Brazil
Revista Brasileira de Geriatria e Gerontologia
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ORIGINAL ARTICLES • Rev. bras. geriatr. gerontol. 28 • 2025 • https://doi.org/10.1590/1981-22562025028.250035.en linkcopy

Open-access Tuberculosis mortality in older individuals and associated factors

AuthorshipSCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective  To analyze the association between tuberculosis mortality in older individuals and sociodemographic, health, and access to services indicators in Brazilian capitals and the Federal District between 2018 and 2020.

Methods  An ecological study whose outcome was the average tuberculosis mortality rate in older adults between 2018 and 2020 was conducted. The rate was calculated using data from the Notifiable Diseases Information System (SINAN) for the period, utilizing the category "Tuberculosis death" for individuals aged ≥60 years. Fourteen variables were selected based on data from the National Household Sample Survey (PNAD), Primary Health Care Secretariat (SAPS), National Registry of Health Facilities (CNES) and Brazilian Institute of Geography and Statistics (IBGE). A multiple linear regression model was used to assess the association of the outcome with the selected variables.

Results  The average tuberculosis mortality rate among older individuals in Brazilian state capitals was 5.8 deaths per 100,000 inhabitants. On analysis, three variables showed an association with tuberculosis mortality in the older adults: Gini index (β=86.122; p=0.006), HIV/TB coinfection (β=0.584; p=0.015), and population coverage of the Family Health Strategy (β=-0.144; p=0.038).

Conclusions  This study revealed that social inequality, measured by the Gini index, HIV/TB coinfection, and lower coverage of the Family Health Strategy, were associated with tuberculosis mortality in older individuals in Brazilian state capitals. These results corroborate studies on the relationship between tuberculosis and socioeconomic and health factors. Furthermore, these findings help inform public policies aimed at combating tuberculosis in older individuals, which should center on improving access to healthcare and reducing inequalities.

Keywords
Tuberculosis; Mortality; Aged; Socioeconomic factors.

Resumo

Objetivo  Analisar associação entre mortalidade por tuberculose em pessoas idosas e indicadores sociodemográficos, de saúde e de acesso a serviços nas capitais brasileiras e Distrito Federal de 2018 a 2020.

Método  Estudo ecológico cujo desfecho foi o coeficiente médio de óbitos por tuberculose de pessoas idosas de 2018 a 2020. O coeficiente foi calculado com dados do Sistema de Informação de Agravos de Notificação (SINAN) utilizando a categoria “Óbito por tuberculose” e faixa etária ≥60 anos de idade. Foram selecionadas 14 variáveis com base em dados da Pesquisa Nacional por Amostra de Domicílios (PNAD), Secretaria de Atenção Primária à Saúde (SAPS), Cadastro Nacional de Estabelecimentos de Saúde (CNES) e Instituto Brasileiro de Geografia e Estatística (IBGE). Utilizou-se o modelo de regressão linear múltipla para avaliar a associação do desfecho com as variáveis selecionadas.

Resultados  O coeficiente médio de mortalidade por tuberculose de pessoas idosas nas capitais brasileiras foi de 5,8 óbitos/100 mil habitantes. Após análise, três variáveis apresentaram associação com o desfecho: índice de Gini (β=86,122; p=0,006); coinfecção HIV/tuberculose (β=0,584; p=0,015) e cobertura da Estratégia de Saúde da Família (β=-0,144; p=0,038).

Conclusões  Este estudo evidenciou que desigualdade social, coinfecção HIV/tuberculose e menor cobertura da ESF possuem relação com a mortalidade por tuberculose em pessoas idosas nas capitais brasileiras. Esses resultados corroboram com estudos sobre a relação da tuberculose com fatores socioeconômicos e de saúde. Ademais, contribuem com subsídios para políticas públicas voltadas para o enfrentamento da tuberculose em pessoas idosas, pautadas na melhoria do acesso à saúde e redução das desigualdades.

Palavras-chave
Tuberculose; Mortalidade; Idoso; Fatores Socioeconômicos.

