Fatal Outcome of Chikungunya Virus Infection in Brazil.

BACKGROUND: Chikungunya virus (CHIKV) emerged in the Americas in 2013 and has caused approximately 2.1 million cases and >600 deaths. A retrospective investigation was undertaken to describe clinical, epidemiological, and viral genomic features associated with deaths caused by CHIKV in Ceará state, northeast Brazil. METHODS: Sera, cerebrospinal fluid (CSF), and tissue samples from 100 fatal cases with suspected arbovirus infection were tested for CHIKV, dengue virus (DENV), and Zika virus (ZIKV). Clinical, epidemiological, and death reports were obtained for patients with confirmed CHIKV infection. Logistic regression analysis was undertaken to identify independent factors associated with risk of death during CHIKV infection. Phylogenetic analysis was conducted using whole genomes from a subset of cases. RESULTS: Sixty-eight fatal cases had CHIKV infection confirmed by reverse-transcription quantitative polymerase chain reaction (52.9%), viral antigen (41.1%), and/or specific immunoglobulin M (63.2%). Co-detection of CHIKV with DENV was found in 22% of fatal cases, ZIKV in 2.9%, and DENV and ZIKV in 1.5%. A total of 39 CHIKV deaths presented with neurological signs and symptoms, and CHIKV-RNA was found in the CSF of 92.3% of these patients. Fatal outcomes were associated with irreversible multiple organ dysfunction syndrome. Patients with diabetes appear to die at a higher frequency during the subacute phase. Genetic analysis showed circulation of 2 CHIKV East-Central-South African (ECSA) lineages in Ceará and revealed no unique virus genomic mutation associated with fatal outcome. CONCLUSIONS: The investigation of the largest cross-sectional cohort of CHIKV deaths to date reveals that CHIKV-ECSA strains can cause death in individuals from both risk and nonrisk groups, including young adults.

Disseminated histoplasmosis and aids: relapse and late mortality in endemic area in North-Eastern Brazil.

The State of Ceará in north-eastern Brazil has one of the highest rates in the world of relapse and death due to disseminated histoplasmosis (DH) in acquired immunodeficiency syndrome (AIDS) patients. The objective of this study is to characterise the relapse and mortality of DH in AIDS cases residents in Ceará. We performed a retrospective analysis of the medical records of AIDS patients who had a first episode of DH from 2002 to 2008. We analysed the outcomes until December 31, 2010. A total of 145 patients participated in the study. The mean clinical follow-up duration was 3.38 years (SD = 2.2; 95% CI = 3.01-3.75). The majority of the subjects were male with a mean age of 35 years (SD = 2.2; 95% CI = 3.01-3.75) and were born in the capital of Ceará. DH was the first manifestation of AIDS in 59% of the patients. The relapse rate was 23.3%, with a disseminated presentation in 90% of these patients. The overall mortality during the study period was 30.2%. The majority of patients who relapsed or died had irregular treatment with antifungals or highly active antiretroviral therapy and did not have active clinical follow-up. High rates of recurrence and mortality were found in AIDS-associated DH in this area of the country.

High prevalence of intestinal infections and ectoparasites in dogs, Minas Gerais State (southeast Brazil).

In the present study, 155 dogs euthanized by the Zoonotic Disease Unit of Uberlândia in Minas Gerais State (Southeast Brazil) were autopsied. Ectoparasites were collected, and the intestinal content of dogs was systematically examined for the presence of helminthic parasites. In total, we isolated 5,155 metazoan parasites of eight species (three intestinal helminth species, five ectoparasite species). The cestode Dipylidium caninum was present in 57 dogs (36.8 %), the nematodes Ancylostoma caninum in 30 (19.4 %) and Toxocara canis in 24 (15.5 %), respectively. Among the ectoparasites, 139 (89.7 %) dogs were infested with Rhipicephalus sanguineus, 115 (74.2 %) with Ctenocephalides felis, 5 (3.2 %) with Tunga penetrans and one specimen (0.7 %) with Amblyomma cajennense, while myiasis was found in one dog (0.7 %). In logistic regression analysis, young age (adjusted odds ratio 5.74; 95 % confidence interval 1.18-27.85) and male sex (3.60; 1.24-10.40) were significantly associated with toxocariasis, and crossbreed dogs (8.20; 1.52-44.31), with dipylidiasis. Male (2.23; 1.12-4.43) and crossbreed dogs (5.17; 1.17-22.83) had also a significant higher number of concomitant parasitoses. Spatial distribution of dogs by neighbourhood identified high-risk areas. Our systematic study shows that dogs in Uberlândia carry a high number of parasites which may cause zoonotic diseases in humans; therefore, further specific evidence-based intervention measures are needed.

