Imperatriz women sex

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Try out PMC Labs and tell us what you think. Learn More. The minimal de-identified dataset to replicate the study findings is available as a Supporting Information file. Leprosy cases diagnosed between and were included. Detection rates stratified by sex and age groups were estimated.

The study of temporal trends was accomplished using the Seasonal-Trend Decomposition method and temporal modeling of detection rates using linear seasonal autoregressive integrated moving average model according to Box and Jenkins method. Trend forecasts were performed for the — period. A total of 3, cases of leprosy were identified, the average incidence among men aged between 30 and 59 years old was Detection rates in total and by sex presented a downward trend, though rates stratified according to sex and age presented a growing trend among men aged less than 15 years old and among women aged 60 years old or over.

The final models selected in the time-series analysis show the forecasts of total detection rates and rates for men and women presented a downward trend for the — period. Even though the forecasts show a downward trend in Imperatriz, the city is unlikely to meet a ificant decrease of the disease burden by Leprosy is an infectious disease caused by Mycobacterium leprae , which mainly affects the skin and peripheral nervous system, resulting in neuropathies and associated problems over the long term, including physical deformities and disabilities [ 1 ]. However, in some nations the elimination of the disease zero transmission and decreased detection of new cases continue to be important challenges for a world without leprosy [ 4 ].

The global detection rate for leprosy in was 1. In the same year, Brazil presented a detection rate of new cases of Brazil has presented a downward trend in the of cases in recent years, from 37, cases in to 28, in [ 5 ]; some regions, though, like the north, midwest and northeast still present high rates of the disease [ 7 ].

According to the authors, there was a ificant decrease in overall detection rates and among individuals younger than 15 years old in the study regions. However, the rate of new cases with grade 2 physical disability per , inhabitants remained stable over the period, suggesting late diagnosis and possibly underreporting of cases. These guidelines reaffirm the importance of adopting epidemiological indicators to monitor the progression of the disease, operational indicators to assess the quality of services and to include an indicator to verify the proportion of cases according to sex, reinforcing the importance of gender in the causality of the disease [ 9 ].

In addition to the fact that leprosy is a tropical disease that has been neglected, its association with poverty and social inequality, the disease presents a sex-specific distribution in terms of morbidity [ 10 — 12 ]; that is, men are more frequently affected than women in most regions of the world including Brazil [ 13 ]. However, in many countries, women are late diagnosed and have a higher proportion of degrees of physical disability, in addition to the fact that the stigma of the disease is greater in women [ 14 ].

Leprosy is a disease known for leading to different representations and effects between men and women, in different social contexts, and as a consequence, it accentuates gender inequalities from the Brazilian sociocultural point of view [ 15 ].

A study carried out in the state of Bahia Northeast region of Brazil by Souza et al. No study was found among time-series studies that included future predictions of leprosy detection rates and that also considered these according to sex. In the same year, the main social indicators are: an illiteracy rate of 9. In the same year, Imperatriz presented a detection rate of SINAN is the Brazilian information system responsible for recording and processing information regarding reportable diseases in the entire country, providing morbidity bulletins and reports.

It is one of the main surveillance systems in Brazil [ 21 ]. The variables adopted in this study include date when leprosy cases were reported in the SINAN notification date , age and sex. After validating the database, detection rates were calculated per month per , inhabitants. The calendar adjustment technique was applied in the calculation considering the of days of each month in order to improve the representation of rates in the study period.

The size of the resident populations used as the denominator was based on the Census and the intercensal estimates — elaborated by the IBGE. Leprosy detection rates were smoothed by the moving average technique, considering the average of three months prior, current and posterior , in order to remove noise and better reveal the underlying causal process. An exploratory analysis of monthly leprosy detection rates smoothed and with calendar adjustment correction was performed according to sex and age group.

Additionally, the Average Monthly Percentage Change AMPC of detection rates was calculated according to sex and age groups, identifying, in terms of average percentage, the rates of increase or decrease over the study period. Afterwards, the progression of the disease trend was characterized according to sex and age using the robust Seasonal-Trend using Loess STL decomposition method by Cleveland et al.

For that, at each point in time t , the time series X t is given by the sum of three components: seasonality S t , trend T t and noise Z t. This decomposition is based on locally weighted regression Loess of the seasonality and trend components.

