Knowledge and stigma of latent tuberculosis infection in Brazil: implications for tuberculosis prevention strategies

Peter F Rebeiro,Marina Cruvinel Figueiredo,Mollie J Cohen,Heather M Ewing,Marshall Eakin,Timothy R Sterling,Elizabeth J Zechmeister,Lauren Saag Peetluk,Kleydson B Andrade

doi:10.1186/s12889-020-09053-1

Abstract

BackgroundTuberculosis (TB) elimination requires treatment of millions of persons with latent M. tuberculosis infection (LTBI). LTBI treatment acceptance depends on population-wide TB knowledge and low stigma, but limited data are available on the relationship between stigma and knowledge. We assessed knowledge of TB disease and LTBI throughout Brazil and examined their association with TB stigma and incidence.MethodsWe performed a nationwide survey with multi-stage probability design through AmericasBarometer from April–May 2017; the sample was representative of Brazil at regional and national levels. Knowledge of and stigma toward TB were assessed by validated survey questions.ResultsSurvey-weighted responses of 1532 individuals suggest that 57% of the population knew LTBI can occur, and 90% would seek treatment for it. Regarding active TB, 85% knew TB symptoms, 70% reported they should avoid contact with someone with active TB, and 24% had stigma toward persons with TB (i.e., thought persons with tuberculosis should feel ashamed, or deserved their illness). In regression models adjusting for clinical and demographic variables, knowledge of LTBI was associated with increased stigma toward persons with TB (adjusted odds ratio [OR] = 2.13, 95% confidence interval [CI]: 1·25–3.63, for “should feel ashamed”; OR = 1·82, 95% CI: 1·15–2·89, for “deserve illness”). Adjusting for regional TB incidence did not affect this association.ConclusionsHigh proportions of this representative Brazilian population had knowledge of LTBI and were willing to seek treatment for it. However, such knowledge was associated with TB-specific stigma. Strategies to educate and implement treatment of latent tuberculosis must include efforts to decrease TB stigma.

Highlights

Tuberculosis (TB) elimination requires treatment of millions of persons with latent M. tuberculosis infection (LTBI)
The AmericasBarometer survey and TB- and Zikaspecific questions were administered to 1532 persons in Brazil: proportional to the population [22], 1322 respondents in urban areas, and 210 in rural areas [23]
Though the models excluding TB knowledge demonstrated no significant associations between incidence and stigma, our results indicate that knowledge of TB symptoms may partially mediate this relationship in the source and/or target populations

Summary

Introduction

Tuberculosis (TB) elimination requires treatment of millions of persons with latent M. tuberculosis infection (LTBI). An estimated 25% of the global population has latent M. tuberculosis infection (LTBI) [2], and approximately 80% of active TB cases are due to reactivation of LTBI [3]. Treatment rates of LTBI, in countries with high TB burden, have been low [6]. Despite recent advances in its health system [7], Brazil remains among the 30 highest TB-burden countries in the world, with a TB incidence of 33·5–44 cases per 100,000 in 2017 [1, 8]. More than 85% of the Brazilian population lives in urban areas, where TB incidence exceeds the national rate. This high burden highlights the importance of treatment of both active TB and LTBI to decrease TB incidence. Treatment for LTBI has been recommended in Brazil since 1995, most patients do not start or complete treatment [9] despite screening and treatment being offered free of charge (minimizing the financial impact of these crucial efforts on individuals) [10]

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Conclusion