Submitted by Setor de Tratamento da Informa??o - BC/PUCRS (tede2@pucrs.br) on 2015-06-15T20:09:23Z No. of bitstreams: 1 470526 - Texto Parcial.pdf: 532172 bytes, checksum: 2b16e26659f3d053651daae2f5b308b8 (MD5) / Made available in DSpace on 2015-06-15T20:09:23Z (GMT). No. of bitstreams: 1 470526 - Texto Parcial.pdf: 532172 bytes, checksum: 2b16e26659f3d053651daae2f5b308b8 (MD5) Previous issue date: 2015-03-31 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES / Objective: in this study, the trends in incidence of tuberculosis (TB) were evaluated using data from DATASUS that include all TB data available in the national system for the period between 2001 and 2012. Methods: this study is a retrospective analysis of data from DATASUS. Data were obtained from the database DATASUS through the Health Information section. Code "tuberculosis" was used to select key data on the results of the study, from 2001 to 2012. There were two selected age groups: children and adolescents aged 0-19 years and adults over 20. It was estimated the annual incidence per 100 000, which was calculated dividing the number of cases per population estimate of the age groups, obtained from the Brazilian PNAD and Census 2010 for all years studied, respectively, and multiplying the result by 100,000. Results: incidence rates showed a reduction when analyzed in the group of adults. However, no significant reduction was observed in the group of children and adolescents. Also, when we conduct regional comparisons, the north and the state of Rio Grande do Sul have shown high incidence rates. Conclusions: it would be important to improve policies for diagnosis and treatment of pediatric patients. The northern, Rio de Janeiro and the RS should be considered priority areas in fighting against TB in Brazil. / Objetivo: neste estudo, foram avaliadas as tend?ncias de incid?ncia de tuberculose (TB) no Brasil, utilizando dados do DATASUS, que incluem todas as notifica??es de TB dispon?veis no conjunto de dados nacional durante o per?odo entre 2001 e 2012. Al?m disso, foram avaliadas as taxas de incid?ncia em diferentes grupos et?rios e regi?es do pa?s. M?todo: o presente estudo ? uma an?lise retrospectiva dos dados do DATASUS, processamento de dados do Sistema ?nico de Sa?de. As informa??es foram obtidas a partir do banco de dados do DATASUS atrav?s da se??o de Informa??o em Sa?de. O c?digo de "tuberculose" foi utilizado para selecionar os principais dados sobre os resultados do estudo, no per?odo entre 2001 a 2012. Os dois grupos et?rios selecionados foram: crian?as e adolescentes com idades entre 0-19 anos e adultos com mais de 20. Foi estimada a incid?ncia anual por 100 mil, que foi calculada dividindo-se o n?mero de casos por estimativa da popula??o dos grupos et?rios, obtidos a partir da PNAD e Censo Brasileiro de 2010 para todos os anos estudados, respectivamente, e multiplicando o resultado por 100.000. Resultados: as taxas de incid?ncia apresentaram uma redu??o expressiva quando analisados no grupo de adultos. Porem, n?o foi observado redu??o na mesma propor??o no grupo de crian?as e adolescentes. Al?m disso, quando realizamos compara??es regionais, a regi?o norte, sudeste e o estado do Rio Grande do Sul apresentam as maiores taxas de incid?ncia. Conclus?es: ? importante intensificar as pol?ticas para diagn?stico e tratamento de tuberculose da faixa et?ria pedi?trica no Brasil. As regi?es norte, Rio de Janeiro e o RS devem ser consideradas regi?es priorit?rias no combate a TB no pa?s.

Orientador: Lilian Castiglioni / Banca: Débora Aparecida Pires de Campos Zuccari / Banca: Fernando Rogério Pavan / Banca: Daisy Nakamura Sato / Banca: Margarete Gotardo de Almeida / Resumo: A tuberculose é considerada um problema prioritário de saúde pública. Há cada vez mais evidências de que, a variação das cepas de M. tuberculosis tem um papel importante no resultado da infecção por tuberculose. No presente estudo, além de descrever os aspectos sociodemográficos, clínico-epidemiológicos e bacteriológicos da tuberculose e relacionar com a distribuição de resistência aos fármacos antituberculose, também objetivou-se avaliar a diversidade dos genótipos de isolados de Mycobacterium tuberculosis utilizando as técnicas de Spoligotipyng (Spacer Oligonucleotide Typing) e MIRU-VNTR (Mycobacterial Interspersed Repetitive Units-variable-number tandem repeats). Com relação à resistência aos fármacos, as culturas de MT e os testes de sensibilidade mostram que cepas de pessoas que fizeram tratamento de TB anterior ou infectados pelo HIV apresentaram mais resistência os fármacos quando comparados aos que não apresentavam essas características (p<0,05). Os casos resistentes, em sua maioria, são de origem pulmonar e apresentam baciloscopia positiva. A análise molecular mostrou que das 377 amostras com perfis completos para 14 loci MIRU-VNTR, os loci 10, 16, 23, 26, 27, 31, 39 e 40 tiveram um alto poder discriminatório (0.6), os loci 2, ETRB e Mtub21 foram moderadamente discriminatórios (0.3) e loci 4, 20 e 24, baixo poder discriminatório (0.3). Dos 250 isolados de M. tuberculosis analisados por spoligotyping, 92 diferentes padrões foram observados e diferentes famílias foram identificadas: Haarlem (H), Latin American and Mediterraneam (LAM), T Family, undesignated (U), S lineage e X Family. Significativa variabilidade genética foi observada nos isolados de M. tuberculosis circulantes na região Noroeste Paulista quando analisados por spoligotyping e MIRU-VNTR / Abstract: Tuberculosis is considered a high priority public health problem. There is increasing evidence that the variation in Mycobacterium tuberculosis strains play an important