Revista da Sociedade Brasileira de Medicina Tropical 49(2):211-221, Mar-Apr, 2016

http://dx.doi.org/10.1590/0037-8682-0065-2016 Major Article

Two decades of tuberculosis in a city in Northeastern Brazil:

advances and challenges in time and space
Amanda Priscila de Santana Cabral Silva[1], Wayner Vieira de Souza[1]
and Maria de Fátima Pessoa Militão de Albuquerque[1]

[1]. Núcleo de Estudos em Saúde Coletiva, Centro de Pesquisas Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Pernambuco, Brasil.

ABSTRACT
Introduction: This study presents two decades of epidemiological data on tuberculosis (TB), in order to understanding the disease
profile and its spatiotemporal dynamics. Methods: This descriptive study was performed in the City of Olinda/Pernambuco,
Brazil, from 1991-2010, and it analyzed new patients with TB living in the city. We used the χ²-test with a p-value <0.05 to
identify differences in trends. Incidence and cluster distribution were identified using spatial scan statistics. Results: In total,
6202 new cases were recorded during the two decades. The highest incidence occurred in 1995 (110 cases/100,000 inhabitants),
and the lowest occurred in 2009 (65 cases/100,000 inhabitants) (β=-1.44; R²=0.43; p=0.0018). The highest mortality occurred
in 1998 (16 deaths/100,000 inhabitants), and the lowest occurred in 2008 (5 deaths/100,000 inhabitants) (β=-0.19; R²=0.17;
p=0.07). There was a male predominance (65%), and ages ranged from 20-49 years (65%). There was a substantial increase in
the number of patients that were cured after treatment (60% to 67%; p<0.001) as well as those tested for HIV (1.9% to 58.5%;
p<0.001). During the first decade, clusters with p-values <0.05 included 29% of the total notified cases, and in the second decade,
that percentage was 12%. Conclusions: We observed a decreasing trend in incidence, which was significant, and mortality rates,
which was not significant. The increased number of laboratory tests performed reflects advances in surveillance, and a reduction
in the proportion of cases in primary clusters suggests, among other things, that the disease is spreading across the region.
Keywords: Tuberculosis. Epidemiological surveillance. Spatial analysis.

immunodeficiency virus (HIV)] levels, revealing some causes

INTRODUCTION of high disease incidence(3) (4) (5) (6).
A tuberculosis surveillance system aligned to a territorial
Tuberculosis (TB) remains a major public health problem, base would link occurrences of the disease to the space where
affecting millions of people each year. In 2010, there were 8.8 it occurs, thus enabling a more appropriate response from health
million new cases worldwide and 1.5 million deaths. In the same services(7) (8). Despite the availability of geospatial analysis
year, Brazil registered 71,000 new cases and 4,800 deaths. At software, application of these technologies within services is
that time while TB incidence in Brazil was 37 cases/100,000 still limited, particularly with regard to surveillance strategies,
inhabitants, the state of Pernambuco had an incidence of 46 which would certainly benefit from information regarding the
cases/100,000 inhabitants, the fourth highest incidence amongst territory, conditions, and determinants of TB incidence in order
Brazilian states. TB-associated mortality, which throughout to optimize resources and prioritize actions.
Brazil was 2.4 deaths/100,000 inhabitants, in the State of Olinda, a municipality within the metropolitan region of
Pernambuco reached 4 deaths/100,000 inhabitants(1) (2). Recife in Pernambuco, is the focus of a study of endemic
Within Brazil, metropolitan municipalities have conditions diseases, including TB(7) (8) (9) (10) (11). TB was previously monitored
that potentiate a higher risk of TB infection, such as a high there for a decade (1991-2000) in research studies using a
population density and large concentrations of poverty. geostatistical approach(7) (8).
The relationships between high rates of TB infection and The present study has made a rare contribution by extending
socioeconomic and demographic determinants have been the epidemiological analysis of TB in the residents of Olinda for
established both on individual (male, young adult) and a 20-year period in order to deepen our knowledge regarding the
population [high illiteracy or co-infection with human profile of the disease and its spatiotemporal dynamics.
This approach can thereby identify trends that may indicate
what strategies and surveillance actions need to be maintained,
optimized, or changed to control disease within the city.
Corresponding author: Dra. Amanda Priscila de Santana Cabral Silva.
e-mail: [email protected]
Received 21 February 2016
Accepted 28 April 2016

