Profile of tuberculosis patients progressing to death, city of São Paulo, Brazil, 2002

Mortality among over 6 million internal and international migrants in Brazil: a study using the 100 Million Brazilian Cohort

Background

To understand if migrants living in poverty in low and middle-income countries (LMICs) have mortality advantages over the non-migrant population, we investigated mortality risk patterns among internal and international migrants in Brazil over their life course.

Methods

We linked socio-economic and mortality data from 1st January 2011 to 31st December 2018 in the 100 Million Brazilian Cohort and calculated all-cause and cause-specific age-standardised mortality rates according to individuals' migration status for men and women. Using Cox regression models, we estimated the age- and sex-adjusted mortality hazard ratios (HR) for internal migrants (i.e., Brazilian-born individuals living in a different Brazilian state than their birth) compared to Brazilian-born non-migrants; and for international migrants (i.e., people born in another country) compared to Brazilian-born individuals.

Findings

The study followed up 45,051,476 individuals, of whom 6,057,814 were internal migrants, and 277,230 were international migrants. Internal migrants had similar all-cause mortality compared to Brazilian non-migrants (aHR = 0.99, 95% CI = 0.98-0.99), marginally higher mortality for ischaemic heart diseases (aHR = 1.04, 95% CI = 1.03-1.05) and higher for stroke (aHR = 1.11, 95% CI = 1.09-1.13). Compared to Brazilian-born individuals, international migrants had 18% lower all-cause mortality (aHR = 0.82, 95% CI = 0.80-0.84), with up to 50% lower mortality from interpersonal violence among men (aHR = 0.50, 95% CI = 0.40-0.64), but higher mortality from avoidable causes related to maternal health (aHR = 2.17, 95% CI = 1.17-4.05).

Interpretation

Although internal migrants had similar all-cause mortality, international migrants had lower all-cause mortality compared to non-migrants. Further investigations using intersectional approaches are warranted to understand the marked variations by migration status, age, and sex for specific causes of death, such as elevated maternal mortality and male lower interpersonal violence-related mortality among international migrants.

Funding

The Wellcome Trust.

Spatial pattern and temporal trend of mortality due to tuberculosis

OBJECTIVES

To describe the epidemiological profile of mortality due to tuberculosis (TB), to analyze the spatial pattern of these deaths and to investigate the temporal trend in mortality due to tuberculosis in Northeast Brazil.

METHODS

An ecological study based on secondary mortality data. Deaths due to TB were included in the study. Descriptive statistics were calculated and gross mortality rates were estimated and smoothed by the Local Empirical Bayesian Method. Prais-Winsten's regression was used to analyze the temporal trend in the TB mortality coefficients. The Kernel density technique was used to analyze the spatial distribution of TB mortality.

RESULTS

Tuberculosis was implicated in 236 deaths. The burden of tuberculosis deaths was higher amongst males, single people and people of mixed ethnicity, and the mean age at death was 51 years. TB deaths were clustered in the East, West and North health districts, and the tuberculosis mortality coefficient remained stable throughout the study period.

CONCLUSIONS

Analyses of the spatial pattern and temporal trend in mortality revealed that certain areas have higher TB mortality rates, and should therefore be prioritized in public health interventions targeting the disease.

Who are the patients with tuberculosis who are diagnosed in emergency facilities? An analysis of treatment outcomes in the state of São Paulo, Brazil

OBJECTIVE

Early tuberculosis diagnosis and treatment are determinants of better outcomes and effective disease control. Although tuberculosis should ideally be managed in a primary care setting, a proportion of patients are diagnosed in emergency facilities (EFs). We sought to describe patient characteristics by place of tuberculosis diagnosis and determine whether the place of diagnosis is associated with treatment outcomes. A secondary objective was to determine whether municipal indicators are associated with the probability of tuberculosis diagnosis in EFs.

METHODS

We analyzed data from the São Paulo State Tuberculosis Control Program database for the period between January of 2010 and December of 2013. Newly diagnosed patients over 15 years of age with pulmonary, extrapulmonary, or disseminated tuberculosis were included in the study. Multiple logistic regression models adjusted for potential confounders were used in order to evaluate the association between place of diagnosis and treatment outcomes.

