INT J TUBERC LUNG DIS 14(1):34–39

© 2010 The Union

Multidrug-resistant pulmonary tuberculosis in Los Altos,

Selva and Norte regions, Chiapas, Mexico

H. J. Sánchez-Pérez,*† A. Díaz-Vázquez,* J. C. Nájera-Ortiz,* S. Balandrano,‡ M. Martín-Mateo§

* Área Académica de Sociedad, Cultura y Salud, El Colegio de la Frontera Sur, San Cristóbal de Las Casas, Chiapas,
† Grupos de Investigación en Salud para América y África Latinas, Ecosur, México, ‡ Departamento de Micobacterias,

Instituto de Diagnóstico y Referencia Epidemiológicos, México DF, México; § Unidad de Bioestadística, Facultad de
Medicina, GRAAL, Universidad Autónoma de Barcelona, Barcelona, Spain

SUMMARY

OBJECTIVES: To analyse the proportion of multidrug-
resistant tuberculosis (MDR-TB) in cultures performed
during the period 2000–2002 in Los Altos, Selva and
Norte regions, Chiapas, Mexico, and to analyse MDR-
TB in terms of clinical and sociodemographic indicators.
M E T H O D S : Cross-sectional study of patients with pul-
monary tuberculosis (PTB) from the above regions. Drug
susceptibility testing results from two research projects
were analysed, as were those of routine sputum samples
sent in by health personnel for processing (n = 114).
MDR-TB was analysed in terms of the various variables
of interest using bivariate tests of association and logis-
tic regression.
R E S U LT S : The proportion of primary MDR-TB was
4.6% (2 of 43), that of secondary MDR-TB was 29.2%
(7/24), while among those whose history of treatment
was unknown the proportion was 14.3% (3/21). Accord-
ing to the logistic regression model, the variables most
highly associated with MDR-TB were as follows: having
received anti-tuberculosis treatment previously, cough
of >3 years’ duration and not being indigenous.
C O N C L U S I O N S : The high proportion of MDR cases
found in the regions studied shows that it is necessary
to significantly improve the control and surveillance of
PTB.
K E Y W O R D S : indigenous population; Mexico; tubercu-
losis; multidrug-resistant; pulmonary

ALARMINGLY HIGH LEVELS of tuberculosis (TB)
continue to be observed worldwide. The World
Health Organization (WHO) estimated an incidence
of 9.27 million cases globally for 2007, a prevalence
of 13.7 million cases and 1.8 million deaths associ-
ated with this disease.1 In 2007, there were an esti-
mated 0.5 million cases of multidrug-resistant TB
(MDR-TB, defined as resistance to both isoniazid
[INH] and rifampicin [RMP]).1
In Mexico, Chiapas is one of the states with the
highest incidence rates of pulmonary tuberculosis
(PTB). According to official 2006 figures, the registered
incidence rate was 16.1 per 100 000 population in
Chiapas, while it was 12.9 for the country as a whole.2
While the registered death rate due to PTB in 2005
was 4.4/100 000 in Chiapas, for the country as a whole
it was 2.1.3 There is evidence that sub-notification and
underdiagnosis of TB (of both cases and deaths) are
very high in Chiapas.4–6
One of the greatest problems for TB control which
is also on the increase is MDR-TB.7 Generally, MDR-
TB occurs as a consequence of inappropriate anti-
tuberculosis treatment. The WHO estimates that over
400 000 cases occur annually.1 While treatment of a
‘normal’ TB case costs under US$150, that of a MDR-
TB case can cost as much as US$16 400, with no
guarantee of cure.8,9 From an economic point of view,
patient deaths and morbidity are much more costly
for a country than anti-tuberculosis treatment.
In Mexico, published data on MDR-TB have only
been available since 1997: in three states of a total
of 32, rates of primary and secondary (or acquired)
MDR-TB were estimated at respectively 2.4% and
22.4%.10 According to WHO estimates for the coun-
try as a whole, the prevalence of MDR-TB is 1–3% in
primary cases.11 For Chiapas, the only reference found
corresponds to six PTB cases in 2000, two of which
were MDR-TB.12
We analysed the MDR-TB results obtained from
two studies carried out in the regions of Los Altos,
Selva and Norte of Chiapas,4,13 as well as from all
sputum samples sent in by health personnel from
these three regions to El Colegio de la Frontera Sur
(Ecosur) for TB diagnosis by culture during the years

