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Revista Brasileira de Epidemiologia

Print version ISSN 1415-790XOn-line version ISSN 1980-5497

Rev. bras. epidemiol. vol.22  São Paulo  2019  Epub Aug 22, 2019

http://dx.doi.org/10.1590/1980-549720190043 

ORIGINAL ARTICLE

Tuberculosis fatality rates in the city of Campinas - São Paulo, Brazil, from 2001 to 2009

Taxas de letalidade por tuberculose na cidade de Campinas, São Paulo, Brasil, de 2001 a 2009

Helenice Bosco de OliveiraI 

Letícia Marin-LéonI 
http://orcid.org/0000-0001-6214-1173

Nanci Michele SaitaII 
http://orcid.org/0000-0002-0203-2765

Jonathan Eric GolubIII 

IDepartment of Collective Health, Universidade Estadual de Campinas - Campinas (SP), Brazil.

IIHospital de Clínicas, Universidade Estadual de Campinas - Campinas (SP), Brazil.

IIIJohns Hopkins Bloomberg School of Public Health - Baltimore (MD), United States.


ABSTRACT:

Introduction:

The mortality rate among tuberculosis patients (TB fatality) has been attributed to irregular chemotherapy, delay in diagnosis, multidrug resistance, and HIV coinfection.

Objective:

To analyze TB fatality rates by sex, clinical presentation and HIV coinfection in Campinas, São Paulo, Brazil.

Methods:

Cohorts of residents in the city of Campinas who either died during treatment for tuberculosis or had the disease confirmed after death were divided into three intervals: 2001-2003, 2004-2006, and 2007-2009. Data were obtained from the database of the Tuberculosis Surveillance System of the University of Campinas, and notifications were gathered through TB-WEB Health São Paulo Secretary. Statistical significance was determined using a chi-square test, considering p < 0.05.

Results:

Between 2001 and 2009, 3,416 TB patients were diagnosed: 2,827 (82.8%) were new TB cases and 589 (17.2%) were retreatments. Between the first and second triennium, the number of new patients decreased by 18%, and 23% among retreatments. Between the second and third intervals, the reduction was 5% and 21%, respectively. General case fatality rate declined from 11.4% to 9.9% across intervals, and was most significant among patients that had previously abandoned treatment (17.3% to 5.1%). Fatality rates among patients coinfected with TB-AIDS were 2-3 times that of patients not infected with TB-AIDS throughout the intervals. Fatality between the first and third triennium among TB-AIDS co-infected patients declined (24.8% to 19.5%), while increasing slightly among non-AIDS TB patients (7.3% to 8%) during this period.

Conclusion:

Though mortality among TB-AIDS patients declined from 2001-2009, rates among non-AIDS TB remained stagnant. Improved TB diagnosis and treatment is needed to further decrease TB mortality in Campinas.

Keywords: Tuberculosis; AIDS; Case fatality rate; Comorbidity; Treatment; Mortality

RESUMO:

Introdução:

A letalidade por tuberculose tem sido atribuída à quimioterapia irregular, à demora no diagnóstico, à multidrogarresistência, à coinfecção com o vírus da imunodeficiência humana (HIV).

Objetivo:

Analisar letalidade por tuberculose segundo sexo, apresentação clínica, presença da coinfecção pelo HIV, em Campinas, São Paulo, Brasil.

Metodologia:

Foram verificadas coortes de residentes em Campinas que morreram durante tratamento para tuberculose e aqueles notificados após óbito, agrupados em três intervalos: 2001-2003, 2004-2006 e 2007-2009. As informações foram obtidas no Banco de Dados para Vigilância da Tuberculose da Universidade Estadual de Campinas (UNICAMP), com captação das notificações no Sistema de Notificação e Acompanhamento de Casos de Tuberculose da Secretaria Estadual de Saúde de São Paulo. A significância estatística foi verificada pelo teste χ2 considerando p < 0,05.

