Co 1. 2. 3.
Med
Med
_______________ orresponding autho Department of He University of Medi Department of Epi Medical Sciences, Center for Commu
Tehran, Iran
Evaluati
Tubercu
laborato
Ahad Bakhtia
Received: 27 S
Abstract
Background
between estima (NTBP) is abou labs with poor
Methods: In
study, first, aft the patient’s li available teleph Results: Ou samples are tes 39% in public a
Conclusion:
recommended r
Keywords: Tu
Conflicts of Interes Funding: None *This work has bee Copyright© Iran
Cite this articl Tuberculosis Pr https://doi.org/10
Introducti Tuberculo around the gl 10.4 million.
dical Journa
J Islam Repub Ir
________________ or: Dr Arash Rashidi ealth Management ical Sciences, Tehra idemiology & Statis Tehran, Iran unicable Diseases Co
on of Tu
losis Pro
ories in T
ri1, Mahshid N
Sep 2017
d: According to ated number o ut 3 million ann
collaboration b the context of ter selecting lab ist with the Mo hone numbers w ut of 23 selecte
sted in public la and private labo Public and priv requirements an
uberculosis, Nat
st: None declared
en published under
University of Medi
le as:Bakhtiari rogram (NTBP) 0.34171/mjiri.33.
on
osis (TB) is th lobe. In 2015
Out of which
al of the Islam
ran. 2019(17 Jul)
_
ian, arash.rashidian & Economic, Scho an, Iran
stics, School of Pub
ontrol, Ministry of H
berculos
ogram (N
Tehran an
Nasehi2, 3, Ara
Published: 1
o the Global tub of TB patients
nually in the wo background with f TB, this is an
boratories based oHME’s databa were called. ed labs, 10 (5
abs. Out of 236 oratories, respe vate sector labo nd standards of
tional Tubercul
rCC BY-NC-SA 1.0 li
ical Sciences
A, Nasehi M, Ra based on data 70
he 10th leadin , the incident h, 1.8 were de
mic Republic
;33.70. https://do
[email protected] ool of Public Health
lic Health, Iran Univ
Health and Medical
sis Under
NTBP) bas
nd NTBP
sh Rashidian*
17 Jul 2019
berculosis (TB) and the numbe orld. In the curr
h NTBP in Teh inventory study d on poor colla ase then, patien
private, 5 publ 633 performed ectively.
oratories will be f the NTBP in th
osis Programs (
icense.
ashidian A, Arab a from laborator
ng cause of d t of TB was a ead, 95% of d
c of Iran (MJ
oi.org/10.34171/m
h, Tehran
versity of
Education, ↑W
Dif num ann pot car ser dia
→
Du sys Mi Tub but ide thir
rreportin
sed on d
P
*1, Mohamma
) Report 2014, er of patients w rent study, we in hran.
y that evaluatin aboration backg nts that were n
lic (other than tests, 1396 ind
e able to signif heir Processes a
(NTBP), Under
b M, Sharafi S, M ries in Tehran
death about deaths
were glob East
IRI)
mjiri.33.70
What is “already
fference betwee mber of patien nually. The WH tential causes o re services, {2 rvices but the d agnosed but are
→What this artic
ue to the lack o stem between l nistry of H berculosis has t are not registe entified the proc rd cause that th
ng to Nat
ata from
ad Arab1, Saee
released by W who are registe nvestigated the
ng the level of u ground with NT not recorded in
PHC)) had in dividuals were p
ficantly reduce and software fo
rreporting, Inve
Mokhtari S. Eval and NTBP. M
e in low-and-m bal incidence r
t Mediterranea
y known” in th
en estimated nu nts who are re HO mentioned f this difference 2} people may disease is not di not registered.
cle adds:
of an integrated laboratories, in ealth, the co
been challenge ered). This stud cesses that need e WHO has me
tional
m
ed Sharafi3, So
World Health Or ered by the Na level of
under-under-reporting TBP and develo NTBP’s list w
dividuals with positive. The un
their failure to or registering pa
entory study
uation of Tuberc
Med J Islam Rep
middle incom rate was 142 i an Region (EM
his topic:
number of TB p registered, is a d the following e: {1} lack of a y have access diagnosed, {3} p
d electronic hea nsurance organ
omprehensive ed (patients ma dy Proved the t d to be improve entioned.
