**4. Social networks in tuberculosis**

70 Current Topics in Tropical Medicine

Nodes are the individual actors within the networks, and ties are the relationships between the actors. The resulting graph-based structures are often very complex. There can be many kinds of ties between the nodes. Research in a number of academic fields has shown that social networks operate on many levels, from families up to the level of nations, and play a critical role in determining the way problems are solved, organizations are run, and the degree to which individuals succeed in achieving their goals (McGrath 1988, Palinkas et al.

In its simplest form, a social network is a map of specified ties, such as friendship, between the nodes being studied. The nodes to which an individual is thus connected are the social contacts of that individual. The network can also be used to measure social capital – the value that an individual gets from the social network. These concepts are often displayed in

Its use in health (Bhardwaj et al. 2010, Lawrence & Fudge 2009), and more on in infectious diseases (Klovdahl et al. 2002), has been recently highlighted, including sexually transmitted infections (Perisse & Costa Nery 2007), as well in TB (Boffa et al. 2011, Waisbord 2007, Curto et al. 2010, Burlandy & Labra 2007, Santos Filho & Santos Gomes 2007, Freudenberg 1995,

Multiple studies have evidenced links between social, economic and biologic determinants to TB, recently using modeling approaches that have been used to understand their contribution to the epidemic dynamics of TB (Murray et al. 2011). Specifically, different authors have evidence for associations between smoking, indoor air pollution, diabetes mellitus, alcohol, nutritional status, crowding, migration, aging and economic trends, and the occurrence of TB infection and/or disease. We outline some methodological problems inherent to the study of these associations; these include study design issues, reverse causality and misclassification of both exposure and outcomes. From a social perspective, multiple analyses can be useful and approaches to modeling the impact of determinants and the effect of interventions as the follow will help: the population attributable fraction model, which estimates the proportion of the TB burden that would be averted if exposure to a risk factor were eliminated from the population, and deterministic epidemic models that capture transmission dynamics and the indirect effects of interventions. Can be stated that by defining research priorities in both the study of specific determinants and the development of appropriate models to assess the impact of addressing these determinants (Murray et al.

Although not considered neglected, TB disproportionally affect resource-constrained areas of the World, including Latin America. In tropical and subtropical areas of this region, the vicious cycle of poverty, disease and underdevelopment is widespread, including TB as one of the significant pathologies involved. The burden of disease associated to TB in this region is highly significant in some countries (eg. Bolivia, Haiti, Brazil, among others). TB has burdened Latin America throughout centuries and has directly influenced their ability to

Therefore, the need for a new paradigm that integrates various public health policies, programs, and a strategy with the collaboration of all responsible sectors is long overdue. In this regard, innovative approaches are required to ensure the availability of low-cost, simple, sustainable, and locally acceptable strategies to improve the health of neglected

develop and become competitive societies in the current climate of globalization.

a social network diagram, where nodes are the points and ties are the lines.

2011, Szell et al. 2010, Zhao et al. 2011, Hawe et al. 2004).

Murray et al. 2011).

**3. Tuberculosis as a social issue** 

2011, Santin & Navas 2011, Juniarti & Evans 2011).

Multiple studies have evidenced links between social, economic and biologic determinants to TB, recently using modeling approaches (Guzzetta et al. 2011, Drewe et al. 2011, Wilson et al. 2011, Bohm et al. 2008, Cook et al. 2007, Cohen et al. 2007, Ayala & Kroeger 2002). Tuberculosis is the archetypal disease of poverty, and social inequalities undermine TB control (Rocha et al. 2011, Lonnroth et al. 2010). Poverty predisposes individuals to TB through multiple mechanisms, such as malnutrition (Rocha et al. 2011, Lonnroth et al. 2010, Cegielski & McMurray 2004), and TB worsens poverty as it increases expenses and reduces income (Rocha et al. 2011, Pantoja et al. 2009, Pantoja et al. 2009, Kemp et al. 2007, Lonnroth et al. 2007, Rajeswari et al. 1999).

Furthermore, poor TB-affected households often experience stigmatization; adding barriers to TB control (Rocha et al. 2011, Atre et al. 2011, Dhingra & Khan 2010, Pungrassami et al. 2010, Jittimanee et al. 2009). Poor people at the greatest risk of TB are therefore, in many settings, also the least able to access TB care (Rocha et al. 2011). Then, socio-economic interventions adapted to the needs of TB-affected households living in impoverished periurban shantytowns and other demographical settings.

The socio-economic interventions can successfully engaged most TB-affected households in an active civil society that was associated with marked improvements in uptake of TB prevention, diagnosis and treatment, resulting in strengthened TB control (Rocha et al. 2011). The development of social networks and SNA, however, has been mostly approached only for investigation of TB outbreaks (Fitzpatrick et al. 2001, Sterling et al. 2000) and fewly in the support with the strategies of the WHO for TB Control (World Health Organization 2011).

