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1.
Lancet Glob Health ; 9(12): e1658-e1666, 2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34695371

RESUMO

BACKGROUND: Advances in SARS-CoV-2 sequencing have enabled identification of new variants, tracking of its evolution, and monitoring of its spread. We aimed to use whole genome sequencing to describe the molecular epidemiology of the SARS-CoV-2 outbreak and to inform the implementation of effective public health interventions for control in Zimbabwe. METHODS: We performed a retrospective study of nasopharyngeal samples collected from nine laboratories in Zimbabwe between March 20 and Oct 16, 2020. Samples were taken as a result of quarantine procedures for international arrivals or to test for infection in people who were symptomatic or close contacts of positive cases. Samples that had a cycle threshold of less than 30 in the diagnostic PCR test were processed for sequencing. We began our analysis in July, 2020 (120 days since the first case), with a follow-up in October, 2020 (at 210 days since the first case). The phylogenetic relationship of the genome sequences within Zimbabwe and global samples was established using maximum likelihood and Bayesian methods. FINDINGS: Of 92 299 nasopharyngeal samples collected during the study period, 8099 were PCR-positive and 328 were available for sequencing, with 156 passing sequence quality control. 83 (53%) of 156 were from female participants. At least 26 independent introductions of SARS-CoV-2 into Zimbabwe in the first 210 days were associated with 12 global lineages. 151 (97%) of 156 had the Asp614Gly mutation in the spike protein. Most cases, 93 (60%), were imported from outside Zimbabwe. Community transmission was reported 6 days after the onset of the outbreak. INTERPRETATION: Initial public health interventions delayed onset of SARS-CoV-2 community transmission after the introduction of the virus from international and regional migration in Zimbabwe. Global whole genome sequence data are essential to reveal major routes of spread and guide intervention strategies. FUNDING: WHO, Africa CDC, Biotechnology and Biological Sciences Research Council, Medical Research Council, National Institute for Health Research, and Genome Research Limited.


Assuntos
COVID-19/epidemiologia , Epidemias , Genoma Viral , Vigilância em Saúde Pública , SARS-CoV-2/genética , Doença Relacionada a Viagens , Adolescente , Adulto , COVID-19/transmissão , COVID-19/virologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Epidemiologia Molecular , Estudos Retrospectivos , Sequenciamento Completo do Genoma , Adulto Jovem , Zimbábue/epidemiologia
2.
Trop Med Int Health ; 26(10): 1248-1255, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34192392

RESUMO

OBJECTIVES: To determine the incidence and major drivers of catastrophic costs among TB-affected households in Zimbabwe. METHODS: We conducted a nationally representative health facility-based survey with random cluster sampling among consecutively enrolled drug-susceptible (DS-TB) and drug-resistant TB (DR-TB) patients. Costs incurred and income lost due to TB illness were captured using an interviewer-administered standardised questionnaire. We used multivariable logistic regression to determine the risk factors for experiencing catastrophic costs. RESULTS: A total of 841 patients were enrolled and were weighted to 900 during data analysis. There were 500 (56%) males and 46 (6%) DR-TB patients. Thirty-five (72%) DR-TB patients were HIV co-infected. Overall, 80% (95% CI: 77-82) of TB patients and their households experienced catastrophic costs. The major cost driver pre-TB diagnosis was direct medical costs. Nutritional supplements were the major cost driver post-TB diagnosis, with a median cost of US$360 (IQR: 240-600). Post-TB median diagnosis costs were three times higher among DR-TB (US$1,659 [653-2,787]) than drug DS-TB-affected households (US$537 [204-1,134]). Income loss was five times higher among DR-TB than DS-TB patients. In multivariable analysis, household wealth was the only covariate that remained significantly associated with catastrophic costs: The poorest households had 16 times the odds of incurring catastrophic costs versus the wealthiest households (adjusted odds ratio [aOR: 15.7 95% CI: 7.5-33.1]). CONCLUSION: The majority of TB-affected households, especially those affected by DR-TB, experienced catastrophic costs. Since the major cost drivers fall outside the healthcare system, multi-sectoral approaches to TB control and linking TB patients to social protection may reduce catastrophic costs.

