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Research Article Morbidity Trends and Risk of Tuberculosis: Mexico 2007–2017 Juan Manuel Bello-L´ opez , 1 Gregorio Le´ on-Garc´ ıa , 2,3,4 Araceli Rojas-Bernab´ e , 4 V.Fern´ andez-S´ anchez , 5 Omar Garc´ ıa-Hern´ andez , 6 Javier Mancilla R´ amirez , 2,4 and Gabriela Ib´ añez-Cervantes 2,4 1 Unidad de Investigaci´ on en Microbiolog´ ıa y Toxicolog´ ıa, Hospital Ju´ arez de M´ exico, Av. Instituto Polit´ ecnico Nacional 5160, Col. Magdalena de las Salinas, 07360 Mexico City, Mexico 2 Hospital de la Mujer, SSA, Salvador D´ ıaz Mir´ on 374, Col. Santo Tomas, 11340 Mexico City, Mexico 3 Centro M´edico y de Investigaciones Cient´ ıficas Fundaci´ on CIAM ESPERAS, A.C., Felipe Carrillo Puerto 181, Col. Popotla, 11400 Mexico City, Mexico 4 Escuela Superior de Medicina, Instituto Polit´ ecnico Nacional, Salvador D´ ıaz Mir´ on, Col. Casco de Santo Tomas, 11340 Mexico City, Mexico 5 UNAM-FES Iztacala, Facultad de Medicina, Mexico, Mexico 6 Unidad de Investigaci´ on en Medicina Experimental, Facultad de Medicina, Universidad Nacional Aut´ onoma de M´ exico, Mexico City, Mexico Correspondence should be addressed to Javier Mancilla R´ amirez; [email protected] and Gabriela Ib´ añez-Cervantes; [email protected] Juan Manuel Bello-L´ opez and Gregorio Le´ on-Garc´ ıa contributed equally to this work. Received 21 August 2018; Revised 14 December 2018; Accepted 20 March 2019; Published 17 April 2019 Academic Editor: Andrea S. Melani Copyright © 2019 Juan Manuel Bello-L´ opez et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. To know the current status of the epidemiological and geographic distribution of tuberculosis and its complication meningeal tuberculosis in Mexico, this work analyzes national surveillance data (ten years) issued by the General Directorate of Epidemiology (GDE). Methods. An observational and retrospective analysis of monthly and annual reports of pulmonary and meningeal tuberculosis cases from January 2007 to December 2017 was performed on the annual reports issued by the GDE in Mexico. e number of cases and incidence were classified by year, state, age group, gender, and seasons. Results. A national case distribution map of pulmonary and meningeal tuberculosis incidence was generated. During this period, a total of 184,003 and 3,388 cases were reported with a median of 16,727.5 and 308 cases per year for pulmonary and meningeal tuberculosis diseases, respectively. e number of cases and incidence of pulmonary and meningeal tuberculosis per year showed that male gender presented a continuous increase in both parameters. e geographic analysis of the distribution of cases of tuberculosis showed that states like Guerrero, Tabasco, and Veracruz presented higher means of tuberculosis cases during this period. Northern states had the highest number of cases in the country compared to other states. In Mexico, pulmonary tuberculosis and meningeal tuberculosis are seasonal. Interestingly, cases of meningeal tuberculosis show an increase during October and November (autumn). Conclusions. In Mexico, during the years 2007–2017, there has been an increase in the proportion of male TB patients. It remains necessary to implement strategies to detect TB in the adult population, especially among men, because tuberculosis could be difficult to recognize in an early stage in the population, and the appearance of resistant strains can cause an increase in the incidence of the disease. 1. Introduction Tuberculosis (TB) is an infectious disease generally transmitted through aerosols containing Mycobacterium tuberculosis [1]. Mycobacterial infections have co-evolved with humans for thousands of years, as demonstrated in archaeological dis- coveries with findings of the disease in human remains [2, 3]. It affects the pulmonary parenchyma with a high degree of Hindawi Canadian Respiratory Journal Volume 2019, Article ID 8295261, 9 pages https://doi.org/10.1155/2019/8295261

