Survey for tuberculosis in an indigenous population of Amazonia: the Suruí of Rondônia, Brazil

Factors Associated with Mortality with Tuberculosis Diagnosis in Indigenous Populations in Peru 2015-2019

OBJECTIVE

To identify factors associated with mortality in indigenous populations diagnosed with tuberculosis in Peru, 2015-2019.

METHODS

We conducted a nested case-control study in a retrospective cohort using the registry of indigenous peoples of the National Health Strategy for TB Prevention and Control of the Ministry of Health of Peru. A descriptive analysis was performed, and then bivariate and multivariate logistic regression was used to evaluate associations between the variables and the outcome (alive-deceased). The results are shown as OR with their respective 95% confidence intervals.

RESULTS

The mortality rate of the total indigenous population of Peru was 1.75 deaths per 100,000 indigenous people diagnosed with TB. The community of Kukama Kukamiria-Yagua reported 505 (28.48%) individuals, followed by the Shipibo-Konibo community with 385. The final logistic model showed that indigenous males (OR = 1.93; 95% CI: 1.001-3.7) with a history of HIV prior to TB (OR = 16.7; 95% CI: 4.7-58.7), and indigenous people in old age (OR = 2.95; 95% CI: 1.5-5.7) were factors associated with a greater chance of dying from TB.

CONCLUSIONS

It is important to reorient health services among indigenous populations, especially those related to improving a timely diagnosis and early treatment of TB/HIV co-infection, to ensure comprehensive care for this population considering that they are vulnerable groups.

Symptom- and chest-radiography screening for active pulmonary tuberculosis in HIV-negative adults and adults with unknown HIV status

BACKGROUND

Systematic screening in high-burden settings is recommended as a strategy for early detection of pulmonary tuberculosis disease, reducing mortality, morbidity and transmission, and improving equity in access to care. Questioning for symptoms and chest radiography (CXR) have historically been the most widely available tools to screen for tuberculosis disease. Their accuracy is important for the design of tuberculosis screening programmes and determines, in combination with the accuracy of confirmatory diagnostic tests, the yield of a screening programme and the burden on individuals and the health service.

OBJECTIVES

To assess the sensitivity and specificity of questioning for the presence of one or more tuberculosis symptoms or symptom combinations, CXR, and combinations of these as screening tools for detecting bacteriologically confirmed pulmonary tuberculosis disease in HIV-negative adults and adults with unknown HIV status who are considered eligible for systematic screening for tuberculosis disease. Second, to investigate sources of heterogeneity, especially in relation to regional, epidemiological, and demographic characteristics of the study populations.

SEARCH METHODS

We searched the MEDLINE, Embase, LILACS, and HTA (Health Technology Assessment) databases using pre-specified search terms and consulted experts for unpublished reports, for the period 1992 to 2018. The search date was 10 December 2018. This search was repeated on 2 July 2021.

SELECTION CRITERIA

Studies were eligible if participants were screened for tuberculosis disease using symptom questions, or abnormalities on CXR, or both, and were offered confirmatory testing with a reference standard. We included studies if diagnostic two-by-two tables could be generated for one or more index tests, even if not all participants were subjected to a microbacteriological reference standard. We excluded studies evaluating self-reporting of symptoms.

DATA COLLECTION AND ANALYSIS

We categorized symptom and CXR index tests according to commonly used definitions. We assessed the methodological quality of included studies using the QUADAS-2 instrument. We examined the forest plots and receiver operating characteristic plots visually for heterogeneity. We estimated summary sensitivities and specificities (and 95% confidence intervals (CI)) for each index test using bivariate random-effects methods. We analyzed potential sources of heterogeneity in a hierarchical mixed-model.

