Resource implications of the latent tuberculosis cascade of care: a time and motion study in five countries.

BACKGROUND: The End TB Strategy calls for global scale-up of preventive treatment for latent tuberculosis infection (LTBI), but little information is available about the associated human resource requirements. Our study aimed to quantify the healthcare worker (HCW) time needed to perform the tasks associated with each step along the LTBI cascade of care for household contacts of TB patients. METHODS: We conducted a time and motion (TAM) study between January 2018 and March 2019, in which consenting HCWs were observed throughout a typical workday. The precise time spent was recorded in pre-specified categories of work activities for each step along the cascade. A linear mixed model was fit to estimate the time at each step. RESULTS: A total of 173 HCWs in Benin, Canada, Ghana, Indonesia, and Vietnam participated. The greatest amount of time was spent for the medical evaluation (median: 11 min; IQR: 6-16), while the least time was spent on reading a tuberculin skin test (TST) (median: 4 min; IQR: 2-9). The greatest variability was seen in the time spent for each medical evaluation, while TST placement and reading showed the least variability. The total time required to complete all steps along the LTBI cascade, from identification of household contacts (HHC) through to treatment initiation ranged from 1.8 h per index TB patient in Vietnam to 5.2 h in Ghana. CONCLUSIONS: Our findings suggest that the time requirements are very modest to perform each step in the latent TB cascade of care, but to achieve full identification and management of all household contacts will require additional human resources in many settings.

Cost and cost-effectiveness of tuberculosis treatment shortening: a model-based analysis.

BACKGROUND: Despite improvements in treatment success rates for tuberculosis (TB), current six-month regimen duration remains a challenge for many National TB Programmes, health systems, and patients. There is increasing investment in the development of shortened regimens with a number of candidates in phase 3 trials. METHODS: We developed an individual-based decision analytic model to assess the cost-effectiveness of a hypothetical four-month regimen for first-line treatment of TB, assuming non-inferiority to current regimens of six-month duration. The model was populated using extensive, empirically-collected data to estimate the economic impact on both health systems and patients of regimen shortening for first-line TB treatment in South Africa, Brazil, Bangladesh, and Tanzania. We explicitly considered 'real world' constraints such as sub-optimal guideline adherence. RESULTS: From a societal perspective, a shortened regimen, priced at USD1 per day, could be a cost-saving option in South Africa, Brazil, and Tanzania, but would not be cost-effective in Bangladesh when compared to one gross domestic product (GDP) per capita. Incorporating 'real world' constraints reduces cost-effectiveness. Patient-incurred costs could be reduced in all settings. From a health service perspective, increased drug costs need to be balanced against decreased delivery costs. The new regimen would remain a cost-effective option, when compared to each countries' GDP per capita, even if new drugs cost up to USD7.5 and USD53.8 per day in South Africa and Brazil; this threshold was above USD1 in Tanzania and under USD1 in Bangladesh. CONCLUSION: Reducing the duration of first-line TB treatment has the potential for substantial economic gains from a patient perspective. The potential economic gains for health services may also be important, but will be context-specific and dependent on the appropriate pricing of any new regimen.

The rise of artificial intelligence reading of chest X-rays for enhanced TB diagnosis and elimination.

We provide an overview of the latest evidence on computer-aided detection (CAD) software for automated interpretation of chest radiographs (CXRs) for TB detection. CAD is a useful tool that can assist in rapid and consistent CXR interpretation for TB. CAD can achieve high sensitivity TB detection among people seeking care with symptoms of TB and in population-based screening, has accuracy on-par with human readers. However, implementation challenges remain. Due to diagnostic heterogeneity between settings and sub-populations, users need to select threshold scores rather than use pre-specified ones, but some sites may lack the resources and data to do so. Efficient standardisation is further complicated by frequent updates and new CAD versions, which also challenges implementation and comparison. CAD has not been validated for TB diagnosis in children and its accuracy for identifying non-TB abnormalities remains to be evaluated. A number of economic and political issues also remain to be addressed through regulation for CAD to avoid furthering health inequities. Although CAD-based CXR analysis has proven remarkably accurate for TB detection in adults, the above issues need to be addressed to ensure that the technology meets the needs of high-burden settings and vulnerable sub-populations.

Lessons for TB from the COVID-19 response: qualitative data from Brazil, India and South Africa.

