ABSTRACT

Objective:

to analyze the distribution of tuberculosis cases in the state of Paraná, Brazil, between 2018 and 2021.

Methods:

this was an ecological study using secondary data obtained from compulsory notifications; detection rates per 100,000 inhabitants were described according to health regions in the state; percentage changes between 2018-2019 and 2020-2021 were calculated.

Results:

a total of 7,099 cases were registered. The highest rates were observed in the health regions of Paranaguá (52.4/100,000 in 2018-2019; 38.2/100,000 in 2020-2021) and Foz do Iguaçu (34.4/100,000 in 2018-2019; 20.5/100,000 in 2020-2021), and the lowest rates in Irati (6.3/100,000 in 2018-2019; 8.8/100,000 in 2020-2021) and Francisco Beltrão (8.5/100,000 in 2018-2019; 7.6/100,000 in 2020-2021); in 2020-2021, it could be seen a decrease in percentage changes in 18 health regions, while there was an increase in four of them, especially Foz do Iguaçu (-40.5%) and Cianorte (+53.6%).

Conclusion:

high rates were found in the coastal and triple border regions; and there was a decline in detection rates in the pandemic period.

Keywords:
Pulmonary Tuberculosis; Epidemiology; Public Health; Spatial Analysis; Ecological Studies

RESUMEN

Objetivo:

analizar la distribución de casos de tuberculosis en Paraná de 2018 a 2021.

Métodos:

estudio ecológico utilizando datos secundarios de notificaciones obligatorias. Se describieron las tasas de detección por 100.000 habitantes según las regiones de salud de Paraná. Se calcularon los cambios porcentuales entre 2018-2019 y 2020-2021.

Resultados:

se registraron 7.099 casos, observándose tasas más altas en las regiones de Paranaguá (52,4/100.000 en 2018-2019 y 38,2/100.000 en 2020-2021) y Foz do Iguaçu (34,4/100.000 en 2018-2019 y 20,5/100.000 en 2020-2021) y menor en Irati (6,3/100.000 en 2018-2019 y 8,8/100.000 en 2020-2021) y Francisco Beltrão (8,5/100.000 en 2018-2019 y 7,6/100.000 en 2020-2021). En 2020-2021, hubo descenso en 18 regiones y aumento en cuatro, con destaque para Foz do Iguaçu (-40,5%) y Cianorte (+53,6%).

Conclusión:

se encontraron altas tasas para las regiones de la costa y la triple frontera, además de una disminución en la detección durante el período de pandemia.

Palabras clave:
Tuberculosis Pulmonar; Epidemiología; Salud Pública; Análisis Espacial; Estudios Ecológicos

INTRODUCTION

Tuberculosis (TB) is a major public health problem and one of the leading causes of deaths from infectious diseases worldwide.¹1. World Health Organization. Global tuberculosis report 2021 [Internet]. Geneva: World Health Organization; 2021 [cited 2022 May 18]. Available from: Available from: https://apps.who.int/iris/rest/bitstreams/1379788/retrieve
https://apps.who.int/iris/rest/bitstream... ⁾ Until the advent of the COVID-19 pandemic in 2020, when historical progress in controlling and coping with several health conditions was reversed, TB was the leading cause of death from a single infectious agent, ranking above acquired immunodeficiency syndrome (or AIDS, as the disease is more commonly known).¹1. World Health Organization. Global tuberculosis report 2021 [Internet]. Geneva: World Health Organization; 2021 [cited 2022 May 18]. Available from: Available from: https://apps.who.int/iris/rest/bitstreams/1379788/retrieve
https://apps.who.int/iris/rest/bitstream... ^)-(33. Fukunaga R, Glaziou P, Harris JB, Date A, Floyd K, Kasaeva T. Epidemiology of tuberculosis and progress toward meeting global targets - worldwide, 2019. MMWR Morb Mortal Wkly Rep. 2021;70(12):427-30. doi: 10.15585/mmwr.mm7012a4
https://doi.org/10.15585/mmwr.mm7012a4...

