The long-running issues of tuberculosis
Authors: Clemax Couto Sant'Anna, Márcia Cortez Bellotti de Oliveira
Journal: The Lancet Global Health (2021)

In their Article about unfavourable tuberculosis outcomes in a national cohort of young people in Brazil, Louisa Chenciner and colleagues1Chenciner L Sidney Annerstedt K Pescarini JM Wingfield T Social and health factors associated with unfavourable treatment outcome in adolescents and young adults with tuberculosis in Brazil: a national retrospective cohort study.Lancet Glob Health. 2021; 9: e1380-e1390Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar have identified that particular vulnerable groups (those living with HIV, young adults [aged 18–24 years], those identifying with Black or Brown skin colour, those with lower educational attainment, those with unhealthy behaviours, and those experiencing homelessness) are the groups most affected by the disease. This pattern is aligned with what has been identified in the literature about tuberculosis in endemic areas. Brazil is one of the five countries with a high tuberculosis burden (with a total incidence of 45 cases [39–52] per 100·000 inhabitants) that presents data on tuberculosis notification, WHO assessment for data quality and coverage, a national registry of mortality and vital data, and a national survey on drug-resistant tuberculosis.2WHOGlobal Tuberculosis Report.https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-report-2019Date: 2019Date accessed: August 9, 2021Google Scholar As a result, Brazil notification data is robust, and the information provided by these databases substantially assists in understanding the tuberculosis scenario under pragmatic conditions. Two important Brazilian programmes—the Brazilian Family Health Strategy and the government cash transfer—have shown to be important in tuberculosis control.3Durovni B Saraceni V Puppin MS et al.The impact of the Brazilian Family Health Strategy and the conditional cash transfer on tuberculosis treatment outcomes in Rio de Janeiro: an individual-level analysis of secondary data.J Public Health (Oxf). 2018; 40: e359-e366Crossref PubMed Scopus (12) Google Scholar However, tuberculosis results from several factors. Carter and colleagues4Carter DJ Glaziou P Lonnroth K et al.The impact of social protection and poverty elimination on global tuberculosis incidence: a statistical modelling analysis of Sustainable Development Goal 1.Lancet Glob Health. 2018; 6: e514-e522Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar estimated that, by 2035, eradicating extreme poverty (ie, by 100%) would reduce tuberculosis incidence by 33·4% and that expanding social protection (100% coverage) would reduce tuberculosis incidence by 76·1%. Both actions together would reduce tuberculosis incidence by 84·3%. Even if reducing extreme poverty by 90% and expanding social protection coverage by 50%, the contribution would still be substantial, reducing tuberculosis incidence by 52·5%. However, Chenciner and colleagues1Chenciner L Sidney Annerstedt K Pescarini JM Wingfield T Social and health factors associated with unfavourable treatment outcome in adolescents and young adults with tuberculosis in Brazil: a national retrospective cohort study.Lancet Glob Health. 2021; 9: e1380-e1390Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar observed that 10% of the young people affected by tuberculosis benefitted from government cash transfers. This observation might show that so-called universal social protection interventions might not reach those that are most affected by tuberculosis, and that specific interventions targeted to this group are desirable. Tuberculosis imposes heavy emotional effects and limitations in everyday life. Legally ensuring the right to be absent from school and work for individuals following tuberculosis diagnosis and during treatment is long overdue. In the Article by Chenciner and colleagues,1Chenciner L Sidney Annerstedt K Pescarini JM Wingfield T Social and health factors associated with unfavourable treatment outcome in adolescents and young adults with tuberculosis in Brazil: a national retrospective cohort study.Lancet Glob Health. 