Accuracy of Determine TB-LAM Ag to detect TB in HIV infected patients associated with diagnostic methods used in Brazilian public health units.

BACKGROUND: Determine TB-LAM Ag (LAM) is a point of care test developed to diagnose tuberculosis (TB). The aim of this study was to evaluate the diagnostic performance of LAM in people living with HIV using Brazilian public health network algorithm for TB diagnosis. METHODS AND FINDINGS: A cross-sectional study design was used to enroll 199 adult patients in two sites in Rio de Janeiro and two in São Paulo. The study enrolled HIV-infected patients with CD4 counts ≤200 cells/mm3 (in the Alere PIMA CD4 assay at study screening), patients coughing for at least 2 weeks or presenting a chest radiography suggestive of TB. LAM, in conjunction with sputum smear microscopy or Xpert MTB/RIF (Xpert) as compared to Mycobacterium tuberculosis culture, which was used as a reference standard. TB prevalence was 24.6%. Overall accuracy of LAM was 79.9% (73.8%-84.9%), positive and negative predictive values were 62.2% (46.1%-75.9%) and 84% (77.5%-88.8%), respectively. The overall LAM sensitivity was 46.9% (33.7%-60.6%) and specificity was 90.7% (84.9%-94.4%). The best performance of LAM was observed among patients with CD4 counts ≤50 cells/mm3 (sensitivity = 70.4% and specificity = 85.9%). When 2 respiratory smears were used in conjunction with LAM, sensitivity increased 22%, as compared to just 2 smears. Furthermore, LAM when used in conjunction with two respiratory smears, was as sensitive as compared to a single one. However, no improvement in TB diagnosis occurred when LAM was used with Xpert as compared to Xpert alone. Among 14 LAM false positive tests, Non-Tuberculosis Mycobacteria were isolated in three cases. CONCLUSION: LAM is a point of care test that increased TB diagnosis in immunosuppressed HIV-infected patients when used in conjunction with smear microscopy, but not when used with Xpert in Brazilian public health network sites. Use of LAM test should be considered in settings where immunosuppressed HIV patients need rapid TB diagnosis.

Accuracy of Determine TB-LAM Ag to detect TB in HIV infected patients associated with diagnostic methods used in Brazilian public health units

BACKGROUND: Determine TB-LAM Ag (LAM) is a point of care test developed to diagnose tuberculosis (TB). The aim of this study was to evaluate the diagnostic performance of LAM in people living with HIV using Brazilian public health network algorithm for TB diagnosis. METHODS AND FINDINGS: A cross-sectional study design was used to enroll 199 adult patients in two sites in Rio de Janeiro and two in São Paulo. The study enrolled HIV-infected patients with CD4 counts ≤200 cells/mm3 (in the Alere PIMA CD4 assay at study screening), patients coughing for at least 2 weeks or presenting a chest radiography suggestive of TB. LAM, in conjunction with sputum smear microscopy or Xpert MTB/RIF (Xpert) as compared to Mycobacterium tuberculosis culture, which was used as a reference standard. TB prevalence was 24.6%. Overall accuracy of LAM was 79.9% (73.8%-84.9%), positive and negative predictive values were 62.2% (46.1%-75.9%) and 84% (77.5%-88.8%), respectively. The overall LAM sensitivity was 46.9% (33.7%-60.6%) and specificity was 90.7% (84.9%-94.4%). The best performance of LAM was observed among patients with CD4 counts ≤50 cells/mm3 (sensitivity = 70.4% and specificity = 85.9%). When 2 respiratory smears were used in conjunction with LAM, sensitivity increased 22%, as compared to just 2 smears. Furthermore, LAM when used in conjunction with two respiratory smears, was as sensitive as compared to a single one. However, no improvement in TB diagnosis occurred when LAM was used with Xpert as compared to Xpert alone. Among 14 LAM false positive tests, Non-Tuberculosis Mycobacteria were isolated in three cases. CONCLUSION: LAM is a point of care test that increased TB diagnosis in immunosuppressed HIV-infected patients when used in conjunction with smear microscopy, but not when used with Xpert in Brazilian public health network sites. Use of LAM test should be considered in settings where immunosuppressed HIV patients need rapid TB diagnosis

Cutaneous tuberculosis and HIV infection at a referral centre in Rio de Janeiro, Brazil.