In 2019, 7.1 million people were diagnosed with TB worldwide, followed by a decline in cases of the disease to approximately 5.8 million in 2020, far short the 10 million expected by the World Health Organization (WHO).¹1. World Health Organization. Global tuberculosis report 2021 [Internet]. Geneva: World Health Organization; 2021 [cited 2022 May 18]. Available from: Available from: https://apps.who.int/iris/rest/bitstreams/1379788/retrieve
https://apps.who.int/iris/rest/bitstream... Brazil and 15 other countries accounted for about 93% of this decline;⁴4. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Boletim Epidemiológico de Tuberculose - 2022. Brasília: Ministério da Saúde; 2022 [citado 2022 Maio 17]. Disponível em: Disponível em: http://www.aids.gov.br/pt-br/pub/2022/boletim-epidemiologico-de-tuberculose-2022
http://www.aids.gov.br/pt-br/pub/2022/bo... in 2021, just over 68,000 cases were reported in the country, 2.7% of them in the state of Paraná.⁴4. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Boletim Epidemiológico de Tuberculose - 2022. Brasília: Ministério da Saúde; 2022 [citado 2022 Maio 17]. Disponível em: Disponível em: http://www.aids.gov.br/pt-br/pub/2022/boletim-epidemiologico-de-tuberculose-2022
http://www.aids.gov.br/pt-br/pub/2022/bo...

The End TB Strategy, a program launched by the WHO in 2015, has set ambitious targets of 90% reduction in TB incidence and 95% reduction in number of TB deaths by 2035.⁵5. World Health Organization. The end TB strategy. Geneva: World Health Organization; 2015 [cited 2022 May 18]. Available from: Available from: https://www.who.int/teams/global-tuberculosis-programme/the-end-tbstrategy
https://www.who.int/teams/global-tubercu... In Brazil, public health has agreed on recommendations formalized by Brazil Free from Tuberculosis: National Plan to End Tuberculosis as a Public Health Problem, a health action plan launched in 2017 and revised in 2021.⁶6. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Brasil Livre da Tuberculose: Plano Nacional pelo Fim da Tuberculose como Problema de Saúde Pública: Estratégias para 2021-2025. Brasília: Ministério da Saúde; 2021 [citado 2022 Maio 17]. Disponível em: Disponível em: https://www.gov.br/saude/pt-br/centrais-deconteudo/publicacoes/publicacoes-svs/tuberculose/plano-nacional-pelo-fim-da-tuberculose-comoproblema-de-saude-publica_-estrategias-para-2021-2925.pdf/view
https://www.gov.br/saude/pt-br/centrais-...

Although successful results have been achieved on the track to end TB, it could be seen that the decline in notifications of cases is still insufficient to meet national and global targets,³3. Fukunaga R, Glaziou P, Harris JB, Date A, Floyd K, Kasaeva T. Epidemiology of tuberculosis and progress toward meeting global targets - worldwide, 2019. MMWR Morb Mortal Wkly Rep. 2021;70(12):427-30. doi: 10.15585/mmwr.mm7012a4
https://doi.org/10.15585/mmwr.mm7012a4... requiring further efforts to improve the capacity of surveillance systems, achieve the agreed-upon targets and, finally, sustainability of TB control.²2. Hino P, Yamamoto TT, Magnabosco GT, Bertolozzi MR, Taminato M, Fornari LF. Impacto da covid-19 no controle e reorganização da atenção à tuberculose. Acta Paul Enferm. 2021;34:eAPE002115. doi: 10.37689/acta-ape/2021AR02115
https://doi.org/10.37689/acta-ape/2021AR... ^),(33. Fukunaga R, Glaziou P, Harris JB, Date A, Floyd K, Kasaeva T. Epidemiology of tuberculosis and progress toward meeting global targets - worldwide, 2019. MMWR Morb Mortal Wkly Rep. 2021;70(12):427-30. doi: 10.15585/mmwr.mm7012a4
https://doi.org/10.15585/mmwr.mm7012a4...

These efforts (or overexertion) should consider the complexity of determinant factors of infection, including available health resources, educational level, income and occupation, population density, climate and living conditions in Brazil. Therefore, it is necessary to direct health interventions for TB control, which depends mainly on the evaluation of populations in their spatial context⁷7. Trauer JM, Dodd PJ, Gomes MGM, Gomes GB, Houben RMGJ, McBryde EM, et al. The importance of heterogeneity to the epidemiology of tuberculosis. Clin Infect Dis. 2019;69(1):159-66. doi: 10.1093/cid/ciy938
https://doi.org/10.1093/cid/ciy938... ^).(88. Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636...

In this sense, the continental dimensions of Brazil and the existence of regional inequalities imply the possibility of dissimilarities in levels of TB transmission, pointing to the importance of studies with different territorial profiles. This study aimed to analyze the distribution of TB cases in the state of Paraná, Southern Brazil, in the period from 2018 to 2021.