3.
PLoS One ; 16(4): e0249523, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33831058

RESUMO

INTRODUCTION: Accurate mapping of spatial heterogeneity in tuberculosis (TB) cases is critical for achieving high impact control as well as guide resource allocation in most developing countries. The main aim of this study was to explore the spatial patterns of TB occurrence at district level in Zimbabwe from 2015 to 2018 using GIS and spatial statistics as a preamble to identifying areas with elevated risk for prioritisation of control and intervention measures. METHODS: In this study Getis-Ord Gi* statistics together with SaTscan were used to characterise TB hotspots and clusters in Zimbabwe at district level from 2015 to 2018. GIS software was used to map and visualise the results of cluster analysis. RESULTS: Results show that TB occurrence exhibits spatial heterogeneity across the country. The TB hotspots were detected in the central, western and southern part of the country. These areas are characterised by artisanal mining activities as well as high poverty levels. CONCLUSIONS AND RECOMMENDATIONS: Results of this study are useful to guide TB control programs and design effective strategies which are important in achieving the United Nations Sustainable Development goals (UNSDGs).


Assuntos
Mycobacterium/isolamento & purificação , Software , Análise Espacial , Tuberculose Pulmonar/epidemiologia , Análise por Conglomerados , Humanos , Estudos Retrospectivos , Fatores de Tempo , Tuberculose Pulmonar/microbiologia , Zimbábue/epidemiologia
4.
Infect Dis Poverty ; 9(1): 146, 2020 Oct 22.
Artigo em Inglês | MEDLINE | ID: mdl-33092651

RESUMO

BACKGROUND: Although effective treatment for malaria is now available, approximately half of the global population remain at risk of the disease particularly in developing countries. To design effective malaria control strategies there is need to understand the pattern of malaria heterogeneity in an area. Therefore, the main objective of this study was to explore the spatial and spatio-temporal pattern of malaria cases in Zimbabwe based on malaria data aggregated at district level from 2011 to 2016. METHODS: Geographical information system (GIS) and spatial scan statistic were applied on passive malaria data collected from health facilities and aggregated at district level to detect existence of spatial clusters. The global Moran's I test was used to infer the presence of spatial autocorrelation while the purely spatial retrospective analyses were performed to detect the spatial clusters of malaria cases with high rates based on the discrete Poisson model. Furthermore, space-time clusters with high rates were detected through the retrospective space-time analysis based on the discrete Poisson model. RESULTS: Results showed that there is significant positive spatial autocorrelation in malaria cases in the study area. In addition, malaria exhibits spatial heterogeneity as evidenced by the existence of statistically significant (P < 0.05) spatial and space-time clusters of malaria in specific geographic regions. The detected primary clusters persisted in the eastern region of the study area over the six year study period while the temporal pattern of malaria reflected the seasonality of the disease where clusters were detected within particular months of the year. CONCLUSIONS: Geographic regions characterised by clusters of high rates were identified as malaria high risk areas. The results of this study could be useful in prioritizing resource allocation in high-risk areas for malaria control and elimination particularly in resource limited settings such as Zimbabwe. The results of this study are also useful to guide further investigation into the possible determinants of persistence of high clusters of malaria cases in particular geographic regions which is useful in reducing malaria burden in such areas.


