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Outbreak of Multidrug-resistant Tuberculosis in Two Secondary Schools
Brote de tuberculosis multirresistente en dos colegios de educación secundaria
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Bilateral cavitating infiltrate in right upper lobe.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In the 1980s, the emergence of HIV/AIDS led to a dramatic increase in the incidence of tuberculosis, primarily in countries with fewer resources, initially sub-Saharan Africa, followed several years later by south-east Asia. In 1993, the World Health Organization (WHO) declared tuberculosis to be a global health emergency.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Epidemics of multi-drug resistant tuberculosis (MDR-TB), defined as <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> infection resistant to isoniazid and rifampicin, were first described in the United States and Europe at the beginning of the 90s. MDR-TB occurs mainly in HIV-infected patients, the transmission pattern is explosive, attack rates are high and incubation periods are short due to the immunosuppressed status of the host and the lack of adequate preventive measures against tuberculosis transmission in hospitals and penitentiary institutions affected by these outbreaks. Healthcare personnel are not exempt from risk.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In 1994, the WHO, together with the International Union against Tuberculosis and Lung Disease, set up their Surveillance of Drug Resistance in Tuberculosis program. Until then, drug resistance had been a minor problem, usually related with poor treatment adherence, and primary multi-drug resistance was very rare.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Poverty, overpopulation, lack of economic resources for obtaining second-line drugs, the absence of effective programs for the management of tuberculosis, the HIV epidemic, and moving populations; all are reasons for the appearance and international dissemination of multi-resistant strains of <span class="elsevierStyleItalic">M. tuberculosis.</span> This has become a worldwide health problem, but one that is unequally distributed – countries such as Brazil, China, India, the Russian Federation, and South Africa are much more severely affected.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Confirmation of diagnosis in a patient with suspected MDR-TB and the considerable delay in starting treatment was an additional problem, since cultures and sensitivity studies had to be performed. This particularly affected the start of second-line treatment.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">6</span></a> The situation has improved, thanks to new techniques that detect <span class="elsevierStyleItalic">M. tuberculosis</span> DNA in respiratory specimens, allowing the diagnosis and detection of isoniazid and/or rifampicin resistance in a matter of hours.<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Tuberculosis epidemics in schools are not uncommon, and when they occur, contact tracing is essential to diagnose secondary cases, to initiate prompt treatment of patients and carriers who require it, and to identify the real index case.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">This is a description of an outbreak of MDR-TB in a school setting and the difficulties we encountered in managing both patients with disease and carriers.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">We conducted an observational, prospective study of an MDR-TB outbreak detected in November 2008 in 2 schools in Onda (O) and Nules (N) in the province of Castellón (Spain). A microepidemic or epidemic outbreak was defined as the appearance of 3 or more cases of tuberculosis related in space and time, or the diagnosis of at least 2 patients generated by the same index case.<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The index case was the first patient diagnosed, and the source case, or real index case, was the patient who was most likely to be the origin of the outbreak. A contact was any person who had shared enclosed spaces with a tuberculosis carrier.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After the index case was detected, contact tracing was performed, in accordance with previously published guidelines,<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">9,10</span></a> using the concentric circles or “stone-in-the-water” model.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The Castellón Public Health Center worked with the health centers in O and N to coordinate contact tracing in the 2 schools in which the index case was employed as a teacher, and among family members. They were also responsible for providing information to the parents of pupils at the school.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Tuberculin testing was performed using the Mantoux technique with 2TU PPD RT 23.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Latent tuberculosis infection was defined as a positive Mantoux test with a 5<span class="elsevierStyleHsp" style=""></span>mm induration at 72<span class="elsevierStyleHsp" style=""></span>h. An initial Mantoux test was performed and repeated 2 months later in cases which were initially negative. Individuals aged over 50 years with a negative result repeated the test 7 days later, to determine the booster effect.</p><p id="par0070" class="elsevierStylePara elsevierViewall">All individuals with a positive Mantoux test had a chest X-ray.</p><p id="par0075" class="elsevierStylePara elsevierViewall">If mycobacteria were cultured, the intraspecific differentiation was identified using restriction fragment length polymorphism (RFLP) analysis of the IS6110 sequence.<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Statistical Analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">Tuberculosis infection and disease attack rates were estimated in contacts and compared using Chi-squared and Fisher statistical tests in the different risk groups. Odds ratio (OR) was used to estimate the association between contacts according to exposure to MDR-TB cases and the 95% confidence interval was calculated. <span class="elsevierStyleItalic">P</span>-values <.05 were considered significant and the Epi-info program version 5 was used for all statistical calculations.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Contact Tracing</span><p id="par0085" class="elsevierStylePara elsevierViewall">The index case taught second year secondary pupils (10<span class="elsevierStyleHsp" style=""></span>h a week) in school O. The previous year he had taught first year pupils. The 2 secondary cases also taught all year grades in school O; their pupils were aged between 11 and 15 years.</p><p id="par0090" class="elsevierStylePara elsevierViewall">After detecting 3 cases among the teachers, we decided to include all pupils, teachers, and non-teaching staff in the contact tracing. A total of 205 of the 207 secondary school pupils (99%) and 200 of the 205 primary and infant school pupils (97.5%) participated. There was a significant increase in positive Mantoux tests between the 1st year and 4th year of secondary school (<span class="elsevierStyleItalic">P</span><.001).