To model the monthly rates of total detection and detection by sex, as well as the forecast of respective trends, we used the linear seasonal autoregressive integrated moving average ARIMA Seasonal model and the usual Box and Jenkins method to choose the appropriate models based on the data structure itself [ 23 ]. T is the transformation to stabilize, if necessary, the variance usually called Box-Cox transformation , while Z t represents the white noise process uncorrelated process, null mean, and constant variance. Letters p and q represent, respectively, the of parameters of autoregressive parts and moving average parts, with the seasonal period of length S , and letters P and Q are the equivalent of these parameters between the seasonal periods.

Letters d and D , respectively, represent degrees of simple differentiation and the seasonal differentiation necessary to transform a non-stationary into a stationary series [ 24 ]. The usual tests of absence of autocorrelation Portmanteau tests: Ljung-Box and Box-Pierce , randomness Rank and Turning Point tests , and normality Kolmogorov-Smirnov test were used to validate the model, in the analysis of the residuals, along with a t-test for zero mean.

Whenever more than one model was appropriate, the best model was chosen considering the parsimony principle and the lowest values of Akaike information criterion AIC and Bayesian information criterion BIC. Afterwards, data and tendency forecasts were performed for the four-year period to No consent forms were ed because only secondary data were used and the participants were not identified, as the data were analyzed anonymously. A total of 3, leprosy cases were reported between and in Imperatriz. The group of individuals younger than 15 years old also presented a large of cases, with a rate of There is a continuous increase in the rates of case detection as the age groups increase, with the lowest rates being for children under 15 years old and the highest for those aged 60 years old or over.

In regard to AMPC trends, the male group younger than 15 years old 0. Fig 2 presents the time trend for total detection in black , among men in red , and among women in blue distributed over the study period. In general terms, the three detection rates present the same decreasing behavior for the study period. Analyzing the comparison between the three trends, it is possible to observe stability in the period from to The time series of the ratio between the detection rates of men and women is shown in Fig 3.

The red line indicates the situation in which both rates would be equal numerator equal to the denominator , and the blue line indicates the time period in that the ratio shows a change in behavior. Over time, the rate of men is generally higher than that of women, noting that, in the period from January to approximately September , the rate of men reached, at most, double that of women; in January this difference exceeded the triple, and the quadruple in A Male and female detection rates ratios; B Equal detection rates between male and female; C Time period between different patterns of ratios.

Women showed slightly higher rates than men between September and December , September , between October and January and, finally, in July Tendency toward leprosy according to sex and age Fig 4 shows a decreasing trend for all age groups and sex, except for men younger than 15 years old and women aged 60 years old or over, reflecting specifically the AMPC by age and sex. Men under 15 years old showed decreasing trends from to , after which they showed an increasing trend until the end of the study period. Women aged 60 years old or over showed a peak of detection between the years and , with a decrease until , and subsequently a continuous growth trend until the year A Men younger than 15 years old; B Men aged between 15 and 29 years old; C Men aged between 30 and 59 years old; D Men aged 60 years old or over; E Women younger than 15 years old; F Women aged between 15 and 29 years old; G Women aged between 30 and 59 years old; H Women aged 60 years old or over.

For women younger than 15 years old and aged between 15 to 29 years old there was a slight increase in the last year. Despite the downward trend seen in the age group between 30 and 59 years old, both among women and men, high rates of disease were found in the entire study period. As ly mentioned, the temporal modeling of leprosy detection rates, total and separated by sex, shows a downward trend, revealing that the series are not stationary.

Thus, we performed Box-Cox transformations to stabilize variance and simple differentiations to stabilize the mean, transforming non-stationary series into stationary series. Some candidate models were chosen and their parameters were estimated when analyzing the autocorrelation and partial autocorrelation functions.

The figures show the adequate adjustment of three models, as well as its forecasts. Forecasts for total detection rates and rates for women and men indicate a downward trend for leprosy in the — period, with behavior very similar between sexes. The present study identified a downward trend in the rate of detection of leprosy in the period from to indicating that such behavior will be maintained in the future, according to the models and time forecasts.

