Abstracts

INTRODUCTION

Approximately one third of the world population is infected with tuberculosis (TB)¹1. Frieden TR, Sterling TR, Munsiff SS, Watt CJ, Dye C. Tuberculosis. Lancet 2003; 62: 887-99.. In the World Health Organization (WHO) Global Tuberculosis report of 2010, it was estimated that there are 9.4 million incident TB cases, 14 million prevalent cases, 1.3 million deaths among people who don't have the human immunodeficiency virus (HIV) and 380,000 deaths among HIV-positive people worldwide every year²2. World Health Organization (WHO). Global Tuberculosis Control: surveillance, planning, financing. WHO Report 2010. Geneva: WHO; 2010..

In developed countries, TB resurfaces as a "re-emerging disease", with the immunodeficiency caused by HIV as its main vehicle, presenting most worrisome characteristics from the standpoint of bacterial resistance. However, emerging or re-emerging, TB has been present in Brazil as a public health problem during the last century³3. Kritski A, Villa TS, Trajman A, Lapa e Silva Jr, Medronho RA, Ruffino-Netto A. Duas décadas de pesquisa em tuberculose no Brasil: estado da arte das publicações científicas. Rev Saúde Pública 2007; 41(Suppl 1): 9-14..

Several reasons can be cited for the increased incidence of the disease: a deteriorating public health system; low effectiveness of control programs; economic crises; intense process of urbanization; increase in the number of people living in shelters and streets; continuous flow of immigrants coming mainly from neighboring countries, where TB is still endemic; and the emergence of an HIV infection epidemic, which puts a new group of patients at risk for TB. The living conditions of a population, such as malnutrition or living in precarious housing, are factors that are also associated with elevated incidence rates⁴4. Dunlap NE, Bass J, Fujiwara P, Hopewell P, Horsburgh Jr CR, Salfinger M, et al. Diagnostic Standards and Classification of Tuberculosis in Adults and Children. Am J Resp Crit Care Medicine 2000; 161(4): 1376-95..

Brazil presented 94,000 new cases of TB in 2006, ranking 16th among the 22 countries with the highest numbers of reported TB cases worldwide. This disease still caused the death of 5.1% of cases diagnosed in the country in 2006, presenting a ratio of 77% treatment success and 9% default from treatment⁵5. World Health Organization (WHO). Global tuberculosis control: surveillance, planning, financing. WHO Report 2008. Geneva: WHO; 2008..

The Directly Observed Treatment Short-course (DOTS) strategy has two distinct stages: first, the deployment and second, the sustainability of actions in the health system⁶6. Santos MLSG, Villa TCS, Vendramini SHF, Gonzáles RIC, Palha PF, dos Santos NSGM, et al. A gerência das ações de controle da tuberculose em municípios prioritários do interior paulista. Rev Texto Contexto Enferm 2010; 19(1): 64-9.. The effectiveness of the strategy will be achieved if there is political will, involvement of health professionals and program funding.

In 1999, the Brazilian Public Health System (SUS) implemented the DOTS strategy, stimulating greater control over the search and treatment of cases. However, a good result by the Brazilian TB Control Program (PNCT) requires, as prerequisites, a good structure, organization and function of the health system in the search for respiratory symptoms, in providing assistance to the TB patient, in the management and funding of the program and in the development of reliable information systems⁷7. Ruffino-Netto A. Tuberculose: a calamidade negligenciada. Rev Soc Bras Med Tropical 2002; 35(1): 51-8..

Thus, the PNCT is based on epidemiological surveillance, prevention and control of cases⁸8. Brasil. Ministério da Saúde. Manual de Recomendações para o Controle da Tuberculose no Brasil. Brasília; 2010.. For effective surveillance, TB cases should be detected early, stimulating the active search for respiratory symptoms. It is estimated that one untreated bacillipherous patient is able to transmit the bacillus for another 10 to 15 people each year⁹9. World Health Organization (WHO). Global tuberculosis control: surveillance, planning, financing. WHO report 2006. Geneva: WHO; 2006., and that 5 to 10% of individuals in contact with the bacillus will come to develop the disease. In efforts to control TB, the active search for cases goes through the community, health facilities in major urban centers and high-risk groups, such as the indigenous, people living in shelters, the homeless, prison system inmates and HIV/AIDS carriers¹⁰10. Santos J. Resposta brasileira ao controle da tuberculose. Rev Saúde Pública 2007; 41(Suppl 1): 89-94..

