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Revista Pan-Amazônica de Saúde

versão impressa ISSN 2176-6223versão On-line ISSN 2176-6223

Rev Pan-Amaz Saude v.1 n.1 Ananindeua mar. 2010 



Detection of respiratory symptoms in the public health network of Belém, Pará State, Brazil



Ivaneide Leal Ataide RodriguesI; Ninarosa Calzavara CardosoII

ICoordenação Estadual de Pneumologia Sanitária, Secretaria de Saúde do Estado do Pará, Belém, Pará, Brasil. Universidade do Estado do Pará, Belém, Pará, Brasil
IICentro de Saúde Escola do Marco, Universidade do Estado do Pará, Belém, Pará, Brasil

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Original Title: Detecção de sintomáticos respiratórios em serviços de saúde da rede pública de Belém, Pará. Translated by: American Journal Experts




Tuberculosis is considered a serious public health problem, and the identification of its respiratory symptoms is of extreme importance to facilitate a precocious diagnosis of the disease. This study aimed to discover the number of respiratory symptomatic patients identified among the people that sought treatment in the local public health network, as well as the number of individuals not identified as symptomatic by its health care providers. Twenty-one health care units in Belém, Pará State, were involved in this study, and 1,008 individuals were surveyed. Selection and analysis of the data collected was carried out using Epi-Info Version 6.0B software. The prevalence rate of respiratory symptomatic patients was 10.03%; their identification was not carried out in 72% of the cases. Of the identified ones, 33% were directed for sputum examination. There was no statistically significant difference (p = 0.07) in the association between the question of cough and its duration. This identification through the search for patients with chronic cough should be a procedure incorporated in the Health Units' daily routine, in order to facilitate an early diagnosis and the immediate treatment of bacilliferous cases, as a form of breaking the transmission chain of the disease.

Keywords: Tuberculosis; Prevalence; Signs and Symptoms Respiratory.




Tuberculosis is still an important public health problem in Brazil and other regions of the world. According to data from the Sistema de Informação de Agravos de Notificação - SINAN (Information System for Notifiable Diseases) of Brazil's Ministry of Health - MS, 80,515 new cases of this disease were reported in 20047. The international goals set by the World Health Organization (WHO) and agreed upon by the Brazilian government are to identify 70% of the total estimated cases of tuberculosis and to cure 85% of these5. Among the different Brazilian regions, the North presents an average of 6,000 new cases per year. Pará is one of the states that present the highest incidence rates, with an average of 3,000 new cases per year, approximately 45% of which are from Belém, the state capital, which reports an average of 1,300 new cases per year11.

Cough is the main symptom of pulmonary tuberculosis. Thus, individuals with chronic cough are suspected tuberculosis carriers. In Brazil, the following concept has been adopted as the definition for respiratory symptomatic subjects (RSSs): any individual that presents with a productive cough lasting three or more weeks3. For several decades, international organizations have recommended the active search for RSSs as a strategy for the early diagnosis of tuberculosis10. The ideal locations to organize the search for such cases are health services, where the detection of cases among RSSs should be a permanent effort, incorporated in the daily activity routine of health care professionals10.

Bacteriological analysis is the main method for diagnosis of tuberculosis, permitting the identification of the main source for transmission, namely patients with sputum smears positive for acid-fast bacilli2. In the medical literature, only a few studies have focused on the identification of RSSs. In Caracas, Venezuela, Armengol and colleagues interviewed 53,314 people, and identified 2,378 (4.46%) RSSs, of which 75 (3.2%) were sickl. In Colombia, Zuluaga and colleagues selected 3,731 subjects 15 years of age or older who were interviewed in their homes, resulting in an estimated prevalence of 2.68 infected individuals per 1000 inhabitants13. In Mexico, Marin and colleagues interviewed 6,748 people. They identified 245 (3.6%) symptomatic and 17 (6.9%) sick patients12.

In Brazil, the currently available information about the detection of RSSs in health services is insufficient. Thus, several different methods are used to estimate the number of RSSs, such as calculating 1% of the population covered by the municipal or state health service, or calculating 5% of the total number of people, aged 15 or older, attending their first appointment at a health service5. For the effective surveillance of tuberculosis, we consider that it is essential to implement early diagnosis of cases through active detection of RSSs.

The goals of this study were to determine the number of RSSs identified among individuals who attend health services and to determine the number of patients not identified as an RSS by these services.



This is a study that describes the prevalence of RSSs among individuals over 15 years old who attend the public health services of the Municipality of Belém in Pará.

This study assessed data from patients in 21 Unidades Básicas de Saúde - UBS (Basic Health Units) located in the Municipality of Belém. Units of the Family Health Strategy Service were excluded because they adopt a domiciliary-based approach for identification of RSSs, i.e., there is no spontaneous demand for the UESF services. To determine the number of people to be interviewed at each UBS, cluster sampling was considered the most appropriate methodology6. In order to use this technique, the number of appointments in each health service was considered. A cumulative population list was compiled based on the list of all the health services in the municipality, yielding the number of appointments per day/year. Because the minimum recommended number of clusters is 30, in order to obtain the sampling interval the total number of appointments each day was divided by 30, and a random number was selected between 1 and the sampling interval. This random number determined the first UBS in the cumulative list to be selected. To select the other units from the list, the sampling interval was added to the random number. To determine the number of people per cluster, the total sample size was divided by 30. Thus, we worked with values varying between 34 and 122 people per unit, resulting in a total number of 1,008 interviewees. This calculation, based on the number of UBS existing in the municipality and the number of appointments held in each one of them, defined the sample.

