Migration and medical screening for tuberculosis / Imigração e triagem médica para tuberculose

ABSTRACT Vulnerable populations, such as migrants and refugees, have an increased risk of tuberculosis disease, especially in the first years after arrival in the host country. The presence of migrants and refugees in Brazil exponentially grew over the period between 2011 and 2020, and approximately 1.3 million migrants from the Global South were estimated to be residing in Brazil, most of whom from Venezuela and Haiti. Tuberculosis control programs for migrants can be divided into pre- and post-migration screening strategies. Pre-migration screening aims to identify cases of tuberculosis infection (TBI) and can be carried out in the country of origin (pre-entry) or in the destination country (at entry). Pre-migration screening can also detect migrants at an increased risk of developing tuberculosis in the future. High-risk migrants are then followed up in post-migration screening. In Brazil, migrants are considered a priority group for the active search for tuberculosis cases. However, there is no recommendation or plan regarding screening for TBI in migrants and refugees. Ensuring prevention, diagnosis, and treatment for TBI and tuberculosis disease in migrant populations is an important aspect of tuberculosis control and elimination. In this review article, we address epidemiological aspects and access to health care for migrants in Brazil. In addition, the migration medical screening for tuberculosis was reviewed.

RESUMO Populações vulneráveis, como imigrantes e refugiados, apresentam maior risco de tuberculose doença, especialmente nos primeiros anos após a chegada ao país de acolhimento. A presença de imigrantes e refugiados no Brasil cresceu exponencialmente no período entre 2011 e 2020, sendo estimado que aproximadamente 1,3 milhão de imigrantes do Sul Global residiam no Brasil, a maioria proveniente da Venezuela e do Haiti. Os programas de controle da tuberculose para imigrantes podem ser divididos em estratégias de triagem pré- e pós-migração. A triagem pré-migração visa identificar casos de tuberculose infecção (TBI) e pode ser realizada no país de origem (pré-entrada) ou no país de destino (no momento da entrada). A triagem pré-migração também pode detectar imigrantes com maior risco de desenvolver tuberculose no futuro. Os imigrantes de alto risco são então acompanhados na triagem pós-migração. No Brasil, os imigrantes são considerados um grupo prioritário para a busca ativa de casos de tuberculose. No entanto, não há recomendação ou plano sobre triagem para TBI em imigrantes e refugiados. Garantir a prevenção, o diagnóstico e o tratamento da TBI e da tuberculose doença em populações imigrantes é um aspecto importante do controle e eliminação da tuberculose. Neste artigo de revisão, abordamos aspectos epidemiológicos e acesso à saúde para imigrantes no Brasil. Além disso, revisou-se a triagem médica de imigrantes para tuberculose.

Follow-up of patients diagnosed with and treated for tuberculosis in Brazil: financial burden on the household / Acompanhamento de pacientes com diagnóstico e tratamento de tuberculose no Brasil: ônus financeiro para a família

ABSTRACT Objective: To evaluate the implications of the proportion of annual family income spent in the pre- and post-diagnosis periods in tuberculosis patients followed for after at least one year after completing tuberculosis treatment in Brazil. Methods: This was a cross-sectional study of tuberculosis patients followed for at least one year after completing tuberculosis treatment in five Brazilian capitals (one in each region of the country). Results: A total of 62 patients were included in the analysis. The overall average cost of tuberculosis was 283.84 Brazilian reals (R$) in the pre-diagnosis period and R$4,161.86 in the post-diagnosis period. After the costs of tuberculosis disease, 71% of the patients became unemployed, with an overall increase in unemployment; in addition, the number of patients living in nonpoverty decreased by 5%, the number of patients living in poverty increased by 6%, and the number of patients living in extreme poverty increased by 5%. The largest proportion of annual household income to cover the total costs of tuberculosis was for the extremely poor (i.e., 40.37% vs. 11.43% for the less poor). Conclusions: Policies to mitigate catastrophic costs should include interventions planned by the health care system and social protection measures for tuberculosis patients with lower incomes in order to eliminate the global tuberculosis epidemic by 2035-a WHO goal in line with the United Nations Sustainable Development Goals.

RESUMO Objetivo: Avaliar as implicações da proporção da renda familiar anual gasta nos períodos pré e pós-diagnóstico em pacientes com tuberculose acompanhados durante pelo menos um ano após o término do tratamento da tuberculose no Brasil. Métodos: Estudo transversal com pacientes com tuberculose acompanhados durante pelo menos um ano após o término do tratamento da tuberculose em cinco capitais brasileiras (uma em cada região do país). Resultados: Foram incluídos na análise 62 pacientes. O custo médio global da tuberculose foi de R$ 283,84 no período pré-diagnóstico e de R$ 4.161,86 no período pós-diagnóstico. Após os custos da doença tuberculosa, 71% dos pacientes ficaram desempregados, com um aumento global do desemprego; além disso, o número de pacientes não pobres diminuiu 5%, o número de pacientes pobres aumentou 6% e o número de pacientes extremamente pobres aumentou 5%. A maior proporção de renda familiar anual para cobrir os custos totais da tuberculose foi observada nos pacientes extremamente pobres (40,37% vs. 11,43% nos menos pobres). Conclusões: As políticas para mitigar os custos catastróficos devem incluir intervenções planejadas pelo sistema de saúde e medidas de proteção social para pacientes de baixa renda com tuberculose, a fim de eliminar a epidemia global de tuberculose até 2035, uma meta da OMS alinhada com os Objetivos de Desenvolvimento Sustentável propostos pela Organização das Nações Unidas.

Prueba Xpert® MTB/RIF para el diagnóstico de Tuberculosis en el Instituto Médico La Floresta

La necesidad de un diagnóstico rápido, sensible y específico para tuberculosis es apremiante; se estiman 4 000 muertes cada día y aproximadamente 28 000 personas se contagian de esta enfermedad. La prueba Xpert®MTB/RIF consiste en un ensayo de diagnóstico in vitro de reacción en cadena de la polimerasa (PCR) en tiempo real automatizada, semicuantitativa, que en tan solo dos horas, permite detectar el ácido desoxirribonucleico (ADN) del complejo Mycobacterium tuberculosis (MTB) y mutaciones asociadas a la resistencia a rifampicina. Objetivo: Describir la experiencia del ensayo Xpert®MTB/ RIF y su valor diagnóstico en Dpto. de Microbiología del Instituto Médico La Floresta, desde abril 2012 hasta abril 2021. Métodos: Estudio descriptivo de muestras respiratorias y de otras procedencias, de pacientes con sospecha de tuberculosis, ensayadas por PCR a través del Xpert®MTB/RIF. Adicionalmente se realizó Ziehl-Neelsen y cultivo por el método de Ogawa Kudoh modificado, dependiendo del volumen de muestra recibida. Resultados: De 618 PCR realizadas, 58 muestras fueron positivas (9,4 %), 56 correspondieron a adultos y 2 a niños, 81 % se clasificaron como tuberculosis pulmonar y 19 % como extrapulmonar. A 37 se les realizó cultivo, de las cuales 10 no desarrollaron crecimiento, y a 33 adicionalmente Ziehl-Neelsen, de las cuales 12 presentaron baciloscopias negativas. En cinco de las muestras se detectó resistencia a rifampicina. Conclusiones: A través de la prueba Xpert®MTB/RIF fue posible detectar MTB en aquellas con baciloscopias negativas, en las que no desarrollaron crecimiento en el cultivo y permitió la rápida instauración de tratamiento en la tuberculosis multirresistente.

