Understanding Barriers and Facilitators to Disaster Preparedness in Federally Qualified Health Centers in the United States: A Mixed Methods Study.

OBJECTIVE: Severe weather events exacerbate existing health disparities due to poorly managed non-communicable diseases (NCDs). Our objective is to understand the experiences of staff, providers, and administrators (employees) of Federally Qualified Health Centers (FQHCs) in Puerto Rico and the US Virgin Islands (USVI) in providing care to patients living with NCDs in the setting of recent climate-related extreme events. METHODS: We used a convergent mixed-methods study design. A quantitative survey was distributed to employees at 2 FQHCs in Puerto Rico and the USVI, assessing experience with disasters, knowledge of disaster preparedness, the relevance of NCDs, and perceived gaps. Qualitative in-depth interviews explored their experience providing care for NCDs during recent disasters. Quantitative and qualitative data were merged using a narrative approach. RESULTS: Through the integration of quantitative and qualitative data, we recognize: (1) significant gaps in confidence and preparedness of employees with a need for more training; (2) challenges faced by persons with multiple NCDs, especially cardiovascular and mental health disorders; and (3) most clinicians do not discuss disaster preparedness with patients but recognize their important role in community resilience. CONCLUSION: With these results, we recommend strengthening the capacity of FQHCs to address the needs of their patients with NCDs in disasters.

Impacto de la recolección de residuos domésticos de gran tamaño sobre potenciales criaderos de mosquitos transmisores del dengue en Asunción, Paraguay

Introducción: Los brotes recurrentes de dengue subrayan la necesidad de abordajes más efectivos en la prevención y control de vectores. A menudo, las intervenciones se centran en un enfoque biomédico y de promoción de la salud desde un enfoque individual, sin integrar factores socioambientales ni ser evaluados científicamente Objetivo: Evaluar el impacto de la recolección de residuos domésticos de gran tamaño sobre potenciales criaderos de mosquitos transmisores del dengue en Asunción, Paraguay durante los años 2017 a 2021. Material y métodos: Estudio cuasiexperimental, longitudinal, donde se encuestaron 350 hogares, como línea de base durante el 2017 y una línea de cierre en 108 hogares en 2021. Se utilizó el método de Diferencia en Diferencia (DID) para comparar la presencia de criaderos antes y después de la intervención en 43 hogares intervenidos y 65 no intervenidos. Resultados: La recolección diferenciada fue utilizada principalmente por aquellos hogares que tenían una gran cantidad de residuos sólidos de gran tamaño, pero no para deshacerse de todos estos objetos, sino sólo de una parte (DID de -52% en el número total de criaderos y DID de 1% en número de hogares con criaderos). Encontramos una reducción significativa en el número de total de criaderos de gran tamaño, pero no observamos diferencias en el número total de hogares con criaderos. Factores subjetivos, como la creencia de que los objetos en desuso podrían llegar a ser útiles en el futuro explicaban en gran medida su presencia en los hogares, incluso con el servicio disponible. Conclusiones: El enfoque de la gestión municipal en los residuos voluminosos puede contribuir a la prevención del dengue por el hecho de que no constituyen residuos de generación rápida en los hogares, y su eliminación puede tener un impacto relativamente duradero. El factor subjetivo relacionado con la presencia de estos criaderos en los hogares debe ser objeto de mayores estudios.

Introduction: Recurrent dengue outbreaks underscore the need for more effective approaches to vector prevention and control. Often, interventions focus on a biomedical and health promotion approach from an individual approach, without integrating socio-environmental factors or being scientifically evaluated. Objetive: To evaluate the impact of large household waste collection on potential breeding sites of dengue-transmitting mosquitoes in Asuncion, Paraguay during the years 2017 to 2021. Material and methods: Quasi-experimental, longitudinal study, where 350 households were surveyed, as a baseline during 2017 and a closing line in 108 households in 2021. The Difference-in-Difference (DID) method was used to compare the presence of breeding sites before and after the intervention in 43 intervened and 65 non-intervened households. Results: Differentiated collection was mainly used by those households that had a large amount of large solid waste, but not to dispose of all these objects, but only part of them (DID of -52% in the total number of breeding sites and DID of 1% in the number of households with breeding sites). We found a significant reduction in the total number of large breeding sites but did not observe differences in the total number of households with breeding sites. Subjective factors, such as the belief that disused objects could become useful in the future, were largely responsible for the reduction in the number of large breeding sites. Conclusions: The municipal management approach to bulky waste can contribute to dengue prevention because it does not constitute rapidly generated waste in households, and its disposal can have a relatively long-lasting impact. The subjective factors related to the presence of these breeding sites in households warrant further study.

Gender Differences in Trends in Incidence and Mortality of Acute Myocardial Infarction in the Small Island Developing State of Barbados.

Objective To determine trends, identify predictors of acute myocardial infarction (AMI) incidence and mortality, and explore performance metrics for AMI care in Barbados. Methods Data on all cases diagnosed with AMI were collected by the Barbados National Registry for Non-Communicable Diseases (BNR) from the island's only tertiary hospital, the Queen Elizabeth Hospital, and the National Vital Registration Department. Participants who survived hospital admission were then followed up at 28 days and one year post event via telephone survey and retrieval of death certificates. Age-standardized incidence and mortality rates were calculated. Determinants of mortality at 28 days were examined in multivariable logistic regression models. Median and interquartile ranges (IQR) were calculated for performance metrics (e.g., time from pain onset to reperfusion). Results In a 10-year period between 2010 and 2019, 4,065 cases of myocardial infarction were recorded. The median age of the sample was 73 years (IQR: 61,83), and approximately half (47%) were female. Over a 10-year period, standardized incidence increased in women on average yearly by three per 100,000 (95% CI: 1 to 6; p=0.02), while in men, the average increase per year was six per 100,000 (95% CI: 4 to 8; p<0.001). There was no increase in 28-day mortality in women; mortality in men increased each year by 2.5 per 100,000 (95% CI: 0.4 to 4.5; p=0.02). The time from arrival at the hospital to the ECG was 44 minutes IQR (20,113). Conclusion AMI incidence and mortality are increasing in Barbados, and men have a higher velocity of mortality rate increase than women, which contradicts global data.