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Cabral Silva APS et al. - Two decades of tuberculosis in a Brazilian city

The number of sectors that formed each cluster was

METHODS identified, together with the number of observed and expected
cases, the relative risk, the p-value, the proportion of cases in
This descriptive historical study was conducted in the City relation to the total that occurred within the municipality, and
of Olinda from 1991 to 2010. In 2010, Olinda had 377,779 the percentage of the total municipality population who reside
inhabitants and 9,296 inhabitants/km², the highest population in the cluster. We also stratified clusters according to the p-value
for testing the homogeneous spatial distribution hypothesis for
density in northeast Brazil(12).
TB incidence into those being less than or equal to 5%, those
Olinda has three homogeneous areas with regard to quality between 5% and 20%, and those greater than 20%. Spatial data
of housing: 1) the coastal zone, which has urban infrastructure analyses were performed with SatScan 9.3.1(18) and Terraview
and vertical density; 2) the central area, a region with irregular 4.2.2(19).
water supply and low sewer/sanitation coverage; and 3) the west,
with poor housing standards and poor urban infrastructure(13). Ethical considerations
Reported cases were obtained from the National System The research project that included this study was submitted
for Notifiable Diseases [Sistema de Informação de Agravos for approval to the Research Ethics Committee at the Centro de
de Notificação (SINAN)](14). Data on mortality and resident Pesquisas Aggeu Magalhães (Number 33878514.4.0000.5190
population were obtained from the Mortality Information - report 782312/2014).
System [Sistema de Informações sobre Mortalidade (SIM)](15)
and the Brazilian Institute of Geography and Statistics Instituto RESULTS
Brasileiro de Geografia e Estatística (IBGE)](12), respectively.
Incidence rates and mortality were calculated for each of the
Between 1991 and 2010, a total of 6,924 TB cases were
years studied. As recommended by the National Tuberculosis
reported, of which 6,202 (89.6%) were new cases, resulting
Control Programme [Programa Nacional de Controle da
in a mean total of 310 new cases/year (Table 1). During the
Tuberculose (PNCT)](16), incidence was calculated from new
study period, the highest incidence occurred in 1995 (110
cases, excluding patients who defaulted or received prior
cases/100,000 inhabitants) and the lowest incidence occurred in
treatment. In order to analyze trends, simple linear regression
2009 (65 cases/100,000 inhabitants). A reduction in incidence
models (y = β0 + β1t) were used, in which TB rates and
was described using the model y = 99.9 - 1.44t (R²=0.43;
years were the dependent (y) and independent (t) variables,
p=0.0018), i.e. 29 cases were avoided per 100,000 inhabitants
respectively. P values <0.05 were considered significant in the
during the twenty years analyzed, a decrease of only 1.7% or
hypothesis test β=0.
almost 100 cases per year (Figure 1). Mortality rates fluctuated,
Profiles of new patients with TB were described in five-year with the highest and lowest occurring in 1998 (16 deaths/100,000
periods (1991-1995, 1996-2000, 2001-2005, and 2006-2010), inhabitants) and 2008 (5 deaths/100,000 inhabitants), respectively.
according to years of schooling, race/color, clinical form, the Despite the decreasing trend, there was no statistical significance
proportion of TB and HIV coinfection, smear and sputum (y = 11.5-0.19t; R²=0.17; p=0.07) (Figure 1).
culture performance, HIV testing, and the situation at case
Although reductions in incidence were observed in both
closure. Race/color was categorized as black and non-black,
sexes, males were the most affected throughout the period,
with the former including black and dark-skinned patients and
during which the male/female ratio remained 2/1. Reductions
the latter including white and indigenous patients(17). Tests were
in incidence were also observed for all age groups, but while
considered as having been performed when results were positive
over 60% of cases concerned patients between 20 and 49 years
or negative, and those classified as in progress were presented
of age, patients older than 50 years were most affected, with
in a separate category.
a rate of 153.6 cases/100,000 inhabitants between 1996 and
TB incidence and proportion were also calculated according 2000 (Table 2). Disease among this group accounts 26.2% of
to sex and age group. To calculate trends, χ² with a 5% cases. Other identified features, although hindered by the high
significance level was used for the five-year analyses. Data proportion of missing records, included the high proportion of
analysis was conducted in Epiinfo7. patients with less than 8 years of study, including those with
Tuberculosis spatial analysis was conducted in five-year no schooling (44%), as well as a predominance of cases within
periods by analyzing the annual mean incidence rates via census the black community (27%) (Table 1). The pulmonary form
tracts and using scan statistics. For this technique, the residences of this disease was detected in over 80% of patients. However,
of the new patients were georeferenced and aggregated by census extrapulmonary form increased when the first and last five-
tracts and five-year periods. The Poisson probability model was year periods were compared [relative risk (RR) =1.33; χ²=8.7;
utilized to test the hypothesis that there was a homogeneous p=0.003] (Table 1). During these two decades, the sputum smear
TB incidence within municipalities throughout all census test was performed in 70% of cases, and the sputum culture was
tracts(18). The scan statistic technique uses circular windows performed increasingly, from 4.3% during the first five years
that correspond to a geographic area. In this study, the clusters to 7% between 2006 and 2010 (χ²=15.0; p=0.0001). The most
included proportions less than or equal to 5% of the resident significant development was related to HIV testing, which rose
population(18). from 1.9% of patients being tested between 1991 and 1995

