How has the municipal availability of the GeneXpert®MTB/RIF system affected the detection of drug-resistant tuberculosis in Brazil?

OBJECTIVE: To evaluate the association between the availability of GeneXpert®MTB/RIF in municipalities and the proportion of people who have access to this diagnostic technology for tuberculosis (TB), as well as the resistance detected by the surveillance system in Brazil. METHODS: We analysed 4998 Brazilian municipalities that reported 432,937 new TB cases between 2015 and 2020. We compared municipalities with and without the availability of GeneXpert®MTB/RIF regarding the effective access to GeneXpert®MTB/RIF diagnosis and the prevalence of detected resistance. RESULTS: Municipalities with at least one GeneXpert®MTB/RIF system had three times (95% CI 2.9-3.0) the access to diagnostic tests and 80.4% (95% CI 70.6%-90.2%) higher detection of resistance, compared with municipalities without this technology. We estimated that there have been 1890 cases of undetected resistance during this period in the country. CONCLUSIONS: The availability of GeneXpert®MTB/RIF system in the municipality increased the sensitivity of the surveillance for detecting TB resistance. PUBLIC HEALTH IMPLICATIONS: It is a priority to strengthen laboratory networks and narrow the gap in access to rapid diagnosis in remote areas to improve the detection and control of drug-resistant tuberculosis.

Trends in tuberculosis incidence and mortality coefficients in Brazil, 2011-2019: analysis by inflection points.

Objective: To analyze the temporal trend of tuberculosis incidence and mortality rates in Brazil between 2011 and 2019. Methods: This was an ecological time series study of tuberculosis incidence and mortality rates in Brazil between 2011 and 2019. Data were extracted from the Notifiable Disease Information System and the Mortality Information System, and population estimates were from the Brazilian Institute of Geography and Statistics. Trends were analyzed by Joinpoint regression, which recognizes inflection points for temporal analysis. Results: The average incidence rate of tuberculosis in Brazil in the period was 35.8 cases per 100 000 population. From 2011 to 2015, this coefficient had an annual percentage change of -1.9% (95% CI [-3.4, -0.5]) followed by an increase of 2.4% (95% CI [0.9, 3.9]) until 2019. The average mortality rate between 2011 and 2019 was 2.2 deaths per 100 000 population, with an average annual percentage change of -0.4% (95% CI [-1.0, 0.2]). Amazonas was the only state with an increase in the annual average percentage variation for the incidence rate (3.2%; 95% CI [1.3, 5.1]) and mortality rate (2.7%; 95% CI [1.0, 4.4]) over the years, while Rio de Janeiro state had an increasing inflection for incidence from 2014 to 2019 (2.4%; 95% CI [1.4, 3.5]) and annual average of decreasing percentage variation (-3.5%; 95% CI [-5.0, -1.9]). Conclusions: During the period analyzed, a decreasing trend in incidence was observed between 2011 and 2015, and an increasing trend for the period from 2015 to 2019. On the other hand, no change in the trend for mortality was found in Brazil.

Brazilian cohort study of risk factors associated with unsuccessful outcomes of drug resistant tuberculosis.

BACKGROUND: Treatment outcomes were evaluated of a cohort of new pulmonary tuberculosis (TB) cases that were rifampicin resistant, multidrug-resistant, or extensively resistant during 2013 and 2014 in Brazil. The objective of this study is to identify factors associated with unfavorable treatment outcomes for drug-resistant TB cases. METHODS: The Brazilian Special Tuberculosis Treatment Information System (SITE-TB) was the main data source. The independent variables were classified into four blocks (block I: individual characteristics; block II: clinical characteristics and proposed treatment; block III: treatment follow-up characteristics; and block IV: TB history). The category of successful therapeutic outcome was compared with lost to follow-up, failure, and death. Considering the multiple outcomes as the dependent variable, the odds ratios (OR) and its respective 95% confidence interval (95% CI) were estimated by multinomial logistic regression. RESULTS: After applying the exclusion criteria, 980 (98.8%) individuals were included in the study. Of these, 621 (63.4%) had successful treatment, 163 (16.6%) lost to follow-up, 76 (7.8%) failed, and 120 (12.2%) died. Important factors associated with lost to follow-up in the final model included use of illicit drugs (OR = 2.5 95% CI: 1.57-3.82). Outcome failure was associated with having disease in both lungs (OR = 2.0; 95% CI: 1.09-3.62) and using more than one or not using injectable medication (OR = 2.8; 95% CI: 1.05-7.69). Major factors for the death outcome were at least 60 years old (OR = 3.4; 95% CI: 1.90-6.03) and HIV positive (OR = 2.7; 95% CI: 1.45-4.83). CONCLUSIONS: The factors associated with unfavorable treatment outcomes were different. Some of these factors are specific to each outcome, which reflects the complexity of providing care to these individuals.

Zika-Associated Microcephaly Epidemic and Birth Rate Reduction in Brazilian Cities.

