IntroduÃÃo: Os estados reacionais da hansenÃase, classificados como tipo 1 (reaÃÃo reversa - RR) e tipo 2 (Eritema Nodoso HansÃnico â ENH) e neurite isolada, levam ao risco potencial de desenvolver incapacidades e deformidades antes, durante o tratamento e apÃs a alta. Necessitam diagnÃstico precoce e tratamento adequado. Este estudo justifica-se pela escassez de estudos sobre ocorrÃncia, seguimento e fatores associados aos episÃdios reacionais apÃs a alta do tratamento especÃfico, bem como o desconhecimento dos problemas enfrentados do diagnÃstico, ao manejo terapÃutico, sob a perspectiva das pessoas com reaÃÃes hansÃnicas. MÃtodos: estudo transversal, a partir da populaÃÃo alvo identificada, consistindo de avaliaÃÃo neurolÃgica simplificada, exame dermato-neurolÃgico e entrevista individual (Projeto MAPATOPI). Foram incluÃdos cinco municÃpios em Ãreas do cluster: AraguaÃna (TO), Floriano (PI), Bacabal e Caxias (MA) e Marabà (PA). A populaÃÃo alvo consistiu de todos os indivÃduos que apresentaram reaÃÃes hansÃnicas, em pÃs-alta do tratamento poliquimioterÃpico, residentes e acompanhados nos serviÃos de saÃde no perÃodo de 2007 a 2009, independente da data de inicio de tratamento. Utilizou-se a comparaÃÃo do escore OMP (olho-mÃo-pÃ) ou EHF (Eyes-Hand-Foot) do diagnÃstico com o atual. Outro desfecho binÃrio utilizado foi analisar a presenÃa de incapacidade 0-1 no escore OMP atual. Na anÃlise binÃria utilizou-se o teste chi quadrado de Pearson. Naquelas associaÃÃes onde o valor esperado era menor que cinco utilizou-se o teste exato de Fischer. Resultados: foram incluÃdos 280 pacientes. 190 (67,9%) eram do sexo masculino. A idade mÃnima de 8 a 85 anos, com media de 46,5 anos. Seis eram menores de 15 anos e cinco entre 15 e 17 anos. A renda mÃdia por mÃs foi de R$ 1077,00 com valores entre R$ 60,00 e R$ 6.000,00 reais. Mais de noventa por cento residia na zona urbana. Quanto à escolaridade 53 (18,9%) eram analfabetos e 53,6% tinham o primeiro grau incompleto. No total 45 (16,1%) foram classificados como PB e 232 (83,7%) foram classificados como MB. A forma clÃnica predominante foi a dimorfa com 115(41,1%), seguida da virchowiana 82 (29,6%). A reaÃÃo tipo 1 estava presente em 104 (37,1%), tipo 2 (18,6%), a neurite isolada (13,9%). A neurite associada foi encontrada em 51,9% dos pacientes com tipo 2. A quantidade de episÃdios reacionais variou de um atà seis episÃdios. Um episÃdio foi desenvolvido por 215 (77,3%). O primeiro episÃdio ocorreu durante o tratamento para 121 (43,2%), seguido, em frequÃncia de ocorrÃncia, em pacientes pÃs-alta. O escore OMP (EHF) no diagnÃstico variou de 0 a 11 e na avaliaÃÃo atual, de 0 a 10, com maior distribuiÃÃo no intervalo entre 1 a 4. Quanto à piora do escore OMP 88/198