Impact of water renewal on the residual effect of larvicides in the control of Aedes aegypti.

This study was carried out to evaluate the residual effect of three larvicides under laboratory conditions for 100 days in Aedes aegypti. The larval mortality rate was measured without water renewal or with daily water renewal (80%). With temephos, there was 100% mortality in both groups until the 70th day. In the Bacillus thuringiensis israelensis (Bti)-WDG test, there was no difference during the first 20 days. With Bti-G, without water renewal, mortality was sustained above 90% for up to 35 days. The second experiment (with water renewal) reduced the mortality to below 90% after the first 20 days. When renewed water was provided, the residual effect was significantly lower for all larvicides.

[Hansen's Disease in the municipality of Fortaleza, CE, Brazil: epidemiological and operational aspects in children under 15-years-old (1995-2006)]. / Hanseníase no município de Fortaleza, CE, Brasil: aspectos epidemiológicos e operacionais em menores de 15 anos (1995-2006).

This is a sectional study that aims to analyze the occurrence of Hansen's disease cases in 15 year-old minors in the Municipality of Fortaleza and notified in SINAN. The epidemiological indicators in this population show hiperendemicity. In operational terms is observed the maintenance of the service concentration in some reference units, in spite of some progress. Late diagnosis, a high degree of incapacity in the diagnosis and low degree of evaluation of contacts registered reveal the fragility of the actions of control. This study emphasizes the possibility of error diagnostic front to the characteristics of the infection in this population. The occurrence of cases of leprosy in this population represents an epidemiologic indicator of great importance and its analysis extends the discussion on operational problems in the network of health services.

Predictive factors for disseminated histoplasmosis in AIDS patients with fever admitted to a reference hospital in Brazil.

INTRODUCTION: In many settings, the lack of sensitive biomarkers of disseminated histoplasmosis (DH) leads to a clinical reliance on older diagnostic methods and delayed treatment initiation. The early recognition of DH is critical for survival, especially in patients with human immunodeficiency virus (HIV). This study aimed to identify clinical and laboratory findings associated with the definitive diagnosis of DH in low-income HIV patients in endemic areas. METHODS: Febrile AIDS patients with suspected DH who were admitted to a reference hospital in northeastern Brazil from January 2006 to January 2007 were evaluated for clinical and laboratory findings associated with DH diagnosis. RESULTS: One hundred seventeen patients with fever were included, and 48 (41%) cases of DH were determined by Histoplasma capsulatum identification. A higher fever (≥38.5ºC), maculopapular/papular rash, splenomegaly, hepatomegaly, wheezing, hemoglobin ≤9.5g/dL, platelets ≤80,000/µL, CD4 count ≤75/µL, aspartate aminotransferase (AST) level ≥2.5 times the upper limit of normal (ULN), lactate dehydrogenase (LDH) ≥5times the ULN; and international normalized ratio (INR) >2 times the ULN were significantly associated with DH. A multivariable analysis identified hepatomegaly [adjusted (a) prevalence ratio (PR)= 1.96; 95% confidence interval (CI): 1.21-3.16), CD4 count ≤75/µL (aPR = 2.02; 95% CI: 1.06-3.83), LDH ≥5 times the ULN (aPR = 2.23; 95% CI: 1.44-3.48), and maculopapular/papular rash (aPR = 1.70; 95% CI: 1.02-2.83) were independent risk factors for DH. CONCLUSIONS: These easily assessed parameters can facilitate clinical decision-making for febrile AIDS patients with suspected DH in low socioeconomic and Histoplasma-endemic regions.

Seroprevalence and spatial distribution dynamics of Yersinia pestis antibodies in dogs and cats from plague foci in the State of Ceará, Northeastern Brazil.

INTRODUCTION: In Brazil, the plague is established in several foci located mainly in the northeastern part of the country, where it alternates between active and quiescent periods. These foci in the State of Ceará have high epidemiological importance. In addition to other plague detection activities, plague areas can be monitored through serological surveys of dogs and cats (domestic carnivores), which, following feeding on plague-infected rodents, can develop mild to severe forms of the disease and produce long-lasting antibodies. This study aimed to characterize the circulation dynamics and spatial distribution of Yersinia pestis antibodies in dogs and cats in plague foci areas of Ceará. METHODS: An ecological study was conducted to analyze the temporal series and spatial distribution of secondary data obtained from domestic carnivore serum surveillance in Ceará's plague areas from 1990 to 2014. RESULTS: Joinpoint analysis revealed that the overall trend was a reduction in antibody-positive animals. The mean proportion of antibody-positivity during the whole study period was 1.5% (3,023/203,311) for dogs, and 0.7% (426/61,135) for cats, with more than 4% antibody-positivity in dogs in 1997 and 2002. Antibody titers ranging from 1/16 to 1/64 were frequent. Despite fluctuations and a significant reduction, in recent years, there were antibody-positive animals annually throughout the study period, and the localities containing antibody-positive animals increased in number. CONCLUSION: Yersinia pestis is actively circulating in the study areas, posing a danger to the human population.

