Exploring the link between adverse childhood experiences and mental and physical health conditions in pregnant Palestine refugee women in Jordan.

OBJECTIVES: Adverse childhood experiences (ACEs) are linked to negative pregnancy outcomes. However, little is known about the prevalence of ACEs and their relationship to mental and health outcomes among pregnant Palestine refugee women. STUDY DESIGN: This was a cross-sectional study. METHODS: Data were collected from 772 pregnant Palestine refugee women with a median (interquartile range) age of 27 (23, 32) years, attending five antenatal clinics in Jordan between February and June 2021. The modified 33-item ACE International Questionnaire was used to assess eight domains of ACEs: (1) marriage and family, (2) relationship with parents, (3) neglect, (4) household dysfunction/domestic violence, (5) abuse, (6) peer violence, (7) community violence, and (8) collective violence. Multivariate logistic regression was used to examine the association between ACEs and mental and health outcomes. The ethical approval was obtained from United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) Research Review Board in May 2020. RESULTS: Eighty-eight percent of women experienced at least one type of ACE, and 26% of women experienced ≥4 types of ACEs. Compared with women with 0-3 types of ACE exposure, those with ≥4 types of ACEs had 1.58 (95% confidence interval [CI] 1.10-2.28) times higher prevalence of obesity before pregnancy, 3.28 (95% CI 1.79-6.03) times higher prevalence of depression during pregnancy, and 2.01 (95% CI 1.39-2.91) times higher prevalence of ever been smoking cigarettes or hookah. CONCLUSIONS: Exposure to ACEs is prevalent among pregnant Palestine refugee women. Exposure to multiple types of ACEs was associated with obesity, mental health conditions, and smoking.

Paediatric continuing medical education needs and preferences of UNRWA physicians in Jordan.

Most physicians who work in the United Nations Relief and Works Agency (UNRWA) infant and child health programme in Jordan are general practitioners with no postgraduate training in paediatrics. Furthermore, in resource-poor or remote settings, the ability to deliver live continuing medical education (CME) is often limited. A questionnaire exploring the resources available for accessing CME, preferences for types of CME, current sources of CME and topics of interest in the field of paediatric care was sent to all 92 physicians practising in UNRWA clinics in Jordan. Of the 89 respondents 80% had attended live medical lectures for CME and 70% CME meetings. Despite most physicians having access to the Internet only 52.8% were interested in Internet-based courses for accessing CME. There was a statistically significant relationship between year of graduation from medical school and preference for Internet-based CME. Implications for CME participation and paediatric CME topics are discussed.

Primary healthcare reform in the United Nations Relief and Works Agency for Palestine Refugees in the Near East.

Palestinian refugees served by the United Nation Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) are experiencing increasing rates of diagnosis of non-communicable diseases. In response, in 2011 UNRWA initiated an Agency-wide programme of primary healthcare reform, informed by the Chronic Care Model framework. Health services were reorganized following a family-centred approach, with delivery by multidisciplinary family health teams supported by updated technical advice. An inclusive clinical information system, termed e-Health, was implemented to collect a wide range of health information, with a focus on continuity of treatment. UNRWA was able to bring about these wide-ranging changes within its existing resources, reallocating finances, reforming its payment mechanisms, and modernizing its drug-procurement policies. While specific components of UNRWA's primary healthcare reform are showing promising results, additional efforts are needed to empower patients further and to strengthen involvement of the community.

Hypertension and treatment outcomes in Palestine refugees in United Nations Relief and Works Agency primary health care clinics in Jordan.

