Contaminação ambiental de uma agroindústria familiar de queijo colonial no sudoeste paranaense / Environmental contamination of a family colonial cheese agroindustry in the southwest of Parana

As falhas na higienização em um estabelecimento de alimentos podem refletir em problemas causando a contaminação ou deterioração do produto produzido. Esta pesquisa foi motivada por reclamações de consumidores informando que os queijos apresentaram fungos, mesmo estando dentro do prazo de validade e por solicitação do Serviço de Inspeção Municipal. O objetivo desta pesquisa foi avaliar a contaminação ambiental em uma agroindústria da agricultura familiar produtora de queijo colonial no Sudoeste Paranaense. Foram realizadas a contagem para aeróbios mesófilos em equipamentos e superfícies que entram em contato com o alimento e análise microbiológica ambiental de bolores e leveduras na sala de secagem dos queijos. A coleta foi realizada com método de esfregaço de suabe estéril para aeróbios mesófilos e semeadas em placas de Petri com Ágar Padrão de Contagem. Para a coleta ambiental foram expostas placas de Petri com ágar Saboraund durante 15 minutos. Os resultados demonstraram ausência de contaminação nas superfícies, mas foram encontrados bolores e leveduras de forma acentuada na sala de secagem dos queijos, o que pode contribuir para a deterioração do produto, diminuindo sua validade. Para minimizar as perdas por contaminação é necessário que o processo de higienização dos ambientes seja realizado de forma eficiente.

Failures in hygiene in a food establishment can result in problems causing contamination or deterioration of the product produced. This research was motivated by complaints from consumers reporting that the cheeses had mold, even though they were within their expiration date and at the request of the Municipal Inspection Service. This research was to evaluate environmental contamination in an agroindustry in the family farm producing colonial cheese in Southwest Paraná. For the microbiological assessment of environmental contamination, counting for mesophilic aerobes was carried out on equipment and surfaces that come into contact with food and, environmental microbiological analysis of molds and yeast in the cheese drying room. The collection was carried out using the sterile swab smear for mesophilic aerobes and seeded in Petri dishes with Counting Standard Agar. For environmental collection, sheets of Petri with Saboraund agar for 15 minutes. The results demonstrated absence of contamination on surfaces. But the presence of molds and yeasts in the drying room cheeses, which can contribute to the deterioration of the product and thus reduce the validity. To minimize losses due to contamination, it is It is necessary that the process of cleaning and disinfecting environments is carried out efficiently.

Higienização de ambiente em agroindústria familiar de embutidos cárneos / Environmental hygienization in family meat product

A higienização é um procedimento importante na indústria de alimentos e sua realização deve ocorrer rotineiramente para evitar que os alimentos sejam contaminados. Além disso, todos os manipuladores de alimentos devem receber treinamentos de modo a entender como ocorrem as contaminações e como evitá-las, para que não ocorra deterioração antecipada dos alimentos e para que não exponham os consumidores ao risco de doenças transmitidas por alimentos em caso de contaminação. Esta pesquisa avaliou o processo de higienização e sua eficiência em superfícies presentes em uma agroindústria da agricultura familiar produtora de embutidos cárneos. Apesar de ter instalações adequadas a agroindústria apresentava inadequações quanto aos produtos utilizados e a frequência inadequada para uma higienização eficiente. Foi realizada análise microbiológica das superfícies dos equipamentos para contagem de aeróbios mesófilos e notou-se uma elevada carga microbiana que indicou uma baixa eficiência no processo de higienização. Sugeriu-se melhorias na higiene ambiental associado à instrução dos colaboradores, para contribuir na promoção da qualidade dos produtos, aumento dos lucros e salvaguardando a saúde do consumidor.

Hygiene is an important procedure in the food industry, and its performance must occur routinely to prevent food from being contaminated. In addition, all food handlers must receive training in order to understand how contamination occurs and how to avoid it, so that there is no anticipated deterioration of food and that consumers are not exposed to the risk of foodborne diseases. in case of contamination by pathogenic microorganisms. Thus, this research evaluated the cleaning process and its efficiency on surfaces present in a family farming agroindustry that produces meat products, which despite having adequate facilities, had some difficulties such as product use and inadequate frequency for eficiente cleaning. After performing a microbiological analysis to count surface mesophilic aerobes, a high level of contamination was noted, relating to low efficiency in the cleaning process. Improvements in environmental hygiene are suggested, associated with the instruction of employees for the implementation of the Standard Operating Hygiene Procedure, promoting improvements in product quality, increasing profits and safeguarding consumer health.