Thus, the present study has two main goals: to describe the profile and analyze the cases of TB reported in the state of Mato Grosso do Sul from 2001 to 2009, according to the chosen variable categories (gender, age, education, ethnicity, municipality, current imprisonment and inclusion of household in border area) and to estimate the proportions of default and mortality, according to year of diagnosis and region of cases studied in order to support the planning of interventions aimed at better TB control in the State.

METHODS

An ecological study was conducted based on data of reported TB cases. The source of data on TB was the System for Disease Surveillance (SINAN)¹¹11. Brasil. Ministério da Saúde. SINAN - Sistema de Informação de Agravos de Notificação. Brasília; 2010., the source of data on the populations was the Brazilian Institute of Geography and Statistics (IBGE)¹²12. Brasil. Ministério do Planejamento, Orçamento e Gestão. IBGE - Instituto Brasileiro de Geografia e Estatística. Brasília; 2010..

In the period from 2001 to 2009, 9,400 cases of TB were reported in Mato Grosso do Sul. After the exclusion of 420 cases as non-TB, for presenting a "change in diagnosis" during treatment, 1,144 TB cases with unknown clinical or only extrapulmonary conditions, and additional five cases with unknown municipality of residence, yielded a total of 7,831 cases of pulmonary TB for analysis.

Incidence rates of pulmonary TB per 100,000 inhabitants/year were calculated using the populations available and for each variable category:gender (male, female), age range, education (up to fourth year of elementary school completed; fifth to eighth year of elementary school completed; high school or higher) and ethnicity (white, black, brown, yellow, indigenous). Municipalities were grouped into macro and microregions according to the Regionalization Plan from the Department of Health of the State of Mato Grosso do Sul¹³13. Mato Grosso Do Sul. Plano Diretor de Regionalização. Secretaria Estadual de Saúde. Disponível em: http://www.conass.org.br/arquivos/file/apresentacao_ses_ms_cib_240809.pdf. (Acessado em 15 de outubro de 2010).
Disponível em: http... .

The expected incidence rates were calculated according to two methods proposed by the Brazilian TB Control Program through the publication of Centro de Referência Professor Hélio Fraga (Professor Hélio Fraga Reference Center)¹⁴14. Brasil. Ministério da Saúde. Fundação Nacional de Saúde. Centro de Referência Professor Helio Fraga. Controle da tuberculose: uma proposta de integração ensino-serviço. 5a. ed. Rio de Janeiro: FUNASA/CRPHF/SBPT; 2002.. In the first method, the largest number of cases from the last three years were selected, which, added to 10% of that value, produced the expected number of cases for the following year. In the second method, the existence of 1% of respiratory symptoms were considered in the general population of a municipality. This method also recommends that one takes into account that 4% among respiratory symptomatic patients correspond to the number of patients called "smear-positive", which are considered carriers of the bacillus. For the present study, an average of the values produced by the two methods was considered as the expected number of TB cases for each year, in each area of cases studied. The expected number of cases for the period 2007-2009 was obtained by the sum of the number of expected cases in each case one of the three years of the study.

The reference to the association of pulmonary TB with four other health conditions (AIDS, diabetes, addiction to alcohol and mental illness) was also studied.

Finally, the coverage of Directly Observed Treatment (DOT) in the various fields of study, as well as the result of developments in the case, was observed for the two most relevant categories to this article: "treatment success" or "default from treatment".

In the case of individuals deprived of their liberty in prisons or police stations, we used data on inmates from the National Penitentiary Department of the Ministry of Justice¹⁵15. Brasil. Ministério da Justiça. Sistema Prisional - InfoPen Estatística. Disponível em: http://portal.mj.gov.br/depen/data/Pages/MJD574E9CEITEMIDC37B2AE94C6840068B16-24D28407509CPTBRIE.htm. (Acessado em 15 de outubro de 2010).
Disponível em: http... . Population data on prison inmates were obtained only for the period from 2007 to 2009.