2021; 9: e1380-e1390Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar those deprived of liberty did not show an increased odds of unfavourable outcomes. This result might indicate that tuberculosis treatment followed under strict supervision leads to better outcomes. Although worrying, the relatively high percentage (16%) of young people who were shown to be deprived of liberty in their study reflects Brazil's violence statistics. Data from the Atlas of Violence (2020) indicates that among male adolescents aged 15–19 years old, homicides account for 59·1% of deaths.5Instituto de Pesquisa AplicadaAtlas da Violência.https://www.ipea.gov.br/atlasviolencia/arquivos/artigos/3519-atlasdaviolencia2020completo.pdfDate: 2020Date accessed: August 9, 2021Google Scholar Among deaths from causes other than tuberculosis among adolescents aged 10–18 years with tuberculosis in Rio de Janeiro, 23·8% of deaths are due to violence.6Oliveira MCB Sant'Anna CC Luiz RR Soares ECC Kritski AL Contribution of Xpert MTB/RIF to clinical diagnosis in adolescents with tuberculosis in Rio de Janeiro, Brazil.Int J Tuberc Lung Dis. 2019; 23: 1115-1121Crossref PubMed Scopus (3) Google Scholar The active contact tracing done by the Brazilian Family Health Strategy through home visits, or even the patient search for clinical visits at the health units, can be hindered in settings where violence prevails. Further, the study shows that illicit drug usage is associated with unfavourable outcomes. Thus, many aspects of social vulnerability might hamper tuberculosis control and elimination. This underlines the important alignment of the Sustainable Developmental Goals with WHO's End TB Strategy in a political level, as stated by WHO.2WHOGlobal Tuberculosis Report.https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-report-2019Date: 2019Date accessed: August 9, 2021Google Scholar Chenciner and colleagues1Chenciner L Sidney Annerstedt K Pescarini JM Wingfield T Social and health factors associated with unfavourable treatment outcome in adolescents and young adults with tuberculosis in Brazil: a national retrospective cohort study.Lancet Glob Health. 2021; 9: e1380-e1390Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar observed an association between HIV seropositivity and unfavourable outcomes, despite a HIV prevalence of 5% among the study participants. Frigati and colleagues7Frigati LJ Wilkinson KA le Roux S et al.Tuberculosis infection and disease in South African adolescents with perinatally acquired HIV on antiretroviral therapy: a cohort study.J Int AIDS Soc. 2021; 24e25671Crossref PubMed Scopus (5) Google Scholar showed the increased risk of developing tuberculosis in perinatally acquired HIV among those aged 9–14 years, even with access to antiretroviral therapy. This evidence illustrates the importance of specialised care for people living with HIV.7Frigati LJ Wilkinson KA le Roux S et al.Tuberculosis infection and disease in South African adolescents with perinatally acquired HIV on antiretroviral therapy: a cohort study.J Int AIDS Soc. 2021; 24e25671Crossref PubMed Scopus (5) Google Scholar According to the 2021 report published by the Brazilian Health Ministry,8Ministério da SaúdeSecretaria de Vigilância em SaúdeBoletim Epidemiológico Panorama epidemiológico da coinfecção TB-HIV no Brasil.http://www.aids.gov.br/pt-br/pub/2021/panorama-epidemiologico-da-coinfeccao-tb-hiv-no-brasil-2020Date: 2021Date accessed: August 3, 2021Google Scholar 51·7% of antiretroviral therapy distribution in 2019 was done during tuberculosis treatment, suggesting late HIV diagnosis. Thus, as reinforced by Chenciner and colleagues,1Chenciner L Sidney Annerstedt K Pescarini JM Wingfield T Social and health factors associated with unfavourable treatment outcome in adolescents and young adults with tuberculosis in Brazil: a national retrospective cohort study.Lancet Glob Health. 2021; 9: e1380-e1390Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar integration between tuberculosis and HIV specialised care for those affected by both diseases is of utmost importance. Moreover, this integration should not be an issue based on the extensive literature already published. The gap in the integration of services should no longer be accepted. Finally, COVID-19 elicits some questions.9Wingfield T Karmadwala F MacPherson P et al.Challenges and opportunities to end tuberculosis in the COVID-19 era.Lancet Respir Med. 2021; 9: 556-558Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar We are approaching the second year of the COVID-19 pandemic, and already more than five vaccines have been developed. Yet, the long-running disease tuberculosis only has the Bacille Calmette–Guérin vaccine. This actuality is emblematic of the tuberculosis situation worldwide. CCS is supported by the Brazilian Council for Research and Technological Development (grant number 302973/2019-2). MCBdO declares no competing interests. Social and health factors associated with unfavourable treatment outcome in adolescents and young adults with tuberculosis in Brazil: a national retrospective cohort studyIn this national cohort of young people with tuberculosis in Brazil, tuberculosis treatment success rates were lower than WHO End TB Strategy targets, with almost a fifth of participants experiencing unfavourable treatment outcomes. Homelessness, HIV, and illicit drug use were the main factors associated with unfavourable outcome. In Brazil, strategies are required to support this underserved group to ensure favourable tuberculosis treatment outcomes. Full-Text PDF Open Access