Prevalence of human cystic echinococcosis in the towns of Ñorquinco and Ramos Mexia in Rio Negro Province, Argentina, and direct risk factors for infection.

BACKGROUND: Cystic echinococcosis (CE) is a parasitic zoonosis caused by infection with the larval stage of Echinococcus granulosus (s.l.). This study investigated the prevalence and potential risk factors associated with human CE in the towns and rural areas of Ñorquinco and Ramos Mexia, Rio Negro province, Argentina. METHODS: To detect abdominal CE cysts, we screened 892 volunteers by ultrasound and investigated potential risk factors for CE using a standardized questionnaire. Prevalence ratio (PR) with 95% confidence intervals (CI) was used to measure the association between CE and the factors investigated, applying bivariate and multivariate analyses. RESULTS: Abdominal CE was detected in 42/892 screened volunteers (4.7%, 95% CI 3.2-6.1), only two of whom were under 15 years of age. Thirteen (30.9%) CE cases had 25 cysts in active stages (CE1, CE2, CE3a, according to the WHO Informal Working Group on Echinococcosis [WHO-IWGE] classification). The most relevant risk factors identified in the bivariate analysis included: living in rural areas (P = 0.003), age > 40 years (P = 0.000), always drinking water from natural sources (P = 0.007), residing in rural areas during the first 5 years of life (P = 0.000) and having lived more than 20 years at the current address (P = 0.013). In the multivariate final model, the statistically significant risk factors were: frequently touching dogs (P = 0.012), residing in rural areas during the first 5 years of life (P = 0.004), smoking (P = 0.000), age > 60 years (P = 0.002) and living in rural areas (P = 0.017). CONCLUSIONS: Our results point toward infection with CE being acquired since childhood and with constant exposure throughout life, especially in rural areas with a general environmental contamination.

Lutzomyia longipalpis (Diptera: Psychodidae) Argentina-Bolivia border: new report and genetic diversity.

American visceral leishmaniasis (AVL) has two main scenarios of transmission as follows: scattered cases in rural areas and urban outbreaks. Urban AVL is in active dispersion from the northeastern border of Argentina-Paraguay-Brazil to the South. The presence of Lutzomyia longipalpis was initially reported in urban environments in the northwestern border of the country. The presence of Lu. longipalpis, environmental variables associated with its distribution, and its genetic diversity were assessed in Salvador Mazza, Argentina, on the border with Bolivia. The genetic analysis showed high haplotype diversity, low nucleotide diversity, and low nucleotide polymorphism index. We discuss the hypothesis of an expanding urban population with introgressive hybridisation of older haplogroups found in their path in natural forest or rural environments, acquiring a new adaptability to urban environments, and the possibility of changes in vector capacity.

Lutzomyia longipalpis (Diptera: Psychodidae) Argentina-Bolivia border: new report and genetic diversity

American visceral leishmaniasis (AVL) has two main scenarios of transmission as follows: scattered cases in rural areas and urban outbreaks. Urban AVL is in active dispersion from the northeastern border of Argentina-Paraguay-Brazil to the South. The presence of Lutzomyia longipalpis was initially reported in urban environments in the northwestern border of the country. The presence of Lu. longipalpis, environmental variables associated with its distribution, and its genetic diversity were assessed in Salvador Mazza, Argentina, on the border with Bolivia. The genetic analysis showed high haplotype diversity, low nucleotide diversity, and low nucleotide polymorphism index. We discuss the hypothesis of an expanding urban population with introgressive hybridisation of older haplogroups found in their path in natural forest or rural environments, acquiring a new adaptability to urban environments, and the possibility of changes in vector capacity.

Malaria epidemiology in Suriname from 2000 to 2016: trends, opportunities and challenges for elimination.

BACKGROUND: Suriname has experienced a significant change in malaria transmission risk and incidence over the past years. The country is now moving toward malaria elimination. The first objective of this study is to describe malaria epidemiological trends in Suriname between 2000 and 2016. The second objective is to identify spatiotemporal malaria trends in notification points between 2007 and 2016. METHODS: National malaria surveillance data resulting from active and passive screening between 2000 and 2016 were used for the temporal trend analysis. A space-time cluster analysis using SaTScan™ was conducted on Malaria Programme-data from 2007 to 2016 comparing cases (people tested positive) with controls (people tested negative). RESULTS: Suriname experienced a period of high malaria incidence during 2000-2005, followed by a steep decline in number of malaria cases from 2005 onwards. Imported malaria cases, mostly of Brazilian nationality and travelling from French Guiana, were major contributors to the reported number of cases, exceeding the national malaria burden (94.2% of the total). Most clusters in notification points are found in the border area between Suriname and French Guiana. Clustering was also found in the migrant clinic in Paramaribo. CONCLUSIONS: Suriname has successfully reduced malaria to near-elimination level in the last 17 years. However, the high malaria import rate resulting from cross-border moving migrants is a major challenge for reaching elimination. This requires continued investment in the national health system, with a focus on border screening and migrant health. A regional approach to malaria elimination within the Guianas and Brazil is urgently needed.

Hidden danger: Unexpected scenario in the vector-parasite dynamics of leishmaniases in the Brazil side of triple border (Argentina, Brazil and Paraguay).

Every year about 3 million tourists from around the world visit Brazil, Argentina and Paraguay´s triple border region where the Iguaçu Falls are located. Unfortunately, in recent years an increasing number of autochthonous canine and human visceral leishmaniasis (VL) cases have been reported. The parasite is Leishmania (Leishmania) infantum and it is transmitted by sand flies (Phlebotominae). To assess the risk factors favorable for the establishment and spread of potential vectors the Centers for Disease Control and Prevention light trap (CDC-light trap) collections were made in the Foz do Iguaçu (FI) and Santa Terezinha de Itaipu (STI) townships and along two transects between them. Our study determined the Phlebotominae fauna, the factors that affect the presence and abundance of Lutzomyia longipalpis and Nyssomyia whitmani, the presence of L. infantum in different sand fly species and which Leishmania species are present in this region. Lutzomyia longipalpis was the prevalent species and its distribution was related to the abundance of dogs. Leishmania infantum was found in Lu. longipalpis, Ny. whitmani, Ny. neivai and a Lutzomyia sp. All the results are discussed within the Stockholm Paradigm and focus on their importance in the elaboration of public health policies in international border areas. This region has all the properties of stable VL endemic foci that can serve as a source of the disease for neighboring municipalities, states and countries. Most of the urban areas of tropical America are propitious for Lu. longipalpis establishment and have large dog populations. Pan American Health Organization´s initiative in supporting the public health policies in the border areas of this study is crucial and laudable. However, if stakeholders do not act quickly in controlling VL in this region, the scenario will inevitable become worse. Moreover, L. (Viannia) braziliensis found in this study supports the need to develop public health policies to avoid the spread of cutaneous leishmaniasis. The consequences of socioeconomic attributes, boundaries and frontiers on the spread of diseases cannot be neglected. For an efficient control, it is essential that urban planning is articulated with the neighboring cities.