Correspondence to: Héctor Javier Sánchez Pérez, El Colegio de la Frontera Sur, Carretera Panamericana y Periférico Sur S/N
29290, San Cristóbal de Las Casas, Chiapas, México. Tel: (+52) 967 674 9000, extn 1510. Fax: (+52) 967 674 9021.
e-mail: hsanchez@ecosur.mx
Article submitted 5 March 2009. Final version accepted 2 August 2009.

2000–2002. The main objective was to calculate the
proportion of MDR-TB, and to analyse MDR-TB in
terms of clinical and socio-demographic indicators.
STUDY POPULATIONS AND METHODS
Study area
The Los Altos, Selva and Norte regions of Chiapas
are zones with very high levels of poverty; the major-
ity of the populations are indigenous Mayan people.
These regions have been most badly affected by the
armed conflict begun in 1994 by the Zapatista Na-
tional Liberation Army.4
Study design and population
This was a cross-sectional study conducted based on
the results obtained in two studies,4,13 as well as on
routine sputum samples sent in to Ecosur for analysis:
1 The project ‘Pulmonary tuberculosis in Los Altos
region of Chiapas: advances or recessions in its
control?’ (PTBA),13 was an active case-finding
study, conducted between March 2000 and March
2002, of coughers aged ⩾15 among patients who
visited the Ministry of Health General Hospital in
San Cristobal de Las Casas, the reference hospital
for 90% of the population of the Los Altos region,
for any reason. There were 487 productive cough-
ers with at least one sputum sample; of 375 cul-
tures performed, 79.5% were negative, 3.7% were
contaminated and 16.8% (n = 63) were PTB.
2 Project ‘Health and Peace’ (H&P)4 was an active
case-finding study of coughers aged ⩾15 years
from a population-based study conducted between
October 2000 and December 2001 in regions most
affected by the armed conflict in Chiapas. There
were 603 productive coughers with at least one
sputum sample. Of 429 cultures performed, 92.3%
were negative, 2.8% were contaminated and 4.9%
(n = 21) were PTB.
3 Sputum samples sent in for processing (routine sam-
ples) were included as a separate group. Between
March 2000 and March 2002, health personnel
in the main governmental and non-governmental
health institutions in the three regions under study
sent sputum samples of 221 coughers for culture
analysis. Of 163 cultures, 78.5% were negative,
3.1% were contaminated and 18.4% (n = 30)
were PTB.
Laboratory testing
In the PTBA and H&P studies, coughers were asked
to provide three sputum samples. Patients were in-
structed in the correct method to obtain and preserve
the samples.14 The samples were transported in dry
ice to the laboratory at Ecosur, where smear testing
using the Ziehl-Neelsen technique and culture analysis
using Löwenstein-Jensen media were conducted.14,15
The routine samples sent to Ecosur were processed
immediately on arrival using the same procedure.
MDR-TB in Chiapas 35
Drug susceptibility testing (DST) was carried out
by the Institute of Epidemiological Diagnosis and Ref-
erence (InDRE) using the BACTEC radiometric tech-
nique.14 InDRE, located in Mexico City, is responsible
for conducting all DST in Mexico.
Statistical analysis
MDR-TB rates were obtained by dividing the MDR
cases by the total number of culture-tested patients.
MDR-TB status was analysed in terms of the various
variables of interest using bivariate tests of associa-
tion and calculation of crude odds ratios (ORs). The
variables analysed were demographic factors (sex,
age, ethnic origin, Spanish-speaking or not [only in-
digenous subjects]), socio-economic factors (occu-
pation, schooling, social security, religion, housing
characteristics [type of floor, electricity, type of cook-
ing facilities, overcrowding], area of residence [urban
vs. rural]), clinical factors (duration of cough, pres-
ence of haemoptysis, fever, weight loss), health ser-
vice utilisation and accessibility indicators (health
agent consulted, history of anti-tuberculosis treat-
ment, treatment default), and family history of PTB.
Logistic regression was used to model MDR-TB
status in terms of those variables found to be signifi-
cantly associated in bivariate analyses. Logistic regres-
sion analysis was restricted to data from the PTBA
and P&H studies, as the only details provided on pa-
tients for whom routine samples were tested were
age, sex and place of residence. All statistical analyses
were performed using SPSS version 11.0. (Statistical
Package for the Social Sciences, Chicago, IL, USA).
Ethical issues
In the PTBA and P&H studies and for the routine
samples, the Helsinki Declaration guidelines were fol-
lowed.16 All patients were directly informed of their
results, which were also delivered to the National Tu-
berculosis Programme (NTP) authorities for treat-
ment management. The H&P study was approved
by the authorities and people of the communities
studied, as well as by a committee of Physicians for
Human Rights.4
RESULTS
Overall, for all three groups, sputum was available
for 1311 individuals, for whom culture analysis was
possible for 967 (73.8%). The remainder could not be
processed due to poor quality (23% of PTBA, 29.5%
of P&H and 34.4% of the routine samples). Of these
967 cultures, 114 (11.8%) were PTB-positive: DST
results were available for 88 (77.2%), and 26 (22.3%)
were contaminated.
With regard to the demographic, socio-economic
and respiratory symptom indicators analysed by type
of study, with the exception of sex, age and place of
residence, we had no data on the patients for the
group of routine samples. Among the PTB-positive
36 The International Journal of Tuberculosis and Lung Disease

