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THEMATIC ARTICLE • Ciênc. saúde coletiva 29 (7) • July 2024 • https://doi.org/10.1590/1413-81232024297.02742024EN copy

Vulnerability to loss of follow-up and death due to tuberculosis among homeless individuals in Brazil: a retrospective cohort study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This retrospective cohort study identified factors associated with loss of follow-up and death due to tuberculosis (TB) in the homeless population (HP) in Brazil, estimating odds ratios (OR) and their 95% confidence intervals (95%CI) by multinomial logistic regression. A total of 3,831 TB cases in this population were analyzed, of which 57.0% had unfavorable outcomes. Loss of follow-up was associated with: history of abandonment (OR=2.38; 95%CI 2.05-2.77), unknown HIV serology (OR=1.79; 95%CI 1.38-2.32), HIV coinfection (OR=1.73; 95%CI 1.46-2.06), drug use (OR=1.54; 95%CI 1.31-1.80), age (OR=0.98; 95%CI 0.97-0.99), mixed clinical form (OR=0.64; 95%CI 0.42-0.97), extrapulmonary form (OR=0.46; 95%CI 0.29-0.73), government beneficiary (OR=0.64; 95%CI 0.50-0.81), and supervised treatment (OR=0.52; 95%CI 0.45-0.60). Regarding death, the following were associated: age (OR=1.03; 95%CI 1.01-1.05), unknown HIV serology (OR=2.39; 95%CI 1.48-3.86), alcohol consumption (OR=1.81; 95%CI 1.27-2.58), and supervised treatment (OR=0.70; 95%CI 0.51-0.96). Overlapping vulnerabilities in the health-disease process of homeless individuals with TB were observed, requiring comprehensive and cross-sectoral care practices.

Key words:
Homeless People; Health Inequities; Tuberculosis; Cohort Studies

Variable		Total			Outcome
Variable		Total			Cure		Loss of follow-up		Death
Sex (n, %)
	Masculine	2,973	77.6	1,295	79.0	1,527	75.7	151	86.3
	Feminine	858	22.4	345	21.0	489	24.3	24	13.7
Race/color (n, %)
	White	968	25.3	382	23.3	557	27.6	29	16.6
	Not white	2,863	74.7	1,258	76.7	1,459	72.4	146	83.4
Age (me/md, dp)
	18 to59 years old	38.0/37.0	9.6	39.0/37.0	10.1	36.8/37.0	9.1	42.1/37.0	9.7
Education (n, %)
	No study	297	7.8	131	8.0	145	7.2	21	12.0
	Up to 8 years	2,965	77.4	1,239	75.5	1,597	79.2	129	73.7
	More than 8 years	569	14.8	270	16.5	274	13.6	25	14.3
Government beneficiary (n, %)
	Yes	355	9.3	190	11.6	146	7.2	19	10.9
	No	3,476	90.7	1,450	88.4	1,870	92.8	156	89.1
Type of entry (n, %)
	Reentry after abandonment	1,502	39.2	432	26.3	1,017	50.4	53	30.3
	Relapse	278	7.3	143	8.8	115	5.8	20	11.4
	New case	2,051	53.5	1,065	64.9	884	43.8	102	58.3
Clinical form (n, %)
	Pulmonary/extrapulmonary	120	3.1	53	3.3	58	2.9	9	5.2
	Extrapulmonary	106	2.8	61	3.7	35	1.7	10	5.7
	Pulmonary	3,605	94.1	1,526	93.0	1,923	95.4	156	89.1
Alcohol consumption (n, %)
	Yes	2,129	55.6	884	53.9	1,122	55.7	123	70.3
	No	1,702	44.4	756	46.1	894	44.3	52	29.7
Diabetes (n, %)
	Yes	113	2.9	58	3.5	48	2.4	7	4.0
	No	3,718	97.1	1,582	96.5	1,968	97.6	168	96.0
Mental illness (n, %)
	Yes	318	8.3	136	8.3	169	8.4	13	7.4
	No	3.513	91.7	1,504	91.7	1,847	91.6	162	92.6
HIV (n, %)
	Yes	934	24.4	300	18.3	604	30.0	30	17.1
	Unknown	336	8.8	113	6.9	198	9.8	25	14.3
	No	2,561	66.8	1,227	74.8	1,214	60.2	120	68.6
DOT (n, %)
	Yes	1,930	50.4	993	60.5	847	42.0	90	51.4
	No	1,901	49.6	647	39.5	1,169	58.0	85	48.6
Drug use (n, %)
	Yes	2,600	67.9	981	59.8	1,509	74.9	110	62.9
	No	1,231	32.1	659	40.2	507	25.1	65	37.1
Tobacco use (n, %)
	Yes	2,309	60.3	951	58.0	1,251	62.1	107	61.1
	No	1,522	39.7	689	42.0	765	37.9	68	38.9