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TABLE 1 - Operational and epidemiological characteristics of patients with tuberculosis in Olinda, Pernambuco State, from 1991 to 2010.
Operational and epidemiological
characteristics 1991-1995 1996-2000 2001-2005 2006-2010 Total
n % n % n % n % n %
Total number of cases 1,747 - 1,981 - 1,649 - 1,547 - 6,924 -
Type of entry
new case 1,647 94.3 1,647 83.1 1,495 90.7 1,413 91.3 6,202 89.6
relapse 57 3.3 153 7.7 83 5 69 4.5 362 5.2
return after abandonment 43 2.4 181 9.2 71 4.3 65 4.2 360 5.2

Schooling (in years)*

0 43 2.6 224 13.6 152 10.2 72 5.1 491 7.9
1–8 162 9.8 802 48.7 618 41.3 653 46.2 2,235 36
9–11 51 3.1 202 12.3 282 18.9 233 16.5 768 12.4
11 and over 9 0.6 64 3.9 95 6.3 89 6.3 257 4.1
not applicable 50 3 40 2.4 42 2.8 45 3.2 177 2.9
not informed 1,332 80.9 315 19.1 306 20.5 321 22.7 2,274 36.7

Raçe/color*
black - - 155 9.4 638 42.7 899 63.6 1,692 27.3
non-black - - 99 6 343 22.9 407 28.8 849 13.7
not informed 1,647 100 1,393 84.6 514 34.4 107 7.6 3,661 59

Form of disease*
pulmonary 1,478 89.7 1,392 84.5 1,225 81.9 1,170 82.8 5,265 84.9
extrapulmonary 167 10.1 202 12.3 213 14.3 185 13.1 767 12.4
pulmonary + extrapulmonary 1 0.1 46 2.8 57 3.8 58 4.1 162 2.6
not informed 1 0.1 7 0.4 - - - - 8 0.1

Case result*
cure 980 59.5 770 46.8 1,036 69.3 948 67.1 3,734 60.2
abandonment 200 12.1 178 10.8 129 8.7 133 9.4 640 10.3
death 107 6.5 196 11.9 171 11.4 154 10.9 628 10.1
others 360 21.9 503 30.5 159 10.6 178 12.6 1,200 19.4