The rapid, sensitive, and specific diagnosis for tuberculosis is urgent; 4 000 deaths are estimated every day and approximately 28 000 people are infected with this disease. The Xpert®MTB/RIF test consists of an automated, semi-quantitative real-time polymerase chain reaction (PCR) in vitro diagnostic assay that, in just two hours, allows the detection of Mycobacterium tuberculosis complex (MTB) DNA and mutations associated with resistance to rifampicin. Objective: To describe the experience of the Xpert®MTB/RIF assay and its diagnostic value in the Department of Microbiology of the La Floresta Medical Institute, from April 2012 to April 2021. Methods: Descriptive study of respiratory samples and other sources, from patients with suspected of tuberculosis, assayed by PCR through Xpert®MTB/RIF. Additionally, Ziehl-Neelsen and culture were performed by the modified Ogawa Kudoh method, depending on the volume of sample received. Results: Of 618 PCR performed, 58 samples were positive (9.4 %), 56 corresponded to adults and 2 to children, 81 % were classified as pulmonary tuberculosis and 19 % as extrapulmonary. Culture was performed on 37, of which 10 did not develop growth, and on 33 additionally Ziehl-Neelsen, of which 12 presented negative bacilloscopy. Rifampicin resistance was detected in five of the samples. Conclusions: Through the Xpert®MTB/RIF test, it was possible to detect MTB in those with negative bacilloscopy, in which they did not develop growth in the culture and allowed the rapid establishment of treatment in multidrug-resistant tuberculosis.

Clinical, laboratory, and radiographic aspects of patients with pulmonary tuberculosis and dysglycemia and tuberculosis treatment outcomes / Aspectos clínicos, laboratoriais e radiográficos de pacientes com tuberculose pulmonar e disglicemia e desfechos do tratamento da tuberculose

ABSTRACT Objective: To analyze the association of dysglycemia with clinical, laboratory, and radiographic characteristics of patients with pulmonary tuberculosis (PTB), as well as with their tuberculosis treatment outcomes. Methods: This was a longitudinal study involving 140 patients diagnosed with PTB (positive cultures for Mycobacterium tuberculosis or positive Xpert MTB/RIF results from sputum samples). Patients were evaluated at diagnosis (M0), after completing the second month of treatment (M2), and at the end of treatment (MEND). At M0, the patients were classified into three groups: normoglycemia+PTB (NGTB); pre-diabetes mellitus+PTB (PDMTB), and diabetes mellitus+PTB (DMTB), in accordance with glycated hemoglobin levels (< 5.7%, 5.7%-6.4%, and ≥ 6.5%, respectively). Treatment outcomes were classified as favorable (cure or treatment completion) and unfavorable (death, loss to follow-up, or treatment failure). Results: In our sample, 76 patients (61.4%) had dysglycemia, 20 of whom (14.3%) had DM at M0. The patients with dysglycemia, in comparison with those in the NGTB group, more frequently presented with positive sputum smear microscopy (94.2% vs. 75.9%; p = 0.003); cavities (80.2% vs. 63.0%; p = 0.03); bilateral lesions (67.4% vs. 46.0%; p = 0.02); and higher median of affected thirds of the lungs (3.0 vs. 2.0; p = 0.03) on chest radiography. No significant differences regarding outcomes were found among the groups, but tuberculosis lethality was higher in the DMTB group than in the PDMTB and NGTB groups (20% vs. 2.2%). Conclusions: PTB patients with dysglycemia had laboratory and radiographic manifestations indicative of more advanced disease, and the risk of death was higher in the DMTB group. These findings reinforce the recommendation for early screening for DM in patients with newly diagnosed tuberculosis in order to reduce the risk of death during treatment.

RESUMO Objetivo: Analisar a associação de disglicemia e características clínicas, laboratoriais e radiográficas em pacientes com tuberculose pulmonar (TBP), bem como a associação de disglicemia e desfechos do tratamento da tuberculose. Métodos: Estudo longitudinal com 140 pacientes com diagnóstico de TBP (culturas de escarro positivas para Mycobacterium tuberculosis ou resultados positivos do teste Xpert MTB/RIF em amostras de escarro). Os pacientes foram avaliados no momento do diagnóstico (M0), após dois meses de tratamento (M2) e no fim do tratamento (MFIM). Em M0, os pacientes foram divididos em três grupos: normoglicemia+TBP (NGTB); pré-diabetes mellitus+TBP (PDMTB) e diabetes mellitus+TBP (DMTB), de acordo com os níveis de hemoglobina glicada (< 5,7%, 5,7%-6,4% e ≥ 6,5%, respectivamente). Os desfechos do tratamento foram classificados em favoráveis (cura ou conclusão do tratamento) e desfavoráveis (óbito, perda de seguimento ou falência do tratamento). Resultados: Em nossa amostra, 76 pacientes (61,4%) apresentavam disglicemia, 20 (14,3%) dos quais apresentavam DM em M0. Os pacientes com disglicemia, em comparação com os do grupo NGTB, apresentaram mais frequentemente baciloscopia de escarro positiva (94,2% vs. 75,9%; p = 0,003); cavidades (80,2% vs. 63,0%; p = 0,03); lesões bilaterais (67,4% vs. 46,0%; p = 0,02) e maior mediana de terços pulmonares acometidos (3,0 vs. 2,0; p = 0,03) na radiografia de tórax. Não foram observadas diferenças significativas entre os grupos quanto aos desfechos, mas a letalidade da tuberculose foi maior no grupo DMTB do que nos grupos PDMTB e NGTB (20% vs. 2,2%). Conclusões: Pacientes com TBP e disglicemia apresentaram manifestações laboratoriais e radiográficas indicativas de doença mais avançada, e o risco de óbito foi maior no grupo DMTB. Esses achados reforçam a recomendação de detecção precoce de DM em pacientes com tuberculose recém-diagnosticada, a fim de reduzir o risco de óbito durante o tratamento.

