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Participatory Planning and Evaluation (CPPE), an approach to community participation and empowerment developed from the work of Rifkin, LaveracK, Pérez, and others. More than just a methodology, CPPE is an approach which encourages comprehensive analysis and participation by various actors at local, regional, and national level in the planning and evaluation of health actions. CPPE has its roots in the 1980s, when an international team of researchers from the Institutes of Tropical Medicine in Antwerp (ITM-Belgium) and Amsterdam (KIT-Netherlands) developed a framework of comprehensive participatory evaluation for nutritional improvement programs. Following its initial application in the Philippines, further work extended the evaluation approach to planning. CPPE was gradually refined with the support of research teams in Indonesia, the Philippines, and Brazil as they applied it in different contexts and projects. Since 2008 projects have been carried out in Cuba to analyze the possibilities offered by CPPE for increasing community participation in health. This article illustrates the rationale and tools employed in CPPE through our experience in Cuba in the urban municipalities of Centro Habana and Las Tunas and in a rural community in the mountains of Cumanayagua. We discuss key methodological components, the conditions needed for the success of CPPE, and potential differences between the Cuban experience and the possible application of CPPE in other contexts.

Background The rate of pulmonary tuberculosis (TB) recurrence is substantial. Identifying risk factors can support the development of prevention strategies.Methods We retrieved studies published between 1 January 1980 and 31 December 2022 that assessed factors associated with undifferentiated TB recurrence, relapse or reinfection. For factors reported in at least four studies, we performed random-effects meta-analysis to estimate a pooled relative risk (RR). We assessed heterogeneity, risk of publication bias and certainty of evidence.Results We included 85 studies in the review; 81 documented risk factors for undifferentiated recurrence, 17 for relapse and 10 for reinfection. The scope for meta-analyses was limited given the wide variety of factors studied, inconsistency in control for confounding and the fact that only few studies employed molecular genotyping. Factors that significantly contributed to moderately or strongly increased pooled risk and scored at least moderate certainty of evidence were: for undifferentiated recurrence, multidrug resistance (MDR) (RR 3.49; 95% CI 1.86 to 6.53) and fixed-dose combination TB drugs (RR 2.29; 95% CI 1.10 to 4.75) in the previous episode; for relapse, none; and for reinfection, HIV infection (RR 4.65; 95% CI 1.71 to 12.65). Low adherence to treatment increased the pooled risk of recurrence 3.3-fold (95% CI 2.37 to 4.62), but the certainty of evidence was weak.Conclusion This review emphasises the need for standardising methods for TB recurrence research. Actively pursuing MDR prevention, facilitating retention in treatment and providing integrated care for patients with HIV could curb recurrence rates. The use of fixed-dose combinations of TB drugs under field conditions merits further attention.PROSPERO registration number CRD42018077867.

Summary: Background: Increased pediatric COVID-19 occurrence due to the SARS-CoV-2 Omicron variant has raised concerns about the effectiveness of existing vaccines. The protection provided by the SOBERANA-02-Plus vaccination scheme against this variant has not yet been studied. We aimed to evaluate the scheme's effectiveness against symptomatic Omicron infection and severe disease in children. Methods: In September 2021, Cuba implemented a mass pediatric immunization with the heterologous SOBERANA-02-Plus scheme: 2 doses of conjugated SOBERANA-02 followed by a heterologous SOBERANA-Plus dose. By December, before the Omicron outbreak, 95.4% of 2–18 years-old had been fully immunized. During the entire Omicron wave, we conducted a nationwide longitudinal post-vaccination case-population study to evaluate the real-world effectiveness of the SOBERANA-02-Plus scheme against symptomatic infection and severe disease in children without previous SARS-CoV-2 infection. The identification of COVID-19 cases relied on surveillance through first line services, which refer clinical suspects to pediatric hospitals where they are diagnosed based on a positive RT-PCR test. We defined the Incidence Rate ratio (IRR) as IRvaccinated age group/IRunvaccinated 1-year-old and calculated vaccine effectiveness as VE = (1—IRR)∗100%. 24 months of age being the ‘eligible for vaccination’ cut-off, we used a regression discontinuity approach to estimate effectiveness by contrasting incidence in all unvaccinated 1-year-old versus vaccinated 2-years-old. Estimates in the vaccinated 3–11 years-old are reported from a descriptive perspective. Findings: We included 1,098,817 fully vaccinated 2–11 years-old and 98,342 not vaccinated 1-year-old children. During the 24-week Omicron wave, there were 7003/26,241,176 person-weeks symptomatic COVID-19 infections in the vaccinated group (38.2 per 105 person-weeks in 2-years-old and 25.5 per 105 person-weeks in 3–11 years-old) against 3577/2,312,273 (154.7 per 105 person-weeks) in the unvaccinated group. The observed overall vaccine effectiveness against symptomatic infection was 75.3% (95% CI, 73.5–77.0%) in 2-years-old children, and 83.5% (95% CI, 82.8–84.2%) in 3–11 years-old. It was somewhat lower during Omicron BA.1 then during Omicron BA.2 variant circulation, which took place 1–3 and 4–6 months after the end of the vaccination campaign. The effectiveness against severe symptomatic disease was 100.0% (95% CI not estimated) and 94.6% (95% CI, 82.0–98.6%) in the respective age groups. No child death from COVID-19 was observed. Interpretation: Immunization of 2–11 years-old with the SOBERANA-02-Plus scheme provided strong protection against symptomatic and severe disease caused by the Omicron variant, which was sustained during the six months post-vaccination follow-up. Our results contrast with the observations in previous real-world vaccine effectiveness studies in children, which might be explained by the type of immunity a conjugated protein-based vaccine induces and the vaccination strategy used. Funding: National Fund for Science and Technology (FONCI-CITMA-Cuba).

Abstract Background Implementation research to improve hypertension control is scarce in Latin America. We assessed the effectiveness of an intervention aimed at primary care practitioners and hypertensive patients in a setting that provides integrated care through an accessible network of family practices. Methods We conducted in Cardenas and Santiago, Cuba, a controlled before-after study in 122 family practices, which are staffed with a doctor and a nurse. The intervention comprised a control arm (usual care), an arm with a component targeting providers (hypertension management workshops), and an arm with, on top of the latter, a component targeting patients (hypertension schools). To evaluate the effect, we undertook a baseline survey before the intervention and an endline survey sixteen months after its start. In each survey, we randomly included 1400 hypertensive patients. Controlled hypertension, defined as a mean systolic and diastolic blood pressure below 140 and 90 mmHg, respectively, was the primary endpoint assessed. We performed linear and logistic regression with a Generalized Estimating Equations approach to determine if the proportion of patients with controlled hypertension changed following the intervention. Results Seventy-three doctors, including substitutes, and 54 nurses from the 61 intervention family practices attended the provider workshops, and 3308 patients −51.6% of the eligible ones- participated in the hypertension schools. Adherence to anti-hypertensive medication improved from 42% at baseline to 63% at the endline in the intervention arms. Under the provider intervention, the proportion of patients with controlled hypertension increased by 18.9%, from 48.7% at baseline to 67.6% at endline. However, adding the component that targeted hypertensive patients did not augment the effect. Compared to patients in the control arm, the adjusted OR of having controlled hypertension was 2.36 (95% CI, 1.73–3.22) in the provider and 2.00 (95% CI, 1.68–2.37) in the provider plus patient intervention arm. Conclusions The intervention’s patient component remains to be fine-tuned. Still, we demonstrate that it is feasible to substantially improve hypertension outcomes by intervention at the primary care level, despite an already relatively high control rate.

Background: the evidence on Public Health interventions to improve deficiencies in the care and control of hypertensive people continues to be insufficient. Objective: to implement a multicomponent intervention to reduce these gaps in the Julio Antonio Mella Polyclinic in the Guanabacoa municipality, to evaluate the intervention process, its effectiveness and the fidelity of its implementation. Method: in relation to the results obtained in the baseline study, national and international technical recommendations, a multicomponent intervention was designed that will have the following components: reorganization of health services, training of health personnel, empowerment of patients and community participation. The effectiveness of the intervention will be evaluated through a quasi-experimental study (before and after). The intervention will cover the aforementioned polyclinic, the ten baseline study clinics, and the population served by them. Two years after the start of implementation, a population survey will be applied again and the difference in the magnitude of the pre-post intervention population gaps will be estimated. In addition, the process will be monitored and the fidelity of the implementation of the intervention will be evaluated. Results: reduce existing gaps in the process of care for hypertensive patients, identify their magnitude in relation to the baseline. Conclusions: the study will provide evidence to the Cuban Ministry of Public Health and other countries, especially in Latin America, to improve the care of chronic patients.