Sputum smear*
performed 1,233 74.9 1,059 64.3 1,008 67.4 1,013 71.7 4,313 69.5
positive 937 828 785 769 3,319
negative 296 231 223 244 994
not performed 412 25 520 31.6 487 32.6 400 28.3 1,819 29.4
not informed 2 0.1 68 4.1 - - - - 70 1.1

Sputum culture*
performed 70 4.3 51 3.1 68 4.5 99 7 288 4.6
positive 43 34 48 54 179
negative 27 17 20 45 109
performed – in progress 23 1.4 75 4.6 107 7.2 93 6.6 298 4.8
not performed 1,552 94.2 1,461 88.7 1,320 88.3 1,221 86.4 5,554 89.6
not informed 2 0.1 60 3.6 - - - - 62 1

HIV Testing*
performed 31 1.9 104 6.3 207 13.8 827 58.5 1,169 18.8
positive 29 54 93 155 331
negative 2 50 114 672 838
performed – in progress 2 0.1 84 5.1 225 15.1 251 17.8 562 9.1
not performed 1,611 97.8 1,384 84 1,063 71.1 335 23.7 4,393 70.8
not informed 3 0.2 75 4.6 - - - - 78 1.3
HIV: human immunodeficiency virus. * Indicators calculated from the total of new cases notified during the five-year period.

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Cabral Silva APS et al. - Two decades of tuberculosis in a Brazilian city

120 30
Incidence Mortality

100 y = -1,44x + 99,857 25

R² = 0,4257

deaths/100,000 inhabitants
80 20
cases/100,000 inhabitants

60 15

40 10

20 5
y = -0,1918x + 11,536
R² = 0,1737

0 0
0

10

12

13

14

15

16

17

18

19

20

21
11

20
Obs: Incidence: β1= -1.44 (CI -2.27;-0.61); p=0.0018; t=0-> y0=99.9; t=20->y20=71.1; i= √(71.1/99.9)- 1= -1.7%
20
Mortality: β1= -0.19 (CI -0.399;+0.15); p=0.0675; t=0-> y0=11.5; t=20->y20=7.7; i= √(7.7/11.5)- 1= -2.0%

FIGURE 1- Incidence and mortality trends for tuberculosis in Olinda, Pernambuco State, from 1991 (t=1) to 2010 (t=20).

TABLE 2 - Distribution, incidence (cases/100,000 inhabitants), and relative risk of new TB cases according to patient age and sex in
Olinda, Pernambuco State, from 1991 to 2010.
1991-1995 1996-2000 2001-2005 2006-2010
  n % incid RR n % incid RR n % incid RR n % incid RR
Age group (years)
<20 215 13.3 28.5 1.0 172 10.6 25.0 0.9 139 9.4 20.0 0.7 123 8.8 19.3 0.7
20–49 1,047 65.0 137.9 1.0 1,023 63.2 127.5 0.9 996 67.6 114.4 0.8 883 63.5 92.2 0.7
≥50 350 21.7 143.5 1.0 424 26.2 153.6 1.1 339 23.0 107.1 0.7 386 27.7 101.5 0.7

Sex
male 1,078 65.5 130.4 1.0 1,008 61.2 121.5 0.9 976 65.3 110.9 0.9 906 64.1 98.6 0.8
female 569 34.5 61.1 1.0 639 38.8 68.3 1.1 519 34.7 51.9 0.8 507 35.9 48.0 0.8
TB: tuberculosis; n: number; %: percentage; incid: incidence; RR: relative risk.

