Assessment of the quality of health information on the Internet: evidence-based accuracy indicators for tuberculosis

Paolucci, Rodolfo; Pereira Neto, André; Nadanovsky, Paulo

doi:10.1590/0103-1104202213501

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ORIGINAL ARTICLE • Saúde debate 46 (135) 06 Jan 2023Oct-Dec 2022 • https://doi.org/10.1590/0103-1104202213501I copy

Assessment of the quality of health information on the Internet: evidence-based accuracy indicators for tuberculosis

About the authors

ABSTRACT

Not long ago, someone had to buy a newspaper, a book, or a magazine or go to a library to obtain information. Today, the Internet quickly facilitates a myriad of information. However, the information provided may be obsolete, incomplete, incorrect, or deliberately false: fake news. In the health field, this information can affect well-being or harm individuals and society. Thus, professionals, researchers, and institutions have assessed the quality of information on health websites to address this issue. Evaluations often verify the accuracy of the information provided. However, the information accuracy indicators have yet to be constructed from Evidence-Based Medicine (EBM). This article aims to build indicators from EBM practices, analyzing the case of tuberculosis. This manuscript proposes 43 information accuracy indicators that evaluated the tuberculosis information available on the Brazilian Ministry of Health. The results indicate that much information needs to be included, and some data must be corrected. This evaluation reiterates the importance of building EBM accuracy indicators. This work intends to encourage new studies about assessing the quality of health information on the Internet.

KEYWORDS
Evidence-based medicine; Internet; Access to information; Indicators (statistics); Tuberculosis

Introduction

Not long ago, someone had to buy a newspaper, a book, or a magazine or go to a distant, not very accessible library to obtain information. Letters were sent by post, and took some time to reach their final destination. Today, the Internet offers new opportunities for access and production of information¹1 Pereira Neto A, Barbosa L, Flynn M. Prefácio da edição brasileira – Há décadas em que nada acontece. Há semanas em que décadas acontecem. In: Pereira Neto A, Flynn M, organizadores. Internet e saúde no Brasil: desafios e tendências. 1. ed. São Paulo: Cultura Acadêmica; 2021. p. 7-18.. Anyone can access, produce, and share the information previously restricted to certain sociocultural groups²2 Pereira Neto A, Paolucci R. Avaliação da qualidade da informação de saúde na internet: análise das iniciativas brasileiras. In: Pereira Neto A, Flynn M, organizadores. Internet e saúde no Brasil: desafios e tendências. 1. ed. São Paulo: Cultura Acadêmica; 2021. p. 257-291.. To this end, it is necessary to acquire an electronic communication device, to have technological conditions of access to the network, and to have the ability to handle these tools. For example, information can be accessed, produced, and shared on a website, blog, or Facebook profile. The volume of information available on the Internet is countless and covers any subject³2 Pereira Neto A, Paolucci R. Avaliação da qualidade da informação de saúde na internet: análise das iniciativas brasileiras. In: Pereira Neto A, Flynn M, organizadores. Internet e saúde no Brasil: desafios e tendências. 1. ed. São Paulo: Cultura Acadêmica; 2021. p. 257-291.. Citizens can have all kinds of information at their disposal very quickly. Much information would only be accessed at the same speed⁴4 Cheng C, Dunn M. Health literacy and the Internet: a study on the readability of Australian online health information. Aust New Zeal J Public Heal. 2015; 39(4):309-14. with the Internet. Digital media are increasingly pervasive and ubiquitous, reaching the point of building ‘smart cities’ and marking their presence in all things that surround and serve us⁵5 João BN, Souza CL, Serravo FA. A systematic review of smart cities and the internet of things as a research topic. Cad EBAPEBR. 2020; 17(4):1115-30..

Health stands out as one of the areas with a growing volume of information available to an increasing number of interested people. The national survey coordinated by the Brazilian Internet Steering Committee (CGI.br) indicates that 45% of Internet users searched for information related to health or health services⁶6 Martinhão MS. Pesquisa sobre o uso das tecnologias de informação e comunicação nos domicílios brasileiros: TIC domicílios 2018. São Paulo: Comitê Gestor da Internet no Brasil; 2019. [acesso em 2022 out 5]. Disponível em: https://www.cgi.br/media/docs/publicacoes/2/12225320191028-tic_dom_2018_livro_eletronico.pdf.
https://www.cgi.br/media/docs/publicacoe... . This type of information has remained Brazilians’ second-largest information search activity, behind only information about products and services. In 2020, the total number of Brazilian Internet users who sought this type of information reached 53%⁷7 Barbosa AF. Pesquisa sobre o uso das Tecnologias de Informação e Comunicação nos domicílios brasileiros: TIC Domicílios 2020: edição COVID-19: metodologia adaptada. São Paulo: Comitê Gestor da Internet no Brasil; 2021. [acesso em 2022 out 5]. Disponível em: https://www.cgi.br/media/docs/publicacoes/2/20211124201233/tic_domicilios_2020_livro_eletronico.pdf.
https://www.cgi.br/media/docs/publicacoe... .

Access to quality health information on the Internet can positively affect health system managers⁸8 Park H, Lee S-I, Hwang H, et al. Can a health information exchange save healthcare costs? Evidence from a pilot program in South Korea. Int J Med Inf. 2015; 84(9):658-66.,⁹9 Spoelman WA, Bonten TN, Waal MWM, et al. Effect of an evidence-based website on healthcare usage: an interrupted time-series study. BMJ Open. 2016; 6(11). and citizens¹⁰10 Eysenbach G. The impact of the Internet on cancer outcomes. CA-A CANCER J Clin. 2003; 53(6):356-71.. Quality information promotes health promotion, as it facilitates the development of skills that give citizens greater decision-making power over their health and self-care¹¹11 Garbin H, Guilam M, Pereira Neto A. Internet na promoção da saúde: um instrumento para o desenvolvimento de habilidades pessoais e sociais. Physis. 2012; 22(1):347-363.,¹²12 Pereira Neto A, Ribeiro B, Guljor AP, et al. Eu quero entrar na rede: análise de uma experiência de inclusão digital com usuários do Caps. Saúde debate. 2020; (44):58-69.. It can also interfere with the traditional asymmetrical doctor-patient relationship¹³13 Garbin HB, Pereira Neto A, Guilam MCR. A internet, o paciente expert e a prática médica: uma análise bibliográfica. Interface – Comum. Saúde, Educ. 2008; (26):579-88.. On the other hand, incorrect, incomprehensible, or outdated information can trigger decision-making harmful to health. Therefore, access to low-quality information can adversely affect the health of citizens.

In this context, Lemos¹⁴14 Lemos A. Cidade e mobilidade. Telefones celulares, funções pós-massivas e territórios informacionais. MATRIZes. 2007; 1(1):121-37. makes a distinction between mass and post-mass media. The first has a centralized flow of information, where firms control the information to serve their financing agents. They play an important social and political role in shaping public opinion. The information is addressed to people in an undifferentiated way, with little interacting possibility. In turn, post-mass media work from networks where anyone can produce information. In this case, there is neither a content producer pole nor dependence on advertising funds. The product is customizable and multidirectional, aimed at particular niches that translate specific interests. These conditions facilitate the flourishing outdated, incomplete, incorrect, or deliberately lying posts: fake news.

Oliveira¹⁵15 Oliveira T. Como enfrentar a desinformação científica? Desafios sociais, políticos e jurídicos intensificados no contexto da pandemia. Liinc em Revista. 2020; (16):e5374. admits three possibilities for addressing disinformation. In his view, this can be accomplished through fact-checking tools. The author also understands that citizens have the competency to make rational decisions based on their search for information. She suggests media and information literacy. Given the amount of information disseminated on a large scale in digital media, quality assessment can be considered another possibility to tackle fake news. It seems imperative to us vis-à-vis websites linked to public institutions.

In the last decade, researchers evaluating the quality of health information on the Internet have advanced in producing knowledge on how to deal with this issue. In a systematic review¹⁶16 Paolucci R, Neto AP. Methods for evaluating the quality of information on health websites: Systematic Review (2001-2014). Lat Am J Dev. 2021; 3(3):994-1056. on evaluation methods, no study used Evidence-Based Medicine (EBM) practices for developing indicators for the criterion of information accuracy: “a criterion to assess the conformity of information with the best and most current scientific evidence available”¹⁶16 Paolucci R, Neto AP. Methods for evaluating the quality of information on health websites: Systematic Review (2001-2014). Lat Am J Dev. 2021; 3(3):994-1056.⁽¹⁵⁹⁾. In these studies, as analyzed in two previous reviews¹⁷17 Eysenbach G, Powell J, Kuss O, et al. Empirical Studies Assessing the Quality of Health Information for Consumers on the World Wide Web. JAMA. 2002; 287(20):2691-700.,¹⁸18 Zhang Y, Sun Y, Xie B. Quality of health information for consumers on the web: A systematic review of indicators, criteria, tools, and evaluation results. J Assoc Inf Sci Technol. 2015; 66(10):2071-84., the information accuracy indicators were constructed through the consensus of experts, scientific and technical manuals, medical guidelines, textbooks, or literature. Paolucci, Pereira Neto, and Nadanovsky¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88. developed a set of methods to fill this gap.

This article aims to build evidence-based indicators addressing the specific case of tuberculosis. Tuberculosis was chosen due to its high incidence and mortality in Brazil, especially among the poor population living in urban areas²⁰20 Brasil. Ministério da Saúde, Secretaria de Vigilância em Saúde. Boletim Epid. 2019 [acesso em 2018 jan 13]; (9). Disponível em: http://portalarquivos2.saude.gov.br/images/pdf/2019/marco/22/2019-009.pdf.
http://portalarquivos2.saude.gov.br/imag... .

Material and methods

We employed the methods developed by Paolucci, Pereira Neto, and Nadanovsky¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88. to build indicators. They propose that information accuracy indicators be based on the best available scientific evidence. This article followed the seven-step set of methods: search strategy, evidence-based information source selection, topic collection and selection, development of the first version of indicators, group analysis, topic analysis, and indicator analysis.

Developing information accuracy indicators

In the first step, carried out on April 17, 2019, we applied the search strategy using the word “tuberculosis” in the ACCESSSS²¹21 McMaster U. About. 2019. [acesso em 2019 maio 30]. Disponível em: https://www.accessss.org/Pages/About.
https://www.accessss.org/Pages/About... meta-search service, which returned 140 results in the fourth level of organization of evidence distributed in three sources of information.

