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n
h
a
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it
a
n
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h
e
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o
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th
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se
a
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s
to
a
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e
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o
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n
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a
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d
trea
tme
n
t,
a
n
d
to
m
e
a
su
re
th
e
imp
a
c
t
o
f
t
u
b
e
rc
u
l
o
sis
o
n
p
a
ti
e
n
ts'
q
u
a
li
t
y
o
f
l
ife.
A
c
ro
ss
-
se
c
ti
o
n
a
l
stu
d
y
wa
s
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a
rried
o
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t
o
n
a
sa
m
p
le
o
f
4
8
0
t
u
b
e
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u
l
o
sis
p
a
ti
e
n
ts.
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e
re
su
lt
s
sh
o
we
d
th
a
t
lo
w
e
d
u
c
a
ti
o
n
lev
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ls
(5
3
.
8
6
%
)
a
n
d
h
ig
h
u
n
e
m
p
lo
y
m
e
n
t
(4
0
.
8
%
)
we
re
p
re
v
a
len
t.
M
o
re
t
h
a
n
5
1
%
o
f
p
a
ti
e
n
ts
d
o
n
o
t
h
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v
e
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e
a
lt
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su
ra
n
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e
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g
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e
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sit
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s
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o
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d
with
in
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a
se
d
p
re
v
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e
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n
d
d
iab
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tes
wa
s
fre
q
u
e
n
t
(4
0
.
1
9
%
).
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7
.
5
0
%
u
se
d
m
e
d
ici
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l
p
l
a
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ts,
a
n
d
1
3
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1
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n
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p
ted
m
e
d
ica
ti
o
n
d
u
e
to
l
o
n
g
trea
tme
n
t
d
u
ra
ti
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n
.
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a
les
we
re
m
o
re
sy
m
p
to
m
-
fre
e
(
p
<
0
.
0
0
0
)
.
M
a
les
h
a
d
m
o
re
se
v
e
re
sy
m
p
t
o
m
s
th
a
n
fe
m
a
les
su
c
h
a
s
sp
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tu
m
(
1
6
3
v
s.
5
8
c
a
se
s),
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ig
h
t
lo
ss
(2
2
4
v
s.
1
3
1
c
a
se
s),
c
o
u
g
h
(1
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8
6
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a
se
s),
a
n
d
h
e
m
o
p
ty
sis
(7
0
v
s.
2
7
c
a
se
s).
Urb
a
n
re
sid
e
n
ts
sh
o
we
d
si
g
n
ifi
c
a
n
t
d
if
fe
re
n
c
e
s
in
tu
b
e
rc
u
lo
sis
t
y
p
e
s
(
p
=
0
.
0
3
4
).
O
c
c
u
p
a
ti
o
n
a
n
d
p
rio
r
trea
tme
n
t
in
fl
u
e
n
c
e
d
tu
b
e
rc
u
lo
sis
d
istri
b
u
t
io
n
a
n
d
e
x
trap
u
lmo
n
a
r
y
tu
b
e
rc
u
l
o
sis
p
re
v
a
len
c
e
(
p
=
0
.
0
0
0
).
2
1
.
4
6
%
we
re
p
e
rm
a
n
e
n
tl
y
a
ffe
c
ted
in
th
e
ir
s
o
c
ial
li
fe
.
Hig
h
e
r
e
d
u
c
a
ti
o
n
lev
e
l
a
n
d
n
o
n
-
sm
o
k
i
n
g
wa
s
li
n
k
e
d
t
o
b
e
tt
e
r
h
e
a
lt
h
(
p
=
0
.
0
1
6
;
p
=
0
.
0
0
2
).
Th
e
se
re
su
lt
s
c
o
n
tr
ib
u
te
t
o
a
b
e
tt
e
r
m
a
n
a
g
e
m
e
n
t
o
f
d
iag
n
o
stic,
trea
t
m
e
n
t,
a
n
d
p
re
v
e
n
ti
o
n
stra
teg
ies
a
d
a
p
ted
t
o
tu
b
e
rc
u
l
o
sis
p
a
ti
e
n
ts
b
y
stre
n
g
t
h
e
n
h
e
a
lt
h
e
d
u
c
a
ti
o
n
a
n
d
p
r
o
m
o
te
ra
p
i
d
a
c
c
e
s
s to
sp
e
c
ialist
c
a
re
.
K
ey
w
o
r
d
s
:
Diag
n
o
s
is
Mo
r
o
cc
o
Qu
ality
o
f
life
T
r
ea
tm
en
t
T
u
b
er
cu
l
o
s
is
T
h
is i
s
a
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p
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c
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a
rticle
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n
d
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CC B
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li
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C
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p
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A
uth
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r
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Yo
u
s
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E
l Bah
i
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ab
o
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ato
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f
Ph
ar
m
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A
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d
E
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v
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en
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Facu
lty
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f
Scien
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s
Sem
lalia,
C
ad
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y
y
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Un
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s
ity
B
d
.
Prin
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My
Ab
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B
.
P.
2
3
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T
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W
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Glo
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R
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C
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p
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[
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.
Ho
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I
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8
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p
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Mo
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d
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q
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f life
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and
…
(
Yo
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a
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i
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1161
ac
tio
n
[
2
]
.
T
h
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Ma
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ality
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wh
er
e
p
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lo
s
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ac
co
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n
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f
o
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h
alf
o
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all
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f
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ts
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th
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ities
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s
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C
o
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tr
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Pro
g
r
am
(
PNLT
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,
th
e
e
p
id
em
io
lo
g
ical
s
itu
atio
n
o
f
th
e
d
is
ea
s
e
is
n
o
t
s
atis
f
ac
to
r
y
.
I
n
th
e
Ma
r
r
a
k
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h
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eg
io
n
,
th
e
s
tu
d
y
o
f
tu
b
er
cu
l
o
s
is
is
cr
u
cial
n
o
t
o
n
ly
to
u
n
d
er
s
tan
d
lo
ca
l
ep
id
em
i
o
lo
g
i
ca
l
d
y
n
am
ics,
b
u
t
also
to
r
esp
o
n
d
to
th
e
s
p
ec
if
ic
n
ee
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o
f
t
h
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m
o
s
t
v
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ln
e
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ab
le
p
o
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u
latio
n
s
.
T
h
is
in
v
o
l
v
es
an
aly
zin
g
r
is
k
f
ac
to
r
s
,
o
b
s
tacle
s
to
tr
ea
tm
en
t
a
n
d
im
p
ac
ts
o
n
p
atien
ts
'
q
u
ality
o
f
life
.
T
h
e
aim
o
f
th
is
s
tu
d
y
is
two
f
o
ld
:
f
ir
s
tly
,
to
ass
ess
th
e
ef
f
ec
tiv
en
ess
o
f
cu
r
r
e
n
t
d
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n
o
s
tic
an
d
tr
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tm
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t
s
tr
ateg
ies,
an
d
s
ec
o
n
d
ly
,
to
m
ea
s
u
r
e
th
e
im
p
ac
t
o
f
tu
b
e
r
cu
lo
s
is
o
n
p
atien
ts
'
q
u
ality
o
f
life
.
B
y
also
lo
o
k
in
g
at
ass
o
ciate
d
f
ac
to
r
s
-
b
e
th
e
y
b
eh
av
io
r
al,
s
o
cio
d
em
o
g
r
ap
h
ic
o
r
en
v
ir
o
n
m
en
tal
-
th
is
r
esear
ch
aim
s
to
p
r
o
v
id
e
r
eliab
le,
in
-
d
e
p
th
d
ata
as a
b
asis
f
o
r
tar
g
eted
i
n
ter
v
en
tio
n
s
.
2.
M
E
T
H
O
D
T
y
p
e
an
d
s
ettin
g
o
f
th
e
s
tu
d
y
:
T
h
is
is
a
d
escr
ip
tiv
e
an
d
an
aly
tical
cr
o
s
s
-
s
ec
tio
n
al
s
tu
d
y
b
ased
o
n
a
s
u
r
v
ey
o
n
th
e
d
iag
n
o
s
is
,
tr
ea
tm
en
t,
q
u
ality
o
f
life
,
an
d
ass
o
ciate
d
f
ac
to
r
s
in
th
e
ep
id
em
io
lo
g
y
o
f
tu
b
er
cu
lo
s
is
in
th
e
Ma
r
r
ak
ec
h
-
Saf
i
r
eg
io
n
(
Mo
r
o
cc
o
)
.
T
h
e
s
u
r
v
ey
was
c
o
n
d
u
cte
d
,
b
etwe
en
2
0
2
3
a
n
d
2
0
2
4
.
T
h
e
s
am
p
le
s
ize
(
3
3
2
p
atien
ts
)
was c
alcu
la
ted
ac
co
r
d
in
g
to
(
1
)
.
(
)
=
×
(
−
)
+
(
×
(
−
)
)
(
1
)
W
ith
: N
(
Po
p
u
latio
n
s
ize)
=
2
,
427
n
=
Sam
p
le
s
ize
Z (Z
-
s
co
r
e)
=
1
.
