Completeness of tuberculosis reporting forms for disease control in individuals with HIV/AIDS in priority cities of Bahia state

Abstracts

The control of HIV / Tuberculosis (TB) co -infection remains a challenge for public health. Notification is mandatory for both diseases and the National Case Registry Database (Sinan) is responsible for the collection and processing of individual forms of reporting and monitoring. The adequate fulfillment of these fields chips (completeness) is essential to follow the dynamics of the disease and set priorities for intervention. The aim of this study was to evaluate the completeness of the notification forms of tuberculosis in the priority municipalities of Bahia (Camaçari , Feira de Santana , Ilhéus , Itabuna, Jequié, Lauro de Freitas , Porto Seguro , Teixeira de Freitas , Paulo Afonso, Barreiras and Salvador) to control the disease in individuals with HIV/AIDS using tabulations obtained from the Sinan in the period from 2001 to 2010. The results showed that despite the completeness of the field HIV be above 50 %, more than half the cases were met as "undone" or "being processed" in all municipalities assessed in the period. The low completeness of reporting forms may compromise the quality of surveillance of TB cases. The results suggest the need for greater availability of HIV testing in these individuals.

Tuberculosis; HIV; Public health surveillance; Disease notification

O controle da coinfecção HIV/Tuberculose (TB) ainda representa um desafio para a saúde pública. Ambas as doenças são de notificação obrigatória e o Sistema Nacional de Agravos de Notificação (SINAN) é o órgão responsável pela coleta e processamento das fichas individuais de notificação e acompanhamento. O preenchimento adequado dos campos destas fichas (completude) é essencial para acompanhar a dinâmica da doença e definir prioridades de intervenção. O objetivo deste estudo foi avaliar a completude das fichas de notificações de tuberculose nos municípios prioritários da Bahia (Camaçari, Feira de Santana, Ilhéus, Itabuna, Jequié, Lauro de Freitas, Porto Seguro, Teixeira de Freitas, Paulo Afonso, Barreiras e Salvador), para controle da doença em indivíduos com HIV/AIDS, através dos relatórios de tabulação do Sinan, no período de 2001 a 2010. Os resultados demonstraram que, apesar da completude do campo HIV estar acima de 50%, mais da metade das fichas estavam preenchidas como "não realizado" ou "em andamento", em todos os municípios avaliados no período. A baixa completude das fichas de notificação pode comprometer a qualidade de vigilância dos casos de TB. Os resultados sugerem a necessidade de maior disponibilidade de teste para HIV nesses indivíduos.

Tuberculose; HIV; Vigilância da população; Notificação de doenças

Introduction

Tuberculosis (TB) was under control in developed countries until the mid-1980s. However, after the emergence of the HIV / AIDS epidemic, the number of TB cases raised sharply. In the 1990s, TB was considered the second epidemic disease in Asia, Africa and Latin America and declared as a global emergency by WHO in 1993¹. From the 1990s to 2012, the overall prevalence of TB dropped off 37%. Yet, the goal of 50% of TB cases reduction set by WHO until 2015is still far from being achieved².

Currently, Brazil ranks the 17th higher for the burden of TB among the 22 higher-burden countries³. Bahia is the third Brazilian state with higher total number of TB cases and the tenth among the states with higher incidence of the disease in the country⁴.

The control of HIV / TB co-infection remains a challenge to public health. Although TB diagnosis and treatment are available, TB causes more than a quarter of deaths in people living with HIV/AIDS worldwide⁵. In addition, approximately 43% of HIV/TB co-infected patients have resistance to tuberculostatic drugs⁶.

The prevalence of HIV/TB co-infection is more frequent in areas with high TB-burden. At the end of the 1990s, the relative risk of HIV/TB co-infection in Latin America was about three times higher than in United States, where HIV prevalence reaches 11% of individuals with TB⁷. In Brazil, 20% of patients infected with Mycobacterium tuberculosis has a positive HIV serology⁸, while in Bahia state, 8.8% of patients hospitalized with TB were infected with HIV⁹.

