ABSTRACT Diabetes mellitus (DM) has important implications for tuberculosis (TB), as it increases the risk for disease activation and is associated with unfavorable TB treatment outcomes. This study analyzed the association between TB and DM (TBDM) in Brazil from 2007 to 2014. This was a retrospective cohort study carried out in 709,429 new cases of TB reported to the national disease notification system of the Brazilian Ministry of Health. Sociodemographic and clinical data, test results, and treatment outcomes were analyzed. TBDM was found in 6.0% of TB cases, mostly in men aged 18-59 years. The lethality rate was 5.1% higher in all age groups with diabetes, except in those older than 60 years of age. The frequency of multi-drug-resistant tuberculosis (MDR-TB) in patients with DM was higher in those without DM, with a 1.6- to 3.8-fold increase in the odds of MDR-TB. The elderly showed an increase in the prevalence of TBDM from 14.3% to 18.2%. Women were more likely to have DM, and elderly women had 41.0% greater chance of having DM. Relapse was significant among patients younger than 17 years of age. TBDM was high in Brazil, affected all age groups, and was associated with unfavorable TB treatment outcomes. We emphasize the need for strategies for the clinical management of diabetic tuberculosis patients in Brazil aiming at minimizing relapses, deaths, and MDR-TB.

Abstract INTRODUCTION: High endemic levels of pulmonary tuberculosis in prisons result from overcrowding, limited access to healthcare, delayed diagnosis, sustained transmission owing to poor control measures, and multidrug resistance. This study evaluated locally implemented measures for early pulmonary tuberculosis diagnosis and evaluated resistance to anti-tuberculosis drugs. METHODS: This transversal study employed data from the Mato Grosso do Sul State Tuberculosis Control Program obtained from 35 correctional facilities in 16 counties for 2 periods (2007-2010 and 2011-2014). RESULTS: Statewide prevalence (per 100,000) was 480.0 in 2007 and 972.9 in 2014. The following indicators showed improvement: alcohol-acid-fast bacillus testing (from 82.7% to 92.9%); cultures performed (55.0% to 81.8%); drug susceptibility testing of positive cultures (71.6% to 62.4%); and overall drug susceptibility testing coverage (36.6% to 47.4%). Primary and acquired resistance rates for 2007-2014 were 21.1% and 30.0%, respectively. Primary and acquired multidrug resistance rates were 0.3% and 1.3%, respectively. CONCLUSIONS: Prevalence rates increased, and laboratory indicators improved as a result of capacity building and coordination of technical teams and other individuals providing healthcare to inmates. Resistance rates were high, thereby negatively affecting disease control.

Abstract Introduction: Despite the high rate of tuberculosis indicators in Brazil, the Federal District shows a low prevalence of the disease. Objective: To analyze the relationship between climatic factors and air quality with tuberculosis in the Brazilian Federal District. Methodology: This was an ecological and descriptive study comparing 3927 new cases of Tuberculosis registered at the Federal District Tuberculosis Control Program with data from the National Institute of Meteorology, Brazilian Institute of Geography and Statistics, Brazilian Agricultural Research Institute, Brasilia Environmental Institute, and the Federal District Planning Company. Results: From 2003 to 2012, there has been a higher incidence of Tuberculosis (27.0%) in male patients in the winter (27.2%). Patients under 15 years of age (28.6%) and older than 64 years (27.1%) were more affected in the fall. For youth and adults (15-64 years), the highest number of cases was reported during winter (44.3%). The disease was prevalent with ultraviolet radiation over 17 MJ/m2 (67.8%; p = <0.001); relative humidity between 31.0% and 69.0% (95.8% of cases; p = <0.00); 12 h of daily sunlight or more (40.6%; p = 0.001); and temperatures between 20 °C and 23 °C (72.4%; p = <0.001). In the city of Taguatinga and surrounding area, pollution levels dropped to 15.2% between 2003 and 2012. Smoke levels decreased to 31.9%. In the Sobradinho region, particulate matter dropped to 13.1% and smoke to 19.3%, coinciding with the reduction of Tuberculosis incidence rates during the same period. Conclusion: The results should guide surveillance actions for Tuberculosis control and elimination and indicate the need to expand observation time to new climate indicators and air quality.