oheil Mokhtar
rganization (W ational Tubercu -reporting of TB
g of TB cases. T oping patient’s were identified,
positive result nder-reporting
report if they c atient informati
culosis Underrepo
epub Iran. 2019
me countries (1 in 100 000 po
MRO) of the
patients and th about 3 million g reasons as th
access to health to health-car patients may b
alth information nization and th
fight agains ay be diagnose
third reason an ed to address th
ri1
WHO), differenc ulosis Program B cases between
To do inventory list we matched and those with
ts. 71.6% of al was, 62.5% and
comply with th ion.
orting to Nationa
9 (17 Jul);33:70
1). In 2015, it pulations. The
World Health
he n he h-re
e
n he st d d he
e ms n
y d h
ll d
e
al 0.
ts e h
Assessing tub
Organization incidence rate for 6 to 7% of 2010 to 2015 EMRO was a TB in the Isl the EMRO, w cess rate of t WHO’s repor ment and pre since 1990, it
However, b difference be and the numb tional Tuberc annually. Thi ing the past se ing reasons a lack of acces have access t diagnosed, {3 istered. Poor relationship w tories, and lac reasons for th will die, som ple. 75% of World Bank h TB will resul the latest esti with drug-res decades, two First, diagnos rectly Observ 2005. Second now. The Sto achieve Mille Development The SDG 3 strategy to sto part of the g related goals SDGs, the go Universal He should face c TB disease. 3 are {1} a pro {2} highligh {3}increasing
Status of TB
Iran's capita is a constant country and t ity, acceptabi established, th culture labora which are cer atory Network network whic
berculosis und
(WHO) with e of 109 per f the global bu 5, the succes about 88% (3) amic Republi was 13 per eac treatment was rt in 2015, th evention of T ts mortality rat based on the etween the est ber of patients culosis Progra s statistical di even years. Th as the potentia
ss to health-c to health-care 3} patients ma registration s with private p ck of mandat he latter. Some me will survive this differen has estimated lt to 30-dollar imates, only sistant TB is d
main strategi sis and treatm ved Treatmen d, the Stop T op TB Strateg ennium Devel t Goals (SDGs
3.3 is to erad op TB was ad goal to eradica of SDGs ar oal on TB ha ealth Coverag
catastrophic h 3 main pillars ogram that is p hted policies
g research acti
B in Tehran (c
al, Tehran, wi t referral base the region. In ility, and qua here are more atories in add rtified by the S rk SRLN (and
ch provide fre
der-reporting
h 670 000 inf 100 000 popu urden of TB in ss rate of TB
). In 2015, the ic (IR) of Iran ch 100 000 po
s about 87% he program fo TB saved 43 te reduced by e WHO’s rep
timated numb s who are reg ams (NTBP) ifference has b
he WHO men al causes of th care services, e services but ay be diagnose systems, lack
hysicians, hos ory reporting e these 3 milli e and contam nce is related d that each do r return (USA
one out of ev detected (6). D
ies were empl ment of TB us nt Short cours TB Strategy, gy was develo lopment Goal s) also conside dicate TB by dopted by the ate TP pande re already m s been linked ge, so that by
health expend of the strateg patient-center
and support ivities and inn
capital of Iran
ith a populatio e for patients Tehran, avail ality of TB t e than 19 sm ition to one r Supranational d we know the ee of charge
through inven
fected persons ulations accou n 2013 (2). Du B treatment in e incidence ra n, as a memb opulations and (4). Accordin or diagnosis, t
million lives 47% (5). port in 2014 ber of TB pat gistered by the is about 3 mi been repeated ntioned the fol his difference , {2} people the disease i ed but are not
and/or inadeq spitals and lab could be pos ion hidden pat minate healthy d to 12 coun llar investmen A $). Accordin very four pat During the past loyed to fight sing DOTS or se, from 1990 since 2006 u oped as a mea s. The Sustain ered TB.
2030. The g e WHO in 201 emic by 2030 met in IR Iran
d with the goa y 2020 no fa ditures becaus gy to eradicat red and integr tive systems; novation (7).
n)
on over 13 mil s from around
lability, acces treatments is mear microscop
egional labora l Reference La em as PHC TB
services). In a
ntory studies
s and unted uring n the ate of ber of d
suc-ng to treat-s and
, the tients e
Na-illion d
dur- llow-: {1}
may is not t reg-quate bora-ssible
tients peo-ntries.
nt on ng to tients t two t TB. r Di-0s to up to an to nable
global 14 as 0. TB n. In al on amily se of te TB rated; and
llion, d the
sibil-well py, 2 ratory abor-B lab
addi-tion of p Tehr acce For PHC activ Un port on T as in Syst port in I.
