Almost 16 people died from tuberculosis per day in Brazil in 2022

Tuberculosis killed almost 16 people per day in Brazil in 2022 – 5,824 deaths were recorded in the period, a number still preliminary, but a record number in more than 20 years of monitoring, according to data from the Ministry of Health. Ten years earlier, for example, the country recorded 4,421 deaths from the disease. The number of new cases also continues to grow: there were 81,539 records in 2022, 3% more than the 78,462 cases diagnosed in 2019, before the Covid-19 pandemic. Data for 2023 has not yet been released by the department.

This scenario puts Brazil very far from achieving the Sustainable Development Goals of the World Health Organization (WHO), which are to reduce mortality from the disease by 75% by 2025 and eliminate it globally by 2030. The Brazilian commitment is to reduce it by By 2030, the incidence of tuberculosis will drop to less than ten cases per 100,000 inhabitants – currently the country has an incidence of 38 cases per 100,000.

March 24th is World Tuberculosis Day and the theme of this year's campaign is “Yes, we can end Tuberculosis!”. The difficulty in achieving WHO goals and reducing the number of cases and deaths is not exclusive to Brazil. Despite the efforts of governments, the BCG vaccine (which protects against severe forms of the disease) and the treatments offered, tuberculosis is still one of the main causes of death from infectious agents in the world, according to the most recent WHO report, released in end of last year.

According to the document, it is estimated that 7.5 million people will be diagnosed with tuberculosis in the world in 2022 – the highest number since the disease began to be monitored in 1995. This number exceeds 7.1 million cases estimates for 2019. According to the WHO, Covid-19 strongly impacted the registration of new cases. During the pandemic, many of them stopped being diagnosed and treated and, therefore, there may be an accumulation of diagnoses and deaths in the coming years.

What is tuberculosis?

Tuberculosis is an infectious and transmissible disease caused by the bacterium Mycobacterium tuberculosis, also known as Koch's bacillus. The most common form of presentation is pulmonary tuberculosis, as the disease primarily affects the lungs. Despite this, the tuberculosis bacillus can affect other organs and systems, including the central nervous system, lymph nodes, pericardium, bones and larynx, among others – these forms are less frequent and are called extrapulmonary tuberculosis. Closed, poorly ventilated environments and crowds favor transmission.

“Pulmonary tuberculosis, in addition to laryngeal tuberculosis, is mainly responsible for maintaining the disease through person-to-person transmission via droplets and aerosols from the sick individual’s respiratory tract. The extrapulmonary forms, without pulmonary involvement, do not transmit from person to person”, explains infectious disease specialist Emy Akiyama Gouveia, from Hospital Israelita Albert Einstein.

Main symptoms

The disease (pulmonary tuberculosis, the most common) is suspected when the patient complains of a chronic cough for three weeks or more, associated with fever (usually at the end of the day), weight loss and night sweats. The diagnosis is made by testing the tuberculosis bacillus in three sputum samples, collected over three days, and a chest X-ray to assess the degree of lung involvement.

“Currently, in places where it is available, it is also possible to carry out a molecular test to search for the bacillus’s DNA in respiratory samples, with excellent sensitivity and the results are ready in up to an hour and a half. In addition to its speed, the test can also assess whether the bacillus is resistant to one of the important antibiotics in the therapeutic arsenal, in this case rifampin”, explains the Einstein doctor.

If the patient is unable to collect sputum, another possibility is to undergo a bronchoscopy exam with bronchoalveolar lavage. If the results are positive, treatment begins with a combination of several antibiotics, which are distributed free of charge by the Unified Health System (SUS).

According to the WHO, if tuberculosis is not treated, the fatality rate is high – reaching 50% of cases. On the other hand, around 85% of cases treated appropriately progress to cure. The main difficulty, however, is correct adherence to treatment, which involves the continuous use of antibiotics for at least six months, which can be extended for another period if there is an infection resistant to the standard medication. The basic scheme consists of two phases of treatment: intensive, which lasts four months, with tablets associated with four antibiotics, and maintenance, which lasts another two months, with two antibiotics associated.