OBJECTIVE: In six United Nations Relief and Works Agency (UNRWA) primary health care clinics in Jordan serving Palestine refugees diagnosed with hypertension, to determine the number, characteristics, programme outcomes and measures of disease control for those registered up to 30 June, 2013, and in those who attended clinic in the second quarter of 2013, the prevalence of disease-related complications between those with hypertension only and hypertension combined with diabetes mellitus. METHOD: Retrospective cohort study with programme and outcome data collected and analysed using E-Health. RESULTS: There were 18 881 patients registered with hypertension with females (64%) and persons aged ≥ 40 years (87%) predominating. At baseline, cigarette smoking was recorded in 17%, physical inactivity in 48% and obesity in 71% of patients. 77% of all registered patients attended clinic in the second quarter of 2013; of these, 50% had hypertension and diabetes and 50% had hypertension alone; 9% did not attend the clinics and 10% were lost to follow-up. Amongst those attending clinic, 92% had their blood pressure measured, of whom 83% had blood pressure <140/90 mm Hg. There were significantly more patients with hypertension and diabetes (N = 966, 13%) who had disease-related complications than patients who had hypertension alone (N = 472, 6%) [OR 2.2, 95% CI 2.0-2.5], and these differences were found for both males [18% vs. 10%, OR 1.9, 95% CI 1.6-2.2] and females [11% vs. 5%, OR 2.4, 95% CI 2.1-2.9]. CONCLUSION: Large numbers of Palestine refugees are being registered and treated for hypertension in UNRWA primary health care clinics in Jordan. Cohort analysis and E-Health can be used to regularly assess caseload, programme outcomes, clinic performance, blood pressure control and cumulative prevalence of disease-related complications. Current challenges include the need to increase clinic attendance and attain better control of blood pressure.

Promoting public-private mix for TB-DOTs: a multi-country study from the WHO Eastern Mediterranean Region.

This study was carried out to document the implementation status of public-private mix (PPM) in 6 member countries of the World Health Organization Eastern Mediterranean Region, with a particular focus on advocacy, communication and social mobilization (ACSM) specific to PPM. Interviews and focus group discussions were held with staff of national tuberculosis control programmes and partners. Four PPM models were being practised. For all models, ACSM specific to PPM was at the elementary stage. Participants perceived that promoting private partners was difficult, specific policy guidelines were deficient and human resources and capacity for both initiatives were lacking across the region. Building ACSM capacity is required along with the development of guidelines and the implementation of country-specific communication plans to carry out local-level advocacy, strategic communication and effective social mobilization to maximize the benefits of PPM.

Training on the Practical Approach to Lung Health: effect on drug prescribing in PHC settings in Jordan.

This study assessed whether training physicians on the Practical Approach to Lung Health (PAL) reduces drug prescribing and the cost of drugs prescribed to respiratory patients in the primary health care setting. Data were compared before and after training general practitioners on standard guidelines for case management of respiratory conditions in primary care. A total of 56 general practitioners practising in 25 health centres in 3 out of 12 governorates of Jordan participated in both the baseline survey (n = 6260 respiratory patients) and the impact survey (n = 2709 patients). Training in PAL decreased by 12.2% the number of drugs prescribed per patient, increased the prescription of inhaled medications and reduced the mean cost of a drug prescription per patient by 8.7%.

Results of the feasibility test of the Practical Approach to Lung Health in the Syrian Arab Republic.

We assessed implementation of the Practical Approach to Lung Health (PAL) in primary care facilities in the Syrian Arab Republic and its short-term impact on respiratory care in patients aged 5+ years. After training on PAL for 76 general practitioners in 75 health centres, referrals and sputum smear examinations for patients increased. The mean number of drugs prescribed per patient decreased by 14.8% and that of antibiotics by 33.3%, while prescriptions for inhaled medications increased. The mean cost of drug prescriptions fell by 26.2%.

Nationwide survey on the prevalence of anti-tuberculosis drug resistance in the Republic of Yemen, 2004.

