A packaged intervention to improve viral load monitoring within a deeply rural health district of South Africa.

BACKGROUND: The KwaZulu-Natal (KZN) province of South Africa has the highest prevalence of HIV infection in the world. Viral load (VL) testing is a crucial tool for clinical and programmatic monitoring. Within uMkhanyakude district, VL suppression rates were 91% among patients with VL data; however, VL performance rates averaged only 38·7%. The objective of this study was to determine if enhanced clinic processes and community outreach could improve VL monitoring within this district. METHODS: A packaged intervention was implemented at three rural clinics in the setting of the KZN HIV AIDS Drug Resistance Surveillance Study. This included file hygiene, outreach, a VL register and documentation revisions. Chart audits were used to assess fidelity. Outcome measures included percentage VL performed and suppressed. Each rural clinic was matched with a peri-urban clinic for comparison before and after the start of each phase of the intervention. Monthly sample proportions were modelled using quasi-likelihood regression methods for over-dispersed binomial data. RESULTS: Mkuze and Jozini clinics increased VL performance overall from 33·9% and 35·3% to 75·8% and 72·4%, respectively which was significantly greater than the increases in the comparison clinics (RR 1·86 and 1·68, p < 0·01). VL suppression rates similarly increased overall by 39·3% and 36·2% (RR 1·84 and 1·70, p < 0·01). The Chart Intervention phase showed significant increases in fidelity 16 months after implementation. CONCLUSIONS: The packaged intervention improved VL performance and suppression rates overall but was significant in Mkuze and Jozini. Larger sustained efforts will be needed to have a similar impact throughout the province.

Progesterone in vitro increases growth, motility and progesterone receptor expression in third stage larvae of Toxocara canis.

The in vitro effect of progesterone in T. canis larvae on their enlargement and motility were evaluated, together to the possible presence of progesterone receptors (PRs). T. canis larvae were cultured in RPMI-1640 with different concentrations of progesterone (0, 20, 40, 80, 400 and 800 ng/mL). Enlargement and increases in motility were dependent on the concentration only from 0 to 80 ng/mL (p < 0.05). The mean percentage of PR + cells in newly obtained larvae as measured by flow cytometry was 8.16 ± 0.4. The number of PR + cells increased depending on concentration from 0 to 80 ng/mL (p < 0.001). Cells obtained from larvae stimulated at any of the studied hormone concentrations showed greater mean fluorescence intensity when compared to non-stimulated cells. Additionally, the expression and location of PR + cells were determined in the larvae. The sequence of an amplicon (420-bp) obtained by PCR from T. canis larvae showed 100% homology with a gene fragment that codes for the PR of the dog. PR + cells were immunolocated using confocal microscopy in the intestinal region of the larvae that had been recently obtained. The results of this study show that T. canis larvae can recognize and respond to the presence of progesterone through a molecule possibly able to bind it. Since we previously observed a similar response to prolactin, we suggest that both hormones could participate sequentially in the reactivation of T. canis larvae in pregnant bitches.

Proteomic profile associated with cell death induced by androgens in Taenia crassiceps cysticerci: proposed interactome.

Androgens have been shown to exert a cysticidal effect upon Taenia crassiceps, an experimental model of cysticercosis. To further inquire into this matter, the Taenia crassiceps model was used to evaluate the expression of several proteins after testosterone (T4) and dihydrotestosterone (DHT) in vitro treatment. Under 2-D proteomic maps, parasite extracts were resolved into approximately 130 proteins distributed in a molecular weight range of 10-250 kDa and isoelectrical point range of 3-10. The resultant proteomic pattern was analysed, and significant changes were observed in response to T4 and DHT. Based on our experience with electrophoretic patterns and proteomic maps of cytoskeletal proteins, alteration in the expression of isoforms of actin, tubulin and paramyosin and of other proteins was assessed. Considering that androgens may exert their biological activity in taeniids through the non-specific progesterone receptor membrane component (PGRMC), we harnessed bioinformatics to propose the identity of androgen-regulated proteins and establish their hypothetical physiological role in the parasites. These analyses yield a possible explanation of how androgens exert their cysticidal effects through changes in the expression of proteins involved in cytoskeletal rearrangement, dynamic vesicular traffic and transduction of intracellular signals.

Short communication: Viable Mycobacterium avium subspecies paratuberculosis in retail artisanal Coalho cheese from Northeastern Brazil.

