Determinant of compliance : The disease and the mechanics of treatment

INTRODUCAO:Em 1998, o Rio de Janeiro era o estado de maior incidencia e mortalidade por tuberculose do Brasil. O Sistema de Informacao de Agravos de Notificacao em Tuberculose (SINAN-TB-RJ) nao era confiavel. OBJETIVO: Utilizar o estudo dos obitos por tuberculose como instrumento de avaliacao do programa de controle de tuberculose. METODO: Foram realizados estudos descritivos do SINAN-TB-RJ e do Sistema de Informacao de Mortalidade em tuberculose do Rio de Janeiro (SIM-TB-RJ) e os dois bancos de dados foram cruzados utilizando-se o programa Reclink. Foi tambem realizado um estudo baseado em prontuarios dos cinco hospitais onde ocorreu o maior numero de obitos por tuberculose. RESULTADOS: Em 1998 foram registrados no SINAN-TB-RJ 16.567 casos de tuberculose em maiores de 14 anos. A forma pulmonar estava presente em 13.989 (84,5%) casos, dos quais 8.223 (56,8%) tiveram baciloscopia positiva. A sorologia anti-HIV, recomendada para todos os pacientes com tuberculose, foi solicitada em apenas 4.141 (25%) casos. No SIM-TB-RJ foram registrados 1.146 obitos, dos quais 478 (41,7%) casos haviam sido notificados no SINAN-TB-RJ, entre 1995 e 1998. Dos 302 prontuarios estudados, em 154 (50,9%) o periodo de internacao foi inferior a 10 dias. O tempo entre o inicio dos sintomas e o diagnostico foi superior a 60 dias em 143 (47,3%) pacientes. Dos 125 pacientes em re-tratamento, para apenas 43 (34,4%) foi prescrito o esquema RHZE recomendado pelo Ministerio da Saude. CONCLUSAO: O estudo demonstra que a tuberculose e sub-notificada, o diagnostico e tardio, a utilizacao dos exames laboratoriais recomendados e baixa e as normas do Ministerio da Saude nao sao cumpridas.

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Óbitos atribuídos à tuberculose no Estado do Rio de Janeiro

INTRODUCAO: A tuberculose tem trazido importantes desafios ao setor de saude. O Brasil tem alta prevalencia da doenca e o Estado do Rio de Janeiro possui as maiores taxas de incidencia do pais. O municipio do Rio de Janeiro e responsavel pela maior notificacao do estado e cerca de 30% dos casos diagnosticados tem origem em hospitais. OBJETIVO: Estimar a prevalencia de resistencia inicial e adquirida e identificar fatores associados a ocorrencia de resistencia em hospital geral referencia para tratamento de AIDS no Rio de Janeiro. METODO: Foram analisadas cepas de Mycobacterium tuberculosis de 165 pacientes, entre agosto de 1.996 e fevereiro de 1.998. RESULTADOS: Vinte por cento (33/165) apresentaram resistencia a pelo menos um medicamento: 13% (22/165) a isoniazida, 1,8% (3/165) a rifampicina e 3,6% (6/165) a ambas. Entre pacientes infectados pelo HIV (52/165), 28,85% (15/52) apresentaram resistencia a pelo menos um farmaco. Resistencia adquirida ocorreu em 12,5% dos pacientes que referiram tratamento anterior (3/24), com associacao significativa com imagem radiologica nao cavitaria (p = 0,05). Resistencia inicial ocorreu em 18,4% dos pacientes virgens de tratamento (26/141), com associacao significativa com ser profissional de saude (p = 0,004), desemprego (p = 0,03) e diarreia (p = 0,01) na analise bivariada. Na analise multivariada, ser profissional de saude manteve-se fortemente associado com a ocorrencia de resistencia inicial (p = 0,002). CONCLUSAO: Taxas de resistencia elevadas foram encontradas nesta serie. Estes achados corroboram a necessidade de que atencao maior seja dada a tuberculose em ambiente hospitalar, em especial no que diz respeito a preocupante associacao entre resistencia nas cepas isoladas e profissionais de saude.

