ABSTRACT:

Introduction:

The burden of tuberculosis has been scarcely explored in developing countries.

Objective:

To estimate the trend of the burden of tuberculosis in the state of Santa Catarina, southern Brazil, from 2007 to 2011.

Methods:

Epidemiological time-series study on tuberculosis notifications and deaths reported in the Disease Notification System and the Mortality Information System between 2007 and 2011. Crude rates of Disability-Adjusted Life Years (DALY) and subcomponents were calculated and standardized by gender and age groups. Segmented linear regression was used to estimate the trends for burden of tuberculosis during the study period.

Results:

There were 696 deaths and 8,598 notifications during the study period. The highest rate was found in 2009, with 91.8 DALY/100,000 inhabitants, and the lowest in 2007, with 67.2 DALY/100,000 inhabitants. The highest burden was among men in economically active age groups. The study showed a non-significant increase of 3.8% per year in DALY rates.

Conclusion:

The burden of tuberculosis remained stable in Santa Catarina, Brazil between 2007 and 2011.

Keywords:
Tuberculosis; Burden of disease; Epidemiology; Mortality; Morbidity; Impact

RESUMO:

Introdução:

A carga da tuberculose vem sendo pouco estudada nos países em desenvolvimento.

Objetivo:

Estimar a tendência da carga da tuberculose no estado de Santa Catarina no período de 2007 a 2011.

Métodos:

Estudo epidemiológico de séries temporais realizado com base em dados de óbitos e notificações por tuberculose reportadas no Sistema de Informação de Mortalidade e no Sistema de Informação de Agravos de Notificação dos residentes no estado de Santa Catarina entre 2007 e 2011. Taxas brutas de anos de vida perdidos ajustados por incapacidade (DALY) e seus subcomponentes foram calculadas e posteriormente padronizadas segundo sexo e faixas etárias. Foi feita análise de regressão linear segmentada para estimar a tendência da carga no período estudado.

Resultados:

Foram observados 696 óbitos e 8.598 notificações de tuberculose nos anos em estudo. A maior taxa deu-se no ano de 2009, com 91,8 DALY/100 mil habitantes, e a menor, no ano de 2007, com 67,2 DALY/100 mil habitantes. Maior carga de tuberculose foi verificada no sexo masculino e em faixas etárias economicamente ativas. Encontrou-se aumento não significativo de 3,8% ao ano nas taxas de DALY no estado no período estudado.

Conclusão:

A carga da tuberculose manteve-se estável em Santa Catarina entre 2007 e 2011.

Palavras-chave:
Tuberculose; Carga da doença; Epidemiologia; Mortalidade; Morbidade; Ambiente

INTRODUCTION

Tuberculosis affects all age groups, but predominantly men in economically active age groups¹1. World Health Organization. Incidence data by World Bank income groups (all years) [Internet]. [cited 17 Oct. 2015]. Available from: http://apps.who.int/gho/data/view.main.57038ALL?lang=en
http://apps.who.int/gho/data/view.main.5... . In 2011, out of 8.7 million who fell ill with tuberculosis, 1.4 million people died worldwide¹1. World Health Organization. Incidence data by World Bank income groups (all years) [Internet]. [cited 17 Oct. 2015]. Available from: http://apps.who.int/gho/data/view.main.57038ALL?lang=en
http://apps.who.int/gho/data/view.main.5... . A study published recently, however, has described the reduction in incidence, prevalence, and mortality rates of tuberculosis in Brazil, the Americas, and worldwide over a period of 20 years. The results showed that mortality was reduced by 70.8, 70.7, and 40.0%, respectively²2. Guimarães RM, Lobo AP, Siqueira EA, Borges TFF, Melo SCC. Tuberculosis, HIV, and poverty: temporal trends in Brazil, the Americas, and worldwide. J Bras Pneumol. 2012;38(4):511-7. http://dx.doi.org/10.1590/S1806-37132012000400014
http://dx.doi.org/10.1590/S1806-37132012... .

