{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T07:17:40Z","timestamp":1783495060375,"version":"3.55.0"},"reference-count":25,"publisher":"Wiley","license":[{"start":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T00:00:00Z","timestamp":1783468800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T00:00:00Z","timestamp":1783468800000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Tropical Med Int Health"],"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To investigate the association between municipal BCG vaccination coverage and extrapulmonary tuberculosis (EPTB) notification rates among children and adolescents in Brazil and to describe their temporal, spatial, and spatiotemporal patterns from 2004 to 2023.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted an ecological study using national Brazilian administrative databases. Temporal trends in EPTB notification rates were assessed using Joinpoint regression and spatiotemporal clusters using retrospective space\u2013time scan statistics. The association between municipal BCG coverage and EPTB notification rates was examined using municipality\u2010year negative binomial models with an offset for the population aged 0\u201319\u2009years. The main model adjusted for calendar year, primary health care team density, and municipal Human Development Index, with sensitivity analyses incorporating urbanicity, HIV case mix, and a CNES\u2010based proxy of registered diagnostic infrastructure. Factors associated with extrapulmonary versus pulmonary presentation were evaluated using multivariable logistic regression.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>EPTB notification rates declined overall but increased among children aged 0\u20134\u2009years. Mortality showed a U\u2010shaped temporal pattern, with a nadir around 2013. Local spatial autocorrelation identified high\u2010high clusters concentrated mainly in the Southeast, Northeast, and North. Space\u2013time scan analyses identified recurrent high\u2010risk clusters, including a large early cluster in 2004\u20132007, a localized cluster in 2015\u20132016, and a recent cluster in 2019\u20132023. Higher municipal BCG coverage was associated with lower EPTB notification rates after adjustment (IRR per 10\u2010percentage\u2010point increase, 0.9755; 95% CI, 0.9646\u20130.9864). Urbanicity had minimal impact, whereas inclusion of registered diagnostic infrastructure shifted estimates toward the null. At the individual level, extrapulmonary presentation was associated with ages 5\u20139 and 10\u201314\u2009years, male sex, and HIV positivity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Lower municipal BCG coverage was associated with higher EPTB notification rates among children and adolescents in Brazil. The association was modest and sensitive to contextual adjustment, particularly to indicators of diagnostic and service infrastructure.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/tmi.70198","type":"journal-article","created":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T07:06:08Z","timestamp":1783494368000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Decline in Calmette\u2010Gu\u00e9rin Bacillus Vaccination Coverage and Change in the Spatiotemporal Pattern of Extrapulmonary Tuberculosis in Children and Adolescents in Brazil: An Ecological Study, 2004\u20132023"],"prefix":"10.1111","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6037-8206","authenticated-orcid":false,"given":"Alice","family":"Ramos\u2010Silva","sequence":"first","affiliation":[{"name":"Programa de P\u00f3s\u2010gradua\u00e7\u00e3o em Patologia, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"},{"name":"Faculdade de Farm\u00e1cia Universidade Federal do Rio de Janeiro  Rio de Janeiro Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-8826-0689","authenticated-orcid":false,"given":"Luiza Silva Trigueiro","family":"de Oliveira","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio Multiusu\u00e1rio de Apoio \u00e0 Pesquisa em, Nefrologia e Ci\u00eancias M\u00e9dicas, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-0666-115X","authenticated-orcid":false,"given":"Marcos Daniel Souza","family":"da Costa","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio Multiusu\u00e1rio de Apoio \u00e0 Pesquisa em, Nefrologia e Ci\u00eancias M\u00e9dicas, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-1952-2914","authenticated-orcid":false,"given":"Matheus","family":"Daudt\u2010Lemos","sequence":"additional","affiliation":[{"name":"Programa de P\u00f3s\u2010gradua\u00e7\u00e3o em Patologia, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"},{"name":"Laborat\u00f3rio Multiusu\u00e1rio de Apoio \u00e0 Pesquisa em, Nefrologia e Ci\u00eancias M\u00e9dicas, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9186-110X","authenticated-orcid":false,"given":"Luis Phillipe","family":"Nagem Lopes","sequence":"additional","affiliation":[{"name":"Instituto de Medicina Social da Universidade Estadual do Rio de Janeiro  Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0101-790X","authenticated-orcid":false,"given":"Elisangela