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OBJECTIVE: We assessed the prevalence of moderate and severe periodontitis and its association with social determinants of health in rural and urban population from the State of Chiapas, in Southern Mexico. MATERIAL AND METHODS: A cross-sectional population-based study was conducted in 2013 comprising people 20 years and older. The determinants were categorized as proximal (age, sex, indigenous origin, diabetes, smoking, diet), intermediate (level of schooling, occupation, medical and dental care), and structural (type of institution of health care provision, residence area). Periodontal status was assessed using the Periodontal Screening and Recording (PSR) Index. RESULTS: In total, 467 persons (72.4% women; mean age 43.0 years [s.d 14.7]) participated. Of them, 76.5% lived in rural areas and 56.7% were of indigenous origin. Participants with moderate and severe periodontitis had a significantly lower toothbrushing frequency (44.1% and 44.8%, respectively), and poorer oral hygiene (90% and 90.3%, respectively) compared with people without periodontitis (29.4% for toothbrushing frequency and 74.5% for oral hygiene). Moderate periodontitis was associated with poor oral hygiene (OR=2.63) and no schooling (OR=1.86). Severe periodontitis was associated with age (OR=1.05), poor oral hygiene (OR=3.99), no schooling (OR=2.08), and the interaction term of rural area and indigenous origin (RM=5.23). CONCLUSIONS: Social determinants of health play an important role in the development of periodontitis. Preventive oral health programs should thus focus on the specific social, economic, and geographical context of the population.

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BACKGROUND: In most low income countries there are twice as many cases of tuberculosis (TB) reported among men than among women, a difference commonly attributed to biological and epidemiological characteristics as well as socioeconomic and cultural barriers in access to health care. The World Health Organization has encouraged gender specific comparisons in TB rates to determine whether women with TB are less likely than men with TB to be diagnosed, reported, and treated. A study was undertaken to identify gender based differences in patients with pulmonary TB and to use this information to improve TB control efforts. METHODS: Individuals with a cough for more than 2 weeks in southern Mexico were screened from March 1995 to April 2003. Clinical and mycobacteriological information (isolation, identification, drug susceptibility testing and IS6110 based genotyping, and spoligotyping) was collected from those with bacteriologically confirmed pulmonary TB. Patients were treated in accordance with official norms and followed to ascertain treatment outcome, retreatment, and vital status. RESULTS: 623 patients with pulmonary TB were enrolled. The male:female incidence rate ratio for overall, reactivated, and recently transmitted disease was 1.58 (95% CI 1.34 to 1.86), 1.64 (95% CI 1.36 to 1.98), and 1.41 (95% CI 1.01 to 1.96), respectively. Men were more likely than women to default from treatment (adjusted OR 3.30, 95% CI 1.46 to 7.43), to be retreated (hazard ratio (HR) 3.15, 95% CI 1.38 to 7.22), and to die from TB (HR 2.23, 95% CI 1.25 to 3.99). CONCLUSIONS: Higher rates of transmitted and reactivated disease and poorer treatment outcomes among men are indicators of gender differentials in the diagnosis and treatment of pulmonary TB, and suggest specific strategies in endemic settings.