INTRODUCTION

Tuberculosis is an infectious and contagious disease caused by Mycobacterium Tuberculosis, transmitted predominantly through contact with respiratory secretions from individuals infected with pulmonary tuberculosis1,2. Infection by Mycobacterium is influenced by a number of factors, such as virulence of the mycobacterium strain, the immune status of the host, as well as presence, proximity and environment of contact with infected individuals2-5. In this context, immunosuppressed individuals, and certain age groups, such as older adults, are more susceptible to infection by tuberculosis and to poorer outcomes4-6.

Tuberculosis constitutes a serious public health problem1,7, given that the disease and its development are associated with social, economic and demographic conditions, and with health service access5,7. In 2022, the tuberculosis mortality rate in Brazilian capitals was 3.6 deaths/100,000 inhabitants7. Also in 2022, a total of 1,069 tuberculosis-related deaths of individuals aged 15-59 years were registered, corresponding to a rate of 3.2 deaths/100,000 7. Although this age group accounts for the greatest absolute number of deaths from the disease, the rate of tuberculosis mortality in the older population (aged ≥60 years) was higher, with a rate of 9.5 deaths/100,000 7in this group, illustrating the seriousness of the infection in older adults.

A number of factors may contribute to tuberculosis-related illness and death in older individuals, such as greater susceptibility to infections, physiological immunosuppression owing to immunosenescence4,5,8, as well as the presence of other diseases6,8,9, in addition to habits such as tobacco or alcohol use5,8. other factors linked to unfavorable outcomes include delayed diagnosis4,5, due to difficulties recognizing the clinical condition, which may be atypical or masked by associated conditions4,5,10,11, and difficulties performing complementary exams4. Furthermore, treatment of tuberculosis in these individuals can be hampered, where polypharmacy is a common phenomenon in older adults, where combining continuous use medications with tuberculosis therapy can lead to serious adverse events9 and resultant lower treatment success rates10,11.

Although the physiological process inherent to aging contributes to the emergence of diseases and health problems4, this factor alone cannot explain the high rates of death from tuberculosis observed in older adults in Brazilian capital cities10. Therefore, studies and approaches addressing tuberculosis in older individuals should take into account its multifactorial nature, given its relevance in the context of Brazil and its demographic transition12,13. Thus, the objective of the present study was to analyze the relationship between tuberculosis mortality in older adults and sociodemographic, health and service access indicators in Brazilian state capitals and the Federal District between 2018 and 2020.

METHOD

A cross-sectional ecological study analyzing the relationship between mortality from tuberculosis in older adults and socioeconomic, health and service access indicators in Brazilian capitals, was carried out. The study was conducted in accordance with the Reporting of Studies Conducted using Observational Routinely-Collected Health Data (RECORD) recommendations. The results of present study were drawn from the final year project by the author, submitted under the graduate program in medicine of the Federal University of Santa Catarina, Araranguá campus, in June 2023.

Public domain secondary data was used from the Notifiable Diseases Information System (SINAN), the National Household Sample Survey (PNAD), the Brazilian Institute of Geography and Statistics (IBGE), Primary Health Care Secretariat (SAPS), and National Registry of Health Facilities (CNES)(Chart 1). The information pertains to 26 Brazilian state capitals and the Federal District for the period spanning between 2018 and 2020, collected in August and September, 2022.

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Table 1
Average tuberculosis mortality rate of older adults in Brazilian capitals and Federal District , per 100,000 inhabitants, 2023.
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Chart 1
Description, source, and year, of independent variables used in the study, for Brazilian capitals and Federal District, 2022.

The decision to assess data from 2018 was taken to ensure statistical analysis with a maximum 5-year dataset using the latest data available. However, due to the COVID-19 pandemic, data for 2021 and 2022 could not be used because there was a significant change in the number of deaths from tuberculosis during these years. However, 2020 was kept in the analysis, since the data from the year still reflected the stability In tuberculosis mortality rates in the overall population, according to the time-series to be examined later.

The decision to analyze the state capital cities was based on the fact that these centers have greater social inequalities, large population concentrations, precarious housing conditions, high migration rates, and uneven distribution of resources13,14.

The dependent variable was defined as the tuberculosis mortality rate of individuals aged ≥60 years, between 2018 and 2020, in Brazilian state capital cities.