Summary: Background: SOBERANA-02 is a COVID-19 conjugate vaccine (recombinant RBD conjugated to tetanus toxoid). Phases 1/2 clinical trials demonstrated high immunogenicity, promoting neutralising IgG and specific T-cell response. A third heterologous dose of SOBERANA-Plus (RBD-dimer) further increased neutralising antibodies. The aim of this study is to evaluate the safety and efficacy of two immunisation regimes: two doses of SOBERANA-02 and a heterologous three-dose combination with SOBERANA-Plus added to it. Methods: From March 8th to June 24th, 2021 we conducted in Havana, Cuba a multicentre randomised, double-blind, placebo-controlled, phase-3 trial evaluating a two doses SOBERANA-02 scheme and a heterologous scheme with one dose SOBERANA-Plus added to it (RPCEC00000354). Participants 19–80 years were randomly assigned to receiving 28 days apart either the two or three dose scheme or placebo. The main endpoint was vaccine efficacy in preventing the occurrence of RT-PCR confirmed symptomatic COVID-19 at least 14 days after the second or third dose in the per-protocol population. We also assessed efficacy against severe disease and, in all participants receiving at least one vaccine/placebo dose, safety for 28 days after each dose. Findings: We included 44,031 participants (52.0% female, 48.0% male; median age 50 years, range 19–80 years; 7.0% black, 24.0% mixed-race, 59.0% white) in a context of initial Beta VOC predominance, with this variant being partially replaced by Delta near the trial's end. Vaccine efficacy in the heterologous combination was 92.0% (95%CI 80.4–96.7) against symptomatic disease. There were no severe COVID-19 cases in the vaccine group against 6 in the placebo group. Two doses of SOBERANA-02 was 69.7% (95%CI 56.5–78.9) and 74.9% (95%CI 33.7–90.5) efficacious against symptomatic and severe COVID-19, respectively. The occurrence of serious and severe adverse events (AE) was very rare and equally distributed between placebo and vaccine groups. Solicited AEs were slightly more frequent in the vaccine group but predominantly local and mostly mild and transient. Interpretation: Our results indicate that the straightforward to manufacture SOBERANA vaccines are efficacious in a context of Beta and Delta VOC circulation, have a favourable safety profile, and may represent an attractive option for use in COVID-19 vaccination programmes. Funding: This study received funds from the National Fund for Science and Technology (FONCI-CITMA-Cuba, contract 2020–20) of the Ministry of Science, Technology and Environment of Cuba.

Introduction Research on public health interventions to improve hypertension care and control in low-income and middle-income countries remains scarce. This study aims to evaluate the effectiveness and assess the process and fidelity of implementation of a multi-component intervention to reduce the gaps in hypertension care and control at a population level in low-income communes of Medellin, Colombia.Methods and analysis A multi-component intervention was designed based on international guidelines, cross-sectional population survey results and consultation with the community and institutional stakeholders. Three main intervention components integrate activities related to (1) health services redesign, (2) clinical staff training and (3) patient and community engagement. The effectiveness of the intervention will be evaluated in a controlled before-after quasi-experimental study, with two deprived communes of the city selected as intervention and control arms. We will conduct a baseline and an endline survey 2 years after the start of the intervention. The primary outcomes will be the gaps in hypertension diagnosis, treatment, follow-up and control. Effectiveness will be evaluated with the difference-in-difference measures. Generalised estimation equation models will be fitted considering the clustered nature of data and adjusting for potential confounding variables. The implementation process will be studied with mixed methods. Implementation fidelity will be documented to assess to which degree the intervention components were implemented as intended.Ethics and dissemination The study protocol has been approved by the Ethics Research Committee of Metrosalud in Colombia (reference 1400/5.2), the Medical Ethics Committee of the Antwerp University Hospital (reference 18/40/424) and the Institutional Review Board of the Antwerp Institute of Tropical Medicine (reference 1294/19). We will share and discuss the study results with the community, institutional stakeholders and national health policymakers. We will publish them in national and international peer-reviewed scientific journals.Trial registration number NCT05011838.

Introduction: People with tuberculosis experience long-term health effects beyond cure, including chronic respiratory diseases. We investigated whether tuberculosis is a risk factor for subsequent lung cancer. Methods: We searched PubMed, Scopus, Cochrane, Latin American and Caribbean Health Sciences Literature and the Scientific Electronic Library Online for cohort and case–control studies providing effect estimates for the association between tuberculosis and subsequent lung cancer. We pooled estimates through random-effects meta-analysis. The study was registered in PROSPERO (CDR42020178362). Results: Out of 6240 records, we included 29 cohort and 44 case–control studies. Pooled estimates adjusted for age and smoking (assessed quantitatively) were hazard ratio (HR) 1.51 (95% CI 1.30–1.76, I2=81%; five studies) and OR 1.74 (95% CI 1.42–2.13, I2=59%; 19 studies). The occurrence of lung cancer was increased for 2 years after tuberculosis diagnosis (HR 5.01, 95% CI 3.64–6.89; two studies), but decreased thereafter. Most studies were retrospective, had moderate to high risk of bias, and did not control for passive smoking, environmental exposure and socioeconomic status. Heterogeneity was high. Conclusion: We document an association between tuberculosis and lung cancer occurrence, particularly in, but not limited to, the first 2 years after tuberculosis diagnosis. Some cancer cases may have been present at the time of tuberculosis diagnosis and therefore causality cannot be ascertained. Prospective studies controlling for key confounding factors are needed to identify which tuberculosis patients are at the highest risk, as well as cost-effective approaches to mitigate such risk.

To better guide dengue prevention and control efforts, the use of routinely collected data to develop risk maps is proposed. For this purpose, dengue experts identified indicators representative of entomological, epidemiological and demographic risks, hereafter called components, by using surveillance data aggregated at the level of Consejos Populares (CPs) in two municipalities of Cuba (Santiago de Cuba and Cienfuegos) in the period of 2010–2015. Two vulnerability models (one with equally weighted components and one with data-derived weights using Principal Component Analysis), and three incidence-based risk models were built to construct risk maps. The correlation between the two vulnerability models was high (tau > 0.89). The single-component and multicomponent incidence-based models were also highly correlated (tau ≥ 0.9). However, the agreement between the vulnerability- and the incidence-based risk maps was below 0.6 in the setting with a prolonged history of dengue transmission. This may suggest that an incidence-based approach does not fully reflect the complexity of vulnerability for future transmission. The small difference between single- and multicomponent incidence maps indicates that in a setting with a narrow availability of data, simpler models can be used. Nevertheless, the generalized linear mixed multicomponent model provides information of covariate-adjusted and spatially smoothed relative risks of disease transmission, which can be important for the prospective evaluation of an intervention strategy. In conclusion, caution is needed when interpreting risk maps, as the results vary depending on the importance given to the components involved in disease transmission. The multicomponent vulnerability mapping needs to be prospectively validated based on an intervention trial targeting high-risk areas.

BackgroundFollowing earlier trials indicating that their potential in dengue vector control was constrained by housing structure, a large-scale cluster-randomized trial of insecticide treated curtains (ITCs) and water jar covers (ITJCs) was undertaken in Venezuela.MethodsIn Trujillo, Venezuela, 60 clusters (6223 houses total) were randomized so that 15 clusters each received either PermaNet insecticide-treated window curtains (ITCs), permanent insecticide-treated water storage jar covers (ITJCs), a combination of both ITCs and ITJCs, or no insecticide treated materials (ITMs). A further 15 clusters located at least 5km from the edge of the study site were selected to act as an external control. Entomological surveys were carried out immediately before and after intervention, and then at 6-month intervals over the following 27 months. The Breteau and House indices were used as primary outcome measures and ovitrap indices as secondary. Negative binomial regression models were used to compare cluster-level values of these indices between the trial arms.ResultsReductions in entomological indices followed deployment of all ITMs and throughout the trial, indices in the external control arm remained substantially higher than in the ITM study arms including the internal control. Comparing the ratios of between-arm means to summarise the entomological indices throughout the study, the combined ITC+ITJC intervention had the greatest impact on the indices, with a 63% difference in the pupae per person indices between the ITC+ITJC arm and the internal control. However, coverage had fallen below 60% by 14-months post-intervention and remained below 40% for most of the remaining study period.ConclusionsITMs can impact dengue vector populations in the long term, particularly when ITCs and ITJCs are deployed in combination.Trial registrationClinicalTrials.gov ISRCTN08474420; www.isrctn.com.

Abstract Background To determine the prevalence of hypertension treatment and control among hypertensive patients in the Cuban municipalities of Cardenas and Santiago and to explore the main associated predictors. Methods Cross-sectional study, with multistage cluster sampling, conducted between February 2012 and January 2013 in two Cuban municipalities. We interviewed and measured blood pressure in 1333 hypertensive patients aged 18 years or older. Hypertension control was defined as blood pressure lower than 140/90 mmHg. Results The mean age ± standard deviation (SD) of participants was 59.8 ± 14 years, the mean systolic and diastolic blood pressure ± SD was 130.0 ± 14.4 and 83.1 ± 9.0 mmHg respectively. The majority of patients (91, 95%CI 90–93) were on pharmacological treatment, 49% with a combination of 2 or more classes of drugs. Among diagnosed hypertensive patients 58% (95%CI 55–61) had controlled hypertension. There was no association between hypertension control and gender, age and socio-economic condition. Levels of hypertension control depended on health area and control furthermore was positively associated with post-primary education, not being obese and white ethnicity: adjusted Odds Ratio (95% CI) 1.71 (1.26–2.34), 1.43 (1.09–1.88) and 1.41 (1.09–1.81) respectively. Conclusions The observed figures are outstanding at the international level and illustrate that hypertension treatment and control are achievable in a resource-constrained setting such as Cuba. The country’s primary health care approach and social equity in access to health care can be seen as key determinants of this success. Nevertheless, there is still room for improvement, as over a third of patients did not have controlled hypertension.