M W
In sess vent stan publ es com linka
In tries rectl be u ing repo lanc the u ly fr
Se
Fi culo but a sis w Com defin duri selec so, t com Da nam addr tiona bora 2014 itive with
M
A in se NTB cem
to the PHC T private and pu ran. Maximal ess to a valid people’s poor C-network tha vely follow pa nder-reporting ant issues tha TB, so that th nsurance orga tems, indicate ing and regist R. Iran are inv
Methods What is an inve
n the context o ing the level tory studies c
dard case def lic and private notified to mparison is d
age (8). nventory studie
s in which TB ly from surve used to improv levels of und orting can also ce systems nee ultimate goal rom notificatio
electing labor
irst, after con osis, laboratori
are known in were identifie mmunicable D ned as irregul ng past years cted as criteri two PHC TB l mpare their und ata about pat me, father’s n ress, telephon ality, type of atory), for the
4, were obtain e results were h negative resu
Matching colle
fter developin elected labora BP’s database mber 2014. Bec
TB lab networ ublic TB labo ly, by a 20 m
center for TB r financial con at provide fre atients with TB g and under-at are mention he difference b anizations, and es a highlight tration rates of
vestigated.
entory study a
of TB, an inve of under-repo compare the finitions reco e health facilit
local and done through
es can help to B incidence ca illance data. I ve estimates of er-reporting. M o help to iden ed to be streng
of measuring on data (8).
ratories and d
sultation with ies which hav public and pr ed in Tehran Diseases of M
lar, discontinu s. Three type a, sputum sm lab network w derreporting w tients with po ame, gender, ne number, na
laboratory (p e period of M ned from selec
recorded. Al ults were colle
cted data wit
ng the list of p tories, obtaine e, for the peri cause the auth
rk, there are a oratories in th minutes’ trave TB diagnosis a
nditions there ree services.
B diagnosis. -diagnosis ar ned in WHO’
between data d National TB t gap(5). In
f TB patients
and why is it
entory study w orting of TB number of c orded in all o
ties with the r national aut a process c
o identify (and an already be In other coun f TB incidenc Measuring le ntify ways in w
gthened to pro the number o
developing pa
h the Departm ve doubtful rep rivate sector f n. Based on D MoHME, wea
uous, and inco es of diagnos mear, cultures, were included with selected l ositive tests, , national cod
ame of the la public, private March 2014 cted labs. Pati lso, the numb ected.
th MoHME’s d
patients with p ed data were c riod of March hors were not
a large numbe he province o el people have
and treatment e are centers in
These center
re among im ’s 2015 repor sources, such B Registration this study, re in laboratorie
important?
was done to as cases. TB in cases meeting
r a sample o records of cas thorities. The called record
d certify) coun e measured di ntries, they can
ce by quantify vels of under which surveil ogress toward of cases direct
atient’s list
ment of Tuber porting system for TB diagno Department o ak reporting i omplete repor stic tests were
and PCR. Al in the study to laboratories.
including ful de, residentia aboratory, na e and PHC la to Septembe ients with pos ber of sample
database
positive result compared with h 2013 to De
t able to deter er of e t. n rs
m-rt
h n
e-s
s- n-g of
s-e
d- n- i-n
y- r- l-ds
t- r-m o-of
s rt e
l-o
ll al a-er
s-s
ts h e-
mine whethe prevalence, a NTBP’s data patients were tients that we fied, and tho called. Quest she or he was the study, con
Ethical cons
The curren Tehran Unive authors have and anonymit
Results
Out of 23 than PHC)) h had its own re ing to NTBP every six mon
Table 1.Public
Number of tests Number of diag
Fig. 1.Share of
Table 2.Status Laboratory The number of No response* Responsiveness The number of The number of The number of Where treatmen
The place wher
Treatment less Treatment more
* The number wa
Priva 252 18%
er patients w a longer time abase. During registered all ere not record ose with avai tions were on s not alive, fir nfidentiality w
siderations
nt study has ersity of Medi
done their b ty of participa
selected labs, had individual egistration sys
was also vary nths. To estim
and private prov
s
gnosed patients
f each section in d
of TB positive pa
calls has been m
s
f deaths before di f deaths during tre f deaths after disc nt has been receiv
re the drug was ta
than 6 months e than 6 months
as not available, the
te, 2, %
were new cas e period was g this time pe
l around the c ded in NTBP’ ilable telepho nly asked from
rst relatives w was the author
received its e ical Sciences best to meet t ants.