</p><p id="par0095" class="elsevierStylePara elsevierViewall">The index case also taught first and third year secondary school pupils in school N (4<span class="elsevierStyleHsp" style=""></span>h a week). All exposed cases participated (93/93, 100%) in contact tracing, including all the pupils that case 1 had taught the previous year. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results from the pupils of both schools.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">No significant differences were observed in the risk of developing infection among secondary pupils at both schools [OR 0.63 (95% CI 0.28–1.42), <span class="elsevierStyleItalic">P</span>=.223]; nor was any significant difference observed when pupils attending classes given by the index case were examined separately [OR 0.51 (95% CI 0.15–1.66), <span class="elsevierStyleItalic">P</span>=.22].</p><p id="par0105" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of all contacts that were studied.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">If we compare the risk of infection among teachers from both schools, teachers at school O show a higher risk [OR 3.43 (95% CI 0.76–17.48) <span class="elsevierStyleItalic">P</span>=.069], probably due to greater exposure. It is interesting to note that none of the 3 teachers who contracted the disease had received BCG vaccination, and if vaccinated contacts (10) are compared to unvaccinated contacts (21), the OR of developing the disease is 0.51 (95% CI 0.0–5.13). This difference is not statistically significant (<span class="elsevierStyleItalic">P</span>=.59), but it may indicate some protective effect from vaccination. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> compares the results in cases exposed and not exposed to MDR-TB cases. The OR of contracting infection was 6.12 (95% CI 2.58–17.59), which is statistically significant (<span class="elsevierStyleItalic">P</span><.001). The overall rate of disease attack was 0.9% and rate of infection 14.4%.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">Chemoprophylaxis with isoniazid was initially recommended. When isolation of multi-resistant <span class="elsevierStyleItalic">M. tuberculosis</span> was confirmed, adults discontinued isoniazid, but children continued to receive it for another 6 months, after their parents were informed. Clinical and radiological follow-up was recommended for at least 2 years.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Description of Cases</span><p id="par0120" class="elsevierStylePara elsevierViewall">Five cases of MDR-TB were diagnosed. Their clinical characteristics are described in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. It is interesting to observe that the delay in obtaining a microbiological diagnosis in the first case was 4 months, while for the last case, results were received within 72<span class="elsevierStyleHsp" style=""></span>h. This improvement is associated with the introduction of polymerase chain reaction (PCR) techniques in respiratory samples in the reference hospital. In the index case, or case 1, the delay in diagnosis was confounded by an initial interpretation of community-acquired pneumonia (see chest X-ray in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Microbiology</span><p id="par0125" class="elsevierStylePara elsevierViewall">All <span class="elsevierStyleItalic">M. tuberculosis</span> isolates obtained from study patients were tested for sensitivity to first-line drugs in the reference laboratory (Hospital General de Castellón). Any strains showing resistance to any drugs were sent to the Carlos III Health Institute in Madrid for further sensitivity studies, and to the Genetics Laboratory of the University of Zaragoza for molecular characterization by RFLP analysis of the IS6100 sequence. Strains with at least 5 copies of the IS6001 sequence were analyzed using spoligotyping. This technique is less discriminative, but it identifies polymorphism in the DR region, containing direct repetitions separated by spacer sequences, which have a wide variability that is used to obtain different hybridization patterns.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Individuals infected with the same strain are included in a cluster. An <span class="elsevierStyleItalic">M. tuberculosis</span> cluster is defined as 2 or more strains whose RFLP patterns reveal an identical number and position of the IS6110 sequence, when there are 5 or more copies, or else 5 copies of identical molecular weight and identical spoligotyping pattern. All our cases had the same spoligotyping pattern, so we could relate them and determine that it was a single strain that had caused the outbreak.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Treatment</span><p id="par0135" class="elsevierStylePara elsevierViewall">When case 4 was diagnosed, this was the first time an <span class="elsevierStyleItalic">M. tuberculosis</span> strain had been isolated in our province. The patient did not present any risk factors for MDR-TB, so she started treatment with ethambutol (25<span class="elsevierStyleHsp" style=""></span>mg/kg), moxifloxacin (400<span class="elsevierStyleHsp" style=""></span>mg/day), prothionamide (15<span class="elsevierStyleHsp" style=""></span>mg/kg, up to 1<span class="elsevierStyleHsp" style=""></span>g/day), and capreomycin 1<span class="elsevierStyleHsp" style=""></span>g intramuscularly 5 days a week until acid-fast bacilli sputum smear became negative, for a period of 18 months. When new cases appeared, we suspected and subsequently confirmed that they were caused by the same strain. The satisfactory clinical and microbiological progress of our patient led us to prescribe the same regimen. Side effects included mild gastrointestinal symptoms, and only case 4 developed severe toxic hepatitis, 10 months after starting treatment. Prothionamide was withdrawn and replaced with cycloserine (15<span class="elsevierStyleHsp" style=""></span>mg/kg, up to 1<span class="elsevierStyleHsp" style=""></span>g/day). The patient completed treatment without incidents after 22 months. All patients achieved a negative sputum culture 4 months into treatment.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">A tuberculosis outbreak in a school setting is a situation of particular concern for public health,<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">13–15,19,20</span></a> but outbreaks have also been described in churches,<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a> bars,<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">17</span></a> buses,<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a> and even in healthcare centers.