Original Article
Effectiveness of tuberculosis treatment*
Effectiveness of tuberculosis treatment
Letícia Nazareth Fernandes da Paz, Maria Deise de Oliveira Ohnishi,
Camila Melo Barbagelata, Fabiana de Arruda Bastos,
João Augusto Figueiredo de Oliveira III, Igor Costa Parente
Abstract
Objective: To analyze the treatment strategies that influence the effectiveness of tuberculosis treatment at
primary care clinics (PCCs) in Brazil. Methods: This was a descriptive, retrospective epidemiological survey based
on the medical records of 588 tuberculosis patients enrolled in the tuberculosis control programs at two PCCs
located in the city of Belém, Brazil: Centro de Saúde Escola do Marco (CSEM) and Unidade Básica de Saúde da
Pedreira (UBSP). The survey was limited to patients enrolled between January of 2004 and December of 2008.
We included only patients between 18 and 59 years of age, and we excluded those who were transferred or were
found to have been misdiagnosed. We collected data regarding age, gender, type of treatment (self-administered
or supervised), co-infection with HIV, and treatment outcome. The health professionals involved in the tuberculosis
control program at the two PCCs were interviewed regarding the strategies used for tuberculosis control and
regarding routine clinical care for tuberculosis patients. Results: There were no significant differences between
the CSEM and UBSP patients regarding age, gender, or co-infection with HIV. Supervised treatment was used
significantly more frequently and the rate of cure was higher at the CSEM than at the UBSP, whereas the rate
of treatment noncompliance was higher at the UBSP than at the CSEM. Conclusions: For patients enrolled in
tuberculosis control programs at PCCs in Brazil, supervised treatment appears to be an extremely important
strategy for reducing the rate of treatment noncompliance.
Keywords: Tuberculosis; Patient dropouts; Patient care planning; Treatment outcome.
Resumo
Objetivo: Analisar as estratégias que influenciam a efetividade do tratamento da tuberculose em Unidades Básicas
de Saúde (UBS). Métodos: Levantamento epidemiológico, descritivo, retrospectivo, envolvendo os prontuários
médicos de 588 pacientes com tuberculose cadastrados no programa de controle da tuberculose, entre janeiro
de 2004 e dezembro de 2008, em duas UBS — Centro de Saúde Escola do Marco (CSEM) e UBS da Pedreira
(UBSP) — localizadas na cidade de Belém (PA). Os critérios de exclusão foram ter idade < 18 anos ou > 59 anos e
ter alta por transferência ou mudança de diagnóstico. Os dados coletados foram idade, sexo, tipo de tratamento
(autoadministrado ou supervisionado), coinfecção por HIV e desfecho do tratamento. Os profissionais de saúde
envolvidos no programa da tuberculose das duas UBS foram entrevistados quanto às estratégias utilizadas no
controle da doença e à rotina de atendimento. Resultados: Não houve diferenças significativas quanto a idade,
sexo e coinfecção com HIV nas duas UBS. A utilização de tratamento supervisionado foi significativamente
maior no CSEM que na UBSP, assim como a taxa de cura, enquanto a taxa de abandono foi maior na UBSP
que no CSEM. Conclusões: Para pacientes cadastrados em programas de controle da tuberculose em UBS no
Brasil, o tratamento supervisionado provavelmente é uma estratégia de extrema importância para se alcançar
uma menor taxa de abandono.
Descritores: Tuberculose; Pacientes desistentes do tratamento; Planejamento de assistência ao paciente;
Resultado de tratamento.
* Study carried out at the Centro de Saúde Escola do Marco and at the Unidade Básica de Saúde da Pedreira, Belém, Brazil.
Correspondence to: Letícia Paz. Passagem Dalva, 333, Marambaia, CEP 66615-080, Belém, PA, Brasil.
Tel. 55 91 8139-9259. E-mail: letpaz@hotmail.com
Financial support: None.
Submitted: 19 July 2011. Accepted, after review: 5 June 2012.
