Factors associated with non-completion of TB preventive treatment in Brazil.

BACKGROUND: Among Brazilian initiatives to scale up TB preventive therapy (TPT) are the adoption of the 3HP regimen (12 weekly doses of rifapentine and isoniazid [INH]) in 2021 and the implementation in 2018 of the TPT surveillance information system. Since then, 63% of the 76,000 eligible individuals notified completed TPT. Recommended regimens in this period were 6H, 9H (6 or 9 months of INH) and 4R (4 months of rifampicin).OBJECTIVE: To analyse the factors associated with TPT non-completion.METHODS: We analysed the cohort of TPT notifications from 2018 to 2020. Robust variance Poisson regression model was used to verify the association of TPT non-completion with sociodemographic, clinical and epidemiological variables.RESULTS: Of the 39,973 TPT notified in the study period, 8,534 (21.5%) were non-completed, of which 7,858 (92.1%) were lost to follow-up. Age 15-60 years (relative risk [RR] 1.27, 95% confidence interval [95% CI] 1.20-1.35), TPT with isoniazid (RR 1.40, 95% CI 1.19-1.64) and Black/mixed race (RR 1.17, 95% CI 1.09-1.25) were associated with a higher risk of non-completion.CONCLUSION: Individuals in situations of social and financial vulnerability such as being Black/pardo race, younger and on longer TPT regimens were more likely to be associated with TPT incompletion.

Childhood tuberculosis and human immunodeficiency virus status in Brazil: a hierarchical analysis.

SETTING: Human immunodeficiency virus (HIV) infection may impact tuberculosis (TB) diagnosis, clinical presentation and treatment outcomes in children as the signs and symptoms of both diseases overlap. OBJECTIVE: To compare the sociodemographic and clinical profiles of childhood TB according to HIV status in Brazil. METHODS: This was a cross-sectional study of data on subjects aged <15 years retrieved from the Brazilian National Electronic Disease Registry (Sistema de Informação de Agravos de Notificação) database on TB to compare TB-HIV coinfected patients and patients with TB only registered between 2007 and 2011. A hierarchical logistic regression model was applied. RESULTS: Of 6091 cases analysed, 780 (12%) were TB-HIV patients, while 5311 (87%) presented with TB only. TB-HIV patients were more likely to be institutionalised (OR 2.22, 95%CI 1.43-3.46), to present with relapsed TB (OR 5.03, 95%CI 2.02-12.5) and be readmitted after treatment default (OR 16.7, 95%CI 4.34-64.46). They were also more likely to have unfavourable outcomes, including default (OR 2.85, 95%CI 1.81-4.49), death due to TB (OR 2.76, 95%CI 1.27-6.03) and death from other causes (OR 5.59, 95%CI 2.63-11.8). CONCLUSION: Our study highlights the challenges of using national registers for research into childhood TB.

Directly observed therapy of tuberculosis in Brazil: associated determinants and impact on treatment outcome.

SETTING: All Brazilian states. OBJECTIVES: To assess the determinants of tuberculosis (TB) in patients undergoing directly observed therapy (DOT) and the impact of DOT on treatment outcomes. DESIGN: This is a cross-sectional study among TB patients aged ⩾18 years conducted in 2011. The primary outcome was the status of DOT received, while the secondary was the outcome of anti-tuberculosis treatment. RESULTS: In 2011, 35 775 (38.3%) subjects received DOT. The odds of receiving DOT were higher in patients with the following characteristics: brown/mestizo patients (OR 1.18, 95%CI 1.14-1.22) and those of other ethnic groups (OR 2.01, 95%CI 1.79-2.27) compared to Whites, alcohol users (OR 1.37, 95%CI 1.28-1.47) and those with mental disorders (OR 1.88, 95%CI 1.54-2.29). The odds of receiving DOT were lower in human immunodeficiency virus positive patients (OR 0.64, 95%CI 0.60-0.68). Patients who did not receive DOT were more likely to default from anti-tuberculosis treatment (OR 0.62, 95%CI 0.57-0.66), die due to TB (OR 0.68, 95%CI 0.61-0.77) and to have unknown treatment outcomes (OR 0.71, 95%CI 0.66-0.76). The adjusted preventable fraction of DOT in the reduction of unfavorable outcomes was 25%. CONCLUSION: Sociodemographic and clinical characteristics are determinants of anti-tuberculosis treatment outcomes in patients undergoing DOT; DOT use led to a 25% reduction in unfavorable outcomes.

Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis.

SETTING: Tuberculosis (TB) is a major public health problem and an important cause of infectious disease-related death in young adults. TB rates are higher in vulnerable populations, including prisoners. OBJECTIVE: To describe the clinical and epidemiological characteristics associated with anti-tuberculosis treatment outcomes in the Brazilian prison population. DESIGN: The study population consisted of prisoners diagnosed with TB identified through the Sistema de Informação de Agravos de Notificação (Information System for Notifiable Diseases) between January 2007 and December 2011. Pearson's χ(2) test was used to compare the proportions and covariates associated with the outcome of interest. These variables were further analysed using the polytomous regression model. RESULTS: Compared to those who completed anti-tuberculosis treatment, prisoners who defaulted from treatment were younger (P < 0.001), less educated (P < 0.001) and more likely to be alcoholic (P < 0.001); they were more likely to have recurrent or relapse TB (P < 0.001) and they were not under directly observed treatment (P < 0.001). Those who died from TB tended to be older (P < 0.001) and alcoholic (P < 0.001); they were also more likely to have received treatment of unknown type (P < 0.001) and to have both pulmonary and extra-pulmonary TB (EPTB). Prisoners who developed multidrug-resistant TB were more likely to experience TB recurrence, return to treatment after default, change treatment centres and have EPTB. CONCLUSION: Our results highlight the need to improve TB control and policies in correctional facilities. Improving treatment outcomes of prisoners will also prevent transmission to other prisoners, their family members, and health professionals.

