Diabetes, undernutrition, migration and indigenous communities: tuberculosis in Chiapas, Mexico.

We investigated the distribution of comorbidities among adult tuberculosis (TB) patients in Chiapas, the poorest Mexican state, with a high presence of indigenous population, and a corridor for migrants from Latin America. Secondary analysis on 5508 new adult TB patients diagnosed between 2010 and 2014 revealed that the most prevalent comorbidities were diabetes mellitus (DM; 19.1%) and undernutrition (14.4%). The prevalence of DM in these TB patients was significantly higher among middle aged (41-64 years) compared with older adults (⩾65 years) (38.6% vs. 23.2%; P < 0.0001). The prevalence of undernutrition was lower among those with DM, and higher in communities with high indigenous presence. Immigrants only comprised 2% of all TB cases, but were more likely to have unfavourable TB treatment outcomes (treatment failure, death and default) when compared with those born in Chiapas (29.5% vs. 11.1%; P < 0.05). Unfavourable TB outcomes were also more prevalent among the TB patients with undernutrition, HIV or older age, but not DM (P < 0.05). Our study in Chiapas illustrates the challenges of other regions worldwide where social (e.g. indigenous origin, poverty, migration) and host factors (DM, undernutrition, HIV, older age) are associated with TB. Further understanding of these critical factors will guide local policy makers and health providers to improve TB management.

The Poor Survival among Pulmonary Tuberculosis Patients in Chiapas, Mexico: The Case of Los Altos Region.

Objective. To analyse survival in patients with pulmonary tuberculosis (PTB) and factors associated with such survival. Design. Study of a cohort of patients aged over 14 years diagnosed with PTB from January 1, 1998 to July 31, 2005. During 2004-2006 a home visit was made to each patient and, during 2008-2009, they were visited again. During these visits a follow-up interview was administered; when the patient had died, a verbal autopsy was conducted with family members. Statistical analysis consisted of survival tests, Kaplan-Meier log-rank test and Cox regression. Results. Of 305 studied patients, 68 had died due to PTB by the time of the first evaluation, 237 were followed-up for a second evaluation, and 10 of them had died of PTB. According to the Cox regression, age (over 45 years) and treatment duration (under six months) were associated with a poorer survival. When treatment duration was excluded, the association between poorer survival with age persisted, whereas with having been treated via DOTS strategy, was barely significant. Conclusions. In the studied area it is necessary that patients receive a complete treatment scheme, and to give priority to patients aged over 45 years.

Multidrug-resistant pulmonary tuberculosis in Los Altos, Selva and Norte regions, Chiapas, Mexico.

OBJECTIVES: To analyse the proportion of multidrug-resistant tuberculosis (MDR-TB) in cultures performed during the period 2000-2002 in Los Altos, Selva and Norte regions, Chiapas, Mexico, and to analyse MDR-TB in terms of clinical and sociodemographic indicators. METHODS: Cross-sectional study of patients with pulmonary tuberculosis (PTB) from the above regions. Drug susceptibility testing results from two research projects were analysed, as were those of routine sputum samples sent in by health personnel for processing (n = 114). MDR-TB was analysed in terms of the various variables of interest using bivariate tests of association and logistic regression. RESULTS: The proportion of primary MDR-TB was 4.6% (2 of 43), that of secondary MDR-TB was 29.2% (7/24), while among those whose history of treatment was unknown the proportion was 14.3% (3/21). According to the logistic regression model, the variables most highly associated with MDR-TB were as follows: having received anti-tuberculosis treatment previously, cough of >3 years' duration and not being indigenous. CONCLUSIONS: The high proportion of MDR cases found in the regions studied shows that it is necessary to significantly improve the control and surveillance of PTB.

Demographic, health services and socio-economic factors associated with pulmonary tuberculosis mortality in Los Altos Region of Chiapas, Mexico.