BACKGROUND: Brazil, India and South Africa are among the top 30 high TB burden countries globally and experienced high rates of SARS-CoV-2 infection and mortality. The COVID-19 response in each country was unprecedented and complex, informed by distinct political, economic, social and health systems contexts. While COVID-19 responses have set back TB control efforts, they also hold lessons to inform future TB programming and services. METHODS: This was a qualitative exploratory study involving interviews with TB stakeholders (n = 76) in Brazil, India and South Africa 2 years into the COVID-19 pandemic. Interview transcripts were analysed using an inductive coding strategy. RESULTS: Political will - whether national or subnational - enabled implementation of widespread prevention measures during the COVID-19 response in each country and stimulated mobile and telehealth service delivery innovations. Participants in all three countries emphasised the importance of mobilising and engaging communities in public health responses and noted limited health education and information as barriers to implementing TB control efforts at the community level. CONCLUSIONS: Building political will and social mobilisation must become more central to TB programming. COVID-19 has shown this is possible. A similar level of investment and collaborative effort, if not greater, as that seen during the COVID-19 pandemic is needed for TB through multi-sectoral partnerships.

CONTEXTE: Le Brésil, l'Inde et l'Afrique du Sud figurent parmi les 30 pays les plus touchés par la TB dans le monde et ont connu des taux élevés d'infection et de mortalité dus au SARS-CoV-2. La réponse au COVID-19 dans chacun de ces pays a été sans précédent et complexe, en raison de contextes politiques, économiques, sociaux et de systèmes de santé distincts. Si les réponses au COVID-19 ont fait reculer les efforts de lutte contre la TB, elles permettent également de tirer des enseignements pour les futurs programmes et services de lutte contre la TB. MÉTHODES: Il s'agit d'une étude exploratoire qualitative comprenant des entretiens avec des acteurs de la lutte contre la TB (n = 76) au Brésil, en Inde et en Afrique du Sud, 2 ans après le début de la pandémie de COVID-19. Les transcriptions des entretiens ont été analysées à l'aide d'une stratégie de codage inductive. RÉSULTATS: La volonté politique ­ qu'elle soit nationale ou infranationale ­ a permis la mise en œuvre de mesures de prévention généralisées au cours de la riposte au COVID-19 dans chaque pays et a stimulé les innovations en matière de prestation de services mobiles et de télésanté. Les participants des trois pays ont souligné l'importance de la mobilisation et de l'engagement des communautés dans les réponses de santé publique et ont noté que l'éducation et l'information sanitaires limitées constituaient des obstacles à la mise en œuvre des efforts de lutte contre la TB au niveau communautaire. CONCLUSIONS: La volonté politique et la mobilisation sociale doivent occuper une place plus centrale dans les programmes de lutte contre la TB. La conférence COVID-19 a montré que c'était possible. Un niveau d'investissement et de collaboration similaire, voire supérieur, à celui observé lors de la pandémie de COVID-19 est nécessaire pour lutter contre la TB par le biais de partenariats multisectoriels.

Factors associated with non-completion of TB preventive treatment in Brazil.

BACKGROUND: Among Brazilian initiatives to scale up TB preventive therapy (TPT) are the adoption of the 3HP regimen (12 weekly doses of rifapentine and isoniazid [INH]) in 2021 and the implementation in 2018 of the TPT surveillance information system. Since then, 63% of the 76,000 eligible individuals notified completed TPT. Recommended regimens in this period were 6H, 9H (6 or 9 months of INH) and 4R (4 months of rifampicin).OBJECTIVE: To analyse the factors associated with TPT non-completion.METHODS: We analysed the cohort of TPT notifications from 2018 to 2020. Robust variance Poisson regression model was used to verify the association of TPT non-completion with sociodemographic, clinical and epidemiological variables.RESULTS: Of the 39,973 TPT notified in the study period, 8,534 (21.5%) were non-completed, of which 7,858 (92.1%) were lost to follow-up. Age 15-60 years (relative risk [RR] 1.27, 95% confidence interval [95% CI] 1.20-1.35), TPT with isoniazid (RR 1.40, 95% CI 1.19-1.64) and Black/mixed race (RR 1.17, 95% CI 1.09-1.25) were associated with a higher risk of non-completion.CONCLUSION: Individuals in situations of social and financial vulnerability such as being Black/pardo race, younger and on longer TPT regimens were more likely to be associated with TPT incompletion.

The COVID-19 and TB syndemic: the way forward.