Resultados:

Entre 2001 e 2009, foram diagnosticados 3.416 pacientes com tuberculose: 2.827 (82,8%) sem tratamento anterior e 589 (17,2%) com retratamentos. Entre o primeiro e o segundo triênio, o número de pacientes novos diminuiu 18% sem tratamento anterior e 23% entre retratamentos. Entre o segundo e o terceiro intervalo, a redução foi de 5 e 21%, respectivamente. A letalidade geral declinou de 11,4 para 9,9%, diferença mais significante entre os que haviam abandonado tratamento anteriormente (17,3 para 5,1%). A letalidade entre pacientes com coinfecção tuberculose-síndrome da imunodeficiência adquirida (Aids) foi 2-3 vezes maior que entre tuberculose sem aids durante todo o período estudado. A letalidade entre o primeiro e o terceiro triênio declinou no grupo com tuberculose-aids (24,8 para 19,5%), enquanto teve ligeiro aumento entre tuberculose sem aids (7,3 para 8%).

Conclusão:

Embora a mortalidade entre pacientes com tuberculose-aids tenha diminuído de 2001-2009, as taxas no grupo tuberculose sem aids permaneceram estagnadas. Melhorias no diagnóstico e no tratamento são necessárias para a redução da mortalidade entre pacientes com tuberculose em Campinas.

Palavras-chave: Tuberculose; Aids; Letalidade; Comorbidade; Tratamento; Mortalidade

INTRODUCTION

Brazil still remains on the World Health Organization’s list of 22 high-burden tuberculosis (TB) countries, although the country has successfully met the Stop TB Partnership target of a 50% reduction in the mortality rate by 20151.

The emergence of the HIV epidemic in the 1980s led to global changes in the epidemiologic trend of tuberculosis morbidity and mortality, reversing decades of declining rates. Prior to the HIV epidemic, TB surveillance and control programs were shortchanged as resources were shifted from the TB program to other programs2, thus setting the stage for a reemerging epidemic in the late 1980s3,4. The advent of antiretroviral treatment (ART) programs in the mid 1990s helped to decrease TB mortality among TB-AIDS patients in Brazil5, particularly because Brazil took the bold step of paying for ART for patients in need6. Furthermore, the expansion of the WHO’s DOTS strategy significantly impacted TB mortality worldwide7.

In Campinas, a large industrial city in the state of São Paulo, the richest in the country, a reduction in case fatality rates was observed between 1993 to 2000 from 18.1% to 13.5%. This reduction was determined to be related to the introduction of ART5. The Campinas health care system is well organized, and at present, primary care is offered at 65 clinics. As in all of Brazil, TB and HIV/AIDS laboratory exams and treatment are free. Treatment of drug sensitive pulmonary tuberculosis with standard anti-tuberculosis drugs is highly efficacious, though some patients receiving these drugs still die. We set out to determine mortality trends in Campinas, specifically, to describe TB case fatality rates by sex, clinical presentation and presence of HIV co-infection in the period of 2001 to 2009, stratified by triennium.

METHODS

TB morbidity and mortality data were abstracted from local registries for residents of Campinas city (the State of São Paulo, Brazil) from January 1, 2001 through December 31, 2009. The analysis included patients that died during treatment and those that were diagnosed after death. Prisoners and all patients with non-tuberculosis mycobacterium were excluded from the study.

Pulmonary TB cases were defined by a sputum positive smear and/or culture for mycobacteria (BK), or suggestive radiology images with respiratory complaints. Extra-pulmonary TB was defined by a positive smear/culture for BK in any secretion, liquid or tissue sample, from radiology, histology or laboratory analysis.

Since 1993, a TB Surveillance Data Bank has been kept by the State University of Campinas. Data were retrieved from the National Notification System (SINAN) administered by the Health Ministry through 2006, and since 2007 from the TB-WEB, run by the São Paulo Health Secretary.

The TB Surveillance Data Bank includes all variables registered in the case notification form, including registration date, smear and culture results, radiology and laboratory analysis, date treatment began, anti-tuberculosis drugs and treatment outcomes. TB-AIDS was defined by the assistant doctor and registered in the comorbidity item of the notification form.

