Objective: To evaluate deaths attributed to multiple causes in which tuberculosis was one of the causes listed. Methods: All deaths among residents of the state of Rio de Janeiro, Brazil, occurring between 1999 and 2001 and for which the death certificate mentioned tuberculosis, were investigated. The World Health Organization guidelines were used in characterizing the underlying and associated (non-underlying) causes of death. Results: In deaths from tuberculosis, conditions related to its natural history were the principal associated causes, together with alcoholism and diabetes. In approximately three-fifths of all deaths for which tuberculosis was listed as an associated cause, the underlying cause of death was acquired immunodeficiency syndrome. High proportion of ill-defined causes of death, low values found for the number of causes informed per death certificate and for TB as an associated cause point towards a certain degree of underestimation of the actual number of TB-related deaths in Rio de Janeiro State. Conclusion: The study shows that the rates of tuberculosis-related mortality in the state of Rio de Janeiro, calculated based on the number of times tuberculosis was listed as a cause of death (underlying or associated), are the highest in the country. Epidemiological studies of mortality are recommended as a means of guiding the activities of the tuberculosis control program.

Keywords: Tuberculosis/mortality; Acquired immunodeficiency syndrome; Multipe cause of death; Brazil

Background: In 1998, tuberculosis incidence and mortality rates in the state of Rio de Janeiro (RJ) were the highest in Brazil. However, the RJ tuberculosis database (SINAN-TBRJ) has proven unreliable. Objective: To evaluate the current tuberculosis control program by analyzing tuberculosis-attributed deaths. Methods: Descriptive studies of the SINAN-TB-RJ and tuberculosis mortality (SIM-TB-RJ) databases were carried out. Both databases were linked using the Reclink program. A study based on medical records was performed in the five hospitals where the greatest numbers of tuberculosis deaths occurred. Results: In the SINAN-TB-RJ database, 16,567 cases were registered in adults (> 14 years of age). Pulmonary disease was present in 13,989 (84.5%), of whom 8223 (56.8%) presented sputum smears that were positive for acid fast bacilli. Anti-HIV testing, recommended for all patients with tuberculosis, was performed in only 4141 (25%) of tuberculosis cases. The SIM-TB-RJ database showed 1146 deaths that were attributed to tuberculosis. Only 478 (41.7%) of those had been reported to the health care system (SINAN-TB-RJ). Among the 302 medical records analyzed, 154 (50.9%)recorded hospitalizations of up to 10 days and 143 (47.3%) had respiratory symptoms for more than 60 days before diagnosis. Among 125 cases of retreatment, the RHZE regimen recommended by the Brazilian Ministry of Health was prescribed for only 43 (34.4%). Conclusion: This study demonstrates weakness in the RJ tuberculosis control program, characterized by delayed diagnosis, limited use of the recommended tests, poor reporting, and non-compliance with the Ministry of Health guidelines.

Keywords: Tuberculosis. Epidemiology. Program Evaluation

The objective of this study was to compare gender differences among tuberculosis patients in a city with a high incidence of tuberculosis. This was a cross-sectional questionnaire-based study involving 560 tuberculosis patients (373 males and 187 females). Sociodemographic and clinical data, as well as data related to diagnostic criteria and treatment outcome, were collected (from the questionnaires and medical records) and subsequently compared between the genders. The median time from symptom onset to diagnosis was 90 days. There were no differences between the genders regarding the clinical presentation, diagnostic criteria, previous noncompliance with treatment, time from symptom onset, number of medical appointments prior to diagnosis, or treatment outcome. Gender-specific approaches are not a priority in Brazil. However, regardless of patient gender, the delay in diagnosis is a major concern.

Keywords: Poverty; Tuberculosis; Income.