The WHO Stop TB Strategy, recently revised (World Health Organization 2011), stated a vision for a TB-free world, with a goal of to dramatically reduce the global burden of TB by 2015 in line with the Stop TB Partnership targets and the Millennium Development Goals (MDGs) which pursue the significant reduction in endemic diseases, such as TB and others, even regional diseases (e.g. Chagas disease), that can represent an impediment in achieving the MDGs (Franco-Paredes et al. 2007). In their components, it is included Empower people with TB, and communities through partnership through: a. Pursue advocacy, communication and social mobilization; b. Foster community participation in TB care, prevention and health promotion; and c. Promote use of the Patients' Charter for Tuberculosis Care (World Health Organization 2011).

In Brazil, one of the countries in Latin America where TB is a major public health problem, recent experiences suggest the importance of networking and civil society participation for TB control (Santos Filho & Santos Gomes 2007). In that country, until 2003, the presence of civil society in the fight against TB took place by means of several initiatives from researchers, healthcare professionals and medicine students, especially from the Sociedade Brasileira de Pneumologia e Tisiologia (Brazilian Thoracic and Tuberculosis Society), Rede

Social Networking in Tuberculosis: Experience in Colombia 73

TB (TB Network) and Liga Científica contra a Tuberculose (Scientific League against Tuberculosis). Since their creation, these entities have been constituted by people who are committed to TB control, though lacking the "community" component represented by people who are affected by and live with the disease (Santos Filho & Santos Gomes 2007). After that in

The actions by the community entities in the fight against tuberculosis have been particularly concentrated on the networking among diverse social and govern mental actors; plus, on making the problem noticeable to their target populations or the general population, aiming their sensitization (Santos Filho & Santos Gomes 2007). For some relevant social actors, such as the Rede TB (TB Network) and the Liga Científi ca (Scientific League), the participation of the community sector in their activities aims at contributing to greater efficacy of their actions and responses to certain problems that are presented. Without the user's voice and perspective, there is the risk of repeating mistakes of not evaluating correctly the efficacy of actions such as applied methods and methodologies in health services (Santos Filho & Santos Gomes 2007). Then, multiple strategies are important in this context of development of new alternatives in the control of TB. The practice of participation, networking, advocacy and multi-sector cooperation will provide the necessary conditions for an effective control of tuberculosis in Brazil, as well in other countries where

Taking in account general epidemiology of TB in Colombia and particularly at a municipality where this strategy of social networking was developed, social conditions were analyzed (Collazos et al. 2010, Jalil-Paier & Donado 2010, Ascuntar et al. 2010, Mateus-Solarte & Carvajal-Barona 2008, Jaramillo 1999). Also, in the scenarios were considered the recent impacts of the health sector reform (Carvajal et al. 2004, Ayala & Kroeger 2002), that also have influenced the TB control programs from a national to a local perspective. Pereira is the capital municipality of the Department of Risaralda (Figure 2). It stands in the center of the western region of the country, located in a small valley that descends from a part of the western Andes mountain chain. Its strategic location in the coffee producing area makes the city an urban center in Colombia, as does its proximity to Bogotá, Cali and Medellín. For 2011, Pereira municipality has an estimated population of 459,690. Official reported records for TB in Risaralda registered a disease incidence for 2011 of 66 cases per 100,000 pop (as 15 December) (which is above the national average rate of 24 cases per 100,000 pop). Pereira is divided into 19 urban submunicipalities: Ferrocarril, Olímpica, San Joaquín, Cuba, Del Café, El oso, Perla del Otún, Consota, El Rocío, El poblado, El jardín, San Nicolás, Centro, Río Otún, Boston, Universidad, Villavicencio, Oriente y Villasantana. Additionally also has rural townships which include Altagracia, Arabia, Caimalito, Cerritos, La Florida, Puerto Caldas, Combia Alta, Combia Baja, La Bella, Estrella- La Palmilla, Morelia, Tribunas. The municipality of Pereira has a diversified economy: the primary sector accounts for 5.7% of domestic product, the secondary sector shows a relative weight of 26.2%, while the tertiary sector is the most representative with a 68.1%. The GDP of Pereira grew by 3.7% in 2004. For 2010, Pereira reported 301 cases of TB (incidence rate of 65.85 cases per 100,000pop). In Pereira, previously reported interventions have been developed and working intersectorially with the academia in order to increase the impact of activities in TB

recent years more organizations were involved in the fight against TB in the country.

they would be applied (Santos Filho & Santos Gomes 2007).

control (Castañeda-Hernández et al. 2012b).

**5. Social networks in tuberculosis in Pereira, Colombia** 


Fig. 1. Tuberculosis epidemiological profile for Colombia according to the World Health

Organization, 2010.

