Fatores associados ao abandono do tratamento da tuberculose em um município prioritário do Brasil: um estudo de coorte

Objectives: For this work was conducted two studies, aiming: i) to evaluate risk factors for default TB treatment by means of a cohort study (study 1) and ii) to compare the incidence of the outcomes of a subgroup of prevalent and incident cases of TB, followed directly, with another accompanied by indirectly through the records of the department of epidemiology of the municipality (study 2). Methods: Study1: We conducted a cohort study involving tuberculosis patients in referral centers in the city Juiz de Fora (JF), Minas Gerais, in the period 2008-2009, comparing those who were cured (n = 172) with those who have dropout (n = 48). To assess factors associated with dropout, we used multivariate theoretical models for determining three hierarchical levels of explanatory variables (distal, intermediate and proximal). The variables were adjusted for within each level, those with a significance level of p 0.20 were transferred to the upper level. In the final multivariate model, the variables that do not present significant were removed until all variables in the model were significant (p 0.05), reaching a level appropriate to the model setting. Study 2: To compare the effects of closures of TB cases followed directly (n = 287) with indirect (n = 216) form, among the reported (n= 503) of the Notifiable Diseases Information System (SINAN), by JF, 2008-2009, a prospective open cohort study was conducted. Results: Study1: Of the closures directly tracked n= 220, 172 (78.2%) and 48 (21.8%) were cured and abandonment as closures. In the model there is a direct association between the intensity of drug use and the incidence of dropouts, and increasing the risk of abandonment towards ex-users (OR= 4.12, 95% CI 1.11 to 15.20), cocaine users alone or in combination with cannabis (OR= 5.67, 95% CI 1.34 to 24.03) and crack users alone or combined with other drugs (OR= 12.25, 95% CI 3.04 to 49.26). Additionally, individuals who drink heavily have a higher risk of dropping out of treatment that individuals who drank in the last year or drink moderately (OR= 2.94, 95% CI 1.08 to 7.99). Study 2: The number / incidence of dropouts was greater (p<0.05) between the monitored directly (53/18, 5%) compared with the monitored indirectly (6/2, 8%) and even with the total notified to SINAN (14/2, 8%). The relative risk (RR) of noncompliance with direct monitoring group was 6.64 (95% CI 2.91 to 15.18). Anyway, there was a higher incidence of dropouts in the population monitored directly, which mostly remained neglected to SINAN. Conclusion: Evidenced the need for effective measures to improve TB control and data quality SINAN-TB and TB should be seen not only in the physical point of view, but also with the complex relationship with the various social factors outside the health unit, which must be taken into account both the prevention and treatment of disease.Objetivos: Para este trabalho foi desenvolvido dois Estudos, objetivando: i) avaliar fatores de risco para o abandono do tratamento da TB, por meio de um estudo de coorte (estudo 1), e ii) comparar a incidência dos desfechos dos tratamentos de um subgrupo de casos prevalentes e incidentes de TB, acompanhado diretamente, com a de outro acompanhado indiretamente, por meio dos registros do departamento de epidemiologia do município (estudo 2). Metodologia: Estudo1: Realizou-se um estudo de coorte envolvendo pacientes notificados com tuberculose em centros de referência, no município Juiz de Fora (JF), Minas Gerais, no período de 2008 a 2009, comparando os que tiveram cura (n=172) com os que abandonaram (n=48). Para avaliar fatores associados ao abandono, utilizou-se modelos teóricos multivariados de determinação com três níveis hierarquizados de variáveis explicativas (distai, intermediário e proximal). As variáveis foram ajustadas entre si dentro de cada nível, aquelas com nível de significância p 0,20 foram transferidas para o nível superior. No modelo multivariado final, as variáveis que não se apresentarem significativas foram removidas até que todas as variáveis do modelo fossem significativas (p 0,05), alcançando um nível de ajuste adequado ao modelo. Estudo 2: Para comparar as incidências de encerramentos dos casos de TB acompanhadas diretamente (n=287) com as de forma indireta (n=216), dentre os notificados (n=503) ao Sistema de Informação de Agravos de Notificação (SINAN), por JF, 2008 a 2009, foi conduzido um estudo de coorte aberto prospectivo. Resultados: Estudol: Do total de encerramentos acompanhados diretamente n=220, 172 (78,2%) e 48 (21,8%) tiveram cura e abandono como encerramentos. No modelo houve uma associação direta entre a intensidade do uso de drogas e a incidência de abandonos, sendo os riscos de abandonos crescentes no sentido ex-usuários (OR= 4,12, 1095% 1,11 — 15,20), usuários de cocaína isolada ou em combinação com maconha (OR= 5,67, IC95% 1,34 — 24,03) e usuários de crack isolado ou combinado com outras drogas (OR=12,25, 1095% 3,04 —49,26). Adicionalmente, Indivíduos que bebem exageradamente tiveram mais risco de abandonar o tratamento que os indivíduos que não beberam no último ano ou bebem de forma moderada (OR= 2,94, 1095% 1,08 — 7,99). Estudo 2: O número/incidência de abandonos foi maior (p<0,05) entre os acompanhados diretamente (53/18,5%), comparado com os acompanhados indiretamente (6/2,8%) e, mesmo com o total notificado ao SINAN (14/2,8%). O risco relativo (RR) de abandono no grupo com acompanhamento direto foi de 6,64 (IC 95% 2,91-15,18). Enfim, verificou-se uma maior incidência de abandonos na população acompanhada diretamente, que, em sua maioria, permaneceu negligenciada ao SINAN. Conclusão: Evidenciou-se a necessidade de medidas efetivas para melhoria do controle da TB e da qualidade dos dados do SINAN-TB e que a tuberculose deve ser vista não só no ponto de vista físico, mas também com a complexa relação com os vários fatores sociais fora da unidade de saúde, os quais devem ser levados em conta tanto na prevenção quanto no tratamento da doença

Profile and follow-up of patients with tuberculosis in a priority city in Brazil

<div><p>OBJECTIVE To analyze the cases of tuberculosis and the impact of direct follow-up on the assessment of treatment outcomes.METHODS This open prospective cohort study evaluated 504 cases of tuberculosis reported in the Sistema de Informação de Agravos de Notificação (SINAN – Notifiable Diseases Information System) in Juiz de Fora, MG, Southeastern Brazil, between 2008 and 2009. The incidence of treatment outcomes was compared between a group of patients diagnosed with tuberculosis and directly followed up by monthly consultations during return visits (287) and a patient group for which the information was indirectly collected (217) through the city’s surveillance system. The Chi-square test was used to compare the percentages, with a significance level of 0.05. The relative risk (RR) was used to evaluate the differences in the incidence rate of each type of treatment outcome between the two groups.RESULTS Of the outcomes directly and indirectly evaluated, 18.5% and 3.2% corresponded to treatment default and 3.8% and 0.5% corresponded to treatment failure, respectively. The incidence of treatment default and failure was higher in the group with direct follow-up (p < 0.05) (RR = 5.72, 95%CI 2.65;12.34, and RR = 8.31, 95%CI 1.08;63.92, respectively).CONCLUSIONS A higher incidence of treatment default and failure was observed in the directly followed up group, and most of these cases were neglected by the disease reporting system. Therefore, effective measures are needed to improve the control of tuberculosis and data quality.</p></div