Abstract

OBJECTIVE:

to describe abandonment rates according to sociodemographic, clinical and epidemiological characteristics of new tuberculosis cases being treated in Pernambuco State, Brazil.

METHODS:

this is a descriptive ecological study using data from the Information System for Notifiable Diseases from 2001 to 2014; the abandonment rate was calculated by the Regional Administration on Health (GERES).

RESULTS:

of the 57,015 new cases, 6,474 (11.3%) abandoned treatment, although abandonment decreased from 16.4% (2001) to 9.3% (2014); the abandonment rate in GERES I Recife, III Palmares, IV Caruaru, VIII Petrolina and IX Ouricuri was still >5% in 2014; the rate was higher in males (11.9%), people aged 20-39 (12.7%), people with incomplete elementary school (12.1%), black-skinned people (13.7%), institutionalized people (12.5%) and those with pulmonary + extrapulmonary tuberculosis (14.1%).

CONCLUSION:

despite the decrease, the abandonment rate remained high; males, adults with low education level, black-skinned people, institutionalized patients and patients with pulmonary + extrapulmonary tuberculosis seemed more prone to abandoning treatment.

Keywords:
Tuberculosis; Treatment Refusal; Medication Adherence; Epidemiology, Descriptive

Introduction

Tuberculosis is an infectious disease with expressive global magnitude. It is estimated that, in 2013, there were nine million new cases and one million tuberculosis-related deaths.¹1. World Health Organization. Global tuberculosis report 2014 [Internet]. Geneva: World Health Organization; 2014 [citado 2016 Aug 21]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/137094/1/9789241564809_eng.pdf
http://apps.who.int/iris/bitstream/10665... Furthermore, a third of the world’s population is believed to be infected with its etiological agent, Mycobacterium tuberculosis, popularly known as Koch bacillus.¹1. World Health Organization. Global tuberculosis report 2014 [Internet]. Geneva: World Health Organization; 2014 [citado 2016 Aug 21]. Disponível em: Disponível em: http://apps.who.int/iris/bitstream/10665/137094/1/9789241564809_eng.pdf
http://apps.who.int/iris/bitstream/10665... ^,22. Ferreira ACG, Silva Júnior JLR, Conde MB, Rabahi MF. Desfechos clínicos do tratamento de tuberculose utilizando o esquema básico recomendado pelo Ministério da Saúde do Brasil com comprimidos em dose fixa combinada na região metropolitana de Goiânia. J Bras Pneumol. 2013 jan-fev;39(1):76-83.

In Brazil, more than one million new cases were confirmed from 2001 to 2014; of these cases, about 70,000 evolved to death.³3. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Detectar, tratar e curar: desafios e estratégias brasileiras frente à tuberculose. Bol Epidemiol. 2015;46(9):1-19. The treatment is available all over the country, provided exclusively by the Brazilian National Health System (SUS), in order to control the illness in the population to achieve the cure target of over 85% and treatment abandonment of less than 5%.⁴4. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília: Ministério da Saúde; 2011 [citado 2016 ago 21]. Disponível em: Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/manual_recomendaçoes_controle_tuberculose.pdf
https://www.nescon.medicina.ufmg.br/bibl... Considering the need for a close relationship with the population and the territory, Primary Health Care is the main gateway for tuberculosis care.⁵5. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política nacional de atenção básica [Internet]. Brasília: Ministério da Saúde; 2012 [citado 2016 ago 21]. (Série A. Normas e Manuais Técnicos); (Série Pactos Pela Saúde, 4). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_atencao_basica_2006.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... Such proximity is essential, since the treatment lasts a long time - at least six months -, and is divided into attack and maintenance phases.⁵5. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política nacional de atenção básica [Internet]. Brasília: Ministério da Saúde; 2012 [citado 2016 ago 21]. (Série A. Normas e Manuais Técnicos); (Série Pactos Pela Saúde, 4). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_atencao_basica_2006.pdf
http://bvsms.saude.gov.br/bvs/publicacoe...

