In this study, we analyzed the number of TB cases in an emergency room (ER) and the susceptibility profile of Mycobacterium tuberculosis strains. Patients were selected from among those treated at the Hospital das Clínicas, in the city of Belo Horizonte, Brazil. Between 2002 and 2005, 240 TB patients were identified. Of those, 117 patients (48.7%) were diagnosed in the ER, 72 (61.5%) presenting positive sputum smear microscopy. Drug susceptibility testing was carried out in 90 strains, of which 80 (89%) were sensitive, 9 (10%) were resistant, and 1 (1%) was multidrug resistant. The incidence of positive smear sputum microscopy and resistant TB strains was high, which calls for the immediate adoption of TB control measures in the ER.

Keywords: Tuberculosis; Disease transmission, infectious; Drug resistance.

Objective: To evaluate the prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients, describing the major clinical syndromes diagnosed and the outcomes of the patients. Methods: A cross-sectional study conducted in the emergency room of a tertiary care university hospital. Between November of 2008 and November of 2009, we reviewed the total number of emergency room visits per day. Children and adults who presented with at least one respiratory symptom were included in the study. The electronic medical records were reviewed, and the major characteristics of the patients were recorded. Results: During the study period, there were 37,059 emergency room visits, of which 11,953 (32.3%) were motivated by respiratory symptoms. The prevalence of emergency room visits due to respiratory symptoms was 28.7% and 38.9% among adults and children, respectively. In adults, the rates of hospitalization and mortality were 21.2% and 2.7%, respectively, compared with 11.9% and 0.3%, respectively, in children. Among the adults, the time from symptom onset to emergency room visit correlated positively with the need for hospitalization (p < 0.0001), the length of the hospital stay (p < 0.0001), and the mortality rate (p = 0.028). Conclusions: We found a high prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients. Our results could inform decisions regarding the planning of prevention measures. Further epidemiological studies are needed in order to clarify the risk factors for severe respiratory symptoms.

Objective: To evaluate the incidence of viral infection in patients with acute asthma treated in the emergency room. Methods: We conducted a cohort study of patients aged 12 and older presenting to the emergency room of the Hospital de Clínicas de Porto Alegre with acute asthma. Nasopharyngeal aspirate was collected, and antigens were detected through indirect immunofluorescence staining for respiratory syncytial virus, adenovirus and influenza, as well as for parainfluenza types 1, 2, 3 and 4. Data were collected regarding demographic characteristics, medical history, the attack that led to the current emergency room visit, and clinical outcomes. Results: From March to July of 2004, 49 patients were examined for viral infection of the respiratory tract. Respiratory viruses were identified in 6 patients (3 with adenovirus, 2 with influenza A, 1 with parainfluenza type 1). The mean age of the patients with viral infection of the respiratory tract was 61.7 ± 11.5 years, compared with 41.7 ± 20.9 years for the patients without such infection (p = 0.027). There were no other significant differences in clinical characteristics or outcomes. Conclusion: The incidence of viral infection of the respiratory tract in acute asthma patients 12 years and older treated in an emergency room was 12.2%, which confirms that viral infection is a significant precipitant of acute asthma for patients in this age bracket.

Keywords: Emergency Service, Hospital; Vírus diseases/prevention & control; Asthma; Respiratory tract infections; Influenza A virus, human

