Objective: To estimate the time elapsed between the onset of symptoms and the initiation of treatment of pulmonary tuberculosis among treatment-naïve patients with positive results in sputum smear microscopy, and to evaluate the variables associated with delays in diagnosis and in treatment initiation. Methods: This was a descriptive exploratory study involving 199 treatment-naïve tuberculosis patients ≥ 12 years of age with AFB-positive sputum smear microscopy results between 2006 and 2008. At their first (treatment initiation) visit to a primary health care clinic in the city of Nova Iguaçu, Brazil, the patients were interviewed and their ancillary test results were reviewed. Results: The medians (and respective interquartile ranges) of the time from symptom onset to the initiation of treatment of pulmonary tuberculosis, from symptom onset to seeking medical attention, from entry into care to diagnosis, and from entry into care to treatment initiation, in weeks, were 11 (6-24), 8 (4-20), 2 (1-8), and 1 (1-1), respectively. The variables gender, age, level of education, previous use of antibiotics, HIV status, site of first medical visit, and radiological extent of tuberculosis showed no associations with the time from entry into care to diagnosis or to treatment initiation. The main reason for the delay in seeking medical attention reported by the patients was their inability to recognize their symptoms as indicators of a disease. Conclusions: Among the patients studied, there was an unacceptably long delay between the onset of symptoms and the initiation of tuberculosis treatment.

Keywords: Tuberculosis/diagnosis; Tuberculosis/therapy; Delayed diagnosis.

The aim of this study was to evaluate the completeness of tuberculosis reporting forms in the greater metropolitan areas of five Brazilian capitals where the incidence of tuberculosis was high in 2010-Salvador, Rio de Janeiro, Cuiabß, Porto Alegre, and BelÚm-using tabulations obtained from the Sistema Nacional de InformaþÒo de Agravos de NotificaþÒo (National Case Registry Database). The degree of completeness was highest in Porto Alegre and Cuiabß, whereas it was lowest in Rio de Janeiro, where there are more reported cases of tuberculosis than in any other Brazilian capital. A low degree of completeness of these forms can affect the quality of the Brazilian National Tuberculosis Control Program, which will have negative consequences for health care and decision-making processes.

Keywords: Tuberculosis; Public health surveillance; Disease notification.

Objetive: To analyze the variables related to smoking initiation among adolescent students in two high schools (one public and one private) in the city of Belém, Brazil, in 2005. Methods: An anonymous self-report questionnaire - comprising 27 closed questions regarding smoking experimentation, smoking habit, access to buying cigarettes, reasons for smoking experimentation, self-perception regarding academic performance, conversations about smoking with the family, and socioeconomic level - was used for data collection. The study comprised 1520 students: 724 (47.6%) from the private school and 796 (52.4%) from the public school. Results: Mean age of participants was 16.5 years. Of the 1520 students evaluated, 669 (44%) reported experimenting with smoking, and 11% smoked regularly. In the public school and the private school, respectively, 51.2% and 36.7% of the participants had experimented with smoking (p = 0); 14.6% and 7%, respectively, were regular smokers (p = 0). We found that, in both schools, the following factors were associated with smoking initiation and current smoking: curiosity, presence of smokers as social contacts, not being praised for not smoking, and perceiving oneself as having poor or mediocre academic performance. Socioeconomic level was found to be associated with experimentation and current smoking only among experimenters of higher socioeconomic classes (A and B) in the private school. Conclusions: Among the students evaluated, the variable most closely associated with smoking was curiosity. Experimentation and regular tobacco use were more common in the public school than in the private school.

Keywords: Smoking; Epidemiologic factors; Students.

