Descriptive study of the implementation and impact of the directly observed treatment, short-course strategy in the São José do Rio Preto municipal tuberculosis control program (1998-2003)

Original Article Descriptive study of the implementation and impact of the directly observed treatment, short-course strategy in the São José do Rio Preto municipal tuberculosis control program (1998-2003)* Cláudia Eli Gazetta1, Silvia Helena Fiqueiredo Vendramini1, Antônio Ruffino-Netto2, Maria Rita de Cássia Oliveira3, Tereza Cristina Scatena Villa4 Abstract Objective: To describe treatment outcomes (cure, noncompliance or death) after the implementation of the Directly Observed Treatment, Short-course (DOTS) strategy for tuberculosis control in the city of São José do Rio Preto, Brazil, between 1998 and 2003. Methods: A descriptive study, based on secondary data (National Case Registry database, Tuberculosis Epidemiology database, and the ‘Black Book’ Registry), was conducted using a specific instrument. The data were analyzed using descriptive statistics. Results: After the implementation of the DOTS strategy, there was a decrease in noncompliance and case detection rates as well as an increase in cure and death rates. The increase in the number of tuberculosis-related deaths might be attributable to three factors: the predominance of the disease in individuals over 50 years of age, tuberculosis/HIV co-infection, and the presence of accompanying diseases. Conclusion: The implementation of the DOTS strategy strengthened the decentralization of the tuberculosis control plans as well as the integration of the Basic Health Care Clinic teams with the Tuberculosis Control Program team. Political commitment of the administrator to tuberculosis control, in conjunction with the policy of benefits and incentives, is essential for the sustainability of the DOTS strategy. Keywords: Tuberculosis; Epidemiology; Health services; Politics; Directly observed therapy. * Study carried out at the Faculdade de Medicina de São José do Rio Preto – FMSJRP, São José do Rio Preto School of Medicine – São José do Rio Preto (SP) Brazil. 1. PhD Professor in the Department of Collective Health Nursing and Professional Orientation of the Faculdade de Medicina de São José do Rio Preto – FMSJRP, São José do Rio Preto School of Medicine – São José do Rio Preto (SP) Brazil. 2. Full Professor at the University of São Paulo – USP – at Ribeirão Preto School of Medicine – Ribeirão Preto (SP) Brazil. 3. Masters; Coordinator of the Tuberculosis Control Program of the São José do Rio Preto Municipal Department of Health, São José do Rio Preto (SP) Brazil. 4. Tenured Professor at the University of São Paulo – USP – at Ribeirão Preto School of Nursing, Ribeirão Preto (SP) Brazil. Correspondence to: Cláudia Eli Gazetta. Rua Jair Martins Mil Homens, 277, Nova Redentora, CEP 15090-080, São José do Rio Preto, SP, Brasil. Phone 55 17 227-7167. E-mail: Submitted: 21 December 2005. Accepted, after review: 12 June 2006. J Bras Pneumol. 2007;33(2):192-198 Descriptive study of the implementation and impact of the directly observed treatment, short-course strategy in the São José do Rio Preto municipal tuberculosis control program (1998-2003) Introduction Brazil ranks fifteenth among the twenty-two countries that are responsible for 80% of the total number of tuberculosis (TB) cases worldwide, with a prevalence of 58 cases per 100,000 inhabitants. Despite being a curable disease, TB still kills at least 6000 people/year in Brazil. The cure rate is 72.2%, and the treatment noncompliance rate is 11.7%, reaching, in some cities, 30 to 40%. It is estimated that 111,000 new cases occur annually. These data represent a great challenge for Brazil in terms of the goals established in conjunction with the World Health Organization (WHO), which has declared TB a global emergency and proposed that the directly observed treatment, short-course (DOTS) strategy be used, with the goals of achieving favorable outcomes in 85% of cases, identifying 70% of all new cases, and reducing treatment noncompliance by 5%.(1) The DOTS strategy consists of five pillars: “Case detection through sputum smear microscopy among patients with respiratory symptoms who seek general health care; standardized, directly observed and monitored, short-course treatment; uninterrupted supply of anti-TB drugs; a system of registering data and information that ensures the evaluation of the treatment; and government commitment to make TB control a priority.”(2) The DOTS strategy proposes “the integration of primary health care as well as the implementation of continuous reform in the health sector.”(3) In 1998, the DOTS strategy was proposed, incorporated into the National Tuberculosis Control Plan,(4) and gradually implemented in Brazilian cities as a strategy within the Unified Health System, encouraging the identification and treatment of new cases by granting benefits upon the signatories of a statement of compliance.(5) The city of São José do Rio Preto (SJRP), with a population of 406,827 inhabitants,(6) is located in the northwest region of the state of São Paulo, which is characterized as a regional center, the headquarters of the 8th administrative region (comprising 96 municipalities), and an area of influence that reaches part of the states of Minas Gerais, Mato Grosso, and Mato Grosso do Sul. According to the 2000 and 2002 editions of the Paulista (state of São Paulo) Social Responsibility Index, SJRP is classified as belonging to the state of 193 São Paulo Group 1 (elite group) with high levels of wealth, longevity, and education. However, there is the official SJRP, which can be compared to cities in first world countries, and the real SJRP, which is characterized by illegal housing developments (in which 5% of the population resides), where there are no schools, squares or health services and whose inhabitants have no property deeds and drink water contaminated by sewage from cesspools.(7) The population structure of the city is similar to that of cities in developed countries, with a decrease in the population aged 0-4 years and a noticeable increase in the economically active population (14 to 49 years of age) as well as in the population aged 50 or older, especially in the population older than 75 years of age.(6,7) In addition to the increased need for equipment and services available for use by the community, the construction of housing units for migrants, stimulated by the National Housing Bank through the Program for Mid-sized Cities (created in order to evaluate the demographic situation in large metropolitan areas), in conjunction with the changes in the health policy of the country, from the 1980s onward, led to the development and growth of public health services in SJRP. The city became a referral center for health care, receiving patients from the region and from other states in Brazil. It has a mean of 4.4 doctors/1000 inhabitants, a rate double that of the state of São Paulo as a whole.(7) In 2003, the risk of developing active TB among the SJRP inhabitants at the lower socioeconomic levels (Class C) was approximately three t (...truncated)