Table 1 Demographic, socio-economic and respiratory symptom indicators among PTB

culture-positive patients in Los Altos, Norte and Selva regions, Chiapas, Mexico, 2000–2002
Routine
PTBA H&P samples Total
(n = 63) (n = 21) (n = 30) (N = 114)
% % % % P value*
Demographic
Male 58.7 52.4 80.0 63.2 0.073
Median age, years 38.0 42.0 36.5 38.0 0.124
Average rank, years† 58.6 65.5 49.5 57.9 0.217
Indigenous language speaker 88.9 85.7 NA 88.1 0.697
Spanish language speaker‡ 57.1 44.4 NA 54.1 0.347
Region of residence
Los Altos 95.2 23.8 73.3 76.3
Selva 1.6 33.3 23.3 13.2
Norte 3.2 42.9 3.3 10.5 <0.001
Socio-economic factors
Employed in agriculture 33.3 42.9 NA 35.7 0.430
No social security 98.4 100.0 NA 98.8 0.561
Third (primary) grade schooling or less 80.3 76.2 NA 79.3 0.687
Residing in a rural community§ 65.1 100.0 80.0 75.4 0.004
Earth floor in dwelling 68.3 61.9 NA 66.7 0.593
No electricity in dwelling 17.7 4.8 NA 14.5 0.144
Cook with wood or charcoal 83.6 95.2 NA 86.6 0.177
Overcrowding¶ 60.3 76.2 NA 64.3 0.189
Catholic 63.6 64.7 NA 63.9 0.936
Respiratory symptoms
Duration of cough, years, median 1.0 3.0 NA 1.1 0.702
Haemoptysis# 48.4 42.9 NA 47.0 0.661
Fever** 75.4 42.9 NA 67.1 0.006
Weight loss†† 80.0 61.9 NA 75.0 0.103
Family history of PTB 29.5 14.3 NA 25.6 0.168

* Among the three groups analysed, unless otherwise specified.

† Kruskal-Wallis test.
‡ Only among indigenous subjects.
§ <2500 inhabitants.
¶ ⩾3 persons per bedroom.
# At the time of the study.

** In the 15 days before the study.

†† Since coughing began.