Despite the decrease in the detection of the disease, Imperatriz will continue to present a high leprosy burden in the year In , Imperatriz presented a total detection rate of Considering the demographic and social characteristics of the study context, the city is presenting rapid demographic growth, attracting immigrants from the north and northeast of the country due to its local economy, which may be influencing the hyperendemicity of the region under study [ 25 , 26 ].

In this context, largest proportion of cases were male, which is in agreement with data provided in the literature, in which those affected by the disease in most world regions are predominately male, including in Brazil [ 27 — 29 ]. The time series of the ratio between the detection rates of men and women showed, over time, the detection rates in men are higher than that of women, reaching, at the end of the study period, a ratio of about 4: 1.

In a few periods of the time series, women had slightly higher detection rates than men. According to the literature, the occurrence of leprosy is higher in men, with a ratio of 2: 1 compared to women, also presenting a high risk of transmission [ 30 , 31 ]. Other factors may also explain the higher occurrence of the disease in men, as individual determinants, such as not seeking medical assistance or only later seeking health services, when compared to the practices of women.

The higher detection rates in men compared to women, in the research scenario, especially in the period from to , are strong indications that transmission is higher in men. Such a finding may be an indication that the male sex is responsible for a large part of the hyperendemicity of the study region, reinforcing the need to recognize and value men's health on the part of managers and health providers in the control of leprosy. The discussion on gender issues allows the strengthening of professional health care practices aimed at men and women, aiming to achieve greater equity in public policies, especially in the context of neglected diseases, such as leprosy [ 10 ].

In terms of age, most of the individuals affected are aged between 30 and 59 years old, followed by the 15 to 29 year old group, though the population over 59 years old presents the highest detection rates. Despite the high rates in the 30 to 59 year age group, it should be noted that the temporal trends in these intervals were decreasing in the study period.

And the 15 to 29 year old interval also showed the highest average percentage decrease in the period from to , which points to an indication of a reduction in bacillus transmission in the studied region [ 32 , 35 ]. The group aged between 30 and 59 years old includes the Brazilian economically active population, interval that the disease hinders labor activities, forcing individuals to stop working or retire early, decreasing the quality of life of workers [ 28 , 36 , 37 ]. In this sense, health services should focus on preventive measures by actively seeking individuals in this age group, in addition to diagnosis of cases, providing timely treatment, and early identification of lesions, the purpose of which is also to prevent physical disability.

Early interventions prevent or minimize the high social costs leprosy imposes from removing this population from productive activities and social relationships [ 28 , 36 — 38 ]. In Imperatriz, in , the estimated population aged 60 years old or over was 16, inhabitants, and in it increased to 21, inhabitants, representing an increase of Countries that registered a decrease in leprosy transmission, with subsequent elimination, observed a change in the profile of the disease, with a drop in detection in younger age groups and an increase in detection of elderly people [ 35 , 42 ].

In Imperatriz, the high detection rates in the population aged 60 years old or over may be an indicative of a change in the epidemiological profile of the disease, despite the municipality still showing levels of hyperendemicity. A decreasing tendency was found in the total detection rates of both men and women from to , however, considering the age groups, women aged 60 years old or over and men aged less than 15 years old showed an increasing trend.

More specifically, the figures reveal that the burden of the disease remains, considering that detection rates are systematically and persistently high for all the age groups addressed. Note the high occurrence of the disease among individuals below 15 years of age, with hyperendemicity parameters [ 9 ], confirming that the disease remains active in the community. The occurrence of leprosy among individuals younger than 15 years old confirms that active foci of transmission remain with early exposure to Mycobacterium leprae [ 44 ].

Potential explanations include difficulty establishing a clinical diagnosis, disease-related stigma, and the weak health promotion and education process, needing improvements in leprosy control actions in these areas [ 15 , 45 , 46 ]. For example, studies conducted in two Brazilian regions in which leprosy is endemic an assessment of health services identified that the local primary health units did not present satisfactory performance in diagnosing individuals younger than 15 years old. The reason for this is that the services health diagnosis was conducted on request, however active case detection in the community is not being conducted.

