A DNA Methylation Signature from Buccal Swabs to Identify Tuberculosis Infection.

BACKGROUND: Tuberculosis (TB) is amongst the largest infectious causes of death worldwide and there is a need for a time- and resource-effective diagnostic method. In this novel and exploratory study, we show the potential of using buccal swabs to collect human DNA and investigate the DNA methylation (DNAm) signatures as a diagnostic tool for TB. METHODS: Buccal swabs were collected from pulmonary TB patients (n= 7), TB exposed (n= 7), and controls (n= 9) in Sweden. Using Illumina MethylationEPIC array the DNAm status was determined. RESULTS: We identified 5644 significant differentially methylated CpG sites between the patients and controls. Performing the analysis on a validation cohort of samples collected in Kenya and Peru (patients, n=26; exposed, n=9; control, n=10) confirmed the DNAm signature. We identified a TB consensus disease module, significantly enriched in TB-associated genes. Lastly, we used machine learning to identify a panel of seven CpG sites discriminative for TB and developed a TB classifier. In the validation cohort the classifier performed with an AUC of 0.94, sensitivity of 0.92, and specificity of 1. CONCLUSION: In summary, the result from this study shows clinical implications of using DNAm signatures from buccal swabs to explore new diagnostic strategies for TB.

Original article: novelty of Canadian manufacture nasopharyngeal swabs for collection of samples being tested for SARS-CoV-2 in a pandemic setting.

Objectives: The COVID-19 pandemic caused a global shortage of nasopharyngeal (NP) swabs, required for RT-PCR testing. Canadian manufacturers were contacted to share NP swab innovations. The primary objective was to determine whether novel NP test swabs were comparable to commercially available swabs regarding user characteristics, ability to collect a specimen, and diagnostic performance using RT-PCR testing. Methods: Participants were randomized by swab (test/control) and nostril (left/right). A calculated positive percent agreement ≥90% was considered successful. Mean Ct values of viral genes and housekeeping gene (RNase P) were considered similar if a Ct difference ≤ 2 between control and test group was obtained. There also was a qualitative assessment of swabs usability. Results: 647 participants were enrolled from Huaycan Hospital in Lima, Peru, distributed over 8 NP swabs brands. Seven brands agreed to share their results. There were no statistically significant differences between the test swabs of these 7 brands and control swabs. Conclusion: All the seven brands are comparable to the commercially available flocked swabs used for SARS-CoV-2 regarding test results agreement, ability to collect a specimen, and user characteristics.

Tuberculosis case notifications and outcomes in Peruvian prisons prior to and during the COVID-19 pandemic: a national-level interrupted time series analysis.

Background: The COVID-19 pandemic has significantly disrupted tuberculosis (TB) programs, making it urgent to focus TB elimination efforts on key populations. People experiencing incarceration are at high risk for TB, however, how COVID-19-related disruptions have impacted incarcerated populations with TB is unknown. Methods: Using Peruvian National TB Program data from Jan 2018 to Dec 2021, an interrupted time series of drug-susceptible (DS) TB case notifications pre- and during COVID-19 was conducted (cut-off date: COVID-19 emergency declaration in Peru, 16 March 2020). The effect of TB care occurring pre-vs. during COVID-19 on TB treatment success in the incarcerated and non-incarcerated populations was explored using logistic regression. Findings: DS-TB cases notified in prisons from Jan 2018 to Dec 2021 (n = 10,134) represented 10% of all cases notified in the country (n = 101,507). In the first week of COVID-19, DS-TB case notifications dropped by 61.2% (95% CI: 59.9-62.7%) in the non-incarcerated population and 17.7% (95% CI: 17.5-17.9%) among the incarcerated population. TB treatment success was significantly lower in people receiving TB care entirely during the COVID-19 pandemic vs. before COVID-19 in the non-incarcerated population (OR: 0.81, 95% CI: 0.78-0.85), but not statistically significantly lower in the incarcerated population (OR: 0.88, 95% CI: 0.76-1.01). Incarceration status was not found to modify the effect of COVID-19 period on TB treatment outcomes (OR: 1.07, 95% CI: 0.92-1.25), although treatment success was higher in the incarcerated population (OR [incarcerated vs. not incarcerated, pre-COVID]: 1.52, 95% CI: 1.39-1.67). Interpretation: Both incarcerated and non-incarcerated populations experienced a large drop in DS-TB case notifications (although higher in the non-incarcerated population). Lower TB treatment success among those receiving care during COVID-19 indicates significant TB service disruptions in the overall population. The finding that incarceration at time of diagnosis was associated with treatment success is plausible in Peru given increased screening and stricter treatment monitoring in prisons. Funding: Canadian Institutes of Health Research (Funding Reference Number: 179418) .