TB (TB Network) and Liga Científica contra a Tuberculose (Scientific League against Tuberculosis). Since their creation, these entities have been constituted by people who are committed to TB control, though lacking the "community" component represented by people who are affected by and live with the disease (Santos Filho & Santos Gomes 2007). After that in recent years more organizations were involved in the fight against TB in the country.

The actions by the community entities in the fight against tuberculosis have been particularly concentrated on the networking among diverse social and govern mental actors; plus, on making the problem noticeable to their target populations or the general population, aiming their sensitization (Santos Filho & Santos Gomes 2007). For some relevant social actors, such as the Rede TB (TB Network) and the Liga Científi ca (Scientific League), the participation of the community sector in their activities aims at contributing to greater efficacy of their actions and responses to certain problems that are presented. Without the user's voice and perspective, there is the risk of repeating mistakes of not evaluating correctly the efficacy of actions such as applied methods and methodologies in health services (Santos Filho & Santos Gomes 2007). Then, multiple strategies are important in this context of development of new alternatives in the control of TB. The practice of participation, networking, advocacy and multi-sector cooperation will provide the necessary conditions for an effective control of tuberculosis in Brazil, as well in other countries where they would be applied (Santos Filho & Santos Gomes 2007).

#### **5. Social networks in tuberculosis in Pereira, Colombia**

Taking in account general epidemiology of TB in Colombia and particularly at a municipality where this strategy of social networking was developed, social conditions were analyzed (Collazos et al. 2010, Jalil-Paier & Donado 2010, Ascuntar et al. 2010, Mateus-Solarte & Carvajal-Barona 2008, Jaramillo 1999). Also, in the scenarios were considered the recent impacts of the health sector reform (Carvajal et al. 2004, Ayala & Kroeger 2002), that also have influenced the TB control programs from a national to a local perspective. Pereira is the capital municipality of the Department of Risaralda (Figure 2). It stands in the center of the western region of the country, located in a small valley that descends from a part of the western Andes mountain chain. Its strategic location in the coffee producing area makes the city an urban center in Colombia, as does its proximity to Bogotá, Cali and Medellín.

For 2011, Pereira municipality has an estimated population of 459,690. Official reported records for TB in Risaralda registered a disease incidence for 2011 of 66 cases per 100,000 pop (as 15 December) (which is above the national average rate of 24 cases per 100,000 pop). Pereira is divided into 19 urban submunicipalities: Ferrocarril, Olímpica, San Joaquín, Cuba, Del Café, El oso, Perla del Otún, Consota, El Rocío, El poblado, El jardín, San Nicolás, Centro, Río Otún, Boston, Universidad, Villavicencio, Oriente y Villasantana. Additionally also has rural townships which include Altagracia, Arabia, Caimalito, Cerritos, La Florida, Puerto Caldas, Combia Alta, Combia Baja, La Bella, Estrella- La Palmilla, Morelia, Tribunas. The municipality of Pereira has a diversified economy: the primary sector accounts for 5.7% of domestic product, the secondary sector shows a relative weight of 26.2%, while the tertiary sector is the most representative with a 68.1%. The GDP of Pereira grew by 3.7% in 2004. For 2010, Pereira reported 301 cases of TB (incidence rate of 65.85 cases per 100,000pop). In Pereira, previously reported interventions have been developed and working intersectorially with the academia in order to increase the impact of activities in TB control (Castañeda-Hernández et al. 2012b).

Social Networking in Tuberculosis: Experience in Colombia 75

Advocacy is intended to secure the support of key constituencies in relevant local, national and international policy discussions and is expected to prompt greater accountability from governmental and international actors. Communication is concerned with informing, and enhancing knowledge among, the general public and people with TB and empowering them to express their needs and take action. Equally, encouraging providers to be more receptive to the expressed wants and views of people with TB and community members will make TB services more responsive to community needs. Social mobilization is the process of bringing together all feasible and practical intersectoral allies to raise people's knowledge of and demand for good-quality TB care and health care in general, assist in the delivery of resources and services and strengthen community participation for sustainability. Thus, ACSM is essential for achieving a world free of TB and is relevant to all aspects of the Stop TB Strategy. ACSM efforts in TB control should be linked with overarching efforts to

promote public health and social development (World Health Organization 2011).

Fig. 3. SNA for Tuberculosis Network in Pereira, Colombia (developed with the Software

the areas of the municipality where most cases are concentrated.

With these considerations in mind, in Pereira a social network for TB was developed. This network include the participation of ex-patients with TB, also healthy general population participated. All of them through the creation of nodes of the network, which were considered for this purposes as communitarian organizations constituted for a common objective and which are present regularly at neighborhoods in the municipality. Nodes were located at the 7 most highly prevalent areas of the municipality, previous to epidemiological analyses of those areas. Then, these locations were oriented to focalize the actions through the impact that, once established, this network would have on the control activities for TB in

In Pereira, with coordination of the TB control program on the top of the organization, a social network was developed with 7 strategically located and voluntary participation nodes

SocNETV 0.81).

