Tuberculosis culture testing at a tertiary care hospital: options for improved management and use for treatment decisions.

SETTING: Chris Hani Baragwanath Hospital, a tertiary care hospital in Johannesburg, South Africa. OBJECTIVES: To determine the proportion of patients with positive Mycobacterium tuberculosis cultures and whether those who were positive were on treatment. DESIGN: Tuberculosis (TB) culture results were obtained from the laboratory for a 3-month period. Positive results were checked against registrations at the hospital TB Care Centre (TBCC). The treatment status of non-registered patients was obtained from various records at the hospital, district clinics and from home visits. RESULTS: Overall, 3909 patients had 5404 samples sent for culture. Of these, 708 patients (18%) had at least one positive culture. The positive yield from 2749 adult sputum samples was 33% and ranged from 6% to 40% for different extra-pulmonary specimens. Among 1160 children, the yield varied from 0% to 12%, with 12% in sputum and gastric washing specimens. Of the 708 culture-positive patients, 429 (61%) patients were registered at the TBCC and were known to have started TB treatment. Of the 279 subjects not registered (39% overall), 100 (36%) died. Only 67 of the 179 survivors were confirmed on treatment, 40 were not on treatment and 72 could not be traced. CONCLUSIONS: Large numbers of TB culture tests were performed, some inappropriately. Study findings highlight inadequacies in the management of culture-confirmed TB at this hospital.

Hyperinsulinism in short-chain L-3-hydroxyacyl-CoA dehydrogenase deficiency reveals the importance of beta-oxidation in insulin secretion.

A female infant of nonconsanguineous Indian parents presented at 4 months with a hypoglycemic convulsion. Further episodes of hypoketotic hypoglycemia were associated with inappropriately elevated plasma insulin concentrations. However, unlike other children with hyperinsulinism, this patient had a persistently elevated blood spot hydroxybutyrylcarnitine concentration when fed, as well as when fasted. Measurement of the activity of L-3-hydroxyacyl-CoA dehydrogenase in cultured skin fibroblasts with acetoacetyl-CoA substrate showed reduced activity. In fibroblast mitochondria, the activity was less than 5% that of controls. Sequencing of the short-chain L-3-hydroxyacyl-CoA dehydrogenase (SCHAD) genomic DNA from the fibroblasts showed a homozygous mutation (C773T) changing proline to leucine at amino acid 258. Analysis of blood from the parents showed they were heterozygous for this mutation. Western blot studies showed undetectable levels of immunoreactive SCHAD protein in the child's fibroblasts. Expression studies showed that the P258L enzyme had no catalytic activity. We conclude that C773T is a disease-causing SCHAD mutation. This is the first defect in fatty acid beta-oxidation that has been associated with hyperinsulinism and raises interesting questions about the ways in which changes in fatty acid and ketone body metabolism modulate insulin secretion by the beta cell. The patient's hyperinsulinism was easily controlled with diazoxide and chlorothiazide.

Tuberculosis at Chris Hani Baragwanath Hospital: an intervention to improve patient referrals to district clinics.

SETTING: A study in 2001 described the process of managing tuberculosis (TB) at Chris Hani Baragwanath hospital, the numbers of patients diagnosed and poor outcomes of referring patients to clinics in the adjacent sub-districts. The present study describes and evaluates an intervention to address the problems. OBJECTIVES: To describe the intervention process (education and referral of TB patients) and the subsequent results over a 2-year period from 2003 to 2005. METHODS: The process of establishing the system and how it was evaluated at district clinics in Johannesburg are described. RESULTS: In the first 2 years of operation, August 2003 to July 2005, 13,138 patients were registered. Extra-pulmonary tuberculosis (EPTB) was diagnosed in 34%. Of the 46% tested for human immunodeficiency virus (HIV), 93% were positive. Successful referral to clinics was achieved for 94% of patients. CONCLUSIONS: Very large numbers of patients are diagnosed with TB at Chris Hani Baragwanath Hospital. A TB care centre has successfully addressed important referral, education and registration requirements for the comprehensive management of TB with links to clinics. It is suggested that this model be applied at other hospitals.

Tuberculosis at Chris Hani Baragwanath Hospital: numbers of patients diagnosed and outcomes of referrals to district clinics.