Drug-resistant tuberculosis: a persistent global health concern.

Drug-resistant tuberculosis (TB) is estimated to cause 13% of all antimicrobial resistance-attributable deaths worldwide and is driven by both ongoing resistance acquisition and person-to-person transmission. Poor outcomes are exacerbated by late diagnosis and inadequate access to effective treatment. Advances in rapid molecular testing have recently improved the diagnosis of TB and drug resistance. Next-generation sequencing of Mycobacterium tuberculosis has increased our understanding of genetic resistance mechanisms and can now detect mutations associated with resistance phenotypes. All-oral, shorter drug regimens that can achieve high cure rates of drug-resistant TB within 6-9 months are now available and recommended but have yet to be scaled to global clinical use. Promising regimens for the prevention of drug-resistant TB among high-risk contacts are supported by early clinical trial data but final results are pending. A person-centred approach is crucial in managing drug-resistant TB to reduce the risk of poor treatment outcomes, side effects, stigma and mental health burden associated with the diagnosis. In this Review, we describe current surveillance of drug-resistant TB and the causes, risk factors and determinants of drug resistance as well as the stigma and mental health considerations associated with it. We discuss recent advances in diagnostics and drug-susceptibility testing and outline the progress in developing better treatment and preventive therapies.

Integrated plasma proteomics identifies tuberculosis-specific diagnostic biomarkers.

BACKGROUNDNovel biomarkers to identify infectious patients transmitting Mycobacterium tuberculosis are urgently needed to control the global tuberculosis (TB) pandemic. We hypothesized that proteins released into the plasma in active pulmonary TB are clinically useful biomarkers to distinguish TB cases from healthy individuals and patients with other respiratory infections.METHODSWe applied a highly sensitive non-depletion tandem mass spectrometry discovery approach to investigate plasma protein expression in pulmonary TB cases compared to healthy controls in South African and Peruvian cohorts. Bioinformatic analysis using linear modeling and network correlation analyses identified 118 differentially expressed proteins, significant through 3 complementary analytical pipelines. Candidate biomarkers were subsequently analyzed in 2 validation cohorts of differing ethnicity using antibody-based proximity extension assays.RESULTSTB-specific host biomarkers were confirmed. A 6-protein diagnostic panel, comprising FETUB, FCGR3B, LRG1, SELL, CD14, and ADA2, differentiated patients with pulmonary TB from healthy controls and patients with other respiratory infections with high sensitivity and specificity in both cohorts.CONCLUSIONThis biomarker panel exceeds the World Health Organization Target Product Profile specificity criteria for a triage test for TB. The new biomarkers have potential for further development as near-patient TB screening assays, thereby helping to close the case-detection gap that fuels the global pandemic.FUNDINGMedical Research Council (MRC) (MR/R001065/1, MR/S024220/1, MR/P023754/1, and MR/W025728/1); the MRC and the UK Foreign Commonwealth and Development Office; the UK National Institute for Health Research (NIHR); the Wellcome Trust (094000, 203135, and CC2112); Starter Grant for Clinical Lecturers (Academy of Medical Sciences UK); the British Infection Association; the Program for Advanced Research Capacities for AIDS in Peru at Universidad Peruana Cayetano Heredia (D43TW00976301) from the Fogarty International Center at the US NIH; the UK Technology Strategy Board/Innovate UK (101556); the Francis Crick Institute, which receives funding from UKRI-MRC (CC2112); Cancer Research UK (CC2112); and the NIHR Biomedical Research Centre of Imperial College NHS.