Fig. 2. Relative location of Pereira, Risaralda, Colombia, South America.

In the country, the strategic plan "*Colombia Libre de Tuberculosis para la Expansión y Fortalecimiento de la Estrategia Alto a la TB, 2010-2015*" (Colombia Free of TB for the Expansion and Enhancement of the Strategy Stop TB, 2010-2015), define as goal the achievement of notifications of new positive baciloscopy cases in more than 70% and a curation rate of at least 85%. In this context the routine surveillance allow to follow management and measurement of the impact of the realized actions by the control programs at municipal, departmental and national level, in order to generate interventions that contribute to achievement of the established goals to stop the advance of TB in the country.

Those considered strategies in the referred plan include the previously mentioned pursue advocacy, communication and social mobilization (ACMS), from the WHO Global Plan to STOP TB (World Health Organization 2011). In the context of wide-ranging partnerships for TB control, advocacy, communication and social mobilization (ACSM) embrace: advocacy to influence policy changes and sustain political and financial commitment; two-way communication between the care providers and people with TB as well as communities to improve knowledge of TB control policies, programmes and services; and social mobilization to engage society, especially the poor, and all allies and partners in the campaign to Stop TB. Each of these activities can help build greater commitment to fighting TB.

Fig. 2. Relative location of Pereira, Risaralda, Colombia, South America.

fighting TB.

In the country, the strategic plan "*Colombia Libre de Tuberculosis para la Expansión y Fortalecimiento de la Estrategia Alto a la TB, 2010-2015*" (Colombia Free of TB for the Expansion and Enhancement of the Strategy Stop TB, 2010-2015), define as goal the achievement of notifications of new positive baciloscopy cases in more than 70% and a curation rate of at least 85%. In this context the routine surveillance allow to follow management and measurement of the impact of the realized actions by the control programs at municipal, departmental and national level, in order to generate interventions that contribute to achievement of the established goals to stop the advance of TB in the country. Those considered strategies in the referred plan include the previously mentioned pursue advocacy, communication and social mobilization (ACMS), from the WHO Global Plan to STOP TB (World Health Organization 2011). In the context of wide-ranging partnerships for TB control, advocacy, communication and social mobilization (ACSM) embrace: advocacy to influence policy changes and sustain political and financial commitment; two-way communication between the care providers and people with TB as well as communities to improve knowledge of TB control policies, programmes and services; and social mobilization to engage society, especially the poor, and all allies and partners in the campaign to Stop TB. Each of these activities can help build greater commitment to Advocacy is intended to secure the support of key constituencies in relevant local, national and international policy discussions and is expected to prompt greater accountability from governmental and international actors. Communication is concerned with informing, and enhancing knowledge among, the general public and people with TB and empowering them to express their needs and take action. Equally, encouraging providers to be more receptive to the expressed wants and views of people with TB and community members will make TB services more responsive to community needs. Social mobilization is the process of bringing together all feasible and practical intersectoral allies to raise people's knowledge of and demand for good-quality TB care and health care in general, assist in the delivery of resources and services and strengthen community participation for sustainability. Thus, ACSM is essential for achieving a world free of TB and is relevant to all aspects of the Stop TB Strategy. ACSM efforts in TB control should be linked with overarching efforts to promote public health and social development (World Health Organization 2011).

Fig. 3. SNA for Tuberculosis Network in Pereira, Colombia (developed with the Software SocNETV 0.81).

With these considerations in mind, in Pereira a social network for TB was developed. This network include the participation of ex-patients with TB, also healthy general population participated. All of them through the creation of nodes of the network, which were considered for this purposes as communitarian organizations constituted for a common objective and which are present regularly at neighborhoods in the municipality. Nodes were located at the 7 most highly prevalent areas of the municipality, previous to epidemiological analyses of those areas. Then, these locations were oriented to focalize the actions through the impact that, once established, this network would have on the control activities for TB in the areas of the municipality where most cases are concentrated.