role in the outcome of infections by tuberculosis. Apart from describing sociodemographic, clinical, epidemiological and bacteriological aspects of tuberculosis (TB) and correlating the distribution of resistance to antituberculosis drugs, one objective of this study was to evaluate the diversity of the genotypes of M. tuberculosis isolates using the Spoligotyping (spacer oligonucleotide typing) and MIRU-VNTR (Mycobacterial Interspersed Repetitive Units variable-number tandem repeats) techniques. With respect to drug resistance, cultures of M. tuberculosis and susceptibility tests showed that strains from people previously submitted to TB treatment or infected with HIV have more resistance to drugs compared to those without these characteristics (p <0.05 ). Resistant cases are mostly pulmonary M. tuberculosis, and have positive smear test results. Molecular analysis showed that of the 377 samples, 14 MIRU-VNTR loci had complete profiles; the 10, 16, 23, 26, 27, 31, 39 and 40 loci had high discriminatory power (0.6) the 2, ETRB and Mtub21 loci were moderately discriminatory (0.3) and 4, 20 and 24 loci had low discriminatory power (0.3). Ninety-two different patterns were observed in the 250 M. tuberculosis isolates analyzed by spoligotyping and different families were identified as Haarlem (H), Latin American and Mediterranean (LAM), T Family, undesignated (U), S lineage and X Family. Significant genetic variability was observed in M. tuberculosis isolates circulating in the northwestern region of Sao Paulo State when analyzed by spoligotyping and MIRU-VNTR / Doutor

Made available in DSpace on 2014-06-11T19:22:21Z (GMT). No. of bitstreams: 0 Previous issue date: 2005-08-23Bitstream added on 2014-06-13T19:07:44Z : No. of bitstreams: 1 arantes_vp_me_arafcf.pdf: 189227 bytes, checksum: 638bb07401067f6d7069131780a79720 (MD5) / Universidade Estadual Paulista (UNESP) / A Tuberculose (TB) continua sendo um grave problema de saúde pública, considerada a principal causa de morte em países subdesenvolvidos de grande população e baixo padrão sanitário. Atualmente o aumento do número de casos em paises subdesenvolvidos e desenvolvidos está associado à queda da qualidade de vida, aglomerações, infecções pelo Human Immunodeficiency Vírus (HIV) e Acquired Immunodeficiency Syndrome (AIDS). Apesar da eficácia dos esquemas terapêuticos utilizados atualmente, nos últimos anos tem-se observado, um aumento na incidência de tuberculose causada pelo M. tuberculosis resistente aos esquemas preconizados para o tratamento da doença, o que reflete falha no emprego dos referidos programas préestabelecidos como eficazes. A busca constante por produtos biologicamente ativos e capazes de combater o M. tuberculosis tem promovido a descoberta de novos compostos capazes de eliminar micobactérias, que sejam menos tóxicos, efetivos e que possam ser menos indutores de resistência, podendo associar dose e redução do número de abandono ao tratamento. Este trabalho tem como principal objetivo determinar o efeito antimicobacteriano de extratos vegetais da biota brasileira, frente a cepas padrão de Mycobacterium tuberculosis H37Rv ATCC 27294, Mycobacterium avium ATCC 25291, Mycobacterium fortuitum ATCC 6841. A metodologia de Microplate Alamar Blue Assay (MABA), foi empregado com o intuito de pesquisar atividade antimicobacteriana, sendo determinado Concentração Mínima Inibitória correspondente a inibir 90% das células viáveis. Os resultados apresentados são promissores, frente à Cepa padrão de M.tuberculosis e M. avium, M.fortuitum destaca-se a grande atividade do extrato de Quassia amara (agente extrator: diclorometano) e Syngonanthus macrolepsis (agente extrator: clorofórmio) com CIM inferior a 200æg/ml para as três espécies testadas. / Tuberculosis (TB) is still a serious problem of public health, considered the main cause of death in undeveloped Countries of great population and low hygiene standard. In the present moment the increase in the number of cases at undeveloped and developed Countries is associated to the drop of life quality, agglomerations, infections from Human immunodeficiency Virus (HIV) and Acquired immunodeficiency Syndrome (AIDS). In spite of the present efficiency of the used therapeutics schemes, in the last years has been observed, an increase in the tuberculosis incidence caused by the M. tuberculosis resistant to the recommended schemes of treatment for the disease, which reflects in failures on the use of the referred programs preestablished as effectives. The constant search for products biologically actives and capable of fighting the M. tuberculosis has promoted the discovery of new compounds capable of eliminating mycobacteries, that are less toxic, effectives and that can be less inducer of resistance, letting associate dose and reduction in the number of treatment abandonment. This survey has the main purpose to determine the antimycobactericide effect of vegetal extracts from the Brazilian biota, in front of the strain standard of Mycobacterium tuberculosis H37Rv ATCC 27294, Mycobacterium avium ATCC 25291, Mycobacterium fortuitum ATCC 6841. The methodology of Microplate Alamar Blue Assay (MABA) was used in the intention to search for antimycobactericide activity, having established a Minimal Inhibitory Concentration correspondent to inhibit 99% of the viable cells. The presented results are promising, in front of the strain standard of M. tuberculosis and M. avium, M. fortuitum stands out the great activity of the Quassia amara extract (extractor agent: dichloromethane) and Syngonanthus macrolepsis (extractor agent: Chloroform) with MIC below 200æg/ml in the three tested species.