MAIN RESULTS

The electronic database search identified 9473 titles and abstracts. Through expert consultation, we identified 31 reports on national tuberculosis prevalence surveys as eligible (of which eight were already captured in the search of the electronic databases), and we identified 957 potentially relevant articles through reference checking. After removal of duplicates, we assessed 10,415 titles and abstracts, of which we identified 430 (4%) for full text review, whereafter we excluded 364 articles. In total, 66 articles provided data on 59 studies. We assessed the 2 July 2021 search results; seven studies were potentially eligible but would make no material difference to the review findings or grading of the evidence, and were not added in this edition of the review. We judged most studies at high risk of bias in one or more domains, most commonly because of incorporation bias and verification bias. We judged applicability concerns low in more than 80% of studies in all three domains. The three most common symptom index tests, cough for two or more weeks (41 studies), any cough (21 studies), and any tuberculosis symptom (29 studies), showed a summary sensitivity of 42.1% (95% CI 36.6% to 47.7%), 51.3% (95% CI 42.8% to 59.7%), and 70.6% (95% CI 61.7% to 78.2%, all very low-certainty evidence), and a specificity of 94.4% (95% CI 92.6% to 95.8%, high-certainty evidence), 87.6% (95% CI 81.6% to 91.8%, low-certainty evidence), and 65.1% (95% CI 53.3% to 75.4%, low-certainty evidence), respectively. The data on symptom index tests were more heterogenous than those for CXR. The studies on any tuberculosis symptom were the most heterogeneous, but had the lowest number of variables explaining this variation. Symptom index tests also showed regional variation. The summary sensitivity of any CXR abnormality (23 studies) was 94.7% (95% CI 92.2% to 96.4%, very low-certainty evidence) and 84.8% (95% CI 76.7% to 90.4%, low-certainty evidence) for CXR abnormalities suggestive of tuberculosis (19 studies), and specificity was 89.1% (95% CI 85.6% to 91.8%, low-certainty evidence) and 95.6% (95% CI 92.6% to 97.4%, high-certainty evidence), respectively. Sensitivity was more heterogenous than specificity, and could be explained by regional variation. The addition of cough for two or more weeks, whether to any (pulmonary) CXR abnormality or to CXR abnormalities suggestive of tuberculosis, resulted in a summary sensitivity and specificity of 99.2% (95% CI 96.8% to 99.8%) and 84.9% (95% CI 81.2% to 88.1%) (15 studies; certainty of evidence not assessed).

AUTHORS' CONCLUSIONS

The summary estimates of the symptom and CXR index tests may inform the choice of screening and diagnostic algorithms in any given setting or country where screening for tuberculosis is being implemented. The high sensitivity of CXR index tests, with or without symptom questions in parallel, suggests a high yield of persons with tuberculosis disease. However, additional considerations will determine the design of screening and diagnostic algorithms, such as the availability and accessibility of CXR facilities or the resources to fund them, and the need for more or fewer diagnostic tests to confirm the diagnosis (depending on screening test specificity), which also has resource implications. These review findings should be interpreted with caution due to methodological limitations in the included studies and regional variation in sensitivity and specificity. The sensitivity and specificity of an index test in a specific setting cannot be predicted with great precision due to heterogeneity. This should be borne in mind when planning for and implementing tuberculosis screening programmes.

Bayesian evidence synthesis to estimate subnational TB incidence: An application in Brazil

BACKGROUND

Evidence on local disease burden and the completeness of case detection represent important information for TB control programs. We present a new method for estimating subnational TB incidence and the fraction of individuals with incident TB who are diagnosed and treated in Brazil.

METHODS

We compiled data on TB notifications and TB-related mortality in Brazil and specified an analytic model approximating incidence as the number of individuals exiting untreated active disease (sum of treatment initiation, death before treatment, and self-cure). We employed a Bayesian inference approach to synthesize data and adjust for known sources of bias. We estimated TB incidence and the fraction of cases treated, for each Brazilian state and the Federal District over 2008-2017.

FINDINGS

For 2017, TB incidence was estimated as 41.5 (95 % interval: 40.7, 42.5) per 100 000 nationally, and ranged from 11.7-88.3 per 100 000 across states. The fraction of cases treated was estimated as 91.9 % (89.6 %, 93.7 %) nationally and ranged 86.0 %-94.8 % across states, with an estimated 6.9 (5.3, 9.2) thousand cases going untreated in 2017. Over 2008-2017, incidence declined at an average annual rate of 1.4 % (1.1 %, 1.9 %) nationally, and -1.1%-4.2 % across states. Over this period there was a 0.5 % (0.2 %, 0.9 %) average annual increase in the fraction of incident TB cases treated.

INTERPRETATION

Time-series estimates of TB burden and the fraction of cases treated can be derived from routinely-collected data and used to understand variation in TB outcomes and trends.

