Guia para Controle de Tuberculose em Instituições de Acolhimento para População em Situação de Rua / Guide to Tuberculosis Control in Reception Institutions for Population in Street Situation

Este guia se destina a profissionais que atuam, principalmente, nas Instituições de Acolhimento destinadas à População em Situação de Rua (PSR). Entretanto, vários conceitos e informações que serão apresentados aqui podem ser usados em outros espaços de acolhimento e de oferta de cuidados a esta população, como os de grupos informais e de organizações públicas, governamentais ou não-governamentais.

Control de la tuberculosis pulmonar en el personal de Enfermería en instituciones hospitalarias / Control of Pulmonary Tuberculosis among the Nursing Personnel in Hospital Institutions

Introducción: La tuberculosis pulmonar es uno de los problemas de salud pública más importante a nivel mundial. El personal de la salud tiene mayor probabilidad de contraer la infección con Mycobacterium tuberculosis por su exposición incrementada a pacientes con la enfermedad. Objetivo: Sistematizar el control de la tuberculosis pulmonar en el personal de enfermería en instituciones hospitalarias. Métodos: Revisión integrativa en las bases de datos SciELO y Medline, mediante los descriptores (DeCS): "tuberculosis/tuberculose", "Personal de Enfermería/pessoal de enfermagem/health personnel", "prevención/prevencao/prevention", a través de los operadores booleanos AND y OR. Se establecen las categorías de análisis para una mejor organización del conocimiento. Se establecieron como criterios de inclusión, artículos completos en español, portugués e inglés, que refirieran de manera clara la metodología y los resultados obtenidos. Se incluyeron 10 referencias, que evidencian que existen diversos factores para la transmisión del bacilo de la tuberculosis, en el personal de atención en salud, como el número de pacientes con tuberculosis pulmonar atendidos al año. Es esencial la concientización de las medidas para su control. Diversas publicaciones documentan experiencias de la aplicación de medidas de control, con sus respectivas recomendaciones, mediante el análisis de sus ventajas, desventajas y en algunos casos, de su rentabilidad. Conclusiones: Las evidencias científicas exponen que las medidas de control de la tuberculosis en las instituciones hospitalarias son una estrategia eficaz para prevenir la transmisión de la enfermedad al personal de enfermería(AU)

Introduction: Pulmonary tuberculosis is one of the most important public health problems worldwide. The healthcare personnel are more likely to contract infection with Mycobacterium tuberculosis, because of their increased exposure to patients with the disease. Objective: To systematize the control of pulmonary tuberculosis among the nursing personnel in hospital institutions. Methods: An integrative review in the SciELO and Medline databases was carried out, using the Health Sciences Descriptors (DeCS) tuberculosis/tuberculose [tuberculosis], Personal de Enfermería/pessoal de enfermagem/health personnel [nursing personnel], prevención/prevenção/prevention, through the Boolean operators AND and OR. The analysis categories were established for better knowledge organization. The established inclusion criterions were complete articles published in Spanish, Portuguese and English, which clearly referred to the methodology and obtained results. Ten references were included, showing that there are several factors for the transmission of the tuberculosis bacillus in the health care personnel, as being the number of patients with pulmonary tuberculosis attended per year. Awareness-raising is essential concerning measures for its control. Publications document experiences regarding the application of control measures, with their respective recommendations, by analyzing their advantages, disadvantages and, in some cases, their cost-effectiveness. Conclusions: Scientific evidence show that tuberculosis control measures in hospital institutions are an effective strategy for preventing transmission of the disease to nursing personnel(AU)

Rastreio radiológico para tuberculose em uma penitenciária do sul do Brasil / Radiological screening for tuberculosis in a prison in the south of Brazil

Introdução: Conhecer o perfil da população privada de liberdade da Penitenciária Modulada de Osório (PMO), do ponto de vista radiológico e estimar a prevalência da tuberculose ativa no presídio.Métodos: Foi realizada análise retrospectiva de 677 radiografias de tórax obtidas para rastreio de tuberculose e de dados da ficha de atendimento do setor de Radiologia no período de julho a outubro de 2019.Resultados: Foram detectadas 150 radiografias alteradas, o que representa 22% dos 677 exames. Dos 150 exames alterados, 109 (16% do total e 72% dos alterados) apresentavam lesões com características de doença granulomatosa. Dos 677 pacientes, 11,5% referiram tratamento atual ou prévio para tuberculose e estes representam 38% dos casos com radiografias alteradas. Foram detectados 50 pacientes sem história prévia de tuberculose com lesões de aspecto muito provavelmente devido a tuberculose com características de doença ativa (7,3% do total), os quais foram encaminhados para investigação como casos novos. Em relação ao questionário aplicado, não foi observada diferença significativa entre os pacientes que referiam ou negavam tosse entre os com exames normais e alterados.Conclusões: Os indivíduos privados de liberdade apresentaram alta prevalência de alterações radiológicas com aspecto sugestivo de doença granulomatosa. Estes achados permitem inferir que na Penitenciária Modulada de Osório há elevada prevalência de tuberculose, provavelmente em níveis semelhantes a outras casas prisionais do Brasil.

Introduction: To determine the radiologic profile of 'the prisoners at Osório Modular Prison and estimate the prevalence of active tuberculosis in the institution.Methods: We retrospectively analyzed 677 chest radiographs obtained for tuberculosis screening and data from the medical records of prisoners seen at the Radiology Department from July to October 2019.Results: Of 677 radiographs, 150 (22%) showed abnormalities. Of these, 109 (16% of total or 72% of abnormal radiographs) showed lesions characteristic of granulomatous disease. Of all 677 patients, 11.5% reported current or previous treatment of tuberculosis, accounting for 38% of all abnormal radiographs. Fifty patients with no previous history of tuberculosis had lesions that were most likely due to active tuberculosis (7.3% of total), and were referred for further investigation as new cases. The responses to the questionnaire revealed no significant difference between patients who reported or denied coughing when comparing those with normal vs abnormal radiographs.Conclusions: Individuals deprived of liberty had a high prevalence of radiologic abnormalities suggestive of granulomatous disease. These findings allow us to infer that there is a high prevalence of tuberculosis at Osório Modular Prison, probably at levels comparable to those of other prison facilities in Brazil.