9
6
e
(
s
tan
d
ar
d
e
r
r
o
r
)
=
5
%
p
(
s
tan
d
ar
d
d
ev
iatio
n
)
=
0
.
5
I
n
o
r
d
er
to
r
em
e
d
y
p
r
o
b
a
b
le
b
iases
an
d
o
th
er
p
o
s
s
ib
le
h
az
ar
d
s
,
an
d
to
r
e
p
r
esen
t
th
e
p
o
p
u
latio
n
ac
cu
r
ately
,
we
in
cr
ea
s
ed
th
e
s
am
p
le
s
ize
to
4
8
0
.
W
e
also
ad
o
p
ted
s
tr
atif
ied
s
am
p
lin
g
b
ased
o
n
th
e
p
r
o
p
o
r
tio
n
o
f
th
e
d
is
ea
s
e
in
ea
ch
p
r
o
v
in
ce
.
Par
ticip
an
ts
wer
e
r
an
d
o
m
ly
s
elec
ted
f
r
o
m
p
atien
ts
u
n
d
er
ca
r
e
at
th
e
d
iag
n
o
s
tic
ce
n
ter
s
f
o
r
tu
b
e
r
cu
l
o
s
is
an
d
r
esp
ir
ato
r
y
d
is
ea
s
es (
C
DT
MR)
o
f
th
e
Ma
r
r
ak
ec
h
-
S
af
i r
eg
io
n
.
I
n
clu
s
io
n
c
r
iter
ia:
Patien
ts
with
T
B
,
p
u
lm
o
n
a
r
y
o
r
e
x
tr
a
-
p
u
l
m
o
n
ar
y
,
u
n
d
er
ca
r
e
at
th
e
C
D
T
MRs
o
f
th
e
Ma
r
r
ak
ec
h
-
Saf
i
r
eg
io
n
d
u
r
in
g
th
e
s
tu
d
y
p
e
r
io
d
wer
e
in
clu
d
ed
.
E
x
clu
s
io
n
cr
iter
ia:
Patien
ts
wh
o
wer
e
u
n
d
er
ca
r
e
f
o
r
a
n
o
n
-
tu
b
e
r
c
u
lo
s
is
r
ea
s
o
n
wer
e
ex
clu
d
ed
.
Data
an
aly
s
is
:
th
e
v
ar
iab
le
s
co
n
s
id
er
ed
wer
e
in
d
icate
d
b
y
th
e
s
o
cio
-
d
em
o
g
r
ap
h
ic
ch
ar
ac
ter
is
tics
o
f
th
e
p
o
p
u
latio
n
(
a
g
e,
s
ex
,
s
o
cial
co
v
er
ag
e,
p
r
o
f
ess
io
n
,
h
o
u
s
eh
o
ld
,
an
d
s
m
o
k
in
g
)
,
th
e
tu
b
er
cu
lo
s
is
d
iag
n
o
s
is
,
th
e
co
-
m
o
r
b
i
d
ities
,
tr
ea
tm
en
t,
th
e
weig
h
t
lo
s
s
,
an
d
p
atien
t
o
u
tco
m
e
.
T
h
e
d
ata
wer
e
an
aly
ze
d
u
s
in
g
SP
SS
p
r
o
g
r
am
(
I
B
M®
SP
SS
®
Stati
s
ti
cs
v
er
s
io
n
2
6
)
.
T
o
s
tu
d
y
th
e
ass
o
ciatio
n
b
etwe
e
n
q
u
alitativ
e
v
ar
ia
b
les
we
u
s
ed
Pear
s
o
n
’
s
χ²
test
,
an
d
to
co
m
p
ar
e
th
e
g
r
o
u
p
m
ea
n
s
we
u
s
ed
Stu
d
en
t’
s
t te
s
t o
f
an
d
ANOV
A
test
.
T
h
e
s
ig
n
if
ican
ce
lev
el
o
f
t
h
e
test
s
was
p
<
0
.
0
5
.
T
h
e
d
ata
wer
e
co
llected
a
f
te
r
o
b
tain
in
g
a
u
th
o
r
izatio
n
f
r
o
m
th
e
Ma
r
r
ak
ec
h
-
Saf
i
R
eg
io
n
al
Hea
lth
Au
th
o
r
ity
No
.
7
9
5
6
/2
0
2
1
.
Patien
t
d
ata
wer
e
k
e
p
t
an
o
n
y
m
o
u
s
an
d
co
n
f
id
e
n
tial,
an
d
t
h
e
a
u
th
o
r
s
d
id
n
o
t
h
av
e
ac
ce
s
s
to
an
y
in
f
o
r
m
atio
n
id
e
n
tify
in
g
in
d
i
v
id
u
al
p
a
r
ticip
an
ts
.
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
Acc
o
r
d
in
g
t
o
th
e
r
esu
lts
in
T
ab
le
1
(
s
ee
Ap
p
en
d
ix
)
,
o
u
r
ep
id
em
io
lo
g
ical
s
tu
d
y
o
f
tu
b
er
cu
lo
s
is
r
ev
ea
led
s
ig
n
if
ican
t
tr
en
d
s
a
n
d
v
e
r
y
im
p
o
r
tan
t
f
ac
to
r
s
in
f
lu
en
cin
g
th
e
p
r
ev
alen
ce
o
f
th
e
d
is
ea
s
e
in
th
e
Ma
r
r
ak
ec
h
-
Saf
i
r
eg
io
n
.
Me
n
wer
e
m
o
r
e
af
f
ec
ted
th
an
w
o
m
en
,
with
a
p
r
o
p
o
r
tio
n
o
f
5
6
.
6
7
%
v
er
s
u
s
4
3
.
3
3
%,
an
d
th
e
s
ex
r
atio
(
M/F)
was
1
.
3
1
.
T
h
e
a
g
e
g
r
o
u
p
m
o
s
t
af
f
ec
ted
was
ad
u
lts
(
o
v
er
4
3
%)
o
f
wo
r
k
i
n
g
a
g
e
(
1
5
-
3
4
)
,
h
ig
h
lig
h
tin
g
th
e
d
is
ea
s
e's
p
o
ten
tial
im
p
ac
t
o
n
ec
o
n
o
m
ic
p
r
o
d
u
ctiv
i
ty
.
A
lo
w
lev
el
o
f
ed
u
ca
tio
n
wa
s
co
m
m
o
n
am
o
n
g
p
atie
n
ts
,
with
2
3
.
8
0
%
h
a
v
in
g
n
o
lev
el
o
f
ed
u
ca
tio
n
a
n
d
3
0
.
0
6
%
h
a
v
in
g
o
n
ly
p
r
im
ar
y
ed
u
ca
tio
n
,
wh
ich
m
ay
lim
it
th
eir
ac
ce
s
s
to
h
ea
lth
in
f
o
r
m
atio
n
a
n
d
ca
r
e
s
er
v
ices.
T
h
e
p
r
ev
alen
ce
o
f
u
n
em
p
lo
y
m
en
t
was
also
n
o
ta
b
le
,
with
4
0
.
8
%
o
f
p
atien
ts
u
n
em
p
lo
y
e
d
.
Ar
o
u
n
d
h
alf
o
f
al
l
p
atien
ts
wer
e
n
o
t
co
v
er
ed
b
y
s
o
cial
s
ec
u
r
ity
,
an
d
o
v
er
5
1
%
o
f
b
en
ef
iciar
ies
wer
e
co
v
er
ed
b
y
R
AM
E
D
(
Me
d
ical
Ass
is
tan
ce
Sch
em
e)
o
r
AM
O
T
ad
am
o
n
(
co
m
p
u
ls
o
r
y
h
ea
lth
in
s
u
r
an
ce
f
o
r
p
e
o
p
le
u
n
ab
le
to
p
ay
th
eir
co
n
tr
ib
u
tio
n
s
)
,
h
ig
h
lig
h
tin
g
th
e
ch
allen
g
es
o
f
ac
ce
s
s
to
h
ea
lth
ca
r
e
an
d
ea
r
ly
d
etec
tio
n
o
f
T
B
.
Fo
r
th
e
co
r
r
elatio
n
b
etwe
en
h
o
u
s
in
g
d
en
s
ity
a
n
d
d
is
ea
s
e
p
r
ev
alen
ce
.
I
t
ap
p
ea
r
s
th
at
h
o
u
s
eh
o
ld
s
with
two
r
o
o
m
s
wer
e
th
e
m
o
s
t
af
f
ec
ted
,
ac
co
u
n
tin
g
f
o
r
4
0
.
5
0
%
o
f
c
ase
s
,
f
o
llo
wed
b
y
th
o
s
e
with
th
r
e
e
r
o
o
m
s
at
3
3
.
4
0
%.
Fu
r
t
h
er
m
o
r
e,
t
h
e
d
is
tr
ib
u
tio
n
o
f
ca
s
es
ac
co
r
d
in
g
t
o
th
e
n
u
m
b
er
o
f
p
eo
p
le
p
er
h
o
u
s
eh
o
ld
s
h
o
wed
th
at
s
ix
-
p
e
r
s
o
n
h
o
u
s
eh
o
ld
s
wer
e
th
e
m
o
s
t
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
14
,
No
.