Costa","family":"Lima","sequence":"additional","affiliation":[{"name":"Faculdade de Farm\u00e1cia Universidade Federal do Rio de Janeiro  Rio de Janeiro Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7638-6814","authenticated-orcid":false,"given":"Claudete Aparecida Ara\u00fajo","family":"Cardoso","sequence":"additional","affiliation":[{"name":"Programa de P\u00f3s\u2010gradua\u00e7\u00e3o Em Ci\u00eancias M\u00e9dicas, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8732-8065","authenticated-orcid":false,"given":"Clemax Couto","family":"Sant'Anna","sequence":"additional","affiliation":[{"name":"Programa de P\u00f3s\u2010gradua\u00e7\u00e3o em Cl\u00ednica M\u00e9dica Universidade Federal do Rio de Janeiro  Rio de Janeiro Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5856-6128","authenticated-orcid":false,"given":"Andrea Alice","family":"Silva","sequence":"additional","affiliation":[{"name":"Programa de P\u00f3s\u2010gradua\u00e7\u00e3o em Patologia, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"},{"name":"Laborat\u00f3rio Multiusu\u00e1rio de Apoio \u00e0 Pesquisa em, Nefrologia e Ci\u00eancias M\u00e9dicas, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"},{"name":"Programa de P\u00f3s\u2010gradua\u00e7\u00e3o Em Ci\u00eancias M\u00e9dicas, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4713-233X","authenticated-orcid":false,"given":"Fabiana Rabe","family":"Carvalho","sequence":"additional","affiliation":[{"name":"Programa de P\u00f3s\u2010gradua\u00e7\u00e3o em Patologia, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"},{"name":"Laborat\u00f3rio Multiusu\u00e1rio de Apoio \u00e0 Pesquisa em, Nefrologia e Ci\u00eancias M\u00e9dicas, Faculdade de Medicina Universidade Federal Fluminense  Niter\u00f3i Rio de Janeiro Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2026,7,8]]},"reference":[{"issue":"6","key":"e_1_2_11_2_1","doi-asserted-by":"crossref","DOI":"10.3390\/pathogens13060467","article-title":"Pediatric Tuberculosis: A Review of Evidence\u2010Based Best Practices for Clinicians and Health Care Providers","volume":"13","author":"Moore B. 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P.","year":"2022","journal-title":"Medicus"},{"key":"e_1_2_11_6_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.ijid.2025.107909","article-title":"Effect of Bacillus Calmette\u2010Gu\u00e9rin Vaccination Against \n                     Mycobacterium tuberculosis\n                   Infection in Children: An Updated Systematic Review and Meta\u2010Analysis","volume":"156","author":"Cai S.","year":"2025","journal-title":"International Journal of Infectious Diseases"},{"issue":"12","key":"e_1_2_11_7_1","doi-asserted-by":"crossref","DOI":"10.3390\/vaccines12121434","article-title":"Vaccination Coverage at Birth in Brazil: Spatial and Temporal Trends in the Impact of COVID\u201019 on Uptake of BCG and Hepatitis B Vaccines","volume":"12","author":"Alves Y. M.","year":"2024","journal-title":"Vaccine"},{"key":"e_1_2_11_8_1","doi-asserted-by":"crossref","DOI":"10.1590\/1984-0462\/2024\/42\/2023020","article-title":"Temporal Trends in Vaccination Coverage in the First Year of Life in Brazil","volume":"42","author":"Neves A. B. B.","year":"2023","journal-title":"Revista Paulista de Pediatria"},{"key":"e_1_2_11_9_1","doi-asserted-by":"crossref","DOI":"10.11606\/s1518-8787.2025059006458","article-title":"BCG Vaccination Decline and Pediatric Tuberculosis Rise in Brazil: Spatial\u2010Temporal Study","volume":"59","author":"Carvalho F. R.","year":"2025","journal-title":"Revista de Sa\u00fade P\u00fablica"},{"issue":"1","key":"e_1_2_11_10_1","doi-asserted-by":"crossref","DOI":"10.3390\/tropicalmed8010012","article-title":"Spatial Distribution and Temporal Trend of Childhood Tuberculosis in Brazil","volume":"8","author":"Costa F. B. P.","year":"2022","journal-title":"Tropical Medicine and Infectious Disease"},{"key":"e_1_2_11_11_1","doi-asserted-by":"crossref","DOI":"10.1186\/1471-2334-14-9","article-title":"Epidemiology of Extrapulmonary Tuberculosis in Brazil: A Hierarchical Model","volume":"14","author":"Gomes T.","year":"2014","journal-title":"BMC Infectious Diseases"},{"issue":"1","key":"e_1_2_11_12_1","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-019-7224-0","article-title":"Spatial and Temporal Analysis of Tuberculosis in an Area of Social Inequality in Northeast Brazil","volume":"19","author":"Lima S. V. M. A.","year":"2019","journal-title":"BMC Public Health"},{"issue":"1","key":"e_1_2_11_13_1","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0247894","article-title":"Time Trend, Social Vulnerability, and Identification of Risk Areas for Tuberculosis in Brazil: An Ecological Study","volume":"17","author":"Paiva J. P. S.","year":"2022","journal-title":"PLoS One"},{"key":"e_1_2_11_14_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.lana.2024.100963","article-title":"Impact of Strategic Public Health Interventions to Reduce Tuberculosis Incidence in Brazil: A Bayesian Structural Time\u2010Series Scenario Analysis","volume":"41","author":"Villalva\u2010Serra K.","year":"2024","journal-title":"Lancet Regional