Educational level and tuberculosis mortality in Colombia: growing inequalities and stagnation in reduction.

We aim to describe the role of educational inequalities, for sex and age groups, in adult tuberculosis (TB) mortality in Colombia, 1999-2017. We linked mortality data to data estimation of the national population based on censuses and surveys to obtain primary, secondary, and tertiary adult (25+ years of age) age-standardized mortality rates (ASMR) by educational level. Thus, a population-based study was conducted using national secondary mortality data between 1999 and 2017. Tuberculosis age-standardized mortality rates were calculated separately by educational level, sex, and age groups, using Poisson regression models. Educational relative inequalities in adult mortality were evaluated by calculating the rate ratio, and the relative index of inequality (RII). Trends and joinpoints were evaluated by annual percentage change (APC). We found that, out of the 19,720 TB deaths reported, 69% occurred in men, and 45% in older adults (men and women, aged 65+). Men presented higher TB mortality rates than women (ASMR men = 7.1/100,000 inhabitants, ASMR women = 2.7/100,000 inhabitants). As mortality was consistently higher in the lowest educational level for both sexes and all age groups, inequalities in TB mortality were found to be high (RII = 9.7 and 13.4 among men and women, respectively) and growing at an annual rate of 8% and 1%. High and increasing inequalities, regarding educational level, in TB mortality in Colombia suggest the need to comprehensively address strategies for reducing TB by considering social determinants and including health education strategies throughout the country.

Educational level and tuberculosis mortality in Colombia: growing inequalities and stagnation in reduction / Nivel educacional y mortalidad por tuberculosis en Colombia: crecientes inequidades y estancamiento en su reducción / Nível de escolaridade e mortalidade por tuberculose na Colômbia: desigualdades crescentes e estagnação na redução da doença

We aim to describe the role of educational inequalities, for sex and age groups, in adult tuberculosis (TB) mortality in Colombia, 1999-2017. We linked mortality data to data estimation of the national population based on censuses and surveys to obtain primary, secondary, and tertiary adult (25+ years of age) age-standardized mortality rates (ASMR) by educational level. Thus, a population-based study was conducted using national secondary mortality data between 1999 and 2017. Tuberculosis age-standardized mortality rates were calculated separately by educational level, sex, and age groups, using Poisson regression models. Educational relative inequalities in adult mortality were evaluated by calculating the rate ratio, and the relative index of inequality (RII). Trends and joinpoints were evaluated by annual percentage change (APC). We found that, out of the 19,720 TB deaths reported, 69% occurred in men, and 45% in older adults (men and women, aged 65+). Men presented higher TB mortality rates than women (ASMR men = 7.1/100,000 inhabitants, ASMR women = 2.7/100,000 inhabitants). As mortality was consistently higher in the lowest educational level for both sexes and all age groups, inequalities in TB mortality were found to be high (RII = 9.7 and 13.4 among men and women, respectively) and growing at an annual rate of 8% and 1%. High and increasing inequalities, regarding educational level, in TB mortality in Colombia suggest the need to comprehensively address strategies for reducing TB by considering social determinants and including health education strategies throughout the country.

Pretendemos describir el papel de las inequidades educacionales, según sexo y grupos de edad, en la mortalidad de adultos por tuberculosis (TB) en Colombia, 1999-2017. Relacionamos datos de mortalidad con la estimación de datos de la población nacional, basada en censos y encuestas, con el fin de obtener las tasas de mortalidad primarias, secundarias, y terciarias de adultos (25+ años) estandarizadas por edad, según el nivel educativo. Se realizó un estudio basado en población, usando datos de mortalidad nacional secundaria entre 1999 y 2017. Las tasas de mortalidad por tuberculosis estandarizadas por edad (ASMR), fueron calculadas separadamente por nivel educacional, sexo, y grupos de edad, usando modelos de regresión de Poisson. Las inequidades educacionales relacionadas con la mortalidad en adultos fueron evaluadas calculando el cociente de tasas, y el índice de inequidad relacionado (RII). Se evaluaron tendencias y joinpoints mediante la variación porcentual anual (APC). Se descubrió que, de las 19.720 muertes informadas por TB, un 69% se produjeron en hombres, y un 45% en hombres y mujeres adultos mayores (65+). Los hombres presentaron tasas de mortalidad más altas por TB que las mujeres (ASMR hombres = 7,1/100.000 habitantes, ASMR mujeres = 2,7/100.000 habitantes). Asimismo, la mortalidad fue consistentemente más alta en los niveles educacionales más bajos y ambos sexos, además en todos los grupos de edad existieron inequidades altas en la mortalidad por TB (RII = 9,7 y 13,4 entre hombres y mujeres, respectivamente) y creciendo a una tasa anual de un 8% y 1%. Las altas y crecientes inequidades por nivel educacional en la mortalidad por TB en Colombia apuntan la necesidad de dirigir estrategias que reduzcan la TB ampliamente, tomando en consideración determinantes sociales e incluyendo estrategias de educación en salud en todo el país.

