ABSTRACT:

Introduction:

Tuberculosis remains as a global public health problem and its occurrence and distribution is associated with social inequalities. Itaboraí is among the priority Brazilian municipalities for tuberculosis control. The study aimed to combine social indicators into a composite indicator to measure differences in living conditions of the population in Itaboraí, as well as evidence of health inequalities related to tuberculosis.

Methods:

An ecological study, with spatial analysis of tuberculosis and its relation to socioeconomic and demographic status of households. Data were obtained from individuals declared in the Mortality Information System (SIM), notified in the Notification of Injury Information System - SINAN or Tuberculosis Special Treatment Information System - SITETB from 2007 to 2013.

Results:

Evidence indicates association between sociodemographic inequalities and occurrence of tuberculosis in the population. Findings point to a lower percentage of healing and a higher percentage of abandonment and death in areas with high social vulnerability, with a relative risk over twice as high than that found in areas of lower vulnerability.

Conclusion:

The study showed strong evidence that the influence of unequal sociodemographic conditions have a negative impact on health conditions of the population in Itaboraí.

Keywords:
Health inequalities; Epidemiological surveillance; Social vulnerability; Spatial analysis

INTRODUCTION

The World Health Organization (WHO)¹1. World Health Organization (WHO). Commission on Social Determinants of Health. A conceptual framework for action on the social determinants of health. Geneva: WHO; 2007. [Internet]. Disponível em: Disponível em: http://www.who.int/social_determinants/resources/csdh_framework_action_05_07.pdf?ua=1 (Acessado em 27 de outubro de 2015).
http://www.who.int/social_determinants/r... defines social determinants as social conditions in which people live and work. Social determinants of health (SDH)²2. Buss PM, Pellegrini Filho A. A saúde e seus determinantes sociais. Physis: Rev Saúde Coletiva 2007; 17(1): 77-93. DOI: 10.1590/S0103-73312007000100006
https://doi.org/10.1590/S0103-7331200700... are economic, social, cultural, ethnic/racial, psychological and behavioral factors that interfere in the onset of diseases. Inequity in health is an inequality that should not exist, since it is avoidable, unfair and unnecessary³3. Whitehead M. A typology of actions to tackle social inequalities in health. J Epidemiol Community Health 2007; 61(6): 473-8. DOI: 10.1136/jech.2005.037242
https://doi.org/10.1136/jech.2005.037242... . The fundamental premise of equity is “social justice”, passing by the processes that reveal inadmissible disparities in health of socially unequal populations⁴4. Barata RB. Epidemiologia e políticas públicas. Rev Bras Epidemiol 2013; 16(1): 3-17. DOI: 10.1590/S1415-790X2013000100001
https://doi.org/10.1590/S1415-790X201300... ^,55. Kawachi I, Subramanian SV, Almeida-Filho N. A glossary for health inequalities. J Epidemiol Community Health 2002; 56(9): 647-52. DOI: 10.1136/jech.56.9.647
https://doi.org/10.1136/jech.56.9.647... .

Health problems related with infectious diseases, such as tuberculosis (TB) and the Acquired Immunodeficiency Syndrome (AIDS), still persist in the scenario of morbidity found in the country⁶6. Carmo EH, Barreto ML, Silva JB. Mudanças nos padrões de morbimortalidade da população brasileira: os desafios para um novo século. Epidemiol Serv Saúde 2003; 12(2): 63-75. DOI: doi.org/10.5123/S1679-49742003000200002
https://doi.org/10.5123/S1679-4974200300... . Some determinants of this scenario is the permanence of structural problems, precarious life conditions and continuous harm to the environment.⁷7. Barreto ML, Carmo EH. Padrões de adoecimento e de morte da população brasileira: os renovados desafios para o Sistema Único de Saúde. Ciênc Saúde Coletiva 2007; 12(Suppl): 1179-90. DOI: 10.1590/S1413-81232007000700003
https://doi.org/10.1590/S1413-8123200700... ^,88. Barreto ML, Teixeira MG, Bastos FI, Ximenes RAA, Barata RB, Rodrigues LC. Saúde no Brasil 3: sucessos e fracassos no controle de doenças infecciosas no Brasil: o contexto social e ambiental, políticas, intervenções e necessidades de pesquisa. The Lancet 2011; 6736(11): 47-60.

