An alumni study of a Master's in international health.

OBJECTIVES: The objective of the study was to clarify the reasons why students who graduated from a Master's programme in international health were joining the programme. Another objective was to document how the Master's degree had influenced the careers of the graduates. STUDY DESIGN: An online survey of students who graduated from a Master's programme in international health, including oral science, between 2010 and 2015. METHOD: The study used an anonymous questionnaire that contained 28 items. Topics included information such as demographics, questions about the reasons for joining the Master's programme and the benefits and influence of the programme on the career of the students. RESULTS: Of the 102 alumni who were invited to participate, 70 responded. The response rate was 69%, and we have no information about the non-responders. The results showed that the main reasons for students enrolling in the programme were to improve their competence and develop their career. Around 63% of the respondents reported that the programme had increased their competencies in the jobs they had, whereas 24% answered that their increased qualifications had enabled them to acquire new positions. Thus successfully completing the programme had a positive influence on the graduates' careers in international health. Most of the graduates, who were working, were typically employed at hospitals and universities. Several graduates had proceeded to gain further qualifications by now being enrolled in a PhD programme. CONCLUSIONS: Among the 70% of responders in this survey, the master's programme had benefitted the alumni and the programme had fulfilled their expectations. The programme had a positive influence on the alumni in areas such as increased competency, development of their careers, new positions and better salaries.

Sexual violence in post-conflict Liberia: survivors and their care.

Using routine data from three clinics offering care to survivors of sexual violence (SV) in Monrovia, Liberia, we describe the characteristics of SV survivors and the pattern of SV and discuss how the current approach could be better adapted to meet survivors' needs. There were 1500 survivors seeking SV care between January 2008 and December 2009. Most survivors were women (98%) and median age was 13 years (Interquartile range: 9-17 years). Sexual aggression occurred during day-to-day activities in 822 (55%) cases and in the survivor's home in 552 (37%) cases. The perpetrator was a known civilian in 1037 (69%) SV events. Only 619 (41%) survivors sought care within 72 h. The current approach could be improved by: effectively addressing the psychosocial needs of child survivors, reaching male survivors, targeting the perpetrators in awareness and advocacy campaigns and reducing delays in seeking care.

Does distance to healthcare facility affect care-seeking for TB-related symptoms in Tanzania?

BACKGROUND: In high TB burden countries, delayed diagnosis remains a big challenge in TB control. The objective of this study is to assess the role of distance between residence and healthcare facility (HCF) on care-seeking among individuals with symptoms associated with pulmonary TB in Tanzania.METHODS: In this cross-sectional study, using data from a national TB survey, coordinates of 300 (residential) sites within 62 clusters were obtained through Google searches and average distances to HCF were calculated per cluster. Univariable and multivariable logistic regression analyses were conducted, with care-seeking behaviour being the primary outcome variable.RESULTS: Distance from residence to HCF had no effect on care-seeking behaviour of individuals with TB-related symptoms in this study (OR 1.00, 95% CI 1.00-1.00). Over 85% of HCFs where care has been sought lack TB diagnostic capacity, mostly comprising dispensaries with staff less educated in TB-related symptoms.CONCLUSION: Care-seeking behaviour among individuals with TB-related symptoms in Tanzania was not found to be associated with distance to HCF. First-line diagnostics should be improved 1) by equipping local dispensaries with basic TB diagnostic capacity, and 2) by educating staff of local dispensaries more thoroughly about basic TB symptoms and the importance of swift referrals.

Association between cholera treatment outcome and nutritional status in children aged 2-4 years in Nigeria.

SETTING: Cholera can aggravate or precipitate malnutrition, and children with severe acute malnutrition (SAM) have a higher incidence and longer duration of diarrhoea. OBJECTIVE: To describe 1) characteristics of and treatment outcomes in children aged 2-4 years with cholera, 2) the case fatality rate (CFR) in all children treated, and 3) the associations between nutritional status, hydration status, treatment administered and hospital outcomes. DESIGN: An observational cohort study of children admitted to one cholera treatment centre in Maiduguri, Nigeria, with a focus on children aged 2-4 years. CFRs were examined by cross tabulation and mean length of stay (LOS) using analysis of variance. RESULTS: SAM was identified in 24% of children aged 2-4 years. The CFR for children aged 2-4 years was 1.4%. As the sample size was small, we did not find any association between nutritional status and death due to cholera. The proportion of children discharged within 2 days was 79%, and the longest stay was 8 days. In general, health facility LOS increased with severity of malnutrition. CONCLUSION: Our study found that nutritional status affected the LOS, but was unable to find an association between malnutrition and fatality among children aged 2-4 years.

