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it remains the highest incidence country in the Western Europe and some areas still have an intermediate incidence&#46; Lisbon and Oporto are the districts with the highest incidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Homeless people&#44; drug users&#44; prisoners and migrants are at increased risk of developing TB&#46; These groups concentrate in urban settings and their numbers tend to have an impact on TB&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6-10</span></a> This work concentrates solely on the migrant movements&#8217; effect on TB&#46; In fact&#44; in many European countries&#44; most cases of tuberculosis occur within the immigrant population&#46; About 26&#46;8&#37; of TB cases reported in the European Union &#40;EU&#41; and European Economic Area countries are of foreign origin&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> Therefore&#44; migrants from high incidence countries have a considerable impact on the tuberculosis burden in low incidence countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">5&#44;10</span></a> Increased risk of TB in this group might be related to higher exposure in the country of origin and&#47;or worse socioeconomic conditions&#44; comparing to the resident population&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As opposed to other European countries&#44; like Iceland&#44; Cyprus&#44; Norway or Sweden&#44; where more than 70&#37; of tuberculosis cases occur in foreign born individuals&#44; in Portugal&#44; this group represents only about 16&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6&#44;10&#44;12</span></a> Nevertheless&#44; TB incidence among immigrants in Portugal is much higher than in non-immigrants and it has been increasing&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">As a consequence of the economic crisis&#44; in the last few years&#44; an increasing number of individuals have left the country to live abroad&#46; Portugal is the EU country with the largest number of emigrants per capita&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> In 2014&#44; the number of emigrants had risen to the double&#44; compared to 2008&#46; The majority are young adults&#44; aged 20&#8211;44 years old&#44; that left Portugal seeking for better working and living conditions abroad&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">15&#44;16</span></a> This age group overlaps with the one most affected by TB&#44; between 25 and 54 years old&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main aim of this study is to describe the decrease in TB in Portugal over the last years purely from a demographical point of view&#46; As such&#44; the authors quantify the effect of the migration movements &#40;immigration and emigration&#41; on the TB notification in Portugal &#40;from 2008 to 2014&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data and Sources</span><p id="par0040" class="elsevierStylePara elsevierViewall">Data on tuberculosis notification were collected from the Portuguese Tuberculosis Surveillance System &#40;SVIG-TB&#41; coordinated by the Directorate General of Health &#40;DGH&#41; during the seven year period ranging from 2008 to 2014&#46; Data on migration movements for the period of study &#40;2008-2014&#41; were collected from Immigration and Borders Service Statistics and Statistics Portugal&#44; the public Portuguese entity responsible for the official statistical information and included&#58; 1&#41; the absolute number of resident immigrants in each year&#59; 2&#41; the absolute number of immigrants entering the country per year&#59; 3&#41; the absolute number of emigrants per year&#59; 4&#41; the migration balance&#44; which refers to the difference between the number of individuals entering and leaving the country&#44; per year&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For the purpose of this paper&#44; TB cases with no information on the country of origin were excluded from the analysis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">As this was a retrospective study and used routinely collected surveillance data&#44; neither ethical approval nor informed consent were required&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Mathematical Analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">The impact of the migration movements on the TB burden was initially addressed separately for immigration and emigration&#44; and simultaneously afterwards&#46; The separate analysis allowed for the study of the influence of each migration phenomenon in isolation&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Firstly&#44; the expected number of TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants for year <span class="elsevierStyleItalic">t</span> &#40;2008&#44; 2009&#44; &#8230;&#44; 2014&#41; under a steady situation of immigration &#40;<span class="elsevierStyleItalic">i&#46;e</span>&#46;&#44; keeping both the number of immigrants and the number of TB-cases among immigrants at their 2008 values&#41; was computed by&#58;<elsevierMultimedia ident="eq0005"></elsevierMultimedia></p><p id="par0275" class="elsevierStylePara elsevierViewall">Here&#44; <span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">NI</span></span>&#40;<span class="elsevierStyleItalic">t</span>&#41; denotes the number of TB-cases within the non-immigrant resident population in year <span class="elsevierStyleItalic">t</span>&#44; <span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">I</span></span>&#40;<span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41; denotes the number of TB-cases within the immigrant population in <span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2008&#44; and <span class="elsevierStyleItalic">P</span>&#40;<span class="elsevierStyleItalic">t</span>&#41; &#40;resp&#46; <span class="elsevierStyleItalic">E</span>&#40;<span class="elsevierStyleItalic">t</span>&#41;&#44; <span class="elsevierStyleItalic">I</span>&#40;<span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41;&#41; represents the number of Portuguese individuals &#40;resp&#46; emigrants&#44; immigrants&#41; in year <span class="elsevierStyleItalic">t</span> &#40;resp&#46; <span class="elsevierStyleItalic">t</span>&#44; <span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41;&#46; Clearly&#44; <span class="elsevierStyleItalic">P</span>&#40;<span class="elsevierStyleItalic">t</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">E</span>&#40;<span class="elsevierStyleItalic">t</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">I</span>&#40;<span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41; corresponds to the total number of individuals resident in Portugal in year <span class="elsevierStyleItalic">t</span>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Then&#44; for each year&#44; the expected number was compared with the observed number of TB-cases &#40;including different annual counts for the number of immigrants and TB-cases among immigrants&#41;&#46; The magnitude of the differences allowed for the evaluation of the impact of the immigration process on the TB incidence&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The model evaluating the impact of the emigration on TB in Portugal followed a similar reasoning&#59; keeping both the number of emigrants and the number of TB-cases among emigrants at its 2008 value&#44; the expected number of TB cases for year <span class="elsevierStyleItalic">t</span> per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants was calculated by<elsevierMultimedia ident="eq0010"></elsevierMultimedia>where the number of TB-cases among emigrants in year <span class="elsevierStyleItalic">t</span>&#44; <span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">E</span></span>&#40;<span class="elsevierStyleItalic">t</span>&#41;&#44; assumed the same per-capita rate as <span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">NI</span></span>&#40;<span class="elsevierStyleItalic">t</span>&#41;&#44; namely<elsevierMultimedia ident="eq0015"></elsevierMultimedia></p><p id="par0080" class="elsevierStylePara elsevierViewall">Indeed&#44; had the TB-emigrants in year <span class="elsevierStyleItalic">t</span> stayed in the country and the difference <span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">E</span></span>&#40;<span class="elsevierStyleItalic">t</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">E</span></span>&#40;<span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41; would have been accounted for in the total number of cases within national territory&#46; The magnitude of the differences between observed and expected counts allowed for the evaluation of the impact of the emigration process on the TB incidence&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The study of the simultaneous effect of immigration and emigration combined the previous two equations&#46; Under a steady scenario of immigration and emigration&#44; the expected number of TB cases for year <span class="elsevierStyleItalic">t</span> per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants would be<elsevierMultimedia ident="eq0020"></elsevierMultimedia></p><p id="par0090" class="elsevierStylePara elsevierViewall">Finally&#44; the relative annual fluctuations observed within the total number of Portuguese residents were compared with the relative annual decreases in the number of TB-cases&#46; For each variable&#44; the relative annual fluctuation between year <span class="elsevierStyleItalic">t</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 and year <span class="elsevierStyleItalic">t</span> was computed as<elsevierMultimedia ident="eq0025"></elsevierMultimedia></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">From 2009 to 2013 there was a steady annual increase in the number of emigrants and essentially a decrease in the number of immigrants&#46; The years 2008 and 2014 have slightly contradicted this trend&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Until 2010&#44; the number of immigrants per year was higher than the number of emigrants&#46; From 2011 to 2014&#44; there was an inversion in