Social determinants of pulmonary tuberculosis in Brazil: an ecological study.

BACKGROUND: Social determinants may influence the incidence and control of tuberculosis (TB). The aim of this study was to evaluate the correlation between social determinants and pulmonary TB (PTB) incidence and treatment outcomes in different regions in Brazil. METHODS: In this ecological study, PTB incidence and treatment outcome rates as well as HIV incidence for all 5560 Brazilian cities as reported to the Brazilian Tuberculosis Program in 2010 were correlated with two social indicators, the Human Development Index (HDI) and Gini Index (GI). Cities were stratified into six groups based on location (metropolitan region or not) and size (small, medium, and large cities), and according to the regions of the country to which they belong. The Spearman correlation coefficient was used to assess the association between variables. RESULTS: In 2010, 68,729 new PTB cases were reported in Brazil, with an incidence rate of 36 cases per 100,000 inhabitants. Incidence rates and PTB mortality demonstrated a weak negative correlation with HDI and a positive correlation with GI. The correlation between HDI and GI with cure, relapse, and lost to follow-up of treatment greatly varied in the different groups of cities and regions of the country evaluated. CONCLUSIONS: There is a weak correlation between HDI and GI and PTB incidence and mortality rate. However, there is great variation between the HDI and GI and cure, relapse, and lost to follow-up in the different groups of cities and regions of the country. This suggests that for TB determination, these outcome variables might be more related to the quality of healthcare provided by services than to social determinants in the general population.

Yield of close contact tracing using two different programmatic approaches from tuberculosis index cases: a retrospective quasi-experimental study.

BACKGROUND: Being a contact of a pulmonary tuberculosis (TB) case is a risk factor for active and latent TB. The objective of this study is to determine the contact tracing yield using two different programmatic definitions of close contact in the city of Rio de Janeiro, Brazil. METHODS: This is a retrospective quasi-experimental study. Data were obtained by reviewing the medical records from TB index cases and their close contacts admitted to the Outpatient TB Clinic of the Institute of Thoracic Diseases, University of Rio de Janeiro. From January 2001 to December 2004, a close contact was defined as an individual who shared an enclosed space with a TB index case for a total period of ≥ 100 hours, whereas from January 2005 to December 2008 the definition of close contact was changed to an individual who shared an enclosed space with a TB index case ≥ 4 hours a week. The primary outcome of this study was newly diagnosed pulmonary TB cases and the secondary outcome was the prevalence of latent TB infection (LTBI) among close contacts during both periods. RESULTS: From 2001-2004, 810 close contacts from 257 index cases were evaluated and the prevalence of active TB and LTBI were 2% (16/810) and 62% (496/794), respectively. From 2005-2008, 1,310 close contacts from 369 index cases were identified and the prevalence of active TB and LTBI were 2.7% (35/1,310) and 69% (877/1,275), respectively. There was not a statically significant difference in the detection of active TB (p = 0.3) between the 2 time periods, but the detection of LTBI was significant higher (p = 0.003). The number needed to screen (contacts/new cases) decreased from 50 to 37 and the number need to contact trace (index cases/new cases) decreased from 16 to 10 from 2001-2004 to 2005-2008. CONCLUSION: In conclusion, the findings of this study suggest that the less conservative definition of TB close contacts (sharing space ≥ 4 h/week) can be a helpful tool for increasing the rate of diagnosis for newly active pulmonary TB cases and for the detection of LTBI among contacts of active pulmonary TB cases.

COPD Assessment Test (CAT) score as a predictor of major depression among subjects with chronic obstructive pulmonary disease and mild hypoxemia: a case-control study.

BACKGROUND: Depression is a common comorbidity among patients with Chronic Obstructive Pulmonary Disease (COPD) and has a significant impact on the course of the disease. The aim of this study is to determine association between COPD Assessment Test (CAT) and major depression among clinically stable out-patient COPD subjects with mild hypoxemia. METHODS: Case-control study. Cases were 30 patients with major depression and controls were 30 patients without depression. Major depression was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders criteria by a psychiatric evaluation. All possible predictive variables were included in a multivariate logistic regression model to assess the association between major depression and each independent variable, while controlling for the sleep parameters. RESULTS: CAT score >20 was associated with major depression (OR 7.88; 95% CI 1.96 - 31.7; p = 0.004). CONCLUSION: CAT score >20 was associated with major depression, suggesting CAT as a predictor variable of major depression among COPD patients with mild hypoxemia, and indicating that an additional specific evaluation for the presence of major depression should be done.

Evaluating the disease and treatment information provided to patients with chronic obstructive pulmonary disease at the time of discharge according to GOLD discharge guidelines.

