Study on deaths by tropical diseases reveal the impact of Chagas disease, schistosomiasis, leishmaniasis and leprosy in Brazil in the last 12 years
Researcher alerts that Brazil’s health services should not underestimate deaths related to leprosy12/02/2016
A research on deaths by neglected tropical diseases in Brazil, between 2000 and 2011, showed that 76,847 people died from diseases such as Chagas (58,928 deaths), schistosomiasis deaths (6,319) and leishmaniasis (3,466 deaths). The impact of these three diseases in the past 12 years is reinforced when noticing that the number of deaths by dengue was lower. An additional data that also called the attention referrers to leprosy, that claimed almost 3 thousand deaths in the period, a smaller number, although very close to what was verified with dengue (a small difference of 220 deaths). This happens because leprosy is usually referred to as a disease of low-lethality in clinical-epidemiological standards.
According to one of the papers authors, Doctor Alberto Novaes Ramos Junior, the records alert the health attention network should not underestimate deaths related to these diseases, including leprosy. We need to care even more – increasingly better – for the people who develop the disease, facing not only physical aspects, but also aspects involving the stigma and stereotype, he said.
The article was published on Februarys edition of the Bulletin of the World Health Organization.
Find below, the exclusive interview with Doctor Alberto with the Brazilian Society of Tropical Medicine (BSTM) about the theme.
BSTM: In the 12 -low-lethality clinical-epidemiological standards dengue (difference of 220 deaths).t 3 thousand deaths in the period, a –year record assessed by your team, over 76 thousand deaths by tropical diseases were reported. Is this number considered alarming even after enhancements involving these diseases?
Doctor Alberto Novaes: The research that returned this number incorporated a population based assessment (nearly 12,500,000 total assessed deaths) in order to identify the deaths related to neglected tropical diseases in Brazil. For this, official databases from the Death Information System from the Health Ministry were used.
It is fundamental to understand this set of diseases are caused by infectious and parasitic agents that mainly affect those people under high individual situation of programmatic vulnerability (regarding health attention networks) and social vulnerability. In fact, they are part of a group of diseases intrinsically associated to poverty, whether as cause or as consequence, with a highly neglected condition of the affected populations. It is important to notice that Brazil is the main responsible for the high morbidity load regarding NTDs in Latin America, with a complex association of different social factors.
The article Mortality from neglected tropical diseases in Brazil, 2000-2011 based on this research, written in the Federal University of Ceará and part of Francisco Rogerlândio Martins-Melos doctorate thesis, advised by professors Huekelbach (main adviser) and Alberto Novaes Ramos Jr. (co-adviser), and counted with professor Carlos Henrique Alencars cooperation. When assessing for 12 years of only basic causes of death without mentioning any of the mentioned NTDs, we identified some 76,900 deaths. Chagas disease was responsible for 76.7% (58,928) of the assessed deaths.
In this study, the NTDs behaving as a chronic condition presented the greatest mortality load, and Chagas disease was responsible for the majority of the deaths, followed by schistosomiasis and leishmaniasis, while leprosy also presented a considerable disease load, despite the classic contrary statements. Dengue flees this timing pattern and was included because it is considered by the World Health Organization (WHO) a NTD, coming fourth place in number of deaths, behind leprosy, but with a small difference. This way, the importance of the NTDs in Brazil becomes a public health problem, despite all advances achieved in the last decades. In the 21st century the challenges of considering the health process transition that Brazil is currently crossing in demographic terms, with population ageing, as well as in epidemiological terms, with a greater insertion of non-transmissible chronic diseases, including nutritional conditions, mental health and problems associated to violent deaths. All this process takes place in a predominantly urban environment.
Furthermore, the great flaws in science, market and public health regarding these diseases must come to light, for example, the diagnostic methods for human cases, identifying hosts, rehabilitation strategies as well as development initiatives. This also involves the development of strategies aiming effective vector and reservoir control and environmental surveillance.
BSTM: The number of deaths by leprosy was considered surprising. Will this trigger the Countrys health system alert?
Doctor Alberto Novaes: Truly surprising, nearly 3,000 deaths placing leprosy as basic cause, lower than dengue, but with a slightly over 200 deaths apart from each other. Leprosy is classically described as being a high morbidity capacity disease due to the skin and nervous damages, but not associated to significant mortality rates. Brazil is the second country in the world in new cases detection, with approximately 30 thousand new yearly cases, what increases the challenge to control it. Many of these cases are still unfortunately diagnosed too late, when inabilities and deficiencies have already installed.
Our group recently published the article Leprosy-related mortality in Brazil: a neglected condition of a neglected disease deepening the analysis, a work from the Francisco Rogerlândio Martins-Melos doctorate thesis and professor Adriana Valéria Assunção Ramoss master’s degree dissertation.
Assessing this data, we identified 7,730 deaths including associated causes besides basic causes. This translates to an increase of 4,730 deaths related to this disease, increasing the sensitivity of the surveillance system. It was also evidenced that great part of the deaths were associated to complications related to leprosy, as severe reaction episodes, adverse side effects of the polychemotherapy medications and severe secondary bacterial infections.
Therefore, the Countrys health attention network is advised that deaths related to leprosy should not be undervalued. We must care increasingly more and better for those who develop the disease, facing not only the physical aspects, but also aspects involving the stigma and the stereotype.
BSTM: Could the data on deaths by NTDs have been underestimated? Is it possible that the number of deaths is much greater? Is there any number closer to reality?
