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Print version ISSN 0104-1169
On-line version ISSN 1518-8345
Rev. Latino-Am. Enfermagem vol.16 no.2 Ribeirão Preto Mar./Apr. 2008
ARTIGO DE REVISÃO
Tuberculosis contact control in Brazil: a liberature review (1984-2004)
Cláudia Eli GazettaI; Maria de Lourdes Sperli Geraldes SantosI; Sílvia Helena Figueiredo VendraminiI; Nadia Antonia Aparecida PolettiI; José Martins Pinto NetoII; Tereza Cristina Scatena VillaIII
IPhD, Nursing Faculty, Medical School at São José do Rio Preto, Brazil, e-mail: firstname.lastname@example.org, email@example.com, firstname.lastname@example.org, email@example.com
IIPhD Nursing Faculty at FEF, e-mail: firstname.lastname@example.org
IIIFull Professor, University of São Paulo at Ribeirão Preto, College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil, e-mail: email@example.com
This study aims to review plans for tuberculosis control through the analysis of measures for tuberculosis contact tracing in Brazil from 1984 to 2004. This article presents a literature review on tuberculosis control published in manuals of the Ministry of Health and the State Department of Health of Sao Paulo, and in Medline and Lilacs databases. There was a gap in the standardization of control measures in the decade from 1984 to 1994. It was concluded that health professionals need to incorporate TB control and prevention actions from the perspective of health surveillance and systematic monitoring.
Descriptors: tuberculosis; contact tracing; epidemiological surveillance
Tuberculosis (TB), a millenary disease, remains a relevant public health issue, despite the significant progress achieved in the late 20th century. The advancements in knowledge and technology have not been enough to affect TB morbidity and mortality, especially in developing countries like Brazil(1).
Considering that TB is relevant in term of its transmission mechanism, it requires special care in searching for symptomatic patients. Thus, every alleged case must be examined and, once the diagnose is confirmed, an epidemiologic investigation must be performed and control measures put into practice, according to the norms by the Ministry of Health (MH) and the state Health Secretariat. The epidemiologic investigation has to include the examination of people living with the patient, aimed at finding the source of infection and learning about other cases originating from the index case(2).
The best prevention strategy is to identify and cure positive cases, which is why sputum smears are one of the most relevant epidemiologic indicators. Sputum smears are currently used to express the magnitude of the TB problem and its tendency in a community(3-4).
The source of infection is often an individual with the pulmonary form of the disease, expelling bacilli to the environment according to his or her bacteriologic index (state). It is estimated that, over one year, a single source of infection in a community can infect, on the average, 10 to 15 people (s)he has contact with(3,5).
When a pulmonary TB patient speaks, sneezes and coughs, (s)he sends different sizes of droplets into the air. The heavier droplets land on surfaces, while the lightest drift in the air or evaporate. Wells' droplet nuclei, measuring up to 5m and containing one to two bacilli, can reach an individual's bronchioles and alveoli and initiate multiplication(4).
There is a consensus among TB researchers that every time one person coughs, he or she sends 3,500 infectious particles into the environment and that, every time people sneeze, they cast out one million particles(5). A study performed at the Clementino Fraga Filho University Hospital (HUCFF) showed that the risk of TB contamination among employees at the hospital was 8.2%, against a national average of 0.8%. These results evidenced the TB contamination risk health professionals face in their everyday work activities(5).
Some authors believe that contact control is one way of diagnosing TB at an early stage and reducing its dissemination(4-10). However, it is observed that this strategy has not been effectively put into practice. Despite the recommendation by the Tuberculosis Control Program (TCP), there is no systematic follow up through registries in the information system(8).
In spite of being a serious public health issue in Brazil, few studies look at the assessment of contacts and disease prevention actions among families and the community as part of the health surveillance program(9-11). Thus, this study is justified by the fact that it is based on the need to learn about what authors on TB in Brazil have addressed regarding contacts.
Hence, the purpose of this study was to perform a systematic literature review on studies about "TB patient contact", available in Brazil from 1984 to 2004, identifying the definitions and use of the search terms comunicantes, contatos, contactantes, as well as associated control measures.
