Download Tuberculosis in Brazil, Johnson

Michael Johnson
Tuberculosis in Brazil
From: Secretary of Health, Brazil
To: Minister of Finance, Brazil
Introduction:
Tuberculosis (TB) is the ninth leading cause of hospital admission and the fourth leading
cause of death by infectious disease in Brazil.i It is estimated that each year 92,000 people are
diagnosed with TB, and of those, 4,000 people will die from the disease.ii Recent data suggests
TB incidence and mortality have fallen in the past 20 years by 26% and 32%, respectively. TB
mostly affects urban populations and undereducated subgroups of the Prada and Branca
ethnicity, though residents in tropical rainforest areas are also affected. Individuals are at high
risk if they are homeless, have HIV/AIDS, partake in criminal activities, or are an indigenous
person. Currently, Brazil spends US$ 74 million per year on the diagnosis and treatment of TB,
a large financial burden. In order to reduce the burden of TB in Brazil, more testing centers need
to be built to increase early diagnosis, DOTS coverage needs to be universally implemented, and
more resources need to be spent on HIV prevention.
Nature and Magnitude:
Many people in Brazil are disabled or killed by TB, a highly treatable bacterial disease.
TB is the ninth leading cause of hospital admission and the fourth leading cause of death by
infectious disease in Brazil.iii It is estimated that each year 92,000 people are diagnosed with
TB, and of those, 4,000 people will die from the disease.iv Additionally, each year around
19,000 HIV-positive people will develop TB and around 1,100 people will develop multidrug
resistant-TB (MDR-TB)v. Brazil alone accounts for 31% of all TB cases in the WHO Latin
America Region. Consequently, WHO has rankedvi Brazil 14th of the 22 countries with the
highest burden of TB.
Incidence and mortality rates of tuberculosis (TB) have fallen in the past twenty years.
There has been a 26% decrease in the incidence rate of TB in the past two decades: in 1990,
there were 51.4 new TB infections for every 100,000 people, whereas in 2008, there were 37.1
new TB infections for every 100,000 people.vii Similarly, the mortality rate of TB in Brazil has
decreased by 32%: in 1990, there were 3.6 deaths from TB for every 100,000 people, while in
2008, there were 2.4 deaths from TB for every 100,000 people.viii
Affected Populations:
TB largely affects people residing in the states of Rio de Janeiro, Amazonas, and São
Paulo. These states contribute more than 40 percent of new TB cases every year, and coinfection with HIV runs as high as 25 percent in some major cities in these states.ix Those living
in Amazonas are typically less educated and have limited access to healthcare facilities. In the
urban cities of Rio de Janeiro and São Paulo, TB prevalence is high partly due to elevated HIV
rates—these cities have large populations who are at high-risk for HIV. TB is the primary cause
of death among HIV/AIDS patients in Brazil.x
Other populations disproportionately affected by TB include those in poor health, the
Branca and Parda ethnic groups, and the undereducated. About 45% of new TB cases in 2008
were Parda, and 39% were Branca. The undereducated are particularly affected: 73% of patients
with TB have had less than 8 years of schooling.xi
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Risk Factors:
Citizens most at risk for developing TB are those without homes, people living with
HIV/AIDS (PLHA), convicts, and indigenous people. Compared to the entire population, people
without homes are sixty times more likely to develop TB, PLHA are thirty times more likely,
convicts are twenty-five times as likely, and indigenous people are four times more likely.xii
People who have TB but do not fully complete their drug treatment regimen are at an
increased risk of having MDR-TB if they redevelop the disease. While only 0.9% of new
infections have MDR-TB, 5.4% of those undergoing retreatment have MDR-TB.xiii Individuals
with MDR-TB are placed at an increased risk for mortality from TB.
Economic and Social Consequences:
The most important consideration when discussing TB’s consequences is the large
financial burden it places on the healthcare system. Maintaining TB treatment programs is
expensive: current governmental resources earmarked for TB screening and treatment exceeds
US$ 74 million per year.xiv And individually, TB causes illness for extended periods, keeping
people from working and leading them to spend large amounts on healthcare.
Priority Action Steps:
In order to reduce the burden of TB in Brazil, more testing centers need to be built to
increase early diagnosis, DOTS coverage needs to be universally implemented, and more
resources need to be spent on HIV prevention.