BACKGROUND: Cutaneous tuberculosis (CTB) is a rare extrapulmonary form of tuberculosis (TB). Despite the increase in the number of cases of TB and HIV, few cases of CTB have been reported. OBJECTIVE: To describe CTB cases among patients with HIV infection from a cohort with tuberculosis. METHODS: We describe a series of 15 CTB and HIV cases, based on secondary data from 2000 to 2016. Diagnosis was based on isolation of Mycobacterium tuberculosis in culture or clinical response to anti-tuberculous treatment associated with positive smear or histopathologic findings from affected skin or an adjacent lymph node. FINDINGS: Scrofuloderma was present in 12 (80%) patients and solitary gumma in three (20%) patients. One case of scrofuloderma was associated with papulonecrotic tuberculid. Seven (46.6%) patients had pulmonary TB. Diagnosis was based on culture in nine patients (60%). The median CD4 cell count was 262 cells/µL. All patients were cured at the end of treatment (median time 6 months). Three patients presented with immune reconstitution inflammatory syndrome. CONCLUSIONS: In this study, CTB associated with HIV infection presented as localised forms or in association with pulmonary TB. In patients with HIV who have subacute and chronic skin lesions, CTB should be considered in differential diagnosis, which may represent a good opportunity for early diagnosis of active TB.

Cutaneous tuberculosis and HIV infection at a referral centre in Rio de Janeiro, Brazil

BACKGROUND Cutaneous tuberculosis (CTB) is a rare extrapulmonary form of tuberculosis (TB). Despite the increase in the number of cases of TB and HIV, few cases of CTB have been reported. OBJECTIVE To describe CTB cases among patients with HIV infection from a cohort with tuberculosis. METHODS We describe a series of 15 CTB and HIV cases, based on secondary data from 2000 to 2016. Diagnosis was based on isolation of Mycobacterium tuberculosis in culture or clinical response to anti-tuberculous treatment associated with positive smear or histopathologic findings from affected skin or an adjacent lymph node. FINDINGS Scrofuloderma was present in 12 (80%) patients and solitary gumma in three (20%) patients. One case of scrofuloderma was associated with papulonecrotic tuberculid. Seven (46.6%) patients had pulmonary TB. Diagnosis was based on culture in nine patients (60%). The median CD4 cell count was 262 cells/µL. All patients were cured at the end of treatment (median time 6 months). Three patients presented with immune reconstitution inflammatory syndrome. CONCLUSIONS In this study, CTB associated with HIV infection presented as localised forms or in association with pulmonary TB. In patients with HIV who have subacute and chronic skin lesions, CTB should be considered in differential diagnosis, which may represent a good opportunity for early diagnosis of active TB.

III Brazilian Thoracic Association Guidelines on tuberculosis.

New scientific articles about tuberculosis (TB) are published daily worldwide. However, it is difficult for health care workers, overloaded with work, to stay abreast of the latest research findings and to discern which information can and should be used in their daily practice on assisting TB patients. The purpose of the III Brazilian Thoracic Association (BTA) Guidelines on TB is to critically review the most recent national and international scientific information on TB, presenting an updated text with the most current and useful tools against TB to health care workers in our country. The III BTA Guidelines on TB have been developed by the BTA Committee on TB and the TB Work Group, based on the text of the II BTA Guidelines on TB (2004). We reviewed the following databases: LILACS (SciELO) and PubMed (Medline). The level of evidence of the cited articles was determined, and 24 recommendations on TB have been evaluated, discussed by all of the members of the BTA Committee on TB and of the TB Work Group, and highlighted. The first version of the present Guidelines was posted on the BTA website and was available for public consultation for three weeks. Comments and critiques were evaluated. The level of scientific evidence of each reference was evaluated before its acceptance for use in the final text.