Caracterização do perfil sociodemográfico dos usuários de profilaxia pré-exposição ao HIV (PrEP) no Ceará / Characterization of the sociodemographic profile of users of hiv pre-exposure prophylaxis (PrEP) in Ceará

Introdução: a PrEP é uma estratégia de prevenção biomédica que consiste no uso de antirretrovirais (ARV) orais com o objetivo de mitigar o risco de adquirir o HIV e, consequentemente, de desenvolver a AIDS. O presente estudo tem como objetivo descrever o perfil sociodemográfico dos usuários com dispensação da PrEP no Ceará, no período de 2018 a 2023. Métodos: trata-se de um estudo transversal descritivo. Os dados foram obtidos por meio do Departamento de HIV/Aids, Tuberculose, Hepatites Virais e Infecções Sexualmente Transmissíveis (DATHI) do Ministério da Saúde por meio do Painel de monitoramento da PrEP. Resultados: observou-se um predomínio de usuários gays e homens que fazem sexo com homens, mas não se consideram gays; autodeclarados como pardos, com alta escolaridade e com faixa etária entre 30 e 39 anos. As dispensações da PrEP apresentaram progressão no período analisado, apesar dos anos de pandemia. Conclusão: embora a PrEP tenha-se mostrado eficaz no controle e declínio no número de infecções pelo HIV, esses dados demonstram que há uma lacuna entre quem se beneficia dela. É um desafio fazer com que a PrEP chegue a quem se pode beneficiar dela e com maior probabilidade de exposição ao HIV indivíduos de baixa escolaridade, pessoas trans, travestis, jovens adultos /adolescentes e não brancos.

Introduction: PrEP is a biomedical prevention strategy that consists of the use of oral antiretrovirals (ARV) to mitigate the risk of acquiring HIV and, consequently, of developing AIDS. The present study aims to describe the sociodemographic profile of users dispensed with PrEP in Ceará from 2018 to 2023. Methods: this is a descriptive cross-sectional study. The data was obtained from the Department of HIV/Aids, Tuberculosis, Viral Hepatitis, and Sexually Transmitted Infections (DATHI) of the Ministry of Health through the PrEP Monitoring Panel. Results: there was a predominance of Gay users and Men who have Sex with Men but do not consider themselves gay; they self-declared as mixed race, highly educated, and aged between 30 and 39 years old. PrEP dispensations showed progression in the period analyzed despite years of pandemic. Conclusion: although PrEP is effective in controlling and declining the number of HIV infections, these data demonstrate that there is a gap between who benefits from it. It is a challenge to make PrEP reach those who can most benefit from it and who are most likely to be exposed to HIV, individuals with low education, trans people, transvestites, young adults/adolescents, and non-whites.

Evaluation by community health agents of the attributes of primary health care for fighting leprosy: a cross-sectional study

OBJECTIVE: To evaluate whether the attributes of Primary Healthcare are present in leprosy control actions in Londrina from Community Health Workers' (CHW) perspectives. METHOD: Observational and evaluative study. Data collection occurred between January and March 2020 in Londrina, Paraná, using the questionnaire "Primary Care Assessment Tool (PCATool) - Hansen's disease - CHW version" and a population-based census of 246 CHWs from 52 Primary Healthcare Units. The analyses used a cutoff point (≥ 6.6), central tendency, and dispersion measures. One-way ANOVA and Tukey's post hoc tests were used to analyze differences. Results: The general performance towards the primary healthcare attributes were evaluated as strong (mean = 6.95 / SD = 1.08) and the essential score (mean = 7.39 / SD = 1.0). On the other hand, the derived score was evaluated as poor (mean = 6.07 / sd = 1.06). Concerning the Access attribute, the rural zone had a lower score than the urban (mean = 4.47 / SD = 1.63). Conclusion: The study highlights issues that can be improved, such as first contact access, catalog of services offered to leprosy patients, information provided to the community, professional training, and differences in PHC performance between urban and rural regions.

Home environment as a risk factor for increased incidence of tuberculosis: a case-control study

Objectives: This study aims to determine the differences in home physical conditions consisting of residential density, home ventilation, air humidity, room temperature and lighting, between TB and non-TB patients. Material and Method: This cross-sectional study used convenience sampling with 84 cases and 85 control group participants. The instruments used were an observation sheet, tape measure, digital thermohygrometer, and digital lux meter LX-90. Chi-square tests were used for data analysis. Results: Home environmental conditions were associated with the risk of TB transmission, namely residential density (p= 0.006/ OR= 3.811), house ventilation (p< 0.001/ OR= 51.066), air humidity (p= 0.001/ OR= 3.496), room temperature (p= 0.029/ OR= 3.046), and lighting (p< 0.001, OR= 54.175). Conclusions: The study found that all elements of the home physical environment have been shown to contribute significantly to tuberculosis transmission, so improving the home physical environment is necessary to control tuberculosis transmission.

Objetivos: Determinar las diferencias entre pacientes con y sin tuberculosis en las condiciones físicas de las residencias respecto a densidad residencial, ventilación residencial, humedad del aire, temperatura ambiente e iluminación. Material y Método: Este estudio transversal utilizó un muestreo intencional con 84 casos y 85 participantes del grupo control. Los instrumentos utilizados fueron hoja de observación, cinta métrica, termohigrómetro y luxómetro digitales LX-90. Se utilizaron pruebas de chi-cuadrado para el análisis de los datos. Resultados: Las condiciones ambientales del hogar están relacionadas con el riesgo de transmisión de tuberculosis, a saber: densidad residencial (p= 0,006/ OR= 3,811), ventilación de la casa (p< 0,001/ OR= 51,066), humedad del aire (p= 0,001/ OR= 3,496), temperatura ambiente (p= 0.029/ OR= 3,046) e iluminación (p< 0,001/ OR= 54,175). Conclusiones: Todos los elementos del entorno físico del hogar contribuyen significativamente a la transmisión de la tuberculosis, por lo que es necesario mejorar el entorno físico del hogar para controlar la transmisión de la tuberculosis.

O objetivo deste estudo é determinar as diferenças nas condições físicas das residências, consistindo em densidade residencial, ventilação residencial, umidade do ar, temperatura ambiente e iluminação entre pacientes com TB e não TB. Material e Método: Estudo transversal que utilizou amostragem intencional com 84 casos e 85 participantes do grupo controle. Os instrumentos utilizados foram folha de observação, fita métrica, termohigrômetro digital e luxímetro digital LX-90. Foram utilizados testes de qui-quadrado para análise dos dados. Resultados: As condições ambientais domiciliares estão relacionadas ao risco de transmissão de TB, nomeadamente densidade residencial (p= 0,006/ OR= 3,811), ventilação da casa (p <0,001/ OR= 51,066), umidade do ar (p= 0,001/ OR= 3,496), temperatura ambiente (p= 0,029/ OR= 3,046) e iluminação (p= <0,001/ OR= 54,175). Conclusões: O estudo concluiu que todos os elementos do ambiente físico da casa demonstraram contribuir significativamente para a transmissão da tuberculose, pelo que é necessário melhorar o ambiente físico da casa para controlar a transmissão da tuberculose.