Recent studies reinforce the assumption that there is a socioeconomic gradient associated with the occurrence and distribution of TB, considered as a public health issue⁹9. Acosta LM, Bassanesi SL. The Porto Alegre paradox: social determinants and tuberculosis incidence. Rev Bras Epidemiol 2014; 17(2): 88-101. DOI: 10.1590/1809-4503201400060008
https://doi.org/10.1590/1809-45032014000... ^,1010. San Pedro A, Oliveira RM. Tuberculose e indicadores socioeconômicos: revisão sistemática da literatura. Rev Panam Salud Pública 2013; 33(4): 294-301. DOI: 10.1590/S1020-49892013000400009
https://doi.org/10.1590/S1020-4989201300... . An important indicator of inequity is the difficulty to access adequate and opportune treatment¹¹11. Pinheiro RS, Andrade VL, Oliveira GP. Subnotificação da tuberculose no Sistema de Informação de Agravos de Notificação (SINAN): abandono primário de bacilíferos e captação de casos em outras fontes de informação usando linkage probabilístico. Cad Saúde Pública 2012; 28(8): 1559-68. DOI: 10.1590/S0102-311X2012000800014
https://doi.org/10.1590/S0102-311X201200... . Itaboraí is among the priority Brazilian municipalities for TB control, since it is in the area comprehended by the Petrochemical Complex of the State of Rio de Janeiro (COMPERJ)¹²12. Brasil. Secretaria de Estado de Saúde do Rio de Janeiro, Gerência de Pneumologia Sanitária. Tuberculose. Boletim da Tuberculose 2014; Rio de Janeiro (RJ) 28. [Internet]. Disponível em: Disponível em: http://riocomsaude.rj.gov.br/Publico/MostrarArquivo.aspx?C=wXJ%2BKouHyII%3D (Acessado em 27 de setembro de 2015).
http://riocomsaude.rj.gov.br/Publico/Mos... .

The objectives of the study were:

METHODOLOGY

Ecological study whose units of analysis were 71 neighborhoods of Itaboraí, conducted a spatial analysis of cases of TB and the relationship with the socioeconomic status of the families living there, mapping vulnerabilities by socioeconomic status and measuring inequalities in the incidence rates between neighborhoods. Data were obtained from the inhabitants, declared in the Mortality Information System (SIM), notified in the Information System for Notifiable Diseases (SINAN), or registered in the Information System of Special Treatments of Tuberculosis (SITETB), between 2007 and 2013.

Itaboraí belongs to the Metropolitan Region of Rio de Janeiro, with an area of 423.95 km² and population density of 514.42 inhab/km². From 2000 to 2010, its population grew at an average annual rate of 1.63% - in Brazil, this rate was 1.17%. The Human Development Index (HDI) was 0.693, in 2010, which places Itaboraí in the median range of development. The estimated population in 2016 was 230,786 inhabitants¹³13. United Nations Development Programme, Fundação João Pinheiro, Instituto de Pesquisa Econômica Aplicada. Atlas do Desenvolvimento Humano no Brasil.. Published 2013. [Internet]. Disponível em: Disponível em: http://atlasbrasil.org.br/2013/pt/perfil_m/itaborai_rj (Acessado em 10 de abril de 2017).
http://atlasbrasil.org.br/2013/pt/perfil... . The city also has high incidence rates of TB, with expressive changes in the urban area, coming from the installation of COMPERJ¹⁴14. Pedro AS, Gibson G, Santos JP, Toledo LM, Sabroza PC, Oliveira RM. Tuberculosis as a marker of inequities in the context of socio-spatial transformation. Rev Saúde Pública 2017; 51: 9. DOI: 10.1590/s1518-8787.2017051006533
https://doi.org/10.1590/s1518-8787.20170... .