Prediction models of COVID-19 fatality in nine Peruvian provinces: A secondary analysis of the national epidemiological surveillance system.

There are initiatives to promote the creation of predictive COVID-19 fatality models to assist decision-makers. The study aimed to develop prediction models for COVID-19 fatality using population data recorded in the national epidemiological surveillance system of Peru. A retrospective cohort study was conducted (March to September of 2020). The study population consisted of confirmed COVID-19 cases reported in the surveillance system of nine provinces of Lima, Peru. A random sample of 80% of the study population was selected, and four prediction models were constructed using four different strategies to select variables: 1) previously analyzed variables in machine learning models; 2) based on the LASSO method; 3) based on significance; and 4) based on a post-hoc approach with variables consistently included in the three previous strategies. The internal validation was performed with the remaining 20% of the population. Four prediction models were successfully created and validate using data from 22,098 cases. All models performed adequately and similarly; however, we selected models derived from strategy 1 (AUC 0.89, CI95% 0.87-0.91) and strategy 4 (AUC 0.88, CI95% 0.86-0.90). The performance of both models was robust in validation and sensitivity analyses. This study offers insights into estimating COVID-19 fatality within the Peruvian population. Our findings contribute to the advancement of prediction models for COVID-19 fatality and may aid in identifying individuals at increased risk, enabling targeted interventions to mitigate the disease. Future studies should confirm the performance and validate the usefulness of the models described here under real-world conditions and settings.

The community as an active part in the implementation of interventions for the prevention and care of tuberculosis: A scoping review.

Interventions involving direct community stakeholders include a variety of approaches in which members take an active role in improving their health. We evaluated studies in which the community has actively participated to strengthen tuberculosis prevention and care programs. A literature search was performed in Pubmed, Scopus, ERIC, Global Index Medicus, Scielo, Cochrane Library, LILACS, Google Scholar, speciality journals, and other bibliographic references. The primary question for this review was: ¿what is known about tuberculosis control interventions and programs in which the community has been an active part?. Two reviewers performed the search, screening, and selection of studies independently. In cases of discrepancies over the eligibility of an article, it was resolved by consensus. 130 studies were selected, of which 68.47% (n = 89/130) were published after 2010. The studies were conducted in Africa (44.62%), the Americas (22.31%) and Southeast Asia (19.23%). It was found that 20% (n = 26/130) of the studies evaluated the participation of the community in the detection/active search of cases, 20.77% (n = 27/130) in the promotion/prevention of tuberculosis; 23.07% (n = 30/130) in identifying barriers to treatment, 46.15% (n = 60/130) in supervision during treatment and 3.08% (n = 4/130) in social support for patient. Community participation not only strengthens the capacities of health systems for the prevention and care of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient and the affected community by identifying barriers and difficulties through of the tuberculosis care cascade. Engaging key community stakeholders in co-creating solutions offers a critical pathway for local governments to eradicate TB.

Guía de práctica clínica para el manejo de cáncer de cuello uterino estadios tempranos / Clinical practice guideline for the management of early-stage cervical cancer