PTB = pulmonary tuberculosis; PTBA = ‘Pulmonary tuberculosis in Los Altos region of Chiapas: advances or reces-
sions in its control’ project13; H&P = ‘Health and Peace’ project4; NA = not available.

patients in the other two studies, statistically signifi-
cant differences were found only for region of resi-
dence, living in a rural community and presence of
fever (Table 1).
Rate of MDR
Of the 88 cultures analysed, 57 (64.8%) were suscep-
tible, 19 (21.6%) were resistant and 12 (13.6%) were
MDR (Table 2); 43 had no history of previous anti-
tuberculosis treatment, of which two (4.6%) were
MDR (primary MDR); 24 had a history of treatment,
of which seven (29.2%) were MDR (secondary or ac-
quired MDR); for a further 21, history information
was not available, although three (14.3%) were MDR.
MDR in relation to the indicators analysed
According to the bivariate analyses, the variables as-
sociated with MDR were non-indigenous status, no
electricity in the home, duration of cough >3 years
and previous history of anti-tuberculosis treatment
(Table 3).
Logistic regression modelling showed that the
variables most likely to be associated with MDR-TB
were previous anti-tuberculosis treatment, cough of
>3 years’ duration and not being indigenous (Table 4).
DISCUSSION
The observed rates of primary and secondary MDR
suggest that in the regions studied, MDR is a public
health problem of alarming proportions, mainly for
the following reasons.
The MDR rates obtained exceeded those calcu-
lated for the country as a whole (by 1–3% for pri-
mary and 20% for secondary MDR-TB).11,17 In Bo-
gota, Colombia, Hernández et al.,found a rate of
2.9% for the period 1995–2006,18 and in California,
Granich et al.,reported a rate of 1.4% for the period
1994–2003.10 In Turkey, Surucuoglu et al. reported
primary and secondary rates of respectively 4.4%
and 22.4%, for the period 1997–2003.19
Another major reason is deficiencies in the NTP.
Although the cultures analysed correspond to the
years 2000–2002, there are no signs to suggest that
the TB situation in these regions has improved. Vari-
ous studies, as well as the official statistics themselves,
 MDR-TB in Chiapas 37