Objective: To estimate the total time elapsed between symptom onset and diagnosis of pulmonary tuberculosis (patient delay plus health care system delay), analyzing the factors associated with delayed diagnosis in the state of Rio de Janeiro, Brazil. Methods: We conducted a questionnaire-based survey involving 218 pulmonary tuberculosis patients treated for two months at 20 health care clinics and 3 hospitals in eight cities within the state of Rio de Janeiro. We collected socioeconomic and demographic data, as well as data regarding the health care system and the medical history of the patients. Results: The median time elapsed from the onset of symptoms to diagnosis was 68 days (interquartile range [IQR]: 35-119 days). The median patient delay (time from symptom onset to initial medical visit) was 30 days (IQR: 15-60 days), and the median health care system delay (time from initial medical visit to diagnosis) was 21 days (IQR: 8-47 days). A cut-off point of 21 days was adopted. The factors independently associated with patient delay were female gender, cough, and unemployment [adjusted OR (95% CI) = 2.7 (1.3-5.6); 11.6 (2.3-58.8); and 2.0 (1.0-3.8), respectively], whereas only female gender was independently associated with health care system delay (OR= 3.2; 95% CI: 1.7-6.0). Conclusions: Delayed diagnosis of pulmonary tuberculosis remains a problem in Rio de Janeiro, increasing the risk of transmission and mortality, that risk being greater for women and the socioeconomically disadvantaged. Patients might not recognize the significance of chronic cough as a health problem. Tuberculosis education programs targeting women might improve this situation.

Keywords: Lung neoplasms; Neoplasm metastasis; Antineoplastic combined chemotherapy protocols; Radiotherapy, computer-assisted.

Objective: The purpose of this study was to describe tuberculosis-related mortality in Espírito Santo, Brazil, evaluating its tendencies in relation to clinical presentation, gender and age bracket. Methods: We conducted a retrospective, descriptive study based on secondary data. For the 1985-2004 period, we investigated all deaths of residents of Espírito Santo in which tuberculosis was given as the underlying cause, as reported in the Brazilian National Mortality Database. Results: The adjusted mortality rates for all forms of tuberculosis paralleled the overall mortality rates in the state, decreasing from 5.6/100,000 inhabitants in 1985 to 2.0/100,000 inhabitants in 2004. Pulmonary tuberculosis was the predominant form of the disease (89.7% of tuberculosis-related deaths) throughout the period studied, and the male/ female mortality rate ratio ranged from 1.1 in 1998 to 3.19 in 2004. Conclusions: We observed a decrease in the mortality rates in all age brackets. Predominance of the pulmonary form, male gender and advanced age was similar to that of overall tuberculosis-related mortality in Brazil.

Keywords: Tuberculosis/epidemiology; Mortality; Information systems.

In view of the fact that the World Health Organization has recommended the use of the mycobacteria growth indicator tube (MGIT) 960 system for the diagnosis of tuberculosis and that there is as yet no evidence regarding the clinical impact of its use in health care systems, we conducted a pragmatic clinical trial to evaluate the clinical performance and cost-effectiveness of the use of MGIT 960 at two health care facilities in the city of Rio de Janeiro, Brazil, where the incidence of tuberculosis is high. Here, we summarize the methodology and preliminary results of the trial. (ISRCTN.org Identifier: ISRCTN79888843 [http://isrctn.org/])

Keywords: Controlled clinical trial; Tuberculosis; Diagnostic tests, routine.

Objective: To evaluate the quality of diagnosis and the epidemiological profile of patients with pleural tuberculosis in the state of Roraima, Brazil, in order to provide technical support for the development and implementation of public policies to combat the disease. Methods: This was a cross-sectional study designed to determine the prevalence of pleural forms of tuberculosis in Roraima between 2005 and 2013 and to evaluate the diagnostic criteria used, as well as their determinants. This study was based on secondary data from the Brazilian Case Registry Database, including all reported cases of pleural tuberculosis in the state during the study period. Diagnoses based on bacteriological or histopathological confirmation were defined as high-quality diagnoses. Results: Among the 1,395 cases of tuberculosis reported during the study period, 116 (8.3%) were cases of pleural tuberculosis, accounting for 38.9% of all cases of extrapulmonary tuberculosis in the sample. The incidence rate of pleural tuberculosis did not follow the downward trend observed for the pulmonary form of the disease during the same period. The prevalence of cases with a high-quality diagnosis was 28.5% (95% CI: 20.4-37.6%). In a univariate analysis, none of the demographic or clinical characteristics collected from the database were found to have a significant impact on the outcome (as explanatory variables). Conclusions: The quality of the diagnoses in our study sample was considered unsatisfactory. Limited access to specific diagnostic methods might have contributed to these results.

Keywords: Tuberculosis/diagnosis; Tuberculosis/epidemiology; Tuberculosis, pleural.

