Determinants of losses in the latent tuberculosis infection cascade of care in Brazil

Clinical-Epidemiological Characteristics and Outcomes of Latent Tuberculosis Treatment at a Tertiary Center in Central-West Brazil from 2017 to 2019

Detailed information concerning latent tuberculosis infection (LTBI) and treatment outcomes is scarce in Brazil. This retrospective cross-sectional study aimed to describe LTB treatment (LTBT) at a tertiary center in Central-West Brazil from 2017 to 2019. We recommended the use of LTBTs before the implementation of a rifapentine-isoniazid (3HP) regimen in Brazil. We conducted a descriptive analysis using chi-square or t-tests to assess differences in the proportions and means. Of 79 notified adult patients (males, 68%; median age, 40 (interquartile range, 30-51) years), most people were living with human immunodeficiency virus (PLHIV) (82%) or receiving immunosuppressant medication (15%), and 92% were receiving their first treatment. Isoniazid (INH) for 6-9 months had previously been proposed for 95% of the patients, with only 35% completeness. Four patients treated with rifampicin (4RMP) completed the regimen (p = 0.009). Adverse events occurred in 19% of the patients. In this Brazilian tertiary center, the target population for LTBT were young PLHIV patients under immunosuppression with low education levels. However, the INH monotherapy dropout rate was 65%. Therefore, shorter courses, such as 3HP and 4RMP, are promising alternatives. Behavioral aspects, education level, and regimen length can influence the course completion, and further studies are required to evaluate the 3HP regime in Brazil.

Possible sex difference in latent tuberculosis infection risk among close tuberculosis contacts

OBJECTIVES

More men than women develop and die of tuberculosis (TB). Fewer data exist on sex differences in latent TB infection (LTBI). We assessed for potential sex differences in LTBI acquisition among close TB contacts.

METHODS

Regional Prospective Observational Research for TB-Brazil is an observational multi-center cohort of individuals with culture-confirmed pulmonary TB and their close contacts. Participants were enrolled from five sites in Brazil from June 2015 - June 2019. Close contacts were followed for 24 months after enrollment, with LTBI defined as a positive interferon-γ release assay (IGRA; QuantiFERON 3rd or 4th generation) at baseline or 6 months. We performed univariate, bivariate, and multivariable logistic regression and propensity-score weighted models to assess odds ratios (OR) and 95% confidence intervals (CI) for LTBI acquisition by birth sex among close contacts.

RESULTS

Of 1093, 504 (46%) female close contacts were IGRA positive compared to 295 of 745 (40%) men. The unadjusted OR for IGRA positivity among women vs men was 1.31 (95% CI: 1.08-1.58). Bivariate adjustments yielded ORs in women vs men ranging from 1.19 to 1.33 (P-value range: <0.01-0.07). Multivariable regression and weighted models yielded similar ORs in women vs men, of 1.14 (95% CI: 0.92-1.41) and 1.15 (95% CI: 0.94-1.40), respectively.

CONCLUSION

The point estimate for LTBI among close TB contacts in Brazil was higher in women, though less pronounced in multivariable models. If the sex difference in LTBI is confirmed in additional settings, studies of possible underlying differences in socio-behavioral factors or TB pathogenesis are warranted.

Determinants of losses in the tuberculosis infection cascade of care among children and adolescent contacts of pulmonary tuberculosis cases: A Brazilian multi-centre longitudinal study

Background

Approximately 10% of the global tuberculosis (TB) burden is in children. Identification, diagnosis, and early treatment of Mycobacterium tuberculosis infection (TBI) is critical to prevent progression to TB in children. The risk of TB, including severe disease, is highest in children <5 years old. We evaluated the cascade of TBI care among child and adolescent TB contacts to identify factors associated with losses in the cascade.

Methods

Close contacts ≤ 18 years old of pulmonary TB patients enrolled between 2015 and 2019 in a multi-centre Brazilian cohort were followed for up to 24 months and classified according to age groups: <5 years, 5-9 years, 10-14 years and 15-18 years. Data on clinical investigation, radiographic examination, IGRA testing at baseline and 6 months, initiation and completion of TB preventive treatment (TPT) were collected. Multivariable regression analyses identified factors associated with TBI and losses in the cascade of care in children and adolescents.

Findings

Among 1795 TB contacts initially identified, 530 (29·5%) were ≤18 years old. Losses for all steps in the cascade were especially high in children <5 years old (88%) because at this age all contacts are recommended to initiate TPT. As a proportion of all children, completion of TPT was low (between 10% and 13%) in all age-groups. Furthermore, multivariable regression revealed that younger age of contacts and TB index cases who were female, had pulmonary cavities, and persistent cough were independently associated with losses in the cascade of care among persons ≤18 years old.

Interpretation

Losses in the TBI cascade were the highest among children <5 years, which was the group at highest risk for TB among the four age groups. The findings highlight the need to improve screening, initiation, and completion of TPT of young children who are close contacts of people with TB in Brazil.

Funding

National Institutes of Allergy and Infectious Diseases.

Latent Tuberculosis Cascade of Care Among Healthcare Workers: A Nationwide Cohort Analysis in Korea Between 2017 and 2018

BACKGROUND

In 2017, Korea implemented nationwide latent tuberculosis infection (LTBI) project targeting healthcare workers (HCWs). We aimed to assess its performance using the cascade of care model.

METHODS

We included 45,503 employees of medical institutions with positive interferon-gamma release assay result who participated between March 2017 and December 2018. We described percentages of LTBI participants completing each step in the cascade of care. Poisson regression model was conducted to assess individual characteristics and factors associated with not-visiting clinics for further care, not-initiating LTBI treatment, and not-completing treatment.