OBJECTIVES: To estimate birth reduction potentially in response to Zika virus-associated microcephaly among the 36 largest Brazilian cities. METHODS: We analyzed the number of live births per month on the basis of information on approximately 8.2 million births from all of Brazil's state capitals and cities that had more than 10 000 annual births. RESULTS: In the second half of 2016, the live birth rate was reduced by 7.78% (95% confidence interval [CI] = 6.64%, 8.89%; P < .001). This reduction was correlated with the Zika virus-associated microcephaly rate. In the cities with the highest microcephaly rate in 2015 (> 1 case per 1000 live births), the reduction in the live birth rate was 10.84% (95% CI = 8.58%, 13.04%). CONCLUSIONS: The birth rate in the largest Brazilian cities during the second half of 2016 was significantly reduced, which is potentially the effect of a birth control recommendation prompted by an epidemiological alert. Public Health Implications. The effects of population-based interventions should be weighed by considering the actual risk of disease and the sociodemographic impact of strategies such as birth control.

Increase in Tuberculosis Cases among Prisoners, Brazil, 2009-20141.

During 2009-2014, incarceration rates in Brazil rose 34%, and tuberculosis (TB) cases among prisoners rose 28.8%. The proportion of national TB cases that occurred among prisoners increased from 6.2% to 8.4% overall and from 19.3% to 25.6% among men 20-29 years of age.

Quality of tuberculosis care at different levels of health care in Brazil in 2013.

Objective To assess 1) the burden and socio-demographic and clinical characteristics of tuberculosis (TB) cases, and 2) the quality of TB care provided to patients who entered and remained within each health care service level (primary, secondary, or tertiary) and those who moved from one level to another, using process and results indicators. Methods This cross-sectional operational research study assessed new smear-positive pulmonary TB cases diagnosed in Brazilian state capitals in 2013 using TB program records and the TB surveillance system. Quality of care was assessed based on process and results indicators including HIV screening, TB contact screening, Directly Observed Treatment (DOT), sputum smear microscopy monitoring, and treatment outcomes. Results There were 12 977 new smear-positive TB cases reported. Of these, 7 964 (61.4%) cases were diagnosed and treated at the primary care level, 1 195 (9.2%) at the secondary level, 1 521 (11.7%) at the tertiary level, and 2 296 (17.7%) at more than one level, with 65% of the latter group moved from the tertiary level to the primary level. The proportion of cases tested for HIV was significantly higher in patients receiving care at the primary level compared to those receiving care at the secondary level (prevalence ratio (PR): 1.17; 95% confidence interval (CI): 1.07-1.28) and those attending more than one service level. Patients attending the tertiary health care level had a 122% higher PR for not doing DOT ("DOT not done") compared to patients at the primary level (PR: 2.22; CI: 2.12-2.32). When the two levels were compared, the prevalence for an unfavorable outcome (lost to follow-up, death from TB, death with TB, transferred out, or not evaluated) was higher at the tertiary health care level. Conclusions Primary health services are successfully incorporating the management of new smear-positive TB cases. Primary health care obtained better operational indicators than secondary or tertiary levels.

Time until tuberculosis recurrence and associated factors in Brazil: a populationbased retrospective cohort study using a linked database.

OBJECTIVE: To calculate the rate of tuberculosis recurrence, estimate its average time until recurrence, and identify factors associated with recurrence in Brazil. METHODS: Retrospective cohort study with a linked database from the Notifiable Diseases Information System. The study included individuals diagnosed with tuberculosis in 2015, focusing on those who experienced their first recurrence within 6.5 years. We estimated the relative risk (RR) and its 95% confidence interval (95%CI), as well as the population attributable fraction (PAF) or the population preventable fraction (PPF) of associated factors. RESULTS: Within a 6.5-year period, 3,253 individuals (6.5%) experienced tuberculosis recurrence, with a median time of 2.2 years. Positively associated factors included: male sex (RR: 1.4; 95%CI 1.3-1.5; PAF: 22.9%), age 30 to 59 years (RR: 3.0; 95%CI 1.6-5.7; PAF: 36.0%), black race (RR: 1.3; 95%CI 1.2-1.5; PAF: 3.5%), mixed race (RR: 1.3; 95%CI 1.2-1.4; PAF: 10.6%), deprivation of liberty (RR: 1.9; 95%CI 1.7-2.1; PAF: 9.1%), pulmonary/mixed clinical form (RR: 1.7; 95%CI 1.4-1.9; PAF: 37.1%), acquired immunodeficiency syndrome diagnosis (RR: 1.8; 95%CI 1.5-1.9; PAF: 4.3%), and alcohol use (RR: 1.2; 95%CI 1.1-1.3; PAF: 2.9%). Negatively associated factors were: 12 or more years of schooling (RR: 0.5; 95%CI 0.4-0.6; PPF: 3.3%) and supervised treatment (RR: 0.9; 95%CI 0.8-0.9; PPF: 4.4%). CONCLUSION: This study revealed high tuberculosis recurrence rates in Brazil, influenced by sociodemographic, compartmental, and social factors, both positively and negatively impacting disease recurrence.

Clusters of heterogeneity of tuberculosis-HIV coinfection in Brazil: a geospatial study.

