Co-occurrence of genes encoding carbapenemase, ESBL, pAmpC and non-ß-Lactam resistance among Klebsiella pneumonia and E. coli clinical isolates in Tunisia.

This study aimed to investigate the molecular mechanisms of carbapenem and colistin resistance in K. pneumoniae and E. coli isolates obtained from hospitalized patients in Carthagene International Hospital of Tunis. A total of 25 K. pneumoniae and 2 E. coli clinical isolates with reduced susceptibility to carbapenems were recovered. Susceptibility testing and phenotypic screening tests were carried out. ESBL, AmpC, carbapenemase and other antibiotic resistance genes were sought by PCR-sequencing. The presence of plasmid-mediated colistin resistance genes (mcr-1-8) was examined by PCR and the nucleotide sequence of the mgrB gene was determined. The analysis of plasmid content was performed by PCR-Based Replicon Typing (PBRT). The clonality of isolates was assessed by PFGE and multilocus sequence typing (MLST). All of the isolates produced carbapenemase activity. They showed a great variation in the distribution of ESBL, AmpC, carbapenemase and other plasmid-mediated resistance determinants. K. pneumoniae isolates carried blaNDM-1 (n = 11), blaOXA-48 (n = 11), blaNDM-1 + blaOXA-48 (n = 1), blaNDM-1 + blaVIM-1 (n = 1), blaOXA-204 (n = 1), along with blaCTX-M , blaOXA , blaTEM , blaCMY , blaDHA and blaSHV genes variants on conjugative plasmid of IncL/M, IncR, IncFIIK , IncFIB, and IncHI1 types. Three sequence types ST101, ST307 and ST15 were identified. The mgrB alteration g109a (G37S) was detected in a single colistin-resistant, NDM-1 and OXA-48-coproducing K. pneumoniae isolate. The two E. coli isolates belonged to ST95, co-produced NDM-1 and CTX-M-15, and harboured plasmid of IncFII and IncFIB types. To our knowledge, this is the first report in Tunisia of NDM-1, OXA-48, and CTX-M-15 coexistence in colistin-resistant K. pneumoniae ST15.

[Virus and Atypical Pathogens Detected in Community-Acquired Lower Respiratory Tract Infection in Infants and Children of Sfax Region, Tunisia]. / Virus et bactéries atypiques détectés dans les infections respiratoires basses communautaires de l'enfant dans la région de Sfax en Tunisie.

Little is known about viral and atypical bacteria pathogen spectra of community-acquired lower respiratory tract infection in children in Tunisia. Thus, a prospective study was carried out between January 2009 and March 2010 in Sfax. Nasopharyngeal aspirates collected from 368 patients (78 with pneumonia and 290 with acute bronchiolitis) were analyzed by indirect immunofluorescence assay and PCR to detect influenza viruses, parainfluenza viruses, respiratory syncytial virus (RSV), human metapneumovirus, human rhinovirus, human enterovirus, adenovirus, coronavirus, Mycoplasma pneumonia (Mpn) and Chlamydia pneumonia (Cpn). One or more etiology was documented in 319 cases (86.7%). The most detected viruses were RSV (42.7%), rhinovirus (32.9%) and adenovirus (28.5%). Co-detection of two or three pathogens was found in 40% of positive samples. This study highlights the importance of respiratory viruses in lower respiratory tract infection in children of Sfax region as well as the high rate of co-detection of multiple viruses, resulting in challenges in clinical interpretation.

