Extensive Mycobacterium tuberculosis circulation in a highly endemic prison and the need for urgent environmental interventions.

Aimed at assessing the circulation of Mycobacterium tuberculosis in a highly endemic prison, this 13-month prospective study was performed on strains isolated from tuberculosis (TB) cases detected passively and actively. We used X-ray screening of newly admitted inmates and mass screening at the beginning of the study and again 1 year later. Of the 94 strains genotyped by restriction fragment-length polymorphism, 79 (84·0%) belonged to one of the 12 identified clusters (2-21 strains each), including two main clusters (18 and 21 cases, respectively). A history of TB treatment was reported in 22/79 (27·8%) clustered cases. Time-space distribution of clustered cases was predominantly consistent with transmission, in micro-epidemics. Given the dominant pattern of exogenous infection and the extensive strain circulation, effective TB control should emphasize reduction of overcrowding and improvement of environmental measures as a complement to detection and treatment of cases.

International institutions, global health initiatives and the challenge of sustainability: lessons from the Brazilian AIDS programme.

The sustainability of successful public health programmes remains a challenge in low and middle income settings. These programmes are often subjected to mobilization-demobilization cycle. Indeed, political and organizational factors are of major importance to ensure this sustainability. The cooperation between the World Bank and the Brazilian AIDS programme highlights the role of international institutions and global health initiatives (GHI), not only to scale up programmes but also to guarantee their stability and sustainability, at a time when advocacy is diminishing and vertical programmes are integrated within health systems. This role is critical at the local level, particularly when economic crisis may hamper the future of public health programmes. Political and organizational evolution should be monitored and warnings should trigger interventions of GHI before the decline of these programmes.

Screening for tuberculosis on admission to highly endemic prisons? The case of Rio de Janeiro State prisons.

SETTING: Rio de Janeiro (RJ) State prisons, where tuberculosis (TB) is highly endemic. OBJECTIVE: To measure TB prevalence, identify risk factors and ascertain the most appropriate screening method among inmates of the RJ prisons. DESIGN: Systematic chest X-rays (CXRs) were performed in 1696 male inmates of three RJ prisons. Inmates were selected for sputum examination and culture if their CXRs showed evidence of any pulmonary, pleural or mediastinal abnormality. TB diagnosis was based on bacteriological results or, if bacteriological results were negative, on response to TB treatment. RESULTS: TB prevalence was 2.7% (46/1696), and 32/46 cases (69%) were bacteriologically confirmed, including 19 smear-positive cases. CXR lesions were extensive in 43% of cases. In the logistic regression model, TB-associated variables were being illiterate (adjusted OR 2.10, 95%CI 1.02-4.34), cough >or=3 weeks (aOR 2.85, 95%CI 1.54-5.27), history of TB treatment (aOR 3.61, 95%CI 1.76-7.39), and living in Rio City suburbs (aOR 4.54, 95%CI 1.02-20.07) and in Rio City (aOR 5.48, 95%CI 1.29-23.33). A screening based on cough >or=3 weeks followed by sputum smear examination would have identified only 9 of the 46 cases. CONCLUSION: These results call for screening on admission to prison based, if feasible, on CXR, and demonstrate the urgent need to improve detention conditions and medical assistance in police remand cells.

Development and evaluation of tuberculosis screening scores in Brazilian prisons.

BACKGROUND: Tuberculosis (TB) is highly endemic in Rio de Janeiro State prisons. In addition to TB screening at entry and passive case detection, active case identification may be warranted. OBJECTIVES: To develop and evaluate performances of scores aimed at identifying "tuberculosis suspects" in order to target TB screening among inmates. METHODS: Systematic chest X-ray screening was carried out in two prisons (n=1910). TB was diagnosed among individuals with X-ray abnormalities by sputum microscopic examination and culture or, if bacteriological results were negative, by response to TB treatment. Using this strategy as a reference, the clinical score proposed in WHO guidelines "TB Control in Prisons" was evaluated. Using the same variables in a logistic regression comparing TB and non-TB cases, another score was developed and evaluated. Finally, a 'new score', based on socio-demographic and clinical variables was developed and evaluated. RESULTS: When applied to our study population (prevalence of active TB: 4.6%), these scores missed many TB cases (sensitivities: 56%, 72%, 74%, respectively). Among the "TB suspects", the probability of finding TB cases was low (positive predictive value: 10%). The scores had high negative predictive values (>97%); specificities (75%, 60%, 67%) were low. Performances were similarly poor for smear-negative and smear-positive cases. CONCLUSION: The scores investigated performed poorly and would be unhelpful to target TB screening. Therefore, systematic X-ray screening may be considered, at least during the initial stages of the reinforced TB programme, in order to reduce the impressive burden of TB.

Prevalence of pulmonary tuberculosis and comparative evaluation of screening strategies in a Brazilian prison.

SETTING: A prison (1171 male inmates) in Rio de Janeiro, Brazil. OBJECTIVES: To determine the prevalence of active pulmonary tuberculosis (TB) and to assess the performance of several screening strategies. DESIGN: In a cross-sectional study, all inmates underwent chest radiographic screening. Subjects with abnormal findings underwent sputum smear examination and sputum culture. Taking this strategy as the reference, we assessed three targeted screening strategies to identify TB suspects: Strategy 1: cough >3 weeks; Strategy 2: WHO score > or = 5; Strategy 3: presence of at least one potentially TB-related symptom. RESULTS: The prevalence of TB cases was 4.6% (48/1052) and 2.7% for definite TB cases. If TB suspects identified by targeted screening had sputum smear examination alone, 37 (86.0%) of the 43 cases would have been missed by Strategy 1, 34/43 (79.1%) by Strategy 2 and 34/43 (79.1%) by Strategy 3. If TB suspects had both sputum smear examination and, for smear-negative subjects, chest radiography, respectively 28/43 (65.1%), 18/43 (41.9%) and 13/43 (30.2%) of cases would have been missed. CONCLUSION: All three targeted screening strategies were unreliable. Given the importance of early TB diagnosis in overcrowded and highly endemic settings, routine radiography-based screening may be warranted.

