THE LEVEL OF PHYSICAL INABILITY OF PATIENTS WITH LEPROSY

Objective: to evaluate the level of physical inability of patients with leprosy. Method: a quantitative, cross-sectional, retrospective study with 73 patients diagnosed with leprosy. For the data collection, there was used pre-structured questionnaire tool containing sociodemographic and epidemiological data extracted from the connectors of the SINAN research and electronic medical records. The data were analyzed using the IBM SPSS, version 21.0. Results: it was found that the male patients with low schooling, dimorphous clinical form, Virchowian and neural pure, operational classification multibacillary leprosy and the presence of one or more nerves affected had a greater chance of presenting some level of physical inability. Conclusion: it underlines the importance of assessing the level of physical inability at the time of diagnosis of leprosy and the guidelines for self-care.Descriptors: Leprosy; Epidemiology; Health Services; Public Health; Risk factors; Nursing. RESUMO Objetivo: avaliar o grau de incapacidade física de pacientes com hanseníase. Método: estudo quantitativo, transversal, retrospectivo, com 73 pacientes diagnosticados com hanseníase. Para a coleta de dados utilizou-se instrumento pré-estruturado contendo dados sociodemográficos e epidemiológicos extraídos das fichas de investigação do SINAN e do prontuário eletrônico. Os dados foram analisados no software IBM SPSS, versão 21.0. Resultados: constatou-se que pacientes do sexo masculino com baixa escolaridade, forma clínica dimorfa, virchowiana e neural pura, classificação operacional multibacilar e a presença de um ou mais nervos afetados tiveram maior chance de apresentar algum grau de incapacidade física. Conclusão: ressalta-se a importância da avaliação do grau de incapacidade física no momento do diagnóstico de hanseníase e as orientações para o autocuidado. Descritores: Hanseníase; Epidemiologia; Acesso aos Serviços de Saúde; Saúde Pública; Fatores de Risco; Enfermagem. RESUMEN Objetivo: evaluar el grado de invalidez física de los pacientes con lepra. Método: estudio cuantitativo, de corte transversal, retrospectivo, con 73 pacientes diagnosticados de lepra. Para la recolección de datos se utilizó un cuestionario estructurado previamente que contenía datos sociodemográficos y epidemiológicos extraídos de los conectores del SINAN de investigación y registros médicos electrónicos. Los datos fueron analizados utilizando IBM SPSS, versión 21.0. Resultados: se encontró que los pacientes masculinos con baja escolaridad, forma clínicas dimorfas, virchowianas y neurales puras, clasificación operacional multibacilar y la presencia de uno o más nervios afectados tuvieron mayor probabilidad de presentar algún grado de invalidez física. Conclusión: se marca la importancia de evaluar el grado de invalidez física en el momento de diagnóstico de la lepra y las directrices para el autocuidado. Descriptores: Lepra; Epidemiología; Accesibilidad a los Servicios de Salud; Salud Pública; Factores de Riesgo; Enfermería. Residence in High Complexity in Health, Multidisciplinary Health Residency Program of the Federal University of Piauí/UFPI. Teresina (PI), Brazil. Email: jaylinne_morais@hotmail.com ORCID: https://orcid.org/0000-0002-2577-7313; Master, Federal University of Piauí/UFPI. Teresina (PI), Brazil. Email: eridazoe@hotmail.com ORCID: https://orcid.org/0000-0002-6162-7558 ORIGINAL ARTICLE Morais JR, Furtado ÉZL. The level of physical inability of patients... English/Portuguese J Nurs UFPE online., Recife, 12(6):1625-32, June., 2018 1626 ISSN: 1981-8963 https://doi.org/10.5205/1981-8963-v12i6a231049p1625-1632-2018 Leprosy still represents a great challenge to health, despite being reached its elimination as a global health problem in the year 2000. Early diagnosis and treatment are essential for prevention and treatment of complications that may arise, physical debility, which can reach the eyes, hands and feet, compromising the quality of life of patients. In addition, it is important to investigate and identify the level of physical disability in leprosy patients at the time of diagnosis, in order to prevent and/or minimize these complications. According to the World Health Organization (WHO), there were recorded more than 213 thousand cases of leprosy in 2014 throughout the world. Approximately 94.0% were detected in only 13 countries and Brazil is one of them, who, along with India and Indonesia are responsible for 81.0% of the cases of the disease. In 2015, there were 28,761 new cases of leprosy in Brazil, being more prevalent in the Northeast region, with 12,848 new cases were notified. In this region, the State of Piauí, who in 2016 gave 755 new cases, with a coefficient of detection of 32,05/100,000 inhabitants. It is chronic, infectious disease caused by Mycobacterium leprae. The bacillus presents tropism for the skin and peripheral nerves, mainly by Schwann cells, which may cause degeneration of the peripheral nervous system, being the neural injury the most important aspect of leprosy and the response of the nervous tissue to the invasion of the nerve by Mycobacterium leprae is highly variable, which may or may not cause functional alterations. When present, this response may cause neural thickening, changes in tactile sensitivity, thermal and painful of the lesion and in the path of damaged nerves, losses in motor function. It causes paralysis and paresis, trophic alterations in specific muscles of the face, hands, and feet, in addition to slow down the functioning of the sebaceous glands and sweat glands, these compromises that are related to the establishment of physical disabilities. The level of physical injury is classified from 0 to II. To evaluate it is recommended to use the set of Semmes-Weinstein