III Diretrizes para Tuberculose da Sociedade Brasileira de Pneumologia e Tisiologia / III Brazilian Thoracic Association Guidelines on Tuberculosis

Diariamente novos artigos científicos sobre tuberculose (TB) são publicados em todo mundo. No entanto, é difícil para o profissional sobrecarregado na rotina de trabalho acompanhar a literatura e discernir o que pode e deve ser aplicado na prática diária juntos aos pacientes com TB. A proposta das "III Diretrizes para TB da Sociedade Brasileira de Pneumologia e Tisiologia (SBPT)" é revisar de forma crítica o que existe de mais recente na literatura científica nacional e internacional sobre TB e apresentar aos profissionais da área de saúde as ferramentas mais atuais e úteis para o enfrentamento da TB no nosso país. As atuais "III Diretrizes para TB da SBPT" foram desenvolvidas pela Comissão de TB da SBPT e pelo Grupo de Trabalho para TB a partir do texto das "II Diretrizes para TB da SBPT" (2004). As bases de dados consultadas foram LILACS (SciELO) e PubMed (Medline). Os artigos citados foram avaliados para determinação do ...

New scientific articles about tuberculosis (TB) are published daily worldwide. However, it is difficult for health care workers, overloaded with work, to stay abreast of the latest research findings and to discern which information can and should be used in their daily practice on assisting TB patients. The purpose of the III Brazilian Thoracic Association (BTA) Guidelines on TB is to critically review the most recent national and international scientific information on TB, presenting an updated text with the most current and useful tools against TB to health care workers in our country. The III BTA Guidelines on TB have been developed by the BTA Committee on TB and the TB Work Group, based on the text of the II BTA Guidelines on TB (2004). We reviewed the following databases: LILACS (SciELO) and PubMed (Medline). The level of evidence of the cited articles was determined, and 24 recommendations ...

Peculiarities of tuberculosis control in a scenario of urban violence in a disadvantaged community in Rio de Janeiro, Brazil.

OBJECTIVE: To describe the difficulties and peculiarities encountered by health professionals during the treatment and investigation of contacts of tuberculosis (TB) patients in disadvantaged communities. METHODS: A qualitative study carried out at health care facilities in Health Programming Area 1.0, located in the city of Rio de Janeiro, Brazil, which has a TB incidence rate of 240/100,000 inhabitants. From among the professionals responsible for visiting and treating TB cases and their contacts, two home visit agents and one clinical nurse were selected to be interviewed for the study. Data were transcribed and structured in the form of quotations, emphasizing the predominant ideas. RESULTS: The central ideas focus on the issue of violence, one significant facet of which is the set of rules imposed by narcotraffickers, and on the barriers to the movement of patients/health professionals for TB treatment, as well as on public safety (police). CONCLUSION: This study provides public health officials, as well as institutions that graduate health professionals, data for reflection and analysis of the difficulties that urban violence creates for the control of TB in a disadvantaged community.

Peculiaridades do controle da tuberculose em um cenário de violência urbana de uma comunidade carente do Rio de Janeiro / Peculiarities of tuberculosis control in a scenario of urban violence in a disadvantaged community in Rio de Janeiro, Brazil

OBJETIVO: Descrever as dificuldades e peculiaridades encontradas por profissionais de saúde durante o tratamento e a investigação de contatos de pacientes com tuberculose (TB) em comunidades carentes. MÉTODOS: Estudo de abordagem qualitativa realizado nas unidades de saúde localizadas na Area Programática 1.0, no município do Rio de Janeiro, Brasil, com taxa de incidência de TB de 240/100.000 habitantes. Foram selecionados para o estudo dois visitadores domiciliares e um auxiliar de enfermagem, responsáveis pela visita e atendimento dos casos de TB e contatos. Os dados foram transcritos e estruturados sob forma de citação, com destaque para as idéias mais predominantes. RESULTADOS: As idéias centrais têm como eixo a dimensão da violência que se expressa através das regras do tráfico de drogas, das barreiras ao deslocamento dos pacientes e profissionais de saúde para o tratamento da TB, e da segurança pública (policiais). CONCLUSÃO: Este estudo fornece dados para reflexão e análise aos formuladores de políticas de saúde e aos órgãos formadores de profissionais de saúde sobre a dificuldade que a violência urbana impõe ao controle da TB em uma comunidade carente.