Effects of working from home on lifestyle behaviors and mental health during the COVID-19 pandemic: A survey study.

The COVID-19 outbreak has led to relevant changes in everyday life worldwide. One of these changes has been a rapid transition to and an increasing implementation of working from home (WH) modality. This study aimed to evaluate the impact of mandatory WH during the COVID-19 pandemic on lifestyle behaviors, Mediterranean diet adherence, body weight, and depression. An online cross-sectional survey was conducted in the early 2022 at the National Research Council of Italy using ad hoc questions and validated scales collecting information on physical activity, sedentary behavior, hobbies/pastimes, dietary habits including adherence to the Mediterranean diet, body weight, and depression during WH compared with before WH. 748 respondents were included in the study. An increased sedentary lifetime was reported by 48% of respondents; however, the subsample of workers who previously performed moderate physical activity intensified this activity. Body weight gain during WH was self-reported in 39.9% of respondents. Mediterranean diet adherence increased (p≪0.001) during WH compared with before WH. The average level of mental health did not record an overall variation; however, the proportion of subjects with mild and moderate depression increased (p = 0.006), while workers who reported values indicative of depression before the transition declared an improvement. These findings highlight health-related impact of WH during the COVID-19 pandemic that may inform future strategies and policies to improve employees' health and well-being.

Evaluation of erector spinae plane block in patients undergoing percutaneous nephrolithotomy in terms of postoperative pain reduction and patient satisfaction.

OBJECTIVES: Intravenous opioids and local anesthetic infiltrations are traditionally used to relieve postoperative pain. With developments in the field of regional anesthesia, several methods are now available for postoperative analgesia. This study aimed to investigate the efficacy of the erector spinae plane block (ESPB) in reducing both intraoperative opioid consumption and postoperative analgesic use in patients undergoing percutaneous nephrolithotomy (PCNL). METHODS: A total of 60 patients who underwent PCNL were divided into two groups: 30 patients who received ESPB (Group I) and 30 patients in the control group (Group II). Intraoperative and postoperative opioid usage were recorded for both groups. The pain levels of the patients were evaluated using visual analog scale (VAS) scores obtained at 1, 3, 6, 12, and 24 hours postoperatively. Postoperative satisfaction of the patients in both groups was also questioned and compared. RESULTS: A significant difference was detected between Group I and Group II patients in terms of intraoperative opioid require-ments (p=0.00), analgesic requirements in the first 24 hours postoperatively (p=0.00), patient satisfaction status (p=0.00), and VAS scores obtained at 0, 3, 6, and 12 hours postoperatively. No significant difference was found in VAS scores at the 24th postoperative hour. CONCLUSION: ESPB is a simple, convenient technique that can be performed under ultrasound guidance. It provides remarkable postoperative analgesia and satisfaction in patients undergoing PCNL.

Compliance with World Health Organization COVID-19 preventive behaviors in rural counties in Western Kenya: a cross-sectional study.

Introduction: the World Health Organization (WHO) recommended various measures to tackle COVID-19, and were adopted by many governments, targeting behavior change among citizens to lower the transmission. There was a paucity of data on the patterns of compliance with different measures within individuals and whether people adhere to all recommended measures or cautiously prefer few but not others. Understanding compliance behaviors and associated factors is important for developing interventions to increase compliance. Methods: cross-sectional study was conducted among adults in the western region of Kenya. A sample of 806 participants was selected using a stratified sampling method. A structured questionnaire was used to gather data from the participants. Compliance was assessed with six behaviors: hand sanitation, proper hygiene, no handshaking, social distancing, and other guidelines. Latent analysis was used to identify behavioral patterns. Descriptive statistics were used to assess demographic characteristics, in terms of frequency distribution, and percentages. Multinomial logistic regression was used to assess the association between demographic characteristics and compliance level. Results: compliance was highest for masking (85.3%), and was lowest for social distancing (60.2%). The majority of participants were found to be full compliers (class 1: 40.5%), there was an increased probability of full compliance among those aged between 18-30 years (OR= 1.042; 95% CI: 0.307-13.052, p < 0.040) compared to those aged ≥70. Conclusion: using facemasks had the highest rate of compliance, followed by hand sanitization and proper hygiene. However, overall, the findings showed that while compliance with some protocol behaviors is high, individuals comply consistently across recommended compliance behaviors.