Mycobacterium avium ssp. paratuberculosis (MAP) is the etiologic agent of paratuberculosis and it potentially plays a role in Crohn's disease. In humans, the main route of transmission of MAP might be the intake of contaminated milk and dairy products. Considering that MAP has already been detected in many types of cheese in different counties, and that Coalho cheese is an important dairy product in northeastern Brazil, the aim of this study was to report the first detection of MAP in retail Coalho cheese in Brazil by PCR and culture. Of 30 retail Coalho cheese samples, 3 (10%) amplified fragments of a similar size to that expected (626 bp) were obtained and viable MAP was recovered by culture from 1 (3.3%) sample. The DNA from the positive culture sample was sequenced and showed 99% identity with the insertion sequence IS900 deposited in GenBank. It was possible to identify the presence of MAP-specific DNA in the analyzed samples for the first time in Brazil, and to recover viable cells from retail Coalho cheese.

Acaricide activity in vitro of Acmella oleracea against Rhipicephalus microplus.

Cattle tick control has been limited by the resistance of these parasites to synthetic acaricides. Natural products are a possible alternative as they have different mechanisms of action. Acmella oleracea is a native plant with a large cultivated area in the Amazon region and could be easily used for large-scale preparation of a commercial product. This study evaluated the in vitro action of the hexane extract of the aerial parts of A. oleracea on larvae and engorged females of the cattle tick Rhipicephalus microplus. Spilanthol was the major constituent with a content of 14.8% in the extract. The hexane extract of A. oleracea was highly effective against larvae of R. microplus with an LC50 of 0.8 mg mL(-1). Against engorged females, hexane extract of A. oleracea reduced oviposition and hatchability of eggs with an LC50 of 79.7 mg mL(-1). Larvae and engorged females were killed by the hexane extract with high efficiency (>95%) at concentrations of 3.1 and 150.0 mg mL(-1), respectively. These results demonstrate that the hexane extract of A. oleracea has significant activity against R. microplus and has potential to be developed into formulations for tick control.

[Communication with a culturally and linguistically diverse population from Primary Care]. / La comunicación con población cultural y lingüísticamente diversa desde la Atención Primaria.

The care of a culturally and linguistically diverse population is a challenge in primary health care due to language barriers and cultural differences. For this reason, good communication and cultural competence of health personnel is key within medical consultation. Thus, during consultations with this group of people, it is the doctor's duty to identify the patient's culture, their perception of the concept of health, in what way and to what extent they want to be informed, and the role they want to assign to the members of their family before the treatment process begins. For this reason, there are interventions that seek to optimize the care provided to these patients and mitigate the cultural barrier, including the use of multimodal digital tools, the use of translators or interpreters, and training of health personnel in communication and intercultural skills.

A new methodology for kerogen maturity estimation based on Raman spectroscopy and chemometric analysis.

Diverse criteria or parameters have been cited as tools to determine the maturity of carbonaceous matter (CM) found in geologic samples using Raman spectroscopy. However, these approaches involve the mathematical decomposition of Raman bands which can vary with the specific method, the software employed, or even the individual user. Data should be treated spectrum by spectrum and a similar spectroscopic pre-treatment should be applied to the whole dataset. All these factors affect the final result and can introduce a wide uncertainty and bias. We propose an alternative chemometric method that avoids these sources of uncertainty by considering the entire spectrum, not just certain regions, while allowing specific regions of interest to be defined. Moreover, spectra pre-treatment is not required. We employ principal component analysis (PCA) across the whole range of spectra. While the method does not provide an absolute maturity value, it allows comparison of different CM in terms of maturity or H:C ratio. In the analysis of coal standards, samples were grouped by maturity.

Multi-analytical characterization of an oncoid from a high altitude hypersaline lake using techniques employed in the Mars2020 and Rosalind Franklin missions on Mars.