Objective: In view of the relevance of co-infection with tuberculosis and human immunodeficiency virus, this study was designed to determine tuberculosis prevalence and identify factors related to tuberculosis in patients residing in a region in which both infections are highly prevalent. Methods: All patients treated during 1999 at the HIV/AIDS Clinic of the Universidade Federal do Rio Grande (Rio Grande Federal University) University Hospital were evaluated retrospectively, from the time of human immunodeficiency virus diagnosis, in terms of the incidence of tuberculosis and its relationship to sociodemographic, behavioral and immunological factors. Results: The sample included 204 patients, and tuberculosis prevalence was found to be 27%. The multivariate analysis showed a significant correlation between the development of tuberculosis and being of African descent (odds ratio: 4.76; 95% confidence interval: 1.93-11.72) and an inverse correlation between the development of tuberculosis and the TCD4+ lymphocyte count at the time of human immunodeficiency virus diagnosis (odds ratio: 0.995; 95% confidence interval: 0.993-0.997). When analyzed separately, other variables were found to be potential risk factors: being of the male gender (odds ratio: 2.49; 95% confidence interval: 1.15-5.39); and using illicit drugs (odds ratio: 2.1; 95% confidence interval: 1.02-4.31). Conclusion: The factors responsible for the development of tuberculosis among patients who are human immunodeficiency virus seropositive include immunological, socioeconomic and demographic factors. The high rate of tuberculosis prevalence among the seropositive patients underscores the urgent need to implement strategies that combine rapid identification and prompt treatment of individuals with active or latent infection, as well as of those with whom they have been in contact.

Keywords: HIV Infections/complications; AIDS-related opportunistic infections/complications; Tuberculosis/etiology; Tuberculosis/epidemiology

Objective: To evaluate clinical, tomographic, and microbiological characteristics of pulmonary disease caused by M. kansasii (MKPD) in patients treated at an outpatient unit from 2006-2016. Methods: We studied thirty eight patients, and analyzed socio demographic, clinical-radiological, laboratory, and therapeutic characteristics. Results: The mean age was 64 years (SD = 10.6; IIQ = 57-72; median = 65.0), and 22 (57.9%) male patients. Pulmonary comorbidity was present in 89.5% of the patients. The most frequent comorbidity was bronchiectasis (78.9%). Previous treatment for pulmonary tuberculosis (PTB) was found in 65.9%. The most used therapeutic regimen was rifampicin, isoniazid and ethambutol (44.7%). Chest tomography (CT) showed bronchiectasis (94.1%), architectural distortion (76.5%), septum thickening (67.6%), and cavities (64.7%). Disease was bilateral in 85.2%. We observed 10.7% resistance to rifampicin, 67.9% resistance to ethambutol, and sensitivity to clarithromycin. Conclusion: In patients with structural lung disease, it is important to search for NTM, the main differential diagnosis with PTB. Chest CT showed different patterns that overlapped with structural disease caused by PTB or other lung diseases. We observed resistance to ethambutol, a drug component of the recommended regimen.

Keywords: Nontuberculous mycobacteria; Mycobacterium kansasii; Epidemiology; Treatment.

Background: Asthma is considered the most common chronic childhood disease. However, there have been few studies on the prevalence of asthma in Brazil. Objective: To assess the prevalence and severity of asthma symptoms in school-age children and adolescents living in the city of Duque de Caxias, located in the greater metropolitan area of Rio de Janeiro. Method: Cross-sectional transversal study using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. The sample comprised students of 6, 7, 13 and 14 years of age. Results: One group of 2334 students between the ages of 6 and 7 and another composed of 4040 students between the ages of 13 and 14 were evaluated. The prevalence of wheezing within the last 12 months in the younger children was 27.7%, vs. 19% among the adolescents (p < 0.0001). There was a predominance of males in the 6-7 age group (29.9% vs. 25.6%; p = 0.01) and of females in the 13-14 age group (21.9% vs. 15.8%; p < 0.0001). The proportion of previously diagnosed cases of asthma was similar (approximately 10%) for both age brackets. Wheezing upon physical exertion was more prevalent among the adolescents (21.4% vs. 7.8%; p < 0.0001). Symptom severity was higher among female adolescents (severe asthma: 6.6% vs. 4.4%; p = 0.001), although no differences among genders were seen in the 6-7 age group. Conclusion: Asthma prevalence in Duque de Caxias is high, as it is in other Brazilian and Latin American cities. Values are higher in the 6-7 age group, in which symptoms were seen predominantly in males. Among the adolescents, the prevalence and severity of symptoms were higher in females, a recent observation that seems to be a new epidemiological trend of asthma.