Improved tools and strategies for the prevention and control of arboviral diseases: A research-to-policy forum.

BACKGROUND: Research has been conducted on interventions to control dengue transmission and respond to outbreaks. A summary of the available evidence will help inform disease control policy decisions and research directions, both for dengue and, more broadly, for all Aedes-borne arboviral diseases. METHOD: A research-to-policy forum was convened by TDR, the Special Programme for Research and Training in Tropical Diseases, with researchers and representatives from ministries of health, in order to review research findings and discuss their implications for policy and research. RESULTS: The participants reviewed findings of research supported by TDR and others. Surveillance and early outbreak warning. Systematic reviews and country studies identify the critical characteristics that an alert system should have to document trends reliably and trigger timely responses (i.e., early enough to prevent the epidemic spread of the virus) to dengue outbreaks. A range of variables that, according to the literature, either indicate risk of forthcoming dengue transmission or predict dengue outbreaks were tested and some of them could be successfully applied in an Early Warning and Response System (EWARS). Entomological surveillance and vector management. A summary of the published literature shows that controlling Aedes vectors requires complex interventions and points to the need for more rigorous, standardised study designs, with disease reduction as the primary outcome to be measured. House screening and targeted vector interventions are promising vector management approaches. Sampling vector populations, both for surveillance purposes and evaluation of control activities, is usually conducted in an unsystematic way, limiting the potentials of entomological surveillance for outbreak prediction. Combining outbreak alert and improved approaches of vector management will help to overcome the present uncertainties about major risk groups or areas where outbreak response should be initiated and where resources for vector management should be allocated during the interepidemic period. CONCLUSIONS: The Forum concluded that the evidence collected can inform policy decisions, but also that important research gaps have yet to be filled.

Quantitative and histological assessment of maternal-fetal transmission of Trypanosoma cruzi in guinea pigs: An experimental model of congenital Chagas disease.

OBJECTIVE: We evaluated the effect of Trypanosoma cruzi infection on fertility, gestation outcome, and maternal-fetal transmission in guinea pigs (Cavia porcellus). METHODS: Animals were infected with T. cruzi H4 strain (TcI lineage) before gestation (IBG) or during gestation (IDG). Tissue and sera samples of dams and fetuses were obtained near parturition. RESULTS: All IBG and IDG dams were seropositive by two tests, and exhibited blood parasite load of 1.62±2.2 and 50.1±62 parasites/µl, respectively, by quantitative PCR. Histological evaluation showed muscle fiber degeneration and cellular necrosis in all infected dams. Parasite nests were not detected in infected dams by histology. However, qPCR analysis detected parasites-eq/g heart tissue of 153±104.7 and 169.3±129.4 in IBG and IDG dams, respectively. All fetuses of infected dams were positive for anti-parasite IgG antibodies and tissue parasites by qPCR, but presented a low level of tissue inflammatory infiltrate. Fetuses of IDG (vs. IBG) dams exhibited higher degree of muscle fiber degeneration and cellular necrosis in the heart and skeletal tissues. The placental tissue exhibited no inflammatory lesions and amastigote nests, yet parasites-eq/g of 381.2±34.3 and 79.2±84.9 were detected in IDG and IBG placentas, respectively. Fetal development was compromised, and evidenced by a decline in weight, crow-rump length, and abdominal width in both groups. CONCLUSIONS: T. cruzi TcI has a high capacity of congenital transmission even when it was inoculated at a very low dose before or during gestation. Tissue lesions, parasite load, and fetal under development provide evidence for high virulence of the parasite during pregnancy. Despite finding of high parasite burden by qPCR, placentas were protected from cellular damage. Our studies offer an experimental model to study the efficacy of vaccines and drugs against congenital transmission of T. cruzi. These results also call for T. cruzi screening in pregnant women and adequate follow up of the newborns in endemic areas.

The applicability of real-time PCR in the diagnostic of cutaneous leishmaniasis and parasite quantification for clinical management: Current status and perspectives.

Cutaneous leishmaniasis (CL) is spread worldwide and is the most common manifestation of leishmaniasis. Diagnosis is performed by combining clinical and epidemiological features, and through the detection of Leishmania parasites (or DNA) in tissue specimens or trough parasite isolation in culture medium. Diagnosis of CL is challenging, reflecting the pleomorphic clinical manifestations of this disease. Skin lesions vary in severity, clinical appearance, and duration, and in some cases, they can be indistinguishable from lesions related to other diseases. Over the past few decades, PCR-based methods, including real-time PCR assays, have been developed for Leishmania detection, quantification and species identification, improving the molecular diagnosis of CL. This review provides an overview of many real-time PCR methods reported for the diagnostic evaluation of CL and some recommendations for the application of these methods for quantification purposes for clinical management and epidemiological studies. Furthermore, the use of real-time PCR for Leishmania species identification is also presented. The advantages of real-time PCR protocols are numerous, including increased sensitivity and specificity and simpler standardization of diagnostic procedures. However, despite the numerous assays described, there is still no consensus regarding the methods employed. Furthermore, the analytical and clinical validation of CL molecular diagnosis has not followed international guidelines so far. A consensus methodology comprising a DNA extraction protocol with an exogenous quality control and an internal reference to normalize parasite load is still needed. In addition, the analytical and clinical performance of any consensus methodology must be accurately assessed. This review shows that a standardization initiative is essential to guide researchers and clinical laboratories towards the achievement of a robust and reproducible methodology, which will permit further evaluation of parasite load as a surrogate marker of prognosis and monitoring of aetiological treatment, particularly in multi-centric observational studies and clinical trials.

Exploring Spatial and Temporal Distribution of Cutaneous Leishmaniasis in the Americas, 2001-2011.