Together, SARS-CoV-2 and M. tuberculosis have killed approximately 5.7 million people worldwide over the past 2 years. The COVID-19 pandemic, and the non-pharmaceutical interventions to mitigate COVID-19 transmission (including social distancing regulations, partial lockdowns and quarantines), have disrupted healthcare services and led to a reallocation of resources to COVID-19 care. There has also been a tragic loss of healthcare workers who succumbed to the disease. This has had consequences for TB services, and the fear of contracting COVID-19 may also have contributed to reduced access to TB services. Altogether, this is projected to have resulted in a 5-year setback in terms of mortality from TB and a 9-year setback in terms of TB detection. In addition, past and present TB disease has been reported to increase both COVID-19 fatality and incidence. Similarly, COVID-19 may adversely affect TB outcomes. From a more positive perspective, the pandemic has also created opportunities to improve TB care. In this review, we highlight similarities and differences between these two infectious diseases, describe gaps in our knowledge and discuss solutions and priorities for future research.

A public health approach to increase treatment of latent TB among household contacts in Brazil.

SETTING: Two consecutive trials were conducted to evaluate the effectiveness of a public health approach to identify and correct problems in the care cascade for household contacts (HHCs) of TB patients in three Brazilian high TB incidence cities.METHODS: In the first trial, 12 clinics underwent standardised evaluation using questionnaires administered to TB patients, HHCs and healthcare workers, and analysis of the cascade of latent TB care among HHCs. Six clinics were then randomised to receive interventions to strengthen management of latent TB infection (LTBI), including in-service training provided by nurses, work process organisation and additional clinic-specific solutions. In the second trial, a similar but streamlined evaluation was conducted in two clinics, who then received initial and subsequent intensive in-service training provided by a physician.RESULTS: In the evaluation phase of both trials, many HHCs were identified, but few started LTBI treatment. After the intervention, the number of HHCs initiating treatment per 100 active TB patients increased by 10 (95%CI - 11 to 30) in the first trial, and by 44 (95%CI 26 to 61) in the second trial.DISCUSSION: A public health approach with standardised evaluation, local decisions for improvements, followed by intensive initial and in-service training appears promising for improved LTBI management.

Uses of tuberculosis mortality surveillance to identify programme errors and improve database reporting.

BACKGROUND: In 2006, 848 persons died from tuberculosis (TB) in Rio de Janeiro, Brazil, corresponding to a mortality rate of 5.4 per 100 000 population. No specific TB death surveillance actions are currently in place in Brazil. SETTING: Two public general hospitals with large open emergency rooms in Rio de Janeiro City. OBJECTIVE: To evaluate the contribution of TB death surveillance in detecting gaps in TB control. METHODS: We conducted a survey of TB deaths from September 2005 to August 2006. Records of TB-related deaths and deaths due to undefined causes were investigated. Complementary data were gathered from the mortality and TB notification databases. RESULTS: Seventy-three TB-related deaths were investigated. Transmission hazards were identified among firefighters, health care workers and in-patients. Management errors included failure to isolate suspected cases, to confirm TB, to correct drug doses in underweight patients and to trace contacts. Following the survey, 36 cases that had not previously been notified were included in the national TB notification database and the outcome of 29 notified cases was corrected. CONCLUSION: TB mortality surveillance can contribute to TB monitoring and evaluation by detecting correctable and specific programme- and hospital-based care errors, and by improving the accuracy of TB database reporting. Specific local and programmatic interventions can be proposed as a result.

Novel tests for diagnosing tuberculous pleural effusion: what works and what does not?

Tuberculous pleuritis is a common manifestation of extrapulmonary tuberculosis and is the most common cause of pleural effusion in many countries. Conventional diagnostic tests, such as microscopic examination of the pleural fluid, biochemical tests, culture of pleural fluid, sputum or pleural tissue, and histopathological examination of pleural tissue, have known limitations. Due to these limitations, newer and more rapid diagnostic tests have been evaluated. In this review, the authors provide an overview of the performance of new diagnostic tests, including markers of specific and nonspecific immune response, nucleic acid amplification and detection, and predictive models based on combinations of markers. Directions for future development and evaluation of novel assays and biomarkers for pleural tuberculosis are also suggested.

Two-step tuberculin skin test and booster phenomenon prevalence among Brazilian medical students.

