Applying the zero-inflated Poisson model with random effects to detect abnormal rises in school absenteeism indicating infectious diseases outbreak.

Records of absenteeism from primary schools are valuable data for infectious diseases surveillance. However, the analysis of the absenteeism is complicated by the data features of clustering at zero, non-independence and overdispersion. This study aimed to generate an appropriate model to handle the absenteeism data collected in a European Commission granted project for infectious disease surveillance in rural China and to evaluate the validity and timeliness of the resulting model for early warnings of infectious disease outbreak. Four steps were taken: (1) building a 'well-fitting' model by the zero-inflated Poisson model with random effects (ZIP-RE) using the absenteeism data from the first implementation year; (2) applying the resulting model to predict the 'expected' number of absenteeism events in the second implementation year; (3) computing the differences between the observations and the expected values (O-E values) to generate an alternative series of data; (4) evaluating the early warning validity and timeliness of the observational data and model-based O-E values via the EARS-3C algorithms with regard to the detection of real cluster events. The results indicate that ZIP-RE and its corresponding O-E values could improve the detection of aberrations, reduce the false-positive signals and are applicable to the zero-inflated data.

Screening diabetes in tuberculosis patients in eastern rural China: a community-based cross-sectional study.

OBJECTIVES: To understand the prevalence of diabetes mellitus (DM) and tuberculosis (TB) comorbidity in rural China and to identify factors associated with TB-DM comorbidity and screening efficacy. METHODS: A community-based cross-sectional study was carried out in four counties in eastern rural China. All TB patients newly registered from April 2013 to March 2014 were screened for DM using fasting blood glucose (FBG). Screening-positive patients were further examined using glycosylated haemoglobin A1C (HbA1c). RESULTS: Ninety-seven (7.7%) of the 1252 recruited TB patients had DM, 44 (45.4%) of whom were newly diagnosed. The DM-TB patients were significantly older than non-diabetics (mean age 57 ± 13 years vs. 49 ± 19 years, P < 0.001). The risk of DM-TB was higher in patients aged >40 years (OR 3.039) and in overweight patients (OR 2.595). The number needed to screen (NNS) among TB patients to identify one case of DM was 12.97. The NNS to identify one new DM patient (27.4) was lower in participants aged >40 years (20.5), those who were illiterate (19.9), those with a family history of DM (9.3), those with missing bacille Calmette-Guérin vaccination (11.3), current smokers (14.2) and those with body mass index >24 (11.4). CONCLUSION: Regular DM screening in TB patients is practical in rural China. Better efficacy of DM-TB detection could be obtained by screening high-risk populations, such as overweight TB patients or those with a family history of DM.

Using daily syndrome-specific absence data for early detection of school outbreaks: a pilot study in rural China.

OBJECTIVES: This paper describes and preliminarily evaluates the usefulness of the daily syndrome-specific absenteeism surveillance system (DSSASS) as an early warning system of school outbreaks in rural China. STUDY DESIGN: We conducted an experimental study in rural areas of Hubei Province from September 19, 2011 to December 31, 2011. METHODS: Nine public elementary schools from two counties were selected as pilot sentinel schools. Daily monitoring data of the absent date and reason, sex, age and class of each absent student was collected and entered into a web database. Reported data were checked daily and field investigation was carried out when there was abnormal absentee aggregation. Descriptive analysis and preliminary evaluation were then conducted after the pilot study. RESULTS: The findings showed that the total average of daily absenteeism rate was 3%, and the absenteeism rate differed by county, school level and grade level. The daily absenteeism rate in illness absentees was highest (2.74%), followed by business absentees (0.13%) and injury absentees (0.09%). The total timeliness report rate was 64.84% and the total incident report rate was 29.22%. One varicella outbreak and one influenza B outbreak were identified, but neither of them was detected by China Information System for Diseases Control and Prevention (CISDCP). The study shows syndrome-specific absenteeism data would be useful for early detection of unusual public health events or outbreaks in school. However, more efforts are needed to enhance the quality of surveillance data, and longer follow-up and more analysis are required to evaluate the system comprehensively. Our study might provide useful experience and evidence for other developing regions or counties establishing similar systems.