Background: There is a wide variability in clinical practice for treating acute asthma (AA) in the emergency room (ER) interfering in the quality of management. Objective: To evaluate the impact of a clinical protocol for care of acute asthma in the ER of the Hospital de Clínicas de Porto Alegre. Method: In this hospital a cross-sectional study was conducted before and after implementation of the protocol, of consecutive patients presenting with acute asthma in the adult ER (age ³ 12 years). The intention was to measure the effect of recommendations on the objective assessment of severity, utilization of diagnostic tools, proposed therapy, not recommended therapy and on the outcomes. Results: The pre-protocol group comprised 108 patients and the protocol group comprised 96 patients. There was a significant increase in the use of pulse oximetry (8% to 77%, p<0.001) and PEFR (5% to 21%, p<0.001). There was an increase in the utilization of radiology (33% to 66%, p<0.001) and in that of blood tests (11% to 25%, p=0.016). There was also an increase in the number of patients receiving the three recommended nebulizations in the first hour (22% to 36%, p=0.04). Although the overall use of corticosteroids did not change, there was a significant increase in the use of oral steroids (8% to 28%, p<0.001). There was no significant difference in the not recommended therapy, time of stay and outcomes. Conclusion: The acute asthma clinical protocol used in the ER was associated to a positive effect on the objective assessment of severity of asthma and on the use of the recommended therapy. No other significant influence on the treatment or on the outcome was perceived.

Keywords: Clinical protocols. Asthma. Emergency medicine.

Objective: To evaluate clinical and pulmonary function measurements taken in the first fifteen minutes of the assessment of acute asthma in the emergency room and used for prognostic purposes. Methods: A prospective cohort study involving consecutive patients with acute asthma. Only patients who were between the ages of 12 and 55 and presented peak expiratory flow rates < or = 50% of predicted were included. Evaluations were performed upon admission, then again at 15 minutes and 4 hours after the initiation of treatment. Treatment included albuterol and ipratropium delivered by metered-dose inhaler with a spacer, together with 100 mg of intravenous hydrocortisone. Favorable outcomes were defined as peak expiratory flow > or = 50% of predicted after 4 hours of treatment, and unfavorable outcomes were defined as peak expiratory flow < 50% after 4 hours of treatment. Results: Favorable outcomes were seen in 27 patients, and unfavorable outcomes were seen in 24 patients. In the multivariate analysis, peak expiratory flow as percentage of predicted was identified as the variable with the highest predictive value. A peak expiratory flow > or = 40% after 15 minutes of treatment showed significant power in predicting a favorable outcome (sensitivity = 0.74, specificity = 1.00, and positive predictive value = 1.00). A peak expiratory flow < 30% after 15 minutes of treatment was predictive of a poor outcome (sensitivity = 0.54, specificity = 0.93, and positive predictive value = 0.87). Conclusion: Our results suggest that measuring peak expiratory flow after 15 minutes of management in the emergency room is a useful tool for predicting outcomes in cases of acute asthma.

Keywords: Asthma; Acute disease; Respiratory mechanics; Prognosis; Emergency Service, Hospital; Cohort studies

Objective: Early tuberculosis diagnosis and treatment are determinants of better outcomes and effective disease control. Although tuberculosis should ideally be managed in a primary care setting, a proportion of patients are diagnosed in emergency facilities (EFs). We sought to describe patient characteristics by place of tuberculosis diagnosis and determine whether the place of diagnosis is associated with treatment outcomes. A secondary objective was to determine whether municipal indicators are associated with the probability of tuberculosis diagnosis in EFs. Methods: We analyzed data from the São Paulo State Tuberculosis Control Program database for the period between January of 2010 and December of 2013. Newly diagnosed patients over 15 years of age with pulmonary, extrapulmonary, or disseminated tuberculosis were included in the study. Multiple logistic regression models adjusted for potential confounders were used in order to evaluate the association between place of diagnosis and treatment outcomes. Results: Of a total of 50,295 patients, 12,696 (25%) were found to have been diagnosed in EFs. In comparison with the patients who had been diagnosed in an outpatient setting, those who had been diagnosed in EFs were younger and more socially vulnerable. Patients diagnosed in EFs were more likely to have unsuccessful treatment outcomes (adjusted OR: 1.54; 95% CI: 1.42-1.66), including loss to follow-up and death. At the municipal level, the probability of tuberculosis diagnosis in EFs was associated with low primary care coverage, inequality, and social vulnerability. In some municipalities, more than 50% of the tuberculosis cases were diagnosed in EFs. Conclusions: In the state of São Paulo, one in every four tuberculosis patients is diagnosed in EFs, a diagnosis of tuberculosis in EFs being associated with poor treatment outcomes. At the municipal level, an EF diagnosis of tuberculosis is associated with structural and socioeconomic indicators, indicating areas for improvement.