For the analyzes in this article, the software used was IBM SPSS Statistics, ver. 19.

The project was approved by the Research Ethics Committee of Universidade Federal do Mato Grosso do Sul, filed under number 1928 CAAE 0019.049.000-11.

RESULTS

Table 1, presents the estimates for the number of pulmonary TB cases expected in several areas of study in the period from 2007 to 2009, after the application of two suggested methods¹⁴14. Brasil. Ministério da Saúde. Fundação Nacional de Saúde. Centro de Referência Professor Helio Fraga. Controle da tuberculose: uma proposta de integração ensino-serviço. 5a. ed. Rio de Janeiro: FUNASA/CRPHF/SBPT; 2002.. It is possible observe that the state of Mato Grosso do Sul as a whole showed a coverage of 92.2%, i.e., the numbers of cases observed and reported to SINAN¹¹11. Brasil. Ministério da Saúde. SINAN - Sistema de Informação de Agravos de Notificação. Brasília; 2010. accounted for 92.2% of those expected to have been detected during the period from 2007 to 2009.

The macroregions of Dourados, with 95.3%, and Campo Grande, with 93.0%, had coverage above 90%, while the Três Lagoas showed a 77.3% coverage. Regarding the microregions, it was observed that Aquidauana, Corumbá and Ponta Porã showed coverage slightly greater than 100%. However, the following regions presented coverage below 80%: the microregion of Nova Andradina (60.5%), the macroregion of Dourados and the microregions of Três Lagoas (79.6%) and Paranaíba (65.2%), both in the macroregion on Três Lagoas.

Table 2 presents yearly incidence rates of pulmonary TB (per 100,000 inhabitants/year), obtained for the macro and microregions of the State.

Table 3 shows the incidence rates of pulmonary TB (per 100,000 inhabitants/year) according to the chosen variable categories with confidence intervals of 95% (95%CI) and their relative risks. Results were presented by the year of occurrence of cases, gender, age, ethnicity, education and area of residence. Very low proportions of missing information were found only on the variables: sex (10 cases or 0.1%) and age (4 cases or 0.0%).

From all of the 7,831 cases of pulmonary TB reported, information on the use of the DOTS technique was only available for 2,745 cases (30%), and it was found that this technique was used in 2,124 (77.4% of cases containing this information).

The results of laboratory tests for HIV were available for only 3,799 TB cases, of which 559 (14.7%) were presented as positive.

With regard to information on default from treatment of the 7,831 cases reported, it was not available for 367 (4.7%) cases. For 569 (7.3%), there were indications that the patient was transferred to another unit for monitoring and treatment, and to 35 (0.4%), it was indicated that the patient had developed multidrug-resistant TB. Of the remaining 6,860 cases of TB, 152 deaths by TB were described, with 2.2% of lethality, and 579 (8.4%) deaths by other causes were described. Therefore, 6,129 cases have reached the end of the treatment, with 5,414 (88.3%) successes and 715 (11.7%) cases classified as "default from treatment". Recalculating the ratio for the 5,414 successful treatment cases and of the 715 cases considered as default, using the total of 7,831 cases of TB reported and analyzed in this article as a denominator, percentages obtained were 69.1 and 9.1%, respectively.

The population of individuals deprived of liberty had the following incidence rates:

Higher risk estimates were obtained in three specific populations as opposed to in the general population (Table 4).

DISCUSSION

Higher risk estimates than in the general population, and even extremely high, were obtained in three specific populations, which certainly requires priority attention of health policies and health network professionals to keep the transmission of tuberculosis under control. The three specific populations are: population living in the border with Bolivia and Paraguay; indigenous population and individuals deprived of liberty (Table 4).

