Initiation of anti-tuberculosis treatment in children following gastric aspirate testing, Botswana, 2008-2012.

SETTING: Diagnosing pediatric tuberculosis (TB) is difficult; to improve diagnosis, gastric aspiration (GA) was performed in 121 Botswana health facilities. OBJECTIVE: To describe treatment initiation and outcomes in children with a positive GA result and those treated empirically. METHODS: Children with smear or culture-positive GA or those clinically diagnosed were referred for anti-tuberculosis treatment. Treatment initiation and outcomes were assessed from February 2008 to December 2012 using name-based matching algorithms of the GA database; treatment initiation was captured in the electronic TB registry. Analyses included descriptive statistics and regression models. RESULTS: GA was conducted in 1268 children. Among these, 121 (9.5%) were GA-positive; and treatment was initiated in 90 (74.3%). An additional 137 (11.9%) were treated empirically. More than a third (36.4%) had known human immunodeficiency virus status (positive or negative); this was significantly associated with TB treatment initiation (adjusted odds ratio [aOR] 1.8, 95%CI 1.3-2.5); P < 0.05). Among the 90 children with a positive GA result, nearly all either completed treatment (78.9%) or were on treatment (20.0%) at the time of data collection. CONCLUSION: We could not find documentation of treatment for more than a quarter of the children with laboratory-confirmed TB, an important gap that calls for further examination. The failure to initiate prompt treatment requires investigation and urgent action.

What a difference a day makes: same-day vs. 2-day sputum smear microscopy for diagnosing tuberculosis.

Setting: Nine district-level microscopy centres in Assam and Tripura, India. Objective: Same-day sputum microscopy is now recommended for tuberculosis (TB) diagnosis. We compared this method against the conventional 2-day approach in routine programmatic settings. Methods: During October-December 2012, all adult presumptive TB patients were requested to provide three sputum samples (one at the initial visit, the second 1 h after the first sample, and the third the next morning) for examination by Ziehl-Neelsen smear microscopy. Detection of acid-fast bacilli with any sample was diagnostic. The first and second spot sample comprised the same-day approach, and the first spot sample and next-day sample comprised the 2-day approach. Results: Of 2168 presumptive TB patients, 403 (18.6%) were smear-positive according to the same-day method compared to 427 (19.7%) by the 2-day method (McNemar's test, P < 0.001). Of the total 429 TB patients, 26 (6.1%) were missed by the same-day method and 2 (0.5%) by the 2-day method. Conclusion: Same-day specimen collection for microscopy missed more TB than 2-day collection. In India, missing cases by using same-day microscopy would translate into a considerable absolute number, hindering TB control efforts. We question the indiscriminate switch to same-day diagnosis in settings where patients reliably return for testing the next day.

Contexte : Neuf centres de microscopie de district dans les états d'Assam et de Tripura, Inde.Objectif : On recommande maintenant une microscopie de frottis le même jour pour le diagnostic de la tuberculose (TB). Nous avons comparé cette méthode par rapport à l'approche conventionnelle en 2 jours dans un contexte de programme de routine.Méthodes : Entre octobre et décembre 2012, tous les patients adultes présumés atteints de TB ont été invités à fournir trois échantillons de crachats (lors de la visite initiale, 1 heure après le premier échantillon et le matin suivant) pour un examen par microscopie de frottis selon Ziehl-Neelsen. La détection de bacilles acido-alcoolo-résistants dans un quelconque échantillon constituait le diagnostic. Les premier et deuxième échantillons ont constitué l'approche du même jour et le premier échantillon plus celui du matin suivant constituaient l'approche en 2 jours.Résultats : Sur les 2168 patients présumés TB, 403 (18,6%) étaient frottis-positifs selon la méthode du même jour comparés à 427 (19,7%) par la méthode en 2 jours (test de McNemar P < 0,001). Sur ce total de 429 patients TB, 26 (6,1%) ont été manqués par la méthode du même jour et 2 (0,5%) par la méthode en 2 jours.Conclusion : Le recueil d'échantillons le même jour pour une microscopie a manqué plus de cas de TB que le recueil en 2 jours. En Inde, une stratégie de microscopie le même jour à ce taux se traduirait par un grand nombre absolu de cas manqués, entravant les efforts de lutte contre la TB. Nous remettons en question le fait de passer sans discrimination au diagnostic du jour même dans des contextes où les patients reviennent de manière fiable pour un test le jour suivant.