Le profil étiologique microbien des infections respiratoires basses (IRB) communautaires de l'enfant a été peu étudié en Tunisie. Une étude prospective a été menée à Sfax entre janvier 2009 et mars 2010 sur 368 enfants hospitalisés pour pneumonie (n = 78) ou bronchiolite aiguë (n = 290). Les aspirations nasopharyngées ont été analysées par immunofluorescence et par PCR à la recherche des virus influenza, virus para-influenza, virus respiratoire syncytial (VRS), métapneumovirus, rhinovirus, entérovirus, adénovirus, coronavirus, Mycoplasma pneumoniae (Mpn) et Chlamydia pneumoniae (Cpn). Une étiologie ou plus a été retrouvée dans 319 cas (86,7 %) : principalement le VRS (42,7 %), des rhinovirus (32,9 %) et des adénovirus (28,5 %). Dans 40 % des prélèvements positifs, deux ou trois agents pathogènes ont été codétectés. Cette étude a permis de montrer la prévalence élevée des virus dans les IRB de l'enfant dans la région de Sfax et leur détection fréquente en co-infection posant la question sur leur rôle pathogène réel.

Antibiotic resistance in Escherichia coli in husbandry animals: the African perspective.

In the last few years, different surveillances have been published in Africa, especially in northern countries, regarding antimicrobial resistance among husbandry animals. Information is still scarce, but the available data show a worrying picture. Although the highest resistance rates have been described against tetracycline, penicillins and sulphonamides, prevalence of plasmid-mediated quinolone resistance genes and extended spectrum ß-lactamase (ESBL) are being increasingly reported. Among ESBLs, the CTX-M-1 group was dominant in most African surveys. Within this group, CTX-M-15 was the main variant both in animals and humans, except in Tunisia where CTX-M-1 was more frequently detected among Escherichia coli from poultry. Certain blaCTX-M-15 -harbouring clones (ST131/B2 or ST405/D) are mainly identified in humans, but they have also been reported in livestock species from Tanzania, Nigeria or Tunisia. Moreover, several reports suggest an inter-host circulation of specific plasmids (e.g. blaCTX-M-1 -carrying IncI1/ST3 in Tunisia, IncY- and Inc-untypeable replicons co-harbouring qnrS1 and blaCTX-M-15 in Tanzania and the worldwide distributed blaCTX-M-15 -carrying IncF-type plasmids). International trade of poultry meat seems to have contributed to the spread of other ESBL variants, such as CTX-M-14, and clones. Furthermore, first descriptions of OXA-48- and OXA-181-producing E. coli have been recently documented in cattle from Egypt, and the emergent plasmid-mediated colistin resistance mcr-1 gene has been also identified in chickens from Algeria, Tunisia and South Africa. These data reflect the urgent need of a larger regulation in the use of veterinary drugs and the implementation of surveillance programmes in order to decelerate the advance of antimicrobial resistance in this continent.

Characterisation of nasal Staphylococcus delphini and Staphylococcus pseudintermedius isolates from healthy donkeys in Tunisia.

REASONS FOR PERFORMING STUDY: Staphylococcus intermedius group (SIG) bacteria can colonise the nares of some animals but are also emerging pathogens in humans and animals. OBJECTIVES: To analyse SIG nasal carriage in healthy donkeys destined for food consumption in Tunisia and to characterise recovered isolates. METHODS: Nasal swabs from 100 healthy donkeys were tested for SIG recovery, and isolates were identified by biochemical and molecular methods. Antimicrobial susceptibility of isolates was tested and detection of antimicrobial resistance and virulence genes was performed. Isolates were typed at the clonal level by multilocus sequence typing and SmaI pulsed-field gel electrophoresis. RESULTS: Staphylococcus delphini and Staphylococcus pseudintermedius (included in SIG) were obtained in 19% and 2% of the tested samples, respectively, and one isolate per sample was characterised. All isolates were meticillin susceptible and mecA negative. Most S. delphini and S. pseudintermedius isolates showed susceptibility to all antimicrobials tested, with the exception of 2 isolates resistant to tetracycline (tet(M) gene) or fusidic acid. The following toxin genes were identified (percentage of isolates): lukS-I (100%), lukF-I (9.5%), siet (100%), se-int (90%), seccanine (19%) and expA (9.5%). Thirteen different pulsed-field gel electrophoresis profiles were identified among the 21 SIG isolates. Additionally, the following 9 different sequence types (STs) were detected by multilocus sequence typing, 6 of them new: ST219 (6 isolates), ST12 (5 isolates), ST220 (3 isolates), ST13, ST50, ST193, ST196, ST218 and ST221 (one isolate each). CONCLUSIONS: Staphylococcus delphini and S. pseudintermedius are common nasal colonisers of donkeys, generally susceptible to the antimicrobials tested; nevertheless, these SIG isolates contain virulence genes, including the recently described exfoliative gene (expA) and several enterotoxin genes, with potential implications for public health. This is the first description of S. delphini in Tunisia. The Summary is available in Chinese - see Supporting information.