INCLUSION AND EXCLUSION CRITERIA

A new case was the one whose notification presented the field “type of entry” as “new case” or “does not know”, in the period between January 1^st, 2007, and December 31^st, 2013. The exclusion criteria were:

STATISTICAL ANALYSIS

Linear regression models were used, according to similar studies,¹⁶16. Yamamura M, Santos Neto M, Freitas IM, Rodrigues LB, Popolin MP, Uchoa AS, et al. Tuberculose e iniquidade social em saúde: uma análise ecológica utilizando técnicas estatísticas multivariadas, São Paulo, Brasil. Pan American Journal of Public Health 2014; 35(4). [Internet]. Disponível em: Disponível em: http://iris.paho.org/xmlui/handle/123456789/8188 (Acessado em 29 de abril de 2016).
http://iris.paho.org/xmlui/handle/123456... ^,1717. Guimarães RM, Lobo AP, Siqueira EA, Borges TF, Melo SC. Tuberculose, HIV e pobreza: tendência temporal no Brasil, Américas e mundo. J Bras Pneumol 2012; 38(4): 511-7. DOI: 10.1590/S1806-37132012000400014
https://doi.org/10.1590/S1806-3713201200... adjusted for the mean of specific incidence rates, in the period of implementation of COMPERJ (2007 - 2013). Secondary data from the Municipal Secretariat and State Secretariat of Health were used, as well as information about geographic and socioeconomic conditions from the Brazilian Institute of Geography and Statistics (IBGE).

The methodological approach was based on:

The theme map of SVI used the digital database per census sector¹⁸18. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE). Geociências. IBGE 2016. [Internet]. Disponível em: Disponível em: http://downloads.ibge.gov.br/downloads_geociencias.htm (Acessado em 3 de junho de 2016).
http://downloads.ibge.gov.br/downloads_g... . Using geoprocessing techniques, the tool Dissolve, SIG ArcGIS, census sectors and the set of attributes were aggregated to create a cartographic base per neighborhood (unit of analysis). The data of the census sectors were transferred to the respective neighborhoods, being used as a reference both for analyses involving the cartographic base and those operating over socioeconomic and demographic elements.

Considering a probable variation in the age structure of the population, by an indirect method, the following were calculated: incidence rate of neighborhoods, adjusted by age, using the municipality’s rate as pattern. After the neighborhood stratification, according to social vulnerability, the cumulative incidence of the population in the middle of the period (census 2010) was calculated¹⁹19. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE). Censo Demográfico 2010. Indicadores Sociais Municipais - Uma análise dos resultados do universo do Censo Demográfico 2010. [Internet]. Disponível em: Disponível em: ftp://ftp.ibge.gov.br/Censos/Censo_Demografico_2010/Cadastro_Nacional_de_Enderecos_Fins_Estatisticos/ (Acessado em 25 de setembro de 2015).
ftp://ftp.ibge.gov.br/Censos/Censo_Demog... , examining the behavior of the rate and the stratum-relative risk.

SVI is the synthetic index of socioeconomic and demographic indicators per neighborhood. Like the Paulista Social Vulnerability Index (PSVI)²⁰20. Kaztman R. Seducidos y abandonados: el aislamiento social de los pobres urbanos. Rev Cepal 2001; 75: 171-189.^,2121. Ferreira MP, Dini NP, Ferreira SP. Espaços e dimensões da pobreza nos municípios do Estado de São Paulo: índice paulista de vulnerabilidade social - IPVS. São Paulo em Perspectiva 2006; 20(1): 5-17., the SVI identifies areas in accordance with gradients in vulnerability in the population. The components of SVI are identified in Table 1. In the statistical data approach, the factor analysis was used and defined the main components, generating two scores - socioeconomic factor and demographic factor -, employed as independent variables in the regression.

The factor analysis followed these conditions²²22. Figueiredo Filho DB, Silva Júnior JÁ. Visão além do alcance: uma introdução à análise fatorial. Opin Publica 2010; 16(1): 160-85. DOI: 10.1590/S0104-62762010000100007
https://doi.org/10.1590/S0104-6276201000... :

The Kaiser criterion (KMO) of the sample was 0.744, higher to the critical threshold of 0.600. The Bartlett’s test (BTS) was statistically significant (p < 0.000). The choice was to analyze the main components because of the facility to sum up the set of data. The declivity diagram was used to analyze the dispersion of factors (two were selected for the abrupt reduction in variance). The Varimax rotation tried to minimize the number of variables with high load in each factor.

The normality of continuous variables was assessed by the Kolmogorov-Smirnov test. Associations between independent variables and the mean incidence rate of TB were tested by simple and multiple linear regression. Explanatory variables that did not present collinearity, assessed by the VIF test (variance inflation factor) were introduced by the model and selected by the Backward Method. In the final phase, it was possible to observe the normality of the residuals using the Shapiro Wilk test (p > 0.05), and absence of heteroskedasticity.

