Determinants of multidrug-resistant tuberculosis in São Paulo-Brazil: a multilevel Bayesian analysis of factors associated with individual, community and access to health services

Influence of COVID-19 on the notification of drug-resistant pulmonary tuberculosis cases

BACKGROUND

To analyze the influence of the COVID-19 pandemic on the process of diagnosis and monitoring of drug-resistant pulmonary tuberculosis (TB) cases reported in the state of Paraná, Brazil, from 2015 to 2020.

METHODS

Ecological study with quantitative approach. This study was based on diagnosed cases of pulmonary TB reported in the Notifiable Disease Information System in residents of Paraná; as well as through the number of confirmed cases of COVID-19 in the state epidemiological bulletin for the year 2020. The study data were analyzed using descriptive statistics.

RESULTS

It was found that, although the number of reported pulmonary TB cases (drug-resistant and general) increased between 2015 and 2019, there was a drop in notification in 2020, the first year of the COVID-19 pandemic. The notification of TB cases was also influenced monthly during the year according to the increase in the number of COVID-19 cases. For cases of drug-resistant pulmonary TB, the provision of diagnostic tests and Directly Observed Treatment decreased by more than half in 2020, especially when compared to 2019.

CONCLUSIONS

In view of these findings, the influence of COVID-19 on the diagnosis and monitoring of drug-resistant and general pulmonary TB cases is evident, showing that the pandemic has compromised the advances of recent decades in achieving the goals established for its eradication by 2035.

Identifying Hotspots of People Diagnosed of Tuberculosis with Addiction to Alcohol, Tobacco, and Other Drugs through a Geospatial Intelligence Application in Communities from Southern Brazil

(1) Background: tuberculosis (TB) is considered one of the leading causes of death worldwide by a single infectious agent. This study aimed to identify hotspots of people diagnosed with tuberculosis and abusive use of alcohol, tobacco, and other drugs in communities through a geospatial intelligence application; (2) Methods: an ecological study with a spatio-temporal approach. We considered tuberculosis cases diagnosed and registered in the Notifiable Diseases Information System, which presented information on alcoholism, smoking, and drug abuse. Spatial Variations in Temporal Trends (SVTT) and scan statistics were applied for the identification of Hotspots; (3) Results: between the study period, about 29,499 cases of tuberculosis were reported. When we applied the SVTT for alcoholism, three Hotspots were detected, one of which was protective (RR: 0.08–CI95%: 0.02–0.32) and two at risk (RR: 1.42–CI95%: 1.11–1.73; RR: 1.39–CI95%: 1.28–1.50). Regarding smoking, two risk clusters were identified (RR: 1.15–CI95%: 1.01–1.30; RR: 1.68–CI95%: 1.54–1.83). For other drugs, a risk cluster was found (RR: 1.13–CI95%: 0.99–1.29) and two protections (RR: 0.70–CI95%: 0.63–0.77; RR: 0.76–CI95%: 0.65–0.89); (4) Conclusion: it was evidenced that in the communities being studied, there exists a problem of TB with drug addiction. The disordered use of these substances may harm a person’s brain and behavior and lead to an inability to continue their treatment, putting the community at further risk for TB.

Key factors influencing multidrug-resistant tuberculosis in patients under anti-tuberculosis treatment in two centres in Burundi: a mixed effect modelling study

Background

Despite the World Health Organization efforts to expand access to the tuberculosis treatment, multidrug resistant tuberculosis (MDR-TB) remains a major threat. MDR-TB represents a challenge for clinicians and staff operating in national tuberculosis (TB) programmes/centres. In sub-Saharan African countries including Burundi, MDR-TB coexists with high burden of other communicable and non-communicable diseases, creating a complex public health situation which is difficult to address. Tackling this will require targeted public health intervention based on evidence which well defines the at-risk population. In this study, using data from two referral anti-tuberculosis in Burundi, we model the key factors associated with MDR-TB in Burundi.