According to data from 2010, Brazil ranks 17 among 22 countries with the highest incidence of tuberculosis¹1. World Health Organization. Incidence data by World Bank income groups (all years) [Internet]. [cited 17 Oct. 2015]. Available from: http://apps.who.int/gho/data/view.main.57038ALL?lang=en
http://apps.who.int/gho/data/view.main.5... . In the state of Santa Catarina, there were 1,700 new cases that year, and the capital city of Florianópolis held the largest number³3. Santa Catarina. Diretoria de Vigilância Epidemiológica. Secretaria de Estado da Saúde. Programa estadual de controle de tuberculose [Internet]. [cited 4 Nov. 2015]. Available from: http://www.dive.sc.gov.br/conteudos/agravos/publicacoes/Tuberculose_SC.pdf
http://www.dive.sc.gov.br/conteudos/agra... . According to the Brazilian Ministry of Health, tuberculosis mortality rates decreased by 31% in the country between 1990 and 2006⁴4. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Guia de vigilância epidemiológica: Caderno 7. Brasília: Ministério de Saúde; 2009.. Another study conducted in 2012 also showed a mortality rate reduction in the state of Santa Catarina from 2002 to 2009⁵5. Traebert J, Ferrer GCN, Nazário NO, Schneider IJC, Silva RM. Temporal trends in tuberculosis-related morbidity and mortality in the state of Santa Catarina, Brazil, between 2002 and 2009. J Bras Pneumol. 2012;38(6):771-5..

Moreover, the major challenge for public health services around the world is to consider not only mortality, but also disability caused by a disease. A proposal that takes into account both mortality and disability is the notion of disease burden of developed by Murray and López⁶6. Murray CJL, López AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard University Press: Cambridge; 1996.. The concept reflects the impact of mortality and health problems that affect quality of life of individuals, which can be measured using the indicator Disability-Adjusted Life Years (DALY)⁶6. Murray CJL, López AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard University Press: Cambridge; 1996..

According to the 2010 Global Burden of Disease Study (GBD)⁷7. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 219 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-223. https://doi.org/10.1016/S0140-6736(12)61689-4
https://doi.org/10.1016/S0140-6736(12)61... the main changes from 1990 to 2010 were reductions in components related to infectious diseases mainly in children, and increased rates of HIV/AIDS and tuberculosis. Tuberculosis proved to be a major cause of DALY among men aged 15-39 years. However, the burden of tuberculosis had a 37.9% drop in 2010 as compared to 1990; nonetheless, there was an increase of 250.5% in burden of tuberculosis/HIV co-infection over the same period⁷7. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 219 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-223. https://doi.org/10.1016/S0140-6736(12)61689-4
https://doi.org/10.1016/S0140-6736(12)61... .

The epidemiology of tuberculosis has been analyzed by different methods in order to provide better understanding of its behavior. However, epidemiological studies that estimate its burden are scarce, especially in developing countries such as Brazil. In addition to the studies developed by the Brazilian National School of Public Health for Brazil⁸8. Escola Nacional de Saúde Pública. Fundação Oswaldo Cruz. Projeto Carga de Doença: relatório final do projeto estimativa da carga de doença do Brasil-1998. FIOCRUZ: Rio de Janeiro; 2002. and for the state of Minas Gerais⁹9. Escola Nacional de Saúde Pública. Fundação Oswaldo Cruz. Relatório Final: carga global de doença do Estado de Minas Gerais, 2005. FIOCRUZ: Rio de Janeiro; 2011., no other studies with the same methodology were found, particularly regarding tuberculosis. An exception to this is the study by Ferrer et al.¹⁰10. Ferrer GC, Silva RM, Ferrer KT, Traebert J. The burden of disease due to tuberculosis in the state of Santa Catarina, Brazil. J Bras Pneumol. 2014;40(1):61-8. http://dx.doi.org/10.1590/S1806-37132014000100009
http://dx.doi.org/10.1590/S1806-37132014... , which has estimated the burden of tuberculosis in the state of Santa Catarina in 2009. However, there are no studies assessing temporal trends at national or regional level.

The objective of this study was to estimate burden of tuberculosis trends in the state of Santa Catarina over 2007-2011.