Causes and Effects of COVID-19 Vaccine Hesitancy Among Pregnant Women and its Association with Adverse Maternal, Placental, and Perinatal Outcomes.

Populations identified to be severely affected by COVID-19, such as pregnant patients, require special consideration in vaccine counseling, access, and provider education. Maternal infection with COVID-19 poses a significant risk to the maternal-fetal dyad with known adverse placenta destruction [1-5]. Despite the widespread access and availability of vaccinations, vaccine hesitancy continues to persist and is highly prevalent in pregnant populations [6-9]. Addressing the multitude of social ecological factors surrounding vaccine hesitancy can aid in providing holistic counseling [10]. However, such factors are foremost shaped by maternal concern over possible fetal effects from vaccination. While changes in policy can help foster vaccine access and acceptance, increasing global provider education and incorporation of motivational interviewing skills are the first steps towards increasing maternal acceptance.

Current barriers to initiating insulin therapy in individuals with type 2 diabetes.

Insulin is an essential drug in the treatment of diabetes, often necessary for managing hyperglycemia in type 2 diabetes mellitus (T2DM). It should be considered in cases of severe hyperglycemia requiring hospitalization, after the failure of other treatments, in advanced chronic kidney disease, liver cirrhosis, post-transplant diabetes, or during pregnancy. Moreover, in specific patient subgroups, early initiation of insulin is crucial for hyperglycemia control and prevention of chronic complications. Clinical guidelines recommend initiating insulin when other treatments fail, although there are barriers that may delay its initiation. The timing of initiation depends on individual patient characteristics. Typically, insulinization starts by adding basal insulin to the patient's existing treatment and, if necessary, progresses by gradually introducing prandial insulin. Several barriers have been identified that hinder the initiation of insulin, including fear of hypoglycemia, lack of adherence, the need for glucose monitoring, the injection method of insulin administration, social rejection associated with the stigma of injections, weight gain, a sense of therapeutic failure at initiation, lack of experience among some healthcare professionals, and the delayed and reactive positioning of insulin in recent clinical guidelines. These barriers contribute, among other factors, to therapeutic inertia in initiating and intensifying insulin treatment and to patients' non-adherence. In this context, the development of once-weekly insulin formulations could improve initial acceptance, adherence, treatment satisfaction, and consequently, the quality of life for patients. Currently, two once-weekly basal insulins, insulin icodec and basal insulin BIF, which are in different stages of clinical development, may help. Their longer half-life translates to lower variability and reduced risk of hypoglycemia. This review addresses the need for insulin in T2DM, its positioning in clinical guidelines under specific circumstances, the current barriers to initiating and intensifying insulin treatment, and the potential role of once-weekly insulin formulations as a potential solution to facilitate timely initiation of insulinization, which would reduce therapeutic inertia and achieve better early control in people with T2DM.

Machine learning prediction of adolescent HIV testing services in Ethiopia.

Background: Despite endeavors to achieve the Joint United Nations Programme on HIV/AIDS 95-95-95 fast track targets established in 2014 for HIV prevention, progress has fallen short. Hence, it is imperative to identify factors that can serve as predictors of an adolescent's HIV status. This identification would enable the implementation of targeted screening interventions and the enhancement of healthcare services. Our primary objective was to identify these predictors to facilitate the improvement of HIV testing services for adolescents in Ethiopia. Methods: A study was conducted by utilizing eight different machine learning techniques to develop models using demographic and health data from 4,502 adolescent respondents. The dataset consisted of 31 variables and variable selection was done using different selection methods. To train and validate the models, the data was randomly split into 80% for training and validation, and 20% for testing. The algorithms were evaluated, and the one with the highest accuracy and mean f1 score was selected for further training using the most predictive variables. Results: The J48 decision tree algorithm has proven to be remarkably successful in accurately detecting HIV positivity, outperforming seven other algorithms with an impressive accuracy rate of 81.29% and a Receiver Operating Characteristic (ROC) curve of 86.3%. The algorithm owes its success to its remarkable capability to identify crucial predictor features, with the top five being age, knowledge of HIV testing locations, age at first sexual encounter, recent sexual activity, and exposure to family planning. Interestingly, the model's performance witnessed a significant improvement when utilizing only twenty variables as opposed to including all variables. Conclusion: Our research findings indicate that the J48 decision tree algorithm, when combined with demographic and health-related data, is a highly effective tool for identifying potential predictors of HIV testing. This approach allows us to accurately predict which adolescents are at a high risk of infection, enabling the implementation of targeted screening strategies for early detection and intervention. To improve the testing status of adolescents in the country, we recommend considering demographic factors such as age, age at first sexual encounter, exposure to family planning, recent sexual activity, and other identified predictors.

