Geoepidemiological Profile of Leprosy in Rondônia, Brazil

The research aimed to evaluate the geoepidemiological profile of leprosy and its spatially uneven production in the state of Rondonia in the period from 2011 to 2014, from the perspective of medical geography, identifying and performing mapping of critical areas of the spatial production of leprosy. The study it is quantitative, descriptive and retrospective research. Information System Diseases and Reportable - the database SINAN (Sistema de Informação de Agravos e Notificáveis) was used. For the clothing of thematic maps was used ArcGIS program. The research universe was created by the registration of all new cases of leprosy reported in the period from 2011 to 2014, living in Rondonia. The State of Rondonia had 2,972 (two thousand nine hundred seventy-two) new cases of leprosy in the period studied, respectively 827 new cases in 2011, 779 in 2012, 2013 686 and 2014 680, which corresponds to 5.24 detection rate in 2011 4.93 2012 3.96 3.88 2013 and 2014 and are classified as hyperendemic area with detection rate/average incidence of 4.50 per 10,000 inhabitants. Leprosy is present in virtually 100% of the municipalities of Rondonia.

Brazil maintains, in recent decades, the most unfavorable situation in America and the diagnosis of the second largest number of cases in the world after India. Leprosy among Brazilians is therefore a public health problem whose elimination program is among the priority actions of the Ministry of Health. The geographical distribution of the disease in Brazil is studied, usually for its macro-regions and states, it does not have a systematic knowledge of their spatial distribution. With the implementation of Notifiable Diseases Information System (SINAN) by the Ministry of Health (MS), co-administered by the Department of Health Surveillance (SVS/MS) and Department of the Unified Health System (Datasus/MS) in a gradual improvement process it is currently possible to develop detailed explorations of disease in different geographical scales 1 . Factors associated with spatial distribution of leprosy, in general, can be grouped into natural and social. Among the natural assumptions, the weather are, relief, vegetation types and particular ecosystems. Among the social premises, it highlights unfavorable living conditions, malnutrition, migration and others. Few investigations of leprosy infection focus on nonhuman sources. The Mycobacterium leprae can survive for months outside the human body and favorable moisture conditions. Thus, wet soils, low temperatures and high environmental humidity favor the survival of the bacillus; Beyond these more known environmental sources, should be considered, also, vegetation, water, some arthropods and monkeys 6.7 . According to the work of Fine et al 8 the most important source of infection are probably non-treated patients multibacillar where multibacillar contacts of patients had a risk of illness five to ten times higher than the general population; however, there are few multibacillary patients in certain areas indicates other sources of infection 9 . In this line of research, we discuss about the meaning of armadillo in the incidence of leprosy since thebeginning of the 70s Opromola 10 states that, although not proved leprosy a zoonotic disease, the presence of bacilli in wild animals would have serious implications for the control and eradication program of the disease in humans. Among the social assumptions associated with the geographic distribution of the disease, reaffirm to poverty, malnutrition or some nutritional deficiencies, as well as unfavorable hygienic conditions and migration. The disease often relates to indicators such as low income or per capita, low education and lack of basic health conditions, among others. Nevertheless, historical documents about the factors associated with the transmission of leprosy suggest that its great spread and rapid decline in medieval Europe are due to the existence of some unknown epidemic factor.
