Tuberculose em Recife, PE: o efeito da estratégia DOTS (Directly Observed Treatment Short-course) e fatores associados ao óbito e ao abandono de tratamento, 1996 a 2005

Abstract

The abandonment of tuberculosis treatment is considered as the main obstacle to control the disease. The persistence of the infection source, increase in mortality and recurrence rate, besides the development of medicament resistant types are related to abandonment of the treatment. The essential components of tuberculosis control policies have been synthesized into a set, which constitutes the DOTS (Directly Observed Treatment Short-course) strategy, recommended by the WHO. This paper is meant to identify the factors associated with deaths and abandonment of treatment in tuberculosis cases for those living in Recife, PE, before and after the implementation of DOTS. Furthermore, it intends to assess the impact of this strategy on epidemiological and operational indicators of the disease such as incidence coefficient, mortality coefficient, mortality rate and percentage of patients abandoning the treatment. Deaths by TB have been compared to those who have survived in a comparison case research with a single event, involving the cases diagnosed from 1996 to 2004. Observing the situation before death, the patients have been analyzed in another case-comparison with more than one result where the variable responses were: healing, death and abandonment of the treatment. Death by TB and the association HIV-AIDS have been confirmed in the Aids and Mortality system. The census was the base for the population data base. At first, analysis by periods have been carried out; pre-DOTS, diagnosis of 1996-2000 and DOTS, from 2001 to 2005; followed by various analysis of the whole set of information. The occurrence and mortality coefficients accumulated by period for 100,000 inhabitants have been, respectively, 82.3 and 13.7 during the pre-DOTS period and 108.6 and 7.1 during the DOTS period. The mortality rates have been 14.8% and 6.0%. The implementation of the DOTS strategy has reduced the risk of death in 50% (OR=0,5; IC95% 0,40-0,70) whereas the supervised treatment has reduced the likelihood of abandonment of the treatment in 28%. In the pre-DOTS death was associated with (p< 0.05): age when diagnosed (OR=1,04; IC95% 1,03-1,05), previous abandonment of the treatment (OR=3,94; IC95% 2,17-7,15) and mixed clinical form (OR=4,91; IC95% 2,17-11,16); whereas, male gender (OR=1,22; IC95% 1,06-1,41) and previous abandonment of the treatment (OR=3,42; IC95% 2,65-4,41) were associated with abandonment of the treatment. In the DOTS period death was associated with: age when diagnosed (OR=1,04; IC95% 1,021,06) and complications associated with TB (OR=2,36; IC95% 1,224,58); whereas low educational level (OR=1,74; IC95% 1,13-2,67), previous abandonment of the treatment (OR=2,44; IC95% 1,41-4,23) recurrence (OR=1,62; IC95% 1,022,56), any associated complication (OR=1,55; IC95% 1,172,04) or being under supervised treatment (OR=0,73; IC95% 0,570,93) were associated to the abandonment of the treatment. Changes in TB mortality and detection indicators have been observed with the implementation of DOTS strategy in Recife. The detection of cases has been extended and the risk of death reduced with a change in death profile. With regard to the cases of abandonment of the treatment, despite the changes in the patients profiles, the strategy impact as compared to this result was lighter. In the patients included in supervised treatment the likelihood to abandon the treatment was slightly reduced. Previous abandonment of the treatment, mainly for patients without HIV/AIDS, continues to be a relevant fact for the mortality rate and to abandon the treatment, therefore it shall be prioritized for inclusion in supervised treatment. The need for improvement in the assistance to elders and to those with low education and integration with other assistance services to other complication factors are also provided herein.