OBJECTIVE: To analyze the geospatialization of tuberculosis-HIV coinfection in Brazil, from 2010 to 2021, and the correlation with socioeconomic, housing, and health indicators. METHODS: An ecological study of Brazilian municipalities and states, with data from HIV and tuberculosis information systems, previously reported by the Ministry of Health. The crude and smoothed coefficients were calculated by the local empirical Bayesian method of incidence of coinfection per 100,000 inhabitants in the population aged between 18 and 59 years. Univariate (identification of clusters) and bivariate (correlation with 20 indicators) Moran's indices were used. RESULTS: A total of 122,223 cases of coinfection were registered in Brazil from 2010 to 2021, with a mean coefficient of 8.30/100,000. The South (11.44/100,000) and North (9.93/100,000) regions concentrated the highest burden of infections. The coefficients dropped in Brazil, in all regions, in the years of covid-19 (2020 and 2021). The highest coefficients were observed in the municipalities of the states of Rio Grande do Sul, Mato Grosso do Sul, and Amazonas, with high-high clusters in the capitals, border regions, coast of the country. The municipalities belonging to the states of Minas Gerais, Bahia, Paraná, and Piauí showed low-low clusters. There was a direct correlation with human development indices and aids rates, as well as an indirect correlation with the proportion of poor or of those vulnerable to poverty and the Gini index. CONCLUSIONS: The spatial analysis of tuberculosis-HIV coinfection showed heterogeneity in the Brazilian territory and constant behavior throughout the period, revealing clusters with high-burden municipalities, especially in large urban centers and in states with a high occurrence of HIV and/or tuberculosis. These findings, in addition to alerting to the effects of the covid-19 pandemic, can incorporate strategic planning for the control of coinfection, aiming to eliminate these infections as public health problems by 2030.

Cost-effectiveness and health impact of screening and treatment of Mycobacterium tuberculosis infection among formerly incarcerated individuals in Brazil: a Markov modelling study.

BACKGROUND: Individuals who were formerly incarcerated have high tuberculosis incidence, but are generally not considered among the risk groups eligible for tuberculosis prevention. We investigated the potential health impact and cost-effectiveness of Mycobacterium tuberculosis infection screening and tuberculosis preventive treatment (TPT) for individuals who were formerly incarcerated in Brazil. METHODS: Using published evidence for Brazil, we constructed a Markov state transition model estimating tuberculosis-related health outcomes and costs among individuals who were formerly incarcerated, by simulating transitions between health states over time. The analysis compared tuberculosis infection screening and TPT, to no screening, considering a combination of M tuberculosis infection tests and TPT regimens. We quantified health effects as reductions in tuberculosis cases, tuberculosis deaths, and disability-adjusted life-years (DALYs). We assessed costs from a tuberculosis programme perspective. We report intervention cost-effectiveness as the incremental costs per DALY averted, and tested how results changed across subgroups of the target population. FINDINGS: Compared with no intervention, an intervention incorporating tuberculin skin testing and treatment with 3 months of isoniazid and rifapentine would avert 31 (95% uncertainty interval 14-56) lifetime tuberculosis cases and 4·1 (1·4-5·8) lifetime tuberculosis deaths per 1000 individuals, and cost US$242 per DALY averted. All test and regimen combinations were cost-effective compared with no screening. Younger age, longer incarceration, and more recent prison release were each associated with significantly greater health benefits and more favourable cost-effectiveness ratios, although the intervention was cost-effective for all subgroups examined. INTERPRETATION: M tuberculosis infection screening and TPT for individuals who were formerly incarcerated appears cost-effective, and would provide valuable health gains. FUNDING: National Institutes of Health. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.

Mass incarceration as a driver of the tuberculosis epidemic in Latin America and projected impacts of policy alternatives: A mathematical modeling study.

Background: Tuberculosis incidence is increasing in Latin America, where the incarcerated population has nearly quadrupled since 1990. The full impact of incarceration on the tuberculosis epidemic, accounting for effects beyond prisons, has never been quantified. Methods: We calibrated dynamic compartmental transmission models to historical and contemporary data from Argentina, Brazil, Colombia, El Salvador, Mexico, and Peru, which comprise approximately 80% of the region's incarcerated population and tuberculosis burden. Using historical counterfactual scenarios, we estimated the transmission population attributable fraction (tPAF) for incarceration and the excess population-level burden attributable to increasing incarceration prevalence since 1990. We additionally projected the impact of alternative incarceration policies on future population tuberculosis incidence. Findings: Population tuberculosis incidence in 2019 was 29.4% (95% UI, 23.9-36.8) higher than expected without the rise in incarceration since 1990, corresponding to 34,393 (95% UI, 28,295-42,579) excess incident cases across countries. The incarceration tPAF in 2019 was 27.2% (95% UI, 20.9-35.8), exceeding estimates for other risk factors like HIV, alcohol use disorder, and undernutrition. Compared to a scenario where incarceration rates remain stable at current levels, a gradual 50% reduction in prison admissions and duration of incarceration by 2034 would reduce population tuberculosis incidence by over 10% in all countries except Mexico. Interpretation: The historical rise in incarceration in Latin America has resulted in a large excess tuberculosis burden that has been under-recognized to-date. International health agencies, ministries of justice, and national tuberculosis programs should collaborate to address this health crisis with comprehensive strategies, including decarceration. Funding: National Institutes of Health.