Factors associated with treatment default by tuberculosis patients in Fez, Morocco.

Interruption in tuberculosis (TB) treatment still remains the most important challenge for control of the disease. This study aimed to identify the determinants of TB treatment default in Fez, Morocco. A 1:2 pair-matched case-control study was carried out in the TB control units in Fez. Cases were defaulters to TB treatment and were matched by age and sex to non-defaulters (controls). Of the 320 patients (108 defaulters, 212 controls), 80.6% were male. The main reason for defaulting reported by patients was the sensation of being cured. Predictive factors for treatment default in the multivariate conditional logistic regression analysis, were: relapsed case (adjusted OR = 4.49; 95% Cl: 1.87-10.8), current smoking (aOR= 2.10; 95% Cl: 1.07-4.14), alcohol use (aOR = 2.92; 95% Cl: 1.04-8.19), being more than 30 minutes away from the health centre (aOR = 3.34; 95% Cl: 1.06-10.5) and perception of having received insufficient explanation about the disease (aOR = 2.87; 95% CI: 1.53-5.36). The rate of defaulting in Fez can be lowered through targeted and realistic measures.

Prevalence and characterisation of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli isolates in healthy volunteers in Tunisia.

The objective of this investigation was to analyse the carriage rate of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli in faecal samples of healthy humans in Tunisia and to characterise the recovered isolates. One hundred and fifty samples were inoculated on MacConkey agar plates supplemented with cefotaxime (2 µg/ml) for ESBL-positive E. coli recovery. The characterisation of ESBL genes and their genetic environments, detection of associated resistance genes, multilocus sequence typing (MLST) and phylogroup typing were performed by polymerase chain reaction (PCR) and sequencing. The presence and characterisation of integrons and virulence factors were studied by PCR and sequencing. ESBL-positive E. coli isolates were detected in 11 of 150 faecal samples (7.3%) and one isolate/sample was further characterised. These isolates contained the blaCTX-M-1 (ten isolates) and blaTEM-52c genes (one isolate). The ISEcp1 (truncated by IS10 in four strains) and orf477 sequences were found upstream and downstream, respectively, of all bla (CTX-M-1) genes. Seven different sequence types (STs) and three phylogroups were identified among CTX-M-1-producing isolates [ST/phylogroup (number of isolates)]: ST58/B1 (3), ST57/D (2), ST165/A (1), ST155/B1 (1), ST10/A (1), ST398/A (1) and ST48/B1 (1). The TEM-52-producing isolate was typed as ST219 and phylogroup B2. Six ESBL isolates contained class 1 integrons with the gene cassettes dfrA17-aadA5 (five isolates) and dfrA1-aadA1 (one). Healthy humans in the studied country could be a reservoir of CTX-M-1-producing E. coli.

Association between smoking status, other factors and tuberculosis treatment failure in Morocco.

BACKGROUND: The association between smoking and tuberculosis (TB) treatment failure has not yet been assessed in Morocco. OBJECTIVE: To evaluate the impact of smoking on the failure rate of patients with TB. METHODS: A cohort of 727 new TB cases was followed between 2004 and 2009. Socio-demographic measurements and smoking status were collected by questionnaire. Treatment failure was defined according to international guidelines. Univariate analyses were used to assess associations of treatment failure with smoking status and demographic characteristics. Multivariate logistic regression was used to adjust for potential confounding. RESULTS: The patients' mean age was 35.0 ± 13.2 years. The monthly household income was <€180 for 71.4% of the patients. The rate of treatment failure was 6.9%. Failure was significantly higher among smokers (9.1% vs. 4.5%; P < 0.01), alcohol drinkers (18.5% vs. 4.9%; P < 0.01), and those with a monthly income of <€180 (8.4% vs. 3.3%; P < 0.01). After adjusting for confounding variables, smoking and low income remained significantly associated with treatment failure (adjusted OR 2.25, 95%CI 1.06-4.76, and 3.23, 95%CI 1.12-9.32). CONCLUSION: Smoking is associated with TB treatment failure in Morocco. Anti-smoking interventions should be incorporated into current TB case management.