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 characterize deaths from pulmonary tuberculosis, according to sociodemographic and operational variables, in the city of São Luís, Brazil, and to describe their spatial distribution. Methods: This was an exploratory ecological study based on secondary data from death certificates, obtained from the Brazilian Mortality Database, related to deaths from pulmonary tuberculosis. We included all deaths attributed to pulmonary tuberculosis that occurred in the urban area of São Luís between 2008 and 2012. We performed univariate and bivariate analyses of the sociodemographic and operational variables of the deaths investigated, as well as evaluating the spatial distribution of the events by kernel density estimation. Results: During the study period, there were 193 deaths from pulmonary tuberculosis in São Luís. The median age of the affected individuals was 52 years. Of the 193 individuals who died, 142 (73.60%) were male, 133 (68.91%) were Mulatto, 102 (53.13%) were single, and 64 (33.16%) had completed middle school. There was a significant positive association between not having received medical care prior to death and an autopsy having been performed (p = 0.001). A thematic map by density of points showed that the spatial distribution of those deaths was heterogeneous and that the density was as high as 8.12 deaths/km2. Conclusions: The sociodemographic and operational characteristics of the deaths from pulmonary tuberculosis evaluated in this study, as well as the identification of priority areas for control and surveillance of the disease, could promote public health policies aimed at reducing health inequities, allowing the optimization of resources, as well as informing decisions regarding the selection of strategies and specific interventions targeting the most vulnerable populations.

Keywords: Tuberculosis, pulmonary/mortality; Communicable disease control; Spatial analysis.

Objective: To identify the factors associated with smoking experimentation and initiation among adolescent students (11-14 years of age). Methods: A cross-sectional, population-based study involving adolescent (middle and high school) students at public and private schools in the city of Salvador, Brazil. A multiple-stage sampling protocol was used. The participants completed an anonymous, voluntary, self-report questionnaire. The dependent variables were age at smoking experimentation and smoking initiation. Sociodemographic and educational variables, as well as those related to media influence and alcohol consumption, were considered independent variables. Multivariate logistic regression analysis was performed, followed by analysis of the fit of the final logistic regression model. Results: The prevalence of smoking experimentation was 16.1% (95% CI: 15.1-17.2). Of the 5,347 students evaluated, 757 had experimented with cigarettes, and 462 (61.2%) of those 757 had done so before the age of 15 (mean age at smoking experimentation, 13.9 ± 1.8 years). Smoking initiation was associated with paternal smoking (OR = 1.53; 83% CI = 1.07-2.19) and with media influence (OR = 2.43; 83% CI: 1.46‑4.04). Smoking experimentation was associated with alcohol consumption (OR = 6.04; 83% CI: 4.62-7.88), having friends who smoke (OR = 3.18; 83% CI: 2.54-3.99), having a boyfriend/girlfriend who smokes (OR = 3.42; 83% CI: 1.78-6.56), and coercive/aggressive educational interventions by the parents (OR = 1.60; 83% CI: 1.26‑2.04). Conclusions: Alcohol consumption and the influence of peers and relatives who smoke showed a strong association with smoking experimentation. Paternal smoking and media influence were found to increase the chances of adolescent smoking.

Keywords: Smoking; Adolescence; Health education; Cross-sectional studies; Epidemiologic factors; Brazil.

Objective: To determine the spatial distribution of tuberculosis in the city of Ribeirão Preto, located in the state of São Paulo, Brazil, between 1998 and 2002, with a focus on the potential spatially-dependent nature of its occurrence. Methods: The secondary Epi-Tb database of the Ribeirão Preto Municipal Secretary of Health. Georeferencing of tuberculosis cases was performed using MapInfo 6.5 software, and the Spring program was used for statistical analysis of spatial data. Results: Through analysis of the existing spatial pattern and those of the previous years analyzed, we found a consistent pattern of spatial distribution of tuberculosis in Ribeirão Preto. Although there are areas that were homogeneous in terms of risk, the highest concentrations of cases were found in one zone, consisting of middle- to lower middle-class neighborhoods, located in the northeast part of the city. Conclusion: These results add to the store of knowledge regarding the spatial distribution of tuberculosis in Ribeirão Preto in various periods, emphasizing the importance of space as a methodological alternative to aid the planning, monitoring and evaluation of health care programs, allowing interventions to be more appropriately directed in order to decrease inequalities in the allocation of health care resources.