(44,4%) pioraram. Entre as variÃveis sÃcio-demogrÃficas, o risco de piora foi associado a: ser analfabeto (RP= 1, 64; IC de 95% 1,21 â 2,21; p=0,003), viÃvo (RP= 1,98; IC de 95% 1,20 â 3,96, p=0,013). E como fator de proteÃÃo ter segundo grau de escolaridade (RP= 0,4; IC de 95% 0,23 â 0,71 p=0,000). Quanto à piora do OMP associada a variÃveis clÃnicas, a forma clÃnica dimorfa (RP= 3,71; IC de 95% 1,00 â 13,70; p=0,009), ter reaÃÃo durante a PQT (RP= 1, 70; IC de 95% 1,13 â 2,54 P=0,004), ter algum nervo espessado ((RP= 1, 78; IC de 95% 1,30 â 3,08; p=0,024). Quanto ao percurso atà o diagnÃstico, a autopercepÃÃo foi encontrada em 240 (85,8%), entre os sinais e sintomas 176 (62,9%) buscaram os serviÃos por dermatoses em geral. Na busca do diagnÃstico, a atenÃÃo primÃria foi a primeira entrada para 95 (34%) na rede de assistÃncia. As principais manifestaÃÃes de reaÃÃes citadas foram sinais dermatolÃgicos 115 (42%) e neurolÃgicos 97 (35,4%). No total, 206/280 (73,5%) responderam que a hanseniase trouxe mudanÃas, problemas e transtornos para a sua vida. Dentre as mudanÃas intrapessoais, as alteraÃÃes fÃsicas tiveram papel importante para 129 (62,6%) participantes. Essas alteraÃÃes levaram a limitaÃÃes do seu desempenho no trabalho e renda, seguindo do comprometimento das atividades de vida diÃria. ConclusÃes: EpisÃdios reacionais agravam o comprometimento fÃsico, psico-social de participaÃÃo social e comprometem o trabalho e a realizaÃÃo das atividades de vida diÃria. à necessÃrio foco na qualidade de vida dos indivÃduos no pÃs-alta, principalmente entre aqueles com incapacidades fÃsicas instaladas. O escore OMP à um importante instrumento para detectar a progressÃo das incapacidades fÃsicas e deve ser utilizado no diagnÃstico, alta e durante os episÃdios reacionais em todos os pacientes. Os serviÃos de atenÃÃo primÃria e secundÃria dos municÃpios envolvidos necessitam melhorar o acompanhamento aos indivÃduos no perÃodo pÃs-alta, nÃo apenas para aqueles indivÃduos com incapacidades jà instaladas (grau um e dois), mas tambÃm naqueles que nÃo apresentaram incapacidades no momento da alta. EvidÃncias apontaram a necessidade do empoderamento das pessoas afetadas pela hansenÃase em lidar eficazmente com os sinais e sintomas de reaÃÃes apÃs a PQT. Sugere-se instituir um sistema de monitoramento e vigilÃncia dos estados reacionais por um perÃodo mÃnimo de seis meses atà cinco anos apÃs a alta, considerando a existÃncia de grupos de pacientes onde o comprometimento neurolÃgico ocorre lenta e silenciosamente, com possibilidade de danos nÃo sà fÃsicos, mas psicossociais. / Introduction: Leprosy reactions are classified as type 1 (reversal reaction - RR), type 2 (Erythema Nodosum Leprosum - ENL) and pure neuritis. These lead to a potential risk of developing disabilities and deformities before and during anti-leprosy treatment as well as after release from treatment (RFT). Reactions must be diagnosed early and treated effectively. This research is justified by the scarcity of studies on the occurrence of reactions, monitoring practices of patients and factors associated with reaction episodes after RFT. We know little about existing diagnostic problems, about case management from the perspective of the affected persons with reactions.Methods: Transversal study design, consisting of a simplified neurological examination, a dermato-neurological examination and interviews of the defined target group. Five municipalities were included in the cluster areas: Araguaina (Tocantins), Floriano (PiauÃ), Bacabal and Caxias (MaranhÃo) and Marabà (ParÃ).