Evaluación del método de Petroff modificado con solución salina para el diagnóstico de micobacterias en el sistema Bact/Alert 3D / Assessment of Petroff method modified with saline solution for the diagnosis of mycobacteria in Bact/Alert 3D system

Introducción: Existen diferentes métodos de descontaminación de muestras pulmonares para el diagnóstico de micobacterias. El Programa Nacional de Control de Tuberculosis recomienda el método de Petroff modificado con solución salina, pero no existen evidencias documentadas que avalen este método. Objetivo: Evaluar el método de Petroff modificado con solución salina para el diagnóstico de micobacterias en el sistema Bact/Alert 3D. Métodos: Se realizó un estudio observacional analítico de pruebas diagnósticas utilizando 100 muestras pulmonares recibidas en el Laboratorio Nacional de Referencia e Investigaciones de Tuberculosis, Lepra y Micobacterias del Instituto Pedro Kourí, abril 2016 enero 2017. La muestra se dividió en 3 alícuotas y se descontaminaron mediante 3 métodos; luego se inocularon en los medios de cultivo sólido y líquido. Se compararon los resultados del cultivo en cuanto: tiempo de detección de crecimiento, tasa de contaminación, por ciento de positividad, además se calcularon indicadores de desempeño. Resultados: Al comparar el método Petroff modificado con solución salina con el Petroff modificado con solución fosfato en Löwenstein Jensen, el tiempo de detección de crecimiento, por ciento de positividad y la tasa de contaminación se comportaron de forma similar y la sensibilidad (93,75 por ciento), concordancia (96,47 por ciento) e índice de Youden (0,91) fueron elevadas. Al compararlo el Petroff modificado con solución salina con el N-Acetil-L-Cisteína, las variables no mostraron diferencias significativas y los Indicadores de Desempeño se comportaron por encima del 93 por ciento, para el medio sólido y líquido. Conclusiones: Los resultados avalan la continuidad del uso del Petroff modificado con solución salina como método de descontaminación de las muestras pulmonares en la red de laboratorios de Cuba y como alternativa en el pretratamiento de las muestras para el medio líquido (Bact/Alert 3D), además constituye un soporte para el Programa Nacional de Control de Tuberculosis(AU)

Introduction: There are different decontamination methods of pulmonary samples for the diagnosis of mycobacteria. The National Program for the Control of Tuberculosis recommends Petroff method modified with saline solution; but there are not documented evidences that endorse it. Objective: Assess Petroff method modified with saline solution for the diagnosis of mycobacteria in Bact / Alert 3D system. Methods: An observational analytic study of diagnostic tests was conducted; there were used 100 pulmonary samples received in the National Laboratory of References and Researches of Tuberculosis, Leprosy and Mycobacteria of Pedro Kourí Institute, from April 2016 to January 2017. The sample was divided in 3 aliquots and those were decontaminated using 3 methods; then, they were inoculated in the solid and liquid culture means. Cultures´ results were compared according to: growth's detection time, contamination rate, percent of positivity; in addition, performance indicators were calculated. Results: When comparing Petroff method modified with saline solution with Petroff method modified with phosphate solution in Löwenstein Jensen, the growth's detection time, the percent of positivity and the rate of contamination behaved similarly, and sensitivity (93,75percent), concordance (96,47percent) and Youden´s index (0,91) were high. When the Petroff method modified with saline solution was compared with N-Acetil-L- Cisteina, the variables did not show significative differences and the behaviour indicators were over 93percent for the solid and liquid mean. Conclusions: The results endorse the continuity of the use of Petroff method modified with saline solution as a decontamination method of pulmonary samples in the network of Cuban laboratories and as alternative to the pre-treatment of the samples for the liquid mean (Bact/Alert 3D); it also constitutes a support for the National Program for the Control of Tuberculosis(AU)

Tuberculosis care cascade for the indigenous population in Colombia: an operational research study / Cascada de atención de la tuberculosis para la población indígena en Colombia: una investigación operativa / Cascata de atenção da tuberculose para os povos indígenas na Colômbia: pesquisa operacional

ABSTRACT Objective. Construct and evaluate the care cascade for pulmonary tuberculosis in the indigenous population of the department of Cauca (Colombia) and identify existing gaps. Methods. Mixed-methods sequential explanatory design. In the first phase, the pulmonary tuberculosis care cascade for the indigenous population of Cauca was evaluated. Data were obtained from secondary sources and all cases diagnosed from 1 January 2016 to 31 December 2017 were included. In the second phase, semi-structured interviews were done with nine program coordinators and 11 nursing auxiliaries to explain identified gaps. Absolute and percentage values were estimated for each of the steps and gaps in the care cascade. Quantitative and qualitative results were triangulated. Results. In 2016 and 2017, an estimated 202 patients with respiratory symptoms were expected to be positive and 106 cases of pulmonary tuberculosis were reported among the indigenous population of the department of Cauca. A gap of 47.5% was found for diagnosis, since only 52.5% of subjects were diagnosed in health services. This gap was explained by poor quality of samples and flawed smear techniques; flaws in correct identification of patients with respiratory symptoms; limited access to diagnostic methods, such as culture and molecular tests; and limited training and high turnover of personnel in health service provider institutions. Conclusions. The tuberculosis control program should focus actions on bridging the gap in case detection in the indigenous population.