RESUMO Objetivo Estimar as taxas de resistência às drogas entre casos de tuberculose pulmonar (TBP) para o estado de Mato Grosso do Sul, Brasil, e especificamente para a região da fronteira com Paraguai e Bolívia, além de identificar fatores de risco associados. Métodos O presente estudo epidemiológico, transversal, enfocou os casos de TBP registrados de janeiro de 2007 a dezembro de 2010 no Sistema de Informação de Agravos de Notificação da Secretaria de Estado de Saúde com resultados do teste de suscetibilidade a rifampicina, isoniazida, etambutol e estreptomicina. Definiram-se como variáveis dependentes o desenvolvimento de resistência a uma única droga e a qualquer combinação de drogas. As variáveis independentes foram ser caso novo ou tratado, residência em região de fronteira ou outra região, presença ou ausência de diabetes e história de alcoolismo. Resultados Foram identificados 789 casos de TBP com teste de suscetibilidade. As características associadas à resistência foram: caso tratado (P=0,0001), região de fronteira (P=0,0142), alcoolismo (P=0,0451) e diabetes (P=0,0708). As taxas de resistência combinada, primária e adquirida no estado foram de 16,3%, 10,6% e 39,0%, e na fronteira, de 22,3%, 19,2% e 37,5%. As taxas de resistência a múltiplas drogas combinada, primária e adquirida no estado foram de 1,8%, 0,6% e 6,3%, e na fronteira, de 3,1%, 1,2% e 12,5%. Conclusões O estado deve, na região de fronteira, realizar cultura em todos os sintomáticos respiratórios, investigar o padrão de resistência nos casos confirmados, adotar o tratamento diretamente observado nos casos de TBP e desencadear ações de saúde conjuntas com os países fronteiriços. Em todo o estado, é necessário monitorar os níveis de resistência adquirida, ampliar a investigação de resistência para todos os casos tratados e adotar o tratamento diretamente observado prioritariamente entre pacientes com alcoolismo e diabetes.

ABSTRACT Objective To estimate the rate of drug resistance among pulmonary tuberculosis (PTB) cases in the state of Mato Grosso do Sul, Brazil, and specifically in the border areas with Paraguay and Bolivia, as well as to identify associated risk factors. Method The present cross-sectional, epidemiological study focused on PTB cases recorded between January 2007 and December 2010 in the State Reportable Disease Information System with results of susceptibility tests to rifampicin, isoniazid, ethambutol, and streptomycin. Dependent variables were development of resistance to a single drug or any combination of drugs. Independent variables were being a new or treated case, living in border areas, presence/absence of diabetes, and history of alcoholism. Results There were 789 TBP cases with susceptibility testing. The following characteristics were associated with resistance: treated case (P = 0.0001), border region (P = 0.0142), alcoholism (P = 0.0451), and diabetes (P = 0.0708). The rates of combined, primary, and acquired resistance for the state were 16.3%, 10.6%, and 39.0%, vs. 22.3%, 19.2%, and 37.5% for the border region. The rates of combined, primary, and acquired multidrug resistance for the state were 1.8%, 0.6%, and 6.3%, vs. 3.1%, 1.2%, and 12.5% for the border region. Conclusions In the border region, the state should investigate drug resistance in all patients with respiratory symptoms, determine the pattern of resistance in confirmed cases, adopt directly observed treatment for cases of PTB, and develop health actions together with neighboring countries. Across the state, the levels of acquired resistance should be monitored, with investigation of resistance in all treated cases and implementation of directly observed treatment especially among patients with diabetes or alcoholism.

