Original Article

Characteristics of pulmonary tuberculosis in a

hyperendemic area—the city of Santos, Brazil*
Características da tuberculose pulmonar em área hiperendêmica —
município de Santos (SP)

Andrea Gobetti Vieira Coelho, Liliana Aparecida Zamarioli,

Carmen Argüello Perandones, Ivonete Cuntiere, Eliseu Alves Waldman

Abstract
Objective: To characterize the profile of patients with pulmonary tuberculosis (PTB) in the city of Santos, Brazil,
according to biological, environmental and institutional factors. Methods: Descriptive study, using the TB surveillance
database, including patients with PTB, aged 15 years or older, residing in the city of Santos and whose treatment
was initiated between 2000 and 2004. Results: We identified 2,176 cases, of which 481 presented a history of TB.
Of those 481 patients, 29.3% were cured, and 70.7% abandoned treatment. In 61.6% of the cases, the diagnosis
was confirmed by sputum smear microscopy, whereas it was confirmed based on clinical and radiological criteria
in 33.8%; 69.0% were male; and 69.5% were between 20 and 49 years of age. There were 732 hospitalizations,
and the mean length of hospital stay was 32 days (first hospitalization). The prevalence of alcoholism, diabetes
and TB/HIV coinfection was, respectively, 11.7%, 8.2% and 16.2%. The prevalence of TB/HIV coinfection decreased
from 20.7% to 12.9% during the study period. The treatment outcome was cure, abandonment, death from TB
and death attributed to TB/HIV coinfection in 71.0%, 12.1%, 3.9% and 2.5%, respectively. The directly observed
treatment, short-course (DOTS) was adopted in 63.4% of cases, and there were no significant differences between
DOTS and the conventional treatment approach in terms of outcomes (p > 0.05). The mean annual incidence of
PTB was 127.9/100,000 population (range: 72.8-272.92/100,000 population, varying by region). The mean annual
mortality rate for PTB was 6.9/100,000 population. Conclusions: In areas hyperendemic for TB, DOTS should be
prioritized for groups at greater risk of treatment abandonment or death, and the investigation of TB contacts
should be intensified.
Keywords: Tuberculosis, pulmonary; Epidemiology, descriptive; Control.

Resumo
Objetivo: Caracterizar o perfil dos pacientes com tuberculose pulmonar (TBP) no município de Santos (SP) segundo
fatores biológicos, ambientais e institucionais. Métodos: Estudo descritivo, com dados obtidos na vigilância da
TB, abrangendo pacientes com TBP maiores de 15 anos de idade, residentes em Santos (SP) e com tratamento
iniciado entre 2000 e 2004. Resultados: Foram identificados 2.176 casos, e 481 apresentavam história prévia de
TB. Desses, 29,3% curaram-se no episódio anterior, e 70,7% abandonaram o tratamento. Em 61,6% e em 33,8%
dos casos, o diagnóstico foi confirmado por baciloscopia e por critérios clínico-radiológicos, respectivamente;
69.0% eram homens, e 69,5% situavam-se entre 20 a 49 anos. Houve 732 hospitalizações, com tempo médio
de permanência de 32 dias na primeira internação. A prevalência de alcoolismo, diabetes e coinfecção TB/HIV
foi de, respectivamente, 11,7%, 8,2% e 16,2%, com declínio dessa última de 20,7% para 12,9% no período de
estudo. O desfecho do tratamento para 71,0%, 12,1%, 3,2% e 3,3% foi, respectivamente, cura, abandono, óbito
por TB e óbito por TB/HIV. O tratamento supervisionado de curta duração foi aplicado em 63,4% dos casos, e não
houve diferenças nos desfechos entre os tipos de tratamento (p > 0,05). A incidência anual média de TBP foi de
127,9/100.000habitantes (variação: 72,8-272,92/100.000 conforme a região). A taxa anual média de mortalidade
por TBP foi de 6,9/100.000 habitantes. Conclusões: Em áreas hiperendêmicas de TB, o tratamento supervisionado
de curta duração deve ser priorizado para os grupos de risco para o abandono de tratamento ou óbito, e a busca
de TB entre contatos deve ser intensificada.
Descritores: Tuberculose pulmonar; Epidemiologia descritiva; Controle.

