Programa de controle do tabagismo em Mato Grosso do Sul: oferta, adesão e efetividade / Smoking control program in Mato Grosso do Sul: offer, adherence and effectiveness / Programa de control del tabaquismo en Mato Grosso do Sul: oferta, adherencia y efectividad

Objetivo: O estudo teve por objetivo avaliar o Programa Nacional de Controle do Tabagismo (PNCT) em Mato Grosso do Sul, taxas de cobertura, abandono, cessação, uso de medicamentos, rede de serviços de saúde e as razões pelas quais algumas Equipes de Saúde da Família de Campo Grande ainda não aderiram ao programa. Métodos: Trata-se de uma pesquisa descritiva, com abordagem quantitativa, baseada em dados primários e secundários sobre o PNCT em Mato Grosso do Sul. Os dados primários foram obtidos por meio de questionário aplicado aos profissionais das Equipes de Saúde da Família (ESF) de Campo Grande, sem oferta do programa e avaliados quanto à frequência e presença de correlação entre as variáveis analisadas utilizando V de Cramer e teste de χ2. Os dados secundários foram obtidos do consolidado do Instituto Nacional de Câncer José Alencar Gomes da Silva com os registros produzidos pelos serviços. Resultados: As taxas de adesão, efetividade e apoio farmacológico na capital e interior foram: 66,80 e 59,79%; 20,58 e 34,91%; 32,14 e 99,86%, respectivamente. A oferta do programa ocorreu em 49,37% municípios e 43,85% das Unidades Básicas de Saúde (UBS) estimadas. Houve correlações entre ser capacitado e implantar o programa; treinamento de ingresso e oferta na UBS. As dificuldades relatadas pelos profissionais foram a pandemia de COVID-19, a sobrecarga e/ou equipe pequena e/ou falta de tempo e a ausência de capacitação/treinamento. Conclusões: O PNCT em Mato Grosso do Sul apresenta baixa cobertura e oferta restrita na rede de saúde, além do desempenho mediano de assistência aos tabagistas. Evidencia-se a necessidade de investimento em capacitação/treinamento, prioritariamente para as ESF de Campo Grande, dando-lhes condições de responder às necessidades de promoção da saúde, reconhecendo o programa como de maior custo-efetividade.

Objective: The objective of this study was to evaluate the National Tobacco Control Program (PNCT) in Mato Grosso do Sul, coverage rates, dropout, cessation, use of medication, the health services network and the reasons why Family Health Teams in Campo Grande have not yet joined the program. Methods: This was a descriptive study with a quantitative approach, based on primary and secondary data on the PNCT in Mato Grosso do Sul. The primary data were obtained by means of a questionnaire administered to Family Health Teams (ESF) in Campo Grande, which did not offer the program and evaluated the frequency and presence of correlation between the variables analyzed using Cramer's V test and the χ2 test. The secondary data were obtained from the consolidated records of the José Alencar Gomes da Silva National Cancer Institute with the records produced by the services. Results: The rates of adherence, effectiveness and pharmacological support in the capital and interior were: 66.80 and 59.79%; 20.58 and 34.91%; and 32.14 and 99.86%, respectively. The program was offered in 49.37% of the municipalities and 43.85% of the Basic Health Units (UBS) estimated. There were correlations between being trained and implementing the program and entry training and provision in the UBS. The difficulties reported by professionals were the COVID-19 pandemic, overload and/or a small team and/or lack of time and the absence of training. Conclusions: The PNCT in Mato Grosso do Sul has low coverage and restricted supply in the health network, in addition to average performance in assisting smokers. There is a clear need to invest in capacitation/training, primarily for the ESF in Campo Grande, enabling them to respond to the needs of health promotion, recognizing the program as more cost-effective.

Objetivo: El objetivo de este estudio fue evaluar el Programa Nacional de Control del Tabaco (PNCT) en Mato Grosso do Sul, las tasas de cobertura, el abandono, la cesación, el uso de medicamentos, la red de servicios de salud y las razones por las que los Equipos de Salud de la Familia en Campo Grande aún no se han unido al programa. Métodos: Se trata de un estudio descriptivo con abordaje cuantitativo, basado en datos primarios y secundarios sobre el PNCT en Mato Grosso do Sul. Los datos primarios se obtuvieron por medio de un cuestionario aplicado a los Equipos de Salud de la Familia (ESF) de Campo Grande, que no ofrecían el programa y evaluaron la frecuencia y la presencia de correlación entre las variables analizadas utilizando la V de Cramer y la prueba de la χ2. Los datos secundarios se obtuvieron de los registros consolidados del Instituto Nacional del Cáncer José Alencar Gomes da Silva con los registros producidos por los servicios. Resultados: Las tasas de adherencia, eficacia y apoyo farmacológico en la capital y en el interior fueron: 66,80 y 59,79%; 20,58 y 34,91%; 32,14 y 99,86%, respectivamente. El programa fue ofrecido en el 49,37% de los municipios y en el 43,85% de las Unidades Básicas de Salud (UBS) estimadas. Hubo correlación entre estar capacitado e implementar el programa; capacitación de entrada y oferta en las UBS. Las dificultades relatadas por los profesionales fueron la pandemia del COVID-19, la sobrecarga y/o un equipo pequeño y/o la falta de tiempo y la ausencia de capacitación. Conclusiones: El PNCT en Mato Grosso do Sul tiene baja cobertura y oferta restringida en la red de salud, además de un desempeño medio en la asistencia a los fumadores. Hay una clara necesidad de invertir en la creación de capacidad / formación, principalmente para la ESF en Campo Grande, lo que les permite responder a las necesidades de promoción de la salud, reconociendo el programa como más rentable.