to a total of 58.5% of cases reported during the last five years p<0.001) and, over the same period, treatment abandonment
(RR=73.6; χ²=1502 9; p<0.001) (Table 1). However, given the was reduced from 12.1% to 9.4% (RR=0.75; χ²=9.4; p=0.002)
evolution of laboratory testing, there is an outstanding number of (Table 1). The model estimates an initial incidence of
results classified as in progress, both for the sputum culture and 99.9 cases / 100,000 inhabitants and a final incidence of
HIV testing, which in the last five years reached 17.8% (Table 1). 71.1 cases/100,000 inhabitants (Figure 1). With an average
Cure rates started at 59.5% in the first five-year period and incidence of 86 cases/100,000 inhabitants, these three values
reached 67.1% between 2006 and 2010 (RR=1.39; χ²=63.0; guided the construction of spatial distribution categories. Rates

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Incidence Clusters
1991- 1995

Incidence (% of census tracts

per class) P-value
< 71.1 (51.0%)
71.1 – 86.0 (10.3%) < 0.05
86.1 – 99.9 (8.2%)
0.05 – 0.20
> 99.9 (30.5%)
>0.20

1996 - 2000

Incidence (% of census tracts

per class)
< 71.1 (45.5%) P-value
71.1 – 86.0 (9.3%)
86.1 – 99.9 (5.7%) < 0.05
> 99.9 (39.5%) 0.05 – 0.20
>0.20

2001- 2005

Incidence (% of census
tracts per class) P-value
< 71.1 (62.2%)
71.1 – 86.0 (12.7%) < 0.05
86.1 – 99.9 (4.7%) 0.05 – 0.20
> 99.9 (20.4%) >0.20

2006- 2010

Incidence (% of census
tracts per class) P-value
< 71.1 (66.6%)
71.1 – 86.0 (7.7%) < 0.05
86.1 – 99.9 (6.0%) 0.05 – 0.20
> 99.9 (19.7%) >0.20
0 3000 6000 9000
meters

FIGURE 2 - Incidence (cases/100,000 inhabitants) and TB clusters according to residential census tracts in Olinda, Pernambuco State, from 1991 to
2010. TB: tuberculosis.

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Cabral Silva APS et al. - Two decades of tuberculosis in a Brazilian city

above 99.9 cases/100,000 inhabitants suggest that, over the territory (Figure 2). Cluster analysis confirmed this hypothesis
study period, the sectors presented (or remained) in a situation by demonstrating that in both five-year periods of the first decade
similar to conditions observed in the early 1990s. almost 30% of cases were concentrated within the clusters
By comparing the four five-year periods, there was a with p<0.05, which had numbers of TB cases greater than
significant reduction in the proportion of census tracts in which would be expected if the spatial distribution was homogeneous.
the incidence was higher than 99.9 cases/100,000 inhabitants, These values were significantly lower in the third and
although with 6% of the confidence interval (CI) 86-99.9, fourth five-year periods, suggesting a greater disease spread
suggesting the possibility of a homogeneous TB trend within the (Figure 2 and Table 3).

TABLE 3 - Characteristics of TB clusters in Olinda, Perambuco State from 1991 to 2010.

Number of cases
Clusters Number of sectors observed expected RR P value Population (%)* Cases (%)**
1991 to 1995
1 8 112 44 2.7 4.0x10-15 3.1 7.8
2 8 97 46 2.2 1.8x10-8 3.2 6.8
3 3 45 18 2.5 4.9x10
-5
1.3 3.1
4 1 24 7 3.4 3.1x10-4 0.5 1.7
5 7 77 46 1.7 0.009 3.2 5.4
6 5 55 30 1.9 0.018 2.1 3.8
7 1 21 8 2.7 0.055 0.6 1.5
8 1 14 4 3.1 0.122 0.3 1.0
9 4 34 18 1.9 0.290 1.3 2.4
10 2 17 7 2.4 0.439 0.5 1.2
11 5 48 30 1.6 0.509 2.1 3.4
12 1 11 5 2.2 0.995 0.3 0.8
1996 to 2000
1 10 145 62 2.5 1.0x10-17 3.7 8.6
2 4 71 25 2.9 6.9x10
-11
1.5 4.2
3 13 110 61 1.9 7.0x10-6 3.6 6.6
4 8 75 41 1.9 0.001 2.4 4.5
5 8 99 59 1.7 0.001 3.5 5.9
6 7 72 45 1.6 0.074 2.7 4.3
7 1 18 7 2.5 0.320 0.4 1.1
8 1 18 7 2.5 0.330 0.4 1.1
9 1 16 6 2.5 0.480 0.4 1.0
10 4 40 24 1.7 0.688 1.4 2.4
11 1 14 6 2.4 0.787 0.3 0.8
12 1 10 4 2.8 0.899 0.2 0.6
13 2 20 11 1.8 0.998 0.7 1.2