Table 2 DST results among PTB culture-positive patients Table 3 Variables associated with multidrug resistance*
in Los Altos, Norte and Selva regions, Chiapas, Mexico, in Los Altos, Norte and Selva regions of Chiapas, Mexico,
2000–2002 2000–2002
Routine MDR
PTBA H&P samples Total % OR (95%CI)
n (%) n (%) n (%) n (%)
Demographic factor
Culture-positive patients Indigenous language speaker
with DST performed 63 21 30 114 No (n = 8) 37.5 5.5 (1.1–29.0)
DST results Yes (n = 61) 9.8
Susceptible to 5 drugs 41 (65.1) 5 (23.8) 11 (36.7) 57 (50.0) Socio-economic factor
Resistant* 12 (19.0) 2 (9.5) 5 (16.6) 19 (16.7) Electricity in dwelling
Multidrug-resistant 7 (11.1) 2 (9.5) 3 (10.0) 12 (10.5) No (n = 10) 40.0 7.1 (1.5–33.7)
No result due to sample Yes (n = 58) 8.6
contamination 3 (4.8) 12 (57.2) 11 (36.7) 26 (22.8) Clinical symptoms
DST results, not including Duration of cough
contaminated cases 60 9 19 88 >3 years (n = 12) 41.7 9.1 (2.0–42.2)
Susceptible 41 (68.3) 5 (55.6) 11 (57.9) 57 (64.8) ⩽3 years (n = 55) 7.3
Resistant 12 (20.0) 2 (22.2) 5 (26.3) 19 (21.6) History of anti-tuberculosis treatment
Multidrug-resistant 7 (11.7) 2 (22.2) 3 (15.8) 12 (13.6) Yes (n = 24) 29.2 8.4 (1.6–44.9)
Type of multidrug No (n = 43) 4.7
resistance 7 2 3 12
Primary 1 1 0 2 * No association with MDR found for the following variables: demographic
factors: sex, age (15–44 years vs. ⩾45 years), whether Spanish spoken or not
Secondary 6 1 0 7
(only indigenous subjects); socio-economic factors: occupation (agriculture,
Unknown 0 0 3 3 other), social security (yes/no), schooling (0–3 years, ⩾4 years), area of resi-
dence (urban, rural), religion (Catholic, other); household-related: type of floor
* 13 resistant to INH, 2 to INH+EMB; 1 to INH+PZA; 2 to SM; 1 to (bare, covered), fuel for cooking (gas, other), overcrowding (<3, ⩾3 per-
SM+EMB. sons per bedroom); clinical symptoms: haemoptisis (yes/no), fever (yes/no),
DST = drug susceptibility testing; PTB = pulmonary tuberculosis; PTBA = weight loss (yes/no), health agent consulted (institutional services, other),
‘Pulmonary tuberculosis in Los Altos region of Chiapas: advances or reces- anti-tuberculosis treatment abandoned (yes/no), family history of PTB (yes/
sions in its control’ project13; H&P = ‘Health and Peace’ project4; INH = iso- no); type of study: (PTBA, H&P, sample sent in).
niazid; EMB = ethambutol; PZA = pyrazinamide; SM = streptomycin. MDR = multidrug resistance; OR = odds ratio; CI = confidence interval; PTB =
pulmonary tuberculosis; PTBA = ‘Pulmonary tuberculosis in Los Altos region
of Chiapas: advances or recessions in its control’ project13; H&P = ‘Health
and Peace’ project4.
demonstrate that in these areas the health system fails
to diagnose cases appropriately and that application
of the DOTS strategy is deficient.20 It is therefore the health services, this would not be the case. Health
likely that many patients remain undiagnosed,4 while service personnel cannot spend so much time locat-
others are not properly followed up, resulting in low ing patients and their corresponding samples; it is
cure rates (<60%), high mortality21 and the emer- therefore very likely that the number of poor quality
gence of considerable numbers of MDR-TB cases. samples would be much higher. The main obstacles to
Thus, whereas in Chiapas the recorded incidence rate obtaining acceptable sputum samples result from bar-
of PTB was 16.1/100 000 in 2006, different studies riers in communication with the indigenous people,
have found prevalence rates of PTB of 161.8/100 0004 who have different cultural conceptions about the
and 276.9/100 000 persons aged ⩾15 years.22 An- health-disease process, and many do not speak Span-
other recent study in the Los Altos region observed a ish, among other aspects. This situation leads to prob-
high rate of mortality due to PTB.21 lems where patients have to be instructed about ex-
In the regions studied, it is extremely difficult to per- actly what kind of sputum samples are required.4–6,13,21
form culture analysis, and even more difficult to con- In addition, the distance of the communities from the
duct DST in those cases that require it. In the present centres where samples are processed, the unsuitable
study the percentage of contaminated cultures was transport conditions and the risk of exposure to sun-
high (22%) due to poor quality sputum samples. It is light or lack of refrigeration, makes preserving and
important to stress that, in the case of the two projects, transporting sputum samples difficult, particularly
considerable effort was dedicated to obtaining those when samples need to be sent for DST to InDRE, in
samples. Under the ‘normal’ operating conditions of Mexico City, from the remote Chiapas communities.

