TIME SERIES OF TUBERCULOSIS MORTALITY IN BRAZIL ( 1980-2001 )

This descriptive study aimed to describe Tuberculosis-related mortality in Brazil between 1980 and 2001, through time series analysis of data from the DATASUS related to cases in which Tuberculosis was the basic cause of death. The mortality rates were calculated per 100,000 inhabitants according to gender and age. We found a decrease in Tuberculosis mortality of approximately 42% for men and 54% for women across the period analyzed. The International Classification of Diseases was used: ICD-9, for the period of 1980 to 1995; ICD-10 for 1996 to 2001. Deaths are related to late diagnosis, which is a problem of organization of the primary health care, as neither prevention actions nor case detections by active search for respiratory symptoms were incorporated into the health professionals’ practice which contributes to higher death rates in more vulnerable groups.


Tuberculosis (Tb) remains a major Public
Health issue.This is especially true in developing countries, considering that 95% of the notified cases and 98% of Tb deaths in the world occur in developing areas (1) .The epidemic is disseminated throughout the general population, where it prevails among young adults.Consequently, this affects these countries' economy, and becomes a permanent medical-social issue.Besides the AIDS epidemic, the socioeconomic situation has increased poverty, thus resulting in difficult access to health services, growing periphery populations, population clusters and migrations in the search for a better quality of life.An additional factor is the weakness of the Public Health system, which has become increasingly ineffective over the last decades (2-3)   .
Several studies have called attention to emerging and reemerging diseases.Some even claim that Tb is a reemerging problem.This statement could be valid for some European countries, and even the United States of America, but not for Brazil.Over the last decades, Tb control has been greatly ignored by public policies, society and even the scientific community, in the illusion that the problem had already been solved and/or was under control (4) .An additional factor is the progressive increase of multiple drug resistant bacilli.
In Brazil, similarly to what occurred in other countries on the American Continent, the National Program elaborated successive Tb control plans to reduce the problem.Nevertheless, the country still has approximately 90.000 notified Tb cases per year, and it is estimated that about 30% of cases are underreported, which could cause an aggravation of the disease in the future (5) .In 2000, Brazil had an incidence rate of 48.4/100000 inhabitants, indicating 82,249 new Tb cases.There were 5,879 notified deaths and a mortality rate of 3.8/100,000 inhabitants.The estimate for new Tb cases was 11/100,000 inhabitants, higher than the identified rate.This difference is directly associated with the system of death notifications, because only 70% of the deaths in the country actually reach the information system, and, among these, about 20-30% are deaths by unclear causes (6) .
In Brazil, Tb mortality began to drop drastically in the 1950s, with the advent of chemotherapy, and the speed of decrease was reduced in the following decades.In Brazilian capitals, this reduction amounted to 61.4% between 1970 and 1979, with an average 10% decrease per year.The North and Northeast have always had the highest average rates.Between 1977 and 1987, the decrease was 51.7%; that is, 5.4% per year.In Brazil, among the notified cases of people aged 13 or more, 26.9% of carriers are co-infected with Tb/HIV (7)   .Today, deaths by Tb mostly result from late diagnosis, and are especially concentrated in deprived social groups, which have less access to health care services.It is estimated that, in developed countries, the minimum diagnosis time for Tb carriers is three months (8) .In developing countries, diagnosis takes much longer, and, consequently, leads to a higher number of carriers and new cases (9) .
Regarding Tb, early detection and treatment is a practical measure to save lives and recover patients' health.Before chemotherapy, 50% of untreated patients died, 25% became chronic and 25% were spontaneously cured.Today, the Tb control method used in society is the active search for symptomatic individuals within the community and treatment of new cases as soon as possible.
The purpose of this study is to outline Tb mortality in Brazil from 1980 to 2001.

METHODOLOGY
The

DISCUSSION
Despite the decrease in Tb mortality that has occurred over time in Brazil, the country is still distant from developed countries' rates, of about 1/100,000 inhabitants.In 2002, Africa stood out as the country with the highest Tb mortality and incidence rates in the world: 83 deaths and 350 annual cases for each 100,000 inhabitants, respectively (12) .The significant presence of Tb mortality in the elderly could be attributed to the weakness of health care services, as previously observed (13)(14) .The Tb death ratio in this specific group is alarming.The prevalence of deaths among men found in this study is in agreement with literature (3,(15)(16) .Men usually take longer to seek health care when compared to women.This could suggest a higher lethality among men.It should also be highlighted that the high prevalence of Tb among men is also ascribed to life habits, including alcohol consumption, a factor strongly associated with Tb.It is also possible that women are more resistant than men and are more health-conscientious.
It is to be considered that one of the main problems in making consistent Tb mortality rate estimates is the availability of reliable information regarding death records.Though mandatory in Brazil, both Tb notification and death records are underreported.
The Tb issue in Brazil reflects the country's development stage, in which determinants of poverty, health system weaknesses and administration deficiencies impair the sustained reduction of a disease marked by the social context.The macroeconomic model has clearly affected the persistence of social inequalities (17) and contributes to maintaining the death chain related to a disease that already has an effective treatment.There have been program actions for over three decades.The persistence of high mortality rates, along with the unequal distribution in the urban environment, reveals health service limitations regarding coverage, quality and equity.to a reduced involvement of civil society.It is expected that, through the DOTS strategy, mortality levels decrease at a higher rate than the number of cases (18) .
Nevertheless, it should be stressed that there is a need for more emphasis on research, focused on encouraging the search for symptomatic individuals, reducing diagnosis time, beginning treatment as soon as possible, appropriately providing antitubercular agents, improving patient care and protecting the health staff from nosocomial Tb.

Figure 1
Figure1presents the evolution of Tb mortality per gender.For all study years, rates for men were higher (nearly twice) than for women, and this tendency remained the same in the following years.The decrease observed over the 22 analyzed years was approximately 42% for Tb deaths in men and 54% in women.However,

Figures 3
Figures3 and 4show that Tb death rates in men have always been higher than in women, regardless of the age group.The gender difference in Tb mortality is astonishing.The Tb mortality rate

Figure 3 -
Figure 3 -Tuberculosis mortality rates per gender and age groups, Brazil, 1980 to 2001

Figure 4 -
Figure 4 -Tuberculosis mortality rates per gender and age groups, Brazil, 1980 to 2001 Possible explanations for this behavior include the growing elderly population, confined to nursing homes, difficult access to health services, taking long to seek medical care, unprepared health professionals about the possibility of this age group having Tb, among other factors that might delay disease diagnosis and often lead to death.Mortality has been attributed to irregular/ inappropriate chemotherapy, late diagnosis, multiple drug resistance and HIV co-infection.Each year, numerous Tb carriers are not identified before their death.These cases represent the health system's failures to detect, diagnose and treat the disease.Deaths are associated with late diagnosis, which is a primary health care organization problem.Since prevention actions as well as the search for symptomatic individuals for case detection have not been incorporated into health professionals' practice, death rates have increased in vulnerable age groups, such as the elderly and co-infected individuals.

2000 2001 Year Rates per 100 thousand inhab.
Time series of tuberculosis... Hino P, Costa-Júnior ML, Sassaki CM, Oliveira MF, Villa TCS, Santos CB.Rev Latino-am Enfermagem 2007 setembro-outubro; 15(5):936-41 www.eerp.usp.br/rlaeThroughout the studied time series, the country has undergone important changes.Regarding Public Health Policies, the implementation of the Single Health System (SHS) in 1988 stands out, which represented a new paradigm in Brazilian health care, either in the political, technological or ideological sense.Like in other countries, fighting Tb is difficult due to low political commitment at different governmental levels, in addition