AIDS and TB are both diseases with mandatory notification at the Sistema de Informação de Agravos de Notificação (Sinan, Brazilian Case Registry Database), organization responsible for collecting and processing individual notification forms and follow-up of the cases¹⁰. Proper completion of all fields of these records (completeness) is essential to survey the disease dynamic and for priority setting of health intervention¹¹. The lack of data exchange between AIDS and TB programs can contribute to adverse outcomes such as mortality, which reaches more than 50% of HIV/TB co-infected patients¹².

In order to restructure and improve the assistance to severe cases of TB (adverse reactions, drug resistance and co-morbidities such as diabetes, hepatitis and HIV / AIDS), the National Tuberculosis Control Program (NTCP) established new criteria to define priority cities for TB control in 2009. The current criteria include all capitals, cities with population greater or equal to 100,000 inhabitants, cities with TB incidence higher than 80% of the national level or with TB mortality higher than the national rate¹³. Currently, there are 181 priority cities in Brazil, 11 of which are located in Bahia⁴.

The aim of this study was to evaluate the completeness of TB notification forms in people living with HIV / AIDS in priority cities for TB control in Bahia state.

Methods

This is a descriptive study, with data collected from Sinan reports for a ten years period (January 2001 to December 2010). The sample included reports from all priority cities in the state of Bahia: Camaçari, Feira de Santana, Ilhéus, Itabuna, Jequié, Lauro de Freitas, Porto Seguro, Teixeira de Freitas, Paulo Afonso and Barreiras, in addition to Salvador, the capital of the state⁴. Data were collected by three undergraduate students previously trained and revised in a second time by the researchers.

Completeness of HIV and AIDS fields of all TB notification forms was analyzed. Additionally, we evaluated seven other variables related to co-infection: sputum smear (1^st and 2^nd from the first month, 2^nd month and 6^th month), sputum culture, clinical presentation of tuberculosis and outcome.

Analysis of completeness was based on the Sinan classification for qualitative assessment: category 1 if there was 0-25% of completeness; category 2 between 25.1% and 50%; Category 3 between 50.1% and 75% and category 4 between 75.1% and 100%¹⁴. The rating previously proposed by Sinan categorized the completeness as excellent if fields were filled up to 90%, regular between 70 and 89% and poor if below 70%¹⁵. Fields "ignored" or "blank" were considered incomplete and excluded.

Results

A total of 44,952 TB notifications forms were evaluated in the priority cities, accounting for 59.7% of all TB cases in the state (75,246) during the ten years of the study. Salvador had the highest absolute number of notifications (33,987), followed by Feira de Santana (2,519), Itabuna (1,740) and Ilhéus (1,417).

Table 1 depicts the completeness of TB notification forms for the HIV and AIDS variables. For HIV field, completeness ranged from 64.7% (Jequié) to 95.6% (Feira de Santana). Jequié and Itabuna were classified as Category 3 and the other cities as category 4.The percentage of fields filled in as "ongoing" or "not performed" accounted for more than 57% in all evaluated cities, ranging from 57.2% in Porto Seguro to 89.6% in Itabuna. Feira de Santana, the city with the highest completeness of HIV field, had the highest percentage of fields filled as "not performed" (84.5%). The number of HIV positive cases was 2,025, representing 4.5% of the notifications in the period (44,952).

Table 1.
Completeness of HIV and AIDS variables, state of Bahia. Period: January, 2001 - December, 2010.

Regarding to the AIDS variable, completeness rates were below 50% in all municipalities, ranging from 10.1% (Barreiras) to 40.6% (Lauro de Freitas). Seven cities were classified as category 1: Barreiras (10.1%), Ilhéus (13.5%), Itabuna (17.5%), Jequié (15.4), Porto Seguro (23.4%), Salvador (23.6%) and Teixeira de Freitas (17.5%), while all others cities were considered as category 2.

