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Vulnerable Populations and Poor TB Treatment Outcome in Brazil: A Nationwide Study of Disease Registry Data
21 Pages Posted: 4 Dec 2023
More...Abstract
Background: Tuberculosis (TB) remains among the deadliest infectious diseases worldwide. A focus on socially vulnerable sub-populations at increased risk of TB is warranted to decrease the disease burden. In this study, we evaluated whether homelessness, living with HIV, incarceration, pregnancy, immigration, drug use, and healthcare work (HCW) are risk factors for unfavourable anti-TB treatment (ATT) outcomes in Brazil through analysis of national disease registry data. Furthermore, we evaluated the independent association of each type of vulnerability with death or loss to follow-up (LTFU) individually.
Methods: We conducted an observational study of TB cases >18 years-old reported to the Brazilian National Notifiable Disease Information System (SINAN) between 2015 and 2022. Only cases with outcomes reported were included in the analyses. Clinical and epidemiologic variables were compared between groups (non-vulnerability, homeless, people deprived of their liberty (PDL), pregnant women, people with HIV (PWH), people who use drugs, immigrants and HCW). Binomial and multinominal logistic regression models were employed to identify characteristics associated with a composite unfavourable TB outcome, or specifically death or LTFU.
Findings: Among 743,823 TB cases reported, 568,368 met inclusion criteria: 375,061 non-vulnerable, 48,693 drug users, 41,558 PDL, 39,358 PWH, 6,701 homeless, 6,450 HCW, 2,234 immigrants, and 2,073 pregnant women; 46,240 cases had more than one vulnerability. Homelessness was the strongest risk factor for unfavourable ATT outcomes in the overall population, followed by living with HIV and, drug use. Pregnancy and immigration were also independent risk factors for unfavourable outcomes. Living with HIV was the main risk for death, whereas homelessness was the major risk factor for LTFU. Directly observed treatment (DOT), incarceration, and HCW were associated with favourable outcomes.
Interpretation: Homelessness, living with HIV and drug use, were strong independent risk factors for unfavourable ATT outcomes in the Brazilian population. Interventions to affect modifiable risk factors for unfavourable ATT outcomes are important to achieve the World Health Organization targets for ATT success. This study also highlights the importance of DOT and the need to provide social protections that could improve TB treatment outcomes in vulnerable populations.
Funding: Intramural research program of the Fundação Oswaldo Cruz.
Declaration of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All other authors declare no competing interests.
Ethical Approval: All data analysed in this study were obtained from a public government program (SINAN-TB) and were pre-processed by the Brazilian Ministry of Health (https://datasus.saude.gov.br/informacoesde-saude-tabnet/). The datasets were verified by eliminating duplicate registrations and ensuring consistency and completeness of registered data, following the regulations dictated by Resolution No. 466/12 on Research Ethics of the National Health Council, Brazil. Written informed consent for participation was not required for this study in accordance with national legislation and institutional requirements.
Keywords: Tuberculosis, vulnerable populations, epidemiology, treatment outcome
Suggested Citation: Suggested Citation