O estudo tem como objetivo descrever o papel das desigualdades educacionais por gênero e grupo etário na mortalidade por tuberculose (TB) em adultos colombianos entre 1999 e 2017. Relacionamos os dados de mortalidade com as estimativas da população nacional, com base nos censos demográficos e inquéritos para obter as taxas de mortalidade padronizadas por idade (TMPI), primárias, secundárias e terciárias, em adultos com 25 anos ou mais, de acordo com o nível de escolaridade. Foi realizado um estudo populacional com o uso de dados de mortalidade secundários entre 1999 e 2017. Foram utilizados modelos de regressão Poisson para calcular separadamente as taxas de mortalidade por tuberculose padronizadas por idade, de acordo com o nível de escolaridade, sexo e grupo etário. As desigualdades educacionais relativas na mortalidade em adultos foram avaliadas pelo cálculo da razão de taxas e o índice relativo de desigualdade (IRD). Foram avaliadas as tendências e os joinpoints através da mudança percentual anual média (APC). Entre os 19.720 óbitos por TB notificados, 69% ocorreram em homens e 45% em homens e mulheres adultos (65+). Os homens apresentaram taxas de mortalidade por TB maiores que as mulheres (TMPI masculina = 7,1/100.000 habitantes, TMPI feminina = 2,7/100.000 habitantes). A mortalidade era mais alta no nível mais baixo de escolaridade em ambos os sexos e em todos os grupos etários, portanto, as desigualdades na mortalidade por TB eram altas (IRD = 9,7 e 13,4 em homens e mulheres, respectivamente), com crescimento anual de 8% e 1%. As desigualdades altas e crescentes na mortalidade por TB de acordo com o nível de escolaridade na Colômbia sugerem a necessidade de adotar estratégias abrangentes para reduzir a carga da tuberculose, levando em conta os determinantes sociais e incluindo estratégias nacionais de educação em saúde.

Lessons learnt from easing COVID-19 restrictions: an analysis of countries and regions in Asia Pacific and Europe.

The COVID-19 pandemic is an unprecedented global crisis. Many countries have implemented restrictions on population movement to slow the spread of severe acute respiratory syndrome coronavirus 2 and prevent health systems from becoming overwhelmed; some have instituted full or partial lockdowns. However, lockdowns and other extreme restrictions cannot be sustained for the long term in the hope that there will be an effective vaccine or treatment for COVID-19. Governments worldwide now face the common challenge of easing lockdowns and restrictions while balancing various health, social, and economic concerns. To facilitate cross-country learning, this Health Policy paper uses an adapted framework to examine the approaches taken by nine high-income countries and regions that have started to ease COVID-19 restrictions: five in the Asia Pacific region (ie, Hong Kong [Special Administrative Region], Japan, New Zealand, Singapore, and South Korea) and four in Europe (ie, Germany, Norway, Spain, and the UK). This comparative analysis presents important lessons to be learnt from the experiences of these countries and regions. Although the future of the virus is unknown at present, countries should continue to share their experiences, shield populations who are at risk, and suppress transmission to save lives.

What is the true tuberculosis mortality burden? Differences in estimates by the World Health Organization and the Global Burden of Disease study.