monofilaments (6 monofilament: 0.05 g, 0.2 g, 2g, 4 g, 10 g and 300 g) at the points of evaluation of sensitivity in the hands and feet and floss (without flavor) for the eyes, taking as a basis the form adopted by the Ministry of Health. The Level 0 corresponds to the absence of disability; Level I concerns the decrease or loss of sensibility in eyes, hands, and feet and Level II refers to abnormalities in eyes, hands or feet or visible deformities and is related to the classification of disease progression time and occurrence of leprosy reactions. ● To assess the level of physical injury of leprosy patients in a university hospital in the Northeast of Brazil. Quantitative study, cross-sectional, retrospective, carried out at a University Hospital in the Northeast of Brazil in April 2017. The population consisted of 100 patients who received a diagnosis of leprosy in this service, in the period from January 2014 to November 2016. The sample consisted of patients who met the following inclusion criteria: they answered via an outpatient or inpatient in the hospital and submitted assessment of the level of physical incapacity at the time of diagnosis of leprosy. In turn, we excluded those who were diagnosed with leprosy in another health service, those who had no level of physical incapacity assessed at the time of diagnosis, as well as the connectors for research with incomplete data. After analysis of the inclusion criteria, 27 patients were excluded from the study. For the data collection form was used with sociodemographic characteristics (gender, schooling, skin color/race, municipality of residence and zone of origin) and epidemiological characteristics (number of cutaneous lesions, clinical form, operational classification, number of nerves affected, use of sputum smear microscopy, initial therapeutic regimen and degree of disability). The data were collected in the Service of Health Surveillance of the University Hospital, where are filed, the connectors of research into diseases and diseases of compulsory notification. Afterwards, the collected data were coded in Microsoft Excel in double-entry spreadsheet, processed in the Software IBM SPSS, version 21.0, and presented in tables. Descriptive statistics were calculated as averages, standard deviations, minimum and maximum for quantitative variables and frequencies for qualitative variables. There was the Chi-square test of Pearson for verification of associations between the sociodemographic and clinical characteristics of the patients and the degree of functional disability. The quantitative variables were dichotomized based on the median of the distribution of values. The categories were OBJECTIVE

English/Portuguese J Nurs UFPE online., Recife, 12(6):1625-32, June., 2018  1626 Leprosy still represents a great challenge to health, despite being reached its elimination as a global health problem in the year 2000. 1 Early diagnosis and treatment are essential for prevention and treatment of complications that may arise, physical debility, which can reach the eyes, hands and feet, compromising the quality of life of patients.In addition, it is important to investigate and identify the level of physical disability in leprosy patients at the time of diagnosis, in order to prevent and/or minimize these complications.
According to the World Health Organization (WHO), there were recorded more than 213 thousand cases of leprosy in 2014 throughout the world.Approximately 94.0% were detected in only 13 countries and Brazil is one of them, who, along with India and Indonesia are responsible for 81.0% of the cases of the disease.In 2015, there were 28,761 new cases of leprosy in Brazil, being more prevalent in the Northeast region, with 12,848 new cases were notified.][3] It is chronic, infectious disease caused by Mycobacterium leprae.The bacillus presents tropism for the skin and peripheral nerves, mainly by Schwann cells, which may cause degeneration of the peripheral nervous system, being the neural injury the most important aspect of leprosy and the response of the nervous tissue to the invasion of the nerve by Mycobacterium leprae is highly variable, which may or may not cause functional alterations. 4hen present, this response may cause neural thickening, changes in tactile sensitivity, thermal and painful of the lesion and in the path of damaged nerves, losses in motor function.It causes paralysis and paresis, trophic alterations in specific muscles of the face, hands, and feet, in addition to slow down the functioning of the sebaceous glands and sweat glands, these compromises that are related to the establishment of physical disabilities. 5e level of physical injury is classified from 0 to II.To evaluate it is recommended to use the set of Semmes-Weinstein monofilaments (6 monofilament: 0.05 g, 0.2 g, 2g, 4 g, 10 g and 300 g) at the points of evaluation of sensitivity in the hands and feet and floss (without flavor) for the eyes, taking as a basis the form adopted by the Ministry of Health.The Level 0 corresponds to the absence of disability; Level I concerns the decrease or loss of sensibility in eyes, hands, and feet and Level II refers to abnormalities in eyes, hands or feet or visible deformities and is related to the classification of disease progression time and occurrence of leprosy reactions.The average age of the participants in this study was 49.8 years old.The majority were male (53.4%), non-literate (27.4%) or with the formation of the first to fourth grade (24.7%) and brown (64.4%).Little more than 2/3 of the patients were from Teresina (67.1%), being a significant portion of these coming from the urban zone of the capital (84.9%).How to epidemiological aspects, 57.5% of the patients had five or more cutaneous lesions and 56.2% had one or more nerves affected.