Keywords: Key words: Asthma. Epidemiology. Severity of illness index. Cross-sectional studies.

Objective: To report demographic and clinical characteristics of patients with asthma who evolved to death, as well as to describe the conditions related to this outcome in a subgroup of patients admitted to the Program for the Control of Asthma and Rhinitis in Bahia (ProAR). Methods: A descriptive, retrospective, observational study. Data from clinical charts and death certificates of 16 patients of 930 subjects with severe asthma monitored at the ProAR Central Reference Center from December 2003 to June 2006 were reviewed. Results: Of the 930 patients participating in the program, 16 (1.72%) died. Of these, there were 10 males and 6 females, ranging in age from 39 to 74 years (median, 55 years); 12 (75%) of the patients were black. Time since diagnosis ranged from 1 to 68 years (median, 30 years). In 43.8 and 53.8%, respectively, there was a personal or family history of atopy. Ex-smokers (<10 pack-years) accounted for 37.5% of the cases. Causes of death listed on the death certificates were as follows: asthma or asthma exacerbations in 8 (50%); respiratory failure in 3 (18.75%); acute heart infarction in 2 (12.5%); hepatitis in 1 (6.25%); hypovolemic shock in 1 (6.25%); and cardiorespiratory arrest in 1 (6.25%). Of the 16 deaths, 13 (81.25%) occurred inside hospitals. Conclusion: Asphyxia and cardiovascular diseases were the most common atributed causes of mortality in this subgroup of patients with severe asthma. Hospital-based mortality, male gender, advanced age, long-term disease and fixed airflow obstruction were the aspects most frequently observed in the cases studied.

Keywords: Mortality; Rhinitis/treatment; Asthma/treatment; Cardiovascular diseases.

Epidemiologic data on idiopathic pulmonary fibrosis are relatively scarce, and its real incidence and prevalence are unknown. Recent studies suggest that idiopathic pulmonary fibrosis mortality is rising in developed countries. Objectives: To describe idiopathic pulmonary fibrosis mortality in the State of Rio Grande do Sul (RS), Brazil, from 1970 to 2000, analyzing its trend and comparing it with that from other countries. Methods: Prevalence study, using data from the Brazilian Institute of Geography and Statistics (IBGE), analyzing death certificates in which idiopathic pulmonary fibrosis was stated as ultimate cause of death. Results: Annual mortality adjusted to population was 0.22/100,000 persons in the 1970's, 0.3/100,000 persons in the 1980's, and 0.48/100,000 persons in the 1990's. Total mortality rised 36% from 1970 to 1980, and 70% from 1980 to 1990. Mortality adjusted to population rised 36% and 60% during the same periods. The rise in both total and adjusted mortality from IPF was statistically significant (p < 0.05). The mean mortality rate per 100,000 persons during 1996 to 1998, however, was 0.683, corresponding to a rise of 70% when compared to the previous three-year period, which was 0.4 (p = 0.0002), probably reflecting encoding practices. Conclusion: There was a significant increase in IPF mortality in RS from 1970 to 2000, in part due to changes in coding practices. This increase is in conformity with observations in other countries, althought mortality rates in RS are considerably lower.

Keywords: Pulmonary fibrosis. Mortality.