Background Hypertension requires life-long medical care, which may cause economic burden and even lead to catastrophic health expenditure. Objective To estimate the extent of out-of-pocket expenditure for hypertension care at a population level and its impact on households’ budgets in a low-income urban setting in Colombia. Methods We conducted a cross-sectional survey in Santa Cruz, a commune in the city of Medellin. In 410 randomly selected households with a hypertensive adult, we estimated annual basic household expenditure and hypertension-attributable out-of-pocket expenditure. For socioeconomic stratification, we categorised households according to basic expenditure quintiles. Catastrophic hypertension-attributable expenditure was defined as out-of-pocket expenditure above 10% of total household expenditure. Results The average annual basic household expenditure was US dollars at purchasing power parity (USD-PPP) $12,255.59. The average annual hypertension-attributable out-of-pocket expenditure was USD-PPP $147.75 (95% CI 120.93–174.52). It was incurred by 73.9% (95% CI 69.4%-78.1%) of patients, and consisted mainly of direct non-medical expenses (76.7%), predominantly for dietary requirements prescribed as non-pharmacological treatment and for transport to attend health care consultations. Medical out-of-pocket expenditure (23.3%) was for the most part incurred for pharmacological treatment. Hypertension-attributable out-of-pocket expenditure represented on average 1.6% (95% CI 1.3%-1.9%) of the total annual basic household expenditure. Eight households (2.0%; 95% CI 1.0%-3.8%) had catastrophic health expenditure; six of them belonged to the two lowest expenditure quintiles. Payments related to dietary requirements and transport to consultations were critical determinants of their catastrophic expenditure. Conclusions Out-of-pocket expenditure for hypertension care is moderate on average, but frequent, and mainly made up of direct non-medical expenses. Catastrophic health expenditure is uncommon and affects primarily households in the bottom socioeconomic quintiles. Financial protection should be strengthened by covering the costs of chronic diseases-related dietary requirements and transport to health services in the most deprived households. Abbreviations NCDs: Non-communicable diseases; LMICs: Low and middle-income countries; WHO: World Health Organization; HTN: hypertension; CVDs: Cardiovascular diseases; OOPE: out-of-pocket expenditure; USD-PPP: US dollars at purchasing power parity; CI: Confidence interval

Objectives: To develop a clinical prediction rule (CPR) for the diagnosis of pleural tuberculosis (PT) in patients with pleural exudates in Peru. Methods: Clinical and laboratory information was collected from patients with exudative pleural effusion attending two reference hospitals in Lima, Peru. Predictive findings associated with PT in a multiple logistic regression model were used to develop the CPR. A definite diagnosis of PT was based on a composite reference standard including bacteriological and/or histological analysis of pleural fluid and pleural biopsy specimens. Results: A total of 238 patients were included in the analysis, of whom 176 had PT. Age, sex, previous contact with a TB patient, presence of lymphadenopathy, and pleural adenosine deaminase (ADA) levels were found to be independently associated with PT. These predictive findings were used to construct a CPR, for which the area under the receiver operating characteristics curve (AUC) was 0.92. The single best cut-off point was a score of ≥60 points, which had a sensitivity of 88%, specificity of 92%, a positive likelihood ratio of 10.9, and a negative likelihood ratio of 0.13. Conclusions: The CPR is accurate for the diagnosis of PT and could be useful for treatment initiation while avoiding pleural biopsy. A prospective evaluation is needed before its implementation in different settings. Keywords: Tuberculosis, Clinical prediction rules, Aadenosine deaminase, Pleural effusion, Peru

Abstract Background Since 2006, the Peruvian National TB program (NTP) recommends voluntary counseling and testing (VCT) for all tuberculosis (TB) patients. Responding to the differential burden of both diseases in Peru, TB is managed in peripheral health facilities while HIV is managed in referral centers. This study aims to determine the coverage of HIV screening among TB patients and the characteristics of persons not screened. Methods From March 2010 to December 2011 we enrolled new smear-positive pulmonary TB adults in 34 health facilities in a district in Lima. NTP staff offered VCT to all TB patients. Patients with an HIV positive result were referred for confirmation tests and management. We interviewed patients to collect their demographic and clinical characteristics and registered if patients opted in or out of the screening. Results Of the 1295 enrolled TB patients, nine had a known HIV diagnosis. Of the remaining, 76.1% (979) were screened for HIV. Among the 23.9% (307) not screened, 38.4% (118) opted out of the screening. TB patients at one of the health care facilities of the higher areas of the district (OR = 3.38, CI 95% 2.17–5.28 for the highest area and OR = 2.82, CI 95% 1.78–4.49 for the high area) as well as those reporting illegal drug consumption (OR = 1.65, CI 95% 1.15–2.37) were more likely not to be screened. Twenty-four were HIV positive (1.9% of all patients 1295, or 2.4% of those screened). Of 15 patients diagnosed with HIV during the TB episode, ten were enrolled in an HIV program. The median time between the result of the HIV screening and the first consultation at the HIV program was 82 days (IQR, 32–414). The median time between the result of the HIV screening and antiretroviral initiation was 148.5 days (IQR 32–500). Conclusions An acceptable proportion of TB patients were screened for HIV in Lima. Referral systems of HIV positive patients should be strengthened for timely ART initiation.

Abstract Background India’s Revised National Tuberculosis (TB) Control Programme (RNTCP) offers free TB diagnosis and treatment. But more than 50% of TB patients seek care from private practitioners (PPs), where TB is managed sub-optimally. In India, there is dearth of studies capturing experiences of TB patients when they navigate through health facilities to seek care. Also, there is less information available on how PPs make decisions to refer TB cases to RNTCP. We conducted this study to understand the factors influencing TB patient’s therapeutic itineraries to RNTCP and PP’s cross referral practices linked to RNTCP. Methods We conducted in-depth interviews on a purposive sample of 33 TB patients and 38 PPs. Patients were categorised into three groups: those who reached RNTCP directly, those who were referred by PPs to RNTCP and patients who took DOT from PPs. We assessed patient’s experiences in each category and documented their journey from initial symptoms until they reached RNTCP, where they were diagnosed and started on treatment. PPs were categorised into three groups based on their TB case referrals to RNTCP: actively-referring, minimally-referring and non-referring. Results Patients had limited awareness about TB. Patients switched from one provider to the other, since their symptoms were not relieved. A first group of patients, self-medicated by purchasing get rid drugs from private chemists over the counter, before seeking care. A second group sought care from government facilities and had simple itineraries. A third group who sought care from PPs, switched concurrently and/or iteratively from public and private providers in search for relief of symptoms causing important diagnostic delays. Eventually all patients reached RNTCP, diagnosed and started on treatment. PP’s cross-referral practices were influenced by patient’s paying capacity, familiarity with RNTCP, kickbacks from private labs and chemists, and even to get rid of TB patients. These trade-offs by PPs complicated patient’s itineraries to RNTCP. Conclusions India aims to achieve universal health care for TB. Our study findings help RNTCP to develop initiatives to promote early detection of TB, by involving PPs and private chemists and establish effective referral systems from private sectors to RNTCP.

Recently, McMahon and colleagues set out to build on a widely-used fidelity framework, assessing the role of moderating factors during the implementation of performance-based financing programs in Malawi. Their attempt draws again the attention to the importance of approaching real word implementation issues from a theoretical perspective. It also highlights the importance of fidelity assessment within process evaluation of health programs. In this comment we argue that theoretical developments in the field of implementation science in global health would benefit from an accurate understanding of existing conceptual frameworks as well as from taking into account all contemporary contributions. Keywords: Implementation research, Implementation fidelity, Conceptual framework, Performance-based financing

BackgroundThe World Health Organization (WHO) has targeted yaws for global eradication. Eradication requires certification that all countries are yaws-free. While only 14 Member States currently report cases to WHO, many more are known to have a history of yaws and some of them may have ongoing transmission. We reviewed the literature and developed a model of case reports to identify countries in which passive surveillance is likely to find and report cases if transmission is still occurring, with the goal of reducing the number of countries in which more costly active surveillance will be required.MethodsWe reviewed published and unpublished documents to extract data on the number of yaws cases reported to WHO or appearing in other literature in any year between 1945 and 2015. We classified countries as: a) having interrupted transmission; b) being currently endemic; c) being previously endemic (current status unknown); or d) having no history of yaws. We constructed a panel dataset for the years 1945-2015 and ran a regression model to identify factors associated with some countries not reporting cases during periods when there was ongoing (and documented) transmission. For previously endemic countries whose current status is unknown, we then estimated the probability that countries would have reported cases if there had in fact been transmission in the last three years (2013-2015).ResultsYaws has been reported in 103 of the 237 countries and areas considered. 14 Member States and 1 territory (Wallis and Futuna Islands) are currently endemic. 2 countries are believed to have interrupted transmission. 86 countries and areas are previously endemic (current status unknown). Reported cases peaked in the 1950s, with 55 countries reporting at least one case in 1950 and a total of 2.35 million cases reported in 1954. Our regression model suggests that case reporting during periods of ongoing transmission is positively associated with socioeconomic development and, in the short-term, negatively associated with independence. We estimated that for 66 out of the 86 previously endemic countries whose current status is unknown, the probability of reporting cases in the absence of active surveillance is less than 50%.DiscussionCountries with a history of yaws need to be prioritized so that international resources for global yaws eradication may be deployed efficiently. Heretofore, the focus has been on mass treatment in countries currently reporting cases. It is also important to undertake surveillance in the 86 previously endemic countries for which the current status is unknown. Within this large and diverse group, we have identified a group of 20 countries with more than a 50% probability of reporting cases in the absence of active surveillance. For the other 66 countries, international support for active surveillance will likely be required.

Fundamento: las enfermedades asociadas al envejecimiento poblacional afectan la morbilidad y la mortalidad de las poblaciones, lo cual hace necesario trazar estrategias de intervención encaminadas a prevenirlas y/o minimizar sus consecuencias. Objetivo: evaluar la efectividad de una intervención cognitiva-conductual aplicada a los ancianos hipertensos en el nivel primario de atención de los municipios de Cárdenas y Santiago de Cuba, durante 2011-2013. Métodos: se realizó un estudio de intervención, con los ancianos hipertensos en dos municipios del país: Santiago de Cuba y Cárdenas. Se tomó como grupo de intervención 399 ancianos de las áreas Carlos Juan Finlay y Héroes del Moncada y como grupo de control 377 ancianos de las áreas Julián Grimau y José Antonio Echeverría. La intervención consistió en aplicar una estrategia sistemática para fomentar el conocimiento de la enfermedad para modificar los estilos de vida. Resultados: el grupo de intervención presentó mayor número de pacientes con conocimientos suficientes de la enfermedad (OR: 1,82), mayor control de la hipertensión (OR: 1,51) y mejor adherencia al tratamiento (OR: 1,70). Modelando las variables explicativas con el control de la hipertensión arterial, resultaron factores protectores para la salud: pertenecer al grupo de intervención (OR: 0,695) y tener adherencia al tratamiento (OR: 0,543). Conclusión: la intervención congnitivo-conductual aplicada a los ancianos en el primer nivel de atención de los municipios estudiados fue efectiva para mejorar el control de la hipertensión arterial, especialmente porque generó una mayor adherencia al tratamiento.