Variable		Loss of follow-up	Death	p-value^†
Variable		OR* (95%CI)	OR* (95%CI)	p-value^†
Sex
	Masculine	0.83 (0.71-0.97)	1.67 (1.07-2.62)	0.001
	Feminine	Reference
Race/color
	White	1.25 (1.08-1.46)	0.65 (0.43-0.99)	<0.001
	Not white	Reference
Age
	18 to 59 years old	0.97 (0.96-0.98)	1.03 (1.01-1.05)	<0.001
Education
	No study	1.09 (0.81-1.45)	1.73 (0.93-3.20)	0.023
	Up to 8 years	1.27 (1.05-1.52)	1.12 (0.71-1.76)	0.023
	More than 8 years	Reference
Government beneficiary
	Yes	0.59 (0.47-0.74)	0.92 (0.56-1.53)	<0.001
	No	Reference
Type of entry
	Reentry after abandonment	2.83 (2.45-3.27)	1.28 (0.90-1.81)	<0.001
	Relapse	0.96 (0.74-1.25)	1.46 (0.87-2.43)	<0.001
	New case	Reference
Clinical form
	Pulmonary/extrapulmonary	0.86 (0.59-1.26)	1.66 (0.80-3.43)	<0.001
	Extrapulmonary	0.45 (0.29-0.69)	1.60 (0.80-3.19)	<0.001
	Pulmonary	Reference
Alcohol consumption
	Yes	1.07 (0.94-1.22)	2.02 (1.44-2.83)	<0.001
	No	Reference
Diabetes
	Yes	0.66 (0.45-0.98)	1.13 (0.51-2.53)	0.086
	No	Reference
Mental disease
	Yes	1.01 (0.79-1.28)	0.88 (0.49-1.60)	0.905
	No	Reference
HIV
	Yes	2.03 (1.73-2.38)	1.02 (0.67-1.55)	<0.001
	Unknown	1.77 (1.38-2.26)	2.26 (1.41-3.62)	<0.001
	No	Reference
DOT
	Yes	0.47 (0.41-0.53)	0.69 (0.50-0.94)	<0.001
	No	Reference
Drug use
	Yes	1.99 (1.73-2.30)	1.13 (0.82-1.56)	<0.001
	No	Reference
Tobacco use
	Yes	1.18 (1.03-1.35)	1.14 (0.82-1.56)	0.043
	No	Reference

Variable		Loss of follow-up	Death	p-value^†
Variable		OR* (95% CI)	OR* (95% CI)	p-value^†
Age
	18 to 59 years old	0.98 (0.97-0.99)	1.03 (1.01-1.05)	<0.001
Government beneficiary
	Yes	0.64 (0.50-0.81)	0.91 (0.55-1.51)	0.001
	No	Reference
Type of entry
	Reentry after abandonment	2.38 (2.05-2.77)	1.34 (0.93-1.92)	<0.001
	Relapse	0.94 (0.72-1.24)	1.40 (0.83-2.35)	<0.001
	New case	Reference
Clinical form
	Pulmonary/extrapulmonary	0.64 (0.42-0.97)	1.68 (0.79-3.58)	<0.001
	Extrapulmonary	0.46 (0.29-0.73)	1.83 (0.90-3.72)	<0.001
	Pulmonary	Reference
Alcohol consumption
	Yes	1.04 (0.90-1.20)	1.81 (1.27-2.58)	0.003
	No	Reference
HIV
	Yes	1.73 (1.46-2.06)	0.86 (0.55-1.34)	<0.001
	Unknown	1.79 (1.38-2.32)	2.39 (1.48-3.86)	<0.001
	No	Reference
DOT
	Yes	0.52 (0.45-0.60)	0.70 (0.51-0.96)	<0.001
	No	Reference
Drug use
	Yes	1.54 (1.31-1.80)	1.27 (0.89-1.81)	<0.001
	No	Reference

Variable		Loss of follow-up	Death	p-value^†
Variable		OR* (95% CI)	OR* (95% CI)	p-value^†
Age
	18 to 59 years old	0.98 (0.97-0.98)	1.02 (1.02-1.03)	<0.001
Government beneficiary
	Yes	0.69 (0.56-0.84)	0.64 (0.41-1.02)	0.001
	No	Reference
Type of entry
	Reentry after abandonment	2.11 (1.92-2.32)	1.38 (1.14-1.67)	<0.001
	Relapse	0.90 (0.77-1.04)	0.89 (0.67-1.18)	<0.001
	New case	Reference
Clinical form
	Pulmonary/extrapulmonary	0.62 (0.47-0.80)	2.43 (1.64-3.59)	<0.001
	Extrapulmonary	0.59 (0.46-0.75)	1.18 (0.77-1.80)	<0.001
	Pulmonary	Reference
Alcohol consumption
	Yes	0.95 (0.87-1.04)	1.58 (1.31-1.90)	<0.001
	No	Reference
HIV
	Yes	1.58 (1.42-1.75)	0.35 (0.25-0.47)	<0.001
	Unknown	2.08 (1.81-2.39)	2.21 (1.78-2.74)	<0.001
	No	Reference
DOT
	Yes	0.28 (0.25-0.31)	0.36 (0.29-0.43)	<0.001
	No	Reference
Drug use
	Yes	1.43 (1.30-1.57)	1.20 (1.00-1.45)	<0.001
	No	Reference

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