Survival time among patients who were diagnosed with tuberculosis, the precocious deaths and associated factors in southern Brazil

Background: A diagnosis of tuberculosis (TB) does not mean that the disease will be treated successfully, since death may occur even among those who are known to the health services. Here, we aimed to analyze patient survival time from the diagnosis of TB to death, precocious deaths, and associated factors in southern Brazil. Methods: We conducted a longitudinal study with patients who were diagnosed with TB and who died due to the disease between 2008 and 2015 in southern Brazil. The starting point for measuring survival time was the patient’s diagnosis date. Techniques for survival analysis were employed, including the Kaplan-Meier test and Cox’s regression. A mixed-effect model was applied for identifying the associated factors to precocious deaths. Hazard ratio (HR) and odds ratio (OR) with 95% confidence intervals (95% CI) were estimated. We defined p value <0.05 as statistically significant for all statistics applied. Results: One hundred forty-six patients were included in the survival analysis, observing a median survival time of 23.5 days. We observed that alcoholism (HR=1.55, 95% CI=1.04-2.30) and being male (HR=6.49, 95% CI=1.03-2.68) were associated with death. The chance of precocious death within 60 days was 10.48 times greater than the chance of early death within 30 days. Conclusion: Most of the deaths occurred within 2 months after the diagnosis, during the intensive phase of the treatment. The use of alcohol and gender were associated with death, revealing inequality between men and women. This study advanced knowledge regarding the vulnerability associated with mortality. These findings must be addressed to fill a gap in the care cascades for active TB and ensure equity in health.publishersversionpublishe

Inequality of gender, age and disabilities due to leprosy and trends in a hyperendemic metropolis: Evidence from an eleven-year time series study in Midwest of Brazil

In the 2019 report, Brazil had a detection rate of 13.23 per 100.000 inhabitants far from the goal of less than 1 leprosy (Hansen’s Disease) case per 10,000 inhabitants describe by the World Health Organization. The present study aimed to investigate the epidemiological situation of leprosy and its trend between 2008 and 2018 in a hyperendemic metropolis in the Central-West region of Brazil. A total of 9.739 leprosy cases were reported between 2008 and 2018. The majority of cases were male (58.37%), with a predominant age of 15 to 59 years (87.55%). The predominant level of education was incomplete elementary school (43.96%). The disability grade at diagnosis showed that 40.19% had G0D and for the G2D was 8.06%.There was a predominance in operational classification of multibacillary cases (72.85%). While detection rate trends in females and the majority of the age groups are decreasing, increases are seen in the detection of male patients and patients already suffering from disabilities. Although declining trends were presented, the metropolis is still not close to elimination showing the need prioritize leprosy actions and to improve care for this disease

Effectiveness and trend forecasting of tuberculosis diagnosis after the introduction of GeneXpert in a city in south-eastern Brazil

Background: To evaluate the effectiveness of a rapid molecular test for the detection of tuberculosis (TB) and to predict the rates of disease in a municipality of Brazil where TB is endemic. Methods: An ecological study was carried out in Ribeirão Preto-SP on a population of TB cases notified between 2006 and 2017. Monthly TB incidence rates and the average monthly percentage change (AMPC) were calculated. In order to identify changes in the series, the breakpoint technique was performed; the rates were modelled and predictions of the incidence of TB until 2025 were made. Results: AMPC showed a fall of 0.69% per month in TB and human immunodeficiency virus (TB-HIV) co-infection, a fall of 0.01% per month in general and lung TB and a fall of 0.33% per month in extrapulmonary TB. With the breakpoint technique, general and pulmonary TB changed in structure in late 2007, and extrapulmonary TB and TB-HIV co-infection changed in structure after 2014, which is considered the cut-off point. The IMA(3) models were adjusted for general and pulmonary TB and TB-HIV co-infection, and the AR(5) models for extrapulmonary TB, and predictions were performed. Conclusions: The rapid molecular test for TB is the method currently recommended by the WHO for the diagnosis of the disease and its main advantage is to provide faster, more accurate results and to already check for drug resistance. It is necessary that professionals encourage the use of this technology in order to optimize the diagnosis so that the treatment begins as quickly as possible and in an effective way. Only by uniting professionals from all areas with health policies aimed at early case identification and rapid treatment initiation it is possible to break the chain of TB transmission so that its rates decrease and the goals proposed by the WHO are achieved

Fatores relacionados, tendência temporal e associação espacial do abandono de tratamento para tuberculose em Ribeirão Preto-SP