continue....

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TABLE 3 - Continuation.
Number of cases
Clusters Number of sectors observed expected RR P value Population (%)* Cases (%)**
2001 to 2005
1 5 58 23 2.6 7.8x10-7 2.1 5.2
2 1 14 2 6.1 1.6x10 0.2
-4
1.2
3 4 35 15 2.4 0.007 1.3 3.1
4 4 35 17 2.1 0.059 1.5 3.1
5 1 15 5 2.8 0.319 0.5 1.3
6 7 44 27 1.7 0.590 2.4 3.9
7 1 15 6 2.5 0.638 0.5 1.3
8 5 29 17 1.8 0.876 1.5 2.6
9 3 19 10 1.9 0.990 0.9 1.7
10 1 7 2 3.0 0.993 0.2 0.6
11 1 7 2 3.0 0.993 0.2 0.6
12 2 17 9 1.9 0.999 0.8 1.5
13 2 13 6 2.0 0.999 0.6 1.2
14 3 21 12 1.7 0.999 1.1 1.9
2006 a 2010
1 11 74 31 2.5 1.2x10-7 2.9 6.8
2 8 63 29 2.3 3.4x10-5 2.6 5.8
3 4 36 17 2.2 0.026 1.5 3.3
4 4 34 16 2.2 0.054 1.5 3.1
5 7 49 27 1.8 0.107 2.5 4.5
6 2 17 6 2.7 0.194 0.6 1.6
7 2 15 7 2.3 0.887 0.6 1.4
8 3 21 11 1.9 0.966 1.0 1.9
9 2 15 8 2.0 0.996 0.7 1.4
10 4 24 15 1.7 0.998 1.3 2.2
11 3 23 14 1.6 0.999 1.3 2.1
12 1 7 3 2.4 0.999 0.3 0.6
TB: tuberculosis; RR: relative risk. *Percentage of the total population in the city living in the cluster. **Percentage of the total number of cases in the city that
occurred within the cluster.

observed through some tuberculosis indicators are in line

DISCUSSION with the advances made in healthcare management (21).
Municipalization, decentralization of actions and services, and
The reduction in TB incidence in Olinda over two decades is strengthening of primary health care through the Family Health
in accordance with the behavior of the disease throughout Brazil Strategy were some outstanding features of the 1990s. In the
as a whole(20). Between 1990 and 2010, while there was a 3.2% 2000s, TB was considered a priority in the National Policy of
Primary Healthcare(22). This was true at a federal level, with
decrease per year in incidence rate across the country(20), but in
the creation of the Secretariat of Health Surveillance(23), and
Olinda, this proportion was 1.7%. During the 20-year period
the PNCT underwent reforms that benefited the integration of
analyzed, only about 100 cases have been avoided. support actions and epidemiological surveillance, especially
If we consider the country as a whole, the improvements within the states and municipalities.