* Study carried out in the Department of Epidemiology of the University of São Paulo School of Public Health, São Paulo, Brazil.
Correspondence to: Eliseu Alves Waldman. Departamento de Epidemiologia, Faculdade de Saúde Pública da Universidade de
São Paulo, Av. Dr. Arnaldo, 715, Cerqueira César, CEP 01246-904, São Paulo, SP, Brasil.
Tel 55 11 3061-7109. E mail: eawaldma@usp.br
Financial support: This study received financial support from the Conselho Nacional de Desenvolvimento Científico e Tecnológico
(CNPq, National Council for Scientific and Technological Development), process no. 309502/2003-9.
Submitted: 29 January 2009. Accepted, after review: 23 June 2009.

J Bras Pneumol. 2009;35(10):998-1007

Characteristics of pulmonary tuberculosis in a hyperendemic area—the city of Santos, Brazil 999

Introduction located in a metropolitan area known as the

Metropolitan Region of the Coastal Atlantic
Brazil is one of the 21 developing countries Forest, situated between the eastern edge of the
that together account for approximately 80% of Atlantic forest and the Atlantic coast. The city
the new cases of tuberculosis (TB) that occur of Santos has a population of approximately
worldwide.(1) In Latin America, Peru and Brazil 420,000 inhabitants and is the most populated
account for 50% of the TB cases.(2) In recent city of the region, as well as being the city of
years, there has been a decrease in the incidence greatest population density in the state of São
of TB in Brazil. However, in 2004, the inci- Paulo, presenting, in the year 2000, an urbani-
dence of TB was still high, i.e., approximately
zation rate of 99.5% and a Human Development
44.6/100,000 population, and the mortality rate
Index of 0.837.(6,7) The São Paulo State Social
was approximately 2.1/100,000 population.(3)
Vulnerability Index for the city of Santos shows
In the state of São Paulo, the 2004 rates
satisfactory indicators, 76.5% of the popula-
of TB-related morbidity and mortality were
tion of the city being classified as presenting
close to the national average (41.9 and
low to no vulnerability (Groups 1 and 2), as well
2.5/100,000 population, respectively).(3) In addi-
tion, 53% of the new TB cases were concentrated as acceptable levels of wealth and education,
in 10 of the 647 cities in the state of São Paulo; although the indicators of longevity are less
those in the greater metropolitan area of Santos than satisfactory (Group 2).(6)
were the most affected by TB, the city of Santos The study population comprised cases of
proper presenting morbidity and mortality rates PTB patients (≥ 15 years of age, residing and
far higher than the national average and there- submitted to treatment in the city of Santos
fore being the city in which the situation raises between January 1, 2000 and December 31,
the most concern.(4) 2004) reported to the TB Surveillance System
In order to develop public health interven- for subdivision IV of the Regional Health District
tions that focus specifically on hyperendemic of the state of São Paulo (RHD-IV, the Greater
areas, it is essential to analyze the indicators Metropolitan Area of Santos).
of the performance of the TB control program, The inclusion criteria were as follows: being
particularly cure rates, treatment abandonment ≥ 15 years of age; residing in the city of Santos;
rates, mortality rates and retreatment rates, as presenting a clinical profile consistent with TB,
well as the coverage of the directly observed the diagnosis being confirmed by sputum smear
therapy, short-course (DOTS) strategy. However, microscopy or by isolation of M. tuberculosis in
the TB surveillance database constitutes a privi- culture; and chest X-ray findings suggestive of
leged source of information for such analysis, TB.
since it comprises all reported cases of the The following were excluded from the
disease. present study: cases in patients treated in the
Considering the magnitude of TB as a public city of Santos but residing in other cities; cases
health issue, the economic importance of the presenting a clinical form of TB other than PTB;
city of Santos and the few published studies cases in patients whose diagnosis was changed;
addressing this issue,(5) we aimed to describe and cases in which there was no available infor-
the behavior of pulmonary TB (PTB) in the city mation that could confirm the case in the data
of Santos, based on data obtained from the TB sources used to investigate such characteristics.
surveillance database. The principal objectives The following data sources were used: the
of the present study were to estimate incidence TB surveillance database of the RHD-IV of the
rates, mortality rates, retreatment rates and São Paulo State Health Department, the data
hospitalization rates, as well as the principal
being compiled from TB case registry database
treatment outcomes (treatment abandonment,
reporting forms; the Center for Epidemiological
cure and death).
Surveillance of the São Paulo State Department of
Methods Health; and the Brazilian Institute of Geography
and Statistics, which provided the demographic
This was a descriptive study, the area of data used to estimate the rates of incidence and
interest of which included the city of Santos, mortality.

