The socioeconomic impact of tuberculosis on children and adolescents: a scoping review and conceptual framework.

BACKGROUND: Tuberculosis (TB) has been repeatedly shown to have socioeconomic impacts in both individual-level and ecological studies; however, much less is known about this effect among children and adolescents and the extent to which being affected by TB during childhood and adolescence can have life-course implications. This paper describes the results of the development of a conceptual framework and scoping review to review the evidence on the short- and long-term socioeconomic impact of tuberculosis on children and adolescents. OBJECTIVES: To increase knowledge of the socioeconomic impact of TB on children and adolescents. METHODS: We developed a conceptual framework of the socioeconomic impact of TB on children and adolescents, and used scoping review methods to search for evidence supporting or disproving it. We searched four academic databases from 1 January 1990 to 6 April 2021 and conducted targeted searches of grey literature. We extracted data using a standard form and analysed data thematically. RESULTS: Thirty-six studies (29 qualitative, five quantitative and two mixed methods studies) were included in the review. Overall, the evidence supported the conceptual framework, suggesting a severe socioeconomic impact of TB on children and adolescents through all the postulated pathways. Effects ranged from impoverishment, stigma, and family separation, to effects on nutrition and missed education opportunities. TB did not seem to exert a different socioeconomic impact when directly or indirectly affecting children/adolescents, suggesting that TB can affect this group even when they are not affected by the disease. No study provided sufficient follow-up to observe the long-term socioeconomic effect of TB in this age group. CONCLUSION: The evidence gathered in this review reinforces our understanding of the impact of TB on children and adolescents and highlights the importance of considering effects during the entire life course. Both ad-hoc and sustainable social protection measures and strategies are essential to mitigate the socioeconomic consequences of TB among children and adolescents.

Pertussis epidemiology prior to the introduction of a maternal vaccination program, Queensland Australia.

Pertussis morbidity is highest in infants too young to be fully protected by routine vaccination schedules. Alternate vaccine strategies are required to maximise protection in this age-group. To understand baseline pertussis epidemiology prior to the introduction of the maternal pertussis vaccination program in 2014, we conducted a retrospective case series analyses of 53 901 notifications and temporal trends from 1997 to 2014. Notifications were highest in infants younger than 4 months of age and highest annual notification rates in infants younger than 1 month of age (308/100 000 per year). Amongst Aboriginal and Torres Strait Islander infants aged younger than 1 month, this rate was 576/100 000 per year. Notification rates were 40% higher amongst women 15-44 years, 62·4/100 000 population compared with men (44·5/100 000) and 90% higher in Aboriginal and Torres Strait Islander women of the same age (38·2/100 000) compared with men (19·7/100 000). Six infant deaths were identified, all younger than 2 months of age. Monitoring epidemiology in at-risk groups - infants too young to be vaccinated, women of childbearing age and Aboriginal and Torres Strait Islander peoples - following implementation of the maternal pertussis vaccination program will be important to assess its impact and safety.

Effect of diabetes on tuberculosis presentation and outcomes in Kiribati.

OBJECTIVES: To determine the association between diabetes and the clinical features and treatment outcomes of TB in Kiribati. METHODS: We enrolled consecutive patients with TB who presented from August 2010 to February 2012 and compared clinical features and TB treatment outcomes for patients with and without diabetes, as measured by haemoglobin A1c assay. Poor outcome was defined as death, default or treatment failure, and good outcome as treatment success or cure. RESULTS: Two hundred and seventy-five eligible persons with TB disease were enrolled; 101 (37%) had diabetes. TB patients with diabetes were more likely to have acid-fast bacilli (AFB) seen on sputum smear microscopy (RR: 1.3; 95% CI: 1.03-1.62). The risk of poor outcome did not differ between patients with or without diabetes (RR: 1.1; 95% CI: 0.5-2.7). CONCLUSION: TB patients with diabetes are more likely than those without to have sputum with AFB on microscopy. This could increase transmission in the community. Early detection of TB by screening patients with diabetes, and the converse, could be important public health interventions where diabetes and TB are prevalent.

Tuberculosis and diabetes mellitus in the Republic of Kiribati: a case-control study.