Background: The World Health Organization (WHO) and the Global Burden of Disease (GBD) study at the Institute for Health Metrics and Evaluation (IHME) periodically provide global estimates of tuberculosis (TB) mortality. We compared the 2015 WHO and GBD TB mortality estimates and explored which factors might drive the differences. Methods: We extracted the number of estimated TB-attributable deaths, disaggregated by age, HIV status, sex and country from publicly available WHO and GBD datasets for the year 2015. We 'standardized' differences between sources by adjusting each country's difference in absolute number of deaths by the average number of deaths estimated by both sources. Results: For 195 countries with estimates from both institutions, WHO estimated 1 768 482 deaths attributable to TB, whereas GBD estimated 1 322 916 deaths, a difference of 445 566 deaths or 29% of the average of the two estimates. The countries with the largest absolute differences in deaths were Nigeria (216 621), Bangladesh (49 863) and Tanzania (38 272). The standardized difference was not associated with HIV prevalence, prevalence of multidrug resistance or global region, but did show correlation with the case detection rate as estimated by WHO [r = -0.37, 95% confidence interval (CI): -049; -0.24] or, inversely, with case detection rate based on GBD data (r = 0.44, 95% CI: 0.31; 0.54). Countries with a recent national prevalence survey had higher standardized differences (higher estimates by WHO) than those without (P = 0.006). After exclusion of countries with recent prevalence surveys, the overall correlation between both estimates was r = 0.991. Conclusions: A few countries account for the large global discrepancy in TB mortality estimates. The differences are due to the methodological approaches used by WHO and GBD. The use and interpretation of prevalence survey data and case detection rates seem to play a role in the observed differences.

The burden of disease in Spain: Results from the Global Burden of Disease 2016. / La carga de enfermedad en España: resultados del Estudio de la Carga Global de las Enfermedades 2016.

BACKGROUND AND OBJECTIVES: The global burden of disease (GBD) project measures the health of populations worldwide on an annual basis, and results are available by country. We used the estimates of the GBD to summarise the state of health in Spain in 2016 and report trends in mortality and morbidity from 1990 to 2016. MATERIAL AND METHODS: GBD 2016 estimated disease burden due to 333 diseases and injuries, and 84 risk factors. The GBD list of causes is hierarchical and includes 3 top level categories, namely: 1) communicable, maternal, neonatal, and nutritional diseases; 2) non-communicable diseases (NCDs), and 3) injuries. Mortality and disability-adjusted life-years (DALYs), risk factors, and progress towards the sustainable development goals (SDGs) are presented based on the GBD 2016 data in Spain. RESULTS: There were 418,516 deaths in Spain in 2016, from a total population of 46.5 million, and 80.5% of them occurred in those aged 70 years and older. Overall, NCDs were the main cause of death: 388,617 (95% uncertainty interval 374,959-402,486), corresponding to 92.8% of all deaths. They were followed by 3.6% due to injuries with 15,052 (13,902-17,107) deaths, and 3.5% communicable diseases with 14,847 (13,208-16,482) deaths. The 5 leading specific causes of death were ischaemic heart disease (IHD, 14.6% of all deaths), Alzheimer disease and other dementias (13.6%), stroke (7.1%), chronic obstructive pulmonary disease (6.9%), and lung cancer (5.0%). Remarkable increases in mortality from 1990 to 2016 were observed in other cancers, lower respiratory infections, chronic kidney disease, and other cardiovascular disease, among others. On the contrary, road injuries moved down from 8th to 32nd position, and diabetes from 6th to 10th. Low back and neck pain became the number one cause of DALYs in Spain in 2016, just surpassing IHD, while Alzheimer disease moved from 9th to 3rd position. The greatest changes in DALYs were observed for road injuries dropping from 4th to 16th position, and congenital disorders from 17th to 35th; conversely, oral disorders rose from 25th to 17th. Overall, smoking is by far the most relevant risk factor in Spain, followed by high blood pressure, high body mass index, alcohol use, and high fasting plasma glucose. Finally, Spain scored 74.3 of 100 points in the SDG index classification in 2016, and the main national drivers of detrimental health in SDGs were alcohol consumption, smoking and child obesity. An increase to 80.3 points is projected in 2030. CONCLUSION: Low back and neck pain was the most important contributor of disability in Spain in 2016. There has seen a remarkable increase in the burden due to Alzheimer disease and other dementias. Tobacco remains the most important health issue to address in Spain.

How do we measure adherence to anti-tuberculosis treatment?

INTRODUCTION: Completion of anti-tuberculosis (TB) treatment is of paramount importance for TB patients, as well as for the global efforts of TB control. However, there is neither a gold-standard measure to monitor adherence to TB treatment nor a widely used definition for different levels of adherence. Areas covered: in this review we aim to describe the different methods used to measure patients' adherence to anti-TB treatment, identifying their main strengths and limitations, with a focus on low resource settings. Expert commentary: there is a need for continuing the quest for a low cost, reliable and acceptable measure of adherence to TB treatment. We should harmonize treatment adherence measurement to allow adequate comparison of different interventions aimed at increasing adherence to TB treatment, although the way we ensure adherence can affect adherence endpoints themselves. The accuracy of adherence measurement is of importance in the context of drug clinical development.