J Bras Pneumol. 2009;35(10):998-1007

1000 Coelho AGV, Zamarioli LA, Perandones CA, Cuntiere I, Waldman EA

In order to avoid loss of information due to tions. For categorical variables, Pearson’s
late recording, the data used in the present study chi-square test and Fischer’s exact test were
were updated through December 31, 2005. used, whereas the Kruskal-Wallis test was used
The variables of interest included sociodemo- for continuous variables.
graphic characteristics, current or previous TB, For the calculation of the mean annual
diagnosis-related aspects, treatment outcomes, rate of incidence of PTB and the mean annual
comorbidities, facility characteristics, morbidity PTB mortality rate for the period of interest,
rate and mortality rate. The data regarding we used, respectively, new cases and deaths as
alcoholism and diabetes that were used in the
the nominators, and the population ≥ 15 years
present study were those registered on the
of age in the middle of the period was used as
reporting forms, i.e., no complementary tests or
the denominator. Each rate was subsequently
investigations were conducted.
divided by five. The city of Santos was geograph-
The data analyzed were provided by the
RHD-IV, in the format for Epi Info, version 6.4. ically divided into six sectors: Shoreline Area;
After the analysis of consistency, the data were Downtown/Port Area; City Center; Northwestern
converted to the program Statistical Package Zone; Hills Area; and Continental Area. The
for the Social Sciences, version 14 (SPSS Inc., Downtown and Port sectors were analyzed as a
Chicago, IL, USA), and the variables were single area because they present similar socio-
regrouped and analyzed. economic characteristics.
The descriptive analysis was performed The present study was approved by the
through the comparison of means and propor- Research Ethics Committee of the Adolfo Lutz

Table 1 - Reported cases of pulmonary tuberculosis and treatment strategy according to sociodemographic
variables. City of Santos, Brazil, 2000-2004.
Characteristic Directly observed treatment, short-course
Subtotala No Yes
n = 2.145 n = 785 n = 1,360
Gender
Female 665 (31.0) 254 (32.4) 411 (30.2)
Male 1,480 (69.0) 531 (67.4) 949 (69.8)
Age
15-19 years 120 (5.6) 47 (6.0) 73 (5.4)
20-49 years 1,494 (69.7) 536 (68.3) 958 (70.4)
50-59 years 282 (13.1) 94 (12.0) 188 (13.8)
≥ 60 years 249 (11.6) 108 (13.8) 141(10.4)
Years of schooling*
None 77 (4.6) 22 (3.6) 55 (5.2)
1-3 years 201 (12.1) 53 (8.6) 148 (14.1)
4-7 years 636 (38.2) 216 (35.2) 420 (39.9)
8-11 years 569 (34.1) 217 (35.3) 352 (33.4)
≥ 12 years 184 (11.0) 106 (17.3) 78 (7.4)
Total 1,667 (100.0) 614 (100.0) 1,053 (100.0)
Area of residence*
Shoreline Area 522 (24.3) 266 (33.9) 256 (18.8)
Downtown/Port Area 501 (23.4) 139 (17.7) 362 (26.6)
City Center 304 (14.2) 119 (15.2) 185 (13.6)
Northwestern Zone 585 (27.3) 168 (21.4) 417 (30.7)
Hills Area 175 (8.2) 76 (9.7) 99 (7.3)
Continental Area 13 (0.6) 9 (1.1) 4 (0.3)
No fixed residenceb 45 (2.1) 8 (1.0) 37 (2.7)
Results presented in n (%). No information regarding the years of schooling in 478 cases. aFor 2,145/2,176 patients, data
regarding the type of treatment were available. bResiding in Santos without fixed residence. *p < 0.05.