the migration flow&#44; and the number of emigrants exceeded the number of immigrants&#44; thus turning the migration balance negative &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The number of TB cases has been consistently decreasing since 2008&#46; Cases occurring in immigrants represented 13&#46;8&#37; of all cases in 2008&#44; 15&#46;2&#37; in 2009 and remained stable at about 16&#37; since 2010&#46; Immigrants have a much higher notification rate of TB than the Portuguese individuals &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Similar to the TB notification rate&#44; the total resident population in Portugal&#44; has essentially decreased over 2008&#8211;2014 &#40;with the exception of a slight increase from 2008 to 2009&#41;&#46; However&#44; the relative annual decrease on the number of residents was lower than the decrease on the TB numbers &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; from 2008 to 2014 there were relatively few immigrants entering Portugal&#46; Fixing both the immigration rate and the TB rate among immigrants at their 2008 values&#44; and considering the variation on emigration that has actually occurred&#44; we&#8217;ve estimated the number of TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants for each studied year &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The differences between the observed and the estimated numbers were residual&#44; ranging from more 0&#46;27 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2010 to less 0&#46;49 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2014&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">On the other hand&#44; emigration rose significantly during the period of study &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; which could have influenced the TB rate in the country to go lower&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The official number of TB cases in emigrants leaving the country in 2008 was 4&#46;87&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46; Assuming that this rate remained constant along 2008&#8211;2014 and that the total number of emigrants did not change either along that period&#44; we estimated annual numbers for TB in Portugal&#46; The observed numbers were only slightly higher than their estimates&#46; The differences were even smaller than those found for the immigration impact &#40;&#60;0&#46;1 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">When looking at both migration movements at the same time&#44; the observed TB rate was again identical to the estimated TB rate &#40;differences between less 0&#46;43 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2014 and more 0&#46;28 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2010&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">The number of TB cases has been decreasing in Portugal &#40;notification rate was 27&#46;8&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2008 vs 21&#46;8 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2014&#41;&#46; Since 2009&#44; the resident population has also been decreasing&#44; but at a slower pace&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; As for that&#44; the decreasing number of TB cases cannot only be due to the reduction in the resident population&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Between 2008 and 2010&#44; the number of immigrants exceeded the number of emigrants &#40;positive migration balance&#41;&#46; Since 2011 until 2014&#44; migration balance turned negative&#46; Moreover&#44; TB rate has been consistently higher among immigrants compared to the native population &#40;&#62;90 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants vs 18&#46;3&#8211;23&#46;9 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#41;&#46; The percentage of TB cases in this group has risen from 13&#46;2&#37; in 2008 to 15&#46;2&#37; in 2009 and remained at about 16&#37; since 2010&#46; This model allowed us to evaluate the impact of the immigration on the TB rate&#46; It showed that&#44; since 2011&#44; as immigration is decreasing&#44; there is a tendency to a lower number of TB cases&#46; However&#44; the differences are very small&#44; representing less than 1 case per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#44; so the impact does not seem to be significant&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A decrease in TB incidence has been the trend in the whole WHO European Region over the last years&#44; where it has fallen by 5&#46;2&#37; each year&#44; since 2005&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Efforts have been made to achieve lower TB rates in Europe&#44; even in low incidence countries&#46; Out of 31 low incidence countries evaluated&#44; more than half &#40;54&#46;8&#37;&#41; reported to have a dedicated national TB programme&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Despite this global trend and even though we failed to demonstrate a significant impact of the immigration global decrease on TB rate&#44; immigrants are still a risk group as in many of their origin countries&#44; infectious diseases&#44; such as TB&#44; are still an important cause of death and morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In low incidence countries&#44; the impact of immigration on the burden of TB has been largely studied&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">10&#44;19-21</span></a> Addressing risk groups is one of the key strategies against TB&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">8&#44;22</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In the recently published action framework of the WHO towards TB elimination in low incidence countries<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">23</span></a> strategies involving migrants are mentioned in three of the eight priority action areas&#58; 1&#41; to address the most vulnerable and hard-to-reach groups&#59; 2&#41; to address special needs of migrants and crossborder issues and 3&#41; to undertake screening for active TB and latent tuberculosis infection &#40;LTBI&#41; in TB contacts and selected high-risk groups&#44; and provide appropriate treatment&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Many efforts have been made to detect TB and LTBI among migrants&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">12</span></a> Some EU countries have implemented screening of migrants before&#44; or at entry&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">24</span></a> Underwood et al&#46; compared contact tracing with new entrant screening in London and found the former to be more effective&#44; as it identifies families and communities at high risk&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">21</span></a> With the recent increase in the number of immigrants coming to Europe as refugees &#40;rising from about 219<span class="elsevierStyleHsp" style=""></span>000 in 2014 to more than one million in 2015&#41;&#44; TB control in this group is also a concern&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">25&#44;26</span></a> Regarding this matter&#44; the ERS&#47;WHO European Region has performed a study in order to document the policies and practices of low and intermediate TB incidence European countries with regards to detection and management of TB and latent TB infection among this vulnerable group&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">26</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In countries where most cases of TB occur in foreign born individuals or where incidence in this group is increasing&#44; despite a decreasing TB rate&#44; as it occurs in Portugal&#44; policies on this subject are of great importance&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">As for the emigration increase over the period of study&#44; our model showed very little differences between the number of observed and expected cases &#40;&#60;0&#46;1 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants each year&#41;&#46; The fact that the differences between observed and expected cases were smaller than those found for the immigration impact can mean that the increase in emigration that we observed over 2008&#8211;2014 has not significantly impact the national TB rate&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">We assumed the TB rate in emigrants to be similar to the TB rate in the Portuguese individuals that stayed in the country&#46; However&#44; we do not know if these individuals had other risk factors for TB or if they became more vulnerable for TB when they moved abroad&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Torres Redondo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">27</span></a> retrospectively analyzed the Portuguese emigrants diagnosed with TB when returning to the country&#44; in the Northern Region in 2014&#46; Most cases &#40;76&#46;3&#37;&#41; had moved to low TB incidence countries and had lived there for more than 2 years &#40;median time of 42&#46;0 months&#41;&#44; which could suggest that exposure to TB could have already occurred in the foreign country&#46; About 67&#37; shared housing with work colleagues&#46; These data suggest that risk for TB might increase when emigrants leave the country as they might experience harder living conditions and economic adversity&#46; Nevertheless&#44; had they stayed in the country they might have been unemployed which also accounts as a risk factor for TB&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Despite the lack of knowledge about this group&#44; our model failed to demonstrate an impact of emigration on TB notification rate&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Individually&#44; the migration movements did not influence TB rate when analyzed by our model&#44; so we tried to look at the impact of both movement altogether&#46; Differences were again very small &#40;&#60;0&#46;5 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabits each year&#41;&#44; so&#44; even when combined&#44; migration movements do not seem to largely influence TB notification rate&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">This might mean that we