One of the most relevant adverse variables is the abandonment of the treatment itself, understood by the Brazilian Ministry of Health as the patient being absent for more than 30 consecutive days after the return date.⁴4. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília: Ministério da Saúde; 2011 [citado 2016 ago 21]. Disponível em: Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/manual_recomendaçoes_controle_tuberculose.pdf
https://www.nescon.medicina.ufmg.br/bibl... This non-adherence generates an impact on the incidence indicators, multidrug resistance, associated diseases and conditions, and mortality.⁵5. Ministério da Saúde (BR). Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Política nacional de atenção básica [Internet]. Brasília: Ministério da Saúde; 2012 [citado 2016 ago 21]. (Série A. Normas e Manuais Técnicos); (Série Pactos Pela Saúde, 4). Disponível em: Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/politica_nacional_atencao_basica_2006.pdf
http://bvsms.saude.gov.br/bvs/publicacoe... On a national level, among the Brazilian federative units, the abandonment rates ranged from 2.8 to 15.9% in 2014.³3. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Detectar, tratar e curar: desafios e estratégias brasileiras frente à tuberculose. Bol Epidemiol. 2015;46(9):1-19. The associated causes for treatment abandonment involve factors intrinsic to the users (use of alcohol and other drugs, false impression of cure and discomfort caused by the lack of food) and extrinsic factors (type of treatment and operationalization of health services).⁶6. Couto DS, Carvalho RN, Azevedo EB, Moraes MN, Pinheiro PGOD, Faustino EB. Fatores determinantes para o abandono do tratamento da tuberculose: representações dos usuários de um hospital público. Saude Debate. 2014 jul-set;38(102):572-81.

Considering the persistence of tuberculosis, the difficulty in maintaining adherence to treatment and the risks of abandoning the treatment, the analysis of spatial compatibility and of the territorial profile of this universe is essential. Above all, in order to align and implement strategic public policies and control measures consistent with the real situation.

This study aimed to describe abandonment rates according to sociodemographic, clinical and epidemiological characteristics of new tuberculosis cases in treatment in Pernambuco State, Brazil, from 2001 to 2014.

Methods

This is a descriptive ecological study with data from the Information System for Notifiable Diseases (Sinan), available on the website of the IT Department of the Brazilian National Health System (Datasus) and updated on May 25^th, 2016.⁷7. Ministério da Saúde (BR). Departamento de Informática do Sistema Único de Saúde. Sistema de Informação de Agravos de Notificação [Internet]. Brasília: Ministério da Saúde; 2016 [citado 16 ago 2016]. Disponível em: Disponível em: http://www.datasus.gov.br
http://www.datasus.gov.br...

Pernambuco, located in the Northeast region of Brazil, is formed by 184 municipalities, in addition to the district of Fernando de Noronha island. According to state health policies, 12 units of Regional Administration on Health (GERES) were created. These units are composed by neighboring municipalities, in order to ensure that SUS works properly, and are organized as follows: I Recife; II Limoeiro; III Palmares; IV Caruaru; V Garanhuns; VI Arcoverde; VII Salgueiro; VIII Petrolina; IX Ouricuri; X Afogados da Ingazeira; XI Serra Talhada; and XII Goiana.

The study population consisted of all individuals registered in the system as a new case, which were closed due to abandonment, reported by the 12 GERES from January 1^st, 2001 to December 31^st, 2014. Cases with the following outcomes were excluded: ignored/blank, cured, death by tuberculosis, death by other causes, referral, change in diagnosis and drug-resistant tuberculosis. Cases registered in 2015 and 2016, subject to several types of changes were not considered, in order to prevent changes in the results.

The abandonment rate of tuberculosis treatment was calculated according to the notifying GERES (I, II, III, IV, V, VI, VII, VIII, IX, X, XI and XII), by dividing the number of abandonments by the total number of new cases of all forms of the disease, in each analyzed unit, multiplied by 100.⁴4. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília: Ministério da Saúde; 2011 [citado 2016 ago 21]. Disponível em: Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/manual_recomendaçoes_controle_tuberculose.pdf
https://www.nescon.medicina.ufmg.br/bibl...