METHODS

This was an ecological study on the health regions of Paraná, conducted using data from the Notifiable Heath Conditions Information System (Sistema de Informação de Agravos de Notificação - SINAN)/Ministry of Health and the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística - IBGE), accessed on May 17, 2022 via the Brazilian National Health System Information Technology Department (Departamento de Informática do Sistema Único de Saúde - DATASUS). This research is anchored in the REporting of studies Conducted using Observational Routinely-collected health Data (RECORD).⁹9. Benchimol EI, Smeeth L, Guttmann A, Harron K, Moher D, Petersen I, et al. The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement. PLoS Med. 2015;12(10):e1001885. doi: 10.1371/journal.pmed.1001885
https://doi.org/10.1371/journal.pmed.100...

The 27 Brazilian Federative Units (FUs) are distributed over five national macro-regions: North, Northeast, Southeast, South and Midwest. Paraná, according to IBGE estimates for 2021, is the most populous state in the South region, with 11,597,484 inhabitants, divided into four health macro-regions and 22 health regions, through which, by means of this decentralized administrative health organization, programs, actions and health services aimed at the population are implemented.¹⁰10. Instituto Brasileiro de Geografia e Estatística. Cidades e estados: Paraná. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2022 [citado 2023 Nov 23]. Disponível em: Disponível em: https://www.ibge.gov.br/cidades-e-estados/pr.html
https://www.ibge.gov.br/cidades-e-estado... ^),(1111. Santos L. Região de saúde e suas redes de atenção: modelo organizativo-sistêmico do SUS. Cien Saude Colet. 2017;22(4):1281-9. doi: 10.1590/1413-81232017224.26392016
https://doi.org/10.1590/1413-81232017224...

The study population was comprised of new cases of pulmonary TB reported on SINAN, obtained among the categories “new case”, “do not know” and “after death”, diagnosed in the period from 2018 to 2021. In order to define the target population, we used the historical landmark Brazil Free from Tuberculosis:⁶6. Ministério da Saúde (BR). Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Brasil Livre da Tuberculose: Plano Nacional pelo Fim da Tuberculose como Problema de Saúde Pública: Estratégias para 2021-2025. Brasília: Ministério da Saúde; 2021 [citado 2022 Maio 17]. Disponível em: Disponível em: https://www.gov.br/saude/pt-br/centrais-deconteudo/publicacoes/publicacoes-svs/tuberculose/plano-nacional-pelo-fim-da-tuberculose-comoproblema-de-saude-publica_-estrategias-para-2021-2925.pdf/view
https://www.gov.br/saude/pt-br/centrais-... ⁾ records made after the implementation of the program in 2018, and the most recent records available on SINAN, on the date when the authors had access to the system database, were included.

The variables “year of diagnosis” and “health region” where the notification was made were analyzed. Data were exported to Microsoft Excel 2016^® software and the absolute and relative frequencies were estimated. Detection rates (DR) were calculated year by year, based on the ratio of the number of cases over the estimated population, for the same period and health region, and the result multiplied by 100,000 inhabitants.

Regarding the rates that were calculated, the choropleth maps were built using the QGIS^® software, version 3.26.3, based on the shapefile with the boundaries of the regions, accessed on the Brazilian Open Data Portal website. The spatial distribution occurred through natural breaks, in which a color scale was assigned: the darkest shades corresponded to the highest rates, and the lightest shades, corresponded to the lowest rates.

Moreover, the data related to the rates were grouped into biennia. Based on the arithmetic mean of the years registered in the periods 2018-2019 and 2020-2021, the percentage change (PC) between both periods was estimated. This calculation was performed by subtracting the rates of the last biennium from the rates of the first biennium, followed by division of the value obtained by the first biennium, and the result multiplied by 100.

As this was a study that used data in the public domain, aggregated and without identification of the participants, its project was exempted from the approval of a Research Ethics Committee (REC). However, the norms and guidelines recommended by the National Health Council (Conselho Nacional de Saúde - CNS), Resolution No. 466 of December 12, 2012, were met.

RESULTS

Between 2018 and 2021, 7,099 new cases of pulmonary TB were reported in the state of Paraná, distributed over the period as follows: 1,883 (26.5%; 16.6/100,000 inhabitants) in 2018; 1,915 (27.0%; 16.7/100,000 inhabitants) in 2019; 1,777 (25.0%; 15.4/100,000 inhabitants) in 2020; and 1,524 (21.5%; 13.1/100,000 inhabitants) in 2021 (data not shown in tables or figures).

As for spatial distribution, the highest detection rates were observed mainly in the Northwest and North macro-regions of the state. It is worth highlighting that the health regions of Paranaguá and Foz do Iguaçu presented the highest rates for all the years analyzed, while the lowest values were found in Irati and Francisco Beltrão (Figure 1).