Within the context of a field trial conducted by the Cuban vector control program (AaCP), we assessed acceptability of insecticide-treated curtains (ITCs) and residual insecticide treatment (RIT) with deltamethrin by the community. We also assessed the potential influence of interviewees' risk perceptions for getting dengue and disease severity.We embedded a qualitative study using in-depth interviews in a cluster randomized trial (CRT) testing the effectiveness of ITCs and RIT in Santiago de Cuba. In-depth interviews (N = 38) were conducted four and twelve months after deployment of the tools with people who accepted the tools, who stopped using them and who did not accept the tools. Data analysis was deductive. Main reasons for accepting ITCs at the start of the trial were perceived efficacy and not being harmful to health. Constraints linked to manufacturer instructions were the main reason for not using ITCs. People stopped using the ITCs due to perceived allergy, toxicity and low efficacy. Few heads of households refused RIT despite the noting reasons for rejection, such as allergy, health hazard and toxicity. Positive opinions of the vector control program influenced acceptability of both tools. However, frequent insecticide fogging as part of routine AaCP vector control actions diminished perceived efficacy of both tools and, therefore, acceptability. Fifty percent of interviewees did feel at risk for getting dengue and considered dengue a severe disease. However, this did not appear to influence acceptability of ITCs or RIT.Acceptability of ITCs and RIT was linked to acceptability of AaCP routine vector control activities. However, uptake and use were not always an indication of acceptability. Factors leading to acceptability may be best identified using qualitative methods, but more research is needed on the concept of acceptability and its measurement.

BACKGROUND:Aedes control interventions are considered the cornerstone of dengue control programmes, but there is scarce evidence on their effect on disease. We set-up a cluster randomized controlled trial in Santiago de Cuba to evaluate the entomological and epidemiological effectiveness of periodical intra- and peri-domiciliary residual insecticide (deltamethrin) treatment (RIT) and long lasting insecticide treated curtains (ITC). METHODOLOGY/PRINCIPAL FINDINGS:Sixty three clusters (around 250 households each) were randomly allocated to two intervention (RIT and ITC) and one control arm. Routine Aedes control activities (entomological surveillance, source reduction, selective adulticiding, health education) were applied in the whole study area. The outcome measures were clinical dengue case incidence and immature Aedes infestation. Effectiveness of tools was evaluated using a generalized linear regression model with a negative binomial link function. Despite significant reduction in Aedes indices (Rate Ratio (RR) 0.54 (95%CI 0.32-0.89) in the first month after RIT, the effect faded out over time and dengue incidence was not reduced. Overall, in this setting there was no protective effect of RIT or ITC over routine in the 17months intervention period, with for house index RR of 1.16 (95%CI 0.96-1.40) and 1.25 (95%CI 1.03-1.50) and for dengue incidence RR of 1.43 (95%CI 1.08-1.90) and 0.96 (95%CI 0.72-1.28) respectively. The monthly dengue incidence rate (IR) at cluster level was best explained by epidemic periods (Incidence Rate Ratio (IRR) 5.50 (95%CI 4.14-7.31)), the IR in bordering houseblocks (IRR 1.03 (95%CI 1.02-1.04)) and the IR pre-intervention (IRR 1.02 (95%CI 1.00-1.04)). CONCLUSIONS:Adding RIT to an intensive routine Aedes control programme has a transient effect on the already moderate low entomological infestation levels, while ITC did not have any effect. For both interventions, we didn't evidence impact on disease incidence. Further studies are needed to evaluate impact in settings with high Aedes infestation and arbovirus case load.

Yaws is a non-venereal treponemal infection caused by Treponema pallidum subspecies pertenue. The disease is targeted by WHO for eradication by 2020. Rapid diagnostic tests (RDTs) are envisaged for confirmation of clinical cases during treatment campaigns and for certification of the interruption of transmission. Yaws testing requires both treponemal (trep) and non-treponemal (non-trep) assays for diagnosis of current infection. We evaluate a sequential testing strategy (using a treponemal RDT before a trep/non-trep RDT) in terms of cost and cost-effectiveness, relative to a single-assay combined testing strategy (using the trep/non-trep RDT alone), for two use cases: individual diagnosis and community surveillance.We use cohort decision analysis to examine the diagnostic and cost outcomes. We estimate cost and cost-effectiveness of the alternative testing strategies at different levels of prevalence of past/current infection and current infection under each use case. We take the perspective of the global yaws eradication programme. We calculate the total number of correct diagnoses for each strategy over a range of plausible prevalences. We employ probabilistic sensitivity analysis (PSA) to account for uncertainty and report 95% intervals.At current prices of the treponemal and trep/non-trep RDTs, the sequential strategy is cost-saving for individual diagnosis at prevalence of past/current infection less than 85% (81-90); it is cost-saving for surveillance at less than 100%. The threshold price of the trep/non-trep RDT (below which the sequential strategy would no longer be cost-saving) is US$ 1.08 (1.02-1.14) for individual diagnosis at high prevalence of past/current infection (51%) and US$ 0.54 (0.52-0.56) for community surveillance at low prevalence (15%).We find that the sequential strategy is cost-saving for both diagnosis and surveillance in most relevant settings. In the absence of evidence assessing relative performance (sensitivity and specificity), cost-effectiveness is uncertain. However, the conditions under which the combined test only strategy might be more cost-effective than the sequential strategy are limited. A cheaper trep/non-trep RDT is needed, costing no more than US$ 0.50-1.00, depending on the use case. Our results will help enhance the cost-effectiveness of yaws programmes in the 13 countries known to be currently endemic. It will also inform efforts in the much larger group of 71 countries with a history of yaws, many of which will have to undertake surveillance to confirm the interruption of transmission.

OBJECTIVE To assess the increased diagnostic yield for pulmonary tuberculosis using bronchial washing cultures compared with sputum cultures. METHODS Study conducted with 61 adults in Lima, Peru, from January 2006 to December 2007. The yield of sputum cultures was compared with the yield of acid-fast bacilli smears and cultures of bronchial washing for diagnosing pulmonary tuberculosis in suspected cases of clinical tuberculosis with negative acid fast bacilli sputum smears. RESULTS Twenty seven (95%CI 32;58) of the cases were eventually diagnosed with smear-negative pulmonary tuberculosis. Bronchial washing samples detected 23 (95%CI 72;99) of the smear-negative pulmonary tuberculosis cases compared with 15 (95%CI 37;74) for sputum cultures (p = 0.02). The incremental diagnostic yield of acid fast bacilli smear and culture of bronchial washing specimens over sputum culture was 44% (95%CI 25;65). CONCLUSIONS In function of the epidemiological context and the resources available, bronchoscopy should be deployed as part of a comprehensive work up that optimizes smear-negative pulmonary tuberculosis diagnosis and minimizes risk and costs.

Introducción: En la utilización de los servicios de salud convergen no solo la necesidad de atención de la población en términos de enfermedad, sino sus creencias, aspectos culturales; pero, sobre todo, el complejo contexto en que se da la prestación de servicios de salud. objetivo: exponer la metodología empleada para el estudio de la utilización de los servicios médicos y alternativos en el área de salud "Marcio Manduley", del municipio de Centro Habana, para la solución de sus problemas de salud. Métodos: se elaboraron tres instrumentos a partir de la revisión documental y la experiencia de nuestros investigadores, las cuales estaban dirigidas a aquellos miembros de las familias que enfermaron en los últimos 30 días o que padecían una enfermedad crónica y que hicieron o no uso de algún servicio de salud o alternativo. Resultados: Se entrevistaron 408 núcleos familiares (1 244 personas) con un promedio de 31,4 familias (95,7 personas por encuestadoras). El 89,0 % de las familias fueron entrevistadas de lunes a viernes (el lunes y el martes fueron los días de mayor captación). Conclusiones: La aplicación de estos instrumentos ofrece una aproximación de cómo se utilizan los servicios de salud y alternativos por la población. Su replicación, perfeccionamiento y adecuación en otros contextos es de gran ayuda a los decisores de salud para fortalecer el trabajo en el nivel primario de atención, y así brindar un servicio de calidad a la población.Introduction: the use of health services converge not only the need for care of the population in terms of illness, but their beliefs, cultural aspects, but above all, the complex context in which the provision of health services is. Objective: to present the methodology used for studing the use of medical and alternative services in Marcio Manduley health area, municipality of Centro Habana, to solve their health problems. Methods: Three instruments were developed from the literature review and the experience of our investigators, aiming those family members who became ill in the last 30 days or suffered from a chronic illness that did or did not use any alternative or health service. Results: We interviewed 408 families (1244 people) with an average of 31.4 families (95.7 people per polling). 89.0% of families were interviewed on weekdays (Mondays and Tuesdays were the days of higher uptake). Conclusions: The application of these tools provides an approximation on how alternative or health services are used by the population. Replication, refinement, and adaptation to other contexts are helpful to health policy makers to strengthen the work in the primary health care level, and thus provide a quality service to the population.