OBJECTIVE: To evaluate the disease and treatment information provided to patients with chronic obstructive pulmonary disease at hospital discharge. METHODS: This was a cross-sectional study including hospitalized patients with chronic obstructive pulmonary disease at three tertiary hospitals. The study was based on seven items of the Global Initiative for Obstructive Lung Disease (GOLD) discharge guidelines. Two hospitals in this study had a Medical Residency Program in Pulmonology, and one did not have the program. RESULTS: Fifty-four patients were evaluated. Large amounts of information were provided concerning effective pharmacological maintenance (item 1), blood gas evaluation/measurement of oxygen saturation (item 2), assessment of inhalation technique (item 4), and maintenance therapy (item 5). Less information was provided regarding comorbidity management planning (item 3), the completion of antibiotic/corticosteroid therapy (item 6) and follow-up with the attending physician or specialist (item 7) had less information. We observed significant differences between hospitals for items 1, 4 and 7, and better performance in hospitals with medical residency in pulmonology. CONCLUSION: Hospitalized patients with chronic obstructive pulmonary disease received little to no information about the seven items addressed by GOLD discharge guidelines. This finding suggests that these guidelines should be used more often by clinicians in hospital with or without medical residency in pulmonology. The lack of specialized care resulted in insufficient amount of information for patients with chronic obstructive pulmonary disease at discharge.

Impact of smoking on sputum culture conversion and pulmonary tuberculosis treatment outcomes in Brazil: a retrospective cohort study.

OBJECTIVE: To evaluate the impact of smoking on pulmonary tuberculosis (PTB) treatment outcomes and the two-month conversion rates for Mycobacterium tuberculosis sputum cultures among patients with culture-confirmed PTB in an area with a moderate incidence of tuberculosis in Brazil. METHODS: This was a retrospective cohort study of PTB patients diagnosed and treated at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro between 2004 and 2012. RESULTS: Of the 298 patients diagnosed with PTB during the study period, 174 were included in the outcome analysis: 97 (55.7%) were never-smokers, 31 (17.8%) were former smokers, and 46 (26.5%) were current smokers. Smoking was associated with a delay in sputum culture conversion at the end of the second month of TB treatment (relative risk = 3.58 &091;95% CI: 1.3-9.86&093;; p = 0.01), as well as with poor treatment outcomes (relative risk = 6.29 &091;95% CI: 1.57-25.21&093;; p = 0.009). The association between smoking and a positive culture in the second month of treatment was statistically significant among the current smokers (p = 0.027). CONCLUSIONS: In our sample, the probability of a delay in sputum culture conversion was higher in current smokers than in never-smokers, as was the probability of a poor treatment outcome.

Humoral response to HspX and GlcB to previous and recent infection by Mycobacterium tuberculosis.

BACKGROUND: Tuberculosis (TB) remains a major world health problem. Around 2 billions of people are infected by Mycobacterium tuberculosis, the causal agent of this disease. This fact accounts for a third of the total world population and it is expected that 9 million people will become infected each year. Only approximately 10% of the infected people will develop disease. However, health care workers (HCW) are continually exposed to the bacilli at endemic sites presenting increased chance of becoming sick. The objective of this work was to identify LTBI (latent tuberculosis infection) among all asymptomatic HCW of a Brazilian Central Hospital, in a three year follow up, and evaluate the humoral response among HCW with previous and recent LTBI to recombinant HspX and GlcB from M. tuberculosis. METHODS: Four hundred and thirty seven HCW were screened and classified into three different groups according to tuberculin skin test (TST) status: uninfected, previous LTBI and recent LTBI. ELISA test were performed to determine the humoral immune response to HspX and GlcB. RESULTS: The levels of IgG and IgM against the HspX and GlcB antigens were the same among HCW with recent and previous LTBI, as well as among non infected HCW. However, the IgM levels to HspX was significantly higher among HCW with recent LTBI (OD = 1.52 +/- 0.40) than among the uninfected (OD = 1.09 +/- 0.50) or subjects with previous LTBI (OD = 0.96 +/- 0.51) (p < 0.001). CONCLUSION: IgG and IgM humoral responses to GlcB antigens were similar amongst all studied groups; nevertheless IgM levels against HspX were higher among the recent LTBI/HCW.

Evaluation of the impact that the changes in tuberculosis treatment implemented in Brazil in 2009 have had on disease control in the country.