Percepções da dengue na perspectiva de uma comunidade rural da costa caribenha na Colômbia / Perceptions of dengue fever from the perspective of a rural community on the Caribbean coast in Colombia / Percepciones del dengue desde la perspectiva de una comunidad rural de la costa Caribe en Colombia

O estudo buscou compreender as percepções sobre a dengue em uma comunidade rural de Córdoba, Colômbia, com o objetivo de orientar ações específicas de enfermagem comunitária voltadas para o cuidado e a educação em saúde de pessoas, famílias e comunidades rurais. Foram realizadas 20 entrevistas semiestruturadas com chefes de família (13 homens e 7 mulheres), selecionados com base nos critérios de serem membros da comunidade há mais de 20 anos, se autoidentificarem como camponeses e terem no mínimo 18 anos de idade. O número de participantes foi determinado após alcançar a saturação teórica. As entrevistas foram transcritas e organizadas em uma matriz de análise para codificação, categorização e análise dos dados. Os achados revelaram três categorias analíticas: busca pelo conhecimento sobre a doença, práticas in situ e cuidados do passado e do presente. As famílias entrevistadas possuem conhecimento básico sobre a doença e o vetor causador, mantendo práticas familiares relacionadas ao uso de plantas medicinais para cuidados familiares e automedicação nas fases iniciais, devido à baixa percepção do risco. As famílias camponesas constroem representações socioculturais baseadas em solidariedade, apoio familiar e respeito pelo conhecimento dos idosos. A enfermagem é apresentada como ator essencial na coleta de práticas de cuidado para a elaboração e aplicação de planos de cuidado contextualizados de acordo com as necessidades do território. A pesquisa foi aprovada com o código SI-FCS-02-22, autorizando sua implementação.

The study sought to understand perceptions about dengue fever in a rural community in Córdoba, Colombia, with the aim of guiding specific community nursing actions aimed at health care and education for people, families and rural communities. 20 semi-structured interviews were carried out with heads of families (13 men and 7 women), selected based on the criteria of being members of the community for more than 20 years, self-identifying as peasants and being at least 18 years of age. The number of participants was determined after reaching theoretical saturation. The interviews were transcribed and organized into an analysis matrix for coding, categorization and data analysis. The findings revealed three analytical categories: search for knowledge about the disease, in situ practices and past and present care. The families interviewed have basic knowledge about the disease and the causative vector, maintaining family practices related to the use of medicinal plants for family care and self-medication in the early stages, due to low risk perception. Peasant families build sociocultural representations based on solidarity, family support and respect for the knowledge of the elderly. Nursing is presented as an essential actor in the collection of care practices for the elaboration and application of care plans contextualized according to the needs of the territory. The research was approved with code SI-FCS-02-22, authorizing its implementation.

El estudio buscó comprender las percepciones sobre el dengue en una comunidad rural de Córdoba, Colombia, para orientar acciones específicas de Enfermería comunitaria sobre cuidado y educación en salud para personas, familias y comunidades rurales, mediante la realización de 20 entrevistas semiestructuradas a los jefes de familia (13 hombres y 7 mujeres), seleccionados a partir de los siguientes criterios: miembros de la comunidad con permanencia de más de 20 años, autorreconocerse como campesinos y tener mínimo 18 años. El número de participantes se obtuvo una vez se alcanzó el punto de saturación teórica. Las entrevistas fueron transcritas y organizadas en una matriz de análisis para su codificación, categorización y análisis. Los hallazgos arrojaron tres categorías analíticas: en búsqueda del conocimiento acerca de la enfermedad, las praxis in situ y cuidados del ayer y del hoy. Las familias entrevistadas poseen conocimiento básico sobre la enfermedad y el vector que la causa, conservan prácticas familiares relacionadas con el uso de plantas medicinales para el cuidado familiar y la automedicación en las fases iniciales ante la baja percepción del riesgo. Las familias campesinas construyen representaciones socioculturales a partir de la solidaridad, apoyo familiar y respeto por el conocimiento de los adultos mayores. Se presenta a Enfermería como actor esencial en la recopilación de prácticas de cuidado para la elaboración y aplicación de los planes de cuidado contextualizados y de cara a las necesidades del territorio. La investigación fue aprobada con el código SI-FCS-02-22, a partir del cual se autoriza su implementación.

Epidemic curves and the profile of patients hospitalized by COVID-19 in a border region / Curvas epidémicas y el perfil de pacientes hospitalizados por COVID-19 en región fronteriza / Curvas epidêmicas e o perfil de pacientes hospitalizados pela COVID-19 em região de fronteira

Objective: to describe the epidemic curves and analyze the epidemiological profile of patients hospitalized with COVID-19 in a triple border city. Method: descriptive-quantitative. The population consisted of COVID-19 cases that required hospitalization, analyzing variables such as: age, gender, race/color, city where they lived, occupation, pregnant woman, institutionalized patient and evolution. Descriptive statistical analysis and analysis of variance and chi-square tests were used. Results: four epidemic curves were identified in the studied period. Among hospitalized cases, males predominated (55%). Cure was the most frequent outcome in curves 1, 2 and 4, but with no statistical difference (p = 0.2916). Curve 3 showed a higher frequency of deaths (41.70%) in relation to cures (38.77%). The mean ages were significantly different between the curves, with curve 4 having the lowest mean age. Conclusion: it was concluded that the epidemic curves were influenced by different situations; unvaccinated population, easing of restrictive measures, reopening of the Brazil-Paraguay border, interruption of control actions, crowding of people and circulation of new variants of the disease. Through the epidemiological profile of hospitalized patients, it was concluded that being male, of mixed race/color, aged between 61 and 85 years, and being deprived of freedom were associated with hospitalization and the occurrence of death.

