Clinical and epidemiological characteristics associated with unfavorable tuberculosis treatment outcomes in TB-HIV co-infected patients in Brazil: a hierarchical polytomous analysis

Abstract Background: TB patients co-infected with HIV have worse treatment outcomes than non-coinfected patients. How clinical characteristics of TB and socioeconomic characteristics influence these outcomes is poorly understood. Here, we use polytomous regression analysis to identify clinical and epidemiological characteristics associated with unfavorable treatment outcomes among TB-HIV co-infected patients in Brazil. Methods: TB-HIV cases reported in the Brazilian information system (SINAN) between January 1, 2001 and December 31, 2011 were identified and categorized by TB treatment outcome (cure, default, death, and development of MDR TB). We modeled treatment outcome as a function of clinical characteristics of TB and patient socioeconomic characteristics by polytomous regression analysis. For each treatment outcome, we used cure as the reference outcome. Results: Between 2001 and 2011, 990,017 cases of TB were reported in SINAN, of which 93,147 (9.4%) were HIV co-infected. Patients aged 15–19 (OR = 2.86; 95% CI: 2.09–3.91) and 20–39 years old (OR = 2.30; 95% CI: 1.81–2.92) were more likely to default on TB treatment than those aged 0–14 years old. In contrast, patients aged ≥60 years were more likely to die from TB (OR = 2.22; 95% CI: 1.43–3.44) or other causes (OR = 2.86; 95% CI: 2.14–3.83). Black patients were more likely to default on TB treatment (OR = 1.33; 95% CI: 1.22–1.44) and die from TB (OR = 1.50; 95% CI: 1.29–1.74). Finally, alcoholism was associated with all unfavorable outcomes: default (OR = 1.94; 95% CI: 1.73–2.17), death due to TB (OR = 1.46; 95% CI: 1.25–1.71), death due to other causes (OR = 1.38; 95% CI: 1.21–1.57) and MDR-TB (OR = 2.29; 95% CI: 1.46–3.58). Conclusions: Socio-economic vulnerability has a significant effect on treatment outcomes among TB-HIV co-infected patients in Brazil. Enhancing social support, incorporation of alcohol abuse screening and counseling into current TB surveillance programs and targeting interventions to specific age groups are interventions that could improve treatment outcomes.

Prevalence and risk factors for latent tuberculosis infection among primary health care workers in Brazil / Prevalência de infecção latente da tuberculose e fatores de risco entre profissionais de saúde na atenção primária no Brasil / Prevalencia de infección latente de la tuberculosis y factores de riesgo entre profesionales de salud en la atención primaria en Brasil

Health care workers (HCW) are at increased risk of latent tuberculosis infection (LTBI) from occupational exposure to Mycobacterium tuberculosis. The objective was to determine the prevalence of and risk factors for LTBI among primary HCW in five Brazilian cities. We conducted a cross-sectional study, from 2011 to 2013, among primary HCW, using a structured questionnaire and an evaluated for LTBI using the Quantiferon-TB Gold in-tube test. The magnitude of the associations was assessed using hierarchical logistic regression models. Among 708 HCW, the LTBI prevalence was 27% (n = 196; 95%CI: 24%-31%). We found that the following factors were positively associated with LTBI in primary HCW: age > 50 years (OR = 2.94; 95%CI: 1.44-5.99), absence of a BCG scar (OR = 2.10; 95%CI: 1.28-3.43), self-reported ex-smoker status (OR = 1.80; 95%CI: 1.04-3.11), being a nurse (OR = 2.97; 95%CI: 1.13-7.83), being a nurse technician (OR = 3.10; 95%CI: 1.26-7.60), being a community health agent (OR = 2.60; 95%CI: 1.06-6.40), and irregular use of N95 masks (OR = 2.51; 95%CI: 1.11-5.98). In contrast, HCWs who do not work in health care facilities with a TB control program were less likely to have LTBI (OR = 0.66; 95%CI: 0.45-0.97). This study demonstrated a substantial occupational risk of LTBI among primary HCW in Brazil. The Brazilian TB control program, as well as local programs, need to target these high-risk HCW with education, as well as with better personal protective equipment to prevent acquisition of new TB infection.

