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BACKGROUND: Individuals who were formerly incarcerated have high tuberculosis incidence, but are generally not considered among the risk groups eligible for tuberculosis prevention. We investigated the potential health impact and cost-effectiveness of Mycobacterium tuberculosis infection screening and tuberculosis preventive treatment (TPT) for individuals who were formerly incarcerated in Brazil. METHODS: Using published evidence for Brazil, we constructed a Markov state transition model estimating tuberculosis-related health outcomes and costs among individuals who were formerly incarcerated, by simulating transitions between health states over time. The analysis compared tuberculosis infection screening and TPT, to no screening, considering a combination of M tuberculosis infection tests and TPT regimens. We quantified health effects as reductions in tuberculosis cases, tuberculosis deaths, and disability-adjusted life-years (DALYs). We assessed costs from a tuberculosis programme perspective. We report intervention cost-effectiveness as the incremental costs per DALY averted, and tested how results changed across subgroups of the target population. FINDINGS: Compared with no intervention, an intervention incorporating tuberculin skin testing and treatment with 3 months of isoniazid and rifapentine would avert 31 (95% uncertainty interval 14-56) lifetime tuberculosis cases and 4·1 (1·4-5·8) lifetime tuberculosis deaths per 1000 individuals, and cost US$242 per DALY averted. All test and regimen combinations were cost-effective compared with no screening. Younger age, longer incarceration, and more recent prison release were each associated with significantly greater health benefits and more favourable cost-effectiveness ratios, although the intervention was cost-effective for all subgroups examined. INTERPRETATION: M tuberculosis infection screening and TPT for individuals who were formerly incarcerated appears cost-effective, and would provide valuable health gains. FUNDING: National Institutes of Health. TRANSLATION: For the Portuguese translation of the abstract see Supplementary Materials section.
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Análise Custo-Benefício , Cadeias de Markov , Programas de Rastreamento , Prisioneiros , Tuberculose , Humanos , Brasil/epidemiologia , Prisioneiros/estatística & dados numéricos , Tuberculose/diagnóstico , Tuberculose/economia , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Programas de Rastreamento/economia , Programas de Rastreamento/métodos , Adulto , Masculino , Feminino , Antituberculosos/uso terapêutico , Antituberculosos/economia , Pessoa de Meia-Idade , Rifampina/uso terapêutico , Rifampina/economia , Mycobacterium tuberculosis/isolamento & purificação , Adulto JovemRESUMO
Human mobility has challenged malaria elimination efforts and remains difficult to routinely track. In Brazil, administrative records from the Ministry of Health allow monitoring of mobility locally and internationally. Although most imported malaria cases are between municipalities in Brazil, detailed knowledge of patterns of mobility is limited. Here, we address this gap by quantifying and describing patterns of malaria-infected individuals across the Amazon. We used network analysis, spatial clustering, and linear models to quantify and characterize the movement of malaria cases in Brazil between 2004 and 2022. We identified sources and sinks of malaria within and between states. We found that between-state movement of cases has become proportionally more important than within-state, that source clusters persisted longer than sink clusters, that movement of cases into sinks was seasonal while movement out of sources was not, and that importation is an impediment for subnational elimination in many municipalities. We elucidate the vast travel networks of malaria infected individuals that characterize the Amazon region. Uncovering patterns of malaria case mobility is vital for effective microstratification within Brazil. Our results have implications for intervention stratification across Brazil in line with the country's goal of malaria elimination by 2035.
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Rural workers are disproportionally exposed to pesticides and might be at an increased risk of developing chronic diseases. Here, we investigated the impact of pesticide exposure on breast cancer (BC) risk and disease profile in rural female workers. This is a case-control study that prospectively included 758 individuals. The study was conducted in the Southwest region of Paraná state in Brazil, a region characterized by family-based agriculture and intensive use of pesticides. We found that this region has a 41% higher BC diagnosis rate and 14% higher BC mortality rate than the mean rates in Brazil, as well as a pesticide trade volume about 6 times higher than the national average. We showed substantial exposure in this population and found that even women who did not work in the fields but performed equipment decontamination and clothes washing of male partners who worked in the fields had urine samples positive for glyphosate, atrazine, and/or 2,4-D. The crude association showed a significantly higher risk of BC among women exposed to pesticides (OR: 1.58, 95% CI 1.18-2.13). Adjusted analyses showed a lower and nonstatistically significant association (OR: 1.30, 95% CI 41 0.87-1.95). Stratification on disease profile showed a significantly higher risk of lymph node metastasis (adjusted OR: 2.19, 95% CI 1.31-3.72) in women exposed to pesticides. Our findings suggest that female populations exposed to pesticides are at a higher risk of developing BC with a more aggressive profile and draw attention to the need to monitor rural populations potentially exposed to pesticides in the field or at home.
