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

Spatial Distribution and Temporal Trend of Childhood Tuberculosis in Brazil

Tuberculosis (TB) in children presents specificities in its diagnosis, which makes it prone to underreporting: therefore, the disease in this group is still a serious public health problem in several countries. We aimed to analyze the spatial distribution and temporal trend of childhood TB in Brazil. An ecological study with time series, spatial analysis, and description of cases in Brazil between 2010–2021 was conducted. A total of 1,054,263 TB cases were reported in the period, with 30,001 (2.8%) in children. The yearly average was 2,500 cases, with a trend toward an increase in the incidence rate in 2018 and 2019 and a decline in 2020. Children under 5 years old represented 38.2% of cases, 5.2% were indigenous, and 424 children (1.4%) died. Sputum culture was performed for 18.4% of pulmonary TB. The incidence rates were higher in municipalities in the north and midwest regions, with high occurrence locations (hot spots), especially on borders with other countries. There was a reduction in childhood TB in 2020, possibly related to the COVID-19 pandemic. Strategies are needed for the identification and monitoring of childhood TB, with reinforcement of professional training for assistance and control, especially in the most vulnerable locations and groups

Treatment of drug-resistant tuberculosis in children and young adolescents in Brazil

Introduction: Drug-resistant tuberculosis (DR-TB) is a global threat and a challenge for public health authorities worldwide. In children, the diagnosis is even more challenging and DR-TB is poorly described in the literature, as are its treatment outcomes. In this study, we aimed to describe the treatment of drug-resistant TB in children and young adolescents in Brazil. Methods: A descriptive epidemiological study of treatment for DR-TB in children under 15 years of age in Brazil between 2013 and 2020. The primary data source was the Information System for Special Tuberculosis Treatments (SITE-TB). Categorical variables were analyzed using relative frequencies (%) and continuous variables by measures of central tendency to characterize the profile of the cases, namely: sociodemographic, clinical characteristics, procedures, tests performed and treatment success. In order to verify the distribution of cases, a spatial analysis was carried out based on the municipality where the cases resided. Results: Between 2013 and 2020, 19,757 tuberculosis (TB) cases occurred in children aged <15 years in Brazil, and 46 cases of treatment for DR-TB were reported during the same period (annual average of 6 cases). Of these, 73.9% were aged 10–14, 65.2% were male, 4.3% were HIV+ and 43.3% were underweight (BMI<18.5) at the start of treatment. 17.4% had previous contact with TB, 69.6% had primary resistance, 47.8% multidrug resistance. The median duration of treatment was 15 months. DOT and standardized treatment regimen were performed in 52.2% of cases. Bacilloscopy was performed for 97.8% (57.8% positive); culture for 89.1% (75.6% positive), rapid molecular test for 73.9% with proven resistance to rifampicin in 55.8%. Susceptibility testing revealed resistance mainly to isoniazid (87.8%) and rifampicin (60.6%). 73.9% of cases were successfully treated and one death was reported. Cases were treated in 26 Brazilian municipalities, with the majority in Rio de Janeiro (15) and São Paulo (4). Conclusion: DR-TB treatment was recorded in <1% of general TB cases in children and young adolescents, suggesting underreporting of drug-resistant cases in the country. Despite the low number of registered cases, the data reflect the situation of DR-TB in this population and describe important aspects of the problem, as the child needs comprehensive, individualized care, with support from different professionals. We recommend a strengthening of the country's referral services for the care of children with DR-TB so that surveillance and health care services can work together to identify and follow up cases

Spatial Distribution and Temporal Trend of Childhood Tuberculosis in Brazil

Tuberculosis (TB) in children presents specificities in its diagnosis, which makes it prone to underreporting: therefore, the disease in this group is still a serious public health problem in several countries. We aimed to analyze the spatial distribution and temporal trend of childhood TB in Brazil. An ecological study with time series, spatial analysis, and description of cases in Brazil between 2010–2021 was conducted. A total of 1,054,263 TB cases were reported in the period, with 30,001 (2.8%) in children. The yearly average was 2,500 cases, with a trend toward an increase in the incidence rate in 2018 and 2019 and a decline in 2020. Children under 5 years old represented 38.2% of cases, 5.2% were indigenous, and 424 children (1.4%) died. Sputum culture was performed for 18.4% of pulmonary TB. The incidence rates were higher in municipalities in the north and midwest regions, with high occurrence locations (hot spots), especially on borders with other countries. There was a reduction in childhood TB in 2020, possibly related to the COVID-19 pandemic. Strategies are needed for the identification and monitoring of childhood TB, with reinforcement of professional training for assistance and control, especially in the most vulnerable locations and groups