Benefícios advindos da técnica de ogawa-kudoh para diagnóstico, controle e avaliação da tuberculose em Mato Grosso do Sul, Brasil / Gains from applying the ogawa-kudoh technique to the diagnosis, control and evaluation of tuberculosis in Mato Grosso do Sul, Brazil

A tuberculose continua sendo grave problema mundial de saúde pública. Seu diagnóstico precoce e tratamento ainda constituem desafios. Entre os recursos diagnósticos, a cultura de Mycobacterium tuberculosis é padrão-ouro. Objetivo: Relatar como a semeadura com a técnica Ogawa-Kudoh foi descentralizada em Mato Grosso do Sul e descrever os benefícios de diagnosticar precocemente a doença e a resistência, bem como o uso dos resultados como fonte de pesquisa. Materiais e Métodos: A técnica foi escolhida por sua simplicidade, sensibilidade e baixo custo, por não requerer centrífuga, estufa ou cabine de segurança biológica e pela facilidade de transporte dos semeados em temperatura ambiente, favorecendo o atendimento de populações distantes dos grandes centros. A descentralização da semeadura ocorreu após identificação ou adaptação de estruturas locais, capacitação de pessoal e fornecimento de insumos. Subsequente apoio técnico, supervisões e monitoramento foram proporcionados. Resultados: O uso da técnica iniciou-se em 1999 no laboratório do Hospital Porta da Esperança, em Dourados, então único serviço para tratamento de tuberculose em povos indígenas. Gradativamente, expandiu-se a outros municípios e populações. Atualmente, cerca de 60% da população sul-mato-grossense é coberta por este recurso laboratorial, destacando-se populações privadas de liberdade, fronteiriças e de áreas prioritárias para o controle da doença. Conclusão: A nova rotina contribuiu para o controle da tuberculose no estado, tanto pelo diagnóstico precoce da doença como da resistência a drogas, favorecendo também estudos e avaliações de relevância epidemiológica.

Worldwide, tuberculosis remains a serious public health problem. Its early diagnosis and treatment still constitute challenges. Mycobacterium tuberculosis culture is the gold standard among diagnostic resources. Objective: To report how culture seeding employing the Ogawa-Kudoh technique was decentralized in Mato Grosso do Sul and describe the benefits obtained from early diagnosis and detection of drug resistance. The use of the resulting data as sources for further research is also reported. Materials and Methods: The technique was selected for its simplicity, sensitivity, and low cost, for not requiring centrifuges, incubators, or biosafety cabins, and for the convenience of seeded plate transportation at room temperature, facilitating the provision of diagnostic services to populations living far from major centers. Decentralization of culture seeding was preceded by identification or adaptation of local structures and by staff training and supply of materials and equipment. Subsequent technical support, supervision, and monitoring were provided. Results: The technique was implemented in 1999 in the laboratory of the Hospital Porta da Esperança, in Dourados county, then the only service providing tuberculosis treatment to indigenous patients, and gradually expanded to other counties and populations. Today, roughly 60% of Mato Grosso do Sul residents are covered by the resource, and more crucially populations deprived of freedom and those living in border regions or areas prioritized for tuberculosis control. Conclusion: The new routine contributed to tuberculosis control in the state, improving early diagnosis and detection of drug resistance and fostering epidemiologically relevant studies and evaluations

A diagnosis of pulmonary tuberculosis and drug resistance among inmates in Mato Grosso do Sul, Brazil.

INTRODUCTION: High endemic levels of pulmonary tuberculosis in prisons result from overcrowding, limited access to healthcare, delayed diagnosis, sustained transmission owing to poor control measures, and multidrug resistance. This study evaluated locally implemented measures for early pulmonary tuberculosis diagnosis and evaluated resistance to anti-tuberculosis drugs. METHODS: This transversal study employed data from the Mato Grosso do Sul State Tuberculosis Control Program obtained from 35 correctional facilities in 16 counties for 2 periods (2007-2010 and 2011-2014). RESULTS: Statewide prevalence (per 100,000) was 480.0 in 2007 and 972.9 in 2014. The following indicators showed improvement: alcohol-acid-fast bacillus testing (from 82.7% to 92.9%); cultures performed (55.0% to 81.8%); drug susceptibility testing of positive cultures (71.6% to 62.4%); and overall drug susceptibility testing coverage (36.6% to 47.4%). Primary and acquired resistance rates for 2007-2014 were 21.1% and 30.0%, respectively. Primary and acquired multidrug resistance rates were 0.3% and 1.3%, respectively. CONCLUSIONS: Prevalence rates increased, and laboratory indicators improved as a result of capacity building and coordination of technical teams and other individuals providing healthcare to inmates. Resistance rates were high, thereby negatively affecting disease control.

A diagnosis of pulmonary tuberculosis and drug resistance among inmates in Mato Grosso do Sul, Brazil

Abstract INTRODUCTION: High endemic levels of pulmonary tuberculosis in prisons result from overcrowding, limited access to healthcare, delayed diagnosis, sustained transmission owing to poor control measures, and multidrug resistance. This study evaluated locally implemented measures for early pulmonary tuberculosis diagnosis and evaluated resistance to anti-tuberculosis drugs. METHODS: This transversal study employed data from the Mato Grosso do Sul State Tuberculosis Control Program obtained from 35 correctional facilities in 16 counties for 2 periods (2007-2010 and 2011-2014). RESULTS: Statewide prevalence (per 100,000) was 480.0 in 2007 and 972.9 in 2014. The following indicators showed improvement: alcohol-acid-fast bacillus testing (from 82.7% to 92.9%); cultures performed (55.0% to 81.8%); drug susceptibility testing of positive cultures (71.6% to 62.4%); and overall drug susceptibility testing coverage (36.6% to 47.4%). Primary and acquired resistance rates for 2007-2014 were 21.1% and 30.0%, respectively. Primary and acquired multidrug resistance rates were 0.3% and 1.3%, respectively. CONCLUSIONS: Prevalence rates increased, and laboratory indicators improved as a result of capacity building and coordination of technical teams and other individuals providing healthcare to inmates. Resistance rates were high, thereby negatively affecting disease control.

[Antituberculosis-drug resistance in the border of Brazil with Paraguay and Bolivia]. / Resistência às drogas antituberculose na fronteira do Brasil com Paraguai e Bolívia.

OBJECTIVE: To estimate the rate of drug resistance among pulmonary tuberculosis (PTB) cases in the state of Mato Grosso do Sul, Brazil, and specifically in the border areas with Paraguay and Bolivia, as well as to identify associated risk factors. METHOD: The present cross-sectional, epidemiological study focused on PTB cases recorded between January 2007 and December 2010 in the State Reportable Disease Information System with results of susceptibility tests to rifampicin, isoniazid, ethambutol, and streptomycin. Dependent variables were development of resistance to a single drug or any combination of drugs. Independent variables were being a new or treated case, living in border areas, presence/absence of diabetes, and history of alcoholism. RESULTS: There were 789 TBP cases with susceptibility testing. The following characteristics were associated with resistance: treated case (P = 0.0001), border region (P = 0.0142), alcoholism (P = 0.0451), and diabetes (P = 0.0708). The rates of combined, primary, and acquired resistance for the state were 16.3%, 10.6%, and 39.0%, vs. 22.3%, 19.2%, and 37.5% for the border region. The rates of combined, primary, and acquired multidrug resistance for the state were 1.8%, 0.6%, and 6.3%, vs. 3.1%, 1.2%, and 12.5% for the border region. CONCLUSIONS: In the border region, the state should investigate drug resistance in all patients with respiratory symptoms, determine the pattern of resistance in confirmed cases, adopt directly observed treatment for cases of PTB, and develop health actions together with neighboring countries. Across the state, the levels of acquired resistance should be monitored, with investigation of resistance in all treated cases and implementation of directly observed treatment especially among patients with diabetes or alcoholism.