RESULTS

Of a total of 50,295 patients, 12,696 (25%) were found to have been diagnosed in EFs. In comparison with the patients who had been diagnosed in an outpatient setting, those who had been diagnosed in EFs were younger and more socially vulnerable. Patients diagnosed in EFs were more likely to have unsuccessful treatment outcomes (adjusted OR: 1.54; 95% CI: 1.42-1.66), including loss to follow-up and death. At the municipal level, the probability of tuberculosis diagnosis in EFs was associated with low primary care coverage, inequality, and social vulnerability. In some municipalities, more than 50% of the tuberculosis cases were diagnosed in EFs.

CONCLUSIONS

In the state of São Paulo, one in every four tuberculosis patients is diagnosed in EFs, a diagnosis of tuberculosis in EFs being associated with poor treatment outcomes. At the municipal level, an EF diagnosis of tuberculosis is associated with structural and socioeconomic indicators, indicating areas for improvement.

Path of infectious diseases in Brazil in the last 50 years: an ongoing challenge

In this article, we comment on the main features of infectious diseases in Brazil in the last 50 years, highlighting how much of this path Revista de Saúde Pública could portray. From 1967 to 2016, 1,335 articles focusing on infectious diseases were published in Revista de Saúde Pública. Although the proportion of articles on the topic have decreased from about 50.0% to 15.0%, its notability remained and reflected the growing complexity of the research required for its control. It is noteworthy that studies design and analysis strategies progressively became more sophisticated, following the great development of epidemiology in Brazil in the recent decades. Thus, the journal has followed the success of public health interventions that permitted to control or eliminate numerous infectious diseases - which were responsible, in the past, for high rates of morbidity and mortality -, and also followed the reemergence of diseases already controlled and the emergence of until then unknown diseases, with a strong impact on the Brazilian population, establishing a little predictable and very challenging path. RESUMO Neste artigo, comentamos as principais características das doenças infecciosas no Brasil, nos últimos 50 anos, destacando o quanto a Revista de Saúde Pública conseguiu capturar essa trajetória. De 1967 a 2016, foram publicados 1.335 artigos na Revista de Saúde Pública com foco em doenças infecciosas. Ainda que a proporção de artigos sobre esse tema tenha declinado de cerca de 50,0% para 15,0%, seu destaque se manteve e refletiu a crescente complexidade das pesquisas necessárias para o seu controle. Nota-se que os desenhos dos estudos e as estratégias de análise ganharam progressivamente maior sofisticação, acompanhando o grande desenvolvimento da epidemiologia no Brasil, nas últimas décadas. Assim, foi registrado não apenas o sucesso de intervenções de saúde pública que permitiram o controle ou a eliminação de inúmeras doenças infecciosas responsáveis, no passado, por elevadas taxas de morbimortalidade, como também a reemergência de males já controlados e o surgimento de doenças até então desconhecidas, com forte impacto na população brasileira, desenhando uma trajetória pouco previsível e muito desafiadora.

Occurrence of tuberculosis cases in Crato, Ceará, from 2002 to 2011: a spatial analisys of specific standards

OBJECTIVE

to analyze the spatial distribution of tuberculosis in Crato, Ceará, Brazil, from 2002 to 2011, aiming to check for a point pattern.

METHODS

This is an ecological, temporal trend and hybrid design study, with a quantitative approach. A total of 261 cases of tuberculosis were geo-referenced and 20 (7.1%) were considered as losses due to the lack of address. The profile of patients in 10 years of study was in accordance with the following pattern: men aged between 20 and 59 years, with low schooling, affected by the pulmonary form of tuberculosis and who were cured from the disease.

RESULTS

The analysis of the spatial distribution of tuberculosis points out that in the period of study, new cases of the disease were not distributed on a regular basis, indicating a clustered spatial pattern, confirmed by the L-function. The map with the density of new cases estimated by the Kernel method showed that the "hot" areas are more concentrated in the vicinity of the central urban area.

CONCLUSION

The study allowed pointing out areas of higher and lower concentration of tuberculosis, identifying the spatial pattern, but it also recognized that the disease has not reached all of the population groups with the same intensity. Those who were most vulnerable were the ones who lived in regions with higher population densities, precarious living conditions, and with intense flow of people.

Death in patients with tuberculosis and diabetes: Associated factors

AIMS

Identify factors associated with death in patients with tuberculosis and diabetes.

METHOD

The descriptive - analytic epidemiologic study using secondary data of tuberculosis cases reported in TBWEB from 1996 to 2014 is used. The profile analysis of the variables in relation to death controlled by the cure of the patients was performed by the software R, the independent variables that could be associated with the dependent variable in a 20% significance level, using the chi-square test. The analysis was performed on an unconditional logistic regression model. Odds ratio (OR) adjusted measures were obtained in order to evaluate the strength of association between independent variables.