OBJECTIVES: To determine the prevalence of resistance to the four major anti-tuberculosis drugs, isoniazid, rifampicin, streptomycin and ethambutol, in Yemen. METHODS: Cluster sampling with probability proportionate to size was applied. Susceptibility to four major anti-tuberculosis drugs was examined. The proportion method using Löwenstein-Jensen medium or Ogawa medium was carried out. RESULTS: A total of 790 primary culture isolates from tuberculosis (TB) cases enrolled at the National Tuberculosis Institute, Yemen, were examined. In the confirmation culture at the supranational reference laboratory, 227 of them failed to grow on the secondary culture or were proved to be mycobacteria other than Mycobacterium tuberculosis and were excluded from further analysis. Among 563 cultures, 510 were obtained from new cases and 53 from previously treated cases. The prevalence of resistance to any four drugs was 9.8% (95%CI 7.0-12.5) among new cases and 17.4% (95%CI 12.0-33.5) among previously treated cases. The prevalence of multidrug-resistant TB was 3.0% (95%CI 1.5-4.5) among new cases and 9.4% (95%CI 0.2-18.7) among previously treated cases. CONCLUSION: The first nationwide prevalence survey on resistance to the four major anti-tuberculosis drugs in Yemen showed a relatively low prevalence of drug-resistant cases, but a high prevalence of multidrug resistance among new cases.

Global elimination of tuberculosis: implementation, innovation, investigation.

The elimination of a public health menace such as tuberculosis is always an attractive proposition. Is it realistic to consider? Selecting elimination as a target engages commitment, identifies challenges and stimulates critical evaluation. Challenges are numerous, including the large pool of latent infection, the long incubation period, the inadequacy of present tools and strategies, poverty and its relation to tuberculosis, the dependence on declining health services, the negative impact of human immunodeficiency virus infection, and the long-term commitment required with present approaches. Although tuberculosis has a tragic impact in causing death and chronic illness, the target for elimination must remain preventing infection, and the aim to achieve a generation free of infection. Targeting decreased mortality or improved health will not be sufficient to guide the critical reflection required to eliminate the causative organism; this can only be achieved by focusing on preventing and eliminating infection. While we have an international consensus on the strategy for controlling tuberculosis, we must also keep in mind that it is not sufficient. We must improve the current strategy as well as develop new tools on which we can base a new strategy if we hope to achieve the objective of elimination of tuberculosis. Reaching the target will require commitment to implementing what we currently have, improving on it in every way possible and keeping our minds and imaginations open to new ways to approach the fight against tuberculosis.

Tuberculosis and HIV in the Eastern Mediterranean Region.

Tuberculosis (TB) is an important public health problem in the Eastern Mediterranean Region of the World Health Organization. Every year the disease kills 136,000 people and affects 630,000 more. HIV is the most significant risk factor for progression from subclinical infection with Mycobacterium tuberculosis to active TB. Although the HIV/AIDS threat in the Region appears to be relatively modest and so far there has been no evidence of an impact of HIV on TB epidemiology in the Region, there is a need to jointly address HIV infection and TB more effectively. In this paper the TB situation in the Region and the measures being taken to combat it are outlined. The impact of HIV infection on TB and the repercussions this could have on theTB situation in the Region are also discussed. Actions that are needed to tackle this double burden are suggested.

[Retreatment of pulmonary tuberculosis--duration of chemotherapy].