Orientador: Fernando Rogério Pavan / Banca: Patricia Bento da Silva / Banca: Jean Leandro dos Santos / Resumo: A tuberculose (TB) é uma doença infecciosa que tem como principal patógeno o Mycobacterium tuberculosis e continua sendo um importante problema de saúde pública mundial, exigindo o desenvolvimento de estratégias para o seu controle. Em 2011 foram notificados 8,7 milhões de casos da doença no mundo. Ao longo dos anos o cenário da doença não tem se mostrado otimista, devido ao aumento de número de casos de TB multi resistente a fármacos (TB-MDR) e o surgimento de cepas de resistência estendida (TB-XDR). A pesquisa de novos fármacos, em um contexto geral, apresenta-se como um enorme desafio científico para a era moderna. Neste sentido, a Química Inorgânica Medicinal tem se mostrado uma ferramenta bastante promissora. Este trabalho objetivou a caracterização da atividade anti- M. tuberculosis intra e extracelular e a citotoxicidade de 158 compostos de coordenação com metais. A citotoxicidade usando linhagens celulares de macrófago (J774A.1) e células epiteliais (VERO) também foi investigada. Diante Os resultados demonstraram que 16 compostos apresentaram uma alta seletividade, ou seja, alta atividade contra o bacilo da tuberculose e baixa citotoxicidade frente às linhagens testadas. Quatro desses 16 compostos selecionados foram analisados quanto a atividade intracelular; dos quais 2 compostos de coordenação de Co (cobalto) mostraram-se promissores quanto a esta atividade. Com base nos resultados encontrados mais estudos serão realizados a fim de garantir a eficácia e segurança desses novos compostos de coordenação candidatos à fármacos para tratamento da tuberculose / Abstract: Not available / Mestre

A tuberculose (TB), ainda, permanece como um problema sÃrio de saÃde pÃblica, desafiando profissionais de saÃde e instituiÃÃes governamentais. Por ser doenÃa de transmissÃo aÃrea, profissionais da Ãrea da saÃde estÃo expostos a risco aumentado de infecÃÃes. Assim, objetiva-se estimar a prevalÃncia de tuberculose infecÃÃo entre os profissionais do Hospital UniversitÃrio Walter CantÃdio (HUWC), da Universidade Federal do Cearà (UFC), verificar a ocorrÃncia do efeito booster e identificar potenciais fatores associados à positividade do teste tuberculÃnico. Utilizou-se um estudo seccional descritivo, com amostra estratificada proporcional, sendo os participantes agrupados de acordo com a ocupaÃÃo (mÃdicos, categoria de enfermagem e demais profissionais) e o setor de trabalho (enfermarias, consideradas de maior probabilidade de risco de transmissÃo, ambulatÃrios, de risco intermediÃrio e demais setores, com risco limitado de transmissÃo). Foram selecionados 380 participantes que se submeteram a um questionÃrio padronizado e ao teste tuberculÃnico, utilizando PPD RT23. Destes voluntÃrios, 79 foram investigados quanto ao efeito booster. As anÃlises foram feitas de acordo com as duas definiÃÃes para positivo, encontradas no Manual de RecomendaÃÃes para Tuberculose, 2010, sendo, positivo quando PPD &#8805; 5 mm para contatos adultos em geral e positivo quando PPD &#8805; 10 mm para profissionais de saÃde. Analisaram-se as associaÃÃes por meio do teste de &#61539;2 e de razÃo de verossimilhanÃa. As mÃdias dos dois grupos de PPD foram analisadas pelo teste t de Student para dados independentes e com variÃncias desiguais. Considerou-se como estatisticamente significante as anÃlises com p < 0,05. A prevalÃncia foi de 75,6% quando se considerou como positivo o resultado de PPD &#8805; 10 mm e de 85,5% quando se considerou positivo o resultado de PPD &#8805;5 mm, levantado a discussÃo sobre o ponto de corte para o profissional da Ãrea da saÃde. Ocorreu efeito booster em 22,78% dos investigados. Os fatores associados com um PPD &#8805;10 mm foram setor de trabalho, ocupaÃÃo, duraÃÃo do vÃnculo empregatÃcio por mais de 10 anos, faixa etÃria acima de 40 anos e carga tabÃgica. Os fatores associados com um PPD &#8805; 5 mm foram setor de trabalho, ocupaÃÃo, duraÃÃo do vÃnculo empregatÃcio por mais de 10 anos e histÃria de contato com paciente com tuberculose. Considerou-se alta a prevalÃncia de tuberculose infecÃÃo entre os profissionais do HUWC, alertando para a necessidade de conscientizaÃÃo urgente do profissional frente à tuberculose, principalmente para Ãqueles sem infecÃÃo, alÃm de implementaÃÃo de medidas administrativas e ambientais, como a realizaÃÃo do PPD na admissÃo do profissional e nos exames periÃdicos para os nÃo reatores.

O presente trabalho estuda alguns aspectos epidemiológicos da tuberculose pulmonar na Casa de Detenção de São Paulo, Brasil, durante o período de 1976 a 1980. São analisados dados relativos à prevalência e incidência da infecção tuberculosa, busca de casos pelo método bacteriológico e taxa de transmissibilidade da infecção. Os resultados mostram elevadas taxas de prevalência e incidência de infecção e de casos de tuberculose naquele Estabelecimento Penal, caracterizando população exposta a um alto risco de infecção e de adoecimento por tuberculose. / This paper presents some epidemiological aspects of pulmonary tuberculosis in a state prision of S.Paulo, Brazi1, from 1976 to 1980. Data concerning both the prevalence and incidence of tuberculosis infection, case finding by the bacteriological method and infectivity rate are analysed. Results show high rates of prevalence and incidence of infection as well as of active cases in that institution, characterizing this population as one being exposed to a high risk of infection and of developing tuberculosis.

