Excess tuberculosis cases and deaths following an economic recession in Brazil: an analysis of nationally representative disease registry data

The impact of the SARS-CoV-2 pandemic on tuberculosis notifications and deaths in the state of São Paulo, Brazil: a cross-sectional study

Background

The state of São Paulo reports the highest number of tuberculosis cases in Brazil. We aimed to analyze the SARS-CoV-2 pandemic's impact on tuberculosis notifications and identify factors associated with reduced notifications and tuberculosis deaths in 2020-2021.

Methods

This retrospective cross-sectional study analyzed data from 126,649 patients with tuberculosis notified in São Paulo from 2016 to 2021. Interrupted time series analysis assessed the pandemic's impact on notifications. Descriptive statistics and logistic regressions identified factors associated with decreased tuberculosis notifications and deaths during the pandemic (2020-2021) compared to the pre-pandemic period (2019).

Findings

Tuberculosis notifications decreased by 10% and 8% in 2020 and 2021, respectively, with declines 2-3 times higher among individuals with no education or deprived of liberty. Contrastingly, tuberculosis notifications increased 68% among corrections workers in 2021. Diagnostics and contact tracing were compromised. Individuals with HIV, drug addiction, or deprived of liberty had lower odds of notification during the pandemic. Black and Pardo individuals or those with diabetes, treatment interruption history, or treatment changes post-adverse events had higher odds of notification. However, adverse events and tuberculosis-diabetes cases have been increasing since 2016. During the pandemic, tuberculosis-related deaths rose 5.0%-12.7%. Risk factors for mortality remained similar to 2019, with Pardo ethnicity, drug addiction and re-treatment post-adverse events emerging as risk factors in 2020/2021.

Interpretation

The pandemic affected tuberculosis notifications and deaths differently among populations, exacerbating inequalities. Treatment interruption, loss of follow-up, and challenges in accessing healthcare led to increased mortality.

Funding

FAPESP, CNPq and CAPES, Brazil.

Predictors of unsuccessful tuberculosis treatment outcomes in Brazil: an analysis of 259,484 patient records

INTRODUCTION

Tuberculosis (TB) causes over 1 million deaths annually. Providing effective treatment is a key strategy for reducing TB deaths. In this study, we identified factors associated with unsuccessful treatment outcomes among individuals treated for TB in Brazil.

METHODS

We obtained data on individuals treated for TB between 2015 and 2018 from Brazil's National Disease Notification System (SINAN). We excluded patients with a history of prior TB disease or with diagnosed TB drug resistance. We extracted information on patient-level factors potentially associated with unsuccessful treatment, including demographic and social factors, comorbid health conditions, health-related behaviors, health system level at which care was provided, use of directly observed therapy (DOT), and clinical examination results. We categorized treatment outcomes as successful (cure, completed) or unsuccessful (death, regimen failure, loss to follow-up). We fit multivariate logistic regression models to identify factors associated with unsuccessful treatment.

RESULTS

Among 259,484 individuals treated for drug susceptible TB, 19.7% experienced an unsuccessful treatment outcome (death during treatment 7.8%, regimen failure 0.1%, loss to follow-up 11.9%). The odds of unsuccessful treatment were higher with older age (adjusted odds ratio (aOR) 2.90 [95% confidence interval: 2.62-3.21] for 85-100-year-olds vs. 25-34-year-olds), male sex (aOR 1.28 [1.25-1.32], vs. female sex), Black race (aOR 1.23 [1.19-1.28], vs. White race), no education (aOR 2.03 [1.91-2.17], vs. complete high school education), HIV infection (aOR 2.72 [2.63-2.81], vs. no HIV infection), illicit drug use (aOR 1.95 [1.88-2.01], vs. no illicit drug use), alcohol consumption (aOR 1.46 [1.41-1.50], vs. no alcohol consumption), smoking (aOR 1.20 [1.16-1.23], vs. non-smoking), homelessness (aOR 3.12 [2.95-3.31], vs. no homelessness), and immigrant status (aOR 1.27 [1.11-1.45], vs. non-immigrants). Treatment was more likely to be unsuccessful for individuals treated in tertiary care (aOR 2.20 [2.14-2.27], vs. primary care), and for patients not receiving DOT (aOR 2.35 [2.29-2.41], vs. receiving DOT).

CONCLUSION

The risk of unsuccessful TB treatment varied systematically according to individual and service-related factors. Concentrating clinical attention on individuals with a high risk of poor treatment outcomes could improve the overall effectiveness of TB treatment in Brazil.

Evaluating social protection mitigation effects on HIV/AIDS and Tuberculosis through a mathematical modelling study

The global economic downturn due to the COVID-19 pandemic, war in Ukraine, and worldwide inflation surge may have a profound impact on poverty-related infectious diseases, especially in low-and middle-income countries (LMICs). In this work, we developed mathematical models for HIV/AIDS and Tuberculosis (TB) in Brazil, one of the largest and most unequal LMICs, incorporating poverty rates and temporal dynamics to evaluate and forecast the impact of the increase in poverty due to the economic crisis, and estimate the mitigation effects of alternative poverty-reduction policies on the incidence and mortality from AIDS and TB up to 2030. Three main intervention scenarios were simulated-an economic crisis followed by the implementation of social protection policies with none, moderate, or strong coverage-evaluating the incidence and mortality from AIDS and TB. Without social protection policies to mitigate the impact of the economic crisis, the burden of HIV/AIDS and TB would be significantly larger over the next decade, being responsible in 2030 for an incidence 13% (95% CI 4-31%) and mortality 21% (95% CI 12-34%) higher for HIV/AIDS, and an incidence 16% (95% CI 10-25%) and mortality 22% (95% CI 15-31%) higher for TB, if compared with a scenario of moderate social protection. These differences would be significantly larger if compared with a scenario of strong social protection, resulting in more than 230,000 cases and 34,000 deaths from AIDS and TB averted over the next decade in Brazil. Using a comprehensive approach, that integrated economic forecasting with mathematical and epidemiological models, we were able to show the importance of implementing robust social protection policies to avert a significant increase in incidence and mortality from AIDS and TB during the current global economic downturn.