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Agricultura , Neoplasias da Mama , Exposição Ocupacional , Praguicidas , Humanos , Brasil/epidemiologia , Neoplasias da Mama/epidemiologia , Feminino , Estudos de Casos e Controles , Pessoa de Meia-Idade , Adulto , População RuralRESUMO
INTRODUCTION: Tuberculosis (TB) causes over 1 million deaths annually. Providing effective treatment is a key strategy for reducing TB deaths. In this study, we identified factors associated with unsuccessful treatment outcomes among individuals treated for TB in Brazil. METHODS: We obtained data on individuals treated for TB between 2015 and 2018 from Brazil's National Disease Notification System (SINAN). We excluded patients with a history of prior TB disease or with diagnosed TB drug resistance. We extracted information on patient-level factors potentially associated with unsuccessful treatment, including demographic and social factors, comorbid health conditions, health-related behaviors, health system level at which care was provided, use of directly observed therapy (DOT), and clinical examination results. We categorized treatment outcomes as successful (cure, completed) or unsuccessful (death, regimen failure, loss to follow-up). We fit multivariate logistic regression models to identify factors associated with unsuccessful treatment. RESULTS: Among 259,484 individuals treated for drug susceptible TB, 19.7% experienced an unsuccessful treatment outcome (death during treatment 7.8%, regimen failure 0.1%, loss to follow-up 11.9%). The odds of unsuccessful treatment were higher with older age (adjusted odds ratio (aOR) 2.90 [95% confidence interval: 2.62-3.21] for 85-100-year-olds vs. 25-34-year-olds), male sex (aOR 1.28 [1.25-1.32], vs. female sex), Black race (aOR 1.23 [1.19-1.28], vs. White race), no education (aOR 2.03 [1.91-2.17], vs. complete high school education), HIV infection (aOR 2.72 [2.63-2.81], vs. no HIV infection), illicit drug use (aOR 1.95 [1.88-2.01], vs. no illicit drug use), alcohol consumption (aOR 1.46 [1.41-1.50], vs. no alcohol consumption), smoking (aOR 1.20 [1.16-1.23], vs. non-smoking), homelessness (aOR 3.12 [2.95-3.31], vs. no homelessness), and immigrant status (aOR 1.27 [1.11-1.45], vs. non-immigrants). Treatment was more likely to be unsuccessful for individuals treated in tertiary care (aOR 2.20 [2.14-2.27], vs. primary care), and for patients not receiving DOT (aOR 2.35 [2.29-2.41], vs. receiving DOT). CONCLUSION: The risk of unsuccessful TB treatment varied systematically according to individual and service-related factors. Concentrating clinical attention on individuals with a high risk of poor treatment outcomes could improve the overall effectiveness of TB treatment in Brazil.