3
,
Sep
tem
b
er
20
25
:
1
1
6
0
-
1
1
7
0
1162
af
f
ec
ted
,
with
2
3
.
2
2
%
o
f
ca
s
e
s
s
u
r
v
ey
ed
.
T
h
ese
r
esu
lts
s
u
g
g
est
an
in
c
r
ea
s
ed
r
is
k
o
f
tu
b
er
c
u
lo
s
is
tr
an
s
m
is
s
io
n
in
s
m
all
liv
in
g
s
p
ac
es,
in
d
icatin
g
th
at
p
r
e
v
en
tio
n
s
tr
ateg
ies
s
h
o
u
ld
p
r
im
ar
ily
tar
g
et
h
ig
h
-
d
en
s
ity
h
o
u
s
eh
o
ld
s
o
cc
u
p
y
i
n
g
s
m
all
s
p
ac
es.
T
h
e
m
ajo
r
ity
o
f
p
r
o
b
ab
le
tu
b
e
r
cu
l
o
s
is
in
f
ec
tio
n
s
wer
e
ass
o
ciate
d
with
an
u
n
k
n
o
wn
p
lace
o
f
r
esid
en
ce
,
ac
co
u
n
tin
g
f
o
r
7
2
.
9
2
%
o
f
ca
s
es,
an
d
th
e
f
am
ily
s
ettin
g
was
th
e
s
ec
o
n
d
m
o
s
t
co
m
m
o
n
p
lace
o
f
in
f
ec
tio
n
.
A
s
ig
n
if
ican
t
p
r
o
p
o
r
tio
n
o
f
T
B
p
atien
ts
also
s
u
f
f
er
f
r
o
m
o
th
e
r
illn
ess
es,
with
d
iab
etes
b
ein
g
th
e
m
o
s
t
f
r
eq
u
en
t
co
m
o
r
b
id
ity
(
4
0
.
1
9
%
o
f
ca
s
es
with
co
m
o
r
b
i
d
ities
)
,
f
o
llo
wed
b
y
ar
ter
ial
h
y
p
er
ten
s
io
n
(
AH)
an
d
an
em
ia.
T
h
is
co
ex
is
ten
ce
o
f
d
is
ea
s
es
ca
n
co
m
p
lic
ate
th
e
d
iag
n
o
s
is
an
d
tr
ea
tm
en
t
o
f
tu
b
er
c
u
lo
s
is
.
I
n
ad
d
itio
n
,
it
is
in
ter
esti
n
g
to
n
o
te
th
at
o
v
er
4
1
%
o
f
p
atie
n
ts
h
ad
u
s
ed
tr
ea
tm
en
ts
p
r
i
o
r
to
c
o
n
s
u
ltin
g
th
e
tu
b
er
cu
lo
s
is
an
d
r
esp
ir
ato
r
y
d
is
ea
s
e
d
iag
n
o
s
tic
ce
n
ter
(
C
DT
MR),
with
a
p
r
ed
o
m
in
an
ce
o
f
th
e
u
s
e
o
f
s
ev
er
a
l
d
r
u
g
s
,
in
clu
d
in
g
a
n
tib
io
tics
,
an
ti
-
in
f
lam
m
ato
r
ies
,
an
d
an
alg
esics
.
Pu
lm
o
n
ar
y
tu
b
er
c
u
l
o
s
is
was
th
e
m
o
s
t
co
m
m
o
n
f
o
r
m
o
f
th
e
d
is
ea
s
e
,
b
u
t
a
s
ig
n
if
ican
t
p
r
o
p
o
r
tio
n
o
f
ex
tr
ap
u
lm
o
n
ar
y
ca
s
es
wer
e
also
p
r
esen
t.
T
h
e
m
o
s
t
co
m
m
o
n
s
y
m
p
t
o
m
s
in
cl
u
d
e
f
e
v
er
a
n
d
weig
h
t
lo
s
s
,
an
d
th
e
m
aj
o
r
ity
o
f
ca
s
es
wer
e
d
is
co
v
er
ed
f
o
llo
win
g
th
e
o
n
s
et
o
f
s
y
m
p
to
m
s
.
All
p
atien
ts
r
ec
eiv
ed
tr
ea
tm
en
t
p
r
escr
ib
ed
b
y
a
d
o
c
to
r
,
b
u
t
s
o
m
e
p
atien
ts
r
ep
o
r
ted
ad
v
er
s
e
ef
f
ec
ts
.
A
s
ig
n
if
ican
t
p
r
o
p
o
r
tio
n
o
f
p
atien
ts
u
s
e
m
ed
icin
al
p
lan
ts
(
2
7
.
5
%).
T
h
e
m
ajo
r
ity
o
f
p
atien
ts
r
esp
ec
ted
th
e
d
o
ct
o
r
'
s
r
ec
o
m
m
en
d
atio
n
s
(
9
5
.
4
2
%),
b
u
t
s
o
m
e
p
atien
ts
s
to
p
p
ed
tak
in
g
th
eir
m
ed
icatio
n
wh
e
n
th
ey
f
elt
b
etter
(
8
.
4
5
%),
s
o
m
e
f
o
r
g
o
t
to
tak
e
th
ei
r
m
ed
i
ca
tio
n
(
2
4
.
2
5
%)
,
an
d
m
o
r
e
t
h
an
4
2
%
f
o
u
n
d
th
e
tr
ea
tm
en
t
r
estrictiv
e
b
ec
au
s
e
o
f
its
u
n
d
esira
b
le
ef
f
ec
ts
in
7
7
.
3
6
%
o
f
ca
s
es.
R
eg
ar
d
in
g
tr
ea
tm
en
t
ad
h
er
e
n
ce
,
1
3
.
1
1
%
o
f
p
atien
ts
(
4
8
in
d
iv
i
d
u
als)
ad
m
it
to
in
ter
r
u
p
tin
g
t
h
eir
m
ed
icatio
n
b
ec
a
u
s
e
o
f
th
e
lo
n
g
d
u
r
atio
n
o
f
tr
ea
tm
en
t.
T
h
is
ca
n
lead
to
d
r
u
g
r
esis
tan
ce
an
d
r
elap
s
e.
I
n
t
er
m
s
o
f
p
er
ce
iv
e
d
e
f
f
icac
y
,
1
.
0
4
%
o
f
p
atien
ts
(
5
in
d
iv
id
u
als)
d
o
n
o
t
b
eliev
e
th
a
t
p
r
escr
ib
ed
m
e
d
icatio
n
will
im
p
r
o
v
e
th
eir
h
ea
lth
,
an
d
1
3
.
3
3
%
(
6
4
in
d
iv
id
u
als)
ar
e
u
n
ce
r
tain
.
T
h
is
m
is
tr
u
s
t
o
r
u
n
ce
r
tain
ty
ca
n
ad
v
e
r
s
ely
af
f
ec
t
co
m
p
lian
ce
with
tr
ea
tm
en
t.
I
n
ter
m
s
o
f
n
u
tr
itio
n
,
8
3
.
5
4
%
o
f
p
atien
ts
(
4
0
1
in
d
iv
id
u
als)
ch
an
g
ed
t
h
e
ir
n
u
tr
itio
n
al
h
ab
its
af
ter
th
e
d
is
ea
s
e.
C
h
an
g
es
in
d
ietar
y
h
ab
its
af
ter
d
iag
n
o
s
is
wer
e
s
tatis
tica
lly
r
elate
d
(
ac
co
r
d
in
g
to
Stu
d
en
t'
s
T
test
)
to
th
e
am
o
u
n
t
o
f
weig
h
t
lo
s
t
d
u
e
to
illn
ess
(
F
=
1
3
.
6
2
6
,
d
o
f
=
4
6
4
,
p
<0
.
0
0
1
)
,
a
n
d
t
h
e
co
r
r
elatio
n
b
etwe
en
th
e
a
m
o
u
n
t
o
f
weig
h
t
lo
s
t
d
u
e
to
illn
ess
an
d
g
en
er
al
h
ea
lth
s
tatu
s
af
ter
tr
ea
tm
en
t w
as h
ig
h
ly
s
ig
n
if
ican
t a
cc
o
r
d
in
g
t
o
th
e
ANOV
A
test
(
F
=
9
9
1
.
6
7
,
d
o
f
=
4
,
p
<0
.
0
0
1
)
.
Fin
ally
,
th
e
s
o
cial
im
p
ac
t
o
f
t
u
b
er
cu
lo
s
is
was
s
ig
n
if
ican
t:
2
1
.
4
6
%
o
f
p
atien
ts
(
1
0
3
in
d
iv
id
u
als)
wer
e
p
er
m
an
en
tly
b
o
th
er
ed
b
y
th
eir
co
n
d
itio
n
in
t
h
eir
s
o
cial
life
,
an
d
1
7
.
7
1
%
(
8
5
in
d
iv
id
u
als)
in
d
icate
d
th
at
t
h
e
d
is
ea
s
e
ca
n
h
av
e
p
r
o
f
o
u
n
d
c
o
n
s
eq
u
en
ce
s
o
n
s
o
cial
in
ter
ac
tio
n
s
an
d
em
o
tio
n
al
well
-
b
ein
g
.