Table 4 Variables associated with multidrug resistance according to logistic regression model,
Los Altos, Norte and Selva regions of Chiapas, Mexico, 2000–2002
95%CI for
Variable β ET Wald Sig Exp (β) Exp (β)
Not being indigenous 2.455 1.200 4.188 0.041 11.644 1.1–122.2
Duration of cough >3 years 2.993 1.071 7.809 0.005 19.942 2.4–162.7
With history of anti-tuberculosis
treatment 2.285 1.003 5.185 0.023 9.826 1.4–70.2
Constant −4.486 1.080 17.237 0.000 0.011
CI = confidence interval.
38 The International Journal of Tuberculosis and Lung Disease
The quantity of poor quality samples affected this
study in two ways: the confidence intervals for statis-
tical analysis were wider, and it reduced the possibility
of analysing MDR as a function of other variables of
interest. As a result, we cannot say whether the quan-
tity of contaminated cultures resulted in an under- or
overestimation of the proportion of MDR-TB found.
Finally, the geographical, economic and cultural
barriers to be overcome in accessing the health ser-
vices,4,22 as well as the highly rural and widely dis-
persed nature of the communities (the vast majority
have fewer than 1000 inhabitants), leads to low rates
of diagnosis and follow-up of cases.
With regard to MDR as a function of the demo-
graphic indicators analysed, it is notable that non-
indigenous patients had higher MDR rates than in-
digenous patients. In the six cases identified among
indigenous patients, two had primary and four sec-
ondary MDR, whereas all three non-indigenous pa-
tients were secondary. Although very few of the cases
analysed were non-indigenous patients, it is possible
that their higher MDR rate was due to more frequent
contact with the health services. Given the deficient
quality of care in the regions studied, this in itself
represents a risk factor for MDR, and suggests that
there are more undiagnosed TB cases among the in-
digenous population (due to lack of access to health
services, absence of active case finding, and, even
when health services are available, failure to diagnose
cases), whereas among the non-indigenous population
more cases are diagnosed, but not necessarily treated
appropriately.20,21 This hypothesis requires further in-
vestigation with a study of appropriate design.
In Mexico, standard first-line anti-tuberculosis
treatment under DOTS consists of HRZE (INH, RMP,
pyrazinamide and ethambutol) for the first 2 months,
followed by HR for 4 months. Since 2005, the Minis-
try of Health has implemented fixed-dose combina-
tions of these four drugs in a single tablet, with the
aim of reducing treatment default and the emergence
of MDR-TB.23 However, for many patients this is
not put into practice, mainly due to the lack of inter-
est by the health services and to a lack of medica-
tions, giving rise to the situation shown here: high
MDR rates and high rates of PTB mortality, as other
studies suggest.4,20,21
Of the socio-economic indicators analysed, the fact
that indicators of this type do not discriminate be-
tween populations at greater or lesser risk of MDR-TB
may be due either to the relative homogeneity of the
socio-economic conditions of the patients studied, or
to the fact that the most important risk factor for
MDR-TB is the quality of anti-tuberculosis treatment.
In terms of the respiratory symptoms analysed,
two aspects were associated with MDR: duration of
cough (>3 years) and history of anti-tuberculosis
treatment. Four of the five cases of MDR identified in
patients with a cough of >3 years’ duration had sec-
ondary resistance, as did all seven patients with a his-
tory of anti-tuberculosis treatment.
Limitations of the study
The main limitations of this study are the lack of de-
tail about patients whose sputum samples were anal-
ysed for TB, as this limited proper analysis of MDR-
TB in terms of other variables of interest; a possible
selection bias among patients studied by the PTBA
Project and in routine samples; the high proportion
of samples for which culture analysis was not possi-
ble (around 23–39%); and the proportion (3%) of
cultures not analysed due to contamination. These
deficiencies are reflected in the wide confidence inter-
vals obtained in the logistic regression. However, we
believe that the main contribution of the study lies in
the fact that it documents the failure of a TB preven-
tion and control programme. The proportion of MDR
cases found alone indicates that the NTP is failing
its patients.
CONCLUSIONS
Given the high proportion of MDR cases found in
the studied regions, it is necessary to significantly im-
prove TB control and surveillance.
References
1 World Health Organization. Global tuberculosis control: epi-
demiology, strategy, financing. WHO report 2009. WHO/HTM/
TB/2009.411. Geneva, Switzerland: WHO, 2009.
2 Sistema Único de Información para la Vigilancia Epidemiológ-
ica, Dirección General de Epidemiología. Incidencia de tuber-
culosis pulmonar (A15-A16) por grupos de edad 2006. Mexico
DF, Mexico: Dirección General de Epidemiología, 2006. http://
www.dgepi.salud.gob.mx/anuario/index.html Accessed Janu-
ary 2008. [Spanish]
3 Secretaría de Salud, Dirección General de Información en Salud.
Cuadro 09. Principales causas de mortalidad en edad produc-
tiva (de 15 a 64 años), 2005. Mexico DF, Mexico: Dirección
General de Epidemiología, 2005. http://sinais.salud.gob.mx/
mortalidad/tabs/m_009.xls Accessed January 2008. [Spanish]
4 Sánchez-Pérez H J, Arana-Cedeño M, Yamín A E. Excluded
people, eroded communities. Realizing the right to health in
Chiapas, Mexico. Boston, MA, USA: Physicians for Human
Rights, El Colegio de la Frontera Sur, Centro de Capacitación
en Ecología y Salud para Campesinos–Defensoría del Derecho
a la Salud, 2006. [Spanish]
5 Sánchez-Pérez H J, Halperin D. Problemas de diagnóstico de la
tuberculosis pulmonar. El caso de la Región Fronteriza de Chia-
pas, México. Atención Primaria 1997; 19: 237–242. [Spanish]
6 Sánchez-Pérez H J, Hernán M, Hernández-Díaz S, Jansá J M,
Halperin D, Ascherio A. Detection of pulmonary tuberculosis
in Chiapas, Mexico. Ann Epidem 2002; 12: 166–172.
7 World Health Organization. Anti-tuberculosis drug resistance
in the world. The WHO/IUATLD Global Project on Anti-
tuberculosis Drug Resistance Surveillance, 2008. Report no. 4.
WHO/HTM/TB/2008.39. Geneva, Switzerland: WHO, 2008.
8 Palmero D J. Pautas latinoamericanas de diagnóstico y trata-
miento de la tuberculosis farmacorresistente. Salud (i) Ciencia
2008; 16: 1366–1375. [Spanish]
9 Caminero-Luna J A. Manejo de los casos en retratamiento de
tuberculosis con sospecha de resistencia a fármacos. Biomedica
2004; 24 (Suppl): S212–S227. [Spanish]