Relative risk (RR) and confidence intervals were used to assess the relationship between the strata, according to vulnerability and incidence. Categorical variables were compared between the groups by the χ² test and the Fisher’s test. The significance level in the analyses was 5%. The data were analyzed with the Statistical Package for the Social Sciences (SPSS) 21.0.

The list of records used the software RecLink III²³23. Camargo Jr KR, Coeli CM. Reclink: aplicativo para o relacionamento de bases de dados, implementando o método probabilistic record linkage. Cad Saúde Pública 2000; 16(2): 439-47. DOI: 10.1590/S0102-311X2000000200014
https://doi.org/10.1590/S0102-311X200000... to carry out the probability method, based on the conjoined use of common fields of databases - for example, name, sex and date of birth -, in order to identify the probability that a pair of records is referring to the same person.

For the verification of deaths, all of those that had as a basic or associated cause the codes A15 - A19 (10th review of the International Classification of Diseases - ICD) were selected. Linkage was conducted in five steps, according to a specific blockage protocol²⁴24. Coeli CM, Camargo Jr KR. Avaliação de diferentes estratégias de blocagem no relacionamento probabilístico de registros. Rev Bras Epidemiol 2002; 5(2): 185-96. DOI: 10.1590/S1415-790X2002000200006
https://doi.org/10.1590/S1415-790X200200... .

For the environmental signature, there were thematic maps referring to the variables of SVI and rates of TB (density of points), in which each point corresponds to one case per one thousand inhabitants. SIG ArcGIS 10.0 was used to create vectorial thematic maps, then transformed in images, exported to SIG Vista Saga and georeferenced in the raster format; the extraction of the environmental signature was conducted by using the signature tool of the system. With the environmental signature, based on the socioeconomic and demographic variables, it was possible to identify in which strata the TB rate was most expressive²⁵25. Silva JX. Geoprocessamento para análise ambiental. Rio de Janeiro 2001; 1. [Internet]. Disponível em: Disponível em: http://www.viconsaga.com.br/lageop/ . (Acessado em 3 de junho de 2016).
http://www.viconsaga.com.br/lageop/... .

The use of an environmental signature occurred similarly to the spectral signature in remote sensing, given the possibility to identify objects because of the unique characteristics of the spectral responses of each target. Therefore, the configuration of the mean spectral behavior of a phenomenon will distinguish it from other objects²⁶26. Rosa AN, Sano EE, Souza EB, Baptista GM, Brites RS, Meneses PR, et al. Sensoriamento Remoto: Princípios. Brasília: UnB; 2012. [Internet]. Disponível em: Disponível em: http://www.cnpq.br/documents/10157/56b578c4-0fd5-4b9f-b82a-e9693e4f69d8 (Acessado em 28 de outubro de 2015).
http://www.cnpq.br/documents/10157/56b57... ^,2727. Silva JX. Sistema de Análise Geo-Ambiental. Análise Ambiental. Instituto de Geociências. Universidade Federal do Rio de Janeiro 2006. [Internet]. Disponível em: Disponível em: http://www.viconsaga.com.br/lageop/saga.php (Acessado em 27 de setembro de 2015).
http://www.viconsaga.com.br/lageop/saga.... .

The environmental signature looked for unique aspects of the incidence of TB in a SIG environment, using plans of georeferenced information, represented by socioeconomic and demographic variables of the SVI. It was possible to identify in which strata, represented by the scales of measurement of the different variables, the incidence was more representative. Being a heuristic procedure²⁵25. Silva JX. Geoprocessamento para análise ambiental. Rio de Janeiro 2001; 1. [Internet]. Disponível em: Disponível em: http://www.viconsaga.com.br/lageop/ . (Acessado em 3 de junho de 2016).
http://www.viconsaga.com.br/lageop/... based on empirical proof about the possible causal associations between the environmental variables, the use of this technique allows associations between the variables expressed in the different scales of measurement, both numeric and categorical.