Avaliamos o rendimento diagnóstico da fibrobroncoscopia óptica no diagnóstico de tuberculose pulmonar com baciloscopia negativa em pacientes atendidos em um hospital de referência em Lima, Peru. Dos 611 pacientes submetidos ao procedimento, 140 (23%) foram diagnosticados com tuberculose com base nas amostras de LBA. Ser mais jovem e do sexo masculino foi associado a culturas positivas. Além disso, 287 pacientes realizaram baciloscopia de escarro após a broncoscopia, e os resultados aumentaram o rendimento diagnóstico em 22% em relação às amostras de LBA. Concluímos que amostras de LBA e de escarro pós-broncoscopia tiveram um bom rendimento diagnóstico nos pacientes com suspeita de tuberculose pulmonar com baciloscopia negativa.We evaluated the diagnostic yield of fiberoptic bronchoscopy for the diagnosis of smear-negative pulmonary tuberculosis in patients treated at a referral hospital in Lima, Peru. Of the 611 patients who underwent the procedure, 140 (23%) were diagnosed with tuberculosis based on the analysis of BAL samples. Being young and being male were significantly associated with positive cultures. In addition, 287 patients underwent post-bronchoscopic sputum smear testing for AFB, the results of which increased the diagnostic yield by 22% over that obtained through the analysis of BAL samples alone. We conclude that the analysis of BAL samples and post-bronchoscopic sputum samples provides a high diagnostic yield in smear-negative patients suspected of having pulmonary tuberculosis.

La revolución científico-técnica ha contribuido al envejecimiento poblacional (mayor proporción de ancianos en la población), y ha impactado al sistema de salud con la utilización más frecuente de servicios, como los del nivel primario de atención, que a su vez no tienen el desarrollo necesario para enfrentar la demanda creciente y especializada de este grupo de edad. Para describir la utilización de los servicios del nivel primario de atención por los ancianos residentes en algunos de los consultorios de tres policlínicos del país durante el año 2006 se hizo un estudio descriptivo. Se calcularon números absolutos, razones de tasas y tasas anuales por habitantes/personas/año por sexo y para el total del grupo en estudio de cada policlínico. Las tasas de utilización fueron 1,22 y 3,53 respectivamente para terrenos y consultas. Los indicadores mostraron diferencias en la organización, calidad y tipo de los servicios brindados entre uno y otro policlínico. El policlínico "Marcio Manduley" tuvo las mayores tasas de utilización (6,00 contra 2,27, respectivamente) para consultas y terrenos; 2,54 contra 6,22 para consultas programadas/no programadas; 8,46 contra 0,31 para prescripciones médicas hechas Sí/No y 4,48 contra 4,49 para actividades preventivas indicadas Sí/No. El Policlínico "Felipe J. Rodríguez" tuvo los indicadores más bajos. Se concluye que la organización del trabajo en los policlínicos repercutió sobre la utilización de los servicios en el nivel primario de atención, como la calidad y el tipo de servicios brindados, y estas diferencias entre policlínicos podrían constituir inequidades en el acceso a estos servicios por los ancianos.The scientific and technological revolution has contributed to population aging (higher proportion of elderly in the population), and it has impact on the health system since it is more frequent the use of primary health care services, which, in turn, does not have the necessary development to meet this growing and specialized demand for this age group. A descriptive study was conducted to describe the use of primary health care services by the elderly residents in some of Cuban medical practices in 2006. Absolute numbers, rate ratios and annual rates per capita/person/year by sex were calculated for the total study group at each clinic. Utilization rates were 1.22 and 3.53 respectively for territory and medical practices. The indicators showed differences in organization, quality, and type of services provided between these medical practices. Marcio Manduley clinic had the highest rates of use -6.00 versus 2.27, respectively, for medical practices and territory; 2.54 versus 6.22 for consultations scheduled/unscheduled, 8.46 versus 0.31 for Yes/No medical prescriptions performed and 4.48 versus 4.49 for Yes/No indicated prevention activities. On the other hand, Felipe J. Rodríguez Polyclinic had the lowest indicators. We conclude that the work organization in polyclinics has impact on the use of primary health care services, quality and type of services provided, and these differences could between polyclinics could be inequities in the access to these services by elderly.

BACKGROUND:Isoniazid and rifampicin are the two most efficacious first-line agents for tuberculosis (TB) treatment. We assessed the prevalence of isoniazid and rifampicin mono-resistance, associated risk factors, and the association of mono-resistance on treatment outcomes. METHODS:A prospective, observational cohort study enrolled adults with a first episode of smear-positive pulmonary TB from 34 health facilities in a northern district of Lima, Peru, from March 2010 through December 2011. Participants were interviewed and a sputum sample was cultured on Löwenstein-Jensen (LJ) media. Drug susceptibility testing was performed using the proportion method. Medication regimens were documented for each patient. Our primary outcomes were treatment outcome at the end of treatment. The secondary outcome included recurrent episodes among cured patients within two years after completion of the treatment. RESULTS:Of 1292 patients enrolled, 1039 (80%) were culture-positive. From this subpopulation, isoniazid mono-resistance was present in 85 (8%) patients and rifampicin mono-resistance was present in 24 (2%) patients. In the multivariate logistic regression model, isoniazid mono-resistance was associated with illicit drug use (adjusted odds ratio (aOR) = 2.10; 95% confidence interval (CI): 1.1-4.1), and rifampicin mono-resistance was associated with HIV infection (aOR = 9.43; 95%CI: 1.9-47.8). Isoniazid mono-resistant patients had a higher risk of poor treatment outcomes including treatment failure (2/85, 2%, p-value

Esta revisión tuvo como objetivo realizar un breve bosquejo acerca de cómo funciona el Modelo de Atención a Crónicos en el mundo, desarrollado por Edward Wagner, con sus diferentes variantes de atención a las enfermedades no transmisibles y sus semejanzas con el modelo cubano de la Atención Primaria de Salud, puesto que el uso de todos esos paradigmas pudiera servir como catalizador para un cambio futuro a escala global, teniendo en cuenta que comparten puntos de coincidencia.This review aimed at making a brief outline on how the care pattern developed by Edward Wagner for chronic patients in the world is carried out. It contains different care variants for non communicable diseases and similarities to the Cuban pattern of Primary Health care, since all those paradigms could be used as a catalyst for a worldwide future change, keeping in mind that they share coincidence points.

INTRODUCCIÓN: No existen muchas publicaciones científicas que aborden los diferenciales de salud entre las provincias de Cuba, ni que documenten los principales factores que impactaron en los resultados de salud de la población durante el período 1989 - 2000. En el año 2002 Fidel Castro destacó la existencia de una serie de errores de conducción y organización durante ese periodo, que a su criterio debilitaron el sistema de salud cubano y propiciaron la aparición de "determinadas desigualdades". OBJETIVO: Describir los principales diferenciales de salud existentes entre los distintos territorios de Cuba (factores determinantes de la salud de los cubanos) durante el período estudiado (2002-2008). MÉTODOS: Se utilizó como unidad geográfica a la provincia. Las catorce provincias cubanas fueron estratificadas sobre la base de tres ejes fundamentales: demográfico, económico y condiciones de vida, con vista a identificar posibles diferenciales de salud (inequidades en salud y en servicios de salud) mediante el empleo de la técnica del coeficiente de Gini y del índice de concentración. RESULTADOS: Se muestran los principales factores o variables con diferenciales de salud presentes en el país por provincias durante el período estudiado, se identificaron los factores o variables que mayores diferenciales exhibieron por cada uno de los ejes demográfico (densidad poblacional), económico (producción mercantil) y condiciones de vida (cobertura sanitaria). Se definen las diferencias existentes entre cada una de las provincias y por regiones y las características muy particulares de la capital cubana como provincia. CONCLUSIONES: Se confirma la hipótesis de que a pesar de la férrea voluntad política del estado de evitar inequidades en salud, aún se observan diferenciales no importantes en el comportamiento de las variables estudiadas por cada uno de los ejes de análisis entre provincias. No obstante, existen diferencias entre el comportamiento de esos diferenciales de acuerdo con los ejes de análisis, aspectos que deben ser y fueron considerados durante el proceso de diseño de políticas sanitarias, de reorganización de los servicios de salud, de formación de capital humano y de abordaje intersectorial de los determinantes no médicos de la salud durante los años más duros del período especial, lo que viene a confirmar el modelo teórico desarrollado previamente por los autores.INTRODUCTION: There is a lack of scientific publications approaching the health differentials among the Cuban provinces and of to document the leading factors with impact on the health results in the population during the period 1989-2000. In 2002 Fidel Castro Rus emphasized on the existence of errors in the management and organization during above mentioned period, that according to his criterion to weaken the Cuban health system and led to appearance of "determined inequalities". OBJECTIVE: To describe the leading health differentials present among the different Cuban territories (determinant health factors for Cubans) during the study period (2002-2008). METHODS: The province was used as geographical unit. The fourteen Cuban provinces were stratified on the base of the three fundamental bases: demographic, economic and life conditions to identify the potential health differentials (inequalities in health and in its services) using the Gini's coefficient technique and the concentration's index. RESULTS: The leading factors or variables with health differentials present in our country by provinces during the study period are showed, identifying the factors or variables with greater differentials by each of the demographic bases (population density), economic (commercial production) and life conditions (health coverage). The differences present among each of the provinces and regions are defined as well as the very particular characteristics of the Cuban capital as province. CONCLUSIONS: The hypothesis that despite the strong political and state will to avoid health inequalities, still there are no-significant differences in the behavior of study variables by each of the bases of analysis among provinces. Nevertheless, there differences among the behavior of such differentials according to analysis's bases, features that be and were considered during the process of health politics design, of reorganization of health services, of human resource training and the intersectorial approach of non-health physicians determinants during the more hard year of special period, confirming the theoretical model previously developed by the authors.

