Pesquisa destaca centros de referência no combate à hanseníase
Um estudo que analisou mais de 1,8 mil casos suspeitos de hanseníase atendidos durante cinco anos no Ambulatório Souza Araújo, do Instituto Oswaldo Cruz (IOC/Fiocruz), aponta para a importância dos centros de referência na atual estratégia para controle da doença. Publicada na revista científica Plos Neglected Tropical Diaseases, a pesquisa investigou o perfil de pacientes recebidos pela unidade em um contexto de mudança no modelo de atenção à hanseníase no Rio de Janeiro, no qual a doença deixou de ser prioritariamente diagnosticada e tratada por especialistas e passou a ser contemplada diretamente pelos médicos da atenção básica.
O trabalho revelou que o Ambulatório Souza Araújo tem expandido seu papel no esclarecimento de casos suspeitos, em apoio às unidades básicas de saúde. Os dados levantados durante o estudo também chamaram atenção para um desafio no combate ao agravo: apesar das medidas para ampliar o acesso ao tratamento, 14% dos pacientes recebidos no Ambulatório durante o período apresentavam lesões avançadas no momento do diagnóstico, prejudicando a função dos olhos, mãos ou pés.
A pesquisa contemplou casos atendidos entre 2010 e 2014, incluindo pacientes encaminhados pelas redes pública e privada e pessoas que procuraram espontaneamente a unidade por suspeita de hanseníase. Entre mais de 1,8 mil pacientes, apenas 465 – um quarto do total – foram confirmados com infecção pelo Mycobacterium leprae, causador da hanseníase. Nos demais casos, os médicos identificaram que outras doenças de pele, incluindo micoses, psoríase e dermatite eczematosa, assim como agravos do sistema nervoso eram a causa das lesões que tinham originado a suspeita de hanseníase.
“Os dados indicam que os médicos da atenção básica, que não são especialistas, estão suspeitando de hanseníase, o que é importante para ampliar o acesso ao tratamento da doença. Porém, em alguns casos, eles não têm certeza do diagnóstico, o que é esperado. Nesta situação, é importante ter um centro de referência, onde essa dúvida pode ser resolvida”, afirma a médica Euzenir Sarno, pesquisadora do Laboratório de Hanseníase do IOC/Fiocruz, unidade responsável pelo Ambulatório Souza Araújo, e coordenadora do estudo. A unidade atua como Serviço de Referência Nacional em Hanseníase junto ao Ministério da Saúde e, nesse contexto, mantém o Ambulatório Souza Araújo, promovendo a integração entre pesquisa e assistência.
A mudança no modelo de atenção à hanseníase no Rio de Janeiro é resultado da expansão da Estratégia de Saúde da Família no estado, com ênfase para a capital. Até 2009, o programa alcançava cerca de 30% da população fluminense, percentual que subiu progressivamente, chegando a quase 50% em 2014. Neste período, o crescimento foi ainda mais acentuado na capital. Até 2009, menos de 10% dos cariocas eram atendidos pelo Saúde da Família.
Em 2014, esse índice chegava a 45%. “No modelo anterior, os pacientes eram encaminhados para serviços especializados de dermatologia, que eram responsáveis pelo diagnóstico e tratamento da hanseníase. Já na Estratégia de Saúde da Família, a doença pode ser diagnosticada e tratada pelos clínicos gerais que fazem o atendimento da população. O objetivo é ampliar o acesso à terapia, uma vez que esses profissionais têm contato frequente com os pacientes e podem identificar o agravo em consultas de rotina”, esclarece Raquel Barbireri, médica do Ambulatório Souza Araújo e primeira autora do estudo.
Com a mudança no modelo de atenção, o perfil de pacientes atendidos no Ambulatório Souza Araújo também passou a apresentar diferenças. Entre 2005 e 2009, apenas 20% dos pacientes tinham passado por apenas uma consulta antes de serem encaminhados para o centro de referência, enquanto 80% tinham sido atendidos previamente em duas ou mais unidades de saúde. Já no período de 2010 a 2014, o percentual de pacientes encaminhados logo após o primeiro atendimento dobrou, alcançando 40%. Ao mesmo tempo, houve um aumento de 16% no encaminhamento de pacientes que, de fato, não apresentavam hanseníase, mas sim outras doenças de pele.
