Avaliação de desempenho do controle da tuberculose em municípios brasileiros

OBJETIVO Avaliar o desempenho no controle da tuberculose dos municípios brasileiros. MÉTODOS Estudo ecológico com municípios brasileiros que notificaram pelo menos quatro casos novos de tuberculose, com no mínimo um caso novo de tuberculose pulmonar entre 2015 e 2018. Os municípios foram estratificados de acordo com a população em < 50 mil, 50–100 mil, 100–300 mil e > 300 mil habitantes e foi utilizado o método k-médias para agrupá-los dentro de cada faixa populacional segundo desempenho de seis indicadores da doença. RESULTADOS Foram incluídos 2.845 municípios brasileiros abrangendo 98,5% (208.007/211.174) dos casos novos de tuberculose do período. Para cada faixa populacional identificou-se três grupos (A, B e C) de municípios segundo desempenho dos indicadores: A os mais satisfatórios, B os intermediários e C os menos satisfatórios. Municípios do grupo A com < 100 mil habitantes apresentaram resultados acima das metas para confirmação laboratorial (≥ 72%), abandono (≤ 5%) e cura (≥ 90%), e abrangeram 2% dos casos novos da doença. Por outro lado, os municípios dos grupos B e C apresentaram pelo menos cinco indicadores com resultados abaixo das metas – testagem HIV (< 100%), exame de contatos (< 90%), tratamento diretamente observado (< 90%), abandono (> 5%) e cura (< 90%) –, e corresponderam a 66,7% dos casos novos de tuberculose. Já no grupo C dos municípios com > 300 mil habitantes, que incluiu 19 das 27 capitais e 43,1% dos casos novos de tuberculose, encontrou-se os menores percentuais de exames de contatos (média = 56,4%) e tratamento diretamente observado (média = 15,4%), elevado abandono (média = 13,9%) e baixa cobertura da atenção básica (média = 66,0%). CONCLUSÕES Grande parte dos casos novos de tuberculose ocorreu em municípios com desempenho insatisfatório para o controle da doença, onde expandir a cobertura da atenção básica pode reduzir o abandono e elevar o exame de contatos e tratamento diretamente observado.OBJECTIVE To evaluate the performance of tuberculosis control in Brazilian municipalities. METHODS This is an ecological study on Brazilian municipalities that notified at least four new cases of tuberculosis, with a minimum of one new case of pulmonary tuberculosis between 2015 and 2018. The municipalities were stratified according to the population in < 50 thousand, 50–100 thousand, 100–300 thousand, and > 300 thousand inhabitants, and the k-means method was used to group them within each population range according to the performance of six indicators of the disease. RESULTS A total of 2,845 Brazilian municipalities were included, comprising 98.5% (208,007/211,174) of new tuberculosis cases in the period. For each population range, three groups (A, B, and C) of municipalities were identified according to the performance of the indicators: A, the most satisfactory; B, the intermediates; and C, the least satisfactory. Municipalities in group A with < 100 thousand inhabitants presented results above the targets for laboratory confirmation (≥ 72%), abandonment (≤ 5%), and cure (≥ 90%), and comprised 2% of new cases of the disease. Conversely, municipalities of groups B and C presented at least five indicators with results below the targets – HIV testing (< 100%), contact investigation (< 90%), directly observed therapy (< 90%), abandonment (> 5%), and cure (< 90%) –, and corresponded to 66.7% of new cases of tuberculosis. In group C of municipalities with > 300 thousand inhabitants, which included 19 of the 27 capitals and 43.1% of new cases of tuberculosis, the lowest percentages of contact investigation (mean = 56.4%) and directly observed therapy (mean = 15.4%) were verified, in addition to high abandonment (mean = 13.9%) and low coverage of primary health care (mean = 66.0%). CONCLUSIONS Most new cases of tuberculosis occurred in municipalities with unsatisfactory performance for disease control. Expanding the coverage of primary health care in these places can reduce abandonment and increase the contact investigation and directly observed therapy

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

Performance evaluation of tuberculosis control in Brazilian municipalities.

OBJECTIVE: To evaluate the performance of tuberculosis control in Brazilian municipalities. METHODS: This is an ecological study on Brazilian municipalities that notified at least four new cases of tuberculosis, with a minimum of one new case of pulmonary tuberculosis between 2015 and 2018. The municipalities were stratified according to the population in 300 thousand inhabitants, and the k-means method was used to group them within each population range according to the performance of six indicators of the disease. RESULTS: A total of 2,845 Brazilian municipalities were included, comprising 98.5% (208,007/211,174) of new tuberculosis cases in the period. For each population range, three groups (A, B, and C) of municipalities were identified according to the performance of the indicators: A, the most satisfactory; B, the intermediates; and C, the least satisfactory. Municipalities in group A with 5%), and cure ( 300 thousand inhabitants, which included 19 of the 27 capitals and 43.1% of new cases of tuberculosis, the lowest percentages of contact investigation (mean = 56.4%) and directly observed therapy (mean = 15.4%) were verified, in addition to high abandonment (mean = 13.9%) and low coverage of primary health care (mean = 66.0%). CONCLUSIONS: Most new cases of tuberculosis occurred in municipalities with unsatisfactory performance for disease control. Expanding the coverage of primary health care in these places can reduce abandonment and increase the contact investigation and directly observed therapy