have to concentrate our efforts in other risk factors&#46; Sousa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> recently found HIV to be the factor with this highest impact&#58; an increase of 10 HIV notifications per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants was associated with a rise of 2 new TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46; Also&#44; an increase of 1000 unemployed subjects per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants was associated with one new case of TB per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Apart from HIV infection&#44; poor living and working conditions&#44; which can facilitate TB transmission and risk factors that impair host&#39;s defense&#44; like malnutrition&#44; smoking&#44; diabetes&#44; alcohol abuse and indoor air pollution have been pointed out as major determinants&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">29-32</span></a>Silicosis also increases the risk of TB by 2&#46;8&#8211;39 times&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">33&#44;34</span></a> Silico-TB can be a challenging diagnosis and treatment must be longer&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">35</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Preventive strategies that target these factors might have an important impact on TB burden&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">These risk factors also add to the risk for TB in the migrant population&#46; Paulino et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a> found that foreign born patients were more likely to be HIV positive&#44; to be employed&#44; homeless or live in shelters&#46; Reducing HIV infection and providing better living conditions might have an even greater impact on TB among migrants&#46; A study performed in Italy by Ingrosso et al&#46; also showed that HIV infection is three times more frequent in foreign born people affected by TB than among Italians&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Altogether&#44; these factors represent areas of intervention towards TB elimination and should all be addressed in national and international TB programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">23</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">In this work&#44; the authors tried to understand the impact of two demographic factors &#8211; the migration movements and the decrease in the total number of residents &#8211; on the burden of TB in Portugal over the 7-year period 2008&#8211;2014&#46; As such&#44; other risk factors such as HIV infection&#44; homelessness or overcrowded housing were assumed to remain constant over that period&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">In conclusion&#44; the changing pattern of migration in Portugal over the period of study &#40;2008&#8211;2014&#41; does not seem to have had a significant impact on the TB notification rate&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authorship</span><p id="par0250" class="elsevierStylePara elsevierViewall">All authors contributed to drafting and review of the manuscript&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interest</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare to have no conflict of interest directly or indirectly related to the manuscript contents&#46;</p></span></span>"
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              "titulo" => "Discusi&#243;n"
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          "titulo" => "Palabras clave"
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          "titulo" => "Introduction"
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        5 => array:3 [
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          "titulo" => "Methods"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Data and Sources"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Mathematical Analysis"
            ]
          ]
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        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Results"
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        7 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Discussion"
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          "identificador" => "sec0035"
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          "identificador" => "sec0040"
          "titulo" => "Conflict of Interest"
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        10 => array:1 [
          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2017-07-05"
    "fechaAceptado" => "2017-07-26"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec933525"
          "palabras" => array:3 [
            0 => "Emigration"
            1 => "Immigration"
            2 => "Tuberculosis"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec933526"
          "palabras" => array:3 [
            0 => "Emigraci&#243;n"
            1 => "Inmigraci&#243;n"
            2 => "Tuberculosis"
          ]
        ]
      ]
    ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tuberculosis notification in Portugal has decreased in the last few years&#46; As a consequence of the economic crisis&#44; emigration has increased and immigration has decreased&#46; Immigrants are a risk group for tuberculosis&#46; Most emigrants are 20&#8211;44 years old and belong to the age group most affected by tuberculosis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the decrease in tuberculosis notification in Portugal over the last years from a demographical point of view&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mathematical analysis was performed to quantify the effect of the migration movements &#40;separately and simultaneously&#41; on tuberculosis notification in Portugal from 2008 to 2014&#46; We calculated the estimated tuberculosis notification for each year during the period of study&#58; 1&#41; fixing immigration rate and tuberculosis rate in immigrants at 2008 values&#59; 2&#41; fixing emigration rate and tuberculosis rate in emigrants at 2008 values&#59; 3&#41; fixing both phenomenons at 2008 values&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The differences between the observed and the estimated numbers were small &#40;&#8804;0&#46;5 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Impact of the migration movements on tuberculosis notification rate does not seem to be significant when analyzed for each phenomenon individually and simultaneously&#44; by our model&#46; This might mean that we have to concentrate our efforts in other risk factors for tuberculosis&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Methods"
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            "identificador" => "abst0020"
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            "titulo" => "Discussion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La notificaci&#243;n de casos de tuberculosis en Portugal ha disminuido en los &#250;ltimos a&#241;os&#46; Como consecuencia de la crisis econ&#243;mica&#44; la emigraci&#243;n ha aumentado y la inmigraci&#243;n ha disminuido&#46; Los inmigrantes son un grupo de riesgo para la tuberculosis&#46; La mayor&#237;a de los emigrantes tienen entre 20 y 44 a&#241;os y pertenecen al grupo de edad m&#225;s afectado por la tuberculosis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir la disminuci&#243;n de la notificaci&#243;n de casos tuberculosis en Portugal en los &#250;ltimos a&#241;os&#44; desde un punto de vista demogr&#225;fico&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis matem&#225;tico para cuantificar el efecto de los movimientos migratorios &#40;por separado y simult&#225;neamente&#41; en la notificaci&#243;n de casos de tuberculosis en Portugal de 2008 a 2014&#46; Se calcul&#243; la notificaci&#243;n de casos de tuberculosis estimada para cada a&#241;o durante el per&#237;odo de estudio&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La notificaci&#243;n estimada de tuberculosis para cada a&#241;o del periodo de estudio se calcul&#243;&#58; <span class="elsevierStyleItalic">1&#41;</span> fijando las tasas de inmigraci&#243;n y de tuberculosis en inmigrantes con datos del a&#241;o 2008&#59; <span class="elsevierStyleItalic">2&#41;</span> fijando las tasas de emigraci&#243;n y de tuberculosis en emigrantes con datos del a&#241;o 2008&#44; y <span class="elsevierStyleItalic">3&#41;</span> fijando ambos fen&#243;menos con datos del a&#241;o 2008&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Las diferencias entre los valores observados y los valores estimados fueron peque&#241;as &#40;&#8804; 0&#44;5 casos&#47;100&#46;000 habitantes&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discusi&#243;n</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Seg&#250;n el modelo matem&#225;tico propuesto en este trabajo&#44; el impacto de los movimientos migratorios en la tasa de notificaci&#243;n de casos de tuberculosis en Portugal no parece ser significativo cuando se analiza cada fen&#243;meno tanto individual como simult&#225;neamente&#46; Estos datos indicar&#237;an que deber&#237;amos concentrar los esfuerzos en identificar otros factores de riesgo para la tuberculosis&#46;</p></span>"
        "secciones" => array:5 [
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            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
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            "identificador" => "abst0035"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
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            "identificador" => "abst0050"
            "titulo" => "Discusi&#243;n"
          ]