A systematic literature review was performed from 1984 to 2004 about TB contacts, using the following descriptors: tuberculose, busca de comunicantes, contatos, quimioprofilaxia, and controle (tuberculosis, contact tracing, contacts, chemoprevention, and control).
The literature review was performed from January 2003 to February 2004, using the LILACS (Latin-American and Caribbean Health Sciences) and SCIELO BRAZIL (Scientific Electronic Library On Line) databases, in addition to electronic pages of the Ministry of Health and the São Paulo State Health Secretariat.
The material was selected according to the following inclusion criteria:
- National articles associated with the evolution of TB contact tracing in Brazil;
- As to the type, the study included articles, manuals, guides and HM plans, guidelines, and consensus;
- Regarding the publication period, the selected material was released between 1984 and 2004. This period was chosen based on the increase in TB cases and the consequent concern with contact tracing;
- As to the themes, publications were considered if they presented the definition of terms and forms of conducts for tracing TB contacts.
Publications were excluded if they did not address the changes in term definition and forms of conduct for TB contact tracing.
Sixty-seven publications were found, 13 of which were selected for analysis in this study. There were seven TB control manuals, two guides, two guidelines published as articles and designed by the Brazilian Society of Pneumology and Tisiology (BSPT) and two plans, as shown in Table 1.
Table 1 presents the general characteristics of the reviewed studies: type and publication year, title and source. It is remarkable that the located publications were manuals, guidelines or plans.
It was observed that every material studied used the terms "controle de comunicantes" (contact tracing), "contatos" (contacts), and "contactantes" as synonyms. Furthermore, it was observed that the official documents published by the Ministry of Health used both the expressions "contatos" and "comunicantes"; and these expressions are also used by Brazilian authors.
The I Brazilian Consensus on Tuberculosis, established in 1997, recommends the term "contactante" be used. But in the II Brazilian Consensus on Tuberculosis, established in 2004, the term used in the guidelines was "contato"(12-18).
Table 3 presents the conduct used for tracing TB contacts from 1984 to 2004.
The term comunicante is defined as the person who maintained contact with patients or bearers of infectious agents, or environments in which they live. The term contactante, on the other hand, refers to any person or animal that has been in contact with the contaminated environment, and have, therefore, had the opportunity of becoming infected(5).
The MH manual of TB control norms, published in 1984, recommended chemoprevention with daily doses of isoniazid at 10 mg/kg for six months. The procedure was initiated for positive-patient contacts, five years old or younger, reactive to TT (not vaccinated with BCG), with normal radiologic exams and no clinical symptoms for TB(12).
In 1987, the Tuberculosis Control manual was published - A proposal to integrate teaching and service, developed through the special collaboration between university professors and TCP technicians. The manual addresses most professionals working in this field(13), and defines comunicantes as "any person, family member or not, living with a tuberculosis patient". This publication maintains the norms established by the MH manual for contact tracing in 1984.
Regarding primary chemoprevention, it was recommended for newborns who had contact with positive patients and could not be kept away from the domicile for three months. After this period, if the source of infection was negative, TT was performed. If reactive, isoniazid treatment was maintained until completing six months. If non-reactive, the isoniazid was interrupted and BCG vaccine was applied. Secondary chemoprevention was recommended in situations such as cases of children five years old or younger, positive-patient contacts, asymptomatic, not vaccinated with BCG, with normal chest XR, and poor or strong TT reaction(13).
In 1989, the MH published another Manual with Tuberculosis Control Norms, maintaining the 1984 conducts, and comunicantes or contatos were defined as "any person, family members or not, living with the tuberculosis patient"(12-14).
In 1992, the third edition of the manual "Tuberculosis Control(15): a proposal to integrate teaching and service" broadens the concept of comunicante, considering them as "any person living with the index-case (the identified patient) at home or any other closed environment, for a long period, and on a daily basis". The manual recommended the following actions: sputum smear for respiratory symptomatic patients, TT for children five years old or younger not vaccinated with BCG, and radiologic exam whenever the resource was available. Strong, asymptomatic, reactive subjects with normal XR should be subject to chemoprevention with isoniazid for six months. Non-reactive subjects were vaccinated with CG or subject to new TT after 20 days. In case the subject remained non-reactive in the second test, BCG vaccine was recommended.