Introdução: Os distúrbios ventilatórios decorrente do comprometimento pulmonar da tuberculose ainda é incerto. A importância da tuberculose na população carcerária é motivo de preocupação mundial. As condições precárias de confinamento favorecem tanto a evolução da infecção para doença, como a sua transmissão. Mesmo antes da prisão, muitos detentos estão expostos a fatores de alto risco para a doença, como desnutrição, higiene escassa, aglomeração de pessoas, residência com pouca ventilação. Objetivo: Estudar a função pulmonar através da espirometria em uma amostra de detentos de duas penitenciárias do município de Guarulhos. Metodologia: Estudo descritivo realizado em duas penitenciárias no município de Guarulhos no período de março de 2008 a maio de 2008. Este estudo fez parte do projeto de pesquisa: A Tuberculose no sistema prisional estudo em duas penitenciárias da cidade de Guarulhos SP, com o objetivo de avaliar diferentes métodos de busca de casos de tuberculose pulmonar, neste sentido foi realizado, aproveitando a população, uma avaliação da capacidade pulmonar através da espirometria. Após a realização do questionário e exames previsto no estudo principal, os detentos que relatavam história de tuberculose no passado ou atualmente, algum comprometimento respiratório, foram indicados para realizar o exame de espirometria. Resultados: Dos 2.436 presos foram indicados 629 indivíduos, 486 não conseguiram realizar a espirometria ,sendo que 143 foram incluídos no estudo. A população estudada constitui-se de homens com a idade media de 34 anos. Cerca de 55,2 por cento da população estudada está em regime fechado há mais de 12 meses. Dos indivíduos que relataram tuberculose no passado, 40,9 por cento apresentaram resultado espirométrico restritivo. Os que relataram doenças pulmonares 22,9 por cento apresentaram resultado espirométrico restritivo. Conclusão: Apesar de muitos detentos apresentarem resultado espirometrico normal, foi identificado que 38,9 por cento dos detentos que relataram doença pulmonar apresentam distúrbio ventilatório. A descoberta do distúrbio ventilatório apresentado pelo preso é de grande importância, pois, deste modo pode ser iniciado o tratamento de doenças respiratórias, melhora dos sintomas e da qualidade de vida desta população. / Introduction: Ventilatory disorders due to pulmonary tuberculosis damage are yet uncertain. The relevance of tuberculosis among prison population is a reason of world concern. The precarious conditions of confinement promote as the evolution of the infection through a disease as its transmission.Even before prison, many prisoners are exposed to high risk factors of getting ill, such as malnutrition, lousy hygiene, people agglomeration, and bad ventilation. Objective: To study the pulmonary function through spirometry in a sample formed by prisoners of two prisions from the municipality of Guarulhos.Methodology: Descriptive study made in two prisions of the municipality of Guarulhos. Data were collected between March and May of 2008. This study has composed the project The tuberculosis in prision system Study in two prisions city Guarulhos (SP), aiming to evaluate different methods of search of pulmonary tuberculosis. In view of this, it was made an evaluation with the same population of their pulmonary capacity through spirometry. After the questionnaire and medical examinations expected in the main study, the subjects reported history of tuberculosis in the past or recently, some with respiratory damages have been selected to the spirometric evaluation.Results: Of the 2.436 prisoners have been selected 629 male being than it is to 143 have been inclusive at this study. The population studied it is man with medium age 34 years old. About 55,2 per cent from the population studied is well into regime closed for more than 12 months. Of individuals who reported tuberculosis 40,9 per cent they presented result spirometric restrictive , the reported that the lung disease 22,9 per cent they presented result spirometric restrictive. Conclusion: Though many prisoners present result normal spirometric, therefore identified 38,9 per cent the many prisoners present Ventilatory disorders. The discovery of ventilatory disorders it´s of great importance because this way can be initiated the tratament of pulmonary disease, improvement of respiratory symptoms and quality of life this population.