T
h
ese
r
esu
lts
h
ig
h
lig
h
t
th
e
im
p
o
r
tan
ce
o
f
a
n
i
n
teg
r
ated
a
p
p
r
o
ac
h
t
o
T
B
m
a
n
ag
em
en
t,
in
clu
d
i
n
g
h
ea
lth
ed
u
ca
tio
n
,
im
p
r
o
v
i
n
g
a
cc
ess
to
h
ea
l
th
ca
r
e,
s
tr
en
g
th
en
in
g
s
o
cial
co
v
er
ag
e
s
y
s
tem
s
,
an
d
co
n
tin
u
in
g
to
m
o
n
ito
r
in
te
r
v
en
in
g
f
ac
to
r
s
to
b
etter
u
n
d
e
r
s
tan
d
an
d
ef
f
ec
tiv
ely
co
m
b
at
T
B
in
th
e
Ma
r
r
ak
e
ch
-
Saf
i r
eg
io
n
.
T
h
is
s
tu
d
y
s
h
o
ws
th
at
m
ales
ar
e
m
o
r
e
af
f
ec
ted
b
y
tu
b
er
c
u
lo
s
is
th
an
f
em
ales,
5
6
.
6
7
%
v
er
s
u
s
4
3
.
3
3
%,
an
d
th
e
s
ex
r
atio
(
M/F)
is
1
.
3
1
.
T
h
is
p
r
e
d
o
m
in
a
n
ce
o
f
m
al
es
is
o
b
s
er
v
ed
in
s
ev
er
al
s
tu
d
ies:
m
ales
ar
e
at
a
h
ig
h
er
r
is
k
o
f
b
ein
g
af
f
ec
te
d
b
y
My
co
b
ac
ter
i
u
m
T
u
b
er
cu
lo
s
is
th
an
f
em
ales
[
3
]
,
[
4
]
.
Un
d
er
-
r
e
p
o
r
tin
g
b
y
f
em
ales
m
ay
b
e
ass
o
ciate
d
with
ac
ce
s
s
to
h
ea
lth
ca
r
e
s
er
v
ices
an
d
th
e
q
u
ality
o
f
s
p
u
tu
m
s
am
p
les
u
s
ed
f
o
r
test
s
[
5
]
.
I
t
co
u
ld
also
b
e
d
u
e
to
m
ale
s
o
cial
an
d
p
r
o
f
ess
io
n
al
ac
tiv
ities
,
wh
ich
m
ay
ex
p
o
s
e
th
em
m
o
r
e
to
tu
b
er
cu
lo
s
is
[
3
]
.
A
lo
w
lev
el
o
f
ed
u
ca
tio
n
was
co
m
m
o
n
am
o
n
g
p
atien
ts
,
wh
ich
m
ay
lim
it
th
eir
ac
ce
s
s
to
h
ea
lth
in
f
o
r
m
atio
n
an
d
ca
r
e
s
er
v
ices.
Hig
h
er
e
d
u
ca
tio
n
lev
els
ar
e
ass
o
ciate
d
with
in
cr
ea
s
ed
p
a
tien
t
awa
r
en
ess
o
f
ca
r
e
an
d
im
p
r
o
v
ed
k
n
o
wled
g
e
o
f
tu
b
e
r
cu
lo
s
is
in
f
ec
tio
n
,
in
clu
d
in
g
p
r
ev
en
tio
n
,
tr
ea
t
m
en
t,
an
d
m
ea
n
s
o
f
in
f
ec
tio
n
.
T
h
is
h
as
b
ee
n
d
em
o
n
s
tr
ated
in
s
tu
d
ies
co
n
d
u
cte
d
in
co
u
n
tr
ies
with
h
ig
h
tu
b
e
r
cu
lo
s
is
in
cid
en
ce
,
in
clu
d
in
g
U
g
an
d
a,
B
an
g
lad
es
h
,
an
d
Pak
is
tan
[
6
]
–
[
8
]
.
T
h
e
le
v
el
o
f
e
d
u
ca
tio
n
h
ad
an
im
p
ac
t
o
n
p
atien
ts
'
h
ea
lth
s
tatu
s
,
with
u
n
ed
u
ca
ted
in
d
iv
i
d
u
als
ten
d
in
g
to
d
escr
ib
e
th
ei
r
h
ea
lth
as
"p
o
o
r
"
o
r
"m
ed
i
o
c
r
e"
d
em
o
n
s
tr
atin
g
th
at
ed
u
ca
tio
n
al
lev
el
is
a
d
eter
m
in
in
g
f
ac
to
r
in
t
h
e
p
er
ce
p
tio
n
o
f
h
ea
lth
s
tatu
s
am
o
n
g
t
h
ese
p
atien
ts
.
T
u
b
er
cu
l
o
s
is
is
s
ee
n
as
a
d
is
ea
s
e
o
f
p
o
v
e
r
ty
a
n
d
an
i
n
d
ic
ato
r
o
f
lo
w
s
o
cio
-
ec
o
n
o
m
ic
s
tatu
s
[
9
]
.
Alth
o
u
g
h
th
e
ass
o
ciatio
n
b
etwe
en
s
o
cio
-
ec
o
n
o
m
ic
v
ar
ia
b
les
an
d
in
cr
ea
s
ed
tu
b
er
cu
lo
s
is
r
elap
s
es
h
as
n
ev
er
b
ee
n
p
r
o
v
en
,
p
o
v
er
ty
m
a
y
,
in
ce
r
tain
s
itu
atio
n
s
,
ac
t
in
d
ir
ec
tly
th
r
o
u
g
h
th
e
u
s
e
o
f
in
ad
eq
u
ate
tr
ea
tm
en
t
[
1
0
]
.
T
h
is
ca
n
b
e
co
n
f
ir
m
e
d
b
y
o
u
r
r
esu
lts
,
wh
ich
s
h
o
w
th
at
4
0
.
8
%
o
f
p
atien
ts
ar
e
u
n
em
p
lo
y
e
d
,
an
d
b
y
th
e
lar
g
e
n
u
m
b
er
o
f
p
atien
ts
wh
o
h
a
v
e
n
o
m
ed
ical
-
s
o
cial
co
v
e
r
ag
e
,
h
ig
h
lig
h
tin
g
th
e
c
h
allen
g
es
o
f
a
cc
ess
to
h
ea
lth
ca
r
e
an
d
ea
r
ly
d
etec
tio
n
o
f
T
B
.
I
t
is
in
ter
esti
n
g
to
n
o
te
th
a
t
th
e
co
r
r
elatio
n
b
etwe
en
h
o
u
s
in
g
d
en
s
ity
,
n
u
m
b
er
o
f
p
eo
p
le
p
er
h
o
u
s
eh
o
ld
,
an
d
d
is
ea
s
e
p
r
ev
alen
ce
s
h
o
ws
th
at
two
-
r
o
o
m
h
o
u
s
eh
o
ld
s
ar
e
th
e
m
o
s
t
af
f
ec
ted
,
with
4
0
.
5
0
%
o
f
ca
s
es
,
an
d
th
at
s
ix
-
p
er
s
o
n
h
o
u
s
eh
o
ld
s
ar
e
th
e
m
o
s
t
af
f
ec
ted
,
ac
co
u
n
tin
g
f
o
r
2
3
.
2
2
%
o
f
ca
s
es.
Pre
v
io
u
s
s
tu
d
ies
h
av
e
s
h
o
wn
a
p
o
s
itiv
e
co
r
r
elatio
n
b
etwe
en
h
o
u
s
eh
o
ld
o
v
er
c
r
o
wd
in
g
an
d
th
e
in
cid
e
n
ce
o
f
tu
b
er
c
u
lo
s
is
[
1
1
]
,
esp
ec
ially
in
p
o
p
u
latio
n
s
with
m
o
r
e
th
a
n
two
p
e
o
p
le
p
er
r
o
o
m
,
in
d
e
v
elo
p
e
d
c
o
u
n
tr
ies,
s
u
ch
as
I
taly
,
Un
ited
States
(
wh
er
e
th
e
r
ate
o
f
h
o
u
s
eh
o
ld
s
with
m
o
r
e
t
h
an
o
n
e
o
cc
u
p
an
t
p
er
r
o
o
m
is
h
ig
h
)
[
1
2
]
.
I
n
W
est
Af
r
ica,
h
o
u
s
eh
o
ld
s
with
6
to
1
0
ad
u
lt
s
o
r
m
o
r
e
th
an
1
0
ad
u
lts
h
ad
a
h
ig
h
er
r
is
k
o
f
tu
b
er
cu
lo
s
is
th
an
h
o
u
s
eh
o
ld
s
with
f
ewe
r
th
an
5
p
eo
p
le
[
1
3
]
.