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2–4</span></a> In this article, we report an outbreak in 2 schools, which was complicated by the fact that it was caused by a multiresistant strain of <span class="elsevierStyleItalic">M. tuberculosis</span>. Schools are an environment in which outbreaks are likely to occur: contact is continuous, classrooms are poorly ventilated, and diagnosis is delayed.<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">19–21</span></a> In countries with high prevalence of MDR-TB, outbreaks in schools are common.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">21</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Case 4 deserves particular attention, since she was diagnosed 1 year before the school outbreak; she presented no risk factors for MDR-TB,<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">22</span></a> having never traveled to countries with high rates of multiresistant strains. This was the first case in our province,<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a> and there was a considerable delay (4 months) in diagnosis before definitive results were received from the reference laboratory. The patient had had contact with case 1, but case 1 could not attend the contact tracing visit. This underlines the importance of well-designed anti-tuberculosis programs,<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">9,10</span></a> since an earlier diagnosis of case 1 may have prevented the outbreak. The index case had done voluntary work in Colombia for 2 summers, and we believe that he may have been infected there. Case 1 infected case 4, and subsequently triggered the school outbreak, so case 1 is considered as the source or real index case. Diagnosis of case 1 was delayed by 2 months, which meant that the schoolchildren and teaching staff started chemoprophylaxis treatment with isoniazid. When drug sensitivity study results were received, isoniazid had to be discontinued. A meeting was held with the parents, and we explained that, in multiresistant cases, no effective drug was available to prevent the infection from developing to tuberculous disease.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a> This generated great anxiety and concern, so after several meetings coordinated by the Public Health Center, we decided to continue clinical and radiological monitoring for at least 2 years in Mantoux-positive cases, as indicated in the guidelines.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a> We offered optional isoniazid, being the less toxic choice in children, in view of the possibility that individuals may be infected with sensitive strains. Perhaps the follow-up period should have been extended, since case 5 was diagnosed after 3 years. Very few studies have been published that confirm the efficacy of treating latent MDR-TB infection, but adverse events do seem to be an issue.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a> Attamma et al. followed up 476 contacts of patients with MDR-TB over a mean duration of 6 years. Patients received isoniazid or a combination of ciprofloxacin and pyrazinamide, and 387 received no treatment. They did not detect any case of MDR-TB, thus supporting the clinical monitoring approach.<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a> The situation has changed since then, since effective chemoprophylaxis with fluoroquinolones has been reported in studies following MDR-TB cases for periods of up to 12 months.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">26</span></a> However, reluctance to use fluoroquinolones in children and teenagers persists, in view of their adverse effects on growing cartilage.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The rate of infection among exposed cases was 14.4%. This is relatively low, compared to other reports of 30%–100% in school outbreaks caused by sensitive <span class="elsevierStyleItalic">M. tuberculosis</span>.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">14,15</span></a> The same is true of the 0.9% rate of disease, which is much lower than other reported MDR-TB outbreaks that were highly explosive, probably due to co-infection with HIV.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2–4</span></a> Kritski et al.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">27</span></a> also reported a rate of 8% in a contact tracing study in MDR-TB, and higher rates have also been reported in school outbreaks of <span class="elsevierStyleItalic">M. tuberculosis</span>.<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">14,15</span></a> This finding concurs with the observation that multiresistant strains cause less secondary cases than sensitive strains,<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">28</span></a> but for epidemiological purposes, we cannot assume that multiresistant strains are less infectious or less virulent than sensitive strains.<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">29</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In our study, the BCG vaccine conferred some protective effect among teachers, as previously noted by Kritski et al.<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">27</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">After diagnosis, treatment was started and cases were closely monitored in monthly clinical check-ups with blood tests and sputum studies, since patients on second-line drugs often encounter toxicity and need encouragement to comply.<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">30,31</span></a> All patients achieved a negative sputum culture within 4 months of starting treatment, and no relapses have been seen to date. This is probably because our patients were immunocompetent, non-HIV carriers, and had a good prognosis for treatment.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">21,32</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">A very important aspect of the study of outbreaks is genotyping of the causative strains. This information may help determine transmission mechanisms and determine if the disease is due to endogenous reactivation or exogenous reinfection, if it is found to be caused by more than 1 strain of <span class="elsevierStyleItalic">M. tuberculosis</span>. Genotyping of a strain is also a starting point for retrospective contact tracing.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">2,14,33–35</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">One limitation of our study is that we could not characterize latent tuberculous infection with interferon gamma release assays (IGRAS), which would have provided greater specificity to Mantoux reactions and tuberculin conversions.</p><p id="par0175" class="elsevierStylePara elsevierViewall">To conclude, we report the first outbreak of MDR-TB in a school setting in Spain. A meticulous study of cases and contacts is crucial, and these individuals must be followed up closely and clearly informed, as the situation can generate considerable anxiety. As globalization continues, we can expect to encounter more tuberculosis caused by multiresistant strains. New technologies must be put to work to provide rapid diagnoses and to guide the right therapeutic intervention.