METHODS: Cases reported in the period of 2001-2011 from 14/18 CL endemic countries were included in this study by using two spreadsheet to collect the data. Two indicators were analyzed: CL cases and incidence rate. The local regression method was used to analyze case trends and incidence rates for all the studied period, and for 2011 the spatial distribution of each indicator was analyzed by quartile and stratified into four groups. RESULTS: From 2001-2011, 636,683 CL cases were reported by 14 countries and with an increase of 30% of the reported cases. The average incidence rate in the Americas was 15.89/100,000 inhabitants. In 2011, 15 countries reported cases in 180 from a total of 292 units of first subnational level. The global incidence rate for all countries was 17.42 cases per 100,000 inhabitants; while in 180 administrative units at the first subnational level, the average incidence rate was 57.52/100,000 inhabitants. Nicaragua and Panama had the highest incidence but more cases occurred in Brazil and Colombia. Spatial distribution was heterogeneous for each indicator, and when analyzed in different administrative level. The results showed different distribution patterns, illustrating the limitation of the use of individual indicators and the need to classify higher-risk areas in order to prioritize the actions. This study shows the epidemiological patterns using secondary data and the importance of using multiple indicators to define and characterize smaller territorial units for surveillance and control of leishmaniasis.

Quality of tuberculosis care at different levels of health care in Brazil in 2013.

Objective To assess 1) the burden and socio-demographic and clinical characteristics of tuberculosis (TB) cases, and 2) the quality of TB care provided to patients who entered and remained within each health care service level (primary, secondary, or tertiary) and those who moved from one level to another, using process and results indicators. Methods This cross-sectional operational research study assessed new smear-positive pulmonary TB cases diagnosed in Brazilian state capitals in 2013 using TB program records and the TB surveillance system. Quality of care was assessed based on process and results indicators including HIV screening, TB contact screening, Directly Observed Treatment (DOT), sputum smear microscopy monitoring, and treatment outcomes. Results There were 12 977 new smear-positive TB cases reported. Of these, 7 964 (61.4%) cases were diagnosed and treated at the primary care level, 1 195 (9.2%) at the secondary level, 1 521 (11.7%) at the tertiary level, and 2 296 (17.7%) at more than one level, with 65% of the latter group moved from the tertiary level to the primary level. The proportion of cases tested for HIV was significantly higher in patients receiving care at the primary level compared to those receiving care at the secondary level (prevalence ratio (PR): 1.17; 95% confidence interval (CI): 1.07-1.28) and those attending more than one service level. Patients attending the tertiary health care level had a 122% higher PR for not doing DOT ("DOT not done") compared to patients at the primary level (PR: 2.22; CI: 2.12-2.32). When the two levels were compared, the prevalence for an unfavorable outcome (lost to follow-up, death from TB, death with TB, transferred out, or not evaluated) was higher at the tertiary health care level. Conclusions Primary health services are successfully incorporating the management of new smear-positive TB cases. Primary health care obtained better operational indicators than secondary or tertiary levels.

Implementation of the national tuberculosis guidelines on culture and drug sensitivity testing in Guatemala, 2013.

Objective To assess whether the National Tuberculosis Program (NTP) guidelines for culture and drug sensitivity testing (DST) in Guatemala were successfully implemented, particularly in cases of smear-negative pulmonary tuberculosis (TB) or previously treated TB, by documenting notification rates by department (geographic area), disease type and category, and culture and DST results. Methods This was a cross-sectional, operational research study that merged and linked all patients registered by the NTP and the National Reference Laboratory in 2013, eliminating duplicates. The proportions with culture (for new smear negative pulmonary cases) and culture combined with DST (for previously treated patients) were estimated and analyzed by department. Data were analyzed using EpiData Analysis version 2.2. Results There were 3 074 patients registered with TB (all forms), for a case notification rate of 20/100 000 population. Of these, 2 842 had new TB, of which 2 167 (76%) were smear-positive pulmonary TB (PTB), 385 (14%) were smear-negative PTB, and 290 (10%) were extrapulmonary TB. There were 232 (8%) previously treated cases. Case notification rates (all forms) varied by department from 2-68 per 100 000 population, with the highest rates seen in the southwest and northeast part of Guatemala. Of new TB patients, 136 had a culture performed and 55 had DST of which the results were 33 fully sensitive, 9 monoresistant, 3 polyresistant, and 10 multidrug resistant TB (MDR-TB). Only 21 (5%) of new smear-negative PTB patients had cultures. Of 232 previously treated patients, 54 (23%) had a culture and 47 (20%) had DST, of which 29 were fully sensitive, 7 monoresistant, 2 polyresistant, and 9 MDR-TB. Of 22 departments (including the capital), culture and DST was performed in new smear-negative PTB in 7 departments (32%) and in previously treated TB in 13 departments (59%). Conclusions Despite national guidelines, only 5% of smear-negative PTB cases had a culture and only 20% of previously treated TB had a culture and DST. Several departments did not perform culture or DST. These short comings must be improved if Guatemala is to curtail the spread of drug resistant forms of TB, while striving to eliminate all TB.

Contrasting trends of tuberculosis in the cities of San Pedro Sula and Tegucigalpa, Honduras, 2005-2014.

Objective To 1) describe and compare the trends of tuberculosis (TB) case notification rates (CNRs) and treatment outcomes in the two largest cities in Honduras (San Pedro Sula and Tegucigalpa) for the period 2005-2014 and 2) identify possible related socioeconomic and health sector factors. Methods This retrospective ecological operational research study used aggregated data from the National TB Program (socioeconomic and health sector information and individual data from the 2014 TB case notification report). Results TB CNRs declined steadily over the study period in Tegucigalpa (from 46 to 28 per 100 000 inhabitants) but remained high in San Pedro Sula (decreasing from 89 to 78 per 100 000 inhabitants). Similar trends were observed for smear-positive TB. While presumptive TB cases examined were similar for both cities, in San Pedro Sula the proportions of presumptive cases with a positive smear; (7.7% versus 3.6%) relapses (8.9% versus 4.2%); and patients lost to follow-up (10.9% versus 2.7%) were significantly higher, and the treatment success lower (75.7% versus 87.0%). San Pedro Sula had lower annual income per capita, fewer public sector health workers and facilities, and a higher and increasing homicide index. The 2014 TB case data from San Pedro Sula showed a significantly lower median age and a higher proportion of assembly plant workers, prisoners, drug abusers, and diabetes. Conclusions The TB rate was higher and treatment success lower, and health care resources and socio-demographic indicators less favorable, in San Pedro Sula versus Tegucigalpa. City authorities, the NTP, and the health sector overall should strengthen early case detection, treatment, and infection control, involving both public and private health sectors.

[Retrospective eco-epidemiology as a tool for the surveillance of leishmaniasis in Misiones, Argentina, 1920-2014]. / La eco-epidemiología retrospectiva como herramienta aplicada a la vigilancia de la leishmaniasis en Misiones, Argentina, 1920-2014.