With the aim of identifying the etiology of acute febrile illness in patients suspected of having dengue, yet with non reagent serum, a descriptive study was conducted with 144 people using secondary serum samples collected during convalescence. The study was conducted between January and May of 2008. All the exams were re-tested for dengue, which was confirmed in 11.8% (n = 17); the samples that remained negative for dengue (n = 127) were tested for rubella, with 3.9% (n = 5) positive results. Among those non reactive for rubella (n = 122), tests were made for leptospirosis and hantavirus. Positive tests for leptospirosis were 13.9% (n = 17) and none for hantavirus. Non reactive results (70.8%) were considered as Indefinite Febrile Illness (IFI). Low schooling was statistically associated with dengue, rubella and leptospirosis (p = 0.009), dyspnea was statistically associated with dengue and leptospirosis (p = 0.012), and exanthem/petechia with dengue and rubella (p = 0.001). Among those with leptospirosis, activities in empty or vacant lots showed statistical association with the disease (p = 0.013). Syndromic surveillance was shown to be an important tool in the etiologic identification of IFI in the Federal District of Brazil.

Com o objetivo de identificar a etiologia de doenças febris agudas, em suspeitos de dengue com sorologia não reagente, realizou-se estudo descritivo com 144 pessoas utilizando amostras de soro coletados na convalescença, entre janeiro e março de 2008. Todos os exames foram re-testados para dengue, sendo as amostras negativas, processadas para rubéola (n = 127). Dentre as não reagentes para rubéola, submeteu-se ao teste para leptospirose (n = 122), e em se permanecendo sem diagnóstico, testou-se para hantavirose. Confirmou-se dengue em 11,8% (n = 17), rubéola em 3,9% (n = 5) e leptospirose em 13,9% (n = 17). Os resultados não reagentes foram considerados como doença febril aguda indiferenciada (DFI) em 70.8% dos casos. Verificou-se associação estatística em baixa escolaridade nos casos de dengue, rubéola e leptospirose (p = 0,009), assim como dispnéia para dengue e leptospirose (p = 0,012), e exantema/petéquias para dengue e rubéola (p = 0,001). Dentre os doentes com leptospirose, as atividades em terreno baldio mostraram-se com diferença estatística significante (p = 0,013). A vigilância sindrômica demonstrou-se como importante ferramenta na identificação de doenças febris agudas no Distrito Federal.

This article analyzes the history of primary health care policy in the Federal District, Brazil, based on the theoretical framework of historical neo-institutionalism, identifying the predominant configurations and trends in the various administrations of the State Health Secretariat (SES-DF) from 1960 to 2007. The study indicates that the characteristics of the Federal District's health policy are dependent on the history of the original health system plans for setting priorities and goals, as well as for the health system's implementation. This influence, in addition to the centralization of decision-making processes and limited political participation, can contribute to making primary care ancillary to hospital care, thus jeopardizing its potential to produce change in the health care model.

Este artigo analisa a trajetória da política de atenção básica à saúde no Distrito Federal, Brasil, a partir do marco teórico do neo-institucionalismo histórico, identificando as conformações e as tendências predominantes nas gestões da Secretaria de Estado da Saúde (SES-DF) no período de 1960 a 2007. O estudo sinaliza que a política de saúde do Distrito Federal apresenta características de dependência da trajetória dos planos de saúde originais na definição de prioridades e metas, bem como na implementação do sistema de saúde. Essa influência, agregada à centralização dos processos decisórios e à limitada participação política, pode contribuir para situar a atenção básica como acessória ao atendimento hospitalar, destituindo-a do seu potencial de produzir mudança no modelo assistencial.

Este artigo analisa a trajetória da política de atenção básica à saúde no Distrito Federal, Brasil, a partir do marco teórico do neo-institucionalismo histórico, identificando as conformações e as tendências predominantes nas gestões da Secretaria de Estado da Saúde (SES-DF) no período de 1960 a 2007. O estudo sinaliza que a política de saúde do Distrito Federal apresenta características de dependência da trajetória dos planos de saúde originais na definição de prioridades e metas, bem como na implementação do sistema de saúde. Essa influência, agregada à centralização dos processos decisórios e à limitada participação política, pode contribuir para situar a atenção básica como acessória ao atendimento hospitalar, destituindo-a do seu potencial de produzir mudança no modelo assistencial.