As knowledge popularized leprosy is still a serious health problem in the world. Besides being a disease aggravated inherent to socioeconomic and cultural borne diseases, it is also marked by the psychological impact generated by deformities, disabilities, stigma causes and people's isolation in society. This fact contributes to decreased self-esteem and self-segregation of leprosy carrier. Precisely for this reason, its sufferers hide their problem in order not to be discriminated against by society 11 . According to Cunha 11 leprosy is known for millennia, in the biblical account was cited as an impurity of mind and their carriers were isolated from society. Hence arose the prejudices about the disease. A public health problem already was considered as caused mutilations, disabilities and that deformed his face and body, with the los s of body parts, has long been known as leprosy until the change of nomenclature for leprosy, through Law Brazilian Federal No. 9010 of March 29, 1995. Leprosy is simple to diagnose, treat and can be cured provided it is diagnosed early because their injuries can lead to physical disabilities. The M. leprae has an interesting feature, has high infectivity and low pathogenicity, it means that many are infected, but few get sick 12 . The production and distribution of leprosy in the state of Rondonia deserve special attention by high detection rates presented, ranking third in the national ranking in reported cases of the disease. The study of the spatial behavior of this indicator can be an important tool to assist in planning, monitoring and evaluation of h ealth actions by directing interventions to reduce the high rates of the disease. So geoepidemiological characterize the pattern of leprosy in the State of Rondonia, means contributing to spatial visualization of leprosy, for applying control measures in places considered risk areas. The research aims to evaluate the geoepidemiológico pattern of leprosy and its spatially uneven production in the state of Rondonia in the period from 2011 to 2014, from the perspective of medical geography and specific objectives, describe the geoepidemiológico pattern of leprosy; identify the spatially uneven production; perform mapping of critical areas of the spatial production of leprosy in the state of Rondonia.

II. METHODS 2.1 Type of study
The study is conducted by quantitative, descriptive and retrospective study. Seeks to identify events (...), or even describe how certain phenomena are distributed in the population, or part of, or their sample quantitatively measuring the problem will contribute to a spatial analysis of leprosy in the state of Rondonia in the 2011 period 2014. The SINAN-NET was developed by SVS / MS together to DATASUS, it aims to modify the information production logic for the analysis on levels of increasingly decentralized health system. Subsidizes the construction of epidemiological surveillance systems of territorial base, to be aware of what happens to the Internet, the transmission of data from reporting daily to the other levels of government, so that these data are available in a timely manner, the three spheres government. The systematic use of data generated by the system from outside decentralized, contributes to the democratization of information, allowing all health professionals have access to information and make available to the community. It is therefore an important tool to assist the planning of health, set intervention properties, in addition to enabling that evaluate the impact of interventions.
The System for Notifiable Diseases Information System (SINAN) is an important system for epidemiological surveillance, was created in 1990 by the Ministry of Health (MOH) in order to collect, process and transmit data on notification of diseases throughout the country, providing information for the analysis of morbidity profile, as well as carry out the process of data collection and transfer related to diseases and reportable diseases. Leprosy is the object of this system, which enables therefore get consolidated information on the disease and the SINAN was the main data for this work 13 . With possession of information obtained ANVISA, the database was done in ArcGIS program for later preparation of thematic maps with spatial distribution of leprosy in the state of Rondonia, containing new cases of distribution map. Because it is study used secondary data there was no need for project submission to a Research Ethics Committee meeting the provisions of Resolution 196 of the CNS/CES. -National Health Council/Committee Ethics and Health Still, It has officially requested authorization from the primary data holders, by application to ANVISA. It was created by the registration of all new cases of leprosy reported in the period from 2011 to 2014, livingin Rondonia. The selection of variables to study based on the relationship of those variables used for the construction of epidemiological and operational indicators officially used by the Ministry of Health. In order to analyze the evolution of leprosy and describe their geographical distribution in Rondonia the following variables were selected, and their categorizations:    Classification of case detection rates per 10,000 inhabitants: low (<0.2); average (0.2-0.9); high (1.0-1.9); very high (2.0 to 3.9); hyperendemic situation (≥4,0) In 2011, 27 (twenty seven) municipalities are presented hyperendemic, implying say that more than 50% of the municipalities of Rondonia are presented in hyperendemic situation. This independent hyperendemic situation of social, demographic, economic, urban, urban or rural, environmental characteristics, among others, the example of Ariquemes municipalities with an incidence rate of 4.0; Ji Parana at a rate of 8.6; Pimenta Bueno with Among the reported cases, it was found that most of them, 1728 (57.7%) occurred in males and 1269 (42.3%) in female persons ( Table 5). The distribution of new cases followed a certain similarity in each period with respect to gender, no significant differences (X2 = 3.0900, p = 0.0787). As for the color classification considerations (inferring ethnicity) specified by the Health's Ministry of Brazil, the analys is of people who contracted leprosy revealed that there was a higher prevalence in b rown color with 1600 new cases (54.2%), followed by white with 1015 (34.4%) of cases. So also in other color categories showed statistically significant differences (x2 = 61.6750 p = 0.000). With regard to the area of residence, most in 2042 (68.2%) of leprosy reported individuals living in urban areas, especially those who reported residing in the more urbanized cities. In the distribution by place of residence differences were significant in relation to areas of subspaces residences (x2 = 21.6104; p = 0.0000). It was found that age of the subjects reported leprosy, ranged from less <15 years greater than 80 years old. The new cases were more prevalent in the age group of 20 to 59 years, 2220 (74%) of cases. Among the new cases that arouse attention, are the <15 years with 6.27%. However, the distribution of new cases with respect to age showed significant differences for the years studied. Multibacillary does not appear different when related between the municipalities. There is also no difference in the distribution of paucibacillary between the municipalities of Rondonia.  Source: SINAN, 2015.