Factors associated with post-mortem notification of tuberculosis cases in Brazil, 2014. / Fatores associados à notificação pós-óbito de casos de tuberculose no Brasil, 2014.

According to the World Health Organization (WHO), 1.6 million deaths and 10.6 million cases of tuberculosis (TB) were reported worldwide in 2021. If treated opportunely with the recommended therapy, 85% of patients with TB are healed. The occurrence of death from TB without prior notification of the disease indicates failure in the timely access to this effective treatment. Therefore, this study aimed to identify TB cases with post-mortem notification in Brazil. This is a nested case-control study using a cohort of new TB cases reported to the Braziliam Information System for Notificable Diseases (SINAN). This study analyzed the following variables: selected characteristics of the individual (gender, age, race/color, education), the municipality (Municipality Human Development Index - M-HDI, poverty rate, size, region, and municipality), health services, and underlying or associated cause of death. Logistic regression was estimated using a hierarchical analysis model. People with TB aged 60 years or older (OR = 1.43), with low educational level (OR = 1.67), and with malnutrition (OR = 5.54), living in municipalities with low M-HDI and medium population size (OR = 1.26), located in the North Region of Brazil (OR = 2.42) had a higher chance of post-mortem notification. Protective factors were HIV-TB coinfection (OR = 0.75), malignant neoplasms (OR = 0.62), and living in cities with broad primary care coverage (OR = 0.79). Vulnerable populations should be prioritized in order to address the obstacles to the access to TB diagnosis and treatment in Brazil.

Segundo a Organização Mundial da Saúde (OMS), estima-se que 1,6 milhão de mortes e 10,6 milhões de casos de tuberculose (TB) ocorreram no mundo em 2021. Quando a doença é oportunamente tratada com o esquema terapêutico recomendado, 85% dos pacientes se curam. A ocorrência de óbito por TB sem notificação anterior denuncia falhas no acesso ao tratamento oportuno e efetivo. Sendo assim, este estudo objetivou caracterizar os casos de TB notificados pós-óbito no Brasil. Trata-se de estudo caso-controle aninhado na coorte de casos novos de TB notificados ao Sistema de Informação de Agravos de Notificação (SINAN). As variáveis analisadas foram: características selecionadas do indivíduo (sexo, idade, raça/cor, escolaridade), do município (Índice de Desenvolvimento Humano Municipal - IDH-M, taxa de pobreza, porte municipal, região e município), dos serviços de saúde e causa básica ou associada de morte. Foi estimada regressão logística respeitando um modelo de análise hierárquico. Pessoas com TB de 60 anos de idade ou mais (OR = 1,43), de baixa escolaridade (OR = 1,67), com desnutrição (OR = 5,54), residentes em municípios com baixo IDH-M, de porte populacional médio (OR = 1,26), na Região Norte (OR = 2,42) apresentaram maior chance de notificação pós-óbito. Fatores protetores foram coinfecção HIV-TB (OR = 0,75), neoplasias malignas (OR = 0,62) e residência em municípios com alta cobertura de atenção básica (OR = 0,79). A priorização das populações vulneráveis é necessária para enfrentar as dificuldades de acesso ao diagnóstico e tratamento da TB no Brasil.

La Organización Mundial de la Salud (OMS) estima que en 2021 se produjeron 1,6 millones de muertes por tuberculosis (TB) y 10,6 millones de casos de esta afección por todo el mundo. Si los pacientes siguen el tratamiento recomendado para la TB, un 85% logran la cura. Las muertes por TB sin notificación previa de caso indican fallas en el acceso a este tratamiento oportuno y efectivo. Por lo tanto, este estudio tuvo como objetivo caracterizar los casos de TB que tuvieron notificación posterior a la muerte en Brasil. Este es un estudio de caso-control anidado dentro de la cohorte de nuevos casos de TB informados al Sistema de Información de Enfermedades de Notificación Obligatoria (SINAN). Las siguientes variables fueron analizadas: características seleccionadas del individuo (sexo, edad, etnia/color, nivel de instrucción) y del municipio (Índice de Desarrollo Humano Municipal -IDH-M, tasa de pobreza, tamaño del municipio, región y municipio), servicios de salud y condiciones y causa de la muerte o su asociación. La regresión logística se estimó desde un modelo de análisis jerárquico. Las personas con TB de 60 años o más (OR = 1,43), con bajo nivel de instrucción (OR = 1,67), con desnutrición (OR = 5,54), residentes en municipios con bajo IDH-M, de tamaño poblacional medio (OR = 1,26) y en la Región Norte (OR = 2,42) tuvieron mayor probabilidad de notificación posterior a la muerte. Los factores protectores fueron la coinfección VIH-TB (OR = 0,75), neoplasias malignas (OR = 0,62) y vivir en ciudades con alta cobertura de atención primaria (OR = 0,79). Es necesario priorizar las poblaciones vulnerables para enfrentar las dificultades de acceso al diagnóstico y tratamiento de la TB en Brasil.