Amerindian genetic ancestry as a risk factor for tuberculosis in an amazonian population

In recent years, the incidence of tuberculosis (TB) has declined worldwide, although this disease still occurs at relatively high rates in Amerindian populations. This suggests that the genetic ancestry of Amerindians may be an important factor in the development of infections, and may account for at least some of the variation in infection rates in the different populations. The present study investigated the potential influence of Amerindian genetic ancestry on susceptibility to tuberculosis in an Amazon population. The study included 280 patients diagnosed with tuberculosis and 138 asymptomatic hospital employees with no history of TB, but who were in contact with bacterially active TB patients. Ancestry analysis was run on a set of 61 Ancestry-Informative Markers to estimate European, African, and Amerindian genetic ancestry using STRUCTURE v2.2. The TB group had significantly higher Amerindian ancestry in comparison with the control group, and significantly lower European ancestry. Amerindian ancestry in the 20–60% range was found to be the principal risk factor for increased susceptibility to TB. The results of the study indicate that Amerindian ancestry is an important risk factor for susceptibility to TB in the admixed population of the Brazilian Amazon region.

Active and passive case-finding in tuberculosis-affected households in Peru: a 10-year prospective cohort study

BACKGROUND

Active case-finding among contacts of patients with tuberculosis is a global health priority, but the effects of active versus passive case-finding are poorly characterised. We assessed the contribution of active versus passive case-finding to tuberculosis detection among contacts and compared sex and disease characteristics between contacts diagnosed through these strategies.

METHODS

In shanty towns in Callao, Peru, we identified index patients with tuberculosis and followed up contacts aged 15 years or older for tuberculosis. All patients and contacts were offered free programmatic active case-finding entailing sputum smear microscopy and clinical assessment. Additionally, all contacts were offered intensified active case-finding with sputum smear and culture testing monthly for 6 months and then once every 4 years. Passive case-finding at local health facilities was ongoing throughout follow-up.

FINDINGS

Between Oct 23, 2002, and May 26, 2006, we identified 2666 contacts, who were followed up until March 1, 2016. Median follow-up was 10·0 years (IQR 7·5-11·0). 232 (9%) of 2666 contacts were diagnosed with tuberculosis. The 2-year cumulative risk of tuberculosis was 4·6% (95% CI 3·5-5·5), and overall incidence was 0·98 cases (95% CI 0·86-1·10) per 100 person-years. 53 (23%) of 232 contacts with tuberculosis were diagnosed through active case-finding and 179 (77%) were identified through passive case-finding. During the first 6 months of the study, 23 (45%) of 51 contacts were diagnosed through active case-finding and 28 (55%) were identified through passive case-finding. Contacts diagnosed through active versus passive case-finding were more frequently female (36 [68%] of 53 vs 85 [47%] of 179; p=0·009), had a symptom duration of less than 15 days (nine [25%] of 36 vs ten [8%] of 127; p=0·03), and were more likely to be sputum smear-negative (33 [62%] of 53 vs 62 [35%] of 179; p=0·0003).

INTERPRETATION

Although active case-finding made an important contribution to tuberculosis detection among contacts, passive case-finding detected most of the tuberculosis burden. Compared with passive case-finding, active case-finding was equitable, helped to diagnose tuberculosis earlier and usually before a positive result on sputum smear microscopy, and showed a high burden of undetected tuberculosis among women.

FUNDING

Wellcome Trust, Department for International Development Civil Society Challenge Fund, Joint Global Health Trials consortium, Bill & Melinda Gates Foundation, Imperial College National Institutes of Health Research Biomedical Research Centre, Foundation for Innovative New Diagnostics, Sir Halley Stewart Trust, WHO, TB REACH, and IFHAD: Innovation for Health and Development.

Epidemiologic situation of tuberculosis in Rio Grande do Sul: an analysis about Sinan's data between 2003 and 2012 focusing on indigenous peoples

Objective:

This article analyzes the epidemiological situation of tuberculosis in the state of Rio Grande do Sul, emphasizing the indigenous population. The data are based on the Information System of Grievance Notification (Sinan) between 2003 and 2012.

Methods:

The notified cases of tuberculosis were analyzed according to age, sex, zone of residence, input type, means of diagnosis, clinical form, anti-HIV exam, medical care, supervised treatment (in Portuguese, TDO), closure, and race.