Assuntos
Malária/epidemiologia , Humanos , Incidência , Análise Espaço-Temporal , Zimbábue/epidemiologia
5.
Int J Infect Dis ; 101: 403-408, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32890725

RESUMO

BACKGROUND: Historical neglect of pediatric tuberculosis (TB), compounding the absence of a universally effective vaccine, highlights the importance of successful treatment in combating the global epidemic. Furthermore, compliance with international standards of pediatric TB treatment remains unknown in many high-burden, resource-limited settings. METHODS: In this cross-sectional study, using TB surveillance data, we assessed the treatment outcomes among 853 pediatric TB cases (<15 years old), a study sample that represented all the pediatric TB cases with treatment outcome records in Harare, Zimbabwe during 2013-2017. We also identified factors associated with treatment outcome by multivariate logistic regression. RESULTS: Of these 853 analyzed cases, 57% were either cured or had completed treatment. In a model accounting for confounding variables, hospital center and pretreatment sputum smear were associated with unfavorable treatment outcome. Cases from Beatrice Road Infectious Disease Hospital were four times as likely to have an unfavorable outcome compared with those from Wilkins Infectious Disease Hospital (adjusted odds ration [aOR]: 4.0; 95% CI 2.9-5.5). Children whose pretreatment sputum smear was positive were 2.4 times as likely to have an unfavorable outcome as those who were negative (aOR: 2.4; 95% CI 1.7-3.6). CONCLUSION: Pediatric TB case management needs to be improved, especially among those with a positive pretreatment sputum smear. Efforts to address TB treatment outcome disparities between clinical settings in high-burden settings, such as Harare, Zimbabwe, are essential in improving global TB control.


Assuntos
Antituberculosos/uso terapêutico , Tuberculose/tratamento farmacológico , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Lactente , Masculino , Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/genética , Mycobacterium tuberculosis/isolamento & purificação , Escarro/microbiologia , Resultado do Tratamento , Tuberculose/epidemiologia , Tuberculose/microbiologia , Zimbábue/epidemiologia
6.
Am J Trop Med Hyg ; 103(1): 214-220, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32431282

RESUMO

Country-specific interventions targeting high-risk groups are necessary for a global reduction in Tuberculosis (TB)/HIV burden. We analyzed the data of 13,802 TB cases diagnosed in Harare, Zimbabwe, during 2013-2017. Pearson's chi-square tests and multivariate logistic regression models were used to identify patient characteristics significantly associated with TB/HIV coinfection. Of the 13,802 TB cases analyzed, 9,725 (70.5%) were HIV positive. A significantly higher odds of having TB/HIV coinfection diagnosis was found among females, patients aged 25-64 years, previously treated cases, and acid-fast bacillus sputum smear-negative cases. Compared with nondisseminated pulmonary TB, miliary TB (adjusted odds ratio [aOR]: 1.469, 95% CI: 1.071, 2.015) and TB meningitis (aOR: 1.715, 95% CI: 1.074, 2.736) both had a significantly higher odds for TB/HIV coinfection, whereas pleural TB (aOR 0.420, 95% CI: 0.354, 0.497) and all other extrapulmonary TB (EPTB) (aOR: 0.606, 95% CI: 0.516 0.712) were significantly less likely to have TB/HIV coinfection. The risk for TB/HIV coinfection varied significantly by patients' sociodemographic and clinical characteristics in Harare. Our finding that different forms of EPTB have different relationships with HIV coinfection has extended the knowledge base about clinical markers for TB/HIV coinfection which can lead to a greater public health impact on eliminating TB/HIV infection.


Assuntos
Coinfecção/epidemiologia , Infecções por HIV/complicações , Tuberculose Pulmonar/complicações , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Coinfecção/microbiologia , Coinfecção/virologia , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/microbiologia , Humanos , Incidência , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores Sexuais , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/virologia , Adulto Jovem , Zimbábue/epidemiologia
7.
PLoS One ; 15(4): e0231637, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32315335