J Bras Pneumol. 2009;35(10):998-1007

Characteristics of pulmonary tuberculosis in a hyperendemic area—the city of Santos, Brazil 1001

Table 2 - Pulmonary tuberculosis and treatment strategy according to the history of tuberculosis and aspects
regarding treatment and comorbidities. City of Santos, Brazil, 2000-2004.
Characteristic Directly observed treatment, short-course
Subtotala No Yes
n = 2,145 n= 785 n= 1,360
History of TB*
No 1,548 (76.5) 599 (80.9) 949 (73.9)
Yes 476 (23.5) 141 (19.1) 335 (26.1)
Total 2,024 (100.0) 740 (100.0) 1,284 (100.0)
Previous outcomeb
Cure 141 (37.3) 44 (39.3) 97 (36.5)
Treatment abandonment 237 (62.7) 68 (60.7) 169 (63.5)
Total 378 (100.0) 122 (100.0) 266 (100.0)
Treatment*
RHZ 1,661 (85.5) 636 (89.2) 1025 (83.3)
RHZE 250 (12.9) 70 (9.8) 180 (14.6)
SZEEt 32 (1.6) 7 (1.0) 25 (2.0)
Total 1,943 (100.0) 713 (100.0) 1,230 (100.0)
Outcomec
Cure 1,525 (71.1) 579 (73.8) 946 (69.6)
Treatment abandonment 256 (11.9) 88 (11.2) 168 (12.4)
Death from TB 67 (3.1) 16 (2.0) 51 (3.8)
Death from TB/HIV 69 (3.2) 32 (4.1) 37 (2.7)
Death from other causesd 54 (2.5) 14 (1.8) 40 (2.9)
Treatment failure 1 (0.1) 0 (0.0) 1 (0.07)
Transfer 149 (6.9) 51 (6.5) 98 (7.2)
Ongoing treatment 24 (1.2) 5 (0.7) 19 (1.4)
Total 2,145 (100.0) 785 (100.0) 1,360 (100.0)
Alcoholism*
No 1,659 (88.3) 647 (92.6) 1,012 (85.8)
Yes 219 (11.7) 52 (7.4) 167 (14.2)
Total 1,878 (100.0) 699 (100.0) 1,179 (100.0)
HIV infection
No 1,700 (83.9) 610 (82.2) 1,090 (84.9)
Yes 295 (16.1) 124 (17.8) 171 (15.1)
Total 1,995 (100.0) 734 (100.0) 1,261 (100.0)
Diabetes
No 1,723 (91.8) 639 (91.4) 1,084 (92.0)
Yes 154 (8.2) 60 (8.6) 94 (8.0)
Total 1,877 (100.0) 699 (100.0) 1,178 (100.0)
Mental disorder
No 1,845 (98.2) 689 (98.6) 1,156 (98.0)
Yes 33 (1.8) 10 (1.4) 23 (2.0)
Total 1,878 (100.0) 699 (100.0) 1,179 (100.0)
TB: tuberculosis; RHZ: therapeutic regimen 1 (Rifampicin, Isoniazid, Pyrazinamide); RHZE: therapeutic regimen 1 combined
with ethambutol (Rifampicin, Isoniazid, Ethambutol, Pyrazinamide); and SZEEt: therapeutic regimen 3 (Streptomycin,
Pyrazinamide, Ethambutol, Ethionamide). Results expressed in n (%). The difference between the number of patients
analyzed and the total for each variable corresponds to the lack of information for each variable. aFor 2,145/2,176 patients,
data regarding the type of treatment were available. bOutcome of the previous treatment. cOutcome of the current treat-
ment. dCause of death was not specified. *p < 0.05.