In this work, a geological sample of great astrobiological interest was studied through analytical techniques that are currently operating in situ on Mars and others that will operate in the near future. The sample analyzed consisted of an oncoid, which is a type of microbialite, collected in the Salar Carachi Pampa, Argentina. The main peculiarity of microbialites is that they are organo-sedimentary deposits formed by the in situ fixation and precipitation of calcium carbonate due to the growth and metabolic activities of microorganisms. For this reason, the Carachi Pampa oncoid was selected as a Martian analog for astrobiogeochemistry study. In this sense, the sample was characterized by means of the PIXL-like, SuperCam-like and SHERLOC-like instruments, which represent instruments on board the NASA Perseverance rover, and by means of RLS-like and MOMA-like instruments, which represent instruments on board the future ESA Rosalind Franklin rover. It was possible to verify that the most important conclusions and discoveries have been obtained from the combination of the results. Likewise, it was also shown that Perseverance rover-like remote-sensing instruments allowed a first detailed characterization of the biogeochemistry of the Martian surface. With this first characterization, areas of interest for in-depth analysis with Rosalind Franklin-like instruments could be identified. Therefore, from a first remote-sensing elemental identification (PIXL-like instrument), followed by a remote-sensing molecular characterization (SuperCam and SHERLOC-like instruments) and ending with an in-depth microscopic analysis (RLS and MOMA-like instruments), a wide variety of compounds were found. On the one hand, the expected minerals were carbonates, such as aragonite, calcite and high-magnesium calcite. On the other hand, unexpected compounds consisted of minerals related to the Martian/terrestrial surface (feldspars, pyroxenes, hematite) and organic compounds related to the past biological activity related to the oncoid (kerogen, lipid biomarkers and carotenes). Considering samples resembling microbialites have already been found on Mars and that one of the main objectives of the missions is to identify traces of past life, the study of microbialites is a potential way to find biosignatures protected from the inhospitable Martian environment. In addition, it should be noted that in this work, further conclusions have been obtained through the study of the results as a whole, which could also be carried out on Mars.

Modelling tuberculosis trends in the USA.

We present a mathematical transmission model of tuberculosis in the USA. The model is calibrated to recent trends of declining incidence in the US-born and foreign-born populations and is used in assessing relative impacts of treatment of latently infected individuals on elimination time, where elimination is defined as annual incidence <1 case/million. Provided current control efforts are maintained, elimination in the US-born population can be achieved before the end of this century. However, elimination in the foreign-born population is unlikely in this timeframe even with higher rates of targeted testing and treatment of residents of and immigrants to the USA with latent tuberculosis infection. Cutting transmission of disease as an interim step would shorten the time to elimination in the US-born population but foreign-born rates would remain above the elimination target.

Use of in situ and confocal Raman spectroscopy to study the nature and distribution of carotenoids in brown patinas from a deteriorated wall painting in Marcus Lucretius House (Pompeii).

Colonisation of wall paintings by microorganisms and other organisms is a well-known problematic phenomenon. Besides taxonomic identification of the biodeteriogen, it is essential to evaluate the consequences of the colonisation, e.g., unsightly coloured patinas. This work proposes new methodology for characterisation of the nature of the main carotenoids and their distribution in brown stains or patinas of a deteriorated wall painting on the north wall of the atrium of Marcus Lucretius House (Pompeii, Italy). Characterisation of the brown patinas and surrounding areas (plaster and polychromy) from the wall painting started with in situ screening using, mainly, a portable Raman instrument with a handheld FTIR (DRIFTS sampling interface) in order to select the sampling areas suitable for further analysis in the laboratory. Two wall painting fragments were then analysed in the laboratory in two steps. First, microscopic observations (SEM and phase-contrast microscopy) were used to determine whether biodeteriogens were present in the samples. In a second step, confocal Raman microscopy (785 and 514 nm excitation lasers) was used to characterise the main biogenic compounds of the brown stains. Because of the resonance Raman effect (514 nm excitation laser), it was possible to obtain reliable Raman features to assign not only the nature of the main biogenic pigments (carotenoids) present in the stains, but also their spatial conformation. Moreover, Raman confocal applications, for example, Raman imaging and depth profiling were also used in a first attempt to determine the distribution of biosynthesised carotenoids in the stains, and to determine the thickness of the brown patinas.

Homogeneity assessment of the SuperCam calibration targets onboard rover perseverance.

