High levels of antimicrobial resistance in Escherichia coli and Salmonella from poultry in Ecuador.

Objective: To describe antimicrobial resistance profiles of Escherichia coli and Salmonella spp. isolated from chicken carcasses and the antimicrobials commonly used in animals in Ecuador and provide information on antimicrobial resistance patterns for implementing evidence-based corrective measures. Methods: Meat samples were collected from chicken carcasses in 199 slaughterhouses across Ecuador as part of a national pilot study for monitoring antimicrobial resistance in agricultural sources in 2019. Samples were tested for E. coli and Salmonella spp. Sensitivity to 10 critically important and three highly important antimicrobials (from a human health perspective) was assessed. The country report submitted to the World Organization for Animal Health was accessed to extract the quantity of antimicrobials produced or imported for use in animals. Results: Of 383 samples, E. coli was isolated from 148 (39%) and Salmonella spp. from 20 (5%) samples. Ninety percent of the isolates were resistant to at least one critically important antimicrobial. Resistance was highest to erythromycin (E. coli 76%; Salmonella spp. 85%) and tetracycline (E. coli 71%; Salmonella spp. 90%). Critically or highly important antimicrobials (colistin, tetracycline, trimethoprim/sulfamethoxazole) formed the bulk (87%) of antimicrobials used in animals as per the World Organization for Animal Health report. Conclusions: High prevalence of antimicrobial resistance in poultry in Ecuador calls for the development of guidelines and regulations on the use of antimicrobials and for engagement with livestock producers. The existing surveillance system needs to be strengthened to improve the monitoring of antimicrobial use and evolving resistance patterns.

Antibiotic consumption in secondary and tertiary hospitals in Colombia: national surveillance from 2018-2020.

Objective: To assess the compliance in secondary and tertiary level hospitals with monthly reporting of antibiotic consumption to the Colombian National Public Health Surveillance System (SIVIGILA-INS), and to describe reported antibiotic consumption during 2018-2020. Methods: This study involved a secondary analysis of antibiotic consumption data reported to SIVIGILA-INS. Frequency of hospital reporting was assessed and compared against expected reports, disaggregated by intensive care units (ICU)/non-ICU wards and geographical regions. Consumption was expressed as defined daily dose (DDD) per 100 occupied beds for seven antibiotics. Results: More than 70% of hospitals reported antibiotic consumption at least once in each of the three years (79% in ICU and 71% in non-ICU wards). Of these, ICU monthly reporting was complete (12 monthly reports per year) for 59% in the period 2018-2019 but only 4% in 2020. Non-ICU reporting was complete for 52% in 2019 and for 2% in 2020. Most regions had an overall decrease in reporting in 2020. Analysis of antibiotic consumption showed an increase for piperacillin/tazobactam, ertapenem, and cefepime from 2019 to 2020. Conclusions: There were gaps in the consistency and frequency of reporting. Efforts are needed to improve compliance with monthly reporting, which declined in 2020, possibly due to the COVID-19 pandemic. Non-compliance on reporting and data quality issues should be addressed with the hospitals to enable valid interpretation of antibiotic consumption trends.

Prevalence and antimicrobial resistance of Escherichia coli and Salmonella spp. in animal feed in Colombia.

Objective: To determine the prevalence and antimicrobial resistance of Escherichia coli and Salmonella spp. in animal feed samples collected between 2018 and 2021 in Colombia. Methods: This was a laboratory-based cross-sectional study using routine data from the program for inspection, surveillance, and control of animal feed at the Colombian Agriculture Institute. Samples of animal feed for swine, poultry, canine, feline, leporine, piscine, and equine species were processed for detection of E. coli and Salmonella spp. using enrichment and selective culture methods. Isolates were tested for antimicrobial susceptibility using an automated microdilution method. Results: Of 1 748 animal feed samples analyzed, 83 (4.7%) were positive for E. coli and 66 (3.8%) for Salmonella spp. The presence of E. coli and Salmonella spp. was highest in feed for poultry (6.4% and 5.5%) and swine (6.1% and 4.3%). Antimicrobial resistance testing was performed in 27 (33%) E. coli isolates and 26 (39%) Salmonella isolates. Among E. coli, resistance was most frequently observed to ampicillin (44.5%) followed by cefazolin (33.3%), ciprofloxacin (29.6%), ampicillin/sulbactam (26%), and ceftriaxone (11.1%). The highest resistance levels in Salmonella spp. isolates were against cefazolin (7.7%) and piperacillin/tazobactam (7.7%). Conclusions: This is the first study from Colombia reporting on the prevalence and antimicrobial resistance of E. coli and Salmonella spp. in animal feed samples. Its results establish a baseline over a wide geographical distribution in Colombia. It highlights the need to integrate antimicrobial resistance surveillance in animal feed due to the emergence of resistant bacteria in this important stage of the supply chain.

High level of infection prevention and control in surveyed hospitals in Colombia, 2021.

Objective: This study aimed to determine the performance of infection prevention and control (IPC) programs in eight core components in level 2 and level 3 hospitals across all provinces in Colombia. Methods: This cross-sectional study used self-assessed IPC performance data voluntarily reported by hospitals to the Ministry of Health and Social Protection during 2021. Each of the eight core components of the World Health Organization's checklist in the Infection Prevention and Control Assessment Framework contributes a maximum score of 100, and the overall IPC performance score is the sum of these component scores. IPC performance is graded according to the overall score as inadequate (0-200), basic (201-400), intermediate (401-600) or advanced (601-800). Results: Of the 441 level 2 and level 3 hospitals, 267 (61%) reported their IPC performance. The median (interquartile range [IQR]) overall IPC score was 672 (IQR: 578-715). Of the 267 hospitals reporting, 187 (70%) achieved an advanced level of IPC. The median overall IPC score was significantly higher in private hospitals (690, IQR: 598-725) than in public hospitals (629, IQR: 538-683) (P < 0.001). Among the core components, scores were highest for the category assessing IPC guidelines (median score: 97.5) and lowest for the category assessing workload, staffing and bed occupancy (median score: 70). Median overall IPC scores varied across the provinces (P < 0.001). Conclusions: This countrywide assessment showed that 70% of surveyed hospitals achieved a self-reported advanced level of IPC performance, which reflects progress in building health system resilience. Since only 61% of eligible hospitals participated, an important next step is to ensure the participation of all hospitals in future assessments.