Objective: To estimate the rates of recurrence, cure, and treatment abandonment in patients with pulmonary tuberculosis treated with a four-drug fixed-dose combination (FDC) regimen, as well as to evaluate possible associated factors. Methods: This was a retrospective observational study involving 208 patients with a confirmed diagnosis of pulmonary tuberculosis enrolled in the Hospital Tuberculosis Control Program at the Institute for Thoracic Diseases, located in the city of Rio de Janeiro, Brazil. Between January of 2007 and October of 2010, the patients were treated with the rifampin-isoniazid-pyrazinamide (RHZ) regimen, whereas, between November of 2010 and June of 2013, the patients were treated with the rifampin-isoniazid-pyrazinamide-ethambutol FDC (RHZE/FDC) regimen. Data regarding tuberculosis recurrence and mortality in the patients studied were retrieved from the Brazilian Case Registry Database and the Brazilian Mortality Database, respectively. The follow-up period comprised two years after treatment completion. Results: The rates of cure, treatment abandonment, and death were 90.4%, 4.8%, and 4.8%, respectively. There were 7 cases of recurrence during the follow-up period. No significant differences in the recurrence rate were found between the RHZ and RHZE/FDC regimen groups (p = 0.13). We identified no factors associated with the occurrence of recurrence; nor were there any statistically significant differences between the treatment groups regarding adverse effects or rates of cure, treatment abandonment, or death. Conclusions: The adoption of the RHZE/FDC regimen produced no statistically significant differences in the rates of recurrence, cure, or treatment abandonment; nor did it have any effect on the occurrence of adverse effects, in comparison with the use of the RHZ regimen.

Keywords: Tuberculosis, pulmonary, Drug combinations; Recurrence.

Objective: To describe the clinical and therapeutic aspects of pulmonary tuberculosis and compare the adverse effects of the treatment and its outcome in elderly and nonelderly patients. Methods: This was a case-control study of 117 elderly individuals (over the age of 60 years) and 464 nonelderly individuals (aged 15-49 years). All subjects presented pulmonary tuberculosis that had been diagnosed and treated at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro between 1980 and 1996. Results: In the elderly group, pulmonary tuberculosis was found to be correlated with diabetes (OR = 3.98; 95% CI = 2.07-7.65; p = 0.001), lung disease (OR = 7.24; 95% CI = 3.64‑14.46; p = 0.001) and heart disease (OR = 5.86; 95% CI = 2.88-11.95; p = 0.001). Smoking (OR = 2.07; 95% CI = 1.26‑3.42; p = 0.002) and alcohol abuse (OR = 1.63; 95% CI = 1.01-2.68; p = 0.041) were also more common in the elderly group. In the elderly group, the treatment more frequently resulted in adverse reactions (OR = 1.62; 95% CI = 1.04-2.54; p = 0.024), especially gastrointestinal reactions (OR = 1.64; 95% CI = 1.01-2.77; p = 0.047), and treatment efficacy was lower: cure rate, 51%; mortality rate, 24%. Treatment adherence was low (approximately 77%) in both groups. Conclusions: In the elderly group, adverse reactions were more common, treatment outcomes were less favorable, there was a greater frequency of clinical complications and deaths related to drug toxicity, and the prevalence of concomitant diseases was higher.

Keywords: Tuberculosis, pulmonary; Aged; Drug therapy; Treatment outcome.

The objective of this study was to describe temporal trends in tuberculosis morbidity and mortality in the state of Santa Catarina, Brazil, between 2002 and 2009. Data regarding mortality and incidence were obtained from the Brazilian Mortality Database and National Case Registry Database, respectively. Crude rates were calculated and standardized by age using the direct method. We estimated annual variation by joinpoint regression, identifying the points at which there were changes in the trends. There was a significant (3.7%) annual decrease in the mortality rate. In the study period, two distinct temporal trends were identified: one between 2002 and 2007, showing a significant (5.9%) annual decrease in the mortality rate; and one between 2007 and 2009, showing an insignificant (2.0%) annual increase. There was also a significant (0.9%) annual reduction in tuberculosis incidence.

Keywords: Tuberculosis/epidemiology; Tuberculosis/mortality; Brazil.

This retrospective molecular study involving restriction fragment length polymorphism, using insertion sequence 6110 as a marker, was conducted in order to provide an initial insight into the genetic diversity of Mycobacterium tuberculosis strains isolated in the slums of the Complexo de Manguinhos, located in the city of Rio de Janeiro, Brazil. Of the 67 strains evaluated, 23 (34.3%) were found to belong to clusters (total clusters, 10). Household and social chains of transmission were associated with clustering, in 20% and 60%, respectively. Living in the Conjunto Habitacional Programado 2 slum was associated with clustering. Although not significant, it is relevant that 26% of the clustered strains presented primary resistance. These findings, although possibly underestimating the prevalence due to the failure to analyze all strains, could help improve the local tuberculosis control program.