Detection of carbapenem resistance genes and cephalosporin, and quinolone resistance genes along with oqxAB gene in Escherichia coli in hospital wastewater: a matter of concern.

AIMS: This study was performed to detect the presence of Escherichia coli resistant to cephalosporins, carbapenems and quinolones in hospital wastewater. METHODS AND RESULTS: Wastewaters from a rural (H1) and an urban (H2) hospital were tested for E. coli resistant to cephalosporins, carbapenem and quinolones. Genes coding for chromosomal and plasmid-mediated resistance and phylogenetic grouping was detected by multiplex polymerase chain reaction (PCR) and for genetic relatedness by rep-PCR. Of 190 (H1 = 94; H2 = 96) E. coli examined, 44% were resistant to both cephalosporins and quinolones and 3% to imipenem. ESBLs were detected phenotypically in 96% of the isolates, the gene blaCTX-M coding for 87% and blaTEM for 63%. Quinolone resistance was due to mutations in gyrA and parC genes in 97% and plasmid-coded aac-(6')-Ib-cr in 89% of isolates. Only in one carbapenem-resistant E. coli, NDM-1 was detected. Nearly 67% of the isolates belonged to phylogenetic group B2. There was no genetic relatedness among the isolates. CONCLUSIONS: Hospital wastewater contains genetically diverse multidrug-resistant E. coli. SIGNIFICANCE AND IMPACT OF THE STUDY: This study stresses the need for efficient water treatment plants in healthcare settings as a public health measure to minimize spread of multidrug-resistant bacteria into the environment.

Qualitative study on perceptions of hand hygiene among hospital staff in a rural teaching hospital in India.

BACKGROUND: Hand hygiene is a simple but underutilized measure to control healthcare-associated infections. AIM: To explore staff perceptions of hand hygiene using focus group discussions (FGDs) in a teaching hospital in India. METHODS: Qualitative study. The FGD guide included questions on transmission of infections, hand hygiene practices and problems with implementation, and ways to improve adherence to hand hygiene recommendations. The FGDs were recorded, transcribed verbatim, translated into English (when conducted in Hindi) and analysed using content analysis. FINDINGS: Two themes emerged: 'inter-relationship of knowledge, beliefs, motivation, practices and needs' and 'roles and responsibilities for sustainable and efficient implementation of context-relevant approaches and interventions'. Staff were generally aware of the importance of hand hygiene for the prevention of healthcare-associated infections, but perceived practical problems with implementation. CONCLUSIONS: The staff suggested various interventions and appeared to be prepared to follow hand hygiene guidelines if the hospital provided the necessary facilities.

Community perceptions of tuberculosis: A qualitative exploration from a gender perspective.

OBJECTIVE: To explore community laypersons' perspective on tuberculosis (TB)-related illness experiences, meanings, behaviours and impact with reference to gender. STUDY DESIGN: Qualitative, conducted in rural Bangladesh. METHODS: Eleven focus group discussions (FGDs) were conducted (six female and five male) in five subdistricts where the non-governmental organization BRAC operates. On average, seven purposively chosen poor, illiterate, non-TB patients participated in each FGD. Discussions were audiotaped, translated verbatim into English and analysed using MAXQDA software for qualitative data analysis, used it to assign codes to text segments to identify themes from participants' narratives. RESULTS: TB was recognized as a deadly disease that could affect anyone. The discussants were fairly aware of the psychological, financial and social impacts of TB. Women faced with adverse consequences more often than men, such as trouble in ongoing and prospective marital affairs. Coughing up sputum in public by women is culturally frowned upon, resulting in enormous suffering. Women tended to describe the clinical features more vaguely than men, and often specified fewer characteristic symptoms such as blood in sputum. CONCLUSIONS: The gender differences in the health and socio-economic impact of TB included perceived causality, curability, stigma, family and community support, fear of disclosure, and use of self-help or home remedies. Interactive health education covering various consequences of TB could be indispensable to changing negative beliefs.