Less than half of the patients underwent sputum smear microscopy (41.1%) and among those who have made this examination, 12.3% showed positive result.Approximately 70.0% of the patients used the multibacillary polychemotherapy.A little over half of the patients presented no physical disability at diagnosis (54.8%) and among those in which it was verified some degree of disability, 31.5% were Level I, while 13.7% had Level II (Table 1).

RESULTS
English/Portuguese J Nurs UFPE online., Recife, 12(6):1625-32, June., 2018  1628 The data in Table 2 show that there was a statistically significant association between sex (p=0.025),schooling (p=0.034),clinical form (p<0.001), operational classification (p<0.001) and number of nerves affected (p=0.002) with the degree of physical incapacity of patients with leprosy.Male patients with incomplete basic education, clinical forms Virchowian dimorphous, neural, and pure, operational classification multibacillary leprosy, and the presence of one or more nerves affected had a greater chance of presenting some degree of physical incapacity.
The predominance of male patients in this study corroborates by the literature that considers the leprosy in adults is more frequent in female in which the risk of exposure is increased and the demand for health services is lower.][8] Considers that a proportion of cases diagnosed with grade II of incapacity is equal to or above 10.0% is considered high, between 5.0 and 9.99%, average, and less than 5% as low.Thus, the percentage of patients with physical disability in this study is considered high, and may be related to low effectiveness of activities of timely detection and/or early diagnosis of the disease and difficulty of access to health services. 9 study carried out by Araújo et al found low frequency of physical disabilities at the beginning of treatment.Contrary to this finding, the survey of Aquino et al showed worrying results: high frequency of disability Level 1 or 2, corroborating the results found in the present study.5,9 The male gender, according to Table 2, it was associated with the degree of inability, followed by the Level II, agreeing with the findings in the literature, in which male patients have a 2.4 times higher chance to evolve with some degree of physical incapacity in relation to female patients.This finding may suggest that men take longer to seek health services when they arise the first manifestations of the disease and, when already on treatment, there are more queries/return those women, as well as the fear that this population has to lose their source of income because of the stigma that surrounds the leprosy.8,10-1-2-3-4 According to race/skin color, in 2015, the detection rate of new cases of leprosy by race in the population of black and mulatto was higher than that observed for the general

DISCUSSION
English/Portuguese J Nurs UFPE online., Recife, 12(6):1625-32, June., 2018 1629 population of the country.It indicates high endemicity of the disease in the population of black and brown color, which is also observed an increase in the proportion of new cases diagnosed in this portion of the population.In this sense, the predominance of brown color found in this study was also evidenced in other, which relate to the brown color to the strong miscegenation existing in the country, mainly in the Northeast. 9, In lation to schooling, the results obtained in this study reinforce the referenced in the literature in which the leprosy, with frequency, relates to indicators such as low schooling, low family income or per capita income and lack of basic conditions of health, among others.It should be emphasized that the illiteracy rate, although it has decreased 4.3 percentage points over the years 2001 to 2014, according to the National Household Sample Survey (PNAD), this last year, Brazil was the 8 th country in the world with the highest rates of illiteracy.Functional illiteracy among adults, with a predominance of this rate in the Northeast region, highlights education as an important social determinant of health. 8,9, A snificant portion of patients diagnosed with leprosy in the studied hospital was founded in the capital and metropolitan regions, as shown in Table 1, a fact also observed in other studies.Thus, it is perceived that, although basic attention is qualified to diagnose and treat leprosy cases and their coverage, it is greater than 97.0% in the municipality in question, with the ability to perform effectively active search of cases.There was a lack of family health teams in identifying suspected cases of the disease, diagnose and institute timely treatment for the confirmed cases. 12-8-10,17he multibacillary clinical form was the most frequent among the patients studied, as found in a study conducted in the capital of the Brazilian northeast with high endemicity.Especially the clinical forms dimorphous and Virchowian, to understand the more severe forms of the disease have higher chances of neural involvement, may lead the individual with leprosy have some degree of physical incapacity.These findings demonstrate that the diagnosis of leprosy was carried out late, there is a higher probability of transmission of the disease, as well as the development of neural complications and physical disabilities in patients. 