SETTING: Chris Hani Baragwanath Hospital, in Johannesburg. South Africa is experiencing a serious epidemic of tuberculosis (TB), with a measured rate of 500 cases per 100,000 population. Patients in public hospitals are referred for treatment to district clinics or to specific TB hospitals. OBJECTIVES: To measure numbers of patients diagnosed with TB, and to describe the type of disease and referral outcomes. METHODS: A descriptive study of patients diagnosed with TB in a tertiary hospital. Data in patient files were collected for medical and paediatric patients, and patients were interviewed by researchers who visited clinics to check if referred patients had attended. RESULTS: In the 8-week study period, 1291 patients were diagnosed with TB: 74% had pulmonary disease and 80% of those tested for HIV were positive; 19% died in hospital, and 21% required transfer to a TB hospital. Only half of the patients referred to clinics attended within 2 weeks. CONCLUSIONS: Patients with advanced TB are commonly seen at this hospital. Notifications were an inadequate record and an unacceptable proportion of patients were lost between hospital and clinics. This study has recommended that opportunities for education and discussion must be provided if patients are to reach clinics successfully.

Effect of increased ART-CPT uptake on tuberculosis outcomes and associated factors, Burundi, 2009-2013.

We retrospectively examined 3579 records of human immunodeficiency virus infected tuberculosis (TB) patients diagnosed from January 2009 to June 2013 in 55 TB treatment facilities in Burundi, to demonstrate whether improvement of combined cotrimoxazole preventive therapy and antiretroviral therapy (ART) uptake was accompanied by improvement of treatment outcomes, and to describe associated factors. Treatment success rates increased from 71% to 80% (P < 0.001). While loss to follow-up and transfer-out rates declined significantly, death rates decreased modestly, and remained high, at 14%. ART uptake was worse in suburban areas and private for-profit institutions. World Health Organization targets could be achieved if peripheral health facilities were prioritised.

Une étude rétrospective conduite de janvier 2009 à juin 2013 au Burundi chez 3579 patients co-infectées par la tuberculose (TB) et le virus de l'immunodéficience humaine dans 55 centres de diagnostic et de traitement de la TB, décrit l'évolution des résultats de traitement antirétroviral (ART) et cotrimoxazole et apprécie les facteurs liés à l'ART. La proportion des succès au traitement a augmenté de 71% à 80% (P < 0,001). Tandis que les taux de perdus de vue et de transferts ont baissé significativement, celui des décès n'a baissé que modestement, tout en restant élevée, à 14%. La couverture en ART est plus faible dans les centres de santé périphériques et dans ceux relevant du privé non lucratif. Les objectifs de l'Organisation Mondiale de la Santé pourraient être atteints si les districts sanitaires ruraux étaient inclus dans la fourniture des soins.

En el presente estudio se analizaron 3579 registros de pacientes aquejados de coinfección por el virus de la inmunodeficiencia humana (VIH) y la tuberculosis (TB) en Burundi de enero del 2009 a junio del 2013, provenientes de 55 establecimientos de tratamiento de la TB, con el objeto de investigar si al aumentar la aceptación del tratamiento preventivo con cotrimoxazol en asociación con el tratamiento antirretrovírico (ART) se mejoraban los desenlaces terapéuticos y también se describieron los factores que se asociaban con esta situación. Las tasas de éxito terapéutico aumentaron de un 71% a un 80% (P < 0,001). Aunque las tasas de pérdida durante el seguimiento y de remisión a otros establecimientos disminuyeron de manera significativa, la disminución de las tasas de mortalidad fue leve y permanecieron en un nivel alto de 14%. La aceptación del ART fue más deficiente en las zonas suburbanas y en los establecimientos privados con ánimo de lucro. Sería posible cumplir con las metas de la Organización Mundial de la Salud si se da prioridad a los establecimientos sanitarios periféricos.

Tuberculosis patient care decentralised to district clinics with community-based directly observed treatment in a rural district of South Africa.

SETTING: A rural district of the Northern Province, South Africa. OBJECTIVES: To measure the effect of decentralisation of a tuberculosis service in a rural area on treatment outcomes. DESIGN: An intervention study that measured treatment outcomes of patients attending district clinics for tuberculosis treatment and compared these with outcomes of patients attending the district hospital. RESULTS: Over the 4-year period 1992-1995, 928 patients were admitted to the tuberculosis unit of the district hospital. In the initial pre-intervention phase, the best estimate of completed treatment for all 503 cases was 61%, and for 206 new smear-positive patients it was 67%. The intervention process established a tuberculosis control programme with directly observed treatment for all patients, and training and supervision of clinic staff. Ninety per cent of all patients had community-based supporters. For most patients, cure was not proven, but assuming success from completion of and proven adherence to treatment, successful outcomes for new smear-positive cases rose to 82% for decentralised (clinic) treatment, and 88% for those patients who lived in the district but attended the hospital for treatment. CONCLUSIONS: These findings suggest that district clinics can achieve the same good results as the hospital. It is recommended that tuberculosis control needs a dedicated co-ordinator at district level to manage the necessary infrastructural and staff resources.

