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BMC Public Health. 2017 May 25;17(1):508. doi: 10.1186/s12889-017-4435-0.

Determinants of tuberculosis transmission and treatment abandonment in Fortaleza, Brazil.

Author information

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building I, Room 1113, Boston, MA, 02115, USA.
Research Department of Infection and Population Health, University College London, London, UK.
Fortaleza Municipal Health Secretariat (SMS-Fortaleza), Fortaleza, CE, Brazil.
University of Fortaleza (UNIFOR), Fortaleza, CE, Brazil.
Federal University of Ceará (UFC), Fortaleza, CE, Brazil.
Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Building I, Room 1113, Boston, MA, 02115, USA.



Tuberculosis (TB) remains a public health problem, despite recent achievements in reducing incidence and mortality rates. In Brazil, these achievements were above the worldwide average, but marked by large regional heterogeneities. In Fortaleza (5th largest city in Brazil), the tuberculosis cure rate has been declining and treatment abandonment has been increasing in the past decade, despite a reduction in incidence and an increase in directly observed therapy (DOT). These trends put efforts to eliminate tuberculosis at risk. We therefore sought to determine social and programmatic determinants of tuberculosis incidence and treatment abandonment in Fortaleza.


We analyzed sociodemographic and clinical data for all new tuberculosis cases notified in the Notifiable Diseases Information System (SINAN) from Fortaleza between 2007 and 2014. We calculated incidence rates for 117 neighborhoods in Fortaleza, assessed their spatial clustering, and used spatial regression models to quantify associations between neighborhood-level covariates and incidence rates. We used hierarchical logistic regression models to evaluate how individual- and neighborhood-level covariates predicted tuberculosis treatment abandonment.


There were 12,338 new cases reported during the study period. Case rates across neighborhoods were significantly positively clustered in two low-income areas close to the city center. In an adjusted model, tuberculosis rates were significantly higher in neighborhoods with lower literacy, higher sewerage access and homicide rates, and a greater proportion of self-reported black residents. Treatment was abandoned in 1901 cases (15.4%), a rate that rose by 71% between 2007 and 2014. Abandonment was significantly associated with many individual sociodemographic and clinical factors. Notably, being recommended for DOT was protective for those who completed DOT, but associated with abandonment for those who did not.


Low socioeconomic status areas have higher tuberculosis rates, and low socioeconomic individuals have higher risk of treatment abandonment, in Fortaleza. Treatment abandonment rates are growing despite the advent of universal DOT recommendations in Brazil. Proactive social policies, and active contact tracing to find missed cases, may help reduce the tuberculosis burden in this setting.


Brazil; Epidemiology; Fortaleza; Social determinants; Spatial analysis; Treatment; Treatment failure; Tuberculosis

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