10 Granich R M, Balandrano S, Santaella A J, et al. Survey of drug
resistance of Mycobacterium tuberculosis in 3 Mexican states,
1997. Arch Intern Med 2000; 160: 639–644.
11 Asociación Latinoamericana de Tórax. Guías latinoamericanas
de diagnóstico y tratamiento de la tuberculosis farmacorresist-
ente 2007. ALAT, 2007. http://www.intramed.net/userfiles/pdf/
57367.pdf Accessed November 2009.
12 Olvera-Castillo R. Farmacorresistencia secundaria en tubercu-
losis. Tendencia en el Instituto Nacional de Enfermedades Res-
piratorias. Rev Inst Nal Enf Resp Mex 2001; 14: 151–159.
[Spanish]
13 Sánchez-Pérez H J. Informe final del Proyecto: tuberculosis
pulmonar en los Altos de Chiapas: ¿avances o retrocesos (clave
19990502008), financiado por el Fondo de Investigación Sis-
tema Benito Juárez (SIBEJ), CONACYT, convocatoria 1999.
San Cristóbal de Las Casas, Chiapas, México: El Colegio de la
Frontera Sur, 2002.
14 Balandrano S, Anzaldo F G, Peña F G, Betancourt M X.
Manual de procedimientos de laboratorio INDRE/SAGAR: 18.
Tuberculosis. México DF, Mexico: Secretaría de Salud, Secre-
taría de Agricultura, Ganadería y Desarrollo Rural, Organiza-
ción Panamericana de la Salud, 1996. [Spanish]
15 Secretaría de Salud. Modificación a la Norma Oficial Mexi-
cana NOM-006-SSA2-1993. Para la prevención y control de la
tuberculosis en la atención primaria a la salud. Diario Oficial
de la Federación, México DF, Mexico. 27 de Septiembre de
2005. [Spanish]
16 World Medical Association. Declaration of Helsinki: ethical
principles for medical research involving human subjects. Ed-
inburgh, Scotland: WMA, 2002.
17 Muñoz-Mendoza W A, Téllez-Medina H A, Baeza-Peña B. Tuber-
OBJECTIFS : Analyser la proportion de tuberculoses à
germes multirésistants (TB-MDR) dans les cultures réali-
sées pendant la période 2000–2002 dans les régions de
Los Altos, Selva et Norte de Chiapas, Méxique, et ana-
lyser les TB-MDR en termes d’indicateurs cliniques et
socio-démographiques.
M É T H O D E S : Etude transversale de patients atteints de
tuberculose pulmonaire (TBP) provenant des régions
mentionnées ci-dessus. Les résultats des tests de sensibi-
lité aux médicaments provenant de deux projets de re-
cherche ont été analysés, de même que ceux obtenus à
partir d’échantillons de crachats envoyés par le person-
nel de santé en vue d’un traitement (n = 114). On a
analysé les TB-MDR en termes de diverses variables
OBJETIVOS: Analizar la proporción de tuberculosis
multidrogorresistente (TB-MDR) en cultivos efectuados
durante el período 2000–2002 en las regiones de los Al-
tos, Selva y Norte de Chiapas, México, y analizar la TB-
MDR según indicadores clínicos y sociodemográficos.
M É T O D O : Estudio transversal de pacientes con tubercu-
losis pulmonar (TBP) de las regiones mencionadas. Se
analizaron los resultados de fármaco-sensibilidad de dos
proyectos, así como de muestras enviadas por el perso-
nal de salud para su procesamiento (n = 114). La TB-
MDR fue analizada en términos de variables de interés,
