Tuberculose infantil: desigualdades sociodemográficas e resistência medicamentosa.

Abstract

Introduction: tuberculosis is still an important public health problem, being one of the ten main causes of death in the world. The epidemiology of tuberculosis is closely related to social determinants, as they influence the risk of exposure, susceptibility, disease progression, time of diagnosis and treatment, as well as adherence and, consequently, treatment success. The disease affects the black, brown, and indigenous ethnic-racial groups unequally, and considering that most studies on tuberculosis include, for the most part, the age group of adults, is importante to perform new studies on tuberculosis especifically for children and teenagers. Objective: to investigate the determinants related to illness, treatment outcome, and drug resistance of tuberculosis in children under 15 years of age in Brazil. Methodology: the thesis is composed of three articles. In the first article, an observational, exploratory, and descriptive study was carried out. The population consisted of all cases of drugresistant tuberculosis in the under 15 and 15 to 19 age groups, whose data came from the Information System for Special Tuberculosis Treatments throughout Brazil, over the period 2008-2019. Data analysis was performed using Fisher's exact test. In the second article, an exploratory retrospective cohort study was carried out. The study population consisted of all cases of tuberculosis in children under 15 years of age. Data came from the Information System for Notifiable Diseases throughout Brazil, from 2008 to 2019. Data analysis was performed using Poisson regression with robust variance, with the calculation of Relative Risk and a confidence interval of 95 %. In the third article, a cohort study was carried out. The study population consisted of all individuals under 15 years of age enrolled in the Cohort of 100 Million Brazilians. Data came from the Single Registry for Social Programs (CadÚnico) and subsequent linkage with tuberculosis data registered, mandatorily, in the Notifiable Diseases Information System throughout Brazil, in the period 2008-2018. In the analysis, hierarchical models were constructed using Poisson regression with robust variance, to investigate the social determinants of childhood tuberculosis in Brazil. The analyzes were developed using the Stata 15 software. It is noteworthy that, although the data are secondary and unidentified, all ethical aspects advocated by resolutions 466/12 and 510/16 involving research with human beings were respected. The project was approved by the research ethics committee of the Instituto de Saúde Coletiva of the Federal University of Bahia (opinion number: 5,075,877). Results: In article 1, 46 (8.3%) cases of drug-resistant tuberculosis were observed in children under 15 years of age and 509 (91.7%) cases in the 15-19 age group. The distribution by sex is different in the two age groups, registering a proportion of 70% of girls in the under-15 age group and 45% in the 15 to 19 age group. Statistically significant differences were observed in race/color, clinical form, place of probable contagion, being in contact with a case of tuberculosis, and carrying out the treatment directly observed. Regarding Article 2, it was noted that black, brown, and indigenous children had a higher risk of having unfavorable outcomes compared to white children (24%, 29%, and 29%,respectively). Children under one year of age had an RR of 1.80 (95%CI: 1.61-2.00) and children aged 1 to 4 years had an RR of 1.19 (95%CI: 1.06 -1.33), comprising the age groups with the highest risk of having an unfavorable outcome. Children diagnosed HIV-positive had an almost three-fold increased risk of poor outcomes than those HIV negative [RR: 2.61; 95%CI: 2.33-2.94)]. Regarding Article 3, 21,619,026 individuals were included, and of these, 5,743 cases of tuberculosis. Of these, 51% of cases occurred in males, 68% in children under 5 years of age, and 60% in people of mixed race/color. Multivariate analysis revealed that the place of residence, such as living in the North and Southeast regions and urban areas, living in a household with a female head of household, lower income, higher household density, and being of black or indigenous race/color were associated with a higher risk of tuberculosis. It is necessary to reduce the incidence of cases of tuberculosis and drug-resistant tuberculosis, especially in children, as well as to achieve the goals and indicators for tuberculosis control established by national and international bodies. It is also essential to reinforce the importance of reporting in the drug-resistant tuberculosis information system (SITE TB) to produce more accurate estimates. The study revealed a marked disparity and a greater risk of an unfavorable outcome from tuberculosis in black, brown and indigenous children and adolescents, in addition to showing that children under five years of age need specific attention, as they have a greater risk of having unfavorable outcomes. This work also contributed to broadening the understanding of the epidemiological situation of childhood tuberculosis during the last decade in Brazil.