[Factors associated with unsuccessful treatment of patients with drug-sensitive tuberculosis in Paraguay]. / Factores asociados al resultado de tratamiento no exitoso de pacientes con tuberculosis sensible en Paraguay.

OBJECTIVE: To determine the factors associated with the unsuccessful treatment of patients diagnosed with drug-sensitive tuberculosis (TB) in Paraguay. METHODS: Retrospective cohort study, with data collected from the national program between January 2016 and March 2017. Unsuccessful treatment was defined as patients who were lost to follow-up, failed treatment, or died. Factors associated with unsuccessful treatment were determined using Poisson regression; the adjusted relative risk (RR) and 95% confidence interval (95% CI) were estimated by health region. RESULTS: A total of 3 034 cases were studied: 2 189 (72.1%) were successfully treated (cured: 1 221 [40.2%], complete treatment: 968 [31.9%]) and 845 (27.9%) were unsuccessfully treated (treatment failure: 40 [1.3%], loss to follow-up: 466 [15.4%] and deaths: 339 [11.2%]). Factors associated with unsuccessful treatment were masculine sex 1.28 (1.14- 1.42), indigenous descent 1.3 (1.09- 1.54), lack of report of area of residence 1.27 (1.02- 1.57), TB/HIV coinfection 1.97 (1, 63- 2.38), illicit drug addiction 1.38 (1.16- 1.63), alcohol consumption 1.25 (1.02- 1.52), previous treatment 1.23 (1.10- 1.38) and lack of treatment monitoring data 4.92 (3.69- 6.56). Being deprived of liberty 0.65 (0.47- 0.89) and TB/diabetes comorbidity 0.80 (0.67- 0.95) were considered protective factors. CONCLUSION: Paraguay has a high percentage of unsuccessful treatment in almost the entire country, without reaching the target proposed by the World Health Organization. Associated risk factors such as HIV, consumption of legal and illicit drugs, and being indigenous highlight the need to revise the treatment strategies with an inter-institutional approach.

Factores asociados al resultado de tratamiento no exitoso de pacientes con tuberculosis sensible en Paraguay

[RESUMEN]. Objetivo. Determinar los factores asociados con el tratamiento no exitoso en pacientes diagnosticados con tuberculosis (TB) sensible en Paraguay. Métodos. Estudio de cohorte retrospectivo, con datos recolectados del programa nacional entre enero de 2016 y marzo de 2017. Se definió tratamiento no exitoso como pacientes que se perdieron en el seguimiento, fracasaron en el tratamiento o fallecieron. Los factores asociados con tratamiento no exitoso se determinaron con regresión de Poisson; se estimó el riesgo relativo (RR) y el intervalo de confianza de 95% (IC95%) ajustados por región sanitaria. Resultados. Se estudiaron 3 034 casos: 2 189 (72,1%) tuvieron tratamiento exitoso (curados: 1 221 [40,2%], tratamiento completo: 968 [31,9%]) y 845 (27,9%) presentaron tratamiento no exitoso (fracaso: 40 [1,3%], pérdida de seguimiento: 466 [15,4%] y fallecidos: 339 [11,2%]). Los factores asociados a tratamiento no exitoso fueron hombres 1,28 (1,14- 1,42), indígenas 1,30 (1,09- 1,54), sin reporte de área de residencia 1,27 (1,02- 1,57), coinfección TB/VIH 1,97 (1,63- 2,38), adicción a drogas ilícitas 1,38 (1,16- 1,63), consumo de alcohol 1,25 (1,02- 1,52), ser previamente tratado 1,23 (1,10- 1,38) y sin datos de supervisión del tratamiento 4,92 (3,69- 6,56). Como factores protectores se consideran ser persona privada de libertad 0,65 (0,47- 0,89), así como la comorbilidad TB/diabetes 0,80 (0,67- 0,95). Conclusión. Paraguay presenta un alto porcentaje de tratamiento no exitoso en casi todo el país, sin alcanzar la meta propuesta por la Organización Mundial de la Salud. Los factores de riesgo asociados como infección por el virus de la inmunodeficiencia humana (VIH), consumo de drogas licitas e ilícitas y el ser indígena revela que es necesario revisar las estrategias dirigidas con abordaje interinstitucional.

[ABSTRACT]. Objective. To determine the factors associated with the unsuccessful treatment of patients diagnosed with drug-sensitive tuberculosis (TB) in Paraguay. Methods. Retrospective cohort study, with data collected from the national program between January 2016 and March 2017. Unsuccessful treatment was defined as patients who were lost to follow-up, failed treatment, or died. Factors associated with unsuccessful treatment were determined using Poisson regression; the adjusted relative risk (RR) and 95% confidence interval (95% CI) were estimated by health region. Results. A total of 3 034 cases were studied: 2 189 (72.1%) were successfully treated (cured: 1 221 [40.2%], complete treatment: 968 [31.9%]) and 845 (27.9%) were unsuccessfully treated (treatment failure: 40 [1.3%], loss to follow-up: 466 [15.4%] and deaths: 339 [11.2%]). Factors associated with unsuccessful treatment were masculine sex 1.28 (1.14- 1.42), indigenous descent 1.3 (1.09- 1.54), lack of report of area of residence 1.27 (1.02- 1.57), TB/HIV coinfection 1.97 (1, 63- 2.38), illicit drug addiction 1.38 (1.16- 1.63), alcohol consumption 1.25 (1.02- 1.52), previous treatment 1.23 (1.10- 1.38) and lack of treatment monitoring data 4.92 (3.69- 6.56). Being deprived of liberty 0.65 (0.47- 0.89) and TB/diabetes comorbidity 0.80 (0.67- 0.95) were considered protective factors. Conclusion. Paraguay has a high percentage of unsuccessful treatment in almost the entire country, without reaching the target proposed by the World Health Organization. Associated risk factors such as HIV, consumption of legal and illicit drugs, and being indigenous highlight the need to revise the treatment strategies with an inter-institutional approach.