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Contribution of the Authors</span><p id="par0180" class="elsevierStylePara elsevierViewall">Dr. Miravet contributed to the follow-up of cases, data acquisition, analysis and interpretation, manuscript preparation and the review of the final version submitted for evaluation; Dr. García participated in the follow-up of cases and the review of the final version submitted for evaluation; Dr. Arnedo participated in contact tracing, data acquisition and interpretation, manuscript preparation and the review of the final version submitted for evaluation; Dr. Bellido participated in contact tracing, data analysis and interpretation, and the review of the final manuscript submitted for evaluation; Dr. Romeu contributed to contact tracing and the review of the final manuscript submitted for evaluation; Dr. Gil contributed to the microbiological study and the review of the final manuscript submitted for evaluation; Dr. Cortés participated in the follow-up of cases, and contributed to the review of the final manuscript submitted for evaluation.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of Interests</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres600713" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec614916" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres600712" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec614915" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical Analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Contact Tracing" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Description of Cases" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Microbiology" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Treatment" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Contribution of the Authors" ] 9 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of Interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-01-21" "fechaAceptado" => "2015-03-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec614916" "palabras" => array:4 [ 0 => "Multidrug-resistant tuberculosi" 1 => "Outbreak" 2 => "Schools" 3 => "Spoligotyping" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec614915" "palabras" => array:4 [ 0 => "Tuberculosis multirresistente" 1 => "Brote" 2 => "Colegio" 3 => "Spoligotyping" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe an outbreak of multidrug-resistant tuberculosis (MDR-TB) in two schools.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a prospective, observational study of an outbreak of MDR-TB in 2 schools located in the towns of Onda and Nules, in the Spanish province of Castellon, from the moment of detection in November 2008 until November 2014, including patient follow-up and contact tracing.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Five cases of MDR-TB were diagnosed. Overall attack rate was 0.9%, and among the contacts traced, 66 had latent tuberculous infection, with an infection rate of 14.4%. Molecular characterization of the 5 <span class="elsevierStyleItalic">M. tuberculosis</span> isolates was performed by restriction fragment length polymorphism (RFLP) analysis of the IS6110 sequence. In all 5 patients, cultures were negative at 4-month follow-up, showing the efficacy of the treatment given. No recurrence has been reported to date.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In the context of globalization and the increased prevalence of MDR-TB, outbreaks such as the one presented here are only to be expected. Contact tracing, strict follow-up of confirmed cases, the availability of fast diagnostic techniques to avoid treatment delay, and chemoprophylaxis, together with the molecular characterization of strains, are still essential.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Descripción de un brote de tuberculosis multirresistente (TB-MDR) en el medio escolar.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se ha realizado un estudio prospectivo y observacional de un brote de TB-MDR en 2 colegios de Onda y de Nules de educación secundaria, en la provincia de Castellón, desde su detección en noviembre de 2008 hasta noviembre de 2014, con seguimiento de los casos y estudio de los contactos.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se diagnosticaron 5 casos de TB-MDR, con una tasa global de ataque de la enfermedad del 0,9% y en el estudio de contactos se detectaron 66 con infección latente tuberculosa, con una tasa de infección del 14,4%. Los 5 aislamientos de <span class="elsevierStyleItalic">M. tuberculosis</span> se estudiaron mediante el análisis del polimorfismo de los fragmentos de restricción (RFLP) de la secuencia IS6110 para su caracterización molecular. En los 5 pacientes el cultivo se negativizó a los 4 meses, demostrando la eficacia del tratamiento pautado, sin recaídas hasta la actualidad.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Con la actual globalización y el aumento de la TB-MDR no es extraño la presentación de un brote como el que presentamos y sigue siendo fundamental el estudio de los contactos, el seguimiento estricto de los casos y la disponibilidad de las técnicas de diagnóstico para no demorar el inicio del tratamiento y la quimioprofilaxis, así como la caracterización molecular de las cepas.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sorribes LM, Pena AA, Blasco JBB, García MAR, Fortuño MG, Sidro PG, et al. Brote de tuberculosis multirresistente en dos colegios de educación secundaria. Arch Bronconeumol. 2016;52:70–75.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 805 "Ancho" => 995 "Tamanyo" => 86460 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray of case 1. Bilateral cavitating infiltrate in right upper lobe.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">1: Classes taught by the index case in school O (2nd year) and N (1st and 3rd years).</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">2: Classes taught by the secondary cases; all years in school O.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">*: tuberculin conversion.</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">School Grade \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">School O Positive \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">Negative \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">Attack Rate (%) \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">School N Positive \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">Negative \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">Attack Rate (%) \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"><span class="elsevierStyleItalic">P</span>-value \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="left" valign="top">1st year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.6 (1–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.5% (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">2nd year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.2 (1–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (*1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">3rd year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (*1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.4 (1–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (*1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.1 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">4th year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (*3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.7 (1–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.7 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">185 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.8 (1–2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.42 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982800.