For data collection, all the subjects answered a questionnaire that included the following aspects: the presence or absence of productive cough with sputum; the duration of cough; whether these issues were observed by the health unit - if positive, whether the patient was referred to sputum bacilloscopy; and, finally, the reason why the patient sought the UBS. The data collection was performed by 42 nursing and medical undergraduate students, distributed in groups of 2 in each UBS and identified as researcher 1 and researcher 2. They worked under the supervision of a graduate professional with knowledge of the research protocol. The researchers were previously trained by the responsible researchers, in a single session, to minimize the risks of bias in the study. Questionnaires were administered by researcher 1. Researcher 2 was responsible for the registration of the RSSs sent for sputum collection in the Livro de Sintomáticos Respiratórios (Book of Respiratory Symptomatic Subjects), which was standardized by Brazil's Ministry of Health. Researchers alternated between these two functions during data collection. In health units without a laboratory, collected material was sent to reference laboratories under the appropriate biosafety and sample preservation conditions, according to the protocol previously established in the UBS. Data collection was performed simultaneously in all 21 health units on September 4, 2006. The procedure started upon initiation of regular activity at the health unit and ended when the scheduled number of interviews for each unit was reached. This procedure was chosen because we considered that working each unit on different days could interfere with the results and that working on a single day would be more viable logistically.

The identified RSSs were analyzed through two bacteriologic sputum examination exams. The first sample was collected at the time of identification, whereas the second was extracted on the following morning. In all cases, regardless of the smear result, a protocol for treatment or follow-up of the case was applied, as set by the norms in the Programa de Controle da Tuberculose (Brazilian Program for Tuberculosis Control)4.

The construction and analysis of the database were performed using the program Epi-Info Version 6.04 B. In the analysis, the following variables were considered: age, gender, the number of persons questioned about the presence or absence of productive cough with sputum, cough duration, the number of persons questioned about productive cough in the health unit, the number of RSSs identified and sent for sputum collection and the number of people questioned about the reason for seeking the health unit.

The research protocol was submitted to the Ethics Committee of the Universidade do Estado de Pará, in Belém, Pará, and was approved April 27, 2006. Formal permission was requested from the health authorities of the Municipality of Belém and was granted under protocol number 18/2006.



A total of 1,008 people attend ing one of the 21 health units were interviewed. Medical appointments were the predominant motive for seeking the health unit, totaling 48% (484) of the interviewees. In terms of gender, 75.1% (757) were females, and there was no statistically significant difference between the genders (p=0.3443). Among the interviewees, 20% (202) answered affirmatively when questioned about coughing. The mean age was 47 years (17 to 84 years ). The age groups that presented a statistical significance for the association with patients that presented cough ranged from 21 to 31 years and over 65 years (Table 1).



In 51.4% of the people who presented with a productive cough (104 people), the duration of coughing was three weeks or more, complying with the adopted definition for an RSS. Among those identified by the researchers as having cough, only 28.2% (57 interviewees) were questioned about coughing in the health unit and, of these, only 33.3% (19 interviewees) were sent for sputum collection (Table 2). Regarding the RSSs identified by the UBS, 16 interviewees (45.7%) were sent for sputum collection.



We did not find a statistically significant difference (p=0.07) for the association between questioning about cough by the professionals from the studied health units and cough duration (Table 3).





In this study, we found a prevalence rate of 10.3% (1 04/1 008) of RSSs in the study sample. We verified that the identification of RSSs does not seem to be a priority because, in 72% of the cases, such identification was not made at the UBS. This demonstrates that the identification of RSSs seeking care at these services is poor, which does not favor the early identification of cases. It is worth emphasizing that, while early diagnosis is a priority, many cases of tuberculosis are believed not to be diagnosed, either due to difficulties in access to the services or to lack of attention by health care professionals in the detection of RSSs8. As to the latter possibility, we should consider that because coughing is not characterized as an acute clinical condition demanding immediate intervention, it is not always adequately valued by the medical staff, which causes the patient to seek other services or to return only when the condition worsens8. Despite being seemingly simple, the identification of RSSs for tuberculosis control is, in fact, a complex procedure, which requires knowledge beyond specialized technical skills. Furthermore, ongoing reinforcement and monitoring is necessary, such that this will be a routine fully developed into the services and incorporated by health care professionals, rather than a one-time action9. Especially in the case of tuberculosis, the lack of RSS identification may result in a delayed disease diagnosis, with implications that affect not only the sick individual, but also for his or her surrounding community.

We showed that although RSS identification by these services has not been trustworthy, an enhancement in the procedure can be noticed when a referral of a patient to sputum smear is analyzed. This improvement demonstrates that health care providers intervene adequately when an RSS is identified.



The results of this study reinforce the importance of the high rate of diagnostic suspicion of tuberculosis when an individual presenting with cough is observed in a health unit, regardless of the primary reason for that visit. We hope that our research can contribute to a greater appreciation of issues concerning the identification of RSSs. Nevertheless, we emphasize that this issue certainly deserves alternate approaches that may result in explanations that cannot be scaled only by statistical data.



We are grateful to the Pan-American Health Organization, which financially supported this research, and to the colleagues from the Coordination of Coordenação de Pneumologia Sanitária of the State of Pará, in particular to the coordinator Sonia Obadia, who supported our proposal and spared no efforts for its realization.



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Ivaneide Leal Ataide Rodrigues
Secretaria de Estado de Saúde Pública
Coordenação de Pneumologia Sanitária
Rua Presidente Pernambuco 498,
Batista Campos

Recebido em / Received / Recibido en: 18/7/2009
Aceito em / Accepted / Aceito en: 22/9/2009