In the second step, we selected DynaMed Plus²²22 DynaMed. About DynaMed Clinical Decision Support Tool. 2019. [acesso em 2019 maio 7]. Disponível em: https://www.dynamed.com/home/about.
https://www.dynamed.com/home/about... as a source of information to develop the indicators as it currently offers evidence-based guidance¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88.. We also considered other similar platforms for collecting adequate information to construct accuracy indicators when making this option. A recent study¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88. compared sources of information similar to DynaMed Plus. In this study, we used DynaMed Plus, as this platform provides synthesized summaries for clinical reference. It stands out for its quality and way of presenting the results¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88., and we also managed to narrow down the search results to 40.

In the third stage, we collected and selected TB-related topics. We applied the exclusion criteria proposed by the authors of the method on topics addressing specific drugs and tests, meta topics, or topics without information¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88.. Thus, we arrived at a total of 20 topics included in our sample.

In the fourth step, we read the topics and wrote the initial version of the indicators. Next, we classified the indicators into groups representing issues relevant to tuberculosis. As a result, we developed the first version of 180 information accuracy indicators (annex 1). However, we considered this number of indicators too extensive to be applied in evaluating health sites aimed at users.

In the fifth step, the group analysis allowed gathering of all indicators in at least one of the dimensions we specified for tuberculosis: prevention, transmission, symptoms, diagnosis, and treatment. In this analysis, we identified 27 indicators that needed to be grouped. The total number of indicators by dimension was as follows: prevention (30), transmission (22), symptoms (22), diagnosis (54), and treatment (60). Some indicators were classified into two dimensions simultaneously. This overview of the number of indicators in each group and possible intersections between them allowed us to reflect on how the sample could be circumscribed to meet the research objectives. It is necessary to shortlist the number of indicators to a feasible set containing essential information to evaluate websites on TB aimed at users. Furthermore, the purpose of health site reviews is not to gather all available evidence on tuberculosis. In this regard, we decided to circumscribe the selected sample of topics found in DynaMed Plus. We, therefore, returned to ponder on the topics included.

In the sixth step, we applied an exclusion criterion in the analysis of topics following the ideas proposed by the authors of the method¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88.. The criterion is related to the incidence of different types of TB. This information was found on the service pages themselves. We can include the types of tuberculosis in the pulmonary and extrapulmonary groups.

Pulmonary TB is estimated to have reached ten million people and caused 1.6 million deaths worldwide in 2017 alone²³23 DynaMed. Record No. T116300. Pulmonary Tuberculosis. 2018. [ acesso em 2019 jul 23]. Disponível em: https://www.dynamed.com/topics/dmp~AN~T116300.
https://www.dynamed.com/topics/dmp~AN~T1... . Regarding extrapulmonary TB, we have the following data: abdominal tuberculosis accounts for 5% of cases of extrapulmonary TB; bone and joint, for 10% of cases; disseminated or miliary, for 20% of cases; genitourinary, for about 5-6% of cases; and TB lymphadenitis, for 35% of cases²⁴24 Paolucci R. Avaliação da qualidade da informação em sites de saúde: indicadores de acurácia baseada em evidência para tuberculose. [tese]. Rio de Janeiro: Fundação Oswaldo Cruz; 2020. 149 p.. Given the higher incidence of pulmonary TB than other forms of the disease, we excluded 99 indicators that contained specific information on extrapulmonary TB and reached a total of 81 indicators.

In the seventh and final stage, we analyzed the included indicators. We evaluated the wordings of the initial version as they were written almost as translations of the original clinical texts found in DynaMed Plus. The wording of the indicator should be intelligible to health professionals and users. Thus, they will be able to observe their presence or not on health websites¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88.. In this analysis, we applied three methods of reformulating, gathering, and excluding indicators, as guided by Paolucci, Pereira Neto, and Nadanovsky¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88..

First, the three exclusion criteria proposed by the authors were used: technical information; considerations about diagnoses or treatments; and information intended for professionals or managers of health systems. The application of these criteria excluded 26 indicators, reducing the total to 55.

Then, we combined indicators with similar or complementary contents. The gathering was made with the information included in more than one indicator and by developing a new indicator wording based on information from two or three indicators. These methods reduced the number of indicators by twelve, totaling 43 information accuracy indicators in the final sample (table 1).

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Table 1
Final version of the 43 ‘accuracy’ indicators for tuberculosis

Finally, we gathered content differently. However, it did not reduce the total because our analysis identified that the indicators involved were better written by transferring a piece of evidence from one indicator to the other. This procedure was performed in only one case.

Website selection

We arbitrarily selected a website to apply the developed indicators¹⁶16 Paolucci R, Neto AP. Methods for evaluating the quality of information on health websites: Systematic Review (2001-2014). Lat Am J Dev. 2021; 3(3):994-1056.. The chosen one is hosted on the Ministry of Health (MS) portal and is a glossary called ‘Health from A to Z’²⁵25 Brasil. Ministério da Saúde. Saúde de A a Z – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-de-a-a-z.
https://www.gov.br/saude/pt-br/assuntos/... . The pages of this glossary provide official information on health approved by the Brazilian Federal Government. For this reason, they are highlighted in Google Search and easily accessible by managers, health professionals, and users. This MS portal can be considered the main information reference for all state and municipal health secretariats. The information available it contains can be considered reliable. We located the topic ‘Tuberculosis’²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... under the letter ‘t’ of the glossary. So, we decided to evaluate the information available on this topic with the developed indicators.

Applying the indicators

Our proposed procedure for applying the accuracy indicators uses the same scale across the board: ‘incorrect’, ‘not found’, ‘incomplete’, and ‘complete’. This scale represents our judgment on the information found on the site when comparing it with the information from the indicators developed. The wording of the indicators was designed to contain all essential and evidence-based information that allows for assessing the quality of the information contained in a website.

Thus, both health professionals and users can evaluate the information. The idea is that the evaluator checks whether the indicator is available on the website and how it is arranged. If the information is not found, the evaluator should consider it ‘not found’.

If it is found but is wrong, the evaluator should consider it ‘incorrect’. Where the information is partial, the evaluator should consider it ‘incomplete’. However, if any part of the information contained in the indicator is wrong, even if another part is correct, we recommend that the evaluator deems it ‘incorrect’ for the indicator. Information should only be assessed as ‘complete’ if found and is correct as per the indicator. We employed this procedure on the selected page on February 24, 2022.

Results

Figure 1 presents the results of the seven stages¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88. for developing information accuracy indicators. We developed 43 indicators to assess the quality of information on tuberculosis for Internet users (table 1). We defined dimensions for tuberculosis to show how they were organized: prevention, transmission, symptoms, diagnosis, and treatment. The indicators are organized into groups within each dimension.

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Figure 1
Methodological flowchart

The prevention dimension contains 16 indicators. It holds the most significant number of indicators, evenly distributed into four groups. The ‘BCG’ group contains information related to the Bacillus Calmette-Guérin (BCG) vaccine as its main subject. The ‘HIV’ group contains indicators with this virus as the main related subject. The group ‘Child guardian’ contains information on preventive actions when those responsible for the children have had contact with TB. The main subject in the fourth group is ‘Children’.

The ‘transmission’ dimension contains six information accuracy indicators organized into five groups. There is only one indicator per group, except the group involving the population of ‘Children’. The ‘General’ group does not contain indicators based on specific information about a population, health condition, or intervention. Indicators in this group include information intended for the general population. This group was also created for all the next dimensions we defined. The group ‘General risk factors’ includes information intended for the general population. The group ‘Risk factors and HIV’ contains indicators of factors specific to people with HIV. The group ‘Risk Factors and Children’ contains two information accuracy indicators for this population. The fifth group, ‘Risk Factors and Resistant Tuberculosis’, is based on information on factors related to drug-resistant types of tuberculosis.

The ‘symptoms’ dimension contains two indicators classified into two groups: ‘General’ and ‘Children’. The ‘TB diagnosis’ dimension contains eight indicators organized into four groups, each with two indicators. The first group is ‘General’, the second is ‘HIV’, and the third is ‘Children’. The fourth group, ‘Resistant Tuberculosis’ contains indicators based on information related to the diagnosis of drugresistant tuberculosis.

The ‘TB treatment’ dimension contains eleven indicators categorized into four groups. The first group, ‘General’, contains three indicators. The second group was classified as ‘HIV’ and contained two indicators. The ‘Resistant Tuberculosis’ group contains five indicators. The fourth group, ‘Side effects’, contains an indicator based on information whose main subject is the possible side effects resulting from a treatment.

We used the procedure for applying the 43 information accuracy indicators on the TB page in the ‘Health from A to Z’ glossary of the MS²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... portal. The information was considered ‘incorrect’ in one indicator, ‘not found’ in 29, ‘incomplete’ in eleven, and ‘complete’ in only two indicators, which reveals poor compliance. Much evidence-based information could be available on this site entirely and correctly. Most of the information was not found or needed to be completed. Also, some information was found to need to be corrected. The complete evaluation result is shown in table 2.

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Table 2
Evaluation of the topic ‘Tuberculosis’ in the MS glossary

Discussion

We highlight four cases that represent the existence of ‘complete’, ‘incomplete’, ‘not found’, and ‘incorrect’ information on the evaluated page.

The first is from the indicator developed within the TB transmission dimension that belongs to the ‘General’ group: ‘Tuberculosis is transmitted by air from one person to another when bacteria are expelled as aerosols by someone with pulmonary tuberculosis’ (Id 131, table 2). When investigating the glossary page, the information found is complete despite being written differently. The evidence supporting this indicator’s development refers to two book chapters²³23 DynaMed. Record No. T116300. Pulmonary Tuberculosis. 2018. [ acesso em 2019 jul 23]. Disponível em: https://www.dynamed.com/topics/dmp~AN~T116300.
https://www.dynamed.com/topics/dmp~AN~T1... . The first is from a manual of clinical microbiology in its tenth edition²⁷27 Pfyffer G, Palicova F. Mycobacterium: General characteristics, laboratory detection, and staining procedures. In: Versalovic J, Carroll K, Funke G, et al., editores. Manual of Clinical Microbiology. 10. ed. Washington: American Society for Microbiology Press; 2011. p. 472-502.. The second is from a book that is in its eighth edition²⁸28 Fitzgerald D, Sterling T, Haas D. Mycobacterium tuberculosis. In: Bennett J, Dolin RBM, editores. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8. ed. New York: Saunders; 2015. p. 2787-2818.. Both references are traditional teaching textbooks and contain consolidated knowledge. They can also be considered outdated because the time required for their production cannot keep up with advances in medical knowledge²⁹29 Burwell DS. Acquiring the evidence: How to find current best evidence and have current best evidence find us. In: Straus SE, Glasziou P, Richardson WS, et al., editores. Evidence-based medicine: how to practice and teach EBM. 5. ed. Elsevier Health Sciences; 2019. p. 57-90.. However, they are referred to as the best evidence in this case. Information on the ‘transmission of tuberculosis’ can be considered consolidated knowledge or has undergone a few changes over the years. In this sense, it is traditionally known information that the glossary makes available in full.