Results:

The highest incidence rates in the period were among Afro-Brazilians, yellow, and indigenous peoples. The cases affected mainly adult men living in urban areas. Indigenous peoples showed the highest rates of notifications among people aged less than 10 years (12%). In the sputum test, missing information and not-performed exams reached more than 50.0% in all periods and groups. The cure was more prevalent among white people (66.2%); indigenous, brown, and Afro-Brazilian people presented the lowest cure rates: 59.4, 58.4, and 60%, respectively.

Conclusion:

Tuberculosis is one of the biggest problems in Rio Grande do Sul. The actions of diagnosis, clinical form, and treatment of the cases have not been implemented as proposed. The indigenous peoples' situation is similar and diverse at the same time in comparison with other peoples from different areas of Brazil. Nevertheless, it is unfavorable on a balanced evaluation of the whole scenario. Furthermore, the discrepancies among races are evident: the indigenous and Afro-Brazilian peoples fill the spread sheet, in general terms, on the worst situation, whereas the white people fill the data with the best health situation.

Prevalence and factors associated with latent tuberculosis infection in an indigenous population in the Brazilian Amazon

INTRODUCTION

Recent studies have shown a high incidence and prevalence of latent tuberculosis infection (LTBI) in indigenous populations around the World. We aimed to estimate the prevalence and annual risk of infection (ARI) as well as to identify factors associated with LTBI in an indigenous population from the Brazilian Amazon.

METHODS

We conducted a cross-sectional study in 2011. We performed tuberculin skin tests (TSTs), smears and cultures of sputum samples, and chest radiographs for individuals who reported cough for two or more weeks. Associations between LTBI (TST ≥5mm) and socio-demographic, clinical, and epidemiological characteristics were investigated using Poisson regression with robust variance. Prevalence ratio (PR) was used as the measure of association.

RESULTS

We examined 263 individuals. The prevalence of LTBI was 40.3%, and the ARI was 2.4%. Age ≥15 years [PR=5.5; 95% confidence interval (CI): 3.5-8.6], contact with tuberculosis (TB) patients (PR=3.8; 95% CI: 1.2-11.9), previous TB history (PR=1.4; 95% CI: 1.2-1.7), and presence of Bacillus Calmette-Guérin (BCG) scar (PR=1.9, 95% CI: 1.2-2.9) were associated with LTBI.

CONCLUSIONS

Although some adults may have been infected years prior, the high prevalence of infection and its strong association with age ≥15 years, history of TB, and recent contact with TB patients suggest that the TB transmission risk is high in the study area.

Sex Differences in Tuberculosis Burden and Notifications in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

BACKGROUND

Tuberculosis (TB) case notification rates are usually higher in men than in women, but notification data are insufficient to measure sex differences in disease burden. This review set out to systematically investigate whether sex ratios in case notifications reflect differences in disease prevalence and to identify gaps in access to and/or utilisation of diagnostic services.

METHODS AND FINDINGS

In accordance with the published protocol (CRD42015022163), TB prevalence surveys in nationally representative and sub-national adult populations (age ≥ 15 y) in low- and middle-income countries published between 1 January 1993 and 15 March 2016 were identified through searches of PubMed, Embase, Global Health, and the Cochrane Database of Systematic Reviews; review of abstracts; and correspondence with the World Health Organization. Random-effects meta-analyses examined male-to-female (M:F) ratios in TB prevalence and prevalence-to-notification (P:N) ratios for smear-positive TB. Meta-regression was done to identify factors associated with higher M:F ratios in prevalence and higher P:N ratios. Eighty-three publications describing 88 surveys with over 3.1 million participants in 28 countries were identified (36 surveys in Africa, three in the Americas, four in the Eastern Mediterranean, 28 in South-East Asia and 17 in the Western Pacific). Fifty-six surveys reported in 53 publications were included in quantitative analyses. Overall random-effects weighted M:F prevalence ratios were 2.21 (95% CI 1.92-2.54; 56 surveys) for bacteriologically positive TB and 2.51 (95% CI 2.07-3.04; 40 surveys) for smear-positive TB. M:F prevalence ratios were highest in South-East Asia and in surveys that did not require self-report of signs/symptoms in initial screening procedures. The summary random-effects weighted M:F ratio for P:N ratios was 1.55 (95% CI 1.25-1.91; 34 surveys). We intended to stratify the analyses by age, HIV status, and rural or urban setting; however, few studies reported such data.