Factores asociados a la mortalidad por tuberculosis en Paraguay, 2015-2016

[RESUMEN]. Objetivo. Describir las características sociodemográficas y clínico-epidemiológicas y determinar los factores asociados a la mortalidad de personas con diagnóstico de tuberculosis en Paraguay. Métodos. Investigación operativa con un diseño de cohortes retrospectivo de los casos diagnosticados con TB en Paraguay entre 2015-2016. Se utilizó la base datos del Programa Nacional de Control de Tuberculosis. Para determinar los factores asociados con mortalidad se utilizaron pruebas chi cuadrado y riesgo relativo (RR) con un intervalo de confianza de 95% (IC95%); además, se ajustó un modelo de regresión múltiple de Poisson robusto. Se utilizó un nivel de significación de 5%. Resultados. Se estudiaron 5 141 casos de TB, de los cuales 11,5% fallecieron, los factores que aumentan el riesgo de muerte fueron: sexo masculino (RR: 1,26 IC; 95%: 1,1-1,50), infección con virus de la inmunodeficiencia humana (VIH) (RR: 4,78; IC 95%: 4,04-5,65) y enfermedad pulmonar obstructiva crónica (RR: 1,70; IC 95%: 1,19-2,42). Como factor protector se identificó ser persona privada de la libertad (RR: 0,37 IC 95%: 0,24-0,61). Conclusiones. El mayor riesgo de muerte lo presentan los hombres y las personas con coinfección TB/VIH y el menor riesgo, las personas privadas de la libertad. Es necesario mejorar el diagnóstico y seguimiento a los casos de TB, con la efectiva implementación del tratamiento directamente observado (TDO) así como el manejo oportuno de enfermedades asociadas como VIH y enfermedad pulmonar obstructica crónica (EPOC).

[ABSTRACT]. Objective. To describe the socio-demographic and clinical-epidemiological characteristics and to determine the factors associated with the mortality of people diagnosed with tuberculosis (TB) in Paraguay. Methods. Operational research with a retrospective cohort design of cases diagnosed with TB in Paraguay between 2015-2016. The database of the National Tuberculosis Control Program was used. Chi-square and relative risk (RR) tests with a 95% confidence interval (95% CI) were used to determine the factors associated with mortality; in addition, a robust Poisson multiple regression model was adjusted. A significance level of 5% was used. Results. Five hundred and forty-one cases of TB were studied, of which 11.5% died. The factors increasing the risk of death were male sex (RR 1.26; 95% CI 1.1-1.50), infection with human immunodeficiency virus (RR 4.78; 95% CI 4.04-5.65) and chronic obstructive pulmonary disease (RR 1.70; 95% CI 1.19-2.42). Being deprived of one’s liberty was a protective factor (RR 0.37; 95% CI 0.24-0.61). Conclusions. The highest risk of death is presented by men and people with TB/HIV coinfection and the lowest risk is presented by people deprived of liberty. There is a need to improve diagnosis and follow-up of TB cases, with effective implementation of directly observed treatment (DOTS) and timely management of associated diseases such as HIV and chronic obstructive pulmonary disease.

[RESUMO]. Objetivo. Descrever as características sociodemográficas e clínico-epidemiológicas e determinar os fatores associados à mortalidade de pessoas diagnosticadas com tuberculose (TB) no Paraguai. Métodos. Pesquisa operacional com desenho de coorte retrospectivo de casos diagnosticados com TB no Paraguai entre 2015-2016. Foi utilizada a base de dados do Programa Nacional de Controle da Tuberculose. Testes de qui-quadrado e risco relativo (RR) com intervalo de confiança de 95% (IC95%) foram utilizados para determinar os fatores associados à mortalidade; além disso, um robusto modelo de regressão múltipla de Poisson foi ajustado. Foi utilizado nível de significância de 5%. Resultados. Foram estudados quinhentos e quarenta e um casos de TB, dos quais 11,5% morreram. Os fatores que aumentaram o risco de morte foram sexo masculino (RR 1,26; IC95% 1,1-1,50), infecção por vírus da imunodeficiência humana (RR 4,78; IC95% 4,04-5,65) e doença pulmonar obstrutiva crônica (RR 1,70; 95 % CI 1,19-2,42). Ser privado de liberdade foi um fator protetor (RR 0,37; IC 95% 0,24-0,61). Conclusões O maior risco de morte é apresentado por homens e pessoas com co-infecção TB / HIV e o menor risco é apresentado por pessoas privadas de liberdade. É necessário melhorar o diagnóstico e o acompanhamento dos casos de TB, com a implementação efetiva do tratamento diretamente observado (DOTS) e o gerenciamento oportuno de doenças associadas, como o HIV e a doença pulmonar obstrutiva crônica.

Factores asociados al cumplimiento de la terapia preventiva con isoniacida en niños en Quito, Ecuador (2014-2016 y 2018)

[RESUMEN]. Objetivo. Conocer el porcentaje de cumplimiento de la terapia preventiva con isoniacida (TPI) en los establecimientos de salud de Quito, Ecuador y sus factores asociados en los niños menores de 5 años. Métodos. Investigación operativa con diseño de cohorte, en la que se obtuvo datos de informes y tarjetas de administración de tratamiento de los niños en TPI de los años 2014 al 2016 y de encuestas ad hoc aplicadas a cuidadores de los niños que recibieron TPI durante el año 2018. Resultados. Los niños menores de 5 años correspondieron a 29,3% del total de los contactos de los casos índices; 73% cumplieron TPI y 88,9% completaron al menos 6 meses de terapia. Se encontró asociación con la carga bacilar del caso índice, con la condición de pertenecer a un determinado distrito y su año de inicio. Se realizaron encuestas a 9 personas, funcionarios de los establecimientos salud y a 9 tutores de los niños; se registraron respuestas diversas sobre el agente causal de la tuberculosis, su transmisión y las características de la terapia preventiva. Conclusiones. La mayoría de los niños menores de 5 años que iniciaron TPI cumplieron con al menos 80% de las dosis prescritas, con determinadas asociaciones y percepciones en los cuidadores. En este contexto, surge la necesidad de realizar nuevas investigaciones operativas, para indagar más ampliamente sobre la adherencia y sobre los conocimientos, actitudes y prácticas de los profesionales de salud, los afectados por tuberculosis y su entorno.