SETTING: Five medical schools in three cities in Rio de Janeiro State, Brazil, with different tuberculosis (TB) incidence rates. OBJECTIVE: To evaluate the prevalence of the booster phenomenon and its associated factors in a young universally BCG-vaccinated TB-exposed population. DESIGN: A two-step tuberculin skin test (TST) was performed among undergraduate medical students. Boosting was defined as an induration > or =10 mm in the second TST (TST2), with an increase of at least 6 mm over the first TST (TST1). The association of boosting with independent variables was evaluated using multivariate analysis. RESULTS: Of the 764 participants (mean age 21.9 +/- 2.7 years), 672 (87.9%) had a BCG scar. The overall booster phenomenon prevalence was 8.4% (95%CI 6.5-10.6). Boosting was associated with TST1 reactions of 1-9 mm (aOR 2.5, 95%CI 1.04-5.9) and with BCG vaccination, mostly after infancy, i.e., after age two years (aOR 9.1, 95%CI 1.2-70.7). CONCLUSION: The prevalence of the booster phenomenon was high. A two-step TST in young BCG-vaccinated populations, especially in those with TST1 reactions of 1-9 mm, can avoid misdiagnosis as a false conversion and potentially reduce unnecessary treatment for latent TB infection.

Tuberculosis teaching in Brazilian medical schools.

To achieve tuberculosis (TB) control, National Tuberculosis Programme guidelines should be implemented effectively. In a survey conducted in 2005-2006, 33 Brazilian medical school coordinators answered a questionnaire about TB education. The median time dedicated to TB was 27 h (4-119 h), spread over several disciplines, mainly biological and clinical. This included 12 h (0-88 h) of practical activities, mainly in university hospitals (53%). The recommendation to offer human immunodeficiency virus testing for TB patients was taught in only 54% of the schools. TB education in Brazil is fragmented and restricted to a biological approach, while field activities are insufficient and carried out in inadequate settings. Important changes to the TB curriculum are necessary.

Cost-effectiveness of the Xpert® MTB/RIF assay for tuberculosis diagnosis in Brazil.

INTRODUCTION: The Xpert® MTB/RIF assay is being implemented as a substitute for sputum smear microscopy (SSM) in many low and high tuberculosis (TB) burden countries, including Brazil, a country with low multidrug resistance and moderate human immunodeficiency virus co-infection rates. SETTING: Brazilian National TB Programme (NTP). OBJECTIVE AND DESIGN: We estimated the incremental cost-effectiveness ratio (ICER) of Xpert as a substitute for two SSM tests in the diagnosis of drug-susceptible TB. The costs for confirming each additional case and for avoiding treatment due to false-positive empirical diagnoses were estimated. RESULTS: The ICER was US$943 for each additional TB diagnosis and US$356 for each additional TB diagnosis with bacteriological confirmation, assuming 80% specificity of clinical diagnosis using both strategies. For every 100 000 patients with suspected TB, the NTP would spend an additional US$1.2 million per year to confirm 3344 more TB patients. The model was highly sensitive to specificity of clinical diagnosis after a negative test. CONCLUSION: Although the NTP has no threshold for cost-effectiveness, our model can provide support for decision makers in Brazil and other countries with a low prevalence of drug resistance among TB patients. Financial benefit can potentially be expected if physicians rely more on a negative Xpert result and empirical treatment is reduced.

Non-completion of latent tuberculous infection treatment among children in Rio de Janeiro State, Brazil.

BACKGROUND: Children with latent tuberculous infection (LTBI) are particularly vulnerable to progression to active tuberculosis (TB), and are thus a priority target for isoniazid preventive therapy (IPT). However, adherence to IPT is poor. We hypothesised that children from poorer families, with reduced access to health care and lack of understanding about the disease are more likely to default from IPT. METHODS: A questionnaire was administered to close child contacts or their parents at the time of prescribing IPT in three cities in Rio de Janeiro State. The children were followed prospectively. Treatment adherence was defined as taking 80% of prescribed doses. RESULTS: Among 1078 children screened for LTBI, 97 (8.9%) did not return for tuberculin skin test (TST) reading; 332 (30.8%) were TST-positive; 115/332 (34.6%) were prescribed IPT, 6 of whom did not initiate treatment and 11 did not adhere during the first 2 months; 25 additional children did not complete IPT. Overall non-completion was four times more frequent among those with lower income. Health care access and knowledge did not improve treatment completion. CONCLUSIONS: Substantial losses to follow-up occurred before IPT prescription; this should be further investigated. Among the children who started isoniazid, low income, but not difficult access or poor knowledge, increased the risk of treatment non-completion.