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  • Research ArticleMorbidity Trends and Risk of Tuberculosis: Mexico 2007–2017

    Juan Manuel Bello-López ,1 Gregorio León-Garcı́a ,2,3,4 Araceli Rojas-Bernabé ,4

    V. Fernández-Sánchez ,5 Omar Garcı́a-Hernández ,6 Javier Mancilla Rámirez ,2,4

    and Gabriela Ibáñez-Cervantes 2,4

    1Unidad de Investigación en Microbioloǵıa y Toxicoloǵıa, Hospital Juárez de México, Av. Instituto Politécnico Nacional 5160,Col. Magdalena de las Salinas, 07360 Mexico City, Mexico2Hospital de la Mujer, SSA, Salvador Dı́az Mirón 374, Col. Santo Tomas, 11340 Mexico City, Mexico3Centro Médico y de Investigaciones Cient́ıficas Fundación CIAM ESPERAS, A.C., Felipe Carrillo Puerto 181, Col. Popotla,11400 Mexico City, Mexico4Escuela Superior de Medicina, Instituto Politécnico Nacional, Salvador Dı́az Mirón, Col. Casco de Santo Tomas,11340 Mexico City, Mexico5UNAM-FES Iztacala, Facultad de Medicina, Mexico, Mexico6Unidad de Investigación en Medicina Experimental, Facultad de Medicina, Universidad Nacional Autónoma de México,Mexico City, Mexico

    Correspondence should be addressed to Javier Mancilla Rámirez; [email protected] and Gabriela Ibáñez-Cervantes;[email protected]

    Juan Manuel Bello-López and Gregorio León-Garcı́a contributed equally to this work.

    Received 21 August 2018; Revised 14 December 2018; Accepted 20 March 2019; Published 17 April 2019

    Academic Editor: Andrea S. Melani

    Copyright © 2019 JuanManuel Bello-López et al. 5is is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

    Background. To know the current status of the epidemiological and geographic distribution of tuberculosis and its complicationmeningeal tuberculosis in Mexico, this work analyzes national surveillance data (ten years) issued by the General Directorate ofEpidemiology (GDE). Methods. An observational and retrospective analysis of monthly and annual reports of pulmonary andmeningeal tuberculosis cases from January 2007 to December 2017 was performed on the annual reports issued by the GDE inMexico. 5e number of cases and incidence were classified by year, state, age group, gender, and seasons. Results. A national casedistribution map of pulmonary and meningeal tuberculosis incidence was generated. During this period, a total of 184,003 and3,388 cases were reported with a median of 16,727.5 and 308 cases per year for pulmonary and meningeal tuberculosis diseases,respectively. 5e number of cases and incidence of pulmonary and meningeal tuberculosis per year showed that male genderpresented a continuous increase in both parameters. 5e geographic analysis of the distribution of cases of tuberculosis showedthat states like Guerrero, Tabasco, and Veracruz presented higher means of tuberculosis cases during this period. Northern stateshad the highest number of cases in the country compared to other states. In Mexico, pulmonary tuberculosis and meningealtuberculosis are seasonal. Interestingly, cases of meningeal tuberculosis show an increase during October and November(autumn).Conclusions. InMexico, during the years 2007–2017, there has been an increase in the proportion of male TB patients. Itremains necessary to implement strategies to detect TB in the adult population, especially among men, because tuberculosis couldbe difficult to recognize in an early stage in the population, and the appearance of resistant strains can cause an increase in theincidence of the disease.

    1. Introduction

    Tuberculosis (TB) is an infectious disease generally transmittedthrough aerosols containing Mycobacterium tuberculosis [1].