Effectiveness of screening for tuberculosis in HIV: a pragmatic clinical trial

ABSTRACT OBJECTIVE: To verify the effectiveness of screening for tuberculosis (TB) on all-cause mortality and tuberculosis cases in newly diagnosed HIV-infected patients through a clinical algorithm based on recommendations of the World Health Organization. METHODS: From March 2014 to April 2016, a pragmatic randomized clinical trial was conducted with newly diagnosed and TB-free HIV-infected adults undergoing antiretroviral therapy for up to one month at a major tertiary hospital for HIV in the state of Pernambuco, Brazil. Participants were randomized into intervention and control groups using an automatically-generated random list, and followed-up for at least 6 months. The intervention group was screened for TB at hospital admission and at every follow-up visit through a series of questions addressing TB-related symptoms (cough, fever, night sweating, and weight loss). Patients presenting with any of these symptoms were referred to a pulmonologist and underwent sputum smear microscopy, sputum culture, and rapid molecular testing (GeneXpert). When at least one test result came back positive, TB treatment was initiated. In turn, if patients tested negative but presented with severe clinal symptoms, TB preventive treatment was initiated. Screening for TB was not performed systematically in the control group. The primary outcome assessed in this study was death from all causes, and secondary outcomes included sensitivity and specificity of this screening test, as well as its detection time. RESULTS: This study evaluated 581 patients, 377 in the intervention group (64.9%) and 204 in the control group (35.1%). In total, 36 patients died during the follow-up period. Of these, 26 (6.9%) were from the intervention group, reaching a cumulative mortality coefficient of 69 per 1,000 inhabitants, and 10 (4.9%) from the control group (p = 0.341), with a cumulative mortality coefficient of 49 per 1,000 inhabitants (p = 0.341).

Diagnosis of tuberculosis: a consensus statement from the Brazilian Thoracic Association / Consenso sobre o diagnóstico da tuberculose da Sociedade Brasileira de Pneumologia e Tisiologia

ABSTRACT Early, accurate diagnosis of tuberculosis is one of the major pillars of the control of the disease. The purpose of this consensus statement is to provide health professionals with the most current, useful evidence for the diagnosis of tuberculosis in Brazil. To that end, the Tuberculosis Committee of the Brazilian Thoracic Association brought together 14 members of the Association with recognized expertise in tuberculosis in Brazil to compose the statement. A nonsystematic review of the following topics was carried out: clinical diagnosis, bacteriological diagnosis, radiological diagnosis, histopathological diagnosis, diagnosis of tuberculosis in children, and diagnosis of latent tuberculosis infection.

RESUMO O diagnóstico precoce e adequado da tuberculose é um dos pilares mais importantes no controle da doença. A proposta deste consenso brasileiro é apresentar aos profissionais da área de saúde um documento com as evidências mais atuais e úteis para o diagnóstico da tuberculose. Para tanto, a Comissão de Tuberculose da Sociedade Brasileira de Pneumologia e Tisiologia reuniu 14 membros da Sociedade com reconhecida experiência em tuberculose no Brasil. Foi realizada uma revisão não sistemática dos seguintes tópicos: diagnóstico clínico, diagnóstico bacteriológico, diagnóstico radiológico, diagnóstico histopatológico, diagnóstico da tuberculose na criança e diagnóstico da tuberculose latente.

Association between the radiological presentation and elapsed time for the diagnosis of pulmonary tuberculosis in the emergency department of a university hospital / Associação entre apresentação radiológica e tempo decorrido para o diagnóstico da tuberculose pulmonar no serviço de emergência de um hospital universitário

ABSTRACT Objective: To evaluate the radiological presentation of patients with pulmonary tuberculosis diagnosed in the emergency department and to investigate its association with the time to diagnosis. Methods: This was a prospective observational study involving patients diagnosed with pulmonary tuberculosis in the emergency department of a tertiary university hospital in southern Brazil. Chest X-rays taken on admission were evaluated by a radiologist. The various patterns of radiological findings and locations of the lesions were described. The main study outcome was the total time elapsed between the initial radiological examination and the diagnosis of tuberculosis. Results: A total of 78 patients were included in the study. The median time from chest X-ray to diagnosis was 2 days, early and delayed diagnosis being defined as a time to diagnosis < 2 days and ≥ 2 days, respectively. Sputum smear positivity was associated with early diagnosis (p = 0.005), and positive culture was associated with delayed diagnosis (p = 0.005). Early diagnosis was associated with the presence of sputum (p = 0.03), weight loss (p = 0.047), cavitation (p = 0.001), and consolidation (p = 0.003). Pulmonary cavitation was found to be an independent predictor of early diagnosis (OR = 3.50; p = 0.028). Conclusions: There is a need for tuberculosis-specific protocols in emergency departments, not only to avoid delays in diagnosis and treatment but also to modify the transmission dynamics of the disease.

RESUMO Objetivo: Avaliar a apresentação radiológica de pacientes com tuberculose pulmonar diagnosticada no serviço de emergência e investigar sua associação com o tempo para o diagnóstico. Métodos: Estudo observacional prospectivo envolvendo pacientes diagnosticados com tuberculose pulmonar no serviço de emergência de um hospital universitário terciário no sul do Brasil. As radiografias de tórax realizadas na admissão foram avaliadas por um radiologista. Foram descritos os diferentes padrões de achados radiológicos e as localizações das lesões. O desfecho principal do estudo foi o tempo total decorrido entre o exame radiológico inicial e o diagnóstico de tuberculose. Resultados: Um total de 78 pacientes foi incluído no estudo. A mediana de tempo entre a radiografia de tórax e o diagnóstico foi de 2 dias, sendo os diagnósticos precoce e tardio definidos como tempo para o diagnóstico < 2 dias e ≥ 2 dias, respectivamente. A positividade da baciloscopia de escarro associou-se ao diagnóstico precoce (p = 0,005), e a cultura positiva associou-se ao diagnóstico tardio (p = 0,005). O diagnóstico precoce associou-se à presença de escarro (p = 0,03), perda de peso (p = 0,047), cavitação (p = 0,001) e consolidação (p = 0,003). A cavitação pulmonar foi um preditor independente de diagnóstico precoce (OR = 3,50; p = 0,028). Conclusões: Há necessidade de protocolos específicos para tuberculose nos serviços de emergência, não apenas para evitar atrasos no diagnóstico e no tratamento, mas também para modificar a dinâmica de transmissão da doença.

Utility of QuantiFERON®-TB gold In-Tube test compared with tuberculin skin test in diagnosing tuberculosis in Indian children with malnutrition

This prospective cohort study was conducted to compare the accuracy of QuantiFERON®-TB (QFT) Gold In-Tube test and tuberculin skin test (TST) in diagnosing tuberculosis (TB) in predominantly bacille Calmette–Guerin-vaccinated children with a high incidence of malnutrition. The sensitivity of the QFT versus the TST was 69.6% versus 52.9% for WHO-defined TB, with specificity of 86% versus 78.3%, respectively. The concordance of the TST and QFT was 79% overall (? = 0.430), 62.5% in those with WHO-defined TB and 85.7% in those without TB. Majority of the QFT+/TST ? discordance was seen in children with TB, whereas majority of the TST+/QFT ? discordance was seen in those without TB. The TST was more likely to be negative in children with moderate-to-severe malnutrition (P = 0.003) compared to the QFT, which was more likely to be positive in younger children. The significantly better performance of the QFT in malnourished children and those at younger ages supports its use for TB diagnosis in these subpopulations.