Nasal carriage of Staphylococcus aureus in healthy humans with different levels of contact with animals in Tunisia: genetic lineages, methicillin resistance, and virulence factors.

Nasal swabs of 423 healthy humans who showed different levels of contact with animals (frequent, 168; sporadic, 94; no contact, 161) were obtained in Tunisia (2008-2009), and 99 of them presented other associated risk factors. Methicillin-resistant Staphylococcus aureus (MRSA) was detected in one of these 423 samples (0.24%), retrieved from a veterinarian. The MRSA isolate was mecA-positive, typed as ST80-t203-SCCmecIVc-agrIII, and contained tet(K), ant(6)-Ia, and aph(3')-IIIa genes encoding tetracycline, streptomycin, and kanamycin resistance, respectively. This MRSA isolate also contained the lukF/lukS virulence gene encoding Panton-Valentine leukocidin. Fifty-four (12.8%) additional nasal samples contained methicillin-susceptible S. aureus (MSSA) and one isolate/sample was characterized. A high diversity of spa types (n = 43; 4 new) and pulsed-field gel electrophoresis (PFGE) types (n = 37) was detected among the 55 recovered S. aureus strains. The percentages of antimicrobial resistance/detected resistance genes were as follows: tetracycline [22%/tet(K)-tet(L)-tet(M)], erythromycin [5%/msrA], ciprofloxacin [14.5%], trimethoprim-sulfamethoxazole [2%/dfrA], streptomycin [11%/ant(6)-Ia], kanamycin [7%/aph(3')-IIIa], amikacin [5%], and chloramphenicol [2%]. Four and two isolates carried the lukF/lukS and eta and/or etb genes, respectively, and always in individuals with contact with animals. Eleven isolates carried the tst gene and were recovered from individuals with different levels of contact with animals.

Knowledge and attitude about antismoking legislation in Morocco according to smoking status.

Despite tobacco control legislation enacted in Morocco in 1996, the Moroccan population appears to have little interest in or awareness of tobacco control measures. This household survey aimed to assess sectional study was conducted on a random sample of 9195 Moroccans. Only 33.3% knew about the antismoking legislation: 38.7% of smokers versus 32.3% of non-smokers. Among the 3050 people who knew about the law, 60.1% knew about the ban on smoking in public areas and 22.4% knew there was an obligatory health warning on tobacco packaging. The attitude questions showed that 27.2% agreed that the price of tobacco products should increase sharply and 45.0% that antismoking legislation should prohibit tobacco sales to children. These data demonstrate low levels of information among Moroccans concerning current tobacco control legislation.

Detection of unrelated Escherichia coli strains harboring genes of CTX-M-15, OXA-1, and AAC(6')-Ib-cr enzymes in a Tunisian hospital and characterization of their integrons and virulence factors.