RESUMEN Objetivo. Construir y evaluar la cascada de atención de la tuberculosis pulmonar en la población indígena del departamento del Cauca (Colombia) e identificar las brechas existentes. Métodos. Metodología mixta con diseño secuencial explicativo. En la primera fase se evaluó la cascada de atención de la tuberculosis pulmonar para la población indígena del Cauca. Se obtuvieron datos de fuentes secundarias y se incluyeron todos los casos diagnosticados entre el 1 de enero del 2016 y el 31 de diciembre de 2017. En la segunda fase, se aplicaron entrevistas semiestructuradas a nueve coordinadores de programa y 11 auxiliares de enfermería para explicar las brechas identificadas. Se estimaron los valores absolutos y porcentuales en cada uno de los pasos y las brechas de la cascada de atención. Se triangularon los resultados cuantitativos y cualitativos. Resultados. Durante 2016 y 2017 se estimaron 202 sintomáticos respiratorios esperados positivos y se notificaron 106 casos de tuberculosis pulmonar en la población indígena del departamento del Cauca. Se encontró una brecha de 47,5% para el diagnóstico, ya que solo 52,5% de los sujetos recibieron el diagnóstico en los servicios de salud. Las explicaciones a esta brecha fueron la mala calidad de muestras y fallas en la técnica del extendido, fallas en la correcta identificación del sintomático respiratorio, acceso limitado a métodos diagnósticos como cultivo y pruebas moleculares, así como capacitación escasa y rotación alta de personal al interior de las instituciones prestadoras de servicios de salud. Conclusiones. Las acciones del programa de control de tuberculosis deben enfocarse en reducir la brecha de detección de casos en la población indígena.

RESUMO Objetivo. Elaborar e avaliar a cascata de atenção da tuberculose pulmonar na população indígena do Departamento de Cauca (Colômbia) e identificar as lacunas existentes. Métodos. Metodologia mista com desenho sequencial explicativo. Na primeira fase, avaliamos a cascata de atenção da tuberculose pulmonar para a população indígena de Cauca. Os dados foram obtidos de fontes secundárias, incluindo todos os casos diagnosticados entre 1 de janeiro de 2016 e 31 de dezembro de 2017. Na segunda fase, realizamos entrevistas semiestruturadas com nove coordenadores do programa e 11 auxiliares de enfermagem para explicar as lacunas identificadas. Estimamos os valores absolutos e percentuais em cada uma das etapas e as lacunas na cascata de atenção. Os resultados quantitativos e qualitativos foram triangulados. Resultados. Nos anos de 2016 e 2017, foi estimada a ocorrência de 202 casos com sintomas respiratórios com diagnóstico esperado positivo; no entanto, os serviços de saúde só diagnosticaram e notificaram 106 casos de tuberculose pulmonar na população indígena do Departamento de Cauca. Portanto, identificamos uma lacuna diagnóstica de 47,5%, já que apenas 52,5% dos casos receberam um diagnóstico nos serviços de saúde. As explicações para esta lacuna foram a má qualidade das amostras e falhas na técnica de esfregaço, falhas na identificação correta dos sintomas respiratórios, acesso limitado aos métodos de diagnóstico, tais como cultura e testes moleculares, bem como capacitação deficiente e alta rotatividade de pessoal nas instituições de saúde. Conclusões. As ações do programa de controle da tuberculose devem se concentrar em reduzir a lacuna na detecção de casos na população indígena.

Genes y determinantes de virulencia de Mycobacterium tuberculosis que contribuyen a la evasión de la respuesta inmune / Mycobacterium tuberculosis genes and virulence determinants that contribute to the immune response evasion

La tuberculosis pulmonar es un problema de salud pública a nivel mundial. La Organización Mundial de la Salud en el año 2018 reportó alrededor de 10 millones de enfermos y 1,5 millones de muertes. Mycobacterium tuberculosis es un patógeno intracelular y el agente causal de la enfermedad. Estudios experimentales de virulencia han permitido determinar un conjunto de genes de virulencia, que le confieren la capacidad de resistir el ambiente hostil en el macrófago, superar la actividad de la respuesta inmune y persistir en el hospedero. El objetivo de la publicación es presentar una revisión de las investigaciones de los últimos 20 años que han demostrado los genes o factores de virulencia de M. tuberculosis que contribuyen a la evasión de la respuesta inmune. Según los resultados de las investigaciones, existen múltiples factores y genes de virulencia que participan en la evasión de la respuesta inmune innata como ESAT-6, PknG, PhoP, ManLAM, SapM, katG, tpx, nuoG, sodA/secA2, pknE y Rv3654c/Rv3655c, mientras existen elementos capaces de modular la respuesta inmune adaptativa. La comprensión de la interacción entre los genes de virulencia y la actividad del sistema inmune, son importantes para estudiar nuevos métodos de diagnóstico, el diseño de nuevas vacunas y por ende, mejorar las medidas de control, prevención y tratamiento de la tuberculosis(AU)

Pulmonary tuberculosis is a public health problem worldwide. The World Health Organization in 2018 reported about 10 million patients and 1.5 million deaths. Mycobacterium tuberculosis, an intracellular pathogen, is the causative agent of the disease. Experimental virulence studies have allowed to determine a set of virulence genes that confer the ability to resist the hostile environment in the macrophage, overcome the activity of the immune response and persist in the host. The objective of the publication is to present a review of the last 20 years investigations that have shown the genes or virulence factors of M. tuberculosis that contribute to the evasion of the immune response. According to the results of the investigations, there are multiple virulence factors and genes that participate in the evasion of the innate immune response such as ESAT-6, PknG, PhoP, ManLAM, SapM, katG, tpx, nuoG, sodA/secA2, pknE and Rv3654c/Rv3655c, while there are elements capable of modulating the adaptive immune response. The understanding of the interaction between the virulence genes and the activity of the immune system, are important to study new diagnostic methods, the design of new vaccines and therefore, to improve the control, prevention and treatment measures of tuberculosis(AU)

Risk of infection and disease progression in children exposed to tuberculosis at home, Colombia / Riesgo de infección y progresión de la enfermedad en niños expuestos a tuberculosis en el hogar, Colombia