Clinical and epidemiological profile of leprosy patients attended at Ceará, 2007-2011.

BACKGROUND: Leprosy is an infectious chronic condition associated with potentially serious physical, social and psychological impacts. OBJECTIVES: To characterize the clinical and epidemiological profile of leprosy patients treated from 2007 to 2011 in the University Hospital of Ceará, Northeastern Brazil. METHODS: This is a retrospective and descriptive study. The study population consisted of residents in the state of Ceará treated in a dermatology clinic between 2007-2011. Clinical and epidemiological data analyzed were obtained from medical records and from the database of national Information System for Notifiable Diseases. RESULTS: 475 cases were analyzed, mostly women (51.8%), aged 45-59 years (35.0%) - mean of 45.2 years at diagnosis - with 6.3% of children under 15 , with low education (73.7%), white color (68.8%), residency in the city of Fortaleza (82.3%), and no defined work occupation (59.6%). At diagnosis, most patients were multibacillary (MB) (65.5%), had borderline clinical form (48.0%), and 22.7% had physical disability (8.0% with grade 2), predominantly in MB cases (p <0.001). We observe worsening of disability in 5.1% of cases post-MDT. The proportion of cases with reactional episodes was 42.7%, mainly during MDT (51.2%). CONCLUSION: This is the first study conducted in this hospital context, revealing late diagnosis, high burden of disease, hidden endemicity, and high social vulnerability in the state of Ceará. This study reinforces the need to strengthen health care network for timely diagnosis and treatment, aiming at longitudinality of assistance.

[Physical disabilities in leprosy patients after discharge from multidrug therapy in Northern Brazil]. / Incapacidades físicas em pessoas acometidas pela hanseníase no período pós-alta da poliquimioterapia em um município no Norte do Brasil.

Chronic sequelae and disabilities are one of the main problems in leprosy. The current study aimed to estimate the prevalence of disabilities in leprosy patients after successfully completing multidrug therapy in Araguaína, Tocantins State, Brazil. This was a cross-sectional study including 282 cases diagnosed from 2004 to 2009. The degrees of disability at diagnosis and at discharge from treatment were collected from medical records and the National Information System for Notifiable Diseases (SINAN). A simplified neurological workup was performed after discharge from treatment. The prevalence of disabilities at diagnosis was 29.4%, and 8.9% of then was grade II. Between diagnosis and discharge, the degree of physical disability worsened in 25% of cases. At diagnosis, the proportion of deformities was significantly higher in men (RR = 1.7; 95%CI: 1.23-2.37). There was a significant association between disability and multibacillary disease (p < 0.001) and occurrence of reactions (p < 0.001). The data show that after discharge from multidrug therapy, in order to prevent chronic sequelae and functional limitations, continuous monitoring is still needed for individuals that have been recorded as cured and thus deleted from the records.

Incapacidades físicas em pessoas que concluíram a poliquimioterapia para hanseníase em Vitória da Conquista, Bahia, Brasil / Physical disabilities after multidrug therapy for leprosy in Vitória da Conquista, Bahia State, Brazil

Objetivo: Estimar a prevalência de incapacidades físicas e fatores associados, em pessoas que concluíram a poliquimioterapia (PQT) para hanseníase. Métodos: Realizou-se estudo transversal (n=222) no município de Vitória da Conquista-Bahia-Brasil, incluindo casos de hanseníase notificados de 2001-2014. As incapacidades físicas foram avaliadas por meio de aplicação de instrumento e avaliação do grau de incapacidade (GI) e do escore olho-mão-pé (OMP). Resultados: A prevalência de incapacidades físicas foi de 64,8% (n=144), e de GI 2 foi de 17,1% (n=38). As incapacidades físicas associaram-se de forma significante com analfabetismo (RP = 1,27; IC 95% = 1,05­1,54), classificação operacional multibacilar (RP = 1,26; IC 95% = 1,01­1,57), ocorrência de episódios reacionais (RP =1,41; IC 95% = 1,14­1,74) e dor/espessamento neural (RP = 1,3; IC 95% = 1,02­1,64). Houve piora do GI em 34 (32,1%) dos casos, considerando o momento do diagnóstico à alta. Conclusões: As incapacidades físicas, inclusive as com deformidades, constituem um importante problema no contexto individual e coletivo dos casos que seguem no pós-alta da PQT. Ressalta-se a necessitando de maior monitoramento e cuidado longitudinal, no sentido de prevenir sequelas específicas da doença.