A snapshot of the biodiversity and clustering of Mycobacterium tuberculosis in Oman using spoligotyping.

SETTINGS: National Tuberculosis Reference Laboratory, Central Public Health Laboratory, Ministry of Health, Oman. OBJECTIVE: To use spoligotyping to explore the genetic population structure and clustering of Mycobacterium tuberculosis isolates among nationals and immigrants in Oman. METHODS: Using spoligotyping, we characterised all available isolates from 2007, and randomly selected isolates from 2005 and 2006. A total of 312 clinical isolates from the same number of patients diagnosed with tuberculosis (TB) in 2005-2007 were included in the study. RESULTS: Of 312 isolates, 69% were in clusters ranging from 2 to 38 isolates. The proportion of clustering was 58% among 2005-2006 samples and 67% among 2007 samples, with higher clustering among Omanis than among immigrants. The study showed that M. tuberculosis Indian family lineages, CAS1_Delhi, CAS and EAI5 were the predominant strains. Around 50% of the immigrants shared strains with Omanis. Twelve of the 19 INH-monoresistant strains and the two multidrug-resistant strains were in clusters (P = 0.81). CONCLUSION: This study demonstrates the predominance in Oman of the strain family commonly found on the Indian sub-continent. A high proportion of immigrant strains were in the same clusters as Omani strains. To better ascertain the transmission dynamics of M. tuberculosis, we recommend that stringent molecular and conventional epidemiological methods be applied.

[Postconditioning is a universal protective phenomenon].

The analysis of the data available in the literature shows that postconditioning enhances cardiac tolerance to the arrhythmogenic impact of reperfusion, prevents the occurrence of the no-reflow phenomenon, and eliminates cardiomyocytic necrosis and apoptosis during reperfusion. Independent clinical observations indicate the high clinical efficiency of postconditioning in patients with acute myocardial infarction. The literature data show that postconditioning enhances the tolerance of the brain, spinal cord, kidneys, liver, intestine, and skeletal muscles to reperfusion injury. The molecular mechanism of the protective action of postconditioning is discussed.

PPM: 'public-private' or 'private-public' mix? The case of Ujjain District, India.

The World Health Organization and the Revised National TB Control Programme (RNTCP) in India have advocated public-private mix as essential for tuberculosis (TB) control. We conducted a cross-sectional sample survey of private providers (with various qualifications) in Ujjain District, India, to study willingness and motivation to collaborate. Most providers were aware of the RNTCP and had referred patients there. All were willing to collaborate, although the areas for collaboration varied between urban and rural providers. General altruism and an opportunity to collaborate with the government were the main motivations. None of the providers had ever been contacted by the RNTCP. Enthusiasm in the private sector has not been effectively exploited by the RNTCP.

Female-male differences at various clinical steps of tuberculosis management in rural Bangladesh.

A registry data-based study of 3,600 patients systematically drawn from out-patient clinic, laboratory and tuberculosis (TB) treatment registers (1200 from each) examined female-male differences at various clinical steps of TB management and compared selective indicators with published results. Female-to-male ratios (FMR) declined at the following clinical steps: respiratory patients seeking out-patient care (0.81), TB suspects submitting sputum for testing (0.52) and smear-positive test results (0.38), but the decline ceased at treatment initiation (0.41). Compared to 1997, the FMR in 2000 had decreased for out-patient clinics and sputum submission for testing, but had increased for smear-positive test results and treatment initiation. More female than male patients who underwent treatment achieved cure (93% vs. 89%). Lower female representation at the different clinical steps of TB management persists.

Managing with maps? The development and institutionalization of a map-based health management information system in Madhya Pradesh, India.