Factors Associated with Unsuccessful Outcomes of Tuberculosis Treatment in 125 Municipalities in Colombia 2014 to 2016.

Our aim was to identify the risk factors associated with unsuccessful outcomes of tuberculosis (TB) treatment in patients diagnosed between 2014 and 2016 in the 125 municipalities of Antioquia, Colombia. We studied a retrospective cohort of patients with TB diagnosed between 2014 and 2016, from national routine surveillance systems, in 125 municipalities of Antioquia. Factors associated with unsuccessful tuberculosis treatment outcomes (treatment failed, lost to follow up, or death) were identified utilizing a Poisson regression with robust variance. Over 3 years, of the 6,739 drug-susceptible tuberculosis patients, 73.4% had successful treatment and 26.6% unsuccessful outcomes (17% lost to follow up, 8.9% deaths, and 0.7% treatment failures). Patients with subsidized health insurance (Relative risk [RR]: 2.4; 95% CI: 2.1-2.8) and without health insurance (RR: 2.5; 95% CI: 2.1-3.0) had a higher risk for unsuccessful tuberculosis treatment compared to those with contributive health insurance. Other risk factors included age over 15 years, male sex, homelessness, people living with HIV, previous treatment, and primary diagnosis during hospitalization. Protective factors were living in a rural area and extrapulmonary disease. It is important to generate strategies that improves tuberculosis diagnosis in primary healthcare institutions. In addition, it is imperative to initiate new research about the barriers and obstacles related to patients, healthcare workers and services, and the health system, including the analysis of urban violence, to understand why the goal of TB treatment success has not been reached.

Impact of incarceration on tuberculosis incidence and its interaction with income distribution inequality in Brazil.

BACKGROUND: Deteriorated conditions in the non-prison population can lead to an approximation of its tuberculosis (TB) risk to that in the prison population. We evaluated the association between incarceration and TB incidence rate and its interaction with population income distribution inequality in Brazilian municipalities (2013-2015). METHODS: We included 954 municipalities with at least one prison. Interaction between the Gini coefficient and prison exposure was analysed in a multiple regression model. We estimated the fraction of TB in the population attributable fraction (PAF) to exposure to prisons according the Gini coefficient. RESULTS: Compared with the non-prison population, the prisoners had 22.07 times (95% confidence interval [CI] 20.38 to 23.89) the risk of TB in municipalities where the Gini coefficient was <0.60 and 14.96 times (95% CI 11.00 to 18.92) the risk where the Gini coefficient was ≥0.60. A negative interaction in the multiplicative scale was explained by a higher TB incidence in the non-prison population in municipalities with a Gini coefficient ≥0.60. The PAF ranged from 50.06% to 5.19% in municipalities with Gini coefficients <0.40 and ≥0.60, respectively. CONCLUSIONS: Interventions to reduce prison exposure would have an ostensible impact in population TB incidence rates mainly in settings with lower Gini coefficients. In those with extreme inequality in income distribution, strategies focused on mitigating the effects of socio-economic factors should also be prioritized.

Regional coordinators of Sao Paulo State prisons in tuberculosis and HIV coinfection care.

OBJECTIVES: to analyze the care provided to individuals with Tuberculosis (TB)-HIV coinfection in prison units in the state of São Paulo, according to the regional coordination of prisons. METHODS: cross-sectional study conducted between 2016 and 2018. A structured questionnaire was applied to 112 directors or health professionals from 168 prison units. Data were analyzed by frequency distribution and multiple correspondence analysis. RESULTS: 92.9% of participants reported active search for respiratory symptoms, 89.3% offer the directly observed treatment (DOT) for all TB cases, 95.5% anti-HIV testing for all inmates, 92.9% offer HIV follow-up in specialized care services and 59.8% antiretroviral drugs for cases of coinfection. An association was identified between the Northwest and Central regional coordinations and deficient human resources and low performance of actions for the diagnosis and follow-up of cases. CONCLUSIONS: although most prison units perform planned actions for the care of coinfected persons, some places need support to guarantee access to these actions.

[Gaps in drug-resistant tuberculosis surveillance: probabilistic database linkage in Brazil]. / Lacunas na vigilância da tuberculose drogarresistente: relacionando sistemas de informação do Brasil.

