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Thesis(M.P.H.M.(Primary Health Care Management))--Mahidol University, 2005.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / A tuberculose (TB) está entre as dez principais causas de morte no mundo, e o Brasil integra um grupo de nações que representam 80% de todos os casos registrados. Uma das maiores barreiras para o efetivo controle da TB é representada pelo atraso no diagnóstico, que faz com que o indivíduo infectado permaneça mais tempo como potencial fonte de transmissão em sua comunidade. O presente estudo tem como principal objetivo determinar a incidência do diagnóstico tardio de TB no município de Boa Vista, e os fatores que influenciam esse fenômeno. O estudo foi desenhado como uma pesquisa quantitativa do tipo corte transversal para avaliar a prevalência de diagnóstico tardio dentre os casos de tuberculose diagnosticados no município de Boa Vista entre janeiro de 2007 a dezembro de 2011, e coletar informações individuais, socioeconômicas e clínicas, potencialmente relacionadas ao diagnóstico precoce e tardio da TB. No período estudado, 426 casos de TB foram registrados e, desses, 186 casos (44%) foram registrados no Hospital Geral de Roraima, instituição de nível terciário no Estado. O diagnóstico tardio incide principalmente na população economicamente ativa, representada pelo paciente do sexo masculino com média de idade de 40 anos. Do ponto de vista social, os principais fatores de risco foram baixa renda nominal e analfabetismo. Em nossa série de diagnósticos tardios, a radiografia de tórax mostrou-se instrumento válido no auxílio diagnóstico de TB. Porém, em relação à baciloscopia, em 38,2% dos casos ela estava negativa, e a prova tuberculínica (PT) revelou-se negativa na grande maioria dos casos, demonstrando que se trata de um exame de menor importância para o diagnóstico de TB, devido grande à quantidade de reações falsonegativas. As principais comorbidades associadas foram alcoolismo, diabetes mellitus e AIDS. O diagnóstico tardio representa uma dificuldade de acesso aos serviços de atenção primária à saúde no município. O profissional de saúde deve ter alto grau de suspeição clínica para o diagnóstico de TB, particularmente diante das três principais comorbidades encontradas: alcoolismo, diabetes mellitus e AIDS. / Tuberculosis (TB) is among the top ten causes of death worldwide, and Brazil integrates a group of nations representing 80% of all reported cases. One of the biggest barriers to effective TB control is represented by the delay in diagnosis, which keeps the infected individual as a potential source of transmission in the community for a longer period. The present study has as main objective to determine the incidence of delayd diagnosis of TB in Boa Vista, and the factors that influence this phenomenon. The present project was designed as a quantitative cross-sectional study, to assess the prevalence of delaid diagnosis among the cases of tuberculosis diagnosed in Boa Vista between January 2007 to December 2011, and to collect individual , socioeconomic and clinical informations, potentially related to the early and late diagnosis of TB. During the study period, 426 cases of TB were registered, and of these, 186 cases (44%) were recorded in the Hospital Geral de Roraima, a tertiary health institution in the state. Delayd diagnosis mainly affects the economically active population, represented by the male patient with a mean age of 40 years. From the social point of view, the main risk factors were lower nominal income and illiteracy. In our series of delayd diagnosis, chest X-ray showed a very effective aid in the diagnosis of TB, but with respect to smear, in 38.2% of cases it was negative, and the tuberculin skin test was also negative in most cases, demonstrating that these are exams of minor importance for the diagnosis of TB, due to large amount of false negative reactions. The main comorbidities were alcoholism, diabetes and AIDS. Delayd diagnosis is related to barriers to access to health services at primary health care level. The health professional must have a high degree of clinical suspicion for the diagnosis of TB, particularly in the face of the three major comorbidities: alcoholism, diabetes and AIDS.