Beta-lactamase characterization was carried out in a collection of 18 extended-spectrum beta-lactamase (ESBL)-positive Escherichia coli isolates from blood (n=8) and urine (n=10) obtained in 2007 in a tunisian Hospital. All isolates were clonally unrelated according to PFGE analysis. Seventeen strains presented the bla(CTX-M-)15 gene associated with bla (OXA-)1 and four of these strains with the (TEM-)1(b) gene. The remaining ESBL-positive strain contained the bla (CTX-M-)9 gene associated with the bla (OXA-)1 and bla (TEM-)1(b) genes. The orf477 sequence was identified downstream of the bla(CTX-M-)15 gene in all 17 bla(CTX-M-)15-positive strains, and ISEcp1 upstream in 15 of them (in eight cases truncated by IS26). The presence of a class 1 integron was demonstrated in 4 of the 18 ESBL-positive strains (22.2%), with dfrA17 + aadA5 (3 strains) and dfrA12 + orfF + aadA2 (1 strain) being the gene cassettes identified. The variant aac(6´)-Ib-cr was found in 15 bla(CTX-M-)15-containing strains. All 18 ESBL-positive strains were typed as phylogroup B2 and contained at least three of the eight tested virulence genes (fimA, papGIII, hlyA, cnf1, papC, aer, eae and bfp). Six bla(CTX-M-)15-positive strains were included in the serotype O25b and one of them was typed as ST131. Another bla(CTX-M-)15-positive strain serotype-O25 was typed as ST638. The bla(CTX-M-)15, aac(6')- Ib-cr, and aac(3)-II genes were co-transferred by conjugation from 7 donor strains to E. coli CSH26 recipient strain. The bla(CTXM-)15 gene is prevalent among ESBL-positive E. coli strains in the studied hospital, that is frequently found together with aac(6')- Ib-cr, and aac(3)-II genes. The detection of the clone O25b-St131 in a bla(CTX-M-)15 strain corroborates its worldwide dissemination.

Burden of smoking in Moroccan rural areas.

The aim of this study was to estimate the prevalence and characteristics of current smoking among rural Moroccans. The population study included 3438 individuals aged 15 years and above from both sexes. The crude prevalence of current smoking (currently smoked and had smoked > 100 cigarettes in lifetime) was 16.9% in the adolescent and adult rural population: 31.0% among men and 1.1% among women. The majority of smokers 74.4% of men and 68.8% of women) began smoking before age 20 years. Multiple logistic regression analysis showed that age, sex, marital status, occupation and region of residence were the strongest determinants of current smoking. These results showed a high prevalence of smoking among males in the rural population of Morocco.

Indoor solid fuel combustion and tuberculosis: is there an association?

OBJECTIVES: To assess the strength of evidence in published articles for an association between indoor solid fuel combustion and tuberculosis. METHODS: PubMed, a private database and Google Scholar were searched up to May 2008, as was the Cochrane Library (2008, issue 4), to identify articles on the association between indoor air pollution and tuberculous infection, tuberculosis disease and tuberculosis mortality. Each article initially chosen as acceptable for inclusion was reviewed for data extraction by three different reviewers using a standard format. Strength of evidence was determined by pre-determined criteria. RESULTS: The full texts of 994 articles were examined for a final selection of 10 possible articles, of which six met the inclusion criteria. All articles investigated the association between exposure to solid fuel (coal and biomass) smoke and tuberculosis disease. Three (50%) of the six studies included in the systematic review showed a significant effect of exposure to solid fuel combustion and tuberculosis disease-one high-quality case-control study and two cross-sectional studies. CONCLUSION: Despite the plausibility of an association, available original studies looking at this issue do not provide sufficient evidence of an excess risk of tuberculosis due to exposure to indoor coal or biomass combustion. Because the number of studies identified was small, new studies are needed before more definitive conclusions can be reached.

[Tobacco consumption among young adults in the two French departments of Savoie in 2008]. / Modes de consommation du tabac des jeunes adultes des deux Savoies en 2008.