T
h
e
s
e
r
esu
lts
s
u
g
g
est
an
in
cr
ea
s
ed
r
is
k
o
f
tu
b
er
cu
l
o
s
is
tr
an
s
m
is
s
io
n
in
s
m
all
liv
in
g
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
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8
8
0
6
E
p
id
emio
lo
g
y
o
f tu
b
ercu
lo
s
is
in
Mo
r
o
cc
o
:
d
i
a
g
n
o
s
is
,
tr
ea
tm
en
t,
q
u
a
lity o
f life
,
and
…
(
Yo
u
s
s
ef
E
l B
a
h
i
)
1163
s
p
a
ce
s
,
wh
ich
m
ea
n
s
th
at
p
r
ev
en
tio
n
s
tr
ateg
ies
s
h
o
u
ld
p
r
im
ar
ily
tar
g
et
h
ig
h
-
d
en
s
ity
h
o
u
s
eh
o
ld
s
wh
er
e
s
m
all
s
p
ac
es a
r
e
o
cc
u
p
ied
b
y
a
la
r
g
e
n
u
m
b
e
r
o
f
p
eo
p
le
.
I
t
is
also
in
ter
esti
n
g
to
n
o
te
th
at
o
v
er
4
1
%
o
f
p
atien
ts
h
ad
b
ee
n
tr
ea
ted
with
an
ti
b
io
tics
,
an
ti
-
in
f
lam
m
ato
r
ies
,
an
d
a
n
alg
esics
,
b
ef
o
r
e
b
ein
g
r
ef
er
r
ed
to
th
e
T
u
b
er
cu
l
o
s
is
an
d
R
esp
ir
ato
r
y
Dis
ea
s
e
D
iag
n
o
s
tic
C
en
ter
(
C
DT
MR).
T
h
is
co
u
ld
in
d
icate
a
ten
d
en
cy
t
o
war
d
s
s
elf
-
m
ed
icatio
n
o
r
n
o
n
-
s
p
ec
if
ic
p
r
escr
ip
tio
n
s
b
ef
o
r
e
t
h
e
d
iag
n
o
s
is
o
f
tu
b
er
cu
lo
s
is
h
as
b
ee
n
co
n
f
ir
m
e
d
.
A
s
tu
d
y
ca
r
r
ie
d
o
u
t
in
Pak
is
tan
s
h
o
wed
t
h
at
o
v
e
r
5
0
%
o
f
p
atien
ts
p
r
ac
ticed
s
elf
-
tr
ea
tm
en
t,
an
d
4
2
%
o
f
th
em
h
ad
f
ir
s
t
u
s
ed
tr
ea
tm
e
n
ts
f
o
r
t
h
eir
T
B
s
y
m
p
to
m
s
[
1
4
]
.
T
h
is
p
r
o
b
lem
o
f
s
elf
-
m
ed
icatio
n
was
also
h
ig
h
lig
h
te
d
b
y
L
iam
a
n
d
T
a
n
g
[
1
5
]
.
T
h
ese
p
r
ac
tices
ca
n
co
n
tr
ib
u
te
to
d
r
u
g
r
esis
tan
ce
,
wh
ich
is
a
m
ajo
r
c
o
n
ce
r
n
in
th
e
tr
ea
tm
en
t
o
f
th
e
d
is
ea
s
e.
T
h
e
2
5
%
o
f
p
atien
ts
r
ep
o
r
ted
u
s
in
g
m
e
d
icin
al
h
e
r
b
s
.
Acc
o
r
d
in
g
to
th
e
Ar
y
a
s
tu
d
y
,
th
e
u
s
e
o
f
m
ed
icin
al
p
lan
ts
h
as
b
ee
n
en
co
u
r
a
g
ed
to
p
alliate
th
e
s
id
e
ef
f
ec
ts
o
f
an
ti
-
tu
b
e
r
cu
lo
s
is
d
r
u
g
s
[
1
6
]
.
I
n
o
u
r
s
tu
d
y
,
u
n
d
e
s
ir
ab
le
ef
f
ec
ts
wer
e
p
r
esen
ted
in
7
7
.
3
6
%
o
f
ca
s
es.
T
r
ad
itio
n
al
C
h
in
ese
m
ed
icin
e
tr
ea
ts
tu
b
er
cu
lo
s
is
with
a
c
o
m
b
in
atio
n
o
f
a
n
ti
-
b
ac
ter
ial
tr
ea
tm
en
ts
an
d
liv
e
r
-
p
r
o
tectin
g
h
e
r
b
s
[
1
7
]
.
Oth
e
r
r
esu
lts
s
h
o
w
th
at
m
o
s
t
T
B
p
atien
ts
u
s
e
b
o
th
b
io
m
ed
ical
an
d
tr
ad
itio
n
al
m
e
th
o
d
s
to
m
a
n
ag
e
T
B
[
1
1
]
,
wh
ich
m
ay
b
e
a
r
ef
lectio
n
o
f
c
u
ltu
r
al
cu
s
to
m
s
o
r
a
lack
o
f
tr
u
s
t
in
m
o
d
er
n
m
e
d
i
cin
e.
T
h
e
1
3
.
3
3
%
o
f
i
n
d
iv
id
u
als
ar
e
u
n
ce
r
tain
th
at
p
r
escr
ib
ed
m
ed
icatio
n
will
im
p
r
o
v
e
t
h
eir
h
ea
lth
.
T
h
is
m
is
tr
u
s
t o
r
u
n
ce
r
tain
ty
ca
n
ad
v
er
s
ely
af
f
ec
t c
o
m
p
lian
ce
with
tr
e
atm
en
t.
W
ith
r
eg
ar
d
to
n
u
t
r
itio
n
,
o
u
r
f
in
d
in
g
s
s
h
o
w
t
h
at
ar
o
u
n
d
8
4
%
o
f
s
u
b
jects
ch
an
g
ed
th
eir
e
atin
g
h
ab
its
af
ter
b
ein
g
af
f
ec
ted
b
y
th
e
d
is
ea
s
e.
Ap
p
r
o
x
im
ately
s
im
ilar
r
esu
lts
ar
e
f
o
u
n
d
in
an
o
th
er
s
tu
d
y
,
wh
ich
s
tates
th
at
7
9
.
5
%
T
B
p
atien
ts
ar
e
u
n
d
er
n
o
u
r
is
h
e
d
[
1
8
]
.
Acc
o
r
d
i
n
g
to
th
e
s
am
e
s
tu
d
y
,
u
n
d
er
n
u
tr
itio
n
was
m
o
r
e
co
m
m
o
n
(
8
3
.
3
%)
in
p
atien
ts
u
n
d
er
g
o
in
g
in
te
n
s
iv
e
th
er
ap
y
th
an
in
n
ewly
d
iag
n
o
s
ed
p
atien
t
s
(
7
6
.
3
%).
T
u
b
er
cu
l
o
s
is
h
as
a
s
ig
n
if
ican
t
s
o
cial
im
p
ac
t
o
f
p
atien
ts
.
I
n
d
ee
d
,
3
9
%
o
f
p
atien
ts
r
ep
o
r
ted
b
ein
g
p
er
m
an
en
tly
o
r
o
f
ten
af
f
ec
ted
b
y
th
e
d
is
ea
s
e,
wh
ich
co
u
ld
h
av
e
p
r
o
f
o
u
n
d
co
n
s
eq
u
e
n
ce
s
o
n
th
eir
s
o
cial
in
ter
ac
tio
n
s
an
d
em
o
tio
n
al
w
ell
-
b
ein
g
.
T
h
ese
r
esu
lts
h
ig
h
lig
h
t
th
e
im
p
o
r
tan
ce
o
f
a
n
in
te
g
r
ated
a
p
p
r
o
ac
h
t
o
T
B
m
an
ag
em
en
t,
in
cl
u
d
in
g
asp
ec
ts
o
f
q
u
ality
o
f
life
a
n
d
s
o
c
ial
in
ter
ac
tio
n
s
.
3
.
1
.
Dis
t
ributio
n
o
f
pu
lm
o
na
ry
a
nd
ex
t
ra
-
pu
lm
o
na
ry
t
ub
er
culo
s
is
ca
s
es
a
cc
o
rding
t
o
v
a
rio
us
dem
o
g
ra
ph
ic
f
a
ct
o
rs
As
s
h
o
wn
in
T
ab
le
2
,
o
u
r
s
tu
d
y
h
ig
h
lig
h
ted
s
ig
n
if
ican
t
d
i
f
f
er
en
ce
s
in
th
e
d
is
tr
ib
u
tio
n
o
f
p
u
lm
o
n
a
r
y
(
PMT
)
an
d
ex
tr
a
-
p
u
lm
o
n
a
r
y
tu
b
er
cu
lo
s
is
(
E
PT)
ac
co
r
d
in
g
to
v
ar
io
u
s
d
em
o
g
r
ap
h
ic
f
ac
to
r
s
.
Me
n
s
h
o
wed
a
h
ig
h
er
p
r
ev
alen
ce
o
f
PMT
(
1
8
3
ca
s
es)
co
m
p
ar
ed
t
o
wo
m
en
(
8
0
ca
s
es),
wh
ile
wo
m
e
n
s
h
o
wed
a
h
ig
h
er
n
u
m
b
er
o
f
E
PT
(
1
2
8
ca
s
es)
co
m
p
ar
ed
to
m
e
n
(
8
9
ca
s
e
s
)
,
with
h
ig
h
ly
m
ar
k
ed
s
tatis
tical
s
ig
n
if
ican
ce
(
p
=
0
.