The treatment scheme was adopted PCT/MB/12 doses 56.6% of cases, followed PCT/PB/less than 12 doses. But two situations arouses much attention, the considerable number adoption of patients who underwent the treatment regimen with more than 24 doses and the record in 2014 when 31.2% of patients did not undergo the treatment (128 cases no dose).  Mathematical models developed for studies of transmission and control of leprosy were used to analyze the impact of the current strategy for the elimination of leprosy on its incidence and project future incidence considering various scenarios. The annual incidence prediction of decline ranged from 2% to 12%, concluding that the elimination strategy reduces transmission, but in a slow 16 . Penna and Penna 17 show a downward trend in the detection rate for Brazil is only predicted after 2010, attributing the fall occurred on operational factors such as a possible decline in the diagnostic coverage, or likely change in the notification process and registration of cases.
The aggregate data from all municipalities of Rondonia, Brazil, show relative stability of detection rates in the last four years. There is evidence that leprosy does not always play in smaller geographical units or in spaces smaller epidemiological heterogeneity, due to the many variables involved in the health-disease, it is scattered with greater or lesser extent throughout the territory of the s tate. Magalhães 18 , when analyzing the evolution of leprosy in different regions of Brazil, found growth trends of endemic ranging, for example, an increase of 9% in the Northeast and 0.7% in the South. In Brazil in 2002, while the case detection rate was 2.62/10,000 inhab, in the northern region this rate was 7.73/10,000 inhab. and in the South region was 0.75/10,000 inhab. which shows an uneven inter-regional development, intra-regional and interstate endemic in the country and suggests the existence of geographical contexts of different vulnerability to the social production of leprosy.
To corroborate the existence of producers geographical contexts of the disease, cite the study by Rodrigues et al 19 in São Paulo, which points to the decline of endemic disease, but allows you to view regions with different magnitudes of the disease, with detection rates higher in the more northern regions of the state. A study conducted in the city of Sobral, Ceará, Brazil, showed that the new case detection rate increased in the 1997-2003 period, rising by over 100% in the last three years of the study 20 .