OBJECTIVE: To analyze the impact that the 2009 changes in tuberculosis treatment in Brazil had on the rates of cure, tuberculosis recurrence, mortality, treatment abandonment, and multidrug-resistant tuberculosis (MDR-TB). METHODS: An ordinary least squares regression model was used in order to perform an interrupted time series analysis of secondary data collected from the Brazilian Tuberculosis Case Registry Database for the period between January of 2003 and December of 2014. RESULTS: The 2009 changes in tuberculosis treatment in Brazil were found to have no association with reductions in the total number of cases (ß = 2.17; 95% CI: -3.80 to 8.14; p = 0.47) and in the number of new cases (ß = -0.97; 95% CI: -5.89 to 3.94; p = 0.70), as well as having no association with treatment abandonment rates (ß = 0.40; 95% CI: -1.12 to 1.93; p = 0.60). The changes in tuberculosis treatment also showed a trend toward an association with decreased cure rates (ß = -4.14; 95% CI: -8.63 to 0.34; p = 0.07), as well as an association with increased mortality from pulmonary tuberculosis (ß = 0.77; 95% CI: 0.16 to 1.38; p = 0.01). Although there was a significant increase in MDR-TB before and after the changes (p < 0.0001), there was no association between the intervention (i.e., the changes in tuberculosis treatment) and the increase in MDR-TB cases. CONCLUSIONS: The changes in tuberculosis treatment were unable to contain the decrease in cure rates, the increase in treatment abandonment rates, and the increase in MDR-TB rates, being associated with increased mortality from pulmonary tuberculosis during the study period.Keywords: Tuberculosis, pulmonary/epidemiology; Tuberculosis, pulmonary/drug therapy; Tuberculosis, pulmonary/mortality; Interrupted time series analysis; Drug resistance, multiple; Drug compounding.

Sleep-disordered breathing in patients with COPD and mild hypoxemia: prevalence and predictive variables.

OBJECTIVE:: To infer the prevalence and variables predictive of isolated nocturnal hypoxemia and obstructive sleep apnea (OSA) in patients with COPD and mild hypoxemia. METHODS:: This was a cross-sectional study involving clinically stable COPD outpatients with mild hypoxemia (oxygen saturation = 90-94%) at a clinical center specializing in respiratory diseases, located in the city of Goiânia, Brazil. The patients underwent clinical evaluation, spirometry, polysomnography, echocardiography, arterial blood gas analysis, six-minute walk test assessment, and chest X-ray. RESULTS:: The sample included 64 patients with COPD and mild hypoxemia; 39 (61%) were diagnosed with sleep-disordered breathing (OSA, in 14; and isolated nocturnal hypoxemia, in 25). Correlation analysis showed that PaO2 correlated moderately with mean sleep oxygen saturation (r = 0.45; p = 0.0002), mean rapid eye movement (REM) sleep oxygen saturation (r = 0.43; p = 0.001), and mean non-REM sleep oxygen saturation (r = 0.42; p = 0.001). A cut-off point of PaO2 ≤ 70 mmHg in the arterial blood gas analysis was significantly associated with sleep-disordered breathing (OR = 4.59; 95% CI: 1.54-13.67; p = 0.01). The model showed that, for identifying sleep-disordered breathing, the cut-off point had a specificity of 73.9% (95% CI: 51.6-89.8%), a sensitivity of 63.4% (95% CI: 46.9-77.9%), a positive predictive value of 81.3% (95% CI: 67.7-90.0%), and a negative predictive value of 53.1% (95% CI: 41.4-64.4%), with an area under the ROC curve of 0.69 (95% CI: 0.57-0.80), correctly classifying the observations in 67.2% of the cases. CONCLUSIONS:: In our sample of patients with COPD and mild hypoxemia, the prevalence of sleep-disordered breathing was high (61%), suggesting that such patients would benefit from sleep studies. OBJETIVO:: Inferir a prevalência e as variáveis preditivas de hipoxemia noturna e apneia obstrutiva do sono (AOS) em pacientes portadores de DPOC com hipoxemia leve. MÉTODOS:: Estudo transversal realizado em pacientes ambulatoriais, clinicamente estáveis, portadores de DPOC e hipoxemia leve (saturação de oxigênio = 90-94%) em um centro clínico especializado no atendimento de doenças respiratórias em Goiânia (GO). Os pacientes foram submetidos à avaliação clínica, espirometria, polissonografia, ecocardiografia, gasometria arterial, teste de caminhada de seis minutos e radiografia de tórax. RESULTADOS:: Foram avaliados 64 pacientes com DPOC e hipoxemia leve, e 39 (61%) apresentaram distúrbios respiratórios do sono (14 com AOS e 25 com hipoxemia noturna isolada). A análise de correlação mostrou moderada correlação da PaO2 com saturação média do sono (r = 0,45; p = 0,0002), saturação média do sono rapid eye movement (REM; r = 0,43; p = 0,001) e saturação média do sono não-REM (r = 0,42; p = 0,001). Um ponto de corte de PaO2 ≤ 70 mmHg (OR = 4,59; IC95%: 1,54-13,67; p = 0,01) na gasometria arterial foi significativamente associada com distúrbios respiratórios do sono. O modelo mostrou que, para identificar distúrbios respiratórios do sono, o ponto de corte teve uma especificidade de 73,9% (IC95%: 51,6-89,8%), uma sensibilidade de 63,4% (IC95%: 46,9-77,9%) e valores preditivos positivo e negativo de 81,3% (IC95%: 67,7-90,0%) e 53,1% (IC95%: 41,4-64,4%), respectivamente. A área sob a curva ROC foi de 0,69 (IC95%: 0,57-0,80), e a proporção de observações corretamente classificadas foi de 67,2% dos casos. CONCLUSÕES:: A elevada prevalência de distúrbios respiratórios do sono em portadores de DPOC e hipoxemia leve nesta amostra (61%) sugere que esses pacientes podem se beneficiar da realização de estudos do sono.