Objetivo: describir las curvas epidémicas y analizar el perfil epidemiológico de los pacientes hospitalizados por COVID-19 en un municipio de triple frontera. Método: descriptivo-cuantitativo. La población se configuró de casos de COVID-19 que requirieron hospitalización, analizando variables como: edad, sexo, raza/color, municipio de residencia, ocupación, gestante, paciente institucionalizado y evolución. Se utilizó el análisis estadístico descriptivo y las pruebas de análisis de varianza y chi-cuadrado. Resultados: se identificaron cuatro curvas epidémicas en el período estudiado. Entre los casos hospitalizados, predominó el sexo masculino (55%). La cura fue el desenlace más frecuente en las curvas 1, 2 y 4, aunque sin diferencia estadística (p = 0,2916). La curva 3 presentó una mayor frecuencia de fallecimientos (41,70%) en relación a la cura (38,77%). El promedio de edad fue significativamente diferente entre las curvas, siendo que la curva 4 presentó el menor promedio de edad. Conclusión: se concluyó que las curvas epidémicas fueron influenciadas por diferentes situaciones; población no vacunada, flexibilización de las medidas restrictivas, reapertura de la frontera Brasil-Paraguay, interrupción de las acciones de control, aglomeración de personas y circulación de nuevas variantes. Por medio del perfil epidemiológico de los enfermos hospitalizados, se concluyó que ser del sexo masculino, de raza/color pardo, en el rango de edad de 61 a 85 años, estar privado de libertad se asociaron con la hospitalización y ocurrencia de fallecimiento.

Objetivo: descrever as curvas epidêmicas e analisar o perfil epidemiológico dos pacientes hospitalizados pela COVID-19 em um município de tríplice fronteira. Método: descritivo-quantitativo. A população configurou-se de casos de COVID-19 que necessitaram de hospitalização, analisando variáveis como: idade, sexo, raça/cor, município de residência, ocupação, gestante, paciente institucionalizado e evolução. Utilizou-se a análise estatística descritiva e os testes análise de variância e qui-quadrado. Resultados: identificaram-se quatro curvas epidêmicas no período estudado. Dentre os casos hospitalizados, predominou o sexo masculino (55%). A cura foi o desfecho mais frequente nas curvas 1, 2 e 4, porém sem diferença estatística (p = 0,2916). A curva 3 apresentou uma maior frequência de óbitos (41,70%) em relação à cura (38,77%). As médias de idade foram significativamente diferentes entre as curvas, sendo que a curva 4 apresentou a menor média de idade. Conclusão: concluiu-se que as curvas epidêmicas foram influenciadas por diferentes situações; população não vacinada, flexibilização das medidas restritivas, reabertura da fronteira Brasil-Paraguai, interrupção das ações de controle, aglomeração de pessoas e circulação de novas variantes. Por meio do perfil epidemiológico dos doentes hospitalizados, concluiu-se que ser do sexo masculino, de raça/cor parda, na faixa etária de 61 a 85 anos, estar privado de liberdade se associaram com a hospitalização e ocorrência de óbito.

Beneficios que reciben los pacientes asmáticos tras la aplicación de un tratamiento fisioterapéutico y rehabilitador

El asma bronquial sigue siendo la enfermedad crónica más frecuente en la infancia. Su prevalencia continúa aumentando a pesar de que en la actualidad se disponen de eficaces manuales terapéuticos para el correcto manejo de los principales síntomas de la enfermedad. El tratamiento no farmacológico de este padecimiento se fundamenta en tres pilares esenciales: la educación sobre la enfermedad, las guías para profesionales y pacientes y la fisioterapia respiratoria. Los pacientes que tienen un tratamiento fisioterapéutico y rehabilitador de manera habitual, tienen una mejoría significativa en el control del asma, especialmente si estos se practican bajo la supervisión de un fisioterapeuta. Los beneficios que los pacientes asmáticos logran con la fisioterapia y la rehabilitación son numerosos y uno de los efectos más importante es el impacto positivo sobre la calidad de vida.

Bronchial asthma continues to be the most common chronic disease in childhood. Its prevalence continues to increase despite the fact that effective therapeutic manuals are currently available for the correct management of the main symptoms of the disease. The non-pharmacological treatment of this condition is based on three pillars: education about the disease, guides for professionals and patients, and respiratory physiotherapy. Patients who have regular physiotherapy and rehabilitation treatment have a significant improvement in asthma control, especially if these are practiced under the supervision of a physiotherapist. The benefits that asthmatic patients achieve with physiotherapy and rehabilitation are numerous and one of the most important effects is the positive impact on quality of life.

Factors associated with unsuccessful treatment outcome for tuberculosis in previously treated patients in Cali, Colombia, during the period 2015-2019 / Factores asociados al tratamiento no exitoso para tuberculosis en pacientes previamente tratados en Cali, Colombia, en el periodo 2015-2019

Introduction. The success rates in the treatment of tuberculosis are suboptimal. Objective. To identify associated factors with the lack of success of antituberculosis treatment in patients with a tuberculosis treatment history. Materials and methods. We performed a retrospective, analytical, observational, and cohort study of patients reentering the Mycobacterium program in Cali, Colombia. We included patients over 15 years old with pulmonary tuberculosis between 2015 and 2019 and a history of tuberculosis treatment. Patients with drug-resistant tuberculosis were excluded. Results. A total of 605 patients with a treatment history were included, 60% due to unfinished treatment and 40% due to relapse. Compared to patients reentering due to relapse (ORa=2.34, CI=1.62-3.38), the independent variables associated with treatment failure at discharge were homelessness (ORa=2.45, CI=1.54-3.89), substance dependence (ORa=1.95, CI=1.24-3.05), tuberculosis/HIV coinfection (ORa=1.69, CI=1.00-2.86), diabetes (ORa=1.89, CI=1.29-2.77), and unfinished previous tuberculosis treatment due to follow-up loss, abandonment, or other causes. Programmatic variables favoring treatment success were voluntary HIV testing counseling (p<0.001) and HIV testing (p<0.001). Conclusion. Homelessness, substance dependence, tuberculosis/HIV coinfection, diabetes, and incomplete previous treatment due to loss to follow-up, abandonment, or treatment failure hindered the success of antituberculosis. These characteristics should be identified and addressed during the initial care of patients reentering treatment for tuberculosis.

