Public transportation and pulmonary tuberculosis, Lima, Peru.The association between public transportation for commuting and pulmonary tuberculosis pulmonary tuberculosis n. Tuberculosis of the lungs. pulmonary tuberculosis Infectious disease Infection by Mycobacterium tuberculosis (TB) was analyzed in workers in Lima, Peru. Traveling in minibuses was a risk factor for pulmonary TB pulmonary TB Pulmonary tuberculosis, see there . Preventive measures need to be taken by health services health services Managed care The benefits covered under a health contract to prevent spread of this disease. ********** Tuberculosis (TB) continues to be an important public health problem in impoverished areas (1-4). It is spread through the air by patients with pulmonary TB (5). Because those most affected by pulmonary TB are persons 15-50 years of age, employment-related characteristics of these persons must be taken into account when studying this disease. In Lima, Peru, residents of peripheral neighborhoods generally use minibuses to travel to work or school and have long commute times. Because public transportation in Latin America Latin America, the Spanish-speaking, Portuguese-speaking, and French-speaking countries (except Canada) of North America, South America, Central America, and the West Indies. routinely carries more passengers than permitted by law, it is plausible to assume that in areas with endemic pulmonary TB, daily use of public transportation may be a risk factor for acquiring TB (6-9). The greatest amount of expectoration expectoration /ex·pec·to·ra·tion/ (ek-spek?ter-a´shun) 1. the coughing up and spitting out of material from the lungs, bronchi, and trachea. 2. sputum. expectoration 1. (productive coughing productive cough n. A cough that expels mucus or sputum from the respiratory tract. ) occurs during the morning commute (6:00 AM-7:00 AM) because of accumulation of bronchial bronchial /bron·chi·al/ (brong´ke-al) pertaining to or affecting one or more bronchi. bron·chi·al adj. Relating to the bronchi, the bronchial tubes, or the bronchioles. secretions at night (10). Given the conditions in which persons travel to work in Lima (long travel times and overcrowding overcrowding overcrowding of animal accommodation. Many countries now publish codes of practice which define what the appropriate volumetric allowances should be for each species of animal when they are housed indoors. Breaches of these codes is overcrowding. on minibuses with closed windows), we analyzed whether use of minibuses was associated with the spread of pulmonary TB as part of a larger study to assess pulmonary TB in the Ate-Vitarte District of this city. The Study The study was conducted in the Ate-Vitarte district (population 365,473), which is located [approximately equal to] 12 km from the center of Lima. It is a marginal urban area that receives immigrants who come to Lima with high rates of TB. The study was reviewed and approved by the ethics committee ethics committee A multidisciplinary hospital body composed of a broad spectrum of personnel–eg, physicians, nurses, social workers, priests, and others, which addresses the moral and ethical issues within the hospital. See DNR, Institutional review board. of the East Lima Health Directorate IV. During July-August 2004, interviews were conducted with a random sample of 150 commuters [greater than or equal to] 15 years of age who had productive coughs for >15 days and who came to health services for treatment. A total of 142 persons agreed to participate: 96 were treated at hospitals and 46 were treated at health centers. Informed consent was obtained from all participants. Interviews were conducted in the health services that persons visited. We obtained demographic and socioeconomic information, as well as information on perceived health, and means of transportation used in commuting. All persons with productive coughs were requested to provide 3 sputum sputum /spu·tum/ (spu´tum) [L.] expectoration; matter ejected from the trachea, bronchi, and lungs through the mouth. sputum cruen´tum bloody sputum. samples (the first immediately after the interview and the other 2 on 2 consecutive days) for smear testing smear test Noun Med same as Pap test Noun 1. smear test - a method of examining stained cells in a cervical smear for early diagnosis of uterine cancer Pap test, Papanicolaou test . Samples were tested by using the Ziehl-Neelsen method, which is used in all epidemiologic surveillance epidemiologic surveillance The ongoing, systematic collection, analysis, and interpretation of health data essential to planning, implementing, and