Phylogeography and transmission of Mycobacterium tuberculosis spanning prisons and surrounding communities in Paraguay.

Recent rises in incident tuberculosis (TB) cases in Paraguay and the increasing concentration of TB within prisons highlight the urgency of targeting strategies to interrupt transmission and prevent new infections. However, whether specific cities or carceral institutions play a disproportionate role in transmission remains unknown. We conducted prospective genomic surveillance, sequencing 471 Mycobacterium tuberculosis complex genomes, from inside and outside prisons in Paraguay's two largest urban areas, Asunción and Ciudad del Este, from 2016 to 2021. We found genomic evidence of frequent recent transmission within prisons and transmission linkages spanning prisons and surrounding populations. We identified a signal of frequent M. tuberculosis spread between urban areas and marked recent population size expansion of the three largest genomic transmission clusters. Together, our findings highlight the urgency of strengthening TB control programs to reduce transmission risk within prisons in Paraguay, where incidence was 70 times that outside prisons in 2021.

Vigilancia de la resistencia del Mycobacterium tuberculosis a los fármacos en Paraguay, 2014 a 2017 / Surveillance of drug resistance of Mycobacterium tuberculosis in Paraguay, 2014 to 2017

El objetivo del estudio fue identificar la resistencia del Mycobacterium tuberculosis a los fármacos en Paraguay, 2014 a 2017. Se realizó un estudio observacional retrospectivo. Se utilizaron los datos del Programa Nacional de Tuberculosis del Paraguay comprendidos entre los años 2014 a 2017. Se incluyeron todos los pacientes con diagnóstico de Tuberculosis que se realizaron un test de resistencia. Se extrajeron los datos en Excel y fueron analizados con Stata 17.0. Se incluyeron 3429 pacientes con tuberculosis que contaban con resultado de al menos una prueba de sensibilidad. La resistencia se encontró en 2.1% de los pacientes. La resistencia a la Rifampicina estuvo presente en el 0.3% de los casos mientras que a la Izionazida en el 0.6% de los casos. La prevalencia de resistencia fue más alta en hombres 3.4 (IC 95% 2.2 - 4.8) p=0.003, que residían en el chaco 6.0 (IC 95% 3.4 - 9.7) p=0.000, previamente tratados 2.7 (IC 95% 1.1 - 5.1) p=0.010. En el modelo se pudo observar que un paciente previamente tratado tiene mayores posibilidades de tener resistencia OR 2.62 (IC 95% 1.1 - 6.24). La prevalencia de resistencia del Mycobacterium tuberculosis a fármacos estuvo relacionada con haber sido previamente tratado

The objective of the study was to identify the resistance of Mycobacterium tuberculosis to drugs in Paraguay, 2014 to 2017. A retrospective observational study was carried out. The data from the National Tuberculosis Program of Paraguay between the years 2014 to 2017 were used. All patients with a diagnosis of Tuberculosis who underwent a resistance test were included. Data were extracted in Excel and analyzed with Stata 17.0. 3429 tuberculosis patients who had a result of at least one sensitivity test were included. Resistance was found in 2.1% of patients. Resistance to Rifampicin was present in 0.3% of cases while to Izionazide in 0.6% of cases. The prevalence of resistance was higher in men 3.4 (95% CI 2.2 - 4.8) p = 0.003, who resided in the Chaco 6.0 (95% CI 3.4 - 9.7) p = 0.000, previously treated 2.7 (95% CI 1.1 - 5.1) p = 0.010. In the model, it was observed that a previously treated patient has a greater chance of having resistance OR 2.62 (95% CI 1.1 - 6.24). The prevalence of resistance of Mycobacterium tuberculosis to drugs was related to having been previously treated

Estado actual, retos y soluciones operacionales a las Búsquedas activas de TB 2019-2020, Paraguay