CONCLUSIONS

TB prevalence is significantly higher among men than women in low- and middle-income countries, with strong evidence that men are disadvantaged in seeking and/or accessing TB care in many settings. Global strategies and national TB programmes should recognise men as an underserved high-risk group and improve men's access to diagnostic and screening services to reduce the overall burden of TB more effectively and ensure gender equity in TB care.

Tuberculosis in indigenous communities of Antioquia, Colombia: epidemiology and beliefs

Morbidity and mortality caused by tuberculosis are increased in most of the Latin-American indigenous communities. Factors that could explain this situation are poverty and limited health services access due to social conflicts and geographical isolation. We determined the frequency of tuberculosis in Colombian indigenous communities and described their knowledge related to transmission and control. We developed a descriptive study and health survey. Interviews were performed to find ancestral knowledge about tuberculosis. Sputum samples from patients with respiratory symptoms were analyzed. 10 indigenous communities were studied, which tuberculosis incidence was 291/100,000. Communities believe that tuberculosis is a body and spirit disease, which transmission is by direct contact or by witchcraft. Tuberculosis incidence in the studied communities was ninefold higher than that of the general population from Antioquia Department. Knowledge exchange could facilitate the community empowerment and implementation of educational activities which might improve the control of the disease.

Burden of tuberculosis in indigenous peoples globally: a systematic review

BACKGROUND

The burden of tuberculosis (TB) in the estimated 370 million indigenous peoples worldwide is unknown.

OBJECTIVE

To conduct a literature review to summarize the TB burden in indigenous peoples, identify gaps in current knowledge, and provide the foundation for a research agenda prioritizing indigenous health within TB control.

METHODS

A systematic literature review identified articles published between January 1990 and November 2011 quantifying TB disease burden in indigenous populations worldwide.

RESULTS

Among the 91 articles from 19 countries included in the review, only 56 were from outside Australia, Canada, New Zealand and the United States. The majority of the studies showed higher TB rates among indigenous groups than non-indigenous groups. Studies from the Amazon generally reported the highest TB prevalence and incidence, but select populations from South-East Asia and Africa were found to have similarly high rates of TB. In North America, the Inuit had the highest reported TB incidence (156/100000), whereas the Metis of Canada and American Indians/Alaska Natives experienced rates of <10/100000. New Zealand's Maori and Pacific Islanders had higher TB incidence rates than Australian Aborigines, but all were at greater risk of developing TB than non-indigenous groups.

CONCLUSION

Where data exist, indigenous peoples were generally found to have higher rates of TB disease than non-indigenous peoples; however, this burden varied greatly. The paucity of published information on TB burden among indigenous peoples highlights the need to implement and improve TB surveillance to better measure and understand global disparities in TB rates.

Impact of latent infection treatment in indigenous populations

The aims of the present study were to identify risk factors associated with latent tuberculosis (TB), examine the development of active disease among contacts, and assess the effectiveness of treating latent infection in indigenous Brazilians from January 2006 to December 2011. This was a retrospective study consisting of 1,371 tuberculosis contacts, 392 of whom underwent treatment for latent infection. Morbidity-from-TB data were obtained from the Information System for Disease Notification (SINAN) database, and the contacts’ data were collected from the clinical records using forms employed by Special Department of Indigenous Health (SESAI) multidisciplinary teams, according to SESAI’s instructions. The variables that were associated with latent infection among the contacts were age (odds ratio [OR]: 1.03; 95% confidence interval [CI]: 1.02–1.04) and close contact with a smear-positive index case (OR: 2.26, 95% CI: 1.59–3.22). The variables associated with the development of active TB among the contacts were a tuberculin skin test (TST) ≥10 mm (relative risk [RR]: 1.12, 95% CI: 1.07–1.17), age (RR: 1.01, 95% CI: 1.00–1.03), and treatment of latent infection (RR: 0.03, 95% CI: 0.01–0.27). The estimated number of latent infection treatments needed to prevent one case of active TB among the contacts was 51 treatments (95% CI: 33–182). In contacts with TST ≥10 mm, 10 (95% CI: 6–19) latent infection treatments were necessary to prevent one case of active TB. Age and close contact with a smear-positive index case were associated with latent TB. Screening with TST is a high priority among individuals contacting smear-positive index cases. Age and TST are associated with the development of active TB among contacts, and treatment of latent infection is an effective measure to control TB in indigenous communities.