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Antituberculosos , Falha de Tratamento , Tuberculose , Humanos , Brasil/epidemiologia , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Antituberculosos/uso terapêutico , Adulto Jovem , Adolescente , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Idoso , Terapia Diretamente Observada , Criança , Pré-Escolar , Fatores de Risco , Lactente , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Resultado do Tratamento , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: In Brazil, many individuals with tuberculosis (TB) do not receive appropriate care due to delayed or missed diagnosis, ineffective treatment regimens, or loss-to-follow-up. This study aimed to estimate the health losses and TB program costs attributable to each gap in the care cascade for TB disease in Brazil. METHODS AND FINDINGS: We constructed a Markov model simulating the TB care cascade and lifetime health outcomes (e.g., death, cure, postinfectious sequelae) for individuals developing TB disease in Brazil. We stratified the model by age, human immunodeficiency virus (HIV) status, drug resistance, state of residence, and disease severity, and developed a parallel model for individuals without TB that receive a false-positive TB diagnosis. Models were fit to data (adult and pediatric) from Brazil's Notifiable Diseases Information System (SINAN) and Mortality Information System (SIM) for 2018. Using these models, we assessed current program performance and simulated hypothetical scenarios that eliminated specific gaps in the care cascade, in order to quantify incremental health losses and TB diagnosis and treatment costs along the care cascade. TB-attributable disability-adjusted life years (DALYs) were calculated by comparing changes in survival and nonfatal disability to a no-TB counterfactual scenario. We estimated that 90.0% (95% uncertainty interval [UI]: 85.2 to 93.4) of individuals with TB disease initiated treatment and 10.0% (95% UI: 7.6 to 12.5) died with TB. The average number of TB-attributable DALYs per incident TB case varied across Brazil, ranging from 2.9 (95% UI: 2.3 to 3.6) DALYs in Acre to 4.0 (95% UI: 3.3 to 4.7) DALYs in Rio Grande do Sul (national average 3.5 [95% UI: 2.8 to 4.1]). Delayed diagnosis contributed the largest health losses along the care cascade, followed by post-TB sequelae and loss to follow up from TB treatment, with TB DALYs reduced by 71% (95% UI: 65 to 76), 41% (95% UI: 36 to 49), and 10% (95% UI: 7 to 16), respectively, when these factors were eliminated. Total health system costs were largely unaffected by improvements in the care cascade, with elimination of treatment failure reducing attributable costs by 3.1% (95% UI: 1.5 to 5.4). TB diagnosis and treatment of false-positive individuals accounted for 10.2% (95% UI: 3.9 to 21.7) of total programmatic costs but contributed minimally to health losses. Several assumptions were required to interpret programmatic data for the analysis, and we were unable to estimate the contribution of social factors to care cascade outcomes. CONCLUSIONS: In this study, we observed that delays to diagnosis, post-disease sequelae and treatment loss to follow-up were primary contributors to the TB burden of disease in Brazil. Reducing delays to diagnosis, improving healthcare after TB cure, and reducing treatment loss to follow-up should be prioritized to improve the burden of TB disease in Brazil.
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Efeitos Psicossociais da Doença , Tuberculose , Adulto , Criança , Humanos , Anos de Vida Ajustados por Qualidade de Vida , Saúde Global , Brasil/epidemiologia , Tuberculose/diagnóstico , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Progressão da Doença , Carga Global da DoençaRESUMO
OBJECTIVE: To investigate birth-to-childhood tracking of linear growth and weight gain across the distribution of length/height and weight for age z-scores and according to household wealth. METHODS: Data from 614 children from the MINA-Brazil Study with repeated anthropometric measurements at birth and up to age five years were used. Z-scores were calculated for length/height (HAZ) and weight (WAZ) according to international standards. Birth-to-childhood tracking was separately estimated using quantile regression models for HAZ and WAZ, extracting coefficients and 95% confidence intervals (95%CI) at the 25th, 50th, and 75th quantiles. In a subgroup analysis, we estimated tracking between birth and age two years, and between ages two and five years. To investigate disparities in tracking, interaction terms between household wealth indexes (at birth and age five years) and newborn size z-scores were included in the models. RESULTS: Tracking coefficients were significant and had similar magnitude across the distribution of anthropometric indices at age five years (HAZ, 50th quantile: 0.23, 95%CI: 0.11 to 0.35; WAZ, 50th quantile: 0.31, 95%CI: 0.19 to 0.43). Greater tracking was observed between ages two and five years, with coefficients above 0.82. Significantly higher tracking of linear growth was observed among children from wealthier households, both at birth, at the lower bounds of HAZ distribution (25th quantile: 0.30, 95%CI: 0.13 to 0.56), and during childhood, in the entire HAZ distribution at five years. For weight gain, stronger tracking was observed at the upper bounds of WAZ distribution at age five years among children from wealthier households at birth (75th quantile: 0.59, 95%CI: 0.35 to 0.83) and during childhood (75th quantile: 0.54, 95%CI: 0.15 to 0.93). CONCLUSION: There was significant tracking of HAZ and WAZ since birth, with indication of substantial stability of nutritional status between ages two and five years. Differential tracking according to household wealth should be considered for planning early interventions for preventing malnutrition.
