Os determinantes da mortalidade por Tuberculose e TB-HIV no Sul do Brasil: Da abordagem espacial à análise de sobrevida / The determinants of tuberculosis and HIV-TB mortality in Southern Brazil: From the spatial approach to the survival analysis

O estudo teve como objetivo analisar os determinantes sociais da saúde associados à mortalidade por TB e verificar as mortes precoces ocorridas por TB e TB/HIV e seus fatores associados, por meio de duas abordagens: uma de base ecológica e uma de base individual, utilizando análise espacial e de sobrevida. O estudo foi realizado na capital do Paraná, Curitiba; e, para análise espacial, foram consideradas as 148 unidades de desenvolvimento humano (UDH). A população de estudo foi composta dos casos de mortes por TB como causa básica (CID 15-19). Para análise de sobrevida, foram acrescidos os casos de mortes pela coinfecção TB/HIV (CID 20.0). Os dados foram obtidos do Sistema de Informação sobre Mortalidade (SIM) e do Sistema de Informações sobre Doenças de Notificação (SINAN) referentes ao período 2008 a 2015. As Unidades de Desenvolvimento Humano foram caracterizadas de acordo com a mortalidade por TB e com as variáveis dos determinantes sociais da saúde. Inicialmente os casos de óbitos por TB foram geocodificados e calculadas taxas de mortalidade bruta, taxa Bayesiana e investigados quanto à autocorrelação espacial e existência de aglomerados de risco por meio da técnica de varredura espacial e obtidos riscos relativos espaciais. Para correlacionar as áreas de risco espacial para mortalidade por TB foi utilizada a regressão logística, tendo como variável dependente área de risco: sim e não, e após avaliado com uso da curva ROC, também foi elaborado um mapa de sobreposição de áreas de risco dos determinantes sociais da saúde e correlacionados com aglomerados de risco para mortalidade. Por último, para investigar as mortes precoces por TB e TB/HIV e fatores associados foi utilizada a técnica de Kaplan-Meier e Regressão de Cox. Foram identificados 131 óbitos por TB, dos quais 126 (96,2%) foram geocodificados e 05 (4,8%) foram excluídos devido a endereços incompletos. Para a primeira fase, foram calculadas as taxas resultado em taxa média bruta de 1,07/100.000 habitantes. As mortes estiveram distribuídas de maneira difusa, porém, com maior concentração nas regiões periféricas e sul do município. Foi detectado um aglomerado espacial de risco na região sul para mortalidade por TB e para variáveis dos determinantes sociais da saúde, sendo onde as piores condições foram detectadas. O estudo confirmou a relação entre os determinantes sociais e as áreas de risco de mortes por TB quando relacionados com a Dimensão 1 extraída com (OR= 0,093; IC95% 0,34-0,25). O mapa de sobreposição dos aglomerados de risco relacionados com aglomerado para mortalidade por TB resultou em um OR= 5,98 (IC95%: 2,41-14,49) e curva ROC= 0,865; IC95%=0,796-0,934. Na segunda fase, ao analisar as mortes precoces por TB, foi encontrada uma mediana de dias sobrevividos de 22 dias, sendo que 88 (59,1%) dos pacientes morreram até 30 dias após o diagnóstico e 107 (72,5%) após 60 dias (mínimo: 1, máximo: 349, D.P: 68,8 e média: 50 dias). Dentre os 179 óbitos analisados, 105 (58,6%) óbitos tinham diagnóstico de TB (CID 15.0-19) e 74 (41,4%) óbitos a coinfecção TB/HIV (CID 20.0). A maioria dos casos ocorreu em pessoas do sexo masculino, 138 (77,1%), da raça/ cor branca predominante 120 (67%) e a média de idade foi de 47 anos (mínimo:20, máximo: 94, mediana: 44, DP: 14). Os resultados corroboram com a necessidade de melhorias múltiplas nas condições de vida da população, com enfoque nas regiões mais vulneráveis (áreas de aglomerados de risco espacial) identificadas e políticas específicas para prevenção do uso de álcool, diante da identificação deste fator associado às mortes precoces