Resistência às drogas antituberculose na fronteira do Brasil com Paraguai e Bolívia / Antituberculosis-drug resistance in the border of Brazil with Paraguay and Bolivia

Objetivo. Estimar as taxas de resistência às drogas entre casos de tuberculose pulmonar (TBP) para o estado de Mato Grosso do Sul, Brasil, e especificamente para a região da fronteira com Paraguai e Bolívia, além de identificar fatores de risco associados. Métodos. O presente estudo epidemiológico, transversal, enfocou os casos de TBP registrados de janeiro de 2007 a dezembro de 2010 no Sistema de Informação de Agravos de Notificação da Secretaria de Estado de Saúde com resultados do teste de suscetibilidade a rifampicina, isoniazida, etambutol e estreptomicina. Definiram-se como variáveis dependentes o desenvolvimento de resistência a uma única droga e a qualquer combinação de drogas. As variáveis independentes foram ser caso novo ou tratado, residência em região de fronteira ou outra região, presença ou ausência de diabetes e história de alcoolismo. Resultados. Foram identificados 789 casos de TBP com teste de suscetibilidade. As características associadas à resistência foram: caso tratado (P=0,0001), região de fronteira (P=0,0142), alcoolismo (P=0,0451) e diabetes (P=0,0708). As taxas de resistência combinada, primária e adquirida no estado foram de 16,3%, 10,6% e 39,0%, e na fronteira, de 22,3%, 19,2% e 37,5%. As taxas de resistência a múltiplas drogas combinada, primária e adquirida no estado foram de 1,8%, 0,6% e 6,3%, e na fronteira, de 3,1%, 1,2% e 12,5%. Conclusões. O estado deve, na região de fronteira, realizar cultura em todos os sintomáticos respiratórios, investigar o padrão de resistência nos casos confirmados, adotar o tratamento diretamente observado nos casos de TBP e desencadear ações de saúde conjuntas com os países fronteiriços. Em todo o estado, é necessário monitorar os níveis de resistência adquirida, ampliar a investigação de resistência para todos os casos tratados e adotar o tratamento diretamente observado prioritariamente entre pacientes com alcoolismo e diabetes.

Objective. To estimate the rate of drug resistance among pulmonary tuberculosis (PTB) cases in the state of Mato Grosso do Sul, Brazil, and specifically in the border areas with Paraguay and Bolivia, as well as to identify associated risk factors. Method. The present cross-sectional, epidemiological study focused on PTB cases recorded between January 2007 and December 2010 in the State Reportable Disease Information System with results of susceptibility tests to rifampicin, isoniazid, ethambutol, and streptomycin. Dependent variables were development of resistance to a single drug or any combination of drugs. Independent variables were being a new or treated case, living in border areas, presence/absence of diabetes, and history of alcoholism. Results. There were 789 TBP cases with susceptibility testing. The following characteristics were associated with resistance: treated case (P=0.0001), border region (P=0.0142), alcoholism (P=0.0451), and diabetes (P=0.0708). The rates of combined, primary, and acquired resistance for the state were 16.3%, 10.6%, and 39.0%, vs. 22.3%, 19.2%, and 37.5% for the border region. The rates of combined, primary, and acquired multidrug resistance for the state were 1.8%, 0.6%, and 6.3%, vs. 3.1%, 1.2%, and 12.5% for the border region. Conclusions. In the border region, the state should investigate drug resistance in all patients with respiratory symptoms, determine the pattern of resistance in confirmed cases, adopt directly observed treatment for cases of PTB, and develop health actions together with neighboring countries. Across the state, the levels of acquired resistance should be monitored, with investigation of resistance in all treated cases and implementation of directly observed treatment especially among patients with diabetes or alcoholism.

Resistência às drogas antituberculose na fronteira do Brasil com Paraguai e Bolívia / Antituberculosis-drug resistance in the border of Brazil with Paraguay and Bolivia

RESUMO Objetivo Estimar as taxas de resistência às drogas entre casos de tuberculose pulmonar (TBP) para o estado de Mato Grosso do Sul, Brasil, e especificamente para a região da fronteira com Paraguai e Bolívia, além de identificar fatores de risco associados. Métodos O presente estudo epidemiológico, transversal, enfocou os casos de TBP registrados de janeiro de 2007 a dezembro de 2010 no Sistema de Informação de Agravos de Notificação da Secretaria de Estado de Saúde com resultados do teste de suscetibilidade a rifampicina, isoniazida, etambutol e estreptomicina. Definiram-se como variáveis dependentes o desenvolvimento de resistência a uma única droga e a qualquer combinação de drogas. As variáveis independentes foram ser caso novo ou tratado, residência em região de fronteira ou outra região, presença ou ausência de diabetes e história de alcoolismo. Resultados Foram identificados 789 casos de TBP com teste de suscetibilidade. As características associadas à resistência foram: caso tratado (P=0,0001), região de fronteira (P=0,0142), alcoolismo (P=0,0451) e diabetes (P=0,0708). As taxas de resistência combinada, primária e adquirida no estado foram de 16,3%, 10,6% e 39,0%, e na fronteira, de 22,3%, 19,2% e 37,5%. As taxas de resistência a múltiplas drogas combinada, primária e adquirida no estado foram de 1,8%, 0,6% e 6,3%, e na fronteira, de 3,1%, 1,2% e 12,5%. Conclusões O estado deve, na região de fronteira, realizar cultura em todos os sintomáticos respiratórios, investigar o padrão de resistência nos casos confirmados, adotar o tratamento diretamente observado nos casos de TBP e desencadear ações de saúde conjuntas com os países fronteiriços. Em todo o estado, é necessário monitorar os níveis de resistência adquirida, ampliar a investigação de resistência para todos os casos tratados e adotar o tratamento diretamente observado prioritariamente entre pacientes com alcoolismo e diabetes.