Introducción: Este artículo resume la guía de práctica clínica (GPC) para el manejo de cáncer de cuello uterino estadios tempranos (IA1, IA2, IB1, IB2 o IIA1) en el Seguro Social del Perú (EsSalud). Objetivo: Proveer recomendaciones clínicas basadas en evidencia para el manejo de cáncer de cuello uterino estadios tempranos en EsSalud. Material y métodos: Se conformó un grupo elaborador de la guía (GEG) que incluyó médicos especialistas y metodólogos. El GEG formuló 8 preguntas clínicas a ser respondidas por la presente GPC. Se realizó búsquedas sistemáticas de revisiones sistemáticas y ­cuando fue considerado pertinente­ estudios primarios en Pubmed, Embase y CENTRAL durante el 2017 - 2018. Se seleccionó la evidencia para responder cada una de las preguntas clínicas planteadas. La certeza de la evidencia fue evaluada usando la metodología Grading of Recommendations Assessment, Development, and Evaluation (GRADE). En reuniones de trabajo periódicas, el GEG usó la metodología GRADE para revisar la evidencia y formular las recomendaciones, los puntos de buenas prácticas clínicas y los flujogramas de manejo. Finalmente, la GPC fue aprobada con Resolución N° 27-IETSI-ESSALUD-2020. Resultados: La presente GPC abordó 8 preguntas clínicas abordando el manejo del cáncer de cuello uterino en estadios tempranos. En base a dichas preguntas se formularon 10 recomendaciones (2 recomendaciones fuertes y 8 recomendaciones condicionales), 7 puntos de buena práctica clínica, y 4 flujogramas. Conclusión: El presente artículo resume la metodología y las conclusiones basadas en evidencias de la GPC para el manejo del cáncer de cuello uterino en estadios tempranos en EsSalud.

Introduction: This article summarizes the clinical practice guideline (CPG) for the management of early stage cervical cancer (IA1, IA2, IB1, IB2 or IIA1) in the Social Security of Peru (EsSalud). Objective: To provide evidence-based clinical recommendations for the management of early stage cervical cancer in EsSalud. Material and methods: A guideline development group (GEG) was formed that included medical specialists and methodologists. The GEG formulated 8 clinical questions to be answered by this CPG. Systematic searches of systematic reviews and -when considered relevant- primary studies were performed in Pubmed, Embase and CENTRAL during 2017 - 2018. Evidence was selected to answer each of the clinical questions posed. The certainty of the evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. In periodic working meetings, the GEG used the GRADE methodology to review the evidence and formulate recommendations, good clinical practice points, and management flowcharts. Finally, the CPG was approved by Resolution No. 27-IETSI-ESSALUD-2020. Results: This CPG addressed 8 clinical questions on the management of early stage cervical cancer. Based on these questions, 10 recommendations were formulated (2 strong recommendations and 8 conditional recommendations), 7 points of good clinical practice, and 4 flowcharts. Conclusion: This article summarizes the methodology and evidence-based conclusions of the CPG for the management of early stage cervical cancer in EsSalud.

Magnitud y Factores asociados a complicaciones de diabetes tipo 2: Análisis de un Sistema de Vigilancia de Diabetes Mellitus / Magnitude and Factors associated with complications of type 2 diabetes: Analysis of a Diabetes Mellitus Surveillance System

