**3. Patch 2: Chine, Ecuador**

a rate of 21 positive PTB smears per hundred patients was found (95% CI=15.5-26.6), and the main factors associated with PTB were age (35-44 years), occupation (engaged in agricultural) and weight loss. Through a logistic regression model, we found that the subgroup of chronic cough patients aged 35-44 years, agricultural workers and who had lost weight, had the greatest likelihood of being PTB positive (68.7% compared to the overall average of 21% in the

In addition, we noted that in the case of men, patients came to the hospital from near, far and very far distant communities, but in the case of women, the majority of them only came from communities which were near or very near. So we decided to carry out other studies in the hospital's area of influence, with the aim of analyzing factors related with the high PTB prevalence among users of secondary level care, not only in terms of health system aspects,

a) In 1997 active case-finding was carried out among all patients aged over 14 years seeking consultation in a random sample of seven primary care centers [8]. We found a PTB positivity rate of 11.1 (95% CI=6.6-17.2) per hundred patients studied. The factors associated with PTB were size and poverty level of the locality of residence. Of the coughers identified, 56% sought

b) In 1998 active case-finding was carried out among those aged over 14 years who had a cough of 15 days or more of duration, in a convenience sample of 1,894 households in 32 communities chosen at random based on the level of poverty and on travel time to reach the nearest health services (< 1 hour, 1 hour and over). In this study we found a rate of 276.9 per 100,000 persons studied (95%CI: 161-443) and that the only factor associated with PTB was blood in sputum, probably due to the homogenous conditions of extreme poverty among the populations

Additionally, we found that the sensitivity of the smear testing was slightly lower than 50% in the primary care centers and in communities, and that the proportion of patients with active PTB that was receiving treatment was only 50% in the primary care centers, and 10.5% in the studied communities [10]. Also, we found high rates of anti-TB treatment defaulting [11], and very high levels of PTB multidrug-resistance (MDR): 4.6% and 29.2% primary and secondary

According to the logistic regression model fitted, the main variables associated with MDR were: having received anti-TB treatment previously, cough of three years or more of duration and not being indigenous. This is the only occasion in all our studies, which the condition of

In 2000-2001 our team, together with Right to Health Defense Group and Physicians for Human Rights, carried out a population-based study to assess health conditions, and access to health services in the conflict zone initiated in 1994 between the EZLN and the Mexican government [6]. We found that the most affected regions by the armed conflict have fared even worse than the rest of Chiapas State. We performed a household survey in the municipalities most affected by the armed conflict among three types of communities: opposition communities, pro-

MDR-TB, respectively. In fact, 14% of all studied PTB patients had MDR.

being indigenous appeared as a protective factor [12].

but of demographic and socioeconomic characteristics:

care for non-respiratory symptoms.

446 Tuberculosis - Current Issues in Diagnosis and Management

studied patients).

studied [9].

During the decade from 1997 to 2006, inequalities of wealth and human development were extremely marked in Ecuador. The indigenous population, such as that residing in the central Andean province of Cotopaxi, has the highest poverty rates, and has many of its basic needs unmet. In Ecuador, up until 2006, the TB Prevention and Control Program was based on passive case finding of patients with respiratory symptoms (health personnel would check whether a patient visiting a health center had a productive cough of more than 15 days of duration). In contrast to what happens in cities, in rural areas the organization and functioning of the program relies on the presence of basic rural health teams; this means that is not uncommon for health personnel to be absent. This situation, among others, has resulted in TB notification being irregular. Although the average incidence reported is 65/100,000,3 given the important level of under-reporting of TB cases, the true extent of the disease in Ecuador is unknown.

specimens. Given the degree of social and geographical exclusion of the community, PTB was

Pulmonary Tuberculosis in Latin America: Patchwork Studies Reveal Inequalities in Its Control – The Cases of Chiapas