BACKGROUND: Chiapas is one of the Mexican states having the highest rates of Pulmonary Tuberculosis (PTB), due to the numerous factors impeding its management and control (poverty, poor housing and nutrition, shortage of health resources, among others). OBJECTIVES: To analyse the PTB mortality of a cohort of patients in Los Altos Region of Chiapas, who had been diagnosed with PTB from January 1, 1998 to December 31, 2002; and, to identify demographic, socioeconomic and health services utilization factors, associated with death from PTB. METHODS: Analysis of a cohort of patients aged over 14 years diagnosed with PTB in the above mentioned period (n = 431) in Los Altos region of Chiapas. The records of the Tuberculosis Programme were reviewed, and patients were located through a search attempting to locate them in their homes. Those found alive were interviewed and asked to provide sputum samples. In the case of deceased patients, a verbal autopsy was obtained from a member of their family. RESULTS: The records of the PTB Programme in the area were incomplete and erroneous in many cases. The results of the home follow-up visits were: 208 (48%) patients located alive, five of whom were still PTB positive (three with multi-drug resistance); 145 (34%) could not be located and 78 (18%) had already died. Apparently, in at least 40 cases, the deaths were associated with PTB. Of these forty, 33 (83%) died without having received any medical care. The factors associated with dying from PTB were: 45 and over years of age (OR = 1.3; 95% CI = 0.98-1.3), 0-3 schooling years (OR = 3.3; 95% CI = 1.1-9.6), engaged in agriculture (OR = 2.2; 95% CI = 1.1-4.4), not living in main villages of their municipality (OR = 1.2; 95% CI = 1.0-1.3), living in a rural community (OR = 2.7; 95% CI = 1.1-6.8), not having been treated in DOTS (OR = 1.2; 95% CI = 1.0-1.3) and having defaulted from treatment (OR = 11.5; 95% CI = 5.3-24.8). CONCLUSIONS: The high rate of mortality due to PTB observed constitutes a serious public health problem deserving attention. There is an urgent need to evaluate and restructure the Tuberculosis Programme in the studied area.

Pulmonary tuberculosis in an indigenous community in the mountains of Ecuador.

SETTING: An aboriginal community of 653 persons. OBJECTIVE: To determine the prevalence of pulmonary tuberculosis (PTB) and to analyse related factors. DESIGN: The total population was surveyed; those with chronic productive cough were asked to provide sputum specimens. PTB was diagnosed by bacilloscopy (acid-fast bacilli [AFB]). An analysis of socio-economic factors and clinical history associated with chronic cough or positive smear for PTB was carried out using multiple correspondence analysis and logistic regression models. RESULTS: Two hundred and two patients were identified with chronic cough and 173 with chronic productive cough. Chronic cough was associated with having a history of PTB (adjusted OR=4.89, 95%CI 2.6-9.4) and with work-related migratory movements (adjusted OR=2.05, 95%CI 1.3-3.3). Of 92 coughers with sputum samples analysed, 44 (47.8%) were PTB-positive, giving a prevalence of 6.7% in the whole population. In the groups aged 15-34 and >or=45 years, women had higher positivity rates than men, whereas in the group aged 35-44 years rates were higher in men. Twenty-seven per cent of families had one to four smear-positive members. CONCLUSION: The Tuberculosis Control Programme in the area studied needs to be strengthened, taking into account the ethnic context, work-related migration and the socio-economic and geographic context.

[Bacteriological quality of human drinking water in high-margination zones in Chiapas]. / Calidad bacteriológica del agua para consumo humano en zonas de alta marginación de Chiapas.