Tuberculosis treatment.

Tuberculosis treatment remains a challenge due to the need to consider, when approaching it, the context of individual and collective health. In addition, social and economic issues have been shown to be variables that need to be considered when it comes to treatment effectiveness. We conducted a critical review of the national and international literature on the treatment of tuberculosis in recent years with the aims of presenting health care workers with recommendations based on the situation in Brazil and better informing decision-making regarding tuberculosis patients so as to minimize morbidity and interrupt disease transmission.

Predicting smear negative pulmonary tuberculosis with classification trees and logistic regression: a cross-sectional study.

BACKGROUND: Smear negative pulmonary tuberculosis (SNPT) accounts for 30% of pulmonary tuberculosis cases reported yearly in Brazil. This study aimed to develop a prediction model for SNPT for outpatients in areas with scarce resources. METHODS: The study enrolled 551 patients with clinical-radiological suspicion of SNPT, in Rio de Janeiro, Brazil. The original data was divided into two equivalent samples for generation and validation of the prediction models. Symptoms, physical signs and chest X-rays were used for constructing logistic regression and classification and regression tree models. From the logistic regression, we generated a clinical and radiological prediction score. The area under the receiver operator characteristic curve, sensitivity, and specificity were used to evaluate the model's performance in both generation and validation samples. RESULTS: It was possible to generate predictive models for SNPT with sensitivity ranging from 64% to 71% and specificity ranging from 58% to 76%. CONCLUSION: The results suggest that those models might be useful as screening tools for estimating the risk of SNPT, optimizing the utilization of more expensive tests, and avoiding costs of unnecessary anti-tuberculosis treatment. Those models might be cost-effective tools in a health care network with hierarchical distribution of scarce resources.

Myocardial performance index correlates with the BODE index and affects quality of life in COPD patients.

BACKGROUND AND OBJECTIVE: COPD, a systemic illness associated with the impairment of different organs, affects patient prognosis and quality of life. The aim of this study was to evaluate the association between right ventricle (RV) function, the BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index (a multifunctional scale for the assessment of mortality risk), and quality of life in patients with COPD. METHODS: A cross-sectional study was carried out in 107 outpatients presenting with stable COPD who underwent clinical assessment, spirometry, arterial blood gas analyses, a 6-minute walk test, electrocardiography, and echocardiogram and who responded to the Saint George's Respiratory Questionnaire (SGRQ). RESULTS: Among the study subjects, 53% (57/107) were males, and the mean age was 65.26±8.81 years. A positive correlation was observed between RV dysfunction measured by the myocardial performance index using tissue Doppler (MPIt) and the BODE index, even after adjustment for age and partial pressure of oxygen (r2=0.47; P<0.01). Patients with alterations in the MPIt had worse quality of life, and a statistically significant difference was found for different domains of the SGRQ. Patients with a normal MPIt had a mean total score of 46.2±18.6, whereas for those with MPIt alterations, the mean total score was 61.6±14.2 (P=0.005). These patients had a 1.49-fold increased risk of exhibiting SGRQ total score above the upper limit of the 95% CI (P=0.01). CONCLUSION: The findings of this study suggest that RV dysfunction as measured by the MPIt was associated with impairment in quality of life and a worse BODE index in COPD patients, irrespective of age and hypoxemia status.

Prevalence of chronic obstructive pulmonary disease among patients with systemic arterial hypertension without respiratory symptoms.