CONTEXTE: Le choléra peut aggraver ou précipiter la malnutrition et les enfants atteints de malnutrition aiguë grave (SAM) ont une incidence plus élevée et une durée plus longue de diarrhée. OBJECTIF: Décrire 1) les caractéristiques et les résultats du traitement d'enfants de 2­4 ans atteints de choléra, 2) le taux de mortalité de tous les enfants traités, et 3) les associations entre état nutritionnel, hydratation, traitement administré et évolution à l'hôpital. SCHÉMA: Cohorte d'observation d'enfants admis au centre de traitement du choléra de Maiduguri, Nigeria, avec un focus sur les enfants de 2­4 ans. Les taux de létalité ont été examinés par tabulation croisée et la durée moyenne de séjour par analyse de la variance. RÉSULTATS: Une SAM a été identifiée chez 24% des enfants de 2­4 ans. Le taux de létalité des enfants de 2­4 ans était de 1,4%. La petite taille de la population n'a pas permis d'observer d'association entre état nutritionnel et décès dû au choléra. La proportion d'enfants sortis en 48h a été de 79% et la durée la plus longue de séjour de 8 jours. En général, la durée de séjour en structure de santé augmentait avec la gravité de la malnutrition. CONCLUSION: Notre étude a constaté que l'état nutritionnel affectait la durée de séjour mais n'a pas permis de trouver une association entre malnutrition et létalité parmi les enfants de 2­4 ans.

Registering initial defaulters and reporting on their treatment outcomes.

This Unresolved Issues article highlights three original articles that appeared last year in the Journal discussing the phenomenon of initial defaulters. There are three important challenges with patients that appear in the laboratory sputum register but are not recorded in the tuberculosis (TB) patient register: the first is how to identify these patients, trace them and get them on to treatment as soon as possible; the second is how to register and report on these cases as part of the case-finding component of TB control; and the third is whether to include these initial default patients in the cohort analysis of treatment outcomes. We recommend a step-wise approach to these challenges and advocate that these patients be included, wherever possible, in the TB patient register and in the cohort analysis of treatment outcomes.

Isoniazid preventive therapy for people living with HIV: public health challenges and implementation issues.

Isoniazid preventive therapy (IPT) is recognised as an important component of collaborative tuberculosis (TB) and human immunodeficiency virus (HIV) activities to reduce the burden of TB in people living with HIV (PLHIV). However, there has been little in the way of IPT implementation at country level. This failure has resulted in a recent call to arms under the banner title of the 'Three I's' (infection control to prevent nosocomial transmission of TB in health care settings, intensified TB case finding and IPT). In this paper, we review the background of IPT. We then discuss the important challenges of IPT in PLHIV, namely responsibility and accountability for the implementation, identification of latent TB infection, exclusion of active TB and prevention of isoniazid resistance, length of treatment and duration of protective efficacy. We also highlight several research questions that currently remain unanswered. We finally offer practical suggestions about how to scale up IPT in the field, including the need to integrate IPT into a package of care for PLHIV, the setting up of operational projects with the philosophy of 'learning while doing', the development of flow charts for eligibility for IPT, the development and implementation of care prior to antiretroviral treatment, and finally issues around procurement, distribution, monitoring and evaluation. We support the implementation of IPT, but only if it is done in a safe and structured way. There is a definite risk that 'sloppy' IPT will be inefficient and, worse, could lead to the development of multidrug-resistant TB, and this must be avoided at all costs.

Mass screening for active case finding of pulmonary tuberculosis in the Russian Federation: how to save costs.

BACKGROUND: In Russia, mass chest X-ray (CXR) screening for tuberculosis (TB) is mandatory.OBJECTIVE: To compare the yield and the cost per TB case detected and the total cost of CXR screening, passive case finding and contact tracing among adolescents and adults in the Arkhangelsk Oblast, Russian Federation, 2013-2017.DESIGN: This was an analysis of costing strategies using aggregated data. Costing information was obtained from the Finance Department of the Arkhangelsk Clinical TB Dispensary, Arkhangelsk, and the Territorial Fund of Mandatory Medical Insurance, Arkhangelsk, Russian Federation.RESULTS: TB cases were detected using CXR screening (n = 684, 46%), contact tracing (n = 61, 4%) and passive case finding (n = 743, 46%). The number of cases detected using CXR screening, contact tracing and passive case finding was respectively 28,753 and 960/100 000. The mean costs/test were respectively US$3.54 (US$12 541/case), US$20.28 (US$2693/case) and US$11.85 (US$1235/case) using CXR screening, contact tracing and passive case finding The number of cases/100 000 in targeted groups was as follows: HIV-positive persons, 645; homeless persons, 461; and migrants, 441. The cost/TB case detected was respectively US$549, US$768 and US$803.CONCLUSION: Mass CXR screening (excluding HIV-positive, migrant and homeless populations) has low yield and high cost per TB case detected. It should be stopped and resources should instead be used to strengthen the screening of targeted high-risk groups, contacts and passive case finding.