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1002 Coelho AGV, Zamarioli LA, Perandones CA, Cuntiere I, Waldman EA

Institute, São Paulo State Health Department, had been made at public health care facilities;
São Paulo, Brazil (Registry no. 25, April, 2006). in 38.2% (789/2,065) of the cases, the diagnosis
had been made at emergency care facilities; in
Results 9,2% (189/2,065) of the cases, the diagnosis
had been made by private practice physicians;
The database analyzed was previously selected
and the remaining cases had been diagnosed at
by the TB surveillance team of the DSR-IV. The
other facilities. The time elapsed between the
database consisted exclusively of confirmed
onset of the respiratory symptoms and the diag-
cases of PTB in patients ≥ 15 years of age and
nosis was less than four weeks in 28.0% of the
residing in the city of Santos, which resulted in
cases; it ranged from four to six weeks in 35.2%
a total of 2,295 patients. Of these, 38 patients
(1.7%) were excluded due to lack of information (465/1,320) of the cases; and it was more than
regarding the locale of treatment, and 81 others six weeks in 36.8% (486/1,320) of the cases.
(3.5%) were excluded because, although they The DOTS had been administered to 63.4%
resided in Santos, they had been treated in (1,360/2,145) of the patients included in the
neighboring cities. Therefore, 2,176 cases of present study, and the DOTS strategy coverage
PTB were included in the present study. increased from 51.9% in 2000 to 81.1% in
Upon completion of the data collection 2004.
(December of 2005), the information regarding There was a predominance of males (69.1%)
treatment outcome was available for approxi- and of individuals in the 20-49 age bracket
mately 99.0% of the patients; the remaining (69.5%). The overall median age was 40 years
1.0% were still under treatment. (35 years for females and 41 years for males). The
The diagnoses had been confirmed based on data regarding the level of education showed that
the following: sputum smear microscopy (61.6% 55.2% (932/1,688) had had up to seven years of
of the cases); clinical and radiological criteria schooling, whereas 44.8% (756/1,688) had had
(33.8% of the cases); sputum culture (2.1% of eight or more years. As can be seen in Table
the cases); histopathological examination (2.1% 1, 50.7% (1,104/2,176) of the cases occurred in
of the cases); and smear microscopy of other the poorer areas of the city (the Northwestern
material (0.4% of the cases). Pulmonary cavita- Zone and Downtown/Port area), whereas 0.8%
tion had been reported in 18% of the cases. In (17/2,176) occurred in an area characterized as
51.8% (1,070/2,065) of the cases, the diagnosis rural (the Continental Area).

350
Rate of incidence per 100,000 population/year

300

250

200

150

100

50

0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 >70
Age bracket

Female Male Total cases of pulmonary TB

Figure 1 - Mean annual rate of incidence of pulmonary tuberculosis (TB) among the population ≥ 15 years of
age, by age bracket and gender. City of Santos, Brazil. 2000-2004.

J Bras Pneumol. 2009;35(10):998-1007

Characteristics of pulmonary tuberculosis in a hyperendemic area—the city of Santos, Brazil 1003