Anchieta et al. Despite this decrease, the authors reaffirm that detection in children under 15 years old remains high in the municipality. The campaign is aimed at students aged 5 to 14 years old, involving approximately 6 million students [ 48 , 49 ]. Although the present study does not measure the impact of this action, the hypothesis arises that the National Campaign for Leprosy may be influencing the detection of cases under the age of 15 years old in the municipality, especially due to the rates found in the investigated period.

It should be noted that the beginning of the campaign is concomitant with the beginning of the growth trend in men under 15 years old Similar to other Brazilian studies, higher detection rates were found among male elderly individuals; however, the growing detection rates found among women aged 60 years old or over differ from other studies conducted in Brazil. According to Monteiro et al. Studies conducted in India [ 50 ], China [ 51 ] and Colombia [ 52 ] report that women seek treatment later than men, a phenomenon that is mainly related to the stigma having a stronger affect for women than men in these countries, leading to late diagnoses and treatment.

A literature review intended to identify the factors that prevent the early detection of leprosy among women shows that in some countries, the diagnosis and onset of the first symptoms take double the time among women, on average, compared to men, in addition to suggesting that women are more likely to initiate treatment late [ 53 ]. In Imperatriz, during the study period, no specific actions were found for women aged 60 years old or over that could explain the growing trend in this age group.

The Enhanced Global Strategy for Further Reducing the Disease Burden Due to Leprosy — from WHO proposed the inclusion of female leprosy cases indicator among the total of new cases, in order to assess and ensure that women are having adequate access to leprosy diagnostic services [ 54 ]. The implementation of this strategy and the creation of this indicator may have impacted the detection among women in the studied scenario, especially in women over 59 years old, considering that from onwards, the trend of this range shows an increasing behavior until , concurrent with the period of validity of the strategy — The also indicate the need to maintain actions to diagnose the disease earlier in the population aged 60 years old or over especially because this age group presents the highest detections rates in the investigated scenario.

Future studies should be carried out in order to understand why women have an increasing trend in detection in the age group above 59 years. Additionally, the models show downward trends for the three detection rates total, men and women in the predictive model for the — period. The leprosy detection rates trends over the years in both the Brazilian and international contexts have depended considerably on operational factors, especially before , due to the intensification of active search for cases to meet the elimination goal proposed by the WHO. Starting in , a decline in the detection rates of new cases was observed, and since a stability of this indicator, caused mainly by a decrease in the intensive search for cases in many countries [ 55 , 56 ].

The decreasing and stationary trends may indicate unchanged operational circumstances, indicating that transmission by Mycobacterium leprae is in progress [ 55 ]. Another aspect possibly related to the stability and decrease of leprosy concerns the estimated large of non-detected cases.

More than four million undetected cases are estimated from to worldwide, which implies a large of people will remain undiagnosed and untreated [ 56 ]. In Norway, where leprosy was a serious public health problem in the 19th century, the reduction in transmission was accompanied by a change in the epidemiological profile of the disease, with a decrease in cases in young age groups and an increase in the proportion of elderly people among the new cases [ 35 ]. In our study, trends and forecasts of decreasing of total and by sex detection, accompanied by high detection rates in the age groups of 60 years old or older, may be indicative that leprosy transmission is decreasing.

A study conducted in India, Brazil and Indonesia identified that the incidence of leprosy up to will decrease and meet the elimination goal at a national level, though its elimination will not be possible for the highly endemic regions in these countries [ 57 ]. The national forecasts of leprosy detection rates may provide a biased view of the disease situation, considering that these rates are masked by the large population size of each country [ 57 ]. Focusing on the regions of a country with high endemicity, such as the one addressed in this study, will give a more realistic representation of the current situation of a country, more accurately reflecting that the distribution of leprosy is becoming increasingly localized [ 57 ].

The of the adjusted models and trends show a decrease in the total detection rates, as well as in detection rates of men and women separately in the study period. In conclusion, the show downward trends of detection rates, in total and by sex. Despite decreasing trends, growing trends were found in terms of age; men aged below 15 years old and women aged 60 years old or over presented increasing detection rates, which is relevant in terms of public policies and strategic actions.

The models and forecasts for total detection rates, as well as detection rates for men and women, revealed downward trends in the study period. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Imperatriz women sex

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Trends and forecasts of leprosy for a hyperendemic city from Brazil's northeast: Evidence from an eleven-year time-series analysis