A comparison of the yield and relative cost of active tuberculosis case-finding algorithms in Zimbabwe.

SETTING: Ten districts and three cities in Zimbabwe. OBJECTIVE: To compare the yield and relative cost of identifying a case of tuberculosis (TB) using the three WHO-recommended algorithms (WHO2b, symptom inquiry only; WHO2d, chest X-ray [CXR] after a positive symptom inquiry; WHO3b, CXR only) and the Zimbabwe active case finding (ZimACF) algorithm (symptom inquiry plus CXR) to everyone. DESIGN: Cross-sectional study using data from the ZimACF project. RESULTS: A total of 38 574 people were screened from April to December 2017; 488 (1.3%) were diagnosed with TB using the ZimACF algorithm. Fewer TB cases would have been diagnosed with the WHO-recommended algorithms. This ranged from 7% fewer (34 cases) with WHO3b, 18% fewer (88 cases) with WHO2b and 25% fewer (122 cases) with WHO2d. The need for CXR ranged from 36% (WHO2d) to 100% (WHO3b). The need for bacteriological confirmation ranged from 7% (WHO2d) to 40% (ZimACF). The relative cost per case of TB diagnosed ranged from US$180 with WHO3b to US$565 for the ZimACF algorithm. CONCLUSION: The ZimACF algorithm had the highest case yield, but at a much higher cost per case than the WHO algorithms. It is possible to switch to algorithm WHO3b, but the trade-off between cost and yield needs to be reviewed by the Zimbabwean National TB Programme.

Challenges and opportunities to prevent tuberculosis in people living with HIV in low-income countries.

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

High success rate of TB treatment among Bhutanese refugees in Nepal.

SETTING: Camps for refugees from Bhutan in south-east Nepal. OBJECTIVES: To evaluate the outcome of treatment of tuberculosis (TB) cases in the refugee camps. DESIGN: Cohort analysis of results of treatment of cases started on treatment from mid-July 1999 to mid-July 2004. RESULT: A total of 1214 patients with TB were notified in the programme. Among these, 631 (52%) were new smear-positive pulmonary tuberculosis (PTB) cases, 175 (14%) new smear-negative PTB cases, 290 (24%) new extra-pulmonary TB (EPTB) cases and 118 (10%) smear-positive retreatment cases. Treatment success was achieved in 1061 (94%). The proportion of new non-smear-positive cases who died on treatment was significantly higher than the corresponding figure for new smear-positive cases (RR 7.57, 95%CI 3.74-15.32 for new smear-negative and 4.22, 95%CI 2.08-8.55 for EPTB). CONCLUSION: High cure rates and low bacteriological failure rates can be achieved in refugee settings if there is close coordination and collaboration between the local health agencies and the National Tuberculosis Programme of the host country.

Pre-treatment loss to follow-up among smear-positive TB patients in tertiary hospitals, Quetta, Pakistan.

Setting: Three public sector tertiary care hospitals in Quetta, Balochistan, Pakistan, with anecdotal evidence of gaps between the diagnosis and treatment of patients with tuberculosis (TB). Objectives: To assess the proportion of pre-treatment loss to follow-up (LTFU), defined as no documented evidence of treatment initiation or referral in TB registers, among smear-positive pulmonary TB patients diagnosed in 2015, and the associated sociodemographic factors. Design: A retrospective cohort study involving the review of laboratory and TB registers. Results: Of 1110 smear-positive TB patients diagnosed (58% female, median age 40 years, 5% from outside the province or the country), 235 (21.2%) were lost to follow-up before starting treatment. Pre-treatment LTFU was higher among males; in patients residing far away, in rural areas, outside the province or the country; and in those without a mobile phone number. Conclusion: About one fifth of the smear-positive TB patients were lost to follow-up before starting treatment. Strengthening the referral and feedback mechanisms and using information technology to improve the tracing of patients is urgently required. Further qualitative research is needed to understand the reasons for pre-treatment LTFU from the patient's perspective.

