ABSTRACT

Tuberculosis remains a major public health problem deeply influenced by inequality. The present study used data from the Brazilian Tuberculosis Case Registry Database in order to compare the rates of tuberculosis treatment success, loss to follow-up, and tuberculosis mortality between the homeless population and the general population of Brazil. The likelihood of tuberculosis treatment success was reduced by approximately 50% in the homeless population. In addition, the rate of loss to follow-up was 2.9 times higher in the homeless population than in the general population, and the rate of tuberculosis mortality was 2.5 times higher in the former.

Keywords: Tuberculosis; Homeless persons; Health information systems; Health policy.

RESUMO

A tuberculose ainda é um importante problema de saúde pública profundamente marcada pela desigualdade. O presente estudo utilizou notificações de casos de tuberculose do Sistema de Informação de Agravos de Notificação para comparar dados sobre sucesso no tratamento, perda de seguimento e óbitos por tuberculose entre a população em situação de rua no Brasil comparando-a com a população geral. Verificou-se que a população em situação de rua apresentou uma probabilidade aproximadamente 50% menor de obter sucesso no tratamento da tuberculose. Além disso, a perda de seguimento e os óbitos foram 2,9 e 2,5 vezes maiores na população em situação de rua quando comparada à população geral.

Palavras-chave: Tuberculose; Pessoas em situação de rua; Sistemas de informação em saúde; Política de saúde.

Worldwide, tuberculosis remains a major public health problem in the 21st century, despite being a treatable and curable disease. In 2015, there were 10.4 million new tuberculosis cases and 1.4 million tuberculosis deaths,(1) tuberculosis being one of the leading causes of death in the world.(2) In Brazil, strategies to fight tuberculosis include several government action plans(3-5) and national initiatives to achieve the United Nations Sustainable Development Goals.(6) Despite an improvement in tuberculosis indicators, Brazil ranked 20th among the countries with the highest tuberculosis burdens and 19th in terms of HIV/tuberculosis coinfection in the world in 2015, therefore remaining on the World Health Organization (WHO) list of priority countries for tuberculosis control in the 2016-2020 period.(3)







Obstacles to the control of tuberculosis in Brazil include historical difficulty in efficiently disseminating tuberculosis-related information, economic crises with negative impacts on poverty rates, unequal distribution of wealth, precarious urbanization, increased HIV infection, poor nutrition, poor sanitation, and an increase in vulnerable populations.(7-9) Vulnerable populations include homeless individuals, who are particularly at risk for tuberculosis because of extreme social exclusion, poor access to health care, violence, and discrimination, as well as strained or no family ties.(7,10,11)







Studies have shown that homeless individuals are at an increased risk for tuberculosis, and rates of comorbidities are higher in the homeless than in the general population.(7-9) However, no studies have examined a wider range of tuberculosis indicators in a large country like Brazil. Therefore, there is a need to study tuberculosis treatment outcomes in the homeless population of Brazil and compare them with those in the general population in order to gain a better understanding of this issue and contribute to the design of effective and equitable health policies. The objective of the present study was to compare the rates of tuberculosis treatment success, loss to follow-up, and tuberculosis mortality(4) between the homeless population and the general population of Brazil (by region) in 2018.







This was a cross-sectional study of data from the Brazilian National Ministry of Health Sistema de Informação de Agravos de Notificação (SINAN, Case Registry Database). Reported new cases of tuberculosis (International Classification of Diseases, 10th revision codes A15-A16) were analyzed in the homeless and general populations. Confirmed tuberculosis was defined as clinically and laboratory or clinically and epidemiologically confirmed cases of tuberculosis, in accordance with the SINAN Tuberculosis Reporting/Surveillance Form definition. (12) After exclusion of tuberculosis cases in special populations and those with missing data on outcomes of interest, 1,530 cases and 54,608 cases were analyzed in the homeless and general populations, respectively.







Outcomes of the study included treatment success, loss to follow-up, and tuberculosis mortality. All indicators were described for Brazil as a whole and for each region of the country. Case distribution was analyzed by sex, level of education, race, presence or absence of alcoholism, smoking status, HIV status, and presence or absence of mental disorder as recorded in the SINAN.(12) Microdata were analyzed with the Stata statistical software package, version 14 (StataCorp LP, College Station, TX, USA). For the three outcomes, the relative differences between the groups were calculated with Pearson's chi-square test. Because the study used public, anonymized data, no research ethics committee approval was required or sought.







Pulmonary tuberculosis accounted for 91.9% of the tuberculosis cases in the homeless population and 81.7% of those in the general population. In the homeless and general populations, there was a predominance of males (83.5% and 65.1%, respectively), individuals who had had 9 years of schooling (83.2% and 69.8%, respectively), and biracial individuals (52.2% and 53.0%, respectively). The homeless and general populations were significantly different in terms of the presence of alcoholism (58.4% vs. 16.8%), smoking (50.4% vs. 22.4%), HIV infection (21.2% vs. 9.1%), and mental disorder (7.3% vs. 2.3%).







