Abstract

Tuberculosis (TB) has a high incidence in several countries and is even more severe in prisoners. We evaluated the completeness of prisoners TB notifications in the Notifiable Disease Information System (SINAN) carried out by prison primary care teams (eAPP) or by other health facilities in the state of Rio Grande do Sul (RS). This descriptive cross-sectional study used prisoners data notifications in the SINAN TB by the eAPP or other health facilities from January 2014 to November 2018. We analyzed the percentage of completeness of the variables: gender, ethnicity, schooling, HIV, entry type, sputum smear, sputum culture, AIDS, ART during TB treatment, directly observed treatment (DOT), sixth-month smear, and closure status. Around 52.9% of TB cases in prisoners were reported by eAPP, and other health facilities reported 47.1% of the cases. Eighty percent of the variables were classified in category 4 (75.1% to 100% completeness). However, the DOT and sixth-month smear variables were classified into category 3 (50.1% and 75% completeness). While it does not compromise the notification of TB in the SINAN, the lack of data can impair the quality of information about the disease.

Key words:
Mycobacterium tuberculosis; Information system; Prisons

Introduction

Brazil has about 90 thousand new TB cases annually, with a higher incidence in population groups with socioeconomic or immunological vulnerability, including prisoners. There is evidence that prison conditions may expand the disease in the general population¹1 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Manual de recomendações para o controle da tuberculose no Brasil. Brasília: Ministério da Saúde; 2019^,22 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Tuberculose. Bol Epidemiológico 2021; número especial. [acessado 2021 out 2] Disponível em: https://www.saude.gov.br/images/pdf/2019/marco/22/2019-009.pdf [link indisponível]
https://www.saude.gov.br/images/pdf/2019... . Individuals enter prisons with a low risk of developing TB, but this risk increases rapidly over five years, 35 times higher than the general population³3 Sacchi FPC, Praça RM, Tatara MB, Simonsen V, Ferrazoli L, Croda MG, Suffys PN, Ko IA, Andrews JR, Croda J. Prisons as reservoir for community transmission of tuberculosis, Brazil. Emerg Infect Dis 2015; 1(3):452-455.

4 Mabud TS, DE Lourdes DAM, Ko AI, Basu S, Walter KS, Cohen T, Mathema B, Colijn C, Lemos E, Croda J, Andrews JR. Evaluating strategies for control of tuberculosis in prisons and prevention of spillover into communities: an observational and modeling study from Brazil. PLoS Med 2019; 16(1):e1002737.^-55 Brasil. Ministério da Saúde (MS). Departamento de doenças de condições crônicas e Infecções sexualmente transmissíveis. Tuberculose: populações vulneráveis [Internet]. 2021. [acessado 2021 ago 18]. Disponível em: http://www.aids.gov.br/pt-br/publico-geral/tuberculose/populacoes-vulneraveis-tuberculose [link indisponível]
http://www.aids.gov.br/pt-br/publico-ger... .

In this context, planning and implementing public health care policies for prisoners are concerns of the World Health Organization (WHO)⁶6 World Health Organization (WHO). Global Tuberculosis Report 2020. [cited 2021 jun 15]. Available from: https://apps.who.int/iris/bitstream/handle/10665/336069/9789240013131-eng.pdf
https://apps.who.int/iris/bitstream/hand... . In Brazil, these public policies were consolidated with the publication of the National Policy for Comprehensive Health Care in the Prison System (PNAISP) in 2014, which guarantees prisoners access to health services through the implementation of prison PHC teams (eAPP). The following attributions of the eAPP stand out: elaborating and implementing health and epidemiological surveillance actions; and monitoring and evaluating specific indicators and health information systems, with data produced in the local health system⁷7 Brasil. Ministério da Saúde (MS). Política Nacional de Atenção Integral à Saúde das Pessoas Privadas de Liberdade no Sistema Prisional (PNAISP) [Internet]. 2014. [acessado 2019 ago 15]. Disponível em: http://www.as.saude.ms.gov.br/wp-content/uploads/2016/06/Cartilha-PNAISP.pdf
http://www.as.saude.ms.gov.br/wp-content... ^,88 Secretária da Saúde do Estado do Rio Grande do Sul. Portaria nº 754/2021, de 28 de outubro de 2021. [acessado 2021 nov 10]. Disponível em: https://saude.rs.gov.br/upload/arquivos/202110/29163619-754.pdf
https://saude.rs.gov.br/upload/arquivos/... .