A retrospective analytical method is presented, based on theoretical eco-epidemiology, applied on a subnational spatial scale. This method was used here to describe scenarios for the transmission of leishmaniasis in the Argentine province of Misiones- bordering Brazil and Paraguay-and formed the basis for recommendations for surveillance and control appropriate to the subnational scale. An exhaustive search of the literature on leishmaniasis in the province was carried out. Three scenarios for the transmission of cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) were found, corresponding to three periods: from 1920 to 1997, during which the transmission of CL distributed over time and space was confirmed; 1998 to 2005, during which there were focal outbreaks of CL; and 2006 to 2014, during which outbreaks were also reported and the geographical dispersion of VL was documented. To describe the risk scenarios and the anthropic processes that produce them, the results were summarized and integrated into the social, historical, and bio-ecological context of each period. Surveillance and control recommendations are based on the territory studied. They include establishing active surveillance to monitor possible rising trends in parasitic and vector circulation, conducting studies of any focal outbreak in order to confirm indigenous transmission and severity. Also, it should be a legal requirement for persons responsible for projects that alter the environment to adopt additional control measures, such as studies assessing transmission risk, risk mitigation, early detection, and timely case management.

La eco-epidemiología retrospectiva como herramienta aplicada a la vigilancia de la leishmaniasis en Misiones, Argentina, 1920-2014 / Retrospective eco-epidemiology as a tool for the surveillance of leishmaniasis in Misiones, Argentina, 1920–2014

Se presenta una metodología analítica retrospectiva, basada en el marco teórico de la eco-epidemiología, anclada en una escala espacial subnacional. Esta metodología, aplicada aquí a la caracterización de escenarios de transmisión de la leishmaniasis en la provincia argentina de Misiones —fronteriza con Brasil y Paraguay— permitió fundamentar recomendaciones de vigilancia y control apropiadas a dicha escala. Se realizó una búsqueda exhaustiva de la literatura sobre leishmaniasis en esa provincia y se determinaron tres escenarios de transmisión de leishmaniasis cutánea (LC) y visceral (LV), correspondientes a tres períodos: 1920-1997, en el que se constató la transmisión de LC, dispersa en el tiempo y el espacio; 1998-2005, en el que hubo brotes focales de LC; y 2006-2014 en el que, además, se registraron brotes y se documentó la dispersión geográfica de la LV. Para caracterizar los escenarios de riesgo y los procesos antrópicos que los producen, los resultados se sintetizaron e integraron en el contexto socio-histórico y bio-ecológico de cada período analizado. Se fundamentan recomendaciones de vigilancia y control en el territorio estudiado, entre ellas, establecer una vigilancia activa para monitorear posibles tendencias al incremento de la circulación parasitaria y vectorial y, ante la aparición de un foco, realizar estudios para verificar la transmisión autóctona y la intensidad del evento. Además, se debe establecer la obligación legal de tomar medidas adicionales de control por los responsables de los proyectos que impliquen modificación ambiental, como la realización de estudios de evaluación del riesgo de transmisión, y acciones de mitigación del riesgo, detección temprana y tratamiento oportuno de los casos.

A retrospective analytical method is presented, based on theoretical eco-epidemiology, applied on a subnational spatial scale. This method was used here to describe scenarios for the transmission of leishmaniasis in the Argentine province of Misiones—bordering Brazil and Paraguay—and formed the basis for recommendations for surveillance and control appropriate to the subnational scale. An exhaustive search of the literature on leishmaniasis in the province was carried out. Three scenarios for the transmission of cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) were found, corresponding to three periods: from 1920 to 1997, during which the transmission of CL distributed over time and space was confirmed; 1998 to 2005, during which there were focal outbreaks of CL; and 2006 to 2014, during which outbreaks were also reported and the geographical dispersion of VL was documented. To describe the risk scenarios and the anthropic processes that produce them, the results were summarized and integrated into the social, historical, and bio-ecological context of each period. Surveillance and control recommendations are based on the territory studied. They include establishing active surveillance to monitor possible rising trends in parasitic and vector circulation, conducting studies of any focal outbreak in order to confirm indigenous transmission and severity. Also, it should be a legal requirement for persons responsible for projects that alter the environment to adopt additional control measures, such as studies assessing transmission risk, risk mitigation, early detection, and timely case management.

Contrasting trends of tuberculosis in the cities of San Pedro Sula and Tegucigalpa, Honduras, 2005–2014 / Contrasting trends of tuberculosis in the cities of San Pedro Sula and Tegucigalpa, Honduras, 2005–2014 Ejecución Tendencias discordantes de tuberculosis en San Pedro Sula y Tegucigalpa, Honduras, del 2005 al 2014

Objective. To 1) describe and compare the trends of tuberculosis (TB) case notification rates (CNRs) and treatment outcomes in the two largest cities in Honduras (San Pedro Sula and Tegucigalpa) for the period 2005–2014 and 2) identify possible related socioeconomic and health sector factors. Methods. This retrospective ecological operational research study used aggregated data from the National TB Program (socioeconomic and health sector information and individual data from the 2014 TB case notification report). Results. TB CNRs declined steadily over the study period in Tegucigalpa (from 46 to 28 per 100 000 inhabitants) but remained high in San Pedro Sula (decreasing from 89 to 78 per 100 000 inhabitants). Similar trends were observed for smear-positive TB. While presumptive TB cases examined were similar for both cities, in San Pedro Sula the proportions of presumptive cases with a positive smear; (7.7% versus 3.6%) relapses (8.9% versus 4.2%); and patients lost to follow-up (10.9% versus 2.7%) were significantly higher, and the treatment success lower (75.7% versus 87.0%). San Pedro Sula had lower annual income per capita, fewer public sector health workers and facilities, and a higher and increasing homicide index. The 2014 TB case data from San Pedro Sula showed a significantly lower median age and a higher proportion of assembly plant workers, prisoners, drug abusers, and diabetes. Conclusions. The TB rate was higher and treatment success lower, and health care resources and socio-demographic indicators less favorable, in San Pedro Sula versus Tegucigalpa. City authorities, the NTP, and the health sector overall should strengthen early case detection, treatment, and infection control, involving both public and private health sectors.