The proportion of patients with a history the cases in which the DOTS strategy had been
of TB was 23.5% (481/2,048). For 342/481 employed, the contacts had been examined in
(71.1%), we obtained information regarding the 30.7% (238/774), whereas the proportion of
time elapsed between the previous and current cases in which contacts had not been examined
treatment. Therefore, the previous episode was 38.2% (159/416) (p < 0.05).
had occurred up to two years before in 43.6% Regarding treatment outcome, 70.6%
(149/342) of the patients, between two and (1,536/2,176) of the patients were cured,
five years before in 22.2% (76/342) and more 12% (262/2,176) abandoned treatment, 3.2%
than five years before in the remaining 34.2% (69/2,176) died from TB and 3.3% (72/2,176) died
(117/342). Regarding the type of discharge from TB/HIV coinfection. For 2.8% (61/2,176) of
from the previous treatment, 67.0% (240/381) the patients, the cause of death was not speci-
abandoned treatment, whereas 37.0% (141/381) fied (Table 2). However, such outcomes varied
were cured. The latter were classified as cases of according to the history of patients. Among
recurrence (Table 2). those who did not present a previous episode of
Regarding comorbidities, 11.7% (222/1,901) PTB, 77.4% were cured, 8.9% abandoned treat-
had a history of alcoholism, 8.3% (158/1,900) ment and 2.9% died from TB. Among those who
had diabetes and 1.7% (33/1,901) had mental presented at least one previous episode of PTB,
disorders. There was information regarding labo- 59.1% were cured, 21.8% abandoned treatment
ratory tests for HIV infection for 2,049/2,176 and 4.8% died from TB.
patients (94.2%), revealing a mean prevalence The mean annual incidence of TB among
of TB/HIV coinfection of 16.2% (332/2,049) in those ≥ 15 years of age in the city of Santos in the
the study period, a prevalence that decreased period of interest was 127.9/100,000 population,
from 20.7% to 12.9% between 2000 and 2004 decreasing from 158.1 to 121.1/100,000 popu-
(Table 1). lation between 2000 and 2004. The risks were
Reinforced regimens (rifampicin-iso- higher for adult males in their economically
productive years. Figure 1 shows that, for the
niazid-ethambutol-pyrazinamide or
sample as a whole, the highest mean annual
streptomycin-pyrazinamide-ethambutol-ethion-
incidence rate was observed among those in
amide) were used in 14.5% (284/1,958) of the
cases (Table 2); the therapeutic regimen was
changed during treatment in 3.7% (76/2,079)
of the cases.
Of the patients for whom information
regarding hospitalization was available, 34.2%
a - Continental area
(616/1,801) had been hospitalized at least once b - Insular area
during treatment. The proportion of hospital-
a
ized patients that presented a previous episode
of TB was 38.2% (152/398), whereas the propor-
tion of patients who were treatment-naïve was
30.7% (396/1,291; p = 0,005). Of the 616 hospi-
b
talized patients, 104 were hospitalized twice,
and 12 were hospitalized three times, totaling
Downtown
732 hospitalizations. The mean length of the Northwestern Rate of incidence of TB
Zone Hills 72.8
hospital stay was 32, 68 and 106 days, respec- 85.8
City Center
tively, for the first, second and third hospital Port 142.3
199.8
stays. Shoreline 272.9
The information regarding the number of a - 185.0
b - 125.0
contacts was available for 55.3% (1,203/2,176)
of the cases, totaling 4,514 contacts. Of these
Figure 2 - Mean annual rate of incidence of pulmonary
4,514 contacts, 1,302 (28.8%) had been effec- tuberculosis (TB) among the population ≥ 15 years
tively examined, and 71 new cases had been of age, by geographic area and region of residence,
identified among them, i.e., 54.5 new cases per per 100,000 population/year. City of Santos, Brazil.
1,000 effectively examined contacts. Among to 2000-2004.

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1004 Coelho AGV, Zamarioli LA, Perandones CA, Cuntiere I, Waldman EA

the 45-49 age bracket (184.7/100,000 popu- Tables 1 and 2 present the characteristics of
lation); for females, the highest rate was the reported cases according to the treatment
observed among those in the 25-29 age bracket strategy adopted. By comparing the character-
(119.7/100,000 population), and for males, the istics of the patients treated under the DOTS
highest rate was observed among those in the strategy with those of the patients submitted
45-49 age bracket (321.6/100,000 population). to the conventional treatment approach, we
The mean annual incidence rates by region observed that those treated under the DOTS
of residence showed an unequal distribution, strategy had had fewer years of schooling
ranging from 72.8 to 272.9/100,000 population (p < 0.001). In addition, the proportion of
in the Shoreline Area and in the Downtown/ patients with a history of alcoholism was
Port Area, respectively. The mean annual inci- higher (p < 0.0001) among patients treated
dence rate in the Continental Area, which has under the DOTS strategy. However, no signifi-
rural characteristics, was 185.0/100,000 popula- cant differences were observed regarding other
tion, compared with 125.0/100,000 population comorbidities (diabetes, TB/HIV coinfection and
in the insular area (consisting of the remaining mental disorder; p > 0.05; Table 1).
five sectors), which is urban (Figure 2). The We also observed a greater coverage of the
mean and median of the annual number of PTB DOTS strategy in the poorer areas of the city
cases in the Continental Area were 3.4 and 3.0,
(p < 0.001), among patients with a history of
respectively.
TB (p < 0.001) and among patients treated with
The mean annual mortality rates for TB,
the reinforced regimen (p = 0.002). However, no
for TB/HIV coinfection and for cases in which
differences in outcomes (cure, treatment aban-
there was no available information regarding the
donment or death) were observed when patients
probable cause of death among those ≥ 15 years
treated under the DOTS strategy were compared
of age in the city of Santos were, respectively,
with those who were not (p > 0.05; Table 2).
4.1, 4.2 and 4.3/100,000 population. The risk of
death among those with TB/HIV coinfection was The analysis of the year-to-year outcomes
higher in the 30-49 age bracket, whereas the risk exclusively for patients treated under the DOTS
of death from TB exclusively was higher among strategy revealed no change in the outcomes as
all patients ≥ 40 years of age (Figure 3). the coverage of the DOTS strategy increased.