In Pereira, with coordination of the TB control program on the top of the organization, a social network was developed with 7 strategically located and voluntary participation nodes

Social Networking in Tuberculosis: Experience in Colombia 77

Arbelaez MP, Nelson KE, Munoz A. 2000. BCG vaccine effectiveness in preventing

Ascuntar JM, Gaviria MB, Uribe L, Ochoa J. 2010. Fear, infection and compassion: social

Atre S, Kudale A, Morankar S, Gosoniu D, Weiss MG. 2011. Gender and community views

Ayala CC, Kroeger A. 2002. Health sector reform in Colombia and its effects on tuberculosis control and immunization programs. *Cad. Saude Publica* 18(6):1771-81 Bhardwaj N, Yan KK, Gerstein MB. 2010. Analysis of diverse regulatory networks in a

Black GF, Weir RE, Chaguluka SD, Warndorff D, Crampin AC et al. 2003. Gamma interferon

Bohm M, Palphramand KL, Newton-Cross G, Hutchings MR, White PC. 2008. Dynamic

Carvajal R, Cabrera GA, Mateus JC. 2004. Effects of the health sector reform upon

Castañeda-Hernández DM, Rodríguez-Morales AJ, Sepulveda-Arias JC. 2012a Importancia

vigilancia epidemiologica de la tuberculosis. *Rev Med Chile* 140:(1)in press Castañeda-Hernández DM, Mondragón-Cardona A, Campo-Betancourth CF, Tobón-García

Cegielski JP, McMurray DN. 2004. The relationship between malnutrition and tuberculosis:

Cohen T, Colijn C, Finklea B, Murray M. 2007. Exogenous re-infection and the dynamics of

Collazos C, Carrasquilla G, Ibanez M, Lopez LE. 2010. Prevalence of respiratory symptomatic in health institutions of Bogota, Colombia. *Biomedica.* 30(4):519-29 Cook VJ, Sun SJ, Tapia J, Muth SQ, Arguello DF et al. 2007. Transmission network analysis

Curto M, Scatena LM, de Paula Andrade RL, Palha PF, de Assis EG et al. 2010. Tuberculosis

in tuberculosis contact investigations. *J Infect Dis.* 196(10):1517-27

community participation. *Rev. Lat. Am. Enfermagem.* 18(5):983-9

Risaralda, Colombia. *Gaceta Médica de Caracas* 120(1):40-47

tuberculosis and its interaction with human immunodeficiency virus infection. *Int.* 

representations of tuberculosis in Medellin, Colombia, 2007. *Int. J Tuberc. Lung Dis.*

of stigma and tuberculosis in rural Maharashtra, India. *Glob. Public Health* 6(1):56-71

hierarchical context shows consistent tendencies for collaboration in the middle levels. *Proceedings of the National Academy of Sciences of the United States of America*

responses induced by a panel of recombinant and purified mycobacterial antigens in healthy, non-mycobacterium bovis BCG-vaccinated Malawian young adults.

interactions among badgers: implications for sociality and disease transmission. *J* 

tuberculosis control interventions in Valle del Cauca, Colombia. *Biomedica.* 24 Supp

del uso de pruebas de medicion de la liberacion de interferon-gamma en la

D, Alzate-Carvajal V, Jiménez-Canizales CE, Rodríguez Morales AJ. 2012b. Impacto de una Actividad Formativa en los Conocimientos, Actitudes y Percepciones (CAP) sobre Tuberculosis (TB) de Estudiantes de Medicina de una Universidad de

evidence from studies in humans and experimental animals. *Int. J Tuberc. Lung Dis.*

tuberculosis epidemics: local effects in a network model of transmission. *J R. Soc* 

control: patient perception regarding orientation for the community and

**7. References** 

*J Epidemiol.* 29(6):1085-91

14(10):1323-9

107(15):6841-6

1:138-48

8(3):286-98

*Interface* 4(14):523-31

*Anim Ecol.* 77(4):735-45

*Clin. Diagn. Lab Immunol.* 10(4):602-11

(Figure 3). This social network included more than 100 people supporting the program of TB in the municipality, then strengthening the control and surveillance activities necessary to reduce and to impact more the actions against the disease.

The nodes were constituted as communitarian organization, recognized by the communities and by the different related institutions, seen as long-lasting entities, with clear objectives and work plans for continued activity at the community. In all cases the participation was completely voluntary and non-profit.

As one of the key aspects of this network, multiple programmed activities were developed, including regularly meetings for discussions and for education on TB, giving multiple and different type of incentives in order to increase the interest on participation, helding workshops and different age-oriented designed activities that include games and handycraft works, but in every case taking in consideration an structured and varied programation to include activities for TB education.

With this social TB network the municipal TB control program pursue to improve case detection and treatment adherence, combat stigma and discrimination, empower people affected by TB and mobilize political commitment and resources for TB.

Further implications of this social network, however, should be analyzed in the long term in order to measure its impact of epidemiological indicators of TB in the municipality.

#### **6. Conclusions**

Tuberculosis control in the XXI century requires new approaches and interventions, particularly those based in education and prevention with a community-based orientation. Programs such as the social network developed in Pereira TB control program, should performed in other highly endemic places. As the WHO recommends to pursue the ACMS (advocacy, communication and social mobilization), strategies as the social network allow to enhance particularly the communication and social mobilization components. Unfortunately at many national plans of TB control, how translate the ACMS in specific actions is not well defined in most occasions.