Objetivo. Describir y comparar las tendencias de las tasas de notificación de casos de tuberculosis y los desenlaces terapéuticos en las dos principales ciudades de Honduras (San Pedro Sula y Tegucigalpa) durante el período del 2005 al 2014; y reconocer los posibles factores socioeconómicos y del sector de la salud que se relacionan con estos resultados. Métodos. Estudio ecológico retrospectivo de investigación operativa con datos agregados del Programa Nacional contra la Tuberculosis. La información socioeconómica y del sector de la salud y los datos individuales se obtuvieron del informe de notificación de casos de tuberculosis del 2014. Resultados. Las tasas de notificación de casos de tuberculosis disminuyeron en forma sostenida durante el período del estudio en Tegucigalpa (de 46 a 28 por 100 000 habitantes) pero permanecieron altas en San Pedro Sula (disminuyeron de 89 a 78 casos por 100 000 habitantes). Se observaron tendencias análogas en los casos de tuberculosis con baciloscopia positiva. Si bien el número de casos con presunción clínica de tuberculosis examinados en ambas ciudades fue equivalente, en San Pedro Sula los casos con baciloscopia positiva, las recaídas (8,9% frente a 4,2%) y los pacientes perdidos durante el seguimiento (10,9% frente a 2,7%) fueron significativamente más frecuentes y la tasa de éxito terapéutico fue más baja (75,7% frente a 87,0%). En San Pedro Sula se observó un ingreso anual por habitante más bajo, menos personal y establecimientos de salud en el sector público, y un índice más alto y creciente de homicidios. Los datos sobre los casos de tuberculosis del 2014 en San Pedro Sula revelaron una mediana de edad de los pacientes significativamente menor y una mayor proporción de trabajadores de instalaciones de montaje, prisioneros, consumidores de drogas y pacientes con diabetes. Conclusiones. En San Pedro Sula la tasa de tuberculosis fue más alta, la tasa de éxito terapéutico fue inferior y los indicadores sobre los recursos de atención de salud y los aspectos sociodemográficos fueron menos favorables en comparación con Tegucigalpa. Las autoridades municipales, el Programa Nacional contra la Tuberculosis y el sector sanitario en general deben fortalecer la detección temprana de casos, el tratamiento y el control de la infección mediante la participación del sector público y el sector privado de la salud. Palabras clave Tuberculosis, zonas

Implementation of the national tuberculosis guidelines on culture and drug sensitivity testing in Guatemala, 2013 / Ejecución de las directrices nacionales de tuberculosis sobre cultivo y antibiograma en Guatemala en el 2013

Objective. To assess whether the National Tuberculosis Program (NTP) guidelines for culture and drug sensitivity testing (DST) in Guatemala were successfully implemented, particularly in cases of smear-negative pulmonary tuberculosis (TB) or previously treated TB, by documenting notification rates by department (geographic area), disease type and category, and culture and DST results. Methods. This was a cross-sectional, operational research study that merged and linked all patients registered by the NTP and the National Reference Laboratory in 2013, eliminating duplicates. The proportions with culture (for new smear negative pulmonary cases) and culture combined with DST (for previously treated patients) were estimated and analyzed by department. Data were analyzed using EpiData Analysis version 2.2. Results. There were 3 074 patients registered with TB (all forms), for a case notification rate of 20/100 000 population. Of these, 2 842 had new TB, of which 2 167 (76%) were smear-positive pulmonary TB (PTB), 385 (14%) were smear-negative PTB, and 290 (10%) were extrapulmonary TB. There were 232 (8%) previously treated cases. Case notification rates (all forms) varied by department from 2–68 per 100 000 population, with the highest rates seen in the southwest and northeast part of Guatemala. Of new TB patients, 136 had a culture performed and 55 had DST of which the results were 33 fully sensitive, 9 monoresistant, 3 polyresistant, and 10 multidrug resistant TB (MDR-TB). Only 21 (5%) of new smear-negative PTB patients had cultures. Of 232 previously treated patients, 54 (23%) had a culture and 47 (20%) had DST, of which 29 were fully sensitive, 7 monoresistant, 2 polyresistant, and 9 MDR-TB. Of 22 departments (including the capital), culture and DST was performed in new smear-negative PTB in 7 departments (32%) and in previously treated TB in 13 departments (59%). Conclusions. Despite national guidelines, only 5% of smear-negative PTB cases had a culture and only 20% of previously treated TB had a culture and DST. Several departments did not perform culture or DST. These short comings must be improved if Guatemala is to curtail the spread of drug resistant forms of TB, while striving to eliminate all TB.

Objetivo. Evaluar la eficacia de la ejecución de las directrices del Programa Nacional contra la Tuberculosis sobre cultivo y antibiograma en Guatemala, sobre todo en los casos de tuberculosis pulmonar con baciloscopia negativa o con antecedentes de tratamiento antituberculoso, mediante la investigación de las tasas de notificación por departamentos (o zonas geográficas), por tipos y categorías de la enfermedad y el examen de los resultados del cultivo y el antibiograma. Métodos. Estudio transversal de investigación operativa en el cual se fusionaron y se vincularon todos los pacientes registrados en el Programa Nacional contra la Tuberculosis y el Laboratorio Nacional de Referencia en el 2013, tras la eliminación de los duplicados. Se calculó la proporción de casos con cultivo (en los casos nuevos de tuberculosis pulmonar con baciloscopia negativa) y de casos con cultivo y antibiograma (en los casos anteriormente tratados) y se analizaron por departamentos. Resultados. Se registraron 3 074 pacientes con diagnóstico de tuberculosis (de todas las formas), lo cual representa una tasa de notificación de 20 casos por 100 000 habitantes. De estos pacientes, 2 842 fueron casos nuevos de tuberculosis, de los cuales 2 167 (76%) con diagnóstico de tuberculosis pulmonar y baciloscopia positiva, 385 (14%) con tuberculosis pulmonar y baciloscopia negativa y 290 casos (10%) con diagnóstico de tuberculosis extrapulmonar. Los casos con antecedentes de tratamiento antituberculoso fueron 232 (8%). Las tasas de notificación (de todas las formas) según el departamento oscilaron entre 2 y 68 casos por 100 000 habitantes y las tasas más altas se observaron en el suroeste y en parte del noreste de Guatemala. De los casos nuevos de tuberculosis, 136 contaban con cultivo y 55 con antibiograma; los resultados de estas pruebas revelaron 33 casos completamente sensibles, 9 casos monorresistentes, 3 casos polirresistentes y 10 casos de tuberculosis multirresistente (MR). Solo 21 (5%) de los casos nuevos de tuberculosis pulmonar y baciloscopia negativa contaban con cultivo. De los 232 pacientes anteriormente tratados, 54 (23%) contaban con cultivo y 47 (20%) con antibiograma, cuyos resultados fueron 29 casos completamente sensibles, 7 monorresistentes, 2 polirresistentes y 9 casos de tuberculosis MR. De 22 departamentos (incluida la capital), en 7 (32%) se efectuaba cultivo y antibiograma a los casos nuevos de tuberculosis pulmonar con baciloscopia negativa y en 13 departamentos (59%) a los casos de tuberculosis anteriormente tratada. Conclusiones. Pese a la existencia de directrices nacionales, solo 5% de los casos de tuberculosis pulmonar con baciloscopia negativa contaba con cultivo y solo 20% de los casos de tuberculosis anteriormente tratada contaba con cultivo y antibiograma. En varios departamentos no se llevaban a cabo cultivos ni antibiogramas. Es preciso que se corrijan estas deficiencias en Guatemala si el país busca limitar la diseminación de la farmacorresistencia en su progreso hacia la eliminación total de la tuberculosis.

