TESTS PERFORMED FOR PULMONARY TUBERCULOSIS DIAGNOSIS IN RIBEIRAO PRETO CITY , BRAZIL

The objective was to analyze the process of examinations for the diagnosis of pulmonary tuberculosis in Ribeirao Preto. This is a survey type study with a quantitative approach. The study population consisted of 84 patients with pulmonary tuberculosis under treatment (aged over 18 years old, living in Ribeirão Preto), from January to April 2009. Data were collected through interviews using a structured questionnaire. Moreover, all tests performed by patients interviewed at the time of diagnosis were raised from the System of Tuberculosis Patients Control of the State of São Paulo (TB-WEB). For data analysis, descriptive statistics were used. It was observed that the performance of tests in the laboratory diagnosis of pulmonary tuberculosis process needs to overcome some organizational, cultural, geographical and economical barriers, since the access to diagnosis has occurred through specialized services, reference for disease control. Palavras-chave: Health Care. Health Evaluation. Diagnosis. Tuberculosis.


INTRODUCTION
In 2014, Brazil has notified more than 76000 new cases of tuberculosis (TB), and 8% of people were died.The country still shows rates of concern in relation to the results of treatment (cure, 72%; death, 8%; neglect, 10%), since these do not reach the goals proposed by the World Health Organization (who), remaining among the 22 countries with the highest burden of disease in the world (1) .The detection rates of cases are also of concern, and studies have identified difficulties in access to health services and Diagnostics (2) contributing to the vicious circle of transmission and deaths by illness (3).
In Brazil, in recent decades, the National Tuberculosis Control Programme (POLICY) has recommended the ambulatory attendance for detection and appropriate treatment as a tool for the control of the disease.However, it is significant the number of cases diagnosed and treated at hospital level, resulting in the disorganization of the health system and the Association of TB to human immunodeficiency virus (HIV) as well as other diseases (4) .
TB, infectious contagious disease caused by Mycobacterium tuberculosis, if not diagnosed early and treated properly, may lead the individual to death, in addition to the dissemination of the same by the population.The disease affects nearly every organ of the body, but the pulmonary form has importance for its leading epidemiological transmissibility.
The diagnosis of TB is still and there is need for increased effectiveness health services to guarantee access to health actions and services needed.The delay in the diagnosis of TB cases may occur due to late health service demand by the patient or by inadequate suspicion of individuals with respiratory symptoms by health professionals.The fact of the infected individuals does not have access to health services contributes to that many cases are not diagnosed, constituting a health Cienc Cuid Saude 2016 Abr/Jun; 15(2): 250-258 inequality.The deterioration of the public health service comes resulting in difficulties of access to these services, scarce qualified human resources for the diagnosis, notification and monitoring the patient with TB and antituberculosis drugs distribution failed, configuring obstacles to the effective control of the disease (5) .
In this sense, the process of conducting tests for the diagnosis of pulmonary TB, you can offer subsidies for the improvement of planning policies in health, assisting primarily on qualification of health services aimed at timely diagnostic tests.
Thus, this article aims analyze the tests required in the process of elucidating the diagnostic pulmonary TB in the city of Ribeirão Preto-SP, from the vision of patients.

