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Universidade Federal do Espírito Santo, Vitória, Espírito Santo, Brazil; ‡ Division of ... nida Maruipe Bairro Santos Dumont, Vitória, ES 29040-091, Brazil.

INT J TUBERC LUNG DIS 17(11):1427–1434 © 2013 The Union

Treatment outcomes of tuberculosis patients in Brazilian prisons: a polytomous regression analysis L. Ribeiro Macedo,*† B. Reis-Santos,† L. W. Riley,‡ E. L. Maciel*† * Post-Graduate Programme in Doenças Infecciosas, and † Laboratory of Epidemiology, Centro de Ciências da Saúde, Universidade Federal do Espírito Santo, Vitória, Espírito Santo, Brazil; ‡ Division of Infectious Disease and Vaccinology, School of Public Health, University of California, Berkeley, California, USA SUMMARY SETTING:

Tuberculosis (TB) is a major public health problem and an important cause of infectious diseaserelated death in young adults. TB rates are higher in vulnerable populations, including prisoners. O B J E C T I V E : To describe the clinical and epidemiological characteristics associated with anti-tuberculosis treatment outcomes in the Brazilian prison population. D E S I G N : The study population consisted of prisoners diagnosed with TB identified through the Sistema de Informação de Agravos de Notificação (Information System for Notifiable Diseases) between January 2007 and December 2011. Pearson’s χ2 test was used to compare the proportions and covariates associated with the outcome of interest. These variables were further analysed using the polytomous regression model. R E S U LT S : Compared to those who completed antituberculosis treatment, prisoners who defaulted from treatment were younger (P < 0.001), less educated (P
8 years of education was inversely associated with treatment default and death due to other causes.

The relationship between alcoholism and TB has been described elsewhere.17,18 Alcoholic subjects are more likely to default from treatment and die from TB. AIDS, which is highly prevalent in prisons,19 is another important risk factor for TB treatment failure,17 and is also associated with death due to other causes. In our data, the group with AIDS group had more alcohol use, mental diseases, other comorbidities such as other respiratory diseases, rheumatic and renal diseases, and were more likely to relapse and default from treatment. In a study conducted in a São Paulo State prison, the overall prevalence of HIV infection was 5.7% (95%CI 3.2–8.2). Promiscuity, unprotected sex, sharing of syringes or needles for illicit drug use and tattooing under unsafe conditions contribute to the spread of HIV in these places.20 The presence of comorbidities was associated with TB treatment default, death due to TB and death due

TB treatment outcomes in Brazilian prisons

to other causes. TB has increasingly been related to chronic non-communicable diseases, and a poorer treatment outcome has been described for such subjects.21,22 Treatment default was related to relapse and retreatment,23,24 while unknown type of treatment was associated with death due to TB, highlighting a disturbing aspect of disease treatment. Prioritising appropriate treatment for these groups of prisoners and intervention strategies that address these problems should be implemented to avoid the spread of drugresistant bacilli. TST was performed in a minority (15%) of study subjects due to limited indications for this specific diagnostic method. These included research on children with active disease and research on latent infection in adults and children.1 Latent infection rates are higher in prisons than in the general population;16,25 this is attributed to overcrowding, poor ventilation and limited access to health services in prisons. CXR, which frequently reveal clinical signs of TB, was performed in only 61% of study patients. Studies conducted in the prisons of Rio de Janeiro suggest that CXR should be used as a screening method for active disease and during follow-up.26 In this study, treatment default rates and deaths due to TB were higher in patients in whom a followup examination was not performed. An association was most clearly observed among patients who did not undergo sputum smear microscopy for initial diagnosis. The lack of a sputum smear result may have delayed the detection of disease, leading to unfavourable outcomes. These issues indicate inadequate health care services stemming from a lack either of available laboratory resources or of health professionals necessary for the clinical management of the disease. Considering the advantages of sputum smear microscopy,6,27 it is essential to use this method for the early diagnosis of the disease. Mycobacterial culture is recommended by the Brazilian Ministry of Health, particularly for TB identification and DST of all samples from incarcerated patients.1 In this study, culture was not performed for most patients who were cured, defaulted from treatment or died due to other causes. Culture was performed in 30% of MDR-TB subjects; there was no information on DST for second-line drugs. The occurrence of EPTB was more frequent among immunocompromised patients,28 and particularly those with HIV, which increases the risk of death due to TB or other diseases and the development of drug resistance.29,30 The difficulty of bacteriological confirmation in EPTB leads to disease aggravation, which may contribute to increased mortality.31 DOT was implemented in Brazil in 1997 to increase adherence to anti-tuberculosis treatment and prevent drug-resistant TB.32 DOT lowers rates of treatment default and death due to other causes,33


and reinforces the importance of adopting this treatment strategy for controlling the disease, especially for incarcerated populations.34

CONCLUSION Our study findings highlight the need for public policies related to correctional facilities. Improving the health of prisoners will also improve the health of the general population, as prisoners frequently come into contact with family members, staff and other people from outside prisons. In addition, DOT should be expanded to all TB prisoners to improve adherence and cure rates. Future studies should assess the attributable risk of prison-to-community disease spread and describe conditions that influence TB transmission in prisons, especially among individuals with MDR-TB. Finally, control strategies implemented to reduce national TB incidence should also target this vulnerable population. Acknowledgements The study was supported by the Edital Doenças Negligenciadas, Conselho Nacional de Pesquisa, Brasilia, Brazil; and the Edital ICHORTA 5U2R TW006883-02, International Clinical Operational and Health Services Research and Training Award, National Institutes of Health, Bethesda, MD, USA. Conflict of interest: none declared.