Directly Observed Therapy Short course (DOTS) is highly cost-effective and needs to be
expanded in order to avert DALYs caused by TB. Currently it is estimated that DOTS coverage
extends to 68% of TB patients, and is available in all high priority municipalities. A 2007 Johns
Hopkins School of Medicine study of the city Rio de Janeiro revealed that the incremental cost
effectiveness ratio for DOTS was $300 per case averted and $3270 per death averted, and that
the program was able to save 5426 DALYs at a cost of $86 per DALY in a population of
250,000. In order to maximize the number of DALYs averted, universal DOTS coverage must
be implemented.
Increasing diagnosis and early treatment of TB is important in limiting the spread of the
disease. Diagnosis using sputum smears requires special laboratory testing centers, but with only
2.1 labs per 100,000 people, TB diagnosis could be improved. The DOTS case detection rate of
sputum smear positive cases was 69% in 2007, just below WHO’s target of 70%. Brazil must
increase its investment into TB diagnosis infrastructure before it can meet international standards
and properly protect the health of its citizens.
HIV incidence rates must also be reduced before substantial reduction in TB’s incidence
rates can be seen. Being HIV-positive is one of the largest risk factors for TB infection, and thus
reducing the spread of HIV will consequently reduce the incidence of TB too. Sex education
programs, contraception distribution, and hypodermic needle exchange programs need to be
expanded to reduce HIV infection rates in Brazil.
i
The Tuberculosis Coalition for Technical Assistance <http://www.tbcta.org/Country/4/Brazil>.
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ii
World Health Organization – Tuberculosis Profile, Brazil.
<https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ/STB_TME/Public/TBCou
ntryProfile&ISO2=BR&outtype=PDF>.
iii
The Tuberculosis Coalition for Technical Assistance <http://www.tbcta.org/Country/4/Brazil>.
iv
World Health Organization – Tuberculosis Profile, Brazil.
<https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ/STB_TME/Public/TBCou
ntryProfile&ISO2=BR&outtype=PDF>.
v
USAID – Tuberculosis Profile, Brazil.
<http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/lac/brazil.pdf>.
vi
USAID – Tuberculosis Profile, Brazil.
<http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/lac/brazil.pdf>.
vii
Improving availability of services in Brazil Dr D. Barreira.ppt
viii
Improving availability of services in Brazil Dr D. Barreira.ppt
ix
USAID – Tuberculosis Profile, Brazil.
<http://www.usaid.gov/our_work/global_health/id/tuberculosis/countries/lac/brazil.pdf>.
x
Dr. Draurio Barreira, NTP Coordinator, Secretaria de Vigliância em Saúde, Brasil. Powerpoint
file.
<http://www.stoptb.org/wg/dots_expansion/assets/documents/Cancun09/Poverty/Improving%20
availability%20of%20services%20in%20Brazil%20Dr%20D.%20Barreira.ppt>.
xi
Dr. Draurio Barreira, NTP Coordinator, Secretaria de Vigliância em Saúde, Brasil. Powerpoint
file.
<http://www.stoptb.org/wg/dots_expansion/assets/documents/Cancun09/Poverty/Improving%20
availability%20of%20services%20in%20Brazil%20Dr%20D.%20Barreira.ppt>.
xii
Dr. Draurio Barreira, NTP Coordinator, Secretaria de Vigliância em Saúde, Brasil.
Powerpoint file.
<http://www.stoptb.org/wg/dots_expansion/assets/documents/Cancun09/Poverty/Improving%20
availability%20of%20services%20in%20Brazil%20Dr%20D.%20Barreira.ppt>.
xiii
World Health Organization – Tuberculosis Profile, Brazil.
<https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ/STB_TME/Public/TBCou
ntryProfile&ISO2=BR&outtype=PDF>.
xiv
Dr. Draurio Barreira, NTP Coordinator, Secretaria de Vigliância em Saúde, Brasil.
Powerpoint file.
<http://www.stoptb.org/wg/dots_expansion/assets/documents/Cancun09/Poverty/Improving%20
availability%20of%20services%20in%20Brazil%20Dr%20D.%20Barreira.ppt>.
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