The likelihood of tuberculosis treatment success was reduced by approximately 50% in the homeless population. The rate of loss to follow-up was 2.9 times higher in the homeless population than in the general population, and the rate of tuberculosis mortality was 2.5 times higher in the former (Table 1).







 
















Tuberculosis indicators were found to be worse in the homeless population in all regions of the country (Table 1). The rate of successful tuberculosis treatment was highest in the general population in the southeastern region of the country (75.9%) and lowest in the homeless population in the southern region (33.5%). With regard to reported loss to follow-up, relative inequality was found to be highest in the northeastern region, whereas the northern region showed the highest rate of loss to follow-up in the homeless population. With regard to tuberculosis mortality, the rates were highest in the central-west and northern regions. These differences can be attributed to poor access to health care, failure to trace contacts of patients with confirmed tuberculosis, and poor infrastructure.(13) In addition, according to the Brazilian Institute of Geography and Statistics, socioeconomic inequalities are deep in the northern and northeastern regions of Brazil.(14)







The results of the present study show that the homeless are particularly vulnerable to tuberculosis. These results corroborate those of a study conducted in the state of São Paulo, Brazil, and showing that tuberculosis treatment failed in 57.3% of the homeless individuals, primarily because of loss to follow-up (39.0%) and death (10.5%).(9)







Data from the Brazilian National Ministry of Health show that approximately 11% of tuberculosis patients do not complete the full course of treatment, being consistent with the findings of the present study.(3) The aforementioned rate is more than twice as high as the mean rate of treatment abandonment considered acceptable by the WHO (i.e., 5%).(2) In the homeless population, the rate of loss to follow-up is 33%, which is approximately three times as high as that considered acceptable by the Brazilian National Ministry of Health and seven times as high as that considered acceptable by the WHO.







Tuberculosis outcomes were found to be worse in the homeless population than in the general population of Brazil in all regions of the country, regardless of social and health inequalities. Homeless individuals are autonomous and have specific health needs. Therefore, there is a need to expand the traditional biomedical approach in order to create bonds of trust and respect between patients and health care teams. (15) In Brazil, street teams known as Consultórios na Rua are responsible for providing health care services to the homeless. However, although many Brazilian municipalities meet the criteria for Consultórios na Rua,(16) only 30% had implemented street teams by the end of 2016.(17) Although the number of street teams in Brazil has increased between 2016 and 2019,(18) it is still 40% below expected.(16,17) This is due to a lack of available health care professionals, a lack of prioritization of the health needs of the homeless, and a lack of adequate financial investment from the federal government, among other reasons.(17)







It is difficult to address the health needs of the homeless because of poor living conditions, mental health conditions, dependence on legal and illegal drugs, comorbidities, marginalization, and limited access to health care.(19) Therefore, it is important to increase access to health care services for the homeless, their needs being respected and addressed.(4) Despite the efforts of health care professionals, the lack of collaboration among the various sectors involved in health care for the homeless can be an obstacle to providing effective health care(11) and achieving shared worldwide goals. Economic growth and a reduction in socioeconomic inequalities, as well as effective and equitable health policies, are also needed in order to meet the population needs, including housing needs.







Health information systems are important tools for evaluation and surveillance studies. However, they have limitations, including inconsistent and missing data. (20) Another possible limitation is the underreporting of tuberculosis in the SINAN. These limitations can be further exacerbated in specific patient groups, such as the homeless. Nevertheless, government health information systems are the best regular source of nationwide data, and their extensive use is an important strategy to improve data quality.







There is a need to improve current tools and create new ones that can address the complexities of providing health care for the homeless. In addition, there is a need to develop intersectoral collaboration to provide comprehensive and equitable health care to the homeless population, with a view to change the model of care for the homeless and, consequently, improve tuberculosis indicators.







AUTHOR CONTRIBUTIONS







ACES, CB, and LSP conceived and designed the study, analyzed the data, and drafted and revised the manuscript; SSS conceived and designed the study, collected and analyzed the data, and drafted the manuscript; AFB provided expert advice and guidance at all stages of the study and manuscript preparation process.







REFERENCES







1. World Health Organization. World health statistics 2017: monitoring health for the SDGs. Geneva: World Health Organization; 2017.