RESUMO

INTRODUCTION: The contribution of high tuberculosis (TB) transmission pockets in propagating area-wide transmission has not been adequately described in Zimbabwe. This study aimed to describe the presence of hotspot transmission of TB cases in Harare city from 2011 to 2012 using geospatial techniques. METHODS: Anonymised TB patient data stored in an electronic database at Harare City Health department was analysed using geospatial methods. Confirmed TB cases were mapped using geographic information system (GIS). Global Moran's I and Anselin Local Moran's I (LISA) were used to assess clustering and the local Getis-Ord Gi* was used to estimate hotspot phenomenon of TB cases in Harare City for the period between 2011 and 2012. RESULTS: A total of 12,702 TB cases were accessed and mapped on the Harare City map. In both 2011 and 2012, ninety (90%) of cases were new and had a high human immunodeficiency virus (HIV)/TB co-infection rate of 72% across all suburbs. Tuberculosis prevalence was highest in the Southern district in both 2011 and 2012. There were pockets of spatial distribution of TB prevalence across West South West, Southern, Western, South Western and Eastern health districts. TB hot spot occurrence was restricted to the West South West, parts of South Western, Western health districts. West South West district had an increased peri-urban population with inadequate social services including health facilities. These conditions were conducive for increased intensity of TB occurrence, a probable indication of high transmission especially in the presence of high HIV co-infection. CONCLUSIONS AND RECOMMENDATIONS: Increased TB transmission was limited to a health district with high informal internal migrants with limited health services in Harare City. To minimise spread of TB into greater Harare, there is need to improve access to TB services in the peri-urban areas.


Assuntos
Transmissão de Doença Infecciosa , Infecções por HIV/epidemiologia , Mycobacterium tuberculosis/patogenicidade , Tuberculose/epidemiologia , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Sistemas de Informação Geográfica , HIV/patogenicidade , Infecções por HIV/complicações , Infecções por HIV/microbiologia , Infecções por HIV/virologia , Acesso aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Análise Espacial , Tuberculose/complicações , Tuberculose/microbiologia , Tuberculose/virologia , População Urbana , Adulto Jovem , Zimbábue/epidemiologia
8.
Int J Infect Dis ; 87: 119-125, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31357057

RESUMO

OBJECTIVE: To determine the prevalence of resistance to rifampicin alone; rifampicin and isoniazid, and second-line anti-TB drugs among sputum smear-positive tuberculosis patients in Zimbabwe. DESIGN: A health facility-based cross-sectional survey. RESULTS: In total, 1114 (87.6%) new and 158 (12.4%) retreatment TB patients were enrolled. MTB was confirmed by Xpert MTB/RIF among 1184 (93%) smear-positive sputum samples. There were 64 samples with Xpert MTB/RIF-determined rifampicin resistance. However, two were rifampicin susceptible on phenotypic drug susceptibility testing. The prevalence of RR-TB was [4.0% (95% CI, 2.9, 5.4%), n=42/1043) and 14.2% (95% CI, 8.9, 21.1%; n=20/141) among new and retreatment patients, respectively. The prevalence of MDR-TB was 2.0% (95% CI, 1.3, 3.1%) and 6.4% (95% CI, 2.4, 10.3%) among new and retreatment TB patients, respectively. Risk factors for RR-TB included prior TB treatment, self-reported HIV infection, travel outside Zimbabwe for ≥one month (univariate), and age <15 years. Having at least a secondary education was protective against RR-TB. CONCLUSION: The prevalence of MDR-TB in Zimbabwe has remained stable since the 1994 subnational survey. However, the prevalence of rifampicin mono-resistance was double that of MDR-TB.


Assuntos
Mycobacterium tuberculosis/efeitos dos fármacos , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Resistente a Múltiplos Medicamentos/microbiologia , Adolescente , Adulto , Idoso , Antibacterianos/farmacologia , Criança , Estudos Transversais , Farmacorresistência Bacteriana , Feminino , Instalações de Saúde , Humanos , Isoniazida/farmacologia , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Mycobacterium tuberculosis/genética , Prevalência , Rifampina/farmacologia , Fatores de Risco , Sensibilidade e Especificidade , Escarro/microbiologia , Inquéritos e Questionários , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Adulto Jovem , Zimbábue/epidemiologia
9.
Int J Mycobacteriol ; 8(2): 185-189, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31210164