The environmental signature assumes that the event of interest is a target or a ground truth, with territorial expression and specific socioeconomic characteristics. Therefore, a situation of health translates itself as a manifestation of the location²⁸28. Barcellos CC, Sabroza PC, Peiter P, Rojas LI. Organização espacial, saúde e qualidade de vida: análise espacial e uso de indicadores na avaliação de situações de saúde. Inf Epidemiol Sus 2002; 11(3): 129-30. DOI: 10.5123/S0104-16732002000300003
https://doi.org/10.5123/S0104-1673200200... .

The attributable risk (AR) and the population attributable risk (PAR) were chosen because the former measures the excess risk in the group exposed associated with exposure, whereas the latter is the measurement of the association influenced by the prevalence of the factor in the general population, measuring the percentage reduction of cases that can be prevented if the risk factor is removed. The AR in the total population is important because it allows knowing which percentage of the event will be reduced by efficient measures of prevention and control²⁹29. Schneider MC, Castillo-Salgado C, Bacallao J, Loyola E, Mujica OJ, Vidaurre M, et al. Métodos de mensuração das desigualdades em saúde. Rev Panan Salud Publica 2002; 12(6): 398-414. DOI: 10.1590/S1020-49892002001200006
https://doi.org/10.1590/S1020-4989200200... .

This project was approved by the Research Ethics Committee (CEP) at the National School of Public Health (ENSP) (process n. 682.428/2014).

RESULTS

In Table 1, KMO is observed and used in the analysis of the main components, with two factors: the first one with eigenvalue, of 4.17, and 46.37% of variance; and the second one with eigenvalue of 2.26, and 25% of the variance. These two factors explained 71.47% of the variability found among the original variables.

As to the number of cases, some authors²²22. Figueiredo Filho DB, Silva Júnior JÁ. Visão além do alcance: uma introdução à análise fatorial. Opin Publica 2010; 16(1): 160-85. DOI: 10.1590/S0104-62762010000100007
https://doi.org/10.1590/S0104-6276201000... suggest samples superior to 50 observations, or a ratio between the number of cases and the number of variables exceeding five to one. In this study, the number of neighborhoods accounted for 71 units, using nine variables in the factor analysis, leading to radio that exceeds seven cases to one.

According to the SVI classification, the number of categories was clustered in: low, mean, high and very high vulnerability (Figure 1), and that categorization identified the groups of neighborhoods in this study. The limits of each neighborhood were defined by the gray line. Some areas did not have enough information in the Census and were not included in the analysis, especially the North area in the COMPERJ.

The SINAN database had 1,182 cases, being 957 “new cases” of TB in all forms (pulmonary, extrapulmonary TB or both). Among the records, 14 had duplicity (double notification of a person in the same period of treatment), leaving 943 identified cases.

This study verified 79 death records, and only 25 (31.6%) of these were found in SINAN notifications. By adding the 54 deaths declared in SIM to the 943 cases of SINAN, there were 997 records. Of these, 159 were excluded (88 with ignored address and 71 with incomplete information about the address). Among the excluded records, most (28.4%) were aged from 30 to 39 years and were male (68.0%). The cumulative incidence rate of the city was 442.8 cases per 100 thousand inhabitants.

In multiple regression, the dependent variable was the mean incidence rate of TB. The independent variables were: socioeconomic factor; demographic factor; household density (five or more people per household); and ratio of sexes in cases of TB. After the confirmation by the Backward Method³⁰30. Zimmer J, Anzanello MJ. A new framework for predictive variable selection based on variable importance indices. Prod 2014; 24(1): 84-93. DOI: 10.1590/S0103-65132013005000030
https://doi.org/10.1590/S0103-6513201300... , two factors of the analysis of the main components remained (socioeconomic and demographic). The final equation was: [Incidence Rate of TB = 95.57 - 30.6 (socioeconomic) - 31.9 (demographic)].

The resulting model (Table 2) presented an adjusted coefficient of determination (R²) that explained 13.8% of the variability in the mean incidence rate of TB (R = 0.413 and adjusted R² = 0.138). There was an inverse correlation between the rate of TB and predictive variables: socioeconomic (ß = -30.6; p < 0.05) and demographic factor (ß = -31.9; p < 0.05). That is, the higher the socioeconomic level, the lower the incidence of TB in the period. And the higher the proportion of children and young women in the household, the lower the incidence. In the model, the mean incidence rate is equal to 95.57 (general mean), when predictive variables are equal to zero. For each increase of unit in the socioeconomic and demographic factors, there was a reduction of 30.6 and 31.9 points in the mean of the response variable.