Quality of tuberculosis care at different levels of health care in Brazil in 2013 / Calidad de la asistencia de la tuberculosis en los diferentes niveles de atención de salud del Brasil en el 2013

Objective. To assess 1) the burden and socio-demographic and clinical characteristics of tuberculosis (TB) cases, and 2) the quality of TB care provided to patients who entered and remained within each health care service level (primary, secondary, or tertiary) and those who moved from one level to another, using process and results indicators. Methods. This cross-sectional operational research study assessed new smear-positive pulmonary TB cases diagnosed in Brazilian state capitals in 2013 using TB program records and the TB surveillance system. Quality of care was assessed based on process and results indicators including HIV screening, TB contact screening, Directly Observed Treatment (DOT), sputum smear microscopy monitoring, and treatment outcomes. Results. There were 12 977 new smear-positive TB cases reported. Of these, 7 964 (61.4%) cases were diagnosed and treated at the primary care level, 1 195 (9.2%) at the secondary level, 1 521 (11.7%) at the tertiary level, and 2 296 (17.7%) at more than one level, with 65% of the latter group moved from the tertiary level to the primary level. The proportion of cases tested for HIV was significantly higher in patients receiving care at the primary level compared to those receiving care at the secondary level (prevalence ratio (PR): 1.17; 95% confidence interval (CI): 1.07–1.28) and those attending more than one service level. Patients attending the tertiary health care level had a 122% higher PR for not doing DOT (“DOT not done”) compared to patients at the primary level (PR: 2.22; CI: 2.12–2.32). When the two levels were compared, the prevalence for an unfavorable outcome (lost to follow-up, death from TB, death with TB, transferred out, or not evaluated) was higher at the tertiary health care level. Conclusions. Primary health services are successfully incorporating the management of new smear-positive TB cases. Primary health care obtained better operational indicators than secondary or tertiary levels.

Objetivo. Evaluar 1) la carga de morbilidad por tuberculosis y las características sociodemográficas y clínicas de los pacientes y 2) la calidad de la atención de la tuberculosis que se presta a los pacientes que acuden y permanecen en cada nivel de los servicios de salud (primario, secundario o terciario) y a los pacientes que se transfirieron a otro nivel, mediante el análisis de los indicadores de funcionamiento de los procesos y los indicadores de resultados. Métodos. En el presente estudio transversal de investigación operativa se analizaron los casos nuevos de tuberculosis pulmonar con baciloscopia positiva que se diagnosticaron en las capitales estatales del Brasil en el 2013, a partir de los registros del programa contra la tuberculosis y los datos del sistema de vigilancia de la enfermedad. Se evaluó la calidad de la atención en función de los indicadores de funcionamiento y los indicadores de resultados como la detección sistemática de la infección por el virus de la inmunodeficiencia humana (VIH), el tamizaje de los contactos de casos de tuberculosis, el tratamiento estrictamente supervisado (conocido como DOT, por su sigla en inglés), la supervisión de la baciloscopia del esputo y los desenlaces terapéuticos. Resultados. Se notificaron 12 977 casos nuevos de tuberculosis con baciloscopia positiva. De los casos notificados, 7 964 (61,4%) se diagnosticaron y recibieron tratamiento en el nivel de atención primaria, 1 195 (9,2%) en el nivel secundario, 1 521 (11,7%) en el nivel terciario y 2 296 pacientes (17,7%) recibieron asistencia en servicios de varios niveles de atención; de este último grupo, el 65% pasó del nivel terciario al nivel primario de atención. La proporción de casos en los cuales se practicó la detección de la infección por el VIH fue significativamente mayor en los pacientes que acudieron al nivel primario de atención, al compararlos con los que recibieron atención en el nivel secundario (razón de prevalencia, [RP]: 1,17; intervalo de confianza [IC] de 95%: de 1,07 a 1,28) y los pacientes tratados en servicios de varios niveles de atención. En los pacientes que acudieron al nivel terciario de atención de salud, la razón de prevalencia de no seguir el DOT fue 122% más alta que en los pacientes atendidos en el nivel primario (RP: 2,22; IC de 95%: de 2,12 a 2,32). Cuando se compararon ambos niveles, la prevalencia de un resultado desfavorable (pérdida durante el seguimiento, defunción por tuberculosis, defunción con tuberculosis, transferido a otro centro o no evaluado) fue más alta en el nivel terciario de atención sanitaria. Conclusiones. Los servicios de atención primaria de salud han incorporado de manera eficaz el tratamiento de los casos nuevos de tuberculosis con baciloscopia positiva. Los indicadores operativos de la atención primaria de salud fueron mejores que los indicadores de la atención de nivel secundario o terciario.

Quality of tuberculosis care at different levels of health care in Brazil in 2013 / Calidad de la asistencia de la tuberculosis en los diferentes niveles de atención de salud del Brasil en el 2013

ABSTRACT Objective To assess 1) the burden and socio-demographic and clinical characteristics of tuberculosis (TB) cases, and 2) the quality of TB care provided to patients who entered and remained within each health care service level (primary, secondary, or tertiary) and those who moved from one level to another, using process and results indicators. Methods This cross-sectional operational research study assessed new smear-positive pulmonary TB cases diagnosed in Brazilian state capitals in 2013 using TB program records and the TB surveillance system. Quality of care was assessed based on process and results indicators including HIV screening, TB contact screening, Directly Observed Treatment (DOT), sputum smear microscopy monitoring, and treatment outcomes. Results There were 12 977 new smear-positive TB cases reported. Of these, 7 964 (61.4%) cases were diagnosed and treated at the primary care level, 1 195 (9.2%) at the secondary level, 1 521 (11.7%) at the tertiary level, and 2 296 (17.7%) at more than one level, with 65% of the latter group moved from the tertiary level to the primary level. The proportion of cases tested for HIV was significantly higher in patients receiving care at the primary level compared to those receiving care at the secondary level (prevalence ratio (PR): 1.17; 95% confidence interval (CI): 1.07–1.28) and those attending more than one service level. Patients attending the tertiary health care level had a 122% higher PR for not doing DOT (“DOT not done”) compared to patients at the primary level (PR: 2.22; CI: 2.12–2.32). When the two levels were compared, the prevalence for an unfavorable outcome (lost to follow-up, death from TB, death with TB, transferred out, or not evaluated) was higher at the tertiary health care level. Conclusions Primary health services are successfully incorporating the management of new smear-positive TB cases. Primary health care obtained better operational indicators than secondary or tertiary levels.