, 10 (5 Privat s with positiv stem. The tim ying, from mo mate the report
viders from provid Priva 6717( 252(1
diagnosed patient
atients (who that
ade
iagnosis eatment charge
ved
aken
phone was turned o Public,
1144, 82%
ses (incidence chosen to se eriod, 20 903 country. Then ’s list were id one numbers
m patients an were asked. Du
’s first priority
ethical code and MoHME. the confident
te, 5 Public (o ve results. Eac me period of re onthly reportin
ting rate, colle
ded services and t
te P
(28.4%) 1
18.1%) 1
ts
were not found in
off on 3 times call, w e) or earch 3 TB n, pa- denti-were nd, if uring y.
from . The tiality
other ch lab
eport-ng to ected
data regis 854 cent (abo fore from them A publ posi labs 62 priv bora and with
Ou NTB Tho offic tered and
their contribution Public
16916(71.6%) 1144(81.9%)
Fig. 2.
be gen collabo
in the NTBP) trac
Public hospital Outside of Tehra Discontinuation Defined centers Special centers h Private pharmaci
wrong phone numb
1 2 3 4 5 6 7 8 9 10
UNDER
-REPORTING
%
a were compar stered individ were male (6 t). For 959 p out 15 percen
igners were f m Azerbaijan, m only was on s Table 1 sho lic labs. Also, itive (TB pati
, (Fig. 1). 2.5%, and 39%
ate laboratori atories with 1
one of the la h 35% match.
ut of 813 TB BP, 618 of t
se with teleph ce of the MoH d telephone nu 334 patients
n in diagnosing T Total 23633 1396(
.Comparing Rep neralized to the w oration backgrou
cked using teleph
an (private clinic) (remaining in the for treatment have been set
ies
er, the phone line w
6
0 0 0 0 0 0 0 0 0 0 0
Publi
red with NTB duals with pos 61.2 percent),
atients, nation nt) were not from Afghanis
one from Ir nly mentioned ows, 71.6% o out of 23633 ent), which 8
% of cases we es, respective 100% match aboratories ha
B cases who them had reg
hone number HME. Out of umber, 284 pa
did not (reas
B patients
3(100%) 100%)
orting Rate in eac hole system & be nd with NTBP)
one calls
)
e test phase)
was sold to another c
2.5
c Labs
BP’s database. sitive results and 542 fema nality was m
Iranian. Alm stan (except f raq, and origi as ‘foreigner of all samples
performed te 82% of them w
ere not found ely (Fig. 2). O
had the best ad the poores
were not reg gistered telep
were followe 618 TB patien ateitnes answe sons were: th
ch section (These elong to the labs w
Private 43 20 23 2 2
-3 8 8 2
-customer, etc.
39
Private La
. Among 1396 (TB patients) ales (38.8 per mentioned, 148 most all of the for one patien
in of three o ’).
