EDITORIAL
Profile of patients bearers of Mycobacterium sp.
Afrânio Lineu Kritski
Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ
An original report on the results found in a mycobacteriology laboratory of a university general hospital and its participation in the activity of tuberculosis control in one of our metropolitan regions, published by Froes GC et al 1) in this journal, is extraordinarily relevant and significant. It should be noted that during the last two decades, in the discussions about the activities of a mycobacteriology laboratory in our country, first priority was given to the implementation and optimization of training and quality control in the public health laboratories (Lacens) only. The plans, critical or not for combat of tuberculosis, carried out by the Health Ministry during this period, did not sufficiently enhance the major contribution that the mycobacteriology laboratories in the general hospitals - university or not- may indeed proffer to control of tuberculosis, mainly in the larger urban centers, where diagnosis of TB is usually carried out at hospital level (2-4).
There are very few reports published in large circulation journals about the implementation of programs of control of hospital TB concurrent with mycobacteriology laboratories in developing countries. This is true in Brazil because public policies makers have been following the international tendency of the seventies and have elected to invest in the strengthening and optimization of control of Tb activities in the primary health units and more recently in the implementation of Family Health Programs (FHP) (4,5). However, it has currently become consensual, even among international organizations, that in countries where upgrading of sanitation is underway it is fundamental that when reorganizing the health system first priority be also given to suitable hierarchy and identification of strategies and funding. The point is that reference units at secondary and tertiary levels, in their great majority public hospitals, may indeed serve as reference and counter-reference for the less complex health units (6). With regard to control of tuberculosis, centers of surveillance in the emergency units that exclusively diagnose TB should be urgently implemented as well as programs for control of hospital TB in units that diagnose and manage TB patients (7) . Participation of the laboratory of mycobacteriology is fundamental in such situations because demand for mycobacteriological tests in these units is about 5 to 10 times greater than in the primary level units.
Even after recent publication of the latest recommendations by the Health Ministry (4,5) which for the first time signal the relevant role played by secondary and tertiary level cares, it becomes clear that in these hospital units greater agility in the strategies of TB control is of utmost urgency. Even more so in the larger urban centers where:
a. implementation of the FHPs is still inadequate, with a persistent excess of patients suspected of active TB in the emergency and first aid units (7,8,9);
b. 26 to 40% of the patients notified of TB are referred from hospital units lacking a mycobacteriology laboratory or coordinated TB control activities (8,9).
c. about 30% of the patients with a diagnosis of probability (with no bacteriological substantiation ) were mistakenly treated, that is to say they had another disease (10)
d. some 42% of the patients bearers of mycobacterial infections had not started treatment because they were unaware of the diagnosis, evidencing poor control of tuberculosis at hospital level (11)
e. about 80% of deaths associated to TB take place (9, 12)
f. in some 75% of deaths, the mycobacteriological test was not performed for lack of a mycobacteriology laboratory where culture tests are available (9, 12)
g. the level of co-infection with HIV and other morbidities is high with often delayed diagnosis due to atypical presentation and/or low level of suspicion of TB among the health professionals (8,9, 13)
h. Lacens do not meet the demand for laboratory tests (culture for mycobacteria) required for a diagnosis of paucibacillary TB among inpatients.
Aspects that were highlighted by the authors Froes GC et al.
a. Carrying out the study would have been easier if good clinical practices had been introduced in the investigation routine of patients in hospital units. This includes correct entries in the medical charts and follow-up of the protocols or manuals of procedures during care of patients with suspicion of TB or confirmed TB.
b. Diagnosis of 66 cases of mycobacterias was possible after performance of 2,279 cultures for mycobacterias collected from 700 individuals investigated.
c. Of the 66 patients diagnosed at the Hospital das Clínicas, 21% came from the first aid service and 20% from the wards. Such data mirrors the shortcoming of primary care, raises casuistry of morbidity mortality and exposes health professionals to the risk of infection by the Mtb, as most hospitals do not have bio-security strategies;
d. Analysis of the clinical follow-up of eight patients(15%) that were not aware of the diagnosis of tuberculosis disclosed that in six, treatment anti-TB was not possible (three were not found and three had died).
e. About 46% of the patients were infected by HIV, due to the high morbidity/ lethality observed in these patients, institution of new rapid and effective techniques for the diagnosis of tuberculosis in reference hospital units becomes mandatory.
f. The faulty awareness of the health professionals, the absence of an organized clinical structure integrated with mycobacteriology laboratories were at blame for diagnostic delay;
g. First national study showing performance of operational research carried out by professionals acting at laboratory level together with those in the clinical area aiming to identify answers for the issues of the clinical-laboratory practice in a tertiary hospital.