Introducción. Las tasas de éxito del tratamiento de la tuberculosis continúan siendo subóptimas. Objetivo. Identificar los factores asociados al tratamiento no exitoso para tuberculosis en pacientes con antecedentes de tratamiento para la tuberculosis. Materiales y métodos. Se realizó un estudio observacional retrospectivo, analítico, de cohorte de pacientes que reingresaron a un programa de micobacterias en Cali, Colombia. Se incluyeron mayores de 15 años con tuberculosis pulmonar entre el 2015 y el 2019 con antecedentes de tratamiento para la tuberculosis. Se excluyeron los pacientes con tuberculosis resistente. Resultados. Ingresaron 605 pacientes con antecedentes de tratamiento, 60 % por tratamiento inconcluso y 40 % por recaída. En comparación con los pacientes que reingresaron por recaída (ORa= 2,34; IC=1,62-3,38), las variables que explicaron de manera independiente el no tener éxito con el tratamiento para la tuberculosis al egreso fueron: estar en situación de calle (ORa = 2,45; IC = 1,54-3,89), ser farmacodependiente (ORa = 1,95; IC=1,24-3,05), tener coinfección tuberculosis/VIH (ORa = 1,69; IC =1,00-2,86) o diabetes (ORa =1,89; IC=1,29-2,77), y el incumplimiento de un tratamiento previo por pérdida de seguimiento, abandono u otras causas. Las variables programáticas que favorecieron el éxito del tratamiento fueron la asesoría de la prueba voluntaria de VIH (p <0,001) y la realización de la prueba de VIH (p < 0,001). Conclusión. Estar en situación de calle, ser farmacodependiente, tener coinfección de tuberculosis y VIH, o diabetes, así como el incumplimiento del tratamiento previo por pérdida del seguimiento, abandono o fracaso del mismo, dificultaron el éxito del tratamiento antituberculoso. En la primera atención al reingreso de los pacientes con tuberculosis se deben identificar y abordar estas características.

Are primary care consultations in Trinidad patient-centered? A cross-sectional study of patients with non-communicable diseases.

BACKGROUND: The aim of this study was to measure the patient's perception of patient centeredness in their consultations for non-communicable diseases (NCDs). We also measured consultation length and patient enablement. METHOD: A cross-sectional study was conducted over 2 months at four primary care clinics at the St. Joseph cluster of the North Central Regional Health Authority (NCRHA) in Trinidad and Tobago. Interviewers timed the consultation and completed post-consultation questionnaires using the Patient Perception of Patient-Centeredness (PPPC) questionnaire and the Patient Enablement Index (PEI). The PPPC is a 14-item (each scored 1-4) Likert-scaled instrument. The total score is averaged and a PPPC score of 4 is the maximum. The PEI measures the ability of the patient to cope with life and their disease. The PEI consists of 6 questions scored 0-2, with a maximum score of 12. RESULTS: There were 180 respondents (response rate = 82.5%). Participants were female (75.6%), aged over 65 years (50.6%), married (51.1%), Indo-Trinidadian (52.2%), and Christian (60.6%). Half achieved a primary school education, and 37.2% secondary. The consultation length ranged between 1.32 and 31.22 min. The average, median and mode of the consultation length were 8.5, 7.74 and 10 min, respectively. The average, median and mode of the measures of patient-centeredness were PPPC (3.67, 3.86 and 4) and PEI score (5.93, 6 and 6). The PPPC average was lower in patients with a stroke (p = 0.022), and higher among those with more than 2 consultation interruptions (p = 0.015) and those who knew the doctor very well (p = 0.015). The PEI score was lower in patients with heart disease (p = 0.022). The consultation length was longer in those with tertiary education (p = 0.044) and those with two consultation interruptions (p = 0.032). PPPC Average and PEI Score correlated well (ρ = 0.408, p < 0.001). The consultation length correlated with the PPPC Average (ρ = 0.168,p = 0.025). CONCLUSION: Primary Care consultations in this cluster of health centres in NCRHA in Trinidad were often patient centered. The consultation length, patient-centeredness, measured with the PPPC instrument, and patient enablement scores, measured with the PEI instrument, in consultations for NCDs in Trinidad compare favourably with international reports.

Integrated control of neglected tropical diseases in Brazil: document review of a national campaign in light of WHO recommendations.

Objective: To describe the results of a national campaign aimed at the integrated control of neglected tropical diseases in Brazil in light of the World Health Organization (WHO) official documentation related to the integration of strategies for the prevention, control, and elimination or eradication of neglected tropical diseases. Methods: A document review that included official WHO documents published between 2007 and 2020 and campaign results extracted from the official technical report produced by the Brazilian Ministry of Health. Results: The integrated control of neglected tropical diseases was gradually incorporated in the WHO documentation over time. Preventive chemotherapy through mass drug administration, intensified case management, and integrated vector management were extensively recommended as strategies for integrated control. The Brazilian campaign was carried out in four iterations between 2013 and 2017. Children aged 5 to 14 years enrolled in municipal public schools nationwide were targeted. In summary, a total of 1 074 and 73 522 new cases of leprosy and trachoma, respectively, were detected. Nearly 18 million doses of preventive chemotherapy for soil-transmitted helminthiasis were administered. More than 700 cases of schistosomiasis were diagnosed and treated. Conclusions: The integrated strategies implemented in Brazil throughout the campaign generated results aligned with the WHO recommendations for the control of neglected tropical diseases, especially those regarding mass drug administration, active case detection, and intensified case management. Therefore, the continuity of the campaign with adequate evaluation tools must be encouraged as a constant public health policy in the Brazilian government agenda.

Estrategias de control de la Equinococosis quística en el Uruguay / Strategies for the control of cystic echinococcosis in Uruguay / Estratégias de controle da equinococose cística no Uruguai

La equinococosis quística es una zoonosis de origen parasitario con distribución cosmopolita. En nuestro país continúa siendo una enfermedad endémica, afectando principalmente pequeños centros poblados y áreas rurales pobres relacionadas a la producción ovina. Los planes de control requieren de un abordaje holístico, con la participación de diferentes instituciones, profesionales y en especial de la comunidad. La cooperación regional busca monitorizar el avance de la enfermedad y centrar las medidas de acción sobre cuatro ejes, definidos según los puntos de intervención más comunes para la quiebra del ciclo de transmisión y la consecuente reducción en incidencia y prevalencia de la enfermedad. La presente revisión utilizó literatura obtenida en diferentes bases de datos, bibliotecas virtuales y sitios web regionales y locales con el objetivo describir las principales estrategias de control, vigilancia y prevención aplicadas actualmente en nuestro país.