OBJECTIVES: To better inform local management of TB-diabetes collaborative activities, we aimed to determine the prevalence of diabetes among persons with and without TB and to determine the association between TB and diabetes in Kiribati, a Pacific Island nation. METHODS: We compared consecutively enrolled TB cases to a group of randomly selected community controls without evidence of TB. Diabetes was diagnosed by HbA1c, and clinical and demographic data were collected. A tuberculin skin test was administered to controls. The chi-square test was used to assess significance in differences between cases and controls. We also calculated an odds ratio, with 95% confidence intervals, for the odds of diabetes among cases relative to controls. Unweighted multivariate logistic regression was performed to adjust for the effects of age and sex. RESULTS: A total of 275 TB cases and 499 controls were enrolled. The diabetes prevalence in cases (101, 37%) was significantly greater than in controls (94, 19%) (adjusted odds ratio: 2.8; 95% CI 2.0-4.1). Fifty-five percent (108) of all diabetic diagnoses were new; this proportion was higher among controls (64.8%) than cases (46.5%). Five patients with TB were screened to detect one patient with diabetes. CONCLUSIONS: There is a strong association between TB and diabetes in Kiribati and bidirectional screening should be conducted in this setting.

Risk factors for TB in Australia and their association with delayed treatment completion.

BACKGROUND: Australia has a low incidence of TB and has committed to eliminating the disease. Identification of risk factors associated with TB is critical to achieving this goal.METHODS: We undertook a prospective cohort study involving persons receiving TB treatment in four Australian jurisdictions. Risk factors and their association with delayed treatment completion (treatment delayed by at least 1 month) were analysed using univariate analyses and multivariate logistic regression.RESULTS: Baseline surveys were completed for 402 persons with TB. Most (86.1%) were born overseas. Exposure to a person with TB was reported by 19.4%. Diabetes mellitus (10.2%), homelessness (9.2%), cigarette smoking (8.7%), excess alcohol consumption (6.0%) and mental illness (6.2%) were other common risk factors. At follow-up, 24.8% of patients had delayed treatment completion, which was associated with adverse events (34.1%, aOR 6.67, 95% CI 3.36-13.27), excess alcohol consumption (6.0%, aOR 21.94, 95% CI 6.03-79.85) and HIV co-infection (2.7%, aOR 8.10, 95% CI 1.16-56.60).CONCLUSIONS: We identified risk factors for TB and their association with delayed treatment completion, not all of which are routinely collected for surveillance purposes. Recognition of these risk factors should facilitate patient-centred care and assist Australia in reaching TB elimination.

The economic burden of TB faced by patients and affected families in Papua New Guinea.

BACKGROUND The costs associated with TB disease can be catastrophic for patients, affecting health and socioeconomic outcomes. Papua New Guinea (PNG) is a high TB burden country and the costs associated with TB are unknown.METHODS We undertook a national survey of TB patients to determine the magnitude of costs associated with TB in PNG, the proportion of households with catastrophic costs and cost drivers. We used a cluster sampling approach and recruited TB patients from health facilities. Descriptive statistics were used to analyse the costs and cost drivers and multivariate logistic regression to determine factors associated with catastrophic costs.RESULTS We interviewed 1,000 TB patients; 19 (1.9%) of them had multidrug-resistant TB (MDR-TB). Costs due to TB were attributable to income loss (64.4%), non-medical (29.9%) and medical (5.7%) expenses. Catastrophic costs were experienced by 33.9% (95% CI 31.0-36.9) of households and were associated with MDR-TB (aOR 4.47, 95% CI 1.21-16.50), hospitalization (aOR 3.94, 95% CI 2.69-5.77), being in the poorest (aOR 3.52, 95% CI 2.43-5.10) or middle wealth tertiles (aOR 1.51, 95% CI 1.03-2.21) or being employed (aOR 2.02, 95% CI 1.43-2.89).CONCLUSION The costs due to TB disease were catastrophic for one third of TB-affected households in PNG. Current support measures could be continued, while new cost mitigation interventions may be considered where needed.

Depression, stigma and quality of life in people with drug-susceptible TB and drug-resistant TB in Vietnam.