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Desnutrição , Aumento de Peso , Recém-Nascido , Humanos , Pré-Escolar , Brasil , Antropometria , Estado NutricionalRESUMO
OBJECTIVE: To identify longitudinal patterns of maternal depression between three months and five years after child's birth, to examine predictor variables for these trajectories, and to evaluate whether distinct depression trajectories predict offspring mental health problems at age 5 years. METHODS: We used data from the Maternal and Child Health and Nutrition in Acre (MINA-Brazil) study, a population-based birth cohort in the Western Brazilian Amazon. Maternal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale (EPDS) at 3 and 6-8 months, and 1 and 2 years after delivery. Mental health problems in 5-year-old children were evaluated with the Strengths and Difficulties Questionnaire (SDQ) reported by parents. Trajectories of maternal depression were calculated using a group-based modelling approach. RESULTS: We identified four trajectories of maternal depressive symptoms: "low" (67.1%), "increasing" (11.5%), "decreasing" (17.4%), and "high-chronic" (4.0%). Women in the "high/chronic" trajectory were the poorest, least educated, and oldest compared with women in the other trajectory groups. Also, they were more frequently multiparous and reported smoking and having attended fewer prenatal consultations during pregnancy. In the adjusted analyses, the odds ratio of any SDQ disorder was 3.23 (95%CI: 2.00-5.22) and 2.87 (95%CI: 1.09-7.57) times higher among children of mothers belonging to the "increasing" and "high-chronic" trajectory groups, respectively, compared with those of mothers in the "low" depressive symptoms group. These differences were not explained by maternal and child characteristics included in multivariate analyses. CONCLUSIONS: We identified poorer mental health outcomes for children of mothers assigned to the "chronic/severe" and "increasing" depressive symptoms trajectories. Prevention and treatment initiatives to avoid the adverse short, medium, and long-term effects of maternal depression on offspring development should focus on women belonging to these groups.
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Depressão Pós-Parto , Depressão , Criança , Gravidez , Humanos , Feminino , Pré-Escolar , Estudos de Coortes , Brasil/epidemiologia , Depressão/epidemiologia , Saúde Mental , Mães , Depressão Pós-Parto/epidemiologiaRESUMO
OBJECTIVE: To describe the prevalence and factors associated with exclusive (EBF) and continued breastfeeding (BF) practices among Amazonian children. METHODS: Data from 1,143 mother-child pairs recorded on the Maternal and Child Health and Nutrition in Acre (MINA-Brazil) birth cohort were used. Information on EBF and BF was collected after childbirth (July 2015-June 2016) and during the follow-up visits at 1 and 6 months postpartum, 1, 2, and 5 years of age. For longitudinal analysis, the outcomes were EBF and BF duration. Probability of breastfeeding practices were estimated by Kaplan-Meier survival analysis. Associations between baseline predictors variables and outcomes among children born at term were assessed by extended Cox regression models. RESULTS: EBF frequencies (95% confidence interval [95%CI]) at 3 and 6 months of age were 33% (95%CI: 30.2-36.0) and 10.8% (95%CI: 8.9-12.9), respectively. Adjusted hazard ratio for predictors of early EBF cessation were: being a first-time mother = 1.47 (95%CI: 1.19-1.80), feeding newborns with prelacteals = 1.70 (95%CI: 1.23-2.36), pacifier use in the first week of life = 1.79 (95%CI: 1.44-2.23) or diarrhea in the first two weeks of life = 1.70 (95%CI: 1.15-2.52). Continued BF frequency was 67.9% (95%CI: 64.9-70.8), 29.3% (95%CI: 26.4-32.4), and 1.7% (95%CI: 0.9-2.8) at 1, 2 and 5 years of age, respectively. Adjusted hazard ratio for predictors of early BF cessation were: male sex = 1.23 (95%CI: 1.01-1.49), pacifier use in the first week of life = 4.66 (95%CI: 2.99-7.26), and EBF less than 3 months = 2.76 (95%CI: 1.64-4.66). CONCLUSIONS: EBF and continued BF duration among Amazonian children is considerably shorter than recommendations from the World Health Organization. Significant predictors of breastfeeding practices should be considered for evaluating local strategies to achieve optimal breastfeeding practices.