Cause of death of patients on treatment for tuberculosis: a study in a rural South African hospital.

SETTING: Tintswalo Hospital, a rural district hospital in South Africa. OBJECTIVES: To assess the quality of data relating to deaths from tuberculosis; to determine the actual cause of death of patients who die whilst on tuberculosis treatment. DESIGN: A descriptive study of all patients who were treated for tuberculosis between January 1992 and June 1996, and who died during their course of treatment. A review of records, X-rays and death certificates of patients whose cause of death was recorded as tuberculosis. Verbal autopsies were done for patients who died at home. Deaths were classified into one of five categories: definitely, likely or possibly due to tuberculosis, unlikely or not due to tuberculosis, based on criteria such as bacteriological confirmation of tuberculosis and the presence of other illnesses. RESULTS: There were 927 cases of tuberculosis and 80 deaths recorded as due to tuberculosis. Valid criteria or detailed information were available for only 68 patients. Only 56% of deaths were confirmed or likely to be due to tuberculosis, and 12% of patients probably did not have tuberculosis at all. The remaining 32% had tuberculosis but died of other illnesses. CONCLUSIONS: The recorded tuberculosis mortality data were clearly inaccurate. There is a need to improve tuberculosis diagnosis, documentation on death certificates, and tracing of treatment interrupters in order to determine whether or not they have died.

Patients' beliefs: do they affect tuberculosis control? A study in a rural district of South Africa.

SETTING: A rural district of South Africa. OBJECTIVES: To describe the beliefs and experiences about tuberculosis of patients and community members and to suggest how these affect presentation to health services and treatment adherence. DESIGN: A descriptive study using structured interviews with individual patients, and focus group interviews with patients and community groups. RESULTS: There is a strong belief in this community that tuberculosis is the result of breaking cultural rules that demand abstinence from sex after the death of a family member and after a woman has a spontaneous abortion. People believe that the resulting disease can only be treated by traditional healers. This delays presentation to hospitals or clinics. There is also a belief in a 'western' type TB that can spread from sufferers or is due to environmental pollution or to smoking or alcohol excesses. A number of factors were cited that influenced adherence to treatment. These included the stigma of TB, the belief that there should be abstinence from sex while on treatment, difficulties accessing health services, long waits and unacceptable health worker attitudes. CONCLUSIONS: With the increasing rates of tuberculosis in South Africa, strenuous measures are needed to implement a good control programme that will increase the cure rate of tuberculosis patients. The results of this study suggest the need for health workers to learn about local beliefs that may influence presentation and adherence, and for traditional and western health workers to collaborate.

Human T cell leukaemia/lymphoma virus infection in pregnant women in the United Kingdom: population study.

OBJECTIVE: To assess the prevalence of human T cell leukaemia/lymphoma virus (HTLV) infection in pregnant women in the United Kingdom. DESIGN: Population study. SUBJECTS: Guthrie card samples from babies born in 1997-8. Samples were linked to data on mother's age and ethnic status and parents' country of birth and then anonymised. SETTING: North Thames Regional Health Authority. MAIN OUTCOME MEASURES: Presence of antibodies against HTLV in eluates tested by gelatin particle agglutination assay and results confirmed by immunoblot. RESULTS: Of 126 010 samples tested, 67 had confirmed antibodies to HTLV (59 HTLV-I, 2 HTLV-II, 6 untyped) and six had indeterminate results. Seroprevalence was 17.0 per 1000 (95% confidence interval 9.2 to 28.3) in infants whose mothers were born in the Caribbean, 3.2/1000 (1.5 to 5.9) with mothers born in west and central Africa, and 6.8/1000 (3.1 to 12.9) in infants of black Caribbean mothers born in non-endemic regions. In infants with no known risk (both parents born in non-endemic regions and mother not black Caribbean) seroprevalence was 0.06-0.12 per 1000. Mother's country of birth, father's country of birth, and mother's ethnic status were all independently associated with neonatal seroprevalence. An estimated 223 (95% confidence interval 110 to 350) of the 720 000 pregnant women each year in the United Kingdom are infected with HTLV. CONCLUSIONS: The prevalence of HTLV and HIV infections in pregnant women in the United Kingdom are comparable. The cost effectiveness of antenatal HTLV screening should be evaluated, and screening of blood donations should be considered.

Attitudes towards involuntary incarceration for tuberculosis: a survey of Union members.