Introducción: Las complicaciones por diabetes tipo 2 (DT2) están incrementando la demanda de servicios especializados en la Seguridad Social Peruana por lo que se torna necesario determinar la magnitud y factores asociados a complicación crónica por DT2 en esta población. Material y Métodos: Estudio transversal-analítico basado en 7875 registros de pacientes con DT2 ≥ 18 años atendidos por consulta externa durante 2016-2017 y notificados en el Sistema de Vigilancia de Diabetes Mellitus de EsSalud. Se evaluaron variables sociodemográficas, clínicas y de comorbilidad mediante un análisis bivariado y un modelo de regresión de Poisson con varianza robusta para determinar la razón de prevalencia a complicación crónica por DT2. Resultados: La complicación microvascular de DT2 estuvo asociado a sexo masculino (RP=1,25; 95%IC: 1,10-1,42; p<0,01), HbA1c>9,0% (RP=1,25; 95%IC: 1,08-1,46; p<0,01), hipertensión arterial (RP=1,30; 95%IC: 1,14-1,49; p<0,01), anemia (RP=1,57; 95%IC: 1,31-1,88; p<0,01), enfermedad tiroidea (RP=1,48; 95%IC: 1,07-2,03; p=0,02), cáncer (RP=1,70; 95%IC: 1,26-2,30; p<0,01) e hígado graso (RP=1,78; 95%IC: 1,28-2,48; p<0,01). El recibir educación para el autocuidado de DT2 mostró asociación negativa con complicación microvascular (RP=0,84; 95%IC: 0,73-0,96; p<0,01). La complicación macrovascular de DT2 estuvo asociado a sexo masculino (RP=1,52; 95%IC: 1,21-1,91; p<0,01), hipertensión arterial (RP=2,72; 95%IC: 1,90-3,91; p<0,01), anemia (RP=1,98; 95%IC: 1,33-2,95; p<0,01) e hígado graso (RP=1,92; 95%IC: 1,03-3,62; p=0,04), mientras que la educación en DT2 mostró asociación negativa (RP=0,47; 95%IC: 0,36-0,61; p<0,01). Conclusiones: La educación en DT2 mostró asociación consistentemente con ausencia de complicación micro y macrovascular, sugiriendo ser un importante factor preventivo. Consideramos necesario evaluar el impacto de la educación mediante diseños apropiados.

Background: Type 2 diabetes (DT2) complications has been increased the demand for specialized services in Peruvian Social Security(EsSalud), so it is necessary to determine the magnitude and factors associated with chronic complication due to DT2 in this population. Material and Methods: Cross-sectional study based on 7875 patients with DT2≥18 years attended by ambulatory care during 2016-2017, notified in the Diabetes Mellitus Surveillance System of EsSalud. Sociodemographic, clinical and comorbidity variables were evaluated using a bivariate analysis and Poisson regression model with robust variance to determine the prevalence ratio of chronic complication due to DT2. Results: The microvascular complication of DT2 was associated with male sex (PR=1.25; 95% CI:1.10-1.42; p<0.01), HbA1c>9.0% (PR=1.25; 95% CI:1.08-1.46; p<0.01), hypertension (PR=1.30; 95% CI: 1.14-1.49; p<0.01), anemia (PR=1.57; 95% CI: 1.31-1.88; p <0.01), thyroid disease (PR=1.48; 95% CI:1.07-2.03; p=0.02), cancer (PR=1.70; 95% CI: 1.26-2.30; p<0.01) and fatty liver (PR=1.78; 95% CI:1.28-2.48; p<0.01). Receiving education for DT2 self-care showed a negative association with microvascular complication (RR=0.84; 95% CI:0.73-0.96; p<0.01). DT2 ́s macrovascular complication was associated with male sex (PR=1.52; 95% CI:1.21-1.91; p <0.01), arterial hypertension (PR=2.72; 95% CI:1.90-3.91; p <0.01), anemia (PR=1.98; 95% CI:1.33-2.95; p<0.01) and fatty liver (PR=1.92; 95% CI:1.03-3.62; p=0.04), while education in DT2 showed a negative association (PR=0.47; 95% CI: 0.36-0.61; p <0,01). Conclusions: Education in DT2 showed an association consistently with the absence of micro and macrovascular complications, suggesting that it is an important preventive factor. We consider it necessary to evaluate the impact of education through appropriate designs.

Situación de la comorbilidad tuberculosis y diabetes en personas adultas en el Perú, 2016-2018