Table 2 shows the completeness of the variables related to the co-infection HIV / TB: The 1^st smear and clinical presentation variables obtained 100% of completeness (category 4) in all evaluated cities. The 2^nd smear variable was classified as category 2 in seven cities and as category 4 in only one, whereas the others cities were classified as category 3. The lowest completeness rates to the variables smear in the 2^nd and in the 6^th month were found in Teixeira de Freitas (29.2% and 16.7% respectively) and the highest in Feira de Santana (89.2% and 79.7%). The outcome field was considered as category 4 for nine cities and category 3 for the other two.

Table 2.
Completeness of the variables: smear, sputum culture, clinical form and outcome in co-infected individuals with TB/HIV, state of Bahia. Period: January, 2001 - December, 2010.

							Completeness n (%)
Individuals		1st		2st	Smear			Smear		Sputum		Clinical		Outcome
with HIV/TB (n)	smear		smear		2nd month		6th month			culture		form
Barreiras (12)	12	(100)	10	(83.3)	10	(83.3)		8	(66.7)	12	(100)	12	(100)	12	(100)
Camaçari (27)	27	(100)	14	(51.9)	22	(81.5)	17	(62.96)		25 (92.59)		27	(100)	26	(96.3)
Feira de Santana (74)	74	(100)	35	(47.3)	66	(89.2)	59		(79.7)	72	(97.3)	74	(100)	71 (95.95)
Ilhéus (45)	45	(100)	20	(44.4)	32 (71.11)		24	(53.33)		36 (80.00)		45	(100)	45	(100)
Itabuna (46)	46	(100)	22	(47.8)	38	(82.6)	31		(67.4)	42	(91.3)	46	(100)	45	(97.8)
Jequié (26)	26	(100)	8	(30.8)	23	(88.5)	16		(61.5)	25	(96.2)	26	(100)	26	(100)
Lauro de Freitas (18)	18	(100)	11	(61.1)	7	(38.4)		6	(33.3)	13	(72.2)	18	(100)	17	(94.4)
Paulo Afonso (8)	8	(100)	6	(75.0)	5	(62.5)	4	(50.00)		8	(100)	8	(100)	8	(100)
Porto Seguro (50)	50	(100)	21	(42.0)	20 (40.00)		14	(28.00)		46 (92.00)		50	(100)	50	(100)
Salvador (1,695)	1,695	(100)	799	(47.1)	664	(39.2)	572		(33.8)	1,247	(73.6)	1,695	(100)	1,162	(68.6)
Teixeira de Freitas (24)	24	(100)	11	(45.8)	7	(29.2)		4	(16.7)	24	(100)	24	(100)	18	(75.0)

The completeness of the variables related to patients with AIDS diagnosis and TB are described in Table 3: the completeness of the 1^st smear was classified as categories 2, 3 and 4 for 2, 6 and 3 cities, respectively. Regarding the 2^nd smear, two cities were classified as completeness 3 (Barreiras and Paulo Afonso) and the others, as categories 1 and 2. In all cities, the smear of the 2^nd and the 6^th months and sputum culture variables were classified as categories 1 and 2. For the variable clinical presentation, all municipalities reached completeness 4 and for the variable outcome, only Salvador was classified as category 3, while the other cities were category 4.

Table 3.
Completeness of the variables: smear, sputum culture, clinical form and outcome in individuals with TB and AIDS, state of Bahia. Period: January, 2001 - December, 2010.