J Bras Pneumol. 2012;38(4):503-510
504
Paz LNF, Ohnishi MDO, Barbagelata CM, Bastos FA, Oliveira III JAF, Parente IC
Introduction
Tuberculosis is considered the leading cause
of death from infectious diseases in adults,(1) and,
despite being an ancient disease, it remains a
serious public health problem worldwide, primarily
affecting developing countries.(2) Early diagnosis
and prompt pharmacological treatment initiation
are essential for effective disease control.(3)
In Brazil, it is estimated that there are
50 million infected individuals and that 85,000
new cases occur each year, 6,000 tuberculosisrelated deaths occurring annually.(4) Among the
22 countries that collectively account for 80%
of all cases of tuberculosis worldwide, Brazil
ranks 19th.(3)
In our country, the problem of tuberculosis
treatment lies in the high rate of treatment
noncompliance, which, in some capitals, can be
as high as 25% of treated patients. The great
concern about the effectiveness of treatment is
due to the fact that noncompliance (or irregular
treatment), in addition to not producing cure,
can give rise to bacteria that are resistant to
standard drugs.(5) This has been a challenge in
the individual treatment of patients.(6,7)
In view of this situation, the objective of
the present study was to analyze the treatment
strategies that influence the effectiveness of
tuberculosis treatment at two primary care clinics
(PCCs) in the city of Belém, Brazil, in order to
identify strategies that can improve adherence
to tuberculosis treatment and be used by other
PCCs in an attempt to increase the effectiveness
of disease control.
Methods
This was a descriptive, retrospective
epidemiological survey of male and female
tuberculosis patients in the 18-59 year age
bracket enrolled in the tuberculosis control
programs at one of two PCCs: Centro de Saúde
Escola do Marco (CSEM) or Unidade Básica
de Saúde da Pedreira (UBSP). The survey was
limited to patients who were enrolled between
January of 2004 and December of 2008 and
who completed the treatment (satisfactorily or
not). We excluded all of the patients who did
not meet the pre-established inclusion criteria,
as well as those for whom there were missing
data in the databases searched. In addition, we
excluded those who were transferred (because
J Bras Pneumol. 2012;38(4):503-510
they no longer constituted cases treated at the
PCCs studied) and those who were found to
have been misdiagnosed (because they no longer
constituted cases of tuberculosis).
In the study period, 638 and 464 patients,
respectively, were diagnosed with tuberculosis at
the CSEM and at the UBSP. After applying the
inclusion and exclusion criteria to the medical
records, we selected a total of 588 patients. Of
those, 249 were enrolled in the CSEM tuberculosis
control program and 339 were enrolled in the
UBSP tuberculosis control program.
The study was performed in two phases.
In the first phase, we analyzed the medical
records of the CSEM and UBSP patients, as well
as the tuberculosis registries of the Brazilian
National Tuberculosis Control Program, together
with databases containing all of the available
information (including test results and the
clinical course of the disease) on those patients.
In the second phase, we interviewed the health
professionals (physicians, nurses, and nursing
technicians) who had been working at the CSEM
or UBSP since at least January of 2004 and who
were involved in providing care for tuberculosis
patients. The interviews were aimed at gathering
information regarding the tuberculosis control
strategies used at the two PCCs.
In the first phase of the survey, we analyzed
possible treatment outcomes (discharge after
cure, treatment noncompliance, and death from
tuberculosis) and the type of treatment (selfadministered or supervised). In addition, we profiled
the treated patients, the profile variables including
gender, age, and co-infection with HIV. In the
second phase, the tuberculosis control strategies
used at the PCCs were analyzed, as was routine
clinical care for tuberculosis patients.
The results obtained were statistically
analyzed by the chi-square test or Fisher’s exact
test (depending on the type of variable) with
the program BioEstat, version 5.0. The level of
significance was set at p < 0.05 (5%).
All of the patients included in the present study
were studied in accordance with the principles
of the Declaration of Helsinki, and the study
project was approved by the Research Ethics
Committee of the Hospital de Clínicas Gaspar
Viana (Protocol nº. 069/09).
Results
Of the 588 selected patients, 249 and 339,
respectively, were treated at the CSEM and
Effectiveness of tuberculosis treatment
at the UBSP. Regarding treatment outcomes
(Table 1), we found a higher rate of cure among
the CSEM patients than among the UBSP patients
(p = 0.0016). We also found that the rate of
treatment noncompliance at the CSEM was within
the goal range established by the Brazilian National
Ministry of Health (i.e., < 5%). In addition, selfadministered treatment prevailed at both PCCs
(57.43% at the CSEM and 98.23% at the UBSP;
Table 2).
There were no statistically significant
differences between the CSEM and UBSP patients
regarding gender, age, or co-infection with HIV
(Tables 3-5). There was a predominance of males
at the two PCCs (Table 3), a finding that is in
agreement with the literature.(9,10) As can be seen
in Table 4, most of the CSEM patients were in
the 18-23 year age bracket, whereas most of
the UBSP patients were in the 24-29 year age
bracket, with no significant differences between
the groups in terms of age. Most of the patients
Table 1 - Distribution, by treatment outcome, of
tuberculosis patients treated at the Centro de Saúde
Escola do Marco and at the Unidade Básica de Saúde
da Pedreira, both located in the city of Belém, Brazil,
2004-2008.