The following variables were considered to characterize the cases:

For the descriptive statistical analysis and distribution of absolute and relative frequency, we used the dynamic resources provided by Microsoft Excel 2010 and Epi Info version 7.1.4. For the construction of maps of abandonment rates according to notifying GERES, we used ArcGIS software 10.4.1. According to the recommendations of the National Health Council (CNS), Resolution No. 510, dated April 7^th 2016,⁸8. Brasil. Conselho Nacional de Saúde. Resolução nº 510, de 07 de abril de 2016. Diário Oficial da República Federativa do Brasil, Brasília (DF) , 2016 mai 24;Seção 1:44. the study was not submitted to a Research Ethics Committee because it used a secondary database and of public domain.

Results

From 2001 to 2014, there were 57,015 new cases of all forms of tuberculosis in the state of Pernambuco; 6,473 of these cases were classified as treatment 'abandonment', which is equivalent to an abandonment rate of 11.3%. During the study period, there was a reduction in this rate, from 16.4% (2001) to 9.3% (2014), although the lowest value (8.3%) has been observed in 2006 (Figure 1).

Figure 2 illustrates the distribution of the treatment abandonment rates in each GERES. In 2001, only three GERES - II Limoeiro, IX Ouricuri and X Afogados da Ingazeira - presented <5% abandonment, whilst two - VII Salgueiro and XI Serra Talhada - had rates that ranged from 5 to 15%, and seven - I Recife, III Palmares, IV Caruru, V Garanhuns, VI Arcoverde, VIII Petrolina and XII Goiana - registered rates from 15 to 26%, far above the recommended. In 2014, most GERES reported <5% abandonment rates - except I Recife, III Palmares IV Caruaru, VIII and IX Ouricuri, where the rates varied from 5 to 15%. The only regional that presented worse indicators was IX Ouricuri.

When we stratified the abandonment rate of tuberculosis treatment according to sociodemographic factors, we noticed that the indicator was higher among males (11.9%), people aged 20-39 years (12.7%), with incomplete elementary education (12.1%) and with black skin color (13.3%), followed by indigenous people (13.2%), individuals institutionalized in psychiatric hospitals (12.6%), and those in orphanages (12.5%) (Table 1).

We could not characterize the abandonment rate in special populations, given that 93 to 99.4% of the records of the variables related to them were ignored or not filled/blank (Table 2).

The distribution of the abandonment rates according to clinical and epidemiological characteristics are shown in Table 3. Abandonment was more frequent among individuals with pulmonary tuberculosis associated with extrapulmonary tuberculosis (14.1%). Among the rates of the extrapulmonary form, we found that 84.2% of the data were ignored or blank, with regard to the specific location affected by the disease. Users of alcohol were the ones who abandoned treatment the most (15.4%), whilst more than 50% of the records of other variables related to associated diseases and disorders were ignored or blank.

Discussion

It is evident that abandonment cases have become less frequent in the state of Pernambuco, in different proportions between the GERES. However, its indicator remains high. We could notice higher frequency of treatment abandonment among males, young adults with low education level, black-skinned, those institutionalized in psychiatric hospitals, patients with pulmonary tuberculosis associated with extrapulmonary tuberculosis and alcohol users.

The proportional decrease of abandonment rates in Pernambuco complies with the one observed in Brazil as a whole, according to a national survey conducted by the Ministry of Health, in 2015.³3. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Detectar, tratar e curar: desafios e estratégias brasileiras frente à tuberculose. Bol Epidemiol. 2015;46(9):1-19. This reduction was initially attributed to the publishing of the Strategic Plan for tuberculosis Control, which was accompanied by effective actions and services that aimed at improving epidemiological and operational indicators related to the disease.⁴4. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília: Ministério da Saúde; 2011 [citado 2016 ago 21]. Disponível em: Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/manual_recomendaçoes_controle_tuberculose.pdf
https://www.nescon.medicina.ufmg.br/bibl...