The SuperCam instrument, onboard the Perseverance rover (Mars 2020 mission) is designed to perform remote analysis on the Martian surface employing several spectroscopic techniques such as Laser Induced Breakdown Spectroscopy (LIBS), Time-Resolved Raman (TRR), Time-Resolved Fluorescence (TRF) and Visible and Infrared (VISIR) reflectance. In addition, SuperCam also acquires high-resolution images using a color remote micro-imager (RMI) as well as sounds with its microphone. SuperCam has three main subsystems, the Mast Unit (MU) where the laser for chemical analysis and collection optics are housed, the Body Unit (BU) where the different spectrometers are located inside the rover, and the SuperCam Calibration Target (SCCT) located on the rover's deck to facilitate calibration tests at similar ambient conditions as the analyzed samples. To perform adequate calibrations on Mars, the 22 mineral samples included in the complex SCCT assembly must have a very homogeneous distribution of major and minor elements. The analysis and verification of such homogeneity for the 5-6 replicates of the samples included in the SCCT has been the aim of this work. To verify the physic-chemical homogeneity of the calibration targets, micro Energy Dispersive X-ray Fluorescence (EDXRF) imaging was first used on the whole surface of the targets, then the relative abundances of the detected elements were computed on 20 randomly distributed areas of 100 × 100 µm. For those targets showing a positive Raman response, micro-Raman spectroscopy imaging was performed on the whole surface of the targets at a resolution of 100 × 100 µm. The %RSD values (percent of relative standard deviation of mean values) for the major elements measured with EDXRF were compared with similar values obtained by two independent LIBS set-ups at spot sizes of 300 µm in diameter. The statistical analysis showed which elements were homogeneously distributed in the 22 mineral targets of the SCCT, providing their uncertainty values for further calibration. Moreover, nine of the 22 targets showed a good Raman response and their mineral distributions were also studied. Those targets can be also used for calibration purposes of the Raman part of SuperCam using the wavenumbers of their main Raman bands proposed in this work.

Classification and identification of organic binding media in artworks by means of Fourier transform infrared spectroscopy and principal component analysis.

Fourier transform infrared spectroscopy is a powerful analytical technique to study organic materials. However, in Cultural Heritage, since the sample under analysis is always a complicated matrix of several materials, data analysis performed through peak-by-peak comparisons of sample spectra with those of standard compounds is a tedious method that does not always provide good results. To overcome this problem, a chemometric model based on principal component analysis was developed to classify and identify organic binding media in artworks. The model allows the differentiation of five families of binders: drying oils, waxes, proteins, gums, and resins, taking into account the absorption bands in two characteristic spectral windows: C-H stretching and carbonyl band. This new methodology was applied in the characterization of binders in three kinds of artworks: papers of historical, archeological, and artistic value, easel paintings, and polychromed stone-based sculptures.

Key parameters to enhance the antibacterial effect of graphene oxide in solution.

Graphene oxide (GO) has lately become an interesting biomaterial due to its stunning properties and versatility, its claimed antimicrobial activity holds promise for potential health applications. Nonetheless, multiple reports investigating GO antibacterial activity lack rigor and uniformity on several aspects which are crucial when evaluating this effect. In this work, we highlight and address these parameters: morphology of the materials, exposure time, exposure methodology and concentration. We investigate the effect of GO and GO-based metallic composites observing these parameters on two pathogenic bacteria. Our nanomaterials have been characterized by means of SEM, EDX, DLS, FTIR and Raman spectroscopies. Escherichia coli and Salmonella Typhimurium suspended in saline solutions (no growth medium) have been exposed to GO (lateral size = 100 nm), silver nanoparticles, ceria nanoparticles, GO/silver and GO/ceria aqueous solutions for 0, 5, 15, 30, 60 and 90 minutes, before plating. Our experiments indicate that no prior exposure of the materials to bacteria (0 min) results in poor inactivation rates independently of concentration, while increasing times of interaction enhance inactivation. Moreover, our experiments show concentration-dependent results showing higher activity for concentrations of 100 µg mL-1; and prove that 30 minutes of exposure are sufficient to deploy the antimicrobial effects of these materials. GO possesses the lowest inactivation rate, and the presence of silver and ceria nanoparticles in the GO surface boosts its antimicrobial effect. Thus, the enhancement of the antibacterial activity of graphene oxide relies on 30 minutes of interaction in water, concentration of 100 µg mL-1, and its decoration by silver/ceria nanoparticles.

Characterization of sedimentary and volcanic rocks in Armintza outcrop (Biscay, Spain) and its implication for Oxia Planum (Mars) exploration.