evaluating public health practice, closely integrated with the timely dissemination of these data to those who need to know in Peru (11). Study participants were considered positive for pulmonary TB if [greater than or equal to] l acid-fast bacilli bacilli /ba·cil·li/ (bah-sil´i) plural of bacillus. bacilli see bacillus. (AFB AFB abbr. acid-fast bacillus AFB Acid-fast bacillus, also 1. Aflatoxin B 2. Aorto-femoral bypass ) were found (11). Results were analyzed by using bivariate bi·var·i·ate adj. Mathematics Having two variables: bivariate binomial distribution. Adj. 1. and multivariate The use of multiple variables in a forecasting model. logistic models logistic models, n.pl statistical models that describe the relationship between a qualitative dependent variable (that is, one that can take only certain discrete values, such as the presence or absence of a disease) and an independent variable. with SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. version 12 software (SPSS Inc., Chicago, IL, USA). Statistical significance was defined as p<0.05. Demographic and socioeconomic characteristics of the study group are shown in Table 1. Variables analyzed for persons tested for pulmonary TB are shown in Table 2. Seventeen (11.9%) of 142 study participants were smear positive (29.6% 1 cross, 41.0% 2 cross, and 29.4% 3 cross). Two persons had been discharged from a TB treatment program <6 months earlier. None of the demographic and socioeconomic indicators analyzed (Table 1) were associated with pulmonary TB. Table 2 shows crude associations between variables and pulmonary TB. The use of a minibus min·i·bus n. pl. min·i·bus·es or min·i·bus·ses A small bus typically used for short trips. minibus Noun a small bus Noun 1. and a commuting time [greater than or equal to] 1 hour had the highest associations with pulmonary TB. Adjusted relationships obtained by logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. that controlled for all variables shown in Table 2 confirmed that commuting to work by minibus was associated with a positive test result for pulmonary TB (adjusted odds ratio 4.90, 95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. 1.04-23.04). Conclusions We observed a pulmonary TB prevalence rate of 12% in persons with chronic productive coughs who came to health services in the study area. This rate was similar to a prevalence of 11% reported in a similar study conducted in an area of poor socioeconomic status socioeconomic status, n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. in Chiapas, Mexico (12). The proportion of persons 15-44 years of age with pulmonary TB in our study was consistent with data of the World Health Organization and the Peruvian Ministry of Health, which show that this age group has the highest prevalence of this disease (5,13,14). Our results also showed that there were no sex-related differences in the frequency of pulmonary TB (13,14). Socioeconomic variables showed no association with pulmonary TB. However, this finding should be interpreted cautiously because of the small sample size, particularly the number of persons who lived in extreme poverty. Another factor that could limit our conclusions is accessibility of persons in areas of extreme poverty to public transportation. The fact that the field work phase of our study could not be increased because of shortages of resources and health center personnel time is also a limitation. The relationship of having pulmonary TB with working at home or away from home showed a positive prevalence ratio of 6.06. Among persons working outside the home, commuting by minibus increased the risk of having pulmonary TB by a factor of 4.09 compared with persons who used individual forms of transportation. A commuting time [greater than or equal to] 1 hour on a minibus also increased the risk for pulmonary TB by a factor of 2.07 (Table 2). Minibuses in Lima increase the risk for pulmonary TB because they are usually overloaded (capacity is often doubled) in the early morning and late evening. Overcrowding, exposure to persons with productive coughs while commuting 2 times a day 5 days a week, and closed windows on minibuses, combined with a high prevalence of pulmonary TB in Lima, increase the risk of acquiring this disease. Because persons with cases of pulmonary TB have more productive coughs in the morning (when more bacilli are released because of their accumulation at night), there is increased risk for transmission of TB to other passengers (15), as has already been suggested by other studies in developing and industrialized in·dus·tri·al·ize v. in·dus·tri·al·ized, in·dus·tri·al·iz·ing, in·dus·tri·al·iz·es v.tr. 1. To develop industry in (a country or society, for example). 