5,8,10n the pure neural form, as there are no cutaneous lesions, only nervous impairment, the diagnosis is hindered or delayed by difficulties in physical examination of this clinical form.As a result, there may be a delay in diagnosis of the disease by the professional, favoring the establishment of some degree of physical inability. 13, In dition, it was found that, on average, the patients had more than one nerve affected.This finding was also evidenced in other studies, thus reinforcing the existing relationship between the increase of the time elapsed since the onset of the first signs and symptoms of leprosy and the initiation of treatment, with higher probability of occurrence of neural damage. 11,20he patients had, on average, more than five lesions being indicated; therefore, the use of multibacillary regimen, associated to immune reactions and intense inflammatory response, causing reactional states, neural lesions severe and permanent.This figure shows a delay in diagnosis, which occurred after the polarization to the more severe forms of the disease and contagious diseases.However, the number of lesions was not associated with the degree of physical incapacity, since a single lesion may contain high loads bacillary, modifying the operational classification of leprosy patient.In some cases of difficult clinical classification, it uses laboratory examination for correct identification of paucibacillary or multibacillary cases, disregarded and the number of lesions identified. 8,11,21n spite of the efforts for the early diagnosis, a considerable contingent of people is still affected by physical disabilities caused by leprosy.It observes, among other factors, the difficulty of access to health services, low-skilled professionals for diagnosis of the disease, poorly qualified professionals to perform the diagnosis of the disease, or who perform short consultations, without thoroughly evaluate the entire body surface area are among the factors that contribute to the late diagnosis of the disease.This results in a delay in the initiation of treatment and a higher chance to evolve with some degree of physical disability. 9y this disease, that treatment occurs in the public health system, which does not lead to death in alarming levels and does not require sophisticated technology for the diagnosis and treatment, the leprosy ends up getting in the background on the priority of care.Therefore, it is necessary to encourage campaigns designed to educate the population regarding the signs and symptoms of the disease; empower health professionals to diagnose and treat leprosy cases, as well as conduct health promotion actions and ensure adequate structure to the health units, in English/Portuguese J Nurs UFPE online., Recife, 12(6):1625-32, June., 2018  1630  order to ensure the access of the population to service. 14, Theputum smear microscopy has high specificity but low sensitivity, being negative in up to 70.0% of the patients with leprosy, not interfering in the occurrence of physical disabilities at the time of diagnosis, fact that has been observed in other studies, so that patients with negative sputum smear microscopy may present some degree of physical incapacity.The realization of this exam is not compulsory, bearing in mind that the diagnosis of leprosy is predominantly clinical.8,11,21 This study allowed us to characterize the patients diagnosed with leprosy in a university hospital, as well as to identify the sociodemographic and epidemiological variables with greater chance of a statistically significant association to the degree of physical inability.
Thus, the results showed that the majority of the study participants had Level 0 physical incapacity, and among those who had some level of disability, predominated the Level I.The average age was 49.8 years old, and the majority of the male gender, not literate, that is self-declared of brown color, from the urban area of Teresina, with an average of 6.4 and 1.5 cutaneous lesions affected nerves.Among the microscopies performed, 9 had positive result and were multibacillary regimen.
Statistically significant associations were observed between the male gender, schooling until the fundamental education, dimorphous and Virchowian forms, pure neural cases multibacillary forms and presence of more than one nerve affected to some degree of physical incapacity.
In this way, it is fundamental to a multidisciplinary approach with early diagnosis, taking into consideration the variables that are directly associated with physical disabilities, implementing actions of prevention and treatment of same, as well as the stimulus to adherence to treatment, in order to avoid complications of the disease.
It is believed that the knowledge of epidemiological and sociodemographic characteristics, as well as the degree of physical incapacity, more frequent among leprosy patients treated in this service, may subsidize the implementation of strategies for prevention of disabilities.In the event of damage that already exist, the adoption of measures to prevent complications, in order to promote improvements in the quality of life of affected patients. 2

Table 2 .
Association between sociodemographic and epidemiological characteristics and the degree of disability of patients with Hansen's disease (n = 73).Teresina (PI), Brazil, 2017.