Health\u2014Americas"},{"issue":"2","key":"e_1_2_11_15_1","doi-asserted-by":"crossref","first-page":"653","DOI":"10.1038\/s41591-024-03381-0","article-title":"Effects of Conditional Cash Transfers on Tuberculosis Incidence and Mortality According to Race, Ethnicity and Socioeconomic Factors in the 100 Million Brazilian Cohort","volume":"31","author":"Jesus G. S.","year":"2025","journal-title":"Nature Medicine"},{"issue":"6","key":"e_1_2_11_16_1","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0252712","article-title":"Spatial Clustering and Temporal Trend Analysis of International Migrants Diagnosed With Tuberculosis in Brazil","volume":"16","author":"Arcencio R. A.","year":"2021","journal-title":"PLoS One"},{"issue":"5","key":"e_1_2_11_17_1","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0232426","article-title":"Incidence and Predictors of Extrapulmonary Tuberculosis Among People Living With HIV in Addis Ababa, Ethiopia: A Retrospective Cohort Study","volume":"15","author":"Alemu A.","year":"2020","journal-title":"PLoS One"},{"issue":"1","key":"e_1_2_11_18_1","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1186\/s40249-023-01157-1","article-title":"Social Protection as a Right of People Affected by Tuberculosis: A Scoping Review and Conceptual Framework","volume":"12","author":"Ferreira M. R. L.","year":"2023","journal-title":"Infectious Diseases of Poverty"},{"key":"e_1_2_11_19_1","doi-asserted-by":"crossref","DOI":"10.1186\/s12879-023-08502-7","article-title":"Facilitators and Barriers to Tuberculosis Active Case Finding in Low\u2010 and Middle\u2010Income Countries: A Systematic Review of Qualitative Research","volume":"23","author":"Fenta M. D.","year":"2023","journal-title":"BMC Infectious Diseases"},{"key":"e_1_2_11_20_1","doi-asserted-by":"crossref","DOI":"10.1016\/j.lana.2024.100765","article-title":"The Impact of the SARS\u2010CoV\u20102 Pandemic on Tuberculosis Notifications and Deaths in the State of Sao Paulo, Brazil: A Cross\u2010Sectional Study","volume":"34","author":"Blume M. C.","year":"2024","journal-title":"Lancet Regional Health\u2014Americas"},{"issue":"3","key":"e_1_2_11_21_1","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph16030296","article-title":"Estimation of the Ecological Fallacy in the Geographical Analysis of the Association of Socioeconomic Deprivation and Cancer Incidence","volume":"16","author":"Lokar K.","year":"2019","journal-title":"International Journal of Environmental Research and Public Health"},{"issue":"6","key":"e_1_2_11_22_1","article-title":"Underreporting and Exhaustiveness of Tuberculosis Surveillance Systems in a Region of Peru: A Capture\u2010Recapture Analysis","volume":"37","author":"Quiroz\u2010Ruiz H. R.","year":"2021","journal-title":"Cadernos De Saude Publica"},{"key":"e_1_2_11_23_1","doi-asserted-by":"crossref","DOI":"10.1590\/0037-8682-0205-2020","article-title":"Clinical and Molecular Diagnosis of Childhood and Adolescent Pulmonary Tuberculosis in Referral Centers","volume":"53","author":"Aurilio R. B.","year":"2020","journal-title":"Revista da Sociedade Brasileira de Medicina Tropical"},{"issue":"5","key":"e_1_2_11_24_1","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph18052264","article-title":"Assessing the Quality of Reporting to China's National Tuberculosis Surveillance Systems","volume":"18","author":"Li T.","year":"2021","journal-title":"International Journal of Environmental Research and Public Health"},{"issue":"11","key":"e_1_2_11_25_1","doi-asserted-by":"crossref","DOI":"10.2196\/27626","article-title":"Evaluation of the National Tuberculosis Surveillance System in Sana'a, Yemen, 2018","volume":"7","author":"Al Kalali F. S. A.","year":"2021","journal-title":"JMIR Public Health and Surveillance"},{"key":"e_1_2_11_26_1","doi-asserted-by":"crossref","first-page":"1241","DOI":"10.1186\/s12913-024-11697-3","article-title":"Individual, Community and Health Systems Factors Influencing Time to Notification of Tuberculosis","volume":"24","author":"Chilala S. B.","year":"2024","journal-title":"BMC Health Services Research"}],"container-title":["Tropical Medicine &amp; International Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/tmi.70198","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/full-xml\/10.1111\/tmi.70198","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/pdf\/10.1111\/tmi.70198","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T07:06:11Z","timestamp":1783494371000},"score":1,"resource":{"primary":{"URL":"https:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/tmi.70198"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,8]]},"references-count":25,"alternative-id":["10.1111\/tmi.70198"],"URL":"https:\/\/doi.org\/10.1111\/tmi.70198","archive":["Portico"],"relation":{},"ISSN":["1360-2276","1365-3156"],"issn-type":[{"value":"1360-2276","type":"print"},{"value":"1365-3156","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,8]]},"assertion":[{"value":"2026-02-07","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-06-23","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-08","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}],"article-number":"tmi.70198"}}