Survival of people living with HIV who defaulted from tuberculosis treatment in a cohort, Recife, Brazil

Background

Tuberculosis is a serious public health problem worldwide. It is the leading cause of death amongst people living with HIV, and default from tuberculosis (TB) treatment in people living with HIV increases the probability of death. The aim of this study was to estimate the survival probability of people living with HIV who default treatment for TB compared to those who complete the treatment.

Methods

This was a longitudinal cohort study of people living with HIV, from June 2007 to December 2013 with two components: a retrospective (for those who started tuberculosis treatment before 2013 for whom failure (death) or censoring occurred before 2013), and prospective (those who started tuberculosis treatment at any time between 2007 and June 2013 and for whom death or censoring occurred after the beginning of 2013), at two referral hospitals for people living with HIV (Correia Picanço Hospital - HCP and at Hospital Universitário Oswaldo Cruz – HUOC), in Recife/PE. A total of 317 patients who initiated TB treatment were studied. Default from TB treatment was defined as any patient who failed to attend their pre-booked return appointment at the health center for more than 30 consecutive days, in accordance with Brazilian Ministry of Health recommendations.

Results

From a cohort of 2372 people living with HIV we analyzed 317 patients who had initiated TB treatment. The incidence of death was 5.6 deaths per 100 persons per year (CI 95% 4.5 to 7.08). Independent factors associated with death: default from TB treatment 3.65 HR (95% CI 2.28 to 5.83); CD4 < 200 cells/mm³ 2.39 HR (95% CI 1.44 to 3.96); extrapulmonary tuberculosis 1.56 HR (95% CI 0.93 to 2.63); smoking 2.28 HR (95% CI 1.33 to 3.89); alcohol light 0.13 HR (95% CI 0.03 to 0.56).

Conclusion

The probability of death in people living with HIV who default TB treatment is approximately four times greater when compared to those who do not default from treatment.

Relatedness and HLA-DRB1 typing may discriminate the magnitude of the genetic susceptibility to tuberculosis using a household contact model

BACKGROUND

Tuberculosis clusters in families may be due to increased household exposure, shared genetic factors, or both. Household contact studies are useful to control exposure because socioeconomic and environmental conditions are similar to all subjects, allowing the evaluation of the contribution of relatedness to disease development.

METHODS

In this study, the familial aggregation of tuberculosis using relatedness and a specific inherited marker (HLA-DRB1) was evaluated. Fifty families, which had at least two cases of tuberculosis diagnosed within the past 5 years, were selected from a cohort of tuberculosis carried out in Recife, Brazil. The first case diagnosed was considered to be a primary case. The secondary attack rate of tuberculosis in household contacts was estimated according to the degree of relatedness. The relative risk of having tuberculosis based on the degree of relatedness household and the population attributable fraction to relatedness were also estimated. HLA-DRB1 typing and attributable etiologic/preventive fractions were calculated among sick and healthy household contacts.

RESULTS

Compared to unrelated contacts, the relative risk for tuberculosis adjusted for age was 1.38 (95% CI 0.86 to 2.21). Relatedness contributed 23% to the development of tuberculosis at the population levels. The HLA-DRB1*04 allele group (OR=2.44; p=0.0324; etiologic fraction=0.15) was overrepresented and the DRB1*15 allele group (OR=0.48; p=0.0488; protective fraction=0.19) was underrepresented among household contacts exhibiting tuberculosis. The presence of DRB1 shared alleles between primary cases and their contacts was a risk factor for tuberculosis (p=0.0281).

CONCLUSION

This household contact model together with the utilisation of two genetic variables permitted the evaluation of genetic factors contributing towards tuberculosis development.

Cytotoxicity of MTA and Portland cement on human ECV 304 endothelial cells

AIM

To evaluate the cytotoxic effects of two brands of mineral trioxide aggregate (MTA) (Pro-Root MTA and MTA Angelus) and Portland cement (PC) on the human ECV 304 endothelial cell line.

METHODOLOGY

Endothelial ECV 304 cells were incubated at 37 degrees C in an atmosphere of 95% air, 5% carbon dioxide and 100% humidity for 7 days and grown in F12 medium supplemented with 10% fetal bovine serum with 50 microg mL(-1) of gentamicin sulphate. Effects of the materials on mitochondrial functions were measured by a colorimetric assay. At each experimental time interval (24, 48 and 72 h), a dimethyl-thiazol-diphenyl tetrazolium bromid assay was conducted to measure cell viability. All assays were repeated three times to ensure reproducibility. Results were expressed as average absorbance (A(570/nm)) +/- SD and the data were analysed statistically by one-way analysis of variance and the Bonferroni post-test. A P-value < 0.05 was considered statistically significant.