Keywords: Tuberculosis/diagnosis; Emergency treatment; Treatment outcome; Delivery of health care.

Objective: To describe the epidemiological monitoring of exposure to tuberculosis in a hospital environment and to analyze the profile of the disease in a general teaching hospital. Methods: A descriptive and retrospective study of tuberculosis cases diagnosed between 2000 and 2006, with the determination of indicators of morbidity and mortality, which were compared with the general population of patients treated at the hospital and with the hospital employees who developed active tuberculosis. Results: There were 763 patients who were treated for active tuberculosis (mean, 109 patients/year), 481 (63.1%) of whom were male. Most of the patients were in the 30-59 year age bracket. Tuberculosis that was exclusively pulmonary or extrapulmonary predominated. However, among the hospitalized patients, the combination of pulmonary and extrapulmonary tuberculosis, as well as exclusively noninfectious tuberculosis, predominated. Comorbidities were more prevalent among the hospitalized patients and among those who evolved to death. Only 52.8% of the cases treated at the hospital were reported. The overall hospital indicators showed longer length of hospital stay and greater mortality among the patients with tuberculosis. The incidence and prevalence show that there was a high risk of exposure to tuberculosis in the hospital during the period studied. Conclusions: The proposed indicators can potentially help standardize epidemiological monitoring procedures for nosocomial tuberculosis, and the epidemiological profile described in this study can contribute to a better understanding of the situation of tuberculosis in Brazil.

Keywords: Tuberculosis/epidemiology; Cross infection/prevention & control; Epidemiologic surveillance/statistics & numerical data; Risk management.

Objective: To determine the epidemiological profile of inpatients at a TB referral hospital. Methods: This was a descriptive, retrospective study of the medical charts of patients with TB hospitalized at the Hospital Estadual Santa Maria (HESM), in the city of Rio de Janeiro, Brazil, between January of 2002 and December of 2003. Data were collected using a standardized form. Results: Of the 451 patients included in the study, 313 (69.4%) had been referred to the HESM from health care clinics, and 302 (67.0%) were male. Most of the patients were in the 30-59  year age bracket, 443 (98.2%) lived in the greater metropolitan region of Rio de Janeiro, and 298 (66.1%) lived in the city of Rio de Janeiro itself. The most common reason for hospitalization was poor health status (in 237, 52.5%). The most common comorbidity was AIDS (in 137, 30.4%). The most common signs and symptoms at admission were weight loss, fever and productive cough. Sputum smear microscopy was positive in 122 (71.0%) of the patients presenting with productive cough at admission. Of the 212 patients being retreated, 156 (73.6%) reported noncompliance with previous treatment. Regarding the outcome, 273 (65.8%) of the patients were referred to municipal health care centers, 83 (18.4%) died, 44 (9.8%) were cured, and 27 (6%) were discharged against medical advice. Conclusions: Providing hospitals specializing in TB is relevant for TB control, especially in metropolitan regions. In addition to taking biosafety measures, these hospitals must be prepared to treat patients with TB-related comorbidities and social problems. This study has resulted in improvements at the HESM.

Keywords: Tuberculosis; Epidemiology; Hospitalization.