Accuracy of a rapid molecular test for tuberculosis in sputum samples, bronchoalveolar lavage fluid, and tracheal aspirate obtained from patients with suspected pulmonary tuberculosis at a tertiary referral hospital / Acurácia do teste rápido molecular para tuberculose em amostras de escarro, lavado broncoalveolar e aspirado traqueal obtidos de pacientes com suspeita de tuberculose pulmonar em um hospital de referência terciária

ABSTRACT Tuberculosis continues to be a major public health problem worldwide. The aim of the present study was to evaluate the accuracy of the Xpert MTB/RIF rapid molecular test for tuberculosis, using pulmonary samples obtained from patients treated at the Júlia Kubitschek Hospital, which is operated by the Hospital Foundation of the State of Minas Gerais, in the city of Belo Horizonte, Brazil. This was a retrospective study comparing the Xpert MTB/RIF test results with those of standard culture for Mycobacterium tuberculosis and phenotypic susceptibility tests. Although the Xpert MTB/RIF test showed high accuracy for the detection of M. tuberculosis and its resistance to rifampin, attention must be given to the clinical status of the patient, in relation to the test results, as well as to the limitations of molecular tests.

RESUMO A tuberculose permanece como um grave problema de saúde pública. O objetivo deste estudo foi avaliar a acurácia do teste rápido molecular Xpert MTB/RIF em amostras pulmonares no Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais, localizado em Belo Horizonte (MG). Trata-se de um estudo descritivo retrospectivo, considerando-se como método padrão a cultura para o bacilo da tuberculose e o teste de sensibilidade fenotípico. O teste Xpert MTB/RIF apresentou ótima acurácia para a detecção da tuberculose e resistência à rifampicina, mas é necessária a atenção a dados clínicos do paciente em relação ao resultado do exame e às limitações dos testes moleculares.

Rapid molecular test for tuberculosis: impact of its routine use at a referral hospital / Teste rápido molecular para tuberculose: avaliação do impacto de seu uso na rotina em um hospital de referência

ABSTRACT Objective: To evaluate the impact of the use of the molecular test for Mycobacterium tuberculosis and its resistance to rifampin (Xpert MTB/RIF), under routine conditions, at a referral hospital in the Brazilian state of Bahia. Methods: This was a descriptive study using the database of the Mycobacteriology Laboratory of the Octávio Mangabeira Specialized Hospital, in the city of Salvador, and georeferencing software. We evaluated 3,877 sputum samples collected from symptomatic respiratory patients, under routine conditions, between June of 2014 and March of 2015. All of the samples were submitted to sputum smear microscopy and the Xpert MTB/RIF test. Patients were stratified by gender, age, and geolocation. Results: Among the 3,877 sputum samples evaluated, the Xpert MTB/RIF test detected M. tuberculosis in 678 (17.5%), of which 60 (8.8%) showed resistance to rifampin. The Xpert MTB/RIF test detected M. tuberculosis in 254 patients who tested negative for sputum smear microscopy, thus increasing the diagnostic power by 59.9%. Conclusions: The use of the Xpert MTB/RIF test, under routine conditions, significantly increased the detection of cases of tuberculosis among sputum smear-negative patients.

RESUMO Objetivo: Avaliar o impacto do teste rápido molecular automatizado Xpert MTB/RIF, utilizado para a detecção de Mycobacterium tuberculosis e sua resistência à rifampicina, em condições de rotina, em um hospital de referência no estado da Bahia. Métodos: Estudo descritivo retrospectivo utilizando o banco de dados do Laboratório de Micobacteriologia do Hospital Especializado Octávio Mangabeira, localizado na cidade de Salvador, e um programa de georreferenciamento. Entre junho de 2014 e março de 2015, foram incluídas no estudo 3.877 amostras de escarro coletadas de pacientes sintomáticos respiratórios em condições de rotina. Todas as amostras coletadas foram submetidas tanto à baciloscopia quanto a Xpert MTB/RIF. Os pacientes foram estratificados por sexo, idade e georreferenciamento. Resultados: Das 3.877 amostras de escarro analisadas, Xpert MTB/RIF detectou a presença de M. tuberculosis em 678 pacientes (17,5%). Desses, 60 (8,8%) apresentaram resistência à rifampicina. O Xpert MTB/RIF detectou 254 pacientes com baciloscopia negativa, representando um acréscimo diagnóstico de 59,9%. Conclusões: A implantação do Xpert MTB/RIF, sob condições de rotina, teve um impacto significativo no aumento da detecção de casos de tuberculose em pacientes com baciloscopia negativa.

Who are the patients with tuberculosis who are diagnosed in emergency facilities? An analysis of treatment outcomes in the state of São Paulo, Brazil / Quem são os pacientes com tuberculose diagnosticados no pronto-socorro? Uma análise dos desfechos do tratamento no Estado de São Paulo, Brasil

ABSTRACT Objective: Early tuberculosis diagnosis and treatment are determinants of better outcomes and effective disease control. Although tuberculosis should ideally be managed in a primary care setting, a proportion of patients are diagnosed in emergency facilities (EFs). We sought to describe patient characteristics by place of tuberculosis diagnosis and determine whether the place of diagnosis is associated with treatment outcomes. A secondary objective was to determine whether municipal indicators are associated with the probability of tuberculosis diagnosis in EFs. Methods: We analyzed data from the São Paulo State Tuberculosis Control Program database for the period between January of 2010 and December of 2013. Newly diagnosed patients over 15 years of age with pulmonary, extrapulmonary, or disseminated tuberculosis were included in the study. Multiple logistic regression models adjusted for potential confounders were used in order to evaluate the association between place of diagnosis and treatment outcomes. Results: Of a total of 50,295 patients, 12,696 (25%) were found to have been diagnosed in EFs. In comparison with the patients who had been diagnosed in an outpatient setting, those who had been diagnosed in EFs were younger and more socially vulnerable. Patients diagnosed in EFs were more likely to have unsuccessful treatment outcomes (adjusted OR: 1.54; 95% CI: 1.42-1.66), including loss to follow-up and death. At the municipal level, the probability of tuberculosis diagnosis in EFs was associated with low primary care coverage, inequality, and social vulnerability. In some municipalities, more than 50% of the tuberculosis cases were diagnosed in EFs. Conclusions: In the state of São Paulo, one in every four tuberculosis patients is diagnosed in EFs, a diagnosis of tuberculosis in EFs being associated with poor treatment outcomes. At the municipal level, an EF diagnosis of tuberculosis is associated with structural and socioeconomic indicators, indicating areas for improvement.