Two hundred and two persons were identified with chronic cough (fifteen days or more), 173 of them, productive. Of 92 coughers in which it was possible analyze their sputum, 44 (48%) were PTB positive (representing 6.7% of the whole population and 11.3% of those aged 15 years and over). Among men, the highest prevalence was in the 35–44 age group (20.6%) and among women in the group aged ≥ 45 years (16.7%). Also, 27% of families had between one and four smear positive members. The factors associated with presence of PTB were: previous history of active TB (OR=6.0; 95% CI=2.9-12.3), haemoptysis (OR=3.8; 95% CI=1.5-10.0), and history of

With the intention of making some contribution to resolving the PTB problem, our team reached an agreement with the inhabitants of the community of Chine, in order to implement the DOTS strategy, while at the same time taking account of aspects of the community's world view. As consequence of this approach, we obtained a cure rate of 100%, confirmed by three negative smear-tests during the anti-TB treatment and cultures at the end of it (there were no

Although TB prevention and control programs encourage patients to visit health services and follow instructions, if they continue in their tendency to give little attention to socioeconomic, cultural and anthropological aspects, the results will be the same. How can better outcomes be expected if health services persist in acting as they always they do, including opening for restricted hours (from 8 am to 12 pm and from 2 to 6 pm)? In our intervention in Chine, symbolic referents, the religious dimension and rituals, as well as aspects of daily life (working hours, school, community and family calendar, seasonal migration, and traditional medical practices,

**Table 2.** Pulmonary Tuberculosis (PTB) and associated factors observed within studies performed by GRAAL members

One of the coauthors of the present work (Olivia Horna), as a nurse responsible for coordi‐ nating the application of DOTS, realized that the TB Program was relaxing various aspects of

PTB was associated with prior history of PTB (OR= 6.0; CI 95%: 2.9-12.3), with haemoptysis (OR=

(Mexico), Chine (Ecuador) and Lima (Peru) http://dx.doi.org/10.5772/54950 449

Cure rate of 100% based on community consent

for the performing of DOTS strategy

3.8; CI 95%: 1.5-10.0).

participating in seasonal migration (OR=2.44; 95% CI=0.91-6.54) [16].

diagnosed only by smear test.

defaults and no deaths) [17].

among others) were taken into account.

CI: Confidence interval; OR: Odds Ratio

**4. Patch 3: Lima, Peru**

in Ecuador.

Chine, Cotopaxi, EcuadorPrevalence of PTB 6.7% in an entire

The main results obtained in Ecuador, are shown in Table 2.

indigenous community


**Table 1.** Pulmonary Tuberculosis (PTB) and associated factors observed within studies performed by GRAAL members in Mexico.

In Chine, an indigenous community of 653 inhabitants, in the parish of Angamarca, located in Cotopaxi Region, over 90% of its population have their basic needs unmet [15]. It is situated at an altitude of 3,500m above sea level and is two hours walk from the nearest health center, which during the period 2000 to 2004 was practically without staff. One of the co-authors of the present work (Natalia Romero) collaborated with the health team of this parish, during her period of rural medical training several years earlier. Following the diagnosis of one PTB case (the schoolmaster) in 2001, we conducted a study between 2001 and 2003, and found a prevalence rate of PTB-positive cases of 6.7% for the community as a whole [16].

On the basis of this single case, we saw the convenience of studying the total population of the community through a household survey (taking into account the experience obtained in Chiapas, México). The data collected was analyzed using the technique of multiple corre‐ spondence analyses, which allowed us to ascertain the risk and exposure factors in the community. All persons with chronic productive cough were asked to provide three sputum

<sup>3</sup> World Health Organization. Ecuador: Health profile. Available at: http://www.who.int/countries/ecu/es/ (accessed 12 August 2012).

specimens. Given the degree of social and geographical exclusion of the community, PTB was diagnosed only by smear test.