BACKGROUND: Policies involving the use of involuntary incarceration for tuberculosis (TB) are highly ethically controversial. To encourage ethical reflection within the International Union Against Tuberculosis and Lung Disease (The Union), the Ethics Advisory Group (EAG) surveyed members regarding their attitudes and values relating to involuntary incarceration for TB. METHODS: Members of the Union TB section were invited to respond to an anonymous web-based survey. The survey included both multiple choice questions describing a range of scenarios regarding involuntary incarceration, and free-text fields inviting respondents to provide general comments on ethical issues. RESULTS: The survey was completed by 194 participants, 33 (17%) of whom were opposed to involuntary incarceration on principle. The age and sex of the respondents was not associated with likelihood of principled opposition; respondents from North America were least likely to be opposed to involuntary incarceration (P = 0.02). Respondents were most likely to consider involuntary incarceration for persons with known multidrug-resistant TB or a history of previous treatment default, and least likely where people lived alone, were university-educated or the main income provider for their families. CONCLUSION: This survey found a wide range of viewpoints regarding involuntary incarceration, and highlights a number of key elements in ethical engagement with the tensions surrounding involuntary incarceration. We provide commentary on approaches to ethical policy making in the light of these findings.

Beneficial effect of isoniazid preventive therapy and antiretroviral therapy on the incidence of tuberculosis in people living with HIV in Ethiopia.

BACKGROUND: IPT with or without concomitant administration of ART is a proven intervention to prevent tuberculosis among PLHIV. However, there are few data on the routine implementation of this intervention and its effectiveness in settings with limited resources. OBJECTIVES: To measure the level of uptake and effectiveness of IPT in reducing tuberculosis incidence in a cohort of PLHIV enrolled into HIV care between 2007 and 2010 in five hospitals in southern Ethiopia. METHODS: A retrospective cohort analysis of electronic patient database was done. The independent effects of no intervention, "IPT-only," "IPT-before-ART," "IPT-and-ART started simultaneously," "ART-only," and "IPT-after-ART" on TB incidence were measured. Cox-proportional hazards regression was used to assess association of treatment categories with TB incidence. RESULTS: Of 7,097 patients, 867 were excluded because they were transferred-in; a further 823 (12%) were excluded from the study because they were either identified to have TB through screening (292 patients) or were on TB treatment (531). Among the remaining 5,407 patients observed, IPT had been initiated for 39% of eligible patients. Children, male sex, advanced disease, and those in Pre-ART were less likely to be initiated on IPT. The overall TB incidence was 2.6 per 100 person-years. As compared to those with no intervention, use of "IPT-only" (aHR = 0.36, 95% CI = 0.19-0.66) and "ART-only" (aHR = 0.32, 95% CI = 0.24-0.43) were associated with significant reduction in TB incidence rate. Combining ART and IPT had a more profound effect. Starting IPT-before-ART (aHR = 0.18, 95% CI = 0.08-0.42) or simultaneously with ART (aHR = 0.20, 95% CI = 0.10-0.42) provided further reduction of TB at ∼ 80%. CONCLUSIONS: IPT was found to be effective in reducing TB incidence, independently and with concomitant ART, under programme conditions in resource-limited settings. The level of IPT provision and effectiveness in reducing TB was encouraging in the study setting. Scaling up and strengthening IPT service in addition to ART can have beneficial effect in reducing TB burden among PLHIV in settings with high TB/HIV burden.

Caring for patients with surgically resectable cancers: experience from a specialised centre in rural Rwanda.

SETTING: Butaro Cancer Centre of Excellence (BCCOE), Burera District, Rwanda. OBJECTIVES: To describe characteristics, management and 6-month outcome of adult patients presenting with potentially surgically resectable cancers. DESIGN: Retrospective cohort study of patients presenting between 1 July and 31 December 2012. RESULTS: Of 278 patients, 76.6% were female, 51.4% were aged 50-74 years and 75% were referred from other district or tertiary hospitals in Rwanda. For the 250 patients with treatment details, 115 (46%) underwent surgery, with or without chemotherapy/radiotherapy. Median time from admission to surgery was 21 days (IQR 2-91). Breast cancer was the most common type of cancer treated at BCCOE, while other forms of cancer (cervical, colorectal and head and neck) were mainly operated on in tertiary facilities. Ninety-nine patients had no treatment; 52% of these were referred out within 6 months, primarily for palliative care. At 6 months, 6.8% had died or were lost to follow-up. CONCLUSION: Surgical care was provided for many cancer patients referred to BCCOE. However, challenges such as inadequate surgical infrastructure and skills, and patients presenting late with advanced and unresectable disease can limit the ability to manage all cases. This study highlights opportunities and challenges in cancer care relevant to other hospitals in rural settings.