“Perhaps the long treatment time is one of the reasons for the individual to abandon care. Another point is that, after only a short period of time using medication, the person already improves clinically, resulting in a false feeling of cure. But the person is not yet cured and, without treatment, the disease will reappear after a few months”, explains the infectious disease specialist, who warns that this is a risk of resistance to treatment. “Individuals who abandon and restart treatments over time may develop the dreaded resistant tuberculosis, with the need to adapt the antibiotic regimen and, eventually, increasing treatment time.”

In September 2023, the SUS incorporated an important new medication into the multidrug-resistant tuberculosis treatment arsenal, pretomanid, which is administered orally and can shorten the treatment time for this condition, in addition to reducing the number of follow-up visits.

According to the infectious disease specialist interviewed by Agência Einstein, there is still a delay in diagnosing tuberculosis because it is often mistakenly treated as pneumonia. “In these cases, the antibiotic even has an action in combating the bacillus, but, as soon as the treatment is finished, the signs and symptoms return. As pneumonia is suspected, the antibiotic is changed, in a never-ending cycle. It is necessary to understand that tuberculosis is present in all layers of the population, at all ages, and the awareness of the population and health professionals is essential so that the diagnosis can be carried out at the appropriate time, as well as the treatment”, warns the doctor, who highlights that an individual with pulmonary or laryngeal tuberculosis without treatment ends up infecting, on average, ten to 15 people after a year.

Income commitment

Although diagnosis and treatment are provided by the SUS free of charge, a study carried out by the Federal University of Espírito Santo (UFES) showed that almost half of patient families spend around 20% of their annual income on the “extra costs” of the treatment, including direct expenses (consultations and extra exams), direct non-medical expenses (transport, food, accommodation and purchase of dietary supplements, among others) and indirect costs (deprivation of income due to job loss, for example) . According to the survey, annual extra expenses totaled, on average, R$8,118.74, almost seven times the value of the minimum wage at the time (2021).

“This study brings to light very important points, as patients, especially those with low income, face difficulties related to day-to-day treatment, such as commuting to health units, the impacts of unemployment or even days lost at work during the isolation period (14 days after starting medications)”, comments the infectious disease specialist. According to her, these patients may also face problems related to the clinical weakness of the disease itself or managing possible side effects of medications.

The study also shows that, if the patient has HIV co-infection and is self-employed, the risk of the family having expenses defined as catastrophic will practically triple. “HIV co-infection brings a point of greater criticality, perhaps due to drug interactions with antiretroviral therapy and the need for monitoring in specialized AIDS treatment centers, units that are not always close to patients’ homes, or often only available in other municipalities. The self-employed worker has another point: he does not have paid sick leave, and consultation days mean days not worked”, says the infectious disease specialist.

What the Ministry of Health says

Despite the setback with an increase in cases and deaths, the Ministry of Health reported in a note that “Brazil is among the 13 countries that managed to recover the detection of people with tuberculosis after the Covid-19 pandemic, which is essential to speed up the treatment of patients.”

The government also attributes the increase in deaths to the pandemic. “Health services were impacted by the public health emergency, possibly reducing their ability to diagnose cases that occurred in 2020 early, resulting in more serious clinical conditions of tuberculosis and worse treatment prognoses”, he assesses.

The Ministry of Health also reported that, “in an unprecedented way, 14 ministries came together to develop strategies to eliminate tuberculosis and ten other diseases and five vertically transmitted infections that affect populations in situations of social vulnerability more intensely through the Interministerial Committee for the Elimination of Tuberculosis and Other Socially Determined Diseases (CIEDDS), which was installed in April 2023. Coordinated by the Ministry of Health, the group is expected to operate until January 2030”.

The government also added that another essential action to prevent serious cases of tuberculosis is to restore high coverage of the BCG vaccine, which is recommended for one dose for newborns. Until 2018, this rate remained above 95%, the target established by the ministry. However, as of 2019, coverage did not exceed 88% (last year it was 76.24%) and data for 2024 indicate vaccination coverage of only 65.59%.

“Stigma and discrimination are major barriers to controlling and combating tuberculosis. Furthermore, the lack of an effective vaccine to prevent the pulmonary form of tuberculosis makes it difficult to reduce cases and eliminate the disease, as does the non-existence and lack of development of drugs for short-term treatment”, he concluded. the note.