Abstract Aim: To assess the risk of tuberculosis (infection and disease) in children less than 15 years' old who are household contacts of pulmonary tuberculosis patients in three Colombian cities (Medellín, Cali, and Popayán). Methods: A cohort of 1,040 children household contacts of 380 adults with smear-positive pulmonary tuberculosis was followed up for 24 months. Study period 2005-2009. Results: Tuberculin skin test was positive (≥10 mm) in 43.7% (95% CI: 39.2-48.2). Tuberculin skin test positivity was associated with age 10-14 years (Prevalence Ratio -PR= 1.43, 95% CI: 1.1-1.9), having a BCG vaccine scar (PR= 1.52, 95% CI: 1.1-2.1), underweight, closer proximity to the index case and exposure time >3 months. The annual risk of infection (tuberculin skin test induration increase of 6 mm or more per year) was 17% (95% CI: 11.8-22.2) and was associated with a bacillary load of the adult index case (Relative Risk -RR= 2.12, 95% CI: 1.0-4.3). The incidence rate of active tuberculosis was 12.4 cases per 1,000 persons-year. Children <5 years without BCG vaccine scar had a greater risk of developing active disease (Hazard Ratio -HR= 6.00, 95% CI: 1.3-28.3) than those with scar (HR= 1.33, 95% CI: 0.5-3.4). The risk of developing active tuberculosis augmented along with the increase from initial tuberculin skin test (tuberculin skin test 5-9 mm HR= 8.55, 95% CI: 2.5-29.2; tuberculin skin test ≥10 mm HR= 8.16, 95% CI: 2.0-32.9). Conclusions: There is a need for prompt interruption of adult-to-children tuberculosis transmission within households. Conducting proper contact investigation and offering chemoprophylaxis to infected children could reduce tuberculosis transmission.

Resumen Objetivo: Evaluar el riesgo de tuberculosis (infección y enfermedad) en niños menores de 15 años de edad convivientes de pacientes con tuberculosis pulmonar en tres ciudades colombianas (Medellín, Cali y Popayán). Métodos: Se siguió durante 24 meses una cohorte de 1,040 niños convivientes de 380 adultos con tuberculosis pulmonar bacilífera. Periodo de estudio 2005-2009. Resultados: La prueba de tuberculina fue positiva (≥10 mm) en el 43.7% (IC 95%: 39.2-48.2), y estuvo asociada con la edad de 10-14 años (Razón de Prevalencia-RP= 1.43, IC 95%: 1.1-1.9), tener cicatriz de la vacuna BCG (RP= 1.52, IC 95%: 1.1-2.1). El riesgo anual de infección (aumento de la induración en la prueba de tuberculina de 6 mm o más al año) fue 17% (IC 95%: 11.8-22.2), y estuvo asociado con mayor carga bacilar en el adulto con tuberculosis pulmonar (Riesgo Relativo-RR= 2.12, IC 95%: 1.0-4.3). La tasa de incidencia de tuberculosis activa fue de 12.4 casos por 1,000 años-persona de seguimiento. Los niños menores de 5 años sin cicatriz de vacuna BCG tuvieron un mayor riesgo de desarrollar tuberculosis activa (Razón de Peligro -HR= 6.00, IC 95%: 1.3-28.3), que quienes tenían cicatriz (HR= 1.33, IC 95%: 0.5-3.4). El riesgo de desarrollar tuberculosis activa aumentó conforme el aumento de la prueba de tuberculina inicial (prueba de tuberculina 5-9 mm HR= 8.55, IC 95%: 2.5-29.2; prueba de tuberculina ≥10 mm HR= 8.16, IC 95%: 2.0-32.9). Conclusión: Es necesario interrumpir rápidamente la transmisión de tuberculosis de adultos a niños en los hogares. Realizar investigaciones de contacto apropiadas y ofrecer quimioprofilaxis a los niños infectados podría reducir la transmisión de la tuberculosis.

Reguladores de la expresión de genes de Mycobacterium tuberculosis: implicaciones en la virulencia y persistencia en la tuberculosis latente / Regulators of Mycobacterium tuberculosis gene expression: implications in virulence and persistence in latent tuberculosis

La tuberculosis pulmonar (TB) es un problema de salud pública a nivel mundial. La Organización Mundial de la Salud estimó para el año 2017 alrededor de 10 millones de personas enfermas y 1,3 millones de muertes. La facultad que posee MTB para modular la respuesta inmune, sobrevivir y persistir bajo el ambiente hostil en el hospedero y en la TB latente ha sido ampliamente investigada, y requiere de regulación y control de la expresión genética. El objetivo es presentar una revisión de las investigaciones relacionadas con los reguladores de la expresión de genes de MTB que están asociados con la virulencia, persistencia y supervivencia en la TB latente. Se hizo una revisión de las investigaciones de los últimos 20 años. Se concluye que MTB posee una maquinaria genética que controla la expresión de genes que participan en virulencia y persistencia, en respuesta a la hipoxia, estrés oxidativo, falta de nutrientes y pH ácido. Entre ellos, participan los sistemas de dos componentes, factores sigma y reguladores transcripcionales. En algunos casos se ha comprobado que funcionan interconectados como una red. Los hallazgos de las investigaciones aportan conocimientos para el descubrimiento de nuevos blancos para el desarrollo de drogas antituberculosas, nuevas vacunas y métodos de diagnóstico de la TB, con el propósito de proveer nuevas estrategias para el control de la enfermedad(AU)

Pulmonary tuberculosis (TB) is a public health problem worldwide. The World Health Organization estimated about 10 million sick people and 1.3 million deaths in 2017. The ability of MTB to modulate the immune response, survive and persist under the hostile environment in the host and in latent TB has been extensively investigated, and requires regulation and control of genetic expression. The objective is to present a review of research related to regulators of MTB gene expression that are associated with virulence, persistence and survival in latent TB. A review of the investigations of the last 20 years was made. Finally, it is concluded that MTB has a genetic machinery that controls the expression of genes that participate in virulence and persistence in response to hypoxia, oxidative stress, lack of nutrients and acidic pH. Among them, two-component systems, sigma factors and transcriptional regulators participate. It has been proven that they work interconnected as a network in some cases. The research findings provide insights for the discovery of new targets for the development of anti-tuberculosis drugs, new vaccines and methods for diagnosis of TB, with the purpose of providing new strategies for disease control(AU)

Programa de intervención comunitaria dirigido a pacientes con riesgo de tuberculosis pulmonar / Project of community intervention directed to patients with risk of Lung Tuberculosis