El Sistema Nacional de Salud de Cuba se ha mantenido, desde su creación, en un permanente proceso de reformas, lo que ha conducido a cambios en el desarrollo paulatino de la atención médica. También se ha venido implantado y desarrollando enfoques, métodos y técnicas para ganar calidad. Una de las dimensiones de la calidad de vida laboral, que influye en la productividad y desarrollo del talento humano de una entidad es el clima organizacional, considerado como la propiedad del ambiente organizacional que es percibida o experimentada por los miembros de la organización y que influye poderosamente en su comportamiento, motivación, desempeño y satisfacción. Existen varios modelos para evaluar el clima organizacional de una unidad, en el caso de salud existe una experiencia positiva, se trata del inventario de clima organizacional, una metodología de la Organización Panamericana de la Salud que se ha utilizado con éxito en Cuba. En el presente artículo se exponen sus bases conceptuales, las técnicas de exploración a través de sus 4 dimensiones; liderazgo, motivación, reciprocidad y participación, su importancia para el buen trabajo de directivos y trabajadores, así como la necesidad de aplicar este tipo de estudio en nuestros servicios de salud. Debemos tener en cuenta que el factor humano es el principal recurso de una institución y su influencia es decisiva en el desarrollo, progreso y éxito de esta. El hombre es y continuará siendo el activo más valioso de una organización.The Cuban National Health System has remained from its onset in a continuous process of reforms leading to changes in the gradual development of medical care. Also, approaches, methods and techniques to increase the quality have been applied and developed. One of the dimensions of the working life quality influencing in productivity and development of human talent of one entity is the organizational environment a perception or experience becoming work property of workers influencing powerfully in its behavior, motivation, performance and satisfaction. There are some forms to assess the organization environment of a unit, in the case of health there is a positive experience, the PAHO inventory of the organizational environment a methodology used successfully in Cuba. In present paper are exposed its conceptual basis, the exploration techniques through its 4 dimensions: lead, motivation, reciprocity and participation. Its significance for the good practice of managers and workers, as well as the need to apply this type of study in our health services. We must to take into account that the human factor is the main resource in a institution and that its influence is decisive in its development and success The man is and will be for ever the part more active of a organization.

The current study evaluated the effectiveness and cost-effectiveness of Insecticide Treated Curtain (ITC) deployment for reducing dengue vector infestation levels in the Cuban context with intensive routine control activities. A cluster randomized controlled trial took place in Guantanamo city, east Cuba. Twelve neighborhoods (about 500 households each) were selected among the ones with the highest Aedes infestation levels in the previous two years, and were randomly allocated to the intervention and control arms. Long lasting ITC (PermaNet) were distributed in the intervention clusters in March 2009. Routine control activities were continued in the whole study area. In both study arms, we monitored monthly pre- and post-intervention House Index (HI, number of houses with at least 1 container with Aedes immature stages/100 houses inspected), during 12 and 18 months respectively. We evaluated the effect of ITC deployment on HI by fitting a generalized linear regression model with a negative binomial link function to these data.At distribution, the ITC coverage (% of households using ≥1 ITC) reached 98.4%, with a median of 3 ITC distributed/household. After 18 months, the coverage remained 97.4%. The local Aedes species was susceptible to deltamethrin (mosquito mortality rate of 99.7%) and the residual deltamethrin activity in the ITC was within acceptable levels (mosquito mortality rate of 73.1%) after one year of curtain use. Over the 18 month observation period after ITC distribution, the adjusted HI rate ratio, intervention versus control clusters, was 1.15 (95% CI 0.57 to 2.34). The annualized cost per household of ITC implementation was 3.8 USD, against 16.8 USD for all routine ACP activities.Deployment of ITC in a setting with already intensive routine Aedes control actions does not lead to reductions in Aedes infestation levels.

Although tuberculosis (TB) is usually curable with antibiotics, poor adherence to medication can lead to increased transmission, drug resistance, and death. Prior research has shown several factors to be associated with poor adherence, but this problem remains a substantial barrier to global TB control. We studied patients in a high-incidence district of Lima, Peru to identify factors associated with premature termination of treatment (treatment default).We conducted a prospective cohort study of adult smear-positive TB patients enrolled between January 2010 and December 2011 with no history of TB disease. Descriptive statistics and multivariable logistic regression analyses were performed to determine risk factors associated with treatment default.Of the 1233 patients studied, 127 (10%) defaulted from treatment. Patients who defaulted were more likely to have used illegal drugs (OR = 4.78, 95% CI: 3.05-7.49), have multidrug-resistant TB (OR = 3.04, 95% CI: 1.58-5.85), not have been tested for HIV (OR = 2.30, 95% CI: 1.50-3.54), drink alcohol at least weekly (OR = 2.22, 95% CI: 1.40-3.52), be underweight (OR = 2.08, 95% CI: 1.21-3.56), or not have completed secondary education (OR = 1.55, 95% CI: 1.03-2.33).Our study identified several factors associated with defaulting from treatment, suggesting a complex set of causes that might lead to default. Addressing these factors individually would be difficult, but they might help to identify certain high-risk patients for supplemental intervention prior to treatment interruption. Treatment adherence remains a barrier to successful TB care and reducing the frequency of default is important for both the patients' health and the health of the community.

We assessed in a case-control study the test-validity of Aedes larval indices for the 2000 Havana outbreak. "Cases" were blocks where a dengue fever patient lived during the outbreak. "Controls" were randomly sampled blocks. Before, during, and after the epidemic, we calculated Breteau index (BI) and house index at the area, neighborhood, and block level. We constructed receiver operating characteristic (ROC) curves to determine their performance as predictors of dengue transmission. We observed a pronounced effect of the level of measurement. The BImax (maximum block BI in a radius of 100 m) at 2-month intervals had an area under the ROC curve of 71%. At a cutoff of 4.0, it significantly (odds ratio 6.00, p

The first major outbreak of Marburg hemorrhagic fever (MHF) outside a laboratory environment occurred in the subdistrict of Watsa, Democratic Republic of Congo, from October 1998 to August 2000. We performed a serosurvey of household contacts of MHF patients to identify undetected cases, ascertain the frequency of asymptomatic Marburg infection, and estimate secondary attack risk and postintervention reproduction number. Contacts were interviewed about their exposure and symptoms consistent with MHF. Blood samples were tested for anti–Marburg immunoglobulin G (IgG). One hundred twenty-one (51%) of 237 identified contacts participated; 72 (60%) were not known to the health authorities. Two participating contacts were seropositive and reported becoming ill after the contact; no serologic evidence for asymptomatic or mild Marburg infection was found. The secondary attack risk was 21%; the postintervention reproduction number was 0.9, consistent with an outbreak sustained by repeated primary transmission, rather than large-scale secondary transmission.

OBJETIVO: explorar las percepciones sobre la participación comunitaria en la prevención del dengue durante la investigación formativa de un proyecto comunitario. MATERIAL Y MÉTODOS: Estudio conducido en tres áreas de salud de Santiago de Cuba durante el año 2000. Se combinan técnicas cualitativas y cuantitativas para explorar opiniones de los profesionales de salud, líderes comunitarios y una muestra aleatoria de población. RESULTADOS: Los profesionales identifican la no participación de la comunidad y sus propias limitaciones para involucrarla activamente en la prevención. Los líderes refieren falta de motivación, y la población vincula la eliminación del vector con el uso de tecnologías. Se perciben barreras en la aceptación de las actividades del programa de control y en general la "participación" es interpretada como "colaboración". CONCLUSIONES: La población ha trasferido responsabilidad del control del Aedes aegypti al sector salud. Se evidencia la necesidad de unificar conceptos sobre la participación comunitaria y conciliar intereses entre usuarios y proveedores de los servicios para lograr una real movilización social.OBJECTIVE:To explore the perceptions about community participation in dengue fever control during formative research for a community project. MATERIAL AND METHODS: This study was conducted in three health areas of the Santiago de Cuba municipality during the year 2000. Qualitative and quantitative techniques were used to explore the opinions of health professionals, community leaders and a random sample of 200 people living in the community. Results. The health professionals who were interviewed judged that difficulties in Aedes aegypti control were due to lack of participation of the community and to limited knowledge of prevention methods. Community leaders considered that the population was poorly motivated. The randomly selected subjects who were interviewed did associate Aedes control with technological intervention. The authors identified barriers to acceptance of control program activities. In general, the concept of "participation" was interpreted as "collaboration". CONCLUSIONS: Our findings show that the community has transferred the responsibility for Aedes aegypti control to the health sector. There is an evident need for unifying the concepts of community participation, as well as for matching the interests of users and health care providers, in order to attain a significant social mobilization.

Objetivo. Confirmar la presencia de brote de dengue en la ciudad de Santa Cruz, Bolivia, así como identificar el denguevirus causal, estimar la tasa de ataque y determinar la proporción de infecciones sintomáticas. Material y métodos. En marzo de 1997 se realizó una encuesta seroepidemiológica con muestreo aleatorio en un distrito céntrico de la ciudad. Se obtuvo información sobre episodios de enfermedad aguda, antecedentes de cuadro febril reciente y muestras de sangre venosa. Se determinó la presencia de IgM antidengue con el método MAC ELISA y se procedió a la tipificación del virus con tecnología de reacción en cadena de la polimerasa. Resultados. Se detectaron anticuerpos IgM en 6.5% de los adultos (IC95% 3.4-9.6) y 5.1% de los niños (IC 95% 2.0-8.2). El virus circulante fue identificado como dengue serotipo 2, genotipo Jamaica. Menos de la mitad de los niños infectados tuvieron una infección sintomática, contra casi 90% de los adultos. Conclusiones. La tasa de ataque estimada es compatible con una epidemia de dengue en Santa Cruz. La introducción del serotipo 2 - Jamaica en el país aumenta el riesgo de dengue hemorrágico.Objective. To confirm an epidemic outbreak of Dengue virus in the city of Santa Cruz, Bolivia, and to determine the serotype of the virus, to estimate the rate of attack and the proportion of symptomatic infections. Material and methods. In March 1997, a seroepidemiological survey was conducted with random sampling in a central district of the city of Santa Cruz, Bolivia. Information on recent acute illness and febrile episodes was gathered, and venous blood samples were obtained. Levels of antidengue IgM were determined by MAC Elisa and the virus was tipified with RT-PCR. Results. IgM antibodies were detected in 6.5% of adults (CI 95% 3.4-9.6) and 5.1% of children (CI 95% 2.0-8.2). Circulating virus was identified as Dengue serotype 2, subgroup Jamaica. Less than half of the infected children experienced a symptomatic infection compared to almost 90% of adults. Conclusions. The estimated attack rates are compatible with a Dengue epidemic outbreak in Santa Cruz. The introduction of the serotype 2/ subgroup Jamaica virus into the country increases the risk of hemorrhagic Dengue.