Discussion
14 Despite the decrease observed in recent years,
the morbidity and mortality rates for PTB in the
100,000 population/year

12
Rate of incidence per

city of Santos reveal the severity of the situa-

10
tion. The mean incidence and mortality rates are
8
far higher than those reported for the state of
6 São Paulo and for Brazil as a whole,(3) as well as
4 being ten times higher than those reported for
2 Cuba.(8)
0 The high incidence observed among indi-
Death from TB

Death from TB/HIV

coinfection

Cause of death
unknown

viduals aged 15-19 years and individuals in their

economically productive years reveals the hyper-
endemic character of TB; this is in contrast with
other communities, which have controlled TB, in
which the elderly are the group most affected by
the disease.(9,10) Another surprising aspect is the
15-19 20-29 30-39 fact that the small rural population of the city
40-49 50-59 r60 presented an incidence that was 48% greater
Figure 3 - Mean annual rate of mortality for than that found in the urban population. Such
pulmonary tuberculosis (TB) among the population data should be interpreted carefully, since the
≥ 15 years of age, by age bracket. City of Santos, rural area has few inhabitants, and the estimated
Brazil. 2000-2004. incidence therefore represents a small number

J Bras Pneumol. 2009;35(10):998-1007

Characteristics of pulmonary tuberculosis in a hyperendemic area—the city of Santos, Brazil 1005

of cases, even if such cases recurred with small and prolonged exposure to M. tuberculosis.(16)
variations in the period. However, due to its importance to the TB control
The heterogeneous form of distribution of program, this issue deserves further investiga-
PTB over the different areas of the city, affecting tion, since it warrants specific interventions.
particularly the poorer, is consistent with the The search for cases among those of patients
concept that there is a social component of the with respiratory symptoms in public health care
epidemiology of the disease.(11,12) facilities and the investigation of contacts are
The considerable proportion of cases of important aspects of the TB control strategy, to
retreatment due to treatment abandonment is which the success of certain programs has been
worrisome because it contributes to the main- attributed.(21) However, we observed that only
tenance of a high risk of infection, since such half of the cases were identified in public health
patients were infectious. Such conditions are care facilities; in one third of such cases, the
extremely favorable to the transmission of TB diagnosis was established more than six weeks
among contacts and to the increase in mortality after the onset of respiratory symptoms, and the
rates, since it is known that retreatment is asso- proportion of contacts investigated was low.
ciated with multidrug-resistant TB(13) and with Treatment outcomes indicate the obstacles
greater severity of the disease.(14,15) faced by the program; however, such outcomes
The fact that one third of the patients with a are similar to those observed, on average, in
history of TB becomes ill again within five years Brazil as a whole,(22) suggesting that the more
after the previous episode suggests an environ- severe conditions of TB in Santos are not related
ment favorable to exogenous reinfection.(16) exclusively to the performance of the program
Some of the characteristics observed in the in the city.
cases under study have been reported to be Biological factors such as the high number of
associated with retreatment; among such char- people living with HIV/AIDS in the city of Santos
acteristics is the significant proportion of young might also be contributing to the hyperendemic
patients,(17) of patients with TB/HIV coinfec- level of TB there.(23)
tion and of patients presenting greater disease However, environmental and institutional
severity, as evidenced by the number of hospi- factors, especially the conditions favorable to
talizations during treatment,(18,19) the increase in the occurrence of multidrug-
Other aspects that merit attention are the resistant TB and to the transmission of TB,
high proportion of patients that were hospi- seem to have a greater influence than do other
talized at least once during treatment and the factors.(24) Nevertheless, the fact that the city of
mean length of hospital stay per hospitaliza- Santos has a wide range of public health care
tion. This illustrates the social cost of TB and facilities, together with the fact that access to
the impact of such cases on the budget of the the diagnosis and treatment of TB is universal
TB control program, since it is estimated that and free, creates the conditions necessary for a
the cost of hospital treatment is 14 times higher decrease in the morbidity and mortality rates for
than that of outpatient treatment.(20) It has TB in the city of Santos.
been demonstrated that 65% of the TB control Certain favorable results should be
program budget is expended for hospitaliza- ­highlighted. One is the decrease in the preva-
tions, and that the families of patients allocate lence of TB/HIV coinfection in the study period,
33% of their income to expenses related to the a finding that is consistent with those of other
maintenance of the patients during hospital studies.(25,26) We also observed a significant
treatment.(20) increase in the coverage of the DOTS strategy
The high proportion of hospitalizations during the study period, an increase that was
can be partly explained by the low adher- higher than that observed for Brazil as a whole.
ence to treatment, which increases the risk of (2)
However, no significant differences in treat-
developing severe forms of the disease,(14,15) or ment outcomes were observed between patients
by the high prevalence of patients with TB/ treated under the DOTS strategy and those who
HIV coinfection,(18) as well as by the fact that were not.
TB is a hyperendemic disease in the community The interpretation of the results of the
studied, creating conditions for a more marked present study should take into consideration not