Níveis tensionais de adultos indígenas Suruí, Rondônia, Brasil

Os povos indígenas no Brasil vivenciam acelerado processo de transição nutricional e epidemiológica, verificando-se a emergência de doenças e agravos não transmissíveis, como hipertensão arterial (HA). Realizou-se, em 2005, um estudo transversal para descrever os níveis tensionais em adultos (> 20 anos) indígenas Suruí, Rondônia, e investigar sua relação com o estado nutricional e o nível socioeconômico (SSE). Foram visitadas 9 aldeias e avaliados 251 indivíduos (87,4% dos elegíveis). As médias de pressão arterial sistólica (PAS) e pressão arterial diastólica (PAD) foram maiores no sexo masculino e superiores às verificadas em 1988, com incremento na média da PAS de 7,9 mmHg e de 1,4 mmHg, em mulheres e homens, respectivamente. A PAS correlacionou-se positivamente com a razão cintura quadril (RCQ) em ambos os sexos, e com a idade, no sexo feminino. A PAD apresentou correlações estatisticamente significativas com todas as variáveis antropométricas, exceto com estatura e área muscular do braço. A prevalência de HA foi de 2,8% (M: 2,4%; F: 3,1%). Essa prevalência foi maior nos indivíduos > 40 anos, com perímetro da cintura (PC) ou RCQ elevados, sobretudo no grupo feminino e também no grupo de mais baixo de SSE. A HA é um problema de saúde emergente entre os Suruí, devendo receber atenção do sistema de saúde e dos pesquisadores.

Association between the PTPN22 1858C/T gene polymorphism and tuberculosis resistance

Previous studies identified the functional polymorphism 1858C/T in the gene PTPN22 in association with several autoimmune diseases and with resistance to tuberculosis (TB). This study is the first to investigate the association between pulmonary TB and the PTPN22 1858C/T polymorphism in the Brazilian Amazon. We conducted a case-control study involving a group of 413 individuals, comprised of 208TB carriers and 205 controls. No significant association between the PTPN22 1858T allele frequency in controls (2.4%) and TB carriers (2.7%, p=0.982, odds ratio (OR)=0.89, 95% confidence interval=0.37-2.13) was identified in the Brazilian Amazon population. An additional evaluation by meta-analysis, however, suggested a protective role of the T allele in relation to TB (pooled OR=0.44, p=0.011). These results suggest that the PTPN22 1858T allele serves as a protective genetic factor for TB in those individuals who carry this minor allele.

[Spatial and temporal distribution of tuberculosis in indigenous and non-indigenous of Rondônia State, Western Amazon, Brazil]

This study analyzed the spatial and temporal distribution of crude and adjusted rates of incidence of tuberculosis (TB) between 1997 and 2006, identifying areas of greatest risk to the indigenous and non-indigenous population of Rondônia State, Brazil. An ecological study was conducted analyzing municipalities and Indian reserves, using the local empirical Bayesian method. The crude average rate of incidence of TB among the non-indigenous population was 35.6/100,000 inhabitants, while for the indigenous population it was 415.0/100,000. Rates greater than 600/100,000 were reported in the Karipuna, Sete de Setembro, Igarapé, Ribeirão and Karitiana reserves. We observed a greater number of cases in under 15 year-olds with little schooling in contrast to the situation in the non-indigenous population. After making adjustments, the rates in some Indian reserves exceeded 240/100,000 inhabitants, while in coinciding municipalities incidence was between the range of 61-120/100,000. The Bayesian method led to decreased overall heterogeneity in rates. Evidence suggests that the indigenous population is more vulnerable to contracting TB and highlighted areas that require further attention to ensure the adequate control of TB in Rondônia.

Tuberculosis in indigenous peoples in the U.S., 2003-2008

OBJECTIVES

We examined trends and epidemiology of tuberculosis (TB) across racial/ethnic groups to better understand TB disparities in the United States, with particular focus on American Indians/Alaska Natives (AI/ANs) and Native Hawaiians/other Pacific Islanders (NH/PIs).