BACKGROUND: As a result of tobacco control measures in France, smoking among adolescents is decreasing. However, this decrease is associated with changes in the way youth are consuming tobacco and turning towards new tobacco products: cheaper forms of tobacco such as rolling or chewing tobacco, or fashionable forms such as narghile. The aim of this study is to describe in young adults: (1) prevalence of tobacco use and main risk factors of daily smoking, (2) the entry mode for tobacco use and (3) prevalence and main risk factors related to "chewing tobacco" used as snuff. METHODS: A descriptive transversal study was undertaken in five private and public high schools in the French Alps region in 2008. Anonymous questionnaires were given out to the students of 12th grade (last year of general secondary education) and BTS (professional training). Smoking prevalence and other forms of tobacco consumption were described, as well as the entry mode in tobacco use. Finally, we used logistic models to identify the main determinants of smoking cigarettes and using chewing tobacco. RESULTS: This study included 920 students: 22.3% (95% IC: 19.6-25.0) were daily smokers and 65.9% (95% IC: 62.8-69.0) had tried tobacco. Approximately 40% had experimented with rolling tobacco, cannabis or narghile. We found the usual determinants of daily smoking: an environment conducive to smoking, and not belonging to a sports club. Around 11% (95% IC: 9.2-13.2) had tried chewing tobacco. Risk factors associated with chewing tobacco were: having a smoking friend (adjusted OR: 3.07; 95% IC: 1.95-4.83), studying in a private school (adjusted OR: 2.57; 95% IC: 1.52-4.31), or being male (adjusted OR: 1.79; 95% IC: 1.15-2.79). CONCLUSION: As found in national studies, cigarette smoking is declining among young adults, but the use of other tobacco products (narghile, chewing tobacco) is emerging. The relatively high consumption rate and the risk factors of chewing tobacco need to be examined in depth in order to organize prevention programs for young adults.

Inequalities in smoking profiles in Morocco: the role of educational level.

BACKGROUND: Cigarette smoking is increasingly associated with lower socio-economic status, indicated by lower educational levels. This association has never been investigated in Morocco. OBJECTIVE: The MARTA survey was undertaken to assess tobacco use in the Moroccan population according to level of education and other socio-demographic characteristics. METHODS: A cross-sectional survey based on a representative sample of the Moroccan population was conducted in 2005-2006. The survey questionnaire gathered socio-demographic information, educational level and smoking status. chi(2) analyses were performed to determine whether the smoking outcome variables differed significantly between different educational levels in relation to demographic variables. Multiple logistic regression analysis was used to calculate the adjusted odds ratio for smoking status according to educational level. RESULTS: A total of 9195 subjects were included in the study; 52% were men and 17.9% illiterate. The overall prevalence of current smoking was 18.0% (95%CI 17.2-18.8): 31.5% (95%CI 30.2-32.9) in males and 3.3% (95%CI 2.8-3.8) in females. The prevalence of current smoking was inversely associated with level of education in men and increased with educational level in women. Illiterate males tended to have a higher probability of being current smokers than males with university-level education (OR 1.93, 95%CI 1.51-2.46). CONCLUSION: These results indicate a need for tobacco control to reach all sectors of society, and especially the illiterate population.

Polymorphism in pbp5 gene detected in clinical Enterococcus faecium strains with different ampicillin MICs from a Tunisian hospital.

The polymorphism in pbp5 gene was investigated in nine unrelated clinical gentamicin-resistant Enterococcus faecium strains with different minimal-inhibitory-concentration values for ampicillin (six ampicillin-resistant and three ampicillin-susceptible). Five alleles were detected when the pbp5 C-terminal region was analysed, two of them in the ampicillin-resistant strains showed a new allele characterised by the Thr416Ala and Val462Ala substitutions. Two different alleles were identified when the pbp5 N-terminal region was studied; one of them in the unique strain (E. faecium 83) that presented very low ampicillin MIC (<0.125 microg/ml) and a nucleotidic mutation implicating a stop codon at 451 position. RT-PCR experiments carried out on five E.faecium positive results indication the expression of this gene. Specific mutations in pbp5 gene could be responsible of the high MIC values of some of the E. faecium strains.

Global perspective on tobacco control. Part I. The global state of the tobacco epidemic.

