The study identified that precocious deaths due to tuberculosis were associated with alcohol consumption. Most of the deaths occurred within 2 months, which evidenced that the diagnoses have been made too late, when the disease was already in its advanced stages. Some studies[9,13,14] investigated the phenomenon of premature death among patients with TB, one such study observing similar results with a median survival time of 21 days in Korea[13]; another study found that 19% of the patients died within 7 days and 41% died within the first month after the start of treatment for TB[14]. Another study, this time developed in Africa, found a mean survival span of 2 months in 53.3% of the people who started their TB treatment, and in this case, mortality among HIV-positive people was higher than for those who were HIV-negative or whose HIV status was unknown[3].
The short survival period found (less than a month) points to the severity of the disease at the moment of diagnosis, suggesting that the diagnosis was very tardy[9,10], which makes us wonder whether the control measures used, such as the directly observed treatment strategy (DOTS), as well as others such as active search, are effectively being implemented in order to achieve effective control of this disease. Another study found a higher percentage of treatment abandonment and a lower rate of cure in those Brazilian municipalities where the DOTS strategy was more widely applied; in contrast, those municipalities that made less use of the strategy obtained poorer results [24].
The difficulty in accessing services at the moment of symptom onset [13], especially in vulnerable groups or when health service providers are not qualified to recognize a cough as being a clinical sign of TB should be borne in mind; one study showed that only 42.2% of all TB patients were diagnosed correctly at their first visit to the health services [25]. This result suggests the need for an attention model that gives higher value to the active search for patients within the territories, and the tracking of TB among the population at large, and in regular appointments for patients living with HIV, not to mention the search for latent TB infection (ITLB) [15,16,24].
Other factors may also be related to the progression and worsening of TB, and these may involve issues that are more specifically related to any one individual patient, such as the decision to seek health advice, which is arrived at through a decision-making process based on prior knowledge and on the ability to judge their own state of health. A study found that 68% of patients living with TB in Zambia took a long time to seek health care, even if they recognised the symptoms of the disease and suspected that they were ill [26]. Health education helps to improve knowledge and also build awareness in the population about their own state of health; in this regard, a randomised study[27] found that after an educational session, the group that had received advice and guidance about TB showed better knowledge, attitudes and practices.
Brazil has a special protocol in place for monitoring the deaths that occur with some mention of TB as one of the causes, a protocol which, among other aims, seeks to investigate these patients’ individual health conditions and their access to health services, as well as analysing and correcting the information that appears in the different information systems used, namely SIM, SINAN and the TB Site [16]. This is a strategic initiative to improve the qualification of the data; however, according to evidence from the study itself, it is important to verify the phase at which the patient passed away, in stratified fashion, whether the case was being monitored by the service and if this happened in the early or the later phase of treatment. This is important because, depending on the phase at which the patient met his or her demise, actions also need to be modulated, as premature death makes us think about whether measures and protocols have been effectively implemented so as to impact on mortality from TB [28].
The difference in survival between people with TB and those with TB/HIV did not show any statistical significance, even though the median of the group with coinfection was higher, meaning that they survived longer than the group that only had TB. One point that could justify this result is the fact that people living with HIV/AIDS often receive ongoing medical monitoring from a multiprofessional team, including medical appointments, examinations and regular administration of medication, which leads to intermittent contact with health professionals and also increases opportunities for recognition of signs and symptoms of TV, which is, in fact, recommended as part of the protocol of caring for these patients: the investigation of TB in every medical appointment [15].
Most people who met their end through TB and coinfection from TB and HIV were male and had a low education level, which agrees with the findings of other studies [13,29]. The most common clinical manifestation was the pulmonary variety, even though there was no association with survival in this particular study. As well as being the most common clinical form, it is also the most relevant, as this is a transmittable form of the disease. A study found that individuals with the pulmonary form had a longer survival period than those with the extrapulmonary form of the disease [30].
The present study found that the use of alcohol increased the chances of premature death from TB. The evidence pointing to the effects of alcohol, within specialised literature, has shown harmful effects with regard to over 200 illnesses and diseases [31] (WHO, 2013), and a metanalysis [32] also found that the use of alcohol was linked to a greater risk (RR 1.35, IC 95% 1,09–1,68) of getting full-blown TB when compared with those who abstained from alcohol. In addition, the risk of the disease developing increased together with an increase in the consumption of ethanol (in grams per day).
There are also other factors which could be linked to the use of alcohol, such as malnutrition, overcrowded housing, and use of other substances [33,34]. Low immunity has already been documented as an explanation which assigns an increased risk for development of TB and of dying of this disease [35]. A study found that patients who died from TB, or who showed an important clinical worsening, also showed low levels of the alpha tumoral necrosis factor (TNF-α), this being a cytokine present in the inflammatory response, which would suggest a low immune response [9], thus showing a progression and worsening of the disease.
The use of drugs other than top-of-the-range drugs for the treatment of TB showed an inverse relationship, i.e. patients using other drugs as supportive therapy survived longer. A study carried out in Brazil showed that the deaths from TB that occurred were in fact associated with other bacterial infections in PLWGA, which could be addressed with the use of complementary therapies, apart from TB itself [11]. Due to monitoring in health services and antiretroviral therapy, PLWHA could be afforded some protection when compared with groups that did not receive any monitoring, which would justify the longer survival within this group, in the present report [15].
In Brazil, there was an increase in primary resistance to isoniazid, from 4.4% to 6.0%, and there were 583 cases of MDRTB (II National Investigation into Resistance to Antituberculosis Medications), which indicates the need to use other medications for the treatment of TB [36]. Treatment of MDRTB is a current challenge that requires the development of other safe and efficient medications.
Regarding the use of top-line drugs, rifampicin (R), isoniazid (H) Pyrazinamide (Z) (scheme: RHZ) and Ethambutol (E) were present in most cases, and only Ethambutol seems to have been used less often, which could be due to the fact that this medication was only included in the initial treatment scheme as of 2009 [36,37] (first 2 months), which would justify the lower occurrence of this drug within the study when compared to the frequency of use of RHZ.
One of the limitations of this study refers to the use of secondary data that were entered into the form in advance, as there were gaps in form-filling or missing information. Only recently (2017) the protocol launched for monitoring deaths with a mention of TB, one of the purposes of this being that of correcting, both quantitatively and qualitatively, the information that appeared in the different information systems, DNIS and MIS.