Objective: To estimate the prevalence of physical disabilities and associated factors in people who completed multidrug therapy for leprosy. Method: A cross-sectional study (n = 222) was carried out in the city of Vitória da Conquista-Bahia-Brazil, including cases of leprosy reported from 2001-2014. Physical disabilities were assessed through instrument application and assessment of the degree of disability (GI) and the eye-hand-foot score (EHF). Results: The prevalence of physical disabilities was 64,8% (n = 144), and GI 2 was 17,1% (n = 38). Physical disabilities were significantly associated with illiteracy (RP = 1,27; 95% CI = 1,05-1,54), multibacillary operational classification (RP = 1,26; 95% CI = 1,01 -1,57), reactional episodes (RP = 1,41; 95% CI = 1,14 ­ 1,74) and pain / neural thickening (RP = 1,3; 95% CI = 1,02-1,64 ). There was worsening of GI in 34 (32,1%) of the cases, considering the time of diagnosis at discharge. Conclusions: Physical disabilities, including those with deformities, constitute an important problem in the individual and collective context of the cases that follow in the post-discharge of MDT. The need for greater monitoring and longitudinal care, in order to prevent specific sequalae of the disease.

Predictive factors for disseminated histoplasmosis in AIDS patients with fever admitted to a reference hospital in Brazil

Abstract INTRODUCTION: In many settings, the lack of sensitive biomarkers of disseminated histoplasmosis (DH) leads to a clinical reliance on older diagnostic methods and delayed treatment initiation. The early recognition of DH is critical for survival, especially in patients with human immunodeficiency virus (HIV). This study aimed to identify clinical and laboratory findings associated with the definitive diagnosis of DH in low-income HIV patients in endemic areas. METHODS: Febrile AIDS patients with suspected DH who were admitted to a reference hospital in northeastern Brazil from January 2006 to January 2007 were evaluated for clinical and laboratory findings associated with DH diagnosis. RESULTS: One hundred seventeen patients with fever were included, and 48 (41%) cases of DH were determined by Histoplasma capsulatum identification. A higher fever (≥38.5ºC), maculopapular/papular rash, splenomegaly, hepatomegaly, wheezing, hemoglobin ≤9.5g/dL, platelets ≤80,000/µL, CD4 count ≤75/µL, aspartate aminotransferase (AST) level ≥2.5 times the upper limit of normal (ULN), lactate dehydrogenase (LDH) ≥5times the ULN; and international normalized ratio (INR) >2 times the ULN were significantly associated with DH. A multivariable analysis identified hepatomegaly [adjusted (a) prevalence ratio (PR)= 1.96; 95% confidence interval (CI): 1.21-3.16), CD4 count ≤75/µL (aPR = 2.02; 95% CI: 1.06-3.83), LDH ≥5 times the ULN (aPR = 2.23; 95% CI: 1.44-3.48), and maculopapular/papular rash (aPR = 1.70; 95% CI: 1.02-2.83) were independent risk factors for DH. CONCLUSIONS: These easily assessed parameters can facilitate clinical decision-making for febrile AIDS patients with suspected DH in low socioeconomic and Histoplasma-endemic regions.

Seroprevalence and spatial distribution dynamics of Yersinia pestis antibodies in dogs and cats from plague foci in the State of Ceará, Northeastern Brazil

Abstract INTRODUCTION: In Brazil, the plague is established in several foci located mainly in the northeastern part of the country, where it alternates between active and quiescent periods. These foci in the State of Ceará have high epidemiological importance. In addition to other plague detection activities, plague areas can be monitored through serological surveys of dogs and cats (domestic carnivores), which, following feeding on plague-infected rodents, can develop mild to severe forms of the disease and produce long-lasting antibodies. This study aimed to characterize the circulation dynamics and spatial distribution of Yersinia pestis antibodies in dogs and cats in plague foci areas of Ceará. METHODS: An ecological study was conducted to analyze the temporal series and spatial distribution of secondary data obtained from domestic carnivore serum surveillance in Ceará's plague areas from 1990 to 2014. RESULTS: Joinpoint analysis revealed that the overall trend was a reduction in antibody-positive animals. The mean proportion of antibody-positivity during the whole study period was 1.5% (3,023/203,311) for dogs, and 0.7% (426/61,135) for cats, with more than 4% antibody-positivity in dogs in 1997 and 2002. Antibody titers ranging from 1/16 to 1/64 were frequent. Despite fluctuations and a significant reduction, in recent years, there were antibody-positive animals annually throughout the study period, and the localities containing antibody-positive animals increased in number. CONCLUSION: Yersinia pestis is actively circulating in the study areas, posing a danger to the human population.