The reemergence of dengue as an important public health problem reflects the difficulties in sustaining vertically organized, effective, control programs and the need for community-based strategies for Aedes aegypti control that result in behavioral change. We aimed to disentangle the relationships between underlying determinants of dengue related practices. We conducted a cross-sectional study in 780 households in La Lisa, Havana, Cuba. A questionnaire and an observation guide were administrated to collect information on variables related to economic status, knowledge on dengue, risk perception and practices associated with Aedes aegypti breading sites. To test a conceptual model that hypothesized direct relationships among all these constructs, we first used Exploratory Factor Analysis with Principal Component Analysis to establish the relationship between observed variables and the underlying latent variables. Subsequently, we tested whether the observed data supported the conceptual model through Confirmatory Factor Analysis. Exploratory Factor Analysis indicated that the items measured could be reduced into five factors with an eigenvalue >1.0: Knowledge on dengue, Intradomiciliar risk practices, Peridomiciliar risk practices, Risk perception and Economic status. The proportion of the total variance in the data explained by these five factors was 74.3%. The Confirmatory Factor Analysis model differed from our hypothesized conceptual model. Only Knowledge on dengue had a significant, direct, positive, effect on Practices. There was also a direct association of Economic status with Knowledge on dengue, but not with Risk perception and Practices. Clarifying the relationship between direct and indirect determinants of dengue related practices contributes to a better understanding of the potential effect of Information Education and Communication on practices and on the reduction of Aedes aegypti breeding sites and provides inputs for designing a community based strategy for dengue control.

BACKGROUND: Children are especially vulnerable during periods of resource shortage such as economic embargoes. They are likely to suffer most from poor nutrition, infectious diseases, and other ensuing short-term threats. Moreover, early life circumstances can have important consequences for long-term health. We examined the relationship between early childhood exposure to the Cuban economic situation in the nineties and the occurrence of atopic diseases later in childhood. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional study of 1321 primary schoolchildren aged 4-14 was conducted in two Cuban municipalities. Asthma, allergic rhinoconjunctivitis and atopic dermatitis were diagnosed using the International Study of Asthma and Allergies in Childhood questionnaire. Children were divided into three groups of exposure to the economic situation in the nineties according to birth date: (1) unexposed; (2) exposed during infancy; (3) exposed during infancy and early childhood. Associations were assessed using multiple logistic regression models. Exposure during infancy had a significant inverse association with the occurrence of asthma (OR 0.56, 95%CI 0.33-0.94) and allergic rhinoconjunctivitis (OR 0.46, 95%CI 0.25-0.85). The associations were stronger after longer exposure, i.e. during infancy and early childhood, for asthma (OR 0.40, 95% CI 0.17-0.95) and allergic rhinoconjunctivitis (OR 0.29, 95%CI 0.11-0.77). No significant associations were found for atopic dermatitis. CONCLUSIONS/SIGNIFICANCE: Exposure to the economic situation in the nineties during infancy and early childhood was inversely associated with asthma and allergic rhinoconjunctivitis occurrence later in childhood. We hypothesize that factors related to this period, such as infectious diseases and undernutrition, may have an attenuating effect on atopic disease development. The exact cause and underlying mechanisms need to be further elucidated.

ObjectiveTo assess the operational effectiveness of long-lasting insecticide treated materials (ITMs), when used at household level, for the control of Aedes aegypti in moderately infested urban and suburban areas.MethodsIn an intervention study, ITMs consisting of curtains and water jar-covers (made from PermaNet) were distributed under routine field conditions in 10 clusters (5 urban and 5 suburban), with over 4000 houses, in Trujillo, Venezuela. Impact of the interventions were determined by comparing pre-and post-intervention measures of the Breteau index (BI, number of positive containers/100 houses) and pupae per person index (PPI), and by comparison with indices from untreated areas of the same municipalities. The effect of ITM coverage was modeled.ResultsAt distribution, the proportion of households with ≥1 ITM curtain was 79.7% in urban and 75.2% in suburban clusters, but decreased to 32.3% and 39.0%, respectively, after 18 months. The corresponding figures for the proportion of jars using ITM covers were 34.0% and 50.8% at distribution and 17.0% and 21.0% after 18 months, respectively. Prior to intervention, the BI was 8.5 in urban clusters and 42.4 in suburban clusters, and the PPI was 0.2 and 0.9, respectively. In both urban and suburban clusters, the BI showed a sustained 55% decrease, while no discernable pattern was observed at the municipal level. After controlling for confounding factors, the percentage ITM curtain coverage, but not ITM jar-cover coverage, was significantly associated with both entomological indices (Incidence Rate Ratio = 0.98; 95%CI 0.97-0.99). The IRR implied that ITM curtain coverage of at least 50% was necessary to reduce A. aegypti infestation levels by 50%.ConclusionDeployment of insecticide treated window curtains in households can result in significant reductions in A. aegypti levels when dengue vector infestations are moderate, but the magnitude of the effect depends on the coverage attained, which itself can decline rapidly over time.

IntroductionIn high multidrug resistant (MDR) tuberculosis (TB) prevalence areas, drug susceptibility testing (DST) at diagnosis is recommended for patients with risk factors for MDR. However, this approach might miss a substantial proportion of MDR-TB in the general population. We studied primary MDR in patients considered to be at low risk of MDR-TB in Lima, Peru.MethodsWe enrolled new sputum smear-positive TB patients who did not report any MDR-TB risk factor: known exposure to a TB patient whose treatment failed or who died or who was known to have MDR-TB; immunosuppressive co-morbidities, ex prison inmates; prison and health care workers; and alcohol or drug abuse. A structured questionnaire was applied to all enrolled participants to confirm the absence of these factors and thus minimize underreporting. Sputum from all participants was cultured on Löwenstein-Jensen media and DST for first line drugs was performed using the 7H10 agar method.ResultsOf 875 participants with complete data, 23.2% (203) had risk factors for MDR-TB elicited after enrolment. Among the group with no reported risk factors who had a positive culture, we found a 6.3% (95%CI 4.4-8.3) (37/584) rate of MDR-TB. In this group no epidemiological characteristics were associated with MDR-TB. Thus, in this group, multidrug resistance occurred in patients with no identifiable risk factors.ConclusionsWe found a high rate of primary MDR-TB in a general population with no identifiable risk factors for MDR-TB. This suggests that in a high endemic area targeting patients for MDR-TB based on the presence of risk factors is an insufficient intervention.

BACKGROUND: Clinical suspects of pulmonary tuberculosis in which the sputum smears are negative for acid fast bacilli represent a diagnostic challenge in resource constrained settings. Our objective was to validate an existing clinical-radiographic score that assessed the probability of smear-negative pulmonary tuberculosis (SNPT) in high incidence settings in Peru. METHODOLOGY/PRINCIPAL FINDINGS: We included in two referral hospitals in Lima patients with clinical suspicion of pulmonary tuberculosis and two or more negative sputum smears. Using a published but not externally validated score, patients were classified as having low, intermediate or high probability of pulmonary tuberculosis. The reference standard for the diagnosis of tuberculosis was a positive sputum culture in at least one of 2 liquid (MGIT or Middlebrook 7H9) and 1 solid (Ogawa) media. Prevalence of tuberculosis was calculated in each of the three probability groups. 684 patients were included. 184 (27.8%) had a diagnosis of pulmonary tuberculosis. The score did not perform well in patients with a previous history of pulmonary tuberculosis. In patients without, the prevalence of tuberculosis was 5.1%, 31.7% and 72% in the low, intermediate and high probability group respectively. The area under de ROC curve was 0.76 (95% CI 0.72-0.80) and scores ≥6 had a positive LR of 10.9. CONCLUSIONS/SIGNIFICANCE: In smear negative suspects without previous history of tuberculosis, the clinical-radiographic score can be used as a tool to assess the probability of pulmonary tuberculosis and to guide the decision to initiate or defer treatment or to requesting additional tests.

Standard short course chemotherapy is recommended by the World Health Organization to control tuberculosis worldwide. However, in settings with high drug resistance, first line standard regimens are linked with high treatment failure. We evaluated treatment outcomes after standardized chemotherapy with the WHO recommended category II retreatment regimen in a prison with a high prevalence of drug resistant tuberculosis (TB). A cohort of 233 culture positive TB patients was followed through smear microscopy, culture, drug susceptibility testing and DNA fingerprinting at baseline, after 3 months and at the end of treatment. Overall 172 patients (74%) became culture negative, while 43 (18%) remained positive at the end of treatment. Among those 43 cases, 58% of failures were determined to be due to treatment with an inadequate drug regimen and 42% to either an initial mixed infection or re-infection while under treatment. Overall, drug resistance amplification during treatment occurred in 3.4% of the patient cohort. This study demonstrates that treatment failure is linked to initial drug resistance, that amplification of drug resistance occurs, and that mixed infection and re-infection during standard treatment contribute to treatment failure in confined settings with high prevalence of drug resistance.

With the 1978 Alma Ata declaration, community participation was brought to the fore as a key component of primary health care. This paper describes how the concepts of people’s participation and empowerment evolved throughout the last three decades and how these evolutions are linked with the global changing socio-economic context. On the basis of a literature review and building on empirical experience with grass roots health programs, three key issues are identified to revive these concepts: The recognition that power, power relations and conflicts are the cornerstone of the empowerment framework; the need to go beyond the community and factor in the broader context of the society including the role of the State; and, considering that communities and society are not homogeneous entities, the importance of class analysis in any empowerment framework.