    Mycobacterial infections have co-evolved with humans forthousands of years, as demonstrated in archaeological dis-coveries with findings of the disease in human remains [2, 3]. Itaffects the pulmonary parenchyma with a high degree of

    HindawiCanadian Respiratory JournalVolume 2019, Article ID 8295261, 9 pageshttps://doi.org/10.1155/2019/8295261

    mailto:[email protected]:[email protected]://orcid.org/0000-0002-9957-3807http://orcid.org/0000-0001-6082-9329http://orcid.org/0000-0002-3851-5881http://orcid.org/0000-0001-9732-2265http://orcid.org/0000-0001-8807-1353http://orcid.org/0000-0002-9236-8149http://orcid.org/0000-0002-7969-0942https://creativecommons.org/licenses/by/4.0/https://creativecommons.org/licenses/by/4.0/https://doi.org/10.1155/2019/8295261

  • infection. Although TB is preventable and curable, it remains amajor public health problem and is one of the most commonopportunistic infections in people living with HIV (PLHIV),mainly in developing countries [4–6]. Extrarespiratory tu-berculosis can be located in different areas of the body. It canaffect one organ or it can be localized simultaneously in dif-ferent organs, such as the lymphatic ganglions, lymphaticvessels, bones, pleural area, urogenital area, meninges, peri-toneum, and skin [7]. 5e compromise of the central nervoussystem represents 5 to 10% of the cases of extrapulmonarylocalization; meningitis is the most frequent condition.

    Meningeal tuberculosis (MTB) is considered the mostdevastating manifestation of the disease [8, 9] with amortality of up to 30% and a high percentage of neurologicalsequelae in survivors.

    5eWorld Health Organization (WHO) reports that, in2016, 10.4 million people got ill with TB, and 1.7 milliondied from the disease (including 0.4 million people withHIV); each year, an estimated occurrence is close to 9million new cases and 1.7 million died from this disease(among them 0.4 million people with HIV) [6]. Worldwide,tuberculosis is among the ten leading causes of death andhealthy life years lost [6]. Over 95% of deaths due to tu-berculosis occur in low- and middle-income countries; thefactors that influence the development of the disease arenutrition, alcoholism, addictions, immunological responseconditions, and economic conditions [10–12]. Although TBheavily affects PLHIV, TB affects vulnerable communitiessuch as those at the extremes of age, immune compro-mised, indigenous, poor, and incarcerated people. In 2016,around 87% of new cases of tuberculosis were registered inthe 30 countries considered to be highly burdened by thisdisease. Seven of them account for 64% of new cases oftuberculosis: India, Indonesia, China, the Philippines,Pakistan, Nigeria, and South Africa [6]. In Mexico, morethan 18,000 new cases and nearly 2,000 deaths were di-agnosed in 2010 due to this cause [13, 14]. In Mexico,tuberculosis continues to be a priority in health due tocomplicated cases at the extremes of age, emergence ofmultidrug resistance, links with other diseases, difficultaccess to health systems in specific areas, and by groups ofhigher levels of vulnerability.5e present work analyzes thenational scrutiny data for pulmonary and MTB publishedby the General Directorate of Epidemiology (GDE), inorder to update and to better understand the epidemiologyof these diseases in Mexico. 5e results presented here canbe useful in the promotion of prevention and can con-tribute to the study of the distribution of the disease in thelast ten years.

    2. Materials and Methods

    2.1. Study Design and Data Collection. 5e design and datacollection study were carried out according to Ibáñez-Cervantes et al. [15]. Briefly, the monthly and annual re-ports of cases of pulmonary and MTB between 2007 and2017 were published by the GDE and were analyzed in anobservational and retrospective manner. 5e GDE receivesthe new reported cases of pulmonary and MTB diseases