0
0
0
)
.
Hab
itat
p
r
o
v
ed
t
o
b
e
a
d
eter
m
in
in
g
f
ac
to
r
,
u
r
b
an
r
esid
en
ts
h
av
in
g
p
u
lm
o
n
ar
y
T
B
with
1
1
0
o
f
ca
s
es
an
d
ex
tr
a
p
u
lm
o
n
ar
y
T
B
with
1
1
5
ca
s
es,
in
d
icatin
g
s
tatis
tical
s
ig
n
if
ican
ce
(
p
=
0
.
0
3
4
)
.
R
u
r
al
an
d
p
er
i
-
u
r
b
an
a
r
ea
s
s
h
o
wed
d
if
f
er
en
t
d
is
tr
ib
u
tio
n
s
with
o
u
t n
o
tab
le
s
tatis
tical
s
ig
n
if
ican
ce
.
Occ
u
p
atio
n
also
in
f
lu
e
n
ce
d
t
h
e
d
is
tr
ib
u
tio
n
o
f
p
u
lm
o
n
ar
y
an
d
ex
tr
a
p
u
lm
o
n
ar
y
T
B
.
U
n
em
p
lo
y
e
d
in
d
iv
id
u
als
r
ec
o
r
d
ed
PT
in
9
2
o
f
ca
s
es
an
d
E
PT
in
1
0
4
o
f
ca
s
es,
wh
ile
wo
r
k
er
s
wer
e
m
o
r
e
af
f
ec
ted
b
y
PT
(
9
3
ca
s
es)
th
an
E
PT
(
4
0
ca
s
es)
,
h
ig
h
lig
h
tin
g
a
s
ig
n
if
ica
n
t
d
if
f
er
en
ce
(
p
=
0
.
0
0
0
)
.
T
h
e
o
th
er
p
r
o
f
ess
io
n
al
ca
teg
o
r
ies
s
h
o
wed
v
ar
y
in
g
tr
e
n
d
s
with
o
u
t
p
r
o
n
o
u
n
ce
d
s
tatis
tical
s
ig
n
if
ican
ce
.
R
eg
ar
d
in
g
t
h
e
u
s
e
o
f
tr
ea
tm
en
t
b
ef
o
r
e
g
o
in
g
to
th
e
h
o
s
p
ital,
th
o
s
e
wh
o
r
ec
eiv
ed
n
o
p
r
io
r
tr
ea
tm
en
t
h
ad
h
ig
h
er
ex
tr
a
p
u
lm
o
n
ar
y
T
B
(
1
6
3
ca
s
es)
co
m
p
ar
ed
to
th
o
s
e
wh
o
d
id
(
5
4
ca
s
es),
with
a
s
ig
n
if
ican
t
d
if
f
er
en
ce
(
p
=
0
.
0
0
0
)
.
Fin
ally
,
th
e
p
r
esen
c
e
o
f
o
th
er
co
n
c
o
m
itan
t
d
is
ea
s
es
s
h
o
wed
n
o
s
ig
n
if
ican
t
co
r
r
elat
io
n
with
tu
b
er
cu
lo
s
is
(
P=0
.
1
9
1
)
,
wh
ich
s
u
g
g
ests
th
at
tu
b
er
cu
lo
s
is
ca
n
d
e
v
elo
p
i
n
d
ep
en
d
en
tly
o
f
o
th
e
r
h
ea
lth
c
o
n
d
itio
n
s
.
R
eg
ar
d
in
g
th
e
T
B
f
o
r
m
,
wo
m
en
ar
e
m
o
r
e
im
p
ac
ted
b
y
E
PT
(
6
1
.
5
4
%
E
PT
v
s
.
3
8
.
4
6
%
PMT
)
wh
ile
m
en
ar
e
m
o
r
e
af
f
ec
ted
b
y
PM
T
(
6
7
.
2
8
%
PMT
v
s
.
3
2
.
7
2
%
E
T
)
.
T
h
e
s
am
e
r
esu
lts
h
av
e
b
ee
n
r
ep
o
r
te
d
b
y
o
th
e
r
r
esear
ch
er
s
in
Mo
r
o
cc
o
[
1
9
]
an
d
o
th
e
r
co
u
n
tr
ies
lik
e
I
r
a
n
[
2
0
]
an
d
Nig
e
r
[
2
1
]
.
Ur
b
an
r
esid
en
ts
ar
e
m
o
r
e
lik
ely
to
d
ev
elo
p
E
T
P
th
an
r
u
r
al/p
er
i
-
u
r
b
an
wh
er
e
th
e
m
o
s
t
f
r
eq
u
en
t
ca
s
es
ar
e
p
u
lm
o
n
ar
y
tu
b
e
r
cu
lo
s
is
(
PMT
)
,
an
d
th
e
s
am
e
r
esu
lt
was
f
o
u
n
d
b
y
C
h
ah
b
o
u
n
e
et
a
l.
[
1
9
]
.
T
h
is
d
if
f
er
en
ce
i
n
th
e
in
cid
en
ce
o
f
p
u
lm
o
n
a
r
y
T
B
ca
n
b
e
ex
p
lain
ed
b
y
t
h
e
f
ac
t o
f
d
if
f
e
r
en
t liv
in
g
co
n
d
itio
n
s
a
n
d
h
ea
lth
ca
r
e
ac
ce
s
s
.
So
m
e
o
cc
u
p
atio
n
s
m
ay
e
x
p
o
s
e
in
d
iv
id
u
als
to
d
if
f
er
e
n
t
r
is
k
f
ac
t
o
r
s
.
Peo
p
le
in
co
n
tact
with
tu
b
er
cu
lo
s
is
p
atien
ts
in
en
cl
o
s
ed
wo
r
k
s
p
ac
es
a
r
e
m
o
r
e
li
k
ely
to
b
e
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ted
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m
o
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o
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u
p
atio
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e
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e
u
n
em
p
lo
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d
in
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d
s
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ts
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m
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wh
ile
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d
d
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Ou
r
r
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f
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r
m
ed
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n
ea
r
lie
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Un
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States
s
tu
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d
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t
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m
e
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cc
u
p
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m
ay
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ab
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f
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p
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r
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f
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m
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[
2
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an
d
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s
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ies s
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s
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m
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[
2
3
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,
[
2
4
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C
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n
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tr
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t
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ef
o
r
e
g
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n
g
to
h
o
s
p
ital,
th
e
m
ajo
r
ity
o
f
E
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p
at
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ts
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ad
n
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v
er
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s
ed
tr
ea
tm
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t,
an
d
m
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s
t
PMT
p
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ts
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ad
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s
ed
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ea
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t
b
ef
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r
e
g
o
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t
o
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s
p
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Pro
b
ab
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e
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less
s
p
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if
ic
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d
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wh
ich
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tr
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t.
I
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PMT
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m
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al
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s
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ch
as p
er
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ten
t c
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g
h
an
d
ch
est p
ain
,
w
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m
o
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p
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tiv
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in
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k
in
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tr
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h
o
s
p
italizatio
n
.
T
h
e
ag
e
o
f
th
e
p
atien
t
is
in
f
lu
en
ce
d
b
y
th
e
ty
p
e
o
f
tu
b
er
cu
l
o
s
is
:
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p
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3
.
2
.
Dis
t
ributio
n o
f
pa
t
ient
s
by
g
ender
a
nd
s
y
m
pto
m
s
I
n
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r
s
tu
d
y
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s
er
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lo
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s
y
m
p
to
m
s
in
b
o
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en
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s
h
o
w
n
in
T
ab
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3
.
T
h
e
r
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lts
s
h
o
w
th
at
m
ales
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e
s
ig
n
if
ic
an
tly
m
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r
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lik
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p
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o
m
atic
,
with
8
5
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2
9
%
o
f
ca
s
es,
th
an
f
em
ales,
wh
o
wer
e
m
o
r
e
o
f
ten
s
y
m
p
to
m
ati
c
-
f
r
ee
with
3
1
.
2
5
%
o
f
ca
s
es
(
p
<0
.
0
0
0
)
.
Fo
r
s
p
ec
if
ic
s
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m
p
to
m
s
:
s
p
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tu
m
an
d
weig
h
t
lo
s
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wer
e
m
o
r
e
f
r
e
q
u
e
n
t
in
m
ales
(
1
6
3
ca
s
es;
2
2
4
c
ases
)
th
an
in
f
e
m
ales
(
5
8
ca
s
es;
1
3
1
ca
s
es),
with
s
tatis
t
ical
s
ig
n
if
ican
ce
; f
o
r
co
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g
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d
h
em
o
p
t
y
s
is
,
m
ales p
r
es
en
ted
th
ese
s
y
m
p
to
m
s
m
o
r
e
o
f
ten
(
1
8
4
ca
s
es; 7
0
ca
s
es)
th
an
f
em
ales
(
8
6
ca
s
es;
2
7
ca
s
es),
with
s
tatis
tical
s
i
g
n
if
ican
ce
.