OBJECTIVE: To analyze the bacteriological quality of drinking water (BQDW) and its association with diarrhoea and intestinal parasites in children 1 to 14 years old, in areas of high levels of poverty in Chiapas, Mexico. MATERIAL AND METHODS: From March to September 1998, drinking water was collected from a random sample of 99 households in the Border Region of Chiapas, Mexico; data on diarrhoeal disease (in the past 15 days) were collected and stool testing for intestinal parasites was performed in children 1 to 14 years old (n = 322). The BQDW was determined by the filtration membrane technique. Intestinal parasitic infections were determined by the Faust Method. The chi 2 statistic was used to analyse factors associated with BQDW. RESULTS: Only 31% of the water samples were adequate for human consumption. The BQDW and the presence of diarrhoea (informed by the mothers of the children) showed no association. Children living in households with inadequate BQDW had a higher prevalence of Entamoeba histolytica and a greater tendency to have intestinal parasites. CONCLUSIONS: It is necessary to develop programs that improve BQDW and to develop education efforts aimed at increasing the use of boiled water and the adequate management and care of community water storage sites.

[Factors associated with Streptococcus group B colonization in pregnant women in Los Altos, Chiapas]. / Factores asociados a la colonización por Streptococcus del grupo B en mujeres embarazadas de Los Altos, Chiapas.

OBJECTIVE: To estimate the prevalence and analyze the factors associated with group B Streptococcus (GBS) colonization in pregnant women of Los Altos, Chiapas, Mexico. MATERIAL AND METHODS: Between February and September 1999, a cross-sectional study was conducted among 910 women who sought delivery care at three public hospitals of San Cristobal de Las Casas, Chiapas. Vaginal and perianal samples were taken for GBS detection by bacteriological culture. Identification of groups and serotypes was performed using latex agglutination. The analysis of factors associated with colonization was done using chi-squared tests and log-linear modeling. RESULTS: GBS colonization was found in 8.6% (95% CI 6.8-10.5) of study subjects. Women with the greatest likelihood of colonization were those with > or = 5 pregnancies, residents of counties with high levels of poverty, working outside the home, and living in homes in which the head of household worked in agriculture (26.8%, OR = 7.25, 95% CI 1.83-28.67). CONCLUSIONS: In the study area, it is necessary that actions aiming to prevent and control infections by GBS be directed principally at those groups of women with the highest probability of colonization, in order to diminish the perinatal transmission of GBS.

[Pulmonary tuberculosis and use of health services in zones of high socioeconomic marginalization in Chiapas, Mexico]. / Tuberculosis pulmonar y uso de servicios del primer nivel de atención en zonas de alta marginación socioeconómica de Chiapas, México.

OBJECTIVE: To estimate the prevalence of pulmonary tuberculosis and to analyze the utilization of health services, in coughers seeking care at primary care centers, within areas of "severe" and "very severe" poverty, in the Border Region of Chiapas, Mexico. MATERIALS AND METHODS: In 1997 an active case finding of patients with cough was carried out among all patients aged over 14 years seeking consultation (n = 2.203) in a random sample of seven primary care centers; 573 coughers were found. RESULTS: A rate of 11.1 positive pulmonary tuberculosis per hundred patients was found (95% CI = 6.6-17.2). The factors associated with positive pulmonary tuberculosis were size and poverty level of the locality of residence. Fifty-six percent of the coughers sought care for non-respiratory symptoms. CONCLUSIONS: It is necessary to improve detection and control of pulmonary tuberculosis at the primary care centers, as well as to develop a health education campaign among the general population, with the aim of increasing the demands for care among coughers and reduce the time elapsed between onset of cough and first medical care.

Tuberculosis pulmonar y uso de servicios del primer nivel de atención en zonas de alta marginación socioeconómica de Chiapas, México / Pulmonary tuberculosis and use of health services among coughers in areas of poverty in Chiapas, Mexico