Objective: To determine the prevalence of latent and active TB among detainees in a prison hospital in Bahia, Brazil. Methods: A cross-sectional study with prospective data collection was carried out comprising 237 inmates in the Bahia State Prison Hospital between July 2003 and April 2004. A standardized questionnaire was applied and completed by medical students. The detainees were systematically submitted to the following tests: tuberculin skin test, chest X-ray (anteroposterior), sputum smear microscopy and culture for mycobacteria. The events of interest were active TB and latent TB. Results: The mean age of the participants was 36.6 years, and 89.9% were male. Smoking and alcohol consumption were reported by 70.0% and 43.9% of the inmates, respectively. A history of treatment for TB was reported by 11.3% of the inmates. Of the inmates evaluated, 36.3% reported cough and 31.4% reported expectoration. Other less common symptoms were asthenia (in 26.2%), weight loss (in 23.1%), loss of appetite (in 17.7%), fever (in 11.3%) and hemoptysis (in 6.7%). Of the 86 inmates tested, none presented positive HIV serology. The prevalence of latent TB was 61.5% (96 of the 156 inmates submitted to tuberculin skin tests), whereas that of active TB was 2.5% (6 of the 237 inmates evaluated). The presence of cough was a determinant of active TB (prevalence ratio = 8.8; 95% CI: 1.04-73.9; p = 0.025). Conclusions: Active and latent TB are highly prevalent among inmates hospitalized in the Bahia State Prison Hospital. Our findings justify the need to implement public policies specifically directed towards the control of TB in this population.

Keywords: Tuberculosis; Prisons; Hospitals; Prevalence.

Objective: To investigate operational aspects of tuberculin skin test (TST) use in tuberculosis control programs and at specialized Brazilian National Sexually Transmitted Diseases/AIDS and Viral Hepatitis Program health care clinics in priority municipalities for tuberculosis control in the state of Mato Grosso do Sul, Brazil. Methods: This was a descriptive, cross-sectional, epidemiological survey. Data on qualifications/training of professionals administering TSTs, timing of the TST, procedures in cases of loss to follow-up (reading), material availability, and material storage were collected through interviews and technical visits. For the 2008-2009 period, we determined the numbers of screenings in vulnerable populations, of TSTs performed, and of patients treated for latent tuberculosis. Results: We interviewed 12 program managers in six municipalities. Some programs/clinics did not perform TSTs. Nursing teams administered the TSTs, results were read by non-specialists, and specialization/refresher courses were scarce. The PPD RT23 was stored in 5-mL flasks under appropriate conditions. Insulin syringes were commonly used. Testing was available during business hours, three times a week. In cases of loss to follow-up, telephone calls or home visits were made. Of the 2,305 TSTs evaluated, 1,053 (46%) were performed in indigenous populations; 831 (36%) were screenings in prisons, performed for training; and only 421 (18%) involved contacts of tuberculosis patients or vulnerable populations. Four vulnerable patients and 126 indigenous subjects were treated for latent tuberculosis. Conclusions: These priority municipalities showed operational difficulties regarding human resources, materials, and data records.

Keywords: Tuberculin test; Health services research; HIV; Latent tuberculosis; Chemoprevention.

Objective: To quantify the number of asthma attacks treated in the emergency room of a public hospital and to study seasonal fluctuations, taking into consideration the local climate, which is characterized by having only two seasons: a rainy/humid season and a dry season. Methods: A retrospective survey was conducted in a community general hospital. A total of 37,642 emergency room consultations related to asthma, bronchitis, pneumonia, upper-airway infection or other respiratory complaints were registered during a two year period. The data from each patient chart were collected for later analysis. Results: Among the respiratory conditions treated, asthma (24.4%) was the second most common diagnosis. Most of the asthma consultations (56.6%) involved children below the age of fifteen. Regression analysis revealed a seasonal variation in the number of asthma consultations, which was significantly higher in March (p = 0.0109), the low points being in August (p = 0.0485) and September (p = 0.0169). The correlation between climate and asthma was most significant in relation to changes in humidity, although the effect was delayed by one month (p = 0.0026) or two months (p = 0.0002). Conclusion: Visits to the emergency room for the treatment of asthma attacks were more frequent during the rainy season, increasing at one to two months after the annual increase in humidity and decreasing in the dry season. This positive correlation raises the possibility of a causal relationship with proliferation of house dust mites and molds.