							Completeness n (%)
Individuals with			1st		2st	Smear		Smear		Sputum		Clinical		Outcome
TB and AIDS (n)		smear		smear		2nd month		6th month		culture		form
Barreiras (11)	8		(72.7)	6	(54.5)	5	(45.4)	5 (45.4)		4 (45.4)		11	(100)	11		(100)
Camaçari (21)	17		(80.9)	7	(33.3)	6	(28.6)	5 (23.8)		5 (23.8)		21	(100)	21		(100)
Feira de Santana (61)	25 (41)			14	(22.9)	7	(11.5)	5	(8.2)	5	(8.2)	61	(100)	58	(95.1)
Ilhéus (34)	23		(67.3)	10	(29.4)	10	(29.4)	8 (23.5)		8 (23.5)		34	(100)	34		(100)
Itabuna (31)	18 (58)			8	(25.8)	8	(25.8)	1	(3.2)	1	(3.2)	31	(100)	30	(96.8)
Jequié (11)	6		(54.5)	3	(27.3)	4	(36.7)	3 (27.3)		3 (27.3)		11	(100)	11		(100)
Lauro de Freitas (16)	14		(87.5)		8 (50)	3	(18.7)	3 (18.7)		3 (18.7)		16	(100)	15	(93.7)
Paulo Afonso (6)	5		(83.3)	4	(66.7)		0 (0)	1 (16.7)		1 (16.7)		6	(100)	6		(100)
Porto Seguro (34)	17 (50)			4	(11.8)	9	(26.5)	9 (26.5)		9 (26.5)		34	(100)	34		(100)
Salvador (1,497)	985		(65.8)	370	(24.7)	165 (11)		106	(7.1)	106	(7.1)	1,497	(100)	1,008	(63.3)
Teixeira de Freitas (26)	15		(57.7)		2 (7.7)	7	(26.9)	3 (11.5)		3 (11.5)		26	(100)	20	(76.9)

Discussion

The results of the present study indicate that the completeness of HIV and AIDS fields of TB notification forms is below the level set by the Brazilian Ministry of Health.

The need to improve access to HIV testing in individuals with tuberculosis has been described in the literature. Sanchez et al.¹⁶evaluated the clinical outcome of TB in individuals infected or not with HIV and reported that the serology was not available for 32% of TB cases reported in Brazil between 2003 and 2008. In the same study, the risk of an unfavorable outcome was three times higher in HIV-infected patients compared to HIV-uninfected individuals. An intermediate risk of unfavorable TB outcome was found in the group who did not perform HIV serology, suggesting the possibility of undiagnosed HIV-infected individuals.

In Brazil, AIDS as well as alcoholism and malnutrition play an important role in determining high TB mortality rates¹⁷.

In the present study, although the completeness of HIV field was considered as categories 3 and 4, more than half of fields were filled as "not performed" or "ongoing" in all cities evaluated. The low number of HIV tests performed contradicts the Brazilian Ministry of Health recommendation for testing the virus infection in all patients with TB¹⁸. This fact might impair the care assistance and delay the development of preventive actions and injury control. The high percentage of fields filled as "ongoing" might be explained by delay in releasing the HIV results or updating the data in Sinan database by local health departments. Appropriate actions should be undertaken to correct these difficulties.

It is noteworthy that WHO considers as priorities to TB control both the availability of HIV tests and antiretroviral therapy for all HIV/TB co-infected individuals².

The "linkage" strategy (record linkage) should be employed in order to recover missing data from databases such as Mortality Information System data, Laboratory Tests Control System of the National Network of CD4 + / CD8 + Lymphocyte Count and viral load, the System of Medication Logistic Control and Sinan / AIDS¹⁹. Using this strategy and training health care professionals of surveillance are needed to improve the completeness of Sinan data.

Regarding the AIDS variable, the completeness was under 50% in all evaluated cities, lower than HIV field. The difference between completeness of HIV and AIDS variables may be related to the guidelines to fill the forms²⁰: filling HIV field is mandatory to launch the notification in the Sinan database, while AIDS field is considered as an essential variable (not filling it affects the development of specific actions for co-infection control, but does not preclude the case report).Likewise, clinical presentation was classified as category 4 in all cities, which might be explained because this is a mandatory filed in patients with AIDS / TB. The outcome field, despite being an essential variable, was classified as category 4 in almost all (10/11) cities, probably due to its importance in defining the effectiveness and quality of National Tuberculosis Control Program actions in the city, especially in regard to HIV / TB co-infection. It is noteworthy that this co-infection is considered a major factor to acquire resistance to tuberculostatic drugs¹⁸, which has become a serious problem in developed and developing countries.