METHODS

Epidemiological time-series study on tuberculosis notification data and death registrations for residents of Santa Catarina state from 2007 to 2011. Data were collected records of individuals diagnosed with pulmonary and extrapulmonary tuberculosis (ICD-10 A15 to A19) from the Information System for Notifiable Diseases (Sinan) and deaths caused by the disease, from the Mortality Information System (SIM/SUS). Intercensal estimates of total population released by the Brazilian Institute of Geography and Statistics (IBGE) for the years 2007, 2008, 2009, and 2011, as well as data from the 2010 census were used to calculate rates.

DALY were estimated by summing the subcomponents YLL (Years of Life Lost) and YLD (Years Lived with Disability)⁶6. Murray CJL, López AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Harvard University Press: Cambridge; 1996.^,77. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 219 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-223. https://doi.org/10.1016/S0140-6736(12)61689-4
https://doi.org/10.1016/S0140-6736(12)61... ^,99. Escola Nacional de Saúde Pública. Fundação Oswaldo Cruz. Relatório Final: carga global de doença do Estado de Minas Gerais, 2005. FIOCRUZ: Rio de Janeiro; 2011.. YLL for each case of death were calculated by the difference between the age at which death occurred and life expectancy, standardized at 80 years for men and 86 for women¹¹11. Wang H, Dwyer-Lindgren L, Lofgren KT, Rajaratnam JK, Marcus JR, Levin-Rector A, et al. Age-specific and sex-specific mortality in 187 countries, 1970-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2071-94. https://doi.org/10.1016/S0140-6736(12)61719-X
https://doi.org/10.1016/S0140-6736(12)61... ^,1212. Salomon JA, Wang H, Freeman M, Vos T, Flaxman AD, Lopez AD, et al. Healthy expectancy 187 countries, 1990-2010: a systematic analysis for the Global Burden Disease Study 2010. Lancet. 2012;380:2144-62. https://doi.org/10.1016/S0140-6736(12)61690-0
https://doi.org/10.1016/S0140-6736(12)61... . YLD were calculated as the product of disease burden predefined by the GBD 2010 (0.331 for tuberculosis and 0.399 for tuberculosis/HIV coinfection)¹³13. Salomon JA, Vos T, Hogan DR, Gagnon M, Naghavi M, Mokdad A, et al. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet. 2012;380:2129-43. https://doi.org/10.1016/S0140-6736(12)61680-8
https://doi.org/10.1016/S0140-6736(12)61... and its duration, based on cases reported. Duration of disease was the same as reported by the Brazilian Global Burden of Disease Study⁸8. Escola Nacional de Saúde Pública. Fundação Oswaldo Cruz. Projeto Carga de Doença: relatório final do projeto estimativa da carga de doença do Brasil-1998. FIOCRUZ: Rio de Janeiro; 2002., i.e., one year for tuberculosis/HIV and 1.5 year for tuberculosis not associated with HIV infection.

After calculation of absolute numbers, crude rates by gender and age groups were calculated by the ratio between each indicator and the estimated population on July 1^st in each year of the series, per 100,000 inhabitants. Then, crude rates were age-standardized by direct method, the world’s population being used as standard¹⁴14. Brasil. Ministério da Saúde. Instituto Nacional do Câncer. Câncer no Brasil: dados dos registros de base populacional [Internet]. [cited 4 Nov. 2015]. Available from: http://www.inca.gov.br/regpop/2003/index.asp?link=conteudo_view.asp&ID=12
http://www.inca.gov.br/regpop/2003/index... .

The standardized rates of YLL, YLD, and DALY were used to analyze the burden of tuberculosis trend in the state of Santa Catarina as a whole and by age groups, through estimated regression equations. For modeling purposes, standard rates of YLL, YLD, and DALY by age group (y) were considered as dependent variables, and the years comprised in the study period as the independent variables (x).

The Joinpoint software, version 4.1.1.5 (Statistical Research and Applications Branch, National Cancer Institute, United States of America), provided by the North-American National Cancer Institute, was used to calculate the annual rate variations from 2007 to 2011. The software executes a segmented linear regression (jointpoint regression) to estimate annual percent change and identify the points at which there is a trend modification. Models were successively adjusted, each time a different number of trend change “points” being assumed. The model chosen had the highest number of points in which the statistical significance (p < 0.05) was maintained. The annual percent change (APC) was calculated from the estimated slope for each line segment (regression coefficient). Statistical significance was estimated by the method of least squares in a generalized linear model, assuming that the rates followed a Poisson distribution and that variations in rates were not constant over the period. For each line segment with estimated slope, 95% confidence intervals (95%CI) were calculated.