The main demographic variables included in this analysis were sex, age, and primary health unit that reported the case. Health variables included type of entrance in the notification system - new case or history of previous treatment (relapse, dropout or failure), clinical presentation (pulmonary and extra-pulmonary), laboratory exams (smear, culture, HIV), presence of other diseases (AIDS, diabetes, alcoholism, etc.), and treatment outcome (cure, county transfer, dropout, death, failure). Thus death data registered in SINAN or TB-WEB underwent confirmation and eventual correction using SIM. The later was used to verify under-notification.

Data tabulation of new cases, relapse, dropout and failure among cases and deaths, calculation of case-fatality rates by period, and stratification by sex, period and clinical form was performed using Epi Info 6.04d and Microsoft Excel 2007 for three periods 2001-2003, 2004-2006 and 2007-2009. Statistical significance among proportions was determined using the chi square test (p < 0.05). Trends were analyzed using the chi square test for linear trends by Epi Info Statcalc, version 6.04.

The project was approved by the Ethics Research Committee of the School of Medical Sciences at the State University of Campinas.

RESULTS

Between 2001 and 2009, 3,416 TB cases were diagnosed. Of these, 2,827 (82.8%) were newly diagnosed TB cases and 589 (17.2%) were retreatment cases. Across the first 3-year intervals, new cases diminished 18%, while retreatment cases declined 23%. The decline was 5 and 21%, respectively, between the second and third intervals. General case fatality rate had a slight but not significant decline from 11.4 to 9.9% between the first and third triennium. Prior treatment dropout was the only group where fatality rate diminished significantly, from 17.3 to 5.1%. There was a decreasing linear trend for retreatment cases vs new cases (p = 0.038), and the same occurred for deaths (p = 0.038) (Table 1).

Table 1. Tuberculosis patients, deaths, and fatality rates in the city of Campinas-SP-Brazil, 2001 to 2009. 

Variables 2001-2003 2004-2006 2007-2009 p-value
n % n % n %
Entrance
New case 1088 81.4 891 82.4 848 84.9 0.087
Relapse 111 8.3 92 8.5 69 6.9 0.336
Previous dropout 133 10.0 95 8.8 79 7.9 0.198
Failure 4 0.3 3 0.3 3 0.3 0.994
Total number of cases 1336 100 1081 100 999 100
Deaths
New case 116 76.3 94 81.0 86 86.9 0.117
Relapse 13 8.6 14 12.1 8 8.1 0.528
Previous dropout 23 15.1 8 6.9 4 4.0 0.007
Failure 0 0 0 0 1 1.0 -
Total number of deaths 152 100 116 100 99 100
Fatality rate
New case 10.7 10.5 10.1 0.929
Relapse 11.7 15.2 11.6 0.701
Previous dropout 17.3 8.4 5.1 0.014
Failure - - 33.3 -
General 11.4 10.7 9.9 0.526

Statcalc linear trend for retreatment patients vs new patients p = 0.038; Statcalc linear trend for retreatment deaths vs new patient deaths p = 0.038.

During the whole study period, 687 (20.1%) patients were notified to have TB-AIDS and 2,729 (79.9%) did not have the coinfection (Table 2). Males constituted the vast majority of cases (68.4%) and deaths (74.1%), both among TB-AIDS and non-AIDS TB patients. The case fatality rate was more than double for TB-AIDS patients compared to non-AIDS TB patients in the first (24.8 and 7.3%) and last triennium (19.5 and 8.0%). In the first triennium, among TB-AIDS patients, male fatality rate was the highest (26%). In the second triennium, the highest was among female (31.1%). Non-AIDS TB men had higher fatality rates than women in all the trienniums. Male TB-AIDS patients compared to non-AIDS TB patients had a decreasing linear trend for cases and deaths (p < 0.001) (Table 2).

Table 2. Tuberculosis patients with and without AIDS, according to sex, death and fatality rates. Campinas, SP, Brazil, 2001 to 2009. 