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Comparison of Mantoux Reaction and Tuberculin Conversion in Schoolchildren in Secondary Schools O and N.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">MDR-TB, multiresistant tuberculosis; NTP, non-teaching personnel.</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="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mantoux (+)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Conversion</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Total Mantoux (+)</th><th class="td" title="table-head " align="left" valign="top" scope="col">MDR-TB \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">MDR-TB \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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"><span class="elsevierStyleItalic">n</span> \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">(%) \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"><span class="elsevierStyleItalic">n</span> \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">(%) \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"><span class="elsevierStyleItalic">n</span> \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">(%) \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"><span class="elsevierStyleItalic">n</span> \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">% \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="left" valign="top"><span class="elsevierStyleItalic">Family and friends</span><span class="elsevierStyleItalic">n: 44</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">State language school</span><span class="elsevierStyleItalic">n: 24</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top"><span class="elsevierStyleItalic">School O</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Primary and infants<span class="elsevierStyleItalic">n</span>: 200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Secondary<span class="elsevierStyleItalic">n</span>: 205 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Teachers and NTP<span class="elsevierStyleItalic">n</span>: 53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top"><span class="elsevierStyleItalic">School N</span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Secondary<span class="elsevierStyleItalic">n</span>: 93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Teachers and NTP<span class="elsevierStyleItalic">n</span>: 24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="9" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Total 643</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982801.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Overall Results from Study of Contacts and Cases of MDR-TB.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">NTP, non-teaching personnel.</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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Exposed Positives \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">Negatives \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">Not Exposed Positives \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">Negatives \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="left" valign="top">Pupils \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">266 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">199 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Teachers and NTP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Family and friends \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">State language school \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">358 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">219 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982799.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Comparison of Mantoux Reaction and Tuberculin Conversion in Individuals Exposed and Not Exposed to MDR-TB Cases.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Case 1 \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">Case 2 \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">Case 3 \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">Case 4 \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">Case 5 \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="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Woman \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Man \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Mantoux \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sputum smear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Positive \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Positive \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Activity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Teacher \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Teacher \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Teacher \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pupil \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Date of diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11/2008 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">01/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">03/2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11/2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">07/2012 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982798.