[ABSTRACT]. Objective. Determine the percentage of children under 5 years of age who completed isoniazid preventive therapy (IPT) in health facilities in Quito, Ecuador, and assess related factors. Methods. Operations research with cohort design. Data were obtained from treatment reports on children in IPT between 2014 and 2016, and from ad hoc surveys of caregivers of children who received IPT in 2018. Results. Children under 5 represented 29.3% of all contacts of index cases; 73% completed IPT and 88.9% had at least six months of therapy. Associations were found with the bacterial load of the index case, with living in a given district, and with the year in which treatment was initiated. Surveys were conducted with nine staff members of health facilities and nine caregivers of children; diverse responses were given regarding the causative agent of tuberculosis, its transmission, and the characteristics of preventive therapy. Conclusions. The majority of children under 5 years of age who initiated IPT completed at least 80% of the prescribed doses, with varying associations and knowledge on the part of their caregivers. In this context, there is a need for further operations research in order to learn more about adherence and about the knowledge, attitudes, and practices of health professionals and those affected by tuberculosis, and their environment.

[RESUMO]. Objetivo. Conhecer a porcentagem de adesão à terapia preventiva com isoniazida (TPI) nas unidades de saúde de Quito, Equador, e os fatores associados à adesão em crianças com menos de 5 anos de idade. Métodos. Pesquisa operacional com desenho de coorte, na qual foram obtidos dados de relatórios e dos cartões de administração de TPI em crianças entre 2014 e 2016, bem como de questionários ad hoc aplicados aos cuidadores das crianças que receberam TPI durante o ano de 2018. Resultados. As crianças com menos de 5 anos de idade representaram 29,3% do total dos contatos dos casos índices; 73% aderiram à TPI e 88,9% completaram pelo menos 6 meses de tratamento. Identificamos associações com a carga bacilar do caso índice, com o distrito de residência do paciente e com o ano de início. Realizamos inquéritos com 9 funcionários das unidades de saúde e com 9 responsáveis pelas crianças, registrando respostas variadas sobre o agente causal da tuberculose, sua transmissão e as características da terapia preventiva. Conclusões. Em sua maioria, as crianças com menos de 5 anos de idade que iniciaram a TPI aderiram a pelo menos 80% das doses prescritas, havendo associações com certos fatores e com os conhecimentos dos cuidadores. Neste contexto, fica clara a necessidade de realizar novos estudos operacionais para compreender melhor a adesão ao tratamento e os conhecimentos, atitudes e práticas dos profissionais da saúde, dos afetados pela tuberculose e das pessoas em seu entorno.

[Factors associated with completion of isoniazid preventive therapy in children in Quito, Ecuador (2014-2016 and 2018)Fatores associados à adesão à terapia preventiva com isoniazida em crianças de Quito, Equador (2014-2016 e 2018)]. / Factores asociados al cumplimiento de la terapia preventiva con isoniacida en niños en Quito, Ecuador (2014-2016 y 2018).

OBJECTIVE: Determine the percentage of children under 5 years of age who completed isoniazid preventive therapy (IPT) in health facilities in Quito, Ecuador, and assess related factors. METHODS: Operations research with cohort design. Data were obtained from treatment reports on children in IPT between 2014 and 2016, and from ad hoc surveys of caregivers of children who received IPT in 2018. RESULTS: Children under 5 represented 29.3% of all contacts of index cases; 73% completed IPT and 88.9% had at least six months of therapy. Associations were found with the bacterial load of the index case, with living in a given district, and with the year in which treatment was initiated. Surveys were conducted with nine staff members of health facilities and nine caregivers of children; diverse responses were given regarding the causative agent of tuberculosis, its transmission, and the characteristics of preventive therapy. CONCLUSIONS: The majority of children under 5 years of age who initiated IPT completed at least 80% of the prescribed doses, with varying associations and knowledge on the part of their caregivers. In this context, there is a need for further operations research in order to learn more about adherence and about the knowledge, attitudes, and practices of health professionals and those affected by tuberculosis, and their environment.

OBJETIVO: Conhecer a porcentagem de adesão à terapia preventiva com isoniazida (TPI) nas unidades de saúde de Quito, Equador, e os fatores associados à adesão em crianças com menos de 5 anos de idade. MÉTODOS: Pesquisa operacional com desenho de coorte, na qual foram obtidos dados de relatórios e dos cartões de administração de TPI em crianças entre 2014 e 2016, bem como de questionários ad hoc aplicados aos cuidadores das crianças que receberam TPI durante o ano de 2018. RESULTADOS: As crianças com menos de 5 anos de idade representaram 29,3% do total dos contatos dos casos índices; 73% aderiram à TPI e 88,9% completaram pelo menos 6 meses de tratamento. Identificamos associações com a carga bacilar do caso índice, com o distrito de residência do paciente e com o ano de início. Realizamos inquéritos com 9 funcionários das unidades de saúde e com 9 responsáveis pelas crianças, registrando respostas variadas sobre o agente causal da tuberculose, sua transmissão e as características da terapia preventiva. CONCLUSÕES: Em sua maioria, as crianças com menos de 5 anos de idade que iniciaram a TPI aderiram a pelo menos 80% das doses prescritas, havendo associações com certos fatores e com os conhecimentos dos cuidadores. Neste contexto, fica clara a necessidade de realizar novos estudos operacionais para compreender melhor a adesão ao tratamento e os conhecimentos, atitudes e práticas dos profissionais da saúde, dos afetados pela tuberculose e das pessoas em seu entorno.

[Factors associated with tuberculosis mortality in Paraguay, 2015-2016Fatores associados à mortalidade por tuberculose no Paraguai, 2015-2016]. / Factores asociados a la mortalidad por tuberculosis en Paraguay, 2015-2016.