[Leprosy diagnosis in municipalities other than the patients' place of residence: spatial analysis, 2001-2009]. / Diagnóstico da hanseníase fora do município de residência: uma abordagem espacial, 2001 a 2009.

The study analyzed the flow of persons with leprosy from their municipality (county) of residence to that of their diagnosis in a highly endemic area in Brazil. The study was based on data from the National Information System for Notifiable Diseases from 2001 to 2009 in the States of Maranhão, Pará, Tocantins, and Piauí. Of the 373 municipalities, 349 (93.6%) had at least one resident with leprosy that had been diagnosed in a different municipality (4,325 cases, or 5.2% of the total). The municipalities with the most cases reported elsewhere were Timon (248) and São José de Ribamar (201), Maranhão State. The municipalities that received the most exogenous cases for diagnosis were São Luís (719), capital of Maranhão, and Teresina (516), capital of Piauí. Goiânia (146), capital of Goiás, and the Federal District (42) also reported numerous cases, even though they are located more than 1,000 km from the endemic area. The flow indicates gaps in the decentralization of comprehensive care for persons with leprosy and calls attention to the difficulties associated with patient monitoring during and after multidrug therapy.

Clinical and epidemiological profile of leprosy patients attended at Ceará, 2007-2011

Abstract: Background: Leprosy is an infectious chronic condition associated with potentially serious physical, social and psychological impacts. Objectives: To characterize the clinical and epidemiological profile of leprosy patients treated from 2007 to 2011 in the University Hospital of Ceará, Northeastern Brazil. Methods: This is a retrospective and descriptive study. The study population consisted of residents in the state of Ceará treated in a dermatology clinic between 2007-2011. Clinical and epidemiological data analyzed were obtained from medical records and from the database of national Information System for Notifiable Diseases. Results: 475 cases were analyzed, mostly women (51.8%), aged 45-59 years (35.0%) - mean of 45.2 years at diagnosis - with 6.3% of children under 15 , with low education (73.7%), white color (68.8%), residency in the city of Fortaleza (82.3%), and no defined work occupation (59.6%). At diagnosis, most patients were multibacillary (MB) (65.5%), had borderline clinical form (48.0%), and 22.7% had physical disability (8.0% with grade 2), predominantly in MB cases (p <0.001). We observe worsening of disability in 5.1% of cases post-MDT. The proportion of cases with reactional episodes was 42.7%, mainly during MDT (51.2%). Conclusion: This is the first study conducted in this hospital context, revealing late diagnosis, high burden of disease, hidden endemicity, and high social vulnerability in the state of Ceará. This study reinforces the need to strengthen health care network for timely diagnosis and treatment, aiming at longitudinality of assistance.

Interruption and defaulting of multidrug therapy against leprosy: population-based study in Brazil's Savannah Region.

BACKGROUND: Low adherence to multidrug therapy against leprosy (MDT) is still an important obstacle of disease control, and may lead to remaining sources of infection, incomplete cure, irreversible complications, and multidrug resistance. METHODOLOGY/PRINCIPAL FINDING: We performed a population-based study in 78 municipalities in Tocantins State, central Brazil, and applied structured questionnaires on leprosy-affected individuals. We used two outcomes for assessment of risk factors: defaulting (not presenting to health care center for supervised treatment for >12 months); and interruption of MDT. In total, 28/936 (3.0%) patients defaulted, and 147/806 (18.2%) interrupted MDT. Defaulting was significantly associated with: low number of rooms per household (OR = 3.43; 0.98-9.69; p = 0.03); moving to another residence after diagnosis (OR = 2.90; 0.95-5.28; p = 0.04); and low family income (OR = 2.42; 1.02-5.63: p = 0.04). Interruption of treatment was associated with: low number of rooms per household (OR = 1.95; 0.98-3.70; p = 0.04); difficulty in swallowing MDT drugs (OR = 1.66; 1.03-2.63; p = 0.02); temporal non-availability of MDT at the health center (OR = 1.67; 1.11-2.46; p = 0.01); and moving to another residence (OR = 1.58; 95% confidence interval: 1.03-2.40; p = 0.03). Logistic regression identified temporal non-availability of MDT as an independent risk factor for treatment interruption (adjusted OR = 1.56; 1.05-2.33; p = 0.03), and residence size as a protective factor (adjusted OR = 0.89 per additional number of rooms; 0.80-0.99; p = 0.03). Residence size was also independently associated with defaulting (adjusted OR = 0.67; 0.52-0.88; p = 0.003). CONCLUSIONS: Defaulting and interruption of MDT are associated with some poverty-related variables such as family income, household size, and migration. Intermittent problems of drug supply need to be resolved, mainly on the municipality level. MDT producers should consider oral drug formulations that may be more easily accepted by patients. Thus, an integrated approach is needed for further improving control, focusing on vulnerable population groups and the local health system.