High level of infection prevention and control in surveyed hospitals in Colombia, 2021 / Nivel avanzado de prevención y control de infecciones en hospitales de Colombia en el 2021 / Alto nível de prevenção e controle de infecções em hospitais da Colômbia, 2021

ABSTRACT Objective. This study aimed to determine the performance of infection prevention and control (IPC) programs in eight core components in level 2 and level 3 hospitals across all provinces in Colombia. Methods. This cross-sectional study used self-assessed IPC performance data voluntarily reported by hospitals to the Ministry of Health and Social Protection during 2021. Each of the eight core components of the World Health Organization's checklist in the Infection Prevention and Control Assessment Framework contributes a maximum score of 100, and the overall IPC performance score is the sum of these component scores. IPC performance is graded according to the overall score as inadequate (0-200), basic (201-400), intermediate (401-600) or advanced (601-800). Results. Of the 441 level 2 and level 3 hospitals, 267 (61%) reported their IPC performance. The median (interquartile range [IQR]) overall IPC score was 672 (IQR: 578-715). Of the 267 hospitals reporting, 187 (70%) achieved an advanced level of IPC. The median overall IPC score was significantly higher in private hospitals (690, IQR: 598-725) than in public hospitals (629, IQR: 538-683) (P < 0.001). Among the core components, scores were highest for the category assessing IPC guidelines (median score: 97.5) and lowest for the category assessing workload, staffing and bed occupancy (median score: 70). Median overall IPC scores varied across the provinces (P < 0.001). Conclusions. This countrywide assessment showed that 70% of surveyed hospitals achieved a self-reported advanced level of IPC performance, which reflects progress in building health system resilience. Since only 61% of eligible hospitals participated, an important next step is to ensure the participation of all hospitals in future assessments.

RESUMEN Objetivo. El objetivo de este estudio es determinar el desempeño de los programas de prevención y control de infecciones (PCI) en relación con ocho componentes básicos en hospitales de nivel 2 y 3 de todas las provincias de Colombia. Métodos. En este estudio transversal se emplearon datos de autoevaluación del desempeño de los programas de PCI informados voluntariamente al Ministerio de Salud y Protección Social por parte de los hospitales durante el 2021. Cada uno de los ocho componentes básicos de la lista de verificación de la Organización Mundial de la Salud incluidos en el Marco de evaluación de prevención y control de infecciones al nivel de establecimientos de atención de salud recibe una puntuación máxima de 100, y la puntuación general del desempeño del programa es la suma de las puntuaciones de estos componentes. Este desempeño se califica según la puntuación general como inadecuado (0-200), básico (201-400), intermedio (401-600) o avanzado (601-800). Resultados. De los 441 hospitales de nivel 2 y nivel 3, 267 (61%) informaron datos sobre su desempeño. La mediana (rango intercuartil [IQR]) de la puntuación general fue de 672 (IQR: 578-715). De los 267 hospitales que proporcionaron información, 187 (70%) alcanzaron el nivel avanzado. La mediana de la puntuación general fue significativamente mayor en los hospitales privados (690, IQR: 598-725) que en los hospitales públicos (629, IQR: 538-683) (p < 0,001). En el caso de los componentes básicos, las puntuaciones más altas fueron para la categoría que evalúa las directrices de PCI (puntuación mediana: 97,5) y más bajas para la categoría que evalúa la carga de trabajo, la dotación de personal y la ocupación de camas (puntuación mediana: 70). La mediana de las puntuaciones generales de PCI varió entre las provincias (p < 0,001). Conclusiones. Esta evaluación a nivel nacional mostró que el 70% de los hospitales encuestados lograron un nivel avanzado autoinformado del desempeño en cuanto a la PCI, lo que refleja el progreso en fortalecimiento de la resiliencia del sistema de salud. Dado que solo participó el 61% de los hospitales que reunían las condiciones, el siguiente paso importante es garantizar la participación de todos los hospitales en futuras evaluaciones.

RESUMO Objetivo. Este estudo teve o objetivo de determinar o desempenho de programas de prevenção e controle de infecções (PCI) quanto a oito componentes centrais em hospitais secundários e terciários de todas as províncias da Colômbia. Métodos. Este estudo transversal utilizou dados de desempenho autoavaliado de PCI enviados voluntariamente pelos hospitais ao Ministério da Saúde e Proteção Social em 2021. Cada um dos oito componentes centrais da lista de verificação na Estrutura de Avaliação de Prevenção e Controle de Infecções da Organização Mundial da Saúde contribui com uma pontuação máxima de 100. A pontuação total de desempenho de PCI é a soma das pontuações nesses componentes. De acordo com a pontuação total, o desempenho de PCI é classificado nas seguintes categorias: inadequado (0-200), básico (201-400), intermediário (401-600) ou avançado (601-800). Resultados. Dos 441 hospitais secundários e terciários, 267 (61%) informaram o desempenho de PCI. A mediana (intervalo interquartil [IIQ]) da pontuação total de PCI foi 672 (IIQ: 578-715). Dos 267 hospitais que disponibilizaram informações, 187 (70%) alcançaram um nível de PCI avançado. A mediana da pontuação total de PCI foi significativamente maior nos hospitais privados (690, IIQ: 598-725) do que nos públicos (629, IIQ: 538-683) (p < 0,001). Entre os componentes centrais, as pontuações mais altas foram observadas na categoria de avaliação das diretrizes de PCI (pontuação mediana: 97,5), ao passo que as mais baixas ocorreram na categoria de avaliação da carga de trabalho, dotação de pessoal e taxa de ocupação de leitos (pontuação mediana: 70). As medianas das pontuações totais de PCI variaram entre províncias (p < 0,001). Conclusões. Esta avaliação nacional mostrou que 70% dos hospitais pesquisados alcançaram um nível avançado de desempenho autorrelatado de PCI, o que demonstra progresso no desenvolvimento de resiliência no sistema de saúde. Como apenas 61% dos hospitais elegíveis participaram, um próximo passo importante é assegurar a participação de todos os hospitais em futuras avaliações.

Prevalence and antimicrobial resistance of Escherichia coli and Salmonella spp. in animal feed in Colombia / Prevalencia y resistencia a los antimicrobianos de Escherichia coli y Salmonella spp. en los alimentos para animales en Colombia / Prevalência e resistência a antimicrobianos de Escherichia coli e Salmonella spp. em ração animal na Colômbia

ABSTRACT Objective. To determine the prevalence and antimicrobial resistance of Escherichia coli and Salmonella spp. in animal feed samples collected between 2018 and 2021 in Colombia. Methods. This was a laboratory-based cross-sectional study using routine data from the program for inspection, surveillance, and control of animal feed at the Colombian Agriculture Institute. Samples of animal feed for swine, poultry, canine, feline, leporine, piscine, and equine species were processed for detection of E. coli and Salmonella spp. using enrichment and selective culture methods. Isolates were tested for antimicrobial susceptibility using an automated microdilution method. Results. Of 1 748 animal feed samples analyzed, 83 (4.7%) were positive for E. coli and 66 (3.8%) for Salmonella spp. The presence of E. coli and Salmonella spp. was highest in feed for poultry (6.4% and 5.5%) and swine (6.1% and 4.3%). Antimicrobial resistance testing was performed in 27 (33%) E. coli isolates and 26 (39%) Salmonella isolates. Among E. coli, resistance was most frequently observed to ampicillin (44.5%) followed by cefazolin (33.3%), ciprofloxacin (29.6%), ampicillin/sulbactam (26%), and ceftriaxone (11.1%). The highest resistance levels in Salmonella spp. isolates were against cefazolin (7.7%) and piperacillin/tazobactam (7.7%). Conclusions. This is the first study from Colombia reporting on the prevalence and antimicrobial resistance of E. coli and Salmonella spp. in animal feed samples. Its results establish a baseline over a wide geographical distribution in Colombia. It highlights the need to integrate antimicrobial resistance surveillance in animal feed due to the emergence of resistant bacteria in this important stage of the supply chain.