This article analyzes the history of primary health care policy in the Federal District, Brazil, based on the theoretical framework of historical neo-institutionalism, identifying the predominant configurations and trends in the various administrations of the State Health Secretariat (SES-DF) from 1960 to 2007. The study indicates that the characteristics of the Federal District's health policy are dependent on the history of the original health system plans for setting priorities and goals, as well as for the health system's implementation. This influence, in addition to the centralization of decision-making processes and limited political participation, can contribute to making primary care ancillary to hospital care, thus jeopardizing its potential to produce change in the health care model.

In order to estimate the incidence of and risk factors for developing tuberculosis, the clinical charts of a retrospective cohort of 281 HIV-positive adults, who were notified to the AIDS Program of the Health Department of Brasilia in 1998, were reviewed in 2003. All the patients were treatment-naive regarding antiretroviral therapy at the time of inclusion in the cohort. Twenty-nine patients were identified as having tuberculosis at the start of the study. Thirteen incident tuberculosis cases were identified during the 60 months of follow-up, with an incidence density rate of 1.24/100 person-years. Tuberculosis incidence was highest among patients with baseline CD4+ T-lymphocyte counts < 200 cells/µl who were not using antiretroviral therapy (incidence = 5.47; 95% CI = 2.73 to 10.94). Multivariate analysis showed that baseline CD4+ T-lymphocyte counts < 200 cells/µl (adjusted hazard ratio [AHR] = 5.09; 95% CI = 1.27 to 20.37; p = 0.02) and non-use of antiretroviral therapy (AHR = 12.17; 95% CI = 2.6 to 56.90; p = 0.001) were independently associated with increased risk of tuberculosis.

Para estimar a incidência e os fatores de risco para desenvolver tuberculose foram revisados em 2003 os < prontuários de uma coorte retrospectiva de 281 adultos infectados pelo HIV que foram notificados ao Programa de Aids da Secretaria de Saúde de Brasília em 1998. Todos os pacientes eram virgens de tratamento anti-retroviral no momento da inclusão na coorte. Vinte e nove pacientes foram identificados com tuberculose na avaliação basal. Treze casos incidentes de tuberculose foram identificados durante os 60 meses de seguimento com densidade de incidência de 1,24/100 pessoas-ano. A incidência de tuberculose foi maior em pacientes com contagens basal de linfócitos T CD4+ < 200 células/µl que não se encontravam em uso de terapia anti-retroviral 5,47 (IC95%=2,73 a 10,94). A análise multivariada demonstrou que a contagem basal de linfócitos T CD4+ < 200 células/µl (adjusted hazard ratio [AHR] =5,09; IC95%=1,27 to 20,37; p =0,02) e o não uso de terapia anti-retroviral (AHR=12,17; IC95%=2,6 to 56,90; p=0,001) estiveram independentemente associados a um risco maior de tuberculose.

The detection rate of leprosy in the district of Paracatu is high in the age group under 15 years-old, including about 6.8/10,000 inhabitants in 2003, and classified as hyperendemic. The study aimed to analyze the application of the PGL-1 (ML Flow) serological test in 56 of 68 school-age patients of the public school system, diagnosed with leprosy through active case finding in Paracatu, Minas Gerais State (2004 to 2006), with 71% classified as paucibacillary. Of these, 85.2% lived in urban areas, 55.8% were female and the disease was predominant in the 10 to 14 year-old age group (95%CI: 0.49-0.89; c²=7.373), with 15 (26.7%) presenting a positive ML Flow result. Five patients showed grade 1 disabilities in the borderline clinical form (40% ML Flow positive). The percentage of leprosy cases among household contacts was 46.4%, 44.9% presenting positive ML Flow test results. The study suggests incorporating the ML Flow test into the health services, since it assists in the operational classification of the disease and in the control of household contacts with positive test results, aimed at early detection of suspected leprosy cases.