RESULTS

No statistically significant difference was shown between any of the experimental materials (P > 0.05).

CONCLUSIONS

The two brands of MTA analysed, as well as the PC, initially showed a similar elevated cytotoxic effect that decreased gradually with time allowing the cell culture to become reestablished.

[Leprosy surveillance in Olinda, Brazil, using spatial analysis techniques]

In the State of Pernambuco, Brazil, leprosy has been mainly an urban disease, with an uneven geographical distribution related at least partially to the way urban space has been occupied and transformed. Spatial analysis may thus become an important tool to establish an epidemiological surveillance system for leprosy. Homogeneous micro-areas were defined in the city of Olinda through the integration of two databases, the Population Census and SINAN, and through the use of digital maps and geoprocessing techniques. Census tracts were classified according to a social deprivation index (SDI), and micro-area homogeneity was based on similar values for this indicator. Cluster analysis (K-means) was used to define cut-offs between strata. The same procedure was repeated using the income variable only. When the association was tested between the mean SDI value and the mean leprosy detection rate for the period 1991-1996, the value obtained for r2 was 66.1% in the multiplicative model, increasing to 84.3% when the income variable was used. To define different intervention strategies, census tracts were regrouped in three levels of risk: high, moderate, and low. The methodology enabled the identification (within each health district) of groups and/or areas with different risk of leprosy, hence allowing for the definition of control measures.

Mortalidade por causas externas em crianças e adolescentes: tendências de 1979 a 1995

OBJETIVO: Analisar a magnitude e a tendência da mortalidade por grupos específicos de causas externas em crianças e adolescentes residentes no Recife, no período de 1979 a 1995. MÉTODOS: Foram utilizados os dados do Sistema de Informação em Mortalidade do Ministério da Saúde e da Secretaria de Saúde de Pernambuco. O grupo estudado, na faixa etária de 0-19 anos, representou 41,8% da população de Recife, em 1991. Utilizou-se o desenho ecológico exploratório tipo série temporal. Analisou-se a tendência para os coeficientes de mortalidade por causas externas e seus grupos específicos segundo sexo e grupo etário, por regressão linear simples. RESULTADOS E CONCLUSÕES: Na série temporal estudada, os coeficientes de mortalidade por causas externas mostraram crescimento, sobretudo por homicídios nos adolescentes, em que se observaram um aumento anual médio de 3,05 e um aumento relativo de 601, 3% ao longo da série. Em 1995, mais de 90% desses homicídios foram perpetrados por arma de fogo. Os dados revelam a magnitude do problema e a necessidade do seu enfrentamento, o qual precisa considerar a complexidade da determinação da violência.

[Underlying cause of death from external causes: validation of official data in Recife, Pernambuco, Brazil]

OBJECTIVE

To validate the underlying cause of death recorded on the death certificates for individuals under 20 years of age who died from external causes in 1995 in Recife, Pernambuco, Brazil.

METHODS

We divided the study into two stages, coding and validation. In both stages we compared the official data concerning causes of death to the data we obtained during our study. We grouped the death certificates into 5 broad categories according to the cause of death; we later subdivided them into 14 categories. We also individually compared the death certificates applying the four-digit system of the International Classification of Diseases, Ninth Revision (ICD-9). We assessed the agreement between the official data and our data in terms of sensitivity and the kappa coefficient. We took as the standard the categorization of the cause of death that we had made during our investigation.

RESULTS

In the coding stage, considering all the external causes of death, the overall agreement between the official data and our study data was 94% for the 5 categories, 92% for the 14 categories, and 81% for the four-digit ICD-9 system. In the validation stage the overall agreement was 94% for the 5 categories, 91% for the 14 categories, and 73% for the four-digit ICD-9 system.

CONCLUSIONS

Our results suggest that for the death certificates to be reliable, the Institute of Legal Medicine must fill them out following recommended standards. In addition, hospitals and police departments must use greater care in completing the transfer slips that accompany the bodies that are sent to the Institute. More accurate data need to be generated and disseminated for a society to better understand its patterns of violence.

