Tuberculosis in a medium-sized city in the Southeast of Brazil: morbidity and mortality rates (1985 - 2003)

Jornal Brasileiro de Pneumologia 31(3) - Mai/Jun de 2005 Original Article Tuberculosis in a medium-sized city in the Southeast of Brazil: morbidity and mortality rates (1985 - 2003)* SILVIA H. F. VENDRAMINI, CLÁUDIA ELI GAZETTA, FRANCISCO CHIARAVALOTTI NETTO, MARIA R. CURY, EDNA B. MEIRELLES, FÁTIMA G. KUYUMJIAN, TEREZA C. S. VILLA Background: Tuberculosis is a disease linked to poverty, unequal distribution of wealth, and urbanization, as well as the epidemics of acquired immunodeficiency syndrome epidemic and multidrug resistance. Objective: To analyze indicators of tuberculosis morbidity and mortality in the city of São José do Rio Preto, Brazil from 1985 to 2003, compared with those in the state of São Paulo and in Brazil at large, and to determine the relationship between the risk of occurrence and socioeconomic level. Method: The following official information systems were utilized: the Sistema de Informação de Mortalidade (SIM, Mortality database), the Notificação de Tuberculose (Epi-Tb, Tuberculosis Notification database), the Sistema de Informação de Agravos de Notificação (SINAN, Case-registry database), the Departamento de Informação e Informática do Sistema Único de Saúde (DATASUS, Information Department of the Brazilian Health Ministry) and the Instituto Brasileiro de Geografia e Estatística (IBGE, Brazilian Institute of Geography and Statistics database). New cases reported in 2003 in the urban area were georeferenced and analyzed. A map of the sectors, each classified as representing one of three socioeconomic classes, was drawn up, showing the respective tuberculosis incidence coefficients. Results: Comparing Brazil as a whole to the state of São Paulo, total incidence coefficients and mortality rates were similar, as were gender-related values. In the city of São José do Rio Preto the rates were consistently lower. The proportion of cases presenting tuberculosis/human immunodeficiency virus coinfection varied from 29% to 37%. In 2002, 59% and 65% of tuberculosis-only and coinfected tuberculosis patients, respectively, were under supervised treatment, with a cure rate of 81% and a treatment-abandonment rate of 1%. The risk of developing active tuberculosis was three times higher in the area presenting the lowest socioeconomic levels. Conclusion: Identification of the areas with different levels of risks for tuberculosis enables the Municipal Health Department to deal with the peculiarities of each region and to prioritize those presenting higher incidences of the disease. J Bras Pneumol 2005; 31(3): 237-43. Key words: Tuberculosis. Epidemiology. Socioeconomic class. Supervised Treatment. Infection. HIV. *Study carried out at the Faculdade de Medicina de São José do Rio Preto - FAMERP Correspondence to: Sílvia Helena F. Vendramini, Rua Jorge Tabachi, 329. CEP 15170-000, Tanabi, SP Phone: 55 17 274-2503. E-mail: e Submitted: 25 May 2004. Accepted, after review: 10 December 2004 237 Vendramini, SHF, et al. Tuberculosis in a medium-sized city in the Southeast of Brazil: morbidity and mortality rates (1985 - 2003) INTRODUCTION Analysis of the tuberculosis (TB) situation worldwide reveals that the disease is related to poverty, poor distribution of wealth and accelerated urbanization, therefore calling for urgent control measures. The acquired immunodeficiency syndrome epidemic and the emergence of multidrug-resistant TB foci have mobilized the world on the issue of TB and alerted health authorities to the need for revitalizing TB control through the use of energetic, efficacious and appropriate measures(1,2). The World Health Organization estimates that one-third of the global population is infected with Mycobacterium tuberculosis. The annual number of new TB cases is 8.7 million, 80% of which are concentrated in 22 countries with higher TB burdens. Among those 22, Brazil ranks fifteenth (3) . Approximately one-third of the 36.1 million people living with human immunodeficiency virus (HIV) at the end of the year 2000 were coinfected with Mycobacterium tuberculosis(4). In view of this situation, it has been recommended over the last decade that the Directly Observed Treatment, Short-course treatment program for TB be expanded. The World Bank states that the Directly Observed Treatment, Short-course is "one of the most cost-effective health interventions available." This strategy has resulted in the cure of over 10 million patients since 1993, when the World Health Organization declared TB a world emergency(5). The number of TB cases in Brazil has been a cause for concern among regional and national health authorities. In 2002, 77,634 new cases were reported: 35,759 in the Southeast, 22,039 in the Northeast, 8,630 in the South, 7,061 in the North and 3,370 in the Midwest*. Nearly 50% of all TB cases in the state of São Paulo are reported in the city of São José do Rio Preto. It is considered a priority in the Tuberculosis Control Program due to the high number of TB patients presenting HIV seropositivity(6). In view of these facts, studies designed to increase understanding of the conditions of occurrence of this disease in the city as a whole, as well as in its various sectors, should be conducted. The objectives of this study were to analyze the indicators of TB-related morbidity and mortality in São José do Rio Preto between 1985 and 2003, compare them with values obtained for the state of São Paulo and for Brazil as a whole, and evaluate the relationship between the risk of occurrence of the disease and socioeconomic level. METHODS São José do Rio Preto is located in the northwest region of the state of São Paulo and, according to the (2004) report released by the Departamento de Informação e Informática do Sistema Único de Saúde (DATASUS, Information Department of the Brazilian Health Ministry), had a population of 382,173 people in 2003. The city is the headquarters for an administrative region comprising 101 municipalities. Information from the Sistema de Informação de Mortalidade (SIM, Mortality database), the Notificação de Tuberculose (Epi-Tb, Tuberculosis Notification database) and the Sistema de Informação de Agravos de Notificação (SINAN, Case-registry database) was utilized. The population counts were obtained from the DATASUS. The data related to the 432 census sectors of the urban area of the city was provided by the Instituto Brasileiro de Geografia e Estatística (IBGE, Brazilian Institute of Geography and Statistics database). The indicators of incidence and mortality were standardized by the population of the state of São Paulo, in 2002. When data regarding new cases or deaths by age bracket were available, the direct method of standardization was utilized, and when they were not, indirect standardization was utilized. The values for incidence and mortality in the city were smoothed through moving averages, because the original numbers presented great fluctuations due to the small number of cases and deaths considered. The new (...truncated)