A detecção da hanseníase no município de Paracatu é elevada em menores de quinze anos, abrangendo cerca de 6,8/10.000 hab. em 2003 e é classificada como hiperendêmica. O estudo objetiva analisar a aplicação do teste sorológico do PGL-1 (ML Flow) em 56 de 68 pacientes escolares da rede pública, diagnosticados com hanseníase através da busca ativa de casos no município de Paracatu - MG (2004 a 2006), sendo 71%, paucibacilares. Cerca de 85,2% dos pacientes residiam na área urbana, 55,8% eram do sexo feminino e a doença predominava no grupo de 10 a 14 anos (IC95%:0,49-0,89%) e χ²=7,376, sendo que 15 (26,7%) com resultado do ML Flow positivo. Cinco pacientes tinham incapacidades do Grau 1, da forma clínica Dimorfa (40% ML Flow positivo). O percentual de casos de hanseníase entre os contatos intradomiciliares foi de 46,4%, sendo que 44,9% deles com resultado do teste do ML Flow positivo. O estudo sugere incorporar o teste ML Flow nos serviços de saúde, uma vez que o mesmo auxilia na classificação operacional da doença, controle de contatos intradomiciliares com resultado do teste positivo, visando à detecção precoce dos casos suspeitos de hanseníase.

A detecção da hanseníase no município de Paracatu é elevada em menores de quinze anos, abrangendo cerca de 6,8/10.000 hab. em 2003, e classificada como hiperendêmica. O estudo objetiva distribuir territorialmente os casos de hanseníase em adolescentes e crianças escolares menores de 20 anos, utilizando a estratégia da busca ativa de casos. Realizou-se um estudo de coorte prospectivo e ecológico com 16.623 escolares entre janeiro de 2004 a junho de 2006. No banco de dados utilizou-se o software Excel e na análise o chi2, Intervalo de Confiança - (IC) 95% e Risco Relativo - (RR). Para o geoprocessamento das informações, aplicou-se o Auto CAD - release 2000. Foram diagnosticados 68 casos da doença, sendo 25,1%, multibacilares. Cerca de 85,2% residiam na área urbana, 55,8% eram mulheres e a doença predominava no grupo de 10 a 14 anos (IC95%: 0,49-0,89%) e chi2 = 7,376. Houve um incremento de 38,2% na detecção dos casos no período, com visibilidade à prevalência oculta. Ao considerar a busca ativa em 2004, as microrregiões do Alto do Açude e Vista Alegre apresentaram maior detecção de casos com 41,5/10.000 habitantes, e RR = 10,9 vezes maior do que o Centro de Paracatu, com detecção de 3,8/10.000 habitantes. Em 2005, destacaram-se Paracatuzinho, Chapadinha, São João Evangelista I e II, Bandeirantes, Aeroporto e Bom Pastor, com detecção de 21,8/10000 habitantes, e RR = 8,7 vezes maior do que Nossa Senhora de Fátima e JK com detecção de 2,5/10.000 habitantes. A hanseníase entre escolares foi predominante nas áreas norte, leste, sudeste e central de Paracatu. O geoprocessamento das informações, por meio da busca ativa nas escolas, permitiu a visibilidade da hiperendemia da hanseníase por região, possibilitando aperfeiçoamento da vigilância da enfermidade.

The detection rate of leprosy in the district of Paracatu is high in people younger than fifteen years of age, with about 6.8/10,000 inhabitants in 2003, therefore classified as hyperendemic. The study aims at territorially distributing the cases of leprosy in teenagers and children still in school, using the case finding strategy. A prospective cohort and ecologic study was used with 16,623 students between January 2004 and June 2006. An Excel spreadsheet was built for the database and the statistical analysis included chi2, Confidence Interval - (IC) of 95% and Relative Risk (RR). The Auto-CAD release 2000 was used for geoprocessing information. 68 cases of the disease were diagnosed (25.1%, multibacilar forms). About 85.2% lived in the urban area, 55.8% were women, and the 10 to 14 year-old age group prevailed (61.7%; 95%IC: 0.49-0.89%). There was an increase of 38.2% in the case detection rate, giving visibility to the unknown prevalence. Considering case finding in 2004, the microregions of Alto do Açude and Vista Alegre presented a higher case detection with 41.5/10,000 inhabitants; and RR=10.9 higher than the center of Paracatu, with the detection of 3.8/10,000 inhabitants. In 2005, the microregions of Paracatuzinho, Chapadinha, São João Evangelista I and II, Bandeirantes, Aeroporto and Bom Pastor stand out, with the detection of 21.8/10,000 inhabitants, and Relative Risk=8.7 times higher than Nossa Senhora de Fátima and J.K with the detection of 2.5/10,000 inhabitants. Geoprocessing of the information, through case finding among students, allowed visibility of the high detection rate of leprosy by region, allowing improvement in the surveillance of the disease in Paracatu.