Keywords: Seasons; Status asthamaticus/etiology; Weather; Pyroglyphidae ; Humidity; Emergency service, hospital

Asthma is a disease with high prevalence in our country and around the world. Although new therapeutic approaches have been recently developed, there appears to be a worldwide increase in morbidity and mortality from asthma. In many institutions, asthma exacerbation is still a common medical emergency. Clinical evidence demonstrates that the first hour of management of acute asthma in the emergency room entails crucial decisions that could be determinant in the clinical outcome. In this non-systematic review, the authors focus on the first hour assessment and treatment of patients with acute asthma and outline an appropriate strategy for their management. Diagnosis, severity assessment, pharmacological treatment, complications, and the decision regarding the place where additional treatment will take place will be considered. It is reasonable to expect that these recommendations will help physicians make appropriate decisions about the first hour care of acute asthma in the emergency room.

Keywords: Asthma. Emergency medicine. Emergency treatment. Clinical procedures. Emergency medical services.

Air pollution is a major public health problem in the Amazon forest and in large Brazilian cities. During September of 2005, high concentrations of smoke from biomass burning were observed in the city of Rio Branco. An ecological study was conducted to evaluate the relationship between daily concentrations of particulate matter < 2.5 μm (PM2.5) and the number of respiratory disease (RD)-related emergency room visits. Daily PM2.5 concentrations exceeded recommended air quality limits on 23 days. The incidence of RDs was higher among children < 10 years of age. There was a significant positive correlation between PM2.5 concentrations and asthma emergency room visits.

Keywords: Air pollution/adverse effects; Fires; Respiratory tract diseases/epidemiology; Asthma; Space-time clustering.

Abstract Objectives: To determine the frequency of adverse effects related to the use of the tuberculosis treatment regimen designated Regimen I and the need for regimen alterations due to these effects. Methods: A retrospective analysis of 329 medical charts of patients who were treated with Regimen I and discharged after cure between March 2000 and April 2006 was carried out at the Tuberculosis Outpatient Clinic, Department of Pulmonology of the Santa Casa de Misericórdia de São Paulo Hospital in the city of São Paulo, Brazil. Adverse effects and the timing of their appearance, as well as subsequent modifications in the treatment regimen, were investigated. Results: We included 297 patients, 146 (49.1%) of whom presented one or more adverse effects related to antituberculosis medications. The frequency of minor side effects was 41.1%, and that of major side effects was 12.8%. The most common reactions were those involving the gastrointestinal tract (40.3%) and the skin (22.1%). Adverse effects were more common in the first and second months of treatment (58.4%). Modification of the treatment regimen was necessary in 11 cases (3.7% of the total sample). Drug-induced hepatitis was the adverse effect that demanded the most regimen changes. Conclusions: In this group of patients, the frequency of adverse effects related to treatment with Regimen I was 49.1%. However, in most of the cases, it was not necessary to modify the treatment regimen due to side effects.

Keywords: Tuberculosis/therapy; Antitubercular agents/adverse effects; Hepatitis, toxic.

Objective: To evaluate the management of asthma attacks in children up to five years of age treated in the pediatric emergency room of a hospital in the metropolitan area of the city of Recife, Brazil, as well as to determine whether the way in which asthma attacks are managed can influence the duration of emergency room visits for such children. Methods: A descriptive, exploratory study employing a quantitative, cross-sectional approach. The study sample comprised 246 children treated for asthma attacks in an emergency room. The approach used was evaluated in comparison with the approach recommended in the III Brazilian Consensus on Asthma Management, as was the length of time each child spent in the emergency room. Results: In 69 (28.1%) of the cases, the medications were used in accordance with the Consensus guidelines. In 34 (13.8%) of the cases, the doses used were those recommended in the Consensus guidelines, and the guidelines regarding nebulization procedures were followed in 33 cases (13.4%). No correlation was found between the approach taken and the length of the emergency room visit. In the logistic regression analysis, we observed that the adjusted risk of being released from the emergency room sooner than recommended in the Consensus guidelines (a length of time sufficient to allow the response to the treatment to be analyzed) was four times and fifteen times greater, respectively, for children with mild persistent asthma and for those with intermittent asthma. Conclusion: Although there are obstacles to using the asthma management approach recommended in the Consensus guidelines (such obstacles including the lack of familiarity with the guidelines on the part of the multidisciplinary team, as well as the lack of recommended material and therapeutic resources), the duration of emergency room visits was found to be related to the degree of asthma severity.