RESUMEN Objetivo. Determinar la prevalencia y resistencia a los antimicrobianos de Escherichia coli y Salmonella spp. en muestras de piensos para animales tomadas entre el 2018 y el 2021 en Colombia. Métodos. Se trata de un estudio transversal realizado en el laboratorio a partir de los datos regulares del programa de inspección, vigilancia y control de alimentos para animales del Instituto Colombiano Agropecuario. Se procesaron muestras de alimentos utilizados en la cría de cerdos, aves de corral, cánidos, félidos, lepóridos, peces y equinos con el fin de detectar E. coli y Salmonella spp. por medio de métodos de enriquecimiento y cultivo selectivo. Se analizó la sensibilidad a los antimicrobianos de las cepas aisladas mediante microdilución automatizada. Resultados. De 1748 muestras de alimentos analizadas, 83 (4,7%) resultaron positivas para E. coli y 66 (3,8%) para Salmonella spp. La presencia de E. coli y Salmonella spp. fue mayor en los alimentos para aves de corral (6,4% y 5,5%) y cerdos (6,1% y 4,3%). Se realizaron pruebas de resistencia a los antimicrobianos en 27 (33%) cepas de E. coli y 26 (39%) de Salmonella. En las cepas de E. coli, se observó una mayor resistencia a la ampicilina (44,5%), seguida de la resistencia a la cefazolina (33,3%), la ciprofloxacina (29,6%), la ampicilina/sulbactam (26%) y la ceftriaxona (11,1%). En el caso de las cepas de Salmonella spp., los niveles de resistencia más elevados fueron para la cefazolina (7,7%) y piperacilina/tazobactam (7,7%). Conclusiones. Este es el primer estudio realizado en Colombia en el que se informa sobre la prevalencia y la resistencia a los antimicrobianos de E. coli y Salmonella spp. en muestras de alimentos para animales. Sus resultados establecen una línea de base para una zona geográfica mucho mayor dentro de Colombia. Se subraya la necesidad de integrar la vigilancia de la resistencia a los antimicrobianos en los alimentos para animales debido a la aparición de bacterias resistentes en esta importante etapa de la cadena de suministro.

RESUMO Objetivo. Determinar a prevalência e a resistência a antimicrobianos de Escherichia coli e Salmonela spp. em amostras de ração animal coletadas entre 2018 e 2021 na Colômbia. Métodos. Estudo transversal de base laboratorial, usando dados de rotina do programa de inspeção, vigilância e controle de ração animal do Instituto Colombiano de Agricultura. Amostras de ração animal para as espécies suína, avícola, canina, felina, leporina, piscina e equina foram processadas para detecção de E. coli e Salmonella spp., usando métodos de enriquecimento e cultura seletiva. Os isolados foram testados quanto à suscetibilidade a antimicrobianos usando um método automatizado de microdiluição. Resultados. Das 1.748 amostras de ração animal analisadas, 83 (4,7%) foram positivas para E. coli e 66 (3,8%) para Salmonella spp. A presença de E. coli e Salmonella spp. foi maior em rações para aves (6,4% e 5,5%) e suínos (6,1% e 4,3%). O teste de resistência a antimicrobianos foi realizado em 27 (33%) isolados de E. coli e 26 (39%) isolados de Salmonella. Em E. coli, a resistência observada com maior frequência foi à ampicilina (44,5%), seguida da cefazolina (33,3%), ciprofloxacino (29,6%), ampicilina/sulbactam (26%) e ceftriaxona (11,1%). Os maiores níveis de resistência em isolados de Salmonella spp. foram contra cefazolina (7,7%) e piperacilina/tazobactam (7,7%). Conclusões. Este é o primeiro estudo da Colômbia a notificar a prevalência e resistência a antimicrobianos de E. coli e Salmonella spp. em amostras de ração animal. Os resultados estabelecem uma linha de base com ampla distribuição geográfica na Colômbia. Destaca-se a necessidade de integrar a vigilância da resistência a antimicrobianos na ração animal, devido ao surgimento de bactérias resistentes nesta importante etapa da cadeia de abastecimento.

Antibiotic consumption in secondary and tertiary hospitals in Colombia: national surveillance from 2018-2020 / Consumo de antibióticos en hospitales de segundo y tercer nivel en Colombia: vigilancia nacional entre 2018 y 2020 / Consumo de antibióticos em hospitais secundários e terciários da Colômbia: vigilância nacional de 2018 a 2020

ABSTRACT Objective. To assess the compliance in secondary and tertiary level hospitals with monthly reporting of antibiotic consumption to the Colombian National Public Health Surveillance System (SIVIGILA-INS), and to describe reported antibiotic consumption during 2018-2020. Methods. This study involved a secondary analysis of antibiotic consumption data reported to SIVIGILA-INS. Frequency of hospital reporting was assessed and compared against expected reports, disaggregated by intensive care units (ICU)/non-ICU wards and geographical regions. Consumption was expressed as defined daily dose (DDD) per 100 occupied beds for seven antibiotics. Results. More than 70% of hospitals reported antibiotic consumption at least once in each of the three years (79% in ICU and 71% in non-ICU wards). Of these, ICU monthly reporting was complete (12 monthly reports per year) for 59% in the period 2018-2019 but only 4% in 2020. Non-ICU reporting was complete for 52% in 2019 and for 2% in 2020. Most regions had an overall decrease in reporting in 2020. Analysis of antibiotic consumption showed an increase for piperacillin/tazobactam, ertapenem, and cefepime from 2019 to 2020. Conclusions. There were gaps in the consistency and frequency of reporting. Efforts are needed to improve compliance with monthly reporting, which declined in 2020, possibly due to the COVID-19 pandemic. Non-compliance on reporting and data quality issues should be addressed with the hospitals to enable valid interpretation of antibiotic consumption trends.