METHODOLOGY
This work was developed from the use of the quantitative approach, being a descriptive study of type investigation.
As a place of study, the city of Ribeirão Preto, situated in the northeast of the State of São Paulo and owned in 2015 1 estimated population of 666,323 inhabitants.The municipality of Ribeirao Preto is considered as a priority in the State of São Paulo for the control of TB and presented in the year 2014, 162 new cases of the disease; 81.5% of cure; 5.6% of abandonment; 9.9% of deaths; and 3.0% related to transfer and treatment failure (6) .
The health system of the municipality is divided into five districts, each of which has a basic unit Health District (UBDS) secondarylevel reference to a certain number of basic health units (UBS) and family health Units (USF); (North District -7UBS and 3UBS -4USF; East-5UBS and 1USF; 5UBS and 12USF -West and central -4UBS).If a patient of TB was diagnosed, the monitoring and the management of the case were carried out by specialized teams of the tuberculosis control program (PCT), distributed in five reference units for the treatment of the disease in the health districts of the municipality.In these services, patients went through periodic medical examinations, receive medication and are monitored by means of examinations, and their interconnecting examined.
The study population consisted of all pulmonary TB patients in treatment (aged 18 years or over resident in the municipality of study) in the data collection period (January-April 2009).During this period, 113 patients were being treated for TB, of which 17 were excluded for presenting the extrapulmonary clinical form; 3 were under 18 years; one belonged to the prison system; 3 did not accept to participate in research and 5 were not found for the interview.That way, it was possible to interview 84 patients with diagnosis of pulmonary TB.
To achieve the goal of the study, data were collected by means of a structured questionnaire, drawn up on the basis of the recommendations of the Ministry of health for the diagnosis of pulmonary TB (7) .
The questionnaire comprised two sections, the first of which involved issues concerning the characterization of patients:sex; age; education; family income; employment; local housing situation; the area of housing; Clinical form of TB; co-infection with HIV; case type and tests carried out.The second section contained questions that address the process of realization of laboratory tests: first health service; examinations requested in the first health service; all the tests were carried out in the service requests that diagnosed TB; forwarding of patient by first health service sought to another service; suspicion of the healthcare professional in the first consultation; payment and/or need for financial support for consultations and examinations to diagnose TB; often the service professional who diagnosed TB asked if there was any difficulty to carry out transport/deliver the tests; often the service professional who diagnosed TB offered transportation and/or transportation voucher to carry out/delivery of exams; guidance for carrying out the examinations; often lacked material (sputum pot, etc.) for carrying out the examinations in service who diagnosed TB; difficulty to deliver sputum pot on diagnosed TB service; receipt of the results of tests carried out; How many times were you need to go to the health service to diagnose TB; days needed to diagnose TB, after his first trip to the health service.
The interviews were conducted in the homes of the sick, and the respondent answered each question on the questionnaire according to rating scales varied as, dichotomous, multiple choice with single and sum (Likert scale).Likert scale, the zero value has been assigned to answer does not know or does not apply and the values of 1 to 5 recorded the degree of preference relation (or agreement) of the questions.Has been prepared and made available to respondents a callout script about the categories of Likert scale response of the questionnaire for the purpose of clarification and optimization of the data collection.Supplementary form, have been raised all the tests carried out by patients interviewed at the relevant period for TB diagnosis in Control system of tuberculosis patients in the State of São Paulo (TB-WEB).
For data analysis, we used the Statistica software, version 9.0 of Statsoft®.It has been calculated the frequency distribution (for nominal variables), measures of mean and median position-and dispersion-standard deviation (for continuous variables).For analysis of the variables with Likert scale of response, it has been calculated the mean value of the scores of answers of all respondents for each question, as this is an arbitrary value that was used operationally to facilitate the analysis and interpretation of results.The values obtained from this calculation received unsatisfactory ratings (close to 1 and 2), regular (around 3) and satisfactory (close to 4 and 5).The synthesis of the data was performed by means of charts and graphs.
After the approval of the Municipal Health Secretariat of Ribeirão Preto-SP, the research project was submitted and approved by the Research Ethics Committee of the school of nursing of Ribeirão Preto -University of São Paulo, as Protocol # 0984/2008.

Characterization of pulmonary TB patients
In Ribeirão Preto, the TB affected more males (70.2%) with mean age of the respondents to 42.4 (15.2 ±) years, being that 92.9% of 18 to 60 years had, showing that TB affects people in productive stage of life, data similar to the findings of research carried out at the national level (8).57.1% had incomplete elementary school, 50% were employed/selfemployed.The median family income was 1.7 minimum wages -minimum wage at that time: R$465,00-(range of 0 to 12.9), and half of those surveyed received up to 2 MW (table 1).The low educational level of the population is part of a set of precarious socioeconomic conditions, which increase the vulnerability to TB, being responsible for the higher incidence and the lowest treatment adherence, as well as, handicaps the access to health services and, consequently, the diagnosis of TB (9) .
In relation to the clinical aspects of the disease, 78 (92.9%) had pulmonary form of the disease only; 79 (94%) were new cases, and 7 (8.3%) were Coinfected with HIV.