Contexte : Centre anticancéreux d'excellence de Butaro (BCCOE), District de Butera, Rwanda.Objectifs : Décrire les caractéristiques, la prise en charge et les résultats à 6 mois de patients adultes se présentant avec des cancers potentiellement extirpables par chirurgie.Schema : Etude rétrospective de cohorte des patients admis entre le 1er juillet et le 31 décembre 2012.Resultats : Sur 278 patients, 76,6% étaient des femmes, 51,4% étaient âgés entre 50 et 74 ans et 75% étaient référés d'un autre district ou d'un hôpital tertiaire du Rwanda. Parmi les 250 patients dont les traitements étaient connus, 115 (46%) ont bénéficié d'une intervention chirurgicale avec ou sans chimiothérapie/radiothérapie. Le temps médian écoulé entre l'admission et la chirurgie était de 21 jours (IQR 2 à 91). Le cancer du sein était le plus fréquent des cancers traités au BCCOE, tandis que les autres cancers (col utérin, colorectal et tumeur cérébrale ou cervicale) étaient généralement opérés dans des hôpitaux tertiaires. Quatre-vingt-dix-neuf patients n'ont eu aucun traitement ; 52% ont été référés à l'extérieur dans les 6 mois, généralement pour un traitement palliatif. A 6 mois, 6,8% étaient décédés ou perdus de vue.Conclusion : De nombreux patients référés au BCCOE pour cancer ont bénéficié d'une intervention chirurgicale. Cependant la prise en charge de tous les cas est confrontée à la limite de capacité chirurgicale et au problème des patients admis tardivement avec un cancer avancé et non extirpable. Cette étude met en lumière les opportunités et les défis de la prise en charge des cancers pour les hôpitaux situés en zone rurale.

Marco de Referencia: El Centro Butaro de Excelencia en Cáncer (BCCOE) del distrito de Burera, en Ruanda.Objetivos: Describir las características, el manejo y el desenlace clínico a los 6 meses de pacientes adultos que se presentaron con cánceres cuyo tratamiento quirúrgico podía ser viable.Métodos: Fue este un estudio retrospectivo de cohortes de los pacientes que acudieron al centro entre el 1° de julio y el 31 de diciembre del 2012.Resultados: Se incluyeron en el estudio 278 pacientes, de los cuales 76,6% eran de sexo femenino, 51,4% tenían entre 50 y 74 años de edad y 75% habían sido remitidos de otro hospital distrital o de centros de atención terciaria de Ruanda. De los 250 expedientes que contaban con detalles sobre el tratamiento, en 115 casos (46%) los pacientes recibieron tratamiento quirúrgico con o sin quimioterapia o radioterapia. La mediana del lapso entre la hospitalización y la cirugía fue 21 días (intervalo intercuartil de 2 a 91). El cáncer de mama fue el tipo más frecuente de cáncer que se trató en el BCCOE y la cirugía de otras formas de cáncer (cuello uterino, colorrectal y de cara y cuello) se realizó principalmente en centros de atención terciaria. Noventa y nueve pacientes no recibieron tratamiento; el 52% de estos se remitió a otras instituciones en los primeros 6 meses, esencialmente con el propósito de recibir tratamiento paliativo. A los 6 meses, el 6,8% de los pacientes había fallecido o se habían perdido durante el seguimiento.Conclusión: Muchos de los pacientes remitidos recibieron tratamiento quirúrgico en el BCCOE. Sin embargo, la posibilidad de tratar todos los casos se ve limitada por obstáculos como una capacidad quirúrgica inadecuada y el hecho de que los pacientes acuden tarde, en una fase avanzada de la enfermedad, con un cáncer inoperable. El presente estudio pone de relieve oportunidades y dificultades en el tratamiento del cáncer que son pertinentes para otros centros hospitalarios en un entorno rural.

Childhood immunisation in Bungoma County, Kenya, from 2008 to 2011: need for improved uptake.

Uptake of immunisations in children aged 1-2 years in Bungoma County, Kenya, was determined as part of the 6-monthly Health and Demographic Surveillance System surveys. A total of 2699 children were assessed between 2008 and 2011. During this time period, full immunisation declined significantly from 84% to 58%, and measles vaccine declined uptake from 89% to 60% (P < 0.001). Each year there was a significant fall-off for the third doses of the oral polio and pentavalent vaccines (P < 0.001). These findings are of concern, as low immunisation coverage may lead to vaccine-preventable disease outbreaks. Further investigations into the reasons for declining immunisation trends are required.