ABSTRACT Objective To estimate the rate of drug resistance among pulmonary tuberculosis (PTB) cases in the state of Mato Grosso do Sul, Brazil, and specifically in the border areas with Paraguay and Bolivia, as well as to identify associated risk factors. Method The present cross-sectional, epidemiological study focused on PTB cases recorded between January 2007 and December 2010 in the State Reportable Disease Information System with results of susceptibility tests to rifampicin, isoniazid, ethambutol, and streptomycin. Dependent variables were development of resistance to a single drug or any combination of drugs. Independent variables were being a new or treated case, living in border areas, presence/absence of diabetes, and history of alcoholism. Results There were 789 TBP cases with susceptibility testing. The following characteristics were associated with resistance: treated case (P = 0.0001), border region (P = 0.0142), alcoholism (P = 0.0451), and diabetes (P = 0.0708). The rates of combined, primary, and acquired resistance for the state were 16.3%, 10.6%, and 39.0%, vs. 22.3%, 19.2%, and 37.5% for the border region. The rates of combined, primary, and acquired multidrug resistance for the state were 1.8%, 0.6%, and 6.3%, vs. 3.1%, 1.2%, and 12.5% for the border region. Conclusions In the border region, the state should investigate drug resistance in all patients with respiratory symptoms, determine the pattern of resistance in confirmed cases, adopt directly observed treatment for cases of PTB, and develop health actions together with neighboring countries. Across the state, the levels of acquired resistance should be monitored, with investigation of resistance in all treated cases and implementation of directly observed treatment especially among patients with diabetes or alcoholism.

Magnitude da tuberculose pulmonar na população fronteiriça de Mato Grosso do Sul (Brasil), Paraguai e Bolívia / Pulmonary tuberculosis among residents of municipalities in Mato Grosso do Sul State, Brazil, bordering on Paraguay and Bolivia / Magnitud de la tuberculosis pulmonar en la población fronteriza de Mato Grosso do Sul (Brasil), Paraguay y Bolivia

Este estudo analisou a magnitude da tuberculose pulmonar no período de 2007 a 2010 em municípios sul-mato-grossenses fronteiriços ao Paraguai e à Bolívia. Na região de fronteira, as taxas de incidência (49,1/100 mil habitantes), de mortalidade (4,0/100 mil) e de abandono do tratamento (11,3%) foram 1,6, 1,8 e 1,5 vez maiores do que na região não fronteiriça. Entre indígenas da fronteira, as taxas de incidência (253,4/100 mil habitantes), mortalidade (11,6/100 mil) e coinfecção por HIV (1,9/100 mil) foram, respectivamente, 6,4, 3,2 vezes e 1,9 vez maiores do que entre os não indígenas nesta região. Estar na região de fronteira revelou-se fator de proteção contra coinfecção por HIV. Constatou-se associação entre ser indígena e não abandonar o tratamento. Conclui-se que a população residente nesses municípios de fronteira vivencia elevado risco de adoecimento, de morte e de abandono do tratamento de tuberculose pulmonar, o que requer ações diferenciadas de vigilância em saúde.

This study analyzed the epidemiological profile of pulmonary tuberculosis from 2007 to 2010 in municipalities (counties) in Mato Grosso do Sul State, Brazil, that border on Paraguay and Bolivia. In the border region, the incidence rate (49.1/100,000 inhabitants), mortality rate (4.0/100,000 inhabitants), and treatment dropout rate (11.3%) were 1.6, 1.8, and 1.5 times higher than in the non-border region. Among indigenous individuals in the border region, the rates for incidence (253.4/100,000 inhabitants), mortality (11.6/100,000 inhabitants), and HIV/TB co-infection (1.9/100,000 inhabitants) were 6.4, 3.2, and 1.9 times higher than in non-indigenous individuals in this region. Living in the border regions was inversely associated with HIV/TB co-infection. Indigenous ethnicity was associated statistically with not abandoning TB treatment. The study concludes that the population residing in these municipalities along the border is exposed to high risk of pulmonary TB and TB mortality and treatment dropout, thus requiring special health surveillance interventions.

Este estudio examinó la magnitud de la tuberculosis pulmonar del 2007 al 2010 en los municipios de Mato Grosso do Sul (Brasil) limítrofes con Paraguay y Bolivia. En la región fronteriza, las tasas de incidencia (49,1/100.000 habitantes), mortalidad (4,0/100.000) y abandono del tratamiento (11,3%) fueron 1,6, 1,8 y 1,5 veces más altas que en la región no fronteriza. En la región fronteriza, las tasas de incidencia (253,4/100.000 habitantes), mortalidad (11,6/100.000) y co-infección por el VIH (1,9/100.000) entre residentes indígenas fueron 6,4, 3,2 y 1,9 veces más altas que en la población no indígena. Vivir en la región fronteriza resultó ser un factor protector contra la co-infección por el VIH. Se identificó asociación entre ser indígena y no abandonar el tratamiento. Los resultados mostraron que la población de estos municipios fronterizos está sujeta a un alto riesgo de enfermedad, muerte y abandono del tratamiento de la tuberculosis pulmonar, lo que requiere acciones de vigilancia de la salud específicas para este contexto.

[Pulmonary tuberculosis among residents of municipalities in Mato Grosso do Sul State, Brazil, bordering on Paraguay and Bolivia]. / Magnitude da tuberculose pulmonar na população fronteiriça de Mato Grosso do Sul (Brasil), Paraguai e Bolívia.

This study analyzed the epidemiological profile of pulmonary tuberculosis from 2007 to 2010 in municipalities (counties) in Mato Grosso do Sul State, Brazil, that border on Paraguay and Bolivia. In the border region, the incidence rate (49.1/100,000 inhabitants), mortality rate (4.0/100,000 inhabitants), and treatment dropout rate (11.3%) were 1.6, 1.8, and 1.5 times higher than in the non-border region. Among indigenous individuals in the border region, the rates for incidence (253.4/100,000 inhabitants), mortality (11.6/100,000 inhabitants), and HIV/TB co-infection (1.9/100,000 inhabitants) were 6.4, 3.2, and 1.9 times higher than in non-indigenous individuals in this region. Living in the border regions was inversely associated with HIV/TB co-infection. Indigenous ethnicity was associated statistically with not abandoning TB treatment. The study concludes that the population residing in these municipalities along the border is exposed to high risk of pulmonary TB and TB mortality and treatment dropout, thus requiring special health surveillance interventions.

