Original Article

Tuberculosis: patient profile, service flowchart, and nurses’

opinions*

Tuberculose: perfil de doentes, fluxo de atendimento e opinião de enfermeiros

Tuberculosis: perfil de enfermos, fluxograma de atención y opinión de enfermeros

Juliano Souza Caliari1, Rosely Moralez de Figueiredo2

ABSTRACT
Objective: To characterize the profile of patients with tuberculosis (TB) and identify the service flowchart, and the opinion of professionals
responsible for the Tuberculosis Control Program of municipalities in the Regional Health Department III of the State of São Paulo. Methods:
A descriptive study of quantitative approach covering 122 notifications identified in the Control System of Patients with Tuberculosis, 2007/2008,
and six interviews with nurses responsible for this program in the region. Results: Of 122 notifications identified, 69% were men, 35% were
unemployed, 25% were alcoholics and 86% had pulmonary TB. The control activities were centralized, and the nurses were responsible for
programs in the region. These professionals identified favorable points of team involvement and ease in requesting examinations. Unfavorable
points included the lack of equipment and professionals, and the delays in obtaining exams. Conclusion: The region has the typical profile for
TB, including aspects of social fragility, centralized control actions, and those in charge do not recognize the centralization of the actions, and
the lack of autonomy of the units or weaknesses of the program..
Keywords: Health services evaluation; Tuberculosis; National health programs

RESUMO
Objetivo: Caracterizar o perfil de pacientes com tuberculose (TB) e identificar o fluxograma de atendimento e a opinião dos profissionais respon-
sáveis pelo Programa de Controle da Tuberculose de municípios do Departamento da Regional de Saúde III do Estado de São Paulo. Métodos:
Estudo descritivo de abordagem quantitativa abrangendo 122 notificações identificadas no Sistema de Controle de Pacientes com Tuberculose,
de 2007/2008, e seis entrevistas com enfermeiros responsáveis por esse Programa, na região. Resultado: Das 122 notificações identificadas,
69% eram de homens, 35% desempregados, 25% etilistas e 86% com TB pulmonar. As ações de controle eram centralizadas, e os enfermeiros
eram os responsáveis pelos programas da região. Estes profissionais apontaram como pontos favoráveis o envolvimento da equipe e a facilidade
em solicitar exames. Como desfavoráveis, a falta de equipamentos e de profissionais e demora na realização de exames. Conclusão: A região
apresenta o perfil típico para TB, incluindo aspectos de fragilidade social, ações de controle centralizadas, e os responsáveis não reconhecem a
centralização das ações e a falta de autonomia das unidades como fragilidades do programa.
Descritores: Avaliação de programas e projetos de saúde; Tuberculose; Programas nacionais de saúde

RESUMEN
Objetivo: Caracterizar el perfil de pacientes con tuberculosis (TB) e identificar el fluxograma de atención y la opinión de los profesionales
responsables del Programa de Control de Tuberculosis de municipios del Departamento de la Región de Salud III del Estado de Sao Paulo.
Métodos: Se trata de un estudio descriptivo con abordaje cuantitativo que abarcó 122 notificaciones identificadas en el Sistema de Control de
Pacientes con Tuberculosis, del 2007/2008, y seis entrevistas a enfermeros responsables de ese Programa, en la región. Resultado: De las 122
notificaciones identificadas, el 69% eran de hombres, el 35% de desempleados, el 25% de etílicos y el 86% de personas con TB pulmonar. Las
acciones de control estaban centralizadas, y los enfermeros eran los responsables de los programas de la región. Estos profesionales señalaron
como puntos favorables el involucramiento del equipo y la facilidad para solicitar exámenes. Como desfavorables, la falta de equipamentos y
de profesionales, demora en la realización de los exámenes. Conclusión: La región presenta el perfil típico para la TB, incluyendo aspectos de
fragilidad social, acciones de control centralizadas, y los responsables no reconocen la centralización de las acciones y la falta de autonomía de
las unidades como fragilidad del programa.
Descriptores: Evaluación de programas y proyectos de salud; Tuberculosis; Programas nacionales de salud

* Study performed at the Tuberculosis Control Program in the counties corresponding to the Region III Health Department of the State of São Paulo - São Carlos
(SP), Brazil.
1
MSc in Nursing, Nursing Graduate School, Federal University of São Carlos – UFSCar – São Carlos (SP), Brazil.
2
PhD, Coordinator, Professor, Nursing Graduate School, Federal University of São Carlos – UFSCar – São Carlos (SP), Brazil.