BACKGROUND: The diagnosis of chronic obstructive pulmonary disease (COPD) is often delayed until later stages of the disease. The purpose of the present study was to determine the prevalence of COPD among adults on treatment for systemic arterial hypertension independently of the presence of respiratory symptoms. METHODS: This cross-sectional study included adults aged ≥40 years with tobacco/occupational exposure and systemic arterial hypertension diagnosed at three Primary Health Care facilities in Goiania, Brazil. Patients were evaluated using a standardized respiratory questionnaire and spirometry. COPD prevalence was measured considering the value of forced vital capacity and/or forced expiratory volume in 1 second <0.70. RESULTS: Of a total of 570 subjects, 316 (55%) met inclusion criteria and were invited to participate. Two hundred and thirty-three (73.7%) patients with arterial hypertension reported at least one respiratory symptom, while 83 (26.3%) reported no respiratory symptoms; 41 (17.6%) patients with arterial hypertension and at least one respiratory symptom, and 10 (12%) patients with arterial hypertension but no respiratory symptoms were diagnosed with COPD (P=0.24). The prevalence of COPD in people with no previous COPD diagnosis was greater among those with no respiratory symptoms (100%) than among those with respiratory symptoms (56.1%) (P=0.01). CONCLUSION: Our findings suggest that regardless of the presence of respiratory symptoms, individuals aged ≥40 years with tobacco/occupational exposure and arterial hypertension may benefit from spirometric evaluation.

Evaluating the disease and treatment information provided to patients with chronic obstructive pulmonary disease at the time of discharge according to GOLD discharge guidelines / Avaliação da doença e informações sobre tratamento fornecidas a pacientes com doença pulmonar obstrutiva crônica no momento da alta, de acordo com diretrizes GOLD para alta hospitalar

ABSTRACT Objective To evaluate the disease and treatment information provided to patients with chronic obstructive pulmonary disease at hospital discharge. Methods This was a cross-sectional study including hospitalized patients with chronic obstructive pulmonary disease at three tertiary hospitals. The study was based on seven items of the Global Initiative for Obstructive Lung Disease (GOLD) discharge guidelines. Two hospitals in this study had a Medical Residency Program in Pulmonology, and one did not have the program. Results Fifty-four patients were evaluated. Large amounts of information were provided concerning effective pharmacological maintenance (item 1), blood gas evaluation/measurement of oxygen saturation (item 2), assessment of inhalation technique (item 4), and maintenance therapy (item 5). Less information was provided regarding comorbidity management planning (item 3), the completion of antibiotic/corticosteroid therapy (item 6) and follow-up with the attending physician or specialist (item 7) had less information. We observed significant differences between hospitals for items 1, 4 and 7, and better performance in hospitals with medical residency in pulmonology. Conclusion Hospitalized patients with chronic obstructive pulmonary disease received little to no information about the seven items addressed by GOLD discharge guidelines. This finding suggests that these guidelines should be used more often by clinicians in hospital with or without medical residency in pulmonology. The lack of specialized care resulted in insufficient amount of information for patients with chronic obstructive pulmonary disease at discharge.

RESUMO Objetivo Avaliar informações sobre a doença e o tratamento fornecidos a pacientes com doença pulmonar obstrutiva crônica no momento da alta hospitalar. Métodos Estudo transversal incluindo pacientes internados com doença pulmonar obstrutiva crônica de três hospitais terciários. O estudo baseou-se em sete itens das diretrizes de alta hospitalar da Global Initiative for Obstructive Lung Disease (GOLD). Dois hospitais participantes deste estudo tinham um Programa de Residência Médica em Pneumologia, e o terceiro não tinha. Resultados Foram avaliados 54 pacientes. Muitas informações foram fornecidas em relação à manutenção farmacológica efetiva (item 1), avaliação de gasometria/medida da saturação de oxigênio (item 2), avaliação da técnica de inalação (item 4) e terapia de manutenção (item 5). Foram fornecidas menos informações em relação ao planejamento do manejo de comorbidade (item 3), a realização de antibioticoterapia/corticoterapia (item 6) e seguimento com o médico assistente ou especialista (item 7). Observaram-se diferenças significativas entre os hospitais para os itens 1, 4 e 7, e melhor desempenho nos hospitais com Programa de Residência Médica em Pneumologia. Conclusão Pacientes hospitalizados com doença pulmonar obstrutiva crônica receberam pouca ou nenhuma informação relacionada aos sete itens abordados pelas diretrizes da GOLD para alta. Esses achados sugerem que essas diretrizes deveriam ser utilizadas com maior frequência por clínicos em hospitais com ou sem Programa Residência Médica em Pneumologia. A falta de atendimento especializado resultou em informação insuficiente para pacientes com doença pulmonar obstrutiva crônica na alta hospitalar.

