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Home Eurosurveillance Monthly Release  1996: Volume 1/ Issue 3 Article 2
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Eurosurveillance, Volume 1, Issue 3, 01 March 1996
Research Articles
The tuberculosis situation in Portugal : a historical perspective to 1994

Citation style for this article: Antunes ML, Fonseca-Antunes A. The tuberculosis situation in Portugal : a historical perspective to 1994. Euro Surveill. 1996;1(3):pii=199. Available online:

M.L. Antunes, A. Fonseca-Antunes

Directorate-General of Health, Lisboa, Portugal.

Historical background

Portugal built its first tuberculosis (TB) hospital in Funchal, Madeira, in 1862. In 1899, Queen Amelia proposed and sponsored a private foundation, with clinics, hospitals, sanatoriums and preventoria, where relatives and other contacts of TB patients were admitted for monitoring and treatment if required. The foundation became a public institution in 1946. The fight against TB has always enjoyed political, social, and public acceptance and generous funding, with all services, including the newest drugs, being provided free of charge: streptomycin was introduced in 1949, rifampicin in 1966, and short course chemotherapy in 1979.

Epidemiological surveillance began in 1951. The system evolved from a manual process to a punch card system and then to a rudimentary computer program using a mainframe computer. Standardised reporting included patient identification with place of residence, site of disease, radiological appearance in the pulmonary cases, bacteriological status, classification by previous treatment, results of BCG vaccination and Mantoux testing, and outcome of disease. As TB cases were treated in the national health system, and rarely in the private sector, the figures were valid and representative of the epidemiological situation. It was believed that over 95% of the patients diagnosed and treated were reported.

The TB prevention programme was formally integrated into the primary health care system in 1984, but this has not been entirely successful. The statutory notification system was retained and still represents comprehensive data on all diagnosed patients. Annual reports have been published since 1988 (1).

In 1991 a computer program was developed to improve the existing system (2), using World Health Organisation (WHO) definitions. This program allowed more detailed information about the cases, quicker and easier exchange of information, and the possibility of correcting the TB programme.

National guidance for the treatment of TB specifies a national drug regimen with three to four drugs, isoniazid, rifampicin, pyrazinamide/ethambutol or streptomycin (HRZ /E or S) given daily under supervision, where possible, in the first two months, followed by four months of isoniazid and rifampicin (HR) given daily or intermittently. Some variations of the basic regimen are considered. Diagnoses are made by bacteriological examination of smears and cultures; detailed identification is performed for every case but the sensitivity of the organism is tested only for patients who require repeat treatment and those for whom treatment fails, defined as a positive smear after five months of treatment. There is a national reference laboratory, which is mainly responsible for quality control, but also tests some samples. Histological examination of biopsies is considered in extrapulmonary cases. Prevention of TB in Portugal consists of BCG vaccination, according to the WHO Expanded Programme on Immunisation, at birth, on school entry at 5 to 6 years, and 11 to 13 years of age for those whose Mantoux tests are negative. The TB prevention programme also includes the screening of contacts and risk groups, and chemoprophylaxis for children under 5 years of age. Screening of contacts has always been incomplete and chemoprophylaxis is rarely used. Evaluation of the TB prevention programme is in progress, but has been slow to implement.

TB remains a public health problem in some parts of Portugal despite the many assets the fight against it has enjoyed. A mean annual decline of 9% was observed in the late 1960s and early 1970s (1). The revolution, social upheaval, and the massive influx of about 500 000 citizens from the former colonies of Africa in poor health and socioeconomic conditions, coming from regions with a high prevalence of TB, increased the number of cases in 1975 and subsequently (figure 1), although proper treatment regimens, adequate drug supply, and specific guidelines remained as permanent features of the national programme.

TB in Portugal in 1994

In 1994, TB in five coastal provinces - Aveiro, Braga, Lisboa, Porto, and Setúbal - accounted for 75% of the 5619 cases in Portugal overall, cases in Lisboa and Porto made up 25% of the national total (figure 2). TB was less common in the inner provinces, where there were very few cases in children.

Sixty-five per cent of TB cases in 1994 were males. The age specific incidence was highest in young adults, as in the developing world, but the incidence was also high in older people, as is found in developed countries. The age distribution has been similar for the past five years (figure 3).

National BCG coverage of newborn babies rose to 91% in 1994 alongside improvements in other childhood indicators. The incidence of TB in children aged 14 years or under, was 21/100 000 population compared with an overall national rate of 51/100 000.

Sixty-three per cent of cases overall and 74% of pulmonary cases were bacteriologically confirmed. The incidence of smear positive cases was 23/100 000 nationwide, with a rate of 24/100 000 in Lisboa and 37 in Porto. Porto represented the worst epidemiological situation in the country, with very high rates in some city boroughs and in some poor fishing and declining industrial communities. Epidemiological analysis indicated the existence of undisclosed sources of infection in these communities, responsible for continuing transmission despite a cure rate of 83% in the district.

Relapses accounted for about 10% of all cases, as in previous years. In children under 5 years one case of miliary TB and seven cases of TB meningitis were diagnosed in 1994. One case was fatal. Overall, 15 cases of TB meningitis occurred in children under 15 years, compared with five cases in both 1992 and 1993. Cases of TB meningitis increased by a factor of 1.6 in all age groups and miliary TB doubled overall with the increase noted specially in males aged 25 to 44 years, who accounted for 50% of the cases. These cases were mainly AIDS related, since TB and HIV are closely linked in Portugal. TB occurred in 54% of the 567 AIDS cases diagnosed in 1994, 15% of the 1256 TB cases in Lisboa, the district most affected by the AIDS epidemic, were HIV positive. Most cases of dual infection were males (82%) aged 25 to 44 years, 52% of whom were drug users, 24% heterosexuals, and 21% homo/bisexuals, whereas the proportions of these respective groups in AIDS cases unrelated to TB were 40%, 33%, and 21%.

Active TB accounted for 242 deaths, a case fatality rate of 2.5/100 000, most of whom were adults over 55 years of age.

Cohort analysis showed a cure rate of 71% nationwide, 3.8% were lost to follow up, and 1.3% became chronic cases.

A prospective study of drug resistance began in 1995, proposed and sponsored by WHO. Preliminary results of 634 patients evaluated, showed that 3.5% of Mycobacterium tuberculosis shows multidrug resistance (at least to isoniazid and rifampicin).


Misplanned, incomplete integration of the TB prevention programme into the primary health care system, under the 1975 and 1984 health reforms, may account for the delay in overcoming the problem of TB, which is also related to slow economic recovery from the African war effort and to migration into overcrowded slums of the large coastal cities. As TB remains an important health problem in Portugal, it calls for a strong public health intervention at local and district levels in the most affected areas, particularly in the districts of Porto and Lisboa.


1. Direcção-Geral da Saúde. Tuberculose em Portugal, 1993. Lisboa, 1994.

2. Serra T, Lopes H, Salema A, Antunes ML. Tuberculosis surveillance and evaluation system in Portugal. Tuber Lung Dis 1992; 73: 345-8.


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