The strategic plan established some goals, such as: (i) 100% of Brazilian municipalities integrated to tackle the disease, (ii) 92% of existing cases diagnosed, (iii) of which at least 85% cured, (iv) reduced incidence in, at least, 50%, and (v) mortality reduction by two thirds; all with deadlines expired in 2007. Moreover, the document stated that abandonment rates of treatment should not exceed 5%.⁴4. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília: Ministério da Saúde; 2011 [citado 2016 ago 21]. Disponível em: Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/manual_recomendaçoes_controle_tuberculose.pdf
https://www.nescon.medicina.ufmg.br/bibl... However, the abandonment rate is far from the established targets - already including the observed decrease -, which emphasizes the need for implementing new systematic strategies related to the operation of the strategic plan, such as: (i) directing the attention to intermediate and peripheral reasons for abandonment, (ii) routine insertion of popular education, (iii) establishment of intersectoral networks coordinated with social assistance, education and culture and also (iv) demand for a more humanized care, in the search for maintaining a relationship with the patient.

Social contexts and life conditions of each region of Pernambuco should be taken into consideration. Due to the territorial heterogeneity, it is clear that the GERES with health responsibility on fewer people present bigger success in maintaining the relationship - such as X Afogados da Ingazeira -, whilst more populous and borderline regions show more difficulties - for instance, I Recife, III Palmares, IV Caruaru, and IX Ouricuri. This difficulty is possibly associated with the increased demand for services and the greater potential for spreading the disease in crowded environments.⁴4. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil [Internet]. Brasília: Ministério da Saúde; 2011 [citado 2016 ago 21]. Disponível em: Disponível em: https://www.nescon.medicina.ufmg.br/biblioteca/imagem/manual_recomendaçoes_controle_tuberculose.pdf
https://www.nescon.medicina.ufmg.br/bibl...

Demographic aspects related to sex, age, schooling and ethnicity/skin color observed during the analysis of the results corroborated with other research surveys conducted in the states of Maranhão,⁹9. Silva PF, Moura GS, Caldas AJM. Fatores associados ao abandono do tratamento da tuberculose pulmonar no Maranhão, Brasil, no período de 2001 a 2010. Cad Saude Publica. 2014 ago;30(8):1745-54.^,1010. Durans JJF, Sá EM, Pereira LFB, Soares DL, Oliveira PS, Aquino DMC, et al. Perfil clínico e sociodemográfico de pacientes que abandonaram o tratamento de tuberculose no município de São Luís - MA. Rev Pesq Saude. 2013 set-dez;14(3):175-8. São Paulo¹¹11. Orfão NH, Andrade RLP, Beraldo AA, Brunello MEF, Scatena LM, Villa TCS. Adesão terapêutica ao tratamento da tuberculose em um município do estado de São Paulo. Cienc Cuid Saude. 2015 out-dez;14(4):1453-61. and Bahia,¹²12. Abreu GRF, Figuereido MAA. Abandono do tratamento da tuberculose em Salvador, Bahia - 2005-2009. Rev Baiana Saude Publica. 2013 abr-jun;37(2):407-22. which focused on analyzing the recorded notifications from 2001 to 2012. Their findings suggest that the intrinsic cultural aspects to the diversity of the regions have no influence on the demographic characteristics of tuberculosis treatment abandonment cases.