OBJECTIVE: To describe the difficulties and peculiarities encountered by health professionals during the treatment and investigation of contacts of tuberculosis (TB) patients in disadvantaged communities. METHODS: A qualitative study carried out at health care facilities in Health Programming Area 1.0, located in the city of Rio de Janeiro, Brazil, which has a TB incidence rate of 240/100,000 inhabitants. From among the professionals responsible for visiting and treating TB cases and their contacts, two home visit agents and one clinical nurse were selected to be interviewed for the study. Data were transcribed and structured in the form of quotations, emphasizing the predominant ideas. RESULTS: The central ideas focus on the issue of violence, one significant facet of which is the set of rules imposed by narcotraffickers, and on the barriers to the movement of patients/health professionals for TB treatment, as well as on public safety (police). CONCLUSION: This study provides public health officials, as well as institutions that graduate health professionals, data for reflection and analysis of the difficulties that urban violence creates for the control of TB in a disadvantaged community.

Tuberculose como doença definidora de síndrome da imunodeficiência adquirida: dez anos de evolução na Cidade do Rio de Janeiro / Tuberculosis as a disease defining acquired immunodeficiency syndrome: ten years of surveillance in Rio de Janeiro, Brazil

OBJETIVO: Analisar a freqüência da tuberculose e das outras principais doenças oportunistas definidoras de síndrome da imunodeficiência adquirida, no momento em que estes casos são notificados, no Município do Rio de Janeiro. MÉTODOS: Análise do banco de dados do Sistema de Vigilância Epidemiológica do Programa de Doenças Sexualmente Transmissíveis e Síndrome da Imunodeficiência Adquirida da Cidade do Rio de Janeiro, no período de 1993 a 2002. RESULTADOS: A expansão da definição de casos de síndrome da imunodeficiência adquirida ocorrida em 1998 criou um aumento substancial no número de casos notificados de síndrome da imunodeficiência adquirida, principalmente por aqueles que passaram a ser definidos pelo critério imunológico. Dentre os casos de síndrome da imunodeficiência adquirida que foram definidos apenas por doença, a candidíase em suas diversas formas manteve-se como a doença oportunista de maior freqüência no momento da notificação. Embora a pneumonia por Pneumocystis carinii se apresentasse como a segunda doença mais freqüente na maioria dos anos observados, a partir de 2001, a tuberculose ultrapassou-a em freqüência, tornando-se a segunda doença mais freqüente no momento da notificação dos casos de síndrome da imunodeficiência adquirida. CONCLUSÃO: Apesar da diminuição do número de casos de síndrome da imunodeficiência adquirida definidos por doença, a tuberculose manteve-se como um importante evento definidor dessa síndrome, sendo atualmente de ocorrência mais freqüente do que a pneumonia por Pneumocystis carinii e a toxoplasmose, provavelmente por sua alta taxa de prevalência na cidade.

OBJECTIVE: To analyze the frequency of tuberculosis and of the other principal opportunistic infections defining acquired immunodeficiency syndrome at the time such cases were reported in the city of Rio de Janeiro, Brazil. METHODS: Analysis of the data compiled in the Rio de Janeiro Municipal Program for the Surveillance of Sexually Transmitted Diseases and Acquired Immunodeficiency Syndrome database from 1993 to 2002. RESULTS: The expanded definition of a case of acquired immunodeficiency syndrome, implemented in 1998, resulted in a substantial increase in the number of reported cases of acquired immunodeficiency syndrome, especially of those defined by immunologic criteria. Among the cases of acquired immunodeficiency syndrome defined only by disease, esophageal candidiasis, in its various forms, remained the most common opportunistic infection present at the time the cases of acquired immunodeficiency syndrome were reported. Although Pneumocystis carinii pneumonia was the second leading opportunistic infection in most of the years evaluated, it was surpassed by tuberculosis in 2001. CONCLUSION: Despite the decreased numbers of cases of acquired immunodeficiency syndrome defined by disease, tuberculosis remains a significant acquired immunodeficiency syndrome-defining event, currently more common than P. carinii pneumonia and toxoplasmosis. This is probably due to the high rate of tuberculosis prevalence in the city.

