Geisa Fregona

Prevalence and incidence of Mycobacterium tuberculosis infection in nursing students in Vitória, Espírito Santo

This prospective study evaluated the incidence of Mycobacterium tuberculosis infection among nursing students at the Federal University of Espírito Santo, using the purified protein derivative test. In parallel, we evaluated whether knowledge on tuberculosis transmission mechanisms had any impact on nursing students attitudes in relation to the risk of tuberculosis infection. The incidence of tuberculin conversion was 10.5% per year (p=0.035, 95% CI = 3.63-17.43), whereas the expected conversion rate in the overall population in Brazil is 0.5% per year. These results indicate nursing students as a group at risk for TB infection. Among the risk factors studied only the use of NIOSH95 masks was associated with protection against infection (RR=0.2). Furthermore there was no statistical difference among students that PPD converted and those who remained negative regarding disease knowledge and the existence of adequate facilities for patient hospitalization. Our data reinforces the need for implementing special biosafety programs targeting this professional group.

Perfil epidemiológico dos casos notificados de tuberculose entre os profissionais de saúde no Hospital Universitário em Vitória (ES) Brasil

OBJECTIVEnTo describe the epidemiological profile of tuberculosis cases reported among health care workers in the Tuberculosis Control Program of the Cassiano Antonio of Moraes University Hospital in Vitoria, Brazil.nnnMETHODSnA retrospective descriptive study of secondary data was conducted between 2002 and 2006.nnnRESULTSnTwenty-five cases of health care workers with tuberculosis were reported: 8 in nursing technicians (32%); 4 in doctors (16%); 3 in nurses (12%); 2 in radiology technicians (8%) and 8 in professionals from other categories (32%). Of those 25 health care workers, 14 (56%) were male and 11 (44%) were female. The incidence of the disease was highest among those from 35 to 39 years of age. The predominant clinical presentation was extrapulmonary (12 cases, 48%), followed by pulmonary (11 cases, 44%) and a combination of the two (2 cases, 8%). Regarding comorbidities, AIDS, alcoholism and smoking, respectively, were present in 33.3% of the study population. Outcomes were as follows: 22 cases of cure (88%); 2 transfers (8%); and 1 death (4%). The proportion of health care workers diagnosed with tuberculosis in the period studied was 2.53%.nnnCONCLUSIONSnThe results show the need for heath care workers who work in the tuberculosis control program to fill out the field professional occupation on the tuberculosis case registry database reporting forms. In addition, this situation draws attention to the need to implement an occupational tuberculosis control program.

O agente comunitário de saúde no controle da tuberculose: conhecimentos e percepções

This study analyzes the knowledge of community health workers in tuberculosis control and their self-perceived knowledge and the importance they ascribe to their role in fighting the disease, in Vitória, Espírito Santo State, Brazil. The study adopted a cross-sectional design, with a pre-tested, semi-structured questionnaire completed by 105 randomly selected health workers. The comparison of proportions between the groups formed by stratification according to time-on-the-job used the chi-squared test with 5% significance. Mean age was 34.5 (+/-9.7) years. Sixty-six community health workers (62.9%) had worked on the job for three years or less. Longer time on the job was positively associated with increased understanding of the disease and activities actually performed in TB control. Still, numerous flaws were observed in TB knowledge and control measures among community health workers. Improvements in continuing education for these workers could foster a more effective contribution to detecting new TB cases in the community and improved treatment adherence by patients.