The aforementioned demographic attributes were also found in a survey conducted in the countryside of São Paulo State, in 2015, with the aim of characterizing tuberculosis cases who had evolved to death.¹³13. Yamamura M, Zanoti MDU, Arcêncio RA, Protti ST, Figueiredo RM. Mortalidade por tuberculose no interior de São Paulo - Brasil (2006-2008). Cienc Cuid Saude. 2015 jul-set;14(3):1259-65. Those findings differ mainly in terms of age and education level from research reports carried out in Pará (2016) and Tocantins (2015), which, seeking to define the profile of the general population with tuberculosis, found that this endemic disease was most frequent among individuals over 40 years of age and with over eight years of schooling.¹⁴14. Freitas WMTM, Santos CC, Silva MM, Rocha GA. Perfil clínico-epidemiológico de pacientes portadores de tuberculose atendidos em uma unidade municipal de saúde de Belém, Estado do Pará, Brasil. Rev Pan-Amaz Saude. 2016 jun;7(2):45-50.

15. Silva EG, Vieira JDS, Cavalcante AL, Santos LGML, Rodrigues APRA, Cavalcante TCS. Perfil epidemiológico da tuberculose no estado de Alagoas de 2007 a 2012. Cien Biol Saude. 2015 nov;3(1):31-46.^-1616. Kamimura QP, Gonçalves KAM, Silva JLG. Caracterização do perfil epidemiológico e sociodemográfico de cidadãos de portadores de tuberculose. Ensaios Cien. 2012 mai;16(6):119-28. Thus, it is clear the great similarity between demographic characteristics of cases of abandonment and deaths associated with tuberculosis, to the detriment of the profile of the general population affected by the disease, we can raise the hypothesis of an association between treatment abandonment and death.

The higher abandonment rates observed among young adults is closely linked to social factors, since the population in this age group is more likely to use drugs and alcohol, which is the leading cause of patients non-adherance.⁹9. Silva PF, Moura GS, Caldas AJM. Fatores associados ao abandono do tratamento da tuberculose pulmonar no Maranhão, Brasil, no período de 2001 a 2010. Cad Saude Publica. 2014 ago;30(8):1745-54.^,1717. Lopes RH, Menezes RMP, Costa TD, Queiroz AAR, Cirino ID, Garcia MCC. Fatores associados ao abandono do tratamento da tuberculose pulmonar: uma revisão integrativa. Rev Baiana Saude Publica. 2013 jul-set;37(3):661-71. Such statements are, therefore, in accordance with the findings presented in this study, in a way that it is clear that alcoholics tend to abandon treatment more often.

Low education levels related to abandonment cases can be a determining factor for the lower level of disease awareness and the lack of knowledge on the its severity, and, therefore, of the possibilities of access to treatment. Lack of knowledge on the disease and the false perception of cure are the second cause more associated with abandonment of tuberculosis treatment.⁹9. Silva PF, Moura GS, Caldas AJM. Fatores associados ao abandono do tratamento da tuberculose pulmonar no Maranhão, Brasil, no período de 2001 a 2010. Cad Saude Publica. 2014 ago;30(8):1745-54. Moreover, even having it clarified to the patient, there is no guarantee that such information is sufficiently effective, due to the fragility of care regarding popular health education.¹⁸18. Sá LD, Gomes ALC, Carmo JB, Souza KMJ, Palha PF, Alves RS, et al. Educação em saúde no controle da tuberculose: perspectiva de profissionais da estratégia Saúde da Família. Rev Eletr Enf. 2013 jan-mar;15(1):103-11.

With regard to the social area, a considerable part of the studied individuals were not in institutionalized situation, although users who had institutional ties to psychiatric hospitals or orphanages abandoned treatment more often. Abandonment is less frequent in long-term, controlled scenarios,¹⁹19. Machado JC, Boldori JDM, Dalmolin MD, Souza WC, Bazzanellae SL, Birkner WMK, et al. A incidência de tuberculose nos presídios brasileiros: revisão sistemática. Rev Aten Saude. 2016 jan-mar;14(47):84-8. for example prisoners, who presented the lowest abandonment rate among the institutionalization subtypes. However, not always is the relationship a synonymous of quality and success in the treatment of tuberculosis; especially in prisons where there is evidence that even with the existence of treatment, the quality of care is poor, reducing the abandonment rate but causing other undesirable situations, such as resistance of the etiologic agent to multiple drugs.¹⁹19. Machado JC, Boldori JDM, Dalmolin MD, Souza WC, Bazzanellae SL, Birkner WMK, et al. A incidência de tuberculose nos presídios brasileiros: revisão sistemática. Rev Aten Saude. 2016 jan-mar;14(47):84-8.