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">M&#58; male&#59; F&#58; female&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total resident population<br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resident inmigrants<br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Emigrants<br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Immigrants<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">a</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Migration balance<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Portuguese individuals<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">c</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>563<span class="elsevierStyleHsp" style=""></span>014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">440<span class="elsevierStyleHsp" style=""></span>277&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20<span class="elsevierStyleHsp" style=""></span>357&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29<span class="elsevierStyleHsp" style=""></span>718&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9361&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>553<span class="elsevierStyleHsp" style=""></span>653&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>573<span class="elsevierStyleHsp" style=""></span>479&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">454<span class="elsevierStyleHsp" style=""></span>191&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16<span class="elsevierStyleHsp" style=""></span>899&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32<span class="elsevierStyleHsp" style=""></span>307&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15<span class="elsevierStyleHsp" style=""></span>408&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>558<span class="elsevierStyleHsp" style=""></span>071&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>572<span class="elsevierStyleHsp" style=""></span>721&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">445<span class="elsevierStyleHsp" style=""></span>262&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23<span class="elsevierStyleHsp" style=""></span>760&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27<span class="elsevierStyleHsp" style=""></span>575&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3815&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>568<span class="elsevierStyleHsp" style=""></span>906&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>542<span class="elsevierStyleHsp" style=""></span>398&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">436<span class="elsevierStyleHsp" style=""></span>822&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43<span class="elsevierStyleHsp" style=""></span>998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19<span class="elsevierStyleHsp" style=""></span>667&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;24<span class="elsevierStyleHsp" style=""></span>331&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>566<span class="elsevierStyleHsp" style=""></span>729&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>487<span class="elsevierStyleHsp" style=""></span>289&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">417<span class="elsevierStyleHsp" style=""></span>042&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51<span class="elsevierStyleHsp" style=""></span>958&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14<span class="elsevierStyleHsp" style=""></span>606&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;37<span class="elsevierStyleHsp" style=""></span>352&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>524<span class="elsevierStyleHsp" style=""></span>641&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>427<span class="elsevierStyleHsp" style=""></span>301&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">401<span class="elsevierStyleHsp" style=""></span>320&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53<span class="elsevierStyleHsp" style=""></span>786&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17<span class="elsevierStyleHsp" style=""></span>554&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;36<span class="elsevierStyleHsp" style=""></span>232&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>463<span class="elsevierStyleHsp" style=""></span>533&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>374<span class="elsevierStyleHsp" style=""></span>822&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">395<span class="elsevierStyleHsp" style=""></span>195&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49<span class="elsevierStyleHsp" style=""></span>572&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19<span class="elsevierStyleHsp" style=""></span>516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;30<span class="elsevierStyleHsp" style=""></span>056&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>404<span class="elsevierStyleHsp" style=""></span>878&nbsp;\t\t\t\t\t\t\n
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              "identificador" => "tblfn0045"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Immigrants entering the country each year&#46;</p>"
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              "identificador" => "tblfn0005"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Migration balance&#58; immigrants<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>emigrants&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Portuguese individuals<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>total resident population<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>emigrants<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>immigrants&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Migration Movements&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TB cases<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TB rate<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TBPI<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">c</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TBPI rate<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TBI<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">e</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; TBI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TBI rate<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TB cases missing origin<br><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2967&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2523&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">410&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2869&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2432&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2714&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2273&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">438&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2609&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2203&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">404&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2606&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2176&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">408&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2399&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1989&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">393&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2264&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1904&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">357&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1631794.png"
              ]
            ]
          ]
          "notaPie" => array:6 [
            0 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">As documented in SVIG-TB&#59; includes the cases for which the country of origin is missing&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">TB rate&#58; TB cases &#40;excluding TB cases with missing origin&#41; per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">TBPI&#58; TB cases in Portuguese individuals<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>TB cases<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>TB cases in immigrants<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>TB cases with missing origin&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0030"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0035">TBPI rate&#58; TBPI cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46;</p>"
            ]
            4 => array:3 [
              "identificador" => "tblfn0035"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0040">TBI&#58; TB cases in immigrants&#46;</p>"
            ]
            5 => array:3 [
              "identificador" => "tblfn0040"
              "etiqueta" => "f"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0045">TBI rate&#58; TBI cases per 100<span class="elsevierStyleHsp" style=""></span>000 resident immigrants&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Tuberculosis Numbers&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resident population decrease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tuberculosis cases decrease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2009&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2010&#8211;2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2011&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2012&#8211;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2013&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1631792.png"
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Variation of the Total Number of Residents and TB Notification Rate&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">O&#58; observed&#59; E&#58; expected&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Observed number of TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 in inhabitants &#40;O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Expected TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants &#40;E&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">O<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;27&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;76&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;02&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;98&nbsp;\t\t\t\t\t\t\n
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Original Article
Migration Flow and Its Impact on Tuberculosis Notification in Portugal
El flujo de migratorio y su impacto en la notificación de tuberculosis en Portugal
Ana Diasa,
Corresponding author
ana.pgrdias@gmail.com

Corresponding author.