As has been previously stated, in the establishment of a social network for TB, previous diagnosis, including geo-referenced characterization, it is necessary to select the areas where the nodes will be established, taking also in consideration the suitability as the willingness of the potential participants of the network in each area and node. Finally, with the mining of the activities described, but also beginning with the idea of raise the awareness about the disease, taking in consideration a high level of diversity on the activities, as has been stated in order to warrant the continuous interest and participation of the network members on it.

In the future, in order to enhance the function and structure of the whole social network, further meetings between the nodes are expected. As now, only nodes interact internally, but the idea for the future activities in this setting is increase the links internally, but also between the main nodes in order to potentially increase the participation in the whole network.

Activities such as the development of social network of TB in Pereira will enhance the prevention, education and surveillance in the community, allowing a better integrated approach to the TB control in these scenarios and increasing the health profile in the community decreasing the lost opportunities for diagnosis and treatment of TB cases, finally leading to an improvement of the TB prevention and control.

#### **7. References**

76 Current Topics in Tropical Medicine

(Figure 3). This social network included more than 100 people supporting the program of TB in the municipality, then strengthening the control and surveillance activities necessary to

The nodes were constituted as communitarian organization, recognized by the communities and by the different related institutions, seen as long-lasting entities, with clear objectives and work plans for continued activity at the community. In all cases the participation was

As one of the key aspects of this network, multiple programmed activities were developed, including regularly meetings for discussions and for education on TB, giving multiple and different type of incentives in order to increase the interest on participation, helding workshops and different age-oriented designed activities that include games and handycraft works, but in every case taking in consideration an structured and varied

With this social TB network the municipal TB control program pursue to improve case detection and treatment adherence, combat stigma and discrimination, empower people

Further implications of this social network, however, should be analyzed in the long term in

Tuberculosis control in the XXI century requires new approaches and interventions, particularly those based in education and prevention with a community-based orientation. Programs such as the social network developed in Pereira TB control program, should performed in other highly endemic places. As the WHO recommends to pursue the ACMS (advocacy, communication and social mobilization), strategies as the social network allow to enhance particularly the communication and social mobilization components. Unfortunately at many national plans of TB control, how translate the ACMS in specific actions is not well

As has been previously stated, in the establishment of a social network for TB, previous diagnosis, including geo-referenced characterization, it is necessary to select the areas where the nodes will be established, taking also in consideration the suitability as the willingness of the potential participants of the network in each area and node. Finally, with the mining of the activities described, but also beginning with the idea of raise the awareness about the disease, taking in consideration a high level of diversity on the activities, as has been stated in order to warrant the continuous interest and participation of the network members on it. In the future, in order to enhance the function and structure of the whole social network, further meetings between the nodes are expected. As now, only nodes interact internally, but the idea for the future activities in this setting is increase the links internally, but also between the main nodes in order to potentially increase the participation in the whole

Activities such as the development of social network of TB in Pereira will enhance the prevention, education and surveillance in the community, allowing a better integrated approach to the TB control in these scenarios and increasing the health profile in the community decreasing the lost opportunities for diagnosis and treatment of TB cases, finally

leading to an improvement of the TB prevention and control.

order to measure its impact of epidemiological indicators of TB in the municipality.

affected by TB and mobilize political commitment and resources for TB.

reduce and to impact more the actions against the disease.

programation to include activities for TB education.

completely voluntary and non-profit.

**6. Conclusions** 

defined in most occasions.

network.


Social Networking in Tuberculosis: Experience in Colombia 79

Lawrence RJ, Fudge C. 2009. Healthy Cities in a global and regional context. *Health* 

Lonnroth K, Aung T, Maung W, Kluge H, Uplekar M. 2007. Social franchising of TB care

Lonnroth K, Castro KG, Chakaya JM, Chauhan LS, Floyd K et al. 2010. Tuberculosis control

Lonnroth K, Williams BG, Cegielski P, Dye C. 2010. A consistent log-linear relationship between tuberculosis incidence and body mass index. *Int. J Epidemiol.* 39(1):149-55 Marais BJ, Schaaf HS. 2010. Childhood tuberculosis: an emerging and previously neglected

Mateus-Solarte JC, Carvajal-Barona R. 2008. Factors predictive of adherence to tuberculosis treatment, Valle del Cauca, Colombia. *Int. J Tuberc. Lung Dis.* 12(5):520-6 Murray M, Oxlade O, Lin HH. 2011. Modeling social, environmental and biological determinants of tuberculosis. *Int. J Tuberc. Lung Dis.* 15 Suppl 2:S64-S70 Orcau A, Cayla JA, Martinez JA. 2011. Present epidemiology of tuberculosis. Prevention and

Palinkas LA, Holloway IW, Rice E, Fuentes D, Wu Q, Chamberlain P. 2011. Social networks

Pantoja A, Floyd K, Unnikrishnan KP, Jitendra R, Padma MR et al. 2009. Economic

Pantoja A, Lonnroth K, Lal SS, Chauhan LS, Uplekar M et al. 2009. Economic evaluation of

Perisse AR, Costa Nery JA. 2007. The relevance of social network analysis on the

Pungrassami P, Kipp AM, Stewart PW, Chongsuvivatwong V, Strauss RP, Van RA. 2010.

