Tuberculosis in Brazil: one country, multiple realities

Cortez, Andreza Oliveira; Melo, Angelita Cristine de; Neves, Leonardo de Oliveira; Resende, Karina Aparecida; Camargos, Paulo

doi:10.36416/1806-3756/e20200119

Brasil

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ORIGINAL ARTICLE • J. bras. pneumol. 47 (02) • 2021 • https://doi.org/10.36416/1806-3756/e20200119 linkcopy

Tuberculosis in Brazil: one country, multiple realities

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective: To identify the determinants of tuberculosis-related variables in the various regions of Brazil and evaluate trends in those variables over the ten-year period preceding the end of the timeframe defined for the United Nations Millennium Development Goals (MDGs).

Methods: This was an ecological analytical study in which we utilized eight national public databases to investigate the 716,971 new tuberculosis cases reported between 2006 and 2015.

Results: Over the study period, there were slight reductions in the prevalence, incidence, and mortality associated with tuberculosis. Brazil did not reach the MDG for tuberculosis-related mortality. Among the performance indicators of tuberculosis control, there were improvements only in those related to treatment and treatment abandonment. In terms of the magnitude of tuberculosis, substantial regional differences were observed. The tuberculosis incidence rate was highest in the northern region, as were the annual mean temperature and relative air humidity. That region also had the second lowest human development index, primary health care (PHC) coverage, and number of hospitalizations for tuberculosis. The northeastern region had the highest PHC coverage, number of hospitalizations for primary care-sensitive conditions, and tuberculosis-related mortality rate. The southern region showed the smallest reductions in epidemiological indicators, together with the greatest increases in the frequency of treatment abandonment and retreatment. The central-west region showed the lowest overall magnitude of tuberculosis and better monitoring indicators.

Conclusions: The situation related to tuberculosis differs among the five regions of Brazil. Those differences can make it difficult to control the disease in the country and could explain the fact that Brazil failed to reach the MDG for tuberculosis-related mortality. Tuberculosis control measures should be adapted to account for regional differences.

Keywords: Tuberculosis/epidemiology; Tuberculosis, pulmonary/epidemiology; Health status indicators; Social determinants of health; Healthcare disparities