The frequent interruption in the treatment of patients in psychiatric hospitals can be linked to the fact that, after discharge, the user finds it difficult to maintain the treatment, which shows that the health care network is not prepared to offer comprehensiveness of care.²⁰20. Larouzé B, Ventura M, Sanchez AR, Diuana V. Tuberculose nos presídios brasileiros: entre a responsabilização estatal e a dupla penalização dos detentos. Cad Saude Publica. 2015 jun;31(6):1127-30. Patients from orphanages may be in the same situation, especially those in short-term stay, who, once out of the guardianship of the State or those in welfare organizations, find barriers to continue treatment, or have no interest in maintaining the necessary link to it.¹⁷17. Lopes RH, Menezes RMP, Costa TD, Queiroz AAR, Cirino ID, Garcia MCC. Fatores associados ao abandono do tratamento da tuberculose pulmonar: uma revisão integrativa. Rev Baiana Saude Publica. 2013 jul-set;37(3):661-71.^,2020. Larouzé B, Ventura M, Sanchez AR, Diuana V. Tuberculose nos presídios brasileiros: entre a responsabilização estatal e a dupla penalização dos detentos. Cad Saude Publica. 2015 jun;31(6):1127-30.

Although determinant socioeconomic factors for abandonment have been mentioned, and their importance is recognized by the literature,²¹21. Basta PC, Marques M, Oliveira RL, Cunha EAT, Resendes APC, Souza-Santos R. Desigualdades sociais e tuberculose: uma análise por raça/cor em Mato Grosso do Sul, Brasil. Rev Saude Publica. 2013;47(5):854-64. when we tried to address issues related to social vulnerabilities inherent to special populations, the data available hindered the analysis.

The clinical and demographic characteristics of the study population identified higher abandonment rates among patients diagnosed with pulmonary + extrapulmonary tuberculosis, whilst in exclusive cases of extrapulmonary tuberculosis, the clinical manifestation was ignored in the vast majority of records, making it impossible to check organs and/or affected tissues in non-pulmonary cases. The higher abandonment incidence among pulmonary cases associated with extrapulmonary may reflect the general situation of vulnerability of the user due to multiple consecutive abandonments, which contributed to strengthening and spreading the etiologic agent.²²22. Bethlem AE. Manifestações Clínicas da Tuberculose Pleural, Ganglionar, Geniturinária e do Sistema Nervoso Central. Pulmão RJ. 2012;21(1):19-22.

In the context of diseases and associated conditions, there was a high incompleteness in the registry of variables, making it impossible to analyze most aspects. However, it should be noted that the information provided by a study published in 2013 showed a reduction in the incidence and mortality of co-infected with tuberculosis-human immunodeficiency virus.²³23. Pinto Neto LFS, Vieira NFR, Cott FS, Oliveira FMA. Prevalência da tuberculose em pacientes infectados pelo vírus da imunodeficiência humana. Rev Bras Clin Med. 2013 abr-jun;11(2):118-22.^,2424. Barbosa IR, Costa ICC. Estudo epidemiológico da coinfecção tuberculose-HIV no nordeste do Brasil. Rev Patol Trop. 2014 jan-mar;43(1):27-38. The fact is also explained by the introduction of more effective new drug schemes.²³23. Pinto Neto LFS, Vieira NFR, Cott FS, Oliveira FMA. Prevalência da tuberculose em pacientes infectados pelo vírus da imunodeficiência humana. Rev Bras Clin Med. 2013 abr-jun;11(2):118-22.^,2424. Barbosa IR, Costa ICC. Estudo epidemiológico da coinfecção tuberculose-HIV no nordeste do Brasil. Rev Patol Trop. 2014 jan-mar;43(1):27-38.