The second case concerns the indicator developed within the ‘TB transmission’ dimension that is part of the group ‘Risk factors and

HIV’: HIV is the most critical risk factor for tuberculosis. People with HIV are 20 to 30 times more likely to develop tuberculosis than HIV-negative people. Risk factors include: (1) residence in tuberculosis-endemic regions, (2) close contact with tuberculosis patients, (3) crowded housing (including incarceration), (4) poor ventilation in the home or work environments, (5) malnutrition, and (6) limited access to quality health care. (Id 93, table 2). We found the following in the glossary:

People Living with HIV (PLHIV)
Tuberculosis in people living with HIV is one of the conditions with the most significant impact on HIV and TB mortality in the country. These people are at greater risk of developing tuberculosis and are often only diagnosed with HIV infection during the investigation/confirmation of TB²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... .

In this case, we considered the glossary information ‘incomplete’. The evidence²⁹29 Burwell DS. Acquiring the evidence: How to find current best evidence and have current best evidence find us. In: Straus SE, Glasziou P, Richardson WS, et al., editores. Evidence-based medicine: how to practice and teach EBM. 5. ed. Elsevier Health Sciences; 2019. p. 57-90. that supported the construction of this indicator refers to a review that investigated the state-ofthe- art knowledge about the HIV-TB relationship³⁰30 DynaMed. Record No. T909352, Latent Tuberculosis Infection in Patients With HIV. 2019. [acesso em 2019 jul 22]. Disponível em: https://www.dynamed.com/topics/dmp~AN~T909352.
https://www.dynamed.com/topics/dmp~AN~T9... . The authors define this relationship as a syndemic, i.e., “convergence of two or more diseases that act synergistically to increase the burden of disease”³¹31 Kwan C, Ernst JD. HIV and tuberculosis: A deadly human syndemic. Clin Microbiol Rev. 2011; 24(2):351- 76.⁽³⁵²⁾. It has had lethal consequences globally. The MS glossary only reports that HIV is “one of the conditions with the greatest impact on mortality”²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... . This information is close to the indicator’s assertion that HIV is the most important risk factor for TB. However, there is a relevant difference: HIV is highlighted in DynaMed Plus, which gives greater centrality to the relationship between the two diseases, a relationship that is currently considered inseparable³⁰30 DynaMed. Record No. T909352, Latent Tuberculosis Infection in Patients With HIV. 2019. [acesso em 2019 jul 22]. Disponível em: https://www.dynamed.com/topics/dmp~AN~T909352.
https://www.dynamed.com/topics/dmp~AN~T9... . The same can be said about developing the disease. The MS glossary states that people with HIV are at greater risk of developing TB²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... . The indicator contains information that this population is 20 to 30 times more likely to develop TB than people without HIV (Id 93, table 2). The indicator provides accurate and quantified risk information, highlighting the problem of this interaction between HIV and TB. Moreover, only some risk factors contained in the indicator are available in the glossary. Therefore, we assessed this information as ‘incomplete’.

The third case is the indicator built within the TB prevention dimension and the ‘BCG’ group, which states that ‘Babies should not be vaccinated with BCG in the following two cases: suspected HIV infection; or born to women with HIV’ (Id 26, table 2). When investigating the glossary page²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... , we did not find any information about vaccine contraindications. We considered this information to be ‘not found’ in the glossary. The evidence³²32 DynaMed. Record No. T905489, Bacille Calmette- Guerin (BCG) Vaccine. 2018. [acesso em 2019 jul 18]. Disponível em: https://www.dynamed.com/topics/dmp~AN~T905489.
https://www.dynamed.com/topics/dmp~AN~T9... that supported the development of this indicator refers to two publications linked to the World Health Organization (WHO). The first is a 2007 publication of its weekly epidemiological bulletin³³33 World Health Organization. Revised BCG vaccination guidelines for infants at risk for HIV infection. Wkly Epidemiol Rec. 2007; 82(21):193-6.. The second document was published in 2015 by one of the prominent international organizations fighting tuberculosis: Stop TB Partnership³⁴34 Stop TB. Partnership. The global plan to stop TB 2011- 2015: Transforming the fight towards elimination of tuberculosis. 2011 [acesso em 2022 out 5]. Disponível em: http://www.stoptb.org/assets/documents/global/plan/TB_GlobalPlanToStopTB2011-2015.pdf.
http://www.stoptb.org/assets/documents/g... . The first evidence reference is a review of the BCG vaccine guidelines for children at risk for HIV³³33 World Health Organization. Revised BCG vaccination guidelines for infants at risk for HIV infection. Wkly Epidemiol Rec. 2007; 82(21):193-6.. The document states that the review originated from the Global Advisory Committee on Vaccine Safety (GACVS) after analyzing more recent data at the time. This review refers to two studies that produced evidence of contraindication for BCG. Published in 2005, the first analyzed the late complications of BCG vaccination in HIV-infected children³⁵35 Fallo A, Torrado L, Sanches A, et al. Delayed complications of Bacille Calmette-Guerin (BCG) vaccination in HIV-infected children. In: 3 IAS Conference on HIV Pathogenesis and Treatment. 2005 jul 25-27. Rio de Janeiro: International AIDS Society; 2005.. The second was conducted at a South African hospital and concluded:

[…] the risk of disseminated BCG disease increases by several hundredfolds in HIV-infected infants, compared to the documented risk in HIV-uninfected infants³⁶36 Hesseling AC, Marais BJ, Gie RP, et al. The risk of disseminated Bacille Calmette-Guerin (BCG) disease in HIV-infected children. Vaccine. 2007; 25(1):14-8.⁽¹⁴⁾.

Revising the guidelines and changing the vaccine recommendation in these cases show the relevance of EBM practice to keep up with the advancement of medical knowledge. The findings of the two mentioned studies are the evidence that triggered the update of guidelines, which, in turn, led to the update of the online clinical text found in DynaMed Plus. The MS glossary is not guided by such practices, as there is no information on cases of contraindication for the BCG vaccine. Moreover, the documents that formed the basis for DynaMed Plus were published at least seven years ago.

This third case is that of the ‘not found’ indicator. The lack of information prevailed in our assessment in 29 out of 43 indicators used. Given this reality, we consider it relevant to make a few more comments on this case. There needs to be more information on all five dimensions defined for TB. Information on the BCG vaccine is missing under ‘prevention’.

Moreover, no data is available on prevention aimed at people living with HIV, children, and those responsible for children who are vulnerable to tuberculosis in some way. Regarding ‘transmission’, no information on risk factors for children and infection with resistant tuberculosis was found. Data on specific symptoms for the child population is also missing. Specific information for the HIV-infected population needs to be included under the ‘diagnosis’. This dimension needs more information on the child population and resistant tuberculosis. Finally, there is a lack of information on treatments aimed at the general population and people with HIV and information on the treatment of resistant tuberculosis and its side effects.

The fourth and final case is the indicator developed within the tuberculosis symptoms dimension and the ‘General’ group: ‘Symptoms suggestive of pulmonary tuberculosis are fever, fatigue, weight loss, night sweats, hemoptysis (blood in the sputum), or cough for two or more weeks; these symptoms combined with pleuritis (chest pain on inspiration and expiration) may also indicate tuberculosis’ (Id 133, table 2). We found the following information in the MS glossary:

What are the symptoms of tuberculosis?
Cough for three weeks or more
Evening fever
Night sweats
Slimming
The main symptom of pulmonary tuberculosis is coughing. This cough can be dry or productive (with phlegm).
IMPORTANT: We recommend that every person with respiratory symptoms, that is, with a cough for three weeks or more, be investigated for tuberculosis²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... .

We considered the glossary information to be ‘incorrect’ in this case. We returned to the DynaMed Plus website to verify the evidence supporting this indicator’s development. It is the result of the analysis of information from three topics: ‘Hemoptysis – Approach to the Patient’³⁷37 DynaMed. Record No. T920582, Hemoptysis – Approach to the Patient. 2018. [acesso em 2019 jul 19]. Disponível em: https://www.dynamed.com/topics/dmp~AN~T920582.
https://www.dynamed.com/topics/dmp~AN~T9... , ‘Pleuritis – Approach to the Patient’³⁸38 DynaMed. Record No. T922350, Pleuritis – Approach to the Patient. 2018. [acesso em 2019 jul 22]. Disponível em: https://www.dynamed.com/topics/dmp~AN~T922350.
https://www.dynamed.com/topics/dmp~AN~T9... , and ‘Pulmonary Tuberculosis’²³23 DynaMed. Record No. T116300. Pulmonary Tuberculosis. 2018. [ acesso em 2019 jul 23]. Disponível em: https://www.dynamed.com/topics/dmp~AN~T116300.
https://www.dynamed.com/topics/dmp~AN~T1... . The evidence available on these topics makes three references.

The first is the book chapter presented in the first case of the indicator on TB transmission²⁸28 Fitzgerald D, Sterling T, Haas D. Mycobacterium tuberculosis. In: Bennett J, Dolin RBM, editores. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. 8. ed. New York: Saunders; 2015. p. 2787-2818.. The second is a paper and concerns the evidence that allowed including pleuritis as one of the possible TB symptoms in the indicator¹⁸18 Zhang Y, Sun Y, Xie B. Quality of health information for consumers on the web: A systematic review of indicators, criteria, tools, and evaluation results. J Assoc Inf Sci Technol. 2015; 66(10):2071-84.. The wording of the indicator considers pleuritis as a symptom. However, this information is not included in the glossary. The third reference is the document entitled ‘International Standards for Tuberculosis Care, Edition 3’⁴⁰40 World Health Organization. International Standards for Tuberculosis Care. 3. ed. 2014. [acesso em 2019 dez 5]. Disponível em: https://www.who.int/publications/m/item/international-standards-fortuberculosis-care-(istc).
https://www.who.int/publications/m/item/... , published in 2014 with funding from important institutions addressing TBs⁴¹41 Management Sciences for Health. Home. 2020 [acesso em 2020 jan 4]. Disponível em: https://www.msh.org.
https://www.msh.org... . The document addresses diagnosis, treatment, and Public Health issues, especially norms. The point we highlight in this document is related to information about the cough symptom.