This thesis presents several nonlinear mathematical models applied to ecoepidemiology and evolution. A detailed study involving predator-prey type models considering an alternative resource for the predator was carried out, investigating the situation of infection in the prey and in the predator on separate models. Such study served as a theoretical contribution to the investigation of problems such as bovine tuberculosis in wild animal species presented in a specific model. We also developed models to explain the evolution of alarm calls in species of birds and mammals. The theoretical framework adopted for those evolution models is that of Population Ecology. The models were developed using Ordinary Diferential Equations (ODEs) to describe the population dynamics. The biological assumptions of the systems that we wanted to analyse were enumerated and explained / Esta tese apresenta vários modelos matemáticos não-lineares aplicados à ecopidemiologia e à evolução. Foi realizado um estudo detalhado envolvendo modelos do tipo predador-presa considerando um recurso alternativo para o predador, investigando situações de infecção na presa e no predador em modelos separados. Tal estudo, serviu de aporte teórico para a investigação de problemas como a tuberculose bovina em espécies de animais selvagens apresentado em um modelo específico. Também desenvolvemos modelos para explicar a evolução dos chamados de alarme em espécies de aves e mamíferos. O quadro teórico adotado para esses modelos de evolução é o da Ecologia de População. Nos modelos desenvolvidos usamos as Equações Diferenciais Ordinárias (EDOs) para descrever a dinâmica populacional. Consideramos pressupostos biológicos dos sistemas biológicos analisados

Cette thèse a pour but de contribuer à une meilleure compréhension de la tuberculose (TB) et desmycobactéries non-tuberculeuses dans la Caraïbe. La tuberculose a hanté l’humanité depuisplusieurs millénaires et reste de nos jours une des maladies infectieuses faisant le plus de victimeschaque année (1,5 millions de décès en 2013). La connaissance de l’épidémiologie de la tuberculoseest essentielle afin de concevoir des programmes de lutte anti-TB adaptés aux spécificitésrégionales et donc plus efficaces. Dans cette optique, la première partie de ce travail fourni un suivià long-terme de la résistance aux antituberculeux observée en Guadeloupe, Martinique et Guyanefrançaise ainsi qu’un aperçu de la diversité génétique et de la résistance aux antituberculeux dansla Caraïbe. Les données montrent une baisse graduelle de la fréquence des infections causées pardes souches résistantes parmi les nouveaux cas de TB dans les départements français d’Amérique.En ce qui concerne la Caraïbe, des différences marquées ont été observées entre les différentsterritoires, ce qui semble refléter le passé historique de cette région.La deuxième partie est consacrée à la phylogénie et l’évolution de M. tuberculosis, étudié à l’aide dedivers marqueurs génétiques comme spoligotypes, LSP, SNP et MIRU-VNTR. Les profils MIRUVNTR(format 12-loci) ont été étudiés afin de déterminer leur utilité comme marqueurphylogénétique. Il a été montré que ce marqueur est adapté pour retracer la phylogénie ducomplexe M. tuberculosis et que la précision du classement basé sur les MIRUs est supérieure àcelle du classement basé sur les spoligotypes. De plus, la technique MIRU-VNTR permetégalement d’observer la diversification évolutive d’une souche de M. tuberculosis au cours del’infection ou alors d’identifier des patients infectés par plusieurs souches de M. tuberculosis enmême temps. Les deux phénomènes ont été observés au cours de ce travail de thèse et les casconcernés sont décrits dans ce deuxième chapitre.Enfin, un premier aperçu de la diversité des mycobactéries non-tuberculeuses isolées desprélèvements cliniques en Guadeloupe, Martinique et Guyane est présenté dans la troisième partiede ce travail. Des différences marquées dans la fréquence d’isolement de certaines espèces ont puêtre observées entre les trois départements français d’Amérique. M. intracellulare par exemple étaitsignificativement plus abondant en Guadeloupe. Cependant l’existence d’une niche écologiquespécifique à cette île n’a pas pu être mise en évidence. La problématique de l’identification desmycobactéries non-tuberculeuses est abordée également à travers une étude rétrospective del’utilisation de hsp65-PRA pour l’identification des mycobactéries dans un laboratoire de routinemais aussi sous forme d’un travail prospectif visant à la mise en place d’un protocoled’identification de mycobactéries non-tuberculeuses avec MALDI-TOF MS. / This thesis aims at providing a better understanding of tuberculosis (TB) and non-tuberculousmycobacteria (NTM) in the Caribbean. TB is an ancient scourge of humanity and remains one ofthe deadliest infectious diseases today having claimed around 1.5 million lives in 2013.Understanding the epidemiology of TB is essential for optimizing regional TB control programs. Inthis context, the first part of this work provides long-term data on drug-resistance in Guadeloupe,Martinique and French Guiana as well as an insight in the genetic diversity and drug-resistance ofM. tuberculosis in twelve Caribbean territories. Encouragingly, the results show a gradual decreaseof drug-resistant TB in newly infected patients in Guadeloupe, Martinique and French Guiana. Onthe Caribbean level, distinct differences were observed from one territory to the next and thecurrent epidemiological landscape seems to reflect the historical past of the region.The second part addresses the phylogeny and evolution of M. tuberculosis using various geneticmarkers such as spoligotyping, large sequence polymorphism (LSP), single nucleotidepolymorphism (SNP), and MIRU-VNTRs. The suitability of 12-loci MIRU-VNTR profiles for use inphylogenetic studies was evaluated and it was found that this marker is not only able to resolvethe evolutionary relationships within the M. tuberculosis complex but also allows to achieve ahigher phylogenetic precision than spoligotyping. MIRU-VNTR also permits the identification ofon-going evolution in TB patients (in-patient microevolution) as well as mixed strain infections.Both phenomena were observed in our setting and the respective cases are described herein.Finally, a first insight in the diversity of NTM isolated from clinical specimen in Guadeloupe,Martinique and French Guiana is provided. The isolation frequency of some NTM species variedconsiderably between the three departments, the most striking example being the relativeabundance of M. intracellulare in Guadeloupe. However, no evidence of a privilegedenvironmental niche/infection source on this island could be found. Last but not least, the subjectof NTM identification is addressed in the form of a retrospective evaluation of hsp65-PRA basedidentification in a routine laboratory and in the form of a prospective study towards theimplementation of a MALDI-TOF MS based identification of NTM at the Pasteur Institute ofGuadeloupe.