Place of treatment
Treatment
CSEM
UBSPa
outcome
n (%)
n (%)
Cure
229 (91.97)
302 (89.09)*
Noncompliance
11 (4.42)
27 (7.96)*
Failure
2 (0.80)
0 (0.00)
Death
7 (2.81)
4 (1.18)
Total
249 (100.00)
333 (98.23)
CSEM: Centro de Saúde Escola do Marco; and UBSP:
Unidade Básica de Saúde da Pedreira. aThe 6 patients who
underwent supervised treatment were excluded. *p = 0.0016.
505
who underwent HIV testing were found to be
HIV negative (Table 5).
Discussion
Treatment noncompliance among tuberculosis
patients has been seen as a major problem in
tuberculosis control, because in addition to causing
individual damage, it endangers public health,
leading to treatment failure and the emergence
of resistant strains.(5,7,8)
Several factors determine or influence
adherence to tuberculosis treatment. Therefore,
in addition to investigating the dynamics of care
and the strategies used at the PCCs studied,
we evaluated some of the characteristics of
the population profile. In general, there were
no significant differences between the CSEM
and UBSP patients regarding gender, age, or
co-infection with HIV. Males and patients in
the 18-29 year age bracket predominated, and
there was a low rate of co-infection with HIV.
Regarding the factors that are important in
assessing the effectiveness of treatment, it is
essential to remember that AIDS is chief among the
diseases that can accompany tuberculosis.(11) We
found that most of the CSEM and UBSP patients
who underwent HIV testing were HIV negative,
which is at odds with some studies,(12,13) in which
most patients were found to have tuberculosis/
HIV co-infection. This might have been due to
the difference between the location in which
our study was conducted and those in which
those studies were conducted in terms of the
incidence of HIV. In Brazil, according to official
data,(14) the incidence of HIV is much lower in
the northern region than in the southeastern
and southern regions, where the aforementioned
studies were conducted. In addition, the rate of
tuberculosis infection is higher in the northern
Table 2 - Distribution, by type of treatment, of
tuberculosis patients treated at the Centro de Saúde
Escola do Marco and at the Unidade Básica de Saúde
da Pedreira, both located in the city of Belém, Brazil,
2004-2008.
Place of treatment
Type of
CSEM
UBSP
treatment
n (%)
n (%)
Self-administered
143 (57.43)
333 (98.23)
Supervised
106 (42.57)
6 (1.77)
Total
249 (100.00)
339 (100.00)
Table 3 - Distribution, by gender, of tuberculosis
patients treated at the Centro de Saúde Escola do
Marco and at the Unidade Básica de Saúde da Pedreira,
both located in the city of Belém, Brazil, 2004-2008.
Place of treatment
Gender
CSEM
UBSP
n (%)
n (%)
Male
126 (50.60)
189 (55.75)*
Female
123 (49.40)
150 (44.25)
Total
249 (100.00)
339 (100.00)
CSEM: Centro de Saúde Escola do Marco; and UBSP:
Unidade Básica de Saúde da Pedreira.
CSEM: Centro de Saúde Escola do Marco; and UBSP:
Unidade Básica de Saúde da Pedreira. *p = 0.2487.
J Bras Pneumol. 2012;38(4):503-510
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Paz LNF, Ohnishi MDO, Barbagelata CM, Bastos FA, Oliveira III JAF, Parente IC
Table 4 - Distribution, by age bracket, of tuberculosis
patients treated at the Centro de Saúde Escola do
Marco and at the Unidade Básica de Saúde da Pedreira,
both located in the city of Belém, Brazil, 2004-2008.
Place of treatment
Age bracket,
CSEM
UBSP
years
n (%)
n (%)
18-23
57 (22.89)
68 (20.06)
24-29
50 (20.08)
71 (20.94)
30-35
37 (14.86)
42 (12.39)
36-41
25 (10.04)
46 (13.57)
42-47
28 (11.24)
56 (16.52)
48-53
33 (13.25)
31 (9.14)
54-59
19 (7.63)
25 (7.37)
Total
249 (100.00)
339 (100.00)
CSEM: Centro de Saúde Escola do Marco; and UBSP:
Unidade Básica de Saúde da Pedreira.
