Brazil is one of the largest countries in the WHO Region of the Americas and it has the highest TB burden in the region. Providing TB control and other health services throughout the country poses immense organizational and logistic challenges. However, the data from recent years indicate a steady downward trend in TB incidence in Brazil. Although DOTS is currently available to only some 35% of the population, a concerted effort is being made to include all of the 315 high-burden municipalities by 2007. There is increasing awareness of the public health importance of TB by the new Brazilian health authorities, who have recognized the DOTS strategy as the best solution to Brazil’s TB control problems. The Brazilian MoH has now prioritized the DOTS strategy in its new programme for TB control. TB and leprosy were declared national priority diseases in 2004 and increased government funds were assigned to control them. In addition, 2004 saw the launch of Brazil’s Stop TB Partnership involving numerous technical and donor agencies and other public and private sector partners in TB control.
System of TB control
Brazil adopted the DOTS strategy in 1998, establishing it in four states as demonstration areas. Brazil has a massive and complex decentralized health-care system. At the state and municipal levels, the TB control programme is represented by local TB coordinators who are responsible to the respective state and municipal health secretaries. Recently, the government created the position of Secretary of Health Surveillance (SVS) within the new structure of the MoH, which has given added priority to TB control. The SVS has also facilitated collaboration of the NTP with the national laboratory and the HIV/AIDS programmes. TB patients are treated in the out patient facilities of the public health service and only a few complicated cases require hospitalization.
TB laboratory services are carried out by the National Public Health Laboratories Network. There is one NRL, 27 central public health laboratories (one per state) and more than 4000 local laboratories.
Surveillance and monitoring
Among the HBCs, Brazil has a relatively comprehensive TB surveillance system, and the observed downward trend in the case notification rate probably represents a real decline in incidence. The rate of fall is about 3% per year both for smear-positive and for all TB cases, but a faster rate of decline should be achievable by an expanded DOTS programme. DOTS coverage increased to 34% in 2003 and the case detection rate to 18%, giving a detection rate of 55% within DOTS areas. However, an estimated 81% of all new smear-positive TB cases are found nationally (by DOTS and non-DOTS services), suggesting that Brazil could meet and even exceed the target of 70% case detection simply by ensuring that patients already notified are correctly diagnosed and treated by DOTS services.
As DOTS coverage increases, the monitoring of patients on treatment needs to be carried out more rigorously. The treatment success rate under DOTS in 2002 was 75%, with 18% of patients lost through default or transfer to other treatment centres without follow-up. A large proportion of patients (29%) completed treatment without evidence of smear conversion. Among patients registered for re- treatment, only 36% were cured. An additional 24% completed treatment, but the demonstration of smear conversion is vital for re-treatment patients, who could be carrying drug-resistant bacilli. Treatment success rates were even lower among the subset of patients receiving re-treatment after default (51%) or failure (42%). As control efforts intensify, Brazil’s system of routine surveillance should be strengthened as the main instrument for monitoring trends in TB cases and deaths and for evaluating the future impact of control measures.
The creation of the SVS will strengthen Brazil’s TB surveillance system by integrating TB with surveillance and control of other endemic diseases and improving coordination; however, it is also important to optimize Brazil’s information system (SINAN) for TB surveillance and DOTS monitoring.
Improving programme performance
The MoH, together with health authorities at state and municipal levels, is working hard to strengthen TB control and to reorganize primary health-care services for DOTS implementation. It is important to ensure better integration and coordination of activities at the primary health-care level, particularly those included in the Family Health Programme (Programa de Saúde da Família – PSF) and the Community Outreach Programme (Programa de Agentes Comunitários – PAC). Training in DOTS TB control is currently being provided to other public and private health-care professionals. However, appropriate training and continuous good quality supervision and monitoring activities from the state to the municipal and from the municipal to the local levels are indispensable for effective DOTS implementation. Training for 20 000 Family Health Teams is planned for 2005. Another important area for improving programme performance is the provision of TB control services in high-risk populations such as the indigenous groups and prison populations.
