Tuberculosis Burden and Determinants of Treatment Outcomes According to Age in Brazil: A Nationwide Study of 896,314 Cases Reported Between 2010 and 2019

Abstract

Approximately 1.4 million people die annually worldwide from tuberculosis. Large epidemiologic studies can identify determinants of unfavorable clinical outcomes according to age, which can guide public health policy implementation and clinical management to improve outcomes. We obtained data from the national tuberculosis case registry; data were reported to the Brazilian National Program (SINAN) between 2010 and 2019. Clinical and epidemiologic variables were compared between age groups (child: <10 years, young: 10-24years, adult: 25-64years, and elderly: ≥65years). Univariate comparisons were performed together with second-generation p-values. We applied a backward stepwise multivariable logistic regression model to identify characteristics in each age group associated with unfavorable TB treatment outcomes. There were 896,314 tuberculosis cases reported during the period. Tuberculosis incidence was highest among adult males, but the young males presented the highest growth rate during the period. Directly observed therapy (DOT) was associated with protection against unfavorable outcomes in all age groups. The use of alcohol, illicit drugs, and smoking, as well as occurrence of comorbidities, were significantly different between age groups. Lack of DOT, previous tuberculosis, race, location of tuberculosis disease, and HIV infection were independent risk factors for unfavorable outcome depending on the age group. The clinical and epidemiological risk factors for unfavorable tuberculosis treatment outcomes varied according to age in Brazil. DOT was associated with improved outcomes in all age groups. Incidence according to age and sex identified adults and young males as the groups that need prevention efforts. This supports implementation of DOT in all populations to improve tuberculosis outcomes.

Keywords: age; extrapulmonary TB; outcomes; pulmonary TB; tuberculosis.

Figure 1

General population TB rates by sex (A) and age group (B) between 2010 and 2019. Mann–Kendal trend test was used to calculate changes in incidence among years. According to sex and/or age group, on panel (A), it is possible to observe that there was a small decrease in the incidence of women with tuberculosis (purple). In age stratification (B), only the incidence in children has not changed over the years. Age Groups: Children (0–9.9 years); young (10–24.9 years); Adults (25–64.9 years); Elderly (≥65 years).

Figure 2

Characteristics of each age group (A–C) and outcome category (D–F). (A) Consumption habits, we observed that young people and adults have greater consumption habits of alcohol, cigarettes, and illegal drugs than children and the elderly. (B) Comorbidities, while adults have a higher prevalence of HIV. The elderly has a higher prevalence of diabetes and hypertension. (C) Outcome description. The frequency of favorable outcome (cure) decreases according to age, being higher in children and lower in the elderly. (D) HIV status. Positive serology for HIV infection is correlated with an unfavorable treatment outcome in young, adults, and elderly. (E) TB Status. Relapse cases of TB are correlated with an unfavorable treatment outcome in young and adults. (F) Observed Treatment. In all age groups, receive a DOT is correlated with a favorable treatment outcome. Age Groups: Children (0–9.9 years); young (10–24.9 years); Adults (25–64.9 years); Elderly(≥65 years).

Figure 3

Backward stepwise logistic regression model test independent associations between all the relevant clinical and epidemiological parameters and treatment outcome in children (0–9 years). The unfavorable outcome was used as reference to test associations. Only parameters which remained with p < 0.05 in in the adjusted model (95%CI: 95% confidence interval) were plotted. Adjustment was performed for each parameter: race (reference: indigenous); male (reference: female); illiterate(reference: literate); prior TB (reference: new case); no DOT (reference: Received DOT).Pulmonary TB (reference: Pulmonary and Extrapulmonary TB); Extrapulmonary TB (Reference: Pulmonary and Extrapulmonary TB); Pulmonary and Extrapulmonary TB (reference: Pulmonary TB); HIV infection (reference: without HIV infection); Alcohol Consumption (reference: no alcohol consumption); Diabetes (reference: no diabetes); Illicit drug use (reference: no illicit drug use); Smoking habit (reference: no smoking). Cancer (reference: no condition); COPD (reference: no condition); Kidney disease (reference: no condition); Hypertension (reference: no condition); Other comorbidities (reference: no condition); Abnormal chest X-ray (reference: normal chest X-ray). TB, tuberculosis; DOT, directly observed treatment; COPD, chronic obstructive pulmonary disease.