Fev
e
r
,
n
o
ct
u
r
n
al
s
wea
tin
g
,
an
o
r
e
x
ia
,
an
d
f
atig
u
e/we
ak
n
ess
wer
e
in
d
ep
en
d
e
n
t
o
f
g
en
d
e
r
.
C
o
n
ce
r
n
in
g
s
y
m
p
to
m
s
ev
er
ity
,
m
ale
s
ten
d
ed
to
p
r
esen
t
v
er
y
s
ev
e
r
e
s
y
m
p
to
m
s
(
3
9
.
7
%
o
f
ca
s
es)
m
o
r
e
f
r
e
q
u
en
tly
th
a
n
f
em
ales
(
2
6
.
4
4
%
o
f
ca
s
es)
a
n
d
f
e
m
ales
ten
d
ed
to
p
r
esen
t
s
y
m
p
to
m
s
with
o
u
t
s
ev
er
ity
(
2
5
%
o
f
ca
s
es)
m
o
r
e
f
r
eq
u
e
n
tly
th
an
m
ales
(
1
1
.
7
6
%
o
f
ca
s
es)
with
a
s
ig
n
if
ican
t d
if
f
er
e
n
ce
(
p
<
0
.
0
0
0
)
.
T
h
e
d
ata
ab
o
u
t
T
B
s
y
m
p
to
m
s
b
etwe
en
m
ales
an
d
f
em
ales
s
u
g
g
ests
th
at
alth
o
u
g
h
m
ales
wer
e
m
o
r
e
lik
ely
to
p
r
esen
t
T
B
s
y
m
p
to
m
s
,
an
d
to
p
r
esen
t
v
e
r
y
s
ev
er
e
s
y
m
p
to
m
s
(
f
ev
er
,
s
p
u
t
u
m
,
wei
g
h
t
lo
s
s
,
co
u
g
h
,
an
d
h
em
o
p
ty
s
is
)
.
Similar
r
esu
lts
in
d
icate
th
at
PMT
s
y
m
p
to
m
s
(
s
u
ch
as
co
u
g
h
,
s
p
u
tu
m
,
an
d
h
e
m
o
p
ty
s
is
)
ar
e
m
u
ch
less
f
r
eq
u
en
t
in
wo
m
e
n
th
an
in
m
en
[
2
5
]
.
B
io
lo
g
ical
an
d
s
o
cio
-
cu
ltu
r
al
f
ac
to
r
s
m
ay
ex
p
l
ain
th
is
d
if
f
er
en
ce
.
T
h
ese
f
in
d
in
g
s
m
ay
h
av
e
im
p
o
r
tan
t
im
p
licatio
n
s
f
o
r
T
B
d
iag
n
o
s
is
an
d
tr
ea
tm
en
t
s
tr
ateg
ies,
h
ig
h
lig
h
tin
g
th
e
n
ee
d
f
o
r
a
g
e
n
d
er
-
d
if
f
er
e
n
ti
ated
ap
p
r
o
ac
h
.
3
.
3
.
Dis
t
ributio
n
o
f
T
B
ca
s
es
a
cc
o
rding
t
o
pla
ce
o
f
re
s
i
dence,
lev
el
o
f
educa
t
io
n,
s
m
o
k
ing
s
t
a
t
us
a
nd
pa
t
ient
s
'
s
t
a
t
e
o
f
hea
lt
h
An
aly
s
is
o
f
th
e
d
ata
in
Fig
u
r
e
1
r
ev
ea
ls
an
in
ter
esti
n
g
d
is
tr
ib
u
tio
n
o
f
t
u
b
er
cu
l
o
s
is
ca
s
es
ac
c
o
r
d
in
g
t
o
p
atien
ts
'
p
lace
o
f
r
esid
en
ce
.
I
n
u
r
b
a
n
ar
ea
s
,
'
ex
ce
llen
t'
an
d
'
v
er
y
g
o
o
d
'
h
ea
lth
s
tatu
s
p
r
ed
o
m
in
ate,
with
4
6
an
d
1
1
0
ca
s
es
,
r
esp
ec
tiv
ely
.
R
u
r
al
ar
ea
s
f
o
llo
w
a
s
im
ilar
tr
en
d
,
alth
o
u
g
h
t
h
e
n
u
m
b
er
s
w
er
e
lo
wer
,
with
2
4
'
ex
ce
llen
t
'
an
d
6
9
'
v
er
y
g
o
o
d
'
ca
s
es.
Per
i
-
u
r
b
an
ar
ea
s
s
h
o
w
th
e
lo
west
n
u
m
b
er
s
,
with
1
1
'
ex
ce
llen
t
'
an
d
4
2
'
v
er
y
g
o
o
d
'
ca
s
es.
C
ases
with
'
p
o
o
r
'
an
d
'
b
ad
'
h
ea
lth
s
tatu
s
wer
e
r
elativ
ely
lo
w
a
n
d
ev
en
l
y
d
is
tr
ib
u
ted
ac
r
o
s
s
th
e
d
if
f
er
e
n
t
r
esid
en
tial
ar
ea
s
.
Statis
tica
lly
,
th
e
p
-
v
alu
e
ass
o
ciate
d
with
th
i
s
d
is
tr
ib
u
tio
n
is
0
.
2
6
1
,
in
d
icatin
g
th
at
th
e
d
if
f
er
en
ce
s
o
b
s
er
v
e
d
ar
e
n
o
t
s
tatis
tically
s
ig
n
if
ican
t.
T
h
is
s
u
g
g
ests
th
at
th
e
p
lace
o
f
r
esid
en
ce
h
as
n
o
m
ajo
r
im
p
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if
ican
t
a
s
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n
ce
an
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s
t
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o
f
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p
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b
u
t
'ex
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p
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ed
o
m
in
at
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n
u
r
b
an
ar
e
a
s
.
C
o
m
p
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ed
to
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p
l
e
w
h
o
l
iv
e
i
n
r
u
r
al
ar
ea
s
,
u
r
b
an
r
e
s
id
en
t
s
ar
e
m
o
r
e
s
u
s
c
ep
tib
le
to
b
e
in
f
ec
ted
[
2
6
]
.
T
h
e
li
ter
atu
r
e
in
d
ic
a
te
s
th
a
t
r
u
r
a
l
ar
e
a
s
ar
e
T
B
p
o
ck
et
s
,
wh
i
ch
i
s
f
u
r
th
er
ac
c
el
er
a
ted
b
y
t
h
e
d
y
n
am
i
c
s
o
f
d
i
s
ea
s
e
k
n
o
w
led
g
e.
T
h
e
s
e
a
r
ea
s
a
r
e
ch
ar
a
ct
er
ize
d
b
y
s
t
ig
m
at
iz
at
i
o
n
,
lead
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g
to
u
n
d
er
-
u
ti
li
za
ti
o
n
o
f
tr
ea
tm
en
t
s
er
v
ic
es
,
d
el
ay
ed
d
i
ag
n
o
s
i
s
,
a
n
d
p
o
o
r
ad
h
er
en
ce
to
tr
e
at
m
en
t
[
2
7
]
,
[
2
8
]
.
Sm
o
k
in
g
h
as
a
n
eg
a
tiv
e
im
p
ac
t
o
n
t
h
e
p
e
r
c
eiv
ed
h
e
al
th
o
f
T
B
p
a
ti
en
ts
,
an
d
s
to
p
p
in
g
s
m
o
k
in
g
i
s
as
s
o
ci
at
ed
w
ith
an
im
p
r
o
v
em
en
t
i
n
p
er
c
ei
v
ed
h
e
al
th
s
t
atu
s
.
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r
r
e
s
u
lt
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c
an
b
e
co
n
f
ir
m
ed
b
y
s
ev
er
a
l
s
tu
d
ie
s
s
u
ch
as
th
e
o
n
e
b
y
T
ac
h
f
o
u
t
i
et
a
l
.
wh
ich
s
t
at
es
th
a
t
th
e
ch
a
n
ce
o
f
ac
q
u
ir
in
g
tu
b
er
c
u
lo
s
is
is
g
r
ea
tly
in
cr
ea
s
ed
b
y
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lco
h
o
l
an
d
to
b
a
cc
o
co
n
s
u
m
p
ti
o
n
[
9
]
.
Ad
d
it
io
n
a
lly
,
s
m
o
k
in
g
h
a
s
a
s
ig
n
if
ic
an
t
co
r
r
e
l
at
io
n
wi
th
d
ea
th
in
T
B
p
a
ti
en
t
s
[
2
9
]
.
An
d
w
ith
u
n
f
av
o
r
ab
le
tr
ea
tm
e
n
t o
u
tc
o
m
e
s
[
3
0
]
.
4.