Although standard chemotherapy for initial treatment of pulmonary tuberculosis has been established, regimens for retreatment of tuberculosis have not yet been established. One hundred fifty nine retreatment pulmonary tuberculosis cases admitted to Fukujuji Hospital were retrospectively analyzed. Regardless of the age at the start of retreatment, majority of cases were treated previously between 1955 and 1960. Bacillary negative conversion rate, duration of chemotherapy, follow-up period and bacteriological relapse rate were compared according to resistance against isoniazid and/or rifampicin. Sixty four cases were sensitive to both INH and RFP. For this group the average duration of chemotherapy was 14.6 months, mean follow up period was 47.3 months and relapse rate was 3.1%. This rate was similar to that of initial treatment cases. Sixty one (94%), were treated with more than two sensitive drugs containing INH and RFP. The 22 INH-resistant and RFP-susceptible cases were treated for 18.6 months and followed up for 55.2 months. The relapse rate of this group was 13.6%. Thirteen cases were treated with more than 2 sensitive drugs containing RFP. Eleven cases were resistant to both INH and RFP. Five of them were surgically operated of which 3 cases were converted to negative and among the nonsurgical cases in this group only one remained sputum positive. All of these retreatment regimens did not contain pyrazinamide and ofloxacin. Although bacillary positive rate of INH and RFP susceptible cases was 13.0% at 6 months after treatment and 5.3% at 12 months after treatment, that of INH resistant and RFP susceptible cases were 25.0% and 12.5%, respectively. A certain rule of retreatment could be obtained from the result of this study.

Cohort analysis of antenatal care and delivery outcomes in pregnancy: a basis for improving maternal health.

Cohort analysis has been the cornerstone of tuberculosis (TB) monitoring and evaluation for nearly two decades; these principles have been adapted for patients with the human immunodeficiency virus/acquired immune-deficiency syndrome on antiretroviral treatment and patients with diabetes mellitus and hypertension. We now make the case for using cohort analyses for monitoring pregnant women during antenatal care, up to and including childbirth. We believe that this approach would strengthen the current monitoring and evaluation systems used in antenatal care by providing more precise information at regular time intervals. Accurate real-time data on how many pregnant women are enrolled in antenatal care, their characteristics, the interventions they are receiving and the outcomes for mother and child should provide a solid basis for action to reduce maternal mortality.

Une analyse de cohorte a été la pierre angulaire du suivi et évaluation de la tuberculose pendant près de deux décennies ; ces principes ont été adaptés aux patients atteints de virus de l'immunodéficience humaine/syndrome de l'immunodéficience acquise sous traitement antiretroviral, ainsi qu'aux patients ayant un diabète et une hypertension. Nous recommandons maintenant l'utilisation d'analyse de cohorte pour le suivi des femmes enceintes en consultation prénatale et jusqu'à l'accouchement inclus. Nous pensons que cette approche renforcerait le système actuel de suivi et évaluation utilisé en consultation prénatale en fournissant des informations plus précises à intervalles réguliers. Des données exactes en temps réel sur le nombre de femmes enceintes enrôlées en consultation prénatale, leurs caractéristiques, l'intervention mise en place et les résultats vis-à-vis de la mère et de l'enfant, devraient fournir une solide base d'action visant à diminuer la mortalité maternelle.

El análisis de cohortes ha constituido la piedra angular del seguimiento y de la evaluación de la tuberculosis durante cerca de dos decenios; estos principios se adaptaron a los pacientes coinfectados por el virus de la inmunodeficiencia humana y la síndrome de la inmunodeficiencia adquirida que reciben tratamiento antirretrovírico y a los pacientes con diabetes e hipertensión. En el presente artículo se defiende la oportunidad de utilizar los análisis de cohortes en el seguimiento de las embarazadas durante el cuidado prenatal, hasta incluir el nacimiento. Se propone que esta estrategia reforzaría los sistemas de seguimiento y evaluación que se practican actualmente en la atención prenatal, pues aportaría información más precisa y a intervalos regulares. Obtener los datos exactos y en tiempo real sobre la forma como las embarazadas se inscriben a la atención prenatal, sus características, las principales intervenciones que reciben y los desenlaces de la madre y el niño aportaría fundamentos sólidos a las actividades encaminadas a disminuir la mortalidad materna.

Estimating the tuberculosis burden in resource-limited countries: a capture-recapture study in Yemen.