IgA antibody responses to Mycobacterium tuberculosis recombinant MPT-64 and MT-10.3 (Rv3019c) antigens in pleural fluid of patients with tuberculous pleurisy.

SETTING: Microbiological tests lack sensitivity for pleural tuberculosis (TB) and histopathology is expensive, time consuming and needs specialised personnel. Immunoassay (ELISA) may be a promising approach in this respect. OBJECTIVE: To evaluate the reactivity of IgA antibody to MPT-64 and MT-10.3 recombinant mycobacterial protein antigens in pleural fluid as a marker of pleural TB, based on the fact that IgA is the main antibody in the mucosa/serosa of the gastrointestinal and respiratory tract. METHOD: Anti-MPT-64 and MT-10.3 IgA response was determined by ELISA in 72 patients with pleural TB and 27 with other pleural conditions. RESULTS: High sensitivities for IgA were measured against MPT-64 (52/72, 72%) and MT-10.3 (52/72,72%) antigens. Combining the sensitivities of both antigens, further increase in sensitivity (55/72, 76%) was obtained with no loss of specificity (96%). Similar IgA reactivity was obtained from culture-negative and culture-positive specimens. In eight pleural TB patients with human immunodeficiency virus (HIV) co-infection, the sensitivity was 88% (7/8). CONCLUSION: To our knowledge, this is the first description of the presence of IgA antibody pleural TB effusion reactive to MPT-64 and MT-10.3, with sensitivity similar to histopathological examination, which is presently considered the gold standard for pleural TB.

Latent tuberculosis infection among undergraduate medical students in Rio de Janeiro State, Brazil.

SETTING: Five medical schools in three cities with different tuberculosis (TB) incidence rates in Rio de Janeiro State, Brazil. OBJECTIVE: To estimate prevalence of and associated factors for latent tuberculosis infection (LTBI) among medical students. DESIGN: A cross-sectional survey was conducted among undergraduate students in pre-clinical, early and late clinical years from schools in cities with low (28/100,000), intermediate (63/100,000) and high (114/100,000) TB incidence rates. Information on socio-demographic profile, previous BCG vaccination, potential TB exposure, co-morbidity and use of respiratory protective masks was obtained. A tuberculin skin test (TST) was performed using the Mantoux technique by an experienced professional. A positive TST, defined as induration > or = 10 mm, was considered LTBI. RESULTS: LTBI prevalence was 6.9% (95%CI 5.4-8.6). In multivariate analysis, male sex (adjusted odds ratio [aOR] 1.8; 95% CI 1.1-3.0), late clinical years (aOR 1.9; 95% CI 1.01-3.5), intermediate TB incidence (aOR 4.3; 95% CI 1.3-14.6) and high TB incidence in the city of medical school (aOR 5.1; 95% CI 1.6-16.8) were significantly associated with LTBI. CONCLUSIONS: The higher prevalence of LTBI in late clinical years suggests that medical students are at increased risk for nosocomial Mycobacterium tuberculosis infection. The implementation of a TB control program may be necessary in medical schools, particularly in cities with higher TB incidence.

Jejunal biopsy in HIV-infected patients.

Forty-nine HIV-infected patients were submitted to peroral jejunal biopsy in order to evaluate the presence of microorganisms and the histomorphometric aspects of the enteric mucosa with subsequent correlation of these findings to the appropriate clinical stage of the disease. Thirty-seven patients fulfilled the CDC criteria for AIDS, of whom 23 presented with diarrhea. Of the 12 patients who had not yet been given an AIDS diagnosis. 3 had persistent generalized lymphadenopathy and 9 were asymptomatic carriers. Flat mucosa was observed in two patients (8.7%) with diarrhea and coccidea. Subtotal villous atrophy and severe lamina propria (LP) mononuclear infiltrate (13%) were found only in patients with diarrhea. Moderate to severe histologic changes were more frequently observed in this group, not always related to the presence of microorganisms. Crypt hyperregeneration was a constant finding. Intraepithelial lymphocyte (IEL) count was decreased in patients with diarrhea. Specific infectious agents were unexpectedly rare for the tropical developing country population studied. The organism most commonly associated with diarrhea was Cryptosporidium sp. (21.7%). The etiology of diarrhea in a significant number of patients remains unclear.

Intestinal immune cells in Strongyloides stercoralis infection.