Corresponding Author: Rosely Moralez de Figueiredo Received article 09/08/2010 and accepted 11/07/2011
Via Washington, Km 235 – Caixa Postal 676. CEP: 13565-905.
São Carlos -SP – Brasil.
e-mail: [email protected] Acta Paul Enferm. 2012;25(1):43-47.
44 Caliari JS, Figueiredo RM

IntroduCTION represent barriers to treatment even when a wide range

of services is offered to the population (14-15).
Tuberculosis (TB) is among the oldest and most well stud- Because healthcare services are widely offered and be-
ied diseases known by humankind. Although TB became cur- cause the incidence of TB still persists in this area, this study
able in the last century, it still poses a major public health chal- sought to characterize the sociodemographic and clinical
lenge in many countries, particularly developing countries (1- 3). profile of patients, to identify the flow of patient care, and
In addition to representing a severe socioeconomic to record the opinions of the professionals in charge of the
problem because of its disproportionate burden on the Tuberculosis Control Programs in the counties correspond-
lower social classes, TB is the leading cause of death by ing to the Region III Health Department (DRSIII) of the
infectious disease in adults globally (4-5). state of São Paulo. Thus, the present study is expected to
In Brazil, 72,000 new cases of TB were registered in 2007, contribute to the advancement of knowledge on this com-
and the national average prevalence was 38.2 cases/100,000 plex subject to inform TB control activities in São Paulo.
inhabitants, with 4,500 deaths associated with this disease.
The most affected group comprised young impoverished METHODS
men who used alcohol and were affected by social problems.
In Brazil, the most vulnerable populations include the fol- This is a descriptive, quantitative study conducted with
lowing: Indians (in whom the incidence is four times higher TB cases registered in the counties of the Central Region
than the national average), individuals co-infected with hu- (São Carlos, Ibaté, Porto Ferreira, Descalvado, Dourado
man immunodeficiency virus (HIV) (30-fold higher risk), and Ribeirão Bonito) of the Region III Health Depart-
individuals in prison (40-fold higher risk), and the homeless ment, which is located in the central area of the state of
(60-fold higher risk). Nevertheless, TB may occur in any São Paulo. The counties were randomly identified by the
social segment regardless of income or education (6). letters A, B, C, D, E, and F to preserve their anonymity.
The state of São Paulo plays a leading role in the This study followed the recommendations of Resolu-
identification and follow-up of TB cases due to a model tion nº 196/96 of the National Health Council regarding
of regional and hierarchical healthcare networks, which research on human beings, and it was approved by the
was established in 1996 and participates in the identifica- Research Ethics Committee of the Federal University of
tion and assessment of regional problems (7-8). Moreover, São Carlos (CEP-UFSCar) ruling nº 351/2008.
in 2006 the online System of Control of Tuberculosis This study was performed in two stages. In Stage A, data
Patients (TBWEB) was established to facilitate the notifica- were collected from the TBWEB between 2007 and 2008
tion, follow-up, and closing of TB cases (9). Nevertheless, to characterize the epidemiological profile of 122 registered
São Paulo, the state with the highest number of TB cases in cases of TB. For this stage, a collection tool was designed
the country, strives to achieve the recommended cure rates. based on the information supplied by the notification forms.
Despite universal, free access to diagnosis and treatment The data were stored in a Microsoft Office Excel 2003 database
and the wide extension of the primary care network, 17,817 TB for subsequent descriptive statistical analyses.
cases were recorded in 2006, of which 15,300 were new cases, In Stage B, interviews were performed with the six
1,417 were relapses, 1,018 were retreatment after treatment professionals in charge of the TB programs after partici-
dropout, and 82 were retreatment after treatment failure (6). pants signed informed consent forms. The interviews were
Social inequality, poverty, the AIDS epidemic, the performed to investigate the flow of care for TB patients
ageing of the population, large migratory movements, in the area and to identify the opinions of the professionals
difficulties in the operationalization of TB control pro- on the strong or weak aspects of the programs.
grams, and uncontrolled population growth are consid-
ered to be the main factors affecting the TB prevalence Results
and population distribution (10-11).
The only preventive measure that truly removes the A total of 122 patients were identified in stage A. Among
risk factors for TB is the elimination of contamination these patients, 84 (69%) were males, and the average age
sources by means of the active identification and proper was 40 years old. At the time of notification, 29% of the
treatment of infected individuals (12-13). patients were retired, 32% were in charge of a household,
Although early diagnosis and specific treatment are and 35% were unemployed. Approximately 70% had at
priorities in the control of the disease, many cases of least one year of education, and 9% had 12 or more years.
TB are not diagnosed rapidly enough due to a lack of Among the patients identified in stage A, 86% had
access to healthcare services or to neglect in the active pulmonary TB, 85% had pulmonary disease for the first
search for subjects with respiratory symptoms (1). Some time, 8% were relapses, and 5% were cases of retreatment.
studies suggest that attrition and the loss of connections Regarding the place of notification, 82 patients (67%)
between patients and healthcare service teams might also were diagnosed and notified at Health Basic Units and

Acta Paul Enferm. 2012;25(1):43-47.