International Migration, Refugees, and Spread of Tuberculosis in Brazil: Analysis of Clusters, Trends, and Associated Factors (2010–2021)

Background: International migration is a global phenomenon with significant implications on the health–disease process due to exposures along transit routes and local/destination epidemiological indicators. We aimed to analyze the transmission and spread of tuberculosis among international migrants and refugees from a spatiotemporal perspective and the associated factors. Method: This was an ecological study of cases of tuberculosis in international migrants in Brazil, between 2010 and 2021. Annual incidence rates were calculated and spatiotemporal scan techniques were used to identify municipalities at risk. Multiple logistic regression was used to identify factors associated with tuberculosis in international migrants. Results: A total of 4037 cases of tuberculosis were reported in Brazil in international migrants. Municipalities at risk for this event were identified using the spatiotemporal scan technique, and a cluster was identified with ITT: +52.01% and ETT: +25.60%. A higher probability of TB infection was identified in municipalities with a TB incidence rate >14.40 cases/100 inhabitants, population >11,042 inhabitants, Gini index >0.49, and illiteracy rate >13.12%. A lower probability was found in municipalities with average per capita household income >BRL 456.43. Conclusions: It is recommended that health authorities implement monitoring and rigorous follow-up in affected areas to ensure proper diagnosis and treatment completion for international migrants, preventing disease spread to other communities

Acquired and Transmitted Multidrug-Resistant Tuberculosis among the Incarcerated Population and Its Determinants in the State of Paran&aacute;&mdash;Brazil

(1) Background: Tuberculosis remains a public health problem in the world. The study analyzed the factors associated with drug-resistant tuberculosis in the prison population of the state of Paran&aacute;. (2) Methods: Ecological study of drug-resistant tuberculosis cases registered in the Paran&aacute; Information System, Brazil (2008 to 2018). We performed descriptive statistics of quantitative parameters calculated with absolute frequencies. Additionally, we used binary regression logistics, where the odds ratio with its respective confidence interval was calculated. (3) Results: Of the 653 cases registered as cases of tuberculosis in the incarcerated population, 98 were drug-resistant tuberculosis. We observed that educational level of up to 8 to 11 years of schooling, negative bacterial culture (test outcome) and no tobacco use were factors associated with the non-development of drug-resistant tuberculosis, while clinically confirmed pulmonary TB and positive sputum smear microscopy in the fourth month of follow-up showed an association for the development of drug resistance. (4) Conclusions: The study showed that clinically confirmed pulmonary TB and a positive sputum smear microscopy in the fourth month of follow-up were associated with drug-resistant tuberculosis

Trend and Spatial Distribution of Drug-Resistant Tuberculosis in Liberty-Deprived Populations in the State of Paran&aacute;, Brazil

(1) Background: Tuberculosis remains a public health problem in the world. This study evaluated the temporal trends, distribution, and spatial associations of drug-resistant tuberculosis in liberty-deprived populations in the state of Paran&aacute;, Brazil. (2) Methods: An ecological study was developed using all cases of drug-resistant tuberculosis in penal establishments reported by the Brazilian Notifiable Diseases Information System between 2008 and 2018. For the time trend, the Prais&ndash;Winsten method was used. To verify the spatial association, the Getis&ndash;Ord Gi* technique was used. (3) Results: During the study period, 653 cases of tuberculosis were reported in the studied population, of which 98 (15%) were drug-resistant. Prais&ndash;Winsten autoregression identified an increasing trend, with APC = 15.08% (95% CI: 0.02&ndash;0.09) from 2008 to 2018; when analyzed from 2012 to 2018, the trend increased even more, with APC = 23.31% (95% CI: 0.01&ndash;0.16). Hotspots were also noted in the north, east, and west macro-regions of the state. (4) Conclusions: The presence of drug-resistant tuberculosis, as well as an increasing trend of these cases, was evidenced in all regions of the state among liberty-deprived populations,. The spatial analysis revealed priority areas for drug-resistant tuberculosis in penal establishments