Objetivo: Estimar la prevalencia de tuberculosis pulmonar, analizar factores asociados a su positividad y analizar el uso de servicios de salud en tosedores usuarios del primer nivel de atención en zonas de alta y muy alta marginación de la Región Fronteriza de Chiapas, México. Métodos: En 1997 se realizó una búsqueda activa de tosedores (n = 573), entre usuarios (n = 2.203) de una muestra aleatoria de siete unidades del primer nivel de atención, a los que se les solicitaron tres muestras de esputo para la realización de baciloscopías y cultivos. Resultados: Se encontró una tasa de positividad a tuberculosis pulmonar de 11,1 por 100 pacientes estudiados (IC 95 por ciento = 6,6-17,2). La positividad a tuberculosis pulmonar se mostró asociada al tamaño y grado de marginación de la localidad de residencia. El 56 por ciento de los tosedores acudió a consulta por síntomas no respiratorios. Conclusiones: Es necesario reforzar la detección y control de la tuberculosis pulmonar en el primer nivel de atención, así como sensibilizar y brindar educación para la salud a la población en general, con el fin de aumentar la demanda de atención a causa de la tos y reducir el tiempo entre el inicio de la tos y la búsqueda de atención (AU)

Social inequalities and health in rural Chiapas, Mexico: agricultural economy, nutrition, and child health in La Fraylesca region.

The objective of this study was to investigate the association between farmers' socioeconomic conditions and their children's health in La Fraylesca, Chiapas. Data were collected using a cross-sectional survey of 1046 households (5546 individuals) sampled from locations in two counties situated in the study area. The survey included anthropometric measurements, a 24-hour dietary recall, stool tests, and childhood mortality data. Children of private farmers and "wealthy peasants" displayed better nutritional status, higher quality diet, lower prevalence of intestinal parasites, and a lower risk of dying than those whose parents were communal farmers, from ejidos, or "poor peasants". The results suggest that using volume of maize production as a classification method proved more valuable than land tenure to identify agricultural groups with different health status. It appears that the main determinants of health differentials are structural inequities in resource distribution. Thus, the impact of medical interventions on inequalities will be limited unless they are accompanied by redistribution of resources.

Pulmonary tuberculosis in the border region of Chiapas, Mexico.

OBJECTIVES: To estimate the prevalence of pulmonary tuberculosis (PTB) in chronic cough patients seeking care at a second level hospital for any complaint, and to identify groups more likely to test TB smear-positive, within the Border Region of Chiapas, Mexico. METHODS: Active case finding of patients with chronic cough (cough of 15 days or more) was carried out among all patients aged over 14 years seeking care for whatever reason in the only hospital in the region for patients not covered by insurance. The coughers identified (n=221) were interviewed and three sputum samples requested for acid-fast smears. In order to identify groups at greater risk a logistic regression model was constructed. RESULTS: A rate of 21 positive PTB smears per hundred patients was found (95% Confidence Interval [CI]=15.5-26.6). The main factors associated with positive PTB were age, occupation and weight loss. The subgroup of chronic cough patients of those aged 35-44 years, agricultural workers and those who had lost weight, had the greatest likelihood of positive PTB smears (68.7%). CONCLUSION: In hospitals that treat rural patients, special efforts should be made to make health personnel more aware of the need to investigate respiratory symptoms in all of their patients, particularly in the subgroups identified with the greatest likelihood of being positive for TB.

[Delivery care in Chiapas, Mexico: who and where does provide it?]. / La atención del parto en Chiapas, México: dónde y quién los atiende?

OBJECTIVE: To identify the place and provider of delivery care; to analyse the relationship between the type of delivery care provider and prenatal care and sociodemographic factors; to identify groups with greater and lesser probability of receiving attention at health centers and to identify the reasons for not attending the health center nearest to the household. MATERIAL AND METHODS: Data on the delivery care of 297 women of La Fraylesca Region, Chiapas, were gathered using multivariate logit models to identify groups. RESULTS: From the total, 32% of childbirths occurred at health centers and 60% at home (mostly with poor sanitary conditions). Only 10% of women with less than 5 prenatal visits, school level under 3 years and whose household head was a peasant were attended by health care personnel. CONCLUSIONS: The accessibility and quality of health centers must be improved, and a programme aimed at increasing the number of deliveries that are attended by trained health care personnel should be implemented.