Características e tendência da AIDS entre idosos no Estado do Espírito Santo

INTRODUCTIONnAIDS among older adults is a public health problem emerging. This study compared the demographic and epidemiological profile and the evolution and trend of the epidemic among men and women aged 50 years and older and 20 to 39 years affected by AIDS in the State of Espirito Santo, Brazil.nnnMETHODSnWe conducted a time serie study with secondary data from SINAN/AIDS for the period January 1991 to December 2006.nnnRESULTSnIn this period were 3,382 reported cases of AIDS in individuals aged 20 to 39 years and 551 cases among individuals with 50 years or older. In both age groups most affected are men. There are differences related to race or color, where the majority of the older is white (45.3% - p-value = 0.044) and the young brown (44.7%, p = 0.003). Illiteracy prevails among the older (17.7% - p-value = 0.001). More than half (80%) of the notifications occurred in cities of medium to large. The main risk factor was heterosexual in both the age groups more frequently to the group of 50 or more (77.3% - p = 0.0001). The cumulative incidence is higher for the age group 20 to 39 years (R(2) = 0.68), but is increasing proportionally between the two bands over the years, with a significant upward trend for both (p<0.01).nnnCONCLUSIONSnThe AIDS epidemic among the elderly can be seen growing among older on the Espirito Santo State.

Importance of Cough and M. tuberculosis Strain Type as Risks for Increased Transmission within Households

Rationale The degree to which tuberculosis (TB) is transmitted between persons is variable. Identifying the factors that contribute to transmission could provide new opportunities for TB control. Transmission is influenced by host, bacterial and environmental factors. However, distinguishing their individual effects is problematic because measures of disease severity are tightly correlated, and assessing the virulence of Mycobacterium tuberculosis isolates is complicated by epidemiological and clinical confounders. Objectives To overcome these problems, we investigated factors potentially associated with TB transmission within households. Methods We evaluated patients with smear-positive (≥2+), pulmonary TB and classified M. tuberculosis strains into single nucleotide polymorphism genetic cluster groups (SCG). We recorded index case, household contact, and environmental characteristics and tested contacts with tuberculin skin test (TST) and interferon-gamma release assay. Households were classified as high (≥70% of contacts with TST≥10 mm) and low (≤40%) transmission. We used logistic regression to determine independent predictors. Result From March 2008 to June 2012, we screened 293 TB patients to enroll 124 index cases and their 731 contacts. There were 23 low and 73 high transmission households. Index case factors associated with high transmission were severity of cough as measured by a visual analog cough scale (VACS) and the Leicester Cough Questionnaire (LCQ), and cavitation on chest radiograph. SCG 3b strains tended to be more prevalent in low (27.3%) than in high (12.5%) transmission households (pu200a=u200a0.11). In adjusted models, only VACS (p<0.001) remained significant. SCG was associated with bilateral disease on chest radiograph (pu200a=u200a0.002) and marginally associated with LCQ sores (pu200a=u200a0.058), with group 3b patients having weaker cough. Conclusions We found differential transmission among otherwise clinically similar patients with advanced TB disease. We propose that distinct strains may cause differing patterns of cough strength and cavitation in the host leading to diverging infectiousness. Larger studies are needed to verify this hypothesis.

Factors associated with nonadherence to TB chemoprophylaxis in Vitória, Brazil: a historical cohort study*

OBJECTIVEnTo describe the factors associated with nonadherence to TB chemoprophylaxis in patients older than 15 years of age treated via referral TB control programs.nnnMETHODSnA historical cohort study was carried out based on medical charts related to cases treated via referral TB control programs in the city of Vitória, Brazil, between 2002 and 2007. Cases of infection with Mycobacterium tuberculosis were stratified into two groups: health care workers (HCW group); and individuals who were not health care workers (NHCW group).nnnRESULTSnA total of 395 patients were included in the study: 35 in the HCW group and 360 in the NHCW group. The mean age in the HCW and NHCW groups was 34.8 and 32.4 years, respectively (p = 0.36). Of the 35 patients in the HCW group, 29 (82.9%) were female, compared with 180 (50.0%) of the 360 patients in the NHCW group. In the HCW and NHCW groups, respectively, 15 (42.9%) and 169 (46.9%) of the patients were contacts of TB cases. In addition, 9 (25.7%) and 157 (78.5%) the HCW and NHCW group patients, respectively, were HIV-infected. Nonadherence to chemoprophylaxis was 37.1% and 21.9% in the HCW and NHCW groups, respectively (p = 0.045). In the multivariate analysis, the factors associated with nonadherence were being a health care worker (OR = 8.60; 95% CI: 2.09-35.41), being HIV-infected (OR = 4.57; 95% CI: 1.2-17.5) and having had contact with a TB patient (OR = 2.65; 95% CI: 1.15-6.12).nnnCONCLUSIONSnIn order to improve adherence to TB chemoprophylaxis, new TB control program strategies are needed, especially for health care workers and HIV-infected patients.