, Rita Gaiob, Pedro Sousac, Marta Gomesd,e, Olena Oliveirae, Raquel Duartee,f,g
a Centro Hospitalar Lisboa Norte EPE, Departamento do Tórax, Lisboa, Portugal
b Departamento de Matemática, Universidade do Porto and Centro de Matemática da Universidade do Porto, Porto, Portugal
c Unidade de Saúde Familiar, Saúde em Família, Agrupamento de Centros de Saúde do Grande Porto III, Maia/Valongo, Maia, Portugal
d Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Departamento de Saúde Ocupacional, Vila Nova de Gaia, Portugal
e ISPUP-EPIUnit, Universidade do Porto, Porto, Portugal
f Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Departamento de Pneumologia, Vila Nova de Gaia, Portugal
g Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Since WHO declared tuberculosis &#40;TB&#41; a global emergency&#44; many efforts have been made worldwide to decrease TB incidence&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">1</span></a> In Portugal&#44; a TB National Programme was implemented in 1995 and in 2006 the &#8220;STOP TB strategy&#8221; was launched to delineate specific goals and strengthen the struggle towards the end of TB&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Eight years later&#44; in 2014&#44; Portugal reached the threshold of low incidence&#44; registering 20 new cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a> Despite this&#44; it remains the highest incidence country in the Western Europe and some areas still have an intermediate incidence&#46; Lisbon and Oporto are the districts with the highest incidence&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Homeless people&#44; drug users&#44; prisoners and migrants are at increased risk of developing TB&#46; These groups concentrate in urban settings and their numbers tend to have an impact on TB&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6-10</span></a> This work concentrates solely on the migrant movements&#8217; effect on TB&#46; In fact&#44; in many European countries&#44; most cases of tuberculosis occur within the immigrant population&#46; About 26&#46;8&#37; of TB cases reported in the European Union &#40;EU&#41; and European Economic Area countries are of foreign origin&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a> Therefore&#44; migrants from high incidence countries have a considerable impact on the tuberculosis burden in low incidence countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">5&#44;10</span></a> Increased risk of TB in this group might be related to higher exposure in the country of origin and&#47;or worse socioeconomic conditions&#44; comparing to the resident population&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">As opposed to other European countries&#44; like Iceland&#44; Cyprus&#44; Norway or Sweden&#44; where more than 70&#37; of tuberculosis cases occur in foreign born individuals&#44; in Portugal&#44; this group represents only about 16&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">6&#44;10&#44;12</span></a> Nevertheless&#44; TB incidence among immigrants in Portugal is much higher than in non-immigrants and it has been increasing&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">As a consequence of the economic crisis&#44; in the last few years&#44; an increasing number of individuals have left the country to live abroad&#46; Portugal is the EU country with the largest number of emigrants per capita&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">14</span></a> In 2014&#44; the number of emigrants had risen to the double&#44; compared to 2008&#46; The majority are young adults&#44; aged 20&#8211;44 years old&#44; that left Portugal seeking for better working and living conditions abroad&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">15&#44;16</span></a> This age group overlaps with the one most affected by TB&#44; between 25 and 54 years old&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The main aim of this study is to describe the decrease in TB in Portugal over the last years purely from a demographical point of view&#46; As such&#44; the authors quantify the effect of the migration movements &#40;immigration and emigration&#41; on the TB notification in Portugal &#40;from 2008 to 2014&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data and Sources</span><p id="par0040" class="elsevierStylePara elsevierViewall">Data on tuberculosis notification were collected from the Portuguese Tuberculosis Surveillance System &#40;SVIG-TB&#41; coordinated by the Directorate General of Health &#40;DGH&#41; during the seven year period ranging from 2008 to 2014&#46; Data on migration movements for the period of study &#40;2008-2014&#41; were collected from Immigration and Borders Service Statistics and Statistics Portugal&#44; the public Portuguese entity responsible for the official statistical information and included&#58; 1&#41; the absolute number of resident immigrants in each year&#59; 2&#41; the absolute number of immigrants entering the country per year&#59; 3&#41; the absolute number of emigrants per year&#59; 4&#41; the migration balance&#44; which refers to the difference between the number of individuals entering and leaving the country&#44; per year&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For the purpose of this paper&#44; TB cases with no information on the country of origin were excluded from the analysis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">As this was a retrospective study and used routinely collected surveillance data&#44; neither ethical approval nor informed consent were required&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Mathematical Analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">The impact of the migration movements on the TB burden was initially addressed separately for immigration and emigration&#44; 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<span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">I</span></span>&#40;<span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41; denotes the number of TB-cases within the immigrant population in <span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2008&#44; and <span class="elsevierStyleItalic">P</span>&#40;<span class="elsevierStyleItalic">t</span>&#41; &#40;resp&#46; <span class="elsevierStyleItalic">E</span>&#40;<span class="elsevierStyleItalic">t</span>&#41;&#44; <span class="elsevierStyleItalic">I</span>&#40;<span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41;&#41; represents the number of Portuguese individuals &#40;resp&#46; emigrants&#44; immigrants&#41; in year <span class="elsevierStyleItalic">t</span> &#40;resp&#46; <span class="elsevierStyleItalic">t</span>&#44; <span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41;&#46; Clearly&#44; <span class="elsevierStyleItalic">P</span>&#40;<span class="elsevierStyleItalic">t</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">E</span>&#40;<span class="elsevierStyleItalic">t</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">I</span>&#40;<span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41; corresponds to the total number of individuals resident in Portugal in year <span class="elsevierStyleItalic">t</span>&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Then&#44; for each year&#44; the expected number was compared with the observed number of TB-cases &#40;including different annual counts for the number of immigrants and TB-cases among immigrants&#41;&#46; The magnitude of the differences allowed for the evaluation of the impact of the immigration process on the TB incidence&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The model evaluating the impact of the emigration on TB in Portugal followed a similar reasoning&#59; keeping both the number of emigrants and the number of TB-cases among emigrants at its 2008 value&#44; the expected number of TB cases for year <span class="elsevierStyleItalic">t</span> per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants was calculated by<elsevierMultimedia ident="eq0010"></elsevierMultimedia>where the number of TB-cases among emigrants in year <span class="elsevierStyleItalic">t</span>&#44; <span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">E</span></span>&#40;<span class="elsevierStyleItalic">t</span>&#41;&#44; assumed the same per-capita rate as <span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">NI</span></span>&#40;<span class="elsevierStyleItalic">t</span>&#41;&#44; namely<elsevierMultimedia ident="eq0015"></elsevierMultimedia></p><p id="par0080" class="elsevierStylePara elsevierViewall">Indeed&#44; had the TB-emigrants in year <span class="elsevierStyleItalic">t</span> stayed in the country and the difference <span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">E</span></span>&#40;<span class="elsevierStyleItalic">t</span>&#41;<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">TB</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">E</span></span>&#40;<span class="elsevierStyleItalic">t</span><span class="elsevierStyleInf">0</span>&#41; would have been accounted for in the total number of cases within national territory&#46; The magnitude of the differences between observed and expected counts allowed for the evaluation of the impact of the emigration process on the TB incidence&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The study of the simultaneous effect of immigration and emigration combined the previous two equations&#46; Under a steady scenario of immigration and emigration&#44; the expected number of TB cases for year <span class="elsevierStyleItalic">t</span> per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants would be<elsevierMultimedia ident="eq0020"></elsevierMultimedia></p><p id="par0090" class="elsevierStylePara elsevierViewall">Finally&#44; the relative annual fluctuations observed within the total number of Portuguese residents were compared with the relative annual decreases in the number of TB-cases&#46; For each variable&#44; the relative annual fluctuation between year <span class="elsevierStyleItalic">t</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 and year <span class="elsevierStyleItalic">t</span> was computed as<elsevierMultimedia ident="eq0025"></elsevierMultimedia></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0095" class="elsevierStylePara elsevierViewall">From 2009 to 2013 there was a steady annual increase in the number of emigrants and essentially a decrease in the number of immigrants&#46; The years 2008 and 