RESUMEN Introducción: La búsqueda activa de casos de Tuberculosis (TB) pretende garantizar la detección temprana para reducir el riesgo de malos resultados de la enfermedad y las consecuencias sociales propias de la misma, así como cortar oportunamente la cadena de transmisión en la comunidad. Objetivo: Determinar el estado actual, retos y soluciones operacionales a las Búsquedas activas en las 18 Regiones Sanitarias del Paraguay. Métodos: Estudio descriptivo retrospectivo de corte transversal, fuente de datos: registros de búsqueda activa disponibles de las regiones sanitarias, sociedad civil y Programa Nacional de Control de Tuberculosis (PNCT) del Paraguay 2019-2020 y Sistema Experto del PNCT (SEPNCT) Para el análisis estadístico se utilizaron medidas de resumen como frecuencias absolutas, relativas y proporciones. Resultados: se analizaron las visitas de campo para búsquedas activas, en tres tipos de intervenciones, 5089 personas investigadas, 26.5% fueron identificadas como SR. La positividad general fue de 5%. Se necesita en promedio de 76 personas para encontrar un caso de TB. Las búsquedas activas que tuvieron mayor impacto fueron las realizadas por el nivel nacional con 49.3% de casos de TB aportados. Conclusiones: Las intervenciones basadas en la comunidad, como el establecimiento de redes de derivación y otras actividades que acercan la información y los servicios sobre la tuberculosis a las personas con síntomas, pueden contribuir a mejorar la notificación de casos de tuberculosis, cortar la cadena de transmisión y reducir la mortalidad por tuberculosis.

SUMMARY Introduction: The active search for cases of Tuberculosis (TB) aims to ensure early detection to reduce the risk of poor outcomes of the disease and the social consequences of the disease, as well as to cut the chain of transmission in the community in a timely manner. Objective . To determine the current status, challenges and operational solutions to the Active Searches in the 18 Health Regions of Paraguay. Methods: Retrospective descriptive cross-sectional study, data source: active search records available from the health regions, civil society and National Tuberculosis Control Program (PNCT) of Paraguay 2019-2020 and Expert System of the PNCT (SEPNCT) For the statistical analysis summary measures such as absolute and relative frequencies and proportions were used. Results: field visits were analyzed for active searches, in three types of interventions, 5089 people investigated, 26.5% were identified as RH. The overall positivity was 5%. It takes an average of 76 persons to find a TB case. The active searches that had the greatest impact were those conducted by the national level with 49.3% of TB cases contributed. Conclusions: Community-based interventions, such as the establishment of referral networks and other activities that bring TB information and services closer to people with symptoms, can help improve TB case notification, cut the chain of transmission, and reduce TB mortality.

Prevalencia de la comorbilidad tuberculosis y diabetes mellitus en Paraguay, 2016 y 2017

[RESUMEN]. Objetivo. Estimar la prevalencia nacional y regional de la comorbilidad tuberculosis (TB) y diabetes mellitus (DM) e identificar los factores asociados con esta comorbilidad en Paraguay. Métodos. Estudio transversal en pacientes con TB notificada en 2016 y 2017 y registrados en la base de datos del Programa Nacional de Control de la TB. La prevalencia de DM, definida por autonotificación, se estimó en pacientes con TB. Para conocer los factores asociados con la comorbilidad TB-DM se empleó un modelo multivariante de regresión binomial para ajustar las razones de prevalencia (RP) según los errores estándar por el clúster de región sanitaria. Resultados. Entre 2016 y 2017 se notificaron 5 315 casos de TB. La prevalencia de la comorbilidad TB-DM fue 6,3% en 2016, 6,0% en 2017 y 6,2% en ambos años. Fue más alta en Itapúa (9,2%), Alto Paraguay (8,0%), Alto Paraná (7,5%), Central (7,4%) y Asunción (7,2%). La mediana de edad de personas con DM fue más alta que la de las que no tenían DM (55 y 33 años; P < 0,001). Tener una edad mayor de 45 años (RP = 18,3), antecedente de hipertensión arterial (HTA) (RP = 2,17), baciloscopía de diagnóstico de tres cruces (RP 1,98), y antecedente de enfermedad pulmonar obstructiva crónica (EPOC) (RP 1,68) estuvieron asociados con mayor comorbilidad. En cambio, se asociaron con menor comorbilidad pertenecer a la población indígena (RP = 0,26), la infección por el virus de la inmunodeficiencia humana (RP = 0,44), historia de adicción a drogas (RP = 0,49), el sexo masculino (RP = 0,64), y la TB extrapulmonar (RP = 0,75). Conclusiones. La prevalencia de la comorbilidad de TB y DM en Paraguay, por autonotificación, fue 6,2% en el periodo 2016-2017 y varió entre las regiones sanitarias. La edad, el sexo, una alta carga bacilar al diagnóstico y la comorbilidad con HTA y EPOC se asociaron a una mayor comorbilidad. Estos hallazgos permitirán priorizar grupos de población para aumentar rendimiento del cribado, diagnóstico, tratamiento y prevención de la comorbilidad TB-DM en Paraguay.