OBJECTIVE: To describe the socio-demographic and clinical-epidemiological characteristics and to determine the factors associated with the mortality of people diagnosed with tuberculosis (TB) in Paraguay. METHODS: Operational research with a retrospective cohort design of cases diagnosed with TB in Paraguay between 2015-2016. The database of the National Tuberculosis Control Program was used. Chi-square and relative risk (RR) tests with a 95% confidence interval (95% CI) were used to determine the factors associated with mortality; in addition, a robust Poisson multiple regression model was adjusted. A significance level of 5% was used. RESULTS: Five hundred and forty-one cases of TB were studied, of which 11.5% died. The factors increasing the risk of death were male sex (RR 1.26; 95% CI 1.1-1.50), infection with human immunodeficiency virus (RR 4.78; 95% CI 4.04-5.65) and chronic obstructive pulmonary disease (RR 1.70; 95% CI 1.19-2.42). Being deprived of one's liberty was a protective factor (RR 0.37; 95% CI 0.24-0.61). CONCLUSIONS: The highest risk of death is presented by men and people with TB/HIV coinfection and the lowest risk is presented by people deprived of liberty. There is a need to improve diagnosis and follow-up of TB cases, with effective implementation of directly observed treatment (DOTS) and timely management of associated diseases such as HIV and chronic obstructive pulmonary disease.

OBJETIVO: Descrever as características sociodemográficas e clínico-epidemiológicas e determinar os fatores associados à mortalidade de pessoas diagnosticadas com tuberculose (TB) no Paraguai. MÉTODOS: Pesquisa operacional com desenho de coorte retrospectivo de casos diagnosticados com TB no Paraguai entre 2015-2016. Foi utilizada a base de dados do Programa Nacional de Controle da Tuberculose. Testes de qui-quadrado e risco relativo (RR) com intervalo de confiança de 95% (IC95%) foram utilizados para determinar os fatores associados à mortalidade; além disso, um robusto modelo de regressão múltipla de Poisson foi ajustado. Foi utilizado nível de significância de 5%. RESULTADOS: Foram estudados quinhentos e quarenta e um casos de TB, dos quais 11,5% morreram. Os fatores que aumentaram o risco de morte foram sexo masculino (RR 1,26; IC95% 1,1-1,50), infecção por vírus da imunodeficiência humana (RR 4,78; IC95% 4,04-5,65) e doença pulmonar obstrutiva crônica (RR 1,70; 95 % CI 1,19-2,42). Ser privado de liberdade foi um fator protetor (RR 0,37; IC 95% 0,24-0,61). CONCLUSÕES: O maior risco de morte é apresentado por homens e pessoas com co-infecção TB / HIV e o menor risco é apresentado por pessoas privadas de liberdade. É necessário melhorar o diagnóstico e o acompanhamento dos casos de TB, com a implementação efetiva do tratamento diretamente observado (DOTS) e o gerenciamento oportuno de doenças associadas, como o HIV e a doença pulmonar obstrutiva crônica.

Treatment outcomes for isoniazid-monoresistant tuberculosis in Peru, 2012-2014.

BACKGROUND: Resistance to isoniazid is the most common form of drug-resistance in tuberculosis. However only a tiny proportion of TB patients in the world have access to isoniazid drug susceptibility testing-the widely implemented Xpert MTB/RIF technology only tests for resistance to rifampicin. Patients with isoniazid mono resistance that is not identified at baseline are treated with a standard regimen that effectively results in rifampicin mono-therapy during the latter four months of the six month treatment course, exposing remaining viable organisms to a single agent and greatly increasing the risk of development of multi drug-resistant TB. Unusually, Peru has pioneered universal pre-treatment drug susceptibility testing with methods that identify isoniazid resistance and has thus identified a large number of individuals requiring tailored therapy. Since 2010, treatment in Peru for isoniazid-resistant tuberculosis without multidrug-resistant tuberculosis (Hr-TB) has been with a standardized nine-month regimen of levofloxacin, rifampicin, ethambutol and pyrazinamide. The objectives of this study were to evaluate the outcomes of treatment for patients with Hr-TB initiating treatment with this regimen between January 2012 and December 2014 and to determine factors affecting these outcomes. METHODS: Retrospective cross-sectional study; case data were obtained from the national registry of drug-resistant tuberculosis. Patients diagnosed with isoniazid resistant TB without resistance to rifampicin, pyrazinamide, ethambutol and quinolones as determined by either a rapid drug susceptibility testing (DST) (nitrate reductase test, MODS, Genotype MTBDRplus) or by the proportion method were included. FINDINGS: A total of 947 cases were evaluated (a further 403 without treatment end date were excluded), with treatment success in 77.2% (731 cases), loss to follow-up in 19.7% (186 cases), treatment failure in 1.2% (12 cases), and death in 1.9% (18 cases). Unfavorable outcomes were associated in multivariate analysis with male gender (OR 0.50, 95% CI 0.34-0.72, p<0.05), lack of rapid DST (OR 0.67, 95% CI 0.50-0.91, p = 0.01), additional use of an injectable second-line anti-tuberculous drug (OR 0.46, 95% CI 0.31-0.70, p<0.05), and treatment initiation in 2014 (OR 0.77, 95% CI 0.62-0.94, p = 0.01). INTERPRETATION: The treatment regimen implemented in Peru for isoniazid resistant TB is effective for TB cure and is not improved by addition of an injectable second-line agent. Access to rapid DST and treatment adherence need to be strengthened to increase favorable results.

[Tuberculosis in Peru: epidemiological situation, progress and challenges for its control]. / Tubersulosis en el Perú: situación epidemiológica, avances y desafíos para su control.

Tuberculosis (TB) is the first cause of death by an infectious agent in the world, the incidence in the population is declining very slowly and drug resistance is currently considered an international crisis. In Peru, the recent TB Prevention and Control Act in Peru (Law 30287) declares the fight against TB of national interest. In recent years, the Ministry of Health's (MINSA) National Health Strategy for the Prevention and Control of Tuberculosis (ESNPCT) has achieved significant progress in the control of this disease; however, challenges still remain to be addressed. This article reviews the epidemiological situation of TB in Peru, systematizes the progress achieved during the management of the ESNPCT >team between the years 2011 and 2015 from the biomedical approach, public management and social determinants of health, also posing challenges to achieving TB control under law 30287 and the "End of TB" strategy of the World Health Organization (WHO).