Variables 2001-2003 2004-2006 2007-2009 p-value
n % n % n %
TB-AIDS
Patients (N = 687)
Female 80 25.7 61 29.5 55 32.5 0.269
Male 231 74.3 146 70.5 114 67.5
Total 311 100 207 100 169 100
Deaths (N = 160)
Female 17 22.1 19 38.0 11 33.3 0.134
Male 60 77.9 31 62.0 22 66.7
Total 77 100 50 100 33 100
Fatality rate
Female 21.3 31.1 20.0 0.283
Male 26.0 21.2 19.3 0.318
Total 24.8 24.2 19.5 0.406
non-AIDS TB
Patients (N = 2,729)
Female 348 33.9 285 32.6 251 30.2 0.250
Male 677 66.1 589 67.4 579 69.8
Total 1,025 100 874 100 830 100
Deaths (N = 207)
Female 19 25.3 18 27.3 11 16.7 0.303
Male 56 74.7 48 72.7 55 83.3
Total 75 100 66 100 66 100
Fatality rate
Female 5.5 6.3 4.4 0.615
Male 8.3 8.2 9.5 0.658
Total 7.3 7.6 8.0 0.876

Statcalc linear trend for TB-AIDS male patients vs non-AIDS TB male patients p < 0.0001; Statcalc linear trend for TB-AIDS male death vs non-AIDS TB male deaths p < 0.001.

TB-AIDS patients had nearly twice or more than three times the fatality rate of non-AIDS TB patients, depending on the clinical form and period (Table 3). In 2001-2003, the highest fatality rate was among TB-AIDS retreatment cases with a pulmonary presentation (31.9%) (Table 3). From 2004 onwards, the highest fatality rates were among TB-AIDS new cases with an extra-pulmonary form (33.3 and 27.3% respectively) (Table 3).

Table 3. Deaths and fatality rates among tuberculosis patients according to clinical presentation and AIDS comorbity. Campinas, SP, Brazil, 2001 to 2009. 

Variables 2001-2003 2004-2006 2007-2009 p-value
n % n % n %
I. New cases
Pulmonary presentation
Patients
TB-AIDS 176 18.9 92 12.5 97 13.5 < 0.001
non-AIDS TB 757 81.1 642 87.5 624 86.5
Total 933 100 734 100 721 100
Deaths
TB-AIDS 43 44.8 22 31.0 16 22.9 0.010
non-AIDS TB 53 55.2 49 69.0 54 77.1
Total 96 100 71 100 70 100
Fatality rate
TB-AIDS 24.4 23.9 16.5 0.288
non-AIDS TB 7.0 7.6 8.7 0.517
Total 10.3 9.7 9.7 0.892
Extra-pulmonary presentation
Patients
TB-AIDS 51 32.9 39 24.8 33 26.0 0.237
non-AIDS TB 104 67.1 118 75.2 94 74.0
Total 155 100 157 100 127 100
Deaths
TB-AIDS 9 45.0 13 56.5 9 56.2 0.708
non-AIDS TB 11 55.0 10 43.5 7 43.8
Total 20 100 23 100 16 100
Fatality rate
TB-AIDS 17.6 33.3 27.3 0.225
non-AIDS TB 10.6 8.5 7.5 0.728
Total 12.9 14.7 12.6 0.855
II. Retreatment
Pulmonary presentation
Patients
TB-AIDS 69 31.5 62 36.7 32 23.0 0.035
non-AIDS TB 150 68.5 107 63.3 107 77.0
Total 219 100 169 100 139 100
Deaths
TB-AIDS 22 66.7 12 63.2 8 61.5 0.936
non-AIDS TB 11 33.3 7 36.8 5 38.5
Total 33 100 19 100 13 100
Fatality rate
TB-AIDS 31.9 19.4 25.0 0.260
non-AIDS TB 7.3 6.5 4.7 0.684
Total 15.1 11.2 9.4 0.241
Extra-pulmonary presentation
Patients
TB-AIDS 15 51.7 14 66.7 7 58.3 0.572
non-AIDS TB 14 48.3 7 33.3 5 41.7
Total 29 100 21 100 12 100
Deaths
TB-AIDS 3 100 3 100 0 - -
non-AIDS TB 0 - 0 - 0 - -
Total 3 100 3 100 0 - -
Fatality rate
TB-AIDS 20.0 21.4 - 0.417
non-AIDS TB - - - -
Total 10.3 14.3 - 0.404

Statcalc linear trend for new pulmonary TB-AIDS patients vs non-AIDS TB patients p = 0.001; Statcalc linear trend for new pulmonary TB-AIDS deaths vs non-AIDS TB deaths p = 0.002.