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Cabral Silva APS et al. - Two decades of tuberculosis in a Brazilian city

With so many advances, the disconcerting question, Information quality is directly related to the completeness
Why have strategies that have proved efficient for the country as of notification and monitoring tools. The present study revealed
a whole been unsuccessful in attaining the required magnitude that the notification forms supplied to Sinan have become more
of effects on TB indicators in the city of Olinda? remains. thorough, now including variables such as race/color. This
The differences observed between Olinda and the rest of the advancement, however, requires caution when interpreting data,
country suggest that this improvement occurs with different since it is not possible to affirm, for example, that in Olinda there
intensities, possibly due to inequalities between municipalities was an increase in notifications from the black community. It is
and intramunicipal scales. probable that this increase was caused by improved registration,
The TB situation within the municipality not only emphasizes and not necessarily by a change in disease.
the need to optimize the strategies already in place but also to Tuberculosis can affect a number of organs and systems,
adopt others that are able to harness data that go beyond those with the pulmonary form, which in Brazil is detected in 85%
inherent to the health sector and may explain the occurrence of of patients aged 15 years and over, being the most common. In
the disease, such as territory-based surveillance. This approach Olinda, the mean ratio of this form is similar to that recorded for
could provide support for planning and executing actions at the entire country. More often than not, pulmonary bacillary TB
different levels, thus positively influencing TB indicators. are relevant to public health since they maintain the transmission
There was an insignificant trend in mortality reduction. In chain of the disease(16).
2010, mortality exceeded double the state and was more than High proportions of pulmonary TB in a community justify
three times the national average. However, these findings may the need for the sputum smear – a simple and safe method
not only be describing the poor prognosis in the city, as they that should be performed by all public health laboratories and
may have been influenced by SIM quality improvement during authorized private laboratories. When performed properly, the
the two decades analyzed(17) (24) (25). This justification does not test is able to detect between 60-80% of pulmonary TB cases(16).
reduce the importance of implementing a mortality surveillance Over the 20-year period, a mean 70% of patients notified during
system that examines routine relationships between databases, the five-year periods performed the test. Throughout all of
home, and hospital; forms of a multidisciplinary technical group Brazil, this ratio varied from 76.4% to 85.3%(16) (33) (34) (35).
to discuss death and partnerships, such as civil society, and Due to its importance, the sputum smear should be
controls programs for sexually transmitted disease- acquired encouraged, along with other features, such as those offered by
immunodeficiency syndrome (STD/AIDS) and viral hepatitis. the GeneXpert system, which allows the simultaneous detection
The higher proportion of male patients is consistent with of Mycobacterium tuberculosis and rifampicin resistance testing
findings in the current literature, with a possible cultural and using sputum(36). A systematic review involving 18 studies
social determination related to exposure(1) (26) (27) (28). Biological and 10,224 biological specimens demonstrated that a single
factors should also be considered, since there are generally Xpert  Mycobacterium tuberculosis (MTB) DNA and resistance
significant sexual differences between respiratory tract infection to rifampicin (RIF)  test detected 90.4% of pulmonary TB cases
(RTI) development and outcomes(29). Males appear to suffer from (98.7% smear-positive and 75% smear-negative)(37).
most commonly forms of RTI, and also they usually experience In pulmonary cases with negative sputum smears, sputum
a more severe disease course with higher mortality rates(29) (30). culture can increase bacteriological diagnosis of the disease by
Being aware that only 5% to 10% of individuals who are exposed up to 30%(16). Given this importance, there has been a modest
to Mycobacterium tuberculosis develop TB and that up to 70% increase in performing sputum culture performance from 4.3%
of people who develop the disease are male(29), researchers to 7%.
should be encouraged to investigate in greater depth the manner During the two decades, HIV testing increased significantly.
in which genetic variations and steroid hormones, for example, However, in 41.5% of the cases, tests were either not performed,
differentially influence disease susceptibility between the sexes. or they were performed but results were still in progress. In
In terms of age, over 60% of cases involved patients who were Brazil, testing is still insubstantial, and in a number of localities
between 20 and 49 years old, although there was a high incidence in the frequency of patients who do not undergo the test is over
those aged 50 years or older. Awareness that this population group 80%(38). The low proportion of HIV testing and culture may
is more sensitive to TB reactivation owing to lower immunity while reflect difficulties in laboratory access, delays in receiving
they have higher occurrences of chronic diseases, the Tuberculosis results, lost tests, or even a lack of updated information systems.
Control Program needs to be linked to disease surveillance Given the estimations in Olinda of patients coinfected with TB
programs, health care programs for the elderly in order to minimize and HIV, both the efforts of professionals who serve patients
adverse outcomes. On the other hand, a reduction in cases involving and the validity of information are jeopardized due to these
patients who are less than 20 years old may indicate a reduction in structural flaws.
active transmission and recent infection. In Brazil, TB is approximately 30 times more common in
In the present study, 45% of patients reported that they received people living with HIV, compared to the incidence in the general
up to eight years of schooling, including the illiterate(25) (31) (32). Low population(39). Hence, the Ministry of Health recommends that
levels of education reflect a set of poor socioeconomic conditions HIV testing be mandatory for patients with detected cases of
that increase vulnerability to TB and consequently the increase TB, and vice versa(16), which is aimed at initiating immediate
disease incidence, while lowering adherence to treatment(32). intervention. Clinical trials have shown that concomitant