Tuberculosis as a disease defining acquired immunodeficiency syndrome: ten years of surveillance in Rio de Janeiro, Brazil.

OBJECTIVE: To analyze the frequency of tuberculosis and of the other principal opportunistic infections defining acquired immunodeficiency syndrome at the time such cases were reported in the city of Rio de Janeiro, Brazil. METHODS: Analysis of the data compiled in the Rio de Janeiro Municipal Program for the Surveillance of Sexually Transmitted Diseases and Acquired Immunodeficiency Syndrome database from 1993 to 2002. RESULTS: The expanded definition of a case of acquired immunodeficiency syndrome, implemented in 1998, resulted in a substantial increase in the number of reported cases of acquired immunodeficiency syndrome, especially of those defined by immunologic criteria. Among the cases of acquired immunodeficiency syndrome defined only by disease, esophageal candidiasis, in its various forms, remained the most common opportunistic infection present at the time the cases of acquired immunodeficiency syndrome were reported. Although Pneumocystis carinii pneumonia was the second leading opportunistic infection in most of the years evaluated, it was surpassed by tuberculosis in 2001. CONCLUSION: Despite the decreased numbers of cases of acquired immunodeficiency syndrome defined by disease, tuberculosis remains a significant acquired immunodeficiency syndrome-defining event, currently more common than P. carinii pneumonia and toxoplasmosis. This is probably due to the high rate of tuberculosis prevalence in the city.

A implantação da estratégia DOTS na cidade do Rio de Janeiro / Implementation of the DOTS strategy in the city of Rio de Janeiro

Introdução: o objetivo deste estudo foi descrever a implementação da estratégia DOTS (Estratégia de Tratamento Diretamente Observado de Curta duração) nos centros de saúde na cidade do Rio de Janeiro, apresentando os resultados obtidos após dois anos de desenvolvimento de projetos-piloto. Métodos: análise dos dados contidos nos "Livros de Registro e Controle do Tratamento", regularmente notificados à Secretaria Municipal de Saúde do Rio de Janeiro, visando avaliar o impacto do tratamento diretamente observado (DOT) nos índices de cura e o efeito da implementação da estratégia DOTS na qualidade do programa de controle da tuberculose (PCT). Resultados: De Janeiro de 1999 a Dezembro de 2001, 3657 casos de TB foram registrados nas áreas onde a estratégia DOTS foi implantada. Destes, 1730 receberam DOT e 1927 receberam tratamento auto-administrado (TAA). Entre os caos novos, 81% dos que receberam DOT e 71% dos que receberam TAA foram tratados com sucesso (OR 1,66, IC 95%: 1,3 -1,8), p<0,01. As taxas de negativação da baciloscopia do escarro após 2 e 3 meses de tratamento foram de 84% e 91% respectivamente para aqueles que receberam DOT e 75% e 83% para o grupo em TAA. Nos centros de saúde onde a estratégia DOTS foi implantada houve, em 3 anos, melhora geral dos índices de cura e de abandono, assim como dos percentuais de baciloscopias realizadas para acompanhamento do tratamento. Conclusão: Pacientes que receberam DOTS tiveram maior chance de cura do que aqueles que receberam TAA. A implantação da estratégia DOTS melhorou a qualidade do PCT.