s are tested in sts, 1396 were were in public
d in public and One of the la
performance st performance
gistered in the hone number ed through TB
nts with regis ered the phone e number wa
e values cannot with poor
Public 575 314 261 13 40 18 101
50 3 100 161 91 196
50 bs
6 ),
r-8 e nt of
n e c
d a-e,
e
e r. B
s-e as
Assessing tub
not available, wrong phone customer, etc rights, a serie place where m status were as asked from re nosis or durin the patient wa in order to a detailed infor All of the re ous reasons w the authors fa of the grievin not continued public hospita private sector
Two PHC T der-reporting Reporting po were registere
Discussion
The incide in men so tha is twice than TB patients w lion (59.2%) million were 12.8% of TB 83% of TB p (totally 198 p study, 15% of million refug them were f show that the demic of TB Afghanistan a are two count the western b flicts. The Un reported that Iran through l ghanistan(14) neighboring c cies and the one of the opt
Registration program for c relationships and NTBP de TB. China aft for reporting a dramatic in (15). South K ing TB in 20 and prevalenc only 67.6% o private sector
berculosis und
, the phone w number, the c.) (Table 2) es of question medicines wer sked. If the pa elatives, wheth ng treatment as dead, due to avoid creating rmation was n
ecorded death were mentione ailed to ask th ng of the fami
d. 104 patien als. 58 cases r, mostly not r TB lab netwo . This labs u olicy. All case
ed in the NTB
n
ence and preva at in some cou
women (9, 1 were recorded
were male an children (5). patients in Ir patients in Ne patients were f patients wer ees migrated from Iraq, Af e extent of this (13). Iran, als and Pakistan, tries with high border, is exp nited Nation H in 2015, abou legal ways, th ). Hence, im countries and
implementatio tions ahead. n and reportin control and ca
between phys efinitely have fter the establi communicabl ncrease in th Korea establish
000; its main ce, but an inv of patients who
r were report
der-reporting
was turned of phone line w ). In complia ns about the tr
re bought or t atient was dea her the patient or after disch o the sensitivi g any concern
ot obtained, w hs were not du ed. In all cases he main cause ly. In 8 cases nts continued
continued the reported. ork were also used the same es in the PHC BP database.
alence of TB ntries, the inc 10). In 2014, d, out of whic nd female, resp
According to ran are foreign ew York, USA registered) (1 e foreigners. I to European fghanistan, an s migration ca so, is surroun on the easte h rates of TB i periencing hi High Commis ut one million hat most of th mproving hea d promoting b on of health
ng TB patien are TB patient sician, pharma e an obvious r ishment of an le diseases in he number of hed an online aim was to c vestigation in o were diagno ed, while all
through inven
ff on 3 times was sold to ano
ance with pa reatment place aken, and dise ad, questions
t died before d harge (Table 2 ity of the issue n for the ralt where applied. ue to TB, and s that were pa e of death bec
the treatment their treatme eir treatment in
examined fo e Registration C TB lab netw
are usually hi idence rate in
about 9.6 mi h 5.4 and 3.2 pectively, and MoHME’s re ners (11). In 2 A, were foreig 12). In the cu In 2015, abou countries, mo nd Syria. Stu an change the nded by this th
ern border of incidence. Ira igh levels of ssion for Refu n refugees en
em were from alth indicator border health
diplomacy ca
nts is a part o ts. Comprehen acies, laborato role in contro n electronic sy 2004 experie f reported pat system for re calculate incid 2006 showed osed and treat
patients in p
ntory studies
call, other atient e, the eases were diag-2). If e and tives, .
vari-assed,
cause t was ent at n the
r un-n aun-nd
work
igher n men illion 2
mil-d one report 2014, gners urrent ut one ost of udies e
Epi-hreat. Iran, aq, on con-ugees ntered m
Af-rs in poli-an be
of the nsive ories, olling ystem enced tients eport-dence d that ted in public
secto natio tion sour 2012 port than Mas 86 a show the i curr Ac mill not r ied were derr beca not h NTB total term grou alize a lit coop
In NTB their them show NTB TB m trati ing leve repo diffe publ vate cent are diag indiv
It base diag Ther migh vario
•U of in diffe
•
es
•
neig
•F to p
or were repor onal health in of TB patien rces, it was re
2 and 2013 w ing and/or no n public ones ssachusetts, Pu and 65%, resp wed that unde
incidence of T ent one (17). ccording to W ion estimate reported (5). in different s e visited/teste eporting in th ause of the lac
have professio BP. In the pri
l, underreport mined for labo und in Tehran ed to the who ttle workload, peration backg n follow-up o
BP, it was fo r medicines fr m were based ws that their BP’s and MoH
medicines thr on and reporti centers into p el of reporting orting belonge erent charges lic and private e centers), mos ters, with the performed i gnosed in pub viduals were r should be not ed on the time gnosis in lab refore some p ht provide di ous reasons. S Using other p nsurance (Ira erent services Temporary re
Stigma, fear ghborhoods, an
Foreigner pat provide their