Introducción: En la actualidad la tuberculosis pulmonar continúa siendo uno de los procesos infecciosos más observados en el mundo. Objetivo: Diseñar un programa de intervención comunitaria dirigido a pacientes con riesgo de tuberculosis pulmonar. Métodos: Se realizó un estudio de tipo descriptivo transversal en el consultorio 9 del Policlínico Docente Mario Antonio Pérez Mollinedo durante el periodo de noviembre de 2015 a marzo de 2017. Se seleccionó una muestra de 56 pacientes de una población de 125 dispensarizados con riesgo de tuberculosis. La estrategia de selección se basó en el muestreo no probabilístico intencional por criterios. Se aplicaron diferentes métodos y técnicas, como el análisis documental y cuestionarios. Para el procesamiento de la información se empleó la estadística descriptiva. Resultados: Los factores de riesgo a los que se encontraban expuestos los pacientes eran: el hábito de fumar (57,1 por ciento); el consumo de bebidas alcohólicas (46,4 por ciento); residir en condiciones de hacinamiento (44,6 por ciento); viviendas con malas condiciones (33,9 por ciento); estar expuestos a más de 2 factores de riesgo (58,9 por ciento); padecer de diabetes mellitus (14,2 por ciento), asma bronquial y enfermedad pulmonar obstructiva crónica (21,4 por ciento); y bajo nivel de conocimiento sobre la tuberculosis pulmonar (83,9 por ciento). Conclusiones: El programa de intervención comunitaria dirigido a pacientes con riesgo de tuberculosis pulmonar, según la evaluación de los especialistas, es pertinente y factible. En la actualidad se encuentra en fase de aplicación en el área de salud donde se realizó la investigación(AU)

Introduction: Nowadays, lung tuberculosis is still one of the most important infectious processes in the world. Objective: To design a project of community intervention directed to patients with risk of lung tuberculosis. Methods: It was carried out a descriptive cross-sectional's type study in the Family Doctor's Office #9 belonging to Mario Antonio Pérez Mollinedo Teaching Policlinic from November, 2015 to March, 2017. It was selected a sample of 56 patients from a population of 125 patients classified as with risk of Tuberculosis. The selection's strategy was based in an intentional non-probabilistic sampling by criteria. Different methods and techniques were applied as documentary analysis and questionnaires. Descriptive statistic and the analysis of qualitative data were used for processing information. Results: The risk factors that these patients were exposed were: smoking habit (57.1 percent); consumption of alcoholic beverages (46.4 percent); to live in overcrowding conditions (44.6 percent); housings with bad conditions (33.9 percent); to be exposed to more than 2 risk factors (58.9 percent); suffering Diabetes Mellitus (14.2 percent); bronchial asthma and COPD (21.4 percent); and low level of knowledge on lung tuberculosis (83.9%). Conclusions: The project of community intervention directed to patients with risk of Lung Tuberculosis, according to the specialists' assessment, it is pertinent and feasible. At the moment is in the application phase in the health area where it was carried out the investigation as part of a thesis of specialty(AU)

Fatores associados com o tabagismo em pacientes com tuberculose pulmonar / Factors associated with smoking in patients with pulmonary tuberculosis

Objetivo: identificar fatores associados ao tabagismo em pacientes com tuberculose (TB) pulmonar. Métodos: estudo transversal utilizando entrevista domiciliar com pacientes em tratamento para tuberculose pulmonar na Atenção Primária à Saúde em Campinas (SP), no período de 2013­2014. Foram incluídos pacientes não institucionalizados com 18 anos ou mais. As características de fumantes, ex-fumantes e não fumantes foram comparadas mediante Qui-quadrado de Pearson. Para comparar fumantes com não fumantes as variáveis com p < 0,20 foram incluídas em regressão logística múltipla. Resultados: dos 195 entrevistados 37,9% eram não fumantes; 24,6% ex-fumantes; e 37,4% fumantes. Em fumantes, observaram-se maiores frequências de pais e cônjuges fumantes em relação aos ex-fumantes. O perfil dos fumantes caracterizou-se por: escolaridade baixa, apresentar falta de ar e uso abusivo de bebidas alcoólicas. Não tentar parar de fumar nos últimos 12 meses associou-se a familiar/amigo que oferece cigarro. Conclusão: destacou-se a necessidade de incluir a família no tratamento do tabagismo e o uso abusivo de álcool em pacientes com TB pulmonar.

Objective: to identify factors associated with smoking in patients with pulmonary tuberculosis. Methods: Cross-sectional study using a home interview with patients undergoing treatment for pulmonary tuberculosis in Primary Health Care in Campinas/SP, Brazil, 2013-2014. Non-institutionalized patients 18 years of age or older were included. The characteristics of smokers, former smokers and nonsmokers were compared using Pearson's chi square. To compare smokers with nonsmokers variables with p <0.20 were included in multiple logistic regression. Results: Of the 195 interviewees, 37.9% were non-smokers, 24.6% were ex-smokers and 37.4% were smokers. In smokers, higher frequencies of smokers among parents and spouses were observed in comparison to ex-smokers. The profile of smokers was characterized by: low schooling, shortness of breath and abusive use of alcoholic beverages. Not trying to quit smoking in the last 12 months was associated with family / friend who offer cigarette. Conclusion: It was highlighted the need to include the family in the treatment of smoking and in the abuse of alcohol in patients with pulmonary TB.

Records in tuberculosis detection: perception of health professionals / Registros en la detección de la tuberculosis: percepción de los profesionales de salud / Registros na detecção da tuberculose: percepção dos profissionais de saúde

Abstract Objective: to know the perception of health professionals about the records produced in the detection of symptomatic respiratory symptoms of tuberculosis. Method: a qualitative study carried out in the municipalities of Sapucaia do Sul and Pelotas (Rio Grande do Sul state). Data were collected between January 2013 and March 2014 with 37 health workers through a semi-structured interview and analyzed in light of the Bardin Content Analysis. Results: three categories emerged, one of which pointed out the potentialities of tuberculosis detection records for case follow-up and two verified the obstacles related to inadequate, excessive duplication of information, requiring physical space for storage and loss of data. records. Conclusion and implications for the practice: the professionals recognize the importance of registries in the detection of tuberculosis, but point out obstacles that make it impossible to apply them in daily life. This information can help municipal managers to reassess the instrument by making advances in the operability of registries in the detection of tuberculosis.