Tuberculosis: patient profile, service flowchart, and nurses’ opinions 45

Family Health Units, 21 patients (17%) at emergency and the teams at the healthcare units where patients were
urgent care services, 11 patients (9%) at hospitals, and 4 originally notified.
patients (3%) postmortem. A total of 101 radiographies, The six interviewed professionals reported the
94 smear microscopy tests, and 25 sputum cultures were following favorable aspects of the program: involve-
performed for diagnostic purposes. ment with the community, strategies used to enhance
A specific anti-TB drug regimen was reported in ap- compliance, and ease of requesting diagnostic tests.
proximately 94% of cases. However, only 48 cases (39%) The unfavorable aspects reported by the professionals
reported on the type of treatment, and among these included the following: lack of skilled teams, lack of
reports, treatment was supervised in 26% of cases and vehicles, lack of rooms suitable for the care of respira-
self-administered in 13% of cases. tory symptomatic subjects, delays in obtaining labora-
Treatment outcome information was reported in 90 tory results, difficulty with scheduling radiographies,
cases (74%); of these cases, 53% reported cure, 11% and a lack of specialized doctors and nurses exclusively
death, 8% dropout, and 1% the transfer of care. In 1% allocated to the program. The centralization of control
of these cases, the diagnosis was changed. activities and the lack of autonomy of the healthcare
The most common comorbidities associated with TB units were not reported as problematic.
were alcohol use (25%), AIDS (18%), diabetes (6%), and
mental illness (3%). DiscussION
Anti-HIV serology was performed in 112 patients (92%).
Sixty-five percent were negative, 18% positive, and 17% were It is important to acknowledge the difficulties associ-
still being processed at the time of data collection. ated with assessing the quality and accuracy of data in
A total of 22 patients required hospitalization. The any study that uses secondary data, including the pres-
average length of stay was 53 days, and the most frequent ent study, which used data from TBWEB. Nevertheless,
indications for hospital admission were social causes, diag- despite the potential flaws inherent to the chosen meth-
nostic clarification, and lack of compliance with treatment. odology, the systematic use of secondary data allows
Stage B identified healthcare units to assist with for tracing the impact of disease and contributes to an
suspected cases, investigate respiratory symptomatic understanding of the trends of the problem.
subjects, and follow-up TB cases in all six investigated This study found that the TB rate in males was 3.2 times
counties. In addition, each county has a small hospital and the rate in females, which is above the national average of
a central hospital where radiological diagnostic tests were 2 males per female (16). At the national level, this rate is at-
performed. Only four of the investigated counties had tributed to males being more active in the labor market and
laboratories performing microbiological and anatomo- thus also more exposed to TB (17). The present study was
pathological diagnostic analyses. Patient samples collected performed in the São Paulo area, where female labor force
in towns E and F were sent to county A for analysis. participation is possibly lower than the national average.
The follow-up of cases was centralized in the ref- The average age reported here is similar to that reported
erence units, and the professionals in charge of the in studies that suggest that TB is shifting towards the older
Tuberculosis Control Programs in all the investigated segments of the population due to the efficacy of the
counties were nurses, BCG vaccination, a reduction in the risk of infection in
In five of the investigated counties, the reference units the community, and the overall ageing of the population (4).
for TB control were included as part of a county healthcare In addition, low education levels imply low profes-
unit. County A had a specific unit allocated to the program. sional qualifications, which might restrict access to both
The active search for respiratory symptomatic individuals the labor market (18) and healthcare services. Moreover,
could be performed by any healthcare unit in the six investi- low education levels may be strongly associated with TB
gated counties. However, procedures for sputum collection deaths due to the failure of individuals to perceive or
varied by county. Counties E and F referred the samples to understand the state of their disease (5, 17).
counties A and D. Sputum collection was performed at a The high incidence of pulmonary TB found in this study
later stage, when patients came back for medical consultation was expected, as the pulmonary system is the most manifes-
three to seven days after the initial appointment. tation site of this disease (6, 13, 19). The clinical assessment and
Patients were referred to the county TB reference the diagnostic tests employed are the most common and
unit for notification and treatment initiation when least expensive techniques to identify pulmonary TB (20-21).
smear microscopy was positive. Notification was per- However, in 26% of the investigated cases, disease noti-
formed at the reference unit in county A. All patients fication was performed outside of the primary care context,
were then referred for follow-up to the reference unit which suggests possible flaws in early detection. These find-
at county A, which also provided the medication. Su- ings corroborate those of a study performed in 2007 in the
pervision of the treatment was the responsibility of same geographical area, where the rate observed was 36% (22).