Desigualdades sociais e tuberculose: analise segundo raca/cor, Mato Grosso do Sul / Desigualdades sociales y tuberculosis: analisis de acuerdo a raza/color, Mato Grosso do Sul, Brasil / Social inequalities and tuberculosis: an analysis by race/color in Mato Grosso do Sul, Brazil

OBJETIVO Analisar características sociodemográficas e clínico-epidemiológicas dos casos de tuberculose e fatores associados ao abandono e ao óbito na vigência do tratamento. MÉTODOS Estudo epidemiológico baseado em dados notificados de tuberculose em indígenas e não indígenas, segundo raça/cor, em Mato Grosso do Sul, entre 2001 e 2009. Realizou-se análise descritiva dos casos de acordo com as variáveis sexo, faixa etária, zona de residência, exames empregados para o diagnóstico, forma clínica, tratamento supervisionado e situação de encerramento, segundo raça/cor. Utilizou-se análise univariada e múltipla por meio de regressão logística para identificar preditores de abandono e óbito, e odds ratio como medida de associação. Foi construída série histórica de incidência, segundo raça/cor. RESULTADOS Registraram-se 6.962 casos novos de tuberculose no período, 15,6% entre indígenas. Houve predomínio em homens e adultos (20 a 44 anos) em todos os grupos. A maior parte dos doentes indígenas residia na zona rural (79,8%) e 13,5% dos registros nos indígenas ocorreram em < 10 anos. A incidência média no estado foi 34,5/100.000 habitantes, 209,0; 73,1; 52,7; 23,0 e 22,4 entre indígenas, amarelos, pretos, brancos e pardos, respectivamente. Doentes de 20 a 44 anos (OR = 13,3; IC95% 1,9;96,8), do sexo masculino (OR = 1,6; IC95% 1,1;2,3) e de raça/cor preta (OR = 2,5; IC95% 1,0;6,3) mostraram associação com abandono de tratamento, enquanto doentes > 45 anos (OR = 3,0; IC95% 1,2;7,8) e com a forma mista (OR = 2,3; IC95% 1,1;5,0) apresentaram associação com óbito. Apesar de representarem 3,0% da população, os indígenas foram responsáveis por 15,6% das notificações no período. ...

OBJETIVO Analizar características sociodemográficas y clínico-epidemiológicas de los casos de tuberculosis y factores asociados con el abandono y el óbito en la vigencia del tratamiento. MÉTODOS Estudio epidemiológico basado en datos notificados de tuberculosis en indígenas y no indígenas, de acuerdo a la raza y el color, en Mato Grosso do Sul, entre 2001 y 2009. Se realizó análisis descriptivo de los casos de acuerdo con las variables sexo, grupo etario, zona de residencia, exámenes empleados para el diagnóstico, forma clínica, tratamiento supervisado y situación de conclusión, de acuerdo a raza/color. Se utilizó análisis univariado y múltiple por medio de regresión logística para identificar predictores de abandono y óbito, y odds ratio como medida de asociación. Se construyó serie histórica de incidencia, de acuerdo a raza/color. RESULTADOS Se registraron 6.962 casos nuevos de tuberculosis en el período, 15,6% entre indígenas. Hubo predominio en hombres y adultos (20 a 44 años) en todos los grupos. La mayor parte de los indígenas enfermos residía en la zona rural (79,8%) y 13,5% de los registros en los indígenas ocurrieron en < 10 años. La incidencia promedio en el estado fue 34,5/100.000 habitantes, 209,0; 73,1; 52,7; 23,0 y 22,4 entre indígenas amarillos, negros, blancos y pardos, respectivamente. Enfermos de 20 a 44 años (OR=13,3; IC95% 1,9;96,8), del sexo masculino (OR = 1,6; IC95% 1,1;2,3) y de raza/color negra (OR= 2,5; IC95% 1,0;6,3) mostraron asociación con abandono del tratamiento, mientras que los enfermos > 45 años (OR= 3,0; IC95% 1,2;7,8) y con la forma mixta (OR= 2,3; IC95% 1,1;5,0) presentaron asociación con óbito. A pesar de representar 3,0% de la población, los indígenas fueron responsables por 15,6% de las ...

OBJECTIVE To describe the sociodemographic and clinical-epidemiological characteristics of tuberculosis cases and identify associated factors with abandoning treatment and death whilst undergoing treatment. METHODS Epidemiological study based on cases of tuberculosis recorded in indigenous and non-indigenous individuals according to race/color in Mato Grosso do Sul, Midwestern Brazil, between 2001 and 2009. Descriptive analysis of the cases was carried out according to the variables of sex, age group, residence, type of test used in the diagnosis, clinical form, supervised treatment and final status, according to race/color. Univariate/multivariate logistic regression analyses were used to identify predictors of abandoning treatment and death, using odds ratio as a measure of association. A time series of incidence according to race/color was constructed. RESULTS In the period, 6,962 new cases of tuberculosis were registered, 15.6% being among indigenous. The illness was predominantly found in men and adults (20-44 years old) in all groups. Most of the indigenous patients lived in rural areas (79.8%) and 13.5% of the records in indigenous occurred in children aged < 10 years. The average incidence in the state was 34.5/100,000 inhabitants, being 209.0, 73.1, 52.7, 23.0 and 22.4 in indigenous, and those with yellow, black, white and brown skin, respectively. Patients aged 20 to 44 years (OR = 13.3, 95%CI 1.9;96.8), male (OR = 1.6, 95%CI 1.1;2.3) and of black race/color (OR = 2.5, 95%CI 1.0;6.3) were associated with abandoning treatment, while patients aged > 45 years (OR = 3.0, 95%CI 1.2;7.8) and with the mixed form (OR = 2.3, 95%CI 1.1;5.0) showed association with death. Although they only account for 3.0% of the population, the indigenous were responsible for 15.6% of cases recorded during the period. CONCLUSIONS Major inequalities in the tuberculosis illness process were found between the categories studied. Incidence in ...

[Social inequalities and tuberculosis: an analysis by race/color in Mato Grosso do Sul, Brazil]. / Desigualdades sociais e tuberculose: análise segundo raça/cor, Mato Grosso do Sul.