The study aimed to assess the coverage and reliability of drug-resistant tuberculosis (DR-TB) case closure in the Information System on Special Treatments for Tuberculosis (SITE-TB in Portuguese) in Brazil from 2013 to 2016, based on probabilistic linkage with the Information System on Diseases of Notification (SINAN), Laboratory Environment Manager (GAL), and Mortality Information System (SIM). The study population consisted of DR-TB cases that initiated treatment from 2013 to 2016 in Brazil. Linkage with SINAN assessed the coverage and estimated underreporting of DR-TB cases. The capture-recapture method was applied, using the Chapman estimator. Linkage with GAL identified cases diagnosed by the laboratory that had not been reported to SITE-TB. Linkage with SIM assessed the reliability of case closure by death in SITE-TB, using the kappa coefficient. We estimated a population of 2,945 (95%CI: 2,365-3,602) new cases of DR-TB with the Chapman estimator. We located 1,626 individuals in the GAL database that had not been reported to SITE-TB, even with laboratory confirmation of drug resistance. PABAK (prevalance and bias adjusted kappa) of 0.86 (95%CI: 0.85-0.87) was classified as excellent for the agreement in death as the outcome between the SITE-TB and SIM databases. The results pointed to persistent gaps related to diagnosis and treatment of DR-TB in Brazil. Underreporting of DR-TB cases in the SITE-TB database poses a challenge for TB control. Identification of these individuals and early start of treatment should be prioritized in health services.

Notifiable Diseases Information System (SINAN): main features of tuberculosis notification and data analysis. / Sistema de Informação de Agravos de Notificação (Sinan): principais características da notificação e da análise de dados relacionada à tuberculose.

The Notifiable Diseases Information System (SINAN) enables knowledge of the profile of people with active tuberculosis (TB) in a country of continental dimensions such as Brazil. Available in all Brazilian municipalities and states, the system enables continuous consolidation of data, evaluation and monitoring of actions related to TB control in the country. The purpose of this paper is to present the specificities of SINAN-Net related to TB, including the follow-up screen, the record linkage and the follow-up report. Additionally, we describe the main variables and indicators and the challenges and limitations of the system.

O Sistema de Informação de Agravos de Notificação (Sinan) possibilita conhecer o perfil das pessoas com tuberculose (TB) ativa em um país continental como o Brasil. Disponível em todos os municípios e estados, o sistema permite contínua consolidação dos dados, avaliação e monitoramento das ações relacionadas ao controle da doença no país. O objetivo deste estudo foi apresentar as especificidades do Sinan-Net referentes à TB, entre elas a tela de acompanhamento, a rotina de vinculação e o boletim de acompanhamento. Adicionalmente, são descritas as principais variáveis e indicadores, os desafios e limitações do sistema.

El Sistema de Información de Agravamientos de Notificación (Sinan) posibilita conocer el perfil de las personas con tuberculosis (TB) activa en un país continental como Brasil. Disponible en todos los municipios y estados, el sistema posibilita una continua consolidación de los datos, evaluación y monitoreo de las acciones relacionadas al control de la enfermedad en el país. El objetivo de este trabajo es presentar las especificidades del Sinan-Net con relación a la TB, entre ellas la pantalla de acompañamiento, la rutina de vinculación y el boletín de acompañamiento. Adicionalmente, describimos las principales variables e indicadores y los desafíos y limitaciones del sistema.

Special Tuberculosis Treatment Information System (SITE-TB) in Brazil: background, description and perspectives. / Sistema de Informação de Tratamentos Especiais de Tuberculose (SITE-TB): histórico, descrição e perspectivas.

The Special Tuberculosis Treatment Information System (SITE-TB) arose mainly from the need to routinely monitor all persons with drug-resistant tuberculosis (DR-TB) in Brazil, as well as to qualify tuberculosis' drug control. Developed by the Professor Hélio Fraga Reference Center and the Management Sciences for Health/Brazil Project, this online system was implemented in 2013 in all Brazilian states. In addition to DR-TB, the system registers people with drug-sensitive tuberculosis with special regimen indications, and those with nontuberculous mycobacterial infections identified by differential diagnosis of tuberculosis. All confirmed tuberculosis cases should be notified on the Notifiable Diseases Information System (SINAN). In situations where treatment with special regimens is necessary, the case is closed on SINAN and notified on SITE-TB. Professionals from tuberculosis reference centers report and monitor these cases on the system, as well as manage tuberculosis' drugs.

O Sistema de Informação de Tratamentos Especiais de Tuberculose (SITE-TB) surgiu da necessidade principal de monitorar, rotineiramente, todas as pessoas com tuberculose drogarresistente (TBDR) no Brasil, e qualificar o controle dos fármacos antituberculose. Desenvolvido pelo Centro de Referência Professor Hélio Fraga e pelo projeto Management Sciences for Health/Brasil, esse sistema online foi implantado em 2013, em todas as Unidades da Federação. Além da TBDR, no SITE-TB são registradas pessoas com tuberculose sensível com indicação de esquema especial, e aquelas com micobacterioses não tuberculosas identificadas por diagnóstico diferencial de tuberculose. Toda pessoa com tuberculose confirmada deve ser notificada no Sistema de Informação de Agravos de Notificação (Sinan). Em situações nas quais se faz necessário tratamento com esquema especial, o caso é encerrado no Sinan e notificado no SITE-TB. Profissionais das unidades de referência para tuberculose fazem a notificação e acompanhamento desses casos no sistema, assim como a gestão dos medicamentos.