Contexte : Trois hôpitaux publics tertiaires à Quetta, Baloutchistan, Pakistan, avec des preuves empiriques d'un fossé entre le diagnostic et le traitement des patients tuberculeux (TB).Objectif : Evaluer la proportion de patients perdus de vue avant le traitement (pas de preuve documentée de mise en route du traitement ou de référence dans les registres TB) parmi les patients atteints de TB pulmonaire à frottis positif diagnostiqués en 2015, et identifier les facteurs sociodémographiques associés.Schéma : Etude rétrospective de cohorte impliquant une revue des registres de laboratoire et de TB.Résultats : Sur 1110 patients TB à frottis positif diagnostiqués (58% de femmes, d'âge médian 40 ans, 5% venant de l'extérieur de la province ou du pays), 235 (21,2%) ont été perdus de vue avant de démarrer le traitement. Cette perte de vue avant le traitement a été plus élevée parmi les hommes ; parmi les patients résidant loin, en zone rurale, hors de la province ou du pays ; et parmi ceux ne possédant pas de téléphone portable.Conclusion : Environ un cinquième des patients TB à frottis positif ont été perdus de vue avant la mise en route du traitement. Il est nécessaire de manière urgente de renforcer les mécanismes de référence et de retro-information et d'avoir une meilleure traçabilité des patients grâce aux techniques d'information. Une autre recherche qualitative est requise afin de comprendre les raisons de cette perte de vue avant le traitement selon la perspective des patients.

Marco de referencia: Tres hospitales de atención terciaria del sector público de Quetta, en la provincia de Balochistán del Pakistán, donde existen datos anecdóticos de un desfase entre el diagnóstico y el tratamiento de los pacientes con tuberculosis (TB).Objetivos: Evaluar la proporción de pérdidas durante el seguimiento antes de comenzar el tratamiento (falta de documentación de la iniciación del tratamiento o la remisión a otros centros en los registros de TB) de los pacientes con TB pulmonar y baciloscopia positiva diagnosticados en el 2015 y analizar los factores socioeconómicos determinantes.Métodos: Un estudio retrospectivo de cohortes a partir del examen de los registros de laboratorio y los registros de TB.Resultados: De los 1110 pacientes con baciloscopia positiva diagnosticados (58% de sexo femenino, mediana de la edad 40 años y 5% procedente de otra provincia o país), 235 (21,2%) se perdieron durante el seguimiento antes de iniciar el tratamiento. Estas pérdidas fueron mayores en los pacientes de sexo masculino; los pacientes que residían en zonas rurales remotas, fuera de la provincia o del país; y en las personas que no contaban con un número de teléfono celular.Conclusión: Cerca de un quinto de los pacientes con diagnóstico de TB y baciloscopia positiva se perdió durante el seguimiento antes de comenzar el tratamiento. Es urgente fortalecer el mecanismo de remisiones y de retroinformación de los resultados y mejorar la localización de los pacientes haciendo uso de la tecnología de la información. Se precisan nuevas investigaciones cualitativas que favorezcan la comprensión de las razones de esta pérdida durante el seguimiento desde la perspectiva de los pacientes.

Childhood tuberculosis in Mauritania, 2010-2015: diagnosis and outcomes in Nouakchott and the rest of the country.

Setting: The National Tuberculosis Programme, Mauritania. Objective: To compare the diagnosis and treatment outcomes of childhood tuberculosis (TB) cases (aged <15 years) registered between 2010 and 2015 inside and outside Nouakchott, the capital city. Design: This was a retrospective comparative cohort study. Results: A total of 948 children with TB were registered. The registration rate was 10 times higher in Nouakchott. The proportion of children among all TB cases was higher inside than outside Nouakchott (7.5% vs. 4.6%, P < 0.01). Under-fives represented 225 (24%) of all childhood TB cases, of whom 204 (91%) were registered in Nouakchott. Extra-pulmonary TB was more common in Nouakchott, while smear-negative TB was less common. Treatment success was similar inside and outside Nouakchott (national rate 61%). The principal unsuccessful outcomes were loss to follow-up outside Nouakchott (21% vs. 11%, P < 0.01) while transfers out were more common in the city (25% vs. 14%, P = 0.01). Being aged <5 years (OR 1.2, 95%CI 1.1-1.5) was associated with an unsuccessful outcome. Conclusion: This study indicates problems in the diagnosis and treatment of childhood TB in Mauritania, especially outside the city of Nouakchott. We suggest strengthening clinical diagnosis and management, improving communications between TB treatment centres and health services and pressing the TB world to develop more accurate and easy-to-use diagnostic tools for children.