[Fulfilling of variables in the declarations of external cause of death of children and adolescents in Recife from 1979 to 1995]

This article analyzes the completion of death certificates related to external causes in children and adolescents residing in Recife, Pernambuco State, Brazil, from 1979 to 1995. The analysis focused on the extent to which the following variables were filled in: personal data (occupation, level of schooling, medical care, confirmation of diagnosis by post-mortem, and type of violence) and place (location and municipality of both occurrence and death). Using the chi-squared method, quantitative and/or qualitative flaws were found in most of the variables analyzed. In 1995, the "schooling" and "medical care" variables were recorded in only 5.7% and 17.9% of cases, respectively. Mismatches were observed between data on place of death and medical care, as well as between place of accident and number of accidents. The results suggest a dissociation between the objective of including the variable in the death certificate and its social function. The study provides the public sector with support for improved collecting and critical analysis of data in the mortality information system.

The use of socioeconomic factors in mapping tuberculosis risk areas in a city of northeastern Brazil

In Brazil the challenge of meeting the needs of those living in deprived areas has generated discussions on replacing the existing approach to epidemiological surveillance with an integrated public health surveillance system. This new approach would supplant the traditional focus on high-risk individuals with a method for identifying high-risk populations and the areas where these persons live. Given the magnitude of the problem that tuberculosis (TB) poses for Brazil, we chose that disease as an example of how such a new, integrated public health surveillance system could be constructed. We integrated data from several sources with geographic information to create an indicator of tuberculosis risk for Olinda, a city in the Brazilian state of Pernambuco. In order to stratify the urban space in Olinda and to check for an association between the resulting TB risk gradient and the mean incidence of the disease between 1991 and 1996, we applied two different methods: 1) a "social deprivation index" and 2) principal component analysis followed by cluster analysis. Our results showed an association between social deprivation and the occurrence of TB. The results also highlighted priority groups and areas requiring intervention. We recommend follow-up that would include treating acid-fast bacilli smear-positive pulmonary TB cases, tracing of these persons' contacts, and monitoring of multidrug-resistant cases, all in coordination with local health services.

[Violence and death: differentials in mortality from external causes in the urban space of Recife, Pernambuco, Brazil, 1991]

This study aimed to describe the amount of (and trends in) violent deaths in the city of Recife, Pernambuco, Brazil, and to analyze their determinants. The article presents the spatial distribution of these deaths for the year 1991 and the differences regarding sex, age, and place of occurrence. It also analyzes the potential role of a series of socioeconomic factors, used as indicators of the population's living conditions. An exploratory ecological study was conducted to compare various groups. In 1991 there were a total of 1181 violent deaths in Recife. The study points to an overall mortality rate from external causes of 90.9/ 100,000 inhabitants. The two age groups 10-39 years and 60 years and over were those at highest risk of death. Males showed excess mortality in all age groups. The most important specific causes of death were homicides and traffic accidents, with 51.3% and 23.4%, respectively, of all violent deaths. The authors discuss the differences in the mortality rate from external causes in different social areas, defined according to living conditions and their relationship to the history of the development of Recife.

[An increase in Hansen's disease in northeastern Brazil]

The epidemiological aspects of hanseniasis in Recife from 1960 to 1985 were studied. Clinical-epidemiological records of 3,923 leprosy patients reported to the Secretaria de Saúde do Estado de Pernambuco were reviewed. The cruce as well as the age, sex and type-specific detection rates were calculated. The way the cases were detected and the time elapsed between the appearance of the first symptoms and the disease was analysed. The analysis of the time trend during the observation period showed an increase in the detection rate with time, rising from 5.5 per 100,000 inhabitants in 1960 to 36.1 per 100,000 inhabitants in 1985. The higher frequency of the tuberculoid type of leprosy and the high percentage of patients under 15 might refleet the expansion of the disease in Recife. The decline and the stabilization in the time elapsed between the appearance of the disease and its detection, from 1979 onwards, indicates a more prompt detection and, as a consequence of that, that the rate of detection is approaching the incidence rate. From 1970 to 1985 the most common means of detecting cases of Hanseniasis was through dermatological consultation followed by disease notification. Only 14.2% of the cases were discovered through the surveillance of contacts. The analysis of the epidemiological and operational indicators suggest that the increase in the detection rate over the period from 1960 to 1985 was due both to expansion of the disease and improvement in control measures. The prevalence rate of Hanseniasis in Recife in December 1984 was 2.04 per 100,000 inhabitants; according to the WHO criteria Recife may be considered an area of high endemicity.