Besides the analysis of the variables, it is important to mention the high degree of incompleteness of information, essential to the proper situational assessment of health indicators applied to tuberculosis. This problem was also reported by researchers of the spatial distribution of tuberculosis cases in Paraíba, in 2013, when they used information recorded in the notification forms.²⁵25. Araújo KMFA, Figueiredo TMR, Gomes LCF, Pinto ML, Silva TC, Bertolozzi MR. Evolução da distribuição espacial dos casos novos de tuberculose no município de Patos (PB), 2001-2010. Cad Saude Colet. 2013 jul-set;21(3):296-302. Insufficient completion of the notification tools suggests fragility in the professional-user communication and operational disruptions in the working process, skills and competences to maintain the relationship with the vulnerable user or carrier of diseases whose treatment requires a long period of time - such as tuberculosis.²⁶26. Lírio M, Santos NP, Passos LA, Kritski A, Galvão-Castro B, Grassi MFR. Completude das fichas de notificação de Tuberculose nos municípios prioritários da Bahia para controle da doença em indivíduos com HIV/AIDS. Cien Saude Coletiva. 2015 abr;20(4):1143-8.

Another study conducted in Pernambuco, in 2014, which aimed to analyze the completeness and consistency of records entered on Sinan, mentioned that the deficiency in the quality of data may be related to the fact that much of the welfare professionals consider that filling the notification form is a dispensable activity, with no significant consequences in the practical setting of their work.²⁷27. Abath MB, Lima MLLT, Lima PS, Silva MCM, Lima, MLC. Avaliação da completitude, da consistência e da duplicidade de registros de violências do Sinan em Recife, Pernambuco, 2009-2012. Epidemiol Serv Saude. 2014 jan-mar;23(1):131-42. However, the flawed or incomplete filling of the notification tool can open significant gaps in the analysis and interpretation of data, and, therefore, in the epidemiological knowledge and planning of activities in the various branches of surveillance, prevention and health care.²⁷27. Abath MB, Lima MLLT, Lima PS, Silva MCM, Lima, MLC. Avaliação da completitude, da consistência e da duplicidade de registros de violências do Sinan em Recife, Pernambuco, 2009-2012. Epidemiol Serv Saude. 2014 jan-mar;23(1):131-42.

Although the abandonment rates of tuberculosis treatment have decreased in Pernambuco, they are above the target set in most GERES, especially in urban and surrounding areas. In most of the scientific literature, demographic and clinical-epidemiological factors converge, and there are no great differences among the findings of different Brazilian states. Besides, abandonment was more frequent among cases of pulmonary and extrapulmonary tuberculosis. The similarity between the abandonment profile, here investigated, and the deaths associated with tuberculosis, revealed by other studies, is worrisome and needs to be further investigated.

We suggest health professionals to pay greater attention to maintaining the relationship with patients who fit the profile described in this study. Not only to prevent abandonments, but also to health services to seek a systematic rebuilding of health practices, towards the provision of a care more aligned with ethical principles and the principle of comprehensiveness of SUS, without neglecting patients.

The main limitation of this study is related to the use of secondary data, with a high amount of lack of information on important variables, hindering the characterization of cases according to some aspects, especially social ones.

A suggestion for new researches is the requisite of in-depth analysis of the explanatory variables and social determinants of treatment abandonment under the territorial perspective. The study on the effectiveness of new strategies to approach the issue, such as popular education, continuous professional education, care humanization and food and nutrition assistance to the user in treatment also represents a vast field of knowledge and practice to be explored, aiming the maintenance and improvement of theoretical and empirical instruments necessary for the control and reduction of tuberculosis.

In the context of health services, it is recommended to health managers and surveillance professionals to develop together systematic routines able to transform the possible misconception of the teams on the importance of notification tools for epidemiological surveillance, improving the quality of information for planning, evaluation, control and auditing in Public Health.

References

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