mediante análisis bivariado (pruebas de asociación) y
regresión logística.
MDR-TB in Chiapas 39
culosis farmacorresistente: un problema emergente en México.
Vox Médica 2007; 8: 11–13. http://www.anmm.org.mx/vox_
medica/2007/n3/Vox_Medica_3_2007_11-13.pdf Accessed Jan-
uary 2008.
18 Hernández J E, Murcia M I, de la Hoz F. Epidemiología mole-
cular de la tuberculosis en Bogotá en aislados clínicos obteni-
dos durante 11 años. Rev Salud Publica 2008; 10: 126–136.
[Spanish]
19 Surucuoglu S, Ozkutuk N, Celik P, et al. Drug-resistant pulmo-
nary tuberculosis in western Turkey: prevalence, clinical char-
acteristics and treatment outcome. Ann Saudi Med 2005; 25:
313–318.
20 Reyes-Guillén I, Sánchez-Pérez H J, Cruz-Burguete J, Izaurieta
de Juan M. Anti-tuberculosis treatment defaulting. An analysis
of perceptions and attitudes in Chiapas, Mexico. Salud Publica
Mex 2008; 50: 251–257.
21 Nájera-Ortiz J C, Sánchez-Pérez H J, Ochoa-Díaz H, Arana-
Cedeño M, Salazar Lezama M A, Martín Mateo M. Demo-
graphic, health services and socio-economic factors associated
with pulmonary tuberculosis mortality in Los Altos region of
Chiapas, Mexico. Int J Epidemiol 2008; 37: 786–795.
22 Sánchez-Pérez H J, Flores-Hernández J A, Jansá J M, Caylá J A,
Martín-Mateo M. Pulmonary tuberculosis in areas of high
levels of poverty in Chiapas, Mexico. Int J Epidemiol 2001;
30: 386–393.
23 Centro Nacional de Vigilancia Epidemiológica. El Dr. J. W. Lee
se reunió con los líderes de los Programas Tuberculosis y VIH/
SIDA de México. Mexico DF, Mexico: CENAVE, 2004. http://
www.cenave.gob.mx/tuberculosis/eventos/omstbsida.htm Ac-
cessed July 2009.
RÉSUMÉ
d’intérêt en utilisant des tests bivariés d’association ainsi
que la régression logistique.
R É S U LTAT S : La proportion des TB-MDR primaires est
de 4,6% (2/43) et celle des TB-MDR secondaires de
29,2% ; elle est de 14,3% (3/21) chez ceux dont les anté-
cédents de traitement sont inconnus. Selon le modèle de
régression logistique construit, les variables qui expri-
ment le mieux le statut de MDR sont les suivantes : un
traitement antituberculeux antérieur, toux depuis plus
de 3 années et ne pas être indigène.
C O N C L U S I O N : Vu la proportion élevée de cas de MDR
décelés dans les régions étudiées, il est nécessaire
d’améliorer de façon significative la lutte et la surveil-
lance de la TBP.
RESUMEN
R E S U LTA D O S : La proporción de TB-MDR primaria
hallada fue de 4,6% (2/43), la de TB-MDR secundaria
de 29,2% (7/24) y, en aquellos pacientes en los que se
desconocieron antecedentes de tratamiento antitubercu-
losis, de 14,3% (3/21). Según el modelo de regresión
logística construido, las variables que mejor explicaron
la condición de TB-MDR fueron tratamiento antituber-
culosis previo, tos de >3 años de duración y no ser
indígena.
C O N C L U S I O N E S : Dada la alta proporción de casos de
TB-MDR encontrada en las regiones estudiadas, es nece-
sario mejorar significativamente el control y la vigilan-
cia de la TBP.