El Sistema de Información de Tratamientos Especiales de Tuberculosis (SITE-TB) surgió principalmente de la necesidad de monitorear rutinariamente todas las personas con tuberculosis drogorresistente (TB-DR) en Brasil y cualificar el control de drogas antituberculosis. Desarrollado por el Centro de Referencia Profesor Hélio Fraga y el proyecto Management Sciences for Health/Brasil, este sistema online fue implantado en 2013 en todos los estados del país. Además de TB-DR, el SITE-TB registra personas con tuberculosis sensible con indicación de régimen especial, y aquellas con micobacteriosis no tuberculosas identificadas por diagnóstico diferencial de tuberculosis. Toda persona con tuberculosis confirmada debe ser notificada en el Sistema de Información de Agravamientos de Notificación (SINAN). Para situaciones en las que se hace necesario tratamiento con régimen especial, el caso se cierra en el SINAN y se notifica en el SITE-TB. Los profesionales de las unidades de referencia para TB son los que hacen la notificación y seguimiento de estos casos en el sistema, así como la gestión de las drogas antituberculosis.

Time until tuberculosis recurrence and associated factors in Brazil: a population-based retrospective cohort study using a linked database / Tempo até a recorrência da tuberculose e fatores associados no Brasil: um estudo de coorte retrospectiva de base populacional usando dados de linkage

ABSTRACT Objective: To calculate the rate of tuberculosis recurrence, estimate its average time until recurrence, and identify factors associated with recurrence in Brazil. Methods: Retrospective cohort study with a linked database from the Notifiable Diseases Information System. The study included individuals diagnosed with tuberculosis in 2015, focusing on those who experienced their first recurrence within 6.5 years. We estimated the relative risk (RR) and its 95% confidence interval (95%CI), as well as the population attributable fraction (PAF) or the population preventable fraction (PPF) of associated factors. Results: Within a 6.5-year period, 3,253 individuals (6.5%) experienced tuberculosis recurrence, with a median time of 2.2 years. Positively associated factors included: male sex (RR: 1.4; 95%CI 1.3-1.5; PAF: 22.9%), age 30 to 59 years (RR: 3.0; 95%CI 1.6-5.7; PAF: 36.0%), black race (RR: 1.3; 95%CI 1.2-1.5; PAF: 3.5%), mixed race (RR: 1.3; 95%CI 1.2-1.4; PAF: 10.6%), deprivation of liberty (RR: 1.9; 95%CI 1.7-2.1; PAF: 9.1%), pulmonary/mixed clinical form (RR: 1.7; 95%CI 1.4-1.9; PAF: 37.1%), acquired immunodeficiency syndrome diagnosis (RR: 1.8; 95%CI 1.5-1.9; PAF: 4.3%), and alcohol use (RR: 1.2; 95%CI 1.1-1.3; PAF: 2.9%). Negatively associated factors were: 12 or more years of schooling (RR: 0.5; 95%CI 0.4-0.6; PPF: 3.3%) and supervised treatment (RR: 0.9; 95%CI 0.8-0.9; PPF: 4.4%). Conclusion: This study revealed high tuberculosis recurrence rates in Brazil, influenced by sociodemographic, compartmental, and social factors, both positively and negatively impacting disease recurrence.

RESUMO Objetivo: Calcular a taxa de recorrência de tuberculose, estimar seu tempo médio e identificar seus fatores associados no Brasil. Métodos: Estudo de coorte retrospectiva com dados de linkage do Sistema de Informação de Agravos de Notificação. Incluímos pessoas diagnosticadas com tuberculose em 2015, com foco naquelas que tiveram sua primeira recorrência em 6,5 anos. Estimamos o risco relativo (RR) e seus intervalos de confiança de 95% (IC95%), assim como a fração atribuível populacional (FAP) ou a fração prevenível populacional (FPP) dos fatores associados. Resultados: No período de 6,5 anos, 3.253 indivíduos (6,5%) tiveram recorrência de tuberculose, com tempo médio de 2,2 anos. Fatores positivamente associados incluíram: sexo masculino (RR: 1,4; IC95% 1,3-1,5; FAP: 22,9%), idade de 30 a 59 anos (RR: 3,0; IC95% 1,6-5,7; FAP: 36,0%), raça/cor preta (RR: 1,3; IC95% 1,2-1,5; FAP: 3,5%) ou raça/cor parda (RR: 1,3; IC95% 1,2-1,4; FAP: 10,6%), privação de liberdade (RR: 1,9; IC95% 1,7-2,1; FAP: 9,1%), forma clínica pulmonar/mista (RR: 1,7; IC95% 1,4-1,9; FAP: 37,1%), diagnóstico de síndrome da imunodeficiência adquirida (RR: 1,8; IC95% 1,5-1,9; FAP: 4,3%) e uso de álcool (RR: 1,2; IC95% 1,1-1,3; FAP: 2,9%). Fatores negativamente associados foram: 12 ou mais anos de estudo (RR: 0,5; IC95% 0,4-0,6; FPP: 3,3%) e tratamento supervisionado (RR: 0,9; IC95% 0,8-0,9; FPP: 4,4%). Conclusão: Revelamos taxas elevadas de recorrência de tuberculose no Brasil, com fatores sociodemográficos, comportamentais e sociais influenciando na recorrência da doença.