The landing site of the next planetary mission lead by ESA (ExoMars 2022) will be Oxia Planum. This location has been chosen due to different reasons, among them, the existence of sedimentary rocks that could host remains of organic matter. The fact that this type of rocks coexists with volcanic ones makes of high importance the study of the processes and the possible interactions that could happen among them. Therefore, in this research work the Armintza outcrop (Biscay, North of Spain) is proposed as an Oxia Planum analogue since it has the dichotomy of volcanic and sedimentary rock layers that is expected on the landing site of the ExoMars 2022 mission. As Raman and visible near infrared spectroscopies will be in the payload of the rover of that mission, they have been used to characterize the samples collected in the Armintza outcrop. With the help of these techniques, feldspars (albite mainly) and phyllosilicates (kaolinite and dickite, together with micas and chlorite minerals) have been identified as the major products on the samples, together with some weathering products (carbonates, sulphates, oxides) and apatite. Moreover, remains of kerogen have been detected in the sedimentary layers in contact with the interlayered lava flows, confirming the capability of similar sedimentary-volcanic layers to trap and store organic remains for millions of years. After establishing which compounds have volcanic or sedimentary origin, and which must be considered alteration phases, we can consider Armintza as a good Oxia Planum analogue.

Development of innovative non-destructive analytical strategies for Mars Sample Return tested on Dar al Gani 735 Martian Meteorite.

This work proposes an innovative non-destructive analytical strategy, based on Confocal Raman micro-spectroscopy, High Resolution Raman Imaging and micro-X-Ray Fluorescence imaging, as part of the quick non-destructive techniques that could be used to characterize the Martian samples from the Mars Sample Return mission when back on Earth. Until that moment, Martian Meteorites are the only Martian samples in our hands to develop such Analytical Strategies. To demonstrate its capabilities, this analytical strategy has been applied to characterize the Dar al Gani 735 Martian Meteorite with the aim to identify the terrestrial and non-terrestrial alterations suffered by the meteorite as a very valuable complementary methodology to the more traditional petrographic analyses and single point measurements. The combination of these techniques allows extracting at the same time elemental, molecular and structural information of the studied area of the sample. The most relevant results on the analyzed DaG 735 shergottite thick samples revealed the presence of several altered mineral phases originated from the temperature and pressure conditions during the shock on Mars (anhydride, calcite and ilmenite), as well as from terrestrial weathering processes that degraded the meteorite from its landing on Earth (calcite and hematite in fractures together with gypsum, mirabilite and thenardite). As most of the conclusive results come from Raman spectroscopy, this study shows the potential of Raman spectroscopy as a key technique in the upcoming new explorations of Mars materials by the Rosalind Franklin rover (Exomars2022 mission from ESA) and the Perseverance rover (Mars2020 mission from NASA), where Raman spectrometers are mounted for the first time in an extra-terrestrial research in the field.

Potential applications of CRISPR/Cas for next-generation biomonitoring of harmful algae blooms: A review.

Research on harmful algal and cyanobacterial blooms (HABs and CHABs) has risen dramatically due to their increasing global distribution, frequency, and intensity. These blooms jeopardize public health, ecosystem function, sustainability and can have negative economic impacts. Numerous monitoring programs have been established using light microscopy, liquid chromatography coupled to mass spectrometry (LC-MS), ELISA, and spectrophotometry to monitor HABs/CHABs outbreaks. Recently, DNA/RNA-based molecular methods have been integrated into these programs to replace or complement traditional methods through analyzing environmental DNA and RNA (eDNA/eRNA) with techniques such as quantitative polymerase chain reaction (qPCR), fluorescent in situ hybridization (FISH), sandwich hybridization assay (SHA), isothermal amplification methods, and microarrays. These have enabled the detection of rare or cryptic species, enhanced sample throughput, and reduced costs and the need for visual taxonomic expertise. However, these methods have limitations, such as the need for high capital investment in equipment or detection uncertainties, including determining whether organisms are viable. In this review, we discuss the potential of newly developed molecular diagnosis technology based on Clustered Regularly Interspaced Short Palindromic Repeats/Cas proteins (CRISPR/Cas), which utilizes the prokaryotic adaptative immune systems of bacteria and archaea. Cas12 and Cas13-based platforms can detect both DNA and RNA with attomolar sensitivity within an hour. CRISPR/Cas diagnostic is a rapid, inexpensive, specific, and ultrasensitive technology that, with some further development, will provide many new platforms that can be used for HABs/CHABs biomonitoring and research.

Portable Raman monitoring of modern cleaning and consolidation operations of artworks on mineral supports.