The discussion of the standard emphasizes the importance of including not only cough but also fever, night sweats, and weight loss as indicators for evaluating tuberculosis⁴⁰40 World Health Organization. International Standards for Tuberculosis Care. 3. ed. 2014. [acesso em 2019 dez 5]. Disponível em: https://www.who.int/publications/m/item/international-standards-fortuberculosis-care-(istc).
https://www.who.int/publications/m/item/... ⁽⁶⁾.

There is a concern about highlighting other symptoms besides cough. In another part of the document, the following guidance appears in the description of the same standard:

All patients, including children, with an unexplained cough lasting two or more weeks or with suggestive unexplained TB findings on chest radiographs should be evaluated for tuberculosis⁴⁰40 World Health Organization. International Standards for Tuberculosis Care. 3. ed. 2014. [acesso em 2019 dez 5]. Disponível em: https://www.who.int/publications/m/item/international-standards-fortuberculosis-care-(istc).
https://www.who.int/publications/m/item/... ⁽⁹⁾.

Then, the document justifies and summarizes the evidence supporting the standard. The data shown in the document consider that cough is one of the symptoms, but it is not the only or the main one.

According to the TB CARE I⁴⁰40 World Health Organization. International Standards for Tuberculosis Care. 3. ed. 2014. [acesso em 2019 dez 5]. Disponível em: https://www.who.int/publications/m/item/international-standards-fortuberculosis-care-(istc).
https://www.who.int/publications/m/item/... , research indicates that 10 to 25% of patients with diagnosed tuberculosis report no cough. The document cites a study conducted in India with 55,561 patients that compared coughing for two or more weeks with coughing for three or more weeks as a reason for performing a diagnostic test⁴²42 Santha T, Garg R, Subramani R, et al. Comparison of cough of 2 and 3 weeks to improve detection of smearpositive tuberculosis cases among out-patients in India. Int J Tuberc Lung Dis. 2005; 9(1):61-8.. It states that the investigation of patients who had a cough for two or more weeks increased the number of suspected TB cases by 61% and confirmed cases by 46%. Santha et al.⁴²42 Santha T, Garg R, Subramani R, et al. Comparison of cough of 2 and 3 weeks to improve detection of smearpositive tuberculosis cases among out-patients in India. Int J Tuberc Lung Dis. 2005; 9(1):61-8. concluded that the screening criterion for sputum microscopy is cough after two weeks.

As mentioned, this fourth and last case is considered ‘incorrect’ according to the evaluation carried out on the page on TB in the MS glossary. Besides not presenting the hemoptysis and pleuritis symptoms, the glossary describes the cough symptom inaccurately. It characterizes cough as the primary symptom, while the evidence guides the importance of highlighting the other symptoms. Another issue is a persistent glossary with outdated information on the duration of cough as a symptom suggestive of TB. The study that identified the benefits of investigating tuberculosis in patients with a cough of two weeks or more dates from 2005⁴²42 Santha T, Garg R, Subramani R, et al. Comparison of cough of 2 and 3 weeks to improve detection of smearpositive tuberculosis cases among out-patients in India. Int J Tuberc Lung Dis. 2005; 9(1):61-8..

Cough is the traditionally known and reported symptom. For example, the official channel of the Ministry of Health on YouTube has a video of a campaign to encourage early TB diagnosis⁴³43 Brasil. Ministério da Saúde. (472) #Tuberculose Filme oficial. [YouTube]. 2011. [acesso em 2019 ago 8]. Disponível em: https://www.youtube.com/watch?v=Dt5zJQsnWzw.
https://www.youtube.com/watch?v=Dt5zJQsn... . It addresses only the cough as a symptom. As in the MS glossary, it is stated that coughing for three or more weeks may indicate TB, and the disease’s cure depends on early diagnosis. The duration of cough, available in the evidence used in the document⁴⁰40 World Health Organization. International Standards for Tuberculosis Care. 3. ed. 2014. [acesso em 2019 dez 5]. Disponível em: https://www.who.int/publications/m/item/international-standards-fortuberculosis-care-(istc).
https://www.who.int/publications/m/item/... , is shorter than the time reported in the glossary²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... and the campaign⁴³43 Brasil. Ministério da Saúde. (472) #Tuberculose Filme oficial. [YouTube]. 2011. [acesso em 2019 ago 8]. Disponível em: https://www.youtube.com/watch?v=Dt5zJQsnWzw.
https://www.youtube.com/watch?v=Dt5zJQsn... . Thus, investigating TB in patients with cough from two weeks onwards could contribute to the early diagnosis of TB and the cure of the disease.

Final considerations

The four cases discussed confirm the importance of the indicators developed in this work based on the EBM practices¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88.. The 43 information accuracy indicators can be translated into other languages and used to assess the quality of TB websites in any country.

In Brazil, the indicators can be used to update the MS TB page²⁶26 Brasil. Ministério da Saúde. Tuberculose – Português (Brasil). 2022. [acesso em 2022 fev 24]. Disponível em: https://www.gov.br/saude/pt-br/assuntos/saude-dea-a-z/t/tuberculose/tuberculose.
https://www.gov.br/saude/pt-br/assuntos/... ‘Health from A to Z’ glossary and align it with the best and most current scientific evidence. Evaluating the glossary with these indicators can be understood as a diagnosis of the quality of the information on this site. Those responsible for the website can access the result and verify the changes or inclusions of information that can be made.

In this sense, all topics in the ‘Health from A to Z’ glossary could be submitted to the same evaluation process. The methods can be replicated for other health issues contained in the glossary¹⁹19 Paolucci R, Neto A, Nadanovsky P. Avaliação da acurácia da informação em sites de saúde: Métodos para construção de indicadores baseados em evidência. Em Questão. 2021; 27(4):137-88.. They will facilitate retrieving reliable scientific evidence to develop information accuracy indicators on any health issue. This glossary evaluation work should be performed urgently to ensure that the website of this national reference public institution is constantly updated and provides correct information.

The problems of low quality and lack of information on portals such as the MS are directly related to the low importance of health information and communication on the Internet for public health managers and researchers. Brazilian science, technology, and innovation policymakers must be aware of new information and communication technologies’ role in societies around the planet.

In the fourth case discussed in this article, the investigation of patients who had a cough for two weeks increased the number of suspected TB cases by 61% and confirmed TB cases by 46%⁴⁰40 World Health Organization. International Standards for Tuberculosis Care. 3. ed. 2014. [acesso em 2019 dez 5]. Disponível em: https://www.who.int/publications/m/item/international-standards-fortuberculosis-care-(istc).
https://www.who.int/publications/m/item/... . These data indicate a significant increase in early diagnosis and, consequently, in the early treatment of the disease. This essential information should be corrected in the MS ‘Health from A to Z’ glossary. Correct information per high information accuracy standards can prevent complications that lead to death and, thus, save lives.

Therefore, this paper addresses a relevant subject in the current academic setting, where the Internet has become one of the most soughtafter sources of health information, especially after the SARS-CoV-2 pandemic. However, interest in information security has remained the same. We recommend that further studies be carried out addressing this discussion.

Financial support: non-existent

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Annex 1
First version of 180 ‘accuracy’ indicators for TB

References

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³⁸
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⁴³
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» https://www.youtube.com/watch?v=Dt5zJQsnWzw

Publication Dates

Publication in this collection
06 Jan 2023
Date of issue
Oct-Dec 2022

History

Received
15 July 2022
Accepted
21 Sept 2022

Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative Commons Attribution, que permite uso, distribuição e reprodução em qualquer meio, sem restrições desde que o trabalho original seja corretamente citado.