Description of the process of conducting tests for the diagnosis of TB
As regards the choice of the type of health service to the first attendance, there was preference for EMT services (PA) (57.1%), as well as found in other studies (10)(11)(12) demonstrating that users generally are conspicuous by their sure customer service, greater availability of time to the public, immediate diagnostic research achievement, as well as give more credibility to the services with greater density of specialists and most technologically sophisticated resources.
It was found that, in the first visit EMT services and specialized services (hospitals, tuberculosis control programs, clinics and private offices), requested mainly the chest xray, and have doctors on call 24 hours a day, which could also justify the increased demand for such services.If, on the one hand, by the normative logic of the health care system, the flow of "spontaneous demand" of user's ready aid and hospitals has been appointed as unwanted, on the other hand, the reality comes showing that this behavior has persisted over time and remained resistant to attempts of reorientation of care model (10) .The basic attention services already have requested the smear of sputum (table 2).Caption: ABS-Basic health service; Pa-Er Source: Interviews with people with TB and TB-WEB.
After the onset of symptoms, patients searching for PA services, had the request, predominantly, x-ray examinations, while the basic care had a higher representation in the request of smear tests.In General, between those whose request for smear and x-ray did not occur in the first health service wanted the time to diagnosis was greater.This result, together with the observation of a high number of referrals, can translate to non-accountability of health professionals for the diagnosis of TB, leaving him in charge of specialized services and reference to disease control (5) .This organization of work reproduces the logic on which compartmentalized structure in the health sector.In this perspective, the actions of the health services are organized predominantly to meet individual or demands arising from campaigns (4) .
During the procedure for diagnostic elucidation (understood from visits to services until the effective diagnosis of TB), 96.4% 95.2% were held, x-ray examination, 90.5% anti-HIV bacilloscopy, 51.2% sputum culture, 14.3% and 11.9% biopsy other tests such as blood, urine, cat scan and MRI.
The majority of patients who have TB as the first suspect in the diagnostic process, conducted the reviews of chest x-ray and sputum smear, and such examinations were also requested, for the most part, patients not informed about this suspicion.For the majority of patients for whom other aggravations were bandied about (pneumonia, neoplasm, dengue fever, allergic cough, flu, weakness, gastric discomfort), there was only x-ray request (table 3).In Figure 1, there is a satisfactory performance of the health services in relation to the "need for payment to carry out tests"; "receiving guidance for carrying out the examinations; "availability of materials for carrying out the examinations; "delivery of the sputum Bowl"; "receipt of the results of tests on the same service requested" and a poor performance in relation to "questioning the professional as to the difficulty to the health service to perform the tests" and "providing transport and/or Valley transport for carrying out the examinations.
The median value for the number of times that the patient needed to go to the health service for the diagnosis of TB was twice (interquartis 1-3), with 65.5% of the patients had all requested tests on the same service who diagnosed TB.Of patients who performed the smear on the first health service sought, the median time to diagnosis was 6 days (range 0 inter-quartis-20), and those who did not was 10 days (range 3-30 inter-quartis).Of the patients who made the first x-ray health service sought, the median time to diagnosis was 7 days (range 1-20 inter-quartis), and those who did not was 16 days (range inter-quartis 7-60).
With regard to the number of times that the patient needed to access the health service for the diagnosis of TB, which was similar to a study conducted in Nepal (13) and that is greater when the basic attention services are the gateway to the diagnosis (14) .In this study, the amount of times that the patient needed to find the health service is plausible, since most patients sought for services of PA, which features x-ray equipment and request such examination to observe lung symptoms suggestive of TB.Throughout the process diagnosis most patients have conducted x-ray, smear and sputum culture, as well as other diagnostic tests not related to suspicion of TB.The smear is a test fast and low cost, but in Brazil, there have been difficulties in implementation and use of the same basic attention services (15) and emergency room, despite being indicated as priority method by the World Health Organization (who) for the detection of TB cases since 1993.
However, it seems that the request of smear in isolation, without the x-ray, does not contribute to the early diagnosis of TB, since performance was similar with respect to the time elapsed when no review was requested (Figure 2).This result has a limitation on the number (n = 6) of patients who mentioned having held just smear, three presented 30 days for the diagnosis and the other presented to 3 to 5 days.
When suspicion is raised by the health care professional, the same can request the smear sputum test, which is performed by a lab that collects daily samples in the health units of the Cienc Cuid Saude 2016 Abr/Jun; 15(2): 250-258 municipality.The results are relatively agile, sometimes in 24 hours after sending the sample and may take up to 5 business days.It is worth mentioning that the positive smears are informed as soon as possible by the laboratory (via phone), enabling immediate start of treatment (10)(11)(12) .

