Evaluation of the rapid scale-up of collaborative TB/HIV activities in TB facilities in Rwanda, 2005-2009.

BACKGROUND: In 2005, Rwanda drafted a national TB/HIV policy and began scaling-up collaborative TB/HIV activities. Prior to the scale-up, we evaluated existing TB/HIV practices, possible barriers to policy and programmatic implementation, and patient treatment outcomes. We then used our evaluation data as a baseline for evaluating the national scale-up of collaborative TB/HIV activities from 2005 through 2009. METHODS: Our baseline evaluation included a cross-sectional evaluation of 23/161 TB clinics. We conducted structured interviews with patients and clinic staff and reviewed TB registers and patient records to assess HIV testing practices, provision of HIV care and treatment for people with TB that tested positive for HIV, and patients' TB treatment outcomes. Following our baseline evaluation, we used nationally representative TB/HIV surveillance data to monitor the scale-up of collaborative TB/HIV activities RESULTS: Of 207 patients interviewed, 76% were offered HIV testing, 99% accepted, and 49% reported positive test results. Of 40 staff interviewed, 68% reported offering HIV testing to >50% of patients. From 2005-2009, scaled-up TB/HIV activities resulted in increased HIV testing of patients with TB (69% to 97%) and provision of cotrimoxazole (15% to 92%) and antiretroviral therapy (13% to 49%) for patients with TB disease and HIV infection (TB/HIV). The risk of death among patients with TB/HIV relative to patients with TB not infected with HIV declined from 2005 (RR = 6.1, 95%CI 2.6, 14.0) to 2007 (RR = 1.8, 95%CI 1.68, 1.94). CONCLUSIONS: Our baseline evaluation highlighted that staff and patients were receptive to HIV testing. However, expanded access to testing, care, and treatment was needed based on the proportion of patients with TB having unknown HIV status and the high rate of HIV infection and poorer TB treatment outcomes for patients with TB/HIV. Following our evaluation, scale-up of TB/HIV services resulted in almost all patients with TB knowing their HIV status. Scale-up also resulted in dramatic increases in the uptake of lifesaving HIV care and treatment coinciding with a decline in the risk of death among patients with TB/HIV.

Tuberculosis transmission and use of methamphetamines in Snohomish County, WA, 1991-2006.

OBJECTIVES: We investigated a cluster of tuberculosis (TB) cases among persons using methamphetamines in Snohomish County, Washington, to determine the extent of the outbreak, examine whether methamphetamine use contributed to TB transmission, and implement strategies to prevent further infections. METHODS: We screened contacts to find and treat persons with TB disease or infection. We then formed a multidisciplinary team to engage substance abuse services partners and implement outreach strategies including novel methods for finding contacts and a system of incentives and enablers to promote finding, screening, and treating patients with TB and their infected contacts. RESULTS: We diagnosed and completed treatment with 10 persons with TB disease. Eight of 9 adult patients and 67% of their adult contacts reported using methamphetamines. Of the 372 contacts, 319 (85.8%) were screened, 80 (25.1%) were infected, 71 (88.8%) started treatment for latent infection, and 57 (80.3%) completed treatment for latent infection. CONCLUSIONS: Collaborative approaches integrating TB control, outreach, incentives, and enablers resulted in high rates of treatment adherence and completion among patients and infected contacts. TB control programs should collaborate with substance abuse programs to address addiction, overcome substance abuse-related barriers to treatment, treat TB, and prevent ongoing transmission.

Towards a more comprehensive understanding of cancer burden in North Carolina: priorities for intervention.

OBJECTIVE: To apply 4 measures of population burden in examining cancer burden in North Carolina and to identify priorities for intervention. METHODS: Four measures were used: incidence, mortality, prevalence, and years of potential life lost (YPLL). The North Carolina Central Cancer Registry provided summary data on incidence and mortality and record-level data that were examined using SEER*Stat software to calculate prevalence. North Carolina vital statistics (mortality) data and life expectancy estimates stratified by age, race, and sex were used to calculate YPLL. Each cancer site was ranked according to burden for each of the 4 individual burden measures and summarized into an overall rank. Burden was examined overall and by sex and race. PRINCIPAL FINDINGS: Four cancers--lung/bronchus, female breast, prostate, and colon/rectum--accounted for approximately 57% of the total cancer incidence, prevalence, mortality, and YPLL in North Carolina. Patterns of burden in gender and race subgroups were similar, although non-whites often had higher mortality rates than did whites despite similar incidence rates. An estimated 207,583 people were living with cancer in 2004 Breast and prostate cancer accounted for 42% of these survivors. Lung/bronchus cancer was the most severe cancer, accounting for more deaths and years of life lost than any other 5 cancers combined. CONCLUSIONS: Each of the 4 measures provides unique insight and guidance for cancer coordination and control efforts. Lung/bronchus, female breast, prostate, and colon/rectum cancers accounted for the majority of North Carolina's cancer burden and should be priorities for intervention.

Programmatic Evaluation of an Algorithm for Intensified Tuberculosis Case Finding and Isoniazid Preventive Therapy for People Living With HIV in Thailand and Vietnam.