La tuberculosis (TB) es la primera causa de muerte por un agente infeccioso en el mundo, la incidencia en la población viene disminuyendo muy lentamente y la resistencia a los medicamentos es actualmente considerada como una crisis internacional. En el Perú, la reciente Ley de Prevención y Control de la TB en el Perú (Ley 30287), declara de interés nacional la lucha contra la TB. En los últimos años, la Estrategia Sanitaria Nacional de Prevención y Control de la Tuberculosis (ESNPCT) del Ministerio de Salud (MINSA), ha obtenido avances significativos en el control de esta enfermedad; sin embargo, aún persisten desafíos que deben ser abordados. El presente artículo revisa la situación epidemiológica de la TB en el Perú, sistematiza los avances logrados durante la gestión del equipo de la ESNPCT entre los años 2011 y 2015 desde el abordaje biomédico, de gestión pública y en las determinantes sociales de la salud, además, plantea desafíos para lograr el control de la TB, en el marco de la Ley 30287 y la estrategia "Fin de la TB" de la Organización Mundial de la Salud (OMS).

Tubersulosis en el Perú: situación epidemiológica, avances y desafíos para su control / Tuberculosis in Peru: epidemiological situation, progress and challenges for its control

RESUMEN La tuberculosis (TB) es la primera causa de muerte por un agente infeccioso en el mundo, la incidencia en la población viene disminuyendo muy lentamente y la resistencia a los medicamentos es actualmente considerada como una crisis internacional. En el Perú, la reciente Ley de Prevención y Control de la TB en el Perú (Ley 30287), declara de interés nacional la lucha contra la TB. En los últimos años, la Estrategia Sanitaria Nacional de Prevención y Control de la Tuberculosis (ESNPCT) del Ministerio de Salud (MINSA), ha obtenido avances significativos en el control de esta enfermedad; sin embargo, aún persisten desafíos que deben ser abordados. El presente artículo revisa la situación epidemiológica de la TB en el Perú, sistematiza los avances logrados durante la gestión del equipo de la ESNPCT entre los años 2011 y 2015 desde el abordaje biomédico, de gestión pública y en las determinantes sociales de la salud, además, plantea desafíos para lograr el control de la TB, en el marco de la Ley 30287 y la estrategia "Fin de la TB" de la Organización Mundial de la Salud (OMS).

ABSTRACT Tuberculosis (TB) is the first cause of death by an infectious agent in the world, the incidence in the population is declining very slowly and drug resistance is currently considered an international crisis. In Peru, the recent TB Prevention and Control Act in Peru (Law 30287) declares the fight against TB of national interest. In recent years, the Ministry of Health's (MINSA) National Health Strategy for the Prevention and Control of Tuberculosis (ESNPCT) has achieved significant progress in the control of this disease; however, challenges still remain to be addressed. This article reviews the epidemiological situation of TB in Peru, systematizes the progress achieved during the management of the ESNPCT >team between the years 2011 and 2015 from the biomedical approach, public management and social determinants of health, also posing challenges to achieving TB control under law 30287 and the "End of TB" strategy of the World Health Organization (WHO).

Avaliação das ações de detecção de casos de tuberculose na atenção primária / Evaluation of detection actions for tuberculosis cases in primary care

Objetivou-se avaliar as ações de detecção de casos de tuberculose nos serviços de atenção primária à saúde de um município do Sul do Brasil. Estudo exploratório, quantitativo, com 76 enfermeiros. Utilizou-se a análise de correspondência múltipla para identificar as associações entre ações para detecção de casos (busca de sintomáticos respiratórios, educação em saúde, discussões sobre tuberculose com lideranças comunitárias) e as características dos serviços (com ou sem estratégia de saúde da família), usando o software Statistica 12. As unidades com estratégia de saúde da família apresentaram melhor resultado para detecção de casos ao associarem-se com a realização regular das ações, enquanto as unidades em que não há equipes de saúde da família a realização da detecção associou-se à infrequência das ações. Conclui-se que existem diferenças entre ambos os serviços em relação ao desempenho das ações de detecção de casos.

The objective was to assess the detection actions of tuberculosis cases in primary care in a city in the South of Brazil. An exploratory, quantitative study, with 76 nurses. A multiple correspondence analysis was used to identify associations between actions to detect cases (search of respiratory symptoms, health education, discussions about tuberculosis with community leaderships) and the services' characteristics (with or without the family health strategy), using the Statistica 12 software. The units with family health strategy presented better result to detect cases when associated with regular actions, while in units without family health teams the performing detection was associated to infrequency of actions. It was concluded that differences exist in both services regarding performance of case detection actions.

Topoisomerase II-α as a predictive factor of response to therapy with anthracyclines in locally advanced breast cancer.

BACKGROUND: Topoisomerase II-α is a molecular target of anthracyclines; several studies have suggested that topoisomerase II-α expression is related to response to anthracycline treatment. The objective of this study was to evaluate if topoisomerase II-α overexpression predicts response to anthracycline treatment in locally advanced breast cancer patients. MATERIAL AND METHODS: Topoisomerase II-α, HER2, estrogen receptor (ER) and progesterone receptor (PR) expression were evaluated by immunohistochemistry in formalin-fixed, paraffin-embedded breast tumors from 111 patients presenting with locally advanced breast cancer between 1995 and 2002. The prognostic value of these markers was analyzed using a multivariate proportional hazards regression model and an interaction analysis between topoisomerase II-α status and dose intensity. RESULTS: Tumors from 40 patients (36%) showed topoisomerase II-α overexpression, 62 patients (56%) for ER, 39 (35%) for PR and 26 (23%) for HER2. There were no significant correlations between topoisomerase II-α expression and response to therapy, progression-free survival (PFS) or overall survival (OS). Anthracycline dose intensity had a significant impact on PFS and OS in patients overexpressing topoisomerase II-α (P=0.010 and 0.027, respectively). Negative PR (P=0.041), positive HER2 (P=0.013) were identified as risk factors in the multivariate model. The multivariate analysis in patients topoisomerase II-α negative shown no significance (HR=0.92, IC 95% 0.39-2.15, P=0.839) while the multivariate analysis in topoisomerase II-α positive, dose intensity shown to be statistically significant (HR=2.725, IC 95% 1.07-6.95, P=0.036). CONCLUSIONS: Our data do not support a correlation between topoisomerase II-α expression in breast cancer patients and improved clinical benefit with anthracycline therapy. However, they do suggest that tumors overexpressing topoisomerase II-α may experience better clinical benefit with higher anthracycline dose intensity.