Objetivo: Describir las características de los pacientes adultos con tuberculosis (TB) y diabetes mellitus (DM) en el Perú, y explorar la asociación de la DM y la mortalidad en personas con TB. Materiales y métodos: Se realizó un análisis secundario de la base de datos del Sistema de Información Gerencial de Tuberculosis de la Dirección de Prevención y Control de Tuberculosis del Ministerio de Salud de Perú. Se incluyeron aquellos pacientes adultos que iniciaron tratamiento con el esquema de TB sensible a los medicamentos los años 2016, 2017 y 2018. Se realizó un análisis descriptivo de los pacientes con TB con DM y un análisis exploratorio para evaluar la asociación de la DM con la mortalidad usando una regresión de Poisson para determinar el riesgo relativo (RR). Resultados: Se registraron 67 524 adultos con TB sensible a los medicamentos, de los cuales se reportaron 6529 (9,7%) personas como TB con DM y 4048 (6,0%) con infección por VIH. De los pacientes reportados con TB con DM, la mayoría eran hombres (60,2%) con una mediana de edad de 53 años. Con relación a la mortalidad, las personas con TB con DM tuvieron una mayor frecuencia de muerte comparado con aquellas personas con TB sin DM (7,2% vs. 5,4%). En el análisis exploratorio de factores asociados a la mortalidad, la DM presentó un RR crudo de 1,32 (IC 95%: 1,20-1,50); sin embargo, esta asociación varió en el modelo ajustado con un RR de 0,93 (IC 95%: 0,84-1,04). Conclusiones: La DM es la comorbilidad más frecuente en pacientes con TB en el Perú, aunque no se encontró asociación con una mayor mortalidad.

Objective: To describe the characteristics of adult patients with tuberculosis (TB) and diabetes mellitus (DM) in Peru, and to explore the association of DM and mortality in people with TB. Materials and methods: We carried out a secondary analysis of the database of the Management Information System of Tuberculosis of the Tuberculosis Prevention and Control Directorate of the Ministry of Health of Peru. Adult patients who started treatment with the scheme for drug-sensitive TB in 2016, 2017 and 2018 were included. We carried out a descriptive analysis of patients with TB and DM, and an exploratory analysis to assess the association of DM with mortality using a Poisson regression to determine the relative risk (RR). Results: We registered 67,524 adults with drug-sensitive TB, of which 6,529 (9.7%) people were reported as having TB and DM; and 4,048 (6.0%) had HIV infection. Of the patients reported with TB and DM, most were men (60.2%) with a median age of 53 years. Regarding mortality, people with TB and DM had a higher frequency of death compared to those with TB without DM (7.2% vs 5.4%). In the exploratory analysis of factors associated with mortality, DM had a crude RR of 1.32 (95% CI: 1.20-1.50); however, this association varied in the adjusted model with a RR of 0.93 (95% CI: 0.84-1.04). Conclusions: DM is the most frequent comorbidity in patients with TB in Peru, although no association with higher mortality was found.

Factores asociados a complicaciones crónicas de diabetes mellitus tipo 2 en pacientes de un hospital general del Seguro Social de Salud del Perú / Associated factors with chronic complications of type-2-diabetes mellitus among patients from a general hospital of the Peruvian social health insurance

RESUMEN Introducción. Las complicaciones crónicas por diabetes mellitus tipo 2 (DMT2) elevan la mortalidad y carga de enfermedad en Perú, siendo necesario evaluar su prevalencia y factores asociados. Métodos. Estudio transversal, analítico, en registros de 212 pacientes adultos con DMT2 atendidos por consulta externa en un hospital general del Seguro Social del Perú, durante el año 2017. Resultados. El 71,6% de los pacientes fueron mayores de 60 años y con un tiempo de enfermedad menor de 6 años (40,5%). El 38,7% de los pacientes tuvieron alguna complicación crónica, principalmente nefropatía (48,8%) y neuropatía (45,1%). La hipertensión arterial (52,4%) y la obesidad (43,7%) fueron las comorbilidades más frecuentes en pacientes con complicaciones crónicas. Las complicaciones por DMT2 estuvieron asociadas al número de consultas médicas y monitoreo glicémico. Conclusiones. Existen factores de riesgos asociados a las complicaciones crónicas de DMT2.