[Problems of diagnosis of pulmonary tuberculosis. The case of the border region of Chiapas (Mexico)]. / Problemas de diagnóstico de tuberculosis pulmonar. El caso de la región fronteriza de Chiapas (México).

OBJECTIVE: To analyze critical factors in the diagnosis of pulmonary tuberculosis at both the primary and secondary levels, in the Border Region of Chiapas, Mexico. DESIGN: A crossover study (from March to September, 1994) PARTICIPANTS: Patients with chronic cough (n = 221) who sought care in the Out-patient Department of the only second level care hospital available in the region for the uninsured population. Each subject was interviewed, three sputum specimens were requested and the clinical charts reviewed. MEASUREMENTS AND MAIN RESULTS: Fourty-four patients were found positive for pulmonary TB of which six came to the hospital for initial care. 38 had already been seen in a primary care setting. Of those 38 only two had been diagnosed previously by acid fast smear. At the hospital level, the underdiagnosis of TBP was 9%. CONCLUSIONS: The quality of care with regard to the diagnosis of pulmonary tuberculosis needs to be improved at both the primary and hospital levels. Health workers need to be sensitized to the symptomatology and trained to request sputum smears when indicated. The general population also needs to be educated with regard to pulmonary tuberculosis so as to demand better services.

[Social welfare and health services in the Fraylesca Region in Chiapas: the use of prenatal care services]. / Bienestar social y servicios de salud en la Región Fraylesca de Chiapas: el uso de servicios de atención prenatal.

OBJECTIVE: To analyze the use of antenatal care services (ACS) in the Fraylesca Region of Chiapas, Mexico, and to identify groups with lower probability of receiving ACS. MATERIAL AND METHODS: In 1994, a health survey was performed on a random sample of 1,100 households, which compiled sociodemographic information and on the use of ACS during the last pregnancy within the two years previous to the study (n = 297 women from 15 to 49 years of age). The groups with lower probability of receiving adequate ACS (5 or more visits) were identified with a log-linear model. RESULTS: Forty-two percent of women received inadequate ACS (0 to 4 visits). Women with better socioeconomic status had higher probability of using ACS adequately than women with lower socioeconomic status: OR 2.47 (Cl 95% 1.12-5.44). CONCLUSIONS: Results provide evidence of the need to improve the quality of ACS, to support the traditional midwives and to improve living conditions of the population.

[Obstacles to overcome in the control of pulmonary tuberculosis in the border region of Chiapas, Mexico]. / Retos a superar en el control de la tuberculosis pulmonar en la región fronteriza de Chiapas, México.

OBJECTIVE: To improve the control of the pulmonary tuberculosis in the Border Region of Chiapas, Mexico. DESIGN: Academic researchers, health development workers from the nongovernmental sector and government health authorities met in a workshop to analyze recent experiences with tuberculosis. RESULTS: Among the important issues addressed were: with regard to official health services, the lack of resources, particularly medication, organizational problems which result in poor or absent communication within and among different health entities, the under diagnosis of cases and the lack of sufficient index of suspicion for tuberculosis among health personnel. With regard to the population at risk, there are profound socio-cultural barriers which include a lack of confidence in the quality of government health care centers and little attention given to chronic cough. Poorest, indigenous and more remote people have less access to care and are more likely to have advanced tuberculosis before seeking treatment if at all. New strategies proposed were to integrate communication efforts in tuberculosis control among all the involved health services, including private physicians, identify those patients at greatest risk, improve diagnostic skills of health providers, develop education campaigns in rural areas. CONCLUSIONS: Certain factors which impede better TB control seem amenable to change, others, such as severe poverty, particularly among peasants and indigeneous people, as well as the current political disruption, will require much broader intersectorial interventions.

[Use of an index of social welfare for health planning at a municipal level]. / Uso de un índice de bienestar social para la planificación de la salud a nivel municipal.