METHODS

We analyzed cases in the U.S. National Tuberculosis Surveillance System and calculated TB case rates among all racial/ethnic groups from 2003 to 2008. Socioeconomic and health indicators for counties in which TB cases were reported came from the Health Resources and Services Administration Area Resource File.

RESULTS

Among the 82,836 TB cases, 914 (1.1%) were in AI/ANs and 362 (0.4%) were in NH/PIs. In 2008, TB case rates for AI/ANs and NH/PIs were 5.9 and 14.7 per 100,000 population, respectively, rates that were more than five and 13 times greater than for non-Hispanic white people (1.1 per 100,000 population). From 2003 to 2008, AI/ANs had the largest percentage decline in TB case rates (-27.4%) for any racial/ethnic group, but NH/PIs had the smallest percentage decline (-3.5%). AI/ANs were more likely than other racial/ethnic groups to be homeless, excessively use alcohol, receive totally directly observed therapy, and come from counties with a greater proportion of people living in poverty and without health insurance. A greater proportion of NH/PIs had extrapulmonary disease and came from counties with a higher proportion of people with a high school diploma.

CONCLUSIONS

There is a need to develop flexible TB-control strategies that address the social determinants of health and that are tailored to the specific needs of AI/ANs and NH/PIs in the U.S.

Aspectos de la fecundidad de mujeres indígenas Suruí, Rondônia, Brasil: una aproximación

OBJETIVOS: caracterizar aspectos de la fecundidad de mujeres indígenas Suruí de la Amazonía brasilera. MÉTODOS: se levantaron y sistematizaron 88 historias reproductivas y de nacimientos, obtenidas a través de visitas domiciliarias en dos aldeas, realizadas en 2004. RESULTADOS: el promedio de edad de la menarquía fue 12 años; las edades medias de entrada a la primera unión y del nacimiento del primer hijo fueron, respectivamente, 13,8 y 15,7 años. El parto ocurrió en la aldea en su mayoría. Las mujeres Suruí presentan un intervalo intergenésico promedio próximo a los 22,8 meses. El promedio de amamantación fue 18,4 meses. El uso de contraceptivos es mínimo y el número de años de estudio de las mujeres es bajo. La tasa de fecundidad total fue de 6,3 hijos. CONCLUSIÓN: si se compara con resultados de otros estudios en pueblos indígenas, la demografía Suruí señala niveles de fecundidad entre moderados y elevados. Los autores argumentan que los hallazgos son relevantes para la prestación de servicios de salud culturalmente compatibles con la realidad Suruí.

Morbidity and mortality disparities among colonist and indigenous populations in the Ecuadorian Amazon

Rural populations living in the northern Ecuadorian Amazon (NEA) experience the highest health burden of any region in the country. Two independent studies of colonist and indigenous groups living in the NEA are used to compare their morbidity and mortality experiences. Colonist data are from a probability sample of land plots in 1999, while indigenous data are from a representative sample of the five largest ethnicities (Quichua, Shuar, Huaorani, Cofan, Secoya) collected in 2001. Poisson regression was used to compare morbidity. Results indicate clear differences in health between populations. Indigenous groups had 30% higher probability of mortality and 63% higher incidence rate of all-cause morbidity compared to colonists. Vector-borne, chronic, gastrointestinal, and diseases of unknown origin were particularly high among indigenous groups. Factors associated with morbidity varied: morbidity rates were similar for the two youngest age groups (0-4 and 5-9), but indigenous people aged 15-39 and 40+ had almost double the morbidity compared to colonists; larger households, later months of data collection and less pollution were associated with less morbidity in both groups; better infrastructure access (electricity and roads) was generally associated with lower morbidity in both groups; and associations of land use were different by group with more cultivation of perennials and fewer annuals associated with less morbidity for colonists, but more for indigenous groups. These results demonstrate the health disparities that exist among indigenous and non-indigenous populations even when living in the same geographic region. Land use itself exemplifies the cultural and contextual differences that are evident in health, since land use decisions are related to broader demographic and economic factors that influence overall ecological and human health. Ongoing population-environment and/or environment-health research needs to recognize the broader factors involved when studying relationships between population health, development and deforestation.

