Missed opportunities for earlier diagnosis of rifampicin-resistant tuberculosis despite access to Xpert® MTB/RIF.

OBJECTIVE: To assess the proportion of rifampicin-resistant tuberculosis (RR-TB) patients with potential earlier RR-TB diagnoses in Khayelitsha, South Africa. DESIGN: We conducted a retrospective analysis among RR-TB patients diagnosed from 2012 to 2014. Patients were considered to have missed opportunities for earlier diagnosis if 1) they were incorrectly screened according to the Western Cape diagnostic algorithm; 2) the first specimen was not tested using Xpert® MTB/RIF; 3) no specimen was ever tested; or 4) the initial Xpert test showed a negative result, but no subsequent specimen was sent for follow-up testing in human immunodeficiency virus-positive patients. RESULTS: Among 543 patients, 386 (71%) were diagnosed with Xpert and 112 (21%) had had at least one presentation at a health care facility within the 6 months before the presentation at which RR-TB was diagnosed. Overall, 95/543 (18%) patients were screened incorrectly at some point: 48 at diagnostic presentation only, 38 at previous presentation only, and 9 at both previous and diagnostic presentations. CONCLUSIONS: These data show that a significant proportion of RR-TB patients might have been diagnosed earlier, and suggest that case detection could be improved if diagnostic algorithms were followed more closely. Further training and monitoring is required to ensure the greatest benefit from universal Xpert implementation.

Adherence and chemoprevention in major cardiovascular disease: a simulation study of the benefits of additional use of statins.

BACKGROUND: In everyday practice, adherence to preventive medication for cardiovascular disease (CVD) is lower than in clinical trials and appears to decline to approximately 50% by about 5 years. The UK body for the evaluation of health technologies, NICE, currently recommends that persons with a >20% 10-year risk of incident cardiovascular disease receive statins. METHODS: Publications on adherence to statin medication in clinical trials and in normal practice were systematically reviewed. Data on CVD-free members of a large southern hemisphere cohort study were used to simulate the expected benefits of contrasting strategies to increase the use of statins. Risks of incident CVD and death from CVD were estimated. RESULTS: A strategy to enhance statin adherence among cohort members meeting NICE statin-prescribing guidelines resulted in about twice as large a reduction in the aggregate risk of CVD death as did a strategy to lower treatment thresholds. CONCLUSIONS: The benefits from increased spending on statin medication will be much greater if they result from enhanced adherence rather than from lowering the medication threshold.

Influenza vaccine uptake among staff in care homes in Nottinghamshire: a random cluster sample survey.

OBJECTIVES: To establish uptake of influenza vaccine amongst care home clinical staff in Greater Nottingham, and to investigate what could be done to improve vaccine uptake in this group. STUDY DESIGN: Postal questionnaire surveys were used. In the first instance, a total sample survey was used. In the second instance, a sample of care home staff was surveyed, randomized at the care home level. METHODS: A postal questionnaire completed by care home matrons was used to obtain a preliminary estimate of staff vaccine uptake. Individual staff questionnaires were then used to validate this finding, and measure attitudes, beliefs and behaviours associated with vaccination. RESULTS: Vaccine uptake among those working in care homes with nursing was found to be low. Vaccine uptake was higher in homes with a policy recommending vaccination of staff. Most respondents who had received vaccination reported that they had done so because of an existing medical condition, rather than because of being a healthcare worker. A statistically significant relationship (P=0.02) was found between individuals' reported beliefs on how well they could resist influenza and their vaccination status. CONCLUSIONS: All care homes for the elderly should have a vaccination policy which recommends staff vaccination. Educational campaigns, vaccination in the workplace and free provision of the influenza vaccine may help to improve vaccine uptake in this group.