[Spatial distribution and breeding site characteristics of Aedes albopictus and Aedes aegypti in Fortaleza, State of Ceará]. / Distribuição espacial e características dos criadouros de Aedes albopictus e Aedes aegypti em Fortaleza, Estado do Ceará

INTRODUCTION: Since the registration of Aedes albopictus in the municipality of Fortaleza in 2005, it has shown rapid dispersion. A study aiming to identify its occurrence areas, breeding sites and associations with Aedes aegypti and other culicids was carried out during 2008. METHODS: Between January and July 2008, samples of immature forms of culicids were gathered from properties located in districts of Fortaleza. Certain features of the breeding sites were highlighted, such as location (indoors or outdoors), presence of covering (protection against impact of sunlight and rain), water turbidity (water clear or not clear), constituent material, volume, height above ground level and simultaneous presence of different species of culicids in the same breeding site. RESULTS: Indoor location was an important factor for the breeding sites for Aedes albopictus [PR = 0.52; 95% CI: 0.33-0.81]. On the other hand, water turbidity and reservoir covering were not shown to be differentiators regarding infestation [p > 0.05]. Absence of water turbidity was significant for Aedes aegypti infestation in breeding sites [PR = 1.14; 95% CI: 1.06-1.22]. CONCLUSIONS: Absence of one of the species from the breeding sites enhanced the infestation by another species. Breeding sites that had not been infested by Aedes albopictus had a prevalence of infestation by Aedes aegypti that was 2.05 times greater [95% CI: 1.72-2.44]. There was no significant association between volume and height of the breeding sites and infestation by both species. Both species were found to be dispersed throughout the municipality, occupying a wide diversity of breeding sites. However, a slight physical separation could be identified, with higher infestation with Aedes albopictus outdoors.

Incapacidades físicas em pessoas acometidas pela hanseníase no período pós-alta da poliquimioterapia em um município no Norte do Brasil / Physical disabilities in leprosy patients after discharge from multidrug therapy in Northern Brazil / Incapacidades físicas en personas afectadas por la hanseniasis en el período post alta de la poliquimioterapia en un municipio en el norte de Brasil

Chronic sequelae and disabilities are one of the main problems in leprosy. The current study aimed to estimate the prevalence of disabilities in leprosy patients after successfully completing multidrug therapy in Araguaína, Tocantins State, Brazil. This was a cross-sectional study including 282 cases diagnosed from 2004 to 2009. The degrees of disability at diagnosis and at discharge from treatment were collected from medical records and the National Information System for Notifiable Diseases (SINAN). A simplified neurological workup was performed after discharge from treatment. The prevalence of disabilities at diagnosis was 29.4%, and 8.9% of then was grade II. Between diagnosis and discharge, the degree of physical disability worsened in 25% of cases. At diagnosis, the proportion of deformities was significantly higher in men (RR = 1.7; 95%CI: 1.23-2.37). There was a significant association between disability and multibacillary disease (p < 0.001) and occurrence of reactions (p < 0.001). The data show that after discharge from multidrug therapy, in order to prevent chronic sequelae and functional limitations, continuous monitoring is still needed for individuals that have been recorded as cured and thus deleted from the records.

Danos neurais contribuem para a incapacidade física na hanseníase. O objetivo foi estimar a prevalência de indivíduos com incapacidade física após a alta de poliquimioterapia da hanseníase em Araguaína, Tocantins, Brasil. Estudo transversal com 282 casos novos de 2004 a 2009. O grau de incapacidade no diagnóstico e na cura foi coletado de prontuários e do Sistema de Informação de Agravos de Notificação. No pós-alta usou-se o formulário de avaliação neurológica simplificada. A prevalência de incapacidade foi de 29,4%, sendo 8,9% grau 2. Houve associação entre incapacidades físicas com multibacilares (p < 0,001) e com episódios reacionais (p < 0,001). No diagnóstico, a ocorrência de deformidades foi 1,7 vez maior nos homens (IC95%: 1,23-2,37). Entre o diagnóstico e a alta houve piora do grau de incapacidade e esta piora foi maior após a alta: 25%. A piora do grau de incapacidade foi mais expressiva após a alta, apresentando associação com multibacilares e episódios reacionais. É preciso monitoramento contínuo de casos em alta, para prevenir sequelas e limitação funcional.