Active case finding of tuberculosis (TB) in an emergency room in a region with high prevalence of TB in Brazil.

SETTING: Public hospital emergency room (ER) in Porto Alegre, Brazil, a setting with high prevalence of tuberculosis (TB) and human immunodeficiency virus (HIV) infection. OBJECTIVE: To determine the prevalence of PTB, using a symptom based active case finding (ACF) strategy in the ER of a public hospital in an area with high prevalence of TB and HIV, as well as variables associated with pulmonary TB diagnosis. METHODS: Cross sectional study. All patients ≥ 18 years seeking care at the ER were screened for respiratory symptoms and those with cough ≥ 2 weeks were invited to provide a chest radiograph and two unsupervised samples of sputum for acid-fast bacilli smear and culture. RESULTS: Among 31,267 admissions, 6,273 (20.1%) reported respiratory symptoms; 197 reported cough ≥ 2 weeks, of which pulmonary TB was diagnosed in 30. In multivariate analysis, the variables associated with a pulmonary tuberculosis diagnosis were: age (OR 0.94, 95% CI: 0.92-0.97; p<0.0001), sputum production (OR 0.18, 95% CI 0.06-0.56; p = 0.003), and radiographic findings typical of TB (OR 12.11, 95% CI 4.45-32.93; p<0.0001). CONCLUSIONS: This study identified a high prevalence of pulmonary TB among patients who sought care at the emergency department of a tertiary hospital, emphasizing the importance of regular screening of all comers for active TB in this setting.

Impact of smoking on sputum culture conversion and pulmonary tuberculosis treatment outcomes in Brazil: a retrospective cohort study / Impacto do tabagismo na conversão de cultura e no desfecho do tratamento da tuberculose pulmonar no Brasil: estudo de coorte retrospectivo

ABSTRACT Objective: To evaluate the impact of smoking on pulmonary tuberculosis (PTB) treatment outcomes and the two-month conversion rates for Mycobacterium tuberculosis sputum cultures among patients with culture-confirmed PTB in an area with a moderate incidence of tuberculosis in Brazil. Methods: This was a retrospective cohort study of PTB patients diagnosed and treated at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro between 2004 and 2012. Results: Of the 298 patients diagnosed with PTB during the study period, 174 were included in the outcome analysis: 97 (55.7%) were never-smokers, 31 (17.8%) were former smokers, and 46 (26.5%) were current smokers. Smoking was associated with a delay in sputum culture conversion at the end of the second month of TB treatment (relative risk = 3.58 &091;95% CI: 1.3-9.86&093;; p = 0.01), as well as with poor treatment outcomes (relative risk = 6.29 &091;95% CI: 1.57-25.21&093;; p = 0.009). The association between smoking and a positive culture in the second month of treatment was statistically significant among the current smokers (p = 0.027). Conclusions: In our sample, the probability of a delay in sputum culture conversion was higher in current smokers than in never-smokers, as was the probability of a poor treatment outcome.

RESUMO Objetivo: Avaliar o impacto do tabagismo no desfecho do tratamento da tuberculose pulmonar (TBP) e na taxa de conversão da cultura de Mycobacterium tuberculosis no escarro ao final do segundo mês de tratamento em pacientes com TBP confirmada por cultura em um local com incidência de tuberculose moderada no Brasil. Métodos: Estudo de coorte retrospectivo envolvendo pacientes com TBP diagnosticados e tratados no Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro entre 2004 e 2012. Resultados: De 298 pacientes com diagnóstico confirmado de TBP no período do estudo, 174 foram incluídos na análise dos desfechos: 97 nunca fumaram (55,7%), 31 eram ex-tabagistas (17,8%), e 46 eram tabagistas atuais (26,5%). O tabagismo foi associado ao atraso na conversão da cultura do final do segundo mês do tratamento (risco relativo = 3,58 &091;IC95%: 1,30-9,86&093;; p = 0,01), assim como ao desfecho de tratamento não favorável (risco relativo = 6,29 &091;IC95%: 1,57-25,21&093;; p = 0,009). A associação entre tabagismo e cultura positiva ao final do segundo mês de tratamento foi estatisticamente significante entre os tabagistas atuais (p = 0.027). Conclusões: Nesta amostra, os pacientes tabagistas atuais apresentaram uma maior probabilidade de atraso na conversão da cultura após dois meses de tratamento e de desfecho de tratamento não favorável do que aqueles que nunca fumaram.

Clinical treatment outcomes of tuberculosis treated with the basic regimen recommended by the Brazilian National Ministry of Health using fixed-dose combination tablets in the greater metropolitan area of Goiânia, Brazil.