A national TB control plan for 2004–2007 was approved by the government in 2004. It aims to strengthen the NTP and to reach 100% DOTS coverage in the 315 priority municipalities that account for an estimated 70% of the country’s TB burden. The plan includes the creation of a training task force to improve HR capacity for TB control, with the goal of offering DOTS services in all basic health-care facilities in all the priority municipalities by the end of 2007. During 2004, five regional meetings were organized to discuss the national TB plan and strategies for DOTS expansion in the first quarter; two more cycles of five regional meetings each were conducted to monitor this plan in the second and third quarter. All 27 state TB control coordinators and the municipal TB control coordinators of the priority municipalities attended one of these meetings. A Task Force Group was created in 2004 to monitor and assist the states and priority cities in DOTS implementation.
Diagnostic and laboratory services
As DOTS services expand to the 315 priority municipalities, laboratory capacity needs to be increased, and quality assurance must be introduced. The TB laboratory manual is under revision and the task force organizing training has begun the strengthening of laboratory services; this will continue in 2005. Laboratory information systems and monitoring and supervision will also be improved. During 2004, three regional managerial courses, with the support of an international consultant, were developed to increase the capacity for sputum smear microscopy and quality assurance. More than 800 laboratory personnel countrywide were trained on those topics.
Brazil is a country with a concentrated HIV epidemic. In 2003, the estimated HIV seroprevalence in the general population was 0.65%. The NTP estimates that the prevalence of HIV among new TB patients was 8%. This is substantially higher than the WHO estimate of 3.8%, which may underestimate the effect of shared risk factors for TB and HIV. ART is available to all HIV-infected individuals (including TB patients) through the public health system. The recently created SVS has contributed to the collaboration between the NTP and the National AIDS Programme, and to better coordination between them. A national TB/HIV plan is now in place and includes the establishment of a TB/HIV coordination body in 2005, plus strategies to increase the provision of VCT to TB patients and to provide DOTS services to HIV-positive individuals suffering from TB.
Links with other health-care providers
Private hospitals and clinics are required to refer TB suspects and cases to government TB facilities. A small number of NGOs are involved in DOTS provision, and the NTP is planning to host a meeting of national NGOs in 2005 to formulate a collaborative agreement. Brazil has no PPM-DOTS taskforce or guidelines, but plans to strengthen ties with the Brazilian Society of Pulmonology and Phthisiology through a collaborative agreement. There are also plans to enhance the involvement of the Brazilian research network in the 2004–2007 national plan for DOTS expansion, particularly in the area of operational research.
Brazil has established effective international technical partnerships with agencies such as PAHO, WHO, IUATLD and CDC to support adequate DOTS implementation and expansion. Funding partners include USAID (two TBCTA projects), DFB and GLRA. The launch of the Stop TB Partnership in Brazil in October 2004 signifies another important step towards involving different sectors of civil society and the community in TB control, as does the launch of a national advocacy plan to disseminate TB and DOTS information.
Budgets and expenditures
The NTP budget has been steadily increasing, from US$ 14 million in 2002 to US$ 21 million in 2005 (a 50% increase in four years). As would be expected in an upper-middle income country, the budget is fully funded and most financing is provided by the government, although grant funding was received in 2004 and is expected in 2005. This sound funding situation reflects the commitment of both the government and the international community to TB control. The budget for first-line drugs has been consistently around US$ 4 million and around US$ 50 per patient. In 2004 and 2005, there has been an increase in the budget for activities aimed at improving case detection and cure rates, including an extensive training programme and upgrading of the laboratory network. NTP expenditures were US$ 14 million, equivalent to about US$ 170 per patient treated, in both 2002 and 2003. When costs not covered by the NTP budget are included (i.e. 2509 dedicated TB hospital beds and visits to clinics for DOT and monitoring during treatment), the cost per patient treated is estimated at US$ 450–550 during the period 2002–2005. The total cost of TB control is estimated at US$ 37–46 million.