Cystic echinococcosis is a zoonosis of parasitic origin with cosmopolitan distribution. In our country it continues to be an endemic disease, affecting mainly small population centers and poor rural areas related to sheep production. Control plans require a holistic approach, with the participation of different institutions, professionals and especially the community. Regional cooperation seeks to monitor the progress of the disease and focus action measures on four axes, defined according to the most common points of intervention to break the transmission cycle and consequently reduce the incidence and prevalence of the disease. This review used literature obtained from different databases, virtual libraries and regional and local websites with the aim of describing the main control, surveillance and prevention strategies currently applied in our country.

A equinococose cística é uma zoonose de origem parasitária com distribuição cosmopolita. Em nosso país, continua a ser uma doença endêmica, afetando principalmente pequenos centros populacionais e áreas rurais pobres relacionadas à produção de ovinos. Os planos de controle exigem uma abordagem holística, com a participação de diferentes instituições, profissionais e, principalmente, da comunidade. A cooperação regional busca monitorar o progresso da doença e concentrar as medidas de ação em quatro eixos, definidos de acordo com os pontos de intervenção mais comuns para interromper o ciclo de transmissão e, consequentemente, reduzir a incidência e a prevalência da doença. Esta revisão utilizou a literatura obtida em diferentes bases de dados, bibliotecas virtuais e sites regionais e locais com o objetivo de descrever as principais estratégias de controle, vigilância e prevenção aplicadas atualmente em nosso país.

Factores asociados al tratamiento no exitoso para tuberculosis en pacientes previamente tratados en Cali, Colombia, en el periodo 2015-2019 / Factors associated with unsuccessful treatment outcome for tuberculosis in previously treated patients in Cali, Colombia, during the period 2015-2019

Introducción. Las tasas de éxito del tratamiento de la tuberculosis continúan siendo subóptimas. Objetivo. Identificar los factores asociados al tratamiento no exitoso para tuberculosis en pacientes con antecedentes de tratamiento para la tuberculosis. Materiales y métodos. Se realizó un estudio observacional retrospectivo, analítico, de cohorte de pacientes que reingresaron a un programa de micobacterias en Cali, Colombia. Se incluyeron mayores de 15 años con tuberculosis pulmonar entre el 2015 y el 2019 con antecedentes de tratamiento para la tuberculosis. Se excluyeron los pacientes con tuberculosis resistente. Resultados. Ingresaron 605 pacientes con antecedentes de tratamiento, 60 % por tratamiento inconcluso y 40 % por recaída. En comparación con los pacientes que reingresaron por recaída (ORa= 2,34; IC=1,62-3,38), las variables que explicaron de manera independiente el no tener éxito con el tratamiento para la tuberculosis al egreso fueron: estar en situación de calle (ORa = 2,45; IC = 1,54-3,89), ser farmacodependiente (ORa = 1,95; IC=1,24-3,05), tener coinfección tuberculosis/VIH (ORa = 1,69; IC =1,00- 2,86) o diabetes (ORa =1,89; IC=1,29-2,77), y el incumplimiento de un tratamiento previo por pérdida de seguimiento, abandono u otras causas. Las variables programáticas que favorecieron el éxito del tratamiento fueron la asesoría de la prueba voluntaria de VIH (p < 0,001) y la realización de la prueba de VIH (p < 0,001). Conclusión. Estar en situación de calle, ser farmacodependiente, tener coinfección de tuberculosis y VIH, o diabetes, así como el incumplimiento del tratamiento previo por pérdida del seguimiento, abandono o fracaso del mismo, dificultaron el éxito del tratamiento antituberculoso. En la primera atención al reingreso de los pacientes con tuberculosis se deben identificar y abordar estas características.

Introduction. The success rates in the treatment of tuberculosis are suboptimal. Objective. To identify associated factors with the lack of success of antituberculosis treatment in patients with a tuberculosis treatment history. Materials and methods. We performed a retrospective, analytical, observational, and cohort study of patients reentering the Mycobacterium program in Cali, Colombia. We included patients over 15 years old with pulmonary tuberculosis between 2015 and 2019 and a history of tuberculosis treatment. Patients with drug-resistant tuberculosis were excluded. Results. A total of 605 patients with a treatment history were included, 60% due to unfinished treatment and 40% due to relapse. Compared to patients reentering due to relapse (ORa=2.34, CI=1.62-3.38), the independent variables associated with treatment failure at discharge were homelessness (ORa=2.45, CI=1.54-3.89), substance dependence (ORa=1.95, CI=1.24-3.05), tuberculosis/HIV coinfection (ORa=1.69, CI=1.00-2.86), diabetes (ORa=1.89, CI=1.29-2.77), and unfinished previous tuberculosis treatment due to follow-up loss, abandonment, or other causes. Programmatic variables favoring treatment success were voluntary HIV testing counseling (p<0.001) and HIV testing (p<0.001). Conclusion. Homelessness, substance dependence, tuberculosis/HIV coinfection, diabetes, and incomplete previous treatment due to loss to follow-up, abandonment, or treatment failure hindered the success of antituberculosis. These characteristics should be identified and addressed during the initial care of patients reentering treatment for tuberculosis.

Leprosy and tuberculosis control scenario of the national program for the improvement of access and quality of primary care in Brazil.

BACKGROUND: In Brazil, despite advances in public health policies aimed at eliminating and controlling infectious and parasitic diseases, the incidence of neglected diseases is still high. The epidemiological scenario in Brazil of diseases such as tuberculosis and leprosy evidences a public policy agenda that has not been resolute in terms of control, nor in terms of elimination. OBJECTIVE: To analyze the actions of diagnosis and treatment of leprosy and tuberculosis in the context of primary health care. METHODS: In this ecological study, data from the third cycle of the Program for the Improvement of Access and Quality of Primary Care were extracted from electronic address of the Primary Health Care Secretariat of Brazil in the area of Actions, Programs and Strategies. A total of 37,350 primary health care teams were that answered the questionnaire were eligible, with variables extracted from leprosy and tuberculosis control actions. The municipalities were grouped according to the characteristic of the Brazilian municipality. The partition chi-square and the Residuals Test were used to assess whether there was a difference in the proportion of tuberculosis and leprosy actions between types of municipalities. Statistics were carried out using Minitab 20 and Bioestat 5.3. RESULTS: Regarding the leprosy treatment location, there is a higher proportion of people referred to be treated at the reference in adjacent rural (p = 0.0097) and urban (p < 0.0001) municipalities; monitoring of people with leprosy referred to the service network (p. = 0.0057) in remote rural areas. Lower proportion of teams requesting bacilloscopy in remote rural areas (p = 0.0019). Rural areas have a higher proportion of teams that diagnose new cases (p = 0.0004). Regarding the actions of diagnosis and treatment of tuberculosis. There is a higher proportion of teams that carry out consultations at the unit itself in rural areas when compared to adjacent intermediaries (p = 0.0099) and urban (p < 0.0001); who requested sputum smear microscopy in adjacent intermediaries (p = 0.0021); X-ray in adjacent intermediaries (p < 0.0001) and urban (p < 0.0001); collection of the first sputum sample in urban (p < 0.0001) and adjacent rural areas (p < 0.0001); directly observed treatment (p < 0.0001) in adjacent rural municipalities. CONCLUSION: There are inequalities in the diagnosis and treatment of leprosy and tuberculosis among the types of municipalities.