BACKGROUND: Drug resistance poses a major barrier to global control of TB - a leading infectious cause of death. Depression and stigma occur commonly among people with TB. However, the relationship between drug-resistant forms of TB, depression and stigma are not well understood.OBJECTIVE: To compare depression, stigma and health-related quality of life (HRQoL), among people with drug-susceptible TB (DS-TB) and multidrug-resistant TB (MDR-TB).METHODS: A cross-sectional study of people treated for DS-TB and MDR-TB in four provinces of Vietnam. The survey included a stigma scale (Vietnamese Tuberculosis Stigma Scale), depression scale (9-item Patient Health Questionnaire) and HRQoL scale (Functional Assessment of Chronic Illness Therapy - Tuberculosis). Differences between the two populations were compared using linear regression.RESULTS: Eighty-one people with DS-TB and 315 people with MDR-TB participated in the study. People with MDR-TB had a higher prevalence of depression than those with DS-TB (difference 17.8%, χ² 8.64). The mean depression and stigma scores were higher for people with MDR-TB than those with DS-TB (adjusted difference [AD] 8.6 and 7.6 respectively). People with MDR-TB reported lower HRQoL than those with DS-TB (AD -23.8).CONCLUSION: Depression and stigma are common among people with TB in Vietnam. Strategies to prevent and treat depressive symptoms and stigma in people with TB are critical to a holistic, patient-centred approach to care.

Management of postgastric bypass noninsulinoma pancreatogenous hypoglycemia.

INTRODUCTION: Postgastric bypass noninsulinoma hyperinsulinemic pancreatogenous hypoglycemia defines a group of patients with postprandial neuroglycopenic symptoms similar to insulinoma but in many cases more severe. There are few reports of patients with this condition. We describe our surgical experience for the management of this rare condition. METHODS: A retrospective study was performed at St. Vincent Hospital, Indianapolis. Fifteen patients were identified with symptomatic postgastric bypass hypoglycemia for the period 2004-2008. All patients were initially treated with medical therapy for hypoglycemia. Nine patients eventually underwent surgical treatment. The preoperative workup included triple-phase contrast CT scan of the abdomen, endoscopic ultrasound of the pancreas, a 72-h fast followed by a mixed meal test, and calcium-stimulated selective arteriography. Intraoperative pancreatic ultrasound also was performed in all patients. Patients then underwent thorough abdominal exploration, exploration of the entire pancreas, and extended distal pancreatectomy. RESULTS: Nine patients underwent surgery. The mean duration of symptoms was 14 months. The 72-h fast was negative in eight patients (as expected). Triple-phase contrast CT scan of the abdomen was negative in eight patients and showed a cyst in the head of pancreas in one patient. Extended distal (80%) pancreatectomy was performed in all nine patients. The procedure was attempted laparoscopically in eight patients but was converted to open in three. One patient had an open procedure from start to finish. Pathology showed changes compatible with nesidioblastosis with varying degrees of hyperplasia of islets and islet cells. Follow-up ranged from 8-54 (median, 22) months. All patients initially reported marked relief of symptoms. Over time, two patients had complete resolution of symptoms; three patients developed occasional symptoms (once or twice per month), which did not require any medication; two patients developed more frequent symptoms (more than twice per month), which were controlled with medications; and two patients had severe symptoms refractory to medical therapy (calcium channel blockers, diazoxide, octreotide). DISCUSSION: Postprandial hypoglycemia after gastric bypass surgery with endogenous hyperinsulinemia is being increasingly recognized and reported in the literature. Our experience with nine patients is one of the largest. The etiology of this condition is not entirely understood. There may be yet unknown factors involved but increased secretion of glucagon-like peptide 1 and decreased grehlin are being implicated in islet cell hypertrophy. There is no "gold standard" treatment-medical or surgical-but distal pancreatectomy to debulk the hypertrophic islets and islet cells is the main surgical modality in patients with severe symptoms refractory to medical management.

Ethics and benefits of systematic screening for active tuberculosis.

Systematic screening for active tuberculosis (TB) provides public health benefits and is part of the End TB Strategy. However, two of WHO's generic principles for screening for disease state that the natural history of the disease in question must be well understood and that there must be benefits to earlier treatment. TB fulfills the first of these only in part, the other has been less well documented. This paper considers the ethical implications of uncertain individual benefits from screening and the current research gaps.