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 Rev Soc Bras Med Trop 49(2):211-221, Mar-Apr, 2016

treatment is able to reduce mortality by over 50%(40). Thus, Finally, it is important to consider that there may be
the high numbers of unperformed blood tests or of those still characteristics directly resulting from the disease control
in progress jeopardizes the timely initiation of treatment and program associated with a higher TB incidence, such as cases
hinders the structuring of public health plans in order to prevent of additional treatment and families with two or more affected
and reduce deaths from TB-HIV. persons in the same household(8). This report reveals that the
With regard to case outcomes, during the two decades, a cure incorporation of mapping within routine health surveillance,
rate of 60.2% was identified, reaching a maximum of 67.1% in along with periodic updates of the associated factors, may
the last five-year period, although the rate was still below the contribute to the organization of health services. On the other
85% recommended by PNCT(41). Throughout the entire period, hand, it reinforces the greater responsibility that health services
treatment abandonment and deaths remained at 10%. The have to face with controlled actions that are able to impact
abandonment of treatment not only affects the rising treatment disease incidence.
costs, but it also affects mortality rates and disease recurrence, After a 20-year period, despite a reduction in incidence and
while facilitating the selection of resistant strains(42) (43). a downward trend in mortality, TB rates in Olinda are higher
However, similar to occurrences in other Brazilian than the mean rates of the state and the country as a whole. The
cities(28) (34) (35), case outcome analysis is hampered by the high low number of smear tests and sputum cultures indicate that the
(19.3%) percentage of cases where circumstances at the end of available technologies are underutilized. The high percentage
treatment were classified as ignored, transferred, or changed of HIV tests in progress exemplifies the fragile feedback of the
treatment, thus suggesting failings in appropriate patient monitoring information system, and it hinders the estimates of TB-HIV
by the health team or insufficient flow of existing information. co-infection in the city as well as planning based on the main
instrument for decision making.
In relation to the spatial analysis method used, it should be
highlighted that the differential of this method lies in the manner Analysis of the spatial distribution of cases demonstrated
with which it characterizes the relevant cluster according to the that relevant clusters remained in the same regions during the
exposed population and the concentration of cases in relation two decades, which not only indicates that these areas presented
to the total within the municipality. Contrary to misgivings similar socioeconomic characteristics during the period, but
concerning the use of grouping sectors with low incidence levels it also indicates that the actions to control the disease need to
to generate clusters(44), this was not an issue in the present analysis. be optimized and made more appropriate for this extremely
vulnerable population group.
The adopted cluster sizes grouped up to a maximum of 5% of
the exposed population with the territory analysis characteristics,
such as the distribution of cases and the exposed population. CONFLICT OF INTEREST
Demarcation of the problem based on census tracts has enabled us
to view the heterogeneous distribution of the disease in urban areas, The authors declare that there is no conflict of interest.
thus enabling intervention planning aimed at specific groups(9).
Although there has been a reduction in incidence in Olinda,
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