Figure 4

Backward stepwise logistic regression model test independent associations between all the relevant clinical and epidemiological parameters and treatment outcome in young group (10–24 years). The unfavorable outcome was used as reference to test associations. Only parameters which remained with p < 0.05 in in the adjusted model (95%CI: 95% confidence interval) were plotted. Adjustment was performed for each parameter: race (reference: indigenous); male (reference: female); illiterate (reference: literate); prior TB (reference: new case); no DOT (reference: Received DOT). Pulmonary TB (reference: Pulmonary and Extrapulmonary TB); Extrapulmonary TB (Reference: Pulmonary and Extrapulmonary TB); Pulmonary and Extrapulmonary TB (reference: Pulmonary TB); HIV infection (reference: without HIV infection); Alcohol consumption (reference: no alcohol consumption); Diabetes (reference: no diabetes); Illicit drug use (reference: no illicit drug use); Smoking habit (reference: no smoking). Cancer (reference: no condition); COPD (reference: no condition); Kidney disease (reference: no condition); Hypertension (reference: no condition); Other comorbidities (reference: no condition); Abnormal chest X-ray (reference: normal chest X-ray). TB, tuberculosis; DOT, directly observed treatment; COPD, chronic obstructive pulmonary disease; Other comorbidities, did not include HAS, kidney disease, cancer, and COPD.

Figure 5

Backward stepwise logistic regression model test independent associations between all the relevant clinical and epidemiological parameters and treatment outcome in adult group (25–64). The unfavorable outcome was used as reference to test associations. Only parameters which remained with p < 0.05 in in the adjusted model (95%CI: 95% confidence interval) were plotted. Adjustment was performed for each parameter: race (reference: indigenous); male (reference: female); illiterate(reference: literate); prior TB (reference: new case); no DOT (reference: DOT indication).Pulmonary TB (reference: Pulmonary and Extrapulmonary TB); Extrapulmonary TB (Reference: Pulmonary and Extrapulmonary TB); Pulmonary and Extrapulmonary TB (reference: Pulmonary TB); HIV infection (reference: without HIV infection); Alcohol Consumption (reference: no alcohol consumption); Diabetes (reference: no diabetes); Illicit drug use (reference: no illicit drug use); Smoking habit (reference: no smoking). Cancer (reference: no condition); COPD (reference: no condition); Kidney disease (reference: no condition); Hypertension (reference: no condition); Other comorbidities (reference: no condition); Abnormal chest X-ray (reference: normal chest X-ray). TB, tuberculosis; DOT, directly observed treatment; COPD, chronic obstructive pulmonary disease.

Figure 6

Backward stepwise logistic regression model test independent associations between all the relevant clinical and epidemiological parameters and treatment outcome in elderly group (≥65 years). The unfavorable outcome was used as reference to test associations. Only parameters which remained with p < 0.05 in in the adjusted model (95%CI: 95% confidence interval) were plotted. Adjustment was performed for each parameter: race (reference: indigenous); male (reference: female); illiterate(reference: literate); prior TB (reference: new case); no DOT (reference: DOT indication); Pulmonary TB (reference: Pulmonary and Extrapulmonary TB); Extrapulmonary TB (Reference: Pulmonary and Extrapulmonary TB); Pulmonary and Extrapulmonary TB (reference: Pulmonary TB); HIV infection (reference: without HIV infection); Alcohol Consumption (reference: no alcohol consumption); Diabetes (reference: no diabetes); Illicit drug use (reference: no illicit drug use); Smoking habit (reference: no smoking). Cancer (reference: no condition); COPD (reference: no condition); Kidney disease (reference: no condition); Hypertension (reference: no condition); Other comorbidities (reference: no condition); Abnormal chest X-ray (reference: normal chest X-ray). TB, tuberculosis; DOT, directly observed treatment; COPD, chronic obstructive pulmonary disease; Other comorbidities: It did not include HAS, kidney disease, cancer, and COPD.