The priority areas and possible pathways for health cooperation in BRICS countries.

As one of the largest alliances of middle-income countries, the BRICS, known as an acronym for five countries including "Brazil, Russia, India, China, and South Africa", represents half of the global population. The health cooperation among BRICS countries will benefit their populations and other middle- and low-income countries. This study aims to summarize the current status of health cooperation in BRICS countries and identify opportunities to strengthen BRICS participation in global health governance. A literature review was conducted to analyze the status, progress, and challenges of BRICS' health cooperation. Content analysis was used to review the 2011-2021 annual joint declarations of the BRICS Health Ministers Meetings. The priority health areas were identified through segmental frequency analysis. Our research suggested that communicable diseases, access to medicine, and universal health coverage appeared most frequently in the content of declarations, indicating the possible top health priorities among BRICS' health collaboration. These priority areas align with the primary health challenges of each country, including the threats of double burden of diseases, as well as the need for improving health systems and access to medicines. Respective external cooperation, inter-BRICS health cooperation, and unified external cooperation are the main forms of health cooperation among BRICS countries. However, challenges such as the lack of a unified image and precise position, lack of practical impact, and weak discourse power have impeded the impact of BRICS on health governance. This study suggests that the BRICS countries should recognize their positioning, improve their unified image, and establish cooperative entities; at the same time, they should increase their practical strength, promote non-governmental cooperation, and expand the cooperation space through the "BRICS Plus" mechanism with countries with similar interests to join.

Understanding the Burden of Kidney Failure in Trinidad and Tobago: A Review of the Epidemiological Data From a Regional Center.

Objective The aim of this study was to determine the incidence of new patients requiring renal replacement therapy and to gather data on sex, age, ethnicity, mortality, and causes of kidney failure in Trinidad and Tobago in comparison with the rest of the world. Method Electronic data were gathered for new patients initiating dialysis between January 1, 2016, and December 31, 2017, including the date of dialysis initiation, age, gender, ethnicity, diagnosis, dialysis access and modality, and outcome at three months and the end of the year. The data were analyzed using simple descriptive statistics via Microsoft Excel (Microsoft Corporation, Redmond, Washington, United States). Results Over a two-year period, 265 new patients underwent renal replacement therapy, of which 51.7% were 50-69 years of age, 53.9% were male, 46% were female, 67.9% were Afro-Trinidadian, and 38.1% had a combination of diabetes mellitus and hypertension as the cause of kidney failure. The incidence rates of treated end-stage renal disease (ESRD) globally in 2016 and 2017 were 306 and 224 per million population, respectively, and mortality for both years was 32% and 32.1%, respectively. Conclusion Our study showed that Trinidad and Tobago has one of the highest incidences of patients initiating renal replacement therapy and mortality rates.

Maternal consumption and perinatal exposure to non-nutritive sweeteners: should we be concerned?

The context for this review is the rapid increase in the use of non-nutritive sweeteners (NNSs) instead of sugar in foods and beverages, a situation so prevalent in some countries that consumers are finding it increasingly challenging to access foods without NNSs. The benefits of consuming NNSs on obesity and diabetes are now being questioned, and studies have shown that they may exert physiological activities, sometimes independently of sweet taste receptor stimulation. Few studies, limited mainly to North American and European countries, have described the consumption of NNSs by pregnant or lactating women and infants. Most focus on beverages rather than foods, but all agree that consumption levels have increased dramatically. Although some studies report a negative impact of NNSs on the risk of preterm birth, increased birth weight and decreased gestational age, the level of evidence is low. Several studies have also reported increased weight gain in infancy, associated with maternal NNS intake. Interestingly, several NNSs have been detected in amniotic fluid and breast milk, usually (but not always) at concentrations below their established detection limit in humans. Unfortunately, the impact of chronic exposure of the fetus/infant to low levels of multiple NNSs is unknown. In conclusion, there is a stark contrast between the galloping increase in the consumption of NNSs and the small number of studies evaluating their impact in at-risk groups such as pregnant and lactating women and infants. Clearly, more studies are needed, especially in Latin America and Asia, to fill these gaps and update recommendations.

Actitudes del autocuidado de pacientes con tuberculosis en enfermeros peruanos luego de un brote hospitalario

Introducción: La tuberculosis es una de las principales causas de morbimortalidad en todo el mundo. Las medidas de prevención son clave para evitar su propagación y el contagio entre profesionales de salud. Objetivo: Determinar las actitudes del autocuidado sobre la tuberculosis en el personal de enfermería luego de un brote infeccioso hospitalario. Métodos: Estudio transversal, en personal de enfermería (n= 94; personal técnico n= 44; 46,8 %). Se incluyó al personal de enfermería voluntario > 18 años, de ambos sexos, que trabaje en el Departamento de Emergencia. Se usó el cuestionario de 15 ítems de Valle (2017), para estimar los conocimientos y actitudes sobre el autocuidado, 3 dimensiones: prevención, diagnóstico y tratamiento de la tuberculosis. Resultados: El promedio de edad de los participantes fue de 44,7 ± 8,8 años, el 88,3 % mujeres y el tiempo promedio de trabajo fue 11,2 ± 7,8 años. Se hallaron diferencias entre los años de servicio, entre los técnicos (8,55 ± 7,94 años) y profesionales (13,48 ± 6,98 años) (p< 0,001). El 100 % presentaron actitudes de aceptación del autocuidado en todas las dimensiones. El 4,5 % y el 27,3 % de técnicos presentaron actitudes de indiferencia en la dimensión diagnóstico y tratamiento de tuberculosis (p= 0,001). Conclusiones: Existen actitudes favorables en el personal de enfermería sobre autocuidado de la tuberculosis luego de un brote en un hospital de Lima, aunque en técnicos de enfermería se reportan actitudes de indiferencia en el diagnóstico y tratamiento de tuberculosis.

