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BackgroundThe COVID-19 pandemic notably impacted tuberculosis notification and detection in Brazil. We estimated the number of unnotified tuberculosis cases by group population over the first two years (2020-2021) of the pandemic.MethodsWe extracted tuberculosis case notifications from routine national surveillance records and population from Ministry of Health. We estimated trends for case notification during pre-pandemic period (2015–2019), stratified by sex, age group, and State with a mixed-effects model. We calculated the unnotified cases during 2020-2021 as the difference between expected, and reported values.ResultsWe estimated 11647 (95% uncertain interval [95%UI]: 829,22466) unnotified cases for 2020; and, 6170 (95%UI: -4629,16968) for 2021; amounting 17817 unnotified cases over the two years. Of the estimated expected tuberculosis cases in 2020 and 2021, 11.2% were not notified. Across sex and age, men aged 30-59 years had the highest number of unnotified cases, and men aged 0-14 years had the highest proportion of unnotified cases. Case underreporting was significant for 13 (of the 27 States) in 2020, and for four in 2021.ConclusionsTuberculosis cases notification decreased substantially during the COVID-19 pandemic in Brazil. Our analysis helped identify the most affected populations to plan strategies to mitigate the effects of the pandemic on tuberculosis control.Research in contextEvidence before this studyA systematic review was conducted to retrieve studies that aimed the impact of the COVID-19 pandemic on tuberculosis detection in PubMed with the following terms: “(TB or tuberculosis) and (incidence or case or notification or burden) and (COVID-19 or pandemic)” from January 2020 to May 2022, returning 189 records. Out of these studies, we analyzed 17 that reported a decrease in tuberculosis notification during the pandemic years, and most of them with data only from the first year of the pandemic. Two studies were carried out with Brazilian data. One of them focused on the number of tuberculosis consultations at the benning of the pandemic, and the other was a government bulletin describing tuberculosis notification. As far as we know, no study has examined the tuberculosis case notification in Brazil during the two years of the pandemic, by group population. Furthermore, none of them had predicted the expected cases considering local trends in both the incidence of tuberculosis and its main determinants.Added value of this studyUsing tuberculosis case reports from routine national surveillance registries, we estimated case notification trends during the pre-pandemic period (2015–2019), stratified by sex, age group, and State and calculated the unnotified cases during 2020-2021. Brazil lost 11647 (95% uncertain interval [95%UI]: 829,22466) tuberculosis cases in 2020; and, 6170 (95%UI: - 4629,16968) in 2021, which represents 11.2% of underreporting in both years. Across sex and age, men aged 30 to 59 years had the highest number of unnotified cases, and men aged 0 to 14 years had the highest proportion of unnotified cases. Case underreporting was significant for 13 (of the 27 States) in 2020, and for four in 2021.Implications of all the available evidenceThe COVID-19 pandemic had a catastrophic effect in tuberculosis notification in Brazil during 2020 and 2021. This resulted in a setback in progress made over decades in tuberculosis control, and highlight the threat posed by tuberculosis transmission. Several lessons learned from response to COVID-19 provide an opportunity to improve the notification of respiratory diseases.

Resumo: O objetivo do trabalho foi avaliar a cobertura e a confiabilidade do encerramento dos casos de tuberculose drogarresistente (TB DR), do Sistema de Informação de Tratamentos Especiais de Tuberculose (SITE-TB), que ocorreram no Brasil no período de 2013 a 2016, a partir de relacionamentos probabilísticos com o Sistema de Informação de Agravos de Notificação (SINAN), Gerenciador de Ambiente Laboratorial (GAL) e Sistema de Informações sobre Mortalidade (SIM). Os casos de TB DR com início de tratamento entre 2013 e 2016 no Brasil constituíram a população do estudo. O relacionamento com o SINAN avaliou a cobertura e estimou a subnotificação dos casos de TB DR. Aplicou-se o método de captura-recaptura, com uso do estimador de Chapman. O relacionamento