OBJECTIVE: To describe the rates of cure, treatment failure, and treatment abandonment obtained with the basic regimen recommended by the Brazilian National Ministry of Health (rifampin, isoniazid, pyrazinamide, and ethambutol for two months, followed by isoniazid and rifampin for four months) involving the use of fixed-dose combination tablets (self-administered treatment), as well as to describe adverse events and their potential impact on treatment outcomes. METHODS: This was a descriptive study based on prospective data obtained from the medical records of tuberculosis patients (> 18 years of age) treated with the basic regimen at either of two primary health care facilities in the greater metropolitan area of Goiânia, Brazil. RESULTS: The study sample comprised 40 tuberculosis patients. The rate of cure was 67.5%, the rate of treatment abandonment was 17.5%, and there were no cases of treatment failure. Of the 40 patients in the sample, 19 (47%) reported adverse reactions, which were mild and moderate, respectively, in 87% and 13% of the cases. It was not necessary to alter the regimen or discontinue the treatment in any of the cases evaluated. CONCLUSIONS: The rate of cure obtained with the self-administered, fixed-dose combination tablet form of the new basic regimen was similar to the historical rates of cure obtained with the previous regimen. The rate of treatment abandonment in our sample was much higher than that considered appropriate (up to 5%).

Prevalence of primary drug resistance in pulmonary tuberculosis patients with no known risk factors for such.

OBJECTIVE: To estimate the prevalence of primary resistance to the drugs in the basic treatment regimen for tuberculosis in treatment-naïve patients with pulmonary tuberculosis and no known risk factors for such resistance, as well as to identify factors potentially associated with drug resistance. METHODS: This was an exploratory cross-sectional study. We analyzed the medical records of the subjects enrolled in two clinical trials of treatments for drug-susceptible tuberculosis between November 1, 2004 and March 31, 2011 at the Prof. Newton Bethlem Outpatient Clinic of the Federal University of Rio de Janeiro Thoracic Diseases Institute, located in the city of Rio de Janeiro, Brazil. The inclusion criteria were being > 18 years of age, testing positive for AFB in the first sputum sample, having a positive culture for Mycobacterium tuberculosis, having undergone drug susceptibility testing, and being treatment-naïve. Patients with a history of imprisonment or hospitalization were excluded, as were those who had been in contact with drug-resistant tuberculosis patients. RESULTS: We included 209 patients. The overall prevalence of primary drug resistance was 16.3%. The overall prevalence of resistance to isoniazid and streptomycin was, respectively, 9.6% and 9.1%, compared with 5.8% and 6.8% for single-drug resistance to isoniazid and streptomycin, respectively. The prevalence of resistance to two or more drugs was 3.8%, and the prevalence of multidrug resistance was 0.5%. No statistically significant associations were found between the variables studied and drug susceptibility testing results. CONCLUSIONS: In this sample, the prevalence of primary drug resistance was high despite the absence of known risk factors.

Evaluation of the impact that the changes in tuberculosis treatment implemented in Brazil in 2009 have had on disease control in the country / Avaliação do impacto das mudanças do tratamento da tuberculose implantadas em 2009 no controle da tuberculose pulmonar no Brasil

ABSTRACT Objective: To analyze the impact that the 2009 changes in tuberculosis treatment in Brazil had on the rates of cure, tuberculosis recurrence, mortality, treatment abandonment, and multidrug-resistant tuberculosis (MDR-TB). Methods: An ordinary least squares regression model was used in order to perform an interrupted time series analysis of secondary data collected from the Brazilian Tuberculosis Case Registry Database for the period between January of 2003 and December of 2014. Results: The 2009 changes in tuberculosis treatment in Brazil were found to have no association with reductions in the total number of cases (β = 2.17; 95% CI: −3.80 to 8.14; p = 0.47) and in the number of new cases (β = −0.97; 95% CI: −5.89 to 3.94; p = 0.70), as well as having no association with treatment abandonment rates (β = 0.40; 95% CI: −1.12 to 1.93; p = 0.60). The changes in tuberculosis treatment also showed a trend toward an association with decreased cure rates (β = −4.14; 95% CI: −8.63 to 0.34; p = 0.07), as well as an association with increased mortality from pulmonary tuberculosis (β = 0.77; 95% CI: 0.16 to 1.38; p = 0.01). Although there was a significant increase in MDR-TB before and after the changes (p < 0.0001), there was no association between the intervention (i.e., the changes in tuberculosis treatment) and the increase in MDR-TB cases. Conclusions: The changes in tuberculosis treatment were unable to contain the decrease in cure rates, the increase in treatment abandonment rates, and the increase in MDR-TB rates, being associated with increased mortality from pulmonary tuberculosis during the study period. Keywords: Tuberculosis, pulmonary/epidemiology; Tuberculosis, pulmonary/drug therapy; Tuberculosis, pulmonary/mortality; Interrupted time series analysis; Drug resistance, multiple; Drug compounding.