Id	Indicators
Prevention and BCG Group dimension
23	[ Indicator ] The BCG vaccine should be given soon after birth in countries with a high prevalence of tuberculosis. It should also be applied if there is no information about the mother having HIV, as the benefits outweigh the risks. [ Evidence ] 1) BCG vaccination as soon as possible after birth in countries with a high tuberculosis (TB) prevalence revaccination not recommended. 2) benefits outweigh risks in infants born to women of unknown HIV status and should be immunized [ Reference ] 1) http://www.dynamed.com/topics/dmp~AN~T905489#Overview 2) http://www.dynamed.com/topics/dmp~AN~T905489#Overview
26	[ Indicator ] Babies should not be vaccinated with BCG in the following two cases: suspected HIV infection; or are born to women with HIV. [ Evidence ] Risks usually outweigh benefits for infants and should not be immunized if HIV infection is suspected or if born to woman with HIV infection [ Reference ]http://www.dynamed.com/topics/dmp~AN~T905489#Overview
29	[ Indicator ] In countries with a low prevalence of tuberculosis, the BCG vaccine should only be considered for children under the following conditions: negative skin test for tuberculosis; continuous exposure to tuberculosis; and cannot receive long-term primary preventive treatment. Besides these conditions, the vaccine should be considered if children cannot be separated from adults under the following conditions: ineffectively treated for tuberculosis; did not receive treatment; or have strains of tuberculosis resistant to isoniazid and rifampicin. [ Evidence ] Centers for Disease Control and Prevention (CDC) recommendations - consider BCG vaccination only in children - with negative TB skin test - with continual exposure - who cannot be separated from adults who - are ineffectively treated or untreated for TB and child cannot be given long-term primary preventive treatment for TB infection - have TB strains resistant to isoniazid and rifampicin [ Reference ]http://www.dynamed.com/topics/dmp~AN~T905489#Overview
41	[ Indicator ] Revaccination of the BCG vaccine as a booster is not recommended. Moreover, the vaccine is unreliable against pulmonary tuberculosis for adults and older children. [ Evidence ] 1) revaccination not recommended 2) BCG is unreliable against adult forms of pulmonary tuberculosis. - efficacy variable (0% to > 80%) in older children and adults, with some reports of net harm ( JAMA 2004 May 5;291(17):2127) [ Reference ] 1) http://www.dynamed.com/topics/dmp~AN~T905489#Overview 2) http://www.dynamed.com/topics/dmp~AN~T905489#Efficacy
Prevention and HIV Group dimension
20	[ Indicator ] HIV patients traveling or working in TB endemic regions should be counseled about the risks of the disease and the need to be tested for latent TB infection. [ Evidence ] Counsel patients with HIV who travel or work in tuberculosis (TB)-endemic regions about the risks of TB and need for testing for latent TB infection (LTBI) upon return. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909161#Prevention-and-Screening
21	[ Indicator ] Patients with HIV and latent tuberculosis infection, with no previous treatment, should receive preventive therapy with isoniazid. [ Evidence ] Patients with HIV and LTBI, no evidence of active TB, and no previous treatment for active or latent TB should receive isoniazid preventative therapy (IPT) (CDC/NIH/IDSA Grade A-I) [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909161#Prevention-and-Screening
22	[ Indicator ] Antiretroviral therapy can reduce the incidence of tuberculosis in patients with HIV infection. [ Evidence ] Antiretroviral therapy may reduce incidence of tuberculosis in patients with HIV infection regardless of baseline CD4 T-cell count (level 2 [mid-level] evidence) [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909161#Prevention-and-Screening
102	[ Indicator ] Preventive therapy with isoniazid for children with HIV infection is associated with reduced mortality and incidence of tuberculosis, but only if they do not receive antiretroviral therapy. However, if babies were immunized with the BCG vaccine, this preventive therapy may not improve TB-free survival, whether or not they have HIV. [ Evidence ] Efficacy of IPT in children with HIV infection IPT may not reduce mortality or active TB in children with HIV infection receiving ART (level 2 [mid-level] evidence) IPT in children with HIV infection not receiving ART associated with reduced mortality and incidence of TB (level 2 [mid-level] evidence) IPT may not improve TB-disease-free survival in infants with or without HIV infection immunized with Bacille Calmette–Guérin (BCG) vaccine (level 2 [mid-level] evidence) [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909352#Isoniazid-preventative-therapy-IPT
Prevention and Child Guardian Group dimension
28	[ Indicator ] If the mother has a positive sputum smear (sputum test) for tuberculosis, the baby should receive 6 months of preventive therapy with isoniazid, followed by immunization with the BCG vaccine. An alternative is to perform a tuberculin skin test after 3 months of isoniazid. If the test is negative, isoniazid should be stopped and the BCG vaccine given. If positive, isoniazid should be continued for another 3 months before the BCG vaccine. [ Evidence ] Breastfeeding infant - has high risk of infection from mother with smear-positive pulmonary TB and high risk of developing TB - should receive 6 months of isoniazid preventive therapy, followed by BCG immunization alternative policy is to give 3 months of isoniazid, then perform tuberculin skin test (TST) - if TST negative, isoniazid should be stopped and BCG vaccination given - if TST positive, isoniazid should be continued for another 3 months, after which it should be stopped and BCG given [ Reference ]http://www.dynamed.com/topics/dmp~AN~T905489#Overview http://www.dynamed.com/topics/dmp~AN~T905489#Recommendations
160	[ Indicator ] When a child guardian has a positive result for tuberculosis and a normal chest radiograph, the recommendations are: it is not necessary to separate the mother from the baby; no special evaluation or therapy for the baby; other family members should be evaluated for tuberculosis; and the mother can breastfeed the baby. [ Evidence ] If mother (or household contact) has positive tuberculin skin test or IGRA and normal chest x-ray(8) no separation of mother and infant required no special evaluation or therapy required for infant other household members should be evaluated for tuberculosis as positive test may represent unrecognized case of contagious tuberculosis mother can breastfeed infant [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Management-of-infant-born-to-mother-with-tuberculosis
161	[ Indicator ] Some measures must be taken when a child guardian has clinical symptoms or X-ray abnormalities compatible with tuberculosis. First, evaluate the baby for congenital tuberculosis and separate the guardian from the child until a complete evaluation is performed. If congenital tuberculosis is excluded, preventive therapy with isoniazid should be used for 3 to 4 months. When the child receives isoniazid, separation is no longer necessary, except under the following conditions regarding those responsible: suspected infection with drug resistant tuberculosis; low adherence to therapy; and directly observed therapy is impossible. If the mother has non-resistant tuberculosis and is treated properly for more than 2 weeks, she is allowed to breastfeed the baby. [ Evidence ] If mother (or household contact) has clinical signs and symptoms or abnormal findings on x-ray consistent with tuberculosis disease(8) immediately report to local health department evaluate infant for congenital tuberculosis separate mother (or household contact) from infant until full evaluation can be done, and if tuberculosis suspected, until mother found not to have tuberculosis mother and child both receive appropriate therapy mother understands and is willing to adhere to infection-control measures once infant receives isoniazid, separation not required unless mother (or household contact) has suspected drug resistant tuberculosis infection has poor adherence to therapy and directly observed therapy not possible women with drug-susceptible infection treated appropriately for ≥ 2 weeks may breastfeed if congenital tuberculosis excluded, give isoniazid for 3-4 months and perform skin test if skin test is positive reassess for tuberculosis disease if tuberculosis disease excluded, continue isoniazid for total of 9 months evaluate infants for signs of tuberculosis monthly during treatment if skin test is negative, and mother has good treatment adherence, discontinue isoniazid [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Management-of-infant-born-to-mother-with-tuberculosis
162	[ Indicator ] The following measures should be taken when a child guardian tests positive for tuberculosis, abnormal chest radiograph results and has no evidence of tuberculosis disease: the child can be considered at low risk of disease and separation is not necessary; the mother should be treated for latent tuberculosis infection; and other family members should be evaluated. [ Evidence ] If mother (or household contact) has positive skin test or IGRA and abnormal findings on chest x-ray but no evidence of tuberculosis disease(8) infant can be assumed to be at low risk of disease, and separation not necessary treat mother for latent tuberculosis infection evaluate other household members [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Management-of-infant-born-to-mother-with-tuberculosis
Prevention and Child Group dimension
153	[ Indicator ] Preventive therapy with isoniazid is considered for all infants and children with latent tuberculosis and no history of previous tuberculosis treatment. Therapy consists of the use of isoniazid for 6 months for children under 5 years of age. [ Evidence ] 1) consider isoniazid preventative therapy for all infants and children with latent tuberculosis infection who have no evidence of active disease or history of previous tuberculosis treatment 2) both the World Health Organization (WHO) and American Academy of Pediatrics (AAP) recommend preventative therapy for children with latent tuberculosis infection (LTBI)(6, 8) WHO recommends isoniazid preventative therapy (10 mg/kg/day, maximum 300 mg/day) for 6 months to children aged < 5 years who are household or close contacts of people with tuberculosis but do not have active disease (WHO Strong recommendation, High-quality evidence) [ Reference ] 1) http://www.dynamed.com/topics/dmp~AN~T908867#Prevention-of-active-disease 2) http://www.dynamed.com/topics/dmp~AN~T908867#Prevention-of-active-disease
154	[ Indicator ] Preventive therapy should be initiated in all children under 4 years of age with impaired immunity who are exposed to patients with contagious tuberculosis, regardless of the results of diagnostic tests. [ Evidence ] Initiate preventative therapy in all children < 4 years old with impaired immunity exposed to patients with contagious tuberculosis regardless of diagnostic testing results [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Prevention-of-active-disease