AIMS: This paper presents the development of a map-based health management information system (mHMIS) in the central Indian province of Madhya Pradesh. Sample outputs and statistics from the system for one district are presented. The implementation dynamics and the preliminary performance of the system are discussed. METHODS: The development of the mHMIS was a collaborative effort between the provincial Department of Health, the medical university and the Danidasupported Madhya Pradesh Basic Health Services project. One of India's most socioeconomically backward provinces, Madhya Pradesh is spread over an area of 304,000 km(2), and has a population of 60.4 million distributed in its 55,392 villages and 394 towns. A primary survey of all healthcare providers (public and private) in the province was done to map these. Secondary data sources for sociodemographic information (census of India), vital statistics and health program indicators (health worker records) were used in developing the system. The process of mapping from obtaining hand-drawn maps of the villages from the commissioner, land records, to final digitizing is also described. CONCLUSIONS: Sample outputs and statistics for one district (Chindwara) from the system are presented. There were 20.35 trained doctors in rural areas and 72.78 in urban areas per 100,000 population. Preliminary experience after a year, advantages, constraints (both systemic limitations and weakness in the mHMIS) to optimal usage, and future prospects for use in this setting are discussed.

Towards the elimination of tuberculosis in a developing country: 25 years of tuberculosis control in Oman.

OBJECTIVE: To analyse trends of tuberculosis (TB) in Oman (1981-2005) in relation to the socio-economic development of the country. METHODS: Data were used from the National Tuberculosis Control Programme (NTP). Information on TB cases' age, sex and type were obtained from the national book (1981-1991) and the computer database (1992-2005). RESULTS: TB notification rates among Omani nationals declined by more than 85% from 1981 to 1995. During the period 1981-1993, the TB notification rate declined by around 15% per year, compared to only 3.6% per year in subsequent years. Males and the age group > or = 50 years have higher rates than females and younger age groups, respectively. Non-nationals contributed 21% of all TB cases notified and 40% of all smear-positive cases. Of cases among nationals notified between 2004 and 2005, 95% had a family income lower than the national average. CONCLUSION: Although TB notification in Oman has declined by more than 85% over the last 25 years, the decline has slowed down over the last 10 years, requiring a detailed analysis of existing TB control measures and implementation of additional measures for TB elimination.

Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India.

SETTING: Ujjain district, Madhya Pradesh, India. OBJECTIVE: To describe and compare health care seeking among men and women with cough of >3 weeks, with special focus on the utilisation of private and public health care. DESIGN: A population-based cross-sectional survey including 45 719 individuals aged > or = 15 years. RESULTS: The prevalence of cough was respectively 2.8% and 1.2% among men and women. The majority of men and women reported seeking health care for their symptoms (69% vs. 71%), but only 23% visited a public provider at some point during their illness. A similar health care seeking pattern was found for patients diagnosed with tuberculosis (TB) in our survey. No significant differences in health care seeking were found between men and women. Only 13% of those seeking care reported having had a sputum smear examination since the onset of cough. Factors associated with sputum examination were history of TB, haemoptysis and visiting a public provider. CONCLUSION: The low utilisation of public health care services and the few sputum examinations reported in this rural Indian setting illustrate the need for improved diagnostic practices as well as involvement of private providers in TB control activities.

Diagnostic delays in access to tuberculosis care in counties with or without the National Tuberculosis Control Programme in rural China.