Methods

A case-control study was conducted from 1^stAugust 2019 to 15^th January 2020 in Kibumbu Sanatorium and Bujumbura anti-tuberculosis centres for cases and controls respectively. In all, 180 TB patients were selected, comprising of 60 cases and 120 controls using incidence density selection method. The associated factors were carried out by mixed effect logistic regression. Model performance was assessed by the Area under Curve (AUC). Model was internally validated via bootstrapping with 2000 replications. All analysis were done using R Statistical 3.5.0.

Results

MDR-TB was more identified among patients who lived in rural areas (51.3%), in patients’ residence (69.2%) and among those with a household size of six or more family members (59.5%).

Most of the MDR-TB cases had already been under TB treatment (86.4%), had previous contact with an MDR-TR case (85.0%), consumed tobacco (55.5%) and were diabetic (66.6 %). HIV prevalence was 32.3 % in controls and 67.7 % among cases. After modelling using mixed effects, Residence of patients (aOR= 1.31, 95%C: 1.12-1.80), living in houses with more than 6 family members (aOR= 4.15, 95% C: 3.06-5.39), previous close contact with MDR-TB (aOR= 6.03, 95% C: 4.01-8.12), history of TB treatment (aOR= 2.16, 95% C: 1.06-3.42), tobacco consumption (aOR = 3.17 ,95% C: 2.06-5.45) and underlying diabetes’ ( aOR= 4.09,95% CI = 2.01-16.79) were significantly associated with MDR-TB. With 2000 stratified bootstrap replicates, the model had an excellent predictive performance, accurately predicting 88.15% (95% C: 82.06%-92.8%) of all observations. The coexistence of risk factors to the same patients increases the risk of MDR-TB occurrence. TB patients with no any risk factors had 17.6% of risk to become MDR-TB. That probability was respectively three times and five times higher among diabetic and close contact MDR-TB patients.

Conclusion

The relatively high TB’s prevalence and MDR-TB occurrence in Burundi raises a cause for concern especially in this context where there exist an equally high burden of chronic diseases including malnutrition. Targeting interventions based on these identified risk factors will allow judicious channel of resources and effective public health planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12233-2.

Causes of multidrug-resistant tuberculosis from the perspectives of health providers: challenges and strategies for adherence to treatment during the COVID-19 pandemic in Brazil

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is a serious phenomenon on a global scale that can worsen with the COVID-19 pandemic. The study aimed to understand the perceptions of health professionals about MDR-TB, their strategies to ensure adherence to treatment and their challenges in the context of the COVID-19 pandemic in a priority municipality for disease control.

METHODS

We conducted a qualitative study and recruited 14 health providers (four doctors, three nurses, three nursing technicians, three nursing assistants and a social worker) working in a city in the state of São Paulo, Brazil. Remote semi-structured interviews were conducted with the participants. For data analysis, the thematic content analysis technique was applied according to the study's theoretical framework.

RESULTS

The study revealed the causes of MDR-TB are associated with poverty, vulnerability, and social risk. A pre-judgement from the providers was observed, namely, all patients do not adhere due their resistance and association with drug abuse or alcoholism. The study also observed difficulty among health providers in helping patients reconstruct and reframe their life projects under a care perspective, which would strengthen adherence. Other issues that weakened adherence were the cuts in social protection and the benefits really necessary to the patients and a challenge for the providers manage that. The participants revealed that their actions were impacted by the pandemic and insecurity and fear manifested by patients after acquiring COVID-19. For alleviating this, medical appointments by telephone, delivery of medicine in the homes of patients and visits by health professionals once per week were provided.

CONCLUSION

The study advances knowledge by highlighting the challenges faced by the health system with the adherence of patients with MDR-TB in a context aggravated by the pandemic. An improvement in DOT is really necessary to help the patients reframe their lives without prejudices, face their fears and insecurity, recover their self-esteem and motivate in concluding their treatment.