Em todo o mundo, menos de 5% dos doentes com tuberculose (TB), sejam casos novos ou previamente tratados, tem a avaliação dos isolados quanto ao perfil de sensibilidade aos antibioticos. No Rio Grande do Sul, estado localizado no sul do Brasil, cerca de 4700 casos novos de TB são registrados a cada ano, com uma taxa de cura de 68,9%, e uma taxa de abandono de 7,5%. A identificação rápida da resistência às drogas, em isolados clínicos de M. tuberculosis é importante para o estabelecimento de uma quimioterapia eficaz bem como para evitar a propagação de cepas resistentes. Os objetivos deste estudo foram caracterizar os pacientes de TB com maior risco de possuir TB-­‐MDR, analisando o perfil de resistência às drogas dos isolados e o perfil epidemiológico desses pacientes. Além disso utilizou-­‐se as amostras clínicas para avaliar o teste comercial (GenoType® MTBDRplus) e para desenvolver e padronizar um novo teste (Detect-­‐TBMR) para detectar as mutações mais frequentes associadas a resistência à INH e RIF. Uma proporção significativamente maior (75% versus 20%, p = 0,009) de pacientes do gênero masculino foi encontrada entre os casos resistentes às drogas do que entre os casos suscetíveis. 43,8% dos pacientes demoraram mais de 30 dias para procurar assistência médica e no grupo TB MDR, 25% dos casos não tinha sido submetido a qualquer tratamento prévio anti-­‐TB. Em nossas amostras, encontramos uma proporção de 48,3% de TB-­‐ MDR. A família T foi a família de spoligotipo mais frequente. Comparado com o método da proporções, a sensibilidade e especificidade do ensaio MTBDRplus foram 82% e 94% para a resistência à RIF, 60% e 94% para resistência à INH. Comparado com sequenciamento, a sensibilidade e especificidade do ensaio MTBDRplus foi 92% e 97% para a resistência à RIF e 100% e 100% para a resistência à INH, respectivamente. Para detectar resistência à RIF e INH, o ensaio Detect-­‐TBMDR mostrou sensibilidade e especificidade de 79,3% e 77,0% e 100% e 65%, respectivamente, em comparação com o método da proporções. Comparado com o sequenciamento, a sensibilidade e especificidade do ensaio Detect-­‐TBMDR foi de 81,2% e 94,7% e 100% e 96,2%, para detectar e resistência à RIF e INH, respectivamente. Ainda existem discordâncias entre o método das proporções e a abordagem molecular, particularmente em relação a resistência à INH. Contudo, estes métodos são muito importantes para o manejo mais rápido e correto dos pacientes, auxiliando na escolha do melhor esquema terapêutico. / In most parts of the world, less than 5% of new and previously treated tuberculosis (TB) patients are tested for multidrug resistance (MDR) TB. In Rio Grande do Sul state, the southern most Brazilian state; approximately 4700 new cases of TB are recorded each year, with a cure rate of 68.9%, and a noncompliance rate of 7.5%. Rapid identification of drug resistance in clinical isolates of Mycobacterium tuberculosis is important to facilitate rapid and adequate chemotherapy of TB, and to prevent the spread of resistant strains. The aim of this study was to characterize TB patients at higher risk of having MDR-TB, to analyze the drug resistance and epidemiological profile of these patients. Use the clinical samples to assess the commercial test (GenoType® MTBDRplus) and develop and standardize a new test (Detect-MDRTB) for detecting the most frequent mutations associated with resistance to INH and RIF. A significantly higher proportion (75% versus 20%, p = 0.009) of males were found among drug-resistant cases than drug susceptible cases. 43.8% of patients took longer than 30 days to seek medical care and in the MDR group 25% of the cases did not undergo any previous anti-TB treatment. In our samples we found a proportion of 48.3% of MDR-TB. The T family was the most frequent spoligotype family. Compared with the proportion method, the sensitivity and specificity of the MTBDRplus assay were 82% and 94% for RIF-resistance, 60% and 94% for INH resistance. Compared with sequencing, the sensitivity and specificity of the MTBDRplus assay were 92% and 97% for RIF-resistance, 100% and 100% for INHresistance. To detect RIF and INH-resistance, the Detect-TBMDR assay showed a sensitivity and specificity of 79.3% and 77.0%, and 100% and 65%, respectively, compared to proportion method. When compared with sequencing, Detect-TBMDR assay, to detect RIF and INH-resistance, showed a sensitivity and specificity of 81.2% and 94.7% and to 100% and 96.2%, respectively. Discordances still exist between the proportion method and molecular approach, particularly regarding INH-resistance. However, these methods are very important for the management faster and correct patient, helping to choose the best treatment regimen.

No description available.

Résumé de la thèse Depuis janvier 2001 nous travaillons au Programme national de Lutte contre la tuberculose du Burkina Faso en tant que son coordonnateur. Nous avons jugé utile d’analyser la détection des cas de tuberculose et leurs résultats de traitement après quelques années de mise en œuvre de ce Programme. Le constat de la faiblesse de nos résultats et la recherche de solution de leur amélioration nous a conduit à mettre en œuvre une recherche sur la base de l’hypothèse suivante. Hypothèse Le présent travail repose sur l’hypothèse qu’une organisation de la lutte contre la tuberculose prenant en compte les préoccupations et les propositions des acteurs (tuberculeux, membres de leurs familles, professionnels de santé, guérisseurs traditionnels, et membres des comité de gestion des services de santé) peut contribuer à améliorer les résultats du programme National Tuberculose (Détection des cas ; Taux de succès au traitement) et ( Meilleure adhésion des professionnels de santé, des patients et de leur proches aux stratégies de prise en charge des malades tuberculeux). Eléments de méthodologie Figure 1 : Schématisation de notre travail Les travaux ont été réalisés au Burkina Faso. La pauvreté et les conditions de vies difficiles (logement, nutrition, climat chaux et sec) favorisent l’installation de la tuberculose. Dans le cadre de l’analyse de base de la lutte antituberculeuse avant l’intervention nous avons réalisé deux études:  Une enquête rétrospective dans six districts sur la période du 1er janvier au 31 décembre 2001. Cette étude visait à identifier les difficultés du système de santé à diagnostiquer et mettre sous traitement les malades atteints de tuberculose.  