Abstract
BackgroundTuberculosis (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.MethodsWe 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.ResultsThere 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.ConclusionLow 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.
Highlights
Tuberculosis (TB) remains a public health problem, despite recent achievements in reducing incidence and mortality rates
Brazil remains one of 22 high TB burden countries (HBCs) that jointly account for 80% of the global burden of disease [2]
Despite a slight decrease in TB incidence rates in recent years, cure rates fell from 86% in 2007 to 68% in 2013, more than 15% below the minimum level recommended by World Health Organization (WHO)
Summary
Tuberculosis (TB) remains a public health problem, despite recent achievements in reducing incidence and mortality rates. 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). Brazil remains one of 22 high TB burden countries (HBCs) that jointly account for 80% of the global burden of disease [2] It was, one of nine HBCs to meet all three TB reduction targets for 2015 established for the MDGs: between 1990 and 2014 the Brazilian TB incidence rate declined from 51.8 to 33.2 cases per 100,000, and both prevalence and mortality rates fell by more than 50% [6]. Treatment abandonment (non-completion not due to healthcare indication) increased from 7.5% to 11.4% [9]
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