Children aged five years or younger, vaccinated, with normal XR and asymptomatic should be kept under observation and forwarded in case of any alteration. Symptomatic subjects, whose exams did not suggest any disease in activity, should be systematically reevaluated. The treatment was recommended for symptomatic children and/or with radiologic changes and diagnosed for TB. Subjects older than five years and respiratory symptomatic should be subject to sputum smear; when repeated negative results are obtained, a chest XR was recommended. Asymptomatic individuals should receive guidance and be followed.
Regarding HIV-positive individuals, the 1992 National Tuberculosis Control Program (NTCP) recommended chemoprotection for asymptomatic individuals with TT greater than 5 mm of induration, while non-reactive individuals should be followed with laboratory immunological examinations with CD-4 counting(15).
In 1995, the NPTC was subject to a new evaluation. Changes were made in contact tracing procedures, but the second definition presented in the previous manual was maintained(1), used in the singular form and replacing the word "paciente" (patient) with "doente" (ill person). The instruction was that all should attend the health unit for exams. Respiratory symptomatic individuals should be subject to the regular routine. Asymptomatic contacts should be subject to chest XR. For children aged five years or older, the 1992 standards were used. BCG vaccination was recommended for 'health workers who regularly provide service to TB and AIDS patients, non-reactive to TT"(1).
In 1996, with the publication of the Emergency Plan (EP) for Tuberculosis Control in the 230 priority municipalities, the following conducts were recommended in terms of contacts: "[ ]to implement case searches, based on the identification of respiratory symptomatic individuals from the spontaneous demand or referred to the unit for consultation; to implement case searches based on bacteriological exam of every respiratory symptomatic individual; to implement case searches based on all forms of exams for TB-case contacts(16).
The I Brazilian Consensus on Tuberculosis(14) replaces the denomination "comunicante" with "contactante", defined as "every person living with a TB patient". Furthermore, they can be classified as intra-domiciliary (people living in the same home of a TB patient), and extra-domiciliary (people who share common environments with a TB patient, which can be leisure, work, or institutional places)(17).
The following criteria were considered priorities in assessing contacts: a) intra-domiciliary symptomatic individuals of pulmonary TB patients; b) aged less than 15 years or more than 60; c) contacts with conditions predisposing to illness (HIV infected, diabetes or any other immunodeficiency); d) institutional extra-domiciliary contacts(17).
A specific conduct was established: to investigate intra-domiciliary contacts aged 15 years or younger, asymptomatic individuals vaccinated with BCG should be observed; those non-vaccinated would be subject to TT and chemoprotection if reactive; if non-reactive, a new TT was recommended after two or three months. Non-reactive individuals should be vaccinated with BCG, and reactive individuals should follow chemoprotection.
Also in agreement with Consensus I, intra-domiciliary subjects aged 15 years or older and symptomatic should be assessed with chest XR, TT, and BAAR, and treated if positive. Asymptomatic individuals should be kept under observation(17).
In 1998, the NPTC recommended, regarding the search for cases among contacts: to identify the respiratory symptomatic individuals among contacts. The identified respiratory symptomatic individuals should be subject to sputum smears. TB-case contacts should be identified and examined. The respiratory symptomatic individuals with repeatedly negative sputum smear results should be examined with XR and/or sputum culture. Healthy individuals should be protected with BCG vaccination and chemoprotection(16).
In 2002, the MH published research instruments for health professionals, emphasizing the importance of monitoring contacts, as presented below(3-4).
The Tuberculosis Control Manual - a Proposal to Integrate Teaching and Service (2002) maintains the definitions of the 1984 and 1995 manuals(5).