Mortality rate was calculated based on the ratio between total number of people aged ≥60 who died from tuberculosis and the resident population aged ≥60 in the capital city in question. The absolute number of older adults who died from tuberculosis was obtained from the SINAN platform for the Brazilian capital cities and the Federal District, in 2018, 2019 and 2020, using the category “Death from tuberculosis” according to the International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10, from A15.0 to A19.9). The 36 codes for clinical presentations of the disease with respiratory transmission were used (Chart 2). The information on the population aged ≥60 years, for both genders, residing in each capital during the period of interest, was obtained from data for PNAD 2018, 2019 and 2020.

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Table 2
Descriptive statistics for sociodemographic, service access and health indicators of Brazilian capitals and Federal District, 2023.
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Chart 2
Clinical forms of tuberculosis according to the International Classification of Diseases and Related Health Problems (ICD-10), Federal District, 2023.

The tuberculosis mortality rate in older adults was calculated for all Brazilian state capitals in 2018, 2019 and 2020, and multiplied by 100,000. This yielded the tuberculosis mortality rate for the capital cities of 26 Brazilian states plus the Federal District. Based on these figures, the average mortality rate of each year for each Brazilian capital city and the Federal District over the period was calculated.

The independent variables were elected based on studies analyzing the relationship between tuberculosis mortality in the general population and socioeconomic, health, and service access factors15,16. Fourteen variables grouped under the categories “Sociodemographic indicators”, “Services access indicators”, and ”Health indicators” were used (Chart 1).

The data were tabulated and descriptive and inferential statistics determined. The association between the dependent variable and independent variables was measured using a multiple linear regression model with backward elimination, and a level of statistical significance of p≤0.05.

The present study was based on secondary data from the public domain and, therefore, the need for approval by the Research Ethics Committee was waived, pursuant to Resolution 510/2016 of the National Board of Health.

DATA AVAILABILITY

The data set underpinning the study results is available from Figshare at 10.6084/m9.figshare.29857043.

RESULTS

Over the period spanning from 2018 to 2020, the average tuberculosis mortality rate of older adults in Brazilian state capital cities was 5.8 deaths/100,000. Mortality rates of older individuals were found to be higher than the national average in 7 capital cities: Manaus, São Luís, Belém, Recife, Rio de Janeiro, Porto Alegre and Boa Vista (Table 1).

The capital cities of the Northeast region had the highest mortality rates in the country, with a regional rate of 7.8 deaths/100,000, while the city of São Luís, Maranhão state, had the highest overall rate of 21.2 deaths/100,000. For the cities in the North region, the average rate was 5.7 deaths/100,000, with the city of Manaus, Amazonas state, registering a rate of 18.3 deaths/100,000 (Table 1).

The capital cities of the South, Southeast and Mid-West regions registered the lowest average mortality rates. The city of Porto Alegre, Rio Grande do Sul state, had the highest rate in these regions at 13.5 deaths/100,000, whereas Florianópolis, Santa Catarina state, had the lowest rate of all Brazil´s state capitals at 0.9/100,000 (Table 1).

The results of the descriptive statistical analysis of the independent variables, classified into sociodemographics, service access, and health indicators, are presented in Table 2. The analysis yielded a mean value of these variables for the Brazilian capital cities over the study period.

The results of the multiple linear regression model between tuberculosis mortality of older adults from 2018 to 2020 and sociodemographic, service access and health indicators, are presented in Table 3. On the output model, after adjustment, 3 variables explained tuberculosis mortality in older adults: Gini index (β=86.122; p=0.006); coinfection by HIV/tuberculosis (β=0.584; p=0.015) and coverage of Family Health Strategy (β= -0.144; p=0.038).

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Table 3
Relationship between tuberculosis mortality in older adults and sociodemographic, health, and service access indicators of Brazilian capitals and Federal District, 2023.

DISCUSSION

This study revealed that social inequality, as measured by the Gini index, coinfection by HIV/tuberculosis, and lower geographic coverage by the Family Health Strategy were associated with tuberculosis mortality in older adults in Brazilian state capitals and the Federal District. These results corroborate the findings of previous studies on tuberculosis in the general population and its relationship with socioeconomic, health and service access factors6,17,18.