Introduction: Tuberculosis continues to be one of the main causes of morbidity and mortality worldwide. Prevention measures are key to prevent its spread and contagion among health professionals. The objective of the present study was to determine the self-care attitudes about tuberculosis in the nursing staff after a hospital infectious outbreak in Perú. Method: A cross-sectional study was conducted in nursing staff (n= 94; technical staff n= 44, 46.8%). Volunteer nursing staff > 18 years old, of both sexes, and who work in the Emergency Department were included. The 15-item questionnaire from Valle (2017) was used to estimate knowledge and attitudes about self-care in nursing staff in 3 dimensions: prevention, diagnosis and treatment of tuberculosis. Results: The average age of the participants was 44.7±8.8 years, 88.3 % were women, and the average working time was 11.2 ± 7.8 years. Difference was found between the years of service, among technicians (8.55 ± 7.94 years) and nursing professionals (13.48 ± 6.98 years) (p< 0.001). A hundred percent of nurses presented attitudes of acceptance of self-care in all dimensions; 4.5 % and 27.3% of nursing technicians presented attitudes of indifference in the tuberculosis diagnosis and treatment dimension (p= 0.001). Conclusions: There are favorable attitudes in the nursing staff about self-care of tuberculosis after an outbreak in a hospital in Lima, although in nursing technicians we report attitudes of indifference in the diagnosis and treatment of tuberculosis.

Adesão ao tratamento da Tuberculose: estratégias biopolíticas de promoção da saúde na vertente neoliberal / Adherence to tuberculosis treatment: biopolitical health promotion strategies in the neoliberal perspective / Cumplimiento del tratamiento de la tuberculosis: tácticas biopolíticas para fomentar la salud en el contexto neoliberal

Objetivo: analisar como as recomendações sobre adesão terapêutica presentes em manuais de controle da tuberculose constituem estratégias biopolíticas de Promoção da Saúde na vertente neoliberal. Método: pesquisa documental e qualitativa que analisou cinco manuais publicados entre 2002 e 2019, a partir da metodologia pós-crítica de inspiração foucaultiana. Resultados: foram identificadas quatro estratégias biopolíticas, que correspondem às categorias analítica deste estudo: i) Exaltação do saber da estatística como fortalecimento da lógica gerencialista; ii) Priorização do tratamento dos casos bacilíferos e instituição de medidas de controle do risco da contaminação como forma de manter a segurança da população saudável; iii) Ênfase discursiva na população vulnerável como forma de omitir corpos precarizados; e iv) Discurso do empreendimento de si para superação da pobreza, como compensação da falta de políticas de proteção social. Conclusões: algumas recomendações de controle da tuberculose consistem em estratégias biopolíticas de Promoção da Saúde na vertente neoliberal, promovendo discursos sanitários que enfatizam os aspectos individuais, como o autocuidado, a autorresponsabilização, a autonomia e o empoderamento do sujeito. Mesmo nos casos em que percebemos associação do adoecimento com determinantes sociais da saúde e com situações de vulnerabilidade, as ações de controle da tuberculose insistem em ações inscritas numa perspectiva gerencialista da saúde. Na prática, parece haver um vazio de políticas de proteção social e de ações capazes de combater as iniquidades, o que é imprescindível para a efetiva adesão terapêutica e para a cura.(AU)

Objective: to analyze how the recommendations on therapeutic adherence present in tuberculosis control manuals constitute biopolitical Health Promotion strategies in the neoliberal perspective. Method: documentary and qualitative research that analyzed five manuals published between 2002 and 2019, based on the post-critical methodology inspired by Foucault. Results: four biopolitical strategies were identified, which correspond to the analytical categories of this study: i) Exaltation of statistical knowledge as a strengthening of managerial logic; ii) Prioritizing the treatment of bacilliferous cases and establishing measures to control the risk of contamination as a way of maintaining the safety of the healthy population; iii) Discursive emphasis on the vulnerable population as a way of omitting precarious bodies; and iv) Discourse about self-employment to overcome poverty, as compensation for the lack of social protection policies. Conclusions: some recommendations for tuberculosis control consist of biopolitical Health Promotion strategies in a neoliberal perspective, promoting health discourses that emphasize individual aspects, such as self-care, self-responsibility, autonomy, and empowerment of the subject. Even in cases where we perceive an association between illness and social determinants of health and situations of vulnerability, tuberculosis control actions insist on actions based on a health managerial perspective. In practice, there appears to be a lack of social protection policies and actions capable of combating inequities, which is essential for effective therapeutic adherence and cure.(AU)

Objetivo: el propósito es examinar de qué manera las directrices sobre el cumplimiento terapéutico en los manuales de control de la tuberculosis representan estrategias biopolíticas de Promoción de la Salud en el contexto neoliberal. Método:Se llevó a cabo una investigación documental cualitativa que analizó cinco Manuales publicados entre 2002 y 2019, utilizando un enfoque postcrítico inspirado en las ideas de Foucault.Resultados: se identificaron cuatro tácticas biopolíticas (categorías de análisis): 1) Enfatizar el valor del conocimiento estadístico como refuerzo de la lógica administrativa; 2) Priorizar el tratamiento de los casos con bacilos y establecer medidas de control del riesgo de contagio para salvaguardar a la población sana; 3) Poner un énfasis discursivo en la población vulnerable para dejar de lado a los cuerpos en situación precaria; y 4) Promover el autoempleo como solución para superar la pobreza, en sustitución de políticas de protección social insuficientes.Conclusiones: algunas recomendaciones dirigidas al control de la tuberculosis adoptan tácticas biopolíticas de fomento de la salud en el marco neoliberal, empleando discursos relacionados con la salud que ponen un énfasis en aspectos individuales como el autocuidado, la asunción de responsabilidad personal, la autonomía y el empoderamiento del individuo. Aun en situaciones en las que se percibe una correlación entre la enfermedad y los factores sociales que afectan la salud, así como con contextos de vulnerabilidad, las medidas de control de la tuberculosis siguen promoviendo enfoques alineados con una perspectiva de gestión...(AU)