CO
NCLU
SI
O
N
T
o
co
n
clu
d
e
,
th
ese
f
in
d
in
g
s
co
u
ld
th
en
b
e
u
s
ed
to
im
p
r
o
v
e
d
iag
n
o
s
is
,
tr
ea
tm
en
t
,
an
d
p
r
ev
en
tio
n
s
tr
ateg
ies,
ad
ap
tin
g
th
em
to
t
h
e
s
p
ec
if
ic
n
ee
d
s
o
f
d
if
f
er
en
t
p
atien
t
g
r
o
u
p
s
,
as
well
as
to
s
tr
en
g
th
en
h
ea
lth
ed
u
ca
tio
n
to
p
r
ev
en
t
s
elf
-
m
ed
icatio
n
an
d
p
r
o
m
o
te
r
ap
id
ac
c
ess
to
s
p
ec
iali
s
t
ca
r
e.
T
h
is
ar
t
icle
co
u
ld
n
o
t
o
n
ly
co
n
tr
ib
u
te
to
th
e
ex
i
s
tin
g
s
c
ien
tific
liter
atu
r
e,
b
u
t
also
h
av
e
a
p
r
ac
tical
im
p
ac
t
b
y
h
elp
in
g
h
e
alth
ca
r
e
p
r
o
f
ess
io
n
als
to
b
etter
u
n
d
er
s
tan
d
an
d
r
esp
o
n
d
to
th
e
n
ee
d
s
o
f
th
eir
p
atien
ts
.
T
h
e
s
tu
d
y
h
as
n
o
tab
le
lim
itatio
n
s
,
s
u
ch
as
a
s
m
all
s
am
p
le
s
ize
an
d
a
lack
o
f
p
o
p
u
latio
n
d
iv
e
r
s
ity
,
wh
ic
h
m
ay
h
in
d
er
th
e
g
en
er
aliza
tio
n
o
f
r
esu
lts
.
Ad
d
itio
n
ally
,
p
o
ten
tial
b
iases
f
r
o
m
s
u
b
jectiv
e
r
esp
o
n
s
es
an
d
r
eg
i
o
n
al
d
i
f
f
er
en
ce
s
in
ca
r
e
ac
ce
s
s
s
h
o
u
ld
b
e
ac
k
n
o
w
led
g
ed
.
Fu
t
u
r
e
r
esear
ch
c
o
u
ld
b
en
ef
it
f
r
o
m
a
la
r
g
er
an
d
m
o
r
e
d
iv
er
s
e
s
am
p
le,
lo
n
g
itu
d
in
al
s
tu
d
ies
to
tr
ac
k
e
v
o
lv
in
g
p
atien
t
n
ee
d
s
,
an
d
in
v
esti
g
atio
n
s
in
to
th
e
ef
f
ec
ts
o
f
v
ar
io
u
s
ed
u
ca
tio
n
al
s
tr
ateg
ies
o
n
s
elf
-
m
ed
icatio
n
an
d
h
ea
lth
ca
r
e
ac
ce
s
s
,
co
n
s
id
er
in
g
cu
ltu
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d
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o
cio
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o
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ic
f
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RE
F
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NC
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S
[
1
]
W
o
r
l
d
H
e
a
l
t
h
O
r
g
a
n
i
z
a
t
i
o
n
,
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G
l
o
b
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l
t
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b
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o
s
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s
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e
p
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t
2
0
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3
,
”
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r
l
d
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l
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h
t
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a
c
c
e
ss
e
d
A
p
r
.
1
4
,
2
0
2
5
)
.
[
2
]
F
.
B
e
j
j
a
,
H
.
H
a
mi
,
F
.
A
b
o
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a
,
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.
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a
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,
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.
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o
k
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t
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r
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,
a
n
d
A
.
S
o
u
l
a
y
m
a
n
i
,
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S
e
v
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f
n
e
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me
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n
g
e
a
l
t
u
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e
r
c
u
l
o
si
s
i
n
M
o
r
o
c
c
o
:
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c
r
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t
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c
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l
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v
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a
t
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o
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c
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s
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f
f
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h
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P
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n
Af
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Me
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.
[
3
]
S
.
N
h
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m
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e
b
o
n
d
e
a
n
d
A
.
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s
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.
[
4
]
J.
N
.
L
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n
e
t
a
l
.
,
“
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s
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n
t
e
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n
a
t
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o
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a
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p
p
.
6
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5
,
2
0
0
9
.
[
5
]
N
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.
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,
E.
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n
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.
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st
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a
n
d
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.
K
.
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w
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n
,
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me
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m,
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t
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3
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–
3
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3
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1
9
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9
.
[
6
]
M
.
M
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n
d
a
d
,
S
.
N
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i
e
s
N
%
Ty
p
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+
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1
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4
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39
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r
15
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8
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3
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(
p
l
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)
94
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No
3
7
4
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1
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21
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28
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D
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s +
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8
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se
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No
2
8
1
5
8
.
5
4
Y
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1
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31
1
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6
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s
9
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s
26
1
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3
M
u
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p
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me
d
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c
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t
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n
s
1
3
2
6
6
.
6
7
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st
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g
t
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me
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t
No
2
1
4
5
7
.
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3
Y
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s
1
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8
4
2
.
4
7
I
f
t
h
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a
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sw
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s
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s
,
w
h
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?
Lo
n
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a
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m
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t
31
1
9
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5
0
A
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1
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7
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3
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t
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k
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me
d
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c
a
t
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o
n
?
No
2
7
8
7
5
.
7
5
Y
e
s
89
2
4
.
2
5
D
o
y
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d
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t
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s?
No
22
4
.
5
8
Y
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s
4
5
8
9
5
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D
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v
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n
s w
h
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l
b
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r
?
No
3
3
6
9
1
.
5
5
Y
e
s
31
8
.
4
5
D
o
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y
o
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d
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c
a
t
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n
b
e
c
a
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se
t
h
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t
r
e
a
t
me
n
t
d
u
r
a
t
i
o
n
i
s
v
e
r
y
l
o
n
g
?
Y
e
s
48
1
3
.
1
1
No
3
1
8
8
6
.
8
9
D
o
y
o
u
t
h
i
n
k
t
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e
m
e
d
i
c
a
t
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o
n
s
p
r
e
s
c
r
i
b
e
d
b
y
t
h
e
d
o
c
t
o
r
w
i
l
l
h
e
l
p
y
o
u
i
m
p
r
o
v
e
y
o
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r
h
e
a
l
t
h
?
No
5
1
.
0
4
Y
e
s
4
1
1
8
5
.
6
3
D
o
n
'
t
k
n
o
w
64
1
3
.
3
3
D
o
y
o
u
e
v
e
r
u
s
e
m
e
d
i
c
i
n
a
l
p
l
a
n
t
s
?
Y
e
s
1
3
2
2
7
.
5
0
No
3
4
8
7
2
.
5
0
Th
e
n
a
t
u
r
e
o
f
m
e
d
i
c
i
n
a
l
p
l
a
n
t
s
F
e
n
u
g
r
e
e
k
42
8
.
7
5
M
e
l
a
n
g
e
57
1
1
.
8
8
O
t
h
e
r
13
2
.
7
1
V
a
r
i
o
u
s
20
4
.
1
7
H
a
v
e
y
o
u
c
h
a
n
g
e
d
y
o
u
r
e
a
t
i
n
g
h
a
b
i
t
s
a
f
t
e
r
t
h
e
d
i
se
a
se
?
Y
e
s
4
0
1
8
3
.
5
4
No
79
1
6
.
4
6
H
a
v
e
t
h
e
r
e
b
e
e
n
t
i
m
e
s w
h
e
n
y
o
u
r
p
h
y
si
c
a
l
o
r
e
mo
t
i
o
n
a
l
h
e
a
l
t
h
h
a
s
h
i
n
d
e
r
e
d
y
o
u
r
s
o
c
i
a
l
l
i
f
e
?
A
l
l
t
h
e
t
i
m
e
1
0
3
2
1
.
4
6
O
f
t
e
n
85
1
7
.
7
1
R
a
r
e
l
y
1
0
3
2
1
.
4
6
N
e
v
e
r
1
8
9
3
9
.
3
8
R
A
M
E
ED
:
M
e
d
i
c
a
l
A
ssi
s
t
a
n
c
e
R
e
g
i
me
,
A
M
O
Ta
d
a
m
o
n
:
c
o
m
p
u
l
so
r
y
h
e
a
l
t
h
i
n
su
r
a
n
c
e
f
o
r
p
e
o
p
l
e
u
n
a
b
l
e
t
o
p
a
y
t
h
e
i
r
c
o
n
t
r
i
b
u
t
i
o
n
s
,
C
N
S
S
:
N
a
t
i
o
n
a
l
S
o
c
i
a
l
S
e
c
u
r
i
t
y
F
u
n
d
,
C
N
O
P
S
:
N
a
t
i
o
n
a
l
F
u
n
d
f
o
r
S
o
c
i
a
l
W
e
l
f
a
r
e
,
TPM
+
:
M
i
c
r
o
s
c
o
p
y
-
p
o
si
t
i
v
e
p
u
l
mo
n
a
r
y
t
u
b
e
r
c
u
l
o
s
i
s,
TG
G
:
l
y
m
p
h
n
o
d
e
t
u
b
e
r
c
u
l
o
s
i
s.
Evaluation Warning : The document was created with Spire.PDF for Python.