The objective of the study was to analyze the social determinants of health associated with TB mortality and to verify the early deaths caused by TB and TB / HIV and their associated factors, through two approaches: one based on an ecological basis and an individual basis using analysis spatial and survival The study was carried out in the capital of Paraná, Curitiba; and for spatial analysis, the 148 human development units (UDH) were considered. The study population was composed of cases of TB deaths as the underlying cause (ICD 15-19). Survival analysis included cases of TB / HIV coinfection deaths (ICD 20.0). Data were obtained from the Mortality Information System (SIM) and the Notification Disease Information System (SINAN) for the period 2008 to 2015. The Human Development Units were characterized according to TB mortality and the variables determinants of health. Initially the cases of TB deaths were geocoded and gross mortality rates, Bayesian taxa were calculated and investigated for spatial autocorrelation and existence of clusters of risk by means of the spatial scanning technique and obtained relative spatial risks. In order to correlate spatial risk areas with mortality from TB, logistic regression was used as a risk variable: yes and no and after being evaluated using the ROC curve, a map of overlapping risk areas of social determinants correlated with clusters of risk for mortality. A total of 131 TB deaths were identified, 126 (96.2%) of which were geocoded and 05 (4%) of the deaths were TB and HIV and associated factors were Kaplan-Meier and Cox Regression. A total of 131 TB deaths were identified, of which 126 (96.2%) were geocoded and 05 (4.8%) were excluded due to incomplete addresses. For the first phase, the results were calculated at a gross average rate of 1.07 / 100,000 inhabitants. The deaths were distributed in a diffuse way, however, with greater concentration in the peripheral and southern regions of the municipality. It was detected a spatial cluster of risk in the southern region for mortality by TB and for variables of the social determinants of health and where the worst conditions were detected. The study confirmed the relationship between social determinants and risk areas for TB deaths when related to Dimension 1 extracted with (OR= 0,093; IC95% 0,34-0,25). The map of overlapping cluster-related risk clusters for TB mortality resulted in an OR= 5.95 IC95%=2.41-14.49 and ROC curve= 0.865 (CI95%= 0.796-0.934). In the second phase, when analyzing the early TB deaths, a median number of surviving days of 22 days was found, of which 88 (59.1%) died within 30 days after diagnosis and 107 (72.5%) after 60 days days (minimum: 1, maximum: 349, SD: 68.8 and average: 50 days). Among the 179 deaths analyzed, 105 (58.6%) deaths had a diagnosis of TB (ICD 15.0-19) and 74 (41.4%) had TB / HIV co-infection (ICD 20.0). The majority of the cases occurred in males, 138 (77.1%), the predominant white race (67%) and the mean age was 47 years (minimum: 20, maximum: 94, median: 44, DP: 14). The results corroborate the need for multiple improvements in the living conditions of the population, with a focus on the most vulnerable regions (areas of agglomerates of spatial risk) identified and specific policies to prevent alcohol use, in view of the identification of this factor associated with early deaths

Socio-economic correlates of bereavement among women - Examining the differentials on social axes

Death, disease and disaster can inflict anyone, anywhere and at any time. While occurrence of such an event could be absolved of any selective strike, the outcome reflects otherwise. Historical deprivations experienced by certain populations have caused more bereavement and sorrow to them than those who have experienced lesser or no deprivation. Therefore, the process which shapes the factors to yield such a result is important and needs to be understood for any policy suggestions and programmatic inputs. Loss of pregnancy and newborn inflicts sorrow and bereavement across space, time and social labyrinth. The degree of bereavement is likely to reduce with time, but space and social context govern the response to it. Therefore, factors contributing to the differentials vary in their demographic, social and economic characteristics. The loss of pregnancy and newborn remains inadequately addressed. Family and community play a significant role in coping. While the developed countries have institutional structure to address coping with the loss, the South Asian countries rely heavily on the family and the community for such support. The present review examines these trajectories across social groups.

Comparison of Early and Late Tuberculosis Deaths in Korea

The cause of death in patients with tuberculosis (TB) may differ according to the phase of anti-tuberculosis treatment. However, there are limited data regarding this issue in Korea. We compared the cause of death of TB patients who died during the early intensive and late continuation phase of treatment. Twenty (56%) of the 36 early deaths were due to TB-related causes, whereas 34 (89%) of the 38 late deaths were due to TB-unrelated causes. This finding suggests that TB-related early deaths mainly attributable to delayed diagnosis should be improved to further reduce the overall TB deaths.