La couverture vaccinale des enfants de âgés de 1 à 2 ans dans la conté de Bungoma au Kenya a été déterminée dans le cadre d'un enquête du Système de surveillance sanitaire et démographique. Au total 2699 enfants ont été évalués de 2008 à 2011. Au cours de cette période, le taux de vaccination complète a diminué de façon significative, de 84% à 58%, et celui de la vaccination contre la rougeole de 89% à 60% (P < 0,001). Chaque année, on a constaté une chute de l'administration de la 3e dose du vaccin polio oral et du vaccin pentavalent (P < 0,001). Ces résultats sont préoccupants car cette faible couverture vaccinale pourrait conduire à des épidémies de maladies évitables. Il est nécessaire de faire d'autres investigations à la recherche des causes de ce déclin de la vaccination.

La vacunación de los niños de 1 a 2 años de edad en el condado de Bungoma, en Kenia, se investigó como parte de las encuestas semestrales del Sistema de Vigilancia Sanitaria y Demográfica. Se evaluaron 2699 niños del 2008 al 2011. Durante este período se observó una disminución considerable de la administración de un esquema completo de vacunación, de 84% a 58%, y la aplicación de la vacuna antisarampionosa disminuyó de 89% a 60% (P < 0,001). En cada año, se redujo de manera notable la administración de la tercera dosis de la vacuna antipoliomielítica oral y la vacuna pentavalente (P < 0,001). Estas observaciones son fuente de preocupación, pues una baja cobertura de vacunación puede dar origen a brotes epidémicos de enfermedades prevenibles. Se justifica la realización de nuevas investigaciones que aclaren las razones de esta tendencia decreciente de las vacunaciones.

The Structured Operational Research and Training Initiative for public health programmes.

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

En 2009, L'Union Internationale contre la Tuberculose et les Maladies pulmonaires (L'Union) et Médecins sans Frontières Bruxelles-Luxembourg (MSF) ont commencé à élaborer un modèle orienté par les résultats pour la formation en recherche opérationnelle. En janvier 2013, l'Union et MSF ont rejoint le Programme Spécial de Recherche et de Formation des Maladies Tropicales (TDR) à l'OMS pour former une initiative baptisée « The Structured Operational Research and Training Initiative (SORT IT) ¼ [Initiative structurée de recherche opérationnelle et de formation]. Celle-ci intègre la formation du personnel des programmes de santé publique et la conduite de recherche opérationnelle en fonction des priorités de leur programme. Les programmes SORT IT consistent en trois ateliers d'une semaine, étalés sur 9 mois, avec des étapes bien définies et des résultats attendus. Cet article décrit la vision, les objectifs et la structure des programmes SORT IT, notamment les critères de sélection des candidats, les projets de recherche qui peuvent être entrepris dans le temps imparti, la structure et les étapes du programme, le tutorat, le suivi et l'évaluation des programmes et les suites du programme en termes de recherche ultérieure, de publications et de conception/mise en œuvre de programmes de formation supplémentaire. Il y a un besoin croissant, national et international, de recherche opérationnelle et de renforcement des capacités dans ce domaine en santé publique. SORT IT vise à répondre à ce besoin en plaidant pour un modèle de formation en recherche opérationnelle basé sur les résultats du personnel de santé publique décrit ici. Il vise également à sécuriser un financement pérenne pour la formation des experts au niveau mondial et national. Enfin, il pourrait servir d'observatoire de suivi et d'évaluation de la recherche opérationnelle en santé publique. Les critères de recrutement de nouveaux partenaires potentiels qui souhaitent rejoindre SORT IT ont été élaborés.

En el 2009, La Unión contra la Tuberculosis y las Enfermedades Respiratorias (La Unión) y Médecins sans Frontières de Bruselas y Luxemburgo comenzaron a desarrollar un modelo de capacitación en investigación operativa orientada por los resultados. En enero del 2013, ambas organizaciones se unieron a un Programa Especial de Investigación y Capacitación en Enfermedades Tropicales de la Organización Mundial de la Salud (OMS), con el fin de poner en marcha una iniciativa denominada SORT IT (acrónimo por the Structured Operational Research and Training Initiative, Iniciativa de Capacitación Estructurada en Investigación Operativa). Esta iniciativa articula la capacitación del personal del programa de salud pública con la realización de una investigación operativa a la cual su propio programa atribuye una prioridad. Los programas SORT IT consisten en tres talleres de una semana cada uno, durante un período de nueve meses, cuyos objetivos principales y productos se definen muy claramente. En el presente artículo se describen la visión, los objetivos y la estructura de los programas SORT IT, incluidos los criterios de selección de los solicitantes, los proyectos de investigación que se pueden emprender dentro del tiempo asignado, los objetivos principales y la estructura del programa, la tutoría, el seguimiento y la evaluación de los programas y lo que puede realizarse después del programa, como las futuras investigaciones, las publicaciones y la organización de otros programas de capacitación. Existe una necesidad creciente de investigación operativa y de creación de capacidades conexas en materia de salud pública a escala nacional e internacional. La iniciativa SORT IT busca satisfacer estas necesidades, mediante la promoción del modelo de capacitación en investigación operativa orientada por los resultados que dirige al personal del programa de salud pública descrito aquí. También busca lograr un financiamiento sostenible con el fin de ampliar la capacitación a escala nacional y mundial. Por último, la iniciativa podría tener una función de observatorio encargado de evaluar la investigación operativa en salud pública. Se redactaron asimismo los criterios dirigidos a los futuros asociados que deseen unirse a la iniciativa SORT IT.