Perfil epidemiológico dos casos de tuberculose multirresistente do Espírito Santo

Estudo retrospectivo de perfil dos casos de TBMR do Espirito Santo, entre 2000 e 2004. Identificou-se 61 pacientes com TBMR, sendo a amostra composta por 57 casos, que tiveram seus prontuarios revisados para obtencao das variaveis estudadas. Estimou-se como prevalencia para a TBMR combinada 0,87% (0,66 - 1,13; IC95%). O teste anti-HIV foi feito em 78,9% dos casos, sendo 11,1% positivos. Investigando co-morbidades, destacaram-se etilismo e tabagismo. Encontrou-se 11 casos de resistencia primaria (RI) e 46 de resistencia adquirida (RA), com media de 2,3 ± 1,3 tratamentos anteriores. Em 35,1% dos casos houve relato de contato previo conhecido com doente de tuberculose, enquanto em 67,9% nao houve ou nega-se ter havido. Dez pacientes (17,5%) foram tratados com o esquema de 1a linha, 18 (31,6%) com o de 2a linha e 27 (47,4%) com o de 3a linha. Dezoito (31,6%) tiveram tratamento auto-administrado, e 39 (68,4%) supervisionado. Quanto ao desfecho, houve cura em 33 casos (71,7%), abandono em 7 (15,2%) e obito em 5 (10,9%), 1 caso de falencia e 11 (19,3%) estao em tratamento. Dos 10 casos encerrados de RI, 80% (8/10) foram curados, contra 69,4% (25/36) dos casos de RA. Concluimos que a prevalencia de TBMR e baixa no ES. A cura foi alcancada em 70% dos casos. As co-morbidades podem ser importante fator interveniente para um desfecho satisfatorio do tratamento. Os resultados enfatizam a necessidade de busca, diagnostico e realizacao de TSA para identificacao da RI e a supervisao do tratamento de todos os casos de tuberculose.

Comparison of Interferon-γ Release Assay to Two Cut-Off Points of Tuberculin Skin Test to Detect Latent Mycobacterium tuberculosis Infection in Primary Health Care Workers

Background An interferon-γ release assay, QuantiFERON-TB (QFT) test, has been introduced an alternative test for the diagnosis of latent Mycobacterium tuberculosis infection (LTBI). Here, we compared the performance of QFT with tuberculin skin test (TST) measured at two different cut-off points among primary health care work (HCW) in Brazil. Methods A cross-sectional study was carried out among HCWs in four Brazilian cities with a known history of high incidence of TB. Results of the QFT were compared to TST results based on both ≥5 mm and ≥10 mm as cut-off points. Results We enrolled 632 HCWs. When the cut-off value of ≥10 mm was used, agreement between QFT and TST was 69% (ku200a=u200a0.31), and when the cut-off of ≥5 mm was chosen, the agreement was 57% (ku200a=u200a0.22). We investigated possible factors of discordance of TST vs QFT. Compared to the TST−/QFT− group, risk factors for discordance in the TST+/QFT− group with TST cut-off of ≥5 mm included age between 41–45 years [ORu200a=u200a2.70; CI 95%: 1.32–5.51] and 46–64 years [ORu200a=u200a2.04; CI 95%: 1.05–3.93], BCG scar [ORu200a=u200a2.72; CI 95%: 1.40–5.25], and having worked only in primary health care [ORu200a=u200a2.30; CI 95%: 1.09–4.86]. On the other hand, for the cut-off of ≥10 mm, BCG scar [ORu200a=u200a2.26; CI 95%: 1.03–4.91], being a household contact of a TB patient [ORu200a=u200a1.72; CI 95%: 1.01–2.92] and having had a previous TST [ORu200a=u200a1.66; CI 95%: 1.05–2.62], were significantly associated with the TST+/QFT− group. No statistically significant associations were found among the TST−/QFT+ discordant group with either TST cut-off value. Conclusions Although we identified BCG vaccination to contribute to the discordance at both TST cut-off measures, the current Brazilian recommendation for the initiation of LTBI treatment, based on information gathered from medical history, TST, chest radiograph and physical examination, should not be changed.