2. countries (6-9). The findings that 41% of persons tested were positive with 2 crosses and 29.4% were positive in 3 crosses indicate poor TB prevention and control programs in the study area and higher probabilities of transmission (15). Despite the limitations of our study, commuting in minibuses was a risk factor for pulmonary TB. Consequently, preventive measures need to be taken by health services to encourage persons with productive coughs to avoid this type of public transportation and to come to health services for diagnosis and treatment. Health services should also be more accessible to persons with pulmonary TB who, for whatever reason, cannot use other forms of transportation. This increased accessibility would include home treatment during the infectious phase of this disease. This study was supported by the Direccion de Salud IV Lima Este and the Grups de Recerca d'America I Africa Llatines-Universidad Autonoma de Barcelona (http://servet.uab.es/graal). References (1.) Beggs CB, Noakes CJ, Sleigh sleigh: see sled. PA, Fletcher LA, Siddiqi K. The transmission of tuberculosis in confined spaces Confined space is a term from labor-safety regulations that refers to an area whose enclosed conditions and limited access make it dangerous. Description A confined space is any space: 1) that has limited or restricted means of entry or exit; 2) is large enough for a : an analytical review Noun 1. analytical review - an auditing procedure based on ratios among accounts and tries to identify significant changes limited review, review - (accounting) a service (less exhaustive than an audit) that provides some assurance to interested parties as to the of alternative epidemiological models. Int J Tuberc Lung Dis. 2003;7:1015-26. (2.) Weissenbacher M, Salvatella R, Hortal M. Desafio de las enfermedades emergentes y reemergentes. Revista Medica medica (māˑ·dē·k del Uruguay. 1998;14:3448. (3.) Jansa JM. y Garcia de Olalla, R Salud e inmigracion: nuevas realidades y nuevos retos. Gac Sanit. 2004;18:207-13. (4.) Garcia-Sanchez I, Pdrez de Oteyza C, Gilsanz Fernandez C. Estudio epidemiologico de la tuberculosis en un hospital de tercer nivel en el ano 2001. Anales de Medicina Intema (Madrid). 2005;22:222-6. (5.) American Thoracic Society American Thoracic Society (ATS ), established in 1905, is an independently incorporated, international, educational and scientific society, serving its 18,000 members world-wide who are dedicated in respiratory and critical care medicine. . Diagnostic standards and classification of tuberculosis in Bissau: incidence in adults and children. Am J Respir Crit Care Med. 2000; 161:1376-95. (6.) Tuberculosis spreads through crowded city buses, Cornell researcher reports. Science Daily. February 1, 1999. [cited 2006 May 7]. Available from http://www.sciencedaily.com/releases/1999/02/990201072734.htm (7.) Rodrigues C, Debanne S, Boffi L, Aparicio J, y Pilheu J. Transmision de la tuberculosis en medios de transporte en el area metropolitana de Buenos Aires Buenos Aires (bwā`nəs ī`rēz, âr`ēz, Span. bwā`nōs ī`rās), city and federal district (1991 pop. . [cited 2006 May 5]. Available from http://www. ub.edu.ar/investigaciones/proyectos_investigacion/proy_area_ amb_urb.htm (8.) Brotes de tuberculosis en ninos que usaban autobus escolar. 200SISIB. [cited 2006 May 7]. Available from http://mazinger.sisib.uchile. cl/repositorio/lb/ciencias_quimicas_y_farmaceuticas/armijor/cap9/ tuberculosis.html (9.) Cayla JA. Estudis en poblacions marginals amb alta prevalencia en paisos desenvolupats: El cas de Barcelona. In: Primer seminari GRAAL 2005: pobresa, marginacio i salut. Barcelona (Spain): Universidad Autonoma de Barcelona, May 22 25, 2005. [cited 2006 May 5]. Available from http://servet.uab.es/graal/ 1%20encuentro%20graal.htm (10.) Ministerio de Salud (MINSA). Norma tecnica de salud para el control de la tuberculosis en el Peril. Estrategia Nacional de Prevencion y Control de la Tuberculosis (ESN-PCT). [cited 2006 May 15]. Available from http://www.minsa.gob.pe/normaslegales/2006/ RM383-2006.pdf (11.) Ministerio de Salud del Peril (MlNSA). Direccion de salud de las personas. Programa National de Control de las Enfermedades Transmisibles/Controt de la Tuberculosis. Actualizacion de la doctrina, normas y procedimientos para el control de la tuberculosis en el Peril. Lima (Peru): Le Ministerio; 2001. (12.) Sanchez Perez HJ, Prat-Monterde D, Jansa JM, Martin-Mateo M. Tuberculosis M. tuberculosis, n the bacterium responsible for tuberculosis, generally a respiratory infection in man; nonrespiratory tuberculosis is considered an indicator disease for AIDS. See also tuberculosis. pulmonary uso de servicios del primer nivel de atencion en zonas de alta y muy alta marginacion socioeconomica de Chiapas, Mexico. Gac Sanit. 