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revisão da literatura sobre o uso do linkage entre bases de dados. Brasília, Brazil: Ministério da Saúde, 2011. [Portuguese] Medeiros D, Sucupira E D, Guedes R M, Costa A J L. [Quality of information about tuberculosis in the municipality of Belford Roxo, Rio de Janeiro, 2006 to 2008]. Cad Saúde Colet (Rio de Janeiro) 2012; 20: 146–152. [Portuguese] Zhang X, Andersen A B, Lillebaek T, et al. Effect of sex, age, and race on the clinical presentation of tuberculosis: a 15-year population-based study. Am J Trop Med Hyg 2011; 85: 285– 290. Muñoz-Sellart M, Cuevas L E, Tumato M, Merid Y, Yassin M A. Factors associated with poor tuberculosis treatment outcome in the Southern Region of Ethiopia. Int J Tuberc Lung Dis 2010; 14: 973–979. Ministério da Saúde/Secretaria de Vigilância em Saúde. Boletim epidemiológico-especial tuberculose. Brasília, Brazil: MdS/SVS, 2012. bolepi_v43_especial_tb_correto.pdf Accessed August 2013. [Portuguese] Bierrenbach A L, Duarte E C, Gomes Adriana B F, Souza M F M. Tendência da mortalidade por tuberculose no Brasil, 1980 a 2004. Rev Saúde Pública 2007; 41 (Suppl 1): 15–23. [Portuguese] Nogueira P A, Abrahao R M, Galesi V M. [Tuberculosis and latent tuberculosis in prison inmates]. Rev Saude Publica 2012; 46: 119–127. [Portuguese] Lawn S D, Zumla A I. Tuberculosis. Lancet 2011; 378: 57–72. Orofino Rde L, Brasil P E, Trajman A, Schmaltz C A, Dalcolmo M, Rolla V C. [Predictors of tuberculosis treatment outcomes]. J Bras Pneumol 2012; 38: 88–97. [Portuguese] Jurgens R, Nowak M, Day M. HIV and incarceration: prisons and detention. J Int AIDS Soc 2011; 14: 26. Coelho H C, Perdoná G C, Neves F R, Passos A D. [HIV prevalence and risk factors in a Brazilian penitentiary]. Cad Saude Publica 2007; 23: 2197–2204. [Portuguese] Dooley K E, Chaisson R E. Tuberculosis and diabetes mellitus: convergence of two epidemics. Lancet Infect Dis 2009; 9: 737– 746. Baker M A, Harries A D, Jeon C Y, et al. The impact of diabetes on tuberculosis treatment outcomes: a systematic review. BMC Med 2011; 9: 81. Berhe G, Enquselassie F, Aseffa A. Treatment outcome of








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smear-positive pulmonary tuberculosis patients in Tigray Region, Northern Ethiopia. BMC Public Health 2012; 12: 537. Talay F, Kumbetli S, Altin S. Factors associated with treatment success for tuberculosis patients: a single center’s experience in Turkey. Jpn J Infect Dis 2008; 61: 25–30. Baussano I, Williams B G, Nunn P, Beggiato M, Fedeli U, Scano F. Tuberculosis incidence in prisons: a systematic review. PLOS Med 2010; 7: e1000381. Sanchez A, Larouzé B, Espinola A B, et al. Screening for tuberculosis on admission to highly endemic prisons? The case of Rio de Janeiro State prisons. Int J Tuberc Lung Dis 2009; 13: 1247–1252. Pedro H S P, Nardi S M T, Ferreira M I P, et al. [Bacilloscopy for pulmonary tuberculosis. Multicenter study of bacilloscopy sputum smears in the diagnosis of pulmonary tuberculosis according to the World Health Organization and Brazilian Ministry of Health]. Revista de Patologia Tropical 2010; 39: 273– 282. [Portuguese] Braun M M, Byers R H, Heyward W L, et al. Acquired immunodeficiency syndrome and extrapulmonary tuberculosis in the United States. Arch Intern Med 1990; 150: 1913–1916. Das S K, Das A, Gangopadhyay A, Sinha A K. Primary disseminated extrapulmonary multidrug resistant tuberculosis. Indian J Med Microbiol 2012; 30: 364–366. Ronaidi N N, Mohd N S, Wan Mohammad Z, Sharina N R, Nik Rosmawati N H. Factors associated with unsuccessful treatment outcome of pulmonary tuberculosis in Kota Bharu, Kelantan. Malays J Public Health Med 2011; 11: 6–15. Lopes A J, Capone D, Mogami R, et al. Extra-pulmonary tuberculosis: clinics and image aspects. Pulmão 2006; 15: 253–261. Gonzales R I, Monroe A A, de Assis E G, Palha P F, Villa T C, Netto A R. [The performance of health services in providing DOTs in households to control tuberculosis]. Rev Esc Enferm USP 2008; 42: 628–634. [Portuguese] Balabanova Y, Drobniewski F, Fedorin I, et al. The directly observed therapy short-course (DOTS) strategy in Samara Oblast, Russian Federation. Respir Res 2006; 7: 44. Sanchez A I M. O tratamento diretamente observado-DOTS e a adesão ao tratamento da tuberculose: significados para os trabalhadores de unidades de saúde da região central do municipio de São Paulo-Brasil. São Paulo, Brazil: Universidade de São Paulo, 2007. [Portuguese]