Keywords: Tuberculosis/epidemiology; Health status indicators; Residence characteristics; Urban health/ statistics & numerical data; Topography, medical

Objective: To determine the compliance with tuberculosis treatment among patients enrolled the tuberculosis control program in the city of Carapicuíba, Brazil, before and after the implementation of the directly observed treatment, short-course (DOTS) strategy. Methods: A retrospective historical cohort study of operational aspects based on records of attendance and treatment evolution of patients in self-administered treatment (SAT) and of those submitted to DOTS. Monthly treatment outcome tables were created, and the probability of compliance with the treatment was calculated for both groups of patients. Results: A total of 360 patients with tuberculosis met the inclusion criteria: 173 (48.1%) in the SAT group; and 187 (51.9%) in the DOTS group. Treatment compliance was 6.1% higher in the DOTS group than in the SAT group. The proportion of patients completing the six months of treatment was 91.6% and 85.5% in the DOTS group and in the SAT group, respectively. Conclusions: The results of this study show that DOTS can be successfully implemented at primary health care clinics. In this population of patients, residents of a city with low incomes and a high burden of tuberculosis infection, DOTS was more effective than was SAT.

Keywords: Tuberculosis; Mycobacterium tuberculosis; Treatment outcome; Medication adherence.

Objective: To determine treatment noncompliance rates among patients participating in a municipal tuberculosis control program and to identify the variables related to noncompliance depending on the type of treatment strategy used. Methods: A longitudinal non-concurrent cohort study was carried out involving two cohorts of patients participating in the Tuberculosis Control Program of the city of Carapicuíba, Brazil. The first cohort comprised 173 patients with tuberculosis treated from January 1, 2003 to December 31, 2003 using self administration of treatment, and the second comprised 187 patients with tuberculosis treated from July 1, 2004 to June 30, 2005 using the directly observed therapy, short-course strategy. Results: Noncompliance rates decreased from 13.3% (self administration of treatment) to 5.9% (directly observed therapy, short-course), a significant difference (p < 0.05). For the self administration of treatment strategy, the variables significantly associated with treatment noncompliance were as follows: being an unregistered worker (relative risk [RR] = 3.06); retreatment (RR = 2.73); alcoholism (RR = 3.10); and no investigation of contacts (RR = 8.94). For the directly observed therapy, short-course strategy, no variables were significantly associated with noncompliance. Conclusion: The directly observed therapy, short-course strategy decreased noncompliance rates and produced better treatment outcomes, even when the risk factors for noncompliance were the same.

Keywords: Tuberculosis; Self administration; Directly observed therapy; Treatment refusal.

Objective: To assess the diagnostic performance of the Xpert MTB/RIF assay, a rapid molecular test for tuberculosis, comparing it with that of AFB staining and culture, in BAL fluid (BALF) samples from patients with clinically suspected pulmonary tuberculosis (PTB) who are sputum smear-negative or produce sputum samples of insufficient quantity. Methods: This was a retrospective study of 140 cases of suspected PTB in patients who were smear-negative or produced insufficient sputum samples and were evaluated at a tertiary teaching hospital in the city of Rio de Janeiro, Brazil. All of the patients underwent fiberoptic bronchoscopy with BAL. The BALF specimens were evaluated by AFB staining, mycobacterial culture, and the Xpert MTB/RIF assay. Results: Among the 140 patients, results for all three microbiological examinations were available for 73 (52.1%), of whom 22 tested positive on culture, 17 tested positive on AFB staining, and 20 tested positive on the Xpert MTB/RIF assay. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy for AFB staining were 68.1%, 96.1%, 88.2%, 87.5%, and 87.6%, respectively, compared with 81.8%, 96.1%, 90.0%, 92.4%, and 91.8%, respectively, for the Xpert MTB/RIF assay. The agreement between AFB staining and culture was 82.3% (kappa = 0.46; p < 0.0001), whereas that between the Xpert MTB/RIF assay and culture was 91.8% (kappa = 0.8; p < 0.0001). Conclusions: In BALF samples, the Xpert MTB/RIF assay performs better than do traditional methods, providing a reliable alternative to sputum analysis in suspected cases of PTB. However, the rate of discordant results merits careful consideration.

Keywords: Tuberculosis; Molecular diagnostic techniques; Bronchoscopy; Bronchoalveolar lavage fluid; Mycobacterium tuberculosis.