Two hundred and two persons were identified with chronic cough (fifteen days or more), 173 of them, productive. Of 92 coughers in which it was possible analyze their sputum, 44 (48%) were PTB positive (representing 6.7% of the whole population and 11.3% of those aged 15 years and over). Among men, the highest prevalence was in the 35–44 age group (20.6%) and among women in the group aged ≥ 45 years (16.7%). Also, 27% of families had between one and four smear positive members. The factors associated with presence of PTB were: previous history of active TB (OR=6.0; 95% CI=2.9-12.3), haemoptysis (OR=3.8; 95% CI=1.5-10.0), and history of participating in seasonal migration (OR=2.44; 95% CI=0.91-6.54) [16].

With the intention of making some contribution to resolving the PTB problem, our team reached an agreement with the inhabitants of the community of Chine, in order to implement the DOTS strategy, while at the same time taking account of aspects of the community's world view. As consequence of this approach, we obtained a cure rate of 100%, confirmed by three negative smear-tests during the anti-TB treatment and cultures at the end of it (there were no defaults and no deaths) [17].

Although TB prevention and control programs encourage patients to visit health services and follow instructions, if they continue in their tendency to give little attention to socioeconomic, cultural and anthropological aspects, the results will be the same. How can better outcomes be expected if health services persist in acting as they always they do, including opening for restricted hours (from 8 am to 12 pm and from 2 to 6 pm)? In our intervention in Chine, symbolic referents, the religious dimension and rituals, as well as aspects of daily life (working hours, school, community and family calendar, seasonal migration, and traditional medical practices, among others) were taken into account.

The main results obtained in Ecuador, are shown in Table 2.


CI: Confidence interval; OR: Odds Ratio

uncommon for health personnel to be absent. This situation, among others, has resulted in TB

important level of under-reporting of TB cases, the true extent of the disease in Ecuador is

given the

Association with age (35-44 years old), working in agricultural, and weight loss.

Presence of blood in sputum; 50% of sensitivity in sputum test performed in PHC setting. High rate of defaulting treatment; and very high MDR-TB rates associated (by Logistic Regression) with previous PTB treatment, cough for more than 3 years and not being indigenous.

deprivation characteristics and no access

Association with poverty level

Cohort of patients with PTB Mortality was associated with poverty and

**Table 1.** Pulmonary Tuberculosis (PTB) and associated factors observed within studies performed by GRAAL members

In Chine, an indigenous community of 653 inhabitants, in the parish of Angamarca, located in Cotopaxi Region, over 90% of its population have their basic needs unmet [15]. It is situated at an altitude of 3,500m above sea level and is two hours walk from the nearest health center, which during the period 2000 to 2004 was practically without staff. One of the co-authors of the present work (Natalia Romero) collaborated with the health team of this parish, during her period of rural medical training several years earlier. Following the diagnosis of one PTB case (the schoolmaster) in 2001, we conducted a study between 2001 and 2003, and found a

On the basis of this single case, we saw the convenience of studying the total population of the community through a household survey (taking into account the experience obtained in Chiapas, México). The data collected was analyzed using the technique of multiple corre‐ spondence analyses, which allowed us to ascertain the risk and exposure factors in the community. All persons with chronic productive cough were asked to provide three sputum

3 World Health Organization. Ecuador: Health profile. Available at: http://www.who.int/countries/ecu/es/ (accessed 12

prevalence rate of PTB-positive cases of 6.7% for the community as a whole [16].

to DOTS.

notification being irregular. Although the average incidence reported is 65/100,000,3

**Setting Frequency Associated Factors**

Prevalence of PTB 11.1% among patients, consulting in primary health centers (PHC) with symptoms suggestive

Prevalence of PTB 277 per 100,000 persons studied in household surveys

suggestive of TB

of TB

448 Tuberculosis - Current Issues in Diagnosis and Management

Prevalence of PTB 21% in a hospitalbased population with symptoms

unknown.

Chiapas, Mexico (only people 15 years of

age and over)

in Mexico.

August 2012).

**Table 2.** Pulmonary Tuberculosis (PTB) and associated factors observed within studies performed by GRAAL members in Ecuador.