Explicar las causas de la no salud ha sido siempre objeto de interés de la comunidad científica, por eso existen numerosos modelos que intentan explicar la determinación de la salud en individuos y poblaciones. Estos modelos reflejan la realidad y los intereses de países muy diferentes al nuestro, lo cual propicia la necesidad de contar con un modelo que explique este proceso desde la realidad concreta cubana. Por este motivo se pretende una actualización conceptual de los componentes del modelo cubano de determinación y/o producción social de la salud. Se realizó un análisis histórico-lógico de las evidencias derivadas de los estudios previos realizados por los autores los cuales fueron expuestos en un taller de integración y sistematización. La salud en Cuba está determinada por la voluntad política, la acción intersectorial y el diseño de políticas sanitarias basadas en la reorganización de los servicios de salud y el desarrollo permanente de su capital humano, además de otros muchos factores que al actuar de manera individual o combinada, se asocian con el estado de salud de la población. Este modelo aporta al análisis espacial del comportamiento de la salud y sus determinantes, el concepto de diferenciales en salud, que nada tiene que ver con las injustas y evitables desigualdades o inequidades en salud. Se reitera la tesis de que a cada espacio y momento concreto le corresponde una explicación específica de cómo se produce la salud socialmente y cuáles son las premisas y factores que contribuyen a ese proceso.To explain the causes of non-health always has been an interesting subject for the scientific community, thus there are many forms designed to explain the health determination in subjects and populations. These forms reflect the reality and the interests of countries vary different to our, allowing the need to count on a form explaining this process from the Cuban specific reality. Hence, this conceptual updating of components of Cuban form of determination and/or social production of health. A historical-logical analysis was carried out of the evidences derived from early studies conducted by the authors, which were exposed to a integration and systematization workshop. The health in Cuba is determined by the political will, the inter-sectors and the design of health politics based on the reorganization of health services and the permanent development of its human resource as well as other many factors hat in a individual or combined way, are associated with the health status of population. Present form provides to health behavior spatial analysis and its determinants, the concept of health differences differing with the unfair and avoidable inequalities in health. It is reiterate the theory that each concrete space or moment deserve an specific explanation on how health is socially produced and which are the premises and factors contributing to this process.

El objetivo del presente estudio fue describir cuáles fueron los factores de impacto en la determinación de la salud de los cubanos durante el período de 1989 a 2000. Se utilizó un diseño cualitativo emergente con tres técnicas básicas: la revisión de documentos, el desarrollo de entrevistas a expertos del sector salud y de otros sectores, incluida la población, y la realización de talleres de sistematización e integración de las evidencias recogidas. Entre los principales factores de impacto positivos se identificaron: las políticas estatales, el desarrollo permanente del Sistema Nacional de Salud, la reorganización de los servicios de salud, la formación de capital humano en salud y el posterior desempeño de este, y el papel de las redes de apoyo social. Entre los factores negativos se registraron el deterioro de las condiciones higiénico-ambientales, la disponibilidad de alimentos y el incremento del consumo de alcohol y productos derivados del tabaco. La voluntad política, la intersectorialidad promovida y controlada por el Estado, la cohesión social y una adecuada organización y perfeccionamiento de los servicios de salud constituyeron las premisas básicas para mejorar o mantener los niveles de salud de la población cubana, especialmente en las condiciones existentes durante el período especial, lo que confirma el modelo teórico desarrollado previamente por los autores.The aim of present paper was to describe the impacting risks on the Cuban health determination during period from 1980 to 2000. We used an emergent qualitative design with three basic techniques: document review, development of interviews to health sector experts, and of other sectors, including the population, training of human beings in health, and the subsequent performance of it, and the role of social support networks. Among negative factors were the deterioration of health-environment conditions, availability of foods, and the increment of alcohol consumption and tobacco derivate products. Among the main factors of a positive impact are included: state policies, the permanent development of Health National System, reorganization of health services, training of health staff, and the subsequent performance of it, the role of social support networks. Among the negative ones are included: deterioration of hygienic-environmental conditions, foods availability, and the increase of alcohol consumption and of tobacco-derived products. Political will, inter-sectorial relations promoted and controlled by State, social cohesion, and a proper organization and improvement of Cuban health services, especially in conditions available during special period, confirming the theoretical model previously developed by authors.

No existen muchas publicaciones nacionales o internacionales que traten el tema de los estudios organizacionales como alternativa para evaluar el rol de los servicios de salud en el proceso de producción social de la salud y, en especial, como un determinante de la salud. En el presente artículo se expusieron aspectos relacionados con este tema, se plantearon las base conceptuales de los estudios organizacionales y se justificó la necesidad de implementar este tipo de estudio en los servicios de salud, para explicar a nivel local cómo se produce la mencionada contribución a la salud de la población, cuáles son sus factores de éxito y cuáles son las áreas susceptibles de mejora. Se expuso una metodología derivada de las lecciones aprendidas y de la experiencia que los autores han alcanzado en este campo, durante más de dos décadas de trabajo en el sistema de salud cubano.There is a lack of national and international publications on organizational studies as a alternative to assess the role of health services in the process of health social production y, specially as a health determinant. In present paper are exposed features related to this matter, are proposed the conceptual bases of organizational studies in health services to explain at local level how is produced the mentioned contribution for population health, which are its success factor, and which are the areas that be improved. We exposed a methodology derived from learned lessons, and the experience gained by authors in this field during more of two decades of work in Cuban health system.

El programa del médico y la enfermera de la familia, iniciado en 1984, resultó también afectado por la crisis económica desencadenada con la caída del campo socialista en Europa del Este en los años 90. Por considerarse el programa un pilar del sistema sanitario cubano, se definió la realización de un estudio descriptivo sobre aspectos relacionados con el funcionamiento de los equipos básicos de salud en los municipios de Centro Habana y San Antonio de los Baños, a partir del año 2003. Durante la investigación se aplicaron técnicas cualitativas y cuantitativas con cálculo de porcentajes para los grupos estudiados de médicos, enfermeras y pacientes. En los resultados se reconoció que la existencia de locales de consulta compartidos por varios equipos básicos de salud representa un elemento a considerar para el desarrollo de la atención primaria. Futuras medidas organizativas que se proponen podrían mejorar la labor que se desarrolla en estas estructuras sanitarias.The family physician and nurse program that started in 1984 was also affected by the economic crisis resulting from the collapse of the socialist field in Eastern Europe during the 90's. Taking into consideration that this program is a milestone of the Cuban health system, it was decided to conduct a descriptive study on the aspects related to the functioning of the basic health equipment in the municipalities of Centro Habana and San Antonio de los Baños from 2003 on. During the investigation, qualitative and quantitative techniques with percentage calculation were applied to the studied groups of physicians, nurses and patients. According to the results, it was recognized that the existence of offices shared by several basic health teams represents an element that should be considered for the development of primary health care. Future organizational measures could improve the work done in these health structures.

El objetivo del presente trabajo fue determinar el uso de los servicios ambulatorios por pacientes asmáticos en edad pediátrica y los gastos de bolsillo relacionados con su atención. Se empleó una cohorte de 232 asmáticos (5 a 14 años), seleccionados aleatoriamente en 2 áreas de salud del municipio Cerro, en Ciudad de La Habana, quienes fueron visitados en sus hogares mensualmente durante 6 meses. Se aplicó un cuestionario que exploró variables relacionadas con la enfermedad y los gastos adicionales por alimentos, transporte y medicamentos. Para el análisis se utilizaron proporciones, medias y percentiles (25-50-75). La media de contactos con los servicios de salud por paciente fue 3,6 (DS 4,5). La utilización de los servicios de emergencia representó el 49,1 % del total de consultas. La severidad de la enfermedad constituyó un factor predictor del uso de los servicios ambulatorios en dieferentes niveles de atención. El 27 % de los pacientes no contactó con los servicios de salud, cuyo uso no se asoció ni a la escolaridad ni a la ocupación de los padres (pThe objective of the present paper was to determine the use of outpatient services by asthmatic pediatric patients and the costs of their care. A cohort of 232 asthmatic children (5 to 14 years of age) was used, who were randomly selected from two health areas of Cerro municipality in the City of Havana and monthly visited at home for 6 months in a row. The administered questionnaire explored variables linked to disease and extra costs from food, transportation and medication. For the analysis, ratios, means and percentiles (25-50-75) were used. The mean of contacts with health care services per patient was 3.6 (SD 4,5). The use of emergency services accounted for 49.1 % of the total number of appointments. The disease severity was a predictive factor for the use of outpatient services at different levels of care. Twenty seven percent of patients did not contact any health service, the use of which was associated neither to schooling nor thetype of work of the parents (p

This study developed a clinical score based on clinical and radiographic data for the diagnosis of smear-negative pulmonary tuberculosis (SNPT). SNPT was defined as a positive culture in Ogawa in a patient with two negative sputum smears. Data from patients admitted to the emergency ward with respiratory symptoms and negative acid-fast bacilli (AFB) smears was analyzed by means of logistic regression to develop the predictive score.Two hundred and sixty two patients were included. Twenty patients had SNPT. The variables included in the final model were hemoptysis, weight loss, age > 45 years old, productive cough, upper-lobe infiltrate, and miliary infiltrate. With those, a score was constructed. The score values ranged from -2 to 6. The area under the curve for the ROC curve was 0.83 (95% CI 0.74-0.90). A score of value 0 or less was associated with a sensitivity of 93% and a score of more than 4 points was associated with a specificity of 92% for SNPT. Fifty-two point twenty-nine percent of patients had scores of less than one or more than four, what provided strong evidence against and in favor, respectively, for the diagnosis of SNPT. The score developed is a cheap and useful clinical tool for the diagnosis of SNPT and can be used to help therapeutic decisions in patients with suspicion of having SNPT.