Nutritional Attributes and Nonvolatile Taste Components of Medicinally Important Wild False Earthstar Mushroom, Astraeus hygrometricus (Agaricomycetes), from India.

Fruiting bodies of Astraeus hygrometricus mushroom grown wild in the forests of Jharkhand, India were investigated for their proximate nutritional composition and taste imparting nonvolatile components. Fruiting bodies contained good amount of total carbohydrates (55.76%), reducing sugars (15.98%), protein (16.02%), and dietary fiber (39.78%) but were low in fat (3.5%), ash (3.8%), and energy (159.5 kcal). Fatty acids were represented by monounsaturated C18:1n9c oleic acid (4.59%) and saturated C16:0 palmitic acid (2.63%). In vitro digestibility of protein is an indicator of its availability to human body and A. hygrometricus has 33.2% in vitro digestibility. Among the minerals found (mg/100 g), potassium (K, 1930.0) was major mineral followed by calcium (Ca, 443.0), magnesium (Mg, 434.0), sodium (Na, 155.0), iron (Fe, 127.0), manganese (Mn, 16.0), and selenium (Se, 1.60). Pro-vitamin D2 (ergosterol) was also determined to be 1.09 mg/g. Analysis of soluble sugars indicated that mannitol (11.22 mg/g) was the major sugar alcohol conferring sweetness to the fruiting bodies. Among total free amino acids (8.20 mg/g), seven essential amino acids (3.9) and eight nonessential amino acids (4.3) were detected. Leucine (0.92) and tyrosine (0.98) were the major essential and nonessential amino acids, respectively. Aspartic (0.61) and glutamic acid (0.63) were also present in AH and responsible for its MSG like taste. Thus, A. hygrometricus is a good source of free essential amino acids and selenium, which is not synthesized by humans. Meaty flavor of the fruiting body of A. hygrometricus was mainly due to umami 5'-guanosine monophosphate (2.43 mg/g). Sweet taste and meaty flavor of the mushroom were due to nonvolatile taste components including soluble sugars and polyols, MSG like aspartic and glutamic acid, and umami 5'-nucleotide. Overall A. hygrometricus proved its edibility as a tasty and nutritional food.

Long-term evaluation of patients undergoing laparoscopic antireflux surgery without bougie placement.

BACKGROUND: Laparoscopic antireflux surgery (LARS) has replaced the open approach in most centers and has become the standard surgical treatment of this disease. One of the controversial technical issues is whether to use a bougie or not at the time of wrap. The aim of the study was to evaluate the long-term consequences of LARS in a series of patients without bougie. METHODS: An institutional review board-approved study was conducted for patients who underwent LARS between 1998 and 2005. Patients were contacted and an SF-12 form was completed. Their charts were reviewed. Patient characteristics, preoperative evaluation, intraoperative details, and postoperative course were studied. RESULTS: Overall, 135 patients were identified who underwent LARS from 1998 to 2005 with no bougie. Only 123 patients could be contacted for the study. Preoperative work-up included EGD in 100%, manometry in 98%, and 24-hour pH study in 25% of patients. Postoperative dysphagia to solids was seen in 11 of 123 (8.9%) patients. One patient (<1%) had dysphagia to liquids. Five patients (4%) had severe dysphagia. EGD and dilatation was required in 5 of 123 (4%) patients. Ten patients (8.1%) had recurrent reflux requiring medication. Also, 4 of 123 (3.2%) patients had bloating symptoms and 2 of 123 (1.6%) patients had difficulty vomiting. The mean follow-up of patients was 38.6 months. CONCLUSIONS: The overall rate of dysphagia in this series following LARS without bougie was 8.9%. Mild to moderate dysphagia was seen in 6 of 123 (4.8%) and 4% patients had severe dysphagia requiring dilatation. Endoscopic dilatation was successful in relieving symptoms in patients with severe dysphagia. The incidence of severe dysphagia reported in the literature is 2-5% and recurrent reflux 5-15%. Rate of dysphagia was comparable to other series reported in the literature, as was the rate of recurrent reflux. Based on our series of patients, LARS without bougie appears to be effective in terms of postoperative dysphagia and recurrent reflux.

Tuberculosis and diabetes mellitus: a dose-response relationship between the odds of tuberculosis and HbA1c.