RESUMO Objetivo: Analisar o impacto das mudanças do tratamento da tuberculose implantadas no Brasil em 2009 no número de casos de cura, de recidiva, de óbitos, de abandono e de tuberculose multirresistente (TBMR). Métodos: Foi realizada uma análise de séries temporais interrompida utilizando o modelo de regressão pelo método dos mínimos quadrados ordinários a partir de dados secundários coletados do Sistema de Informação de Agravos de Notificação da Tuberculose entre janeiro de 2003 e dezembro de 2014. Resultados: A análise mostrou independência entre as mudanças do tratamento e a redução do número total de casos (β = 2,17; IC95%: −3,80 a 8,14; 189 p = 0,47), a redução do número de novos casos (β = −0,97; IC95%: −5,89 a 3,94; p =190 0,70) e do abandono do tratamento (β = 0,40; IC95%: 199 −1,12 a 1,93; p = 0,60). Demonstrou ainda tendência à associação com a diminuição da cura (β = −4,14; IC95%: −8,63 a 0,34; p = 0,07) e associação com aumento da mortalidade por tuberculose pulmonar (β = 0,77; IC95%: 0,16 a 1,38; p = 0,01). A TBMR aumentou significativamente tanto no período anterior quanto no período posterior às mudanças do tratamento (p < 0,0001), embora de forma independente da intervenção (β = 0,13; IC95%: −0,03 a 0,29; p = 0,12). Conclusões: As mudanças no tratamento não impediram nem a diminuição na taxa de cura e nem o aumento do abandono e da TBMR; por outro lado, se associaram ao aumento de óbitos por tuberculose pulmonar durante o período do estudo.

Time from symptom onset to the initiation of treatment of pulmonary tuberculosis in a city with a high incidence of the disease.

OBJECTIVE: To estimate the time elapsed between the onset of symptoms and the initiation of treatment of pulmonary tuberculosis among treatment-naïve patients with positive results in sputum smear microscopy, and to evaluate the variables associated with delays in diagnosis and in treatment initiation. METHODS: This was a descriptive exploratory study involving 199 treatment-naïve tuberculosis patients > 12 years of age with AFB-positive sputum smear microscopy results between 2006 and 2008. At their first (treatment initiation) visit to a primary health care clinic in the city of Nova Iguaçu, Brazil, the patients were interviewed and their ancillary test results were reviewed. RESULTS: The medians (and respective interquartile ranges) of the time from symptom onset to the initiation of treatment of pulmonary tuberculosis, from symptom onset to seeking medical attention, from entry into care to diagnosis, and from entry into care to treatment initiation, in weeks, were 11 (6-24), 8 (4-20), 2 (1-8), and 1 (1-1), respectively. The variables gender, age, level of education, previous use of antibiotics, HIV status, site of first medical visit, and radiological extent of tuberculosis showed no associations with the time from entry into care to diagnosis and to treatment initiation. The main reason for the delay in seeking medical attention reported by the patients was their inability to recognize their symptoms as indicators of a disease. CONCLUSIONS: Among the patients studied, there was an unacceptably long delay between the onset of symptoms and the initiation of tuberculosis treatment.

Tuberculosis treatment / Tratamento da tuberculose

ABSTRACT Tuberculosis treatment remains a challenge due to the need to consider, when approaching it, the context of individual and collective health. In addition, social and economic issues have been shown to be variables that need to be considered when it comes to treatment effectiveness. We conducted a critical review of the national and international literature on the treatment of tuberculosis in recent years with the aims of presenting health care workers with recommendations based on the situation in Brazil and better informing decision-making regarding tuberculosis patients so as to minimize morbidity and interrupt disease transmission.

RESUMO O tratamento da tuberculose permanece um desafio em função da necessidade de que, em sua abordagem, seja considerado o contexto da saúde do indivíduo e da saúde coletiva. Adicionalmente, as questões sociais e econômicas têm-se mostrado como variáveis a ser consideradas na efetividade do tratamento. Ao revisarmos de forma crítica a literatura científica nacional e internacional sobre o tratamento da tuberculose nos últimos anos, tivemos como objetivos apresentar aos profissionais da área de saúde as recomendações baseadas na realidade brasileira e fornecer os subsídios necessários para a melhor tomada de decisão frente ao paciente com tuberculose, de modo a minimizar a morbidade e interromper a transmissão da doença Em função disso, o TDO é recomendado.