Tuberculose em Juiz de Fora, Minas Gerais: distribuição espacial dos casos e ênfase no abandono de tratamento nos períodos 2008/2009 e 2018/2019

Abstract

The present research had the results presented in two articles that contemplated the following objectives: (i) to characterize cases of pulmonary tuberculosis attended at referral centers of the Juiz de Fora county, to discover their spatial distribution and the relationship to primary health care (PHC) coverage (article 1); and (ii) to evaluate the risk factors for the TB treatment default in a priority city in Brazil and to compare the incidences in two periods: before and after changing the scheme for fixed-dose combination (FDC) (article 2) . This is a prospective cohort with patients who started treatment for TB in secondary and tertiary referral centers in the municipality of Juiz de Fora, Minas Gerais, Brazil, in the periods 2008/2009 and 2018/2019. Article 1 included 154 patients from the 2018/2019 period who were interviewed and had georeferenced addresses for making the points map with the distribution of tuberculosis, Kernel technique for case densities and calculating the nearest neighbor to evidence the presence of clusters. Article 2 encompassed patients from both periods, using survival analysis techniques to compare cases with treatment terminated by cure with those who abandoned treatment, covering a total of 296 patients included. The results were as follows: (i) Article 1 showed that the average age of patients was 43 years, with a predominance of males, low education and late diagnosis performed in reference centers; there were clusters of cases in regions of social vulnerability and; with the majority of patients seen at referral centers residing in areas covered by PHC. In addition, it demonstrates the weakness of PHC in TB control, as evidenced by the late diagnosis of the disease and the failure of patients to attend to this level of care, even when the patient lives in regions covered by the family health strategy. (ii) Article 2 showed that, excluding the other treatment outcomes, 247 (83.5%) cases were closed as a cure and 49 (16,5%) as treatment abandonment, which occurred mainly after the intensive phase (65,3%). It is noteworthy that the cases followed up before changing the medication regimen had an increased risk for abandonment when compared with those who used the FDC regimen (HR 2.25; 95% CI: 1.03 - 4.94; p 0.042). In addition to the follow-up period, the use of legal and illegal drugs and the treatment center were predictors independently associated with the abandonment of TB treatment. The results of the two articles reinforce a hospitalcentered model, which still exists in the care of patients with tuberculosis, opposite to that recommended worldwide. The last article strengthens the evidence that the presentation of drugs in DFC improves treatment adherence. The knowledge of the predictors of abandonment verified in this study, especially alcoholism, drug addiction and the type of center involved in the treatment, can be used by managers, professionals of Epidemiological Surveillance and health care to direct the care provided in the approach to patients with TB. In addition, these factors reinforce that TB treatment adherence and completeness go beyond the biomedical sphere and involve many other social determinants that need to be equally addressed.