Excess tuberculosis cases and deaths following an economic recession in Brazil: an analysis of nationally representative disease registry data

Abstract

Summary: Background: In 2019, tuberculosis incidence and mortality in Brazil were 46 and 3·3 per 100 000 population, respectively, and the country has reported rising tuberculosis case rates since 2016, following an economic crisis beginning in mid-2014. We aimed to estimate the number of excess tuberculosis cases and deaths during the recession period, and assessed potential causes. Methods: In this multi-level regression modelling study, we extracted tuberculosis case notifications from Brazil's National Notifiable Disease Information System (known as SINAN), and tuberculosis deaths from the Mortality Information System (known as SIM), for all ages. We fitted mixed-effects regression models estimating trends in these outcomes—stratified by sex, age group, and state—during the pre-recession period (Jan 1, 2010–Dec 31, 2014). We calculated excess cases and deaths between Jan 1, 2015, and Dec 31, 2019 (the recession period) as the difference between reported values and a counterfactual of continued pre-recession trends. We examined the relationship between excess cases and possible explanatory factors using ordinary least squares regression. We tested the robustness of our findings to alternative model specifications related to the pre-recession period and criteria for defining tuberculosis deaths. Findings: We estimated 22 900 excess tuberculosis cases (95% uncertainty interval 18 100–27 500) during 2015–19. By 2019, reported cases were 12% (10–13) higher than predicted by historical trends. 54% (44–66) of excess cases occurred among 20–29-year-old men. In this group, reported cases in 2019 were 30% (25–36) higher than predicted. Excess cases were positively associated with an increasing fraction of cases among incarcerated individuals (p=0·001) and higher unemployment (p=0·04) at the state level. Estimated excess deaths for 2015–19 were not statistically significant from 0 (−600 [–2100 to 1000]). These results were robust to alternative definitions of the pre-recession period and criteria for defining tuberculosis deaths. Interpretation: Tuberculosis cases in Brazil rose substantially in 2015–19 during the recession, largely affecting young men. This increase seems to be linked to increasing tuberculosis transmission among incarcerated populations. Rising tuberculosis case rates threaten tuberculosis control in Brazil, and highlight the threat posed by prison-based tuberculosis transmission. Funding: US National Institutes of Health. Translation: For the Portuguese translation of the abstract see Supplementary Materials section.