Rajeswari R, Balasubramanian R, Muniyandi M, Geetharamani S, Thresa X, Venkatesan P.

Rocha C, Montoya R, Zevallos K, Curatola A, Ynga W et al. 2011. The Innovative Socio-

Rodríguez Morales AJ, Lorizio W, Vargas J, Fernández L, Durán B, Husband G, Rondón A,

Santos Filho ET, Santos Gomes ZM. 2007. Strategies for tuberculosis control in Brazil: networking and civil society participation. *Rev. Saude Publica* 41 Suppl 1:111-6

and implementation of evidence-based practices in public youth-serving systems: a

evaluation of public-private mix for tuberculosis care and control, India. Part I. Socio-economic profile and costs among tuberculosis patients. *Int. J Tuberc. Lung* 

public-private mix for tuberculosis care and control, India. Part II. Cost and cost-

epidemiology and prevention of sexually transmitted diseases. *Cad. Saude Publica*

Tuberculosis and AIDS stigma among patients who delay seeking care for

1999. Socio-economic impact of tuberculosis on patients and family in India. *Int. J* 

economic Interventions Against Tuberculosis (ISIAT) project: an operational

Vargas K, Barbella RA, Dickson SM. 2008. Malaria, Tuberculosis, VIH/SIDA e Influenza Aviar: ¿Asesinos de la Humanidad? *Rev Soc Med Quir Hosp Emerg Perez* 

control programs. *Enferm. Infecc. Microbiol. Clin.* 29 Suppl 1:2-7

through private GPs in Myanmar: an assessment of treatment results, access, equity

and elimination 2010-50: cure, care, and social development. *Lancet* 375(9728):1814-29

*promotion international* 24 Suppl 1:i11-i18

and financial protection. *Health Policy Plan.* 22(3):156-66

problem. *Infect Dis. Clin. North Am.* 24(3):727-49

mixed-methods study. *Implement. Sci* 6:113

effectiveness. *Int. J Tuberc. Lung Dis.* 13(6):705-12

tuberculosis symptoms. *Int. J Tuberc. Lung Dis.* 14(2):181-7

assessment. *Int. J Tuberc. Lung Dis.* 15 Suppl 2:S50-S57

*Dis.* 13(6):698-704

23 Suppl 3:S361-S369

*de Leon* 39(1):52-76

*Tuberc. Lung Dis.* 3(10):869-77


Dhingra VK, Khan S. 2010. A sociological study on stigma among TB patients in Delhi.

Dim CC, Dim NR, Morkve O. 2011. Tuberculosis: a review of current concepts and control

Drewe JA, Eames KT, Madden JR, Pearce GP. 2011. Integrating contact network structure

Fitzpatrick LK, Hardacker JA, Heirendt W, Agerton T, Streicher A et al. 2001. A preventable

Francis J, Reed A, Yohannes F, Dodard M, Fournier AM. 2002. Screening for tuberculosis among orphans in a developing country. *Am. J Prev. Med* 22(2):117-9 Franco-Paredes C, Jones D, Rodriguez-Morales AJ, Santos-Preciado JI. 2007. Commentary:

Franco-Paredes C, Von A, Hidron A, Rodriguez-Morales AJ, Tellez I et al. 2007. Chagas

Galimi R. 2011. Extrapulmonary tuberculosis: tuberculous meningitis new developments.

Garcia-Rodriguez JF, Alvarez-Diaz H, Lorenzo-Garcia MV, Marino-Callejo A, Fernandez-

Ginsberg AM. 2000. A proposed national strategy for tuberculosis vaccine development.

Glaziou P, Floyd K, Raviglione M. 2009. Global burden and epidemiology of tuberculosis.