Tobacco smoking is losing adherents in some countries, and a number of international developments may dramatically change the choices people make concerning tobacco. However, the growth of chronic obstructive pulmonary disease (COPD) in the world is nevertheless assured-tobacco consumption is rising globally because of increased consumption in many low-income countries. Risk of COPD is strong wherever smokers are found, and even among former smokers, it remains high for decades. Both COPD and smoking produce lower measurable quality of life assessment, but little attention is given to the association, apart from noting that cessation rates are poor among COPD patients. Tobacco smoking rates vary; men usually smoke more than women in overall consumption and in prevalence. Current available estimates are 49% for men and 8% for women in low- and middle-income countries, and 37% for men and 21% for women in high-income countries. These figures give little information, however, because there can be variations within and across populations. What is important is that about a third of all adults in the world currently smoke, and that it will take a tremendous turnaround to put a halt to the overall growth of tobacco use. Smoking-related COPD rates will continue to be high for some time. The future of COPD is related most dramatically to low- or middle-income countries, where more than four in five current smokers in the world live. The predictable health consequences of smoking, including an enormous burden in COPD, have only begun to emerge.

Tobacco and tuberculosis: a qualitative systematic review and meta-analysis.

OBJECTIVES: To assess the strength of evidence in published articles for an association between smoking and passive exposure to tobacco smoke and various manifestations and outcomes of tuberculosis (TB). Clinicians and public health workers working to fight TB may not see a role for themselves in tobacco control because the association between tobacco and TB has not been widely accepted. A qualitative review and meta-analysis was therefore undertaken. METHODS: Reference lists, PubMed, the database of the International Union Against Tuberculosis and Lung Disease and Google Scholar were searched for a final inclusion of 42 articles in English containing 53 outcomes for data extraction. A quality score was attributed to each study to classify the strength of evidence according to each TB outcome. A meta-analysis was then performed on results from included studies. RESULTS: Despite the limitations in the data available, the evidence was rated as strong for an association between smoking and TB disease, moderate for the association between second-hand smoke exposure and TB disease and between smoking and retreatment TB disease, and limited for the association between smoking and tuberculous infection and between smoking and TB mortality. There was insufficient evidence to support an association of smoking and delay, default, slower smear conversion, greater severity of disease or drug-resistant TB or of second-hand tobacco smoke exposure and infection. CONCLUSIONS: The association between smoking and TB disease appears to be causal. Smoking can have an important impact on many aspects of TB. Clinicians can confidently advise patients that quitting smoking and avoiding exposure to others' tobacco smoke are important measures in TB control.

Providing and monitoring quality service for smoking cessation in tuberculosis care.

All tobacco smokers should be identified and provided with a smoking cessation intervention (SCI) during tuberculosis (TB) treatment. To ensure that this occurs, the intervention process should be recorded and monitored. Monitoring is the best guarantee that care is standardised and offered equitably to all patients. It allows for evaluation of processes and outcomes so that population needs can be identified and appropriate techniques added or updated. In this article we propose steps for brief intervention as a part of the monitoring process, using model forms and suggested procedures for filling them in. The suggested forms are a modified TB treatment card that includes information about tobacco use, an SCI patient card to be added to the patient's TB treatment folder, SCI registers and SCI quarterly report forms and a tobacco use questionnaire for evaluation of services.

Helping patients to stop smoking.

Cognitive-behavioural strategies can be used for smokers who request assistance in stopping smoking. These strategies are based on social learning theory, which defines smoking cessation as a process of breaking all of the emotional and situational ties that have been established with the act of smoking. To do this, the quitting smoker needs to understand the addiction process as well as conditioned responses to it in dealing with withdrawal symptoms and craving. The health worker can help the quitting smoker by providing techniques to understand what and how smoking reinforces itself, to enhance and maintain motivation to remain abstinent, to encourage using a social support system and to plan the coping techniques that might be used. Both acts (behaviours) and thinking (cognitions) can be powerful tools in persevering to cope with craving and to manage undesirable side-effects of cessation. These include identifying the antecedents (cues to use tobacco) and the consequences of using tobacco to identify critical emotions and situations where coping is most necessary, finding activities to replace the act of lighting a cigarette, mentally preparing for craving and keeping at bay unhelpful thoughts (such as 'I'll just take one last puff'). Mental preparation is also necessary to understand and to avoid or limit the side effects of cessation.