BACKGROUND: The lack of applicable population-based methods to measure tuberculosis (TB) incidence rates directly at country level emphasises the global need to generate robust TB surveillance data to ascertain trends in disease burden and to assess the performance of TB control programmes in the context of the United Nations Millenium Development Goals and World Health Organization targets for TB control. OBJECTIVE: To estimate the incidence of TB cases (all forms) and sputum smear-positive disease, and the level of under-reporting of TB in Yemen in 2010. METHODS: Record-linkage and three-source capture-recapture analysis of data collected through active prospective longitudinal surveillance within the public and private non-National Tuberculosis Programme sector in twelve Yemeni governorates, selected by stratified cluster random sampling. RESULTS: For all TB cases, the estimated ratio of notified to incident cases and completeness of case ascertainment after record linkage, i.e., the ratio of detected to incident cases, was respectively 71% (95%CI 64-80) and 75% (95%CI 68-85). For sputum smear-positive TB cases, these ratios were respectively 67% (95%CI 58-75) and 76% (95%CI 66-84). CONCLUSION: We estimate that there were 13 082 (95%CI 11 610-14 513) TB cases in Yemen in 2010. Under-reporting of TB in Yemen is estimated at 29% (95%CI 20-36).

Diabetes mellitus and treatment outcomes in Palestine refugees in UNRWA primary health care clinics in Jordan.

SETTING: Six primary health care clinics in Jordan, serving Palestine refugees diagnosed with diabetes mellitus (DM). OBJECTIVES: To report on the number and characteristics of new DM patients registered in the second quarter of 2013 and of all DM patients ever registered by 30 June 2013, with treatment outcomes and cumulative burden of late-stage complications. DESIGN: A descriptive cohort study using routine data collected through e-Health. RESULTS: Of the 288 new patients in Q2 2013 and 12 548 patients ever registered with DM by 30 June 2013, smoking, physical inactivity and obesity were recorded in 19%, 50% and 47%, respectively. In Q2 2013, 9740 (78%) patients attended a clinic, with >99% having undergone disease control measures: of these, 72% had postprandial blood glucose ⩽ 180 mg/dl, 71% had blood cholesterol < 200 mg/dl, 82% had blood pressure < 140/90 and 40% had body mass index < 30 kg/m(2). Late-stage complications were present in 1130 (11.6%) patients who attended a clinic, with cardiovascular disease and stroke being the most common. Several differences in outcomes were found between males and females. CONCLUSION: There is a high burden of disease due to DM at primary health care clinics in Jordan. Cohort analysis using e-Health is a vital way to assess management and follow-up.

Tuberculosis case finding in twenty-two countries of the Eastern Mediterranean Region.

A hypothetical model has been developed to evaluate the efficiency of the case-finding process in 22 countries of the Eastern Mediterranean Region. The model is based on the patient's pathway to care in a stepwise approach from the community to the tuberculosis (TB) management units. Performance was measured using indicators for each of the components of the Stop TB strategy, and a scoring system was developed. The indicators significantly associated with TB case detection were then reported. This tool can assist countries in evaluating the efficiency of their surveillance system in detecting cases.

Primary healthcare reform in the United Nations Relief and Works Agency for Palestine Refugees in the Near East

Palestinian refugees served by the United Nation Relief and Works Agency for Palestine Refugees in the Near East [UNRWA] are experiencing increasing rates of diagnosis of non-communicable diseases. In response, in 2011 UNRWA initiated an Agency-wide programme of primary healthcare reform, informed by the Chronic Care Model framework. Health services were reorganized following a family-centred approach, with delivery by multidisciplinary family health teams supported by updated technical advice. An inclusive clinical information system, termed e-Health, was implemented to collect a wide range of health information, with a focus on continuity of treatment. UNRWA was able to bring about these wide-ranging changes within its existing resources, reallocating finances, reforming its payment mechanisms, and modernizing its drug-procurement policies. While specific components of UNRWA's primary healthcare reform are showing promising results, additional efforts are needed to empower patients further and to strengthen involvement of the community