The 2002 Epidemiologic Surveillance Guide(3) recommends that: contact control be performed mainly for contacts living with positive-TB patients, especially intra-domiciliary, and adults living with patients aged five years or younger, in order to identify the infection source. In addition, the assessment of pulmonary TB-case domiciliary contacts with positive sputum smears should follow these recommendations: asymptomatic intra-domiciliary adult contacts, observation and instructions; symptomatic, sputum smears (if negative, observation and instructions, and treat positive cases). Children aged 15 years or less, and not vaccinated, should be subject to TT (if non-reactive, vaccinate with BCG, and, if reactive, chest teleradiography should be performed and, if suggestive for TB and with clinical symptoms, should proceed to treatment). Children with normal chest XR and without clinical symptoms should be forwarded to chemoprotection. Children vaccinated and asymptomatic should only receive instructions. Symptomatic children presenting a vaccination scar should be subject to sputum smear and a chest XR (when suggestive for TB and with clinical symptoms, they should be forwarded for treatment). In cases of normal XR and absence of clinical symptoms, symptomatic medication and follow up should be carried out.
Indications for chemoprotection were maintained for newborns living in an infection focus, and extended to children aged 15 years or younger, not vaccinated with BCG, who had contact with a positive pulmonary-TB case, without TB-disease signs, reactive to TT of 10mm or more.
The II Brazilian Guidelines on Tuberculosis, designed by BSPT in 2004, recommended the conduct proposal in children, TB patient contacts, which determined that diagnosis should be based on clinical examinations, radiologic results, and TT, regardless of the vaccination scar. The history of contact with a TB patient, positive or not, should be valued mainly for children of school age or younger, due to the time of exposure to the transmission focus(18).
In 2004, a new plan is established for the NPTC, which recommends the following actions for TB epidemiologic surveillance: to implement a strategic investigation for an active TB search in emergency hospital services in large urban centers, in groups with greater risks, including indigenous populations, alcoholics, as well as shelter, prison, street populations and people living in risk areas attended by the health units, and also every positive-TB case contact; and intensify contact examination for every TB patient(8).
Thirteen publications were analyzed in this study, seven of which were TB control manuals, two guides, and two guidelines published as articles and designed by the Brazilian Society of Pneumology and Tisiology (BSPT) and two plans. The analyzed material shows growing concern with contact monitoring in Brazil, and also that health service conducts were only proposed in the late 1990's.
The analysis of this material permitted the conclusion that, over ten years, from 1984 to 1994, there were no changes in concepts and conducts on the standardization of actions for the control of TB patient contacts. The conducts were restricted to the people living within the same environment, focused on the family only.
The marginal position that TB contact surveillance actions occupied as an intervention proposal (conduct) for all health services until the late 1990s was reviewed due to the increase in TB cases in that period, which triggered the expansion in concepts and conduct proposals that integrate prevention actions in a systematic way.
Regarding contact analysis and assessment, it is concluded that both the definition and conducts presented in the MH manuals and class associations have been broadened.
As from 1994, the expanded communicant concept has supported the control actions because, instead of considering exclusively the people living with the patients, it included all those people with any direct contact with the patient, at home or at work. Furthermore, it also included priority groups such as HIV-positive individuals, individuals with respiratory symptoms for over three weeks, people living in institutions and health workers who dealt with TB patients. The understanding about the protective action toward the transmission of the TB bacillus was improved. This conduct includes the use of medications, such as chemoprevention with isoniazid, as well as specific action by the health team involved with active case searching. In 2002, it was proposed that communicants be followed with deadlines and through home visits.
Another important issue that occurred in the late 1990s was the reorganization of the cities' health systems through the decentralization of TCP actions to all health services, thus integrating primary health care services. There was an increase in the incorporation of contact assessment activities, which became normatized in TB control manuals.
These standards are valid until today. However, health service organizations face some operational challenges. There is a lack of systematization of contact assessment activities in terms of monitoring and epidemiologic surveillance actions performed by TCP and primary care teams.
Therefore, readjusting the Communicant Control Form can be an important measure to identify the non-assessed individuals and elaborate service and follow-up protocols for TB communicants. Epidemiologic surveillance and monitoring TB and communicants in an integrated fashion through the information systems (SINAN, EPI- TB, WEB-TB) that do not contemplate contact follow-up.
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Recebido em: 7.11.2006
Aprovado em: 3.12.2007