TB is a notifiable disease, and the health unit that identifies the case is responsible for notifying it, which is carried out by completing the notification form, including information on patient identification, service, and clinical and epidemiological data. Data in this form must be entered into the Notifiable Disease Information System (SINAN) database, which is the official system for collecting and processing individual forms of mandatory legal notification, currently the primary source of data for TB surveillance in the country⁹9 Brasil. Ministério da Saúde (MS). Portaria GM/MS nº 2325, de 8 de dezembro de 2003. Define a relação de doenças de notificação compulsória para todo território nacional. Diário Oficial da União 2003; 8 dez.^,1010 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Sistema de Informação de Agravos de Notificação - SINAN: Relatórios - Manual de operações. Brasília: MS; 2015..

Information systems such as SINAN are essential tools for epidemiological surveillance, but problems can occur in data quality involving producers, managers, and users at all stages of the information production cycle. Thus, the analysis and evaluation of epidemiological data can also be performed through SINAN. SINAN’s technical areas monitor the percentage of field completion of the notification forms, establishing parameters to assess the completion of the database. These cutoff percentage values are used to evaluate data from other information systems¹¹11 Correia LOS, Padilha BM, Vasconcelos SML. Métodos para avaliar a completitude dos dados dos sistemas de informação em saúde do Brasil: uma revisão sistemática. Cien Saude Colet 2014; 19(11):4467-4478.^,1212 Moreira CMM, Maciel NLE. Completude dos dados do Programa de Controle da Tuberculose no Sistema de Informação de Agravos de Notificação no Estado do Espírito Santo, Brasil: uma análise do período de 2001 a 2005. J Bras Pneumol 2008; 34(4):225-229. qualitatively.

The proper completion of these forms (completeness) is essential and must be regularly updated by the health unit team, as it directs recommendations and provides subsidies for decision-making. If these issues are not considered, the knowledge generated based on these data may not adequately represent the reality studied¹²12 Moreira CMM, Maciel NLE. Completude dos dados do Programa de Controle da Tuberculose no Sistema de Informação de Agravos de Notificação no Estado do Espírito Santo, Brasil: uma análise do período de 2001 a 2005. J Bras Pneumol 2008; 34(4):225-229.

13 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Sistema de Informação de Agravos de Notificação - SINAN: normas e rotinas. Brasília: MS; 2007.^-1414 Lírio M, Santos NP, Passos LAR, Kritski A, Galvão-Castro B, Grassi MFR. Completude das fichas de notificação de tuberculose nos municípios prioritários da Bahia para controle da doença em indivíduos com HIV/Aids. Cien Saude Colet 2015; 20(4):1143-1148.. In this context, the study aimed to evaluate the completeness of prisoners TB notifications in SINAN performed by prison primary care teams (eAPP) or other health facilities in the state of Rio Grande do Sul (RS).

Methods

This descriptive, cross-sectional study was conducted from secondary data obtained from SINAN TB through access granted by the State Health Secretariat of RS on December 18, 2020. Prisoners with TB in the state of RS reported from January 2014 to December 2018 were included in the study. Individuals without prison information at the time of TB notification and those under 18 years of age were excluded.

In 2019, RS had about 41 thousand prisoners distributed in 109 penal institutions¹⁵15 Departamento Penitenciário Nacional (DEPEN). Relatórios analíticos [Internet]. 2020. [acessado 2021 set 30]. Disponível em: http://antigo.depen.gov.br/DEPEN/depen/sisdepen/infopen/relatorios-analiticos/RS/rs [link indisponível]
http://antigo.depen.gov.br/DEPEN/depen/s... . According to the Ministry of Health, in 2020, 33 multidisciplinary eAPPs in RS were responsible for articulating and providing comprehensive care to around 19,000 prisoners ¹⁶16 Brasil. Ministério da Saúde (MS). Saúde Prisional [Internet]. 2021 [acessado 2021 set 25]. Disponível em: http://aps.saude.gov.br/ape/pnaisp/monitoramento
http://aps.saude.gov.br/ape/pnaisp/monit... .

The term completeness refers to the degree of completion of each field of the variables analyzed, measured by the proportion of notifications with a field completed with a different category from those indicating the lack of data. Fields completed in the SINAN as unknown, with a situation in progress, or fields that indicated lack of data without information or blank data were considered incomplete¹⁷17 Brasil. Ministério da Saúde (MS). Sistema de Informação de Agravos de Notificação - SINAN: Relatórios - Manual de operações. Brasília: MS; 2015.. Completeness was calculated and compared between two groups: 1) TB notifications by eAPP and 2) TB notifications by other health facilities (hospitals, emergency care units, health posts).

