Abstract
SummaryBackgroundUniversal health coverage is one of the WHO End TB Strategy priority interventions and could be achieved—particularly in low-income and middle-income countries—through the expansion of primary health care. We evaluated the effects of one of the largest primary health-care programmes in the world, the Brazilian Family Health Strategy (FHS), on tuberculosis morbidity and mortality using a nationwide cohort of 7·3 million individuals over a 10-year study period.MethodsWe analysed individuals who entered the 100 Million Brazilians Cohort during the period Jan 1, 2004, to Dec 31, 2013, and compared residents in municipalities with no FHS coverage with residents in municipalities with full FHS coverage. We used a cohort design with multivariable Poisson regressions, adjusted for all relevant demographic and socioeconomic variables and weighted with inverse probability of treatment weighting, to estimate the effect of FHS on tuberculosis incidence, mortality, cure, and case fatality. We also performed a range of stratifications and sensitivity analyses.FindingsFHS exposure was associated with lower tuberculosis incidence (rate ratio [RR] 0·78, 95% CI 0·72–0·84) and mortality (0·72, 0·55–0·94), and was positively associated with tuberculosis cure rates (1·04, 1·00–1·08). FHS was also associated with a decrease in tuberculosis case-fatality rates, although this was not statistically significant (RR 0·84, 95% CI 0·55–1·30). FHS associations were stronger among the poorest individuals for all the tuberculosis indicators.InterpretationCommunity-based primary health care could strongly reduce tuberculosis morbidity and mortality and decrease the unequal distribution of the tuberculosis burden in the most vulnerable populations. During the current marked rise in global poverty due to the COVID-19 pandemic, investments in primary health care could help protect against the expected increases in tuberculosis incidence worldwide and contribute to the attainment of the End TB Strategy goals.FundingTB Modelling and Analysis Consortium (Bill & Melinda Gates Foundation), Wellcome Trust, and Brazilian Ministry of Health.TranslationFor the Portuguese translation of the abstract see Supplementary Materials section.
Highlights
Tuberculosis is among the ten leading causes of death worldwide and is considered a poverty-related disease; a high tuberculosis burden is frequently observed in populations with low socioeconomic status, with restricted access to food and precarious housing conditions.[1]
According to the WHO End TB Strategy, the expansion of universal health coverage (UHC) is one of the most feasible and effective interventions that could reduce the tuberculosis burden by 2025.3 As reaffirmed in the recent Declaration of Astana,[4] primary health care should be considered the cornerstone of universal health coverage and its expansion and improvement could represent the fastest way to get closer to this goal
We evaluated all relevant indicators on the pathway from infection to mortality from tuberculosis as follows: tuberculosis incidence, tuberculosis cure rate, tuberculosis case-fatality, and tuberculosis mortality rates, for the general population and for strata defined by demographic and socioeconomic characteristics, such as income, sex, and age
Summary
Tuberculosis is among the ten leading causes of death worldwide and is considered a poverty-related disease; a high tuberculosis burden is frequently observed in populations with low socioeconomic status, with restricted access to food and precarious housing conditions.[1]. During the COVID-19 pandemic, a substantial increase in the worldwide tuberculosis burden has been predicted due to the disruption of tuberculosis health services and an increase in poverty, especially in LMICs.[2] rapid and widespread interventions are urgently needed to mitigate the effects of the pandemic on tuberculosis. According to the WHO End TB Strategy, the expansion of universal health coverage (UHC) is one of the most feasible and effective interventions that could reduce the tuberculosis burden by 2025.3 As reaffirmed in the recent Declaration of Astana,[4] primary health care should be considered the cornerstone of universal health coverage and its expansion and improvement could represent the fastest way to get closer to this goal. Studies have shown that FHS can reduce infant and Lancet Glob Health 2022; 10: e390–97
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