The target population consisted of all resident individuals with leprosy reactions after being released from multidrug therapy, who presented themselves to the health services in the period 2007 to 2009, regardless of the date of start of treatment. We compared the EHF (eye-hand-foot) scores at diagnosis and during the respondentsâ examinations. In another analysis we compared the presence of disability scores (0-1) to the current EHF scores. In the analysis we used the Chi square test and for those associations where the expected value was less than 5 we used Fischerâs exact test. Results: A total of 280 patients were included in the study. Of those, 190 (67.9%) were male. The ages ranged from 8 to 85 years, with a mean of 46.5 years. Six patients were under 15 years and five aged between 15 and 17 years. The average monthly income of the respondents was R$ 1,077.00 (around â400) with values between R$ 60 (â22) and R$ 6,000 (â2200). More than ninety per cent lived in urban areas. As for education, 53 persons (18.9%) were illiterate and 53.6% had an incomplete primary education. In total 45 patients (16.1%) were classified as PB and 232 (83.7%) were classified as MB. The predominant clinical form (Madrid classification) was dimorphous in 115 (41.1%) cases, followed by 82 lepromatous forms (29.6%). Type 1 reaction was present in 104 patients (37.1%), type 2 reactions in 18.6% of cases and pure neuritis in 13.9%. An associated neuritis was found in 51.9% of patients with type 2 reactions. The frequency of reaction episodes ranged from one to six. One episode only was developed by 215 patients (77.3%). The first episode occurred during anti-leprosy treatment for 121 patients (43.2%), followed in frequency of occurrence by patients after RFT. The EHF score at the time of diagnosis ranged
from 0 to 11. At the time of the examination the EHF score range was 0-10, with a predominance of scores between 1 and 4. In 88 out of 198 patients (44.4%) their scores worsened. The risk of worsening was associated with the following socio-demographic variables: being illiterate (PR = 1.64, 95% CI: 1.21 - 2.21, p = 0.003), being widower (PR = 1.98, 95% CI: 1.20 - 3.96, p = 0.013). A protective factor was found: having completed secondary school education (PR = 0.4, 95% CI: 0.23 - 0.71 p = 0.000). Worsening of the EHF scores was associated with borderline leprosy (PR = 3.71, 95% CI: 1.00 - 13.70, p = 0.009), having had a reaction during MDT (PR = 1, 70; 95% CI 1.13 to 2.54 P = 0.004), and the presence of a thickened nerve (PR = 1, 78, 95% CI: 1.30 - 3.08 p = 0.024). In the patientsâ health seeking behaviour towards diagnosis, self-perception of symptoms was reported by 240 respondents (85.8%). Dermatological symptoms were the main complaint, in 176 (62.9%) cases. Primary health care services were the first point of entry for 95 patients (34%). The main reaction symptoms mentioned were of dermatological nature, in 115 (42%) cases Neurological complaints were mentioned by 97 (35.4%) respondents. In total, 206 out of the 280 patients (73, 5%) responded that leprosy brought about changes, problems and troubles in their lives. Among the intrapersonal changes, physical changes played an important role for 129 (62.6%) participants. These changes led to limitations in work performance and income, as well as causing restrictions in activities of daily living. Conclusions: Episodes of reactions worsen physical and psycho-social impairments, reduce social participation, cause problems at work and hamper activities of daily living. It is necessary to focus on the quality of life of individuals after RFT, especially among those with already established physical disabilities. The EHF score is an important tool to detect the progression of physical disability. The tool should be used in the diagnostic procedure, at the time of RFT and during reactions for all patients. Primary health care services and reference centres in the municipalities involved need to improve monitoring persons after RFT. Improved monitoring is needed not just in those patients with existing disabilities (DG1 and DG2), but also for those without disability present at discharge. Evidence indicates the need for empowerment of people affected by leprosy to deal effectively with the signs and symptoms of reaction after MDT. It is suggested to establish a system for monitoring and surveillance of reactions for a period of minimally six months up to five years after RFT. This surveillance is especially important considering that patients may develop neurological impairment gradually and without presenting symptoms, with the subsequent possibility of physical and psycho-social harm.
| Identifer | oai:union.ndltd.org:IBICT/oai:www.teses.ufc.br:2533 |
| Date | 27 February 2012 |
| Creators | Maria de Jesus Freitas de Alencar |
| Contributors | Jorg Heukelbach, Maria Leite Wand Del Rey de Oliveira, LÃgia Regina Franco Sansigolo Kerr, Maria da GraÃa Souza Cunha, Josà Augusto da Costa Nery |
| Publisher | Universidade Federal do CearÃ, Programa de PÃs-GraduaÃÃo em SaÃde PÃblica, UFC, BR |
| Source Sets | IBICT Brazilian ETDs |
| Language | Portuguese |
| Detected Language | English |
| Type | info:eu-repo/semantics/publishedVersion, info:eu-repo/semantics/doctoralThesis |
| Format | application/pdf |
| Source | reponame:Biblioteca Digital de Teses e Dissertações da UFC, instname:Universidade Federal do Ceará, instacron:UFC |
| Rights | info:eu-repo/semantics/openAccess |
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