The detection rate of leprosy in the district of Paracatu is high in people younger than fifteen years of age, with about 6.8/10,000 inhabitants in 2003, therefore classified as hyperendemic. The study aims at territorially distributing the cases of leprosy in teenagers and children still in school, using the case finding strategy. A prospective cohort and ecologic study was used with 16,623 students between January 2004 and June 2006. An Excel spreadsheet was built for the database and the statistical analysis included chi2, Confidence Interval - (IC) of 95% and Relative Risk (RR). The Auto-CAD release 2000 was used for geoprocessing information. 68 cases of the disease were diagnosed (25.1%, multibacilar forms). About 85.2% lived in the urban area, 55.8% were women, and the 10 to 14 year-old age group prevailed (61.7%; 95%IC: 0.49-0.89%). There was an increase of 38.2% in the case detection rate, giving visibility to the unknown prevalence. Considering case finding in 2004, the microregions of Alto do Açude and Vista Alegre presented a higher case detection with 41.5/10,000 inhabitants; and RR=10.9 higher than the center of Paracatu, with the detection of 3.8/10,000 inhabitants. In 2005, the microregions of Paracatuzinho, Chapadinha, São João Evangelista I and II, Bandeirantes, Aeroporto and Bom Pastor stand out, with the detection of 21.8/10,000 inhabitants, and Relative Risk=8.7 times higher than Nossa Senhora de Fátima and J.K with the detection of 2.5/10,000 inhabitants. Geoprocessing of the information, through case finding among students, allowed visibility of the high detection rate of leprosy by region, allowing improvement in the surveillance of the disease in Paracatu.

A detecção da hanseníase no município de Paracatu é elevada em menores de quinze anos, abrangendo cerca de 6,8/10.000 hab. em 2003, e classificada como hiperendêmica. O estudo objetiva distribuir territorialmente os casos de hanseníase em adolescentes e crianças escolares menores de 20 anos, utilizando a estratégia da busca ativa de casos. Realizou-se um estudo de coorte prospectivo e ecológico com 16.623 escolares entre janeiro de 2004 a junho de 2006. No banco de dados utilizou-se o software Excel e na análise o chi2, Intervalo de Confiança - (IC) 95% e Risco Relativo - (RR). Para o geoprocessamento das informações, aplicou-se o Auto CAD - release 2000. Foram diagnosticados 68 casos da doença, sendo 25,1%, multibacilares. Cerca de 85,2% residiam na área urbana, 55,8% eram mulheres e a doença predominava no grupo de 10 a 14 anos (IC95%: 0,49-0,89%) e chi2 = 7,376. Houve um incremento de 38,2% na detecção dos casos no período, com visibilidade à prevalência oculta. Ao considerar a busca ativa em 2004, as microrregiões do Alto do Açude e Vista Alegre apresentaram maior detecção de casos com 41,5/10.000 habitantes, e RR = 10,9 vezes maior do que o Centro de Paracatu, com detecção de 3,8/10.000 habitantes. Em 2005, destacaram-se Paracatuzinho, Chapadinha, São João Evangelista I e II, Bandeirantes, Aeroporto e Bom Pastor, com detecção de 21,8/10000 habitantes, e RR = 8,7 vezes maior do que Nossa Senhora de Fátima e JK com detecção de 2,5/10.000 habitantes. A hanseníase entre escolares foi predominante nas áreas norte, leste, sudeste e central de Paracatu. O geoprocessamento das informações, por meio da busca ativa nas escolas, permitiu a visibilidade da hiperendemia da hanseníase por região, possibilitando aperfeiçoamento da vigilância da enfermidade.