Daños neurales contribuyen a la incapacidad física en la hanseniasis. El objetivo fue estimar la prevalencia de individuos con incapacidad física, tras el alta de poliquimioterapia de la hanseniasis en Araguaína, Tocantins, Brasil. Estudio transversal con 282 casos nuevos de 2004 a 2009. El grado de incapacidad en el diagnóstico y en la cura se recogió de historiales médicos y del sistema de información de quejas por notificación. En el post alta se usó el formulario de evaluación neurológica simplificada. La prevalencia de incapacidad fue de un 29,4%, siendo un 8,9% grado 2. Hubo asociación entre incapacidades físicas con multibacilares (p < 0,001) y con episodios reaccionales (p < 0,001). En el diagnóstico, la ocurrencia de deformidades fue un 1,7 veces mayor en los hombres (IC95%: 1,23-2,37). Entre el diagnóstico y el alta hubo un empeoramiento del grado de incapacidad y ese empeoramiento fue mayor tras el alta: un 25%. El empeoramiento del grado de incapacidad fue más expresivo tras el alta, presentando asociación con multibacilares y episodios reaccionales. Es preciso el monitoreo continuo de casos en alta, para prevenir secuelas y limitación funcional.

Saúde bucal na agenda da política de DST/ AIDS no Brasil, Ceará e Fortaleza / Oral health in the policy agenda for STD/AIDS in Brazil, Ceará and Fortaleza

A magnitude da infecção pelo vírus da imunodeficiência humana (HIV) é inquestionável, apresentando impactos individuais e coletivos. Assim, torna-se evidente a necessidade de políticas públicas que orientem a atenção e assistência à saúde de Pessoas Vivendo com HIV/Aids (PVHA), em especial à saúde bucal, que caracteriza-se pela área de maior exclusão social na história das políticas públicas no Brasil. Buscou-se discutir as estratégias políticas de assistência odontológica a PVHA no Brasil, no Ceará e em Fortaleza por meio de uma pesquisa qualitativa do tipo análise documental, baseada no exame do conteúdo de documentos e páginas oficiais disponíveis nas três esferas de governo. Na esfera federal, verificou-se apenas um documento direcionando a atenção odontológica a PVHA presente na Política Nacional de Saúde Bucal e gerando ações de capacitação de cirurgiões-dentistas (CD) para assistência a essa população. No âmbito estadual, localizou-se somente documentos referentes aos Planos de Ações e Metas (PAM), do Programa Estadual de DST/Aids, com o mesmo direcionamento. Fortaleza apresentou a maior quantidade e abrangência de documentos sobre essa temática, propondo ações de capacitação para CD e universalização do acesso à saúde bucal para PVHA. A agenda específica de cada política indica prioridades dentro das diretrizes gerais. Observou-se que, dentro da agenda do Programa Nacional de DST/Aids, a saúde bucal parece ainda não estar entre os objetivos principais, cabendo predominantemente aos estados e municípios definir como relevante a implementação de ações direcionadas a saúde bucal dessa população, evidenciando-se a necessidade de avançar na discussão sobre a saúde bucal de PVHA.

The magnitude and impacts of infection from the Human Immunodeficiency Virus (HIV) are unquestioned. It is therefore apparent that there is a need for public policies that guide public health services for people living with HIV/Aids (PLHA), especially in dental health, which has been characterized as the area of greatest social exclusion in Brazilian public policy. This study has sought to review the policy strategies in buccal health for PLHA in Brazil, Ceará state and Fortaleza municipality using the analysis of documents and official decrees from the three levels of government. At the federal level, it was found only one document guiding of dental care for PLHA that outlines training activities for oral surgeons to treat this population. At the state level, we only found documents that make reference to the Plan of Activities and Goals from the State STD/AIDS Program, which gives the same training outlines. The municipality of Fortaleza presented the highest quantity and scope of documentation in this area, proposing training activities for oral surgeons and the universal coverage of dental health care for PLHA. The specific agenda for each policy indicates its priority within the overall guidelines. It was observed that within the agenda of the National STD/AIDS Program, buccal health does not appear to be among the main objectives, falling to the states and municipalities to define the relevance of implementing services directed towards dental health of this population. This shows the need to move forward in the discussion of dental health policies for PLHA.

Diagnóstico da hanseníase fora do município de residência: uma abordagem espacial, 2001 a 2009 / Leprosy diagnosis in municipalities other than the patients' place of residence: spatial analysis, 2001-2009

Caracterizar o fluxo de pessoas afetadas pela hanseníase, do município de residência para o de diagnóstico, em área de alta endemicidade no Brasil. Estudo baseado em dados do Sistema de Informação de Agravos e Notificação de 2001-2009, nos estados do Maranhão, Pará, Tocantins e Piauí. Dos 373 municípios, 349 (93,6%) tiveram pelo menos um residente afetado pela hanseníase notificado em outro município (4.325 casos, 5,2% dos notificados). Os municípios com maior número de casos notificados fora de sua residência foram Timon (248) e São José de Ribamar (201), no Maranhão. Os municípios que mais receberam casos para diagnóstico foram São Luís (719) e Teresina (516). Destacam-se Goiânia (146) e o Distrito Federal (42) como polos de notificações de casos residentes no agregado, mesmo a mais de 1.000km de distância da área. O fluxo observado indica lacunas na descentralização do processo de atenção integral à pessoa afetada pela hanseníase e chama atenção para as dificuldades e desafios associados com o acompanhamento durante e após a poliquimioterapia.