Following the Resolution by the Brazilian National Health Council (CNS 466/12), the principles of autonomy, beneficence, non-maleficence, justice, and equity were preserved. This study analyzed secondary non-nominal data of public access, presented on a consolidated basis, with no possibility of harming individuals or institutions. Furthermore, the study was approved by the Research Ethics Committee of Universidade do Sul de Santa Catarina (Committee Opinion No. 474110).

RESULTS

The year 2009 was shown to have the highest number of deaths (n = 161) and notifications (n = 1,701), as well as crude DALY rates (106.5 DALY/100,000 inhabitants).

YLL rates were higher among men in all years of study. The highest rate was that of 2009 (108.1 YLL/100,000 male inhabitants) and the lowest in 2007 (74.1 YLL/100,000 male inhabitants), as shown in Table 1. Age groups 40-44 and 35-39 had the highest YLL rates (Table 1).

YLD rates were higher among men in all years of study. The uppermost rate was in 2011 (16.9 YLD/100,000 male inhabitants), and the lowest in 2007 (15.1 YLD/100,000 male inhabitants), as shown in Table 2. The 15-29 age range had the highest YLD rates in most years of the study period, except for 2011, in which both the 25-29 and 30-34 age groups had the highest YLD rates (1.4 YLD/ 100,000 inhabitants), as Table 2 also displays.

DALY rates were higher among men in all years of study. The highest rate was from 2011 (116.3 DALY/100,000 male inhabitants), and the lowest in 2009 (81.5 DALY/100,000 male inhabitants), as presented in Table 3. The 40-45 age group had the highest DALY rates (18.2 DALY/100,000 inhabitants), as shown also in Table 3.

The results of time-series studies are shown in Table 4. A non-significant increase of 4.5% per year (95%CI -9.0 - 20.0) in the YLL rates can be seen for the state of Santa Catarina during the study period. No statistically significant changes in YLL rates were observed between age groups for the years comprised in the research. There was also a non-significant decline of 0.2% per year (95%CI -3.6 - 3.4) in YLD rates. No statistically significant changes in YLD rates were observed throughout the study period. A non-significant increase of 3.8% per year (95%CI -7.4 - 16.4) in DALY rates was also pointed out. No statistically significant changes were observed in DALY rates when comparing age groups over the period of study. The overall behavior of YLL, YLD and DALY standardized rates by gender are displayed in Figure 1.

DISCUSSION

Although the epidemiology of tuberculosis has been assessed by different methodologies, there are few studies in Brazil measuring the burden generated by the disease. Furthermore, no other known study has assessed the temporal behavior of DALY rates in Brazil. This study may contribute to better understanding the behavior of tuberculosis effects in the southern state of Santa Catarina, in terms of early mortality and disability.

The highest DALY rate was observed in 2009 (91.8 DALY/100,000 inhabitants) and the lowest in 2007 (67.2 DALYs/100,000 inhabitants). According to the GBD (2010), tuberculosis ranked 11 among the leading causes of premature death and generated a rate of 11.2 YLL/100,000 inhabitants¹⁵15. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2095-128. https://doi.org/10.1016/S0140-6736(12)61728-0
https://doi.org/10.1016/S0140-6736(12)61... . The disease accounted for 98 YLD/100,000 inhabitants¹⁶16. Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzati M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2163-96. https://doi.org/10.1016/S0140-6736(12)61729-2
https://doi.org/10.1016/S0140-6736(12)61... . Therefore, tuberculosis accounted for 2% of total DALY in 2010⁹9. Escola Nacional de Saúde Pública. Fundação Oswaldo Cruz. Relatório Final: carga global de doença do Estado de Minas Gerais, 2005. FIOCRUZ: Rio de Janeiro; 2011.. In Arab countries, the number of DALY increased over the years from 105,415 in 1990 to 112,053 in 2010¹⁷17. Mokdad AH, Jaber S, Aziz MIA, AlBuhairan F, AlGhaithi A, AlHamad NM, et al. The state of health in the Arab word, 1990-2010: an Analysis of the burden of diseases, injuries, and risk factors. Lancet. 2014;383(9914):309-20. https://doi.org/10.1016/S0140-6736(13)62189-3
https://doi.org/10.1016/S0140-6736(13)62... .