Trata-se de estudo investigativo de mão dupla acerca do art déco enquanto expressão primaz do moderno - não modernista - na Obra Getuliana, que assinalada pelos inúmeros edifícios públicos erigidos no período de 1930 a 1945, contribuiu para disseminá-lo no país. A princípio buscou-se explicitar em forma de panorama, uma parcela da vultosa produção arquitetônica oficial desse período, a cargo das seções de engenharia e arquitetura dos ministérios civis. Para tal, recorreu-se ao universo das exposições propagandísticas das realizações do governo estadonovista, ocorridas a partir de 1938 no antigo Distrito Federal, nas quais a Obra Getuliana esteve em evidência. A saber: Exposição do 30º aniversário do Ministério da Viação e Obras Públicas (1938); Exposição do Estado Novo (1938); Exposição do Ministério da Guerra (1941); e Exposição de Edifícios Públicos (1944). Como meio de se atestar o proposto, particularizou-se as produções do Ministério da Viação e Obras Públicas (MVOP) e Ministério da Educação e Saúde (MES), centradas respectivamente na arquitetura postal do Departamento de Correios e Telégrafos (DCT) e hospitalar relativa aos sanatórios para tuberculosos. Intentou-se também remontando o \"sistema de obras\" criado em 1939 para coordenar a referida produção oficial, e gerido pelo Departamento Administrativo do Serviço Público (DASP), entendê-la como alvo da política de racionalização dos serviços públicos pelo órgão máximo do executivo. Evidenciar as preocupações arquitetônicas oficiais relacionadas à estética e monumentalidade requeridas para os edifícios públicos nascidos dentro de um contexto político autoritário, mas progressista, foi outra forma de se averiguar a preponderância do art déco na Obra Getuliana. Nesse quesito, lançou-se mão da Revista do Serviço Público (1937-), veículo de comunicação entre Governo e funcionalismo, e de importantes registros da Obra e seu \"sistema\". / This is a two way investigative study about Art Deco whereas prime expression of the modern, but not modernist, in the Obra Getuliana, which was marked by numerous public buildings erected in the period from 1930 to 1945, thereby contributing to disseminate it in the country. At first we tried to explain it in shaped of panorama, a portion of the bulky official architectural production of this period, in charge of the sections of civil engineering and architecture departments. To this end, we adopted the universe of propagandistic exhibition of the achievements of the New State government occurred since 1938 in the former Federal District , in which the Obra Getuliana was in evidence . Namely : Exhibition of the 30th anniversary of the Ministry of Roads and Public Works (1938) ; Exposition of the New State (1938); Exhibition of the Ministry of War (1941) and Exhibition of Public Buildings (1944). As a means of proving the proposed, it was particularized the productions of the Ministry of Roads and Public Works (MVOP) and Ministry of Education and Health (MES), centered respectively on postal architecture of the Department of Posts and Telegraphs (DCT) and hospital on sanatoriums for tuberculosis. It was also attempted reassembling the \"system of works\" created in 1939 to coordinate such official production , and managed by the Administrative Department of Public Service (DASP),to understand it as a target for rationalization of public services policy by the highest body of the executive . Another way to determine the preponderance of art deco style in Obra Getuliana was to highlight the oficial architectural concerns related to aesthetics and monumentality required for those public buildings that were born within an authoritarian political context, but progressive. In this aspect, it made use of the Journal of Public Service (1937), vehicle of communication between government and civil service, and important records of the Obra and its \"system\".