In Table 3, neighborhoods with “high” and “very high” vulnerability were combined in a single category (high). The final configuration of neighborhoods by SIV was: neighborhoods of low (20); medium (31) and high vulnerability (20). As to new cases, the risk of TB was 33% lower (RR = 0.67) in neighborhoods with medium SVI (p < 0.001) in relation to the group with low SVI. For the percentage of cure, relative risk was 32% lower (RR = 0.68) in neighborhoods of medium vulnerability (p < 0.001), whereas in neighborhoods with high vulnerability, the risk (RR = 0.78) was 22% lower (p < 0.001). As to the percentage of abandonment there was twice as many risls (RR = 2.23) in the neighborhoods with high vulnerability (p < 0.05). The proportion of deaths showed risk almost twice as high (RR = 1.98) in neighborhoods with high vulnerability (p < 0.05) in comparison to those that are not exposed (low SVI).

There was no association for the percentage of HIV (Human Immunodeficiency Virus) among neighborhoods, but it is important to mention that almost half of the risk of the coinfection TB/HIV was found in neighborhoods of medium and high vulnerability (RR = 0.52 and RR = 0.57). As to the risk of multi-resistant TB (MRTB), there was no significant association between neighborhoods.

In the analysis of ARs (Table 3) the following stand out: lower population risk (18.5%) for new cases in neighborhoods with mean SVI; lower probability of attributable cure (AR = 22.9% and AR = 15.8%) to those exposed (medium and high SVI); percentage reduction of the number of healed cases in the population (PAR = 14.5 and 10.8%), with medium and high SVI; increasing percentage of abandonment in neighborhoods with high SVI (PAR = 37.8%); and increasing percentage of deaths in neighborhoods with high vulnerability (PAR = 32.5%). All statistics were obtained by the χ² test and by Fisher’s exact test³¹31. Sullivan KM, Dean A, Soe MM. OpenEpi: A web-based epidemiologic and statistical calculator for public health. Public Health Rep 2009; 124(3): 471-4. DOI: 10.1177/003335490912400320
https://doi.org/10.1177/0033354909124003... .

In Figure 2, the percentage of the main variables analyzed according to the environmental signature were verified (vulnerability map). The levels of aggregation of the variables, according with the incidence rate of TB, were defined by adapting the natural breaks method for the intervals.

It was observed that neighborhoods with the highest percentage of young women responsible for the household (17.30 - 37.72) had lower proportion of area including records of cases (4.21%). The neighborhoods with a higher number of people aged between 10 and 29 years (16.27 - 31.76) presented 7.38% of the area with record of cases. Neighborhoods with higher household income per capita (618.30 - 1,156,27) and higher mean income of the women in charge (1,339,08 - 2,263,58) had 8.55 and 9.44%, respectively, of an area with new cases (Figure 2).

DISCUSSION

The results of the analysis suggest an association between sociodemographic inequalities and the occurrence of TB in the population of Itaboraí. The estimations found indicate that the higher socioeconomic status and the higher proportion of children and young women in the households, the lower the incidence of TB in the period. There is a lower percentage of cure and higher percentage of abandonment and death in areas with more social vulnerability, with relative risk values twice as high as those in the lower vulnerability areas. The results also show social and spatial inequalities related with the incidence of TB, which corroborate findings in other studies¹⁴14. Pedro AS, Gibson G, Santos JP, Toledo LM, Sabroza PC, Oliveira RM. Tuberculosis as a marker of inequities in the context of socio-spatial transformation. Rev Saúde Pública 2017; 51: 9. DOI: 10.1590/s1518-8787.2017051006533
https://doi.org/10.1590/s1518-8787.20170... ^,3232. Oren E, Koepsell T, Leroux BG, Mayer J. Area-based socio-economic disadvantage and tuberculosis incidence. Int J Tuberc Lung Dis 2012; 16(7): 880-5. DOI: 10.5588/ijtld.11.0700
https://doi.org/10.5588/ijtld.11.0700... .

Important information about government income transfer programs available um other studies¹⁴14. Pedro AS, Gibson G, Santos JP, Toledo LM, Sabroza PC, Oliveira RM. Tuberculosis as a marker of inequities in the context of socio-spatial transformation. Rev Saúde Pública 2017; 51: 9. DOI: 10.1590/s1518-8787.2017051006533
https://doi.org/10.1590/s1518-8787.20170... , contributed with the outcomes of the analyses in this study.