SETTING: The main hospital tuberculosis (TB) clinic in South Tarawa, the capital of the Republic of Kiribati, a Pacific nation located in the central Pacific Ocean.OBJECTIVE: To determine if higher levels of HbA1c were associated with greater odds of TB.DESIGN: A case-control study to assess the association between TB and diabetes (DM). We recruited 275 TB cases and 498 controls (persons without signs and symptoms of TB), aged 18 years and above. A standardised questionnaire was administered and HbA1c was measured in all participants.RESULTS: The median HbA1c among cases was 6.0%; among controls it was 5.6% (P < 0.001). Comparing cases to controls, the odds ratio for TB was 2.8 (95%CI 2.0-4.1). Adjusted odds ratios for TB associated with HbA1c groupings of 5.7-6.4%, 6.5-8.5% and >8.5% were 1.5, 2.7 and 4.3, respectively (P ≦ 0.001 for trend).CONCLUSIONS: The median HbA1c was higher among TB patients than controls. As the HbA1c rose so did the odds of TB. This demonstrates the importance of targeted TB screening of people with DM in TB-endemic settings. Optimal glycaemic control is also crucial as this reduces DM-related end organ damage and may also reduce TB risk.

Four of five tuberculosis patients experience catastrophic costs related to TB diagnosis and care in Timor-Leste.

SETTING: Seventeen health care facilities that report to the national tuberculosis (TB) programme in Timor-Leste. Participants were TB patients.OBJECTIVE: To determine the proportion of TB patients who experienced catastrophic costs due to their TB diagnosis and care, and the magnitude and composition of these costs.DESIGN: This was a cross-sectional health facility-based survey, conducted in 17 DOTS centres between October 2016 and March 2017. TB patients were interviewed by trained nurses using a standardised questionnaire.RESULTS: Among the 457 TB patients who participated (response rate 96.6%), the median age was 32 years; 39.2% were from the capital, Dili. The patient was the main income earner in 26.3% of households. Annual individual and household incomes before and after TB diagnosis decreased by respectively 30.4% and 31.1%. Using a cut-off of 20% of annual household income, 83.0% of patients experienced catastrophic costs related to their TB diagnosis and care. Income loss and nutritional supplementation accounted for respectively 40.7% and 37.9% of these costs.CONCLUSION: Four of five TB patients in Timor-Leste experienced catastrophic costs related to TB diagnosis and care. Financial and social protection to mitigate against these costs are urgently needed, in addition to universal health coverage.

Measuring the economic burden for TB patients in the End TB Strategy and Universal Health Coverage frameworks.

Tuberculosis (TB) is a disease of poverty. Ensuring access to health care without the risk of financial hardship due to out-of-pocket health care expenditures (Universal Health Coverage [UHC]) is essential for providing accessible care to underprivileged populations, but this is not enough. The End TB Strategy promotes both patient-centred TB services and social protection measures, which aim to mitigate the economic hardship faced by TB patients and their households due to direct medical and non-medical expenditures, as well as to lost income. The strategy includes a target that no families should face catastrophic total costs due to TB. The indicator linked to this target aims to capture the total economic burden linked to TB care, and thus differs from the 'catastrophic expenditure on health' indicator, a key component of the UHC monitoring framework aligned with the Sustainable Development Goals. Countries, and particularly high TB burden countries, are expected to conduct nationally representative TB patient cost surveys to establish baseline measurements for the catastrophic costs indicator. Findings from these surveys should also help identify entry points for developing policies to ensure better financial and social protection for TB patients. In this paper, we define the key measurable concepts for TB patient cost surveys, notably the types of costs that are captured, and related affordability measures. We discuss methods for measuring these notions in the UHC framework and contrast them with how they are measured in TB patient cost surveys.

Pancreatic neuroendocrine microadenomatosis presenting as a functional VIPoma.

Pancreatic microadenomas are benign tumors of neuroendocrine origin less than 5 mm in size. Whereas most microadenomas are non-functional; a few rare functional pancreatic microadenomas have been described in the setting of multiple endocrine neoplasia type one (MEN-1). In this report, we describe a unique case of multiple functional microadenomas of the pancreatic head in a patient who presented with persistent secretory diarrhea, refractory hypokalemia, metabolic acidosis and elevated plasma vasoactive intestinal peptide (VIP) levels. Following extensive serologic, radiographic and endoscopic work up, our patient underwent open pancreaticoduodenectomy with subsequent resolution of diarrheal symptoms and electrolyte abnormalities on postoperative follow up.