Within 1992-2002, the burden of tuberculosis in Serbia generated the following rates: 0.094 YLD/1,000 inhabitants, 0.864 YLL/1,000 inhabitants, and 0.958 DALY/1,000 inhabitants¹⁸18. Gledovic Z, Vlajinac H, Perkmezovic T, Sipetic SG, Grgurevic A, Pesut D, et al. Burden of tuberculosis in Serbia. Am J Infect Control. 2006;34(10):676-9. https://doi.org/10.1016/j.ajic.2006.03.013
https://doi.org/10.1016/j.ajic.2006.03.0... . In Thailand, tuberculosis accounted for 1.4% of overall DALY in 2009¹⁹19. Aungkulanon S, Kusreesakul K, Kunnathum J, Bundhamcharoen. Decreasing the burden of infectious disease in Thailand. Lancet. 2013;381. https://doi.org/10.1016/S0140-6736(13)61265-9
https://doi.org/10.1016/S0140-6736(13)61... . In Mexico, tuberculosis ranked 18 among the causes of premature death in 1990 (1.2% of total YLL), and 26 in 2010²⁰20. Lozano R, Dantés HG, Latorre FG, Corona AJ, Rincón JCC, Marina FF, et al. La carga de enfermedad, lesiones, factores de riesgo y desafíos para el sistema de salud em México. Salud Publica Méx. 2013;55(6):580-94. http://dx.doi.org/10.21149/spm.v55i6.7304
http://dx.doi.org/10.21149/spm.v55i6.730... , which represents a significant drop in the ranking of burden-generating causes. In 2009, a study also conducted in the state of Santa Catarina reported a rate of 92.25 DALY/100,000 inhabitants¹⁰10. Ferrer GC, Silva RM, Ferrer KT, Traebert J. The burden of disease due to tuberculosis in the state of Santa Catarina, Brazil. J Bras Pneumol. 2014;40(1):61-8. http://dx.doi.org/10.1590/S1806-37132014000100009
http://dx.doi.org/10.1590/S1806-37132014... . The findings of our study are, for the most part, lower to those reported by other authors. It should be noted that burden rates found by other authors differ from ours due to different methods used.

As it was expected, the burden of tuberculosis in Santa Catarina was higher among men than among women, which agrees with previously published epidemiological studies⁷7. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 219 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-223. https://doi.org/10.1016/S0140-6736(12)61689-4
https://doi.org/10.1016/S0140-6736(12)61... ^,1010. Ferrer GC, Silva RM, Ferrer KT, Traebert J. The burden of disease due to tuberculosis in the state of Santa Catarina, Brazil. J Bras Pneumol. 2014;40(1):61-8. http://dx.doi.org/10.1590/S1806-37132014000100009
http://dx.doi.org/10.1590/S1806-37132014... ^,2020. Lozano R, Dantés HG, Latorre FG, Corona AJ, Rincón JCC, Marina FF, et al. La carga de enfermedad, lesiones, factores de riesgo y desafíos para el sistema de salud em México. Salud Publica Méx. 2013;55(6):580-94. http://dx.doi.org/10.21149/spm.v55i6.7304
http://dx.doi.org/10.21149/spm.v55i6.730... . Mexico experienced a 56% incidence of tuberculosis among men in 1990-2010²⁰20. Lozano R, Dantés HG, Latorre FG, Corona AJ, Rincón JCC, Marina FF, et al. La carga de enfermedad, lesiones, factores de riesgo y desafíos para el sistema de salud em México. Salud Publica Méx. 2013;55(6):580-94. http://dx.doi.org/10.21149/spm.v55i6.7304
http://dx.doi.org/10.21149/spm.v55i6.730... , whereas in the Brazilian state of Minas Gerais, the rate was even higher (60.6%)⁹9. Escola Nacional de Saúde Pública. Fundação Oswaldo Cruz. Relatório Final: carga global de doença do Estado de Minas Gerais, 2005. FIOCRUZ: Rio de Janeiro; 2011.. In Serbia, the incidence rate was 72.7% among men in 1992-2002¹⁸18. Gledovic Z, Vlajinac H, Perkmezovic T, Sipetic SG, Grgurevic A, Pesut D, et al. Burden of tuberculosis in Serbia. Am J Infect Control. 2006;34(10):676-9. https://doi.org/10.1016/j.ajic.2006.03.013
https://doi.org/10.1016/j.ajic.2006.03.0... .