OBJECTIVE: To describe the sociodemographic and clinical-epidemiological characteristics of tuberculosis cases and identify associated factors with abandoning treatment and death whilst undergoing treatment. METHODS: Epidemiological study based on cases of tuberculosis recorded in indigenous and non-indigenous individuals according to race/color in Mato Grosso do Sul, Midwestern Brazil, between 2001 and 2009. Descriptive analysis of the cases was carried out according to the variables of sex, age group, residence, type of test used in the diagnosis, clinical form, supervised treatment and final status, according to race/color. Univariate/multivariate logistic regression analyses were used to identify predictors of abandoning treatment and death, using odds ratio as a measure of association. A time series of incidence according to race/color was constructed. RESULTS: In the period, 6,962 new cases of tuberculosis were registered, 15.6% being among indigenous. The illness was predominantly found in men and adults (20-44 years old) in all groups. Most of the indigenous patients lived in rural areas (79.8%) and 13.5% of the records in indigenous occurred in children aged < 10 years. The average incidence in the state was 34.5/100,000 inhabitants, being 209.0, 73.1, 52.7, 23.0 and 22.4 in indigenous, and those with yellow, black, white and brown skin, respectively. Patients aged 20 to 44 years (OR = 13.3, 95%CI 1.9;96.8), male (OR = 1.6, 95%CI 1.1;2.3) and of black race/color (OR = 2.5, 95%CI 1.0;6.3) were associated with abandoning treatment, while patients aged > 45 years (OR = 3.0, 95%CI 1.2;7.8) and with the mixed form (OR = 2.3, 95%CI 1.1;5.0) showed association with death. Although they only account for 3.0% of the population, the indigenous were responsible for 15.6% of cases recorded during the period. CONCLUSIONS: Major inequalities in the tuberculosis illness process were found between the categories studied. Incidence in the indigenous population was consistently higher than recorded in any other group, reaching more than six times the national average. It was among those with black and brown skin that the worst treatment results were observed, as they were twice as likely to abandon treatment as the indigenous. Poor program performance was strongly associated with abandoning treatment and death. It is thought that as long as there is no reduction in poverty inequalities in health indicators will remain.

Tuberculin skin test: operational research in the state of Mato Grosso do Sul, Brazil.

OBJECTIVE: To investigate operational aspects of tuberculin skin test (TST) use in tuberculosis control programs and at specialized Brazilian National Sexually Transmitted Diseases/AIDS and Viral Hepatitis Program health care clinics in priority municipalities for tuberculosis control in the state of Mato Grosso do Sul, Brazil. METHODS: This was a descriptive, cross-sectional, epidemiological survey. Data on qualifications/training of professionals administering TSTs, timing of the TST, procedures in cases of loss to follow-up (reading), material availability, and material storage were collected through interviews and technical visits. For the 2008-2009 period, we determined the numbers of screenings in vulnerable populations, of TSTs performed, and of patients treated for latent tuberculosis. RESULTS: We interviewed 12 program managers in six municipalities. Some programs/clinics did not perform TSTs. Nursing teams administered the TSTs, results were read by non-specialists, and specialization/refresher courses were scarce. The PPD RT23 was stored in 5-mL flasks under appropriate conditions. Insulin syringes were commonly used. Testing was available during business hours, three times a week. In cases of loss to follow-up, telephone calls or home visits were made. Of the 2,305 TSTs evaluated, 1,053 (46%) were performed in indigenous populations; 831 (36%) were screenings in prisons, performed for training; and only 421 (18%) involved contacts of tuberculosis patients or vulnerable populations. Four vulnerable patients and 126 indigenous subjects were treated for latent tuberculosis. CONCLUSIONS: These priority municipalities showed operational difficulties regarding human resources, materials, and data records.

Teste tuberculínico: pesquisa operacional no Mato Grosso do Sul / Tuberculin skin test: operational research in the state of Mato Grosso do Sul, Brazil

OBJETIVO: Investigar a operacionalização da utilização do teste tuberculínico (TT) em programas de controle de tuberculose e em serviços de assistência especializada do Programa Nacional de Doenças Sexualmente Transmissíveis/AIDS e Hepatites Virais em municípios prioritários para o controle da tuberculose no estado de Mato Grosso do Sul. MÉTODOS: Estudo epidemiológico descritivo, transversal, do tipo inquérito. A formação profissional dos responsáveis pela realização do TT, existência de treinamentos, período de realização dos TTs, conduta em caso de perda de leitura, insumos disponíveis e sua conservação foram levantados por meio de entrevistas e visitas técnicas. O número de inquéritos em populações vulneráveis, número de TTs realizados e número de pacientes em tratamento de tuberculose latente entre 2008 e 2009 foram também levantados. RESULTADOS: Foram entrevistados 12 gestores de seis municípios. Alguns programas/serviços não realizavam o TT. A equipe de enfermagem realizava os TTs, não havia leitores especialistas, e treinamentos eram raros. A conservação dos frascos de PPD RT23 (5 mL) era adequada. Frequentemente utilizava-se a seringa de insulina. A realização de TT ocorria no horário comercial, três vezes na semana. Em caso de perda de leitura em alguns locais, realizava-se contato telefônico ou visita domiciliar. O total de TT realizados foi de 2.305, dos quais 1.053 (46 por cento) foram realizados em populações indígenas, 831 (36 por cento) foram realizados em ambientes prisionais para fins de treinamento (inquéritos), e apenas 421 (18 por cento) foram realizados em contatos de pacientes com tuberculose e em populações vulneráveis. O tratamento de tuberculose latente foi realizado em 4 pacientes vulneráveis e em 126 indígenas. CONCLUSÕES: Os municípios prioritários demonstraram dificuldades operacionais em relação a recursos humanos, insumos e registros de informação.