RESUMO

Background: Biobanking of Mycobacterium tuberculosis (Mtb) sputum samples for future research activities recommends the use of -70°C or -80°C freezers. Infrastructure for biobanking is not readily available in the majority of low-income countries. This study aimed to assess the recovery rate of Mtb isolates stored at room temperature for more than 6 years in Zimbabwe. Methods: Census samples of all confirmed rifampicin-resistant/multidrug-resistant tuberculosis isolates that were stored in mycobacterial growth indicator tubes (MGITs) at room temperature from 2011 to 2016 were identified and retrieved. The samples were subcultured on MGIT and 7H10 solid media for the extraction of genomic deoxyribonucleic acid using the phenol/chloroform method followed by precipitation with isopropanol. Results: A total of 248/400 (62%) isolates were successfully recovered. Recovery rates increased with declining time since the last culture, with 51% for samples stored for 6 years which increased to 77% for those stored for 1 year. The isolates that grew but were contaminated during the first subculture at the National Microbiology Reference Laboratory in Harare could not be recovered through decontamination because of limited resources. Decontamination was only possible during the second culture at the University of Stellenbosch. Conclusion: Storage of Mtb isolates at room temperature is a viable option in low-income countries where currently recommended biobanking procedures may not be available. This low-cost biobanking will facilitate research activities years later as new questions arise. Standard infection prevention and control when handling Mtb samples stored under room temperature for long periods is strongly recommended as these bacteria remain viable longer than previously reported.


Assuntos
DNA Bacteriano/isolamento & purificação , Viabilidade Microbiana , Mycobacterium tuberculosis/isolamento & purificação , Manejo de Espécimes/métodos , Bancos de Espécimes Biológicos , Temperatura Baixa , Contagem de Colônia Microbiana , Estudos Transversais , Países em Desenvolvimento , Humanos , Mycobacterium tuberculosis/crescimento & desenvolvimento , Fatores de Tempo , Zimbábue
10.
Am J Trop Med Hyg ; 99(3): 601-607, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30014829

RESUMO

Pediatric tuberculosis (TB) represents a major barrier to reducing global TB mortality, especially in countries confronting dual TB and human immunodeficiency virus (HIV) epidemics. Our study aimed to characterize pediatric TB epidemiology in the high-burden setting of Harare, Zimbabwe, both to fill the current knowledge gap around the epidemiology of pediatric TB and to indicate areas for future research and interventions. We analyzed de-identified data of 1,051 pediatric TB cases (0-14 years) found among a total of 11,607 TB cases reported in Harare, Zimbabwe, during 2011-2012. We performed Pearson's χ2 test and multivariate logistic regression analysis to characterize pediatric TB and to assess predictors of HIV coinfection. Pediatric TB cases accounted for 9.1% of all TB cases reported during 2011-2012. Approximately 50% of pediatric TB cases were children younger than 5 years. Almost 60% of the under-5 age group were male, whereas almost 60% of the 10-14 age group were female. The overall HIV coinfection rate was 58.3%. Odds for HIV coinfection was higher for the 5-9 age group (adjusted odds ratio [AOR]: 2.77, 95% confidence interval [CI]: 1.97-3.94), the 10-14 group (AOR: 3.57, 95% CI: 2.52-5.11), retreatment cases (AOR: 6.17, 95% CI: 2.13, 26.16), and pulmonary TB cases (AOR: 2.39, 95% CI: 1.52, 3.75). In conclusion, our study generated evidence that pediatric TB, compounded by HIV coinfection, significantly impacts children in high-burden settings. The findings of our study indicate a critical need for targeted interventions.