BACKGROUND: Strongyloides stercoralis can cause a wide spectrum of disease in man, ranging from a chronic asymptomatic infection to a hyperinfective, often fatal syndrome. In rodents, spontaneous expulsion of Strongyloides spp occurs after experimental infection. Mast cells, goblet cells, and eosinophils have been identified as possible effectors of this expulsion. AIMS: To investigate intestinal histopathology and mucosal immunity in immunocompetent patients with chronic S stercoralis infection. METHODS: Jejunal biopsies were performed in 19 immunocompetent patients with a positive stool examination for S stercoralis and few or no symptoms, and in seven healthy controls. Specimens were processed for histopathological analysis and stained by the immunoperoxidase technique, using the following monoclonal antibodies: CD2, CD3, CD4, CD8, anti-T cell receptor (TcR) gamma/delta, RFD1 and RFD7 (two different macrophage markers), Ki67+ (proliferating) cells, antihuman leucocyte antigen (HLA)-DR, and anticollagen IV. In addition, CD25+ cells, mast cells, IgE expressing cells, calprotectin containing cells, and neutrophil elastase positive cells were stained by the alkaline phosphatase method. RESULTS: Jejunal morphology and the numbers of different T cell subsets, mast cells, IgE expressing cells, eosinophils, and goblet cells were unaffected by S stercoralis infection. Conversely, the numbers of mature macrophages and dividing enterocytes in the crypts were reduced significantly. Crypt enterocytes did not express HLA-DR in both groups. The expression of HLA-DR by villus enterocytes was also comparable in patients and controls. There were no activated (CD25+) cells in the mucosa of either patients or controls. CONCLUSIONS: Compared with seven healthy uninfected volunteers, a group of 19 Brazilians with clinically mild strongyloides infection showed no abnormality of mucosal structure and no increase in non-specific inflammatory cells. Likewise, there was no increase in mucosal T cells or macrophages.

Pleural tuberculosis and human immunodeficiency virus co-infection.

SETTING: Department of internal medicine in a general hospital in Rio de Janeiro, Brazil, which provides secondary care to the poor population. OBJECTIVE: The aim of this study was to evaluate the prevalence of human immunodeficiency virus (HIV) infection in patients with pleural tuberculosis (TB) and to compare its manifestations in HIV-negative and HIV-infected patients. DESIGN: Cross-sectional study. METHODS: Forty-three patients with a final diagnosis of pleural TB were submitted to HIV testing (ELISA), chest X-ray, and thoracentesis for biochemical, cytological and bacteriological analysis. Pleural tissue was obtained in 36 patients for histopathological examination. PPD testing was performed in 29 patients. Whenever productive cough was present, sputum acid-fast smears and culture for Mycobacterium tuberculosis were performed. RESULTS: The HIV prevalence was high (30%). TB symptoms were similar in both groups. Atypical radiological aspects were observed in HIV-infected patients with concurrent pulmonary TB (P = 0.03). Pleural fluid, tissue aspects and PPD testing were comparable in both groups. CONCLUSION: Only atypical radiographic patterns in patients with concurrent pulmonary TB were indicative of HIV infection. Therefore, a high index of suspicion is necessary for the early recognition of HIV/TB co-infection. We suggest that all patients presenting with pleural TB should be screened for anti-HIV antibodies.

The study of tuberculosis-attributed deaths as a tool for disease control planning in Rio de Janeiro, Brazil.

SETTING: Two tuberculosis (TB) reference hospitals and three general hospitals in Rio de Janeiro (RJ). OBJECTIVE: To analyze TB-attributed deaths as a tool for evaluating the TB control program in RJ. DESIGN: Retrospective study based on 302 medical records selected from the 1998 death database. RESULTS: Of 1146 registered adult (>14 years) TB-attributed deaths in RJ, 328 occurred in five hospitals, and 302 records were analyzed. Median age was 47.5 (17-89) years; 237 (78.5%) were male. Median time elapsed from onset of symptoms until diagnosis was 60 (7-730) days; median hospitalization was 60 (0-517) days. Acid-fast bacilli sputum smears were performed in 200 (69%) of 290 cases of pulmonary disease. Among 32 (36%) smear-negative patients, culture was done in only one. The recommended regimen (RHZ) was used in 175 (58%). Among 125 re-treatment patients, 55 (44%) were on RHZ instead of RHZE. Notification to health authorities was recorded in 131 (43.4%) cases. CONCLUSION: In RJ, young people die from TB. Major issues identified in the public health system were poor detection and notification and a high default rate, perpetuating the spread of TB. Treating professionals do not follow guidelines, and political commitment is needed to ensure TB control in the state and in the country.