Smoking and 2-month culture conversion during anti-tuberculosis treatment.

OBJECTIVE: To investigate risk factors for delayed sputum culture conversion to negative during anti-tuberculosis treatment, with an emphasis on smoking. DESIGN: Nested case-control study of adults with non-cavitary, culture-confirmed pulmonary tuberculosis (TB) participating in an anti-tuberculosis treatment trial in Brazil. A case of delayed culture conversion was a patient who remained culture-positive after 2 months of treatment. Odds ratios with 95% confidence intervals were calculated. RESULTS: Fifty-three cases and 240 control patients were analyzed. Smokers had three-fold greater odds of remaining culture-positive after 2 months of treatment (P = 0.007) than non-smokers, while smokers and ex-smokers who smoked >20 cigarettes a day had two-fold greater odds of remaining culture-positive after 2 months of treatment (P = 0.045). CONCLUSION: Cigarette smoking adversely affects culture conversion during anti-tuberculosis treatment. Support for smoking cessation should be considered to improve outcomes in TB control programs.

Reduction of contamination of mycobacterial growth indicator tubes using increased PANTA concentration.

We assessed the effect of a double concentration of supplemental polymyxin B, amphotericin B, nalidixic acid, trimethoprim and azlocillin (PANTA) added to the Mycobacterial Growth Indicator Tube (MGIT) on contamination and positivity rates in 216 sputum cultures. Contamination rates were respectively 12.9% and 5.5% for samples processed using standard and double PANTA concentrations (P = 0.0001, McNemar's test). Thirty-five per cent of cultures performed using standard PANTA and 36.5% of those performed using two-fold PANTA concentrations were positive for Mycobacterium tuberculosis, compared to 25.9% of cultures inoculated on Ogawa medium. These results suggest that the use of MGIT with 2× PANTA may be useful in reducing culture contamination without reducing the diagnostic yield.

Spatial patterns of pulmonary tuberculosis incidence and their relationship to socio-economic status in Vitoria, Brazil.

OBJECTIVE: To investigate spatial patterns of the incidence of pulmonary tuberculosis (TB) and its relationship with socio-economic status in Vitoria, Espirito Santo, Brazil. DESIGN: In a 4-year, retrospective, territory-based surveillance study of all new pulmonary TB cases conducted in Vitoria between 2002 and 2006, spatial patterns of disease incidence were compared using spatial clustering statistics (Anselin's local indicators of spatial association [LISA] and Getis-Ord Gi* statistics), smoothed empirical Bayes estimates and model-predicted incidence rates. Spatial Poisson models were fit to examine the relationship between socio-economic status and TB incidence. RESULTS: A total of 651 TB cases were reported across 78 neighborhoods, with rates ranging from 0 to 129 cases per 100,000 population. Moran's I indicated strong spatial autocorrelation among incidence rates (0.399, P < 0.0001), and four areas of high incidence were identified by LISA and Gi* statistics. Smoothed spatial empirical Bayes estimates demonstrate that two of these areas range from 70 to 90 cases/100,000, while the other two range from 40 to 70 cases/100,000. TB incidence and socio-economic status had a significant curvilinear relationship (P = 0.02). CONCLUSIONS: Data derived from these spatial statistical tools will help TB control programs to allocate TB resources to those populations most at risk of increasing TB rates and to target areas where TB control efforts need to be concentrated.

Delay in diagnosis of pulmonary tuberculosis at a primary health clinic in Vitoria, Brazil.

SETTING: Primary health clinics in Vitoria, Espirito Santo, Brazil. OBJECTIVE: To identify risk factors associated with patient and health care delays among patients seeking care at primary health clinics. METHODS: A prospective study among tuberculosis (TB) patients diagnosed in Vitoria between 1 January 2003 and 30 December 2007. A questionnaire ascertained the date of onset and duration of TB symptoms and medical records were reviewed. Between-group distributions of delay were compared and multivariate logistic regression was performed. RESULTS: Of 304 patients, 296 (97%) reported at least one TB symptom presenting for the first time to a qualified health service; 244 (80%) reported cough > 3 weeks. Median health care delay was 30 days (range 5-68), and median total delay was 110 days (range 26-784). Multivariate analysis revealed any cough (OR(adj) 7.35, 95%CI 2.40-22.5) and weight at TB diagnosis < 60 kg (OR(adj) 5.92, 95%CI 1.83-19.1) to be associated with patient delay of ≥ 30 days. Factors increasing risk of prolonged delay (≥ 90 days) were age ≥ 30 years (OR(adj) 1.93, 95%CI 1.09-3.43) and chest pain (OR(adj) 2.42, 95%CI 1.29-4.53). CONCLUSION: Improving health care workers' education regarding TB symptoms and implementing active case finding in targeted populations may reduce delays.

Comparison of two concentrations of NALC-NaOH for decontamination of sputum for mycobacterial culture.

This study compared the effect of using two different concentrations of sodium hydroxide (NaOH) in the N-acetyl-L-cysteine-sodium hydroxide (NALC-NaOH) method for sputum decontamination on smear and culture positivity and the proportion of contaminated cultures: 14% of cultures were contaminated using the standard final 1% NaOH concentration during processing compared to 11% contaminated cultures using a final 1.25% NaOH concentration (P < 0.008). The proportion of cultures positive for mycobacteria decreased from 21% to 11% for sputum processed with 1% and 1.25% final NaOH concentrations, respectively (P < 0.001). Our findings suggest that a small reduction in culture contamination did not justify the considerable loss of positive cultures.