Une étude rétrospective de cohortes. Elle a couvert la période 1995- 2003. Cette étude a porté sur le suivi du traitement des tuberculeux pendant 9 ans de mise en œuvre du Programme National de lutte contre la Tuberculose au Burkina Faso. Dans le cadre de notre intervention nous avons réalisé quatre études :  Une étude qualitative : vingt-huit groupes focalisés et 68 entrevues approfondies avec (des patients tuberculeux, des représentants de la communauté, des membres du comité de gestion du centre de santé, des guérisseurs traditionnels et des professionnels de la santé) pour savoir leurs perceptions de la stratégie de prise en charge des cas de tuberculose appliquée par le Programme National de lutte contre la Tuberculose.  Trois études descriptives à visée analytique en vue d’évaluer les résultats de deux ans d’intervention (Les résultats de la décentralisation de la prise en charge des tuberculeux de l’hôpital de district vers le centre de santé périphérique. Les effets de l’intervention sur les étapes de la détection des cas de tuberculose. Et la contribution des guérisseurs traditionnels au contrôle de la tuberculose au Burkina Faso).  Nous avons fait une analyse de situation deux ans après la fin de l’intervention pour voir ce qu’il reste du processus et des résultats dans les districts d’intervention et aussi ce qui se passait dans les districts témoins. Principaux résultats de ces études : Avant intervention  La première étude dans le cadre de l’analyse de base de la lutte antituberculeuse au Burkina Faso a montré que le niveau de dépistage des cas de tuberculose pulmonaire à microscopie positive est faible, du fait de la déperdition des cas dans chacune des étapes qui conduisent au diagnostic de la tuberculose. Le dépistage est dépendant de l’efficacité opérationnelle des personnels des services de santé, ainsi que du recourt au (centre de diagnostic et de traitement de la tuberculose) CDT par les patients suspects référés.  La deuxième étude a analysé neuf ans de suivi des tuberculeux par le programme national de lutte contre la tuberculose et a trouvé que le taux de négativation des examens de crachats de contrôle du deuxième mois de traitement a baissé de façon régulière depuis 1997. Cela pourrait être du à certaines caractéristiques des patients telles que des affections associées ou surtout à un traitement incorrect (irrégularité dans la prise des médicaments, doses insuffisantes, apparition de résistances ?) Les résultats de l’intervention  L’intervention a commencé par l’étude de l’accessibilité et de l’adhésion au traitement de la tuberculose. Elle révèle que les patients tuberculeux expérimentent trois groupes interdépendants de difficultés pour terminer avec succès leur traitement (difficultés pour arriver au centre de santé, difficultés pour aller régulièrement au centre de traitement, difficultés à l’intérieur du centre de santé). Ces difficultés sont compliquées par des facteurs d’accessibilité géographique, de pauvreté et de genre. La mise en œuvre pendant deux ans du paquet d’activités défini de façon consensuel par les acteurs (Patients tuberculeux, professionnels de santé, guérisseurs traditionnels, membres de la communauté) a apporté plusieurs résultats :  Pendant les premiers ateliers qui réunissaient les représentants des malades, des professionnels de santé et des guérisseurs traditionnels, les échanges étaient quasiment impossibles. Les malades ne voulaient pas s’exprimer devant les professionnels de santé, les guérisseurs traditionnels se méfiaient des professionnels de santé et ceux-ci monopolisaient la parole comme si ils étaient les détenteurs de tout le savoir. A partir du quatrième atelier, les échanges sont devenus vraiment interactifs et chaque type de participant disait vraiment ce qu’il pensait et abordait tous les sujets de la réunion sans se faire d’auto censure).  L’identification des tousseurs et des tousseurs chroniques parmi les patients adultes de la consultation générale s’est améliorée (respectivement de 10,6% à 14% et de 1,1% à 1,8%). La référence des patients suspects de tuberculose vers le laboratoire pour les examens de crachats s’est aussi améliorée (de 66% à 78,3%). Cependant notre étude a mis en exergue un problème important et à résoudre qui est la faible accessibilité du laboratoire pour les patients suspects de tuberculose).  En milieu rural plus de 46% des patients suspects ont opté pour la collecte de crachats sur place plutôt que de se rendre au laboratoire de l’hôpital pour les examens de crachats. La détection des cas de tuberculose a augmenté de (14 cas pour 100 000 habitants à 15) dans les districts témoins contre une augmentation de (14 cas pour 100 000 habitants à 26) pour les districts d’intervention. Nous n’avons pas noté de différence significative entre les taux de succès de traitement en comparant les districts d’intervention avec les districts témoins.  Les associations des guérisseurs traditionnels ont identifié 248 patients suspects de tuberculose dont 44 (17,74%) ont été confirmés positifs. Ils ont ramené 87 malades absents au traitement. Justifiant ainsi de l’utilité de leur implication). Nous avons fait une sortie de collecte de données et d’analyse de la situation dans les districts sites d’intervention en août 2008, soit plus de deux ans après la fin de l’intervention pour savoir ce qu’il en restait : • La décentralisation de la prise en charge des cas de tuberculose de l’hôpital de district vers les centres de santé périphériques est reprise dans les plans d’action des districts concernés. • Nous avons constaté que les outils de gestions des cas (fiche et carte de traitement du CSPS du tuberculeux, bulletin d’examen de crachats, fiche de rapport d’activités tuberculose du CSPS, registre transitoire de la tuberculose du CSPS) sont toujours là et utilisés par les professionnels de santé. • Les associations d’anciens malades sont encore là. Elles tiennent leurs réunions périodiques même si elles sont irrégulières. • Les associations de guérisseurs traditionnels mènent encore des activités de référence de patients suspects de tuberculose aux centres de santé dans le district de Gorom. • La supervision croisée ne se fait plus entre les trois districts d’intervention. Elle a été jugée difficile à organiser par insuffisance de ressources humaines et matériels selon les médecins chefs de district. • Au Burkina Faso les directions régionales de la santé et les districts ont une certaine autonomie pour le choix des activités à inclure dans les plans d’action annuels. Dés 2006 les districts témoins ont planifié les activités suivantes (décentralisation de la collecte des crachats et du traitement des tuberculeux , implication des associations à base communautaire, utilisation des outils de gestion de la tuberculose dans les centres de santé périphériques. Ils ont aussi utilisé le module de formations des professionnels de santé de l’intervention dès 2006). des La détection des cas de tuberculose était de 26 cas pour 100 000 habitants dans les districts sites de l’intervention contre 15 cas pour 100 000 habitants pour les témoins en fin de l’intervention. Deux