Keywords: Tuberculosis; Epidemiology, molecular; Mycobacterium tuberculosis/transmission; Polymorphism, Restriction Fragment Length.

Introduction: Since 1981 the State Health Office has taken over the treatment and hospitalization of all tuberculosis cases in the State of São Paulo, southeastern Brazil. A decrease in both the incidence and the percentage of admissions due to tuberculosis has been observed during this period. Objective: To analyze the evolution of the reasons that led tuberculosis patients to hospitalization and correlate these reasons with hospitalization length and the type of discharge. Material and methods: A sample of 1,805 patients' records compiled between 1981 and 1995 at five tuberculosis hospitals in the State of São Paulo was reviewed. Results: The main reason for admission was general poor health, followed by cachexy. Increasing alcoholism was also observed. Among those who stayed in hospital for less than one week, the most frequent reasons for hospitalization were "other pathologies" and "respiratory insufficiency". These cases also showed the shortest average hospitalization length whereas the longest was presented by the patients admitted for social reasons and treatment failure. The patients with respiratory insufficiency presented the highest rate of dropouts and death. The highest rate of requested discharge was observed among the patients admitted due to drug intolerance whereas those admitted due to social reasons and alcoholism showed the highest rate of disciplinary release. The hospital that admitted females was the one with the highest rate of requested release, whereas in the hospitals that admitted males disciplinary release and dropouts were the most frequent types of discharge.

Keywords: Pulmonary tuberculosis. Length of stay. Health services research. Specialized hospitals. Patient discharge.

Objective: To analyze the temporal trend of tuberculosis cure indicators in Brazil. Methods: An ecological time-series study using administrative data of reported cases of the disease nationwide between 2001 and 2022. We estimated cure indicators for each federative unit (FU) considering individuals with pulmonary tuberculosis, tuberculosis-HIV coinfection, and those in tuberculosis retreatment. We used regression models using joinpoint regression for trend analysis, reporting the annual percentage change and the average annual percentage change. Results: For the three groups analyzed, we observed heterogeneity in the annual percentage change in the Brazilian FUs, with a predominance of significantly decreasing trends in the cure indicator in most FUs, especially at the end of the time series. When considering national indicators, an average annual percentage change of -0.97% (95% CI: -1.23 to -0.74) was identified for the cure of people with pulmonary tuberculosis, of -1.11% (95% CI: -1.42 to -0.85) for the cure of people with tuberculosis-HIV coinfection, and of -1.44% (95% CI: -1.62 to -1.31) for the cure of people in tuberculosis retreatment. Conclusions: The decreasing trends of cure indicators in Brazil are concerning and underscore a warning to public authorities, as it points to the possible occurrence of other treatment outcomes, such as treatment discontinuity and death. This finding contradicts current public health care policies and requires urgent strategies aiming to promote follow-up of patients during tuberculosis treatment in Brazil.

Keywords: Tuberculosis; Time factors; Retrospective studies; Brazil.

Objective: The aim of this study was to determine the prevalence of macrolide-resistant S. pneumoniae and to identify its phenotypic and genotypic characteristics. Methods: Strains of S. pneumoniae isolated in the city of Porto Alegre between May 2002 and August 2004 from samples collected from different anatomical sites were analyzed. For the agar diffusion test, disks of erythromycin, clarithromycin, azithromycin and clindamycin were used. The minimum inhibitory concentrations of erythromycin were determined for macrolide-resistant isolates by the agar dilution method. Macrolide-resistant isolates were phenotyped by agar diffusion test and genotyped by polymerase chain reaction. Results: A total of 229 pneumococcal strains were evaluated, 12 (5.2%) of which were macrolide-resistant. Among the 12 resistant strains, 9 (75%) presented the MLSB phenotype, and 3 (25%) presented the M phenotype. Polymerase chain reaction testing indicated that 8 MLSB phenotype isolates harbored the ermB gene only, whereas the mefE gene was present in all 3 M phenotype isolates. One MLSB phenotype isolate presented both genes. Conclusion: In Porto Alegre, the S. pneumoniae resistance to macrolides is still low since such resistance is due primarily to the presence of the ermB gene expressing the MLSB phenotype.