Contexte : Programme National Tuberculose, Mauritanie.Objectif : Comparer les résultats en termes de diagnostic et de traitement des cas de tuberculose (TB) de l'enfant (<15 ans) enregistrés entre 2010 et 2015 dans la capitale, Nouakchott, et à l'extérieur de la capitale.Schéma : Une étude rétrospective comparative de cohorte.Résultats : Au total, 948 enfants atteints de TB ont été enregistrés. Le taux d'enregistrement a été 10 fois plus élevé à Nouakchott. La proportion des enfants parmi tous les cas de TB a été plus élevée à Nouakchott qu'à l'extérieur (7,5% contre 4,6% ; P < 0,01). Les enfants âgés de <5 ans ont constitué 225 cas, soit 24% de tous les cas de TB de l'enfant, dont 204 (91%) ont été enregistrés à Nouakchott. La TB extra-pulmonaire a été plus fréquente à Nouakchott, tandis que la TB à frottis négatif a été moins fréquente. Le taux de réussite du traitement a été similaire à Nouakchott et à l'extérieur (taux national de 61%). Les principaux résultats défavorables ont été les pertes de vue à l'extérieur de Nouakchott (21% vs. 11% ; P < 0,01), tandis que les transferts ont été plus fréquents dans la capitale (25% vs. 14% ; P = 0,01). L'âge inférieur à 5 ans a été associé à un résultat défavorable (OR 1,2 ; IC95% 1,1­1,5).Conclusion : Cette étude a mis en évidence les problèmes de diagnostic et de traitement de la TB de l'enfant en Mauritanie, surtout hors de Nouakchott. Nous suggérons de renforcer le diagnostic clinique et la prise en charge, d'améliorer la communication entre les centres de traitement de la TB et les services de santé et de pousser le milieu de la TB à élaborer des outils de diagnostic plus précis et faciles à utiliser pour les enfants.

Marco de referencia: El Programa Nacional contra la Tuberculosis de Mauritania.Objetivo: Comparar los diagnósticos y los desenlaces terapéuticos de los casos de TB en los niños (<15 años de edad) registrados del 2010 al 2015 en la capital Nouakchot y fuera de esta ciudad.Método: Estudio de cohortes retrospectivo comparativo.Resultados: En general, se registraron 948 niños con TB. La tasa de registro fue 10 veces más alta en Nouakchot. La proporción de niños en todos los casos de TB fue más alta en Nouakchot que fuera de la capital (7,5% contra 4,6%; P < 0,01). De todos los casos de TB en la infancia, 225 fueron niños <5 años de edad (24%), de los cuales 204 se registraron en Nouakchot (9%). La TB extrapulmonar fue más frecuente en la capital y se observó allí una menor frecuencia de casos con baciloscopia negativa. La tasa de éxito terapéutico fue equivalente en Nouakchot y fuera de la ciudad (tasa nacional 61%). Fuera de la capital, el principal desenlace desfavorable fue la pérdida durante el seguimiento (21% contra 11%; P < 0,01) y en Nouakchot fueron las transferencias a otros centros (25% contra 14%; P = 0,01). La edad <5 años se asoció con un desenlace desfavorable (cociente de posibilidades 1,2; IC95% 1,1­1,5).Conclusión: El presente estudio pone de manifiesto los problemas del diagnóstico y el tratamiento de la TB en Mauritania, sobre todo fuera de la capital Nouakchot. Se recomienda fortalecer el diagnóstico clínico y el tratamiento, con una mejor comunicación entre los centros de tratamiento de la TB y los servicios de salud y urgir en el mundo de la TB el desarrollo de medios diagnósticos dirigidos a los niños que sean más exactos y de utilización sencilla.

High mortality in tuberculosis patients despite HIV interventions in Swaziland.