RESULTS

Proportions of visiting clinics and initiating and completing treatment in HCWs were 54.9%, 38.5%, and 32.0%, respectively. Despite of less likelihood of visiting clinics and initiating LTBI treatment, older age ≥ 65 years were more likely to complete treatment (adjusted relative risk [aRR], 0.80; 95% confidence interval [CI], 0.64-0.99), compared to young age < 35 years. Compared to nurses, doctors were less likely to visit clinic; however, were more likely to initiate treatment (aRR, 0.88; 95% CI, 0.81-0.96). Those who visited public health centers were associated with not-initiating treatment (aRR, 1.34; 95% CI, 1.29-1.40). When treated at private hospitals, 9-month isoniazid monotherapy was less likely to complete treatment, compared to 3-month isoniazid and rifampicin combination therapy (aRR, 1.33; 95% CI, 1.16-1.53).

CONCLUSION

Among employees of medical institutions with LTBI, only one third completed treatment. Age, occupation, treatment center, and initial regimen were significantly related to LTBI treatment performance indicators. Rifampicin-based short treatment regimens were effective under standard of care.

DISCOURSES OF HEALTH PROFESSIONALS ON LATENT TUBERCULOSIS INFECTION AND THE USE OF ISONIAZID

ABSTRACT Objective to understand the collective thinking and action of health workers in relation to Latent Tuberculosis Infection and its treatment with Isoniazid. Method qualitative study with 22 health professionals from four cities in Brazil and the Federal District. Data collection occurred through a semi-structured group interview in March 2019, with an average duration of one hour and thirty minutes. Content analysis was performed using the Collective Subject Discourse technique. Results the professionals' discourses revealed uncertainties related to the prevention and treatment of Latent Tuberculosis Infection, the "fear of error" and inadequate forms of use of Isoniazid 300 mg, the power of the decision on the treatment of Latent Tuberculosis Infection, the difficulties of integration between services and the organization of care flows. Conclusion although the emphasis in the professionals' discourse considers objective aspects in the management of Latent Tuberculosis Infection, subjective manifestations related to the need to address the fears that affect the decision about treatment and possible medication errors were identified, among others, and to think about this process in a collaborative way, which considers autonomy in acting, both of professionals and of the person with Latent Tuberculosis Infection.

DISCURSOS DE PROFISSIONAIS DE SAÚDE SOBRE INFECÇÃO LATENTE POR TUBERCULOSE E USO DE ISONIAZIDA

RESUMO Objetivo compreender o pensar e o agir coletivo de trabalhadores da saúde em relação à Infecção Latente por Tuberculose e ao uso da Isoniazida no enfrentamento da doença. Método estudo qualitativo com 22 profissionais de saúde de quatro cidades do Brasil e do Distrito Federal. A coleta de dados ocorreu mediante realização de entrevista coletiva semiestruturada, em março de 2019, com duração média de uma hora e trinta minutos. Realizou-se análise de conteúdo pela técnica do Discurso do Sujeito Coletivo. Resultados os discursos dos profissionais revelaram incertezas relacionadas à prevenção e ao tratamento da Infecção Latente por Tuberculose, ao “medo de errar” e formas inadequadas de uso da Isoniazida 300 mg, ao poder da decisão sobre o tratamento da Infecção Latente por Tuberculose, às dificuldades da integração entre os serviços e à organização de fluxos assistenciais. Conclusão embora a ênfase no discurso dos profissionais considere aspectos objetivos no manejo da Infecção Latente por Tuberculose, foram identificadas, dentre outras, manifestações subjetivas relacionadas à necessidade de trabalhar os receios que afetam a decisão sobre o tratamento e os possíveis erros de medicação, e de pensar esse processo de forma colaborativa, que considere autonomia no agir, tanto dos profissionais quanto da pessoa com Infecção Latente por Tuberculose.

The cascade of care for latent tuberculosis infection in congregate settings: A national cohort analysis, Korea, 2017-2018

Background

In 2017, Korea implemented a nationwide project to screen and treat latent tuberculosis infection (LTBI) in high-risk for transmission public congregate settings. We aimed to assess programme success using a cascade of care framework.

Materials and methods

We undertook a cohort study of people from three congregate settings screened between March 2017 and December 2018: (1) first-grade high school students, (2) employees of educational institutions, (3) employees of social welfare facilities. We report percentages of participants with LTBI completing each step in the cascade of care model. Poisson regression models were used to determine factors associated with not visiting clinics, not initiating treatment, and not completing treatment.

Results

Among the 96,439 participants who had a positive interferon-gamma release assay result, the percentage visiting clinics for further assessment, to initiate treatment, and who then completed treatment were 50.7, 34.7, and 28.9%, respectively. Compared to those aged 20-34 years, individuals aged < 20 years and aged ≥ 65 years were less likely to visit clinics, though more likely to complete treatment once initiated. Using public health centres rather than private hospitals was associated with people "not initiating treatment" (adjusted risk ratio [aRR], 3.72; 95% confidence interval [CI], 3.95-3.86). Nine-month isoniazid monotherapy therapy was associated with "not completing treatment," compared to 3-month isoniazid and rifampin therapy (aRR, 1.28; 95% CI, 1.16-1.41).

Conclusion

Among participants with LTBI from three congregate settings, less than one third completed treatment. Age, treatment centre, and initial regimen were important determinants of losses to care through the cascade.