Variable	Numerator	Denominator	Unit	Source
Magnitude of tuberculosis (2006-2015)
TB prevalence	Current number of TB cases	Resident population in the same location and year	Cases/100,000 population	¹ ^, ¹¹
PTB prevalence	Current number of cases of PTB	Resident population in the same location and year	Cases/100,000 population	¹⁰ ^, ¹¹
TB incidence	Total new cases of TB (all forms) in a given period, location, and year	Resident population in the same location and year	Cases/100,000 population	¹
Smear-positive PTB incidence	Total new cases of smear-positive PTB in a given location and year	Resident population in the same location and year	Cases/100,000 population	¹
TB-related mortality	Number of deaths due to TB in a given location and year	Resident population in the same location and year	Deaths/100,000 population	¹ for 2006-2014
TB-related mortality	Number of deaths due to TB in a given location and year	Resident population in the same location and year	Deaths/100,000 population	³² for 2015
Indicators of TB control (2006-2015)
First SSM positive	Total number of first SSMs that were positive in a given location and year	Number of cases of PTB or PTB+EPTB in the same location and year	%	¹¹
SSM in the 2nd month	Number of SSMs performed by the end of the 2nd month of treatment in a given location and year	Number of first SSMs that were positive in the same location and year	%	¹¹
SSM in the 6th month	Number of SSMs performed by the end of the 6th month of treatment in a given location and year	Number of first SSMs that were positive in the same location and year	%	¹¹
Patients in DOT	Number of TB cases in which DOT was used in a given location and year	Number of TB cases in the same location and year	%	¹¹
Retreatment after relapse or treatment abandonment	Number of cases of relapse or treatment abandonment reported in a given location and year	Number of TB cases reported in the same location and year	%	¹¹
Sputum culture in patients previously treated for TB	Number of previously treated cases of TB (relapse or readmission after treatment abandonment) submitted to sputum culture in a given location and year	Number of previously treated cases of TB in the same location and year	%	¹¹
Treatment abandonment	Number of cases closed due to treatment abandonment in a given location and year	Number of cases closed in the same location and year	%	¹¹
Health care indicators (2008-2015)
BCG vaccine coverage	Number of BCG vaccinations in children < 1 year of age in a given location and year	Resident population < 1 year of age in the same location and year	%	¹⁴
Density of physicians	Number of physicians registered with the CNES in a given location and year	Resident population in the same location and year	Physicians/10,000 population	¹⁵ ^, ¹¹
Density of nurses	Number of nurses registered with the CNES in a given location and year	Resident population in the same location and year	Nurses/10,000 population	¹⁵ ^, ¹¹
Density of pharmacists	Number of pharmacists registered with the CNES in a given location and year	Resident population in the same location and year	Pharmacists/10,000 population	¹⁵ ^, ¹¹
PHC coverage	Number of people seen by PHC teams × 3,000 in a given location and year	Resident population in the same location and year	%	¹³
Hospitalization for PCSCs	Number of hospitalizations for PCSCs in a given location and year	Total clinical hospitalizations in the same location and year	%	¹³
Socioeconomic indicators (2006-2015)
Hospitalizations for TB	Total hospitalizations for TB in a given location and year	Number of TB cases in the same location and year	Hospitalizations/100 TB cases	¹⁰ ^, ¹⁶
Length of hospital stay	Days spent in the hospital for TB in a given location and year	Number of hospitalizations for TB in the same location and year	Mean number of days	¹⁶
Cost of hospitalization for TB	Amount spent on hospitalizations for TB in a given location and year	Number of days of hospitalization for TB in the same location and year	US$/day	¹⁶
In-hospital mortality	Number of deaths due to TB in a given location and year	Number of hospital admissions for TB in the same location and year	100	¹⁶
Summary (2008-2015)
TB incidence rate	Total new cases of TB (all forms) in a given period, location, and year	Resident population in the same location and year	Cases/100,000 population	¹
TB mortality rate	Number of deaths due to TB in a given location and year	Resident population in the same location and year	Cases/100,000 population	¹ ^, ⁴¹
Density of physicians	Number of physicians registered with the CNES in a given location and year	Resident population in the same location and year	Physicians/10,000 population	¹⁵ ^, ¹⁰
Density of nurses	Number of nurses registered with the CNES in a given location and year	Resident population in the same location and year	Nurses/10,000 population	¹⁵ ^, ¹⁰
Density of pharmacists	Number of pharmacists registered with the CNES in a given location and year	Resident population in the same location and year	Pharmacists/10,000 population	¹⁵ ^, ¹⁰
PHC coverage	Number of people seen by PHC teams × 3,000 in a given location and year	Resident population in the same location and year	%	¹³
Hospitalizations for TB	Number of hospitalizations for treatment of TB in a given location and year	Number of TB cases in the same location and year	Admissions/100 TB cases	¹⁰ ^, ¹⁵
Cost of hospitalization for TB	Amount spent on hospitalizations for TB in a given location and year	Number of days of hospitalization for TB in the same location and year	US$/day	¹¹
Demographic density	Population of the region	Area of the region in km²	Population/km²	¹¹
HDI	Geometric mean of the income, education, and longevity indices			^-
Temperature	-	-	°C	¹²
Relative humidity	Actual vapor pressure	Saturation vapor pressure at the ambient temperature	%	¹²
Latitude	Distance from the Equator			Degree