SETTING: All health facilities providing tuberculosis (TB) care in Swaziland. OBJECTIVE: To describe the impact of human immunodeficiency virus (HIV) interventions on the trend of TB treatment outcomes during 2010-2013 in Swaziland; and to describe the evolution in TB case notification, the uptake of HIV testing, antiretroviral therapy (ART) and cotrimoxazole preventive therapy (CPT), and the proportion of TB-HIV co-infected patients with adverse treatment outcomes, including mortality, loss to follow-up and treatment failure. DESIGN: A retrospective descriptive study using aggregated national TB programme data. RESULTS: Between 2010 and 2013, TB case notifications in Swaziland decreased by 40%, HIV testing increased from 86% to 96%, CPT uptake increased from 93% to 99% and ART uptake among TB patients increased from 35% to 75%. The TB-HIV co-infection rate remained around 70% and the proportion of TB-HIV cases with adverse outcomes decreased from 36% to 30%. Mortality remained high, at 14-16%, over the study period, and anti-tuberculosis treatment failure rates were stable over time (<5%). CONCLUSION: Despite high CPT and ART uptake in TB-HIV patients, mortality remained high. Further studies are required to better define high-risk patient groups, understand the reasons for death and design appropriate interventions.

Contexte : Toutes les structures de santé offrant une prise en charge de la tuberculose (TB) au Swaziland.Objectif : Décrire l'impact des interventions pour le virus de l'immunodéficience humaine (VIH) sur les tendances des résultats du traitement de la TB en 2010­2013, au Swaziland. Décrire l'évolution de la notification des cas de TB, la couverture du test VIH, de le traitement antirétroviral (TAR) et du traitement préventif au cotrimoxazole (CPT) et la proportion de patients coinfectées par TB-VIH avec les mauvais résultats du traitement incluant la mortalité, les abandons et les échecs du traitement.Schéma : Etude descriptive rétrospective basée sur les données agrégées du programme national TB.Résultats : Entre 2010 et 2013, les notifications de cas de TB auSwaziland ont diminué de 40%, le test VIH a augmenté de 86% à 96%, la couverture du CPT a augmenté de 93% à 99% et la couverture du TAR parmi les patients tuberculeux est passée de 35% à 75%. Le taux de coinfection TB-VIH est resté autour de 70% et la proportion de cas de TB-VIH avec des résultats médiocres a diminué de 36% à 30% entre 2010 et 2013. La mortalité est restée élevée entre 14% et 16% pendant la période d'étude et les taux d'échec du traitement TB ont été stables dans le temps (<5%).Conclusion : En dépit d'une couverture élevée du CPT et du TAR parmi les patients TB-VIH, la mortalité est restée élevée. D'autres études sont nécessaires pour mieux définir les groupes de patients à haut risque, pour mieux comprendre les causes de décès et pour concevoir des interventions appropriées.

Marco de referencia: Todos los establecimientos de salud que prestan atención antituberculosa en Swasilandia.Objetivo: Describir la repercusión de las intervenciones contra el virus de la inmunodeficiencia humana (VIH) sobre la evolución de los desenlaces terapéuticos de la tuberculosis (TB) del 2010 al 2013 en Swasilandia. Describir la evolución de la notificación de casos de TB, la aceptación de la prueba diagnóstica del VIH, el tratamiento antirretrovírico (TAR) y del tratamiento preventivo con cotrimoxazol (CPT) y la proporción de pacientes coinfectados por el VIH y el bacilo de la TB que presenta desenlaces terapéuticos desfavorables como la mortalidad, la pérdida durante el seguimiento y el fracaso del tratamiento.Método: Fue este un estudio descriptivo retrospectivo a partir de los datos agregados del Programa Nacional contra la TB.Resultados: Del 2010 al 2013, la notificación de casos de TB en Swasilandia disminuyó un 40%, la aceptación de la prueba diagnóstica del VIH aumentó de 86% a 96%, la utilización del CPT aumentó del 93% al 99% y en los pacientes con TB, y la aceptación del TAR aumentó del 35% al 75%. La tasa de coinfección permaneció alrededor del 70% y la proporción de estos pacientes que presentaba desenlaces desfavorables disminuyó del 36% en el 2010 al 30% en el 2013. Durante el período del estudio la mortalidad permaneció alta, entre el 14% y 16%, y las tasas de fracaso del tratamiento antituberculoso permanecieron estables con el transcurso del tiempo (menos del 5%).Conclusión: Pese a una alta aceptación del CPT y el TAR por parte de los pacientes coinfectados por el VIH y la TB, la mortalidad sigue siendo alta. Se precisan nuevos estudios que definan con mayor precisión los grupos de pacientes con alto riesgo de desenlaces desfavorables y que contribuyan a comprender las causas de las defunciones y a diseñar intervenciones apropiadas.

Prevalence of pulmonary tuberculosis in adult population of Tanzania: a national survey, 2012.