BACKGROUND: Tuberculosis (TB) screening affords clinicians the opportunity to diagnose or exclude TB disease and initiate isoniazid preventive therapy (IPT) for people living with HIV (PLHIV). METHODS: We implemented an algorithm to diagnose or rule out TB among PLHIV in 11 HIV clinics in Thailand and Vietnam. We assessed algorithm yield and uptake of IPT and factors associated with TB disease among PLHIV. RESULTS: A total of 1448 PLHIV not yet on antiretroviral therapy (ART) were enrolled and screened for TB. Overall, 634 (44%) screened positive and 119 (8%) were diagnosed with TB; of these, 40% (48/119) were diagnosed by a positive culture following a negative sputum smear microscopy. In total, 55% of those eligible (263/477) started on IPT and of those, 75% (196/263) completed therapy. The prevalence of TB disease we observed in this study was 8.2% (8218 per 100,000 persons): 46 and 25 times the prevalence of TB in the general population in Thailand and Vietnam, respectively. Several factors were independently associated with TB disease including being underweight [aOR (95% CI): 2.3 (1.2 to 2.6)] and using injection drugs [aOR (95% CI): 2.9 (1.3 to 6.3)]. CONCLUSIONS: The high yield of TB disease diagnosed among PLHIV screened with the algorithm, and higher burden among PLHIV who inject drugs, underscores the need for innovative, tailored approaches to TB screening and prevention. As countries adopt test-and-start for antiretroviral therapy, TB screening, sensitive TB diagnostics, and IPT should be included in differentiated-care models for HIV to improve diagnosis and prevention of TB among PLHIV.

The North Carolina Youth Empowerment Study (NCYES): a participatory research study examining the impact of youth empowerment for tobacco use prevention.

This article describes the North Carolina Youth Empowerment Study (NC YES), a 3-year participatory evaluation of youth programs addressing tobacco use prevention. The study goals of NC YES were to (1) convene an advisory board comprised of lay youths and adults in a participatory research process, (2) document the characteristics of youth programs for tobacco use prevention and control in North Carolina, and (3) track the role of youth involvement in initiating and implementing 100% tobacco-free policies in local school districts. The NC YES Statewide Advisory Board helped guide the evaluation process, reviewed study protocols and data collection instruments, and helped interpret preliminary findings. Both quantitative and qualitative methods(e.g., telephone interviews and written questionnaires) were used to gather data from youth and adult leaders to achieve these aims. Lessons learned about the process of conducting participatory evaluation approaches and summary findings about the role of youths in policy advocacy efforts are presented.

Correlates of bidi use among youth.

OBJECTIVES: To identify characteristics associated with youth bidi use. METHODS: The New Jersey Youth Tobacco Survey is a self-administered school-based survey that uses a 2-stage cluster sample design to obtain a representative statewide sample; 9589 students (grades 7-12) participated. Logistic regression was used to generate an adjusted odds ratio (OR) for current bidi use for each variable, controlling for gender, race, and school grade. RESULTS: Higher odds for current bidi use were noted for black and Hispanic students, users of other tobacco products, and students that perceived bidis as safer than cigarettes. CONCLUSIONS: These results suggest specific groups that should be targeted for intervention.

Tuberculosis and substance abuse in the United States, 1997-2006.

BACKGROUND: Tuberculosis (TB) control efforts are often ineffective in controlling TB among patients who use illicit drugs or abuse alcohol (substance abuse). This study examined the prevalence of substance abuse among TB cases reported in the United States and assessed the relation between substance abuse and indicators of TB transmission. METHODS: A cross-sectional analysis was performed of data on US TB cases in patients 15 years or older reported from 1997 through 2006. Analyses included number and proportion of patients with TB characterized by substance abuse and associations between substance abuse, sputum smear status, treatment failure, and inclusion in a county-level genotype cluster. RESULTS: Of 153,268 patients with TB, 28,650 (18.7%) reported substance abuse, including 22,293 of 76,816 US-born patients (29.0%). Multivariate analysis showed that, among patients negative for human immunodeficiency virus, odds of sputum smear-positive disease were 1.8 (99% confidence interval [CI], 1.7-1.9) times greater among those who reported substance abuse; this association was weaker among patients with human immunodeficiency virus infection (odds ratio [OR], 1.2; 99% CI, 1.1-1.4). Among female patients, odds of treatment failure were 2.4 (99% CI, 1.9-3.0) times greater among those who reported substance abuse. The association was weaker among male patients (OR, 1.5; 99% CI, 1.3-1.7). Patients who abused substances were more likely to be involved in a county-level genotype cluster (US-born: OR, 2.3; 99% CI, 2.0-2.7; foreign-born: 1.5; 1.2-2.0). CONCLUSIONS: Substance abuse is the most commonly reported behavioral risk factor among patients with TB in the United States. Patients who abuse substances are more contagious (eg, smear positive) and remain contagious longer because treatment failure presumably extends periods of infectiousness. Increased transmission is consistent with our finding that patients who abuse substances were more likely to be involved in a localized genotype cluster, which can represent recent transmission.

Bidi cigarette use among young adults in 15 states.

BACKGROUND: There is a paucity of research on bidi use in the US and the few studies conducted have focused solely on adolescents. This article describes patterns and explores factors associated with bidi use among young adults, aged 18-24. METHODS: Data from 63,728 adults, including 5,324 young adults, aged 18-24, were derived from an optional tobacco module on the 2001 Behavioral Risk Factor Surveillance System, administered by 15 states. Logistic regression was utilized to examine factors associated with ever and current bidi use among young adults. RESULTS: Nearly two thirds of adults who reported current bidi use were under the age of 25; 16.5% of young adults reported ever use and 1.4% reported current bidi use. Among young adults, higher rates of ever and current bidi use were noted for males, blacks, and current cigarette smokers. CONCLUSIONS: The rates of ever bidi use among young adults may reflect experimentation with bidis during adolescence and raises questions about whether bidis may act as a gateway product to regular cigarette use. The disparities among certain subgroups are noteworthy and deserve further exploration. Tobacco prevention and control programs should address all forms of tobacco use and be cognizant of emerging products.