These differences in incidence rates originate in different causes. As for the inmates, in which was found a relative risk of 25.2 (95%CI 22.3 - 28.5) compared to the general population of the state of Mato Grosso do Sul, it is known that confinement favors the transmission and maintenance of TB¹⁶16. Nogueira PA, Abrahão RMCM. A infecção tuberculosa e o tempo de prisão da população carcerária dos Distritos Policiais da zona oeste da cidade de São Paulo. Rev Bras Epidemiol 2009; 12(1): 30-8.

17. Sánchez AR, Massari V, Gerhardt G, Barreto AW, Cesconi V, Pires J, et al. A tuberculose nas prisões do Rio de Janeiro, Brasil: uma urgência de saúde pública. Cad Saúde Pública 2007; 23(3): 545-52. ^{- 18}18. Moreira TR, Fávero JL, Maciel ELN. Tuberculose no sistema prisional capixaba. Rev Bras Pesq Saúde 2010; 12(1): 26-33.. Indeed, overcrowding, poor ventilation and poor standards of hygiene and cleanliness put inmates in conditions of high risk for TB. This facilitation of the transmission of the disease's bacillus is especially worrisome, because it is observed that the prison population in Brazil has grown consistently, from 108.6 prisoners per 100,000 inhabitants in 1997 to 229.7 in 2007¹⁶16. Nogueira PA, Abrahão RMCM. A infecção tuberculosa e o tempo de prisão da população carcerária dos Distritos Policiais da zona oeste da cidade de São Paulo. Rev Bras Epidemiol 2009; 12(1): 30-8..

The socio-demographic composition of the Brazilian prison population indicates that Brazilians inmates are mostly men aged 20 - 29 years with little education and coming from a low socioeconomic status¹⁶16. Nogueira PA, Abrahão RMCM. A infecção tuberculosa e o tempo de prisão da população carcerária dos Distritos Policiais da zona oeste da cidade de São Paulo. Rev Bras Epidemiol 2009; 12(1): 30-8.. In addition, the average length of stay in Brazilian prisons of 30 months¹⁶ 16. Nogueira PA, Abrahão RMCM. A infecção tuberculosa e o tempo de prisão da população carcerária dos Distritos Policiais da zona oeste da cidade de São Paulo. Rev Bras Epidemiol 2009; 12(1): 30-8.indicates high mobility, with reintegration of inmates to communities, and mobility by circulating from one prison to another, actions that facilitate the dispersal of TB. Reincarceration may also be another important mechanism in maintaining intramural transmission in prisons. It is important to note that a TB patient can come to transmit the disease to other inmates, to prison system professionals, visitors and individuals in the community, on the occasion of their release, on probation or final¹⁶16. Nogueira PA, Abrahão RMCM. A infecção tuberculosa e o tempo de prisão da população carcerária dos Distritos Policiais da zona oeste da cidade de São Paulo. Rev Bras Epidemiol 2009; 12(1): 30-8..

This situation can be even more worrisome, for example, in the state of Rio de Janeiro, which presented, in 2004, an incarceration rate of 3,137 inmates per 100,000 inhabitants/year, or 3.1 times the average in state of Mato Grosso do Sul, with 1,023 inmates per 100,000 inhabitants/year in the period from 2007 to 2009¹⁹19. Secretaria de Estado de Administração Penitenciária do Rio de Janeiro. Relatório técnico anual do Programa de Controle da Tuberculose. Rio de Janeiro: Superintendência de Saúde, Secretaria de Estado de Administração Penitenciária do Rio de Janeiro; 2004. ^{, 20}20. Secretaria de Estado de Saúde do Rio de Janeiro. Relatório técnico anual do Programa de Pneumologia Sanitária. Rio de Janeiro: Superintendência de Estado de Saúde do Rio de Janeiro; 2004..

The indigenous population, also identified in this article with a higher risk than the general state population, with a relative risk of 7.32 (95%CI 6.1 - 8.8), has been presenting, for a long time, lower resistance to TB. Cunha, in 1992²¹21. Cunha MC. Historia dos Índios no Brasil. São Paulo: Companhia das Letras; 1992., argued that a typical form of the TB bacillus had not yet been found in non-acculturated Brazilian indigenous populations, and concluded that indigenous peoples could be exposed to a particularly virulent strain of Mycobacterium tuberculosis. The researcher also commented that there is a probability that catechist priests from colonization times were diagnosed with TB, and therefore have been responsible for the transmission of the disease among indigenous populations. These early historical events and the currently prevailing conditions in the indigenous populations' lives may have contributed to these differences in prevalence.