ABSTRACT Introduction. The chronic complications of type-2-diabetes mellitus (T2DM) increase mortality and burden of disease in Peru, then it is necessary to evaluate its prevalence and associated factors. Methods. Cross-sectional study in records of 212 adult outpatients with T2DM attended by a social security general hospital in Peru, during 2017. Results. 71,6% of patients were older than 60 years and with a time of illness less than 6 years (40,5%). 38,7% of the patients had any chronic complication, mainly nephropathy (48,8%) and neuropathy (45,1%). Hypertension (52,4%) and obesity (43,7%) were the most frequent comorbidities in outpatients with chronic complications. Complications from DMT2 were associated with the medical consultations and glycemic monitoring. Conclusions. There are risk factors associated to chronic complications of DMT2.

Comorbilidad de tuberculosis y diabetes: Problema aún sin resolver / Tuberculosis and diabetes co-morbidity: An unresolved problem

La comorbilidad entre tuberculosis y diabetes ha sido descrita desde principios del siglo XX. En países desarrollados donde se ha pasado de la disminución de la enfermedades infecciosas a un incremento de enfermedades no transmisibles, así como en aquellos países que aún tienen alta prevalencia de enfermedades infecciosas pero con incremento de las no transmisibles, se observa que la prevalencia de la comorbilidad entre tuberculosis y diabetes se está incrementando, volviendo el manejo clínico y el control a nivel de salud pública un nuevo reto para cualquier sistema de salud. Esta revisión intenta mostrar las evidencias disponibles hasta la actualidad y poner en conocimiento algunas líneas de investigación que se están comenzando a desarrollar para entender dicho problema. En países como el Perú donde hay una transición epidemiológica, mayor investigación permitiría conocer y describir mejor las características y el impacto de esta comorbilidad.

Co-morbidity between tuberculosis and diabetes has been described since the early 20th century. In developed countries, where there has been a decrease of infectious diseases with an increase of non-communicable diseases, as well as those countries who still have a high prevalence of infectious diseases but an increase of non-communicable diseases, it is observed that the prevalence of co-morbidity between tuberculosis and diabetes is increasing, making clinical management and control at the public health level a new challenge for health systems. This review aims to show the current available evidence that can inform research lines being developed to understand the problem. In countries like Peru, where there is an epidemiological transition, further research could allow us to understand and describe in a better way the characteristics and impact of this co-morbidity.

Conocimientos, actitudes y prácticas sobre la enfermedad de Carrión en población rural de Ancash, Perú / Knowledge, attitudes, and practices about Carrión's disease in rural Ancash, Peru

OBJETIVO: Evaluar el conocimiento, las prácticas y las actitudes sobre la enfermedad de Carrión (bartonelosis) en poblaciones rurales con antecedentes de brotes epidémicos. MÉTODOS: Estudio transversal realizado en las poblaciones de Huaripampa, Orcosh y Opayaco (Ancash, Perú) durante el mes de julio del 2010, utilizando una encuesta para evaluar el conocimiento, las prácticas y las actitudes sobre la enfermedad de Carrión. Se entrevistó solo a mayores de 18 años que tuviesen una antigüedad mínima de un año residiendo en esos poblados. RESULTADOS: Se realizaron encuestas a un total de 276 pobladores, de los cuales 36,6% fueron hombres y 72,5% no había oído hablar de la enfermedad de Carrión. Entre los que la conocían, la mayoría (38,7%) indicó que se contagia mediante picaduras, mientras que 26% manifestó no conocer la forma de contagio. Con respecto a las acciones que deberían tomarse en caso de presentar la enfermedad de Carrión, 69,3% de los encuestados refirieron que acudirían a un centro de salud y más de la mitad informó haber recomendado prácticas preventivas a familiares o conocidos en el pasado. CONCLUSIONES: A pesar de tratarse de comunidades históricamente afectadas por la enfermedad de Carrión, los pobladores de estas tres comunidades no mostraron un nivel adecuado de conocimientos, actitudes o prácticas para su prevención. En vista de ello, y teniendo en cuenta que este padecimiento ha presentado brotes cíclicos, se hace perentorio diseñar e implementar un programa que eduque a los habitantes de estos poblados -poniendo el foco en el papel de los usos y costumbres- sobre cómo prevenir la enfermedad de Carrión, así como el resto de las principales enfermedades endémicas de la región.