RESUMO Objetivo: O diagnóstico e tratamento precoce da tuberculose são determinantes de melhores desfechos e controle eficaz da doença. Embora a tuberculose deva ser diagnosticada e tratada idealmente na atenção primária à saúde, uma porcentagem dos pacientes recebe o diagnóstico no pronto-socorro. Nosso objetivo foi descrever as características dos pacientes de acordo com o local onde o diagnóstico de tuberculose foi feito e determinar se há relação entre o local do diagnóstico e os desfechos do tratamento. Um objetivo secundário foi determinar se há relação entre indicadores municipais e a probabilidade de diagnóstico de tuberculose no PS. Métodos: Analisamos dados provenientes do banco de dados do Programa de Controle da Tuberculose do Estado de São Paulo, referentes ao período de janeiro de 2010 a dezembro de 2013. Foram incluídos no estudo pacientes recém-diagnosticados com mais de 15 anos de idade e tuberculose pulmonar, extrapulmonar ou disseminada. Modelos de regressão logística múltipla ajustados para levar em conta possíveis fatores de confusão foram usados para avaliar a relação entre o local do diagnóstico e os desfechos do tratamento. Resultados: De um total de 50.295 pacientes, 12.696 (25%) foram diagnosticados no PS. Em comparação com os pacientes que foram diagnosticados no ambulatório, os pacientes diagnosticados no PS eram mais jovens e mais vulneráveis socialmente. A probabilidade de tratamento com desfechos ruins, incluindo perda de seguimento e óbito, foi maior nos pacientes diagnosticados no PS (OR ajustada: 1,54; IC95%: 1,42-1,66). Nos municípios, a probabilidade de diagnóstico de tuberculose no PS relacionou-se com baixa cobertura da atenção primária, desigualdade e vulnerabilidade social. Em alguns municípios, mais de 50% dos casos de tuberculose foram diagnosticados no PS. Conclusões: No Estado de São Paulo, um em cada quatro pacientes com tuberculose é diagnosticado no PS; o diagnóstico de tuberculose no PS está relacionado com tratamento com desfechos ruins. Nos municípios, o diagnóstico de tuberculose no PS está relacionado com indicadores estruturais e socioeconômicos e indica pontos que precisam melhorar.

Needle Aspiration and Cytology for Suspected Osteoarticular Tuberculosis in Children

@#Introduction: Early diagnosis of osteoarticular tuberculosis (OATB) is essential to prevent significant functional disability. There is no single test for diagnosis. Despite an array of investigations available, definitive diagnosis at early stage before starting antitubercular drugs is still a challenge. Materials and Methods: A cross sectional study was carried out between February 2016 and October 2017. All children less than 18 years of age with suspected osteoarticular tuberculosis were included. The cases were subjected to simple needle aspiration from whichever site was accessible. Multiple sample aspirations were done at site of involvement. Smears were prepared from the aspirated material. Results: Ziehl-Neelsen staining for Acid Fast Bacilli (AFB) showed deep pink red rods under light microscopy. Features suggestive of tuberculosis can be seen by May-GrünwaldGiemsa (MGG) staining. Auramine-O staining method of detecting AFB under fluorescent microscope shows the bacilli as greenish yellow slender curved rods in dark background. Fluorescent microscopy has higher sensitivity and comparable specificity. In our study, microbiological confirmation of OATB could be done in 100% cases where the lesion could be accessed for aspiration. The molecular techniques are relatively more expensive and not available everywhere. Conclusion: Meticulous search for AFB in a well stained smear using three different staining methods provides a direct evidence of infection over costly imaging especially in poor patients seen in resource limited settings.

Tuberculosis and latent infection in employees of different prison unit types / Tuberculose e infecção latente em funcionários de diferentes tipos de unidades prisionais

ABSTRACT OBJECTIVE Estimate the prevalence of active tuberculosis and latent tuberculosis infection among the staff that is in contact and the staff that is not in contact with prisoners, and investigate factors associated with latent tuberculosis infection in this population. METHODS Observational cross-sectional study, conducted from 2012 to 2015, in employees of different prison units in the municipality of Franco da Rocha, SP. It consisted of the application of a questionnaire, application and reading of the tuberculin test, sputum smear microscopy, sputum culture, and radiological examination. The association between the qualitative variables was calculated by the Pearson's chi-squared test. The sociodemographic and clinical-epidemiological factors related to the latent tuberculosis infection were evaluated by the logistic regression with the odds ratios (OR) calculation and their respective intervals with 95% of confidence (95%CI). RESULTS A total of 1,059 employees were examined, 657 (62.0%) of prisons, 249 (23.5%) of CASA Foundation units and 153 (14.5%) of custodial and psychiatric treatment hospitals. The tuberculin test was applied and read for 945 (89.2%) professionals. Of these, 797 (84.3%) were contacts of detainees and 148 (15.7%) were not. Among prison staff, the factors associated with latent tuberculosis infection were: contact with detainee (OR = 2.12, 95%CI 1.21-3.71); male gender (OR = 1.97, 95%CI 1.19-3.27); between 30 and 39 years old (OR = 2.98, 95%CI 1.34-6.63), 40 to 49 years old (OR = 4.32, 95%CI 1.94-9.60), and 50 to 59 years old (OR = 3.98, 95%CI 1.68-9.43); nonwhite color or race (OR = 1.89, 95%CI 1.29-2.78); and smoker (OR = 1.64, 95%CI 1.05-2.55). There were no positive test on sputum smear microscopy and culture. Of the 241 (22.8%) professionals who underwent radiological examination, 48 (19.9%) presented alterations of which 11 were suspected of tuberculosis. CONCLUSIONS Prison employees who have direct contact with detainees are 2.12 times more likely to become infected with Mycobacterium tuberculosis in the work environment and consequently to become ill with tuberculosis and should be targeted for disease prevention and control.

RESUMO OBJETIVO Estimar a prevalência de tuberculose ativa e de infecção latente da tuberculose entre funcionários contatos e não contatos de detentos, e investigar fatores associados à infecção latente da tuberculose nesta população. MÉTODOS Estudo observacional do tipo transversal, realizado no período de 2012 a 2015, em funcionários de diferentes unidades prisionais do município de Franco da Rocha, SP. Consistiu na aplicação de um questionário, aplicação e leitura da prova tuberculínica, baciloscopia e cultura dos escarros e exame radiológico. A associação entre as variáveis qualitativas foi calculada pelo teste qui-quadrado de Pearson e os fatores sociodemográficos e clínico-epidemiológicos relacionados à infecção latente da tuberculose foram avaliados pela regressão logística com o cálculo das odds ratios (OR) e seus respectivos intervalos com 95% de confiança (IC95%). RESULTADOS Foram examinados 1.059 funcionários, sendo 657 (62,0%) de penitenciárias, 249 (23,5%) de unidades da Fundação CASA e 153 (14,5%) de hospitais de custódia e tratamento psiquiátrico. Foi aplicada e lida a prova tuberculínica em 945 (89,2%) profissionais. Desses, 797 (84,3%) eram contatos de detentos e 148 (15,7%) não eram. Entre funcionários das penitenciárias, os fatores associados com a infecção latente da tuberculose foram os seguintes: ter contato com detento (OR = 2,12; IC95% 1,21-3,71); ser do sexo masculino (OR = 1,97; IC95% 1,19-3,27); estar na faixa etária entre 30 e 39 anos (OR = 2,98; IC95% 1,34-6,63), 40 a 49 anos (OR = 4,32; IC95% 1,94-9,60) e 50 a 59 anos (OR = 3,98; IC95% 1,68-9,43); ser da cor ou raça não branca (OR = 1,89; IC95% 1,29-2,78); e ser fumante (OR = 1,64; IC95% 1,05-2,55). Não houve exame positivo na baciloscopia e na cultura. Dos 241 (22,8%) profissionais que realizaram o exame radiológico, 48 (19,9%) apresentaram alterações, dos quais 11 eram suspeitos de tuberculose. CONCLUSÕES Os funcionários das penitenciárias que têm contato direto com os detentos têm 2,12 vezes mais chance de se infectar pelo Mycobacterium tuberculosis no âmbito de trabalho e, consequentemente, de adoecer por tuberculose, devendo ser alvos de ações de prevenção e controle da doença.