Clusters of heterogeneity of tuberculosis-HIV coinfection in Brazil: a geospatial study / Clusters da heterogeneidade da coinfecção tuberculose-HIV no Brasil: um estudo geoespacial

ABSTRACT OBJECTIVE To analyze the geospatialization of tuberculosis-HIV coinfection in Brazil, from 2010 to 2021, and the correlation with socioeconomic, housing, and health indicators. METHODS An ecological study of Brazilian municipalities and states, with data from HIV and tuberculosis information systems, previously reported by the Ministry of Health. The crude and smoothed coefficients were calculated by the local empirical Bayesian method of incidence of coinfection per 100,000 inhabitants in the population aged between 18 and 59 years. Univariate (identification of clusters) and bivariate (correlation with 20 indicators) Moran's indices were used. RESULTS A total of 122,223 cases of coinfection were registered in Brazil from 2010 to 2021, with a mean coefficient of 8.30/100,000. The South (11.44/100,000) and North (9.93/100,000) regions concentrated the highest burden of infections. The coefficients dropped in Brazil, in all regions, in the years of covid-19 (2020 and 2021). The highest coefficients were observed in the municipalities of the states of Rio Grande do Sul, Mato Grosso do Sul, and Amazonas, with high-high clusters in the capitals, border regions, coast of the country. The municipalities belonging to the states of Minas Gerais, Bahia, Paraná, and Piauí showed low-low clusters. There was a direct correlation with human development indices and aids rates, as well as an indirect correlation with the proportion of poor or of those vulnerable to poverty and the Gini index. CONCLUSIONS The spatial analysis of tuberculosis-HIV coinfection showed heterogeneity in the Brazilian territory and constant behavior throughout the period, revealing clusters with high-burden municipalities, especially in large urban centers and in states with a high occurrence of HIV and/or tuberculosis. These findings, in addition to alerting to the effects of the covid-19 pandemic, can incorporate strategic planning for the control of coinfection, aiming to eliminate these infections as public health problems by 2030.

RESUMO OBJETIVO Analisar a geoespacialização da coinfecção tuberculose-HIV no Brasil, de 2010 a 2021, e a correlação com indicadores socioeconômicos, habitacionais e sanitários. MÉTODOS Estudo ecológico dos municípios e estados brasileiros, com dados dos sistemas de informação do HIV e da tuberculose, previamente relacionados pelo Ministério da Saúde. Foram calculados os coeficientes brutos e suavizados pelo método bayesiano empírico local de incidência da coinfecção, por 100 mil habitantes, na população entre 18 e 59 anos. Empregaram-se os índices de Moran univariado (identificação de clusters) e bivariado (correlação com 20 indicadores). RESULTADOS Foram registrados 122.223 casos de coinfecção no Brasil, de 2010 a 2021, com coeficiente médio de 8,30/100 mil. As regiões Sul (11,44/100 mil) e Norte (9,93/100 mil) concentraram a maior carga das infecções. Houve queda dos coeficientes no Brasil, em todas as regiões, nos anos de covid-19 (2020 e 2021). Os maiores coeficientes foram visualizados nos municípios do Rio Grande do Sul, do Mato Grosso do Sul e do Amazonas, com aglomerados alto-alto nas capitais, em regiões de fronteira e no litoral do país. Os municípios pertencentes aos estados de Minas Gerais, da Bahia, do Paraná e do Piauí apresentaram clusters baixo-baixo. Houve correlação direta com os índices de desenvolvimento humano e as taxas de aids, bem como indireta com a proporção de pobres ou vulneráveis à pobreza e o índice de Gini. CONCLUSÕES A análise espacial da coinfecção tuberculose-HIV demonstrou heterogeneidade no território brasileiro e comportamento constante ao longo do período, revelando clusters com municípios de alta carga, principalmente nos grandes centros urbanos e nos estados com ocorrência elevada do HIV e/ou da tuberculose. Esses achados, além de trazerem um alerta para os efeitos da pandemia da covid-19, podem incorporar o planejamento estratégico para o controle da coinfecção, visando à eliminação dessas infecções como problemas de saúde pública até 2030.

[Low birth weight and associated factors]. / Baixo peso ao nascer e fatores associados.

Birth weight is a measure commonly used to assess circumstances at childbirth. This study had the objective of analyzing the connection between birth weight and maternal variables according to Certificates of Live Birth. The design was transversal, descriptive, analytical, and the sample was formed by 4015 birth certificates from Maringá Municipality, Paraná, Brazil, in the year 2001. Prevalence of low birth weight was of 7.6%. The variables that show significant association with low birth weight are the following: parity, 50.11% of women were giving birth for the first time (x2 = 18.01); female newborn (x2 = 3.98); number of prenatal check ups < 7 check ups (x2 = 74.49); prematurity (x2 = 1357.97) and normal delivery (x2 = 12.80). The study of Certificates of Live Birth variables is an instrument of vital importance for planning actions targeting both mothers and children's health.