Does the type of treatment supporter influence tuberculosis treatment outcomes in Zimbabwe?

Zimbabwe National Tuberculosis Guidelines advise that direct observation of anti-tuberculosis treatment (DOT) can be provided by a family member/relative as a last resort. In 2011, in Nkayi District, of 763 registered tuberculosis (TB) patients, 59 (8%) received health facility-based DOT, 392 (51%) received DOT from a trained community worker and 306 (40%) from a family member/relative. There were no differences in TB treatment outcomes between the three DOT groups, apart from a higher frequency rate of 'no reported outcomes' for those receiving family-based DOT. Family members should be trained to use a suitable DOT support package.

Les directives nationales en matière de tuberculose au Zimbabwe conseillent que l'observation directe du traitement antituberculeux (DOT) puisse être fournie par un membre de la famille ou par un autre parent, et ce en dernier ressort. En 2011, dans le District de Nkayi, 762 patients tuberculeux ont été enregistrés, parmi lesquels 59 (8%) ont reçu un DOT à partir des services de santé, 392 (51%) un DOT provenant d'un travailleur formé de la collectivité et 306 (40%) d'un membre de la famille ou d'un autre parent. Il n'y a pas eu de différences en matière de résultats du traitement de la TB entre ces trois groupes DOT, à l'exception d'une fréquence plus élevée de non-signalement des résultats chez ceux recevant un DOT par un membre de leur famille. Les membres de la famille devraient être formés à utiliser un ensemble adéquat de soutien au DOT.

Las directrices nacionales sobre la tuberculosis (TB) en Zimbabue recomiendan que, como último recurso, un miembro de la familia nuclear o extensa se pueda encargar de la observación directa del tratamiento antituberculoso (DOT). En el 2011, en el Distrito de Nkayi se registraron 763 pacientes con diagnóstico de TB, de los cuales 59 (8%) recibieron el DOT en un establecimiento de salud, 392 (51%) lo recibieron de un trabajador comunitario capacitado y 306 pacientes (40%) lo recibieron de un miembro de su familia nuclear o extensa. No se observaron diferencias en los desenlaces terapéuticos entre los tres grupos, con la excepción de una mayor frecuencia de desenlaces no comunicados en el grupo donde un familiar suministraba el tratamiento. Es preciso capacitar a los miembros de la familia sobre la utilización de un módulo apropiado de apoyo al DOT.

Oops, what about ethics?

Ethics approval of research studies is essential for the protection and rights of study subjects, whether this is for prospective research or record reviews. This article shares a painful lesson learned from a field experience where the appropriate steps for obtaining ethics approval were not followed by a young researcher. This researcher had embarked on an operational research project, but had omitted to seek ethics approval from a local ethics committee. Young researchers, particularly from low- and middle-income countries, need to learn about the importance and value of ethics.

L'approbation éthique des études de recherche est essentielle pour la protection et les droits des sujets de l'étude, que celle-ci soit destinée à une recherche prospective ou qu'elle consiste en une révision de dossiers. Cet article partage une pénible leçon provenant d'une expérience sur le terrain dans laquelle les étapes appropriées d'obtention des accords éthiques n'ont pas été suivies par un jeune chercheur. Ce chercheur s'est embarqué dans un projet de recherche opérationnelle, mais a omis de solliciter l'approbation éthique du comité local d'éthique. Il y a lieu de veiller à ce que les jeunes chercheurs, principalement ceux provenant de pays à revenus faibles ou moyens, s'informent au sujet de l'importance et de la valeur des données éthiques.

La aprobación de los estudios científicos por parte del comité de ética es primordial para la protección de las personas que participan y el respeto de sus derechos, ya sea en las investigaciones prospectivas o en los análisis de las historias clínicas. Por conducto del presente artículo se comparte una dolorosa enseñanza extraída de una experiencia en el terreno, en la cual un joven investigador no cumplió con las etapas necesarias en materia de aprobación por el comité de ética. El investigador se lanzó en un proyecto de investigación operativa, pero omitió buscar la aprobación del comité local de ética. Los jóvenes investigadores, sobre todo en los países de ingresos bajos e intermedios, deben aprender la importancia y la utilidad de los aspectos éticos de su trabajo.