Objetivou-se identificar fatores relacionados, classificar a tendência temporal e identificar áreas com associação espacial do abandono de tratamento para tuberculose em Ribeirão Preto, São Paulo. Estudo ecológico; população composta pelos casos notificados entre 2006 a 2017. Realizou-se o teste qui-quadrado para identificar fatores relacionados. Para a tendência temporal, utilizou-se o método de Prais-Winsten para classificar a tendência temporal do evento e calculada sua porcentagem de variação anual. Para verificar associação espacial, utilizaram-se as técnicas G e Gi*. Foram notificados 146 casos de abandono do tratamento da doença no período; como fatores de risco foi identificado pessoas sem escolaridade, retratamentos pós-abandono e falência prévia; como proteção casos novos identificados pela busca ativa, não ter coinfecção Tuberculose-HIV e não fazer uso de álcool ou drogas. A taxa de abandono apresenta tendência crescente (APC=1,6%; IC95% 0.02–3.48). O estudo evidencia o aumento do abandono de tratamento, contrariando as políticas direcionadas pelo End TB Strategy. Descritores: Tuberculose; Cooperação e Adesão ao Tratamento; Saúde Pública; Análise Espacial

Impacto do teste rápido molecular GeneXpert® MTB/RIF na detecção da tuberculose: tendências temporais e territórios vulneráveis

Objetivo: evaluar el impacto de la prueba rápida molecular GeneXpert®&nbsp;MTB/RIF en la detección de tuberculosis, analizar la tendencia temporal del evento e identificar territorios vulnerables en un municipio brasileño. Método: estudio ecológico realizado en Ribeirão Preto, São Paulo, Brasil, municipio considerado prioritario en el control de la tuberculosis por el elevado número de casos. Se utilizó el método de Prais-Winsten para clasificar la tendencia temporal y la técnica de Series de Tiempo Interrumpidas para identificar cambios en la incidencia de la enfermedad. Se aplicó un análisis de intensidad de Kernel para identificar áreas vulnerables. Resultados: la tendencia temporal de la tuberculosis disminuyó un 18,1%/año y un 6,9%/año en los menores de 15 años. La incidencia de tuberculosis disminuyó un 6,67%/año en el Distrito Norte y aumentó un 17,5%/año en el Distrito Este. La tuberculosis resistente, después de la implementación de la Prueba Molecular Rápida, aumentó un 0,6% anual. Los Distritos Sur y Oeste presentaron una mayor densidad de casos, con un rango de 45 a 79 casos de tuberculosis por kilómetros cuadrados (km2). Conclusión: aunque la tuberculosis resistente no representa un problema en el escenario, el estudio mostró un aumento en la incidencia, lo que genera una señal de alerta. El uso del análisis espacial permitió identificar áreas prioritarias, para que puedan llevarse a cabo acciones de vigilancia en salud.Objective: to assess the impact of the GeneXpert®&nbsp;MTB/RIF rapid molecular test on tuberculosis detection, to analyze the temporal trend of the event and to identify vulnerable territories in a Brazilian municipality. Method: an ecological study carried out in Ribeirão Preto, São Paulo, Brazil, a municipality considered a priority in tuberculosis control due to the high number of cases. To classify the temporal trend, the Prais-Winsten method and the Interrupted Time Series were used to identify changes in the disease incidence. Kernel intensity analysis was applied to identify vulnerable areas. Results: the temporal trend of tuberculosis decreased by 18.1%/year and by 6.9%/year for children under 15 years old. The North District decreased by 6.67%/year and the East District increased by 17.5%/year in the incidence of tuberculosis. Resistant tuberculosis, after the implementation of the Rapid Molecular Test, increased by 0.6% per year. The South and West Districts showed a higher density of cases, with a range from 45 to 79 tuberculosis cases per square kilometer (km2). Conclusion: although resistant tuberculosis is not a problem in the scenario, the study showed an increase in its incidence, which puts it on alert. The use of spatial analysis enabled the identification of priority areas, putting them in evidence for health surveillance actions.Objetivo: avaliar o impacto do teste rápido molecular GeneXpert®&nbsp;MTB/RIF na detecção da tuberculose, analisar a tendência temporal do evento e identificar territórios vulneráveis em município brasileiro. Método: estudo ecológico realizado em Ribeirão Preto, São Paulo, Brasil, município considerado prioritário no controle da tuberculose devido ao elevado número de casos. Para classificar a tendência temporal foi utilizado o método de Prais-Winsten e a Série Temporal Interrompida para identificar mudanças na incidência da doença. Aplicou-se a análise de intensidade de Kernel para a identificação de áreas vulneráveis. Resultados: a tendência temporal da tuberculose apresentou decréscimo de 18,1%/ano e de 6,9%/ano em menores de 15 anos. O Distrito Norte apresentou decréscimo de 6,67%/ano e o Distrito Leste crescimento de 17,5%/ano, na incidência de tuberculose. A tuberculose resistente, após a implementação do teste rápido molecular, apresentou aumento de 0,6% por ano. Os Distritos Sul e Oeste apresentaram maior densidade de casos, com variação de 45 a 79 casos de tuberculose por quilômetro quadrado (km2). Conclusão: apesar da tuberculose resistente não ser um problema no cenário, o estudo evidenciou um crescimento na sua incidência, o que o coloca em estado de alerta. O uso da análise espacial possibilitou a identificação das áreas prioritárias, colocando-as em evidência para ações de vigilância em saúde

challenges and strategies for adherence to treatment during the COVID-19 pandemic in Brazil