Les réfugiés palestiniens secourus par l'Office de secours et de travaux des Nations Unies pour les réfugiés de Palestine dans le Proche-Orient [UNRWA] sont confrontés à une recrudescence des maladies non transmissibles. En conséquence, l'UNRWA a lancé en 2011 un programme de réforme des soins de santé primaires à l'échelle de l'Office, guidé par le modèle de soins chroniques. Les services de santé ont été réorganisés sur la base d'une approche orientée vers la famille, avec des prestations de santé dispensées par des équipes de médecine familiale multidisciplinaires soutenues par un conseil technique mis à jour. Un système d'information clinique exhaustif, appelé e-Health, a été mis en œuvre pour collecter une grande quantité d'informations, l'accent étant mis sur la continuité du traitement. L'UNRWA a été en mesure de mener ces changements d'envergure à partir des ressources existantes, en réattribuant des fonds, en réformant ses mécanismes de paiement, et modernisant ses politiques d'approvisionnement en médicaments. Si les composants spécifiques de la réforme de l'UNRWA en matière de soins de santé primaires donnent des résultats prometteurs, davantage d'efforts doivent être déployés pour autonomiser davantage encore les patients et renforcer l'engagement communautaire

Paediatric continuing medical education needs and preferences of UNRWA physicians in Jordan

إن معظم الأطباء الذين يعملون في برنامج صحة الرضع والأطفال التابع لوكالة الأمم المتحدة لغوث وتشغيل اللاجئن الأونروا في الأردن هم ممارسون عامون لم يدرَّبوا بعد التخرج عى طب الأطفال. وعاوة عى ذلك فإن القدرة على تقديم تعليم طبي مستمر مباشر - في الأماكن شحيحة الموارد أو في المناطق النائية - غالباً ما تكون محدودة. فقد أُرسل لجميع الأطباء ال 92 الذين يمارسون العمل في عيادات الأونروا في الأردن استبيان لاستقصاء الموارد المتاحة والمصادر الحالية للتعليم الطبي المستمر، واستكشاف ما يفضلونه من أناط التعليم الطبي المستمر، والوقوف عى الموضوعات ذات الاهتام في مجال الرعاية الطبية للأطفال. فذكر % 80 من المجيبن ال 89 أنهم حضروا محاضرات طبية مباشرة للتعليم الطبي المستمر، كما ذكر % 70 أنهم حضروا اجتماعات للتعليم الطبي المستمر. وعلى الرغم من أن معظم الأطباء تتوافر لديهم إمكانية الوصول إلى الإنترنت فإن % 52.8 منهم فقط كان مهتاً بدورات شبكة الإنترنت للحصول عى التعليم الطبي المستمر. وكانت هناك علاقة ذات دلالة إحصائية بين سنة التخرج من كلية الطب وبين تفضيل التعليم الطبي المستمر عن طريق شبكة الإنترنت. إن الآثار المترتبة عى المشاركة في التعليم الطبي المستمر ومواضيع التعليم الطبي المستمر في مجال طب الأطفال هي قيد المناقشة.

Most physicians who work in the United Nations Relief and Works Agency (UNRWA) infant and child health programme in Jordan are general practitioners with no postgraduate training in paediatrics. Furthermore, in resource-poor or remote settings, the ability to deliver live continuing medical education (CME) is often limited. A questionnaire exploring the resources available for accessing CME, preferences for types of CME, current sources of CME and topics of interest in the field of paediatric care was sent to all 92 physicians practising in UNRWA clinicsin Jordan. Of the 89 respondents 80% had attended live medical lectures for CME and 70% CME meetings. Despite most physicians having access to the Internet only 52.8% were interested in Internet-based courses for accessing CME. There was a statistically significant relationship between year of graduation from medical school and preference for Internet-based CME. Implications for CME participation and paediatric CME topics are discussed.

