Brazil
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Tuberculosis (TB) remains an important public health problem in Brazil, which ranks
14th on the list of 22 high-burden TB countries in the world. Brazil accounts for 31
percent of all TB cases in the World Health Organization’s (WHO’s) Latin American
Region. According to WHO’s report Global Tuberculosis Control 2009, Brazil had an
estimated 92,102 new TB cases in 2007 and an estimated incidence of 48 cases per
100,000 population, a 3.2 percent decline from the previous year. Brazil’s budget for
TB control more than doubled between 2002 and 2006 due to renewed political
commitment to promote DOTS (the internationally recommended strategy for TB
control) as the official TB policy. The DOTS case detection rate of sputum smearpositive
(SS+) cases was 69 percent in 2007, just below WHO’s target of 70 percent.
WHO estimates that 14.1 percent of new adult TB patients are infected with HIV,
although this varies from more than 20 percent in the port city of Santos in São Paulo
State to less than 10 percent in other areas. Brazil was the first high-burden country to
offer antiretroviral therapy to all TB-HIV co-infected patients. There were an estimated
1,056 cases of MDR-TB in 2007, 30 percent of whom received treatment, but as of
March 2009, extensively-drug resistant TB has also been found in Brazil.
Brazil adopted DOT (directly observed treatment) in 1998, initially implementing it in
demonstration areas in four states. Since then, it has increased from 7 percent in 2000
to 86 percent in 2006, but fell to 75 percent in 2007. The Ministry of Health (MOH)
intends to implement DOT in 100 percent of 315 municipalities that are responsible
for 70 percent of Brazil’s TB disease burden. As of 2008, 87 percent of these priority
municipalities have at least one SS+ TB patient in DOT. The greatest challenge for
Brazil is not only to extend the coverage of the DOTS strategy to 100 percent of
priority municipalities, but to also include more SS+ pulmonary patients in DOT during
their entire treatment course in order to reach WHO’s treatment success rate target
of 85 percent.
USAID Approach and Key Activities
USAID is working with Brazil’s National TB Control Program (NTCP), the Pan
American Health Organization (PAHO), and Management Sciences for Health (MSH) to
combat Brazil’s TB epidemic. USAID is strategically focused on the states of Rio de
Janeiro and São Paulo because they contribute more than 40 percent of new TB cases
every year and because co-infection with HIV runs as high as 25 percent in some major
cities in these two states. Moreover, because the threat of drug resistance is increasing
in these areas due to immigration, detection and treatment must be both timely and
complete. A primary goal of USAID’s strategy in Brazil is to increase the number of SS+
patients in DOT throughout the whole course of treatment. In fiscal year 2008,
USAID funds for TB programming in Brazil totaled $3.2 million. USAID support
includes the following activities:
- Enhancing monitoring and evaluation capacity through support to the TB
information and registry system
- Supporting efforts to integrate TB into basic health care units and introducing
the use of community-based DOTS
- Expanding and improving the management information system for MDR-TB
- Strengthening laboratory services and training at the National Public Health
Laboratory and for TB Reference Laboratory managers in quality testing and
new technologies for identifying MDR-TB
- Increasing the availability of drugs for TB treatment and improving retreatment
drug regimens
- Adjusting the development of fixed-drug combination products to include ethambutol as a fourth drug for the first-line
treatment regimen
- Aiding information, education, and communication activities
- Supporting an innovative border partnership between Brazil and Peru that focuses on preventing and treating
communicable and vector-borne diseases such as TB, malaria, and HIV/AIDS
- Introducing DOT in four large HIV/AIDS clinics – two in Rio de Janeiro State and two in the city of São Paulo – and
expanding culture capacity at these clinics by implementing drug susceptibility testing at initial diagnosis to address
challenges of HIV-associated TB and MDR-TB
USAID Program Achievements
USAID has worked closely with the MOH at the national, state, and municipal levels, as well as the PAHO, the U.S. CDC, and
MSH. USAID initially worked with the Tuberculosis Coalition for Technical Assistance to accelerate DOTS expansion and now
supports the Tuberculosis Control Assistance Program (TB CAP). When USAID’s program to expand DOTS began, only 7
percent of Brazilians had access to health services that provided DOT. Now, 87 percent of Brazil’s 315 priority municipalities are
offering directly observed treatment. USAID support has contributed to the following achievements:
- Trained more than 32,000 health professionals at all levels of the health care system
- Increased the national pulmonary SS+ case detection rate in DOTS services from 8 percent in 2002 to 55 percent in
2006 through support for training in TB microscopy and quality control and management of information systems
- Expanded DOTS in USAID target areas, which increased the percentage of SS+ patients receiving DOT from 0 to 73
percent in newly implemented municipalities
- Provided mobilization and training activities in an additional 20 priority municipalities, which increased the percentage of
health centers providing DOT from 32 to 81
- Increased access to DOT through primary health care services using family health and community outreach workers in
poor communities
- Increased the number of MDR-TB treatment centers using a drug management information system from 63 in 2004 to
122 in 2007
- Reduced sputum smear examination turnaround time for outpatients and emergency room patients in project areas
- Provided intensive training in sputum smear microscopy in three municipalities, which led to a correct diagnosis rate of
95 percent
- Ensured the use of the TB registry at the health service level and accurate reporting to the national health information
system, resulting in an increase in known treatment outcomes
- Supported the use of a management tool for state laboratory quality control and a laboratory commodity management
information system to be used in the TB drug quality testing program
- Developed a joint NTCP-National HIV/AIDS Coordination Committee action plan that includes measures for testing TB
patients for HIV infection and screening HIV/AIDS patients for TB
- Assisted the Brazilian National Tuberculosis Reference Laboratory in evaluating the currently used drug regimen for TB
treatment failures
- Leveraged $12 million in air time from major television networks to raise public awareness
Case Detection and Treatment Success Rates Under DOTS
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Note: DOTS treatment success rate for 2007 will be reported in the WHO Report 2010.
Source: Global Tuberculosis Control WHO Report 2009 |
Partnerships
Partnerships are an important element in combating TB in Brazil. USAID works with the state and municipal health secretariats of
Rio de Janeiro and São Paulo, TB CAP, and MSH. The TB CAP members are the KNCV Tuberculosis Foundation, WHO/PAHO,
the U.S. CDC, the International Union Against Tuberculosis and Lung Disease, and the American Thoracic Society. The Damien
Foundation helped provide training, supervision, equipment, and supported information, education, and communication activities
in 2008. The Brazilian Stop Tuberculosis Partnership formed in 2004 has supported social mobilization efforts for TB control. The
Professor Hélio Fraga National Reference Laboratory and the Brazilian Society of Pneumology and Respiratory Medicine also have
key technical roles. In May 2007, Brazil received the first parcel of funding, $8.8 million, from the Global Fund to Fight AIDS,
Tuberculosis and Malaria, part of a $27 million grant for DOTS expansion in the 11 metropolitan areas with the greatest disease
burden.
May 2009
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