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BACKGROUND: Tuberculosis, declared a global emergency by the World Health Organization, continues to be an important public health problem in Mexico, included in the first twenty causes of death. OBJECTIVE: To know the impact of drug resistance of Mycobacterium tuberculosis on treatment outcome, need of re-treatment and mortality in a cohort of patients with pulmonary tuberculosis receiving directly observed therapy, short course (DOTS). METHODS: We conducted a population-based study in a suburban region in Southern Mexico. People who had been coughing for more than two weeks underwent sputum acid-fast bacilli smear. Patients with a positive smear were recruited and underwent clinical exam, chest X-ray, HIV testing, and sputum cultures. Identification, drug susceptibility testing and restriction fragment length polymorphism analysis (RFLP) were performed in all isolates. Patients were followed every 12 months for new episodes of tuberculosis and vital status. Patients were referred for clinical care to the local program of tuberculosis. Deaths were corroborated with death certificates. Informed consent was obtained from participants. RESULTS: Between March 1995 and February 1999, tuberculosis was diagnosed in 371 patients who were followed for an average of 32 months. M. tuberculosis was cultured from 316 patients; resistance to any drug occurred in 25.0% of isolates (primary 18.8%, acquired 49.2%); only to isoniazid in 6.8% (primary 7.3%, acquired 4.8%); to isoniazid and rifampin in 6.2% (primary 1.6%, acquired 23.8%). Patients with drug resistance had a higher probability of treatment failure (OR = 16.9, CI 95% 4.5-63.0) and patients with MDR strains had a higher probability of need of re-treatment (RR = 24.4, CI 95% 8.8-67.6), and of death (RR = 4.0, CI 95% 1.5-10.7). Additional variables were found to be associated with subsequent episodes of disease and mortality: Cocaine use, chronic disease, type of radiological lesions, HIV co-infection, non-compliance and treatment delay, as well as RFLP clustering. CONCLUSIONS: In this study, we observed that drug resistance showed a severe impact on the outcome and survival; drug-resistance was the most significant factor for these negative outcomes; DOTS may not be sufficient in areas where drug resistance is considerable, and patient follow-up for longer periods of time, as compared to evaluation at the end of treatment, provides additional information which is useful for prevention and control programs.

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Results from prospective surveillance of nosocomial infections (NIs) in a small community hospital were evaluated, and a case-control study was conducted. The rate of 1.4 NIs per 100 discharges determined by prospective surveillance was found to be underestimated. Prematurity, pediatric service, surgery, length of stay, and age were independently associated with NI.

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OBJECTIVE: To identify risk factors associated with tuberculin reactivity in healthcare workers (HCWs). DESIGN: Cross-sectional survey of tuberculin reactivity (2 TU of purified protein derivative (PPD) RT23, using the Mantoux two-step test). SETTING: Two general hospitals located in a region with a high prevalence of tuberculosis and high bacille Calmette-Guerin (BCG) coverage. PARTICIPANTS: Volunteer sample of HCWs. RESULTS: 605 HCWs were recruited: 71.2% female; mean age, 36.4 (standard deviation [SD], 8.2) years; 48.9% nurses, 10.4% physicians, 26.8% administrative personnel; mean time of employment, 10.9 (SD, 6.7) years. PPD reactivity (> or =10 mm) was found in 390 (64.5%). Multivariate analysis revealed an association of tuberculin reactivity with occupational exposure in the hospital: participation in autopsies (odds ratio [OR], 9.3; 95% confidence interval [CI95], 2.1-40.5; P=.003.), more than 1 year of employment (OR, 2.4; CI95, 1.1-5.0; P=.02), work in the emergency or radiology departments (OR, 2.0; CI95, 1.03-3.81; P=.04), being physicians or nurses (OR, 1.5; CI95, 1.04-2.11; P=.03), age (OR, 1.04; CI95, 1.02-1.07 per year of age; P<.001), and BCG scar (OR, 2.1; CI95, 1.2-3.4; P=.005). CONCLUSIONS: Although the studied population has a high baseline prevalence of tuberculosis infection and high coverage of BCG vaccination, nosocomial risk factors associated with PPD reactivity were identified as professional risks; strict early preventive measures must be implemented accordingly.

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BACKGROUND: Consequences of drug-resistant tuberculosis (TB) in developing countries using directly observed treatment, short-course (DOTS), are not well defined. OBJECTIVE: To determine the impact of drug resistance on clinical outcome and transmission of TB under programmatic conditions. PATIENTS AND METHODS: A prospective cohort and molecular epidemiologic study was conducted in southern Mexico. Between March 1995 and February 1998 all patients with persistent cough whose sputa had acid-fast bacilli (AFB) underwent clinical and mycobacteriologic evaluation (species identification, drug susceptibility testing, and IS6110-based genotyping). Treatment was provided in accordance with Mexico's National Tuberculosis Program. Clinical and microbiologic outcomes and molecular epidemiologically defined transmission were measured. RESULTS: Mycobacterium tuberculosis was isolated from 238 of the 284 AFB smear-positive persons. The overall rate of resistance was 28.4% (new, 20.7%; retreated, 54.7%), and 10.8% (new, 3.3%; retreated, 35.8%) had multi-drug-resistant TB (ie, resistance to isoniazid and rifampin). After treatment, 75% (new, 81.0%; retreated, 52.8%) were cured, 8% (new, 7.8%; retreated, 7.5%) abandoned therapy, 9% (new, 3.9%; retreated, 28.3%) had treatment failure, and 4% (new, 3.3%; retreated, 7.5%) died. Another 2% of patients relapsed, and 9% died during a median of 24.4 months of follow-up. Drug-resistance was a strong independent risk factor for treatment failure. Being infected with multi-drug-resistant TB was the only factor associated with a decreased likelihood of being in a restriction fragment length polymorphism cluster. CONCLUSIONS: Despite the use of DOTS, patients with drug-resistant TB had a dramatically increased probability of treatment failure and death. Although multi-drug-resistant TB may have a decreased propensity to spread and cause disease, it has a profoundly negative impact on TB control.