The information obtained in this study is based on data collected in 2022 on deaths from tuberculosis in Brazilian state capitals and the Federal District, among older adults, in 2018, 2019 and 2020. The year 2020 marked the start of the COVID-19 pandemic, events which shifted the tuberculosis situation in Brazil. Following the outbreak, there was a decline in tuberculosis testing in the country, a decrease in notifications and cure rates, as well as an increase in treatment abandonment7,19. Some factors, such as changes in routine and difficulties accessing health services, redeployment of professionals and resources, in addition to loss of follow-up of patients undergoing treatment, were cited as reasons contributing to the changes in tuberculosis statistics seen in Brazil during the pandemic17,20,21.

Relative to previous years, there was a decline in the incidence of tuberculosis among the general population, with registered cases decreasing from 37.0 and 37.3 per 100,000 inhabitants in 2018 and 2019, respectively, to 32.7/100,000 in 20207. However, the rate of tuberculosis mortality in the general population during the study period remained stable relative to previous years, with rates of 2.17 and 2.15 deaths per 100,000 in 2018 and 2019, respectively, versus 2.15 deaths/100,000 in 20207. In the ensuing years, tuberculosis mortality reached the highest values recorded since 2013, with rates of 2.4 and 2.7 deaths/100,000 in 2021 and 2022, respectively7. This shift in pattern, together with the study objective, whose scope did not include the analysis of tuberculosis-related deaths among older adults amid the pandemic, led to the exclusion of these data from the statistical analysis. Thus, it was decided to retain the analysis of data only for the years 2018, 2019 and 2020.

In the present study, the socioeconomic variable “Gini index” exhibited a statistically significant association with death from tuberculosis among older individuals. The index reflects social, economic, and service access inequalities, suggesting that, in Brazilian capitals, social inequalities explain the high rate of mortality from the disease in older adults22.

Although the social determinants associated with mortality of older adults due to tuberculosis have not been widely explored in the scientific literature, studies highlight that the social environment, inequities, and precarious living conditions of some population groups directly influence the risk of death from the disease10,16. Tuberculosis for example, because it is prevalent in poorer underserved areas, is influenced by external factors, such as low income and education, low quality housing and food, besides the presence of other chronic diseases without proper treatment10,16.

Moreover, these issues are exacerbated in cities with urban sprawl and stark social inequalities, such as Brazilian capitals, together with poor urban infrastructure and difficulties in health care provision, particularly with respect to Primary Care14,16. These factors, in major urban centers, also impact the risk of infection by tuberculosis, in as much as they promote greater frequency and intensity of contact with people living with the active disease, while also favoring reactivation of the latent disease in previously infected individuals14,16.

In addition to social inequality, this study revealed the relationship between HIV/tuberculosis coinfection in the general population and tuberculosis mortality of older adults in Brazilian state capitals. Irrespective of age, people living with HIV/AIDS are at greater risk of contamination by the tuberculosis-causing bacillus, development of active tuberculosis, reactivation of latent infection, and death from the disease23,24. This can be explained by the relationship between immunosuppression and risk of tuberculosis progression, constituting one of the leading causes of hospitalization and death among people with HIV4.

In this context, addressing HIV/tuberculosis coinfection in older adults is important, given that the incidence of coinfected individuals is rising with the aging of the population25. This is related to the growing number of cases of sexually transmitted infections and people living with HIV, and also to the increase in new infections and reactivation of latent cases in older adults23. Furthermore, older individuals living with HIV who acquire tuberculosis experience an increase in viral replication, speeding up progression to AIDS18,26.

Another factor involved is the delay and difficulty receiving diagnosis and treatment for both tuberculosis and HIV in older adults, largely due to physiological, social and individual factors. These circumstances underscore the importance of screening for HIV at the time of tuberculosis diagnosis for all individuals, particularly older adults4,25. When individuals are diagnosed with both diseases, integrated care should be provided, taking into account the interaction between anti-retrovirus and tuberculosis treatments, as well as the interaction of these therapies with continuous use medications and their impact on tolerability of drugs. The factors and specificities of HIV/tuberculosis coinfection in older individuals contribute to worse outcomes23,24, including lower cure rates, and higher rates of treatment abandonment and mortality23.