Os profissionais de saúde apresentam risco aumentado de infecção latente da tuberculose (ILTB) em função da exposição ocupacional ao Mycobacterium tuberculosis. O estudo teve como objetivo estimar a prevalência da ILTB e fatores de risco entre profissionais de saúde na atenção primária em cinco cidades brasileiras. Realizamos um estudo transversal entre 2011 e 2013 entre profissionais de saúde na atenção primária, usando um questionário estruturado, e avaliamos a ILTB com o teste Quantiferon-TB Gold In-Tube. A magnitude das associações foi avaliada com o uso de modelos de regressão logística hierárquica. Entre 708 profissionais de saúde, a prevalência de ILTB era 27% (n = 196; IC95%: 24%-31%). Os seguintes fatores mostraram associação positiva com ILTB entre profissionais de saúde na atenção primária: idade > 50 anos (OR = 2,94; IC95%: 1,44-5,99), ausência de cicatriz de BCG (OR = 2,10; IC95%: 1,28-3,43), ex-tabagista (OR = 1,80; IC95%: 1,04-3,11), profissão enfermeiro (OR = 2,97; IC95%: 1,13-7,83), profissão técnico de enfermagem (OR = 3,10; IC95%: 1,26-7,60), profissão agente comunitário de saúde (OR = 2,60; IC95%: 1,06-6,40) e uso irregular de máscaras N95 (OR = 2,51; IC95%: 1,11-5,98). Enquanto isso, os profissionais de saúde que não trabalham em serviços de saúde que dispõem de programa de controle da TB tem menor probabilidade de apresentar ILTB (OR = 0,66; IC95%: 0,45-0,97). O estudo demonstrou risco ocupacional substancial de ILTB entre profissionais de saúde na atenção primária no Brasil. O programa brasileiro de controle da tuberculose, assim como os programas locais, devem focar esses profissionais de saúde, de risco elevado, através de atividades educativas, assim como, equipamento de proteção individual melhor para prevenir a aquisição de novos casos de infecção pela tuberculose.

Los profesionales de salud presentan un riesgo aumentado de infección latente de la tuberculosis (ILTB), en función de la exposición ocupacional al Mycobacterium tuberculosis. El objetivo del estudio fue estimar la prevalencia de la ILTB y sus factores de riesgo entre profesionales de salud en la atención primaria en cinco ciudades brasileñas. Realizamos un estudio transversal entre 2011 y 2013 entre profesionales de salud en la atención primaria, usando un cuestionario estructurado, y evaluamos la ILTB con el test Quantiferon-TB Gold In-Tube. La magnitud de las asociaciones fue evaluada con el uso de modelos de regresión logística jerárquica. Entre 708 profesionales de salud, la prevalencia de ILTB era 27% (n = 196; IC95%: 24%-31%). Los siguientes factores mostraron una asociación positiva con ILTB entre profesionales de salud en la atención primaria: edad > 50 años (OR = 2,94; IC95%: 1,44-5,99), ausencia de cicatriz de BCG (OR = 2,10; IC95%: 1,28-3,43), ex-fumador (OR = 1,80; IC95%: 1,04-3,11), profesión enfermero (OR = 2,97; IC95%: 1,13-7,83), profesión técnico de enfermería (OR = 3,10; IC95%: 1,26-7,60), profesión agente comunitario de salud (OR = 2,60; IC95%: 1,06-6,40) y uso irregular de máscaras N95 (OR = 2,51; IC95%: 1,11-5,98). Por otra parte, los profesionales de salud que no trabajan en servicios de salud que disponen de programa de control de la TB tienen una menor probabilidad de presentar ILTB (OR = 0,66; IC95%: 0,45-0,97). El estudio demostró riesgo ocupacional substancial de ILTB entre profesionales de salud en la atención primaria en Brasil. El programa brasileño de control de la tuberculosis, así como los programas locales, deben centrarse en esos profesionales de salud, de riesgo elevado, a través de actividades educativas, así como un mejor equipamiento de protección individual para prevenir el surgimiento de nuevos casos de infección por tuberculosis.