    across the country on a monthly and annual basis. 5e GDEonly reports confirmed cases of tuberculosis. 5e diagnosisof the cases inMexico is made by sputum smear microscopy;if this is negative, culture is done for M. tuberculosis. Oncethe case is confirmed, it is reported to the GDE. 5e epi-demiological data for the period 2007–2017 were taken frommorbidity yearbooks found in http://www.epidemiologia.salud.gob.mx/anuario/html/anuarios.html. 5e data re-ported in this website were previously generated and ana-lyzed by the Health Department through its SUAVEwebplatform (http://www.sinave.gob.mx). All data of pulmo-nary and MTB diseases cases were statistically analyzed byusing Microsoft Excel 2013 (Microsoft Corporation, Red-mond, WA, USA) by month, year, states, and demographicvariables (age group and gender). Additionally, an incidenceanalysis of PTB incidence by season was performed (per100,000 habitants). An analysis of variance (ANOVA) wasalso calculated in order to evaluate significant differencesover time (p � 0.05), per data/year and month. A nationaldistribution map showing the pulmonary and MTB in-cidence during the analyzed period was generated [15].

    3. Results

    3.1. Distribution of New Cases of Pulmonary and MeningealTuberculosis Diseases in 2007–2017. Each month, the GDEreceives the reported cases of pulmonary and meningealtuberculosis (MTB) diseases throughout the country. In thiswork, the incidence reports and new cases of pulmonary andMTB diseases from 2007 to 2017 were analyzed. 5e reg-ulatory policies in Mexico established the obligatory noti-fication of cases of pulmonary and MTB diseases. Duringthis period, a total of 184,003 and 3,388 cases were reported,respectively, with a median of 16,727.5 and 308 cases peryear for pulmonary and MTB diseases (Table 1).

    3.2. Distribution of New Cases and Incidence of PTB Diseases.5e analysis of the number of cases and incidence of PTBdiseases by year showed that the male gender presented asignificant difference in the incidence and number of casesduring all the years analyzed (2007–2017), compared to thefemale gender (Figure 1). Initial and final incidences for theten years were 17.16 versus 10.45 and 18.19 versus 9.62 forthe male (Figure 1(a)) and female gender (Figure 1(b)),respectively. In 2016, the male gender presented an increasein both parameters (18.01/10 739 cases), while in 2012, aslight decrease in the incidence and number of cases re-ported in the female gender (9.84/5887 cases) was observed.Finally, the incidence and number of cases in 2017 for bothgenders was 9.86/6,087 cases and 18.01/11,014 cases forfemale and male gender, respectively.

    3.3. Pattern of New Cases and Incidence of Meningeal Tu-berculosis Diseases. 5e incidence and number of cases forMTB diseases presented an important increase since 2015,with initial values of 0.32/188 cases and 0.15/80 cases, andfinal values of 0.48/288 cases and 0.21/134 cases (2017) forthe male (Figure 1(a)) and female (Figure 1(b)) gender,

    2 Canadian Respiratory Journal

    http://www.epidemiologia.salud.gob.mx/anuario/html/anuarios.htmlhttp://www.epidemiologia.salud.gob.mx/anuario/html/anuarios.htmlhttp://www.sinave.gob.mx

  • respectively. Interestingly in 2014, an increase in the in-cidence and number of cases reported in both genders wasobserved.

    3.4. Incidence of Pulmonary and Meningeal TuberculosisDiseases per Age Groups and Gender. 5e analysis of theincidence (per 100,000 inhabitants) increased in bothsexes from 15 to 19 years old and increased in each ageband through the final age band of >65. 5e incidence inthe remaining age groups in the female gender wasgradually increasing, depending on the increase in age inthe population (Figure 2). In the male gender, a higherincidence was observed from 15 years old. In contrast, thefemale gender presented incidences up to two times lowerin comparison with the male gender in all the age groupsfrom 20 years onwards. 5e statistical analysis (p � 0.05)per age group and gender revealed that in both mani-festations of the disease, it was higher in the male pop-ulation in all age groups (Figures 1 and 2). Likewise, inmeningeal tuberculosis, there is a slight increase inchildren of both sexes, compared to the presentation ofPTB.