Offer of primary care services and detection of tuberculosis incidence in Brazil / Oferta de serviços pela atenção básica e detecção da incidência de tuberculose no Brasil

ABSTRACT OBJECTIVE To evaluate the association between the health services offered by primary care teams and the detection of new tuberculosis cases in Brazil. METHODS This was an ecological study covering all Brazilian municipalities that registered at least one new tuberculosis case (diagnosed between 2012 to 2014 and notified in the Information System of Notifiable Diseases) and with at least one primary care team evaluated by the second cycle of the National Program for Improving Access and Quality of Primary Care (PMAQ-AB). The variables of the PMAQ-AB were classified as proximal or distal, according to their relation with the tuberculosis diagnosis. Then, they were tested hierarchically in multiple models (adjusted by States) using negative binomial regression. RESULTS An increase of 10% in the primary health care coverage was associated with a decrease of 2.24% in the tuberculosis detection rate (95%CI -3.35- -1.11). Regarding the proximal variables in relation to diagnosis, in the multiple model, the detection of tuberculosis was associated with the proportion of teams that conduct contact investigation (increase in Incidence Rate Ratio [IRR] = 2.97%, 95%CI 2.41-3.53), carry out tuberculosis active case finding (increase in IRR = 2.17%, 95%CI 1.48-2.87), and request culture for mycobacteria (increase in IRR = 1.87%, 95%CI 0.98-2.76). CONCLUSIONS The variables related to the search actions were positively associated with the detection of new tuberculosis cases, which suggests a significant contribution to the strengthening of the sensitivity of the surveillance system. On the other hand, primary care coverage was inversely associated with the tuberculosis detection rate, which could represent the overall effect of the primary care on transmission control, probably from the identification and early treatment of cases.

RESUMO OBJETIVO Avaliar a associação entre os serviços de saúde ofertados por equipes de atenção básica e a detecção de casos novos de tuberculose no Brasil. MÉTODOS Estudo ecológico, abrangendo todos os municípios brasileiros que registraram pelo menos um caso novo de tuberculose (diagnosticado entre 2012 a 2014 e notificado no Sistema de Informação de Agravos de Notificação) e com pelo menos uma equipe de atenção básica avaliada pelo segundo ciclo do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). As variáveis do PMAQ-AB foram classificadas como próximais ou distais, segundo a sua relação com o diagnóstico de tuberculose. Em seguida, foram testadas hierarquicamente em modelos múltiplos (ajustados por Unidade Federada), usando regressão binomial negativa. RESULTADOS Um incremento de 10% na cobertura da atenção básica esteve associado à redução de 2,24% na taxa de detecção de tuberculose (IC95% -3,35- -1,11). No que se refere às variáveis proximais ao diagnóstico, no modelo múltiplo, a detecção da tuberculose esteve associada à proporção de equipes que: realizam vigilância de contatos (incremento na Razão de Taxas de Incidência [RTI] = 2,97%; IC95% 2,41-3,53); fazem busca ativa de casos de tuberculose (incremento na RTI = 2,17%; IC95% 1,48-2,87); e, ofertam cultura para micobactérias (incremento na RTI = 1,87%; IC95% 0,98-2,76). CONCLUSÕES As variáveis relacionadas às ações de detecção estiveram positivamente associadas à detecção de casos novos de tuberculose, sugerindo uma contribuição significativa ao fortalecimento da sensibilidade do sistema de vigilância. Por outro lado, a cobertura da atenção básica esteve inversamente associada à taxa de detecção de tuberculose, o que poderia representar o efeito global da atenção básica sobre o controle da transmissão, provavelmente, através da identificação e tratamento precoce de casos.

Current use and acceptability of novel diagnostic tests for active tuberculosis: a worldwide survey / Uso atual e aceitabilidade de novos testes diagnósticos para tuberculose ativa: um inquérito mundial

ABSTRACT Objective: To determine the current use and potential acceptance (by tuberculosis experts worldwide) of novel rapid tests for the diagnosis of tuberculosis that are in line with World Health Organization target product profiles. Methods: A multilingual survey was disseminated online between July and November of 2016. Results: A total of 723 individuals from 114 countries responded to the survey. Smear microscopy was the most commonly used rapid tuberculosis test (available to 90.9% of the respondents), followed by molecular assays (available to 70.7%). Only a small proportion of the respondents in middle- and low-income countries had access to interferon-gamma-release assays. Serological and lateral flow immunoassays were used by more than a quarter (25.4%) of the respondents. Among the respondents who had access to molecular tests, 46.7% were using the Xpert assay overall, that proportion being higher in lower middle-income countries (55.6%) and low-income countries (76.6%). The data also suggest that there was some alignment of pricing for molecular assays. Respondents stated they would accept novel rapid tuberculosis tests if available, including molecular assays (acceptable to 86.0%) or biomarker-based serological assays (acceptable to 81.7%). Simple biomarker-based assays were more commonly deemed acceptable in middle- and low-income countries. Conclusions: Second-generation molecular assays have become more widely available in high- and low-resource settings. However, the development of novel rapid tuberculosis tests continues to be considered important by tuberculosis experts. Our data also underscore the need for additional training and education of end users.