Introduction: The objective of this study is to describe the implementation of DOTS (Directly Observed Treatment, Short course) strategy in health centers in the city of the Rio de Janeiro presenting the results 2 years after teh development of pilot projects. Methods: analysis of data recorded on the "TB treatment and outcome registration books", regularly reported to the City Health Secretariat, to evaluate the results of the directly observed therapy (DOT) on the treatment success rates and the effect of DOTS implementation on the equality of the TB control program. Results: From January 1999 to December 2001, 3,657 TB cases were registered in the areas where the DOTS strategy was implemented. Of these, 1,730 received directly observed treatment (DOT) and 1,927 received self-administered treatment (SAT). In the DOT group 81% of the new cases were treated successfully, whereas in the SAT 71% of the new cases were treated successfully (OR1,66, 95% CI:1,3 -1,8, p <0,01). The sputum smear conversion rates for the new cases after 2 and 3 months' treatment were respectively 84% and 91% for the group on DOT and 75% and 83% for those on SAT. In the health centers where the DOTS strategy was implemented there was a general improvement on the cure and default rates, and also on the proportion of patients monitored bacteriologically during treatment. Conclusion: patients receiving DOT were much more likely to complete treatment than those receiving SAT. The implementation of the DOTS strategy improved the quality of the TB control program.

Situação epidemiológica da tuberculose no munícipio do Rio de Janeiro: Revisão dos casos notificados de 1995 a 2000 / Epidemiology of tuberculosis in Rio de Janeiro city: Cases from 1995 to 2000

Introdução: a rede municipal de saúde do Rio de Janeiro vem sendo reorganizada e ampliada para fazer frente à demanda de controle da tuberculose que continua representando endemia importante entre nós. Os autores apresentam os dados epidemiológicos, demográficos e clínicos, assim como informações sobre as ações do Programa de Controle de Tuberculose do Município do Rio de Janeiro com a finalidade de descrever o perfil desta doença em nossa cidade. Material e métodos: estudo de prevalência sobre tuberculose no período compreendido entre 1995 e 2000. Resultados: a incidência de tuberculose em 2000 foi de 112/ 100.000 habitantes (o dobro da média nacional) e vem se mantendo neste patamar desde 1994. Os casos de retratamento representaram , em média, 20% do total de casos notificados no período de entre 1995 e 2000. Apesar de encontrar-se em ligeiro declínio desde 1997, a taxa média de abandono do tratamento continuou elevada em 1999 (15%). Conclusão: diante deste quadro epidemiológico, faz-se necessária a implantação e implementação de novas estratégias que contribuam para a melhoria do Programa de Tuberculose da Cidade.

HIV specific humoral immune response in Rio de Janeiro, Brazil

Efforts to characterize HIV-1 polymorphism and anti-HIV immune response are being made in areas where anti-HIV/AIDS vaccines are to be employed. Anti-HIV-1 humoral immune response is being studied in infected individuals resident in Rio de Janeiro, in distinct cohorts involving recent seroconvertors, pregnant women or intravenous drug users (IDU). Comparative analysis of specificity of antibody response towards epitopes important for anti-HIV-1 immune response indicate quantitative differences between cohorts, with an exceptionally strong response in IDUs and weakest response in pregnant women. However, a comparative analysis between pregnant women cohorts from Rio de Janeiro and Rio Grande do Sul indicated an even lower response (with exception of the anti-V3-C clade peptide recognition) for the southern cohort. Studied analysing the immune function of the humoral response indicate a quite elevated occurrence of antibodies capable of neutralizing heterologous primary HIV-1 isolates from Rio de Janeiro. Attempts to correlate seroreactivity with HIV-1 neutralization with respect to HIV-1 polymorphism were not very successfull: while the Brazilian B clade B" variant could be recognized by binding assays, no significant distinction of HIV-1 clades/variants was observed in viral neutralization assays.

Epidemiologia da Tuberculose no Município do Rio de Janeiro / - Revisão dos casos notificados de 1995 a 1997

Os autores apresentam dados epidemiológicos, demográficos e clínicos dos casos de tuberculose (TB) notificados à Gerência de Pneumologia Sanitária da Secretaria Municipal de Saúde do Rio de Janeiro (SMS - RJ) no período de 1995 à 1997. As informações obtidas a partir das notificações de casos e óbitos de tuberculose são descritas neste artigo com a finalidade de apresentar o perfil da doença no município do Rio de Janeiro. Tal conhecimento permitirá a identificação das necessidades e a definição de prioridades para o planejamento de ações de combate à TB