RESUMEN Objetivo. Evaluar el cumplimiento de los hospitales de segundo y tercer nivel en la presentación mensual de información sobre el consumo de antibióticos en el Sistema Nacional de Vigilancia en Salud Pública de Colombia (SIVIGILA-INS) y describir el consumo de antibióticos reportado en el período 2018-2020. Métodos. Este estudio incluyó un análisis secundario de los datos del consumo de antibióticos reportado en SIVIGILA-INS. Se evaluó la frecuencia de los informes hospitalarios y se comparó con los informes esperados, desglosados por unidad de cuidados intensivos (UCI) y otros servicios distintos a la UCI, y por región geográfica. El consumo se expresó en dosis diaria definida (DDD) por 100 camas ocupadas para siete antibióticos. Resultados. Más del 70% de los hospitales notificaron el consumo de antibióticos al menos una vez en cada uno de los tres años (79% en la UCI y 71% en los servicios distintos a la UCI). De estos, el 59% de las UCI completaron los informes mensuales (12 informes en un año) entre el 2018 y el 2019, pero solo el 4% en el 2020. El 52% de los servicios distintos a la UCI completó los informes en el 2019 y el 2% en el 2020. En la mayoría de las regiones hubo una disminución general de la notificación en el 2020. El análisis del consumo de antibióticos mostró un aumento de piperacilina/tazobactam, ertapenem y cefepima del 2019 al 2020. Conclusiones. Se encontraron disparidades en la coherencia y en la frecuencia de la presentación de informes. Es necesario destinar esfuerzos para mejorar el cumplimiento de la notificación mensual, que disminuyó en el 2020 posiblemente debido a la pandemia de COVID-19. La falta de cumplimiento en la presentación de los reportes y los problemas de calidad de los datos deben abordarse con los hospitales para facilitar la interpretación válida de las tendencias de consumo de antibióticos.

RESUMO Objetivo. Avaliar o cumprimento da exigência de notificar mensalmente o consumo de antibióticos em hospitais secundários e terciários ao Sistema Nacional de Vigilância em Saúde Pública da Colômbia (SIVIGILA-INS) e descrever o consumo informado de antibióticos de 2018 a 2020. Métodos. Este estudo envolveu uma análise secundária dos dados de consumo de antibióticos enviados para o SIVIGILA-INS. A frequência de notificação pelos hospitais foi avaliada e comparada com a frequência esperada. Os dados foram desagregados entre unidades de terapia intensiva (UTIs) e enfermarias gerais e por regiões geográficas. O consumo foi expresso como dose diária definida (DDD) por 100 leitos ocupados para sete antibióticos. Resultados. Mais de 70% dos hospitais notificaram consumo de antibióticos pelo menos uma vez em cada um dos três anos (79% na UTI e 71% nas enfermarias gerais). Entre eles, 59% dos hospitais enviaram todas as notificações relativas a UTIs (12 notificações mensais) no período de 2018 a 2019, mas apenas 4% o fizeram em 2020. No caso das enfermarias gerais, 52% dos hospitais enviaram todas as notificações em 2019 e 2% o fizeram em 2020. A maioria das regiões teve uma diminuição geral no número de notificações enviadas em 2020. A análise do consumo de antibióticos revelou um aumento no uso de piperacilina/tazobactam, ertapeném e cefepima de 2019 para 2020. Conclusões. Houve lacunas na uniformidade e frequência das notificações. São necessários esforços para melhorar o cumprimento da exigência de notificações mensais, que, possivelmente devido à pandemia de COVID‑19, diminuiu em 2020. Problemas relacionados ao não cumprimento da exigência de notificação e à qualidade dos dados devem ser resolvidos junto aos hospitais para permitir uma interpretação válida das tendências de consumo de antibióticos.

High levels of antimicrobial resistance in Escherichia coli and Salmonella from poultry in Ecuador / Niveles elevados de resistencia antimicrobiana de las bacterias Escherichia coli y Salmonella en aves de corral en Ecuador / Altos níveis de resistência aos antimicrobianos em Escherichia coli e Salmonella de aves de criação no Equador

ABSTRACT Objective. To describe antimicrobial resistance profiles of Escherichia coli and Salmonella spp. isolated from chicken carcasses and the antimicrobials commonly used in animals in Ecuador and provide information on antimicrobial resistance patterns for implementing evidence-based corrective measures. Methods. Meat samples were collected from chicken carcasses in 199 slaughterhouses across Ecuador as part of a national pilot study for monitoring antimicrobial resistance in agricultural sources in 2019. Samples were tested for E. coli and Salmonella spp. Sensitivity to 10 critically important and three highly important antimicrobials (from a human health perspective) was assessed. The country report submitted to the World Organization for Animal Health was accessed to extract the quantity of antimicrobials produced or imported for use in animals. Results. Of 383 samples, E. coli was isolated from 148 (39%) and Salmonella spp. from 20 (5%) samples. Ninety percent of the isolates were resistant to at least one critically important antimicrobial. Resistance was highest to erythromycin (E. coli 76%; Salmonella spp. 85%) and tetracycline (E. coli 71%; Salmonella spp. 90%). Critically or highly important antimicrobials (colistin, tetracycline, trimethoprim/sulfamethoxazole) formed the bulk (87%) of antimicrobials used in animals as per the World Organization for Animal Health report. Conclusions. High prevalence of antimicrobial resistance in poultry in Ecuador calls for the development of guidelines and regulations on the use of antimicrobials and for engagement with livestock producers. The existing surveillance system needs to be strengthened to improve the monitoring of antimicrobial use and evolving resistance patterns.

RESUMEN Objetivo. Describir los perfiles de resistencia antimicrobiana de las bacterias Escherichia coli y Salmonella spp. aisladas en carne de pollo y los antimicrobianos comúnmente empleados en animales en Ecuador, así como proporcionar información sobre los patrones de resistencia a los antimicrobianos para poner en marcha medidas correctivas basadas en la evidencia. Métodos. Se recogieron muestras de carne de pollo en 199 mataderos de todo Ecuador en el marco de un estudio piloto nacional para monitorear la resistencia a los antimicrobianos en fuentes agrícolas en el 2019. Se analizaron las muestras en busca de E. coli y Salmonella spp. Se evaluó la sensibilidad a diez antimicrobianos de importancia crítica y tres muy importantes (para la salud humana). Se accedió al informe de país presentado ante la Organización Mundial de Sanidad Animal para obtener la cantidad de antimicrobianos producidos o importados para su uso en animales. Resultados. De 383 muestras, se aisló E. coli en 148 (39%) y Salmonella spp. en 20 (5%). En total, 90% de las cepas aisladas fueron resistentes a al menos un antimicrobiano de importancia crítica. Hubo una mayor resistencia a la eritromicina (E. coli: 76%; Salmonella spp.: 85%) y a la tetraciclina (E. coli: 71%; Salmonella spp.: 90%). Los antimicrobianos de importancia crítica o muy importantes (colistina, tetraciclina, trimetoprima/sulfametoxazol) constituyeron la mayor parte (87%) de los antimicrobianos empleados en animales según el informe de la Organización Mundial de Sanidad Animal. Conclusiones. Debido a la alta prevalencia de la resistencia a los antimicrobianos en las aves de corral en Ecuador, son imprescindibles la elaboración de directrices y regulaciones sobre el uso de antimicrobianos y el compromiso con los productores pecuarios. Es necesario fortalecer el sistema de vigilancia existente para mejorar el seguimiento del uso de antimicrobianos y de la evolución de los patrones de resistencia.