The health of indigenous populations is facing a problem of major consequence since TB control involves the detection and treatment of alcoholics, because of the importance of this condition in curing TB. In a study conducted in Carapicuíba, São Paulo, it was found that alcoholism was the most prevalent comorbidity to TB, associated with default from treatment²²22. Vieira AA, Ribeiro SA. Abandono do tratamento de tuberculose utilizando-se as estratégias tratamento auto-administrado ou tratamento supervisionado no Programa Municipal de Carapicuíba, São Paulo, Brasil. [Internet] J Bras Pneumol 2008; 34(3).. This study indicates that alcoholism may be the most important risk factor for poor prognosis and a favorable outcome of the disease treatment²³23. Deheinzelin D, Takagaki TY, Sartori AMC, Leite OHM, Amato Neto V, Carvalho CRR. Fatores preditivos de abandono de tratamento por pacientes com tuberculose. Rev Hosp Clin Fac Med São Paulo 1996; 51(4): 131-5.

24. Pablos-Méndez A, Knirsch CA, Barr RG, Lerner BH, Frieden TR. Nonadherence in tuberculosis treatment: predictors and consequences in New York City. Am J Med 1997; 102(2): 164-70.

25. Anibarro L, Lires JA, Iglesias F, Vilariño C, Baloria A, Lis JM, et al. Factores sociales de riesgo para la falta de cumplimiento terapéutico en pacientes con tuberculosis en Pontevedra. Gac Sanit 2004; 18(1): 38-44.

26. Oliveira HB, Moreira-Filho DC. Abandono de tratamento e recidiva da tuberculose: aspectos de episódios prévios, Campinas, SP, Brasil, 1993-1994. Rev Saúde Pública 2000; 34(5): 437-43. ^{- 27}27. Burman WJ, Cohn DL, Rietmeijer CA, Judson FN, Sbarbaro JA, Reves RR. Noncompliance with directly observed therapy for tuberculosis. Epidemiology and effect on the outcome of treatment. Chest 1997; 111(5): 1168-73..

A survey conducted by Marques and Cunha²⁸28. Marques AMC, Cunha RV. A medicação assistida e os índices de cura de tuberculose e de abandono de tratamento na população indígena Guarani-Kaiwá no município de Dourados, Mato Grosso do Sul, Brasil. Cad Saúde Pública 2003; 19(5): 1405-11., with the indigenous population of Dourados, Mato Grosso do Sul, confirms the extreme poverty that afflicts the indigenous populations, resulting in, among other health conditions, malnutrition, which entails a greater illness by depressing the cellular immunity mechanism. The researchers claim that, associated with malnutrition, this population is in horrible living conditions in densely populated households, with a single room, without ventilation, which would result in a higher infectious load. In addition, the indigenous population has a higher incidence rate among children and adolescents, which reveals recent infection by contact with individuals with bacilliferous TB and shows the need for greater control. It is observed that outpatient treatment associated with domiciliary assisted treatment has produced promising results.

Finally, in the border areas, there was a relative risk of 1.74 (95%CI 1.46 - 2.07), lower than in inmates and indigenous populations, but statistically higher than in the general population of the state of Mato Grosso do Sul. These populations are really more open and near the general population, since their only special characteristic is that its inhabitants live in municipalities near the border with Paraguay and Bolivia.

In fact, a higher incidence of TB in these areas is linked, most likely, to the import of active cases, and therefore transmitters, from foreigners who are in Brazil, either as new residents or just showing some more intense coexistence, which is sufficient for the occurrence of transmission, with production of new TB cases detected by health services. There may have also been errors in the information on residence of reported cases, which were counted as residents in Brazil although they were really resident in municipalities in Paraguay or Bolivia. There may even be individuals who have chosen to go through the TB treatment in Brazil.