Resumen Objetivo: conocer la percepción de los profesionales de salud acerca de los registros producidos en la detección de los sintomáticos respiratorios de tuberculosis. Método: estudio de abordaje cualitativo realizado en los municipios de Sapucaia do Sul y Pelotas (estado de Rio Grande do Sul). Los datos fueron recolectados entre enero de 2013 y marzo de 2014 con 37 trabajadores de salud, a través de una entrevista semiestructurada y estos se analizaron a la luz del Análisis de Contenido de Bardin. Resultados: emergieron tres categorías, una señalando las potencialidades de los registros de la detección de la tuberculosis para el seguimiento de los casos y dos comprobaron los obstáculos que se relacionaron con el llenado inadecuado, excesivo, con informaciones duplicadas, exigiendo espacio físico para el almacenamiento y extravío de registros. Conclusión e implicaciones para la práctica: los profesionales reconocen la importancia de los registros en la detección de la tuberculosis, pero apuntan obstáculos que imposibilitan la aplicabilidad en el cotidiano. Estas informaciones pueden auxiliar a los gestores municipales para reevaluar los instrumentos, produciendo avances en cuanto a la operacionalidad de los registros en la detección de la tuberculosis.

Resumo Objetivo: Conhecer a percepção dos profissionais de saúde acerca dos registros produzidos na detecção dos sintomáticos respiratórios de tuberculose. Método: Estudo de abordagem qualitativa realizado nos municípios de Sapucaia do Sul e Pelotas (estado do Rio Grande do Sul). Os dados foram coletados entre janeiro de 2013 e março de 2014 com 37 trabalhadores de saúde, através de entrevista semiestruturada e analisada à luz da Análise de Conteúdo de Bardin. Resultados: Emergiram três categorias, uma apontando as potencialidades dos registros da detecção da tuberculose para o acompanhamento dos casos e duas verificaram os entraves que se relacionaram com o preenchimento inadequado, excessivo, com duplicação de informações, exigindo espaço físico para armazenamento e extravio dos registros. Conclusão e implicações para a prática: Os profissionais reconhecem a importância dos registros na detecção da tuberculose, porém apontam entraves que impossibilitam a aplicabilidade no cotidiano. Estas informações podem auxiliar os gestores municipais para reavaliarem os instrumentos produzindo avanços quanto a operacionalidade dos registros na detecção da tuberculose.

Avaliação do tratamento diretamente observado e do sistema de informação do programa de controle da tuberculose em unidades de saúde da família no município do Rio de Janeiro / Evaluation of directly observed therapy and the information system of the tuberculosis control program in family health units in the municipality of Rio de Janeiro

O estudo teve como objetivo avaliar a implementação do Tratamento Diretamente Observado e do Sistema de Informação da Tuberculose em dez unidades de Atenção Primária à Saúde da Área de Planejamento 2.1 do município do Rio de Janeiro.Trata-se de pesquisa avaliativa do tipo análise de implementação, descritiva, de abordagem mista, que adotou como eixo metodológico o estudo de casos múltiplos com duas unidades de análise. Os dados foram coletados no período de junho 2018 a fevereiro de 2019 por meio de entrevista semi-estruturada aplicada aos profissionais de saúde, além da observação direta de campo e do levantamento de registros de dados secundários. Participaram do estudo 135 profissionais de saúde, sendo 26 enfermeiros, 25 médicos e 84 agentes comunitários de saúde. O acesso a esses profissionais se deu por meio da entrevista semi-estrutura e da observação direta das consultas médicas e de enfermagem. Foram coletados dados de 260 prontuários, notificações de tuberculose no SINAN e registros no Livro de Acompanhamento e Registro dos casos (Livro Verde). Os dados qualitativos foram analisados com base na proposta de Laurence Bardin, sendo construídas três categorias: Percepção dos profissionais sobre o Tratamento Diretamente Observado; o TDO no processo de trabalho das equipes de saúde e a Influência do contexto externo nas ações de controle da tuberculose. Para a análise dos dados quantitativos realizou-se estatística descritiva com cálculo de frequência simples e percentuais, para a classificação da implementação na Matriz de Análise e Julgamento. Os resultados das entrevistas mostraram que os profissionais compreendem a importância do TDO e o oferecem TDO como primeira opção de tratamento, porém não conseguem efetivar esta prática em suas rotinas assistenciais. O cotidiano onde as unidades de saúde estão inseridas exige dos profissionais abordagens alternativas para a efetivação desta prática. Com relação ao grau de implementação, os resultados mostraram que o TDO e o SI apresentam-se parcialmente implementados na AP 2.1. Fragilidades como baixo número de solicitação de exames diagnósticos, realização de teste rápido para HIV, ausência de consultas mensais de acompanhamento, baixa completude e atualização dos dados nas notificações de tuberculose e divergências nas informações no SINAN e no Livro Verde, permanecem como desafios para avançar na ampliação da vigilância e no controle dos casos de tuberculose.Recomenda-se o investimento em capacitações sistematizadas para os profissionais com vistas a otimizar as ações preconizadas pelo Ministério da Saúde e o Programa Municipal de Controle da Tuberculose, de modo a garantir habilidades e competência técnica para o manejo oportuno e adequado da TB bem como dos registros nos sistemas de informação que permitam verificar a qualidade das atividades desenvolvidas.

