Determinants of tuberculosis transmission and treatment abandonment in Fortaleza, Brazil.
Determinants of tuberculosis transmission and treatment abandonment in Fortaleza, Brazil.
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DOI：
10.1186/s12889-017-4435-0
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发表时间：
2017-05-25
影响因子：
4.5
通讯作者：
Castro MC
中科院分区：
文献类型：
--
作者：
Harling G;Lima Neto AS;Sousa GS;Machado MMT;Castro MC
尽管最近在降低发病率和死亡率方面取得了成就，但结核病仍然是一个公共卫生问题。在巴西，这些成就高于世界平均水平，但区域差异很大。在福塔莱萨（巴西第五大城市），结核病治愈率在下降，放弃治疗的人数在增加，尽管发病率有所下降，直接观察治疗有所增加。这些趋势使消除结核病的努力面临风险。因此，我们试图确定结核病发病率和治疗放弃福塔莱萨的社会和规划的决定因素。我们分析了2007年至2014年期间福塔莱萨法定传染病信息系统（希南）中报告的所有新发结核病病例的社会人口统计学和临床数据。我们计算了福塔莱萨117个社区的发病率，评估了它们的空间聚类，并使用空间回归模型来量化社区水平协变量与发病率之间的关联。我们使用分层逻辑回归模型来评估个人和社区水平的协变量如何预测结核病治疗放弃。在研究期间报告了12，338例新病例。各社区的病例率在靠近市中心的两个低收入地区显著正聚集。在一个调整后的模型中，结核病发病率在识字率较低、污水处理能力和凶杀率较高以及自报黑人居民比例较高的社区明显较高。1901例（15.4%）放弃治疗，2007年至2014年期间上升了71%。遗弃与许多个体社会人口统计学和临床因素显著相关。值得注意的是，被推荐进行DOT对那些完成DOT的人有保护作用，但对那些没有完成DOT的人来说，这与放弃有关。在福塔莱萨，社会经济地位低的地区结核病发病率较高，社会经济地位低的个人放弃治疗的风险较高。尽管巴西出现了普遍的DOT建议，但放弃治疗的比率仍在上升。积极的社会政策和主动的接触者追踪以发现漏诊病例，可能有助于减少这种情况下的结核病负担。本文的在线版本（doi：10.1186/s12889-017-4435-0）包含补充材料，可供授权用户使用。
Tuberculosis (TB) remains a public health problem, despite recent achievements in reducing incidence and mortality rates. In Brazil, these achievements were above the worldwide average, but marked by large regional heterogeneities. In Fortaleza (5th largest city in Brazil), the tuberculosis cure rate has been declining and treatment abandonment has been increasing in the past decade, despite a reduction in incidence and an increase in directly observed therapy (DOT). These trends put efforts to eliminate tuberculosis at risk. We therefore sought to determine social and programmatic determinants of tuberculosis incidence and treatment abandonment in Fortaleza. We analyzed sociodemographic and clinical data for all new tuberculosis cases notified in the Notifiable Diseases Information System (SINAN) from Fortaleza between 2007 and 2014. We calculated incidence rates for 117 neighborhoods in Fortaleza, assessed their spatial clustering, and used spatial regression models to quantify associations between neighborhood-level covariates and incidence rates. We used hierarchical logistic regression models to evaluate how individual- and neighborhood-level covariates predicted tuberculosis treatment abandonment. There were 12,338 new cases reported during the study period. Case rates across neighborhoods were significantly positively clustered in two low-income areas close to the city center. In an adjusted model, tuberculosis rates were significantly higher in neighborhoods with lower literacy, higher sewerage access and homicide rates, and a greater proportion of self-reported black residents. Treatment was abandoned in 1901 cases (15.4%), a rate that rose by 71% between 2007 and 2014. Abandonment was significantly associated with many individual sociodemographic and clinical factors. Notably, being recommended for DOT was protective for those who completed DOT, but associated with abandonment for those who did not. Low socioeconomic status areas have higher tuberculosis rates, and low socioeconomic individuals have higher risk of treatment abandonment, in Fortaleza. Treatment abandonment rates are growing despite the advent of universal DOT recommendations in Brazil. Proactive social policies, and active contact tracing to find missed cases, may help reduce the tuberculosis burden in this setting. The online version of this article (doi:10.1186/s12889-017-4435-0) contains supplementary material, which is available to authorized users.