Patients' perceptions regarding multidrug-resistant tuberculosis and barriers to seeking care in a priority city in Brazil during COVID-19 pandemic: A qualitative study

This study aimed to analyze the discourses of patients who were diagnosed with multidrug-resistant tuberculosis, the perception of why they acquired this health condition and barriers to seeking care in a priority city in Brazil during the COVID-19 pandemic. This was an exploratory qualitative study, which used the theoretical-methodological framework of the Discourse Analysis of French matrix, guided by the Consolidated Criteria for Reporting Qualitative Research. The study was conducted in Ribeirão Preto, São Paulo, Brazil. Seven participants were interviewed who were undergoing treatment at the time of the interview. The analysis of the participants' discourses allowed the emergence of four discursive blocks: (1) impact of the social determinants in the development of multidrug-resistant tuberculosis, (2) barriers to seeking care and difficulties accessing health services, (3) perceptions of the side effects and their impact on multidrug-resistant tuberculosis treatment, and (4) tuberculosis and COVID-19: a necessary dialogue. Through discursive formations, these revealed the determinants of multidrug-resistant tuberculosis. Considering the complexity involved in the dynamics of multidrug-resistant tuberculosis, advancing in terms of equity in health, that is, in reducing unjust differences, is a challenge for public policies, especially at the current moment in Brazil, which is of accentuated economic, political and social crisis. The importance of psychosocial stressors and the lack of social support should also be highlighted as intermediary determinants of health. The study has also shown the situation of COVID-19, which consists of an important barrier for patients seeking care. Many patients reported fear, insecurity and worry with regard to returning to medical appointments, which might contribute to the worsening of tuberculosis in the scenario under study.

HIV infection and multidrug resistant tuberculosis: a systematic review and meta-analysis

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) in HIV infected individuals is a serious threat to global efforts to combat tuberculosis. Inconsistent findings on the association between HIV infection and MDR-TB were present in many studies. We aimed to review existing data on the relationship between HIV infection and MDR-TB systematically to assess the contribution of HIV on MDR-TB worldwide. We also investigated the patterns of MDR-TB by age, country-wise income, study designs, and global regions.

METHODS

We utilized PubMed, Google Scholar, and ScienceDirect databases to select eligible studies for meta-analysis that were published between January 12,010, and July 30, 2020. The random-effects model was used to obtain the pooled odds ratio of the crude association between HIV and MDR-TB with a 95% confidence interval. We investigated the potential publication-bias by checking funnel plot asymmetry and using the Egger's test. Moreover, we assessed the heterogeneity using the I² statistic. Sensitivity analysis was performed based on sample size and adjustment factors. The protocol was registered with PROSPERO-CRD42019132752.

RESULTS

We identified 1603 studies through a database search, and after subsequent eliminations we selected 54 studies including 430,534 TB patients. The pooled odds of MDR-TB was 1.42 times higher in HIV-positive patients than HIV-negative patients (OR=1.42,CI=1.17-1.71, I²=75.8%). Subgroup analysis revealed that the estimated pooled odds for South-East Asian countries was 1.86, which is the highest in WHO regions (OR=1.86,CI=1.30-2.67, I²=0.00%), followed by Europe and Africa. The effect estimate was found to be higher for primary MDR-TB (OR=2.76,CI=1.70-4.46, I²=0.00%). There was also a trend towards increased odds of MDR-TB for HIV patients older than 40 years (OR=1.56,CI=1.17-2.06). The association was found to be significant in high-burden TB countries (OR=1.75, CI=1.39-2.19) and in high-income countries (OR=1.55, CI=1.06-2.27).

CONCLUSION

Such findings indicate that HIV infection raises the risk of MDR-TB, and after contrasting it with the results of the earlier pooled study, it appeared to be an upward risk trend. Moreover, we found that the risk is the highest in the South-East Asian region. A balanced allocation of resources is needed to halt both primary and secondary MDR-TB, particularly in HIV infected people with 40 years of age and older.