SETTING: Tanzania is classified as one of the 22 high tuberculosis (TB) burden countries; however, the true burden of TB disease in the country remains unknown. OBJECTIVE: To assess the prevalence of bacteriologically confirmed pulmonary TB (PTB) in the adult population. DESIGN: This was a community-based cluster randomised survey with proportional-to-population-size selection of primary sampling units (districts). Participants were screened for TB using a symptom questionnaire and chest X-ray (CXR). Those with abnormal CXR and/or at least one symptom suggestive of TB were classified as individuals with presumptive TB, and asked to submit three sputum specimens for smear microscopy and culture. RESULTS: The weighted prevalence for sputum smear-positive TB cases was 249 per 100 000 adult population (95%CI 192-305) and that for bacteriologically confirmed TB cases was 293/100 000 (95%CI 228-358). Individuals aged ⩾45 years comprised 55% (71/129) of the identified smear-positive cases, but just 28% (6793/24 648) of the notified TB cases. CXR screening identified more TB cases than symptom screening. When weighted for human immunodeficiency virus prevalence among notified new smear-positive cases, the overall case detection of incident TB cases in 2012 was between 37% and 48%. CONCLUSIONS: The prevalence of sputum smear-positive PTB and bacteriologically confirmed PTB in the adult population was higher than previous World Health Organization estimates. There is a potential underestimation of the number of bacteriologically confirmed PTB cases in the adult population. The age distribution of prevalent cases suggests an epidemiological shift towards the older generations, which has been a sign of successful TB control activities in the past. However, the survey shows that many infectious TB cases are currently missed by the National Tuberculosis Programme.

Population impact of factors associated with prevalent pulmonary tuberculosis in Tanzania.

SETTING: Tanzania has an estimated tuberculosis (TB) prevalence of 295 per 100 000 adult population. There is currently no nationally representative information on factors associated with TB in Tanzania. OBJECTIVE: To determine the demographic and clinical factors associated with bacteriologically confirmed TB in the adult general population of Tanzania. DESIGN: A case-control study nested in a nationally representative TB prevalence survey. All patients with bacteriologically confirmed pulmonary TB (PTB) constituted cases and a representative sample of people without bacteriologically confirmed PTB constituted controls. We calculated adjusted odds ratios (aORs) to identify factors associated with TB. RESULTS: Age groups 25-34 years (aOR 3.7, 95%CI 1.5-8.8) and 55-64 years (aOR 2.5, 95%CI 1.1-5.5), male sex (aOR 1.6, 95%CI 1.1-2.3) and low body mass index (BMI) (aOR 1.7, 95%CI 1.1-2.8) were significantly associated with TB. Association with human immunodeficiency virus (HIV) and diabetes mellitus (DM) was not statistically significant. The population attributable fraction (PAF) was 2% (95%CI -2 to 5) for DM and 3% (95%CI -2 to 8) for HIV. CONCLUSION: Being in an older age group, being male and having a low BMI were associated with bacteriologically confirmed PTB. On the population level, classic risk factors for TB have no major effect on prevalent TB from which future transmission may occur.

Did FIDELIS projects contribute to the detection of new smear-positive pulmonary tuberculosis cases in China?

Setting: The first phase of the Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB (FIDELIS) projects in China started in 2003. Objective: To determine whether the FIDELIS projects contributed to the increased case detection rate for new smear-positive pulmonary tuberculosis (PTB) in China. Methods: We compared the case notification rates (CNRs) in the intervention year with those of the previous year in the FIDELIS areas, then compared the difference between the CNRs of the intervention year and the previous year in the FIDELIS areas with those in the non-FI-DELIS areas within the province. Results: There was an increase in the CNR in the intervention year compared with the previous year for all the project sites. The differences between the CNR in the intervention year and the previous year ranged from 6.4 to 31.1 per 100 000 population in the FIDELIS areas and from 2.9 to 20.4/100 000 in the non-FIDELIS areas. Differences-in-differences analysis shows that the differences in the CNRs in the FIDELIS areas were not statistically significantly different from those in the non-FIDELIS areas (P = 0.393). Conclusion: The FIDELIS projects may have contributed to the increase in case detection of new smear-positive PTB in China, but the level of evidence is low.