Rol actual de la ecografía en la evaluación de la artritis psoriática / The current role of the ultrasound in the assessment of psoriatic arthritis

La artritis psoriática es una enfermedad inflamatoria crónica y heterogénea que afecta articulaciones, tendones, entesis, piel y uñas. Indudablemente, a lo largo de los últimos años la ecografía se ha ido perfilando como un método de imágenes imprescindible en la práctica cotidiana reumatológica, no sólo por su bajo costo y su mayor sensibilidad respecto al examen físico, sino por la capacidad de detectar compromiso subclínico y permitir el monitoreo de la evolución de la enfermedad. El incesante crecimiento tecnológico orientado al diseño de equipos dotados de sondas de alta frecuencia y módulos power Doppler altamente sensibles permite actualmente apreciar alteraciones morfo-estructurales con una resolución inferior al décimo de milímetro, y detectar el mínimo flujo sanguíneo presente en los microvasos de los tejidos superficiales. No obstante estas ventajas, aún son pocos los estudios que demuestran la utilidad de la ecografía en la artritis psoriática. El objetivo principal de esta revisión es demostrar el potencial actual de la ecografía en el estudio de pacientes con artritis psoriática mediante la ilustración de alteraciones a nivel de articulaciones, tendones, entesis, piel y uñas.

Psoriatic arthritis (PsA) is a chronic and heterogeneous inflammatory disease that involves joints, tendons, enthesis, skin and nails. Without doubt, ultrasound has become a rapidly evolving technique that is gaining more and more importance among rheumatologists. The continuous technological advances in the field of ultrasound has allowed the development of equipment provided with high and variable frequency probes and very sensitive power Doppler, which permit both the detailed study (with resolution power of 0.1 mm) of morphostructural changes and the sensitive detection of blood flow, even in small vessels of superficial tissues. To date most of the studies have been aimed at investigating its capacity in the assessment of joints, tendons and entheses in psoriatic arthritis patients. Less attention has been paid to demonstrate the potential of ultrasound in the evaluation of skin and nails.The aim of this study is to show the main high frequency greyscale and power Doppler ultrasound findings in patients with psoriatic arthritis at joint, tendon, enthesis, skin and nail level.

Factores asociados con el conocimiento y tamizaje para cáncer de cuello uterino (examen de Papanicolaou) en mujeres peruanas en edad fértil. Análisis del periodo 1996-2008 / Factors associated with knowledge and screening of cervical cancer (PAP test) in Peruvian women of childbearing age. Analysis of period 1996-2008

Objetivo: Determinar la frecuencia, características sociodemográficas y factores de relación interpersonal asociados a la realización del examen de Papanicolaou (PAP) en mujeres peruanas en edad fértil (MEF). Materiales y métodos: Se utilizó la base de datos de las Encuestas Demográficas y de Salud Familiar (ENDES) realizadas en los años 1996, 2000, 2004 y 2008. Se consideró como variables dependientes las preguntas: ¿Ha oído o escuchado de la prueba de Papanicolaou? y ¿Le hicieron una prueba de Papanicolaou en los últimos cinco años?. Las características sociodemográficas y de relación interpersonal fueron consideradas como variables independientes. Dichas variables ingresaron al análisis bivariado y de regresión logística, para determinar los factores que se encuentran asociados. Resultados: El porcentaje de MEF que se han realizo algún PAP fue de 42.8%, 45.7%, 47.3% y 45.6% para los años 1996, 2000, 2004 y 2008 respectivamente. Mientras que el porcentaje de MEF que ha escuchado sobre el PAP fue de 78.3%, 85.1%, 89.8% y 91.4% para los mismos años. Durante los cuatro años analizados, el vivir en la costa y en zona urbana fueron las variables asociadas con haber escuchado sobre el PAP. Mientras que el haberse realizado algún PAP sólo estuvo asociada con el vivir en la costa, en forma consecuente durante los cuatro años analizados. Conclusiones: Las frecuencias de realización de PAP obtenidas son representativas de la realidad nacional. Comparadas con lo reportado por otros países de América del sur, nuestra cobertura es baja. Existen factores asociados al cumplimiento del PAP que puede ser modificados con el objetivo de mejorar la cobertura del PAP, método de tamizaje de elección para el cáncer de cuello uterino.

Objectives: To determinate the frecuency, sociodemographics characteristics and interpersonal factors associated with cervical cancer screening in Peruvian women of childbearing age. Methods: We used the database of the national Demographic and Family Health (DHS) survey conducted in 1996, 2000, 2004 and 2008. We considered as dependent variable teh questions: Have you heard of the PAP smear? and Have you had a PAP smear in the last 5 years? Sociodemographics characteristics and interpersonal factors were considered as independent variables. Dependent and independent variables were used in the bivariate and multivariate analysis in order to determinate which factors were associated. Results: The percentage of women in childbearing age with any PAP smear was 42.8%, 45.7%, 47.3% and 45.6% for 1996, 2000, 2004 and 2008 respectively. While the percentage of women in childbearing age who had heard about PAP smear was 78.3%, 85.1%, 89.8% and 91.4% for the same years. During the 4 years analyzed, living in the coast and in urban areas were associated with having heard of PAP test. While only having had a previously PAP smear was associated with living in the coast in a consistetd manner during the four years analyzed. Conclusions: The frequency of cervical cancer screening obtained in this study are representative of the national reality. The coverage in Peru is low compared with other South American countries. There are some factors associated with PAP smear that can be modified to improve its coverage, knowing that it is the screening method of choice for cervical cancer.