ans environ après l’intervention la détection est devenue 24,5 cas pour 100 000 habitants dans les districts d’intervention contre 23,9 cas pour 100 000 habitants dans les districts témoins pour une moyenne nationale de 20,5 cas. Le taux de succès au traitement était de 75% dans les districts témoins et de 74,3% dans les districts d’intervention pour une moyenne nationale de 72,8%. Conclusion générale Pour finir on peut dire que les éléments du paquet d’activités qui sont restés deux ans après la fin de l’intervention méritent d’être repris, organisés et intégrés dans la démarche de prise en charge des malades tuberculeux dans le Programme National de Lutte contre la Tuberculose. Ce qui a manqué le plus, deux ans après l’intervention c’est la supervision des acteurs par une équipe de santé technique compétente et à effectif suffisant. La tuberculose est une maladie et la prise en charge des cas est une activité d’abord médicale. Les activités peuvent être renforcées et les résultats améliorés par une collaboration de divers acteurs autour de l’équipe de santé. Le registre de la tuberculose du centre de santé qui se situe à l’hôpital de district doit rester la pièce principale du processus de prise en charge des malades tuberculeux. C’est dans ce registre que toutes les données de tous les tuberculeux pris en charge dans le district doivent figurer. L’équipe médicale responsable de ce registre est responsable du devenir de tous les patients tuberculeux dans le district. La décentralisation de la prise en charge des cas de l’hôpital de district vers le centre de santé périphérique implique des devoirs de l’équipe médicale du CDT à l’endroit des prestataires de soins des CSPS. A ce titre l’équipe médicale du CDT doit superviser et aider les CSPS dans une mise en œuvre efficace des taches qui leurs sont confiées. Les membres organisés de la communauté peuvent apporter beaucoup dans l’information de la population sur la tuberculose, à condition que les contenus des messages soient élaborés sur une base d’informations techniques médicales vraies. La visite à domicile et l’accompagnement des malades graves par les associations seront utiles quand ils seront faits dans une synergie et une complémentarité de l’équipe médicale responsable du registre de la tuberculose. L’identification de plus de patients suspects de tuberculose et leur orientation vers les centres de santé par les associations n’aura de résultats que quand il existera un dispositif efficace de réponse dans le centre de santé ( laboratoires équipés animés par des techniciens de laboratoires motivés, compétents, en nombre suffisant et régulièrement supervisés par des superviseurs eux même compétents) ; ( prestataires de soins formés à l’écoute des patients, motivés et supervisés régulièrement par des superviseurs compétents). Notre étude nous enseigne qu’il est utile de prendre le temps nécessaire d’avoir les propositions des acteurs pour élaborer des stratégies qui rencontreront le plus possible leur adhésion. Notre étude nous enseigne aussi que plus il y a d’acteurs plus nous devons mettre en place des efforts de suivi, de supervision et d’accompagnement. Le renforcement du système de santé (agents de santé compétents, motivés, équipés, supervisés et en nombre suffisant) est nécessaire pour la pérennisation de toute initiative et résultats de santé / SUMMARY OF THE THESIS Since January in 2001 I am the National Tuberculosis Programme Manager in Burkina Faso. I though it would be helpful to analyse TB cases detection and the outcomes of there treatment after a few years of tuberculosis control. Because of low results and looking how to improve them we made a research with the following hypothesis. Hypothesis This research is based on the hypothesis that organising tuberculosis control buy taking into consideration the concerns and the propositions of the stakeholders (TB patients, members of their famil, health workers, traditional healers, and members of the health centre Management committee) we can contribute to improving the results of the National Tuberculosis Control Programme (TB cases detection, treatment success ) and (good adherence of health workers , TB patients and their relatives to the strategies of health care to tuberculosis patients). Figure 1 : Our work plan The research was conducted in Burkina Faso. Poverty and difficult living conditions (accommodation, nutrition, hot and dry climate) are favourable for the spread of tuberculosis As part of the basic analysis of tuberculosis control before the intervention, we carried out two researches:  A retrospective research in six districts between 1st January and 31st December 2001. This research was aimed at analysing the health system capacity to diagnose and to put patients infected with tuberculosis on treatment.  A retrospective study of groups. It covered the period 1995- 2003. This study bordered on monitoring the treatment during the 9 years of implementation of the National Tuberculosis Control Programme in Burkina Faso. As part of our intervention we carried out four studies:  A qualitative study : twenty eight focused groups and 68 detailed discussions sessions with ( tuberculosis patients, representatives of the community , members of the Health Centre Management Committee, traditional healers and health professionals) to sample their views on the tuberculosis treatment strategy applied by the National Tuberculosis Control Programme.  Three analytic and descriptive studies, to evaluate the results of the two years of intervention. (Results of decentralisation of tuberculosis care, from district hospital to peripheral health centres. The effects of the intervention on the stages of detection of tuberculosis cases. And the contribution of traditional healers to tuberculosis control in Burkina Faso).  We also looked for what was remaining from the process and the results of the intervention two years after the and of the intervention in the intervention district and what was happing in the witness districts. Principal results of these studies Before intervention  The first study into the basic analysis of tuberculosis control in Burkina Faso showed that there is a low rate of positive microscopic pulmonary tuberculosis, because of losses in cases in each of the stages leading to the diagnosis of tuberculosis. Cases detection is dependent on the operational efficiency of health services staff, as well as the using of the (Tuberculosis diagnosis and treatment centres) CDT by the suspected tuberculosis patients.  