RESUMO Objetivo. Descrever perfis de resistência aos antimicrobianos em Escherichia coli e Salmonella spp. isoladas de carcaças de frango e os antimicrobianos comumente usados em animais no Equador e fornecer informações sobre padrões de resistência aos antimicrobianos para implementar medidas corretivas baseadas em evidências. Métodos. Foram coletadas amostras de carne de carcaças de frango em 199 abatedouros em todo o Equador como parte de um estudo piloto nacional para monitorar a resistência aos antimicrobianos de origem agrícola em 2019. Foram testadas amostras de E. coli e Salmonella spp. Foi avaliada a sensibilidade a 10 agentes antimicrobianos de importância crítica e três agentes antimicrobianos muito importantes (do ponto de vista da saúde humana). O relatório do país apresentado à Organização Mundial de Saúde Animal foi acessado para extrair a quantidade de antimicrobianos produzidos ou importados para uso em animais. Resultados. De 383 amostras, E. coli foi isolada em 148 (39%) e Salmonella spp. em 20 (5%). Noventa por cento dos isolados foram resistentes a pelo menos um antimicrobiano de importância crítica. A resistência foi maior à eritromicina (E. coli, 76%; Salmonella spp., 85%) e à tetraciclina (E. coli, 71%; Salmonella spp., 90%). Antimicrobianos de importância crítica ou muito importantes (colistina, tetraciclina, trimetoprim/sulfametoxazol) responderam pela maior parte (87%) dos antimicrobianos utilizados em animais, conforme o relatório da Organização Mundial de Saúde Animal. Conclusões. A alta prevalência de resistência aos antimicrobianos na avicultura no Equador exige o desenvolvimento de diretrizes e regulamentos sobre o uso de antimicrobianos e o envolvimento com os produtores de gado e avícolas. O sistema de vigilância existente precisa ser reforçado para melhorar o monitoramento do uso de antimicrobianos e a evolução dos padrões de resistência.

Planning for resilience in screening operations using discrete event simulation modeling: example of HPV testing in Peru.

BACKGROUND: The World Health Organization (WHO) has called for the elimination of cervical cancer. Unfortunately, the implementation of cost-effective prevention and control strategies has faced significant barriers, such as insufficient guidance on best practices for resource and operations planning. Therefore, we demonstrate the value of discrete event simulation (DES) in implementation science research and practice, particularly to support the programmatic and operational planning for sustainable and resilient delivery of healthcare interventions. Our specific example shows how DES models can inform planning for scale-up and resilient operations of a new HPV-based screen and treat program in Iquitos, an Amazonian city of Peru. METHODS: Using data from a time and motion study and cervical cancer screening registry from Iquitos, Peru, we developed a DES model to conduct virtual experimentation with "what-if" scenarios that compare different workflow and processing strategies under resource constraints and disruptions to the screening system. RESULTS: Our simulations show how much the screening system's capacity can be increased at current resource levels, how much variability in service times can be tolerated, and the extent of resilience to disruptions such as curtailed resources. The simulations also identify the resources that would be required to scale up for larger target populations or increased resilience to disruptions, illustrating the key tradeoff between resilience and efficiency. Thus, our results demonstrate how DES models can inform specific resourcing decisions but can also highlight important tradeoffs and suggest general "rules" for resource and operational planning. CONCLUSIONS: Multilevel planning and implementation challenges are not unique to sustainable adoption of cervical cancer screening programs but represent common barriers to the successful scale-up of many preventative health interventions worldwide. DES represents a broadly applicable tool to address complex implementation challenges identified at the national, regional, and local levels across settings and health interventions-how to make effective and efficient operational and resourcing decisions to support program adaptation to local constraints and demands so that they are resilient to changing demands and more likely to be maintained with fidelity over time.

The Waiting Game - How Cooperation Between Public and Private Hospitals Can Help Reduce Waiting Lists.

Prolonged waiting to access health care is a primary concern for nations aiming for comprehensive effective care, due to its adverse effects on mortality, quality of life, and government approval. Here, we propose two novel bargaining frameworks to reduce waiting lists in two-tier health care systems with local and regional actors. In particular, we assess the impact of 1) trading patients on waiting lists among hospitals, the 2) introduction of the role of private hospitals in capturing unfulfilled demand, and the 3) hospitals' willingness to share capacity on the system performance. We calibrated our models with 2008-2018 Chilean waiting list data. If hospitals trade unattended patients, our game-theoretic models indicate a potential reduction of waiting lists of up to 37%. However, when private hospitals are introduced into the system, we found a possible reduction of waiting lists of up to 60%. Further analyses revealed a trade-off between diagnosing unserved demand and the additional expense of using private hospitals as a back-up system. In summary, our game-theoretic frameworks of waiting list management in two-tier health systems suggest that public-private cooperation can be an effective mechanism to reduce waiting lists. Further empirical and prospective evaluations are needed.

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

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

Towards the integration of lean principles and optimization for agricultural production systems: a conceptual review proposition.

Operative planning in agricultural production has historically had the objective of improving yields and quality. Sowing, cropping, and harvesting are usually treated independently, and waste and the sustainability of operations are generally not integrated into operational planning methodologies for agricultural production. This study shows the need to have a clear and precise methodology to minimize waste in agricultural production systems to ensure sustainability. This need is addressed with a novel methodological guide to minimizing waste in agricultural operations, crop maintenance, and harvesting. The proposed methodology is founded on the use of lean manufacturing as a waste-management tool. Lean manufacturing principles allow agricultural operations and the variables that represent wastes to be identified, mathematical models to be built, constraints to be defined, and the cost of waste to be illustrated, as well as its minimization through an objective function. To guide implementation, we propose a conceptual model to explain the construction of a mathematical model that represents the development of decision variables on agricultural operations with the elements to consider and the constraints and theoretical proposal of the necessary objective function. The proposed conceptual model and the constructed methodology constitute a novel development within agricultural production systems that could be used by decision makers and farmers. © 2019 Society of Chemical Industry.

Analysis of the Influence of Standard Time Variability on the Reliability of the Simulation of Assembly Operations in Manufacturing Systems.