Funding Information: The study was supported by the São Paulo Research Foundation (FAPESP) [Grant 2018/14337–0], the National Council for Scientific and Technological Development (CNPq) [Grant 130160/2020–2] and Research Productivity Grant from the National Council for Scientific and Technological Development (CNPq) [Grant 304483/2018–4 - PQ modality (Level 1C)]. Publisher Copyright: © 2021, The Author(s).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.publishersversionpublishe

Temporal trend of tuberculosis incidence and its spatial distribution in Macapá – Amapá

OBJETIVO: Avaliar a tendência temporal da incidência da tuberculose após a implementação do teste rápido molecular, identificar se a tuberculose apresenta variação sazonal e classificar o território de acordo com a densidade de casos e as áreas de risco em Macapá-AP. MÉTODOS: Estudo ecológico composto por casos de tuberculose registrados no SINAN entre 2001 e 2017. Foi utilizado o teste Prais-Winsten para classificar a tendência temporal da incidência e a Série Temporal Interrompida para identificar mudanças na tendência temporal antes e depois da implementação do teste rápido molecular, além de verificar a sazonalidade no município. Utilizou-se o estimador de Kernel para classificar a densidade de casos e estatística de varredura para identificar áreas de risco da tuberculose. RESULTADOS: Foram identificados 1730 casos, observando-se que a tendência temporal da incidência de tuberculose foi decrescente (-0,27% por mês, IC95% −0,13 a −0,41). Não houve mudança de nível na série temporal após a implantação do teste molecular GeneXpert® MTB/RIF, porém, o período pós teste foi classificado como crescente em termos da incidência (+2,09% por mês, IC95% 0,92 a 3,27). Quanto à variação sazonal, apresentou crescimento (+13,7%/mês, IC95% 4,71 a 23,87) nos meses de dezembro a junho, referente ao período de chuvas – chamado inverno amazônico – e decréscimo (-9,21% por mês, IC95% −1,37 a −16,63) nos demais períodos. Por meio de Kernel, foram classificadas áreas com alta densidade de casos nos distritos Central e Norte e, com a estatística de varredura, foram identificados três aglomerados de proteção, AE1 (RR = 0,07), AE2 (RR = 0,23) e AE3 (RR = 0,36), e um aglomerado de alto risco, AE4 (RR = 1,47). CONCLUSÃO: A tendência temporal da incidência de tuberculose se revelou decrescente na série temporal, todavia, um crescimento na detecção foi observado após introdução do TRM-TB, e ainda se evidenciou que há comportamento sazonal da tuberculose. A distribuição dos casos foi heterogênea, com tendência de concentração em territórios vulneráveis e de risco, evidenciando um padrão de desigualdade da doença no território.OBJECTIVE: To evaluate the temporal trend of tuberculosis incidence after the implementation of the rapid molecular test (RMT-TB), to identify whether tuberculosis presents seasonal variation and to classify the territory according to case density and risk areas in Macapá, Amapá. METHODS: Ecological study of tuberculosis cases registered in the Sistema de Informação de Agravos de Notificação (SINAN – Information System for Notifiable Diseases) between 2001 and 2017. We used the Prais-Winsten test to classify the temporal trend of incidence and the interrupted time series to identify changes in the temporal trend before and after the implementation of the rapid molecular test, and to verify seasonality in the municipality. The Kernel estimator was used to classify case density and scan statistics to identify areas of tuberculosis risk. RESULTS: A total of 1,730 cases were identified, with a decreasing temporal trend of tuberculosis incidence (−0.27% per month, 95%CI −0.13 to −0.41). The time series showed no change in level after the implementation of the GeneXpert®MTB/RIF molecular test; however, the incidence increased in the post-test period (+2.09% per month, 95%CI 0.92 to 3.27). Regarding the seasonal variation, it showed growth (+13.7%/month, 95%CI 4.71 to 23.87) from December to June, the rainy season – called amazon winter season –, and decrease (−9.21% per month, CI95% −1.37 to −16.63) in the other periods. We classified areas with high density of cases in the Central and Northern districts using Kernel and identified three protection clusters, SC1 (RR = 0.07), SC2 (RR = 0.23) and SC3 (RR = 0.36), and a high-risk cluster, SC4 (RR = 1.47), with the scan statistics. CONCLUSION: The temporal trend of tuberculosis incidence was decreasing in the time series; however, detection increased after the introduction of RMT-TB, and tuberculosis showed seasonal behavior. The case distribution was heterogeneous, with a tendency to concentrate in vulnerable and risk territories, evidencing a pattern of disease inequality in the territory