Table 5 - Tuberculosis/HIV co-infection in tuberculosis
patients treated at the Centro de Saúde Escola do
Marco and at the Unidade Básica de Saúde da Pedreira,
both located in the city of Belém, Brazil, 2004-2008.
Place of treatment
Tuberculosis/HIV
CSEM
UBSP
co-infection
n (%)
n (%)
Present
9 (5.03)
8 (5.75)*
Absent
170 (94.97)
131 (94.25)
Total
179 (100.00)
139 (100.00)
CSEM: Centro de Saúde Escola do Marco; and UBSP:
Unidade Básica de Saúde da Pedreira. *p = 0.9588.
region than in the southern and southeastern
regions.(14)
Regarding the type of treatment (Table 2), the
CSEM is set apart by one peculiarity: the use of
directly observed treatment, short-course (DOTS).
In Brazil, the DOTS strategy was implemented
in 1998 and increased the rate of detection
by 18%, as well as significantly increasing
tuberculosis treatment success rates.(4) The DOTS
strategy is recommended by the World Health
Organization and is based on direct supervision
of antituberculosis drug intake (at least three
weekly observations in the first two months and
one weekly observation for the duration of the
treatment). In addition, the DOTS strategy plays
an essential role in improving treatment adherence
and, consequently, in increasing cure and discharge
rates. The implementation of supervised treatment
in countries such as Peru has been shown to
J Bras Pneumol. 2012;38(4):503-510
be an effective strategy, reducing the rates of
treatment noncompliance.(15)
In Brazil, the DOTS strategy has been
implemented at various facilities in recent years.
However, because of problems that are inherent
to the current public health system, such as
limited human and financial resources, there are
operational difficulties in the use of DOTS for
most patients undergoing tuberculosis treatment.
(16)
Therefore, although DOTS was implemented
at the CSEM in 2002, most patients still undergo
self-administered treatment.
Unlike what occurred at the CSEM, supervised
treatment was not used at the UBSP during most
of the study period, having been implemented
in the second half of 2008.
When analyzing the mechanisms of care
delivery at the two PCCs between January of
2004 and December of 2008, we observed the
differences between the use of DOTS and the
use of self-administered treatment, as well as the
strategies used for improving treatment success.
In this context, the CSEM provides two
lines of care for the diagnosis and treatment
of tuberculosis: primary health care, accounting
for 80% of cases; and specialty care referral.
Primary health care is related to patients who
seek medical attention on their own initiative.
Patients with symptoms of tuberculosis are first
referred to the nursing ward, where they are
interviewed regarding epidemiological links, risk
factors, and the possible presence of another
medical condition, two sputum samples being
collected for sputum smear microscopy. Typically,
the first sample is collected on the same day and
the second sample is collected on the following
day. Sputum smear microscopy is performed in
the CSEM laboratory. In addition, for all patients,
vulnerable contacts, such as children, are traced
and notified. Therefore, as is recommended by the
Brazilian National Ministry of Health,(4) the patients
treated at the CSEM receive instructions regarding
their treatment before starting chemotherapy. In
the initial interview, they receive information, in
accessible language, regarding the characteristics
of the disease and the treatment regimen to
be used, including drugs, treatment duration,
benefits of regular medication use, consequences
of treatment noncompliance, and possible adverse
drug effects. However, only patients who have
clinical complications during the course of the
treatment or who are referred for specialist care
Effectiveness of tuberculosis treatment
consult with the CSEM physicians. This is due to
the fact that the CSEM has no team providing care
exclusively for tuberculosis patients. In addition,
the CSEM is a referral center for tuberculosis and
therefore receives a larger number of patients.
At the CSEM, in contrast to the World Health
Organization recommendation, DOTS is not used
in all cases of active tuberculosis, priority being
given to the following cases: smear-positive
cases; cases of treatment noncompliance; cases
of recurrence; cases of treatment failure; and
patients facing social risks (such as alcoholism,
poor nutrition, and living alone).(16) According
to Morrone et al.,(17) one way to overcome the
difficulties in adopting supervised treatment
is to restrict it to patients who really need it,
preventing noncompliance with the assigned
treatment.
Patients receiving DOTS are therefore selected
on the basis of the aforementioned priorities
and undergo two phases of treatment: the first
phase, in which the patient has to report to the
clinic Monday through Friday for follow-up and
medication intake; and the second phase, in which
the patient reports to the clinic twice a week.