The study analyzed the flow of persons with leprosy from their municipality (county) of residence to that of their diagnosis in a highly endemic area in Brazil. The study was based on data from the National Information System for Notifiable Diseases from 2001 to 2009 in the States of Maranhão, Pará, Tocantins, and Piauí. Of the 373 municipalities, 349 (93.6%) had at least one resident with leprosy that had been diagnosed in a different municipality (4,325 cases, or 5.2% of the total). The municipalities with the most cases reported elsewhere were Timon (248) and São José de Ribamar (201), Maranhão State. The municipalities that received the most exogenous cases for diagnosis were São Luís (719), capital of Maranhão, and Teresina (516), capital of Piauí. Goiânia (146), capital of Goiás, and the Federal District (42) also reported numerous cases, even though they are located more than 1,000km from the endemic area. The flow indicates gaps in the decentralization of comprehensive care for persons with leprosy and calls attention to the difficulties associated with patient monitoring during and after multidrug therapy.

Análise dos fatores de risco ou de proteção para fluorose dentária em crianças de 6 a 8 anos em Fortaleza, Brasil / Analysis of protection or risk factors for dental fluorosis in 6 to 8 year-old children in Fortaleza, Brazil

OBJETIVO: Investigar os fatores de risco ou de proteção para a fluorose dentária na dentição permanente de crianças de 6 a 8 anos em um bairro no Município de Fortaleza, Brasil. MÉTODOS: Este estudo de caso-controle incluiu 67 crianças com fluorose nos incisivos superiores e inferiores permanentes erupcionados, conforme o índice de Dean, e 57 controles. A presença de fluorose foi determinada como variável dependente. Os dados acerca das variáveis independentes foram obtidos através de entrevistas com os pais das crianças. O teste exato de Fisher foi utilizado para verificar a existência de associação entre fluorose e as variáveis independentes. Foi calculada a razão de chances (odds ratio, OR) para verificar a associação e a probabilidade de fluorose no grupo-caso, ambos com significância de 95 por cento. RESULTADOS: Houve associação significativa da fluorose com tipo de moradia (própria, alugada ou ocupada), mas não com fonte de água para consumo ou uso de dentifrícios fluoretados e suplementos de flúor. Na análise univariada, o risco de fluorose foi maior em crianças que iniciaram o consumo de leite em pó reconstituído com água antes dos 2 anos de idade (OR = 4,53; IC95 por cento: 1,07 a 26,74) e nas que não mamaram (OR = 6,66; IC95 por cento: 1,61 a 38,62). Na análise multivariada, somente a amamentação apresentou associação com a fluorose (4,54; IC95 por cento: 1,21 a 16,66). CONCLUSÕES: A amamentação se configurou como fator de proteção contra a fluorose. É preciso estabelecer critérios de classificação mais específicos para permitir a investigação de relações entre fluorose e classe socioeconômica.

OBJECTIVE: To investigate protection or risk factors for dental fluorosis in permanent teeth of 6 to 8 year-old children in a neighborhood of Fortaleza, Brazil. METHODS: This case-control study included 57 controls and 67 children with fluorosis affecting superior and inferior incisors teeth as determined by the Dean classification criteria. Presence of fluorosis was considered as the dependent variable. Data concerning independent variables were obtained through interviews with the parents. Fisher's exact test was used to determine associations between fluorosis and the independent variables. Odds ratios (OR) were calculated to investigate associations and likelihood of fluorosis in the case group, with 95 percent significance level. RESULTS: Fluorosis was significantly associated with type of housing (owned, rented or squatted), but not with the source of drinking water or use of fluoridated toothpaste and fluoride supplements. Univariate analysis showed that the risk of fluorosis was higher in children who began drinking powdered milk mixed with water before 2 years of age (OR = 4.53; IC95 percent: 1.07-26.74) and in those who did not breastfeed (OR = 6.66; IC95 percent: 1.61-38.62). In the multivariate analysis, only breastfeeding was associated with fluorosis (4.54; IC95 percent: 1.21-16.66). CONCLUSIONS: Breastfeeding was a protection factor against fluorosis. More specific categorization criteria must be established to investigate relationships between fluorosis and socioeconomic class.