RESUMEN Objetivo Evaluar 1) la carga de morbilidad por tuberculosis y las características sociodemográficas y clínicas de los pacientes y 2) la calidad de la atención de la tuberculosis que se presta a los pacientes que acuden y permanecen en cada nivel de los servicios de salud (primario, secundario o terciario) y a los pacientes que se transfirieron a otro nivel, mediante el análisis de los indicadores de funcionamiento de los procesos y los indicadores de resultados. Métodos En el presente estudio transversal de investigación operativa se analizaron los casos nuevos de tuberculosis pulmonar con baciloscopia positiva que se diagnosticaron en las capitales estatales del Brasil en el 2013, a partir de los registros del programa contra la tuberculosis y los datos del sistema de vigilancia de la enfermedad. Se evaluó la calidad de la atención en función de los indicadores de funcionamiento y los indicadores de resultados como la detección sistemática de la infección por el virus de la inmunodeficiencia humana (VIH), el tamizaje de los contactos de casos de tuberculosis, el tratamiento estrictamente supervisado (conocido como DOT, por su sigla en inglés), la supervisión de la baciloscopia del esputo y los desenlaces terapéuticos. Resultados Se notificaron 12 977 casos nuevos de tuberculosis con baciloscopia positiva. De los casos notificados, 7 964 (61,4%) se diagnosticaron y recibieron tratamiento en el nivel de atención primaria, 1 195 (9,2%) en el nivel secundario, 1 521 (11,7%) en el nivel terciario y 2 296 pacientes (17,7%) recibieron asistencia en servicios de varios niveles de atención; de este último grupo, el 65% pasó del nivel terciario al nivel primario de atención. La proporción de casos en los cuales se practicó la detección de la infección por el VIH fue significativamente mayor en los pacientes que acudieron al nivel primario de atención, al compararlos con los que recibieron atención en el nivel secundario (razón de prevalencia, [RP]: 1,17; intervalo de confianza [IC] de 95%: de 1,07 a 1,28) y los pacientes tratados en servicios de varios niveles de atención. En los pacientes que acudieron al nivel terciario de atención de salud, la razón de prevalencia de no seguir el DOT fue 122% más alta que en los pacientes atendidos en el nivel primario (RP: 2,22; IC de 95%: de 2,12 a 2,32). Cuando se compararon ambos niveles, la prevalencia de un resultado desfavorable (pérdida durante el seguimiento, defunción por tuberculosis, defunción con tuberculosis, transferido a otro centro o no evaluado) fue más alta en el nivel terciario de atención sanitaria. Conclusiones Los servicios de atención primaria de salud han incorporado de manera eficaz el tratamiento de los casos nuevos de tuberculosis con baciloscopia positiva. Los indicadores operativos de la atención primaria de salud fueron mejores que los indicadores de la atención de nivel secundario o terciario.

Implementation of the national tuberculosis guidelines on culture and drug sensitivity testing in Guatemala, 2013 / Ejecución de las directrices nacionales de tuberculosis sobre cultivo y antibiograma en Guatemala en el 2013

ABSTRACT Objective To assess whether the National Tuberculosis Program (NTP) guidelines for culture and drug sensitivity testing (DST) in Guatemala were successfully implemented, particularly in cases of smear-negative pulmonary tuberculosis (TB) or previously treated TB, by documenting notification rates by department (geographic area), disease type and category, and culture and DST results. Methods This was a cross-sectional, operational research study that merged and linked all patients registered by the NTP and the National Reference Laboratory in 2013, eliminating duplicates. The proportions with culture (for new smear negative pulmonary cases) and culture combined with DST (for previously treated patients) were estimated and analyzed by department. Data were analyzed using EpiData Analysis version 2.2. Results There were 3 074 patients registered with TB (all forms), for a case notification rate of 20/100 000 population. Of these, 2 842 had new TB, of which 2 167 (76%) were smear-positive pulmonary TB (PTB), 385 (14%) were smear-negative PTB, and 290 (10%) were extrapulmonary TB. There were 232 (8%) previously treated cases. Case notification rates (all forms) varied by department from 2–68 per 100 000 population, with the highest rates seen in the southwest and northeast part of Guatemala. Of new TB patients, 136 had a culture performed and 55 had DST of which the results were 33 fully sensitive, 9 monoresistant, 3 polyresistant, and 10 multidrug resistant TB (MDR-TB). Only 21 (5%) of new smear-negative PTB patients had cultures. Of 232 previously treated patients, 54 (23%) had a culture and 47 (20%) had DST, of which 29 were fully sensitive, 7 monoresistant, 2 polyresistant, and 9 MDR-TB. Of 22 departments (including the capital), culture and DST was performed in new smear-negative PTB in 7 departments (32%) and in previously treated TB in 13 departments (59%). Conclusions Despite national guidelines, only 5% of smear-negative PTB cases had a culture and only 20% of previously treated TB had a culture and DST. Several departments did not perform culture or DST. These short comings must be improved if Guatemala is to curtail the spread of drug resistant forms of TB, while striving to eliminate all TB.