Objectif : Déterminer si les projets de la « Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB ¼ (FIDELIS), commencés en 2003, ont contribué à une augmentation de la détection des cas de tuberculose pulmonaire (TBP) à frottis positif en Chine.Méthodes : Nous avons comparé le taux de notification des cas (CNR) pendant l'année d'intervention avec celui de l'année précédente dans les zones FIDELIS. Nous avons également comparé la différence du CNR de l'année d'intervention et de l'année précédente dans les zones FIDELIS et les zones non FIDELIS à l'intérieur de la province.Résultats : Il y a eu une augmentation du CNR pendant l'année d'intervention comparée à l'année précédente dans tous les sites du projet. Cette différence de CNR entre l'année d'intervention et l'année précédente allait de 6,4 à 31,1 par 100 000 habitants dans les zones FIDELIS et de 2,9 à 20,4/100 000 dans les zones non FIDELIS. L'analyse des écarts dans les différences a montré que les différences de CNR dans les zones FIDELIS n'étaient pas statistiquement significatives par rapport à aux zones non FIDELIS (P = 0,393).Conclusions : Les projets FIDELIS pourraient avoir contribué à l'augmentation de la détection des cas nouveaux de TBP à frottis positif en Chine, mais le niveau de preuves reste faible.

Marco de referencia: La primera fase de ejecución del Fondo para la Expansión Innovadora de DOTS mediante Iniciativas Locales para Detener la Tuberculosis (FIDELIS, por su acrónimo en inglés), en la China, comenzó en 2003.Objetivo: Determinar si los proyectos de la iniciativa FIDELIS contribuían a aumentar la detección de casos nuevos de tuberculosis pulmonar (TBP) con baciloscopia positiva en la China.Métodos: Se comparó la tasa de notificación de casos (CNR) durante el año de la intervención, con la tasa del año anterior en las zonas vinculadas con el proyecto FIDELIS, y se examinó además la diferencia de la CNR durante el año de la intervención y el año anterior en zonas de la provincia que no participaron en el proyecto.Resultados: Durante el año de la intervención, se observó un aumento de la CNR con respecto al año anterior en todos los centros del proyecto. Las diferencias de la CNR en ambos períodos en las zonas que participaron en el proyecto FIDELIS oscilaron entre 6,4 y 31,1 por 100 000 habitantes; en las zonas donde no hubo intervención las diferencias de la tasa de notificación oscilaron entre 2,9 y 20,4/100 000. Al comparar estos resultados, no se puso en evidencia una diferencia significativa en las CNR al comparar las zonas que practicaron la intervención y las zonas fuera del proyecto FIDELIS (P = 0,393).Conclusión: Es posible que los proyectos FIDELIS hayan contribuido a mejorar la tasa de detección de casos nuevos de TBP con baciloscopia positiva en la China, pero la fuerza demostrativa de las pruebas científicas es escasa.

Health care-seeking behaviour among people with cough in Tanzania: findings from a tuberculosis prevalence survey.

SETTING: The study was conducted within a nation-wide population-based tuberculosis (TB) prevalence survey in the adult population in Tanzania. OBJECTIVE: To assess the health care-seeking behaviour of coughers presumed to have TB. DESIGN: A survey in which participants were screened for TB using a symptom questionnaire and chest X-ray (CXR). Those with cough of ⩾ 2 weeks and/or who were coughing blood were interviewed about their health care-seeking behaviour and socio-demographic and clinical factors. RESULTS: Of 3388 people with presumptive TB, 31.0% (1051/3388) had sought treatment for their symptoms. Of these, about 42% (445/1051) sought care at sites with TB diagnostic capacity, where sputum examination was performed in 37.1% (165/445) and CXR in 28.1% (125/445). In sites with limited TB diagnostic capacity, fewer than 1% were referred for sputum examination or CXR. Individuals with additional symptoms were more likely to seek treatment. Knowledge about TB was significantly associated with care seeking at sites with TB diagnostic capacity. CONCLUSIONS: A third of the persons with cough symptoms consistent with TB had sought health care. About 42% sought care in sites with TB diagnostic capacity, but most did not undergo TB diagnostic procedures, precluding a timely diagnosis.

Can the number of patients with presumptive tuberculosis lost in the general health services in Pakistan be reduced?

The frequency of patients with presumptive tuberculosis (TB) who are not investigated by sputum smear microscopy is unknown in Pakistan. Using a simple intervention comparing patient and laboratory registers, patients with presumptive TB were identified in two districts from July to December 2013, a list of missing patients was prepared and the patients traced. The intervention significantly reduced the number of patients with presumptive TB lost, from 8.5% before the intervention to 6.9% after. A systematic comparison of out-patient and laboratory registers, followed by tracing missing persons, can reduce the proportion of patients with presumptive TB lost before diagnosis.