157	[ Indicator ] In the prevention of tuberculosis in children with latent infection, rifapentine and isoniazid directly observed once a week for 3 months appear to be as effective as isoniazid once a day for 9 months. [ Evidence ] Directly observed rifapentine plus isoniazid once weekly for 3 months appears as effective as isoniazid once daily for 9 months in preventing tuberculosis in children with LTBI (level 2 [mid-level] evidence) [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Prevention-of-active-disease
158	[ Indicator ] Four-month rifampicin may be as effective as 9-month isoniazid in children with latent tuberculosis infection. [ Evidence ] Four-month rifampicin may be as effective as 9-month isoniazid in children with LTBI (level 2 [mid-level] evidence) [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Prevention-of-active-disease
Transmission and General Group dimension
131	[ Indicator ] Tuberculosis is transmitted through the air from one person to another when the bacteria are sprayed in an aerosol by a person with pulmonary tuberculosis. [ Evidence ] M. tuberculosis is spread through the air from one person to another when bacteria are aerosolized from a person with pulmonary TB. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T116300#Background
Transmission and General Risk Factors Group dimension
132	[ Indicator ] Risk factors for pulmonary tuberculosis are: (1) close contact with a person with infectious tuberculosis; (2) children under 5 years of age with a positive tuberculin skin test; (3) people who immigrated from regions of the world with high rates of tuberculosis; (4) groups with high rates of tuberculosis transmission, including people with HIV infection, injecting drug users and people living on the street; (5) work or reside with people at high risk of tuberculosis in facilities or institutions; (6) medical conditions that weaken the immune system such as treatment with immunosuppressive drugs, diabetes, malignancy, organ transplantation, silicosis, substance abuse disorder, severe kidney disease, or low body weight. [ Evidence ] Risk factors for developing TB include: Close contacts of a person with infectious TB disease. Children < 5 years old who have a positive tuberculin skin test. Persons who have immigrated from regions of the world with high rates of TB. Groups with high rates of TB transmission including persons with HIV infection, injection drug users, and homeless persons. Working or residing with people at high risk for TB in facilities or institutions. Medical conditions that weaken the immune system such as HIV infection, treatment with immunosuppressive medications, diabetes, malignancy, organ transplantation, silicosis, substance abuse disorder, severe kidney disease, or low body weight. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T116300#Background
Transmission and Risk Factors and HIV Group dimension
93	[ Indicator ] HIV is the most important risk factor for tuberculosis. People with HIV are 20 to 30 times more likely to develop tuberculosis than HIV-negative people. Risk factors include: (1) residence in tuberculosis-endemic regions, (2) close contact with tuberculosis patients, (3) crowded housing (including incarceration), (4) poor ventilation in home or work environments, (5) malnutrition and (6) limited access to quality health care. [ Evidence ] About 32% of patients with TB are co-infected with HIV. HIV is the single most important risk factor for TB and persons with HIV are 20-30 times more likely to develop TB than HIVnegative persons. Additional risk factors include residence in TB-endemic regions, close contact with patients with TB, crowded housing (including incarceration), poor ventilation in living or working quarters, poor nutrition, and limited access to quality health care. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909352#Background
Transmission and Risk Factors and Children Group dimension
27	[ Indicator ] There is a high risk of infection and development of tuberculosis while breastfeeding if mothers test positive for a sputum smear (sputum test). [ Evidence ] breastfeeding infant - has high risk of infection from mother with smear-positive pulmonary TB and high risk of developing TB [ Reference ]http://www.dynamed.com/topics/dmp~AN~T905489#Overview
139	[ Indicator ] Factors associated with an increased risk of developing tuberculosis in children include recent acquisition of infection, younger age, compromised immunity (particularly HIV infection), and chronic comorbidities such as diabetes mellitus. [ Evidence ] Major risk factors for acquisition of infection include birth or residence in an endemic area, exposure to adults with active TB, and exposure to second hand smoke. Factors associated with increased risk of progressing from latent infection to active disease include recent acquisition of infection, younger age, immunocompromise, particularly HIV infection, and chronic comorbidities such as diabetes mellitus. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Background
Transmission and Risk Factors and Resistant TBs dimension
52	[ Indicator ] The risk factors for resistant tuberculosis are: (1) previous treatment exceeding one month; (2) history of treatment failure or TB relapse; (3) poor adherence or non-completion of medications during previous treatment; (4) exposure to people with this type of disease; (5) or to persons whose standard treatment is failing or has failed; (6) delayed treatment; (7) positive sputum smear (sputum test) after two months of combination therapy; (8) HIV; (9) foreign birth; (10) younger age; (11) female; (12) previous arrest; (13) and residence or travel to an area with a high prevalence of drug resistant tuberculosis. [ Evidence ] 1) Risk factors for MDR and XDR TB: - prior TB treatment (> 1 month) - failure of a TB treatment regimen containing second-Line drugs including an injectable agent and a fluoroquinolone - close contact with a patient with MDR TB, XDR TB, or with a patient whose treatment regimen including second-line drugs is failing or has failed - delayed treatment - HIV - foreign birth - younger age - female sex - previous imprisonment 2) Risk factors for MDR TB include: exposure to persons with MDR TB a history of TB with treatment failure or relapse poor adherence to or not completing anti- TB medications during previous TB treatment positive sputum smears after 2 months of standard anti-TB combination therapy residence in or travel to area with a high prevalence of drug resistance [ Reference ] 1) http://www.dynamed.com/topics/dmp~AN~T908130#Background 2) http://www.dynamed.com/topics/dmp~AN~T907301#Background
Symptoms and General Group dimension
133	[ Indicator ] Symptoms suggestive of pulmonary tuberculosis are fever, fatigue, weight loss, night sweats, cough, or hemoptysis (blood in the sputum). These symptoms combined with pleuritis (chest pain on inspiration and expiration) can also indicate tuberculosis. [ Evidence ] 1) Suspect pulmonary tuberculosis (TB) in patients with suggestive symptoms including fever, fatigue, weight loss, night sweats, cough, or hemoptysis. 2) inflammation of parietal pleura resulting in sudden and intense chest pain on inhalation and exhalation(1) ask about symptoms that may appear in combination with pain malaise may indicate malignancy(3) pleural effusion(1) tuberculosis(1) rheumatoid arthritis(1) weight loss may indicate malignancy(3) pleural effusion(1) tuberculosis(1) rheumatoid arthritis(1) fever may indicate(1) pneumonia tuberculosis familial Mediterranean fever systemic lupus erythematosus medication-induced pleuritis (Clin Chest Med 2004 Mar;25(1):141) other infection night sweats may indicate malignancy(3) pleural effusion (including malignant pleural effusion)(1) tuberculosis(1) rheumatoid arthritis(1) 3) Diagnostic testing for cause of hemoptysis may include: - blood tests, including coagulation testing and interferon-gamma release assay or Mantoux screen if suspected tuberculosis [ Reference ] 1) http://www.dynamed.com/topics/dmp~AN~T116300#Evaluation 2) http://www.dynamed.com/topics/dmp~AN~T922350#Description http://www.dynamed.com/topics/dmp~AN~T922350#History-of-present-illness-HPI 3) http://www.dynamed.com/topics/dmp~AN~T920582#Evaluation
Symptoms and Children Group dimension
144	[ Indicator ] Symptoms suggestive of tuberculosis in children are cough and/or fever, weight loss or failure to thrive, lymphadenopathy (enlarged lymph nodes), hepato/splenomegaly (enlarged liver/ spleen), meningitis, ascites, or others. [ Evidence ] Consider the diagnosis of tuberculosis (TB) in children born in endemic areas or with known exposure to an adult with active TB, presenting with cough and/or fever, weight loss or failure to thrive, lymphadenopathy, hepato- or splenomegaly, meningitis or ascites, or other suggestive signs and symptoms. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Evaluation
Diagnosis and General Group dimension
130	[ Indicator ] Pulmonary tuberculosis is the clinical syndrome of infection of the respiratory system caused by the mycobacterium tuberculosis. [ Evidence ] Pulmonary tuberculosis (TB) refers to the clinical syndrome associated with infection of the respiratory system caused by Mycobacterium tuberculosis. The World Health Organization estimates that in 2017, 10 million people developed TB and 1.6 million died from the disease, with 9,093 cases reported in the United States. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T116300#Background
134	[ Indicator ] The diagnosis of pulmonary tuberculosis is confirmed with the identification of mycobacteria in the respiratory sample of patients with symptoms of the disease. Tests used for diagnosis include sputum smear (sputum test), nucleic acid amplification test, and liquid and solid mycobacterial culture test (gold standard for diagnosis). The diagnosis is often complemented with radiological abnormalities of the chest and evidence of the immune response by the tuberculin skin test and/or by the interferon gamma release test. [ Evidence ] Identification of Mycobacterium tuberculosis in respiratory specimen confirms diagnosis of pulmonary TB in patients with compatible clinical symptoms. Tests used for bacteriologic diagnosis include: Acid fast bacillus (AFB) smear microscopy, though this test is not specific to M. tuberculosis. Nucleic acid amplification testing (NAAT). Liquid and solid mycobacterial culture (gold standard for diagnosis). Diagnosis often supplemented with additional evidence such as: Chest x-ray abnormalities. Evidence of immune response by tuberculin skin test (TST) and/or interferon gamma release assay (IGRA), though these tests will also be positive in patients with previously treated TB or latent TB infection. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T116300#Evaluation
Diagnosis and HIV Group dimension