The objective of the study was to evaluate the implementation of the Directly Observed Treatment and the Tuberculosis Information System in ten Primary Health Care units of Planning Area 2.1 in the city of Rio de Janeiro. This is a descriptive, mixed approach, implementation analysis-type evaluation study that adopted as its methodological axis the study of multiple cases with two analysis units. Data were collected from June 2018 to February 2019 through a semi-structured interview applied to health professionals, in addition to direct field observation and the survey of secondary data records. The study involved 135 health professionals, 26 of whom were nurses, 25 physicians and 84 community health agents. Access to these professionals was through semi-structured interview and direct observation of medical and nursing consultations. Data were collected from 260 medical records, tuberculosis notifications in the SINAN, and records in the Follow-up and Case Registry Book (Green Book). The qualitative data were analyzed based on Laurence Bardin's proposal, and three categories were constructed: Perception of professionals on Directly Observed Treatment; ODT in the work process of health teams, and the Influence of the external context on tuberculosis control actions. For the quantitative data analysis, descriptive statistics with simple frequency calculation and percentiles were performed, for the classification of the implementation in the Analysis and Judgment Matrix. The results of the interviews showed that professionals understand the importance of OCD and offer it as the first option for treatment, but are not able to carry out this practice in their care routines. The daily routine in which health units are inserted requires alternative approaches from professionals to carry out this practice. Regarding the degree of implementation, the results showed that OCD and IS are partially implemented in PA 2.1. Weaknesses such as low diagnostic test requests, rapid HIV testing, absence of monthly follow-up visits, low completeness and updating of data on tuberculosis notifications, and differences in information in SINAN and the Green Paper remain challenges to advancing surveillance and control of tuberculosis cases. It is recommended that investment be made in systematic training for professionals to optimize the actions recommended by the Ministry of Health and the Municipal Tuberculosis Control Program in order to ensure skills and technical competence in the timely and appropriate management of TB, as well as records in information systems that allow verification of the quality of the activities developed.

Detecção da tuberculose: a estrutura da atenção primária à saúde / Detección de la tuberculosis: la estructura de la atención primaria de salud / Detection of tuberculosis: the structure of primary health care

Resumo OBJETIVO Analisar a estrutura da atenção primária à saúde para a detecção de casos de tuberculose em dois municípios do Rio Grande do Sul. MÉTODO Descritivo, avaliativo utilizando métodos mistos, com observação da estrutura física em 69 unidades de atenção primária à saúde; e entrevistas semi-estruturadas com 10 indivíduos. Realizado entre os anos de 2014 e 2016. Utilizou-se análise estatística descritiva e análise de conteúdo. RESULTADOS Nas 50 unidades de Pelotas observou-se ausência de: potes (24%); formulários (53,1%), livro de registro (48%) e transporte do material até o laboratório (86%). Nas 19 unidades de Sapucaia do Sul havia disponibilidade destes insumos. A ausência de profissionais, a rotatividade dos recursos humanos e a deficiência de capacitações foram as principais deficiências estruturais. CONCLUSÃO Conclui-se que há diferenças estruturais entre os municípios, e sugere-se à adoção da coordenação da atenção à tuberculose em Pelotas.

Resumen OBJETIVO Analizar la estructura de la atención primaria de salud para detección de casos de tuberculosis en dos municipios del Rio Grande do Sul. MÉTODO Descriptivo, evaluativo con uso métodos mixtos, aplicando la observación acerca de la estructura física de 69 unidades de atención primaria de salud; y entrevistas semiestructuradas con 10 individuos. Realizado entre 2014 y 2016. Análisis estadístico descriptivo y análisis de contenido. RESULTADOS En las 50 unidades de Pelotas no había: pote de esputo (24%); formularios de solicitud (53,1%); libro de registro (48%) y transporte de esputo al laboratorio (86%). En Sapucaia do Sul las 19 unidades tenían disponibilidad de estos materiales. La falta de profesionales, el cambio de los profesionales y la deficiencia de formación continua fueron las principales deficiencias estructurales. CONCLUSIÓN Existen diferencias estructurales entre los municipios, y se sugiere la adopción de la coordinación de la atención para la tuberculosis en Pelotas.

Abstract OBJECTIVE To analyze the structure of primary health care for the detection of tuberculosis cases in two municipalities of Rio Grande do Sul. METHOD Descriptive, evaluative mixed methods research, with direct observation of the physical structure of 69 primary health care units; and semi-structured interviews with 10 subjects. Conducted between 2014 and 2016. Using descriptive statistics and content analysis for data analysis. RESULTS In the 50 units in Pelotas there was an absence of: pots (24%); forms (53.1%), register books (48%) and of transportation of material to the laboratory (86%). In the 19 units of Sapucaia do Sul, these inputs were available. The absence of professionals, the turnover of human resources and the lack of training, emerged as the main structural deficiencies. CONCLUSION There are structural differences between municipalities. The study suggests that Pelotas should adopt tuberculosis care coordination.

Evaluation of the impact that the changes in tuberculosis treatment implemented in Brazil in 2009 have had on disease control in the country / Avaliação do impacto das mudanças do tratamento da tuberculose implantadas em 2009 no controle da tuberculose pulmonar no Brasil

ABSTRACT Objective: To analyze the impact that the 2009 changes in tuberculosis treatment in Brazil had on the rates of cure, tuberculosis recurrence, mortality, treatment abandonment, and multidrug-resistant tuberculosis (MDR-TB). Methods: An ordinary least squares regression model was used in order to perform an interrupted time series analysis of secondary data collected from the Brazilian Tuberculosis Case Registry Database for the period between January of 2003 and December of 2014. Results: The 2009 changes in tuberculosis treatment in Brazil were found to have no association with reductions in the total number of cases (β = 2.17; 95% CI: −3.80 to 8.14; p = 0.47) and in the number of new cases (β = −0.97; 95% CI: −5.89 to 3.94; p = 0.70), as well as having no association with treatment abandonment rates (β = 0.40; 95% CI: −1.12 to 1.93; p = 0.60). The changes in tuberculosis treatment also showed a trend toward an association with decreased cure rates (β = −4.14; 95% CI: −8.63 to 0.34; p = 0.07), as well as an association with increased mortality from pulmonary tuberculosis (β = 0.77; 95% CI: 0.16 to 1.38; p = 0.01). Although there was a significant increase in MDR-TB before and after the changes (p < 0.0001), there was no association between the intervention (i.e., the changes in tuberculosis treatment) and the increase in MDR-TB cases. Conclusions: The changes in tuberculosis treatment were unable to contain the decrease in cure rates, the increase in treatment abandonment rates, and the increase in MDR-TB rates, being associated with increased mortality from pulmonary tuberculosis during the study period. Keywords: Tuberculosis, pulmonary/epidemiology; Tuberculosis, pulmonary/drug therapy; Tuberculosis, pulmonary/mortality; Interrupted time series analysis; Drug resistance, multiple; Drug compounding.