OBJECTIVE: To investigate operational aspects of tuberculin skin test (TST) use in tuberculosis control programs and at specialized Brazilian National Sexually Transmitted Diseases/AIDS and Viral Hepatitis Program health care clinics in priority municipalities for tuberculosis control in the state of Mato Grosso do Sul, Brazil. METHODS: This was a descriptive, cross-sectional, epidemiological survey. Data on qualifications/training of professionals administering TSTs, timing of the TST, procedures in cases of loss to follow-up (reading), material availability, and material storage were collected through interviews and technical visits. For the 2008-2009 period, we determined the numbers of screenings in vulnerable populations, of TSTs performed, and of patients treated for latent tuberculosis. RESULTS: We interviewed 12 program managers in six municipalities. Some programs/clinics did not perform TSTs. Nursing teams administered the TSTs, results were read by non-specialists, and specialization/refresher courses were scarce. The PPD RT23 was stored in 5-mL flasks under appropriate conditions. Insulin syringes were commonly used. Testing was available during business hours, three times a week. In cases of loss to follow-up, telephone calls or home visits were made. Of the 2,305 TSTs evaluated, 1,053 (46 percent) were performed in indigenous populations; 831 (36 percent) were screenings in prisons, performed for training; and only 421 (18 percent) involved contacts of tuberculosis patients or vulnerable populations. Four vulnerable patients and 126 indigenous subjects were treated for latent tuberculosis. CONCLUSIONS: These priority municipalities showed operational difficulties regarding human resources, materials, and data records.

[Drug resistance profile of Mycobacterium tuberculosis in the state of Mato Grosso do Sul, Brazil, 2000-2006]. / Perfil de resistência de Mycobacterium tuberculosis no estado de Mato Grosso do Sul, 2000-2006.

OBJECTIVE: To determine the drug resistance profile of Mycobacterium tuberculosis in the state of Mato Grosso do Sul, Brazil, between 2000 and 2006. METHODS: Descriptive study of reported tuberculosis cases in the Brazilian Case Registry Database. We included only those cases in which M. tuberculosis culture was positive and sensitivity to drugs (rifampicin, isoniazid, streptomycin and ethambutol) was tested. Löwenstein-Jensen and Ogawa-Kudoh solid media were used for cultures, as was an automated liquid medium system. Sensitivity tests were based on the proportion method. RESULTS: Among the 783 cases evaluated, males predominated (69.7%), as did patients in the 20-49 year age bracket (70%), a diagnosis of pulmonary tuberculosis (94.4%) and positive HIV serology (8.6%); 645 (82.4%) were new cases, and 138 (17.6%) had previously been treated. Resistance to at least one drug was found in 143 cases (18.3%). The primary resistance (PR) rate was, respectively, 8.1%, 1.6%, 2.8% and 12.4%, for monoresistance, multidrug resistance (MDR), other patterns of resistance and resistance to at least one drug, whereas the acquired resistance (AR) rate was 14.5%, 20.3%, 10.9% and 45.7%, respectively, and the combined resistance (CR) rate was 9.2%, 4.9%, 4.2% and 18.3%, respectively. In PR, streptomycin was the most common drug, whereas isoniazid was the most common in AR and CR (7.2% and 3.7%, respectively). CONCLUSIONS: These high levels of resistance undermine the efforts for tuberculosis control in Mato Grosso do Sul. Acquired MDR was 12.7 times more common than was primary MDR, demonstrating that the previous use of drug therapy is an indicator of resistance. These levels reflect the poor quality of the health care provided to these patients, showing the importance of using the directly observed treatment, short course strategy, as well as the need to perform cultures and sensitivity tests for the early diagnosis of drug resistance.

Perfil de resistência de Mycobacterium tuberculosis no estado de Mato Grosso do Sul, 2000-2006 / Drug resistance profile of Mycobacterium tuberculosis in the state of Mato Grosso do Sul, Brazil, 2000-2006

OBJETIVO: Determinar o perfil de resistência a drogas de Mycobacterium tuberculosis no estado de Mato Grosso do Sul no período entre 2000 e 2006. MÉTODOS: Estudo descritivo de casos notificados de tuberculose no Sistema de Informação de Agravos de Notificação, com cultura positiva para M. tuberculosis e testes de sensibilidade a rifampicina, isoniazida, estreptomicina e etambutol. Para as culturas, utilizaram-se os meios sólidos Lõwenstein-Jensen e Ogawa-Kudoh, assim como um sistema automatizado com meio líquido; para os testes de sensibilidade, o método das proporções. RESULTADOS: De 783 casos, 69,7 por cento eram de pacientes masculinos, na faixa etária de 20-49 anos (70 por cento), com forma pulmonar (94,4 por cento) e sorologia positiva para HIV (8,6 por cento); 645 (82,4 por cento) eram casos novos, e 138 (17,6 por cento) eram casos tratados. Identificou-se qualquer resistência em 143 casos (18,3 por cento). A taxa de resistência primária (RP) foi, respectivamente, 8,1 por cento, 1,6 por cento, 2,8 por cento e 12,4 por cento, para monorresistência, multirresistência (MR), outros padrões de associação de drogas e qualquer resistência, ao passo que a taxa de resistência adquirida (RA) foi, respectivamente, 14,5 por cento, 20,3 por cento, 10,9 por cento e 45,7 por cento, e a taxa de resistência combinada (RC) foi, respectivamente, 9,2 por cento, 4,9 por cento, 4,2 por cento e 18,3 por cento. A estreptomicina foi a droga mais comum na RP (3,4 por cento), e a isoniazida foi a mais comum na RA e RC (7,2 por cento e 3,7 por cento, respectivamente). CONCLUSÕES: Os níveis de resistência são elevados, prejudicando o controle da tuberculose em Mato Grosso do Sul. A MR adquirida, 12,7 vezes superior à MR primária, evidencia o uso prévio de medicamentos como indicativo de resistência. Os níveis refletem a fragilidade da atenção ao doente, mostrando a importância do tratamento diretamente observado, assim como das culturas e testes de sensibilidade ...

OBJECTIVE: To determine the drug resistance profile of Mycobacterium tuberculosis in the state of Mato Grosso do Sul, Brazil, between 2000 and 2006. METHODS: Descriptive study of reported tuberculosis cases in the Brazilian Case Registry Database. We included only those cases in which M. tuberculosis culture was positive and sensitivity to drugs (rifampicin, isoniazid, streptomycin and ethambutol) was tested. Lõwenstein-Jensen and Ogawa-Kudoh solid media were used for cultures, as was an automated liquid medium system. Sensitivity tests were based on the proportion method. RESULTS: Among the 783 cases evaluated, males predominated (69.7 percent), as did patients in the 20-49 year age bracket (70 percent), a diagnosis of pulmonary tuberculosis (94.4 percent) and positive HIV serology (8.6 percent); 645 (82.4 percent) were new cases, and 138 (17.6 percent) had previously been treated. Resistance to at least one drug was found in 143 cases (18.3 percent). The primary resistance (PR) rate was, respectively, 8.1 percent, 1.6 percent, 2.8 percent and 12.4 percent, for monoresistance, multidrug resistance (MDR), other patterns of resistance and resistance to at least one drug, whereas the acquired resistance (AR) rate was 14.5 percent, 20.3 percent, 10.9 percent and 45.7 percent, respectively, and the combined resistance (CR) rate was 9.2 percent, 4.9 percent, 4.2 percent and 18.3 percent, respectively. In PR, streptomycin was the most common drug, whereas isoniazid was the most common in AR and CR (7.2 percent and 3.7 percent, respectively). CONCLUSIONS: These high levels of resistance undermine the efforts for tuberculosis control in Mato Grosso do Sul. Acquired MDR was 12.7 times more common than was primary MDR, demonstrating that the previous use of drug therapy is an indicator of resistance. These levels reflect the poor quality of the health care provided to these patients, showing the importance of using the directly observed treatment, ...