com o GAL identificou casos diagnosticados pelo laboratório que não estavam notificados no SITE-TB. O relacionamento com o SIM avaliou a confiabilidade do encerramento óbito no SITE-TB, utilizando o coeficiente kappa. Estimou-se uma população de 2.945 (IC95%: 2.365-3.602) casos novos de TB DR com o estimador de Chapman. No GAL, foram encontrados 1.626 indivíduos não notificados no SITE-TB, mesmo com exame laboratorial confirmatório de resistência aos medicamentos antiTB. Classificou-se como excelente, PABAK (prevalance and bias adjusted kappa) de 0,86 (IC95%: 0,85-0,87), a concordância entre o desfecho óbito do SITE-TB e o SIM. Os resultados mostraram que ainda temos lacunas relacionadas ao diagnóstico e ao tratamento da TB DR no Brasil. A subnotificação no SITE-TB de casos de TB DR representa um desafio para o controle da doença. A localização desses indivíduos e o início precoce do tratamento devem constituir uma ação priorizada nos serviços de saúde. Abstract: The study aimed to assess the coverage and reliability of drug-resistant tuberculosis (DR-TB) case closure in the Information System on Special Treatments for Tuberculosis (SITE-TB in Portuguese) in Brazil from 2013 to 2016, based on probabilistic linkage with the Information System on Diseases of Notification (SINAN), Laboratory Environment Manager (GAL), and Mortality Information System (SIM). The study population consisted of DR-TB cases that initiated treatment from 2013 to 2016 in Brazil. Linkage with SINAN assessed the coverage and estimated underreporting of DR-TB cases. The capture-recapture method was applied, using the Chapman estimator. Linkage with GAL identified cases diagnosed by the laboratory that had not been reported to SITE-TB. Linkage with SIM assessed the reliability of case closure by death in SITE-TB, using the kappa coefficient. We estimated a population of 2,945 (95%CI: 2,365-3,602) new cases of DR-TB with the Chapman estimator. We located 1,626 individuals in the GAL database that had not been reported to SITE-TB, even with laboratory confirmation of drug resistance. PABAK (prevalance and bias adjusted kappa) of 0.86 (95%CI: 0.85-0.87) was classified as excellent for the agreement in death as the outcome between the SITE-TB and SIM databases. The results pointed to persistent gaps related to diagnosis and treatment of DR-TB in Brazil. Underreporting of DR-TB cases in the SITE-TB database poses a challenge for TB control. Identification of these individuals and early start of treatment should be prioritized in health services. Resumen: El objetivo de este trabajo fue evaluar la cobertura y fiabilidad del cierre de casos de tuberculosis resistente a multiple medicamentos (TB DR; por sus siglas en portugués) en el Sistema de Información de Tratamientos Especiales de Tuberculosis (SITE-TB), que se produjeron en Brasil durante el período de 2013 a 2016, a partir de relaciones probabilísticas con el Sistema de Información de Enfermedades de Notificación (SINAN por sus siglas en portugués), Gestor de Ambiente de Laboratorio (GAL) y Sistema de Información sobre Mortalidad (SIM). La población del estudio fueron los casos de TB DR con inicio de tratamiento entre 2013 y 2016 en Brasil. La relación con el SINAN evaluó la cobertura y estimó la subnotificación de los casos de TB DR. Se aplicó el método de captura-recaptura, utilizando el estimador de Chapman. La relación con el GAL identificó casos diagnosticados por el laboratorio que no estaban notificados en el SITE-TB. La relación con el SIM evaluó la fiabilidad del cierre óbito en el SITE-TB, utilizando el coeficiente kappa. Se estimó que para una población de 2.945 (IC95%: 2.365-3.602) casos nuevos de TB DR con el estimador de Chapman. Se encontraron en el GAL a 1.626 individuos no notificados en el SITE-TB, incluso con examen de laboratorio confirmatorio de resistencia a los medicamentos antiTB. Se clasificó como excelente, PABAK (prevalance and bias adjusted kappa) de 0,86 (IC95%: 0,85-0,87), la concordancia entre el resultado óbito del SITE-TB y el SIM. Los resultados mostraron que todavía existen lagunas relacionadas con el diagnóstico y el tratamiento de la TB DR en Brasil. La subnotificación en el SITE-TB de casos de TB DR representa un desafío para el control de la enfermedad. La localización de esos individuos y el inicio precoz del tratamiento debe ser una acción priorizada en los servicios de salud.