It is worth noting that, in developing countries, 80% of people with tuberculosis are in the 15-59-year range²¹21. Chirinos NEC, Meirelles BHS. Fatores associados ao abandono do tratamento da tuberculose: uma revisão integrativa. Texto Contexto Enferm. 2011;20(3):599-406., most of them being men framed in the economically active population, has and so there is a negative impact on economic growth and social development, generating poverty and social exclusion²¹21. Chirinos NEC, Meirelles BHS. Fatores associados ao abandono do tratamento da tuberculose: uma revisão integrativa. Texto Contexto Enferm. 2011;20(3):599-406.. According to a study conducted in Santa Catarina, the age range 30-44 was most affected¹⁰10. Ferrer GC, Silva RM, Ferrer KT, Traebert J. The burden of disease due to tuberculosis in the state of Santa Catarina, Brazil. J Bras Pneumol. 2014;40(1):61-8. http://dx.doi.org/10.1590/S1806-37132014000100009
http://dx.doi.org/10.1590/S1806-37132014... , whereas GBD 2010 reported the age group 15-49 years as the most affected⁷7. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 219 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-223. https://doi.org/10.1016/S0140-6736(12)61689-4
https://doi.org/10.1016/S0140-6736(12)61... . In the Arab world, people mostly affected were aged 30-39 years¹⁷17. Mokdad AH, Jaber S, Aziz MIA, AlBuhairan F, AlGhaithi A, AlHamad NM, et al. The state of health in the Arab word, 1990-2010: an Analysis of the burden of diseases, injuries, and risk factors. Lancet. 2014;383(9914):309-20. https://doi.org/10.1016/S0140-6736(13)62189-3
https://doi.org/10.1016/S0140-6736(13)62... , and in Thailand, 30-59 years²¹21. Chirinos NEC, Meirelles BHS. Fatores associados ao abandono do tratamento da tuberculose: uma revisão integrativa. Texto Contexto Enferm. 2011;20(3):599-406.. In this study, the most affected group was composed of people aged 30-44 years, giving support to the findings of Ferrer et al.¹⁰10. Ferrer GC, Silva RM, Ferrer KT, Traebert J. The burden of disease due to tuberculosis in the state of Santa Catarina, Brazil. J Bras Pneumol. 2014;40(1):61-8. http://dx.doi.org/10.1590/S1806-37132014000100009
http://dx.doi.org/10.1590/S1806-37132014... .

Trends in the burden of tuberculosis were stable, given that no statistically significant differences were found, which is in line with a study conducted in Thailand¹⁹19. Aungkulanon S, Kusreesakul K, Kunnathum J, Bundhamcharoen. Decreasing the burden of infectious disease in Thailand. Lancet. 2013;381. https://doi.org/10.1016/S0140-6736(13)61265-9
https://doi.org/10.1016/S0140-6736(13)61... and GDB estimates for 1990-2020²²22. Murray CJT, Lopez AD. Alternative projections of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet. 1997;349:1498-504. https://doi.org/10.1016/S0140-6736(96)07492-2
https://doi.org/10.1016/S0140-6736(96)07... . Another study conducted in Santa Catarina on mortality analysis between 2002 and 2009 showed two distinct trends: first, a reduction by 5.9% in mortality rate per year, between 2002-2007, and second, a non-significant increase by 2% annually, between 2007-2009⁵5. Traebert J, Ferrer GCN, Nazário NO, Schneider IJC, Silva RM. Temporal trends in tuberculosis-related morbidity and mortality in the state of Santa Catarina, Brazil, between 2002 and 2009. J Bras Pneumol. 2012;38(6):771-5..