SETTING: A county covered by the National Tuberculosis Control Programme (NTP) (Jianhu) and a nonprogramme county (Funing) in Jiangsu Province, China. OBJECTIVE: To compare diagnostic delays among tuberculosis (TB) patients between counties with and without the NTP, and to study the impact of demographic, socioeconomic and policy factors on the delays. DESIGN: A cohort study of 493 newly diagnosed TB patients registered in the study sites during 2002 was conducted using a structured questionnaire interview. RESULT: The median total diagnostic delay was longer in Jianhu County, 31 (14-68) days, compared to Funing County, 19 (12-34) days, with a shorter patient's delay (10 vs. 16 days, P < 0.05) but a longer doctor's delay (6 vs. 0 days, P < 0.01) in Jianhu than in Funing. Smear-positive TB accounted for 86% of patients in Jianhu, compared to 37% in Funing. Less educated and uninsured patients had longer patient's or doctor's delays in Jianhu, while in Funing poor patients and farmers had both longer patient's and doctor's delays. CONCLUSION: The subsidised NTP leads to a shorter patient's delay, but a longer doctor's delay, with a substantially higher proportion of smear-positive TB diagnosis. Education, medical insurance, poverty and the system of TB control can influence patients' access to TB care.

Lay health worker intervention with choice of DOT superior to standard TB care for farm dwellers in South Africa: a cluster randomised control trial.

SETTING: Farms in the Boland health district, Western Cape Province, South Africa. OBJECTIVE: To evaluate the effect of lay health workers (LHWs) on tuberculosis (TB) control among permanent farm workers and farm dwellers in an area with particularly high TB prevalence. DESIGN: Pragmatic, unblinded cluster randomised control trial. METHODS: This trial measured successful treatment completion rates among new smear-positive (NSP) adult TB patients on 106 intervention farms, and compared them with outcomes in patients on 105 control farms. Farms were the unit of randomisation, and analysis was by intention to treat. RESULTS: A total of 164 adult TB patients were recruited into the study, 89 of whom were NSP. The successful treatment completion rate in NSP adult TB patients was 18.7% higher (P = 0.042, 95%CI 0.9-36.4) on farms in the intervention group than on farms in the control group. Case finding for adult NSP TB cases was 8% higher (P = 0.2671) on farms in the intervention group compared to the control group. CONCLUSION: Trained LHWs were able to improve the successful TB treatment rate among adult NSP TB patients in a well-established health service, despite reduction of services.

Should the 'bleach microscopy method' be recommended for improved case detection of tuberculosis? Literature review and key person analysis.

SETTING: It has been proposed that the sensitivity of direct sputum smear microscopy can be improved if sputum is liquefied with sodium hypochlorite (NaOCl or household bleach), and concentrated by centrifugation before acid-fast staining. OBJECTIVE: To summarise the results of the studies of the bleach method for improved sensitivity of sputum microscopy and to describe the opinions and knowledge of key persons in National Tuberculosis Control Programmes (NTPs) about this method. DESIGN: We searched Medline, EMBASE and Web of Science for studies comparing the bleach method to direct sputum smear microscopy in low- or middle-income countries. Each study was assessed regarding methodology and field applicability. We also sent out questionnaires concerning the bleach method to key persons in NTPs in 85 countries. RESULTS: In 15 of the 19 studies identified there was a statistically significant improvement in the proportion of positive tests or sensitivity ranging from 7-253%. The majority (73%) of the key persons had heard of the bleach method. Forty-four per cent thought it could improve case detection in their countries, while 49% did not know; 93% of them would promote the bleach method; the most common reasons for doing so would be recommendations from the WHO or the IUATLD, or favourable studies performed in their own country. The bleach method was used routinely in only three countries. CONCLUSION: There is enough evidence to recommend the evaluation and introduction of the bleach method in most settings where mycobacterial culture is not performed routinely.

Do women with tuberculosis have a lower likelihood of getting diagnosed? Prevalence and case detection of sputum smear positive pulmonary TB, a population-based study from Vietnam.