The paucity of information in all fields with low completeness may still be related to the misconception of some health professionals that reporting forms represent a purely bureaucratic issue, with no impact on the panorama of public health²¹.

Several models for evaluation of tuberculosis control program has been proposed and factors such as lack of technical and managerial autonomy, absence of human, financial and material resources as well as failure of integration between programs have been identified as major problems for development of actions to the disease control²².

It is important to point that a limitation of this study is using secondary data with probable delay in the records updating by local health departments. In addition, it was not possible to determine the prevalence of the co-infection HIV / TB, due to the low number of HIV tests performed. However, the results obtained are relevant. This is a pioneer study since evaluates the priority cities to TB notification in Bahia, for a decade. The knowledge of these results may elicit actions to reverse the current scenario.

References

• ¹
  Dye C, Scheele S, Dolin P, Pathania V, Raviglione MC. WHO Global Surveillance and Monitoring Project. Global Burden of Tuberculosis: Supplemental Appendixes. JAMA 1999; 282(7):677-686.
• ²
  World Health Organization (WHO). Global Report Tuberculosis 2013. Geneva: WHO; 2013.
• ³
  Brasil. Ministério da Saúde (MS). Portal da Saúde notícias. [homepage onthe Internet]. [cited 2012 May 24]. Disponível em http://portal.saude.gov.br/portal/aplicacoes/noticias/default.cfm?pg=dspDetalheNoticia &id_area=124&CO_NOTICIA=1165.
  » http://portal.saude.gov.br/portal/aplicacoes/noticias/default.cfm?pg=dspDetalheNoticia &id_area=124&CO_NOTICIA=1165
• ⁴
  Bahia. Diretoria de Vigilância Epidemiológica (DIVEP) da Bahia. Boletim Epidemiológico da Tuberculose - Bahia, 2011. [homepage onthe Internet]. [cited 2012 May 24]. Disponível em http://www.suvisa.ba.gov.br/sites/default/files/BoletimTBdez2011_0_0.pdf
  » http://www.suvisa.ba.gov.br/sites/default/files/BoletimTBdez2011_0_0.pdf
• ⁵
  Ghebreyesus TA, Kazatchkine M, Sidibé M, Nakatani H. Tuberculosis and HIV: time for an intensified response. Lancet 2010; 375(9728):1757-1758.
• ⁶
  Campos PE, Suarez PG, Sanchez J, Zavala D, Arevalo J, Ticona E, Nolan CM, Hooton TM, Holmes KK. Multidrug-resistant Mycobacterium tuberculosis in HIV-infected persons, Peru. Emerg Infect Dis 2003; 9(12):1571-1578.
• ⁷
  Santos JS, Beck ST. A coinfecção tuberculose e HIV: um importante desafio - Artigo de revisão. RBAC 2009; 41(3):209-215.
• ⁸
  Brasil. Ministério da Saúde (MS). Co-infecção HIV/TB: resposta nacional e integração das agendas. [homepage on the Internet]. [cited 2012 Oct 16]. Disponível em: http://portal.saude.gov.br/portal/.../painel3_aids_mariangela _draurio.pdf
  » http://portal.saude.gov.br/portal/.../painel3_aids_mariangela _draurio.pdf
• ⁹
  Matos ED, Lemos ACM, Bittencourt C, Mesquita CL, Kuhn PC. Prevalence of HIV Infection in Patients Hospitalized for Tuberculosis in Bahia, Brazil. Braz J Infect Dis 2007; 11(2):208-211.
• ¹⁰
  Brasil. Portaria GM/MS nº 2325, de 8 de dezembro de 2003. Define a relação de doenças de notificação compulsória para todo território nacional. Diário Oficial da União 2003; 9 dez.
• ¹¹