Objective: To analyze the association between clinical/epidemiological characteristics and outcomes of tuberculosis treatment in patients with concomitant tuberculosis and chronic kidney disease (CKD) in Brazil. Methods: We used the Brazilian Ministry of Health National Case Registry Database to identify patients with tuberculosis and CKD, treated between 2007 and 2011. The tuberculosis treatment outcomes were compared with epidemiological and clinical characteristics of the subjects using a hierarchical multinomial logistic regression model, in which cure was the reference outcome. Results: The prevalence of CKD among patients with tuberculosis was 0.4% (95% CI: 0.37-0.42%). The sample comprised 1,077 subjects. The outcomes were cure, in 58%; treatment abandonment, in 7%; death from tuberculosis, in 13%; and death from other causes, in 22%. The characteristics that differentiated the ORs for treatment abandonment or death were age; alcoholism; AIDS; previous noncompliance with treatment; transfer to another facility; suspected tuberculosis on chest X-ray; positive results in the first smear microscopy; and indications for/use of directly observed treatment, short-course strategy. Conclusions: Our data indicate the importance of sociodemographic characteristics for the diagnosis of tuberculosis in patients with CKD and underscore the need for tuberculosis control strategies targeting patients with chronic noncommunicable diseases, such as CKD.

Keywords: Tuberculosis/epidemiology; Renal insufficiency, chronic/epidemiology; Risk factors; Logistic models.

Background: Tuberculosis cure is dependent upon treatment adherence. Objective: To analyze the results of tuberculosis treatment in public health clinics in the city of Campinas, in the state of São Paulo, Brazil, during 2002. Method: From a cohort of 484 patients diagnosed with tuberculosis, we evaluated 436. Treatment outcomes were described for all patients, whether new patients or patients in retreatment, including those presenting the pulmonary form, with or without acquired immunodeficiency syndrome (AIDS) comorbidity. Results: The success rate was 68.6% (72.3% among non-AIDS patients and 57.6% among AIDS patients). Among new cases, the non-AIDS group presented a 2.2-times greater chance of presenting favorable results. In the AIDS group, no differences were observed between new patients and those in retreatment. Among the unfavorable outcomes, only lethality presented a difference (18.9% among AIDS patients and 8.0% among non-AIDS patients). In patients presenting the pulmonary form, the success rate was similar between those who were initially acid-fast bacilli positive and those who were not. Conclusion: The tuberculosis control program in Campinas presented low effectiveness. In comparison to the 2001 national cohort, success rates were higher for non-AIDS patients but lower for AIDS patients. The higher success rate among cases of tuberculosis without AIDS was primarily derived from the treatment of new cases. The unfavorable profile of tuberculosis patients co-infected with AIDS, characterized by the (18.9%) lethality and the (15.3%) noncompliance, were partially responsible for the lower success rate seen among such patients. It is notable that such high proportions of noncompliant patients were seen in a city providing easy access to treatment. In order to improve the program, medical teams should receive further training in supervised treatment, health education and techniques for interacting with patients, all of which will require considerable investment.

Keywords: Key words: Tuberculosis. Treatment Refusal. Retreatment. Acquired Immunodeficiency Syndrome. Comorbidity

Objective: To compare clinical, radiological, and laboratory characteristics of individuals with pulmonary tuberculosis co-infected or not with HIV. Methods: A cross-sectional study, in which signs and symptoms were assessed by anamnesis and physical examination in patients hospitalized with pulmonary tuberculosis. The results of sputum smear microscopy and culture for Mycobacterium tuberculosis, as well as hemoglobin levels and CD4+ T-cell counts, were obtained from medical records, and chest X-ray reports were consulted. Results: We included 50 pulmonary tuberculosis patients, who were divided into two groups (HIV-positive and HIV-negative; n = 25 per group). The mean age of the participants was 38.4 ± 10.5 years; 46 (92%) were males; and 27 (54%) were White. Expectoration was presented by 21 (84%) and 13 (52%) of the patients in the HIV-negative and HIV-positive groups, respectively (p = 0.016). Radiological findings of cavitation were present in 10 (43%) and 2 (10%) of the patients in the HIV-negative and HIV-positive groups, respectively (p = 0.016), whereas an interstitial pattern was observed in 18 (78%) and 8 (40%), respectively (p = 0.012). The mean hemoglobin level was 11.1 ± 2.9 g/dL and 9.3 ± 2.2 g/dL in the HIV-negative and HIV-positive groups, respectively (p = 0.015). Conclusions: In our sample of tuberculosis patients, expectoration was less prevalent, hemoglobin levels were lower, and cavitation was less common, as was an interstitial pattern, among those co-infected with HIV than among those without HIV co-infection.