During the study period in the State of Rondonia, the 2972 (two thousand nine hundred seventy-two) new cases

International Journal of Advanced Engineering Research and Science (IJAERS)
[Vol-5, Issue-7, July-2018] https: //dx.doi.org/10.22161/ijaers.5.7.23  ISSN: 2349-6495(P) | 2456-1908(O) of leprosy have tended to decline, without, however, show significant differences, ranking as hyperendemic area with detection rate / average incidence of 4.50 per 10,000 inhabitants. Leprosy is present in virtually 100% of the municipalities of Rondonia. Leprosy is considered one of the public health problems in different regions of the world. In the state of Rondonia -Brazil, it is one of the major endemic problems related to health. Recognize the different aspects related to the disease can aid in characterizing different areas of the region, contributing to the changes related to the welfare of the population. Among the reported cases, it was found that most of them, 1728 (57.7%) occurred in males and gender in 1269 (42.3%) in female people. In Mato Grosso, Brazil, from 1996 to 2007, higher detection rates for males were observed in all regional groups. Magalhães and Rojas 21 found higher rates for males in all the states of the North and Midwest. Increase in detection rates for males was observed in the endemic declining situation 22 . Leprosy notification data in Portugal 23 showed a peak incidence for males aged 25 to 29 years. A study conducted in Fernandópolis 24 to characterize the contacts of leprosy profile who became ill reported a percentage of 59.7% of cases among men. The Barro study (2005) showed that for males increased incidence occurred in the age group 35-44 years, while for females this increase was in the range 45-54 years. Another study in Coari in Amazonas state, Brazil, showed percentage of 70.8% of cases for males 25 . Study by Queiroz 26 in relation to the distribution of cases by sex is observed that the detection rates for males are shown higher in all regional state of Mato Grosso. In the state, the evolution of the detection rate for both sexes plays that observed for the set of data. However, the first to the last period, reducing the detection rate among men was lower (1.4%) than in women (6.7%). For the detection by age, Mato Grosso, it is noted that the coefficients are higher in older age groups, especially in the ages 15 to 44 and 45 years and older, observing increase in these two age groups and reducing the intermediate period during the last period 26 . Considered trend indicator of the leprosy endemic the detection rate in children under 15 years has shown a slight decrease. In the study by Magalhães and Rojas 21 in Mato Grosso, the analysis shows that by age stratum under 15 years detection coefficients are within hyperendemicity parameter, and only in group I showed reduced. Considered a trend indicator of endemic disease, which reflects early exposure to M. leprae, this indicator had a wide variation in the first period in the various regional. The 2007 data published by WHO in its latest annual report also show the same variation in this age group in the various regions of the world and between regions within the same continent. In Africa, for example, proportions were found 2.89% in Togo to 37.96% in Comoros. In the Americas 0.32% proportions in Argentina to 14.02 in the Dominican Republic 27 . Variations of this indicator in several Brazilian regions were also observed by Magalhães and Rojas 21 (2005) , which reported increases of 335% in the Northeast to negative in the South and North. The authors also report that in the Midwest state of Mato Grosso stands out among the other states with an increase of 421% in the detection of cases of children under 15 years. Studies show that in the endemic declining situation, the age of new cases detected shifts to older age groups 2 . For Queiroz 26 the highest coefficients are concentrated in the older age groups, the detection of leprosy in the state of Mato Grosso, remained stable among the population 45 years or more. In the same study the rise of the coefficients among children under 15 years points to a worsening of the epidemiological situation in the period. As for the distribution by race / color, it was observed that there was a predominance over the whole period and in all municipalities for the mulatto (54.2%) except for the municipalities of the southern region of the state where prevails the white population. However, there were no significant differences when compared to the municipalities as ethnic/predominant color. Maybe justifies this frequency considering that for the state of Rondonia predominant brown color. Name et al 28 for analysis of the University Hospital data BSB observed that the patients reported, 57% were brown, white and 27% black 13.2%, East Indian corresponded to 2% of the cases. Given these diverging in relation to white and brown observed in studies and in the IBGE (2000). Thus, one of the factors that may be related is on the migratory process of the population or disabled in the settings for skin color observed by the people, for the color record is defined by the declarant of the concept itself, and may thus have influenced the data from this survey. For Queiroz 26 leprosy can occur in all races (OPS, 1983). In a recently published study, Santos et al 29 found in 76.7% proportion of non -whites (brown