RESUMEN Objetivo Evaluar la eficacia de la ejecución de las directrices del Programa Nacional contra la Tuberculosis sobre cultivo y antibiograma en Guatemala, sobre todo en los casos de tuberculosis pulmonar con baciloscopia negativa o con antecedentes de tratamiento antituberculoso, mediante la investigación de las tasas de notificación por departamentos (o zonas geográficas), por tipos y categorías de la enfermedad y el examen de los resultados del cultivo y el antibiograma. Métodos Estudio transversal de investigación operativa en el cual se fusionaron y se vincularon todos los pacientes registrados en el Programa Nacional contra la Tuberculosis y el Laboratorio Nacional de Referencia en el 2013, tras la eliminación de los duplicados. Se calculó la proporción de casos con cultivo (en los casos nuevos de tuberculosis pulmonar con baciloscopia negativa) y de casos con cultivo y antibiograma (en los casos anteriormente tratados) y se analizaron por departamentos. Resultados Se registraron 3 074 pacientes con diagnóstico de tuberculosis (de todas las formas), lo cual representa una tasa de notificación de 20 casos por 100 000 habitantes. De estos pacientes, 2 842 fueron casos nuevos de tuberculosis, de los cuales 2 167 (76%) con diagnóstico de tuberculosis pulmonar y baciloscopia positiva, 385 (14%) con tuberculosis pulmonar y baciloscopia negativa y 290 casos (10%) con diagnóstico de tuberculosis extrapulmonar. Los casos con antecedentes de tratamiento antituberculoso fueron 232 (8%). Las tasas de notificación (de todas las formas) según el departamento oscilaron entre 2 y 68 casos por 100 000 habitantes y las tasas más altas se observaron en el suroeste y en parte del noreste de Guatemala. De los casos nuevos de tuberculosis, 136 contaban con cultivo y 55 con antibiograma; los resultados de estas pruebas revelaron 33 casos completamente sensibles, 9 casos monorresistentes, 3 casos polirresistentes y 10 casos de tuberculosis multirresistente (MR). Solo 21 (5%) de los casos nuevos de tuberculosis pulmonar y baciloscopia negativa contaban con cultivo. De los 232 pacientes anteriormente tratados, 54 (23%) contaban con cultivo y 47 (20%) con antibiograma, cuyos resultados fueron 29 casos completamente sensibles, 7 monorresistentes, 2 polirresistentes y 9 casos de tuberculosis MR. De 22 departamentos (incluida la capital), en 7 (32%) se efectuaba cultivo y antibiograma a los casos nuevos de tuberculosis pulmonar con baciloscopia negativa y en 13 departamentos (59%) a los casos de tuberculosis anteriormente tratada. Conclusiones Pese a la existencia de directrices nacionales, solo 5% de los casos de tuberculosis pulmonar con baciloscopia negativa contaba con cultivo y solo 20% de los casos de tuberculosis anteriormente tratada contaba con cultivo y antibiograma. En varios departamentos no se llevaban a cabo cultivos ni antibiogramas. Es preciso que se corrijan estas deficiencias en Guatemala si el país busca limitar la diseminación de la farmacorresistencia en su progreso hacia la eliminación total de la tuberculosis.

Contrasting trends of tuberculosis in the cities of San Pedro Sula and Tegucigalpa, Honduras, 2005 and 2014 / Tendencias discordantes de tuberculosis en San Pedro Sula y Tegucigalpa, Honduras, del 2005 al 2014

ABSTRACT Objective To 1) describe and compare the trends of tuberculosis (TB) case notification rates (CNRs) and treatment outcomes in the two largest cities in Honduras (San Pedro Sula and Tegucigalpa) for the period 2005–2014 and 2) identify possible related socioeconomic and health sector factors. Methods This retrospective ecological operational research study used aggregated data from the National TB Program (socioeconomic and health sector information and individual data from the 2014 TB case notification report). Results TB CNRs declined steadily over the study period in Tegucigalpa (from 46 to 28 per 100 000 inhabitants) but remained high in San Pedro Sula (decreasing from 89 to 78 per 100 000 inhabitants). Similar trends were observed for smear-positive TB. While presumptive TB cases examined were similar for both cities, in San Pedro Sula the proportions of presumptive cases with a positive smear; (7.7% versus 3.6%) relapses (8.9% versus 4.2%); and patients lost to follow-up (10.9% versus 2.7%) were significantly higher, and the treatment success lower (75.7% versus 87.0%). San Pedro Sula had lower annual income per capita, fewer public sector health workers and facilities, and a higher and increasing homicide index. The 2014 TB case data from San Pedro Sula showed a significantly lower median age and a higher proportion of assembly plant workers, prisoners, drug abusers, and diabetes. Conclusions The TB rate was higher and treatment success lower, and health care resources and socio-demographic indicators less favorable, in San Pedro Sula versus Tegucigalpa. City authorities, the NTP, and the health sector overall should strengthen early case detection, treatment, and infection control, involving both public and private health sectors.

RESUMEN Objetivo Describir y comparar las tendencias de las tasas de notificación de casos de tuberculosis y los desenlaces terapéuticos en las dos principales ciudades de Honduras (San Pedro Sula y Tegucigalpa) durante el período del 2005 al 2014; y reconocer los posibles factores socioeconómicos y del sector de la salud que se relacionan con estos resultados. Métodos Estudio ecológico retrospectivo de investigación operativa con datos agregados del Programa Nacional contra la Tuberculosis. La información socioeconómica y del sector de la salud y los datos individuales se obtuvieron del informe de notificación de casos de tuberculosis del 2014. Resultados Las tasas de notificación de casos de tuberculosis disminuyeron en forma sostenida durante el período del estudio en Tegucigalpa (de 46 a 28 por 100 000 habitantes) pero permanecieron altas en San Pedro Sula (disminuyeron de 89 a 78 casos por 100 000 habitantes). Se observaron tendencias análogas en los casos de tuberculosis con baciloscopia positiva. Si bien el número de casos con presunción clínica de tuberculosis examinados en ambas ciudades fue equivalente, en San Pedro Sula los casos con baciloscopia positiva, las recaídas (8,9% frente a 4,2%) y los pacientes perdidos durante el seguimiento (10,9% frente a 2,7%) fueron significativamente más frecuentes y la tasa de éxito terapéutico fue más baja (75,7% frente a 87,0%). En San Pedro Sula se observó un ingreso anual por habitante más bajo, menos personal y establecimientos de salud en el sector público, y un índice más alto y creciente de homicidios. Los datos sobre los casos de tuberculosis del 2014 en San Pedro Sula revelaron una mediana de edad de los pacientes significativamente menor y una mayor proporción de trabajadores de instalaciones de montaje, prisioneros, consumidores de drogas y pacientes con diabetes. Conclusiones En San Pedro Sula la tasa de tuberculosis fue más alta, la tasa de éxito terapéutico fue inferior y los indicadores sobre los recursos de atención de salud y los aspectos sociodemográficos fueron menos favorables en comparación con Tegucigalpa. Las autoridades municipales, el Programa Nacional contra la Tuberculosis y el sector sanitario en general deben fortalecer la detección temprana de casos, el tratamiento y el control de la infección mediante la participación del sector público y el sector privado de la salud.