With regard to the percentage change of TB detection rates, it could be seen a decrease in all macro-regions, the highest was found in the West region (-22.8%). The health regions also showed variation, with a decrease in 18 of them, especially Foz do Iguaçu (-40.5%), Apucarana (-32.3%), União da Vitória (-29.9%) and Paranaguá (-27.2%), and an increase in four of them, with Cianorte (+53.6%) being the most significant (Table 1).

DISCUSSION

The distribution of TB cases showed, among the years analyzed, a higher concentration in the North and Northwest macro-regions of Paraná, in addition to high rates in the health regions of Paranaguá and Foz do Iguaçu, and low rates in Irati and Francisco Beltrão. In 2020-2021, there was a decrease for almost all regions in the pandemic period, especially Foz do Iguaçu.

It is common knowledge that TB is a social disease of biological aspects, whose occurrence and transmission are connected to inequality and socioeconomic determinants.⁸8. Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636... ^),(1212. Khan MK, Islam MN, Ferdous J, Alam MM. An overview on epidemiology of tuberculosis. Mymensingh Med J. 2019;28(1):259-66.^),(1313. Prado Junior JC, Medronho RA. Spatial analysis of tuberculosis cure in primary care in Rio de Janeiro, Brazil. BMC Public Health. 2021;21(1):1841. doi: 10.1186/s12889-021-11834-1
https://doi.org/10.1186/s12889-021-11834... These characteristics are related to the contexts in which individuals live, given the high incidence found in vulnerable areas.⁸8. Zhang Q, Song W, Liu S, An Q, Tao N, Zhu X, et al. An ecological study of tuberculosis incidence in China, from 2002 to 2018. Front Public Health. 2022;18(9):766362. doi: 10.3389/fpubh.2021.766362
https://doi.org/10.3389/fpubh.2021.76636... ^),(1414. Pereira TV, Nogueira MC, Campos EMS. Spatial analysis of tuberculosis and its relationship with socioeconomic indicators in a medium-sized city in Minas Gerais. Rev Bras Epidemiol. 2021;24(suppl 1):e210021. doi: 10.1590/1980-549720210021.supl.1
https://doi.org/10.1590/1980-54972021002...

In Paraná, there was a predominance of cases in the North and Northwest macro-regions, close to the states of São Paulo and Mato Grosso do Sul, as well as in the border regions between the state and two South American countries - Argentina and Paraguay - and in the regions closest to the state’s coastal regions.

Border regions are considered marginalized, peripheral areas with deficit in socioeconomic integration, directly impacting the health of society.¹⁵15. Nogueira VD, Xavier-Gomes LM, Barbosa TLA. Mortalidade por homicídios em linha de fronteira no Paraná, Brasil. Cien Saude Colet. 2020;25(8):3107-18. doi: 10.1590/1413-81232020258.28522018
https://doi.org/10.1590/1413-81232020258... From the epidemiological point of view, it is important to consider the common characteristics of these regions, especially between twin cities, as in the health region of Foz do Iguaçu.¹⁶16. Aikes S, Rizzotto MLF. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cad Saude Publica. 2018;34(8):e00182117. doi: 10.1590/0102-311X00182117
https://doi.org/10.1590/0102-311X0018211... ⁾

Therefore, the articulation of surveillance actions between countries is fundamental, given that for the transmission of the disease, there is no territorial limit.¹⁶16. Aikes S, Rizzotto MLF. Integração regional em cidades gêmeas do Paraná, Brasil, no âmbito da saúde. Cad Saude Publica. 2018;34(8):e00182117. doi: 10.1590/0102-311X00182117
https://doi.org/10.1590/0102-311X0018211... The intense cross-border flow toward Paraná reflects the search for more qualified health systems, overloading the services and negatively affecting the indicators of border health regions in the state.¹⁷17. Hortelan MS, Almeida ML, Fumincelli L, Zilly A, Nihei OK, Peres AM, et al. Papel do gestor de saúde pública em região de fronteira: scoping review. Acta Paul Enferm. 2019;32(2):229-36. doi: 10.1590/1982-0194201900031
https://doi.org/10.1590/1982-01942019000...

Furthermore, the highest detection may be associated with ecological factors. Territories with the lowest altitudes, such as the Paranaguá region, and the highest temperatures, such as in the North and Northwest macro-regions, report the highest rates of TB notification.¹⁸18. Gelaw YA, Yu W, Magalhães RJS, Assefa Y, Williams G. Effect of temperature and altitude difference on tuberculosis notification: a systematic review. J Glob Infect Dis. 2019;11(2):63-8. doi: 10.4103/jgid.jgid_95_18
https://doi.org/10.4103/jgid.jgid_95_18... ⁾ However, there is no consensus on this issue.