OBJECTIVE: The aim of this article is to analyze the influence of the variability of the standard time in the simulation of the assembly operations of manufacturing systems. BACKGROUND: Discrete event simulation (DES) has been used to provide efficient analysis during the design of a process or scenario. However, the modeling activities of new configurations face the problem of data availability and reliability when it comes to seeking standard times that are effective in representing the actual process under analysis, especially when the process cannot be monitored. METHOD: The methods-time measurement (MTM) is used as a source of standard times for simulation. Assembly activities were performed at a Learning Factory facility, which provided the necessary structure for simulating real production processes. Simulation performances using different variability of standard times were analyzed to define the impact of data characteristics. RESULTS: The MTM standard time presented an error of approximately 5%. The definition of the data variability of standard times and the statistical distribution impacts were shown in the simulation results, with errors above 6% being observed, interfering with the model reliability. CONCLUSION: Based on the study, to increase the adherence of a simulation to represent a real process, it is recommended to use triangular distributions with central values greater than those established via the MTM for the representation of the standard times of new assembly processes or scenarios using DES. APPLICATION: The study contributions can be applied in assembly line design, providing a reliable model representing real processes and scenarios.

[Loss to follow-up in patients treated for multidrug-resistant tuberculosis in EcuadorA Perda de seguimento de pacientes tratados para tuberculose multirresistente a medicamentos no Equador]. / Pérdida en el seguimiento de pacientes tratados por tuberculosis resistente a rifampicina o multidrogorresistente en Ecuador.

OBJECTIVE: Determine the incidence of loss to follow-up (LTFU) in patients treated for rifampicin-resistant tuberculosis (RR-TB) or multidrug-resistant tuberculosis (RR/MDR-TB), and the factors associated with this discharge status in Ecuador. METHODS: Retrospective cohort study of patients with RR/MDR-TB who followed the World Health Organization's 18-24-month treatment regimen in 2014 and 2015, as reported by the Ministry of Health of Ecuador. The incidence of LTFU was determined, and clinical and epidemiological manifestations of cases discharged as LTFU were compared with those discharged as successfully treated. Survival was analyzed with Cox regression in order to evaluate factors associated with LTFU. RESULTS: Of 328 cases, 270 (82.3%) were analyzed because they had a reported discharge status. Discharge as LTFU accounted for 39.6% of cases, and as successfully treated, 50.4%. The risk factors associated with LTFU were: previous discharge as LTFU in a previous TB episode [hazard ratio (HR): 2.96 (1.53-5.73), P < 0.001]; addiction to alcohol or drugs [HR: 2.82 (1.10-7.23), P = 0.031]; and having an Xpert® diagnosis (TB-RR) [HR: 1.53 (1.0-2.35), P = 0.048]. Of the total LTFU, 43% occurred after nine months of treatment. CONCLUSION: The incidence of LTFU in patients with RR/MDR-TB in Ecuador is above the average for the Region of the Americas. The three identified factors support implementation of shorter regimens and patient-centered care, in line with the End TB Strategy.

OBJETIVO: Determinar o percentual de perda de seguimento de pacientes tratados para tuberculose resistente à rifampicina (TB-RR) ou tuberculose multirresistente a medicamentos (TB-MR) e os fatores associados à interrupção do tratamento no Equador. MÉTODOS: Estudo de coorte retrospectivo de casos de pacientes com TB-RR/TB-MR tratados em 2014 e 2015 com o esquema farmacológico de 18 a 24 meses de duração da Organização Mundial da Saúde (OMS) que foram notificados ao Ministério da Saúde do Equador. Foi determinado o percentual de perda de seguimento e foram comparadas as características clínicas e epidemiológicas dos casos de interrupção do tratamento por perda de seguimento e daqueles com alta por sucesso no tratamento. Uma análise da sobrevida com o modelo de regressão de Cox foi realizada para avaliar os fatores associados à perda de seguimento. RESULTADOS: De 328 casos registrados, 270 (82,3%) foram incluídos na análise por terem tido sua interrupção ou alta notificadas. Houve interrupção por perda de seguimento em 39,6% dos casos e alta por sucesso no tratamento em 50,4%. Os fatores de risco associados à perda de seguimento foram: história de perda de seguimento em tratamento anterior de TB, razão de riscos (hazard ratio, HR) 2,96 (1,53­5,73, P < 0,001); consumo excessivo de álcool ou drogas, HR 2,82 (1,10­7,23, P = 0,031); e diagnóstico de tuberculose pelo teste Xpert® (TB-RR), HR 1,53 (1,0­2,35, P = 0,048). A perda de seguimento ocorreu após nove meses de tratamento em 43% dos casos. CONCLUSÃO: O percentual de perda de seguimento de pacientes com TB-RR/TB-MR no Equador está acima da média da Região das Américas. Os três fatores identificados no estudo reforçam ser necessário implementar esquemas de tratamento mais curtos e prestar atenção centrada no paciente, segundo as recomendações da Estratégia pelo Fim da Tuberculose.

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

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

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

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

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

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

Análise geoepidemiológica, operacional e social da coinfecção TB/HIV no estado de São Paulo / Geoepidemiological, operational and social analysis of TB / HIV coinfection in the state of São Paulo

Este estudo teve como objetivo analisar o contexto geoepidemiológico, operacional e social da coinfecção TB/HIV no estado de São Paulo. Foi realizada uma pesquisa operacional, com delineamento ecológico, nos 645 municípios pertencentes ao estado de São Paulo. Foram considerados os casos novos de TB coinfectados com HIV, notificados e registrados no TBWEB, no período de 2010 a 2015. O estudo foi elaborado em três etapas: analisar a qualidade e gestão da atenção à coinfecção TB/HIV no estado de São Paulo, utilizando análise de agrupamento e análise de correspondência múltipla; analisar a cobertura do tratamento diretamente observado nos municípios e sua associação com a ocorrência de coinfecção TB/HIV e desfechos desfavoráveis, utilizando o Índice Local de Moran, com interpolação espacial a partir de três modelos distintos, e estatística de varredura espacial, com auxílio dos softwares ArcGis e SaTScan. Aplicou-se ainda Modelos Bayesianos Hierárquicos por meio do software R pelo pacote R-INLA; identificar a associação de indicadores sociais e de serviços de saúde com a ocorrência da coinfecção TB/HIV no estado de São Paulo, utilizando o Generalized additive models for location, scale and shape (GAMLSS) como modelo de regressão semiparamétrico. Com os resultados da primeira etapa observou-se importantes diferenças entre os municípios no que tange à qualidade da atenção, a saber, os municípios paulistas com desempenho satisfatório apresentam elevada cobertura de Programa de Agentes Comunitários de Saúde e Estratégia de Saúde da Família, sendo prioritários para o controle da TB e os municípios de desempenho insatisfatório tiveram associação com a alta taxa de incidência de aids e elevada proporção de casos de coinfecção TB/HIV. Na segunda etapa evidenciou-se que a região metropolitana de São Paulo e baixada santista concentraram as maiores incidências da coinfecção, assim como para o abandono do tratamento. Os municípios com menor cobertura de TDO tinham menor chance de formarem territórios de risco para a incidência e para o abandono de tratamento. Os que apresentaram cobertura de TDO entre 31 e 79% tinham maior probabilidade de desenvolverem territórios de risco para o abandono. Na terceira etapa, identificou-se que tiveram maior impacto na coinfecção da TB/HIV, as seguintes variáveis: sexo masculino, maior número de diagnóstico da TB após o óbito, maior abandono de tratamento, elevado índice de desenvolvimento humano, municípios com unidades prisionais e pior distribuição de renda. Também se observou associação entre coinfecção e maior cobertura da ESF e média de enfermeiros por mil habitantes. A partir da realização desta pesquisa, o estudo pode subsidiar os gestores e formuladores de políticas para melhorarem as operações dos Programas de Controle da Tuberculose e do HIV/aids e resolver problemas na prestação de serviços de saúde, principalmente voltados à população com ambas as doenças