It is also possible that Brazilians have been infected in other South American countries, where they work and live and where the prevalence of TB may be higher or even has less epidemiologic surveillance of cases, as well as less detection and treatment offer.

An important aspect in the discussion of TB at the border is a necessary focus on control programs in the three countries. Brazil, Paraguay and Bolivia have huge social inequalities, with increased poverty, lack of access to services, population growth and urban concentration, which impact negatively on endemic diseases, including TB, and result in major challenges in the field of infectious diseases. A serious problem includes the emergence of resistance to existing TB treatment drugs, emergence of multidrug resistant forms (MDR-TB) and, more recently, in 2006, the form called extensively drug-resistant TB (XDR-TB)²⁹29. Dalcolmo MP, Andrade MKN, Picon PD. Tuberculose multirresistente no Brasil: histórico e medidas de controle. Rev Saúde Pública 2007; 41(Suppl. 1): 34-42..

Data on genre were obtained from 7,821 TB cases, with 2,436 cases occurring in females (31.1%) and 5,385 in males (68.9%), values close to those found in research conducted in hospital care (30.1 and 69.9%) and in the basic health network (33.8 and 66.2%) of the city of São Paulo³⁰30. Perrechi MCT, Ribeiro SA. Tratamento de tuberculose: integração entre assistência e rede básica na cidade de São Paulo. J Bras Pneumol 2009; 35(11): 1100-6.. These researchers also found, in the 20-59 years age group, the majority of TB cases, with 81.4% in hospitalized patients and 80.8% in outpatients, slightly higher values than those found for Mato Grosso do Sul in this study, 72.4% (Table 3).

With regard to education, Falcão³¹31. Falcão AB. Estudo comparativo do tratamento supervisionado da TB com o auto-administrado. Bol Pneumol Sanit 2006; 14(1): 21-5. found a higher rate of TB among individuals with less than eight years of education, which, among patients undergoing supervised treatment, corresponded to 70.9%, and among those undergoing self-administered treatment, accounted for 71.7%. In the present study, for the two modes of treatment, 85.3% of the cases in Mato Grosso do Sul accounted for this level of education.

This article presents a spatial reorganization since the state has very small municipalities, where rates would be unstable. We chose to work with micro and macroregions in order to better stabilize the estimates. In fact, many times, this fact could be observed.

In the general population, and also in some specific populations, TB cases may go unnoticed. In this study, it was expected that this had occurred exactly in the most affected populations: indigenous populations, inmates and border populations. This potential underestimation, however, would indicate that the problem can be much more severe than what was found in this article, and would require more efficient strategies for TB control in our environment. An active search for respiratory symptoms, through surveys and health education activities, would be crucial to detect cases and decrease the disease's occult prevalence, in the search for disease control by health services.

Thus, the results obtained for these three populations analyzed, of course, do not reflect the entirety of cases in the state. We recognize the existence of a national problem and, when analyzing the difference between the numbers of reported and expected cases, one can observe an underreporting of cases. The proposed process for estimating the number of TB cases expected to be detected in a given year of study can present problems. However, ruling out problems in these estimates, it is possible to question whether a smaller number of cases have occurred solely by faults in the information registry system, which must have occurred, but at an insufficient degree to explain all the observed differences between the number of expected and detected cases by the TB control program³²32. Hijjar AM, Oliveira MJPR, Teixeira GM. A tuberculose no Brasil e no Mundo. [cited 2014 Feb 10]. Bol Pneumol Sanit 2001; 9(2)..

This study sought to show the importance of discussing territoriality more adequately in Brazil. It would require a constant reevaluation of all health programs is needed for populations in each of the areas where they live. Then, it will be possible to correct the incidence rate of TB for specific populations in the state of Mato Grosso do Sul, taking into account populations in each place of residence and considering their specificities and differences. In conclusion, in the light of the present study, it is necessary to discuss more efficient strategies to control tuberculosis in the various territories of the state of Mato Grosso do Sul if we actually want to minimize this endemic to acceptable levels in our environment.

REFERENCES

Publication Dates

History