The results also revealed a decrease in the detection of the disease. Surveillance is a primary action of public health;¹⁹19. Magnabosco GT, Órfão NH, Brunello MEF, Wysocki AD, Lopes LM, Campoy LT. Novas doenças e ameaças antigas: a repercussão da covid-19 no manejo da tuberculose. Saude Coletiva (Barueri). 2020;10(54):2639-44. doi: 10.36489/saudecoletiva.2020v10i54p2639-2644
https://doi.org/10.36489/saudecoletiva.2... ^),(2020. Siqueira TC, Martellet MG, Tavernard GLN, Silva VM, Moura STS, Silva LAF, et al. Percepção de enfermeiros: enfoque na família e orientação para a comunidade nas ações de tuberculose. Cienc Cuid Saude. 2020;19:e50175. doi: 10.4025/ciencuidsaude.v19i0.50175
https://doi.org/10.4025/ciencuidsaude.v1... however, it is recognized that weak surveillance systems can lead to underreporting of TB.²¹21. Silva GDM, Duarte EC, Cruz OG, Garcia LP. Identificação de microrregiões com subnotificação de casos de tuberculose no Brasil, 2012 a 2014. Epidemiol Serv Saude. 2020;29(1):e2018485. doi: 10.5123/S1679-49742020000100025
https://doi.org/10.5123/S1679-4974202000... It is possible that this weakness may be accentuated in the context of COVID-19. Studies conducted in India and Sierra Leone showed a reduction of 63.3% and 70.0% in TB notifications, respectively.²²22. Arentz M, Ma J, Zheng P, Vos T, Murray CJL, Kyu HH. The impact of the COVID-19 pandemic and associated suppression measures on the burden of tuberculosis in India. BMC Infect Dis. 2022;22(1):92. doi: 10.1186/s12879-022-07078-y
https://doi.org/10.1186/s12879-022-07078... ^),(2323. Lakoh S, Jiba DF, Baldeh M, Adekanmbi O, Barrie U, Seissay AL, et al. Impact of COVID-19 on tuberculosis case detection and treatment outcomes in Sierra Leone. Trop Med Infect Dis. 2021;6(3):154. doi: 10.3390/tropicalmed6030154
https://doi.org/10.3390/tropicalmed60301...

The centralization of health actions and services in coping with the pandemic has put up barriers to the control of pre-existing conditions.²⁴24. Souza ASR, Amorim MMR, Melo ASO, Delgado AM, Forêncio ACMCC, Oliveira TV, et al. Aspectos gerais da pandemia da covid-19. Rev Bras Saude Mater Infant. 2021;21(Suppl 1):529-46. doi: 10.1590/1806-9304202100S100003
https://doi.org/10.1590/1806-9304202100S... ^),(2525. Couto MT, Barbieri CLA, Matos CCSA. Considerações sobre o impacto da covid-19 na relação indivíduosociedade: da hesitação vacinal ao clamor por uma vacina. Saude Soc. 2021;30(1):e200450. doi: 10.1590/S0104-12902021200450
https://doi.org/10.1590/S0104-1290202120... Therefore, it is understood that the interruption of health care activities has had significant impacts on the detection and management of TB.²⁶26. Jain VK, Iyengar KP, Samy DA, Vaishya R. Tuberculosis in the era of COVID-19 in India. Diabetes Metab Syndr. 2020;14(5):1439-43. doi: 10.1016/j.dsx.2020.07.034
https://doi.org/10.1016/j.dsx.2020.07.03... ^),(2727. Fei H, Yinyin X, Hui C, Ni W, Xin D, Wei C, et al. The impact of the COVID-19 epidemic on tuberculosis control in China. Lancet Reg Health West Pac. 2020;3:100032 doi: 10.1016/j.lanwpc.2020.100032
https://doi.org/10.1016/j.lanwpc.2020.10... In this scenario, it can be seen that the achievements in TB control were threatened in the pandemic scenario.

It is noteworthy that this research has limitations. The use of secondary data may be subject to errors in filling out and underreporting/sub-detection of cases, especially in a context aggravated by the pandemic. Another limitation of this study is related to detection rates calculated based on population estimates, which may not reflect the actual population size.

It can be concluded that this study showed a decrease in the detection of TB as a possible consequence of overload in health care and epidemiological surveillance, given the emergence of COVID-19. The analysis of spatial distribution pointed to a greater detection of TB cases in certain areas of the state of Paraná, suggesting relationships between these occurrences and ecological and socioeconomic aspects.

REFERENCES

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