RESULTS

Looking into the database TBWEB, from 1996 to 2014, 5361 cases of TB were reported, and from these cases, 4447 contained information about the closure and were complete. Patients with TB and DM represented 306 cases (6.35%). In relation to death, protective factors were: diabetes with OR: 0.69; follow up received during the treatment of medium and high complexity services, with OR: 0.51 and the other type with OR: 0.56.

CONCLUSION

Diabetes appeared as a protective factor for death in patients with tuberculosis in this study. The development of studies like this allows the expansion of knowledge on the TB-DM association.

Spatial analysis of deaths from pulmonary tuberculosis in the city of São Luís, Brazil

OBJECTIVE

To characterize deaths from pulmonary tuberculosis, according to sociodemographic and operational variables, in the city of São Luís, Brazil, and to describe their spatial distribution.

METHODS

This was an exploratory ecological study based on secondary data from death certificates, obtained from the Brazilian Mortality Database, related to deaths from pulmonary tuberculosis. We included all deaths attributed to pulmonary tuberculosis that occurred in the urban area of São Luís between 2008 and 2012. We performed univariate and bivariate analyses of the sociodemographic and operational variables of the deaths investigated, as well as evaluating the spatial distribution of the events by kernel density estimation.

RESULTS

During the study period, there were 193 deaths from pulmonary tuberculosis in São Luís. The median age of the affected individuals was 52 years. Of the 193 individuals who died, 142 (73.60%) were male, 133 (68.91%) were Mulatto, 102 (53.13%) were single, and 64 (33.16%) had completed middle school. There was a significant positive association between not having received medical care prior to death and an autopsy having been performed (p = 0.001). A thematic map by density of points showed that the spatial distribution of those deaths was heterogeneous and that the density was as high as 8.12 deaths/km2.

CONCLUSIONS

The sociodemographic and operational characteristics of the deaths from pulmonary tuberculosis evaluated in this study, as well as the identification of priority areas for control and surveillance of the disease, could promote public health policies aimed at reducing health inequities, allowing the optimization of resources, as well as informing decisions regarding the selection of strategies and specific interventions targeting the most vulnerable populations.

[Improved quality of tuberculosis data using record linkage.]

The aim of this study was to improve data quality on tuberculosis (TB) after record linkage and outcome correction through probabilistic linkage between the Information System for Notifiable Diseases (SINAN) and the Mortality Information System (SIM). Record linkage was conducted between SINAN records for Brazil in 2008 and 2009 in order to exclude notifications not removed by routine SINAN procedures performed by States and Municipalities. The databases were constructed according to the case outcomes. Linkage between SINAN and SIM used the database resulting from record linkage and SIM data that mentioned TB as the underlying or associated cause from 2008 to 2010 in Brazil. Record linkage decreased the percentage of new cases closed with patient transfer as the outcome, ranging from 34.8% in 2008 to 35.5% in 2009. After linkage between SINAN and SIM, the percentage of TB deaths among new cases increased, varying around 15%. The results highlight the need for attention to data quality for TB treatment outcomes in SINAN.

Two vicious circles contributing to a diagnostic delay for tuberculosis patients in Arkhangelsk

SETTING

Delay in tuberculosis (TB) diagnosis increases the infectious pool in the community and the risk of development of resistance of mycobacteria, which results in an increased number of deaths.

OBJECTIVE

To describe patients' and doctors' perceptions of diagnostic delay in TB patients in the Arkhangelsk region and to develop a substantive model to better understand the mechanisms of how these delays are linked to each other.

DESIGN

A grounded theory approach was used to study the phenomenon of diagnostic delay. Patients with TB diagnostic delay and doctors-phthisiatricians were interviewed.

RESULTS

A model named 'sickness trajectory in health-seeking behaviour among tuberculosis patients' was developed and included two core categories describing two vicious circles of diagnostic delay in patients with TB: 'limited awareness of the importance to contact the health system' and 'limited resources of the health system' and the categories: 'factors influencing health-seeking behaviour' and 'factors influencing the health system effectiveness'. Men were more likely to report patient delay, while women were more likely to report health system delay.

CONCLUSIONS

To involve people in early medical examinations, it is necessary to increase alertness on TB among patients and to improve health systems in the districts.