Guzzetta G, Ajelli M, Yang Z, Merler S, Furlanello C, Kirschner D. 2011. Modeling socio-

Hawe P, Webster C, Shiell A. 2004. A glossary of terms for navigating the field of social

Hoek KG, Van RA, van Helden PD, Warren RM, Victor TC. 2011. Detecting drug-resistant tuberculosis: the importance of rapid testing. *Mol. Diagn. Ther.* 15(4):189-94 Jalil-Paier H, Donado G. 2010. Socio-political implications of the fight against alcoholism and tuberculosis in Colombia, 1910-1925. *Rev Salud Publica (Bogota. )* 12(3):486-96 Jaramillo E. 1999. Tuberculosis and stigma: predictors of prejudice against people with

Jittimanee SX, Nateniyom S, Kittikraisak W, Burapat C, Akksilp S et al. 2009. Social stigma

Kemp JR, Mann G, Simwaka BN, Salaniponi FM, Squire SB. 2007. Can Malawi's poor afford

tuberculosis diagnosis in Lilongwe. *Bull. World Health Organ* 85(8):580-5 Klovdahl AS, Graviss EA, Musser JM. Infectious disease control: combining molecular

and knowledge of tuberculosis and HIV among patients with both diseases in

free tuberculosis services? Patient and household costs associated with a

network analysis. *J Epidemiol. Community Health* 58(12):971-5

into tuberculosis epidemiology in meerkats in South Africa: Implications for

outbreak of tuberculosis investigated through an intricate social network. *Clin.* 

improving the health of neglected populations in Latin America. *BMC Public Health* 7:11

disease: an impediment in achieving the Millennium Development Goals in Latin

Rial A, Sesma-Sanchez P. 2011. Extrapulmonary tuberculosis: epidemiology and

demography to capture tuberculosis transmission dynamics in a low burden

*Indian J Tuberc.* 57(1):12-8

*Infect Dis.* 33(11):1801-6

programme in Nigeria. *Niger. J Med* 20(2):200-6

control. *Prev. Vet. Med* 101(1-2):113-20

America. *BMC Int. Health Hum. Rights* 7:7

*Eur. Rev Med Pharmacol. Sci* 15(4):365-86

*Clin. Infect Dis.* 30 Suppl 3:S233-S242

*Clin. Chest Med* 30(4):621-36, vii

setting. *J Theor. Biol.* 289:197-205

tuberculosis. *J Health Psychol.* 4(1):71-9

biological and network methods. 8, 73-99. 2002.

Thailand. *PLoS. One.* 4(7):e6360

risk factors. *Enferm. Infecc. Microbiol. Clin.* 29(7):502-9 Garg RK. 2010. Tuberculous meningitis. *Acta Neurol. Scand.* 122(2):75-90


**6** 

*Brazil* 

**Molecular Characterization of Dengue Virus** 

**Circulating in Manaus, the Capital City** 

*Foundation for Tropical Medicine Dr. Hector Vieira Dourado (FMT/HVD)* 

The term dengue, of Spanish origin, was used to describe joint pain from an illness that attacked the British during the epidemic that affected the Spanish West Indies from 1927- 1928. Dengue was brought to the American continent to the Old World during the colonization in the late eighteenth century. However, it is not possible to say according to the historical record if the outbreaks were caused by dengue virus, as its symptoms are similar to those of several other infections, especially yellow fever (Holmes et al., 1998). The etiology of dengue has been credited to the miasma theory, bacterial or protozoan infection and finally to an ultramicroscopic agent. Similarly, transmission has been considered by

The isolation of dengue virus (DENV) occurred in the 1940s during the epidemics of Nagasaki (1943) and Osaka (1944). The first known strain is coined DENV Mochizuki (Kimura & Hotta, 1944). In 1945, the Hawaii strain was isolated, and that same year other DENVs showing antigenic characteristics of different serotypes were isolated in New Guinea. The first two strains were designated serotype 1 and serotype 2. In 1956, other strains designated as serotype 3 and 4 were isolated. Thus, four dengue serotypes are

Genetic variation within each serotype was first demonstrated by serological techniques. Subsequently analysis of the viral genome showed that DENV-1and DENV-2 can be classified as having five genotypes or subtypes each while DENV-3 and DENV-4having four and two respectively (Rico-Hesse, 1990, Lanciotti et al., 1994). Recently, Rico-Hesse et al (2003) reviewed the classification of DENV genotypes by the analysis and comparison of the nucleotide sequence of the complete E gene of various strains. As a result it was defined thatDENV-2 and DENV-3 have four genotypes while DENV-1 and DENV-4 have five and

Dengue Fever, a vector-borne disease, is the most important arboviral disease worldwide. Dengue viruses (DENVs) belong to the genus *Flavivirus*, family *Flaviviridae*. These are singlestranded positive-sense RNA viruses. DENV are grouped into four antigenically related but distinct serotypes named DENV-1, 2, 3 and 4.The four serotypes of DENV are diverse and

known to date: DENV-1, DENV-2, DENV-3 and DENV-4 (Martinez Torres, 1990).

**1. Introduction** 

**1.1 Etiology** 

respiratory airway and finally, by mosquitoes.

three genotypes respectively (Cunha & Nogueira, 2005).

**of the State of Amazonas, Brazil** 

Regina Maria Pinto de Figueiredo