The second study before intervention which analysed nine years of tuberculosis control by the National Tuberculosis Control Programme, discovered that the rate of negativation at the 2 month follow- up sputum examination has fallen steadily since 1997. This could be due to certain characteristics of patients due to an incorrect treatment (irregularity in taking medicines, insufficient dosages, and appearance of resistance?). Results of the Intervention  The intervention began with a study of accessibility and adherence to treatment of tuberculosis. It reveals that Tuberculosis patients experiment with three interdependent groups of difficulties for a successful treatment (difficulty in arriving at health centres, difficulties in regularly visiting treatment centres, difficulties within the health centre). These difficulties are further compounded by geographical accessibility factors, poverty and gender. The two years of implementation of the packet of activities collectively defined by stakeholders (Tuberculosis patients, health services providers, and community members) has yield a lot of results:  During the earlier workshops which brought together representatives of the patients, health services providers and traditional healers, deliberations were almost impossible. Patients did not want to talk in front of health service providers, traditional healers mistrusted health services providers and the latter monopolised all discussions, as if they were the only repository of all knowledge. From the fourth workshop however, discussions became really interactive and each type of participant expressed his thought and tackled all topics at the meeting without any ill-feeling.  Identification of coughers and chronic coughers among adult patients of general consultation improved (respectively from from 10.6% to 14% and from 1.1% to 1.8%). Reference of suspected tuberculosis patients to laboratories for sputum smear examination also improved (from 66% to 78.3%). However, our study highlighted an important problem which needs immediate solution. This problem is the low utilisation of laboratories by suspected tuberculosis patients.  In the rural areas more than 46% of suspected patients opted for the collection of sputum samples on the spot instead of going to the hospital laboratory for the sputum smear examination. Detection of tuberculosis cases increased from (14 cases per 100 000 inhabitants to 15) in pilot districts and it increase from (14 cases per 100 000 inhabitants to 26) in intervention districts. There was no significant difference between the two successful treatment rates, when we compared the intervention districts with the pilot districts.  Traditional healers associations identified 248 suspected tuberculosis patients, out of whom 44 (17. 74%) were confirmed positive. They brought 87 absentee patients for treatment, thereby justifying the usefulness of their involvement. We made the analysis of the situation in the intervention districts in august 2008, two years after the end of the intervention in order to know what was remaining: . The decentralization of taking care of TB cases from the district hospital to the peripheral health center was written in the concerned districts year planning. . We have noticed that the tools of cases management (CSPS therapy form and card of the TB patients, expectorations exams bulletin, CSPS TB activities report form, transitory register of the CSPS TB) are still there and used by the health care providers of this level. . Associations of TB patients still exist. They hold their periodic meeting even if it is not regular. . Associations of traditional healers are still holding activities to send patients suspected of TB to health center in the district of Gorom. . Crossed supervision is not more done between the three districts of intervention. It has been judged difficult to organize because of insufficient human resources and material according to the chiefs doctors of the district. . At the end of the intervention detection of TB cases was of 26 cases for 100 000 inhabitants in the districts of intervention against 15 cases for 100 000 inhabitants for the witnesses. Almost two years after the intervention the detection became 24, 5 cases for 100 000 inhabitants in the intervention district against 23, 9 case for 100 000 inhabitants in the witness districts. The significant difference that was existing between witnesses and intervention districts disappeared two years after the intervention. General conclusion As conclusion we can say that elements of activities that remained two years after the end of intervention are good to be taken , organized and integrated in the National Tuberculosis Program approach of taking care of TB Patients. What lacked the most, two years after the intervention is the supervision of the stakeholders’ by a competent health technical team. TB is a disease and taking care of the cases is first a medical activity. Activities can be reinforced and the results improved by a collaboration of various stakeholders around the health team. TB register of the health center that is located at the district hospital must remain the key piece of the TB patients managing process. It is in this register that all the data of all the TB patients cared in the district must be. The medical team responsible of this register is responsible of the becoming of all the TB patients in the district. The decentralization of taking care of TB cases from the district hospital to the peripheral health centers implies duties of the CDT medical team towards CSPS’ health care providers. Because of that the CDT medical team must monitor and help CSPS in the efficient implementation of the tasks assigned to them. Members of organized community can bring a lot in the information of the population on TB, at the condition that the contents of messages are elaborated on a base of true technical medical information. Home visit and support to the patient seriously sick by the association will be useful when they will be done in a synergy and complementarily of the medical team responsible for the TB register. Identification of more patients suspected of TB and their orientation to health centers by the associations will only have results when there will be an efficient response in the health system (equipped laboratories animated by motivated , competent, and regularly monitored laboratories technicians by monitors who are also competent); (health care providers trained to listen to the patients, motivated and regularly monitored by competent monitors). Our study teaches us how useful it is to take necessary time to have stakeholders’ proposals in order to elaborate strategies that will meet the most their adhesion. Our study teaches us also that the more there are players the more we must put in place follow up, monitoring and support efforts, The building of a strong health system (competent, motivated, equipped, monitored health staffs) is necessary for the durability of all health initiative and results.