“Na maioria dos casos, os dermatologistas do Ambulatório Souza Araújo não precisaram realizar biópsias das lesões para identificar os casos de outras doenças dermatológicas. Porém, o diagnóstico diferencial da hanseníase, pelo exame visual, pode ser difícil para um profissional de saúde que não é especializado no tema. Nesse contexto, o papel do centro de referência se torna ainda mais importante, uma vez que atua inserido no Sistema Único de Saúde”, ressalta Euzenir.
Como referência, o Ambulatório Souza Araújo desempenha atividades de diagnóstico, tratamento e prevenção da hanseníase. O atendimento é feito por uma equipe multiprofissional e pode incluir a realização de biópsias e outros procedimentos. Após o diagnóstico, os pacientes com casos simples podem ser encaminhados para tratamento em unidades básicas de saúde, próximas de suas residências.
O Ambulatório segue com os atendimentos de maior complexidade, incluindo casos de recidiva, quando a doença retorna após o tratamento, e reações inflamatórias, complicação que pode afetar os pacientes antes, durante ou após o tratamento. Em 2014, a unidade recebeu o Certificado de Acreditação Internacional pela Joint Commission International (JCI), maior e mais antiga comissão acreditadora dos Estados Unidos. O documento atesta o alinhamento com padrões de excelência internacional em qualidade e segurança no atendimento aos pacientes.
DIAGNÓSTICO TARDIO
Apesar do grande número de unidades de saúde no Rio de Janeiro, o estudo detectou atraso no diagnóstico da hanseníase, o que foi considerado surpreendente pelas pesquisadoras. Entre 262 pacientes que tiveram o grau de incapacidade física avaliado no momento do diagnóstico, 40% apresentavam algum nível de perda de sensibilidade ou de movimento. Em 14% dos casos, foram identificadas lesões avançadas, que prejudicavam a função dos olhos, das mãos ou dos pés, classificadas como incapacidade física de grau 2. O resultado foi pior do que o observado em um levantamento anterior, realizado no Ambulatório Souza Araújo entre 2003 e 2007, no qual 32% dos pacientes apresentaram algum nível de redução da sensibilidade ou de movimentos e 12% revelaram grau 2 de incapacidade física.
“Apesar da expansão no acesso aos serviços de saúde, continua existindo demora no diagnóstico da hanseníase. Isso é um problema grave porque as deformidades e incapacidades físicas, que são associadas ao forte estigma da hanseníase, podem ser prevenidas com o tratamento precoce”, diz Euzenir, lembrando que o índice de lesões avançadas detectadas no Rio de Janeiro é classificado com alto pelo Ministério da Saúde. Em 2014, 11% dos pacientes diagnosticados com hanseníase no estado e na capital fluminense apresentaram incapacidade física de grau 2.
De acordo com os cientistas, é comum que o percentual de quadros graves diagnosticados aumente quando o total de casos da doença se reduz, o que contribui para explicar o resultado observado na pesquisa. No estado do Rio, o número de novos casos de hanseníase detectados caiu aproximadamente pela metade entre 2005 e 2014, passando de mais de 2,5 mil para menos de 1,5 mil. Nesse cenário, na medida em que os casos mais simples são tratados com facilidade, restam os pacientes com apresentações complexas, que podem ser difíceis de diagnosticar durante os atendimentos por profissionais de saúde que não são especializados. Por outro lado, uma vez que o agravo se torna menos frequente, os médicos podem deixar de considerar a infecção como uma opção de diagnóstico ao avaliar lesões dermatológicas, o que também pode contribuir para o diagnóstico em momento tardio da evolução da doença.
Considerando que o resultado reflete as dificuldades para o diagnóstico da hanseníase, as pesquisadoras enfatizam a necessidade de investimentos no desenvolvimento de ferramentas que possam facilitar a detecção da doença. “Além de realizar o atendimento, o centro de referência realiza pesquisas e, no Laboratório de Hanseníase, temos projetos para desenvolvimento de métodos de diagnóstico que poderiam auxiliar os profissionais de saúde no objetivo de detectar precocemente a doença. O investimento nesse tipo de iniciativa é muito importante para continuarmos avançando no enfrentamento da hanseníase”, completa Raquel.
Maíra Menezes (IOC/Fiocruz)
Fonte: AFN
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