The WHO points out that the main social determinants responsible for the occurrence of TB at a global level are social inequality, AIDS and the constant migration between regions³³33. World Health Organization (WHO). Global Tuberculosis Control 2011. WHO; 2011. [Internet]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/44728/1/9789241564380_eng.pdf (Acessado em 27 de setembro de 2015).
http://apps.who.int/iris/bitstream/10665... ^,3434. Lacerda SN, Temoteo RC, Figueiredo TM, Luna FD, Sousa MA, Abreu LC, et al. Individual and social vulnerabilities upon acquiring tuberculosis: a literature systematic review. Int Arch Med 2014; 7(1): 35. DOI: 10.1186/1755-7682-7-35
https://doi.org/10.1186/1755-7682-7-35... . It was possible to predict that areas with worse life conditions presented with higher number of cases of TB and diseases related with poverty. There was also prevalence of cases in adults and in the male sex, as reported in the global literature³⁵35. Nava-Aquilera E, Andersson N, Harris E, Mitchell S, Hamel C, Shea B, et al. Risk factors associated with recent transmission of tuberculosis: systematic review and meta-analysis. Int J Tuberc Lung Dis 2009; 13(1): 17-26..

However, some neighborhoods with low vulnerability showed high incidence rates of TB, even with adjustment by age. A possible explanation is that neighborhoods are not homogeneous clusters, with sectors in different socioeconomic conditions. Another possibility is the implementation of COMPERJ, which generated social change for the search of better life conditions, with migration of workers to central neighborhoods, due to the higher level of urbanization, access to services and health care.

A recent study³⁶36. Lafaiete RS, Silva CB, Oliveira MG, Motta MC, Villa TC. Investigação sobre o acesso ao tratamento de tuberculose em Itaboraí/RJ. Esc Anna Nery 2011; 15(1): 47-53. DOI: 10.1590/S1414-81452011000100007
https://doi.org/10.1590/S1414-8145201100... showed that 54% of the patients registered in the Tuberculosis Control Program (PCT) never received a household visit from the professional following up the treatment. Also, 62% of the individuals claimed they paid for transportation until the health unit, revealing problems in the provision of transportation. This information indicates that aspects related with the surveillance of the condition and the management of health services are determinant to understand the epidemiological picture.

There was no association between the percentage of new cases of positive TB and HIV, however, the estimations found in neighborhoods of medium and high vulnerability represent about half the risk of coinfection. These findings are in accordance with those in other studies, which suggest there is discrimination when seropositivity is diagnosed, inducing the patient to look for access and treatment in health units that are further from the household³⁷37. Pereira PP, Monteiro S, Villela W. Estigma e Saúde. Editora Fiocruz 2013. Ciênc Saúde Coletiva 2015; 20(4): 1307-8. DOI: 10.1590/1413-81232015204.00092014
https://doi.org/10.1590/1413-81232015204... ^,3838. Monteiro S, Villela WV, Knauth D. Discrimination, stigma, and AIDS: a review of academic literature produced in Brazil (2005 - 2010). Cad Saúde Pública 2012; 28(1): 170-6. DOI: 10.1590/S0102-311X2012000100018
https://doi.org/10.1590/S0102-311X201200... .

Differences regarding the access and the stigma coming from the HIV infection are probable sources of bias in epidemiological analyses, because the notification depends on the proper investigation of the case. Also, the reception of these patients should consider precarious social conditions and the emotional impact generated by the TB/HIV comorbidity, usually greater than that experienced by TB individually³⁹39. Santos Neto M, Silva FL, Sousa KR, Yamamura M, Popolin MP, Arcêncio RA. Perfil clínico e epidemiológico e prevalência da coinfecção tuberculose/HIV em uma regional de saúde no Maranhão. J Bras Pneumol 2012; 38(6): 724-32. DOI: 10.1590/S1806-37132012000600007
https://doi.org/10.1590/S1806-3713201200... .