2014 have slightly contradicted this trend&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Until 2010&#44; the number of immigrants per year was higher than the number of emigrants&#46; From 2011 to 2014&#44; there was an inversion in the migration flow&#44; and the number of emigrants exceeded the number of immigrants&#44; thus turning the migration balance negative &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The number of TB cases has been consistently decreasing since 2008&#46; Cases occurring in immigrants represented 13&#46;8&#37; of all cases in 2008&#44; 15&#46;2&#37; in 2009 and remained stable at about 16&#37; since 2010&#46; Immigrants have a much higher notification rate of TB than the Portuguese individuals &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Similar to the TB notification rate&#44; the total resident population in Portugal&#44; has essentially decreased over 2008&#8211;2014 &#40;with the exception of a slight increase from 2008 to 2009&#41;&#46; However&#44; the relative annual decrease on the number of residents was lower than the decrease on the TB numbers &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">As shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; from 2008 to 2014 there were relatively few immigrants entering Portugal&#46; Fixing both the immigration rate and the TB rate among immigrants at their 2008 values&#44; and considering the variation on emigration that has actually occurred&#44; we&#8217;ve estimated the number of TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants for each studied year &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46; The differences between the observed and the estimated numbers were residual&#44; ranging from more 0&#46;27 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2010 to less 0&#46;49 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2014&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">On the other hand&#44; emigration rose significantly during the period of study &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#44; which could have influenced the TB rate in the country to go lower&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The official number of TB cases in emigrants leaving the country in 2008 was 4&#46;87&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46; Assuming that this rate remained constant along 2008&#8211;2014 and that the total number of emigrants did not change either along that period&#44; we estimated annual numbers for TB in Portugal&#46; The observed numbers were only slightly higher than their estimates&#46; The differences were even smaller than those found for the immigration impact &#40;&#60;0&#46;1 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">When looking at both migration movements at the same time&#44; the observed TB rate was again identical to the estimated TB rate &#40;differences between less 0&#46;43 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2014 and more 0&#46;28 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2010&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">The number of TB cases has been decreasing in Portugal &#40;notification rate was 27&#46;8&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2008 vs 21&#46;8 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants in 2014&#41;&#46; Since 2009&#44; the resident population has also been decreasing&#44; but at a slower pace&#44; as shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; As for that&#44; the decreasing number of TB cases cannot only be due to the reduction in the resident population&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Between 2008 and 2010&#44; the number of immigrants exceeded the number of emigrants &#40;positive migration balance&#41;&#46; Since 2011 until 2014&#44; migration balance turned negative&#46; Moreover&#44; TB rate has been consistently higher among immigrants compared to the native population &#40;&#62;90 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants vs 18&#46;3&#8211;23&#46;9 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#41;&#46; The percentage of TB cases in this group has risen from 13&#46;2&#37; in 2008 to 15&#46;2&#37; in 2009 and remained at about 16&#37; since 2010&#46; This model allowed us to evaluate the impact of the immigration on the TB rate&#46; It showed that&#44; since 2011&#44; as immigration is decreasing&#44; there is a tendency to a lower number of TB cases&#46; However&#44; the differences are very small&#44; representing less than 1 case per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#44; so the impact does not seem to be significant&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">A decrease in TB incidence has been the trend in the whole WHO European Region over the last years&#44; where it has fallen by 5&#46;2&#37; each year&#44; since 2005&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">5</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Efforts have been made to achieve lower TB rates in Europe&#44; even in low incidence countries&#46; Out of 31 low incidence countries evaluated&#44; more than half &#40;54&#46;8&#37;&#41; reported to have a dedicated national TB programme&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">17</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Despite this global trend and even though we failed to demonstrate a significant impact of the immigration global decrease on TB rate&#44; immigrants are still a risk group as in many of their origin countries&#44; infectious diseases&#44; such as TB&#44; are still an important cause of death and morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">18</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">In low incidence countries&#44; the impact of immigration on the burden of TB has been largely studied&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">10&#44;19-21</span></a> Addressing risk groups is one of the key strategies against TB&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">8&#44;22</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In the recently published action framework of the WHO towards TB elimination in low incidence countries<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">23</span></a> strategies involving migrants are mentioned in three of the eight priority action areas&#58; 1&#41; to address the most vulnerable and hard-to-reach groups&#59; 2&#41; to address special needs of migrants and crossborder issues and 3&#41; to undertake screening for active TB and latent tuberculosis infection &#40;LTBI&#41; in TB contacts and selected high-risk groups&#44; and provide appropriate treatment&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Many efforts have been made to detect TB and LTBI among migrants&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">12</span></a> Some EU countries have implemented screening of migrants before&#44; or at entry&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">24</span></a> Underwood et al&#46; compared contact tracing with new entrant screening in London and found the former to be more effective&#44; as it identifies families and communities at high risk&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">21</span></a> With the recent increase in the number of immigrants coming to Europe as refugees &#40;rising from about 219<span class="elsevierStyleHsp" style=""></span>000 in 2014 to more than one million in 2015&#41;&#44; TB control in this group is also a concern&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">25&#44;26</span></a> Regarding this matter&#44; the ERS&#47;WHO European Region has performed a study in order to document the policies and practices of low and intermediate TB incidence European countries with regards to detection and management of TB and latent TB infection among this vulnerable group&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">26</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In countries where most cases of TB occur in foreign born individuals or where incidence in this group is increasing&#44; despite a decreasing TB rate&#44; as it occurs in Portugal&#44; policies on this subject are of great importance&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">As for the emigration increase over the period of study&#44; our model showed very little differences between the number of observed and expected cases &#40;&#60;0&#46;1 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants each year&#41;&#46; The fact that the differences between observed and expected cases were smaller than those found for the immigration impact can mean that the increase in emigration that we observed over 2008&#8211;2014 has not significantly impact the national TB rate&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">We assumed the TB rate in emigrants to be similar to the TB rate in the Portuguese individuals that stayed in the country&#46; However&#44; we do not know if these individuals had other risk factors for TB or if they became more vulnerable for TB when they moved abroad&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Torres Redondo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">27</span></a> retrospectively analyzed the Portuguese emigrants diagnosed with TB when returning to the country&#44; in the Northern Region in 2014&#46; Most cases &#40;76&#46;3&#37;&#41; had moved to low TB incidence countries and had lived there for more than 2 years &#40;median time of 42&#46;0 months&#41;&#44; which could suggest that exposure to TB could have already occurred in the foreign country&#46; About 67&#37; shared housing with work colleagues&#46; These data suggest that risk for TB might increase when emigrants leave the country as they might experience harder living conditions and economic adversity&#46; Nevertheless&#44; had they stayed in the country they might have been unemployed which also accounts as a risk factor for TB&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Despite the lack of knowledge about this group&#44; our model failed to demonstrate an impact of emigration on TB notification rate&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Individually&#44; the migration movements did not influence TB rate when analyzed by our model&#44; so we tried to look at the impact of both movement altogether&#46; Differences were again very small &#40;&#60;0&#46;5 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabits each year&#41;&#44; so&#44; even when combined&#44; migration movements do not seem to largely influence TB notification rate&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">This might mean that we have to concentrate our efforts in other risk factors&#46; Sousa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">28</span></a> recently found HIV to be the factor with this highest impact&#58; an increase of 10 HIV notifications per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants was associated with a rise of 2 new TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46; Also&#44; an increase of 1000 unemployed subjects per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants was associated with one new case of TB per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">Apart from HIV infection&#44; poor living and working conditions&#44; which can facilitate TB transmission and risk factors that impair host&#39;s defense&#44; like malnutrition&#44; smoking&#44; diabetes&#44; alcohol abuse and indoor air pollution have been pointed out as major determinants&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">29-32</span></a>Silicosis also increases the risk of TB by 2&#46;8&#8211;39 times&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">33&#44;34</span></a> Silico-TB can be a challenging diagnosis and treatment must be longer&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">35</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">Preventive strategies that target these factors might have an important impact on TB burden&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">These risk factors also add to the risk for TB in the migrant population&#46; Paulino et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">13</span></a> found that foreign born patients were more likely to be HIV positive&#44; to be employed&#44; homeless or live in shelters&#46; Reducing HIV infection and providing better living conditions might have an even greater impact on TB among migrants&#46; A study performed in Italy by Ingrosso et al&#46; also showed that HIV infection is three times more frequent in foreign born people affected by TB than among Italians&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">36</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Altogether&#44; these factors represent areas of intervention towards TB elimination and should all be addressed in national and international TB programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">23</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">In this work&#44; the authors tried to understand the impact of two demographic factors &#8211; the migration movements and the decrease in the total number of residents &#8211; on the burden of TB in Portugal over the 7-year period 2008&#8211;2014&#46; As such&#44; other risk factors such as HIV infection&#44; homelessness or overcrowded housing were assumed to remain constant over that period&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">In conclusion&#44; the changing pattern of migration in Portugal over the period of study &#40;2008&#8211;2014&#41; does not seem to have had a significant impact on the TB notification rate&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Authorship</span><p id="par0250" class="elsevierStylePara elsevierViewall">All authors contributed to drafting and review of the manuscript&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interest</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare to have no conflict of interest directly or indirectly related to the manuscript contents&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tuberculosis notification in Portugal has decreased in the last few years&#46; As a consequence of the economic crisis&#44; emigration has increased and immigration has decreased&#46; Immigrants are a risk group for tuberculosis&#46; Most emigrants are 20&#8211;44 years old and belong to the age group most affected by tuberculosis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To describe the decrease in tuberculosis notification in Portugal over the last years from a demographical point of view&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Mathematical analysis was performed to quantify the effect of the migration movements &#40;separately and simultaneously&#41; on tuberculosis notification in Portugal from 2008 to 2014&#46; We calculated the estimated tuberculosis notification for each year during the period of study&#58; 1&#41; fixing immigration rate and tuberculosis rate in immigrants at 2008 values&#59; 2&#41; fixing emigration rate and tuberculosis rate in emigrants at 2008 values&#59; 3&#41; fixing both phenomenons at 2008 values&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The differences between the observed and the estimated numbers were small &#40;&#8804;0&#46;5 cases&#47;100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Impact of the migration movements on tuberculosis notification rate does not seem to be significant when analyzed for each phenomenon individually and simultaneously&#44; by our model&#46; This might mean that we have to concentrate our efforts in other risk factors for tuberculosis&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La notificaci&#243;n de casos de tuberculosis en Portugal ha disminuido en los &#250;ltimos a&#241;os&#46; Como consecuencia de la crisis econ&#243;mica&#44; la emigraci&#243;n ha aumentado y la inmigraci&#243;n ha disminuido&#46; Los inmigrantes son un grupo de riesgo para la tuberculosis&#46; La mayor&#237;a de los emigrantes tienen entre 20 y 44 a&#241;os y pertenecen al grupo de edad m&#225;s afectado por la tuberculosis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Describir la disminuci&#243;n de la notificaci&#243;n de casos tuberculosis en Portugal en los &#250;ltimos a&#241;os&#44; desde un punto de vista demogr&#225;fico&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis matem&#225;tico para cuantificar el efecto de los movimientos migratorios &#40;por separado y simult&#225;neamente&#41; en la notificaci&#243;n de casos de tuberculosis en Portugal de 2008 a 2014&#46; Se calcul&#243; la notificaci&#243;n de casos de tuberculosis estimada para cada a&#241;o durante el per&#237;odo de estudio&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La notificaci&#243;n estimada de tuberculosis para cada a&#241;o del periodo de estudio se calcul&#243;&#58; <span class="elsevierStyleItalic">1&#41;</span> fijando las tasas de inmigraci&#243;n y de tuberculosis en inmigrantes con datos del a&#241;o 2008&#59; <span class="elsevierStyleItalic">2&#41;</span> fijando las tasas de emigraci&#243;n y de tuberculosis en emigrantes con datos del a&#241;o 2008&#44; y <span class="elsevierStyleItalic">3&#41;</span> fijando ambos fen&#243;menos con datos del a&#241;o 2008&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Las diferencias entre los valores observados y los valores estimados fueron peque&#241;as &#40;&#8804; 0&#44;5 casos&#47;100&#46;000 habitantes&#41;&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discusi&#243;n</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Seg&#250;n el modelo matem&#225;tico propuesto en este trabajo&#44; el impacto de los movimientos migratorios en la tasa de notificaci&#243;n de casos de tuberculosis en Portugal no parece ser significativo cuando se analiza cada fen&#243;meno tanto individual como simult&#225;neamente&#46; Estos datos indicar&#237;an que deber&#237;amos concentrar los esfuerzos en identificar otros factores de riesgo para la tuberculosis&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Introducci&#243;n"
          ]
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            "identificador" => "abst0035"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "M&#233;todos"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Discusi&#243;n"
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        ]
      ]
    ]
    "multimedia" => array:11 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">M&#58; male&#59; F&#58; female&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total resident population<br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resident inmigrants<br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Emigrants<br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Immigrants<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">a</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Migration balance<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Portuguese individuals<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">c</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>563<span class="elsevierStyleHsp" style=""></span>014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">440<span class="elsevierStyleHsp" style=""></span>277&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20<span class="elsevierStyleHsp" style=""></span>357&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29<span class="elsevierStyleHsp" style=""></span>718&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9361&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>553<span class="elsevierStyleHsp" style=""></span>653&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>573<span class="elsevierStyleHsp" style=""></span>479&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">454<span class="elsevierStyleHsp" style=""></span>191&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16<span class="elsevierStyleHsp" style=""></span>899&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32<span class="elsevierStyleHsp" style=""></span>307&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15<span class="elsevierStyleHsp" style=""></span>408&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>558<span class="elsevierStyleHsp" style=""></span>071&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>572<span class="elsevierStyleHsp" style=""></span>721&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">445<span class="elsevierStyleHsp" style=""></span>262&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23<span class="elsevierStyleHsp" style=""></span>760&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27<span class="elsevierStyleHsp" style=""></span>575&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3815&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>568<span class="elsevierStyleHsp" style=""></span>906&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>542<span