Sexually transmitted infections and the HPV-related burden: evolution of Italian epidemiology and policy.

Sexually transmitted infections (STIs) are a major public health problem worldwide, with a high prevalence between the ages of 15 and 25 in most Western countries. High notification rates of chlamydia, gonorrhea, and syphilis are reported in the WHO European Region, with differences between countries. In Italy, the total number of STIs alerts increased by 18% from 2020 to 2021. HPV is the most common sexually transmitted infection; globally one in seven women is infected by this virus, and certain sexual behaviors are important risk factors for HPV-related cancers, particularly cervical cancer (CC), anogenital cancers and cancers of the head and neck. The burden of CC is relevant worldwide, in particular in Europe CC is the third leading cause of cancer-related deaths in women aged 15-44. This HPV-related tumor is preventable through a combined strategy of vaccination and screening for precursor lesions. In Italy, the coverage of organized screening varies from region to region and the average HPV vaccination rate is still far from the expected optimal threshold of 95% at the age of 12. To address the challenges of health promotion and HPV prevention, priority actions are needed such as: promoting education and information at every level, from schools to healthcare professionals. In Italy, education of adolescents on sexual and reproductive health, still remains critical, regionally inhomogeneous and much lower than in other European countries. Equitable measures need to be taken, and schools are an important place for health promotion activities.

The impact of health beliefs and trust in health information sources on SARS-CoV-2 vaccine uptake.

Background: Health beliefs may mediate the relationship between trust and vaccination decisions, as confidence in online health information has expanded quickly. However, little is known about how health attitudes and trust in health information affect COVID-19 vaccine intention. This study aimed to assess the effect of health beliefs and trust in information sources on the willingness to receive a COVID-19 vaccine among the general public in Saudi Arabia. Methods: This study was designed and carried out at the Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia. Selected items were extracted from the Saudi Residents' Intention to Get Vaccinated Against COVID-19 (SRIGVAC) survey. They were categorized and validated into constructs of a health belief model (the perceived threat of COVID-19, vaccine-related benefits, barriers, and safety concerns) and trust in health information (from online platforms and health authorities/providers). Regression analysis and parallel mediation were used to assess the predictors of vaccination intentions. Results: Based on the responses of 3,091 participants, vaccine-related barriers and safety concerns negatively influenced vaccination intention, whereas vaccine benefits and the perceived threat of COVID-19 were positively correlated with vaccination intention. Trust in online health information had a direct relationship with intentions (ß = 0.09, p < 0.0001) as well as indirect relationships through the perceived benefits (ß = 0.095), the perceived barriers (ß = -0.029), and the perceived safety concerns toward the vaccine (ß = -0.010). The relationship between the willingness to vaccinate and trust in authentic information was fully mediated by all domains of health beliefs, with indirect coefficients of 0.004, 0.310, -0.134, and -0.031 for the perceived threat, vaccine benefits, barriers, and safety concerns, respectively. Conclusion: The relationship between the willingness to vaccinate and trust in authentic information was fully mediated by all domains of health beliefs. Vaccine coverage in Saudi Arabia can be optimized by targeting the health beliefs of the general public.

Preparing correctional settings for the next pandemic: a modeling study of COVID-19 outbreaks in two high-income countries.