Marco de referencia: Nueve centros distritales de microscopia de Assam y Tripura en la India.Objetivo: Actualmente se recomienda en el diagnóstico de la tuberculosis (TB) practicar la baciloscopia del esputo el mismo día de la consulta. En el presente estudio se comparó este método con la estrategia corriente de baciloscopia en dos días que se aplica en las prácticas programáticas.Métodos: De octubre a diciembre del 2012 se solicitó a todos los adultos con presunción diagnóstica de TB que aportaran tres muestras de esputo (en el momento de la consulta inicial, una hora después y a la mañana siguiente), con el fin de practicar el examen microscópico con la coloración de Ziehl-Neelsen. El criterio diagnóstico fue la detección de bacilos acidorresistentes en cualquiera de las muestras. La primera y la segunda muestras inmediatas constituyeron la estrategia del mismo día y la primera muestra inmediata y la muestra del día siguiente constituyeron la estrategia de 2 días.Resultados: En los 2168 pacientes con presunción de TB, se confirmó el diagnóstico en 403 casos (18,6%) con el método del mismo día y en 427 (19,7%) con la estrategia de 2 días (prueba de McNemar P < 0,001). Del total de 429 pacientes con diagnóstico de TB, se pasaron por alto 26 casos cuando se recogieron las muestras el mismo día (6,1%) y 2 casos cuando se recogieron durante 2 días (0,5%).Conclusión: La recogida de muestras destinadas a la baciloscopia en el mismo día omitió el diagnóstico de más casos de TB que la recogida de muestras en 2 días. En la India, pasar por alto el diagnóstico de casos con el examen microscópico realizado el mismo día tendría como consecuencia omitir una cifra absoluta de pacientes muy alta, que entorpecería los resultados de las iniciativas de control de la TB. En el presente artículo se pone en duda la utilidad de un cambio indiscriminado hacia el método de diagnóstico en el mismo día, en los entornos donde se puede confiar en que los pacientes regresarán al día siguiente para completar las muestras de esputo.

Alcohol use, drunkenness and tobacco smoking in rural western Kenya.

OBJECTIVES: To describe the prevalence of smoking and alcohol use and abuse in an impoverished rural region of western Kenya. METHODS: Picked from a population-based longitudinal database of demographic and health census data, 72 292 adults (≥18 years) were asked to self-report their recent (within the past 30 days) and lifetime use of tobacco and alcohol and frequency of recent 'drunkenness'. RESULTS: Overall prevalence of ever smoking was 11.2% (11.0-11.5) and of ever drinking, 20.7% (20.4-21.0). The prevalence of current smoking was 6.3% (6.1-6.5); 5.7% (5.5-5.9) smoked daily. 7.3% (7.1-7.5) reported drinking alcohol within the past 30 days. Of these, 60.3% (58.9-61.6) reported being drunk on half or more of all drinking occasions. The percentage of current smokers rose with the number of drinking days in a month (P < 0.0001). Tobacco and alcohol use increased with decreasing socio-economic status and amongst women in the oldest age group (P < 0.0001). CONCLUSIONS: Tobacco and alcohol use are prevalent in this rural region of Kenya. Abuse of alcohol is common and likely influenced by the availability of cheap, home-manufactured alcohol. Appropriate evidence-based policies to reduce alcohol and tobacco use should be widely implemented and complemented by public health efforts to increase awareness of their harmful effects.