and black) and Thomas et al 30 . (2003) found a rate of 82.1% among non -whites. Both figures suggest that, even in populations they evaluated the detection rate among nonwhites should be greater than among whites. According to Queiroz 26 there is still a poor record of race/color variable. In their study only 1% of leprosy cases records had information "Race / Color," and in the second period only 58%. The distribution of the detection rate by race / color showed that the detection rate among non -whites is higher in all groups except in places influenced by the composition of the population. The distribution of leprosy by race / color depends on the regional peculiarities in the formation and or mixing of the population 26 36 showed that in the state of Ceará, leprosy is associated with a high level of poverty and rapid, uncontrolled urbanization. Magalhães and Rojas 21 also indicate that the focal distribution of leprosy, the association with unfavorable living conditions, mainly socioeconomic, and the relationship between poverty and leprosy, confirm the role of social deterioration in the production of this disease. They emphasize, however, that although the relationship between poverty and the disease is not questionable, does not mean that everywhere under these conditions are endemic, with, according to the authors, the need for micro environments favorable to the existence and survival of the pathogen, as well as other factors favorable to its transmission. In relation to clinical forms of leprosy, there was a gradual increase in the proportions of dimorphic forms in all population strata in Mato Grosso and, albeit with some fluctuations, a reduction in the proportion of tuberculoid forms, except for regional Rondonópolis, where the reverse was observed 26 . In Mato Grosso, there is a stabilization of indeterminate forms the three periods, a gradual reduction in the proportion of tuberculoid and virchowianas and 64% increase in dimorphic proportions throughout the period 26 . In regional Rondonópolis prevailed Indeterminate and Tuberculoid forms, but in the last period there was a slight reduction in the latter, also noting it is an increase of over 100% in dimorphic proportions throughout the period. The patient Multibacillary is the main source of infection as it has a high bacterial load in the dermis and mucous membranes and can eliminate bacilli in the external environment. It is assumed that leprosy is transmitted by the respiratory tract which needs further studies. However, there is no conclusive evidence that the transmission is exclusively by respiratory tract, can occur through the skin when there are ulcerated or traumatic skin lesions. The properties of an ecological study does not enable individual risk check, but enable the analysis of the risk of variability in ecological terms. This type of study is of fundamental importance for the understanding of the social and environmental determinants of the health-disease, in which the socioeconomic status of the A gradual increase in the proportion may indicate clinical form Borderline difficulties classification by clinical form or even because the regimen for dimorphic forms and virchowianas is longer. In this case physicians may be more likely to conduct which in case of doubt it takes a longer duration of therapeutic regimen 33 .
Although he maintained throughout the period prevalence of borderline forms in the state, one can observe a predominance of tuberculoid forms. This form would be a trend indicator of the disease. The increase in the frequency of detection of tuberculoid forms, especially in the Midwest and Northeast has already been reported by Motta and Zuniga 34 , who completed pointing strong possibility of increase in the transmission of leprosy in Brazil, warning of a major concern situation for Public Health authorities.

IV. FINAL CONSIDERATIONS
During the study period were reported 2,972 new cases of leprosy, with an average detection rate of 4.50, hyperendemic situation. Predominant male with 57.7%, brown ethnicity with 54.2%, in the urban area 68.2% and in the age group 20 to 59 years with 74%. As for operational classification of the disease was predominant Multibacillary with 64.2%. There were 48.2% of the dimorphic form, tuberculoid 21%, 15.9% Undefined and 13.3% virchowian. Prevailed treatment PQT/MB/12 doses to 56.6%, with the output mode of treatment with 81.4% cure and only 3% of withdrawal. In 2014, the 52 districts of Rondonia, 42% have hyperendemic detection rates, very high 27% to about 10% high. The production and distribution of leprosy not follow a spatial pattern in Rondonia, reflecting social and different environmental conditions, Mycobacterium leprae and identifying critical subespacialidades the territory. Throughout the period studied leprosy remained hyperendemic and still no signs of exhaustion cases, whether it be analyzed by reference to the whole of the State of Rondonia population. The identification of the leprosy carrier profile enables the creation of policies in health, more planned and targeted manner to the risk group. In this sense, they are essential to information campaigns about the disease and its early symptoms are promoted. Also important is the disclosure about the care facilities, since the carrier of this disease should go to health facilities to receive the dose of medication supervised.