  Brasil. Ministério da Saude (MS). Sinan - Sistema de Informação de Agravos de Notificação. Portal da Saúde. O que é o Sinan. [homepage on the internet]. [cited 2012 May 24]. Disponível em: http://dtr2004.saude.gov.br/sinanweb/index.php?name=Tnet
  » http://dtr2004.saude.gov.br/sinanweb/index.php?name=Tnet
• ¹²
  Miranda AE, Golub JE, Lucena FF, Maciel NE, Gurgel MF, Dietze R. Tuberculosis and AIDS co-morbidity in Brazil: linkage of the tuberculosis and AIDS databases. Braz J Infect Dis 2009; 13(2):137-141.
• ¹³
  Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Vigilância das Doenças Transmissíveis. Programa Nacional de Controle da Tuberculose. Nota técnica n° 15 CGPNCTIDEVEP/SVSIMS. Define critérios para a priorização de municípios no controle da tuberculose no Brasil. [homepage on the internet]. [cited 2012 Sep 28]. Disponível em: http://portal.saude.gov.br/portal/arquivos/pdf/nota_tecnica_prioritarios.pdf
  » http://portal.saude.gov.br/portal/arquivos/pdf/nota_tecnica_prioritarios.pdf
• ¹⁴
  Brasil. Ministério da Saúde (MS). Sinan - Sistema de Informação de Agravos de Notificação. Tuberculose: instruções para o preenchimento da ficha de notificação/investigação. [homepage on the internet]. [cited 2012 May 24]. Disponível em: http://www.sms.rio.rj.gov.br/coe/GTSINAN/Documenta%E7%E3oSINAN/Documenta%E7%E3odosistema/Instrucionaisdepreenchimentodasfichas/Tuberculose.pdf.
  » http://www.sms.rio.rj.gov.br/coe/GTSINAN/Documenta%E7%E3oSINAN/Documenta%E7%E3odosistema/Instrucionaisdepreenchimentodasfichas/Tuberculose.pdf.
• ¹⁵
  Brasil. Ministério da Saúde (MS). Programa Nacional de Controle da Tuberculose. Manual de Recomendações para o Controle da Tuberculose no Brasil. Brasil: MS; 2011.
• ¹⁶
  Sanchez M, Bartholomay P, Arakaki-Sanchez D, Enarson D, Bissell K, Barreira D, Harries A, Kritski A. Outcomes of TB treatment by HIV status in national recording systems in Brazil, 2003-2008. PLoS One 2012; 7(3):e33129.
• ¹⁷
  Vicentin G, Santo AH, Carvalho MS. Mortalidade por tuberculose e indicadores sociais no município do Rio de Janeiro. Cien Saude Colet 2002; 7(2):253-263.
• ¹⁸
  Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Departamento de Vigilância Epidemiológica. Manual de recomendações para o controle da tuberculose no Brasil. Brasília: MS; 2011.
• ¹⁹
  Almeida MA, Alencar GP. Informações em Saúde: Necessidade de Introdução de Mecanismos de Gerenciamento dos Sistemas. Informe Epidemiológico do SUS 2000; 9(4):241-248.
• ²⁰
  Brasil. Ministério da Saúde (MS). Secretaria de Vigilância em Saúde. Sistema de Informação de Agravos de Notificação: Dicionário de Dados - SINAN NET. [acessado 2012 set 28]. Disponível em: http://dtr2004.saude.gov.br/sinanweb/novo/Documentos/SinanNet/dicionario/DIC_DADOS_Tuberculose.pdf
  » http://dtr2004.saude.gov.br/sinanweb/novo/Documentos/SinanNet/dicionario/DIC_DADOS_Tuberculose.pdf
• ²¹
  Santos NP, Lírio M, Passos LAR, Dias JP, Kritski AL, Galvão-Castro B, Grassi MFR. Completude das fichas de notificações de tuberculose em cinco capitais do Brasil com elevada incidência da doença. Jornal Brasileiro de Pneumologia 2013; 39(2):221-225.
• ²²
  Oliveira LGD, Natal S, Felisberto E, Alves CKA, Santos EM. Modelo de avaliação do programa de controle da tuberculose. Cien Saude Colet 2010; 15(Supl. 1):997-1008.

Publication Dates

• Publication in this collection
  Apr 2015

History

• Received
  13 Oct 2014
• Accepted
  23 Nov 2014