We analyzed the following variables from the TB notification form:gender, ethnicity, schooling, HIV, entry type, sputum smear, sputum culture, AIDS, ART during TB treatment, directly observed treatment (DOT), sixth-month smear, and closure status.

The qualitative assessment of completeness was based on the SINAN classification: category 1, with 0 to 25% completeness; category 2, between 25.1% and 50%; category 3, between 50.1% and 75%; and category 4, between 75.1% and 100% completeness¹⁷17 Brasil. Ministério da Saúde (MS). Sistema de Informação de Agravos de Notificação - SINAN: Relatórios - Manual de operações. Brasília: MS; 2015.. We performed descriptive analyses by frequency distribution, absolute numbers, and proportions using the statistical analysis software Statistical Package for the Social Sciences (SPSS), version 20.0.

Although this is research based on data extracted from secondary sources, it is noteworthy that the prerogatives of confidentiality and anonymity of data and information collected were preserved in compliance with the ethical precepts established in Resolution N° 466/12 of the National Health Council. The Research Ethics Committee of the School of Public Health/State Health Secretariat of RS approved the study under Opinion nº 3.047.876.

Results

During the study period, 1,881 (52.9%) TB cases in prisoners were reported by eAPPs (Figure 1), and 1,676 (47.1%) TB cases in prisoners were reported by other health facilities, corresponding to 11.3% of the total TB cases reported in the state of RS.

The completeness (completion percentage) of each variable analyzed is described in Table 1. The variables gender, entry type, sputum smear, schooling, ethnicity, HIV, sputum culture, AIDS, ART, and closure status were classified under SINAN’s category 4 (75.1% and 100% completeness) in the notifications by eAPPs and other health establishments. DOT and sixth-month smear variables were classified in SINAN’s category 3 (50.1% and 75% of completeness) in the notifications by eAPPs and other health establishments.

Discussion

We observed that more than 80% of the variables evaluated were classified in category 4 (75.1% to 100% of completion), both in notifications made by eAPP and other health facilities. However, we still observed categories that indicate low data completion in the SINAN, such as the variables classified in category 3 in this study. We can infer that completeness is directly related to the existing fields to be completed for each variable on the SINAN form and the classification of completing these fields as essential or mandatory, per the Ministry of Health¹³13 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Sistema de Informação de Agravos de Notificação - SINAN: normas e rotinas. Brasília: MS; 2007..

We emphasize that the entry type and sputum smear variables were 100% completed, as they are the only ones in the study without unknown, in progress, not informed/blank in their fields, which means that completion is not 100%. Likewise, according to the rules and instructions for completing in the SINAN, these are mandatory fields whose lack of data hinders the inclusion of the notification in SINAN¹⁸18 Brasil. Ministério da Saúde (MS). Vigilância epidemiológica da tuberculose: análise de indicadores operacionais e epidemiológicos a partir da base de dados do Sinan versão 5.0. Brasília: MS; 2019..

The same occurs for the gender variable. However, this variable has an unknown field available for completion. Therefore, completing 100% of this variable can be justified because the responsible professional fills it out based on the type of penal institution (female or male) where the prisoners are located or even by observation at the time of completing the form.

The completeness of the variables ethnicity, schooling, AIDS, ART, DOT, sixth-month smear, and closure status was less than 100%, mainly due to a large number of notifications with categories unknown, no information, or blank, since these are mostly related to the lack of completing the field and not to the informant’s lack of knowledge¹⁹19 Romero DE, Cunha CB. Avaliação da qualidade das variáveis epidemiológicas e demográficas do Sistema de Informações sobre Nascidos Vivos, 2002. Cad Saude Publica 2007; 23(3):701-714..

Studies have already shown weaknesses in TB epidemiological surveillance systems, such as the lack of completeness of variables. In this context, it is suggested that some areas, such as prisoners, be prioritized for improving TB surveillance since differentiated strategies to face this critical public health problem are required in this population²⁰20 Santos NP, Lírio M, Passos LAR, Dias PJ, Kritski AL, Galvão-Castro B, Grassi MFR. Completude das fichas de notificações de tuberculose em cinco capitais do Brasil com elevada incidência da doença. J Bras Pneumol 2013; 39(2):221-225.^,2121 Silva GDM, Bartholomay P, Cruz OG, Garcia PL. Avaliação da qualidade dos dados, oportunidade e aceitabilidade da vigilância da tuberculose nas microrregiões do Brasil. Cien Saude Colet 2017; 22(10):3307-3319..