[ABSTRACT]. Objective. To estimate the national and regional prevalence of tuberculosis (TB) and diabetes mellitus (DM) co-morbidity and identify the factors associated with this co-morbidity in Paraguay. Methods. Cross-sectional study in patients with TB notified in 2016 and 2017 and registered in the database of the National TB Control Program. The prevalence of self-reported DM was estimated in patients with TB. A multivariate binomial regression model was used to know the factors associated with TB-DM co-morbidity to adjust the prevalence ratios (PR) according to standard errors by health region. Results. Between 2016 and 2017, 5 315 cases of TB were reported. The prevalence of TB-DM co-morbidity was 6.3% in 2016, 6.0% in 2017, and 6.2% in both years. It was highest in Itapua (9.2%), Alto Paraguay (8.0%), Alto Parana (7.5%), Central (7.4%) and Asuncion (7.2%). The median age of people with DM was higher than that of those without DM (55 vs 33 years; P < 0.001). Being older than 45 years (RP = 18.3), history of hypertension (RP = 2.17), diagnostic baciloscopy +++ (RP 1.98), and history of chronic obstructive pulmonary disease (COPD) (RP 1.68) were associated with greater co-morbidity. A lower co-morbidity was associated with belonging to the indigenous population (RP = 0.26), human immunodeficiency virus infection (RP = 0.44), history of drug dependence (RP = 0.49), male sex (RP = 0.64), and extrapulmonary TB (RP = 0.75). Conclusions. The prevalence of self-reported co-morbidity of TB-DM in Paraguay was 6.2% in 2016-2017 and varied between health regions. Age, sex, high bacillary burden at diagnosis and co-morbidity with hypertension and COPD were associated with higher co-morbidity. These findings will allow prioritizing population groups to increase screening performance, diagnosis, treatment and prevention of TB-DM co-morbidity in Paraguay.

[RESUMO]. Objetivo. Estimar a prevalência nacional e regional de comorbidade entre tuberculose (TB) e diabetes mellitus (DM) no Paraguai e identificar os fatores associados a essa comorbidade. Métodos. Estudo transversal em pacientes com TB notificados em 2016 e 2017 e cadastrados na base de dados do Programa Nacional de Controle da TB. A prevalência de DM, definida por autorrelato, foi estimada em pacientes com TB. Para conhecer os fatores associados à comorbidade TB-DM, foi utilizado um modelo de regressão binomial multivariada para ajustar as razões de prevalência (RP) de acordo com os erros padrão do cluster da região de saúde. Resultados. Em 2016 e 2017 foram notificados 5 315 casos de TB. A prevalência de comorbidade TB-DM foi de 6,3% em 2016, 6,0% em 2017 e 6,2% para o período dos 2 anos. As prevalências mais altas foram observadas em Itapúa (9,2%), Alto Paraguai (8,0%), Alto Paraná (7,5%), Central (7,4%) e Assunção (7,2%). A mediana de idade foi mais alta em pessoas com DM do que naquelas sem DM (55 e 33 anos; P <0,001). Ter idade superior a 45 anos (RP = 18,3), história de hipertensão arterial (HAS) (RP = 2,17), baciloscopia diagnóstica (+++) (RP = 1,98) e história de doença pulmonar obstrutiva crônica (DPOC) (RP = 1,68) foram associados a maior comorbidade. Por sua vez, pertencer à população indígena (RP = 0,26), infecção pelo vírus da imunodeficiência humana (RP = 0,44), histórico de dependência de drogas (RP = 0,49), sexo masculino (RP = 0,64) e TB extrapulmonar (RP = 0,75) estiveram associados a menor comorbidade. Conclusões. A prevalência de comorbidade TB-DM no Paraguai, determinada a partir de autorrelato, foi de 6,2% no período 2016-2017 e variou entre as regiões de saúde. Idade, sexo, alta carga bacilar no diagnóstico e comorbidade com HAS e DPOC foram fatores associados a maior comorbidade. Esses achados permitirão priorizar grupos populacionais para aumentar o desempenho da triagem, diagnóstico, tratamento e prevenção da comorbidade TB-DM no Paraguai.