This study aimed to analyze the geoepidemiological, operational and social context of tuberculosis and HIV coinfection in the state of São Paulo. An operational research with ecological design was carried out in the 645 municipalities of the state of São Paulo. New cases of TB coinfected with HIV, reported and registered at TBWEB, were considered during the period from 2010 to 2015. The study was conducted in three stages: quality analysis and management of attention to TB / HIV coinfection in the state of São Paulo, using cluster analysis and selected correspondence analysis; to analyze the directly observed treatment coverage in the municipalities and its association with the occurrence of TB / HIV coinfection and unfavorable outcomes, using the Moran Local Index, with spatial interpolation from three different models, and spatial scanning statistics, with the assistance of ArcGis and SaTScan software. Hierarchical Bayesian Models was also applied through the R software by the R-INLA package; to identify an association of social indicators and health services with the occurrence of TB / HIV coinfection in the state of São Paulo, using the Generalized Additive Models for Location, Scale and Shape (GAMLSS) as a semiparametric regression model. With the results of the first stage, it was observed important differences between the municipalities regarding the quality of care, namely, the municipalities of São Paulo with satisfactory performance have high coverage of Community Health Agents Program and Family Health Strategy, being priorities for TB control and poorly performing municipalities were associated with a high incidence rate of AIDS and a high proportion of TB / HIV coinfection cases. In the second stage, it was evidenced that the metropolitan region of São Paulo and the Baixada Santista are concentrated as the highest incidence of coinfection, as for the abandonment of treatment. Municipalities with lower DOTS coverage were less likely to form risky territories for incidence and abandonment of treatment. Those reporting DOTS coverage between 31 and 79% were more likely to develop risky abandonment territories. In the third stage, it was identified that it had the greatest impact on the TB / HIV currency, according to the following factors: male gender, higher number of TB diagnoses after death, higher abandonment of treatment, high human development index, municipalities with units of service and worse income distribution. They also include an association between coinfection and higher Family Health Strategy coverage and average nurses per 1,000 population. From this research, the study can support managers and policy makers to improve the operations of Tuberculosis and HIV / AIDS Control Programs and solve problems in health services, especially for those population with both diseases

Cobertura de tratamento diretamente observado segundo o risco de coinfecção tb/hiv e desfechos desfavoráveis / Cobertura de tratamiento directamente observado según riesgo de coinfección tb/vih y desenlaces desfavorables / Coverage of directly observed treatment according to the risk of tuberculosis/hiv coinfection and unfavorable outcomes

RESUMO Objetivo: analisar a cobertura do tratamento diretamente observado segundo o risco de coinfecção tuberculose/vírus da imunodeficiência humana e desfechos desfavoráveis. Método: estudo ecológico com dados secundários relacionados aos 10.389 casos novos de coinfecção notificados no estado de São Paulo de 2010 a 2015. Dados analisados pelo Índice Local de Moran, estatística de varredura espacial e Modelos Bayesianos Hierárquicos. Resultados: região metropolitana de São Paulo e Baixada Santista concentraram maior incidência de coinfecção e abandono ao tratamento. Baixa cobertura de tratamento diretamente observado esteve associada aos territórios em risco para a coinfecção e maior risco de abandono. Município de São Paulo, região litorânea e região de Ribeirão Preto apresentaram maior incidência de óbito, o qual não apresentou relação com a cobertura do tratamento diretamente observado. Conclusão: baixa cobertura de tratamento diretamente observado apresentou associação com maior risco de coinfecção e abandono do tratamento.

RESUMEN Objetivo: Analizar la cobertura del tratamiento directamente observado según el riesgo de coinfección tuberculosis/virus de la inmunodeficiencia humana y desenlaces desfavorables. Método: Estudio ecológico con datos secundarios relacionados con los 10.389 nuevos casos de coinfección informados en el estado de São Paulo de 2010 a 2015. Datos analizados mediante Índice Local de Moran, estadística de muestreo espacial y Modelos Bayesianos Jerárquicos. Resultados: La región metropolitana de São Paulo y Baixada Santista concentraron mayor incidencia de coinfección y abandono del tratamiento. La baja cobertura de tratamiento directamente observado estuvo asociada a las áreas con riesgo de coinfección y mayor grado de abandono. El Municipio de São Paulo, la región litoral y el área de Ribeirão Preto expresaron mayor incidencia de decesos, no relacionándose ello con la cobertura del tratamiento directamente observado. Conclusión: La baja cobertura de tratamiento directamente observado mostró asociación com mayor riesgo de coinfección y abandono del tratamiento.

ABSTRACT Objective: To analyze the coverage of directly observed treatment according to the risk of tuberculosis/human immunodeficiency virus coinfection and unfavorable outcomes. Methods: Ecological study with secondary data related to 10,389 new cases of coinfection notified in the state of São Paulo, Brazil, from 2010 to 2015. They were analyzed by applying local Moran's index, spatial scan statistics, and hierarchical Bayesian models. Results: The São Paulo metropolitan area and Baixada Santista concentrate the highest incidence of coinfection and treatment default. Low coverage of directly observed treatment was associated with areas at risk for the coinfection and higher withdrawal risk. The city of São Paulo, the coastal region, and the Ribeirão Preto area showed a higher incidence of deaths, which did not show an association with the coverage of directly observed treatment. Conclusion: Low coverage of directly observed treatment was associated with a higher risk of coinfection and treatment default.