The variables with a situation in progress as a completion option, such as the variable HIV and sputum culture, also did not achieve 100% completeness. It is noteworthy that knowledge of HIV serology is essential so that ART is available promptly (two to eight weeks after the start of TB treatment) for TB co-infected individuals¹1 Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Manual de recomendações para o controle da tuberculose no Brasil. Brasília: Ministério da Saúde; 2019^,66 World Health Organization (WHO). Global Tuberculosis Report 2020. [cited 2021 jun 15]. Available from: https://apps.who.int/iris/bitstream/handle/10665/336069/9789240013131-eng.pdf
https://apps.who.int/iris/bitstream/hand... .

On the other hand, the Ministry of Health must recommend that all prisoners submit to sputum culture for a subsequent sensitivity test. Therefore, the lack of completeness observed in this and other studies for the sputum culture variable probably occurred, as this method requires 20 to 60 days to obtain results. These data are not updated in this context, showing the need to correct this obstacle¹⁴14 Lírio M, Santos NP, Passos LAR, Kritski A, Galvão-Castro B, Grassi MFR. Completude das fichas de notificação de tuberculose nos municípios prioritários da Bahia para controle da doença em indivíduos com HIV/Aids. Cien Saude Colet 2015; 20(4):1143-1148.^,2020 Santos NP, Lírio M, Passos LAR, Dias PJ, Kritski AL, Galvão-Castro B, Grassi MFR. Completude das fichas de notificações de tuberculose em cinco capitais do Brasil com elevada incidência da doença. J Bras Pneumol 2013; 39(2):221-225..

Furthermore, we did not observe any discrepancy in the classification of the categories between the data completed by the eAPPs or other health facilities. However, we emphasize that 52.9% of TB notifications in the state of RS were performed by eAPPs, which is extremely important, as it reflects the efficient work of these teams and the policy implemented, besides reducing the need to relocate prisoners for servicing in external units. Considering that RS is a pioneer in Brazil in the municipalization and co-financing of eAPPs, since the implementation of these teams, a set of effective strategies for the diagnosis of TB in penal institutions of RS has been observed, limiting the burden of the disease¹⁶16 Brasil. Ministério da Saúde (MS). Saúde Prisional [Internet]. 2021 [acessado 2021 set 25]. Disponível em: http://aps.saude.gov.br/ape/pnaisp/monitoramento
http://aps.saude.gov.br/ape/pnaisp/monit... ^,2222 Ely KZ, Dotta RM, Jarczewski CA, Valim ARM, Possuelo LG. Bacteriological diagnosis of tuberculosis in prison inmates: actions taken by the primary health care teams in prisons. J Bras Pneumol 2020; 46(2):e20190179..

Completing the notification form is vital for defining the effectiveness and quality of actions in municipal and state TB control programs. Moreover, the forms should be completed or updated monthly until the end of the TB treatment¹²12 Moreira CMM, Maciel NLE. Completude dos dados do Programa de Controle da Tuberculose no Sistema de Informação de Agravos de Notificação no Estado do Espírito Santo, Brasil: uma análise do período de 2001 a 2005. J Bras Pneumol 2008; 34(4):225-229.. Improving completeness requires, among other factors, training, continuing education programs, appreciation of health professionals, and strengthening primary care since issues such as the high workload of eAPPs and the turnover of professionals can adversely influence the follow-up of patients with TB¹⁶16 Brasil. Ministério da Saúde (MS). Saúde Prisional [Internet]. 2021 [acessado 2021 set 25]. Disponível em: http://aps.saude.gov.br/ape/pnaisp/monitoramento
http://aps.saude.gov.br/ape/pnaisp/monit... ^,2323 Liporaci SFQ, Soares CCE, Barbosa AP, Guazzi M, Pio EJ. Acompanhamento da notificação dos casos de tuberculose pulmonar com confirmação laboratorial no município do Rio de Janeiro. Acad Rev Cient Saude 2018; 3(1):1-6.. The use of secondary data was a limitation of the study. However, the results are relevant because 100% of TB cases reported in prisoners in RS were evaluated over five years, comparing eAPPs with other health facilities.

Furthermore, the data generated by the system are essential to know the reality and, thus, formulate adequate evidence-based policies and be used in the planning, implementation, and evaluation of health programs. The professionals completing the TB notification forms in the SINAN should participate in continuing education activities, especially regarding the epidemiological surveillance of TB. We also emphasize that the work carried out by the eAPPs increases the completion of TB notifications among prisoners in RS.

References

Publication Dates

History