Regarding the deaths by TB, the highest relative risk in the neighborhoods with high vulnerability highlights the importance of the epidemiological surveillance in the interruption of the chain of transmission⁴⁰40. Selig L, Kritski AL, Cascão AM, Braga JU, Trajman A, Carvalho RM. Proposta de vigilância de óbitos por tuberculose em sistemas de informação. Rev Saúde Pública 2010; 44(6): 1072-8. DOI: 10.1590/S0034-89102010000600012
https://doi.org/10.1590/S0034-8910201000... . Of the total of deaths, only 31.6% were notified in SINAN. That is, 68.4% were unknown by the PCT, and supposedly none of the contacts was assessed.

SIG allows the recovery of the location based on the selection of a piece of information, and vice-versa. This ability can be used to identify cases coming from primary or secondary data, allowing the elaboration of environmental signatures. Once the occurrence of interest is defined - probable association between sociodemographic determinants and occurrence of TB -, the database can be consulted regarding the important characteristics of the target-area, defining its signature, recognizing the area of occurrence and the coverage of georeferenced information plans²⁵25. Silva JX. Geoprocessamento para análise ambiental. Rio de Janeiro 2001; 1. [Internet]. Disponível em: Disponível em: http://www.viconsaga.com.br/lageop/ . (Acessado em 3 de junho de 2016).
http://www.viconsaga.com.br/lageop/... .

The technique of environmental signature is different from multivariate analyses and SVI, since it is associated with the georeferenced data base (matricial structure) and because it can operate and identify attributes/topology, expressed in different scales (ratio, interval, ordinal, nominal). The technique enables the transit between different information plans at the location of the event, identifying its singularities.

The data of the environmental signature corroborate findings in several scientific studies¹⁶16. Yamamura M, Santos Neto M, Freitas IM, Rodrigues LB, Popolin MP, Uchoa AS, et al. Tuberculose e iniquidade social em saúde: uma análise ecológica utilizando técnicas estatísticas multivariadas, São Paulo, Brasil. Pan American Journal of Public Health 2014; 35(4). [Internet]. Disponível em: Disponível em: http://iris.paho.org/xmlui/handle/123456789/8188 (Acessado em 29 de abril de 2016).
http://iris.paho.org/xmlui/handle/123456... , in which the variables related with gender (male), age group (25 - 49 years), lower income and schooling were associated with TB significantly, revealing inequality in the access to information and higher exposure of the male population.

An important limitation of the study refers to the adjustment by age. Adjustment by gender would also help correct possible biases related with the different strata. The gender ratio was used for cases of TB in the linear regression to overcome this limitation.

To use clustered data, ecological studies are limited by secondary sources, for example, quality control restriction and discrepancy of data coming from information systems. The lack of information from the municipality of origin in SINAN, SITETB and SIM also prevent deeper analyses about migration. In other investigations¹¹11. Pinheiro RS, Andrade VL, Oliveira GP. Subnotificação da tuberculose no Sistema de Informação de Agravos de Notificação (SINAN): abandono primário de bacilíferos e captação de casos em outras fontes de informação usando linkage probabilístico. Cad Saúde Pública 2012; 28(8): 1559-68. DOI: 10.1590/S0102-311X2012000800014
https://doi.org/10.1590/S0102-311X201200... ^,4141. Bartholomay P, Oliveira GP, Pinheiro RS, Vasconcelos AM. Melhoria da qualidade das informações sobre tuberculose a partir do relacionamento entre bases de dados. Cad Saúde Pública 2014; 30(11): 2459-70. DOI: 10.1590/0102-311X00116313
https://doi.org/10.1590/0102-311X0011631... , the collection of complementary data in the TB Record Book and in the Laboratory Record Book contributed with monitoring and the feedback of systems.

By using AR and PAR, this study tried to measure the percentage of cases that could be prevented if the causal factor were neutralized, being an important measure to implement public health policies⁴²42. Denholm J, Trauer J, McBryde E. Smoking and tuberculosis risk: high attributable risk in a low-incidence environment. Glob J Epidemiol Public Health 2016; 2(1): 15-17. DOI: 10.12974/2313-0946.2015.02.01.2
https://doi.org/10.12974/2313-0946.2015.... .

CONCLUSION

The study demonstrated strong evidence that the influence of unequal sociodemographic conditions tends to produce pernicious effects on the health conditions of the population in Itaboraí. The conclusion is that the control and reduction of inequalities in the occurrence of TB are based on the need to search for more knowledge about its determinants and use of new investigation strategies.

References

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