OBJECTIVE: The aim was to estimate the gender-specific prevalence of tuberculosis (TB) through screening. A further aim was to calculate case detection within the Vietnamese National TB program. STUDY DESIGN AND SETTING: A population-based survey of 35,832 adults was performed within an existing sociodemographic longitudinal study in Bavi district, northern Vietnam. Cases were identified by a screening question about prolonged cough and further diagnosed with sputum examination and a chest X-ray. RESULTS: The estimated prevalence of pulmonary TB among men was 90/100,000 (95% CI 45-135/100,000) and among women 110/100,000 (95% CI 63-157/100,000). Case detection in the district was estimated to 39% (95% CI 20-76%) among men and 12% (95% CI 6-26%) among women. CONCLUSION: TB prevalence was similar among men and women. Case detection among men and women was significantly lower than the reported national case detection of 80%, and there was a significant underdetection of female cases. These findings warrant actions, and emphasize the need to perform similar studies in different contexts.

An economic analysis of persons with prolonged cough in rural northern Vietnam.

SETTING: Epidemiological surveillance in the Bavi district, northern Vietnam. OBJECTIVE: To compare the prevalences of prolonged cough across socio-economic groups defined by income, expenditure and official classification. To investigate inequalities using the Illness Concentration Index. DESIGN: Interviews in 11,547 randomly selected households with 35,832 persons aged 15 years or more. Prolonged cough was identified in 559 persons (1.5%). RESULTS: Differences between cough prevalences were found for all socio-economic indicators, but were less clear for expenditure. Lower economic groups reported higher prevalences than higher groups, and prevalences were higher among the elderly. Male was similar to female prevalence. The illness gap between the poor and rich was wider for men. The Illness Concentration Index confirmed these findings. CONCLUSION: Inequalities were found when using both different socio-economic indicators and different analysis approaches.

Knowledge about tuberculosis and its treatment among new pulmonary TB patients in the north and central regions of Vietnam.

SETTING: Tuberculosis (TB) units in 42 districts in north and central Vietnam were included in the study. OBJECTIVES: To describe patients' knowledge of TB and to evaluate the impact of the National Tuberculosis Programme's health education. DESIGN: New pulmonary TB patients who had received TB treatment for a minimum of 1 month were interviewed using a structured questionnaire. RESULTS: A total of 364 patients were interviewed; 93% of respondents reported receiving TB information from the health staff. Apart from health education, many patients reported TB information from the TV. This was more common among men than women (71.4% vs. 51.3%). The average knowledge score was 7.07 +/- 2.02 (maxium 10). This was significantly associated with level of education and receiving health education. More than half of the patients expressed fear of being known as TB patients in the community. CONCLUSIONS: Knowledge about TB and its treatment was generally high. Marginalised groups with limited access to media and low education levels may benefit from specially targeted educational interventions. To reduce stigma and the impact of social consequences of TB, an ongoing health education programme designed to increase the knowledge level in the whole population appears warranted.

Private tuberculosis care provision associated with poor treatment outcome: comparative study of a semi-private lung clinic and the NTP in two urban districts in Ho Chi Minh City, Vietnam. National Tuberculosis Programme.

SETTING: Ho Chi Minh City, Vietnam. OBJECTIVE: To compare tuberculosis case management and treatment outcome between a semi-private chest clinic and a publicly run national tuberculosis programme (NTP). METHOD: Prospective, non-randomised, comparative cohort study. Case-management and treatment outcome was determined for 176 patients treated in the semi-private clinic and 326 patients treated in the NTP. RESULTS: In the semi-private clinic cohort, significantly fewer patients completed treatment and/or were cured than in the NTP cohort (48.9% vs. 85.0%, P < 0.001). Among patients with sputum-positive pulmonary TB, significantly fewer were cured in the semi-private clinic cohort compared to the NTP cohort (22.2% vs. 79.2%, P < 0.001), and treatment success was significantly lower (35.2% vs. 79.7%. P < 0.001). Adjustment for a number of potential confounders did not change these findings significantly. CONCLUSIONS: Treatment outcome was considerably better in the NTP than in the semi-private clinic. The difference is not likely to be due to differences in patient characteristics or in provider knowledge. Different financial incentives for the providers in the two settings and ways of paying for services by patients are possible reasons for the observed difference in the quality of case management and treatment outcome.