    3.5. Geographical Distribution of Pulmonary and MeningealTuberculosis Diseases. 5e incidence of PTB diseasesduring the ten years analyzed in the 32 states of theMexican Republic was analyzed. States with the highestincidence of PTB are on the northern border, led by BajaCalifornia State, followed by the southwest region; thelowest incidence rate was detected in some central states ofthe country. 5e geographic analysis of the distribution ofcases of tuberculosis showed that states like Guerrero,Tabasco, and Veracruz presented higher means of tuber-culosis cases during this period. Northern states like BajaCalifornia, Sinaloa, and Sonora had the highest number ofcases in the country compared to the other northern states.In particular, the states located in the north-center of thecountry, such as Guanajuato, Queretaro, and Zacatecas,presented the lowest number of new cases during theanalyzed period. Although Tlaxcala is located in the eastpart of the country, the number of cases of tuberculosis waslower compared to that in most of the states in thisgeographical zone (Figure 3).

    In the case of meningeal tuberculosis, the distribution ofincidence rate concentrates on the states of Baja CaliforniaNorte and Sur, and Aguascalientes followed by an abruptdecrease in the incidence rate in the state of Campeche withan average distribution in all other states.

    3.6. Seasonal Distribution of PTB Diseases. In order toidentify the possible seasonal distribution of PTB disease(Figure 4), the information of new cases was categorized bymonth/year and was analyzed by distribution within theyearly seasons (winter, spring, summer, and autumn). 5elargest number of cases was identified in spring and summer(March–July). A gradual decline of new cases spanning inthe autumn season was identified in September, with arebound in October. 5ese results reflect a relationshipbetween the environmental changes in temperature and thepresence of humidity by season and the number of new casesof PTB diseases.

    4. Discussion

    In this retrospective study, the incidence reports for pul-monary and MTB disease in Mexico from 2007 to 2017emitted by the General Directorate of Epidemiology wereanalyzed. In a general manner, PTB incidence began toregister a gradual increase. According to the Pan AmericanHealth Organization, Mexico presented a decrease in theincidence of tuberculosis as of 1998; however, the resultsreported here show an increasing trend as of 2011. 5enumber of new cases of PTB registered annually increasedfrom 14550 in 2007 to 15457 in 2011, reaching 17101 casesin 2017 (Table 1). 5is reflected an increase of 17.5% of newcases. In all cases, the reported PTB rate was higher formales than for females (Figure 1). 5is has been reported inanother study that suggests that the age of TB infection isdifferent in women than in men [16, 17]. 5is trendcontinues in MTB (Figure 1), a difference that is oftenattributed to biological and epidemiological characteristics,as well as to socioeconomic and cultural barriers to accesshealth care [18].

    Furthermore, it has been observed that factors such as alow level of socioeconomic status and geographically oreconomically marginalized population, are associated withmorbidity from tuberculosis. 5e poor living conditionsdiminish immunity, making possible the appearance of thedisease. Available reports suggest that 95% of patients withtuberculosis disease live in the low- and middle-incomecountries, especially in southeast Asia [17, 19–21]. 5eWHO estimated that, in the last two decades, there has beena progressive increase in the number of cases of tuber-culosis across the globe due to an increase in incidence ofhuman immunodeficiency virus (HIV), low economicstatus of nations, and migration and emergence of resistantstrains of tuberculosis bacillus [22]. 8–9 million peopledevelop the disease per year, and approximately twomillion people die [19].

    In children, the incidence of tuberculosis followed thesame downward trend as the global incidence in both

    Table 1: New reported cases of tuberculosis during 2007–2017.

    Year Pulmonary tuberculosis Meningeal tuberculosis2007 14550 2172008 15035 2832009 14856 2662010 15384 3712011 15457 2902012 17870 2982013 18093 2712014 18251 3132015 18477 2842016 18929 3732017 17101 422

    Canadian Respiratory Journal 3

  • conditions, with the remark that between 2013 and 2014, thisindicator registered the same value (Figure 2) in the case ofPTB. In 2017, compared to 2007, the incidence of PTB inchildren had decreased by 54%.5is result is important sincethe high morbidity due to tuberculosis in children is par-ticularly relevant in public health, it indicates the high degreeof transmission of Mycobacterium tuberculosis in thecommunity [14]. However, it may be that tuberculosis inchildren is often misdiagnosed and there is a possibility thatcases will be lost.