Regarding the strategies employed at the
CSEM, it is of note that the number of visits
to the clinic for medication intake in the two
treatment phases is higher than that recommended
by the Brazilian National Ministry of Health.
This peculiarity of the CSEM is essential for
the effectiveness of tuberculosis treatment, given
that the first two to three months of treatment
is when noncompliance is most likely to occur,
which underscores the importance of adopting
measures to reduce noncompliance as soon as
the treatment begins. Therefore, the strategy
of frequent follow-up visits is an intervention
designed to be implemented at the beginning of
treatment and has been shown to have favorable
results.(18)
Other strategies that have been used at the
CSEM since the implementation of DOTS on
September 16, 2002, in order to increase treatment
effectiveness include material incentives, such
as transportation passes and meals (breakfast or
porridge), and non-material incentives, such as
caring for patients and providing clarification to
families. This caring refers to improved access to
treatment—given that one of the reasons that can
lead to noncompliance is the distance between
the place of residence and the hospital or health
507
care facility(11)—and to giving weight to patient
complaints. Osterberg & Blaschke(19) found that
providing little or no information regarding the
possible side effects of the medication is one of
the major obstacles to treatment compliance.
In contrast, reaching out to patients and family
members fosters mutual understanding of views
on the disease and its treatment, promotes
clarification, and attempts to establish a bond
that will promote trust in scientific knowledge.(1)
This clarification is essential, given that families
play a role in providing support to tuberculosis
patients, although in some cases families are
unable to provide the support required in order to
achieve favorable results. Providing information
to and raising awareness of families are essential
so that families do not negatively affect treatment
compliance.
Still on the topic of supervised treatment, a
group strategy is adopted at the CSEM. Therefore,
patients receive the medication at the same time
of day, which facilitates rapport and stimulates
the exchange of information. This strategy allows
patients not to feel isolated and helpless.
Self-administered treatment, which is
another form of treatment at the CSEM, is also
given appropriate attention. According to the
professionals interviewed, the priorities include
“treating patients well and listening carefully to
them” and “giving weight to their complaints”,
as well as “ensuring the quality of sputum smear
microscopy”. Patients undergoing self-administered
treatment receive sufficient medication for 30 days
of treatment during a six-month period.
In cases of failure to attend a routine visit,
either for self-administered treatment or for
DOTS, the CSEM immediately contacts the patient
or family members. First, whenever possible,
telephone contact is attempted in order to clarify
the reason for the absence. Subsequently, if the
first contact attempt fails, a representative of
the clinic goes to the place of residence of the
patient in a final attempt to bring the patient
back to treatment.
Secondary care referral, which is also available
at the CSEM, corresponds to scheduled demand.
This type of care allows clarification of difficult
cases, such as complicated cases that do not
progress as expected, as well as diagnostic
elucidation of smear-negative cases suspected
of treatment failure, multidrug resistance, and
adverse effects.
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Paz LNF, Ohnishi MDO, Barbagelata CM, Bastos FA, Oliveira III JAF, Parente IC
At the CSEM, the care provided to tuberculosis
patients includes HIV serology, and, since 2008,
rapid HIV testing has been performed at the
clinic itself. If the test result is positive, the
patient is referred to the AIDS referral center,
which is prepared to treat the two infections,
given that immunocompromised patients should
receive twice as much attention because they
are at a higher risk of developing the disease
and its complications.(4) In addition, co-infection
with HIV/AIDS is an important factor for the
unfavorable outcome of tuberculosis treatment.(20)
Therefore, early diagnosis of co-infection allows
health care providers to adjust the treatment
to the actual needs of the patient and reduces
the weaknesses resulting from HIV infection,
guaranteeing integrated health care and increasing
treatment effectiveness.
A similar analysis of the mechanism of care
provision for tuberculosis patients at the UBSP
revealed that the organizational structure is as
follows: completion of a general care form; first
medical visit, in which clinical examination is
performed; referral for laboratory tests (two
sputum smear microscopy tests); and second
medical visit or a nursing visit. Patients with
a positive sputum smear are enrolled in the
program, and notification, investigation, and
treatment control forms are completed. At this
point, patients receive counseling about the
disease and the treatment, undergo a thorough
history taking, are prescribed the medications,
and are referred for HIV testing at the clinic itself,
where rapid HIV testing began to be performed
in 2008 (as it did at the CSEM).