Expresión de FOXP3 en Linfoma/Leucemia T del adulto / FOXP3 expression in Lymphoma / Leukemia adult T

Foxp3 es un gen regulatorio clave requerido para el desarrollo y función de las células T regulatorias CD25+ CD4+ (Treg), una subpoblación de células T especializadas en el mantener el balance entre la inmunidad y la tolerancia. Este estudio tiene como objetivo determinar la especificidad y el valor pronóstico de la expresión de Foxp3 en el Linfoma de células T. Un estudio retrospectivo fue realizado en 33 pacientes colectados de pacientes con Linfoma /Leucemia T del adulto (ATLL), la expresión de Foxp3 en células tumorales fue detectado en 8/33(24%) casos de ATLL. No hubo diferencia estadística en sobrevida global entre el ATLL Foxp3 (+) y el ATLL Foxp3 (-). La expresión de Foxp3 puede darse en un subgrupo de ATLL y no es un factor pronóstico en esta entidad.

Foxp3 is a key regulatory gene required for the development and function of regulatory CD4+CD25+T cells (Treg), a subpopulation of T-cells specialized in maintaining the balance between immunity and tolerance. This study aimed to determine the specifity and prognostic value of the expression of Foxp3 in T cell Lymphoma. A retrospective study was performed on 33 patients collected from patients with Adult T lymphoma/leukemia (ATLL) in a general hospital from Peru. FOXP3 expression in tumour cells was confined to 8/33 of ATLL cases (24%). No statistic difference in overall survival betweeen (+) Foxp3 ATLL and (-) Foxp3 ATLL was found. FOXP3 is expressed in a subgroup of ATLL and it is nota prognostic factor in this entity.

Nivel de pobreza asociado al estadio de gravedad del cáncer ginecológico / Relationship of gynaecologic cancer stage and poverty

Objetivo: Determinar la relación entre el nivel de pobreza y el estadio al momento del diagnóstico de cáncer ginecológico. Diseño: Estudio ecológico de grupos múltiples. Lugar: Instituto Nacional de Enfermedades Neoplásicas (INEN). Participantes: Mujeres que buscaron atención por cáncer de cuello uterino y mama. Métodos: A partir del registro estadístico del INEN, para el quinquenio 2000-2004, se determinó la proporción de pacientes que buscaron atención por cáncer de cuello uterino y mama que llegaron en estadios avanzados (III y IV), provenientes de Lima y Callao. Para la determinación del nivel de pobreza del distrito de procedencia de las pacientes, se empleó el mapa de pobreza de Foncodes 2006, clasificando a los distritos de Lima y Callao en deciles, según el índice de carencias. Se calculó el coeficiente de correlación de Spearman para establecer la correlación entre la proporción de pacientes que presentaban un estadio avanzado de cáncer ginecológico y el nivel de pobreza. Principales medidas de resultados: Casos nuevos de cáncer de mama y de cuello uterino y nivel de pobreza. Resultados: En el período estudiado, se registró 2.956 casos nuevos de cáncer de mama y 2.547 de cáncer de cuello uterino. El 50,7% de los casos de cáncer de mama y el 44,1% de cáncer de cuello uterino buscaron atención cuando ya tenían un estadio avanzado. Se estableció una correlación directa estadísticamente significativa entre el nivel de pobreza y casos avanzados de cáncer de mama (rho=0,81, p < 0,001) y entre el nivel de pobreza y casos avanzados de cuello uterino (rho=0,92, p < 0,001). Conclusiones: Se determinó una correlación directa fuerte entre el nivel de pobreza y casos avanzados de cáncer ginecológico, en pacientes atendidas en el INEN, en el periodo 2000-2004. Este podría ser un indicador de inequidad en el acceso a servicios de salud en la población de Lima y Callao.

Objective: To determine the relationship between poverty and stage at diagnosis of gynaecologic cancer. Design: Multiple groups ecologic study. Setting: Instituto Nacional de Enfermedades Neoplasicas (INEN - National Institute of Cancer). Participants: Women with both cervical and breastcancer. Methods: From 2000-2004 INEN statistics registry we determined the proportion of patients from Lima and Callao who sought care for both cervical and breast cancer advanced stages (III and IV). We registered the patients' district of origin poverty level by using the 2006 Foncodes poverty map, ranking the districts of Lima and Callao in deciles according to the deprivation index. The Spearman correlation coefficient was calculated to establish the proportion of patients with advanced stage of a gynaecologic cancer and the level of poverty. Main outcome measures: New cases of both breast and cervical cancer and poverty. Results: During the period studied there were 2.956 new cases of breast cancer and 2.547 new cases of cervical cancer; 50,7% of breast cancer and 44,1% of cervical cancer cases sought care with an advanced stage of the disease. A statistically significant direct correlation was found between poverty level and advanced cases of breast cancer (rho = 0,81, p < 0,001) and between poverty and advanced cases of cervical cancer (rho=0,92, p < 0,001). Conclusions: We found a strong correlation between poverty level and advanced cases of gynaecologic cancer in patients attended at INEN in the period 2000-2004. This could be an indicator of access inequality to health services in the population of Lima and Callao.