Doctor Alberto Novaes: In fact they were underestimated. Parallel analysis conducted by our team in the same 12-year period, based not only in basic causes (commonly used by the WHO and Brazil’s Health Ministry in their analysis), but considering the associated causes from the death declarations, and showed the number of deaths by NTDs raises to almost 101,080, a difference of 23,967 if compared to this articles result.
There is a considerable under-reporting of NTDs as causes of deaths also due to the performance of the attention and surveillance networks in the Countrys different regions, generally in the North, Northeast and Center-West regions. The vulnerability of the people affected by these diseases, beyond the individual and social points-of-view, also brings to light factors as difficulty accessing the health networks, especially those involving greater technological density. This means the problem in much greater than what was verified in the last decades.
Others published studies conducted by our team (listed below, at the end of the text) also pointed this undersized pattern for other NTDs, when assessed singly and in more details, reinforcing the alert for greater confrontation of these diseases in the public health networks as real public health problems. For example, Chagas disease: 58,928 deaths as basic cause and 72,586 as basic and associated causes (difference of 13,658 deaths); schistosomiasis: 6,319 deaths as basic cause and 8,756 as basic and associated causes (difference of 2,437 deaths); visceral leishmaniasis (specifically): 2,727 deaths as basic cause and 3,322 deaths as basic and associated causes (difference of 595 deaths) and cysticercosis: 1,130 deaths as basic cause and 1,829 deaths as basic and associated causes (difference of 699 deaths).
Which should be the main control measures to contain the deaths by NTDs in Brazil?
Doctor Alberto Novaes: Generally speaking, for those affected by the four main NTDs I reffered to, pointed in this study, there is an obvious need to integrate attention and care for these diseases in the Countrys health attention network, from basic attention (primary health attention) to greater technology density attention. These people and their families need to be better cared of, in a longitudinal manner, from the completeness perspective, from its territory.
Since great part of the chronic conditions should have an early diagnosis for opportune treatment, demanding the development of simpler diagnostic methods, with adequate accuracy and able to be used in the field. The existence of co-morbidities as non-transmissible chronic diseases (high blood pressure and diabetes, for example) associated to the human ageing process and acquired immunodeficiency related conditions, as HIV/AIDS infection or induced, as resulting from chemotherapy or corticosteroid treatments should be monitored. The presence of co-morbidities or co-infections could aggravate these diseases evolution, increasing the morbimortality. Another factor facing severe clinical and psychological complications include the stigma and social exclusion related to some of these NTDs. For those in more advanced or complicated phases of the disease, there is a clear need for rehabilitation through different strategies, including clinics, physiotherapy, surgeries, psychological treatment and social reinsertion. It is fundamental that these actions seek the affected people, families and communities to fully face the impacts caused by these diseases. This includes: 1 – Including people in the general society, 2 – Empowering these people as a way to stimulate the full participation in the society and possibility to define their own life objectives and 3 – sustainability of the confrontation programs in face of the different dimensions (beyond the health sector) of these diseases as a way to ensure basic life conditions and working along with people affected by NTDs and the general society to break the existing barriers.
For those people who are not infected but currently live (or used to live) from an endemicity context, it is fundamental to develop actions aiming to prevent new infections. This could be achieved by health promotion actions: health and environmental education, environmental surveillance, sanitary surveillance, social policies seeking inclusive basic sanitation, water security and others. It is necessary to face the great social inequalities which are still present in the country, aiming inclusive human development. Furthermore, specific protection actions should be studied, among others, developing new vaccines.
Depending on which NTD, regarding parasites, vectors and intermediate hosts, it is fundamental to strengthen surveillance and control actions in the Country, in a local perspective and integrated to the different regional scenarios. The strengthening of the Countrys laboratory network dedicated to studies, identification, classification, monitoring and evaluation must be supported. There are variables as seeking new insecticides and molluscicides with enhanced human safety, environmentally justifiable, besides monitoring/evaluating systematically the different resistance patterns developed against these products used by the endemic control teams through time.
All these actions demand organization and strengthening of the Brazilian Unified Health Systems (SUS) attention and surveillance network, not only in its structure or necessary materials, but with qualified professionals able to develop these actions, both in upper levels as in technical levels. Unfortunately many health professionals, including physicians, do not acknowledge these diseases as public health issues, or are unable to handle and control them adequately. It is notorious how health courses in the Country, including Medical School, how the time dedicated for these diseases was reduced in the curricula. This way it is necessary to engage in educational reforms guided by the current Curricular Guidelines (the Medical School guidelines were updated in 2014). The same way, the guidelines for permanent education in health with emphasis in general NTDs, involving not only endemic agents, but also community health agents.
At last, having in mind the gaps of consistent evidences, other studies conducted by our group for the past 5 years have tried to strengthen and evidence the NTDs load in Brazil, either by estimating prevalence, as with Chagas disease, or by identifying the patterns and space-time trends. Along these publications, we reinforced the need to strengthen components of epidemiology and health surveillance, management, permanent education, full-time attention, information and communication, as well as operational or not researches.
We demonstrated the geographic overlap of high-risk-of-death areas related to NTDs while highlighting the need to implement integrated control measures in places with greater morbidity and mortality. This assessment series also showed the spacial distribution of mortality related to NTDs in Brazils cities is closely related to socioeconomic, demographic and environmental/climatic indicators, besides proving that important relevant geographic changes, can be used as indicators for NTD control and surveillance. In order to achieve so, data from different bases were used (IBGE, IPEA, INPE, PNUD, MDS, SISAM and DATASUS).
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