M édi a
Interval o de confi ança (95%) 4,7 Caption: V45-Need to be serviced or perform tests; V49 -Questioning how the difficulty of professional transport to perform the examinations; V50-providing transport and/or Valley transport for carrying out the examinations; V51-receiving guidance for carrying out the examinations; V52-availability of materials for carrying out the examinations; V53--Difficulty to deliver sputum pot; V54a -Receipt of the results of tests on the same service you requested.Despite the potential of smear, it presents limitations as a low sensitivity and usually depending on the symptoms presented needs the complement of other tests, such as x-rays and the culture.Both also feature limitations, as the absence of radiological changes in up to 15% of cases of pulmonary TB (especially immuno compromised) and slow playback of Bacillus in sputum culture that involves time-consuming diagnosis.Such limitations could be overcome by greater investment in the application of new methods of diagnosis, but it is essential to the development of clinical diagnosis/epidemiology, since patients often do not have respiratory symptoms, as found in a study where 67% of cases of pulmonary TB that presented themselves in an emergency service reported clinical nonspecific complaints, infectious lung and no aggravations traumatic lesions (16) .
In addition to the tests for the diagnosis of TB, after the confirmation of the disease, should be offered serologic testing for HIV in order to investigate the possibility of Association of two infections and thus establish the therapeutic scheme of appropriate treatment (8) .In view of the recommendation of the Ministry of health, the majority of TB patients of the municipality has conducted this survey, and in this study, 8.3% were Coinfected with HIV.
As regards the evaluation of patients with regard to difficulties of displacement, not to offer transportation to Ida Valley health services in order to perform the exams are barriers of access to diagnosis and therefore treatment (10) .In this study it was possible to identify important barriers that distance health services patients/users and deserve attention of the local managers.It should be noted that the organizational and cultural barriers signal the need to improve the Organization of attention focused on the management of chronic conditions such as TB requiring professional qualifications aimed at the recognition of aspects of the social environment of the users as a factor of vulnerability for the illness process for TB, including gender issues for adjustments in the provision of health services actions.Furthermore, the geographical and economic barriers were also present in the study as factors strongly related to access to TB diagnosis in terms of the profile of vulnerability of the subjects, whose life and work context, are usually unfavorable and permeated by financial constraints.

FINAL CONSIDERATIONS
The present study shows that the exams have a great contribution to the diagnosis of pulmonary TB, however there has been systematic differentiated examination request in accordance with the health service sought, reflecting on time to the effective diagnosis of the disease.This suggests the need for permanent education of working professionals in the various points of health from the public, as well as the joint definition of intervention protocols and conducts clinics that systematize the exam request a case with suspected TB.

THANKS TO:
The authors thanks the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP).

Figure 1 :
Figure 1: Distribution of the confidence intervals of the relevant variables to responses of pulmonary TB patients in relation to the performance of diagnostic tests, Ribeirão Preto-SP, 2009.

Figure 2 .
Figure 2. Distribution of medians and quartiles of time elapsed until the diagnosis of pulmonary TB from the examinations requested in the first health service sought by the patient, Ribeirão Preto-SP, 2009.

Table 1 :
Frequency distribution of some socio-demographic and clinical variables of pulmonary TB patients in the city of Ribeirão Preto-SP, 2009.

Table 2 :
Frequency distribution of x-ray request and smear during the first visit of pulmonary TB patients to health services in the city of Ribeirão Preto-SP, 2009.

Table 3 :
Frequency distribution of x-ray request and smear front of the type of diagnostic suspicion performed in the first health services visited by sick in the city of Ribeirão Preto-SP, 2009