Quality and management of care to tuberculosis/HIv coinfection in the State of São Paulo, Brazil / Calidad y gestión en la atención de la coinfección tuberculosis y VIH en el Estado de São Paulo / Qualidade e gestão da atenção à coinfecção tuberculose e HIV no Estado de São Paulo

ABSTRACT Objective: to analyze the quality and management of care to tuberculosis/HIV coinfection in the state of São Paulo, Brazil. Methods: a descriptive study involving municipalities having at least five cases of tuberculosis/HIV coinfection in the Brazilian state of São Paulo notified in the tuberculosis notification system. To analyze the quality and management of care to tuberculosis/HIV coinfection, indicators were designed, based on tuberculosis evaluability assessment studies, and validated in Brazil. The municipalities were grouped according to their care quality and then submitted to multiple correspondence analysis. Results: the study formed a group with 18 municipalities (42.86%) with satisfactory care and management quality, and another group with 24 municipalities (57.14%) with a quality characterized as unsatisfactory. In the municipalities that showed a satisfactory result, the investigation identified a low proportion of tuberculosis/HIV coinfection, a low AIDS incidence rate, intermediate population size, and high coverage of the Community Health Workers' Program and Family Health Strategy. The municipalities with unsatisfactory quality had a high proportion of tuberculosis/HIV coinfection and a high AIDS incidence rate. Conclusion: the study reveals the defining characteristics of quality and management of care to tuberculosis/HIV coinfection as chronic conditions, bringing relevant elements regarding the mobilization of resources and investments in the municipalities where these are necessary. Additionally, the investigation shows that health results are critical where care quality is unsatisfactory, pointing out the need for reorganizing care and the management of actions involving control of tuberculosis/HIV coinfection in these contexts.

RESUMEN Objetivo: analizar la calidad y gestión en la atención de la coinfección tuberculosis y VIH en el estado de São Paulo. Método: estudio descriptivo, realizado en municipios donde residen al menos cinco casos de coinfección de tuberculosis y VIH en el estado de São Paulo, informados al sistema de notificaciones de tuberculosis. Para analizar la calidad de atención y gestión de la coinfección tuberculosis/VIH fueron elaborados indicadores basados en estudios evaluativos en tuberculosis validados en Brasil. Los municipios fueron agrupados según su calidad de atención, sometiéndoselos luego a análisis de correspondencia múltiple. Resultados: el estudio conformó un grupo con 18 municipios (42,86%) de calidad de atención y gestión satisfactorias, y otro con 24 (57,14%) municipios caracterizados como no satisfactorios. En los municipios con resultados satisfactorios se identificó baja proporción de coinfección tuberculosis y VIH, baja tasa de incidencia de SIDA, cantidad poblacional mediana, elevada cobertura de Agentes Comunitarios de Salud y Estrategia Salud de la Familia. En los municipios no satisfactorios se observó alta proporción de coinfección tuberculosis e VIH y tasa de incidencia de SIDA. Conclusión: el estudio evidencia las características que definen la calidad de atención y gestión de la coinfección tuberculosis y VIH como condiciones crónicas, destacando elementos relevantes respecto de movilización de recursos e inversión en los municipios donde eso resulta necesario. Además, muestra que los resultados sanitarios son críticos donde no hay calidad de atención satisfactoria, expresando necesidad de reorganización de la atención y gestión de las acciones que involucran al control de la coinfección tuberculosis y VIH en tales contextos.

RESUMO Objetivo: analisar a qualidade e gestão da atenção à coinfecção tuberculose e HIV no estado de São Paulo. Método: estudo descritivo, realizado com municípios de residência de pelo menos cinco casos de coinfecção tuberculose e HIV no estado de São Paulo, notificados no sistema de notificações de tuberculose. Para análise da qualidade da atenção e gerenciamento da coinfecção tuberculose e HIV foram construídos indicadores, com base em estudos de avaliabilidade em tuberculose, validados no Brasil. Os municípios foram agrupados conforme sua qualidade da atenção e depois foram submetidos à análise de correspondência múltipla. Resultados: no estudo, formou-se um grupo com 18 municípios (42,86%) com satisfatória qualidade da atenção e gerenciamento, e outro grupo com 24 (57,14%) municípios caracterizados como não satisfatório. Nos municípios com resultado satisfatório, identificou-se baixa proporção de coinfecção tuberculose e HIV, baixa taxa de incidência de aids, porte populacional médio, elevada cobertura de Programas de Agentes Comunitários de Saúde e Estratégia Saúde da Família. Para os demais municípios com qualidade não satisfatória, observou-se alta proporção de coinfecção tuberculose /HIV e taxa de incidência de aids. Conclusão: o estudo evidencia as características definidoras da qualidade da atenção e gerenciamento da coinfecção tuberculose e HIV enquanto condições crônicas, trazendo elementos relevantes no que tange à mobilização de recursos e investimentos nos municípios onde isso se faz necessário. Além disso, mostra que os resultados sanitários são críticos onde não há satisfatória qualidade da atenção, mostrando a necessidade de reorganização da assistência e do gerenciamento das ações que envolvem o controle da coinfecção tuberculose e HIV nesses contextos.

Teoría de colas aplicada al estudio del sistema de servicio de una farmacia / Queueing theory applied to the study of the service system of a pharmacy

Con frecuencia las instituciones que brindan servicios deben tomar decisiones respecto al caudal de clientes que reciben, así como la capacidad de servicio con que cuentan. Sin embargo, a diario se presenta un fenómeno común y cotidiano: las colas o líneas de espera, las que se generan cuando la demanda excede a la oferta. En este contexto aparece la teoría de colas, la cual no resuelve el problema, pero ofrece información para tomar decisiones, sobre la base de la predicción de algunas características sobre la cola y el sistema de servicio. Un escenario evidente en el sector salud, donde se generan constantemente líneas de espera son las farmacias. En la Farmacia Hospitalaria Principal de Santiago de Cuba, se modeló la venta de medicamentos desde este enfoque, al no contar con otras herramientas que con su aplicación apoyaran la toma de decisiones. Por ello el objetivo del trabajo es determinar desde el enfoque de la teoría de colas, las variables y medidas de rendimiento del sistema de servicio de dicha Farmacia, para la toma de decisiones a corto y mediano plazo, en función de ofrecer un mayor y mejor servicio. Como resultado se determinó que, para el sistema de servicio actual, existe una alta probabilidad de que se generen colas, y que los clientes permanezcan en ella por más de 5 minutos; recomendando garantizar la disponibilidad de los dependientes, reducir el número de clientes en la cola, hacer más amena la estancia en ella, así como valorar y evaluar su rediseño(AU)

Often the institutions that provide services must make decisions regarding the number of clients they receive, as well as the service capacity they have. However, there is a daily and everyday phenomenon: queues or waiting lines, which are generated when demand exceeds supply. In this context, queueing theory appears, which does not solve the problem, but provides information needed to make decisions, based on the prediction of some characteristics about the queue and the service system. A clear context in the health branch, where there are constantly waiting lines are pharmacies. In the Municipal Community Pharmacy of Santiago de Cuba, the sale of medicinal products was modeled from this approach, since there are no other applied tools that support decision making. Therefore, the objective of the work is to determine from the approach of queueing theory, the variables and measures of performance of the service system of the said Pharmacy, for the decision making in the short and medium term, in function of offering a greater and better service. As a result, it was determined that, for the current service system, there is a high probability that queues will be generated, and that customers will stay in it for more than 5 minutes; recommending to guarantee the availability of dependents, reduce the number of clients in the queue, make the stay in it more enjoyable, as well as assess and evaluate its redesign(AU)