Abstract
BackgroundTuberculosis (TB) control programs face the challenges of decreasing incidence, mortality rates, and drug resistance while increasing treatment adherence. The Brazilian TB control program recommended the decentralization of patient care as a strategy for combating the disease. This study evaluated the performance of this policy in an area with high default rates, comparing epidemiological and operational indicators between two similar municipalities.MethodsThis study analyzed epidemiological and operational indicators on new cases of pulmonary tuberculosis reported in the Brazilian Notifiable Diseases Information System between 2006 and 2015. In addition, to characterize differences between the populations of the two studied municipalities, a prospective cohort study was conducted between 2014 and 2015, in which patients with new cases of culture-confirmed pulmonary tuberculosis were interviewed and monitored until the disease outcome. A descriptive analysis, the chi-square test, and a Poisson regression model were employed to compare TB treatment outcomes and health care indicators between the municipalities.ResultsTwo thousand three hundred nine cases were evaluated, of which 207 patients were interviewed. Over the 2006–2015 period, TB incidence per 100,000 population in the municipality with decentralized care was significantly higher (39%, 95% CI 27–49%) in comparison to that of the municipality with centralized care. TB treatment default rate (45%, 95% CI 12–90%) was also higher in the municipality with decentralized care. During the two-year follow-up, significant differences were found between patients in centralized care and those in decentralized care regarding treatment success (84.5 vs. 66.1%), treatment default (10.7 vs. 25.8%), illicit drug use (27.7 vs. 45.9%), and homelessness (3.6 vs. 12.9%). The operational indicators revealed that the proportion of control smear tests, medical imaging, and HIV tests were all significantly higher in the centralized care. However, a significantly higher proportion of patients started treatment in the early stages of the disease in the municipality with decentralized care.ConclusionsThese data showed a low success rate in TB treatment in both municipalities. Decentralization of TB care, alone, did not improve the main epidemiological and operational indicators related to disease control when compared to centralized care. Full implementation of strategies already recommended is needed to improve TB treatment success rates.
Highlights
Tuberculosis (TB) control programs face the challenges of decreasing incidence, mortality rates, and drug resistance while increasing treatment adherence
The recommendations of the Directly Observed Treatment Short-Course (DOTS) strategy were established based on observations made of the health services and the acknowledgement that their lack of organization to ensure the detection and cure of TB patients was a major problem in TB control [2, 3]
Data on a 10-year period (2006 to 2015) were retrieved from the Notifiable Diseases Information System (SINAN), available on the TABNET platform of the Santa Catarina Epidemiological Surveillance Department (DIVE/SC), and a prospective cohort study was performed with patients diagnosed with culture-confirmed pulmonary tuberculosis who started treatment between 2014 and 2015
Summary
Tuberculosis (TB) control programs face the challenges of decreasing incidence, mortality rates, and drug resistance while increasing treatment adherence. The Brazilian TB control program recommended the decentralization of patient care as a strategy for combating the disease. The Directly Observed Treatment Short-Course (DOTS) strategy, recommended by the World Health Organization (WHO) since 1993, remains as the main pillar for TB control programs. This strategy was based on a model developed by Karel Styblo in 1970, using a management approach for case detection and treatment through supplying basic health units (BHUs) with the necessary resources and personnel to perform the diagnosis, treatment, recording, and progress reporting of TB patients in areas with 100,000 to 150,000 inhabitants [2]. The process of decentralization has not been adopted by all Brazilian municipalities designated as priorities by the National Tuberculosis Control Program (PNCT)
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