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Peer-reviewedCC BYInternational Journal of Infectious Diseases

Risk and determinants of tuberculosis recurrence: a 12-year population-based cohort study

  • Evelyn Lepka de Lima1
  • Isadora Salles2
  • Silvia Cohn2
  • Ana Angélica Bulcão Portela Lindoso3
  • Suely Fukasava4
  • Jonathan E. Golub5
  • Samyra R. Cox6
6 affiliations
  1. 1Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Tuberculosis Control Program, Municipal Health Secretariat of Guarujá, Guarujá, São Paulo, Brazil; Corresponding author. Evelyn Lepka de Lima, Department of Epidemiology, Boston School of Public Health, Boston University, 715 Albany Street, Boston, MA 02118, USA.
  2. 2Johns Hopkins School of Medicine, Center for Tuberculosis Research, Baltimore, MD, USA
  3. 3Emilio Ribas Institute of Infectious Diseases, Epidemiology Surveillance, São Paulo, Brazil; São Paulo State Department of Health, Epidemiologic Surveillance Center, São Paulo, Brazil
  4. 4São Paulo State Department of Health, Epidemiologic Surveillance Center, São Paulo, Brazil
  5. 5Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Johns Hopkins School of Medicine, Center for Tuberculosis Research, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, International Health, Baltimore, MD, USA
  6. 6Johns Hopkins Bloomberg School of Public Health, International Health, Baltimore, MD, USA; Corresponding author. Samyra R. Cox, Department of International Health, Global Disease Epidemiology & Control Program, Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Baltimore, MD 21205, USA.
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Abstract

Objectives: Tuberculosis recurrence remains a challenge to elimination efforts in high-burden settings. We aimed to estimate the incidence and timing of tuberculosis recurrence and to identify its risk factors to inform post-treatment care. Methods: We conducted a population-based cohort study of tuberculosis survivors successfully treated for a first tuberculosis episode from 2013 through 2024 in São Paulo state, Brazil. Data were obtained from the state tuberculosis surveillance system (TBweb), and deaths were identified through linkage with the national mortality database. We applied competing risks survival analysis to estimate incidence and assess risk factors for recurrence. Covariates included demographic, clinical, behavioral, and social vulnerability indicators, measured at treatment initiation for the first tuberculosis episode. Risk factor models were stratified by age (<15 vs ≥15 years). Results: Among 154,579 individuals who completed treatment for a first episode of tuberculosis, we identified 9464 first recurrences over a median follow-up of 5.4 years (IQR 2.5-8.2). The overall recurrence incidence was 1127.2 per 100,000 person-years. Rates were highest between 3 and 12 months after treatment completion, yet recurrence incidence remained over 1000 per 100,000 person-years in the 2-5 years after treatment completion. In adults, hospitalization (adjusted subdistribution hazard ratio [aSHR] 2.53, 95% confidence interval 2.36-2.71), and incarceration during the initial episode (aSHR 2.30, 2.13-2.48), together with pulmonary tuberculosis as initial diagnosis (aSHR 2.10, 1.87-2.35), were the strongest independent risk factors for recurrence. In children, HIV (aSHR 6.38, 2.64-15.40) was the strongest predictor. Conclusion: The high and persistent risk of tuberculosis recurrence reinforces the importance of post-treatment care with risk-based follow-up strategies.

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Cite

BibTeXRIS
BibTeX
@article{lima2026risk,
  title = {{Risk and determinants of tuberculosis recurrence: a 12-year population-based cohort study}},
  author = {Evelyn Lepka de Lima and Isadora Salles and Silvia Cohn and Ana Angélica Bulcão Portela Lindoso and Suely Fukasava and Jonathan E. Golub and Samyra R. Cox},
  journal = {International Journal of Infectious Diseases},
  year = {2026},
  month = nov,
  doi = {10.1016/j.ijid.2026.109179},
  url = {https://doi.org/10.1016/j.ijid.2026.109179},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - Risk and determinants of tuberculosis recurrence: a 12-year population-based cohort study
AU  - Evelyn Lepka de Lima
AU  - Isadora Salles
AU  - Silvia Cohn
AU  - Ana Angélica Bulcão Portela Lindoso
AU  - Suely Fukasava
AU  - Jonathan E. Golub
AU  - Samyra R. Cox
PY  - 2026
DA  - 2026/11/06
JO  - International Journal of Infectious Diseases
DO  - 10.1016/j.ijid.2026.109179
UR  - https://doi.org/10.1016/j.ijid.2026.109179
AB  - Objectives: Tuberculosis recurrence remains a challenge to elimination efforts in high-burden settings. We aimed to estimate the incidence and timing of tuberculosis recurrence and to identify its risk factors to inform post-treatment care. Methods: We conducted a population-based cohort study of tuberculosis survivors successfully treated for a first tuberculosis episode from 2013 through 2024 in São Paulo state, Brazil. Data were obtained from the state tuberculosis surveillance system (TBweb), and deaths were identified through linkage with the national mortality database. We applied competing risks survival analysis to estimate incidence and assess risk factors for recurrence. Covariates included demographic, clinical, behavioral, and social vulnerability indicators, measured at treatment initiation for the first tuberculosis episode. Risk factor models were stratified by age (<15 vs ≥15 years). Results: Among 154,579 individuals who completed treatment for a first episode of tuberculosis, we identified 9464 first recurrences over a median follow-up of 5.4 years (IQR 2.5-8.2). The overall recurrence incidence was 1127.2 per 100,000 person-years. Rates were highest between 3 and 12 months after treatment completion, yet recurrence incidence remained over 1000 per 100,000 person-years in the 2-5 years after treatment completion. In adults, hospitalization (adjusted subdistribution hazard ratio [aSHR] 2.53, 95% confidence interval 2.36-2.71), and incarceration during the initial episode (aSHR 2.30, 2.13-2.48), together with pulmonary tuberculosis as initial diagnosis (aSHR 2.10, 1.87-2.35), were the strongest independent risk factors for recurrence. In children, HIV (aSHR 6.38, 2.64-15.40) was the strongest predictor. Conclusion: The high and persistent risk of tuberculosis recurrence reinforces the importance of post-treatment care with risk-based follow-up strategies.
SN  - 1201-9712
SN  - 1878-3511
ER  -