Although no consensus exists in the literature on whether the population aged ≥60 is the largest group of patients coinfected with HIV/tuberculosis, studies show a 209% increase in the incidence of this coinfection in older adults between 2002 and 2012 in Brazil23, impacting mortality rates. Besides the consequences of this coinfection on health of the individual, with a direct association with worse outcomes, it also exacerbates poverty, social inequality, and lack of access to care, fueling a cycle of vulnerability and marginalization of older individuals with tuberculosis18,27.

Also, there was a statistically significant association between the population coverage of the Family Health Strategy and the study outcome, where areas with low coverage had higher rates of mortality due to tuberculosis in older adults28. The Family Health Strategy, representing an important model for health care and prevention of deaths from tuberculosis, is able to assist from the early stages of the disease28. This care model helps identify suspected cases, providing diagnoses, following up treatments and monitoring contacts, as well as promoting disease prevention actions28. Thus, the low population coverage represents contingents of the population without access to these care technologies, contributing to higher mortality.

Locations with high population coverage by Family Health Strategy teams have a lower incidence tuberculosis, higher rate of notification of new cases, higher cure rate29, and low tuberculosis mortality rates28. Moreover, these areas tend to have a lower likelihood of submitting incomplete (ignored or left blank) notifications, or reporting cases with extrapulmonary disease30. In cases of reinfection, individuals who are followed by the Family Health Strategy have lower probability of HIV/tuberculosis coinfection and unfavorable outcomes30.

Tuberculosis mortality in socioeconomically vulnerable individuals is lower in areas with higher coverage by Family Healthy Strategy teams28,29. Regarding this aspect, Durovni et al.30 found an association between the presence of these teams and higher rates of treatment success, in both new patients and individuals with disease recurrence, independently of socioeconomic or health variables30.

The Family Health Strategy can help reduce tuberculosis mortality by establishing a bond with patients, allowing closer supervision of older individuals by health professionals30. This can be achieved through home visits, comprehensive long-term follow-up of patients, and by directly observed therapy and active search of missing patients30. The implementation of directly observed therapy by professionals in daily contact with vulnerable patients involves provision of emotional support and monitoring of adverse effects of medications, regarded as an effective strategy for frail older adults4. Additionally, Family Health Strategy teams are able to promote access to Brazilian National Health (SUS) services, an important model of care and prevention of death from tuberculosis in older individuals29.

This study has some limitations, principally in relation to the use of secondary data. While tuberculosis is a compulsory notifiable disease, underreporting and incorrect or incomplete filling out of notification forms hampers access to robust data reflecting the actual mortality rates of the disease. Also, the use of independent variables is also constrained by the lack of a centralized information system. In addition, the context of the COVID-19 pandemic precluded the inclusion of the most recent data on tuberculosis mortality in Brazil. Given that mortality rates registered in 2021 and 2022 differed significantly, data for these years were not included to better meet the primary objective of the study of analyzing tuberculosis in older individuals from a multidimensional perspective, as opposed to exploring the impact of the pandemic on tuberculosis mortality in this population group.

Further studies investigating tuberculosis in older adults from a multidimensional perspective considering social context should be conducted to help inform disease control strategies and public policies aimed at treating older individuals with tuberculosis.

CONCLUSION

Tuberculosis is an emerging infectious disease of global concern, particularly in locations with stark inequalities and poor access to healthcare. The present study investigating socioeconomic, health, and service access indicators, helped elucidate tuberculosis mortality in older adults in Brazilian state capitals and the Federal District. Of the 14 variables analyzed, the factors social inequality, coinfection by HIV/tuberculosis, and low coverage by the Family Health Strategy, were found to be associated with the outcome.

Although a disease predominantly affecting younger individuals, the unfavorable outcomes and high mortality rates of tuberculosis in older individuals in large urban center underscores the importance of the issue in the context of an aging population. Hence, the study results highlight the importance of an interdisciplinary approach to tuberculosis, in view of its relationship with social, economic and individuals determinants.

  • Funding
    No financial support was received for this study.

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Edited by

  • Edited by
    Larissa Neves Quadros

Publication Dates

  • Publication in this collection
    17 Oct 2025
  • Date of issue
    2025

History

  • Received
    13 Apr 2025
  • Accepted
    13 Aug 2025
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