There were 488 new TB-AIDS patients, 365 (74.8%) of which had a pulmonary presentation. This proportion was 86.5% among the 2,339 non-AIDS TB patients. Comparing the third with the first triennium, these cases decreased by 44.9% among TB-AIDS patients and 17.6% among non-AIDS TB patients. A decreasing linear trend was observed for new cases of pulmonary TB-AIDS and deaths when compared with non-AIDS TB cases (p = 0.001 and p = 0.002) (Table 3).

DISCUSSION

In Campinas, the total number of TB patients has diminished in relation to the annual mean of the first years (1997-2000)5 with Highly Active Antiretroviral Therapy (HAART) both among male and female patients with and without HIV.

Fatality rates in the period from 2001 to 2009 were lower than in the period from ­1997-2000 among TB non-AIDS patients5. No consistent differences in the trend of fatality rates were observed among the sexes.

The predominance of the male sex among both TB non-AIDS and TB-AIDS patients is a fact observed by many authors8,9 and also previously described in the city5.

Before HAART in Campinas, the number of TB-AIDS patients represented 28.7% of all TB cases5. This proportion dropped to 24.6% after HAART was introduced5. In the years covered by this study, it gradually decreased to 23.3% (2001-2003), 19.1% (2004-2006) and 16.9% (2007-2009).

In consonance with several studies10 performed in Campinas, TB-AIDS cases presented much higher fatality rates (19.5 to 24.8%) than TB non-AIDS cases (7.3 to 8.0%). Similar fatality rates were observed in 2000-2006 in the State of Espírito Santo, Brazil (28.8% among TB-AIDS patients and 5.9% among non-AIDS TB patients)11. In a sample of 2,473 hospitalized patients in the city of São Paulo, Brazil in 2001, fatality rates were similar for TB-AIDS cases (24%) but much higher among non-AIDS TB cases (15.1%), which can be explained by the severity of the clinical presentation of patients that need hospital care, considering that disseminated TB that killed 66% of the patients with this clinical form12. In a cohort of 887 pulmonary TB patients followed for two years in a Tanzanian city13, fatality among the TB-AIDS cases (29.7% in 471 patients) was similar to that in Campinas, and quite lower among non-AIDS TB cases (3.6% in 416 patients). In spite of this later fatality13, it can be argued that important efforts need to be done in Campinas to reduce fatality among pulmonary TB patients without HIV.

The lack of significant reduction in the fatality rates of TB-AIDS in Campinas denotes no real improvement in treatment. On the other hand, the reduction in the proportion of patients with TB-AIDS represents an advancement in the prevention and control of AIDS, since less people become ill with TB-AIDS. In New York City, between 1995 and 2004, the fatality rate of TB-AIDS decreased from 26% to 14%14. In Cambodia, a study of 490 non-AIDS TB patients and 339 TB-AIDS patients treated in TB clinics, observed a case-fatality rate of 37% in 2004 when HAART had not been implemented, and a 18% rate in 2005, when it was used along with anti-TB treatment15. In the same years, among non-AIDS TB patients, the fatality rate remained at 5%15. As observed by Lawn et al.16, to reduce mortality among AIDS patients, early diagnosis and ARV treatment must be improved, because mortality is associated with low CD4 cell count, less than 50 cells/µl, and an advanced stage of the disease. In Rio de Janeiro, Brazil, the proportion of AIDS patients with tuberculosis diagnosed annually decreased from 24.4% in 1995 to 15.2% in 1998, but from 1995 to 2004, there was no further improvement. Pacheco et al.17 pointed out that to reduce TB incidence among AIDS patients, earlier HIV/AIDS diagnosis and ART initiation is needed.