Keywords: Emergency medicine; Pediatrics; Asthma; Status asthmaticus

Objective: To evaluate the radiological presentation of patients with pulmonary tuberculosis diagnosed in the emergency department and to investigate its association with the time to diagnosis. Methods: This was a prospective observational study involving patients diagnosed with pulmonary tuberculosis in the emergency department of a tertiary university hospital in southern Brazil. Chest X-rays taken on admission were evaluated by a radiologist. The various patterns of radiological findings and locations of the lesions were described. The main study outcome was the total time elapsed between the initial radiological examination and the diagnosis of tuberculosis. Results: A total of 78 patients were included in the study. The median time from chest X-ray to diagnosis was 2 days, early and delayed diagnosis being defined as a time to diagnosis < 2 days and ≥ 2 days, respectively. Sputum smear positivity was associated with early diagnosis (p = 0.005), and positive culture was associated with delayed diagnosis (p = 0.005). Early diagnosis was associated with the presence of sputum (p = 0.03), weight loss (p = 0.047), cavitation (p = 0.001), and consolidation (p = 0.003). Pulmonary cavitation was found to be an independent predictor of early diagnosis (OR = 3.50; p = 0.028). Conclusions: There is a need for tuberculosis-specific protocols in emergency departments, not only to avoid delays in diagnosis and treatment but also to modify the transmission dynamics of the disease.

Keywords: Tuberculosis/diagnosis; Emergency medical services; Radiography, thoracic.

Objective: To determine the availability of noninvasive positive-pressure ventilation equipment, as well as the level of expertise and familiarity of physicians, nurses and physiotherapists with noninvasive positive-pressure ventilation in the intensive care units of public, private and teaching hospitals in the greater metropolitan area of São Paulo, Brazil. Methods: On-site administration of questionnaires. Results: Noninvasive positive-pressure ventilation equipment was widely available and was more commonly found in private hospitals than in teaching hospitals. Such equipment was least available in public hospitals, in which the predominant method was the use of mechanical ventilators designed for invasive ventilation and adapted to noninvasive positive-pressure ventilation. In private hospitals, continuous flow ventilators were more common, whereas, in teaching hospitals, ventilators specifically designed for noninvasive ventilation were typically employed. All physiotherapists felt themselves capable of initiating noninvasive positive pressure ventilation, compared with 72.6% of physicians and 33.3% of nurses. Physicians and physiotherapists presented high percentages of correct answers when asked about the indications and contraindications for the use of noninvasive positive-pressure ventilation. Over a one year period, more physiotherapists read articles about noninvasive positive-pressure ventilation and participated in related classes than did physicians, who in turn did so more than did nurses. Conclusion: Noninvasive positive-pressure ventilation equipment is widely available in the greater metropolitan area of São Paulo, although differences exist among public, private and teaching hospitals in terms of the type of equipment used. Physicians and physiotherapists exhibited considerable knowledge regarding the indications and contraindications for the use of noninvasive positive-pressure ventilation. More physiotherapists felt themselves able to initiate noninvasive positive-pressure ventilation, and their knowledge of the subject was more current than was that of physicians or nurses.