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Clinical Characteristics of Cases of Multiresistant Tuberculosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0180" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "WHO declares tuberculosis a global emergency" ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Soz Praventivmed" "fecha" => "1993" "volumen" => "38" "paginaInicial" => "251" "paginaFinal" => "252" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8212917" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0185" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hospital outbreak of multidrug-resistant <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> infections. Factors in transmission to staff and HIV-infected patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Beck-Sague" 1 => "S.W. Dooley" 2 => "M.D. Hutton" 3 => "J. Otten" 4 => "A. Breedu" 5 => "J.T. Crawford" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "1992" "volumen" => "268" "paginaInicial" => "1280" "paginaFinal" => "1286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1507374" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0190" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An outbreak of multidrug-resistant tuberculosis among hospitalized patients with acquired immunodeficiency syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.R. Edlin" 1 => "J.I. Tokars" 2 => "M.H. Grieco" 3 => "J.T. Crawford" 4 => "J. Williams" 5 => "E.M. Sordillo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "N Engl J Med" "fecha" => "1992" "volumen" => "236" "paginaInicial" => "1514" "paginaFinal" => "1521" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0195" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multidrug-resistant tuberculosis outbreak on an HIV ward Madrid, Spain, 1991–1995" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "Centers for Disease Control and Prevention (CDC)" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "MMWR Morb Mortal Wkly Rep" "fecha" => "1996" "volumen" => "45" "paginaInicial" => "330" "paginaFinal" => "333" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8602134" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0200" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multidrug-resistant tuberculosis around the world: what progress has been made?" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Falzan" 1 => "F. Mirzayev" 2 => "F. Wares" 3 => "I. Garcia" 4 => "M. Zignol" 5 => "N. Linh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00101814" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2014" "volumen" => "45" "paginaInicial" => "150" "paginaFinal" => "160" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25261327" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0205" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment of multidrug-resistant tuberculosis: evidence and controversies" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.A. Caminero" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Tuberc Lung Dis" "fecha" => "2006" "volumen" => "10" "paginaInicial" => "829" "paginaFinal" => "837" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16898365" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0210" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rapid molecular detection of tuberculosis and rifampin resistance" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Boehme" 1 => "P. Nabeta" 2 => "D. Hillermann" 3 => "M. Nicol" 4 => "S. Shenai" 5 => "F. Krapp" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa0907847" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2010" "volumen" => "363" "paginaInicial" => "1005" "paginaFinal" => "1015" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20825313" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0215" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical efficacy of direct DNA secuencing analysis on sputum specimens for early detection of drug-resistant mycobacterium tuberculosis in a clinical setting" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.H. Choi" 1 => "K. Lee" 2 => "H.R. Kang" 3 => "Y. Hwang" 4 => "S.H. Jang" 5 => "D.G. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.09-0150" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2010" "volumen" => "137" "paginaInicial" => "393" "paginaFinal" => "400" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19741059" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0220" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Documento de consenso sobre el estudio de contactos en los pacientes tuberculosos: Grupo de estudio de contactos de la Unidad de Investigación en Tuberculosis de Barcelona" ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "1999" "volumen" => "112" "paginaInicial" => "151" "paginaFinal" => "156" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0225" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnóstico y tratamiento de la tuberculosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Ruiz" 1 => "R. Blanquer" 2 => "J.L. Calpe" 3 => "J.A. Caminero" 4 => "J. Caylá" 5 => "J. Dominguez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2008" "volumen" => "44" "paginaInicial" => "551" "paginaFinal" => "566" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19006636" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0230" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microepidemics of tuberculosis: the Stone in the pond principle" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Veen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Tuberc Lung Dis" "fecha" => "1992" "volumen" => "73" "paginaInicial" => "73" "paginaFinal" => "76" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0235" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Usefulness of spoligotyping to discriminate IS6110 low-copy-number mycobacterium tuberculosis complex strains cultured in Denmark" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Bauer" 1 => "A.B. Andersen" 2 => "K. Kremer" 3 => "H. Miörner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Clin Microbiol" "fecha" => "1999" "volumen" => "37" "paginaInicial" => "2602" "paginaFinal" => "2606" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10405409" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0240" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Estudio de los brotes de tuberculosis que han generado informes epidemiológicos en Cataluña (1998–2002)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.M. Bran" 1 => "J.A. Caylá" 2 => "A. Domínguez" 3 => "N. Camps" 4 => "P. Godoy" 5 => "A. Orcau" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Bonconeumol" "fecha" => "2006" "volumen" => "42" "paginaInicial" => "260" "paginaFinal" => "266" ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0245" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microepidemias de tuberculosis en 5 brotes escolares: importancia de la tipificación genética de las cepas en su evaluación e interpretación" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. Marcos" 1 => "D. Díaz" 2 => "I. Ursua" 3 => "M. Fernández-Albalat" 4 => "H. Verea" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2007" "volumen" => "43" "paginaInicial" => "611" "paginaFinal" => "616" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17983545" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0250" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brote de tuberculosis en un colegio de primaria: descripción y consideraciones sobre el valor de jugo gástrico en el manejo de microepidemias" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Tagarro" 1 => "S. Jiménez" 2 => "A. Sánchez" 3 => "A. Arroyo" 4 => "J. Aracil" 5 => "A. Cañete" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Enferm Infec Microbiol Clin" "fecha" => "2011" "volumen" => "29" "paginaInicial" => "90" "paginaFinal" => "95" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0255" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outbreak of tuberculosis in a church" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.K. Dutt" 1 => "J.B. Metha" 2 => "B.J. Whitaker" 3 => "H. Westmoreland" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1995" "volumen" => "107" "paginaInicial" => "447" "paginaFinal" => "452" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7842776" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0260" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outbreak of tuberculosis among regular patrons of a neighborhood bar" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.E. Kline" 1 => "L.L. Hedemark" 2 => "S.F. Davies" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199507273330404" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "1995" "volumen" => "333" "paginaInicial" => "222" "paginaFinal" => "227" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7791838" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0265" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Exposición a Mycobacterium tuberculosis durante un viaje en autobús" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Extremera Montero" 1 => "R. Moyano Acost" 2 => "B. Gómez Pozo" 3 => "P. Bermúdez Ruiz" 4 => "J. López Méndez" 5 => "S. Aguilar Rivas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2001" "volumen" => "116" "paginaInicial" => "182" "paginaFinal" => "185" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0270" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Community-based outbreaks of tuberculosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. Raffalh" 1 => "K.A. Sepkowitz" 2 => "D. Amstrong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Inter Med" "fecha" => "1996" "volumen" => "156" "paginaInicial" => "1053" "paginaFinal" => "1060" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0275" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of a tuberculosis outbreak in a rural Missouri high school" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Phillips" 1 => "J. Carlile" 2 => "D. Smith" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatrics" "fecha" => "2004" "volumen" => "113" "paginaInicial" => "514" "paginaFinal" => "519" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0280" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conglomerado de casos de tuberculosis multidrogorresistente en un colegio del distrito de Ica, Perú" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Torres" 1 => "V. Sardón" 2 => "M.G. Soto" 3 => "R. Anicama" 4 => "H. Arroyo-Hernández" 5 => "C.V. Munayco" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Perú Med Exp Salud Pública" "fecha" => "2011" "volumen" => "28" "paginaInicial" => "497" "paginaFinal" => "502" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22086631" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0285" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for multidrug resistant tuberculosis in Europe: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Fanstini" 1 => "D.J. Hall" 2 => "C.A. Perucci" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2005.045963" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2006" "volumen" => "61" "paginaInicial" => "158" "paginaFinal" => "163" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16254056" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0290" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Evolución de las resistencias a <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> en la provincia de Castellón. Años 1992–1998" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Marin" 1 => "F. Gonzalez" 2 => "R. Moreno" 3 => "F. Pardo" 4 => "P. Prada" 5 => "A. Arnedo" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2000" "volumen" => "36" "paginaInicial" => "551" "paginaFinal" => "556" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11149197" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0295" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adverse event associated with pirazinamide and levofloxacin in the treatment of latent multidrug-resistand tuberculosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. Papartavros" 1 => "L.R. Dolovich" 2 => "A. Holbrook" 3 => "L. Witehead" 4 => "M. Loeb" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "CMAJ" "fecha" => "2002" "volumen" => "167" "paginaInicial" => "131" "paginaFinal" => "136" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12160118" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0300" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of tuberculosis in close contacts of patients with multidrug-resistant tuberculosis: a nation wide cohort" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Attamma" 1 => "D. Chemtob" 2 => "S. Attamma" 3 => "A. Fraser" 4 => "E. Rosman" 5 => "M. Paul" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2008.100974" "Revista" => array:5 [ "tituloSerie" => "Thorax" "fecha" => "2009" "volumen" => "64" "paginaInicial" => "271" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19252032" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0305" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment for LIBI in contacts of MDR-TB patients, Federated States of Micronesia, 2009–2012" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Bamrah" 1 => "R. Brostrom" 2 => "F. Dorina" 3 => "L. Setik" 4 => "R. Song" 5 => "L.M. Kawamura" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.5588/ijtld.13.0028" "Revista" => array:6 [ "tituloSerie" => "Int J Tuberc Lung Dis" "fecha" => "2014" "volumen" => "18" "paginaInicial" => "912" "paginaFinal" => "918" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25199004" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0310" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transmision of tuberculosis to close contacts of patients with multidrug-resistant tuberculosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.C. Kritski" 1 => "M.J. Marques" 2 => "M.F. Rabahi" 3 => "M.A. Vieira" 4 => "E. Wernec-Barroso" 5 => "C.E. Carvalho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.153.1.8542139" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "1996" "volumen" => "153" "paginaInicial" => "331" "paginaFinal" => "335" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8542139" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0315" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of drug resistance on the generation of secondary cases of tuberculosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Burgos" 1 => "K. DeRiemer" 2 => "P.M. Small" 3 => "P.C. Hopewell" 4 => "C.L. Daley" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/379895" "Revista" => array:6 [ "tituloSerie" => "J Infect Dis" "fecha" => "2003" "volumen" => "188" "paginaInicial" => "1878" "paginaFinal" => "1884" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14673768" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0320" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The epidemiological fitness cost of drug resistance in <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "F. Luciani" 1 => "S.A. Sisson" 2 => "H. Jiang" 3 => "A.R. Francis" 4 => "M.M. Tanaka" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1073/pnas.0902437106" "Revista" => array:6 [ "tituloSerie" => "Proc Natl Acad Sci U S A" "fecha" => "2009" "volumen" => "106" "paginaInicial" => "14711" "paginaFinal" => "14715" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19706556" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0325" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Management of patients with multidrug-resistant/extensively drug-resistant tuberculosis in Europe: a TBNET consensus statement" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Lange" 1 => "I. Abubakar" 2 => "J.W. Alffenaar" 3 => "G. Bothamley" 4 => "J.A. Caminero" 5 => "A.C. Carvalho" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00188313" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2014" "volumen" => "44" "paginaInicial" => "23" "paginaFinal" => "63" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24659544" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0330" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Common errors in multidrug-resistant tuberculosis management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "I. Monedero" 1 => "J.A. Caminero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1586/17476348.2014.856758" "Revista" => array:6 [ "tituloSerie" => "Expert Rev Respir Med" "fecha" => "2014" "volumen" => "8" "paginaInicial" => "15" "paginaFinal" => "23" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24329041" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0335" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Treatment outcomes of multidrug-resistant tuberculosis: a systematic review and metaanalysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.C. Johnston" 1 => "N.C. Shahidi" 2 => "M. Sadatsafaci" 3 => "J.M. Fitzgerald" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0006914" "Revista" => array:5 [ "tituloSerie" => "PLoS One" "fecha" => "2009" "volumen" => "4" "paginaInicial" => "e6914" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19742330" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0340" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiología molecular de la tuberculosis: principales hallazgos y su aplicación en España" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Garcia Pachón" 1 => "J.C. Rodriguez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2005" "volumen" => "41" "paginaInicial" => "618" "paginaFinal" => "624" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16324601" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0345" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systematic molecular characterization of multidrug-resistant mycobacterium tuberculosis complex isolates from Spain" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. Samper" 1 => "M.J. Iglesias" 2 => "L. Rabanaque" 3 => "I. Gómez" 4 => "M.C. Lafoz" 5 => "S. Jiménez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1128/JCM.43.3.1220-1227.2005" "Revista" => array:6 [ "tituloSerie" => "J Clin Microbiol" "fecha" => "2005" "volumen" => "43" "paginaInicial" => "1220" "paginaFinal" => "1227" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15750087" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0350" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multistate outbreak of MDR TB identified by genotype cluster investigation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.M. Barry" 1 => "T.J. Gadner" 2 => "E. Funk" 3 => "E. Oren" 4 => "K. Field" 5 => "T. Shaw" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3201/eid1801.110671" "Revista" => array:6 [ "tituloSerie" => "Emerg Infect Dis" "fecha" => "2012" "volumen" => "18" "paginaInicial" => "113" "paginaFinal" => "116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22260877" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:3 [ "titulo" => "Acknowledgement" "texto" => "<p id="par0190" class="elsevierStylePara elsevierViewall">We thank Dr. Caminero Luna for his suggestions regarding patient treatment.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005200000002/v1_201601300120/S1579212915004358/v1_201601300120/en/main.assets" "Apartado" => array:4 [ "identificador" => "9374" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005200000002/v1_201601300120/S1579212915004358/v1_201601300120/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915004358?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 3 | 8 |
| 2024 October | 36 | 22 | 58 |
| 2024 September | 31 | 17 | 48 |
| 2024 August | 44 | 35 | 79 |
| 2024 July | 39 | 26 | 65 |
| 2024 June | 38 | 23 | 61 |
| 2024 May | 84 | 25 | 109 |
| 2024 April | 38 | 18 | 56 |
| 2024 March | 22 | 17 | 39 |
| 2024 February | 16 | 21 | 37 |
| 2023 March | 8 | 2 | 10 |
| 2023 February | 32 | 15 | 47 |
| 2023 January | 29 | 31 | 60 |
| 2022 December | 48 | 40 | 88 |
| 2022 November | 59 | 22 | 81 |
| 2022 October | 31 | 40 | 71 |
| 2022 September | 27 | 32 | 59 |
| 2022 August | 31 | 34 | 65 |
| 2022 July | 31 | 47 | 78 |
| 2022 June | 30 | 30 | 60 |
| 2022 May | 39 | 43 | 82 |
| 2022 April | 25 | 30 | 55 |
| 2022 March | 41 | 33 | 74 |
| 2022 February | 37 | 32 | 69 |
| 2022 January | 37 | 37 | 74 |
| 2021 December | 30 | 39 | 69 |
| 2021 November | 36 | 43 | 79 |
| 2021 October | 60 | 47 | 107 |
| 2021 September | 35 | 40 | 75 |
| 2021 August | 42 | 34 | 76 |
| 2021 July | 21 | 35 | 56 |
| 2021 June | 26 | 23 | 49 |
| 2021 May | 34 | 28 | 62 |
| 2021 April | 43 | 67 | 110 |
| 2021 March | 37 | 21 | 58 |
| 2021 February | 22 | 26 | 48 |
| 2021 January | 25 | 16 | 41 |
| 2020 December | 19 | 16 | 35 |
| 2020 November | 17 | 15 | 32 |
| 2020 October | 29 | 20 | 49 |
| 2020 September | 28 | 16 | 44 |
| 2020 August | 19 | 11 | 30 |
| 2020 July | 24 | 23 | 47 |
| 2020 June | 26 | 8 | 34 |
| 2020 May | 32 | 22 | 54 |
| 2020 April | 39 | 20 | 59 |
| 2020 March | 28 | 13 | 41 |
| 2020 February | 28 | 20 | 48 |
| 2020 January | 40 | 18 | 58 |
| 2019 December | 43 | 16 | 59 |
| 2019 November | 32 | 21 | 53 |
| 2019 October | 25 | 16 | 41 |
| 2019 September | 21 | 12 | 33 |
| 2019 August | 25 | 19 | 44 |
| 2019 July | 21 | 20 | 41 |
| 2019 June | 29 | 24 | 53 |
| 2019 May | 28 | 12 | 40 |
| 2019 April | 27 | 23 | 50 |
| 2019 March | 30 | 15 | 45 |
| 2019 February | 29 | 20 | 49 |
| 2019 January | 32 | 18 | 50 |
| 2018 December | 22 | 22 | 44 |
| 2018 November | 97 | 20 | 117 |
| 2018 October | 176 | 26 | 202 |
| 2018 September | 48 | 7 | 55 |
| 2018 May | 53 | 0 | 53 |
| 2018 April | 42 | 4 | 46 |
| 2018 March | 104 | 3 | 107 |
| 2018 February | 57 | 6 | 63 |
| 2018 January | 76 | 4 | 80 |
| 2017 December | 56 | 6 | 62 |
| 2017 November | 14 | 5 | 19 |
| 2017 October | 17 | 6 | 23 |
| 2017 September | 16 | 9 | 25 |
| 2017 August | 14 | 17 | 31 |
| 2017 July | 9 | 12 | 21 |
| 2017 June | 21 | 10 | 31 |
| 2017 May | 27 | 17 | 44 |
| 2017 April | 16 | 14 | 30 |
| 2017 March | 5 | 7 | 12 |
| 2017 February | 13 | 7 | 20 |
| 2017 January | 5 | 2 | 7 |
| 2016 December | 7 | 13 | 20 |
| 2016 November | 14 | 10 | 24 |
| 2016 October | 24 | 20 | 44 |
| 2016 September | 20 | 6 | 26 |
| 2016 August | 22 | 3 | 25 |
| 2016 July | 18 | 8 | 26 |
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