La plupart des médecins qui travaillent pour le programme de santé du nourisson et de l’enfant en Jordanie à l’Office de secours et de travaux des Nations Unis pour les réfugiés de Palestine dans le Proche-Orient (UNRWA) sont des médecins généralistes sans spécialisation en pédiatrie. Par ailleurs, dans un contexte de ressources limitées ou dans des zones isolées, la capacité à dispenser une formation médicale continue (FMC) est souvent limitée. Un questionnaire étudiant les ressources disponibles qui permettent d’accéder à la formation médicale continue, les types de formation préférés, les sources actuelles de formation médicale continue et les sujets d’intérêt dans le domaine des soins pédiatriques a été envoyé à l’ensemble des 92 médecins exerçant dans des cliniques de l’UNRWA en Jordanie. Sur un total de 89 répondants, 80 % avaient assisté en personne à des conférences médicales dans le cadre de la formation médicale continue et 70 % à des réunions de formation médicale continue. Si la plupart des médecins avaient accès à l'Internet, seuls 52,8 % étaient intéressés par des cours en ligne permettant d’accéder à la formation médicale continue. Il existait une relation statistiquement significative entre l’année de fin d’études en faculté de médecine et la préférencepour une formation médicale continue sur l'Internet. Les implications pour une participation à la formation médicale continue et les sujets de formation médicale continue en pédiatrie sont en cours de discussion.

Estimating tuberculosis case detection rate in resource-limited countries: a capture-recapture study in Egypt.

SETTING: Most countries endemic and highly endemic for tuberculosis (TB) still do not have reliable TB surveillance systems. Indirect estimation of TB incidence is needed to monitor the performance of the National Tuberculosis Programme (NTP) in the context of the World Health Organization implementation and impact targets for TB control. OBJECTIVE: To estimate the case detection rate (CDR) of all TB cases and sputum smear-positive TB cases in Egypt in 2007. METHODS: Record linkage and three-source capture-recapture analysis of data collected through active prospective longitudinal surveillance within the public and private non-NTP sector in four Egyptian governorates selected by stratified cluster random sampling. RESULTS: For all TB cases, the estimated CDR of NTP surveillance and completeness of case ascertainment after record linkage was respectively 55% (95%CI 46-68) and 62% (95%CI 52-77). For sputum smear-positive TB cases, these proportions were respectively 66% (95%CI 55-75) and 72% (95%CI 60-82). CONCLUSION: This pilot study shows that representative sampling, prospective surveillance in the non-NTP sector, record linkage and capture-recapture analysis can improve CDR estimation. For global, standardised and reliable use, this methodology should be further developed. Until then, all resource-limited countries should strengthen their national surveillance systems in the context of the Stop TB strategy.

The decline of tuberculosis in Yemen: evaluation based on two nationwide tuberculin surveys.

SETTING: Yemen. OBJECTIVE: To review the epidemiological situation of tuberculosis (TB) in Yemen by conducting a tuberculin survey and by comparing the results obtained with those of a previous tuberculin survey from 1991. DESIGN: A nationwide tuberculin survey enrolling 31,276 schoolchildren aged between 7 and 12 years. RESULTS: Skin indurations were recorded for 28,499 schoolchildren, of whom 16,927 (59.4%) had no bacille Calmette-Guérin (BCG) scar. Analysis of the distribution of indurations was difficult as it did not show any bimodal pattern. Prevalence of infection and annual risk of tuberculosis infection (ARTI) were thus estimated using the mirror image and mixture methods, and not the cut-off point method. The two methods indicated similar results: respectively 0.45% and 0.51% for prevalence of infection, and 0.05% and 0.05% for ARTI. In comparison with the 1991 tuberculin survey, the average annual decline of ARTI was 9.0% by the mirror method and 5.5% by the mixture method. CONCLUSION: Yemen seems to have a low ARTI (0.05%), and TB infection seems to be declining considerably. Analysis of the survey results highlighted the limitations of tuberculin surveys in countries with comparable epidemiological situations.