The study aimed to assess the coverage and reliability of drug-resistant tuberculosis (DR-TB) case closure in the Information System on Special Treatments for Tuberculosis (SITE-TB in Portuguese) in Brazil from 2013 to 2016, based on probabilistic linkage with the Information System on Diseases of Notification (SINAN), Laboratory Environment Manager (GAL), and Mortality Information System (SIM). The study population consisted of DR-TB cases that initiated treatment from 2013 to 2016 in Brazil. Linkage with SINAN assessed the coverage and estimated underreporting of DR-TB cases. The capture-recapture method was applied, using the Chapman estimator. Linkage with GAL identified cases diagnosed by the laboratory that had not been reported to SITE-TB. Linkage with SIM assessed the reliability of case closure by death in SITE-TB, using the kappa coefficient. We estimated a population of 2,945 (95%CI: 2,365-3,602) new cases of DR-TB with the Chapman estimator. We located 1,626 individuals in the GAL database that had not been reported to SITE-TB, even with laboratory confirmation of drug resistance. PABAK (prevalance and bias adjusted kappa) of 0.86 (95%CI: 0.85-0.87) was classified as excellent for the agreement in death as the outcome between the SITE-TB and SIM databases. The results pointed to persistent gaps related to diagnosis and treatment of DR-TB in Brazil. Underreporting of DR-TB cases in the SITE-TB database poses a challenge for TB control. Identification of these individuals and early start of treatment should be prioritized in health services.

Dissertação (mestrado)—Universidade de Brasília, Faculdade de Medicina, Núcleo de Medicina Tropical, 2015. Ainda que com o advento da terapia antorretroviral a tuberculose continua como a principal causa de óbito por doença infecciosa definida entre as pessoas que vivem com HIV/aids. O objetivo desse trabalho foi verificar os fatores associados ao óbito na coinfecção TB-HIV no Brasil no ano de 2011. Foi realizado um estudo do tipo caso controle, com análise por regressão logística multivariada. A fonte de dados para os casos de tuberculose foi o Sinan TB. Com o objetivo de qualificar os dados, o Sinan TB foi relacionado com o Sinan Aids, Siscel e Siclom. Para verificação dos óbitos foi realizado o relacionamento com o SIM. Nos resultados, demonstrou-se que os fatores de risco para o óbito foram: idade >50 anos (OR=2,48; IC95% 1,01 a 6,08), uso de álcool (OR=1,84; IC95% 1,45 a 2,34) e forma clínica da TB (pulmonar e extrapulmonar) (OR=1,85; IC95% 1,36 a 2,52). Os fatores observados como proteção foram: a realização do LT-CD4+ (OR=0,68; IC95% 0,54 a 0,86), estar em TARV (OR=0,50; IC95%0,39 a 063) e estar em TDO (OR=0,69; IC95% 0,39 a 0,63). Os resultados demonstram uma situação de alerta em relação a coinfecção TB-HIV no Brasil, apesar dos avanços na estruturação da assistência à saúde no país, o acesso a um seguimento da coinfecção TB-HIV integral ainda é limitado, o que favorece a alta mortalidade nessa população. Há necessidade de revisão das estratégias nacionais, com priorização da coinfecção TB-HIV pelos programas de tuberculose e de HIV/Aids, matriciamento da assistência de tal modo que profissionais capacitados façam o diagnóstico oportuno da tuberculose e do HIV, além do início em tempo adequado do tratamento antirretroviral. Even with the advent of antiretroviral therapy, tuberculosis still remains the main cause of death from infectious disease among people living with HIV / AIDS. The purpose of this study was to verify the associated factors with TB and HIV co-infection deaths in Brazil in 2011. A case-control study was conducted through multivariate logistic regression analysis. The Information System for Notifiable Diseases (Sinan) was the data source for TB cases, and for data qualification other databases from the Ministry of Health were used, such as: laboratory (Siscel), antiretroviral (Siclom) and Sinan AIDS databases, and from the Mortality Information System (SIM). The results were considered risk factors for mortality: age> 50 years (OR=2.48; IC95% 1.01 to 6.08), alcohol use (OR=1.84; IC95% 1.45 to 2.34) and clinical form of pulmonary and extrapulmonary TB (OR=1.85; IC95% 1.36 to 2.52). Factors considered protection were the LT-CD4+ conducted (OR=0.68; IC95% 0.54 to 0.86), being on ART (OR=0.50; IC95%0.39 a 0.63) and be in DOT (OR=0.69; IC95% 0.39 a 0.63). The results describe an alarm situation related to TB/HIV co-infection in Brazil. Despite the progresses related to the structure reform in the health care services in the country, access to TB/HIV integral follow up is still limited, which favors high mortality rates among this population. There is an evident need for national strategies updates regarding recognizing the importance of TB/HIV co-infection to both diseases programmes (TB and HIV/AIDS). The organization of assistance so that trained providers are able to early diagnose TB and HIV, in addition to timely starting antiretroviral treatment.