Assuntos
Coinfecção/epidemiologia , Infecções por HIV/epidemiologia , Tuberculose/epidemiologia , Adolescente , Criança , Pré-Escolar , Coinfecção/microbiologia , Coinfecção/virologia , Feminino , HIV/isolamento & purificação , Infecções por HIV/microbiologia , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Fatores de Risco , Tuberculose/virologia , Tuberculose Pulmonar/epidemiologia , Tuberculose Pulmonar/virologia , Zimbábue/epidemiologia
11.
BMC Res Notes ; 8: 575, 2015 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-26475610

RESUMO

BACKGROUND: Tuberculosis (TB) has remained one of the major public health problems in Zimbabwe with an estimated incidence rate of 552 per 100,000 persons in 2013. The aim of this study was to describe the trends in acid-fast bacilli (AFB) sputum-smear positive (SSP) TB overall and within subpopulations for the period during 2008-2011 in Zimbabwe. Results of this study will contribute towards the evaluation and implementation of targeted TB control interventions. METHODS: A cross-sectional study design was used to analyze 40, 110 SSP TB patient records routinely collected during 2008-2011. Incidence trends of SSP TB were described by province, sex, and age group. A Mantel-Haenszel Chi Statistic was calculated to compare each provincial SSP TB notification rate to the national SSP TB notification rate. RESULTS: SSP TB notification rates were higher in the two main urban provinces, the western provinces and Manicaland. The 25-44 year age group accounted for the largest proportion of notified SSP TB. However, the 55-64 year and 65+ age groups had SSP TB notification rates in 2011 higher than the 2008 value. Finally, the average SSP TB notification rate in males was 23% higher than in females. CONCLUSION: The findings of this study suggest that TB control has successfully decreased the notification rate of SSP TB in Zimbabwe during 2008-2011. However, the disproportionate distribution of SSP TB among different regions and subpopulations of the country highlights the need for more targeted interventions to accelerate the decline of TB in Zimbabwe.


Assuntos
Mycobacterium tuberculosis/isolamento & purificação , Escarro/microbiologia , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/epidemiologia , Adolescente , Adulto , Distribuição por Idade , Idoso , Criança , Pré-Escolar , Estudos Transversais , Notificação de Doenças/estatística & dados numéricos , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Microscopia , Pessoa de Meia-Idade , Saúde Pública/estatística & dados numéricos , Distribuição por Sexo , Tuberculose Pulmonar/microbiologia , Zimbábue/epidemiologia
12.
J Trop Pediatr ; 60(1): 27-32, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23982829

RESUMO

BACKGROUND: Failure to thrive (FTT) is a sign of tuberculosis (TB) and human immunodeficiency virus (HIV) infection. We assessed TB and HIV prevalence in children with FTT at one clinic in Botswana. METHODS: In July 2010, we screened all children attending a 'Well Child' clinic for FTT. Children with FTT were referred to a paediatrician who: (i) assessed causes of FTT, (ii) evaluated for HIV and TB and (iii) reviewed the patient chart for evaluations for TB and HIV. RESULTS: Of 919 children screened, 176 (19%) had FTT. One hundred eighteen (67%) children saw a paediatrician, and of these, 95 (81%) completed the TB evaluation. TB was newly diagnosed in 6 of 95 (6%). At review, HIV status was known in 23 of 118 (19%). Ninety-five had an unknown HIV status. Forty-five (47%) tested for HIV; all tested HIV-negative. CONCLUSION: TB and HIV screening among children with FTT diagnosed TB in 6% of cases completing an evaluation, but no new HIV infections.


Assuntos
Insuficiência de Crescimento/etiologia , Infecções por HIV/diagnóstico , Infecções por HIV/epidemiologia , Programas de Rastreamento/métodos , Tuberculose/diagnóstico , Tuberculose/epidemiologia , Botsuana/epidemiologia , Criança , Pré-Escolar , Estudos Transversais , Insuficiência de Crescimento/diagnóstico , Insuficiência de Crescimento/epidemiologia , Feminino , Seguimentos , Infecções por HIV/complicações , Humanos , Lactente , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Ambulatório Hospitalar , Prevalência , Fatores Socioeconômicos , Tuberculose/complicações , População Urbana/estatística & dados numéricos
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