2. World Health Organization. Global Tuberculosis Report. Executive Summary. Geneva: World Health Organization; 2019.







3. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. [homepage on the Internet]. Brasília: Ministério da Saúde [cited 2020 Mar 1]. Ministério da Saúde. Brasil Livre da Tuberculose: evolução dos cenários epidemiológicos e operacionais da doença. Boletim Epidemiológico 2019;50(9). [Adobe Acrobat document, 18p.] Available from: http://portalarquivos2.saude.gov.br/images/pdf/2019/marco/22/2019-009.pdf







4. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Brasília: Ministério da Saúde [cited 2020 Mar 1]. Guia de Vigilância em Saúde : 3rd ed. 2019. [Adobe Acrobat document, 741p.]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/guia_vigilancia_saude_3ed.pdf







5. Brasil. Ministério da Saúde [homepage on the Internet]. Brasília: Ministério da Saúde [cited 2020 Mar 1]. Portaria No 399 de 22 de Fevereiro de 2006. [about 23 screens]. Available from: http://bvsms.saude.gov.br/bvs/publicacoes/prtGM399_20060222.pdf







6. United Nations [homepage on the Internet]. New York City: United Nations [updated 2015 Oct 21; cited 2020 Mar 1]. General Assembly. Resolution adopted by the General Assembly on 25 September 2015. Transforming our world: the 2030 Agenda for Sustainable Development. 2015. 35p. Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E







7. Craig GM, Zumla A. The social context of tuberculosis treatment in urban risk groups in the United Kingdom: a qualitative interview study. Int J Infect Dis. 2015;32:105-110. http://dx.doi.org/10.1016/j.ijid.2015.01.007







8. Bamrah S, Yelk Woodruff RS, Powell K, Ghosh S, Kammerer JS, Haddad MB. Tuberculosis among the homeless, United States, 1994-2010. Int J Tuberc Lung Dis. 2013;17(11):1414-1419. http://dx.doi.org/10.5588/ijtld.13.0270







9. Ranzani OT, Carvalho CR, Waldman EA, Rodrigues LC. The impact of being homeless on the unsuccessful outcome of treatment of pulmonary TB in São Paulo State, Brazil. BMC Med. 2016;14:41. http://dx.doi.org/10.1186/s12916-016-0584-8







10. Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Atenção Básica. Manual sobre o cuidado à saúde junto a população em situação de rua. Brasília: Ministério da Saúde; 2012. p. 98.







11. Rosa ADS, Santana CLA. Street Clinic as good practice in Collective Health. Rev Bras Enferm. 2018;71(suppl 1):465-466. http://dx.doi.org/10.1590/0034-7167-201871sup102







12. Brasil. Ministério da Saúde. Sistema de Informação de Agravos de Notificação [homepage on the Internet]. Brasília: Ministério da Saúde. Ficha de Notificação/Investigação Tuberculose; 2014. Available from: http://portalsinan.saude.gov.br/images/documentos/Agravos/Tuberculose/Tuberculose_v5.pdf







13. Barbosa IR, Pereira LM, Medeiros PF, Valentim RS, Brito JM, Costa ÍC. Spatial distribution analysis of tuberculosis in Northeastern Brazil, 2005-2010 [Article in Portuguese]. Epidemiol Servicos Saude. 2013;22(4):687-695. http://dx.doi.org/10.5123/S1679-49742013000400015







14. Brasil. Instituto Brasileiro de Geografia e Estatística (IBGE) [homepage on the Internet]. Rio de Janeiro: IBGE; [updated 2008 Dec 18; cited 2020 Jun 8]. IBGE lança Mapa de Pobreza e Desigualdade 2003. Available from: https://censo2010.ibge.gov.br/noticias-censo.html?view=noticia&id=1&idnoticia=1293&busca=1&t=ibge-lanca-mapa-pobreza-desigualdade-2003







15. Hallais JA, Barros NF. Street Outreach Offices: visibility, invisibility, and enhanced visibility [Article in Portuguese]. Cad Saude Publica. 2015;31(7):1497-1504. https://doi.org/10.1590/0102-311X00143114







16. Brasil. Ministério da Saúde [homepage on the Internet]. Brasília: Ministério da Saúde [cited 2020 Mar 1]. Portaria No 123, de 25 de janeiro de 2012. [about 2 screens]. Available from: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2012/prt0123_25_01_2012.html







17. Medeiros CRS, Cavalcante P. The implementation of the Brazilian health program for the homeless population - Consultório na Rua: obstacles and advantages [Article in Portuguese]. 2018;27(3):754-768. Available from: http://dx.doi.org/10.1590/s0104-12902018170946







18. Brasil. Ministério da Saúde. Tecnologia da Informação a Serviço do SUS (DATASUS) [homepage on the Internet]. Brasília: Ministério da Saúde [cited 2020 Mar 25]. TabNet Win32 3.0. Procedimentos Hospitalares do SUS por local de internação - Brasil. Available from: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sih/cnv/qiuf.def







19. Hino P, Monroe AA, Takahashi RF, Souza KMJ, Figueiredo TMRM, Bertolozzi MR. Tuberculosis control from the perspective of health professionals working in street clinics. Rev Lat Am Enfermagem. 2018;26:e3095. http://dx.doi.org/10.1590/1518-8345.2691.3095







20. Silva GDMD, Bartholomay P, Cruz OG, Garcia LP. Evaluation of data quality, timeliness and acceptability of the tuberculosis surveillance system in Brazil's micro-regions. Cien Saude Colet. 2017;22(10):3307-3319. http://dx.doi.org/10.1590/1413-812320172210.18032017