Introduction: Correctional facilities are high-priority settings for coordinated public health responses to the COVID-19 pandemic. These facilities are at high risk of disease transmission due to close contacts between people in prison and with the wider community. People in prison are also vulnerable to severe disease given their high burden of co-morbidities. Methods: We developed a mathematical model to evaluate the effect of various public health interventions, including vaccination, on the mitigation of COVID-19 outbreaks, applying it to prisons in Australia and Canada. Results: We found that, in the absence of any intervention, an outbreak would occur and infect almost 100% of people in prison within 20 days of the index case. However, the rapid rollout of vaccines with other non-pharmaceutical interventions would almost eliminate the risk of an outbreak. Discussion: Our study highlights that high vaccination coverage is required for variants with high transmission probability to completely mitigate the outbreak risk in prisons.

Text And Telephone Screening And Referral Improved Detection And Treatment Of Maternal Mental Health Conditions.

Effective screening and referral practices for perinatal mental health disorders, perinatal substance use disorders (SUDs), and intimate partner violence are greatly needed to reduce maternal morbidity and mortality. We conducted a randomized controlled trial from January 2021 to April 2023 comparing outcomes between Listening to Women and Pregnant and Postpartum People (LTWP), a text- and telephone-based screening and referral program, and usual care in-person screening and referral within the perinatal care setting. Participants assigned to LTWP were three times more likely to be screened compared with those assigned to usual care. Among participants completing a screen, those assigned to LTWP were 3.1 times more likely to screen positive, 4.4 times more likely to be referred to treatment, and 5.7 times more likely to attend treatment compared with those assigned to usual care. This study demonstrates that text- and telephone-based screening and referral systems may improve rates of screening, identification, and attendance to treatment for perinatal mental health disorders and perinatal SUDs compared with traditional in-person screening and referral systems. System-level changes and complementary policies and insurance payments to support adoption of effective text- and telephone-based screening and referral programs are needed.

Consensus Guidelines for Influenza Vaccination in Patients with Diabetes.

Influenza is a prevalent health issue encountered in daily practice. Patients with diabetes mellitus face a higher risk of infections, including influenza, owing to the compromised immune system associated with diabetes. This susceptibility arises from the potential of diabetes mellitus to weaken the immune system. Moreover, elevated blood glucose levels can create a conducive environment for the growth of bacteria and viruses. This consensus is formulated by a multidisciplinary team to serve as practical guidance for the administration of influenza vaccinations to patients with diabetes mellitus in daily practice.

Global vaccine coverage and childhood survival estimates: 1990-2019.

Objective: To quantify the association between reduction in child mortality and routine immunization across 204 countries and territories from 1990 to 2019. Methods: We used child mortality and vaccine coverage data from the Global Burden of Disease Study. We used a modified child survival framework and applied a mixed-effects regression model to estimate the reduction in deaths in children younger than 5 years associated with eight vaccines. Findings: Between 1990 and 2019, the diphtheria-tetanus-pertussis (DTP), measles, rotavirus and Haemophilus influenzae type b vaccines were significantly associated with an estimated 86.9 (95% confidence interval, CI: 57.2 to 132.4) million fewer deaths in children younger than 5 years worldwide. This decrease represented a 24.2% (95% CI: 19.8 to 28.9) reduction in deaths relative to a scenario without vaccines. The DTP and measles vaccines averted 46.7 (95% CI: 30.0 to 72.7) million and 37.9 (95% CI: 25.4 to 56.8) million deaths, respectively. Of the total reduction in child mortality associated with vaccines, 84.2% (95% CI: 83.0 to 85.1) occurred in 73 countries supported by Gavi, the Vaccine Alliance, with an estimated 45.4 (95% CI: 29.8 to 69.2) million fewer deaths from 2000 to 2019. The largest reductions in deaths associated with these four vaccines were in India, China, Ethiopia, Pakistan and Bangladesh (in order of the size of reduction). Conclusion: Vaccines continue to reduce childhood mortality significantly, especially in Gavi-supported countries, emphasizing the need for increased investment in routine immunization programmes.

Knowledge and practices related to snakebite prevention, China: a cross-sectional study.