OBJECTIVE: To assess knowledge, attitudes, and practices about Carrión's disease (bartonellosis) in rural communities with a history of epidemic outbreaks. METHODS: A cross-sectional survey study was conducted in the communities of Huaripampa, Orcosh, and Opayaco (Ancash, Peru) in July 2010, to assess knowledge, attitudes, and practices about Carrión's disease. Interviewees were aged >18 years and had resided in the community for at least one year. RESULTS: A total of 276 residents were surveyed; 36.6% were men, and 72.5% had not heard of Carrión's disease. Of those familiar with it, most (38.7%) said that it spreads through bites, and 26% did not know how it spreads. Regarding actions to take if Carrión's disease develops, 69.3% of respondents said they would go to a health center and over half reported having recommended preventive practices to relatives or acquaintances in the past. CONCLUSIONS: Even though these three communities have a history of Carrión's disease, their inhabitants did not demonstrate adequate knowledge, attitudes, or practices for preventing it. In view of this, and given that this illness has cyclical outbreaks, it is imperative to design and implement a program to educate residents of these communities-focusing on the role of habits and customs-about how to prevent Carrión's disease, as well as the region's other main endemic diseases.

Tuberculosis: Un enfoque de Derechos Humanos / Tuberculosis: A Human Rights approach

La tuberculosis es una enfermedad que ha acompañado a la humanidad desde sus inicios, y a pesar de existir tratamiento para la mayoría de los casos, es una de las enfermedades que incrementa la brecha de inequidad. Lamentablemente, los esfuerzos para combatir esta enfermedad no han sido en la mayoría de veces enfocados como una enfermedad social, haciendo que los esfuerzos y recursos no lleguen a la solución completa. Este articulo intenta plantear si un enfoque de Derechos Humanos colaboraría con los enfoques biomédicos y de salud pública para combatir la Tuberculosis.

Tuberculosis is a disease affceting manking form very early ages, and despite the availability of appropriate therapy for most cases, it is a disease that increases the gap between the rich and the poor. Unfortunately, the efforts to fight this disease have not been focused on its socio-economic nature, leading these strategies and resources to fall short. This paper tries to show if an approach based on Human Rights is able to complement biomedical and public health measures in the fight against Tuberculosis.

Pruebas de sensibilidad para Mycobacterium tuberculosis / Drug susceptibility tests for Mycobacterium tuberculosis

Los regímenes de tratamiento no adecuado y los problemas de adherencia del paciente han ocasionado que las tasas de resistencia de Mycobacterium tuberculosis hayan aumentado en el mundo, originando así la aparición de las cepas multidrogo resistentes (MDR) y con resistencia extensa a drogas (XDR). El Perú presenta altas tasas de TB-MDR, y ya se han reportado casos de TB-XDR. Las pruebas de sensibilidad buscan detectar los casos con cepas resistentes, permitiendo otorgar el mejor tratamiento al paciente y evitando la propagación de la enfermedad a otras personas. Esta revisión de pruebas de sensibilidad dirigida al médico noespecialista, se ha enfocado en las pruebas de sensibilidad disponibles según la Norma Técnica para el control de la Tuberculosis y otras que se encuentran en investigación.

Inadequate treatment regimens and poor compliance have led to increased rates of drug resistance in Mycobacterium tuberculosis around the world, leading to the emergence of multidrug resistant (MDR) and extensively drug resistant (XDR) strains. In Peru MDR-TB rates are amongst the highest in the world and XDR-TB cases have been reported for almost a decade. Drug susceptibility tests detect cases with resistant strains, providing the best treatment option to the patient and diminishing the spread of the disease. This review is directed at the non-specialist physician, focusing upon the drug susceptibility testsapproved by the National TB Program of Peru and others currently still under research.