J Bras Pneumol. 2009;35(10):998-1007

1006 Coelho AGV, Zamarioli LA, Perandones CA, Cuntiere I, Waldman EA

only the intrinsic limitations of the surveillance de Dados. c2004 - [cited 2005 Apr 5]. Available from:
but also underreporting, the lack of complete http://www.seade.gov.br/produtos/imp/index.php
7. Informações dos Municípios Paulistas [database on the
information and the difficulties that arise from Internet]. São Paulo: Secretaria de Estado de Economia
working with multiple data sources, as well as e Planejamento. Fundação Sistema Estadual de Análise
the fact that only cases of PTB were analyzed. de Dados. c2007 - [cited 2007 Apr 5]. Available from:
The data regarding alcoholism and diabetes http://www.seade.gov.br/produtos/imp/index.php.
8. Marrero A, Caminero JA, Rodríguez R, Billo NE.
should be interpreted with caution, since they
Towards elimination of tuberculosis in a low income
were not verified by means of laboratory tests country: the experience of Cuba, 1962-97. Thorax.
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which there was information regarding treatment M, Mori T. Current epidemiological trend of tuberculosis
in Japan. Int J Tuberc Lung Dis. 2002;6(5):415-23.
outcomes (99.0%) ensures the quality of the 10. Borroto Gutiérrez S, Armas Pérez L, González Ochoa
data collected in the present study. The consist- E, Peláez Sánchez O, Arteaga Yero AL, Sevy Court J.
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About the authors

Andrea Gobetti Vieira Coelho
Assistant in Technological and Scientific Research. Adolfo Lutz Institute-Santos, Santos, Brazil.

Liliana Aparecida Zamarioli

Scientific Researcher. Adolfo Lutz Institute-Santos, Santos, Brazil.

Carmen Argüello Perandones

Director. Epidemiological Surveillance, Regional Health Care Division of the Greater Metropolitan Area of Santos, São Paulo State
Department of Health, Santos, Brazil.

Ivonete Cuntiere
Nurse. Tuberculosis Control Plan of Santos, Epidemiological Surveillance, Santos City Hall, Santos, Brazil.

Eliseu Alves Waldman

Professor. Department of Epidemiology of the University of São Paulo School of Public Health, São Paulo, Brazil.

J Bras Pneumol. 2009;35(10):998-1007