Objective: To assess knowledge and practices related to snakebite prevention among Chinese residents. Methods: By using a multistage random sampling approach augmented by snowball sampling, we surveyed residents from 10 provinces, one municipality and one autonomous region south of the Yangtze River Basin between May 2022 and February 2023. We supplemented the data with a national online survey. We used a χ2-test to identify differences in knowledge and behaviour across various demographic characteristics. We conducted multifactor logistic regression analyses to evaluate factors potentially influencing snakebite knowledge and practices. Findings: We obtained 55 775 valid survey responses, 16 200 respondents from the face-to-face survey and 39 575 respondents from the online survey. Only 25.7% (14 325) respondents demonstrated adequate knowledge about snakebites whereas 25.6% (14 295) respondents knew basic first-aid practices or preventive behaviours. Age, marital status, educational attainment, occupation, type of residence and frequency of exposure to nature are significant independent variables affecting snakebite knowledge (P-values: < 0.05). On the other hand, gender, age, marital status, educational attainment, occupation and type of residence were significant independent variables affecting the behaviour of snakebite prevention and first aid (P-values: < 0.05). Conclusion: There is a notable shortfall in knowledge, first aid and preventive behaviours among Chinese residents regarding snakebites. Misguided first aid practices can severely compromise the effectiveness of evidence-based therapeutic interventions. Consequently, improving health education concerning snakes and snakebites in this population is needed.

Investigating the effect of education based on PRECEDE-PROCEED model on the preventive behaviors of musculoskeletal disorders in a group of nurses.

Background: One of the most important occupational complications that could occur in nurses is musculoskeletal disorders. In this study, we designed an educational intervention based on the PRECEDE-PROCEED model to investigate its effects on a group of nurses on preventive behaviors of musculoskeletal disorders. Methods: A total of 120 nurses working in Izeh City, Iran, participated in this semi-experimental study. The sampling was performed through a convenient sampling method, and the participants were randomly assigned to the experimental and control groups (60 participants for each group). Both groups filled out a questionnaire based on the PRECEDE-PROCEED model before and 2 months after the educational program as part of the data collection process. The data were examined using a paired t-test, an independent t-test, and a chi-square test after being entered into SPSS version 24. Results: According to the findings, prior to the intervention, there was no difference between the two groups in terms of their knowledge (p = 0.221), attitude (p = 0.136), enabling factors (p = 0.325), reinforcing factors (p = 0.548), self-efficacy (0.421), and behavior (0.257) levels. However, following the intervention, a substantial rise was witnessed in the experimental group in each of the mentioned variables (p = 0.001). Conclusion: In the current study, education based on the PRECEDE-PROCEED model led to the improvement of knowledge, attitude, enabling and reinforcing factors, self-efficacy, and finally preventive behaviors with musculoskeletal disorders in the participants. Considering the importance of the role of health education in promoting behaviors related to musculoskeletal disorders in nurses and the importance of observing related behaviors in preventing long-term complications, the necessity of education in a wider dimension and with different tools is felt more and more in society. Therefore, longer interventions with this aim could be carried out on nurses and other healthcare personnel.

Epidemiology of and programmatic response to tuberculosis in Solomon Islands: analysis of surveillance data, 2016-2022.

Objective: To identify progress and challenges in the national response to tuberculosis (TB) in Solomon Islands through an epidemiological overview of TB in the country. Methods: A descriptive analysis was conducted using the national TB surveillance data for 2016-2022. Case notifications, testing data, treatment outcomes and screening activities were analysed. Results: The number of case notifications was 343 in 2022, with an average annual reduction of the case notification rate between 2016 and 2022 of 4.7%. The highest case notification rate was reported by Honiara City Council (126/100 000 population) in 2022. The number of people with presumptive TB tested by Xpert® rapidly increased from zero in 2016 to 870 in 2022. Treatment success rate remained consistently high between 2016 and 2022, ranging from 92% to 96%. Screening for HIV and diabetes mellitus (DM) among TB patients in 2022 was 14% and 38%, respectively. Most patients (97%) were hospitalized during the intensive phase of treatment in 2022; in contrast, during the continuation phase, the proportion of patients treated at the community level increased from 1% in 2016 to 63% in 2022. Despite an increase in household contact investigations, from 381 in 2016 to 707 in 2021, the uptake of TB preventive treatment (TPT) was minimal (7% among eligible child contacts). Discussion: This epidemiological analysis in Solomon Islands reveals both notable achievements and challenges in the country's TB programme. One major achievement is a potential actual reduction in TB incidence. Challenges identified were potential underdetection of cases in rural areas, suboptimal community-based care, and insufficient contact tracing and uptake of TPT. It is crucial to address these challenges (e.g. by optimizing resources) to advance the national TB response.