rted. In 2008, surance data nts. Through evealed that 1 were underrep
reporting wa (5). The repo uerto Rico, an pectively (16) erreporting is TB in Greece i
WHO’s report TB patients e In the current sectors, so th ed in PHC-ne
e public secto ck of auto rep onal staff who vate sector, u ting was 57.5 oratories with n province and le system or c , as well as in ground, the sit of patients w ound that som from private p d on medica healthcare pr HME’s policie rough PHC-ne ing cannot be public, and p g and simultan
ed to public c for the sput e centers in Ir st of the peop
highest repu n public cen lic centers, w referred to the ted that patien e of treatment boratories wa patients who fferent inform Some of the re people’s insur anian health i with different esidence, and
from the irr nd employers ients may be residential ad
, in addition t also were use comparing th 1.5 and 6.7% ported to NT as higher in pr orting rate of and Nassau Co
). Another stu about 80%. I is five times h
on TB in 201 either are not t study, under hat almost all etwork were or was 62.5%,
porting system o are skilled fo underreporting %.This perce h the worst re
d certainly can country. In sm in laboratories ituation is diff who were not me of them w
pharmacies (a al doctor pre roviders were es about free etwork. Sensit e investigated private, becau neously the lo centers. With tum smear an ran (two time ple prefer to go utation. While
nter, 80% o which implies ese centers (pu nts’ informatio in hospitals a as separate a
were diagno mation during easons may be rance book, b
insurance com nt prices)
therefore diff
rational view
illegal immig ddress or ma
to NTBP data ed for registra hese two data % of patients in TBP. Underre rivate hospital TB patients in ounty was 81 udy in Greece In other word higher than the
15, 37% of 9.6 t diagnosed o rreporting var patients who
reported. Un , it was mainly m and also did for reporting to g was 39%. In entage was de
eporting back nnot be gener mall cities with
s with a good ferent.
registered in were receiving although all o escriptions). I not aware o distribution o tivity of regis through divid se the highes owest level o regard to the nd cultures in es more in pri
o to the public e 69% of test
f cases were that high risk ublic). on registration and the time o
and different sed in the lab g treatment fo
e as follow: ecause of lack mpanies cove
ferent address
w of relatives
grants and fea ay have not a
a,
a-a n
e-s n 1, e d, e
6 or
r-o
n-y d o n e- k- r-h d
n g of It of of s- d-st of e n
i-c ts e k
n of t. b or
k er
s-s,
ar a
fixed place fo
•Initial sho
•Using fak
•Using the laboratory
•Using the
Also, the f incomplete re
•Samples w center usually mation
•Laborator phone numbe
•Patients a With regard bility for reg reporting her mation are re tients, also, a multiple data system can b health insuran But, before it panies must mentioned as health book, level (laborat sis.
For homoge sis level, WH information s tration, Bacte ment, and An tems, a patien increase the c WHO’s fram gorize data b age group, m HIV/AIDS)(1 be Provide th based on the and, if the p problems still solution. Bas TREND, and that laborator revealed that Then, using th dates for thes
Iran’s fifth employing EH ing innovativ as the backbo the beginning sian word tha beginning of registered. Us reduce the nu
or living ock resulted fr ke names in th e address of re
e address of an
following reas ecording of pa
which have b y are not che
ries consider er as sufficient are not willing
d to what men gistering a pa
r or him to N egistered at t are not totally a sources and
e a helpful w nce data can a ts implementa employ EHR problems are software for tories), and ill
eneity of reco HO has provi such as Age or eriological res natomical site nt identifier H credibility of mework NTBP based on regi mortality, co 18)– currently hese categori assumption t patients do no l will exist. E sed on the co d SYSTEM w
ries are using MoHME’s r he MoHME’s e softwares w h developed p
HRs. EHR is t ve healthcare
one of the hea g of 2016, inte at means apple f 2017 more
sing this infor umber of unreg
rom a positive he diagnosis ph
elatives who a
nother individ
sons can be m atients’ inform been sent from
ecked for ful
the name, fa t information g to provide in
ntioned above atient in the l NTBP, becaus
the diagnosis y reported. In
‘each patien way to address also be helpfu ation, all heal Rs. Almost all
e intra-sectora registering pa legal migrants
orded informa ided a framew
r age group, S sults, History of disease. F Homogeneity o
obtained resu P programs wi ons, province morbidities ( y NTBP’s dat ies. The WHO
that the enter ot provide co Employing EH
ollected infor were the most g. Investigatin
recommendati s recommenda will be helpful. plan (2012-16 the main requ
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onclusion
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t information. ween insuranc national heal t impact on thi
cknowledgm
authors woul mmunicable dis
onflict of Inter
authors decla
eferences uberculosis Fact
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