References for scientific papers: why not standardise to one global style?

The different reference styles demanded by journals, both for in-text citations and manuscript bibliographies, require that significant time and attention be paid to minute detail that constitute a tedious obstacle on the road to publication for all authors, but especially for those from resource-limited countries and/or writing in a second language. To illustrate this, we highlight different reference styles requested by five popular journals to which operational research papers are often submitted. We call for a simpler, standardised format for in-text and bibliography reference citations, so that researchers can concentrate on the science and its interpretation rather than fonts and punctuation.

Les différents styles de référence sollicités par les revues, à la fois pour les citations dans le texte et pour les bibliographies du manuscrit, exigent un temps significatif et une attention à des détails minimes qui constituent un obstacle ennuyeux sur la voie de la publication pour tous les auteurs, mais particulièrement pour ceux provenant de pays à ressources limitées et/ou écrivant dans une deuxième langue. Pour illustrer ce fait, nous insistons sur les différents styles de référence exigés par cinq revues populaires vers lesquelles les articles de recherche opérationnelle sont fréquemment envoyés. Nous demandons un format plus simple et plus standardisé pour les citations des références dans le texte et dans la bibliographie, afin que les chercheurs puissent se concentrer sur la science et son interprétation plutôt que sur les polices et la ponctuation.

Los estilos diferentes de presentación de las referencias que solicitan las publicaciones periódicas en materia de citas bibliográficas en el texto y en la bibliografía de los artículos exigen un tiempo conside-rable y una atención minuciosa, lo cual representa un tedioso obstáculo en el proceso de publicación para todos los autores y, en mayor medida, para los autores de los países con recursos limitados o que escriben en un segundo idioma. Con el propósito de ilustrar este problema, se pusieron de manifiesto las diferencias de estilo exigidas por cinco periódicos a los cuales se presentan con mayor frecuencia los artículos de investigación operativa, con miras a su publicación. El artículo hace un llamado a la utilización de un formato más sencillo y normalizado, de manera que los investigadores se puedan concentrar en los aspectos científicos y la interpretación de los datos, en lugar de ocuparse de las fuentes tipográficas y los signos de puntuación.

Tuberculosis treatment outcomes among hospital workers at a public teaching and national referral hospital in Kenya.

SETTING: Kenyatta National Hospital (KNH), Nairobi, Ken-ya, a large referral and teaching hospital. OBJECTIVE: 1) To document tuberculosis (TB) case notification rates and trends; 2) to describe demographic, clinical and workplace characteristics and treatment outcomes; and 3) to examine associations between demographic and clinical characteristics, HIV/AIDS (human immunodeficiency virus/acquired immune-deficiency syndrome) treatment and anti-tuberculosis treatment outcomes among hospital workers with TB at KNH during the period 2006-2011. DESIGN: A retrospective cohort study involving a review of medical records. RESULTS: The TB case notification rate among hospital staff ranged between 413 and 901 per 100 000 staff members per year; 51% of all cases were extra-pulmonary TB; 74% of all cases were among medical, paramedical and support staff. The TB-HIV coinfection rate was 60%. Only 75% had a successful treatment outcome. Patients in the retreatment category, those with unknown HIV status and those who were support staff had a higher risk of poor treatment outcomes. CONCLUSION: The TB case rate among hospital workers was unacceptably high compared to that of the general population, and treatment outcomes were poor. Infection control in the hospital and management of staff with TB requires urgent attention.

Research ethics in The Union: an 8-year review of the Ethics Advisory Group.

SETTING: The Ethics Advisory Group (EAG) of the International Union Against Tuberculosis and Lung Disease (The Union) was established in 2004 to provide ethical guidance and promote ethical standards within The Union, including reviews of proposed research projects associated with The Union. OBJECTIVES: To describe research proposal reviews conducted by the EAG in the period 2005-2012 in terms of 1) annual numbers, 2) the Union departments in which the proposals originated, 3) study designs, 4) regions and countries where studies were to be conducted, 5) study topics, 6) problems encountered by the EAG, and 7) review outcomes. DESIGN: Descriptive study of application records of the EAG. RESULTS: A total of 292 applications were reviewed; 79% were proposals for operational research; 85% were from Africa and Asia, with 64% from India, South Africa, Malawi, Kenya and Zimbabwe. Tuberculosis was the topic in 68%; only three studies in the 8 years were on other lung diseases. Several problems encountered are highlighted. All applications were approved except six, either immediately or after modification. CONCLUSION: The proposal review process of the EAG serves to maintain ethical standards of research within The Union. Ideas for expanding the scope of the EAG are discussed.