Increased rates of HIV/AIDS and tuberculosis were noted⁷7. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 219 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2197-223. https://doi.org/10.1016/S0140-6736(12)61689-4
https://doi.org/10.1016/S0140-6736(12)61... . In a spatial analysis in Brazil, high incidence of co-infections was reported in southern and southeastern coastal areas²³23. Rodrigues-Júnior AL, Ruffino-Netto A, Castilho EA. Distribuição espacial do índice de desenvolvimento humano, da infecção pelo HIV e da comorbidade AIDS-tuberculose: Brasil, 1982 - 2007. Rev Bras Epidemiol. 2014;17(Suppl. 2):204-15. http://dx.doi.org/10.1590/1809-4503201400060017
http://dx.doi.org/10.1590/1809-450320140... . In Santa Catarina, there was an increase in the number of cases until 2001, followed by a reduction. However, the authors²³23. Rodrigues-Júnior AL, Ruffino-Netto A, Castilho EA. Distribuição espacial do índice de desenvolvimento humano, da infecção pelo HIV e da comorbidade AIDS-tuberculose: Brasil, 1982 - 2007. Rev Bras Epidemiol. 2014;17(Suppl. 2):204-15. http://dx.doi.org/10.1590/1809-4503201400060017
http://dx.doi.org/10.1590/1809-450320140... emphasize that this should not be seen as a control of the opportunistic disease, but as lack of follow-up of patients infected by HIV. This factor may contribute to the non-reduction in the burden of tuberculosis.

One of the factors that may have interfered with incidence and mortality rates of tuberculosis was the implementation of the so-called Directly Observed Treatment in Brazil. This model is essential for the control of tuberculosis. It aims at increasing patient compliance and cure, detecting sources of infection, standardizing treatment, and monitoring disease progress⁴4. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Guia de vigilância epidemiológica: Caderno 7. Brasília: Ministério de Saúde; 2009.. In addition, the Brazilian National Program for Tuberculosis Control and Monitoring Visits²⁴24. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Programa Nacional de Controle da Tuberculose [Internet]. [cited 12 Mar. 2015]. Available from: http://dive.sc.gov.br/conteudos/publicacoes/APRES_PADRAO_MAI_2017_REDUZIDA.pdf
http://dive.sc.gov.br/conteudos/publicac... may be contributing to tuberculosis control through improved access of vulnerable populations to prevention, diagnosis, and treatment²⁴24. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Programa Nacional de Controle da Tuberculose [Internet]. [cited 12 Mar. 2015]. Available from: http://dive.sc.gov.br/conteudos/publicacoes/APRES_PADRAO_MAI_2017_REDUZIDA.pdf
http://dive.sc.gov.br/conteudos/publicac... .