Keywords: HIV; Tuberculosis; Acquired immunodeficiency syndrome.

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 evaluate the effect that the distribution of food baskets to tuberculosis (TB) patients has on treatment outcomes at a primary health care clinic. Methods: Retrospective comparative study of the medical and social aspects of 142 patients at a primary health care clinic in the city of Duque de Caxias, Brazil. The patients were divided into two groups: the first group included 68 patients treated with standard regimens (between September of 2001 and December of 2003); and the second group included 74 patients treated with the same regimens but also receiving food baskets on a monthly basis (between January of 2004 and July of 2006). Results: The statistical comparison between the two groups revealed that the cure rate was higher in the group receiving the food baskets (87.1% vs. 69.7%), whereas the rate of noncompliance was markedly lower (12.9% vs. 30.3%). Conclusions: The results indicate that the distribution of food baskets can be a useful strategy to improve compliance with TB treatment at primary health care clinics.

Keywords: Tuberculosis; Nutritional support; Treatment outcome; Ambulatory health services.

Objective: To analyze symptoms at different times of day in patients with COPD. Methods: This was a multicenter, cross-sectional observational study conducted at eight centers in Brazil. We evaluated morning, daytime, and nighttime symptoms in patients with stable COPD. Results: We included 593 patients under regular treatment, of whom 309 (52.1%) were male and 92 (15.5%) were active smokers. The mean age was 67.7 years, and the mean FEV1 was 49.4% of the predicted value. In comparison with the patients who had mild or moderate symptoms, the 183 (30.8%) with severe symptoms were less physically active (p = 0.002), had greater airflow limitation (p < 0.001), had more outpatient exacerbations (p = 0.002) and more inpatient exacerbations (p = 0.043), as well as scoring worse on specific instruments. The most common morning and nighttime symptoms were dyspnea (in 45.2% and 33.1%, respectively), cough (in 37.5% and 33.3%, respectively), and wheezing (in 24.4% and 27.0%, respectively). The intensity of daytime symptoms correlated strongly with that of morning symptoms (r = 0.65, p < 0.001) and that of nighttime symptoms (r = 0.60, p < 0.001), as well as with the COPD Assessment Test score (r = 0.62; p < 0.001), although it showed only a weak correlation with FEV1 (r = −0.205; p < 0.001). Conclusions: Dyspnea was more common in the morning than at night. Having morning or nighttime symptoms was associated with greater daytime symptom severity. Symptom intensity was strongly associated with poor quality of life and with the frequency of exacerbations, although it was weakly associated with airflow limitation.

Keywords: Pulmonary disease, chronic obstructive; Signs and symptoms, respiratory; Quality of life; Disease progression; Brazil.

Objectives: This study describes the epidemiological profile of cases of repeated treatment of tuberculosis occurring among residents of the city of Recife in the year of 1997. Material and methods: A cross-sectional study was performed and 240 cases of repeated treatment were studied, representing 16.2% of all cases of tuberculosis. Results: Interruption of previous treatment was the principal reason for repeated treatments (55.8%), followed by cases of recurrence of the disease (39.2%). Patients undergoing repeated treatment for tuberculosis are characterized as predominantly male, ages between 30 and 49, with little or no school education, with a significant predominance of pulmonary tuberculosis. It is striking that 42.7% of the cases of repeated treatment had a history of two or more previous courses of treatment. With regard to the outcome of the repeated treatment, 52.5% of the cases showed unfavorable results. Among these, 44.2% of the patients gave up the course of treatment and 39.6% followed it for the first month. The cases that returned for treatment following recurrence showed a higher percentage of successful outcomes (56.7%), in comparison to those that returned after interrupting previous treatment (40.2%), this difference being statistically significant (χ2 = 19,55; p < 0,01). It was found that, among the cases of pulmonary tuberculosis, 27.1% resumed chemotherapy without undergoing the Koch bacillus catarrh test and only 27.1% carried out BK culture with sensitivity test. Conclusions: The results show the need to enhance tuberculosis treatment and follow-up procedures within the sphere of the health care service. An adequate treatment is the cheapest method to avoid drug resistance and should be understood as a strategy to improve the tuberculosis surveillance system.

Keywords: Tuberculosis. Pulmonary tuberculosis. Repeated treatment.