    5e rate of PTB increases considerably in both sexes, fromthe age of 15, and it shows a considerable increase in olderadults. Inmeningeal tuberculosis, it is important tomention thehigh increase in the incidence rate in the male sex compared tothe female gender. 5e main factors that contributed to theincreasing number of extrarespiratory tuberculosis cases are theincreased number of immunocompromised people and theincrease of elderly segments of the population [23].

    Tuberculosis disease is a contagious infection that un-treated or improperly treated has a significant fatality. It

    20

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    Figure 1: Incidence rate of new cases of PTB and MTB (per 100,000 inhabitants) in male (a) and female (b) in the Mexican territory for2007–2017. Data are expressed in the logarithmic form.

    4 Canadian Respiratory Journal

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    (a)

    Figure 3: Continued.

    Canadian Respiratory Journal 5

  • MéxicoTlaxcala

    ZacatecasAguascalientes

    GuanajuatoCiudad de México

    MichoacánQueretaro

    PueblaHidalgoMorelosYucatán

    JaliscoDurango

    San Luis PotosíCampeche

    Quintana RooCoahuila

    OaxacaChihuahua

    ColimaNuevo León

    ChiapasBaja California Sur

    VeracurzTabascoNayaritSinaloaSonara

    TamaulipasGuerrero

    Baja California Norte0.00 10.00 20.00

    Cases of tuberculosis30.00 40.00 50.00

    Stat

    es o

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    Respiratory tuberculosisMeningeal tuberculosis

    (b)

    Figure 3: Geographic distribution of the incidence rates (per 100,000 populations) of PTB andMTB in theMexican territory for 2007–2017.

    1600

    1400

    1200

    1000

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    400

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    Winter Spring Summer Autumn Winter

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    Figure 4: Seasonal variation of the mean of new cases of PTB and MTB in Mexico during ten years (2007–2017).

    6 Canadian Respiratory Journal

  • affects more commonly the adult population in the mostproductive years and until the end of their lives, thus havingeconomic and social consequences [14]. In the analysis bystates, the highest number of cases was found in BajaCalifornia in both conditions (Figure 3). 5ese results areconsistent with other studies [24, 25] showing the highestincidence and prevalence rates of tuberculosis and multi-drug resistance [26].

    5e factors associated with the high mortality from PTBin Baja California are immigration [27], HIV infection[28–30], multidrug resistance [20], and use of illegal in-travenous drugs [30]. Likewise, this state shares one of thebusiest borders in the world with the United States, whichfacilitates the concentration of immigrants from othercountries and other states. Migrants have several risk factorsthat make them more susceptible to this disease, the mostcommon is the rural-urban internal migration (from thecountryside to the city), but external migration is also aconstant, complex, and changing social phenomenon that cangenerate new social scenarios. Migrants can hardly remainstable in a community, coupled with the limited access tohealth services and difficulties related to political and eco-nomic aspects of social protection and education. 5is is oneof the critical factors that can affect the incidence of TB in allforms and especially meningeal TB. 5is phenomenon couldbe contributing to this resurgence, as migrant peoplereturning to Mexico after living a period of time out of ourcountry in poor health conditions can be spreading thedisease to the susceptible population, and migrants initiallytreated in Mexico and travelling to other countries cannotcomplete a proper treatment schedule [31, 32].

    5e distribution of tuberculosis in the different geo-graphical areas of the country (Figure 3) is affected by the highprevalence and co-incidence of tuberculosis andHIV infection[33–35]. Currently, tuberculosis is considered as a disease thatrepresents the result of an immune imbalance in qualitativeand quantitative terms. Immunological insufficiency maydepend on different clinical and/or social factors, for example,comorbidities such as diabetes mellitus [36–38].