Tuberculosis is a social problem, and most patients have poor education. Although treatment is available in the public health system, there are still some barriers, for example, poor access to transportation to health facilities and lost workdays²⁵25. Figueiredo TMRM, Villa TCS, Scatena LM, Gonzales RIC, Ruffino-Netto A, Nogueira JA, et al. Performance of primary healthcare services in tuberculosis control. Rev Saúde Pública. 2009;43(5):825-31. http://dx.doi.org/10.1590/S0034-89102009005000054
http://dx.doi.org/10.1590/S0034-89102009... ^,2626. Scatena LM, Villa TCS, Ruffino Netto A, Kritski AL, Figueiredo TMRM, Vendramini SHF, et al. Difficulties in the accessibility to health services for tuberculosis diagnoses in Brazilian municipalities. Rev Saúde Pública. 2009;43(3):389-97. http://dx.doi.org/10.1590/S0034-89102009005000022
http://dx.doi.org/10.1590/S0034-89102009... . In addition, adherence to the incorporation of Directly Observed Treatment approach by primary care professionals is low (named in Brazil as “Family Health Strategy”)²⁷27. Souza MSPL, Aquino R, Pereira SM, Costa MCN, Barreto ML, Natividade M, et al. Fatores associados ao acesso geográfico aos serviços de saúde por pessoas com tuberculose em três capitais do Nordeste brasileiro. Cad Saúde Pública. 2015;31(1):111-20. http://dx.doi.org/10.1590/0102-311X00000414
http://dx.doi.org/10.1590/0102-311X00000... ^,2828. Arakawa T, Arcêncio RA, Scatolin BE, Scatena LM, Ruffino-Netto A, Villa TCS. Accessibility to tuberculosis treatment: assessment of health service performance. Rev Latino-Am Enfermagem. 2011;19(4):1994-2002. http://dx.doi.org/10.1590/S0104-11692011000400019
http://dx.doi.org/10.1590/S0104-11692011... . In Santa Catarina, only 66.9% of the new cases identified were accompanied by the Directly Observed Treatment approach²⁹29. Santa Catarina. Secretaria do Estado da Saúde. DIVE: Informativo Epidemiológico, tuberculose no estado de Santa Catarina, 2011 [Internet]. Santa Catarina: Secretaria do Estado da Saúde; 2011 [cited 14 Nov. 2015]. Available from: http://www.dive.sc.gov.br/index.php?option=com_remository&Itemid=27&func=selectfolder&cat=75
http://www.dive.sc.gov.br/index.php?opti... , while the recommendation of the Ministry of Health is 100%³⁰30. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Agenda Estratégica da Secretaria de Vigilância em Saúde 2011-2015 [Internet]. Brasília: Ministério da Saúde; 2011 [cited 14 Nov. 2016]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/agenda_estrategica_SVS_2011_2015.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... . There are, however, differences in the commitment of state’s health macro-regions management to face this disease³¹31. Mendonça SA, Franco SC. Avaliação do risco epidemiológico e do desempenho dos programas de controle de tuberculose nas Regiões de Saúde do estado de Santa Catarina, 2003 a 2010. Epidemiol Serv Saúde. 2015;24(1):59-70. http://dx.doi.org/10.5123/S1679-49742015000100007
http://dx.doi.org/10.5123/S1679-49742015... . Nevertheless, it is important to note that the Directly Observed Treatment approach can be effective, especially if there is a guardian-supervised Directly Observed Treatment, usually a member of the family. A study conducted in Vitória/ES pointed out a 9-time greater chance of cure when compared to standard Directly Observed Treatment (community health worker supervised)³²32. Prado TN, Wada N, Guidoni LM, Golub JE, Dietze R, Maciel ELN. Cost-effectiveness of community health worker versus homebased guardians for directly observed treatment of tuberculosis in Vitória, Espírito Santo State, Brazil. Cad Saúde Pública. 2011;27(5):944-52. http://dx.doi.org/10.1590/S0102-311X2011000500012
http://dx.doi.org/10.1590/S0102-311X2011... .

A survey carried out in several Brazilian cities showed that tuberculosis-related decentralized actions by primary health care approach did not produce satisfactory results as to access to disease diagnosis and treatment²⁶26. Scatena LM, Villa TCS, Ruffino Netto A, Kritski AL, Figueiredo TMRM, Vendramini SHF, et al. Difficulties in the accessibility to health services for tuberculosis diagnoses in Brazilian municipalities. Rev Saúde Pública. 2009;43(3):389-97. http://dx.doi.org/10.1590/S0034-89102009005000022
http://dx.doi.org/10.1590/S0034-89102009... . There is a need for better integration between the Family Health Strategy and the Directly Observed Treatment approach to ensure effective access to diagnosis and treatment²⁵25. Figueiredo TMRM, Villa TCS, Scatena LM, Gonzales RIC, Ruffino-Netto A, Nogueira JA, et al. Performance of primary healthcare services in tuberculosis control. Rev Saúde Pública. 2009;43(5):825-31. http://dx.doi.org/10.1590/S0034-89102009005000054
http://dx.doi.org/10.1590/S0034-89102009... . These can be some of the factors that have influenced the trend of keeping the disease burden stable, not declining, in the present study, as noted worldwide.

CONCLUSIONS

The burden of tuberculosis in the state of Santa Catarina, southern Brazil, remained stable during the study, given that no significant changes in YLL, YLD, and DALY rates were observed in 2007-2011.

ACKNOWLEDGEMENTS

We thank PROSUC/CAPES and the Brazilian Ministry of Education for the doctoral scholarship for ET.

REFERENCES

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