RESUMO Objetivo: Determinar o uso atual e a aceitação potencial (por especialistas em tuberculose em todo o mundo) de novos testes rápidos para o diagnóstico de tuberculose que estão alinhados com os perfis de produtos alvo da Organização Mundial da Saúde. Métodos: Um inquérito multilingue foi divulgado on-line entre julho e novembro de 2016. Resultados: Um total de 723 indivíduos de 114 países respondeu ao inquérito. A baciloscopia foi o teste rápido para tuberculose mais utilizado (disponível para 90,9% dos entrevistados), seguida de ensaios moleculares (disponível para 70,7%). Apenas uma pequena proporção dos entrevistados de países de renda média e baixa tinha acesso a ensaios de liberação de IFN-γ. Imunoensaios de fluxo lateral e testes sorológicos eram utilizados por mais de um quarto dos entrevistados (25,4%). Entre os entrevistados que tinham acesso a testes moleculares, 46,7% utilizavam o teste Xpert de forma geral, sendo essa proporção maior em países de renda média baixa (55,6%) e renda baixa (76,6%). Os dados também sugerem que houve algum alinhamento de preços para testes moleculares. Os entrevistados afirmaram que aceitariam novos testes rápidos para tuberculose, se disponíveis, incluindo testes moleculares (aceitáveis para 86,0%) ou testes sorológicos baseados em biomarcadores (aceitáveis para 81,7%). Testes simples baseados em biomarcadores foram mais comumente considerados aceitáveis nos países de renda média e baixa. Conclusões: Os testes moleculares de segunda geração tornaram-se mais amplamente disponíveis em locais tanto com poucos quanto com muitos recursos. No entanto, o desenvolvimento de novos testes rápidos para tuberculose continua a ser considerado importante por especialistas em tuberculose. Nossos dados também ressaltam a necessidade de maior formação e educação dos usuários finais.

Problems in serum antibody detection of smear-and culture-negative pulmonary tuberculosis / 中华微生物学和免疫学杂志

More than 60% of active tuberculosis(TB) patients are smear- and culture-negative, constituting a prime group in the prevention and control of TB in China. In the existing laboratory testing technologies, immunological diagnosis is more advantageous than etiological diagnosis in the detection of smear-and culture-negative TB. Serum antibody detection reagents are cheap,easy to operate and time-sav-ing,and have been widely used in China. However,these agents are not stable in sensitivity and specificity, and because of that their accuracy in the diagnosis of smear-and culture-negative TB is doubtful. In this re-view,we summarize some problems in the use of serum antibody detection among smear- and culture-nega-tive pulmonary TB patients and discuss possible methods to solve these problems expecting to provide some ideas for promoting its development,application and policy formulation.

Pleural tuberculosis in the state of Roraima, Brazil, between 2005 and 2013: quality of diagnosis / Tuberculose pleural no estado de Roraima no período de 2005-2013: qualidade diagnóstica

Objective: To evaluate the quality of diagnosis and the epidemiological profile of patients with pleural tuberculosis in the state of Roraima, Brazil, in order to provide technical support for the development and implementation of public policies to combat the disease. Methods: This was a cross-sectional study designed to determine the prevalence of pleural forms of tuberculosis in Roraima between 2005 and 2013 and to evaluate the diagnostic criteria used, as well as their determinants. This study was based on secondary data from the Brazilian Case Registry Database, including all reported cases of pleural tuberculosis in the state during the study period. Diagnoses based on bacteriological or histopathological confirmation were defined as high-quality diagnoses. Results: Among the 1,395 cases of tuberculosis reported during the study period, 116 (8.3%) were cases of pleural tuberculosis, accounting for 38.9% of all cases of extrapulmonary tuberculosis in the sample. The incidence rate of pleural tuberculosis did not follow the downward trend observed for the pulmonary form of the disease during the same period. The prevalence of cases with a high-quality diagnosis was 28.5% (95% CI: 20.4-37.6%). In a univariate analysis, none of the demographic or clinical characteristics collected from the database were found to have a significant impact on the outcome (as explanatory variables). Conclusions: The quality of the diagnoses in our study sample was considered unsatisfactory. Limited access to specific diagnostic methods might have contributed to these results.

Objetivo: Avaliar a qualidade dos diagnósticos e o perfil epidemiológico de portadores de tuberculose pleural no estado de Roraima, visando embasar tecnicamente o fomento e a aplicação de políticas públicas para o enfrentamento dessa doença. Métodos: Estudo transversal, desenhado para determinar a prevalência de formas pleurais da tuberculose em Roraima entre 2005 e 2013 e avaliar os critérios diagnósticos utilizados e seus determinantes. Este estudo foi baseado na revisão de dados secundários do Sistema de Informação de Agravos de Notificação, incluindo todos os casos notificados como tuberculose pleural no estado durante o período de estudo. Diagnósticos baseados em confirmação bacteriológica ou histopatológica foram definidos como de qualidade. Resultados: Dos 1.395 casos de tuberculose notificados no período do estudo, 116 (8,3%) foram da apresentação pleural, totalizando 38,9% das formas extrapulmonares na amostra. A taxa de incidência dessa apresentação clínica não acompanhou a tendência decrescente da forma pulmonar da doença no período. A prevalência de diagnósticos de qualidade encontrada foi de 28,5% (IC95%: 20,4-37,6%) e, na análise univariada, nenhuma variável explicativa dentre as características demográficas e clínicas coletadas do banco de dados tiveram um impacto significativo no desfecho (como variáveis explicativas). Conclusões: A qualidade dos diagnósticos na amostra estudada foi considerada insatisfatória. O acesso limitado a métodos diagnósticos específicos pode ter contribuído para esses resultados.

Atrasos na suspeita e no diagnóstico de tuberculose e fatores relacionados / Delays in tuberculosis suspicion and diagnosis and related factors

RESUMO: Objetivo: Medir os atrasos na suspeita e no diagnóstico de tuberculose (TB) e identificar fatores relacionados. Métodos: O atraso na suspeita foi definido como o tempo entre a percepção, pelo doente, dos sintomas até a procura pelo primeiro atendimento e no diagnóstico, como o tempo entre o primeiro atendimento até a realização do diagnóstico. Foram entrevistados 100 doentes, diagnosticados e notificados em 2008 e 2009, atendidos em serviços de saúde (SSs) de São José do Rio Preto, para os quais foram quantificados os atrasos. As possíveis variáveis explicativas foram obtidas das entrevistas e de informações secundárias disponíveis no sistema de vigilância. Os endereços dos casos e dos serviços de saúde foram geocodificados. As variáveis foram analisadas por regressão linear múltipla e, quando da identificação de dependência espacial dos seus resíduos, por regressão espacial. Resultados: As medianas, tanto para o atraso na suspeita como no diagnóstico, foram 15 dias. O atraso na suspeita foi modelado por regressão linear e mostrou-se associado positivamente com as distâncias percorridas pelos doentes para obter o primeiro atendimento e negativamente com a religião (não cristã). O atraso no diagnóstico foi modelado por regressão espacial e mostrou-se associado positivamente com idade e número de vezes que o doente procurou o SS e negativamente com a classificação do caso (TB pulmonar). Conclusão: O estudo revelou lacunas nas ações de controle da TB relacionadas aos doentes e à organização dos serviços e mostrou a importância de se levar em conta a dependência espacial dos fenômenos analisados.

