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Age at onset of the disease ranged from 4 to 63 years mean Figure 2 shows distribution of patients according to age at disease onset and at the last visit before the prevalence day.
At the time of the survey, the clinical course of the disease was as follows: patients had relapsing-remitting MS, 48 primary progressive MS, 78 secondary progressive MS, and 22 progressive MS with relapses. Fig 4 shows the distribution of the population according to some key scores of the EDSS. These three cities share ethnic, economical and cultural features, and are situated in Southeastern Brazil. In the first investigation, for the prevalence year of , MS cases women and men were identified and the prevalence rate was 4. In the second survey, for the prevalence year of , the number of identified cases increased to men and women and the rate changed to Probably, a more complete case ascertainment and the more widely use of the magnetic resonance imaging as an ancillary diagnostic tool can be accounted for the over three fold increase in the number of recognized patients.
It has been pointed out that an almost universal rule concerning prevalence of MS is that later studies of the same area show higher rates than do earlier surveys and that modern laboratory diagnostic investigations may potentially influence prevalence rates 2. Therefore, the strict methodology strengthens the reliability of the present prevalence study.
Yet, the prevalence rate as provided by the present survey is probably underestimated as we failed to have access to data from some small hospitals and rehabilitation clinics, as well as to files from about one-fourth of all neurologists in town.
On the other hand, if one takes into account that the in the present study we surveyed all major hospitals and all MRI services in the city, as well as the file of the State Health Agency, which provides free medication for all relapsing-remitting MS patients in the state, and additionally scrutinized the files of the MS societies in the city, one may be able to evaluate how careful we have been to catch all MS patients living in the city.
The resulting data provide, for the first time in Latin America, the onset-adjusted prevalence rate, which is a more precise measure than crude prevalence 3.
This is still more difficult if a well-organized and centralized registry system is not available, as it happens in both cities. For a number of cases, we had to interview patients by telephone or even examine them for differential diagnosis. On the other hand, only a few smaller sized communities in Brazil may fit appropriate for MS prevalence studies as most of them lack well organized medical care systems and are usually bereft of resources to identify their MS patients with acceptable diagnostic accuracy.
The recently reported prevalence rate of 17 per , in Botucatu 25 is very close to ours. However, it is well known that very small gains or losses in the number of cases may cause enormous change in the prevalence rate in places where its frequency is not high. In spite of Botucatu's highly organized health system, the small number of recognized cases in its MS prevalence study makes this caution necessary.
These recent formal epidemiological studies of MS performed in Southeastern Brazil have established a prevalence rate much higher in the country than that previously estimated through less appropriate survey methodology The distribution of MS in Latin America is still largely unknown as few surveys employing formal epidemiological methodology have been conducted. The calculated prevalence rate was 1.
More recently, a few papers emphasized an increased frequency of identified cases of MS in different areas of the country. A survey in the state of Chihuahua, at the border with the United States, collected 98 MS patients corresponding to a prevalence rate of 12 per , 6 In Colombia, whose territory is divided by the tropic of Capricorn, prevalence rates from 1. Interesting enough, the survey in the different Colombian provinces 5 shows a relatively lower prevalence in Antioquia, whose population is mainly made up of Caucasians directly descendants from Spaniards, differently from the predominantly miscegenated residents of other provinces 5.
In Argentina, data collected from four hospitals in Buenos Aires suggested prevalence rates between As Brazil's territory covers tropical and subtropical latitudes, it is probable that the frequency of MS is direct related to the increase of south latitude. Such a gradient has been reported in other countries, as in Australia However, one has to keep in mind that a stronger Caucasian genetic background distinguishes the population of Southeastern from those living in Northern and Northeastern Brazil.
Good quality surveys of MS prevalence, associated with genetic characterization of populations in selected Brazilian cities, may shed some light upon the interaction of genetic and environment factors determining the frequency of MS in different populations and regions of the country. Compston A, Wekerle H. The genetics of multiple sclerosis. McAlpine's Multiple Sclerosis.
Philadelphia: Churchill Livingstone Elsevier; Compston A, Confavreux C. The distribution of multiple sclerosis. The accuracy of prevalence rates of multiple sclerosis: a critical review. Neuroepidemiology ; Prevalence of multiple sclerosis in Buenos Aires, Argentina, using the capture-recapture method. Eur J Neurol ; Rev Neurol ; Arch Neuroscien Mex ; Acta Neurol Colomb ;15 Suppl :S6. A systematic review of the epidemiology of multiple sclerosis in South America.
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Multiple sclerosis: report on cases from Curitiba, Southern Brazil and comparison with other Brazilian series. Arq Neuropsiquiatr ; Arq Neuropsiquiatr , Grzesiuk AK. Multiple sclerosis: study of patients with relapsing-remitting form registered at Minas Gerais Secretary of State for Health.
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