Acta Paul Enferm. 2012;25(1):43-47.

46 Caliari JS, Figueiredo RM

Adequate chemotherapy appears to be the most pow- The interviewed nurses acknowledged programmatic
erful tool against TB (23); however, poor treatment compli- flaws in both infrastructure and logistics. These flaws result
ance due to multiple treatment interruptions contributes in delayed diagnoses and represent obstacles to program
to the development of resistant bacilli (24). Supervised success, and they also favor the risk of TB transmission at
treatment, which was reported in only 26% of the cases the occupational level (31-33). Nevertheless, nurses did not
investigated in the present study, had a positive impact report as problematic the centralization of activities or
on both cure and dropout outcomes because it ensures the lack of autonomy of the local units.
regularity in the use of medication and the maintenance The decentralization of the anti-TB activities has
of treatment for the recommended duration (23). extends beyond the mere supervision of drug intake or
The cure rate (53%) and dropout rate (8%) reported supervised treatment. The development of bonds between
here are below the World Health Organization (WHO) patients and the healthcare team is noted as a significant
recommendations for cure rate and dropout rate of 85% factor for compliance with treatment because patients are
and 5%, respectively (11, 25). important in the care process, and they appreciate having
Alcohol use (25%) was the most frequent comor- a certain degree of autonomy in decision making (15).
bidity reported in the present study. Alcohol use and In many cities in Brazil, TB control efforts led to a
other forms of chemical dependency hinder treatment reorganization of the healthcare model and health facili-
compliance due to the lifestyles adopted by the affected ties, which are now based on a decentralized and integrated
individuals (26). AIDS (18%) is considered the most severe network for diagnosis and treatment. These changes were
comorbidity because it increases the incidence of infec- aimed at making horizontal the actions of surveillance and
tion and disease complications (27). The high number of the prevention and control of disease and at enhancing the
HIV serologic tests performed in the investigated cases bonds between the population and healthcare providers.
(92%), which is close to the recommended goal (28), is an In this context, the Family Health Strategy plays a major
indication of the concern with AIDS. role because it represents the entrance to the healthcare
Hospital admissions associated with social causes system and promotes the development of bonds between
point to possible flaws in the support networks for this healthcare professionals and users through supportive
population, which make it impossible for individuals to listening and co-responsibility for treatment (13).
complete treatment as outpatients.
Nurses play a major role, as they are the profession- ConclusION
als responsible for the TB program in many cities. The
number of nurses involved in healthcare management Although the Central Region of the Region III Health
has increased due to the nurses’ good performance as Department provides many healthcare services, TB cases
supervisors, managers, and coordinators. The duties of remain in this region. Cure rates and dropouts are below
these nurses include the planning and development of ac- the WHO goals, and some patients have social risk fac-
tivities focused on assisting patients and meeting the goals tors, such as low education levels and unemployment.
established by the healthcare programs (29). As a result, the Many TB control activities in the investigated area are cen-
responsibilities and activities of the nurses in the different tralized in a single county, which may result in delayed diagnosis
healthcare facilities have grown. This increases in the nurs- and treatment, particularly due to the multiple steps required
es’ responsibilities was confirmed during the interviews, for users to receive care upon accessing the healthcare system.
where the nurses emphasized the inadequate number of Nurses play a major role, as they are responsible for
professionals exclusively allocated to the TB programs. the TB control activities in all counties. The nurses who
Regarding the flow of patient care, suspected TB cases were interviewed for this study reported the following
might be identified at any healthcare facility in the investi- favorable points of the program: the involvement with
gated counties. Consequently, the programmatic expecta- the community, the use of strategies to enhance compli-
tions regarding the identification of active cases can be met ance, and the ease of requesting diagnostic tests.
by anyone, regardless of professional training or function The nurses also noted several weak points of the pro-
in the healthcare units (30). Conversely, the activities cor- gram: the lack of training of the teams, the lack of rooms
responding to the later stages of diagnosis and treatment suitable for care, delays in receiving test results, and a lack
are still centralized in a single specialized unit in county A. of specialized doctors and nurses exclusively allocated to the
Such centralization explicitly conflicts with the recom- program. The centralization of activities was not perceived
mendations of the National Program for the Control of as a hindrance to the efficacy of TB control activities.
Tuberculosis. An acknowledged strategy for TB control Studies assessing the local conditions and the percep-
requires follow-up activities to be performed by the tions of the participating healthcare teams are essential to
healthcare teams of the source units to strengthen the transcend the purely biological and reductionist view of TB
bonds with patients (1, 15). and to inform assessments of the ongoing applied strategies.

Acta Paul Enferm. 2012;25(1):43-47.

Tuberculosis: patient profile, service flowchart, and nurses’ opinions 47

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