Trends and forecasts of leprosy for a hyperendemic city from Brazil’s northeast: Evidence from an eleven-year time-series analysis

This study’s objective was to estimate the temporal trends of leprosy according to sex and age groups, as well as to estimate and predict the progression of the disease in a hyperendemic city located in the northeast of Brazil. This ecological time-series study was conducted in Imperatriz, Maranhão, Brazil. Leprosy cases diagnosed between 2006 and 2016 were included. Detection rates stratified by sex and age groups were estimated. The study of temporal trends was accomplished using the Seasonal-Trend Decomposition method and temporal modeling of detection rates using linear seasonal autoregressive integrated moving average model according to Box and Jenkins method. Trend forecasts were performed for the 2017–2020 period. A total of 3,212 cases of leprosy were identified, the average incidence among men aged between 30 and 59 years old was 201.55/100,000 inhabitants and among women in the same age group was 135.28/100,000 inhabitants. Detection rates in total and by sex presented a downward trend, though rates stratified according to sex and age presented a growing trend among men aged less than 15 years old and among women aged 60 years old or over. The final models selected in the timeseries analysis show the forecasts of total detection rates and rates for men and women presented a downward trend for the 2017–2020 period. Even though the forecasts show a downward trend in Imperatriz, the city is unlikely to meet a significant decrease of the disease burden by 2020

Temporal trends in areas at risk for concomitant tuberculosis in a hyperendemic municipality in the Amazon region of Brazil.

This ecological study was performed in the municipality of Manaus, in northern Brazil. The population comprised cases with concomitant pulmonary and extrapulmonary TB, registered on the Notifiable Diseases Information System (SINAN), between January 1, 2009 and December 31, 2018. For risk cluster detection, spatial and spatiotemporal scanning statistical techniques were used. The Spatial Variation in Temporal Trends (SVTT) approach was used to detect and infer clusters for significantly different time trends

Evolução temporal e distribuição espacial da hanseníase em município de baixa endemicidade em São Paulo

Objective: To analyze the spatial and temporal distribution of leprosy in a scenario of low endemicity in the state of São Paulo, Brazil. Methods: Ecological study with leprosy casesin Ribeirão Preto, between 2006 to 2016. The temporal trend of leprosy detection was verified through the decomposition of time series and identified areas of high and low occurrence of the disease using the Getis-Ord Gi* technique. Results: There were 890 cases and the detection rate showed an increasing trend in the period from 2011 to 2015, with an average growth of 1% per month. Areas of high occurrence of the disease were identified in the northern region of the city (99% and 95% confidence). Conclusion: The temporal analysis showed that the rate of detection of leprosy showed an increasing trend, and the spatial analysis showed that the region of the municipality with the highest occurrence of the disease is characterized by presenting the greatest social inequalities.Objetivo: Analizar la distribución espacial y temporal de la lepra en un escenario de baja endemicidad en el estado de São Paulo, Brasil. Métodos: Estudio ecológico con casos de lepra de Ribeirão Preto, entre 2006 y 2016. La tendencia temporal de la detección de lepra se verificó a través de la descomposición de series de tiempo e identificaron áreas 5 de alta y baja ocurrencia utilizando la técnica Getis-Ord Gi*. Resultados: Fueran 890 casos y la tasa de detección mostró una tendencia creciente en el período de 2011 a 2015, con un crecimiento promedio de 1% mensual. Se identificaron áreas de alta ocurrencia de la enfermedad en la región norte de la ciudad (99% y 95% de confianza). Conclusión: El análisis temporal mostró que la tasa de detección de lepra mostró una tendencia creciente y análisis espacial mostró que la región del municipio con mayor ocurrencia de la enfermedad se caracteriza por presentar las mayores desigualdades sociale.Objetivo: Analisar a distribuição espacial e temporal da hanseníase em cenário de baixa endemicidade no estado de São Paulo, Brasil. Métodos: Estudo ecológico, sobre casos de hanseníase notificados em no município de Ribeirão Preto, entre 2006 e 2016. A tendência temporal da taxa de detecção de hanseníase foi verificada mediante decomposição de séries temporais, e identificadas as áreas de alta e de baixa ocorrência da doença utilizando-se a técnica Getis-Ord Gi*. Resultados: Foram 890 casos, e a taxa de detecção apresentou uma tendência crescente no período analisado, com crescimento médio de 1% ao mês. Identificou-se áreas de alta ocorrência da doença na região norte do município (99% e 95% de confiança). Conclusão: A taxa de detecção de hanseníase apresentou tendência temporal crescente, e a análise espacial permitiu visualizar que a 4 região do município com maior ocorrência da doença se caracteriza por apresentar as maiores desigualdades sociais