ABSTRACT: Objective: To measure the delays in tuberculosis (TB) suspicion and diagnosis and to identify factors related. Methods: We defined the delay in TB suspicion as the time between the perception of the symptoms by the patient and the search for health-care service and the diagnosis, as the time between the first visit to the health-care service and the diagnosis. We interviewed 100 patients treated at the health services in São José do Rio Preto that were diagnosed and reported/notified in 2008 and 2009, and the delays were quantified. We obtained the possible explanatory variables from interviews and secondary information available in the surveillance system. The addresses of TB patients and health-care services were geocoded. Variables were assessed by multiple linear regression analysis and, when spatial dependency was detected, by spatial regression. Results: The median values for the delays in TB suspicion and diagnosis were both 15 days. The first was modeled by linear regression and a positive relationship was found with the distances covered by the patients in order to get primary health-care service. The last was modeled by spatial regression and a positive relationship was found with the age and the frequency with the patients sought health-care services and a negative relationship with the pulmonary clinical form. Conclusion: The study revealed the existence of gaps in TB control activities related to the patients and the organization of the health-care services and showed the importance of taking into account the spatial dependence of the phenomena analyzed.

Ensayo Xpert MTB/RIF en el diagnóstico de tuberculosis / Xpert® MTB/RIF assay for tuberculosis diagnosis

Xpert MTB/RF is an automatic methodology that uses the polymerase chain reaction to detect in less than two hours the presence of Mycobacterium tuberculosis and also informs about the sensibility to rifampicin. This technology has good sensibility and even better specificity in respiratory samples. In non-respiratory samples the sensibility is lower. We analyzed the results of samples sent to the Laboratory of Tuberculosis of the Instituto Nacional del Tórax-Chile (National Thorax Institute) during the last two years since we started to use this technology. We analyzed 529 samples, 384 (73%) of them were respiratory in origin and 145 (27%) were non-respiratory. Only 43 samples were positive for Mycobacterium tuberculosis, 33 from respiratory samples, and 10 from other sources. 17 smear negative samples were culture positive for Mycobacterium tuberculosis; 15 of them were detected by Xpert; 351 samples were culture negative, 17 of them were positive by Xpert, the majority in patients under treatment for tuberculosis or with old tuberculosis. Ten of 10 culture positive patients from non-respiratory samples were positive with Xpert. The interpretation of Rifampicin resistance, when its prevalence in a given population is low, like is the case in Chile, requires confirmation by using standard methods.

Xpert MTB/RIF es un método automatizado basado en la reacción de la polimerasa en cadena que permite en menos de dos horas detectar la presencia de ADN de Mycobacterium tuberculosis y, además, informa la susceptibilidad a la Rifampicina. Esta técnica, que está disponible en el Instituto Nacional del Tórax (INT) desde hace dos años, tiene una buena sensibilidad y una mejor especificidad en muestras respiratorias. En muestras no respiratorias el rendimiento, aunque inferior, sigue siendo clínicamente útil. Se analizaron 529 muestras enviadas al Laboratorio de Tuberculosis del INT, comparándolas con el cultivo de Koch en medio sólido que es el "gold standard". El 73% (384) de las muestras fueron respiratorias y sólo 145 (27%) no respiratorias (líquido pleural, orina y líquido cefalorraquídeo). Del total de las muestras, 43 resultaron positivas para tuberculosis, de ellas, 33 eran de origen respiratorio y 10 no respiratorio. Todos los pacientes que tenían baciloscopias positivas fueron confirmados por el Xpert. De los 17 enfermos con baciloscopias negativas y cultivos positivos, 15 fueron detectados con el Xpert. De los 351 pacientes con cultivos negativos de las muestras respiratorias, 17 resultaron positivos por el Xpert, pero 8 de éstos estaban en tratamiento o habían tenido una tuberculosis anteriormente. En las muestras no respiratorias, de 10 pacientes con cultivos positivos el Xpert detectó los 10, demostrando también una excelente sensibilidad. En cuanto a la resistencia a Rifampicina, cuando la prevalencia de ésta en una población es baja, como ocurre en Chile, requiere confirmación por las técnicas estándar.

Drug-resistant tuberculosis in subjects included in the Second National Survey on Antituberculosis Drug Resistance in Porto Alegre, Brazil / Tuberculose resistente em pacientes incluídos no II Inquérito Nacional de Resistência aos Fármacos Antituberculose realizado em Porto Alegre, Brasil

OBJECTIVE: To describe the prevalence of multidrug-resistant tuberculosis (MDR-TB) among tuberculosis patients in a major Brazilian city, evaluated via the Second National Survey on Antituberculosis Drug Resistance, as well as the social, demographic, and clinical characteristics of those patients. METHODS: Clinical samples were collected from tuberculosis patients seen between 2006 to 2007 at three hospitals and five primary health care clinics participating in the survey in the city of Porto Alegre, Brazil. The samples were subjected to drug susceptibility testing. The species of mycobacteria was confirmed using biochemical methods. RESULTS: Of the 299 patients included, 221 (73.9%) were men and 77 (27.3%) had a history of tuberculosis. The mean age was 36 years. Of the 252 patients who underwent HIV testing, 66 (26.2%) tested positive. The prevalence of MDR-TB in the sample as a whole was 4.7% (95% CI: 2.3-7.1), whereas it was 2.2% (95% CI: 0.3-4.2) among the new cases of tuberculosis and 12.0% (95% CI: 4.5-19.5) among the patients with a history of tuberculosis treatment. The multivariate analysis showed that a history of tuberculosis and a longer time to diagnosis were both associated with MDR-TB. CONCLUSIONS: If our results are corroborated by other studies conducted in Brazil, a history of tuberculosis treatment and a longer time to diagnosis could be used as predictors of MDR-TB. .

OBJETIVO: Descrever a prevalência de tuberculose multirresistente (TBMR) em pacientes com tuberculose em uma importante cidade brasileira através do II Inquérito Nacional de Resistência aos Fármacos Antituberculose, assim como as características sociais, demográficas e clínicas desses pacientes. MÉTODOS: De 2006 a 2007, amostras clínicas de pacientes de três hospitais e das cinco unidades básicas de saúde participantes do inquérito realizado em Porto Alegre foram coletadas e submetidas ao teste de sensibilidade aos fármacos. A confirmação das espécies de micobactérias ocorreu por métodos bioquímicos. RESULTADOS: Foram incluídos 299 pacientes. Desses, 221 (73,9%) eram homens e 77 (27,3%) tinham história de tuberculose. A idade média foi de 36 anos. Dos 252 pacientes testados para HIV, 66 (26,2%) estavam infectados. A prevalência da TBMR na amostra geral foi de 4,7% (IC95%: 2,3-7,1); enquanto essa foi de 2,2% (IC95%: 0,3-4,2) nos pacientes virgens de tratamento e de 12,0% (IC 95%: 4,5-19,5) naqueles com história de tratamento antituberculose. A análise multivariada mostrou que história de tuberculose e maior tempo para o diagnóstico associaram-se a TBMR. CONCLUSÕES: Caso esses resultados sejam confirmados em outros estudos no Brasil, a história de tratamento antituberculose e o maior tempo para o diagnóstico poderão ser utilizados como preditores de TBMR. .