Operational studies that encompass laboratory and clinical activities such as portrayed in this article, when disclosing to the reader the problems and solutions encountered show that even professionals rendering services as long as the laboratory and/or clinical procedures whose standard operational procedures (SOP) are accomplished, may ponder, analyze their own data and indeed carry out :OPERATIONAL RESEARCH. Results achieved with such surveys are of extreme relevance for a country where college graduate technicians are not accustomed nor feel suited to carry out research and produce scientific knowledge in the domain of health. Furthermore, such results tend to supply the information needed to carry out new interventions and/or approaches as well as to convince the municipal and/or state managers about their feasibility and significance. This is how we begin to give more value to the technique and less to the politics of the interactions within the health area.
Finally, the healthful movement of the Brazilian university professionals must be enhanced, because while performing activities of university extensions they begin to promote a joint action with the professional of a network of services in the combat against a disease prevalent in our milieu and usually neglected.
REFERENCÊS
1. Froes GC, Coutinho RL, Nardy de Ávila M, Cançado LR, Spindola de Miranda S. Perfil e seguimento dos pacientes portadores de Mycobacterium sp. do Hospital das Clínicas da Universidade Federal de Minas Gerais. J Pneumol 2003;29:365-70.
2. Kritski AL, Ruffino-Netto A. Health sector reform in Brazil: impact on tuberculosis control and perspectives. Int J Tuberc Lung Dis 2000;4: 622-6.
3. Ministério da Saúde. Fundação Nacional de Saúde. Centro de Referência Prof. Hélio Fraga/Manual de bacteriologia da tuberculose. 2ª ed., Rio de Janeiro, 1994.
4. Ministério da Saúde. Fundação Nacional de Saúde. Centro de Referência Prof. Hélio Fraga/ Sociedade Brasileira de Pneumologia e Tisiologia. Controle da tuberculose Uma proposta de integração ensino-serviço. 5ª ed., Rio de Janeiro, 2002.
5. Ministério da Saúde. Fundação Nacional de Saúde. Tuberculose Guia de Vigilância epidemiológica, Brasília, 2002.
6. World Health Organization (WHO). Report 2003 www.WHO/CDS/TB/2003.
7. Muzy de Souza GR, Gonçalves M, Carvalho ACC. Controle de infecção hospitalar por tuberculose. Pulmão RJ 1997;6:220-7.
8. Brito L. Tuberculose nosocomial: medidas de controle de engenharia. Boletim de Pneumologia Sanitária, 2001;9:33-50.
9. Galesi V. Tuberculose em hospitais na cidade de São Paulo. Tese de Doutorado Universidade de São Paulo, 2003 (no prelo).
10. Kritski AL, Conde MB, Muzy de Souza GR. Tuberculose. Do Ambulatório à Enfermaria. Ed. Kritski AL. 2ª ed. São Paulo: Editora Atheneu, 2000;212.
11. Anjos Moreira J, Froes GC, Spindola de Miranda S. Cases of tuberculosis diagnosed at Federal University Hospital/Belo Horizonte/MG/Brazil 33rd World Conference on Lung Health of the International Union Against Tuberculosis and Lung Disease (IUATLD). Montreal, Canada, 6-10 October 2002. Int J Tuberc Lung Dis. 2002 Oct;6(Suppl 1):1-210.
12. Selig L, Belo MT, Teixeira EG, Cunha AJ, Brito R, Sanches K, Luna AL, Muller M, Gamba C, Belo C, Vento F, Trajman A. The study of tuberculosis-attributed deaths as a tool for disease control planning in Rio de Janeiro, Brazil. Int J Tuberc Lung Dis. 2003; 7:855-9.
13. Machado de Lacerda AP. Tuberculose e Infecção pelo Vírus da Imunodeficiência Humana: Estudo Descritivo da Co-infecção antes e depois da introdução do Esquema HAART num Hospital de Referência no período de 1995 a 2000. Dissertação de Mestrado, UFRJ, Faculdade de Medicina, 2002. 115p.
Publication Dates
-
Publication in this collection
15 June 2004 -
Date of issue
Dec 2003