RESUMO Objetivo: Analisar o impacto das mudanças do tratamento da tuberculose implantadas no Brasil em 2009 no número de casos de cura, de recidiva, de óbitos, de abandono e de tuberculose multirresistente (TBMR). Métodos: Foi realizada uma análise de séries temporais interrompida utilizando o modelo de regressão pelo método dos mínimos quadrados ordinários a partir de dados secundários coletados do Sistema de Informação de Agravos de Notificação da Tuberculose entre janeiro de 2003 e dezembro de 2014. Resultados: A análise mostrou independência entre as mudanças do tratamento e a redução do número total de casos (β = 2,17; IC95%: −3,80 a 8,14; 189 p = 0,47), a redução do número de novos casos (β = −0,97; IC95%: −5,89 a 3,94; p =190 0,70) e do abandono do tratamento (β = 0,40; IC95%: 199 −1,12 a 1,93; p = 0,60). Demonstrou ainda tendência à associação com a diminuição da cura (β = −4,14; IC95%: −8,63 a 0,34; p = 0,07) e associação com aumento da mortalidade por tuberculose pulmonar (β = 0,77; IC95%: 0,16 a 1,38; p = 0,01). A TBMR aumentou significativamente tanto no período anterior quanto no período posterior às mudanças do tratamento (p < 0,0001), embora de forma independente da intervenção (β = 0,13; IC95%: −0,03 a 0,29; p = 0,12). Conclusões: As mudanças no tratamento não impediram nem a diminuição na taxa de cura e nem o aumento do abandono e da TBMR; por outro lado, se associaram ao aumento de óbitos por tuberculose pulmonar durante o período do estudo.

Protective effect of metformin against tuberculosis infections in diabetic patients: an observational study of south Indian tertiary healthcare facility

ABSTRACT Background: World Health Organization estimated that people with diabetes (DM) are at 2-3 times higher risk for tuberculosis (TB). Studies have shown that DM not only increases the risk of active TB, but also puts co-affected persons at increased risk of poor outcomes. Objectives: To determine the protective effect of metformin against TB in DM patients and also, to investigate the relationship between poor glycemic control and TB. Methods: A case-control study was conducted over 8 months, where cases and controls were selected based on the inclusion and exclusion criteria of the study. The diabetics diagnosed with TB were selected as study group (SG = 152) and without TB were as control group (CG = 299). Exposure status of metformin in both groups were analyzed. Results: The mean (SD) age of both CG and SG were 55.54 ± 11.82 and 52.80 ± 11.75, respectively. Majority of the subjects in the study were males. The mean hospital stay of SG and CG were 7 days and 6 days, respectively. Poor glycemic control (HbA1c > 8) observed in SG (51.7%) vs CG (31.4%). HbA1c value <7 is associated protective factor for TB occurrence [OR = 0.52 (95% CI 0.29-0.93)]. The protective effect of metformin against TB was 3.9-fold in diabetics (OR = 0.256, 0.16-0.40). Conclusion: Poor glycemic control among diabetics is a risk factor for TB occurrence. The result shows metformin use is a protective agent against TB infection in diabetics. Hence, incorporation of metformin into standard clinical care would offer a therapeutic option for the prevention of TB.

Prevalence of pulmonary tuberculosis among household contacts in Hyderabad, Sindh: active contact tracing in children with tuberculosis

Background: Tuberculosis [TB] in children is clearly linked to TB in adults therefore active household contact tracing is an important method of early diagnosis and treatment particularly in high-TB-burden countries

Objectives: To estimate the prevalence of TB among household contacts of children suffering from tuberculosis using active contact tracing and linking them to TB program for treatment

Subjects and Methods: A total of 125 children suffering from active tuberculosis [index cases] aged 12 years or less were randomly selected from the outpatient department of a tertiary care hospital of Hyderabad. Using their home address, all house hold members of the index cases [sharing one kitchen] were identified. The households were visited by a team including a doctor and the supported staff and were screened for TB using history, physical examination, sputum for AFB and X-ray of chest. Clinical suspects were divided in to two populations, equal to or less than 12 years of age and greater than this age. All suspected cases were brought to outpatient's department of the hospital where children were examined and diagnosed by pediatrician and adults were examined by the pulmonologist

Results: There were 125 children and 1365 household members. Prevalence of active TB in adult household contacts was 8.1% and among children was 5.7%. Mother, father, grand parents or siblings were the source of disease spread in children. Family history of TB was present in 95% [pulmonary 78%, extra-pulmonary 22%]

Conclusion: Tuberculosis in children is mostly spreading from household member hence deeply required to undertake active contact tracing in each new case that is diagnosed or being treated

Policy message: National and Provincial TB programs should advocate and undertake active screening of all household contacts of all TB cases

The mc2-CMX vaccine induces an enhanced immune response against Mycobacterium tuberculosis compared to Bacillus Calmette-Guérin but with similar lung inflammatory effects

Although the attenuated Mycobacterium bovis Bacillus Calmette-Guérin (BCG) vaccine has been used since 1921, tuberculosis (TB) control still proceeds at a slow pace. The main reason is the variable efficacy of BCG protection against TB among adults, which ranges from 0-80%. Subsequently, the mc2-CMX vaccine was developed with promising results. Nonetheless, this recombinant vaccine needs to be compared to the standard BCG vaccine. The objective of this study was to evaluate the immune response induced by mc2-CMX and compare it to the response generated by BCG. BALB/c mice were immunised with both vaccines and challenged withMycobacterium tuberculosis (Mtb). The immune and inflammatory responses were evaluated by ELISA, flow cytometry, and histopathology. Mice vaccinated with mc2-CMX and challenged with Mtb induced an increase in the IgG1 and IgG2 levels against CMX as well as recalled specific CD4+ T-cells that produced T-helper 1 cytokines in the lungs and spleen compared with BCG vaccinated and challenged mice. Both vaccines reduced the lung inflammatory pathology induced by the Mtb infection. The mc2-CMX vaccine induces a humoral and cellular response that is superior to BCG and is efficiently recalled after challenge with Mtb, although both vaccines induced similar inflammatory reductions.