Intensity of exposure to pulmonary tuberculosis determines risk of tuberculosis infection and disease

Household contacts of pulmonary tuberculosis (TB) patients are at increased risk of TB infection and disease. However, their risk in relation to the intensity of exposure remains unknown. We studied smear-positive TB cases and their household contacts in Vitória, Brazil. We collected clinical, demographic and radiographic information from TB cases, and obtained tuberculin skin test (TST) and QuantiFERON-TB Gold (QFT) results from household contacts. We measured intensity of exposure using a proximity score and sleep location in relation to the TB index case and defined infection by TST ≥10u2005mm or QFT ≥0.35u2005UI·mL−1. We ascertained secondary TB cases by reviewing local and nationwide case registries. We included 160 TB index cases and 894 household contacts. 464 (65%) had TB infection and 23 (2.6%) developed TB disease. Risk of TB infection and disease increased with more intense exposures. In an adjusted analysis, the proximity score was associated with TB disease (OR 1.61, 95% CI 1.25–2.08; p<0.000); however, its diagnostic performance was only moderate. Intensity of exposure increased risk of TB infection and disease among household contacts; however, its diagnostic performance was still suboptimal. A biomarker to target preventive therapy is urgently needed in this at-risk population. More intense exposures are associated with higher risk of TB infection and disease among close contacts of TB cases http://ow.ly/PnQW30gapxK

Treatment outcomes of MDR-tuberculosis patients in Brazil: a retrospective cohort analysis

BackgroundMultidrug-resistant tuberculosis (MDR-TB) is a threat for the global TB epidemic control. Despite existing evidence that individualized treatment of MDR-TB is superior to standardized regimens, the latter are recommended in Brazil, mainly because drug-susceptibility tests (DST) are often restricted to first-line drugs in public laboratories. We compared treatment outcomes of MDR-TB patients using standardized versus individualized regimens in Brazil, a high TB-burden, low resistance setting.MethodsThe 2007–2013 cohort of the national electronic database (SITE-TB), which records all special treatments including drug-resistance, was analysed. Patients classified as MDR-TB in SITE-TB were eligible. Treatment outcomes were classified as successful (cure/treatment completed) or unsuccessful (failure/relapse/death/loss to follow-up). The odds for successful treatment according to type of regimen were controlled for demographic and clinical variables.ResultsOut of 4029 registered patients, we included 1972 recorded from 2010 to 2012, who had more complete outcome data. The overall success proportion was 60%. Success was more likely in non-HIV patients, sputum-negative at baseline, with unilateral disease and without prior DR-TB. Adjusted for these variables, those receiving standardized regimens had 2.7-fold odds of success compared to those receiving individualized treatments when failure/relapse were considered, and 1.4-fold odds of success when death was included as an unsuccessful outcome. When loss to follow-up was added, no difference between types of treatment was observed. Patients who used levofloxacin instead of ofloxacin had 1.5-fold odds of success.ConclusionIn this large cohort of MDR-TB patients with a low proportion of successful outcomes, standardized regimens had superior efficacy than individualized regimens, when adjusted for relevant variables. In addition to the limitations of any retrospective observational study, database quality hampered the analyses. Also, decision on the use of standard or individualized regimens was possibly not random, and may have introduced bias. Efforts were made to reduce classification bias and confounding. Until higher-quality evidence is produced, and DST becomes widely available in the country, our findings support the Brazilian recommendation for the use of standardized instead of individualized regimens for MDR-TB, preferably containing levofloxacin. Better quality surveillance data and DST availability across the country are necessary to improve MDR-TB control in Brazil.