Indigenous health part 1: determinants and disease patterns

The world's almost 400 million Indigenous people have low standards of health. This poor health is associated with poverty, malnutrition, overcrowding, poor hygiene, environmental contamination, and prevalent infections. Inadequate clinical care and health promotion, and poor disease prevention services aggravate this situation. Some Indigenous groups, as they move from traditional to transitional and modern lifestyles, are rapidly acquiring lifestyle diseases, such as obesity, cardiovascular disease, and type 2 diabetes, and physical, social, and mental disorders linked to misuse of alcohol and of other drugs. Correction of these inequities needs increased awareness, political commitment, and recognition rather than governmental denial and neglect of these serious and complex problems. Indigenous people should be encouraged, trained, and enabled to become increasingly involved in overcoming these challenges.

CE. Morbidade hospitalar em crianças indígenas Suruí menores de dez anos, Rondônia, Brasil: 2000 a 2004

OBJETIVOS: analisar o perfil de morbidade hospitalar de crianças indígenas atendidas na rede de serviços do Sistema Único de Saúde. MÉTODOS: Foram investigados 380 registros de internação hospitalar de crianças indígenas Suruí menores de 10 anos de idade atendidas na rede hospitalar do município de Cacoal, Rondônia, a partir de dados coletados no Hospital Materno-Infantil, instituição pública, e no Hospital Infantil e Maternidade Menino Jesus, instituição particular, no período de 2000 a 2004. Esses dois hospitais concentram o atendimento a indígenas no município. Utilizou-se a Classificação Internacional de Doenças (CID), 10.ª revisão, para a classificação dos diagnósticos. RESULTADOS: as doenças do aparelho respiratório - Cap. X (58,2%) figuraram como o principal motivo de internação hospitalar. Doenças infecciosas e parasitárias (Cap I) apresentaram-se como a segunda maior causa (35,0%) e afecções originadas no período perinatal (Cap XVI) como a terceira (3,2%). Outras causas contribuíram individualmente com menos de 1,5% do total, que somadas não atingiram 4%. A maioria das internações (65,5%) foram de crianças <2 anos de idade. O tempo médio de internação foi significativamente superior no hospital público em relação ao privado. CONCLUSÕES: O perfil de morbidade hospitalar observado nas crianças Suruí evidencia não somente a precariedade das suas condições de saúde, como também problemas estruturais no que tange às ações de atenção básica. Recomenda-se a realização de estudos que visem aprofundar aspectos epidemiológicos relacionados às internações hospitalares em populações indígenas, fundamentais para o desenvolvimento de ações de saúde mais adequadas.

The burden of tuberculosis in indigenous peoples in Amazonia, Brazil

Tuberculosis (TB) stands out as one of the principal infectious diseases affecting Amazonian Indians. Recent research indicates that incidence rates among indigenous peoples may be as much as ten times higher than those of the general Brazilian population. Purified protein derivative reactivity in Amazonia is low compared with populations of European descent; anergy rates usually surpass 50%, even under high BCG coverage. An annual risk of infection of 1.2-2.2% points to high rates of transmission. Whether or not particular susceptibility to TB is linked to genetics, Amazonian Indians face a disproportionately high risk of contracting and dying from TB.

Detection of Mycobacterium tuberculosis in sputum from Suruí Indian subjects, Brazilian Amazon

This investigation aimed at the detection of Mycobacterium tuberculosis (MTB) in the sputum of Suruí Indian subjects from Amazonia, Brazil. Polymerase chain reaction analyses were positive for 12 samples, five of which were also culture-positive (N = 147). Four MTB genotypes were identified, one of which showed resistance to rifampicin and isoniazid. The study also highlighted one village complex as of particular importance, considering the relatively high number of tuberculosis cases reported and of MTB isolates obtained.

Padrões radiológicos da tuberculose pulmonar em indígenas Suruí de Rondônia, Amazônia

Foram analisados padrões radiológicos de 23/33 (69,7%) dos indígenas Suruí tratados em 2003-2004. Observou-se 44,8% de consolidações não homogêneas, 10,3% de cavitações e 39,1% de acometimentos múltiplos do parênquima. Apesar de 36% dos doentes avaliados terem apresentado radiografias normais, o tratamento específico foi iniciado sem que tivessem sido esgotadas as possibilidades de investigação diagnóstica.