Any restoration performed on cultural heritage artworks must guarantee a low impact on the treated surfaces. Although completely risk-free methods do not exist, the use of tailor-made procedures and the continuous monitoring by portable instrumentation is surely one of the best approaches to conduct a modern restoration process. In this work, a portable Raman monitoring, combined sometimes with spectroscopic techniques providing the elemental composition, is the key analysis technique in the three-step restoration protocol proposed: (a) in situ analysis of the surface to be treated (original composition and degradation products/pollutants) and the cleaning agents used as extractants, (b) the thermodynamic study of the species involved in the treatment in order to design a suitable restoration method and (c) application and monitoring of the treatment. Two cleaning operations based on new technologies were studied and applied to two artworks on mineral supports: a wall painting affected by nitrate impact, and a black crusted stone (chalk) altarpiece. Raman bands of nitrate and gypsum, respectively, decreased after the step-by-step operations in each case, which helped restorers to decide when the treatment was concluded, thus avoiding any further damage to the treated surface of the artworks.

The effect of Mycoplasma and mycoplasma removal agent on the hydrolase activity in fibroblasts of patients with lysosomal diseases.

This study was designed to evaluate the effect of mycoplasma contamination on acid hydrolase activity and the action of the mycoplasma removal agent (MRA), in cultures of human fibroblasts from individuals with lysosomal diseases. For this purpose, we measured the activity of the b-galactosidase, arylsulphatase B (ASB), hexosaminidase A and a-glucosidase enzymes. The activity of the above mentioned enzymes in fibroblasts contaminated by mycoplasma was measured before and after the addition of the MRA. The results were then compared to the enzymatic activity in contamination-free cultures. Only the ASB enzyme showed significant alteration in activity both in the presence of mycoplasma and MRA. The remaining enzymes did not suffer significant interference by the presence of the two agents. Of the four enzymes tested, three did not suffer significant alterations by the presence of the mycoplasma nor from the MRA. However, the activity measured in the ASB enzyme increased significantly in the presence of mycoplasma and MRA and could lead to a doubtful diagnosis. Therefore, we suggest that contamination should be prevented by using aseptic techniques as well as the MRA in those fibroblast cultures that cannot be discarded.

Tuberculosis surveillance and its discontents: the ethical paradox.

In June 2017, the World Health Organization issued the Guidelines on Ethical Issues in Public Health Surveillance. Using the frame of public health ethics, the guidance declared that countries have an affirmative duty to undertake surveillance and that the global community had an obligation to support those countries whose resources limited their capacity. The centrality of TB surveillance has long been recognized as a matter of public health practice and ethics. Nevertheless, contemporary global realities make clear that TB surveillance falls far short of the goal of uniform notification. It is this reality that necessitated the paradoxical turn to research studies that require informed consent and human subjects' ethical review, the very burdens that mandated notification were designed to overcome.

Epidemiology and risk factors for extrapulmonary tuberculosis in Lebanon.

SETTING: Lebanon is a relatively low TB-burden country, but has a high proportion of extrapulmonary tuberculosis (EPTB). Concern has been expressed that Syrian-born refugees could add to the TB burden and rates of EPTB: since 2011, >1 000 000 Syrian refugees have entered Lebanon.OBJECTIVE: The Lebanese National Tuberculosis Programme (NTP) sought to identify factors for the high proportion of EPTB and to assess the potential impact of Syrian refugees.DESIGN: NTP line-listed data from 2014-2015 were analyzed with logistic regression identified risk factors for EPTB. A trend analysis for 2011-2015 assessed TB burden by nationality and site of TB.RESULTS: Of 1347 reported TB cases from 2014 to 2015, 507 (38%) were EPTB and 46% were Lebanese. In analysis limited to Lebanese-born, the proportion of EPTB cases was relatively stable, 47% in 2011 and 52% in 2015. Modeling identified risk factors for EPTB as being female (aOR 1.79, 95%CI 1.39-2.32) and 5-15 years old (aOR 3.31, 95%CI 1.47-7.45) compared with children aged <5 years. Between 2011 and 2015, the proportion of TB cases among Syrian-born increased from 3% in 2011 to 21% in 2015 (P < 0.001); however, the proportion of EPTB versus PTB cases among Syrians remained stable (P = 0.264).CONCLUSION: Syrian TB cases increased almost 10-fold in five years (2011-2015) but their contribution to EPTB did not change. The high proportion of EPTB in Lebanon and those aged 5-15 years merits further investigation.