12	[ Indicator ] The diagnosis of tuberculosis in patients with HIV is challenging due to the high frequency of negative cases on sputum smear (sputum test), the atypical radiographic presentation, and even extrapulmonary manifestations. [ Evidence ] Diagnosis of tuberculosis (TB) in patients with HIV is challenging due to high frequency of smear-negative cases, atypical radiographic presentation, and extrapulmonary manifestations. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909161#Evaluation
13	[ Indicator ] All patients with HIV and suspected tuberculosis should have a chest X-ray immediately. For symptomatic patients with normal chest radiographs, sputum test and culture should be considered. [ Evidence ] All patients with suspected TB should have chest x-ray early in the course of investigation (Strong recommendation). - Radiologic presentation of chest x-ray varies with state of immunodeficiency. - In patients with CD4 T-cell count > 350 cells/mm3, presentation may resemble that in patients uninfected with HIV including upper lobe infiltrates, cavitation, and pleural disease. - In patients with profound immunocompromise, cavitation is less common and x-ray findings may include pleural effusion, lower or middle lobe infiltrates, miliary infiltrates, mediastinal adenopathy, interstitial nodules, or normal x-ray. - Consider sputum smear and culture in symptomatic patients with normal chest x-rays. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909161#Evaluation
Diagnosis and Children Group dimension
145	[ Indicator ] Children with suspected tuberculosis infection should have a tuberculin skin test or interferon gamma release test. If the result is positive, they should have a complete physical examination, including a careful neurological evaluation and a chest X-ray. If the result is negative, further evaluation is considered in children who remain at risk of acquiring tuberculosis, as a negative result does not exclude active disease. [ Evidence ] Screen children with suspected latent or active infection using either a tuberculin skin test (TST) or interferon gamma release assay (IGRA). TST is preferred in children < 5 years old, but IGRA is preferred in children ≥ 5 years old with history of bacille Calmette-Guérin (BCG) vaccination. Either test is acceptable in children > 5 years old who lack a history of BCG vaccination. In children who screen positive, perform a thorough physical examination, including a careful neurologic assessment and a chest x-ray. In children who screen negative, consider additional evaluation in those who remain at increased risk for TB, as a negative result does not rule out active disease. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Evaluation
146	[ Indicator ] In the absence of bacterial confirmation, the diagnosis of tuberculosis can be made clinically based on risk factors, symptoms, and/or chest X-ray features. [ Evidence ] In the absence of bacterial confirmation, the diagnosis can be made clinically based on risk factors, signs and symptoms and/or characteristic chest x-ray findings. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908867#Evaluation
Diagnosis and Resistant TB Group dimension
51	[ Indicator ] Multi-resistant tuberculosis is the form of tuberculosis resistant to at least isoniazid and rifampicin. Extensively resistant tuberculosis, in addition to these two drugs, is resistant to any fluoroquinolone and at least one of the three injectable drugs: amikacin, kanamycin or capreomycin. [ Evidence ] 1) MDR TB is defined as TB caused by Mycobacterium tuberculosis resistant to at least isoniazid and rifampicin. An estimated 460,000 cases of MDR TB emerged globally in 2017. 2) XDR TB is defined as TB caused by Mycobacterium tuberculosis resistant to isoniazid, rifampicin, any fluoroquinolone, and at least 1 of 3 injectable second-line drugs (amikacin, kanamycin, or capreomycin). [ Reference ] 1) http://www.dynamed.com/topics/dmp~AN~T907301#Background 2) http://www.dynamed.com/topics/dmp~AN~T908130#Background
105	[ Indicator ] The signs of multi and extensively resistant tuberculosis do not differ from common tuberculosis. The diagnosis is traditionally confirmed with culture and drug susceptibility testing. [ Evidence ] 1) The clinical presentation of MDR TB does not differ from that of drug-susceptible TB. MDR TB diagnosis is traditionally confirmed with culture and drug-susceptibility testing. 2) Clinical presentation of XDR TB does not differ from that of drug-susceptible TB. XDR TB diagnosis is confirmed with culture and drug-susceptibility testing. [ Reference ] 1) http://www.dynamed.com/topics/dmp~AN~T907301#Evaluation 2) http://www.dynamed.com/topics/dmp~AN~T908130#Evaluation
Treatment and General Group dimension
58	[ Indicator ] Every patient hospitalized with suspected tuberculosis should be allocated to airborne infection isolation with appropriate infection control measures for both healthcare workers and visitors. [ Evidence ] Any hospitalized patient with suspected TB or who has acid-fast bacilli (AFB) smear-positive sputum should be placed in airborne infection isolation with appropriate infection control measures for providers and visitors. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908130#Management
115	[ Indicator ] Directly observed therapy is preferable to self-administered therapy for the routine treatment of patients with all forms of tuberculosis. [ Evidence ] Directly observed therapy (DOT) is preferred over self-administered therapy (SAT) for routine treatment of patients with all forms of tuberculosis (Weak recommendation). [ Reference ]http://www.dynamed.com/topics/dmp~AN~T910018#Management
135	[ Indicator ] The recommended treatment for pulmonary tuberculosis is: initial phase of two months with isoniazid, rifampicin, pyrazinamide and ethambutol; and a 4-month continuation phase with isoniazid plus rifampicin. [ Evidence ] The recommended empiric treatment for newly diagnosed pulmonary TB caused by Mycobacterium tuberculosis susceptible to all first-line drugs is a 2-month initial or intensive phase followed by a 4-month continuation phase (Strong recommendation). The 2-month initial phase consists of isoniazid, rifampicin, pyrazinamide, plus ethambutol. The 4-month continuation phase consists of isoniazid plus rifampicin. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T116300#Management
Treatment and HIV Group dimension
17	[ Indicator ] Treatment in patients with HIV and suspected tuberculosis should be started immediately, even before the full diagnosis is confirmed. Treatment regimens for adults with HIV infection follow the same principles as treatment for adults without HIV. [ Evidence ] Start empiric treatment in patients with HIV and suspected tuberculosis (TB) until diagnostic work-up is complete (Strong recommendation). - Recommendations for antituberculosis treatment regimens in adults with HIV infection follow the same principles as for adults without HIV infection. - Initial phase consists of a 4-drug regimen of isoniazid (INH), rifampicin (or rifabutin), pyrazinamide, and ethambutol daily for 2 months (Strong recommendation). - Continuation phase consists of a 2-drug regimen of INH plus rifampicin (or rifabutin) daily for drug-susceptible TB (Strong recommendation). [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909161#Management
18	[ Indicator ] Corticosteroids are recommended for the treatment of tuberculosis in HIV patients with central nervous system involvement or pericardial disease. [ Evidence ] Corticosteroids are recommended for patients with CNS or pericardial disease (Strong recommendation). [ Reference ]http://www.dynamed.com/topics/dmp~AN~T909161#Management
Treatment and Resistant TB Group dimension
55	[ Indicator ] Multi- and extensively resistant tuberculosis should only be treated by specialists in these types of disease. Before obtaining drug susceptibility test results, appropriate treatment should be initiated in patients suspected of having these types of tuberculosis. [ Evidence ] 1) MDR TB should be managed by experts with experience in the treatment of drug-resistant TB. Prior to receipt of drug-susceptibility testing results, empiric treatment for MDR TB should be started in those in whom MDR TB is suspected. 2) XDR TB should be managed by only those expert in the treatment of drug-resistant TB. Prior to receipt of drug-susceptibility testing results, empiric treatment for XDR TB should be started in those in whom XDR TB is suspected. [ Reference ] 1) http://www.dynamed.com/topics/dmp~AN~T907301#Management 2) http://www.dynamed.com/topics/dmp~AN~T908130#Management
56	[ Indicator ] Treatment of extensively drug-resistant tuberculosis is guided by the results of drug susceptibility testing as follows: always try to use 3 or more previously unused drugs that have passed testing and consider regimens of four to six drugs, including one injectable. [ Evidence ] Treatment is guided by drug-susceptibility testing results: - Always try to use ≥ 3 previously unused drugs that have demonstrated in vitro susceptibility and consider regimens with 4-6 medications, including an injectable (Strong recommendation). [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908130#Management
57	[ Indicator ] For treatment of extensively resistant tuberculosis, therapy directly observed at home or in hospital should be performed daily. [ Evidence ] - Institute daily hospital-based or home-based directly observed therapy (DOT) (Strong recommendation). [ Reference ]http://www.dynamed.com/topics/dmp~AN~T908130#Management
107	[ Indicator ] The initial treatment of multidrug-resistant tuberculosis includes at least 5 antibiotics. It lasts at least 9 to 12 months. It may last longer depending on the results of drug susceptibility tests. [ Evidence ] Initial treatment includes ≥ 5 antibiotics. Duration is at least 9-12 months, and may be longer depending on drug susceptibility results. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T907301#Management
108	[ Indicator ] None of the potential treatments for people infected with multidrug resistant tuberculosis have been fully tested for efficacy and these treatments are often poorly tolerated. [ Evidence ] None of the potential regimens for persons infected with MDR TB have been tested fully for efficacy, and these regimens are often poorly tolerated [ Reference ]http://www.dynamed.com/topics/dmp~AN~T907301#Contact-investigation
Treatment and Side Effects Group dimension
136	[ Indicator ] The treatment of pulmonary tuberculosis with isoniazid should be supplemented with pyridoxine to prevent side effects in patients with nutritional deficiency, diabetes, HIV infection, renal failure, alcoholism, in pregnant and lactating women and in children. [ Evidence ] Supplement isoniazid treatment with pyridoxine 25 mg/day in patients with nutritional deficiency, diabetes, HIV infection, renal failure, or alcoholism, in pregnant and breastfeeding women, and in children to prevent adverse events. [ Reference ]http://www.dynamed.com/topics/dmp~AN~T116300#Management