Bidirectional screening of tuberculosis patients for diabetes mellitus and diabetes patients for tuberculosis

To assess the feasibility and results of screening diabetes mellitus (DM) patients for tuberculosis (TB) and TB patients for DM within the routine health care setting. Prospective observational study carried out within the Diabetes Centre and Pulmonary Medicine Department from February 2012 to September 2012. The screening for active TB in DM and DM in TB patients is followed as per the guidelines of the Revised National Tuberculosis Control Programme and national programmes in India. Total of 307 patients diagnosed with TB during the study period. Among the TB patients 9.77% were smokers, 19.54% were known cases diabetes, and 15.96% were newly diagnosed cases of diabetes. Total of 4,118 diabetes patients were screened for TB in which 111 patients found to have TB. The strengths of this study are that we implemented screening within the routine health system. It is feasible to screen DM patients for TB resulting in high rates of TB detection.

The establishment of bonds between professional and patient in TB treatment: the performance of primary health care services in a city in the interior of São Paulo

This study evaluated the performance of health care services implementing TB control actions in relation to the establishment of bonds between health professionals and patients in São José do Rio Preto, SP, Brazil from the perspective of patients, health professionals, and managers. A total of 108 patients, 37 health professionals and 15 managers were interviewed through a questionnaire containing 10 indicators of bond-establishment based on the instruments of the Primary Care Assessment Tool, adapted to evaluate tuberculosis control in Brazil. The three groups of actors considered the establishment of bonds satisfactory, though opinions of patients and managers differed in almost all indicators. This fact indicates that the view of managers is still predominantly focused on bureaucratic and administrative aspects, which shows the need for managers to integrate more management and care actions.

'The tubercular diabetic': the impact of diabetes mellitus on tuberculosis and its threat to global tuberculosis control

The incidence and prevalence of diabetes mellitus (DM) is rapidly increasing across the globe. Tuberculosis (TB), meanwhile, remains a significant problem in low and middle income countries fuelled by high rates of HIV/AIDS. This article explores the long recognised but underappreciated connection between the two, revealing that DM makes a substantial contribution to the burden of incident TB around the world and may also worsen TB severity and treatment outcome. The dual management of the diseases may be challenging but must be addressed, both in low and high income settings, because the rising worldwide diabetes burden poses a threat to global TB control.

Proposal for tuberculosis death surveillance in information systems

OBJECTIVE

To propose a tuberculosis-related death surveillance strategy based on the Brazilian Mortality Information System.

METHODS

Data on 55 tuberculosis-related deaths, which occurred in two large hospitals in Rio de Janeiro, Southeastern Brazil, between September 2005 and August 2006, were obtained from the SIM. These cases were searched and compared with cases in the National Notification System (Sinan). The increment in the number of notifications and completeness of data were evaluated, as well as entry type and outcome in Sinan.

RESULTS

Of the 55 deaths, 28 were registered in Sinan. Comparison between systems allowed for the following corrections: 27 new cases were notified, 14 new notifications performed by the hospitals where death occurred and ten outcomes corrected. This represented an increment of 41/144 (28%) notifications by these two hospitals in 2006. Nine cases, previously classified as unconfirmed tuberculosis were reclassified as bacteriologically confirmed, and another five cases were reclassified from tuberculosis to AIDS as the primary cause of death.

CONCLUSIONS

The proposed surveillance system for tuberculosis-related death was useful to increase data completeness, decrease under-notification and cases with unknown outcome, to evaluate epidemiological surveillance and death certificate quality and to trace previously unidentified contacts.

Epidemiological monitoring of tuberculosis in a general teaching hospital

OBJECTIVE

To describe the epidemiological monitoring of exposure to tuberculosis in a hospital environment and to analyze the profile of the disease in a general teaching hospital.

METHODS

A descriptive and retrospective study of tuberculosis cases diagnosed between 2000 and 2006, with the determination of indicators of morbidity and mortality, which were compared with the general population of patients treated at the hospital and with the hospital employees who developed active tuberculosis.

RESULTS

There were 763 patients who were treated for active tuberculosis (mean, 109 patients/year), 481 (63.1%) of whom were male. Most of the patients were in the 30-59 year age bracket. Tuberculosis that was exclusively pulmonary or extrapulmonary predominated. However, among the hospitalized patients, the combination of pulmonary and extrapulmonary tuberculosis, as well as exclusively noninfectious tuberculosis, predominated. Comorbidities were more prevalent among the hospitalized patients and among those who evolved to death. Only 52.8% of the cases treated at the hospital were reported. The overall hospital indicators showed longer length of hospital stay and greater mortality among the patients with tuberculosis. The incidence and prevalence show that there was a high risk of exposure to tuberculosis in the hospital during the period studied.