[Prevalence of comorbidity tuberculosis and diabetes mellitus in Paraguay, 2016 and 2017Prevalência de comorbidade tuberculose-diabetes mellitus no Paraguai, 2016 e 2017]. / Prevalencia de la comorbilidad tuberculosis y diabetes mellitus en Paraguay, 2016 y 2017.

OBJECTIVE: To estimate the national and regional prevalence of tuberculosis (TB) and diabetes mellitus (DM) co-morbidity and identify the factors associated with this co-morbidity in Paraguay. METHODS: Cross-sectional study in patients with TB notified in 2016 and 2017 and registered in the database of the National TB Control Program. The prevalence of self-reported DM was estimated in patients with TB. A multivariate binomial regression model was used to know the factors associated with TB-DM co-morbidity to adjust the prevalence ratios (PR) according to standard errors by health region. RESULTS: Between 2016 and 2017, 5 315 cases of TB were reported. The prevalence of TB-DM co-morbidity was 6.3% in 2016, 6.0% in 2017, and 6.2% in both years. It was highest in Itapua (9.2%), Alto Paraguay (8.0%), Alto Parana (7.5%), Central (7.4%) and Asuncion (7.2%). The median age of people with DM was higher than that of those without DM (55 vs 33 years; P < 0.001). Being older than 45 years (RP = 18.3), history of hypertension (RP = 2.17), diagnostic baciloscopy +++ (RP 1.98), and history of chronic obstructive pulmonary disease (COPD) (RP 1.68) were associated with greater co-morbidity. A lower co-morbidity was associated with belonging to the indigenous population (RP = 0.26), human immunodeficiency virus infection (RP = 0.44), history of drug dependence (RP = 0.49), male sex (RP = 0.64), and extrapulmonary TB (RP = 0.75). CONCLUSIONS: The prevalence of self-reported co-morbidity of TB-DM in Paraguay was 6.2% in 2016-2017 and varied between health regions. Age, sex, high bacillary burden at diagnosis and co-morbidity with hypertension and COPD were associated with higher co-morbidity. These findings will allow prioritizing population groups to increase screening performance, diagnosis, treatment and prevention of TB-DM co-morbidity in Paraguay.

OBJETIVO: Estimar a prevalência nacional e regional de comorbidade entre tuberculose (TB) e diabetes mellitus (DM) no Paraguai e identificar os fatores associados a essa comorbidade. MÉTODOS: Estudo transversal em pacientes com TB notificados em 2016 e 2017 e cadastrados na base de dados do Programa Nacional de Controle da TB. A prevalência de DM, definida por autorrelato, foi estimada em pacientes com TB. Para conhecer os fatores associados à comorbidade TB-DM, foi utilizado um modelo de regressão binomial multivariada para ajustar as razões de prevalência (RP) de acordo com os erros padrão do cluster da região de saúde. RESULTADOS: Em 2016 e 2017 foram notificados 5 315 casos de TB. A prevalência de comorbidade TB-DM foi de 6,3% em 2016, 6,0% em 2017 e 6,2% para o período dos 2 anos. As prevalências mais altas foram observadas em Itapúa (9,2%), Alto Paraguai (8,0%), Alto Paraná (7,5%), Central (7,4%) e Assunção (7,2%). A mediana de idade foi mais alta em pessoas com DM do que naquelas sem DM (55 e 33 anos; P <0,001). Ter idade superior a 45 anos (RP = 18,3), história de hipertensão arterial (HAS) (RP = 2,17), baciloscopia diagnóstica (+++) (RP = 1,98) e história de doença pulmonar obstrutiva crônica (DPOC) (RP = 1,68) foram associados a maior comorbidade. Por sua vez, pertencer à população indígena (RP = 0,26), infecção pelo vírus da imunodeficiência humana (RP = 0,44), histórico de dependência de drogas (RP = 0,49), sexo masculino (RP = 0,64) e TB extrapulmonar (RP = 0,75) estiveram associados a menor comorbidade. CONCLUSÕES: A prevalência de comorbidade TB-DM no Paraguai, determinada a partir de autorrelato, foi de 6,2% no período 2016-2017 e variou entre as regiões de saúde. Idade, sexo, alta carga bacilar no diagnóstico e comorbidade com HAS e DPOC foram fatores associados a maior comorbidade. Esses achados permitirão priorizar grupos populacionais para aumentar o desempenho da triagem, diagnóstico, tratamento e prevenção da comorbidade TB-DM no Paraguai.