Although extra-pulmonary TB is more difficult to diagnose than pulmonary TB, in Campinas, their fatality rates were not significantly different among new and retreatment cases, and among non-AIDS TB and TB-AIDS cases. Since clinical presentation does not contribute to differences in fatality rates, it may be observed that once extra-pulmonary presentations are diagnosed, they are adequately treated.

In essence, treating patients with a previous history of TB might be more difficult than treating new cases, because of immunologic deficiencies among relapse patients, resistance to adherence among dropouts, or multidrug resistance among failures. Nevertheless, in Campinas, a significant reduction in fatality rates among patients with previous dropout (p < 0.014) was observed. This data points to better management of retreatment patients, with a provable improvement in the quality of management, resulting in higher adherence to treatment.

Most conditions related to higher TB incidence and TB fatality are poor living conditions, being homeless, unhealthy lifestyle (smoking and alcoholism)1, all of which are in some degree related to poor schooling18,19. Health Education is an important issue in the management of TB. It has been observed that people that have a general knowledge about TB have better care-seeking behavior and understand the need of daily and prolonged treatment20, having higher adherence to treatment. In Rio de Janeiro, in populations living in slums, it was observed that when community health workers were engaged in Directly Observed Treatment Short-courses (DOTS), the patients adherence to treatment was higher21. These professionals are able to communicate with efficiency among poor people, reducing social inequalities in health.

Interrupting treatment during the intensive phase has been associated with increased risk of death22, and it represents lack of adherence. In Campinas, as in all of Brazil, DOTS is considered to be present when 24 doses are supervised in the first 60 days of treatment23. This lower number of supervised doses might be a point to be improved in order to reduce morbidity and mortality. In Rio de Janeiro, patients’ engagement in DOTS conducted by community health workers resulted in higher cure rates and lower fatality, when compared to self-administered therapy21.

Some limitations of this manuscript, with secondary data, include lack of information to track dropouts and transfers. As such, our fatality rates may be underreported. Also, the lack of information from DOTS at an individual level impairs the possibility of evaluating the importance of this factor. In TB-AIDS cases, the lack of clinical severity variables, such as CD4 cell count, is a barrier in understanding the degree in which it contributes to fatality rates.

CONCLUSION

Although the absolute number of cases, mainly those with a pulmonary presentation and with TB-AIDS, decreased in Campinas, non-AIDS TB and TB-AIDS fatality rates have not diminished, except for previous dropouts, which remain much higher than in other countries or cities reported in this paper. Epidemiological surveillance has an important role in evaluating the adequate registration of the compulsory notification form and in monitoring TB cases reported in a municipality.

Considering that TB is curable, and thus deaths from this disease are avoidable, the quality of the diagnosis process - treatment initiation and adequate quality of treatment, including direct supervision according to the terms defined by the WHO and patient follow-up - must be constantly revised in order to decrease fatality rates in Campinas.

ACKNOWLEDGEMENTS

We thank the coordinators of the TB State Program who gave us access to the TB-WEB, enabling the direct research of notification forms in order to maintain the TB Surveillance Data Bank of the State University of Campinas. We are grateful to ICOHRTA-Brazil (International Clinical, Operational and Health Services Research training awards for AIDS and Tuberculosis) and John’s Hopkins University for having awarded two of the authors with a summer training program on TB at John’s Hopkins University.

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Financial support: none.

Received: March 19, 2013; Accepted: August 05, 2015

Corresponding author: Helenice Bosco de Oliveira. Rua Waldyr Aparecido da Silva, 60, Residencial II, Condomínio Barão do Café, Barão Geraldo, CEP: 13085-065, Campinas, SP, Brazil. E-mail: helenice@unicamp.br

Conflict of interests: nothing to declare

Author’s contributions: All of the authors contributed to the paper, but the first and the second authors came up with the subject matter, since is a continuation of their work from a previous decade. The third author did her master’s degree working with HIV-TB co-infection in the city of Campinas and the fourth author assisted in reviewing the material.

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