class="elsevierStyleHsp" style=""></span>398&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">436<span class="elsevierStyleHsp" style=""></span>822&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43<span class="elsevierStyleHsp" style=""></span>998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19<span class="elsevierStyleHsp" style=""></span>667&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;24<span class="elsevierStyleHsp" style=""></span>331&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>566<span class="elsevierStyleHsp" style=""></span>729&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>487<span class="elsevierStyleHsp" style=""></span>289&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">417<span class="elsevierStyleHsp" style=""></span>042&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51<span class="elsevierStyleHsp" style=""></span>958&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14<span class="elsevierStyleHsp" style=""></span>606&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;37<span class="elsevierStyleHsp" style=""></span>352&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>524<span class="elsevierStyleHsp" style=""></span>641&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>427<span class="elsevierStyleHsp" style=""></span>301&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">401<span class="elsevierStyleHsp" style=""></span>320&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53<span class="elsevierStyleHsp" style=""></span>786&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17<span class="elsevierStyleHsp" style=""></span>554&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;36<span class="elsevierStyleHsp" style=""></span>232&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>463<span class="elsevierStyleHsp" style=""></span>533&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>374<span class="elsevierStyleHsp" style=""></span>822&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">395<span class="elsevierStyleHsp" style=""></span>195&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49<span class="elsevierStyleHsp" style=""></span>572&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19<span class="elsevierStyleHsp" style=""></span>516&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;30<span class="elsevierStyleHsp" style=""></span>056&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10<span class="elsevierStyleHsp" style=""></span>404<span class="elsevierStyleHsp" style=""></span>878&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1631791.png"
              ]
            ]
          ]
          "notaPie" => array:3 [
            0 => array:3 [
              "identificador" => "tblfn0045"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Immigrants entering the country each year&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Migration balance&#58; immigrants<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>emigrants&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Portuguese individuals<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>total resident population<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>emigrants<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>immigrants&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Migration Movements&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at2"
            "detalle" => "Table "
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        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">M&#58; male&#59; F&#58; female&#59; TB&#58; tuberculosis&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TB cases<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TB rate<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TBPI<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">c</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TBPI rate<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TBI<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">e</span></a><br><span class="elsevierStyleItalic">N</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; TBI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TBI rate<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TB cases missing origin<br><span class="elsevierStyleItalic">N</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2967&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2523&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">410&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;1&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2869&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2432&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">437&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2714&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2273&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">438&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2609&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2203&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">404&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2606&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2176&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">408&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;0&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2399&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1989&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">393&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;0&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2264&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1904&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">357&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;0&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">As documented in SVIG-TB&#59; includes the cases for which the country of origin is missing&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0020"
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            2 => array:3 [
              "identificador" => "tblfn0025"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">TBPI&#58; TB cases in Portuguese individuals<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>TB cases<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>TB cases in immigrants<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>TB cases with missing origin&#46;</p>"
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            3 => array:3 [
              "identificador" => "tblfn0030"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0035">TBPI rate&#58; TBPI cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants&#46;</p>"
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            4 => array:3 [
              "identificador" => "tblfn0035"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0040">TBI&#58; TB cases in immigrants&#46;</p>"
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            5 => array:3 [
              "identificador" => "tblfn0040"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0045">TBI rate&#58; TBI cases per 100<span class="elsevierStyleHsp" style=""></span>000 resident immigrants&#46;</p>"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Tuberculosis Numbers&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Resident population decrease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tuberculosis cases decrease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2009&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2010&#8211;2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2011&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2012&#8211;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;08&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2013&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">O&#58; observed&#59; E&#58; expected&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Observed number of TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 in inhabitants &#40;O&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Expected TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 inhabitants &#40;E&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">O<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;89&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#46;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;03&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8722;0&#46;49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "tabla" => array:2 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Observed number of TB cases per 100<span class="elsevierStyleHsp" style=""></span>000 in inhabitants &#40;O&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">O<span class="elsevierStyleHsp" style=""></span>&#8722;<span class="elsevierStyleHsp" style=""></span>E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;77&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&#46;64&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#46;64&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;71&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&#46;62&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22&#46;82&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;02&nbsp;\t\t\t\t\t\t\n
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0260" class="elsevierStylePara elsevierViewall">Rita Gaio was partially supported by <span class="elsevierStyleGrantSponsor" id="gs1">CMUP</span> &#40;<span class="elsevierStyleGrantNumber" refid="gs1">UID&#47;MAT&#47;00144&#47;2013</span>&#41;&#44; which is funded by <span class="elsevierStyleGrantSponsor" id="gs2">FCT</span> &#40;Portugal&#41; with national &#40;<span class="elsevierStyleGrantSponsor" id="gs3">MEC</span>&#41; and European structural funds &#40;<span class="elsevierStyleGrantSponsor" id="gs4">FEDER</span>&#41;&#44; under the partnership agreement PT2020&#46;</p> <p id="par0265" class="elsevierStylePara elsevierViewall">This work was supported by the contribution of Iceland&#44; Liechtenstein and Norway&#44; through the <span class="elsevierStyleGrantSponsor" id="gs5">EEA</span> Grants&#44; under the Public Health Initiatives Programme &#40;PT 06&#41;&#44; grant number <span class="elsevierStyleGrantNumber" refid="gs5">138DT1</span>&#46;</p>"
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Article information
ISSN: 03002896
Original language: English
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