensal de óbitos por essa causa, referente ao período de 1979 a 1995 no Estado do Ceará, foram obtidos do Sistema de Informação de Mortalidade (SIM) do Ministério da Saúde. Estruturou-se uma rede com dois neurônios na camada de entrada, 12 na camada oculta, um neurônio na camada de saída e um na camada de memória. Todas as funções de ativação eram a função logística. O treinamento foi realizado pelo método de backpropagation, com taxa de aprendizado de 0,01 e momentum de 0,9, com dados de janeiro de 1979 a junho de 1991. O critério para fim do treinamento foi atingir 22.000 epochs. Compararam-se os resultados com os de um modelo de regressão binomial negativa. RESULTADOS: A predição da rede neural a médio prazo foi adequada, em dezembro de 1993 e novembro e dezembro de 1994. O número de óbitos registrados foi superior ao limite do intervalo de confiança. Já o modelo regressivo detectou sobremortalidade a partir de março de 1992. CONCLUSÕES: A rede neural se mostrou capaz de predição, principalmente no início do período, como também ao detectar uma alteração concomitante e posterior à ocorrência da epidemia de cólera. No entanto, foi menos precisa do que o modelo de regressão binomial, que se mostrou mais sensível para detectar aberrações concomitantes à circulação da cólera.

[A challenge for the public health system in Brazil: dengue control]. / Um desafio para a saúde pública brasileira: o controle do dengue.

This article presents a critical analysis of the traditional strategy used to control Aedes aegypti using "health surveillance patrols", with periodic visits to all urban buildings. The strategy is not viable and/or is administratively unfeasible at present, since it has been proposed since the 1980s but has not been implemented. Brazilian health reform prioritized the expansion of coverage for basic health services, and not measures to control specific diseases. A. aegypti, which was reintroduced and began the reoccupation of its old habitat in 1976, is currently in a process of re-infesting the country until reaching equilibrium. This public health problem relates to the urban environment and is thus a problem that affects everyone, both the population and government, and not merely the health sector. The article highlights the need for joint action in sanitation and the environment. The population's role should also be reshaped as effective and permanent, separating the rights and duties of government and the population, i.e., making a clear distinction between the public and private domains. The danger of resurgence of yellow fever should be considered when establishing a new, feasible strategy for dealing with the dengue problem.

Um desafio para a saúde pública brasileira: o controle do dengue / Dengue control: a challenge for the public health system in Brazil

Este artigo problematiza a estratégia tradicional de controle do Aedes aegypti por meio do trabalho de guardas sanitários, com visitas periódicas a todas as edificações urbanas. Ela näo é viável e/ou näo tem factibilidade administrativa atualmente, já que vem sendo proposta desde a década de 80 e näo é implementada. A reforma sanitária brasileira priorizou a ampliaçäo da cobertura dos serviços básicos de saúde e näo as ações de controle de doenças específicas. O A. aegypti reintroduzido para iniciar a reocupaçäo de seu antigo habitat em 1976, está atualmente em um processo de reocupaçäo do país até atingir seu equilíbrio Isto como problema de saúde coletiva, diz respeito ao meio ambiente urbano, portanto um problema de todos, populaçäo e poder público, näo apenas da área de saúde. A necessidade da atuaçäo conjunta da área de saneamento e meio ambiente neste caso é ressaltada. Deve-se também repensar a contribuiçäo da populaçäo como efetiva e permanente, separando obrigações e direitos do poder público e da populaçäo, separando o público do privado. O perigo do reaparecimento da febre amarela deve ser considerado no estabelecimento de uma nova estratégia factível e viável para lidar com o problema do dengue

Reflexões sobre a epidemiologia atual / Reflections about current epidemiologic research / Réflexions sur l' epidemiologie actuelle

A definição da epidemiologia como o estudo das doenças e sua distribuição na população utiliza dois conceitos centrais: população e doença. Este trabalho discute a compreensão destes dois conceitos pelos epidemiologistas e também a teoria do estilo de vida enquanto teoria etiológica implícita nos modernos estudos epidemiológicos. Aponta ainda a relação entre categorias nosológicas e teorias etiológicas, enfatizando o caráter instrumental destas categorias e teorias. O afastamento entre a epidemiologia e a saúde pública é abordado, assim como sua relação com as ciências sociais. Por fim, aponta a possibilidade de múltiplas perspectivas na escolha de uma causa entre vários aspectos dos mecanismos de produção de uma doença.

The definition of epidemiology as the study of the causes of disease in human population is based on two main concepts: population and disease. This paper discusses these concepts as perceived by epidemiologists. It also discusses the life-style theory as the disease causation theory that guides modern epidemiological studies. The paper emphasizes the instrumental aspect of disease concepts and of causation theories, and discuss the relationship between epidemiology and public health, and between epidemiology and social sciences. This paper points that disease do not have a cause but mechanism of production. The production of disease is a result of genetic determined organic responses to environmental exposures. The cause is a choice of some aspect of this mechanism.

L'Epiderniologie se définit comme l'étude des maladies et de leur distribution dans la population. En tant que discipline scientifique, elle se fonde donc sur ces deux concept centraux. Cet article discute l'interprétation de ces deux idées par les épiderniologues, ainsi que la théorie du "style de vie", considerée comme théorie étiologique implicite par la plupart des recherches épidemiologiques modemes. La relation entre les catégories nosologiques et les théories étiologiques y est aussi analysée, en particulier du point de vue du rôle joué par ces catégories et ces théories comme instrument pour la compréhension de la réalité. L'écart croissant entre l'épidemiologie et la santé publique, et leur relation avec les sciences sociales, y est aussi abordé. Finalement, l'article suggere la possibilité d'existence de perspectives multiples pour le choise d'une cause, entre les divers aspects qui peuvent aider à expliquer la génese et la production des maladies.

Contaminación del aire y mortalidad infantil por neumonía / Air pollution and infant mortality due to neumonia

En este trabajo se investiga la relación entre la contaminación del aire, medida por la concentración de particulas suspendidas en la atmósfera, y la mortalidad infantil por nemonía en el área metropolitana de Rio de Janeiro. Se utilizó el análisis de regresión lineal múltiple (método progresivo o stepwise) para las tasas de mortalidad infantil por neumonía, por diarrea y por todas las causas en 1980, según la zona geográfica y los indicadores nivel de ingresos y grado de contaminación. Mientras que la variable "proporción de familias con ingresos superiores a dos salarios mínimos" se incluyo en la regresión correspondiente a los tres tipos de mortalidad infantil, el índice medio de contaminación tuvo un coeficiente estadísticamente significativo (b = 0,2208;t = 2,670; P = 0,0137) solo en el caso de la mortalidad por neumonía. Esto sugiere que existe una asociación biológica, pero esta debe considerarse con la precaucion que exige todo estudio ecológico. Hemos llegado a la conclusión de que es preciso incluir indicadores de la calidad del aire en estudios de las infecciones respiratorias agudas en los países en desarrollo

Air pollution and infant mortality from pneumonia in the Rio de Janeiro Metropolitan Area

The authors report the results of an investigation into the possible association between air pollution and infant mortality from pneumonia in Rio de Janeiro Metropolitan Area. This investigation employed multiple linear regression analysis (stepwise method) for infant mortality from pneumonia in 1980, including the study population's areas of residence, incomes, and pollution exposure as independent variables. With the income variable included in the regression, a statistically significant association was observed between the average annual level of particulates and infant mortality from pneumonia. While this finding should be accepted with caution, it does suggest a biological association between these variables. The authors' conclusion is that air quality indicators should be included in studies of acute respiratory infections in developing countries