Trata-se de estudo investigativo de mão dupla acerca do art déco enquanto expressão primaz do moderno - não modernista - na Obra Getuliana, que assinalada pelos inúmeros edifícios públicos erigidos no período de 1930 a 1945, contribuiu para disseminá-lo no país. A princípio buscou-se explicitar em forma de panorama, uma parcela da vultosa produção arquitetônica oficial desse período, a cargo das seções de engenharia e arquitetura dos ministérios civis. Para tal, recorreu-se ao universo das exposições propagandísticas das realizações do governo estadonovista, ocorridas a partir de 1938 no antigo Distrito Federal, nas quais a Obra Getuliana esteve em evidência. A saber: Exposição do 30º aniversário do Ministério da Viação e Obras Públicas (1938); Exposição do Estado Novo (1938); Exposição do Ministério da Guerra (1941); e Exposição de Edifícios Públicos (1944). Como meio de se atestar o proposto, particularizou-se as produções do Ministério da Viação e Obras Públicas (MVOP) e Ministério da Educação e Saúde (MES), centradas respectivamente na arquitetura postal do Departamento de Correios e Telégrafos (DCT) e hospitalar relativa aos sanatórios para tuberculosos. Intentou-se também remontando o \"sistema de obras\" criado em 1939 para coordenar a referida produção oficial, e gerido pelo Departamento Administrativo do Serviço Público (DASP), entendê-la como alvo da política de racionalização dos serviços públicos pelo órgão máximo do executivo. Evidenciar as preocupações arquitetônicas oficiais relacionadas à estética e monumentalidade requeridas para os edifícios públicos nascidos dentro de um contexto político autoritário, mas progressista, foi outra forma de se averiguar a preponderância do art déco na Obra Getuliana. Nesse quesito, lançou-se mão da Revista do Serviço Público (1937-), veículo de comunicação entre Governo e funcionalismo, e de importantes registros da Obra e seu \"sistema\". / This is a two way investigative study about Art Deco whereas prime expression of the modern, but not modernist, in the Obra Getuliana, which was marked by numerous public buildings erected in the period from 1930 to 1945, thereby contributing to disseminate it in the country. At first we tried to explain it in shaped of panorama, a portion of the bulky official architectural production of this period, in charge of the sections of civil engineering and architecture departments. To this end, we adopted the universe of propagandistic exhibition of the achievements of the New State government occurred since 1938 in the former Federal District , in which the Obra Getuliana was in evidence . Namely : Exhibition of the 30th anniversary of the Ministry of Roads and Public Works (1938) ; Exposition of the New State (1938); Exhibition of the Ministry of War (1941) and Exhibition of Public Buildings (1944). As a means of proving the proposed, it was particularized the productions of the Ministry of Roads and Public Works (MVOP) and Ministry of Education and Health (MES), centered respectively on postal architecture of the Department of Posts and Telegraphs (DCT) and hospital on sanatoriums for tuberculosis. It was also attempted reassembling the \"system of works\" created in 1939 to coordinate such official production , and managed by the Administrative Department of Public Service (DASP),to understand it as a target for rationalization of public services policy by the highest body of the executive . Another way to determine the preponderance of art deco style in Obra Getuliana was to highlight the oficial architectural concerns related to aesthetics and monumentality required for those public buildings that were born within an authoritarian political context, but progressive. In this aspect, it made use of the Journal of Public Service (1937), vehicle of communication between government and civil service, and important records of the Obra and its \"system\".

Thesis (MPH.) -- University of Limpopo, 2017. / The present study presents data about the prevalence and determinants of sputum smear non-conversion in smear positive tuberculosis patients. Despite the intervention by the Sekhukhune District Department of Health through continual training and workshops of professional nurses in respect of the NTCP, there are still more challenges observed in terms of TB management. Aim: To investigate the prevalence and determinants of sputum smear non-conversion in smear positive PTB patients after intensive phase of treatment. Method: Quantitative, descriptive retrospective study of TB records was conducted. Data collection was done by extracting data from ETR.net and exporting it to excel. Data cleaning was done before analysis. Data analysis was done using the computer Statistical Package Software for Social research (SPSS) volume 23.1. Findings: 834 TB patients’ records were extracted from the ETR.net database. 34% of records were available at 2 – months; 57% of the patients were males; also, 81% of the patients were diagnosed/treated at PHC facilities; 52% of the patients were HIV positive; 69% percent of the patients who were smear positive grading p+++ failed to convert after two months. In the univariate logistic regression patients with age 20 – 29 were observed to be 4.9 times likely (O.R. = 4.97) to be sputum positive (P = 0.142).Sputum grade 3(p+++) at the time of diagnosis was found to be significantly associated (P = 0.031) with sputum non – conversion after intensive phase of treatment. Conclusion: Two month sputum smear non-conversion is associated with pre-treatment sputum smear grading.