It is of note that the rate of tuberculosis/
HIV co-infection was lower at the UBSP than
at the CSEM. This is an important difference
between the two PCCs, given that measures for
prevention and control of HIV and tuberculosis
cannot be considered separately. Tuberculosis/
HIV co-infection should be identified at the
beginning of treatment so that individualized
follow-up procedures can be implemented.(20)
We found that most of the patients treated at
the UBSP received self-administered treatment.
This type of treatment requires that patients
return to the clinic once a month for a routine
visit and to receive medications, the clinical and
etiological status being monitored.
The UBSP team consists of a general
practitioner, a nurse, and a nursing technician, and
J Bras Pneumol. 2012;38(4):503-510
this team provides care exclusively for tuberculosis
patients, who can also be monitored by a dentist
and a psychologist as needed. In cases of failure
to attend a routine visit, the health care team
telephones the patient or family members in an
attempt to prevent treatment noncompliance.
As occurs at the CSEM, the UBSP health care
team reaches out to patients and their family
members, providing information regarding the
disease and the treatment to be followed, in
order to establish a bond that will promote trust
in the team.
It is of note that, until the second half of
2008, tuberculosis control at the UBSP was
based exclusively on self-administered treatment.
However, after the implementation of DOTS, only
a few special cases received supervised treatment
during the study period, including patients with
a low level of education and without adequate
family support.
Although DOTS was officially implemented
in the second half of 2008 at the UBSP, the
clinic still has no structure for the program,
because there is no adequate space to welcome
patients and there are no financial resources for
providing breakfast or other incentives, such as
transportation passes.
Analysis of the types of care provided to
tuberculosis patients and the strategies used
at each PCC investigated in the present study
revealed different values in terms of treatment
outcomes. Although the cure rates at both PCCs
were higher than that set by the Brazilian National
Ministry of Heath,(4) i.e., 85% of the estimated
number of cases of tuberculosis, the rate of
cure was statistically higher at the CSEM than
at the UBSP.
With regard to treatment noncompliance
(Table 1), only the CSEM achieved the national
goal set by the Brazilian National Ministry of
Health (rate of noncompliance < 5%),(4) with
two or three cases of noncompliance per year.
In comparison with the literature, the rate of
noncompliance observed at the CSEM was relatively
lower than were those found at other health
care clinics in Brazil(9,10) providing supervised
treatment.
In view of this, we can infer that the use of
supervised treatment with additional strategies
(i.e., scheduling a higher number of visits to the
clinic than that recommended by the Brazilian
National Ministry of Health and administering the
Effectiveness of tuberculosis treatment
treatment in a collective fashion) contributes to
a lower rate of noncompliance at the CSEM and
should be adopted by other health care clinics
in an attempt to improve the effectiveness of
tuberculosis treatment.
On the basis of these results and considering
that there were no statistically significant
differences between the CSEM and UBSP patients
in terms of age, gender, or co-infection with HIV,
we can state that the influence of these factors,
although present, as discussed earlier, does not
explain the better outcome at the CSEM.
In conclusion, DOTS has proven to be
an effective strategy to reduce the rates of
noncompliance with tuberculosis treatment,(21)
reducing the risk of disease transmission in the
community and resulting in major changes in
the epidemiological indicators of tuberculosis. In
addition, for better results in terms of treatment
effectiveness, a higher number of visits to the PCCs
can be scheduled in the first two to three months
of treatment and the strategy of administering the
medication in a collective fashion can be used.
It should be noted that the results obtained
and discussed in the present study confirm the
need for further studies focusing on obtaining
data that are more precise and accurate for
the development of strategies to improve the
effectiveness of tuberculosis treatment and reduce
noncompliance.
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J Bras Pneumol. 2012;38(4):503-510
510
Paz LNF, Ohnishi MDO, Barbagelata CM, Bastos FA, Oliveira III JAF, Parente IC
About the authors
Letícia Nazareth Fernandes da Paz
Medical Student. Pará State University, Belém, Brazil.
Maria Deise de Oliveira Ohnishi
Assistant Professor I. Pará State University; Adjunct Professor. Pará State University Center; and Pulmonologist. João de Barros
Barreto University Hospital, Belém, Brazil.
Camila Melo Barbagelata
Medical Student. Pará State University, Belém, Brazil.
Fabiana de Arruda Bastos
Medical Student. Pará State University, Belém, Brazil.
João Augusto Figueiredo de Oliveira III
Medical Student. Pará State University, Belém, Brazil.
Igor Costa Parente
Medical Student. Pará State University, Belém, Brazil.
J Bras Pneumol. 2012;38(4):503-510