Hepatitis A among health workers in Paris hospitals. Occupational Health Physicians of Paris Hospital (AP-HP)

To design a vaccination strategy against hepatitis A among hospital employees, we carried out a serological survey against hepatitis A virus (HAV) infection in 10 university hospitals in the Paris area. Subjects under 60 years of age were consecutively enrolled by occupational health services and tested for IgG to HAV by ELISA. Of the 1,516 subjects recruited, 926 were health workers (HW), 322 clerks, and 268 cooks or kitchen employees. Among HW and clerks the HAV seroprevalence was 53.8 percent (95 percent CI: 44.0-65.6), increasing with age and being higher among Europe (83.6 percent vs 45.6 percent, P < .001). Age correlated closely with the duration of hospital work, so only age was taken into account for further analysis. The HAV seroprevalences among HW and clerks originating from Europe were close (48.8 percent vs 42.6 percent) and remained so after adjustment for age. HAV seroprevalences in HW caring for adults and those caring for children were also similar (45.2 percent vs 40.1 percent). Seroprevalence was higher in assistant nurses than in nurses (51.3 percent vs 39.8 percent, P < .02). Among cooks and kitchen employees, 53.4 percent were HAV-seropositive. This study shows that hospital employees need not routinely be vaccinated against HAV; the decision should be taken by the occupational physician according to the type of work, but should be routine for cooks and kitchen employees. The need for prevaccinal screening for anti-HAV should be assessed in the light of employees' geographical origin and age.(Au)

Human T lymphotropic virus type I (HTLV-I) infection in neurological patients in Salvador, Bahia, Brazil.

HTLV-I infection represents a major health concern in endemic areas throughout the world, such as Salvador, the main city of Bahia State, with socio-demographic characteristics similar to sub-Saharan African cities, located in the Northeast of Brazil. In order to provide an estimate of the frequency distribution, and range of neurological manifestations potentially related to HTLV-I infection in this city, we conducted a cross-sectional clinical-epidemiological study to determine the prevalence of this infection in patients with neurological diseases. Patients exhibiting vascular diseases, tumoral diseases or trauma were excluded. Over a period of 16 months, we studied 322 consecutive patients with chronic neurological diseases, who attended the neurological clinics of two major hospitals in Salvador. Overall, the prevalence of HTLV-I infection among the patients was 20.9% (67/320). However, the prevalence among the 104 patients with chronic myelopathy was 50.0% (52/104). It was observed that the major prevalence of HTLV-I was between the ages of 40 and 60 years with a female predominance. Our data indicate that, in Salvador city, HTLV-I is associated with chronic myelopathies or myeloneuropathies, which seem to be the only neurological diseases associated with HTLV-I.

[Epidemiology of HTLV-I infection in its hyperendemic foci (Japan, tropical Africa, Caribbean)]. / Epidémiologie de l'infection par HTLV-I dans ses foyers d'hyperendémie (Japon, Afrique intertropicale, Caraïbes).

HTLV-1 infection is endemic in Japan, black Africa, the Caribbean and several regions of South America. In these foci, the infections is very heterogeneously distributed (variations from village to village, intrafamilial clustering). The virus is transmitted from mother to child, and breast feedings seems to play a major role. Sexual transmission is usually from man to woman. The frequency of transmission by blood transfusion must not be underestimated. It justifies the systematic detection of HTLV-1 infection in areas where it is economically feasible.

Lack of perinatal transmission of hepatitis B virus infection in Senegal, West Africa.

Between 1977 and 1980, 1442 pregnant women in Thies, Senegal, were tested for serologic markers of hepatitis B virus (HBV) infection. Of these, 9.8% were HBsAg(+), 59.9% were anti-HBs(+), and 15.6% had anti-HBc alone. Of 116 HBsAg(+) pregnant women, only 19.8% were HBeAg(+), a much lower proportion of infectious carriers than seen in Asian populations. Cord blood from 1353 babies was HBsAg(-), implying that the babies were not infected prior to birth. Four hundred sixty-two babies, including 88 born to HBsAg(+) mothers, were observed for 2 weeks to 38 months after birth. In contrast to observations in Asia, none of the babies became HBsAg(+) before 5 months of age, and only three of the 16 born to HBeAg(+) mothers became HBsAg(+) within the first year of life; all three developed chronic infections (i.e., HBsAg(+) for greater than or equal to 6 months. In the second year of life, six of 34 babies born to HBsAg(+), HBeAg(-)/anti-HBe(-) mothers became infected with HBV, and four of the six developed chronic infections. During the first 3 years of life, infections occurred at a higher rate in infants born to HBsAg(+) (17%) than to HBsAg(-) (4%) women. The latter group of infants included 4.0% of those born to anti-HBs(+) mothers, 4.6% born to anti-HBcAg(+), and 3.2% born to uninfected women. These observations indicate that HBV infections in Senegal usually do not occur perinatally, but do occur at high incidence later in infancy and childhood. Such infections can be prevented by the use of hepatitis B vaccine alone; administration of hepatitis B immune globulin should not be needed.