2000; 14:268-76. (13.) Bishai WR, Graham NM, Harrington S, Pope DS, Hooper N, Astemborski J, et al. Molecular and geographic patterns geographic pattern A general descriptor for lesions in which large areas of one color, histologic pattern, or radiologic density with variably scalloped borders sharply interface with another color, pattern or density, fancifully likened to national boundaries of tuberculosis transmission after 15 years of directly observed therapy directly observed therapy Therapeutics A strategy for ensuring Pt compliance with therapy, where a health care worker or designee watches the Pt swallow each dose of prescribed drugs. See Patient compliance. Cf Directed observation. . JAMA JAMA abbr. Journal of the American Medical Association . 1998;280:1679-84. (14.) Godoy P, Noguds A, Alseda M, Manonelles A, Artigues A, Garcia M. Factores de riesgo asociados a pacientes con TB con microscopia de esputo positiva. Gac Sanit. 2001;15:506-12. (15.) Beggs CB, Noakes CJ, Sleigh PA, Fletcher LA, Siddiqi K. The transmission of tuberculosis in confined spaces and analytical review of alternative epidemiological models. Int J Tuberc Lung Dis. 2003;7:1015-26. Olivia J. Horna-Campos, * Hector J. Sanchez-Perez, ([dagger]) Inma Sanchez, * Alfredo Bedoya, ([double dagger double dagger n. A reference mark (  ) used in printing and writing. Also called diesis.Noun 1. ]) and Miguel Martin * * Universidad Autonoma de Barcelona, Barcelona, Spain; ([dagger]) Colegio de la Frontera Sur, Chiapas, Mexico; and ([double dagger]) Direccion de Salud IV Lima Este, Lima, Peru Address for correspondence: Olivia J. Horna-Campos, Unidad de Bioestadistica, Facultad de Medicina, Universidad Autonoma de Barcelona, Edificio M, Cerdanyola del Valles, 08193 Bellaterra, Barcelona, Spain; email: ohornac@hotmail.com Ms Horna-Campos is completing her PhD in public health at the Universidad Autonoma de Barcelona, Spain. Her primary research interest is pulmonary tuberculosis health services in impoverished areas.
Table 1. Demographic and socioeconomic characteristics of
142 persons tested for pulmonary tuberculosis, Lima, Peru
Characteristic Value
Women, % 55.6
Mean age, y 35.7
Indigenous (Quechua), % 38.7
15-44 years of age, % 77.5
Immigrants, % 60.6
Education, %
Illiterate 8.5
Primary school 20.4
Secondary school or higher 71.1
Household indicators, %
Only 1 room 18.3
Roof of solid material 41.5
Electricity 97.8
Connection to public water supply 56.3
Toilet with running water 58.5
Overcrowded conditions * 39.4
Social security 15.5
Occupation, men (n = 63), %
Street peddlers 68.3
Students 17.5
Another job 12.7
Not working 1.6
Occupation, women (n = 79), %
Street peddlers 39.2
Housewives 43.0
Students 13.9
Another job 3.8
Means of transportation,
Public transportation 45.7
Individual transportation 26.8
Do not travel to work 27.5
Time spent commuting, ([dagger]) %
30 min to 1 h 60.0
[greater than or equal to] 1 h 40.0
* More than 3 persons sleeping in the same room.
([dagger]) Of those using public transportation, n = 65.
Table 2. Variables analyzed in 142 persons tested
for pulmonary tuberculosis, Lima, Peru *
AFB smear-- AFB smear--
Variable positive, n/N (%) negative, n/N (%)
Occupation away from home 16/17 (94.1) 87/125 (69.6)
Commuter transport by minibus 14/16 (87.5) 51/87 (58.6)
Commuting time [greater than
or equal to] 1 h 8/16 (50) 20/87 (23)
History of pulmonary
tuberculosis 4/17 (23.5) 24/125 (19.2)
Previous contact with
tuberculosis 7/17 (41.2) 40/125 (32.0)
cases (family)
Overcrowded conditions 6/17 (35.3) 50/125 (40)
Total,
Variable n/N (%) OR (95% CI)
Occupation away from home 103/142 (72.5) 6.99 (0.89-54.61)
Commuter transport by minibus 65/103 (63.1) 4.9 (1.06-23.09)
Commuting time [greater than
or equal to] 1 h 28/103 (27.2) 3.35 (1.12-10.10)
History of pulmonary
tuberculosis 28/142 (19.7) 1.29 (0.38-4.33)
Previous contact with
tuberculosis 47/142 (33.1) 1.49 (0.53-4.20)
cases (family)
Overcrowded conditions 56/142 (39.4) 0.818 (0.28-2.35)
Positive
Variable prevalence ratio
Occupation away from home 6.06
Commuter transport by minibus 4.09
Commuting time [greater than
or equal to] 1 h 2.07
History of pulmonary
tuberculosis 1.25
Previous contact with
tuberculosis 1.41
cases (family)
Overcrowded conditions 0.83
* AFB, acid-fast bacilli; OR, odds ratio; CI, confidence interval
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