Keywords: Ventilators, mechanical; Positive-pressure respiration/methods; Respiratory insuficiency; Intensive care units; Hospitals

Objective: Knowledge of acute asthma management in children is a subject that has rarely been explored. The objective of this study was to assess the level of such knowledge among health professionals in the city of Recife, Brazil. Methods: This was a cross-sectional survey involving 27 pediatricians and 7 nurses, all with at least two years of professional experience, at two large pediatric teaching hospitals in Recife. The participants completed a self-administered multiple-choice questionnaire. Results: The pediatricians and nurses all possessed insufficient knowledge regarding the use of metered dose inhalers, nebulization, and types/doses of medications, as well as techniques for decontamination and disinfection of the equipment. Conclusions: Insufficient knowledge of acute asthma management in children can lead to less effective treatment in hospitals such as those evaluated here. Educational programs should be developed in order to minimize this problem.

Keywords: Asthma; Health knowledge, attitudes, practice; Nebulizers and vaporizers.

Objective: To assess the relative frequency of incident cases of interstitial lung diseases (ILDs) in Brazil. Methods: This was a retrospective survey of new cases of ILD in six referral centers between January of 2013 and January of 2020. The diagnosis of ILD followed the criteria suggested by international bodies or was made through multidisciplinary discussion (MDD). The condition was characterized as unclassifiable ILD when there was no specific final diagnosis following MDD or when there was disagreement between clinical, radiological, or histological data. Results: The sample comprised 1,406 patients (mean age = 61 ± 14 years), and 764 (54%) were female. Of the 747 cases exposed to hypersensitivity pneumonitis (HP)-related antigens, 327 (44%) had a final diagnosis of HP. A family history of ILD was reported in 8% of cases. HRCT findings were indicative of fibrosis in 74% of cases, including honeycombing, in 21%. Relevant autoantibodies were detected in 33% of cases. Transbronchial biopsy was performed in 23% of patients, and surgical lung biopsy, in 17%. The final diagnoses were: connective tissue disease-associated ILD (in 27%), HP (in 23%), idiopathic pulmonary fibrosis (in 14%), unclassifiable ILD (in 10%), and sarcoidosis (in 6%). Diagnoses varied significantly among centers (?2 = 312.4; p < 0.001). Conclusions: Our findings show that connective tissue disease-associated ILD is the most common ILD in Brazil, followed by HP. These results highlight the need for close collaboration between pulmonologists and rheumatologists, the importance of detailed questioning of patients in regard with potential exposure to antigens, and the need for public health campaigns to stress the importance of avoiding such exposure.

Keywords: Lung diseases, interstitial/epidemiology; Alveolitis, extrinsic allergic/epidemiology; Connective tissue diseases/epidemiology, Sarcoidosis/epidemiology; Idiopathic pulmonary fibrosis/epidemiology

Objective: To evaluate the implications of the proportion of annual family income spent in the pre- and post-diagnosis periods in tuberculosis patients followed for after at least one year after completing tuberculosis treatment in Brazil. Methods: This was a cross-sectional study of tuberculosis patients followed for at least one year after completing tuberculosis treatment in five Brazilian capitals (one in each region of the country). Results: A total of 62 patients were included in the analysis. The overall average cost of tuberculosis was 283.84 Brazilian reals (R$) in the pre-diagnosis period and R$4,161.86 in the post-diagnosis period. After the costs of tuberculosis disease, 71% of the patients became unemployed, with an overall increase in unemployment; in addition, the number of patients living in nonpoverty decreased by 5%, the number of patients living in poverty increased by 6%, and the number of patients living in extreme poverty increased by 5%. The largest proportion of annual household income to cover the total costs of tuberculosis was for the extremely poor (i.e., 40.37% vs. 11.43% for the less poor). Conclusions: Policies to mitigate catastrophic costs should include interventions planned by the health care system and social protection measures for tuberculosis patients with lower incomes in order to eliminate the global tuberculosis epidemic by 2035-a WHO goal in line with the United Nations Sustainable Development Goals.

Keywords: Tuberculosis/diagnosis; Tuberculosis/therapy; Costs and cost analysis; Financial stress; Brazil.