Melanoma maligno de vulva en el Instituto Nacional de Enfermedades Neoplásicas: experiencia de 50 años / Malignant vulvar melanoma at the National Institute of Neoplastic Diseases: Fifty years experience

Objetivo: Determinar las características clínicas del melanoma maligno vulvar en el Instituto Nacional de Enfermedades Neoplásicas (INEN). Material y métodos: Estudio observacional longitudinal, se recolectó información de los casos de melanoma vulvar diagnosticados en el INEN, Lima-Perú, entre 1955 y 2004, a partir de la revisión de las historias clínicas. Se realizó el cálculo de distribuciones de frecuencia, medidas de tendencia central y dispersión, y curvas de supervivencia de Kaplan-Meier. Resultados: Se registraron 60 casos de melanoma vulvar. Se observa una tendencia creciente del número de casos diagnosticados por quinquenio. El promedio de edad fue 56.8 años, mientras que la mediana del tiempo promedio de enfermedad fue 6 meses. El lugar más frecuente de aparición de la lesión fue el lado izquierdo (30%), seguido de la región clitoriana (26.7%). La molestia más frecuentementereferida fue la presencia de una tumoración (91.7%), seguida de prurito (68.3%). La mediana del área del tumor fue 12cm2. El 53.3% presentócompromiso de los ganglios inguinales derecho e izquierdo y el 31.7% no presentó compromiso ganglionar inguinal. El 46.7% presentómetástasis, siendo el compromiso pulmonar el más frecuente (10% del total de casos). El tratamiento recibido fue principalmente del tipo soloquirúrgico radical (50%). La supervivencia a cinco años fue del 9.9%.Conclusiones: El melanoma vulvar es una neoplasia con una tendencia creciente en su diagnóstico, las pacientes buscan atención médica concuadros bastante avanzados y la supervivencia a cinco años es tan solo del 9.9%.

Objective: To determine the clinical characteristics of malignant vulvar melanoma at the National Institute of Neplastic Diseases, Lima-Peru (INEN). Methods: Longitudinal observational study. Information from cases of vulvar melanoma diagnosed at INEN between 1955 and 2004 was collected after reviewing the medical records. We performed the calculation of frequency distributions, measures of central tendency and dispersion, and Kaplan-Meier survival curves. Results: There were 60 cases of vulvar melanoma. There is a growing trend in the number of cases diagnosed at five years periods. The average age was 56.8 years, while the median time of disease was 6 months. The most frequent site of the injury was the left side (30%), followed by clitoral region (26.7%). The sign/symptom most frequently mentioned was the presence of a tumor (91.7%), followed by itching (68.3%). The median area of the tumor was 12cm2. 53.3% had the commitment of right and left groin lymph nodes and 31.7% did not have inguinal lymphnode involvement. The 46.7% had metastases, with lungs as the most common commitment (10% of total cases). The treatment was mainlyradical surgeryl (50%). The survival to five years was 9.9%. Conclusions: The vulvar melanoma is a cancer with an increasing trend in their diagnosis, patients seeking medical care at well advanced stages and survival to five years is only 9.9%.

Feasibility and cost-effectiveness of standardised second-line drug treatment for chronic tuberculosis patients: a national cohort study in Peru.

BACKGROUND: There are no data on the feasibility and cost-effectiveness of using second-line drugs to treat patients with chronic tuberculosis, many of whom are infected with multidrug resistant (MDR) strains of Mycobacterium tuberculosis, in low or middle-income countries. METHODS: A national programme to treat chronic tuberculosis patients with a directly observed standardised 18-month daily regimen, consisting of kanamycin (3 months only), ciprofloxacin, ethionamide, pyrazinamide, and ethambutol, was established in Peru in 1997. Compliance and treatment outcomes were analysed for the cohort started on treatment between October, 1997, and March, 1999. Total and average costs were assessed. Cost-effectiveness was estimated as the cost per DALY gained. FINDINGS: 466 patients were enrolled; 344 were tested for drug susceptibility and 298 (87%) had MDR tuberculosis. 225 patients (48%) were cured, 57 (12%) died, 131 (28%) did not respond to treatment, and 53 (11%) defaulted. Of the 413 (89%) patients who complied with treatment, 225 (55%) were cured. Among MDR patients, resistance to five or more drugs was significantly associated with an unfavourable outcome (death, non-response to treatment, or default; odds ratio 3.37, 95% CI 1.32-8.60; p=0.01). The programme cost US $0.6 million per year, 8% of the National Tuberculosis Programme budget, and US $2381 per patient for those who completed treatment. The mean cost per DALY gained was $211 ($165 at drug prices projected for 2002). INTERPRETATION: Treating chronic tuberculosis patients with high levels of MDR with second-line drugs can be feasible and cost-effective in middle-income countries, provided a strong tuberculosis control programme is in place.

Vigilancia de la resistencia a los medicamentos antituberculosos en el Perú, 1995-96 / Surveillance about the antituberculosis drugs resistance in Peru, 1995-96

La tuberculosis es un importante y serio problema de salud en el Perú. La resistencia antibiótica constituye un problema emergente de magnitud no totalmente definida. A fin de determinar la prevalencia de la resistencia del M. tuberculosis a los medicamentos antituberculosos e iniciar un estudio de vigilancia, se efectuó un proyecto multicéntrico en 31 subregiones de salud del país, que incluyó muestras de esputo de pacientes diagnosticados de TB, con baciloscopia positiva precedentes de 814 hospitales y centros de salud. Se completó una muestra de 1958 pacientes nuevos y antes trabajos de quienes se obtuvo muestras de esputo, las cuales se cultivaron en los medios de Lowenstein-Jensen y Ogawa y los aislamientos fueron sometidos a pruebas de sensibilidad a los medicamentos anti TB por el método de las proporciones. Los resultados fueron: resistencia a uno o más medicamentos en el 15,4 de 1500 casos de TB no tratados previamente (NT), y en el 36,0 de 458 casos ya tratados (AT). la multirresistencia (MR) afectó a 2,4 de los pacientes NT y un 15,7 de los AT. En 9 casis (0,4) se reportó positividad para HIV, de los cuales seis no tratados (NT) fueron sensibles a los medicamentos anti TB y los otros 3 ya tratados (AT) un (1) caso fue sensible y 2 resistentes de éstos uno de ellos MR. El estudio permitió el fortalecimiento de la Red Nacional de Laboratorios en TB del país, contribuyendo a la seguridad y a la oportunidad en el diagnóstico y control de la enfermedad