OBJECTIVE: This paper analyzes the relationship between a living standards index for small areas based on census data and information on morbidity and health care utilization. MATERIAL AND METHODS: The information was gathered through a health interview survey of a random sample of 1 238 households from rural areas of Tlaxcala, Mexico. RESULTS: The population from localities with lower living standards showed significantly higher prevalences of morbidity and worse self-reported health status measures, as compared to localities with higher living standards. On the contrary, higher living standards were related with a greater utilization of health services. CONCLUSIONS: The approach proved to be useful in discriminating localities and areas of high and low prevalence of morbidity and utilization of health care services, which in turn could be used to identify those areas where needs are greatest. The implications of the results for health planning and resource allocation (based on population health needs and underlying social conditions) at the local level are discussed.

[AIDS mortality in Mexico from 1983 to 1992. The trends and years of potential life lost]. / La mortalidad por el SIDA en México de 1983 a 1992. Tendencias y años perdidos de vida potencial.

OBJECTIVE: To describe trends in AIDS mortality in Mexico from 1983 to 1992, as well as years of potential life lost (YPLL) and years of potential productive life lost (YPPLL) due to AIDS. MATERIAL AND METHODS: A retrospective review of databases available in Mexico that code mortality from AIDS was performed. Since AIDS was not coded specifically as a cause of death until 1988, for the period 1983-1987 the database of AIDS cases from the national AIDS registry provided by the Instituto Nacional de Diagnóstico y Referencia Epidemiológicos of the Ministry of Health was used. For the 1988-1992 period, a review of the mortality registry was provided by the Dirección General de Estadística, Informática y Evaluación of the Ministry of Health. To calculate YPLL and YPPLL we used the upper limit of expected life in Mexico for 1990 (70.79 years for men and 75.71 for women). RESULTS: Through 1992, there have been 8,204 deaths attributable to AIDS in Mexico (86% were men) with a rate of 2.9 deaths/100,000. In 1992 AIDS was the 19th leading cause of death in the country. The most affected age groups are the 25-34 and 35-44 years-old (especially amongst men) in which AIDS has now displaced pulmonary tuberculosis, suicide and self-inflicted injuries, diabetes mellitus, cerebro-vascular disease and alcohol dependency syndrome as leading causes of death in men. Our data suggests that AIDS has caused, from 1983 through 1992, 247,045 YPLL in men and 48,703 in women as well as 206,211 YPPLL in men and 29,793 in women. CONCLUSIONS: AIDS is at present one of the leading causes of death in Mexico. However, due to under-reporting, these estimates should be considered conservative and as lower-bound estimates. This data suggests that professionals are over-represented among AIDS cases, in comparison with the 1990 Population Census. This does not happen to be the case among women who are housewives.

[The serological exam for the human immunodeficiency virus (HIV) as part of the premarital exams]. / El examen serológico para el virus de la inmunodeficiencia humana (VIH) como parte de los exámenes prenupciales.

Due to the presence of the acquired immune deficiency syndrome (AIDS), it has been frequently stated, by several segments of the society, that mandatory human immunodeficiency virus (HIV) testing as premarital requirement is useful for AIDS prevention. The usefulness of these tests among general population are discussed, as well as some problems for its eventual implementation, concluding that this screening procedure is impractical, inefficient and expensive as a public health measure. The overall HIV prevalence in Mexico is very low (4 per 10,000), therefore, a person from this population with a positive screening test, has a slight chance of being truly infected (16%), in other words, screening tests have a low positive predictive value in general population. Conversely, having a negative screening test, predicts this state accurately (negative predictive value greater than 99%). Several problems arise when HIV screening tests are applied: logistics, for example avoidance of the tests, economic, ethic, and human rights problems, among others. It is concluded that mandatory HIV screening tests are not cost-efficient and that there are other options, for instance education, which would imply better changes for HIV prevention.