Violência de gênero contra a mulher: considerações éticas e morais / Gender-based violence against women: ethical and moral considerations

Introdução: a violência de gênero pode ser definida como qualquer ato de violência baseado na diferença de genero e que resulta em sofrimento e danos físicos, sexuais e/ou psicológicos da mulher, incluindo ameaças, coerção e privação da liberdade. A violência representa um problema social e histórico e, por suas consequências, tanto na saúde mental quanto na saúde fisica da mulher, constitui um problema de saúde pública. Objetivo: pretende­se através deste artigo refletir acerca dos problemas sociais e familiares relacionados à violência de gênero contra a mulher, através de uma análise ética e moral. Materiais e métodos: neste estudo teórico­bibliográfico procedeu­se a uma revisão de artigos científicos indexados na base de dados SCIELO. Como critérios de inclusão, foram consideradas as publicações no período de 1980 a 2007 nos idiomas inglês, português e espanhol. Resultados: foram analisados e discutidos: o panorama internacional sobre violência, políticas públicas para proteção à mulher, violência a luz de uma nova legislação, análise moral, ética e dialética da violência e questões de gênero. Conclusão: considera­se que para reduzir a violência há necessidade do estabelecimento de uma conexão entre os direitos humanos e sociais, numa perspectiva jurídica, ética e moral que perpassa transformações de atitude e de sentimentos humanos relacionados a si mesmo e aos outros.

Introduction: gender-based violence can be defined as any act of Violence that is grounded in gender differences and which results in distress and physical, sexual, and/or psychological injury to women and includes the use of threats, coercion, and deprivation of freedom. Violence has been a social and istorical issue whose impact on the mental and physical health of women makes it a public­health problem. Objective: the purpose of this article was to conduct an analySis of ethical and moral aspects in order to examine social and family issues related to gender­based Violence against women. Methods:.in these bibliographyc­theoretical study it was realized a review of eieiitific articles at SCIELO. The inclusion criterion were publications from 1980 to 2007, in english. portuguese and spanish. Results: it was analysed and discussed: the international view about violence, public politics tor the women protection, the new legislation, morale, ethics and dialetic analysis of Violence and gender questions. Conclusion: reducing Violence requires the development of a connection between human and social rights, in terms of a Juridical, ethics, and morale perspective, encompassing changes not only in attitude, but also in human feelings towards others and self.

Contribuição do LACEN-MS no diagnóstico da tuberculose e da resistência às drogas antituberculosas em Mato Grosso do Sul / The contribution of the Public Health Central Laboratory of Mato Grosso do Sul to the diagnosis

Com a disseminacao da AIDS e o surgimento de cepas de Mycobacterium tuberculosis resistentes a quimioterapicos, a tuberculosetem recrudescido mundialmente. Avaliar a demanda ao Laboratorio Central de Mato Grosso do Sul (LACEN-MS) por diagnostico de M. tuberculosis e a prevalencia da resistencia a drogas antituberculose entre casos notificados ao SINAN em 2000-2006. Estudo descritivo de dados de cultivo e de testes de sensibilidade (com metodo das proporcoes) a rifampicina, isoniazida, estreptomicina e etambutol de casos notificados. Materiais biologicos (pulmonares e/ou extrapulmonares) de casos suspeitos foram semeados emmeios Lowenstein–Jensen e Ogawa–Kudoh e no sistema automatizado Bactec MGIT 960. No periodo, 66 dos 78 municipios enviaram 18 392 amostras, sendo 2 009 (10,9%) positivas. Em 1 174 (58,4%) destas realizou-se TS. Selecionaram-se 783 (66,7%) para o levantamento de resistencia, sendo 645 (82,4%) de casos nunca tratados e 138 (17,6%) com registro de tratamento. Constatou-se resistencia primaria, adquirida e combinada em 12,4%, 45,7% e 18,3% dos casos, respectivamente. O LACEN-MS atendeu 84,6% dos municipios. Entre os casos notificados ao SINAN verificou-se alta resistencia, com tuberculose multirresistente adquirida em 20,3%, evidenciando o uso previo de medicamentos como indicador de resistencia.

With the spread of AIDS and the emergence of drug-resistant Mycobacterium tuberculosis strains, tuberculosis has made a vigorous comeback worldwide. To evaluate the demands placed on the Public Health Central Laboratory of the State of MatoGrosso do Sul (LACEN-MS) for the diagnosis of M. tuberculosis and to determine the prevalence of antituberculosis drug resistanceamong cases notified to the Brazilian Information System of Notifiable Hazards (SINAN) in 2000-2006. A descriptive study of the results of culture tests and of sensitivity tests performed for rifampicin, isoniazid, streptomycin, and ethambutol (proportion method) on material from notified cases. Pulmonary and/or extrapulmonary materials from suspected cases were seeded on Lõwenstein–Jensen and Ogawa–Kudoh. The Bactec MGIT 960 automated system was used. In the period investigated, 18 392 samples referred by 66 of the 78 counties in Mato Grosso do Sul were analyzed, 2 009 (10.9%) of which were positive. Sensitivity tests were performed on 1 174 (58.4%) of these. Resistance was investigated in 783 (66.7%) cases, of which 645 (82.4%) were naive to treatment and 138 (17.6%) had been previously treated. Primary, acquired, and combined resistance were found in 12.4%, 45.7%, and 18.3% of cases, respectively. LACEN-MS served 84.6% of Mato Grosso do Sul’s counties. Acquired multidrug resistance was found in 20.3% of the notified cases,demonstrating that previous use of drug therapy can be viewed as an indicator of resistance.