Resection of a mature cystic teratoma of the liver harboring a carcinoid tumor.

Cystic teratomas are rare pluripotent embryonic tumors which most commonly originate in gonadal organs. Extra-gonadal cystic teratomas are exceedingly uncommon, accounting for only 1% of all cystic teratomas, and have been reported in unusual locations including the kidney, mediastinum and liver. These extra-ovarian cystic teratomas have also been known to harbor other neoplasms including carcinoid tumors. In this report, we describe a unique case of a hepatic cystic teratoma occurring as a combined tumor with a carcinoid in a young female. The patient underwent elective laparoscopic resection of her tumor after extensive radiographic and endoscopic work-up for chronic, non-localizable abdominal pain. We believe the carcinoid tumor arose de novofrom committed differentiation of a cell line within the teratoma, and not metastatic spread.

Research ethics committees in the Pacific Islands: gaps and opportunities for health sector strengthening.

There has been a range of developments in recent years to stimulate increasing public health research activity throughout the Pacific. Development of local capacity for ethics committee review and oversight is, however, frequently underdeveloped. This is reflected in the number of Pacific Island nations where ethics committees have not been established or where only informal processes exist for ethics review and oversight. This is problematic for the optimal development of relevant and culturally appropriate research, and building up local ethics committees should be part of continued research development in the Pacific. Three areas in which local ethics committees may add value are 1) offering better capacity to reflect local priorities, 2) providing broader benefits for research capacity building, and 3) assisting to strengthen systems beyond research ethics. This article considers benefits and challenges for ethics committees in the Pacific, and suggests directions for regional development to further strengthen public health research activity.

Il y a eu toute une gamme de développements au cours des dernières années visant à stimuler un accroissement des activités de recherche en santé publique à travers la région Pacifique. Cependant, le renforcement des capacités locales de révision et de surveillance par les comités d'éthique est fréquemment sous-développé. Ceci est reflété par le nombre de nations insulaires du Pacifique où aucun comité d'éthique n'a été mis en place ou seules des procédures informelles de revue et de surveillance existent. Ceci pose un problème pour le bon développement d'une recherche pertinente et culturellement appropriée ; la mise en place de comités d'éthique locaux devrait faire partie du développement continu de la recherche dans le Pacifique. Trois domaines dans lesquels les comités d'éthique locaux pourraient avoir une valeur ajoutée sont 1) offrir une meilleure capacité de refléter les priorités locales, 2) apporter des bénéfices plus grands pour le renforcement des capacités de recherche, et 3) contribuer à renforcer les systèmes au-delà de l'éthique de la recherche. Cet article envisage les bénéfices et les défis des comités d'éthique dans le Pacifique et suggère des orientations pour le développement régional afin de développer davantage les activités de recherche en santé publique.

En los últimos años se ha observado una diversidad de progresos que estimulan las actividades de investigación en salud pública en toda la región del Pacífico. Sin embargo, la creación de competencias locales en materia de comités de ética y supervisión suele ser deficiente. Esta situación se refleja en el número de estados insulares del Pacífico que aun no cuentan con comités de ética o donde se practica solo un proceso informal de examen de los aspectos éticos y de supervisión de los estudios clínicos. Estas circunstancias representan un obstáculo al desarrollo óptimo de una investigación pertinente y culturalmente apropiada; la creación de comités de ética debe formar parte del desarrollo continuo de la investigación en el Pacífico. Estos comités aportarían ventajas en tres esferas principales, a saber: 1) una mayor capacidad de responder a las prioridades locales; 2) la ampliación de las ventajas que ofrece el fortalecimiento de la capacidad de realizar investigaciones; y 3) el mejoramiento de los sistemas de salud, más allá del terreno de la ética de la investigación. En el presente artículo se examinan las ventajas y las dificultades que presentan los comités de ética en la región del Pacífico y se proponen orientaciones para el desarrollo regional que promuevan la actividad de investigación en salud pública.