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SETTING: A community in Southern Mexico with a high prevalence of tuberculosis. OBJECTIVE: To characterize the transmission dynamics in a region with a DOTS-based tuberculosis control program. DESIGN: Community-based screening of chronic coughers between 1 March 1995 and 31 August 1996. Individuals with acid-fast bacilli (AFB) in their sputum were enrolled, interviewed, and had mycobacterial cultures and fingerprinting performed. In-depth interviews were conducted on all persons with DNA fingerprinting. RESULTS: AFB smears were performed on 1424 individuals, 124 of whom were microbiologically confirmed. Of the 95 cases for whom bacterial DNA fingerprints were available, 38 were in clusters. The largest cluster involved seven individuals who were members of a social network centered on a series of unlicensed bars. CONCLUSION: This population-based molecular epidemiologic study showed that a focus of transmission within a social network accounted for one fourth of transmission which rapidly progressed to disease. These observations raise questions about the potential benefit of targeted tuberculosis control interventions in health jurisdictions approaching WHO-defined DOTS benchmarks.

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OBJECTIVE: To determine the impact of drug resistance (DR) on the clinical outcome and transmission of tuberculosis under programmatic conditions. METHODS: Prospective cohort and molecular epidemiologic study in the Orizaba Health Jurisdiction of Mexico. Between March 1995 and July 1999, chronic coughers with positive acid-fast bacilli (AFB) detected in sputum smear underwent clinical and mycobacteriologic evaluation (species identification, drug susceptibility testing and IS6110-based genotyping). Treatment was provided in accordance with official norms. RESULTS: Mycobacterium tuberculosis was isolated from 326/387 AFB-positive cases. The rate of DR was 24.2% and that of multidrug resistance (MDR, defined as resistance to both isoniazid and rifampin at least) was 7.7%; 78% were cured, 8% abandoned treatment, 6% failed treatment, and 5% died. An additional 13.5% received retreatment and 8.9% died during a median 28.6 months of follow up. Factors associated with DR by multivariate analysis were chronicity of tuberculosis (OR 4.8, 95%CI 2.7-8.4, P < 0.001), age >40 years (OR 1.9, 95%CI 1.1-3.2, P = 0.02) and indigenous origin (OR 0.3, 95%CI 0.13-0.75, P = 0.01). Cox-adjusted relative risks showed that MDR (RR 2.5, 95%CI 1.02-6.16, P = 0.04), HIV infection (RR 31.3, 95%CI 11.6-84.8, P < 0.001), and chronicity of tuberculosis (RR 2.1, 95%CI 1.0-4.4, P = 0.06) were associated with mortality, controlling for age. Predictors of retreatment were DR (not including MDR) (RR 2.2 95%CI 0.89-5.31, P < 0.087), MDR (RR 12.6, 95%CI 5.46-28.88, P < 0.001), and living in a household with an earthen floor (RR 2.8, 95%CI 1.27-6.13, P = 0.011). Being infected with MDR-TB was the only factor associated with a decreased likelihood of being in an RFLP cluster (OR 0.31, 95%CI 0.12-0.81, P = 0.02). CONCLUSIONS: Although MDR-TB may have a decreased propensity to spread and cause disease, it has a profoundly negative impact on tuberculosis control.

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