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Aleitamento Materno , Saúde da Criança , Recém-Nascido , Criança , Feminino , Gravidez , Humanos , Masculino , Lactente , Prevalência , Brasil/epidemiologia , MãesRESUMO
OBJECTIVE: This study aimed to describe the prevalence and predictors of childhood anemia in an Amazonian population-based birth cohort study. METHODS: Prevalence of maternal anemia was estimated at delivery (hemoglobin [Hb] concentration < 110 g/L) in women participating in the MINA-Brazil birth cohort study and in their children, examined at ages one, two (Hb < 110 g/L), and five (Hb < 115 g/L). Moreover, ferritin, soluble transferrin receptor, and C-reactive protein concentrations were measured in mothers at delivery and in their 1- and 2-year-old children to estimate the prevalence of iron deficiency and its contribution to anemia, while adjusting for potential confounders by multiple Poisson regression analysis (adjusted relative risk [RRa]). RESULTS: The prevalence 95% confidence interval (CI) of maternal anemia, iron deficiency, and iron-deficiency anemia at delivery were 17.3% (14.0-21.0%), 42.6% (38.0-47.2%), and 8.7% (6.3-11.6)%, respectively (n = 462). At one year of age (n = 646), 42.2% (38.7-45.8%) of the study children were anemic, 38.4% (34.6-42.3%) were iron-deficient, and 26.3 (23.0-29.9) had iron-deficiency anemia. At two years of age (n = 761), these values decreased to 12.8% (10.6-15.2%), 18.1% (15.5-21.1%), and 4.1% (2.8-5.7%), respectively; at five years of age (n = 655), 5.2% (3.6-7.2%) were anemic. Iron deficiency (RRa = 2.19; 95%CI: 1.84-2.60) and consumption of ultra-processed foods (UPF) (RRa = 1.56; 95%CI: 1.14-2.13) were significant contributors to anemia at 1 year, after adjusting for maternal schooling. At 2 years, anemia was significantly associated with maternal anemia at delivery (RRa: 1.67; 95%CI: 1.17-2.39), malaria since birth (2.25; 1.30-3.87), and iron deficiency (2.15; 1.47-3.15), after adjusting for children's age and household wealth index. CONCLUSIONS: Anemia continues to be highly prevalent during pregnancy and early childhood in the Amazon. Public health policies should address iron deficiency, UPF intake, maternal anemia, and malaria to prevent and treat anemia in Amazonian children.
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Anemia Ferropriva , Anemia , Deficiências de Ferro , Malária , Gravidez , Humanos , Feminino , Pré-Escolar , Anemia Ferropriva/epidemiologia , Estudos de Coortes , Prevalência , Brasil/epidemiologia , Hemoglobinas/análise , Hemoglobinas/metabolismo , Anemia/epidemiologiaRESUMO
BACKGROUND: Malarial infections are often missed by microscopy, and most parasite carriers are asymptomatic in low-endemicity settings. Whether parasite detectability and its ability to elicit symptoms change as transmission declines remains unclear. METHODS: We performed a prospective panel survey with repeated measurements on the same participants over 12 months to investigate whether Plasmodium vivax detectability by microscopy and risk of symptoms upon infection varied during a community-wide larviciding intervention in the Amazon basin of Brazil that markedly reduced vector density. We screened 1096 to 1400 residents in the intervention site for malaria by microscopy and quantitative TaqMan assays at baseline and twice during intervention. RESULTS: We found that more P vivax infections than expected from their parasite densities measured by TaqMan assays were missed by microscopy as transmission decreased. At lower transmission, study participants appeared to tolerate higher P vivax loads without developing symptoms. We hypothesize that changes in the ratio between circulating parasites and those that accumulate in the bone marrow and spleen, by avoiding peripheral blood microscopy detection, account for decreased parasite detectability and lower risk of symptoms under low transmission. CONCLUSIONS: P vivax infections are more likely to be subpatent and remain asymptomatic as malaria transmission decreases.