TB treatment outcomes in Brazilian prisons


RÉSUMÉ C O N T E X T E : La tuberculose (TB) constitue un problème majeur de santé publique et une cause importante des décès liés aux maladies infectieuses chez les jeunes adultes. Les taux de TB sont plus élevés dans les populations vulnérables, notamment les prisonniers. O B J E C T I F : Décrire les caractéristiques cliniques et épidémiologiques en association avec les résultats du traitement de la TB dans une population carcérale au Brésil. S C H É M A : La population de l’étude a consisté en prisonniers chez qui le diagnostic de TB a été porté et qui ont été identifiés au travers du Sistema de Informação de Agravos de Notificação (Système d’Information pour les Maladies à Déclaration) entre janvier 2007 et décembre 2011. On a utilisé le test χ2 de Pearson pour comparer les proportions et les covariables en association avec le résultat intéressant. Ces variables ont été analysées de façon complémentaire par un modèle de régression polytomique. R É S U LTAT S : Par comparaison avec ceux qui ont achevé leur traitement TB, les prisonniers qui ont abandonné

sont plus jeunes (P < 0,001), moins éduqués (P < 0,001) et susceptibles d’être alcooliques (P < 0,001). Ils sont plus susceptibles de souffrir de reprise ou de rechute de TB (P < 0,001), et ils ne sont pas sous traitement directement observé (P < 0,001). Ceux qui sont décédés de TB ont tendance à être plus âgés (P < 0,001) et alcooliques (P < 0,001) ; ils sont susceptibles d’avoir reçu un traitement de type inconnu (P < 0,001) et de souffrir à la fois de TB pulmonaire et extrapulmonaire. Les prisonniers chez qui une TB à germes multirésistants s’est développée ont encouru des rechutes, sont revenus au traitement après abandon, ont changé de centre de traitement et sont atteints de TB extrapulmonaire. C O N C L U S I O N : Nos résultats illustrent la nécessité de rénover la lutte et les politiques contre la TB dans les centres d’incarcération. L’amélioration du résultat du traitement TB chez les prisonniers préviendra également la transmission vers d’autres prisonniers, vers les membres de la famille et vers les professionnels de la santé.


La tuberculosis (TB) representa un problema mayor de salud pública y una causa importante de mortalidad relacionada con las enfermedades infecciosas en los adultos jóvenes. Las tasas de TB son más altas en las poblaciones vulnerables, incluidos los reclusos. O B J E T I V O : Describir las características clínicas y epidemiológicas que se asocian con los desenlaces del tratamiento antituberculoso en la población reclusa en el Brasil. M É T O D O : La población del estudio consistió en los reclusos con diagnóstico de tuberculosis, detectados por conducto del Sistema de Informação de Agravos de Notificação (Sistema de Información de Enfermedades de Notificación Obligatoria) entre enero del 2007 y diciembre del 2011. Se aplicó la prueba de la χ2 de Pearson a fin de comparar las proporciones y las covariables asociadas con el desenlace de interés. Se completó el análisis de las variables mediante un modelo de regresión politómico. R E S U LTA D O S : Comparados con los pacientes que completaron el tratamiento antituberculoso, los reclusos que MARCO DE REFERENCIA:

lo abandonaron eran más jóvenes (P < 0,001), contaban con un nivel inferior de instrucción (P < 0,001), era probable que fuesen alcohólicos (P < 0,001), exhibían además una mayor probabilidad de presentar TB recurrente o recaídas (P < 0,001) y no recibían un tratamiento directamente observado (P < 0,001). Las personas que fallecieron por causa de la TB tendían a ser mayores (P < 0,001) y alcohólicas (P < 0,001), era probable que hubiesen recibido un tratamiento de tipo desconocido (P < 0,001) y presentaban TB pulmonar y también extrapulmonar. Los reclusos que presentaron TB multidrogorresistente sufrían TB recurrente, habían comenzado de nuevo el tratamiento después de un abandono, cambiaron de centro de tratamiento y presentaban TB extrapulmonar. C O N C L U S I Ó N : Estos resultados destacan la necesidad de actualizar el control de la TB y las políticas de manejo en los establecimientos correccionales. Al mejorar los desenlaces terapéuticos de los reclusos se previene además la transmisión a otras personas detenidas, a los miembros de la familia y se contribuye a la protección de los profesionales de salud.

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