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Resistência aos medicamentos anti-tuberculose de cepas de Mycobacterium tuberculosis isoladas de pacientes atendidos em hospital geral de referência para tratamento de AIDS no Rio de Janeiro

Background: Gender is a social determinant of health. In view of the substantial burden of tuberculosis (TB), it is important
to look into the gender issues related to utilization of services.
Aims: To find out gender differences in health care seeking behaviour of tuberculosis patients.
Methods: A cross sectional study, using integrated mixed method, was conducted in Chandigarh (India). Systematic random
sample was used to interview 109 TB patients (54 men and 55 women) from eight randomly selected health institutions.
Results: More women (40%) resorted to home remedies or medicines without prescription at the onset of symptoms
compared to men (13%). More men (87%) consulted qualified medical practitioners compared to the women (60%).
Consultations from private doctors were more common among men. Mean delay in diagnosis was more in men (60 days)
than women (33 days). Main reasons for delay, in men and women respectively, were late referral by doctor (37% vs 26%),
long distance to health institution (29% vs 28% ), prolonged use of self-medication (30% vs 26%), and financial constraints
(7% vs 17%). More women (20.8%) reported missing a prescribed dose of treatment as compared to men (11.1%).
However, 10% men were on re-treatment compared to none of the women.
Conclusions: Delay in diagnosis was more in men than women. More delay occurred due to delayed referral by doctors among
men and due to financial constraints among women. Hence, gender differences in health care seeking behaviour should be
kept in mind while selecting programme strategies.

Gender differences in health care seeking behaviour of tuberculosis patients in chandigarh

Objectives: To determine whether the incidence of tuberculosis with pregnancy is more common than would be expected from the crude birth rate; to see whether there is significant delay in the diagnosis of tuberculosis during pregnancy. Design: A cross-sectional survey. Setting: 13 tuberculosis clinics within different European countries and the USA. Population/sample: All patients with tuberculosis seen at these clinics for a period > 1 year. Instrument: Questionnaire survey based on continuous data collection. Main outcome measures: number and proportion of women with tuberculosis who were pregnant; timing of diagnosis in relation to pregnancy, including those who were pregnant or delivered in the 3 months prior to the diagnosis of TB and those who developed TB within 3 months after delivery. Pregnancy occurred in 224 (1.5 %) of 15,217 TB patients and followed the expected rate predicted from the crude birth rate for the clinic populations. TB was diagnosed more commonly in the 3 months after delivery (n = 103) than during pregnancy (n = 68; χ
 2 = 25.1, P < 0.001). TB is diagnosed more frequently after delivery, despite variations in local TB incidence and healthcare systems.

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Pregnancy in patients with tuberculosis: a TBNET cross-sectional survey.

The treatment of tuberculosis (TB) is ranked as the most cost effective of all therapeutic programmes in terms of cost per year of life saved. Nevertheless, TB kills or debilitates more adults aged between 15 and 59 years than any other disease in the world; furthermore, about 2 to 4% of the burden of disease, 7% of all deaths and 26% of all preventable deaths are directly attributable to TB. About one-third of the world's population is infected with the TB bacillus. In the developing world, more women of childbearing age die from TB than from causes directly associated with pregnancy and childbirth. The death of adults in their prime, who are parents, community leaders and producers in most societies, causes a particularly onerous burden besides being a serious public health problem. In the poorest countries, where the magnitude of the TB problem is greatest, those TB control strategies that are economically feasible tend to be less effective. Therefore, in low and middle income countries, cost-effectiveness considerations aimed at prioritising resource allocation in the health sector in general, and in TB control programmes in particular, are of paramount importance. Operationally, the main components of a TB control programme are: (i) detection and treatment of TB; and (ii) prevention of TB through BCG vaccination and chemoprophylaxis. Priority should be given to ensuring that TB patients complete their prescribed course of chemotherapy. Adequate treatment is the most effective way of preventing the spread of TB and the emergence of drug resistance. This article reviews evidence of the effectiveness and cost effectiveness of different approaches to TB care, particularly those that are applicable to low income countries, in both HIV-infected and noninfected patients. Financial implications and ways to implement directly observed therapy for TB in large urban areas are discussed, and the need to address some relevant operational issues is highlighted. The current role of chemoprophylaxis and BCG vaccination is also reviewed.

Roberto Iunes

Papers

Cost Effectiveness of Antituberculosis Interventions