Characteristics	Brazil as a whole	Region
Characteristics	Brazil as a whole	Northern	Northeastern	Southeastern	Southern	Central-west
TB incidence (cases/100,000 population)	36.8 (33.2-39.0)	44.9 (38.9-47.5)	36.2 (31.0-40.7)	39.8 (37.1-42.1)	31.4 (28.8-32.9)	23.1 (21.3-24.9)
TB-related mortality (deaths/100,000 population)	2.4 (2.2-2.6)	2.4 (2.2-2.7)	2.9 (2.6-3.1)	2.5 (2.3-2.7)	1.6 (1.3-1.8)	1.5 (1.3-1.6)
Hospitalization for TB^b (admissions/100 TB cases)	14.0 (12.8-15.4)	11.3 (10.1-12.6)	17.0 (13.9-20.2)	12.4 (10.9-13.6)	15.1 (13.3-17.5)	15.7 (13.9-17.8)
Cost/day of hospitalization for TB^b (US$)	38.4 (26.0-49.3)	28.6 (16.0-40.6)	40.2 (28.0-48.9)	36.9 (25.6-49.6)	42.1 (27.4-52.7)	34.5 (19.6-42.0)
PHC coverage (%)	67.5 (64.8-73.0)	59.5 (56.1-68.2)	75.2 (72.7-80.3)	62.8 (59.7-68.2)	72.4 (69.1-78.4)	65.4 (62.5-68.7)
Density of health care workers^b
Physicians (staff/10,000 population)	15.3 (13.7-17.1)	8.0 (7.2-9.4)	10.0 (8.9-11.4)	19.8 (17.8-21.8)	16.5 (14.6-18.9)	15.7 (14.0-17.4)
Nurses (staff/10,000 population)	7.4 (5.3-9.8)	5.6 (4.2-7.5)	6.6 (4.8-8.6)	8.2 (5.8-11.0)	7.7 (5.6-10.5)	6.9 (4.8-9.2)
Pharmacists (staff/10,000 population)	1.5 (1.0-1.8)	1.3 (0.9-1.6)	1.2 (0.7-1.5)	1.4 (1.2-1.7)	2.1 (1.3-2.7)	1.7 (1.0-2.2)
Demographic density (inhabitants/km²)	23.0 (22.0-24.0)	4.2 (3.9-4.5)	35.2 (33.8-36.4)	89.4 (85.8-92.7)	48.9 (47.0-50.7)	9.0 (8.3-9.6)
HDI^c	0.744 (0.705-0.761)	0.701 (0.684-0.718)	0.685 (0.660-0.703)	0.773 (0.754-0.786)	0.779 (0.756-0.795)	0.769 (0.753-0.780)
Temperature (°C)	25.9 (14.3-34.2)	28.0 (21.7-33.6)	27.0 (19.8-34.2)	24.0 (16.4-29.7)	21.3 (14.3-24.9)	26.9 (20.1-31.0)
Relative air humidity (%)	74.5 (63.0-84.8)	81.5 (77.2-84.7)	72.6 (63.0-78.7)	73.5 (68.6-78.0)	79.0 (77.1-80.7)	69.7% (65.0-76.1)
Latitude, range of extremes	5,2188 ↔ −33,5861	5,2188 ↔ −13,3218	1,2015 ↔ −18,1367	14,3747 ↔ −25,0318	−22,5937 ↔ −33,5861	−7,7107 ↔ −23,8424

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Sociedade Brasileira de Pneumologia e Tisiologia SCS Quadra 1, Bl. K salas 203/204, 70398-900 - Brasília - DF - Brasil, Fone/Fax: 0800 61 6218 ramal 211, (55 61)3245-1030/6218 ramal 211 - São Paulo - SP - Brazil
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[TFN1] TB: tuberculosis; PTB: pulmonary tuberculosis; SSM: sputum smear microscopy; EPTB: extrapulmonary tuberculosis; DOT: directly observed treatment; PHC: primary health care; PCSCs: primary care-sensitive conditions; CNES: Cadastro Nacional de Estabelecimentos de Saúde ([Brazilian] National Registry of Health Care Facilities); PHC: primary health care; HDI: Human Development Index.