Id	Indicator	Evaluation	Excerpt extracted from the topic 'Tuberculosis' of the Glossary 'Health from A to Z' of the Ministry of Health
Prevention and BCG Group dimension
23	The BCG vaccine should be given soon after birth in countries with a high prevalence of tuberculosis. It should also be applied if there is no information about the mother having HIV, as the benefits outweigh the risks.	Incomplete	The BCG (Bacillus Calmette-Guérin) vaccine, offered in the Unified Health System (SUS), protects children from the most severe forms of the disease, such as miliary tuberculosis and meningeal tuberculosis. The vaccine is available in the vaccination rooms of the basic health units and some maternity hospitals. IMPORTANT: This vaccine must be given to children at birth, or, at most, up to four years, 11 months and 29 days.
26	Babies should not be vaccinated with BCG in the following two cases: suspected HIV infection; or born to women with HIV.	Not found
29	In countries with a low prevalence of tuberculosis, the BCG vaccine should only be considered for children under the following conditions: negative skin test for tuberculosis; continuous exposure to tuberculosis; and cannot receive long-term primary preventive treatment. Besides these conditions, the vaccine should be considered if children cannot be separated from adults under the following conditions: ineffectively treated for tuberculosis; did not receive treatment; or have strains of tuberculosis resistant to isoniazid and rifampicin.	Not found
41	Revaccination of the BCG vaccine as a booster is not recommended. Moreover, the vaccine is unreliable against pulmonary tuberculosis for older adults and children.	Not found
Prevention and HIV Group dimension
20	HIV patients traveling or working in TB endemic regions should be counseled about the risks of the disease and the need to be tested for latent TB infection.	Complete	Thus, diagnosing and treating LTBI is an important prevention strategy to prevent the development of the active form of the disease, especially for: - household contacts of people diagnosed with TB - children - HIV infection - people using immunosuppressive treatments IMPORTANT: Latent infection with Mycobacterium tuberculosis should be investigated and treated and active tuberculosis diagnosed and treated early for people living with HIV.
21	Patients with HIV and latent tuberculosis infection, with no previous treatment, should receive preventive therapy with isoniazid.	Incomplete	Thus, it is important that the health team evaluate the contacts of people with TB and offer the exam for the diagnosis of LTBI to the population groups mentioned above, per the criteria for indicating the preventive treatment. Learn more about the Surveillance Protocol for Latent Infection by Mycobacterium tuberculosis in Brazil
22	Antiretroviral therapy can reduce the incidence of tuberculosis in patients with HIV infection.	Incomplete	Early diagnosis of HIV infection in people with tuberculosis and timely initiation of antiretroviral treatment reduce mortality.
102	Preventive therapy with isoniazid for children with HIV infection is associated with reduced mortality and incidence of tuberculosis, but only if they do not receive antiretroviral therapy. However, if babies were immunized with the BCG vaccine, this preventive therapy may not improve TB-free survival, whether or not they have HIV.	Not found
Prevention and Child Guardian Group dimension
28	If the mother has a positive sputum smear (sputum test) for tuberculosis, the baby should receive 6 months of preventive therapy with isoniazid, followed by immunization with the BCG vaccine. An alternative is to perform a tuberculin skin test after 3 months of isoniazid. If the test is negative, isoniazid should be stopped and the BCG vaccine given. If positive, isoniazid should be continued for another 3 months before the BCG vaccine.	Not found
160	When a child guardian has a positive result for tuberculosis and a normal chest radiograph, the recommendations are: it is not necessary to separate the mother from the baby; no special evaluation or therapy for the baby; other family members should be evaluated for tuberculosis; and the mother can breastfeed the baby.	Not found
161	Some measures must be taken when a child guardian has clinical symptoms or X-ray abnormalities compatible with tuberculosis. First, the baby should be evaluated for congenital tuberculosis and the guardian should be separated from the child until a complete evaluation is carried out. If congenital tuberculosis is excluded, preventive therapy with isoniazid should be used for 3 to 4 months. When the child receives isoniazid, separation is no longer necessary, except under the following conditions regarding those responsible: suspected infection with drug resistant tuberculosis; low adherence to therapy; and directly observed therapy is not possible. If the mother has non-resistant tuberculosis and is treated properly for more than 2 weeks, she is allowed to breastfeed the baby.	Not found
162	The following measures should be taken when a child guardian tests positive for tuberculosis, abnormal chest radiograph results, with no evidence of tuberculosis disease: the child can be considered at low risk of disease and separation is not necessary; the mother should be treated for latent tuberculosis infection; and other family members should be evaluated.	Not found
Prevention and Child Group dimension
153	Preventive therapy with isoniazid is considered for all infants and children with latent tuberculosis and no history of previous tuberculosis treatment. Therapy consists of the use of isoniazid for 6 months for children under 5 years of age.	Not found
154	Preventive therapy should be initiated in all children under 4 years of age with impaired immunity who are exposed to patients with contagious tuberculosis, regardless of the results of diagnostic tests.	Not found
157	In the prevention of tuberculosis in children with latent infection, rifapentine and isoniazid directly observed once a week for 3 months appear to be as effective as isoniazid once a day for 9 months.	Not found
158	4-month rifampicin may be as effective as 9-month isoniazid in children with latent tuberculosis infection.	Not found
Transmission and General Group dimension
131	Tuberculosis is transmitted through the air from one person to another when the bacteria are sprayed in an aerosol by a person with pulmonary tuberculosis.	Complete	Tuberculosis transmission occurs via the respiratory route, through the elimination of aerosols produced by coughing, speaking or sneezing of a person with active (pulmonary or laryngeal) TB, without treatment; and inhalation of aerosols by a susceptible individual.
Transmission and General Risk Factors Group dimension
132	Risk factors for pulmonary tuberculosis are: (1) close contact with a person with infectious tuberculosis; (2) children under 5 years of age with a positive tuberculin skin test; (3) people who immigrated from regions of the world with high rates of tuberculosis; (4) groups with high rates of tuberculosis transmission, including people with HIV infection, injecting drug users and people living on the street; (5) work or reside with people at high risk of tuberculosis in facilities or institutions; (6) medical conditions that weaken the immune system such as treatment with immunosuppressive drugs, diabetes, malignancy, organ transplantation, silicosis, substance abuse disorder, severe kidney disease, or low body weight.	Incomplete	Besides factors related to each person’s immune system and exposure to the bacillus, illness from tuberculosis is often linked to substandard living conditions. Thus, some population groups may be in greater vulnerability. The table below shows some of these populations and their respective risks of illness compared to the general population. Poorly ventilated cells, reduced sunlight and difficult access to health services: these are some of the factors that contribute to the high number of tuberculosis cases in the prison system.
Transmission and Risk Factors and HIV Group dimension
93	HIV is the most important risk factor for tuberculosis. People with HIV are 20 to 30 times more likely to develop tuberculosis than HIV-negative people. Risk factors include: (1) residence in tuberculosisendemic regions, (2) close contact with tuberculosis patients, (3) crowded housing (including incarceration), (4) poor ventilation in home or work environments, (5) malnutrition and (6) limited access to quality health care.	Incomplete	People Living with HIV (PLHIV) Tuberculosis in people living with HIV is one of the conditions with the greatest impact on HIV and tuberculosis mortality in the country. These people are at higher risk of developing TB, and are often only diagnosed with HIV infection during investigation/confirmation of TB.
Transmission and Risk Factors and Children Group dimension
27	There is a high risk of infection and development of tuberculosis while breastfeeding if mothers have a positive sputum smear test.	Not found
139	Factors associated with an increased risk of developing tuberculosis in children include recent acquisition of infection, younger age, compromised immunity (particularly HIV infection), and chronic comorbidities such as diabetes mellitus.	Not found
Transmission and Risk Factors and Resistant TBs dimension
52	The risk factors for resistant tuberculosis are: (1) previous treatment for more than one month; (2) history of treatment failure or relapse of tuberculosis; (3) poor adherence or non-completion of medications during previous treatment; (4) exposure to people with this type of disease; (5) or to people whose standard treatment is failing or has failed; (6) delayed treatment; (7) positive sputum smear (sputum test) after two months of combination therapy; (8) HIV; (9) foreign birth; (10) younger age; (11) female; (12) previous arrest; (13) and residence or travel to an area with a high prevalence of drug-resistant tuberculosis.	Not found
Dimensão Sintomas e Grupo Geral
133	Symptoms suggestive of pulmonary tuberculosis are fever, fatigue, weight loss, night sweats, hemoptysis (blood in the sputum), or coughing for two or more weeks. These symptoms combined with pleuritis (chest pain on inspiration and expiration) can also indicate tuberculosis.	Incorrect	What are TB symptoms? - Cough for 3 weeks or more - Evening fever - Night sweats - Slimming The main symptom of pulmonary tuberculosis is coughing. This cough can be dry or productive (with phlegm). IMPORTANT: It is recommended that every person with respiratory symptoms, that is, who has had a cough for three weeks or more, be investigated for tuberculosis.
Dimensão Sintomas e Grupo Children
144	Symptoms suggestive of tuberculosis in children are cough and/or fever, weight loss or failure to thrive, lymphadenopathy (enlarged lymph nodes), hepato- splenomegaly (enlarged liver/spleen), meningitis, ascites, or others.	Not found
Dimensão Diagnóstico e Grupo Geral
130	Pulmonary tuberculosis is the clinical syndrome of infection of the respiratory system caused by the mycobacteria tuberculosis.	Incomplete	Tuberculosis is an infectious and transmissible disease caused by the bacterium Mycobacterium tuberculosis, also known as Koch’s bacillus. The disease primarily affects the lungs (pulmonary form), although it can affect other organs and/or systems.
134	The diagnosis of pulmonary tuberculosis is confirmed with the identification of mycobacteria in the respiratory sample of patients with symptoms of the disease. Tests used for diagnosis include sputum smear (sputum test), nucleic acid amplification test, and liquid and solid mycobacterial culture test (gold standard for diagnosis). The diagnosis is often complemented with radiological abnormalities of the chest and evidence of the immune response by the tuberculin skin test and/or by the interferon gamma release test	Incomplete	How is TB diagnosed? The following tests are used to diagnose TB: - smear - rapid molecular test for tuberculosis - culture for mycobacteria IMPORTANT: These tests are essential to identify the tuberculosis bacillus and are used to confirm the bacteriological diagnosis of the disease.
Diagnosis and HIV Group dimension
12	The diagnosis of tuberculosis in patients with HIV is challenging due to the high frequency of negative cases on sputum smear (sputum test), the atypical radiographic presentation, and even extrapulmonary manifestations.	Incomplete	ATTENTION: For the diagnosis of tuberculosis among the most vulnerable populations (deprived of liberty, indigenous people, people living with HIV, people living on the street, and health professionals), it is recommended that everyone with cough REGARDLESS OF THE TIME OF DURATION and/or chest X-ray suggestive of tuberculosis be evaluated by the health team and perform sputum collection for sputum smear or TRM-TB, culture and sensitivity test.
13	All patients with HIV and suspected tuberculosis should have a chest X-ray immediately. Sputum tests and culture should be considered for symptomatic patients with normal chest radiographs.	Incomplete	ATTENTION: For the diagnosis of tuberculosis among the most vulnerable populations (deprived of liberty, indigenous people, people living with HIV, people living on the street, and health professionals), it is recommended that everyone with cough REGARDLESS OF THE TIME OF DURATION and/or chest X-ray suggestive of tuberculosis be evaluated by the health team and perform sputum collection for sputum smear or TRM-TB, culture and sensitivity test.
Dimensão Diagnóstico e Grupo Children
145	Children with suspected tuberculosis infection should have a tuberculin skin test or interferon gamma release test. If the result is positive, they should have a complete physical examination, including a careful neurological evaluation and a chest X-ray. If the result is negative, further evaluation is considered in children who remain at risk of acquiring tuberculosis, as a negative result does not exclude active disease.	Not found
146	TB diagnosis can be made clinically based on risk factors, symptoms, and/or chest X-ray features In the absence of bacterial confirmation.	Not found
Diagnosis and Resistant TB Group dimension
51	Multi-resistant tuberculosis is the form of tuberculosis resistant to at least isoniazid and rifampicin. Extensively resistant tuberculosis, in addition to these two drugs, is resistant to any fluoroquinolone and at least one of the three injectable drugs: amikacin, kanamycin or capreomycin.	Not found
105	The signs of multi and extensively resistant tuberculosis do not differ from common tuberculosis. The diagnosis is traditionally confirmed with culture and drug susceptibility testing.	Not found
Treatment and General Group dimension
58	Every patient hospitalized with suspected tuberculosis should be allocated to airborne infection isolation with appropriate infection control measures for both healthcare workers and visitors.	Not found
115	Directly observed therapy is preferable to self-administered therapy for the routine treatment of patients with all forms of tuberculosis.	Incomplete	One of the main strategies to promote treatment adherence is Directly Observed Treatment (DOT). DOT consists of observing the person with tuberculosis taking the medication under the observation of a health professional or other trained professionals, such as social assistance professionals, among others, provided they are supervised by health professionals. This treatment regimen should ideally be carried out on every working day of the week, or exceptionally, three times a week. The place and time for performing DOT must be agreed with the person and with the health service.
135	The recommended treatment for pulmonary tuberculosis is: initial phase of two months with isoniazid, rifampicin, pyrazinamide and ethambutol; and a 4-month continuation phase with isoniazid plus rifampicin.	Incomplete	Tuberculosis treatment lasts at least six months, is free of charge and is available through the Unified Health System (SUS). Four drugs are used for the treatment of tuberculosis cases using the basic regimen: rifampicin, isoniazid, pyrazinamide, and ethambutol.
Treatment and HIV Group dimension
17	Treatment in patients with HIV and suspected tuberculosis should be started immediately, even before the full diagnosis is confirmed. Treatment regimens for adults with HIV infection follow the same principles as treatment for adults without HIV.	Not found
18	Corticosteroids are recommended for the treatment of tuberculosis in patients with HIV who have central nervous system involvement or pericardial disease.	Not found
Treatment and Resistant TB Group dimension
55	Multi- and extensively resistant tuberculosis should only be treated by experts in these types of disease. Before obtaining drug susceptibility test results, appropriate treatment should be initiated in patients suspected of having these TB types.	Not found
56	Treatment of extensively drug-resistant tuberculosis is guided by the results of drug susceptibility testing as follows: always try to use 3 or more previously unused drugs that have passed testing and consider regimens of four to six drugs, including one injectable.	Not found
57	Directly observed therapy at home or in hospital should be performed daily for treatment of extensively resistant tuberculosis.	Not found
107	The initial treatment of multidrug-resistant tuberculosis includes at least 5 antibiotics. It lasts at least 9 to 12 months. It may last longer depending on the results of drug susceptibility tests.	Not found
108	None of the potential treatments for people infected with multidrug resistant tuberculosis have been fully tested for efficacy and these treatments are often poorly tolerated.	Not found
-Treatment and Side Effects Group dimension
136	the treatment of pulmonary tuberculosis with isoniazid should be supplemented with pyridoxine to prevent side effects in patients with nutritional deficiency, diabetes, HIV infection, renal failure, alcoholism, in pregnant and lactating women, and in children.	Not found

Centro Brasileiro de Estudos de Saúde RJ - Brazil
E-mail: revista@saudeemdebate.org.br

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