    In Mexico, tuberculosis is associated with diseases such asdiabetes (20%), malnutrition (13%), HIV/AIDS (10%), andalcoholism (6%). 5e importance of this relationship lies inthe fact that these diseases are not only conditioners of tu-berculous infection, but they can also affect the healing andsurvival of the affected people [14]. Regarding the analysis ofgeographical and seasonal distribution of the disease (Fig-ure 4), an increase fromMarch to July was observed, reachinga maximum peak in May, months of high temperature andheavy rains in the center and south of the country that canaffect the immune system and facilitate the dispersion of thepathogen. A sharp decrease during the dry months of Sep-tember and December was observed. Likewise, it is importantto mention that when a tuberculous disease occurs, thesymptoms (cough, fever, night sweats, weight loss, etc.) can bemild for many months. 5is leads to patients delay in seekingmedical attention, which can result in reports that could causean under estimation of cases, and moreover, these patientscould transmit the bacteria to other people. For more than ayear, a patient with tuberculosis can infect 10 to 15 people by

    close contact, if he or she does not have the appropriatetreatment [16]. In Mexico, the purpose of the TuberculosisAction Program is to provide people affected by tuberculosisand the population at risk a better quality of life throughpermanent and integrated actions of promotion, prevention,treatment and surveillance of tuberculosis, and reducing therisk of getting sick and dying from it [14].

    Although the health system inMexico is heterogeneous inorigin, the government has taken on the task of improving itwithout losing sight of the homogenization in elementaryaspects of public health, prevention, diagnosis, and treatment[14]. Due to some problems of functioning of the healthsystem in the management of the disease, such as the lack ofdetection of existing cases, the abandonment of treatmentand, more recently, the appearance of resistance to antitu-berculous drugs [27], the results presented here that show acontinuous increase in the disease, whichmay continue, couldrepresent in the foreseeable future, a serious health problemnot only in the country, but also regionally or globally.

    However, it is important to mention that this study didnot present the cases caused by resistant strains, or if thepatients finished their treatment, these data may be of in-terest for the development of health strategies.

    5. Conclusion

    5is work shows that the increase of cases in the malepopulation presents a continuous increase in the analyzedyears; therefore, it is necessary to implement strategies todetect this disease in the adult population because tuber-culosis could be difficult to recognize in an early stage in thepopulation, and the appearance of resistant strains can causean increase in the incidence of the disease.

    Data Availability

    5e data used to support the findings of this study are in-cluded within the supplementary information file.

    Disclosure

    5e findings and conclusions in this report are those of theauthors and do not necessarily represent the official positionof the General Directorate of Epidemiology.

    Conflicts of Interest

    5e authors declare that they have no conflicts of interestregarding the publication of this article.

    Authors’ Contributions

    Juan Manuel Bello-López and Gregorio León-Garćıa con-tributed equally to this work.

    Supplementary Materials

    5e epidemiological data for the 2007–2017 period were takenfrom themorbidity yearbooks that can be found at http://www.epidemiologia.salud.gob.mx/anuario/html/anuarios.html. 5e

    Canadian Respiratory Journal 7

    http://www.epidemiologia.salud.gob.mx/anuario/html/anuarios.htmlhttp://www.epidemiologia.salud.gob.mx/anuario/html/anuarios.html

  • monthly and annual reports of cases of pneumonia and MTBbetween 2007 and 2017 were published by the GDE. 5e GDEreceives the new reported cases of pulmonary tuberculosisdiseases and meningeal tuberculosis diseases throughout thecountry, monthly and annually. 5e data published on thiswebsite were previously generated and analyzed by the De-partment of Health through its SUAVEweb platform (http://www.sinave.gob.mx). In this supplementary information fileare shown all the cases of pulmonary diseases and MTB bymonth, year, and demographic variables (age group and sex)that were used for this study. (Supplementary Materials)

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