CONCLUSIONS

The proposed indicators can potentially help standardize epidemiological monitoring procedures for nosocomial tuberculosis, and the epidemiological profile described in this study can contribute to a better understanding of the situation of tuberculosis in Brazil.

Risk factors associated with death in patients who initiate treatment for tuberculosis after two different follow-up periods

INTRODUCTION: Mortality from tuberculosis, which should be a rare event, still affects a large portion of the population of developing countries. In this context, Recife, a city in the northeast of Brazil where this study was developed, has the highest tuberculosis mortality rates of the Brazilian capitals. OBJECTIVE: To analyze survival probability and identify risk factors for death from tuberculosis in a cohort of patients living in Recife who started treatment for tuberculosis. METHODOLOGY: A cohort of newly diagnosed TB cases was followed up from the beginning of treatment (in 2001-2003) until June 2007. Survival probability was estimated by Kaplan-Meier method; and Cox Regression analysis was used to identify risk factors. RESULTS: At the end of the follow-up period, the survival probability after beginning TB treatment was 95.9%. Older ages, positivity for HIV and late initial treatment were statistically associated with death from TB in one year follow-up. When the analysis was done considering the total period of follow-up, older ages, positivity serology for HIV, late initial treatment, weight loss, and history of previous treatment remained in the multivariate Cox regression model. CONCLUSION: A more comprehensive analysis, specifically for deaths from tuberculosis as the underlying and non-underlying cause, allowed identification of a greater number of predictive factors that would otherwise not be detected if follow-up had lasted only until the end of treatment. These results can guide feasible interventions for health services aiming to reduce case-fatality from tuberculosis.

Tuberculosis and diabetes mellitus: convergence of two epidemics

The link between diabetes mellitus and tuberculosis has been recognised for centuries. In recent decades, tuberculosis incidence has declined in high-income countries, but incidence remains high in countries that have high rates of infection with HIV, high prevalence of malnutrition and crowded living conditions, or poor tuberculosis control infrastructure. At the same time, diabetes mellitus prevalence is soaring globally, fuelled by obesity. There is growing evidence that diabetes mellitus is an important risk factor for tuberculosis and might affect disease presentation and treatment response. Furthermore, tuberculosis might induce glucose intolerance and worsen glycaemic control in people with diabetes. We review the epidemiology of the tuberculosis and diabetes epidemics, and provide a synopsis of the evidence for the role of diabetes mellitus in susceptibility to, clinical presentation of, and response to treatment for tuberculosis. In addition, we review potential mechanisms by which diabetes mellitus can cause tuberculosis, the effects of tuberculosis on diabetic control, and pharmacokinetic issues related to the co-management of diabetes and tuberculosis.

Is it better to be rich in a poor area or poor in a rich area? A multilevel analysis of a case-control study of social determinants of tuberculosis

BACKGROUND

Tuberculosis is known to have socio-economic determinants at individual and at area levels, but it is not known whether they are independent, whether they interact and their relative contributions to the burden of tuberculosis.

METHODS

A case-control study was conducted in Recife, Brazil, to investigate individual and area social determinants of tuberculosis, to explore the relationship between determinants at the two levels and to calculate their relative contribution to the burden of tuberculosis. It included 1452 cases of tuberculosis diagnosed by the tuberculosis services and 5808 controls selected at random from questionnaires completed for the demographic census. Exhaustive information on social factors was collected from cases, using the questionnaire used in the census. Socio-economic information for areas was downloaded from the census. Multilevel logistic regression investigated individual and area effects.

RESULTS

There was a marked and independent influence of social variables on the risk of tuberculosis, both at individual and area levels. At individual level, being aged >or=20, being male, being illiterate, not working in the previous 7 days and possessing few goods, all increased the risk of tuberculosis. At area level, living in an area with many illiterate people and where few households own a computer also increased this risk; individual and area levels did not appear to interact. Twice as many cases were attributable to social variables at individual level than at area level.

CONCLUSIONS

Although individual characteristics are the main contributor to the risk of tuberculosis, contextual characteristics make a substantial independent contribution.