Immunogenicity and immunization costs of adjuvanted versus non-adjuvanted hepatitis B vaccine in chronic kidney disease patients.

Hepatitis B virus (HBV) vaccination is recommended for all susceptible chronic pre-hemodialysis and hemodialysis patients. This study assessed the immunogenicity of HBV vaccines (adjuvanted and non-adjuvanted) in chronic kidney disease patients vaccinated at the Hospital Clinic of Barcelona (Spain) between January 2007 and July 2012. In addition, the costs for the health system were evaluated accor-ding to the proportion of vaccine responders after receiving either vaccine. Patients receiving 3 doses of hepatitis B adjuvanted vaccine were 3 times more likely to seroconvert than patients immunized with non-adjuvanted vaccines, OR 3.56 (95% CI 1.84-6.85). This resulted in fewer patients requiring a second course of HBV vaccination and fewer outpatient visits, saving more than €9,500 per 100 patients. The higher immunogenicity of the adjuvanted HBV vaccine would counterbalance the lower costs associated with the non-adjuvanted vaccine.

Non-tuberculous mycobacteria in children: muddying the waters of tuberculosis diagnosis.

Non-tuberculous mycobacteria (NTM) are a large family of acid-fast bacteria, widespread in the environment. In children, NTM cause lymphadenitis, skin and soft tissue infections, and occasionally also lung disease and disseminated infections. These manifestations can be indistinguishable from tuberculosis on the basis of clinical and radiological findings and tuberculin skin testing. A diagnostic and therapeutic problem for respiratory physicians and other clinicians is therefore evident, particularly in settings where childhood tuberculosis is common, and bacteriological confirmation of any mycobacterial disease is difficult because of low availability of laboratory services in low-resource settings and the inherent paucibacillary nature of mycobacterial disease in childhood. The epidemiology of NTM varies by world region, and attempts to understand the burden of NTM disease and to identify risk factors in the paediatric population are hampered by inadequate mandatory NTM reporting and the overlap of clinical presentation with tuberculosis. The immune response to both NTM and Mycobacterium tuberculosis is based on cellular immunity and relies on the type-1 cytokine pathway. The disruption of this immune response by genetic or acquired mechanisms, such as mendelian susceptibility to mycobacterial disease or HIV, might result in predisposition to mycobacterial infections. Published diagnostic and management guidelines do not provide specific advice for diagnosis of NTM in children, from whom the quantity and quality of diagnostic samples are often suboptimum. Treatment of NTM infections is very different from the treatment of tuberculosis, depends on the strain and anatomical site of infection, and often involves antibiotic combinations, surgery, or both. In this Review, we summarise the epidemiological and clinical features of NTM infection in children, with a specific focus on the implications for public health in settings with a high endemic burden of childhood tuberculosis.

Educating on professional habits: attitudes of medical students towards diverse strategies for promoting influenza vaccination and factors associated with the intention to get vaccinated.

BACKGROUND: Influenza vaccination coverage in medical students is usually low. Unlike health care workers, there is little information on the attitudes to and predictors of vaccination among medical students, and their attitudes towards institutional strategies for improving rates are unknown. METHODS: This cross-sectional study evaluated the effect of three influenza vaccination promotional strategies (Web page, video and tri-fold brochure) on medical students' intention to get vaccinated and associated factors. A total of 538 medical students were asked to answer an anonymous questionnaire assessing the intention to get vaccinated after exposure to any of the promotional strategies. Sociodemographic data collected included: sex, age, university year, influenza risk group and cohabiting with member of a risk group. RESULTS: Four hundred twenty-one students answered the questionnaire, of whom 312 (74.1%) were female, 113 (26.8%) had done clinical rotations, and 111 (26.6%) reported intention to get the flu shot. Logistic regression showed the web group had a greater intention to get vaccinated than the reference group (OR: 2.42 95% CI: 1.16-5.03). Having done clinical rotations (OR: 2.55 95% CI: 1.36-4.38) and having received the shot in previous flu seasons (OR: 13.69 95% CI: 7.86-23.96) were independently associated with the intention to get vaccinated. CONCLUSION: Given that previous vaccination is a factor associated with the intention to get vaccinated, education on vaccination of health care workers should begin while they are students, thereby potentiating the habit. In addition, the intention to get vaccinated was greater during the clinical phase of the university career, suggesting this is a good time to introduce promotion strategies. Online promotional campaigns, such as a thematic Web to promote vaccination of health workers, could improve the intention to get vaccinated.