Person-centered strategies for delivering TB diagnostic services in Lima, Peru.

SETTING: Lima, Peru. OBJECTIVE: To close the gap in TB diagnosis, TB diagnostic services must match care-seeking preferences. We sought to identify preferred strategies for delivering TB diagnostic services and to determine whether preferences differ among demographic groups. DESIGN: During May 2022-January 2023, we recruited adults who recently initiated treatment for pulmonary TB. We used an object-case best-worst scaling instrument to assess the desirability of nine hypothetical strategies for delivering TB diagnostic services. A t-test was used to assess differences in preference scores between groups. RESULTS: Among 150 participants, the strategies with the highest preference scores were an integrated mobile unit offering screening for multiple conditions, expedited attention at the health center, and home-based screening. These were strongly preferred by 42%, 25%, and 27% of participants, respectively, and 80% of participants strongly preferred at least one of the three. Expedited attention at the health center scored more highly among people who experienced >2 months delay in TB diagnosis compared to those who experienced a more rapid diagnosis (0.37 ± 0.06 vs. 0.17 ± 0.06; P = 0.031). CONCLUSION: Providing person-centered TB diagnostic services at diverse access points could help reach different populations, which could promote early diagnosis and help close the diagnosis gap.

CONTEXTE: Lima, Pérou. OBJECTIF: Pour combler les lacunes dans le diagnostic de la TB, les services de diagnostic de la TB doivent correspondre aux préférences en matière de recherche de soins. Nous avons cherché à identifier les stratégies préférées pour la prestation de services de diagnostic de la TB et à déterminer si les préférences diffèrent entre les groupes démographiques. MÉTHODE: De mai 2022 à janvier 2023, nous avons recruté des adultes ayant récemment commencé un traitement contre la TB pulmonaire. Nous avons utilisé un instrument d'évaluation du meilleur et du pire pour évaluer la désirabilité de neuf stratégies hypothétiques de prestation de services de diagnostic de la TB. Un test-t a été utilisé pour évaluer les différences dans les scores de préférence entre les groupes. RÉSULTATS: Parmi les 150 participants, les stratégies ayant les scores de préférence les plus élevés étaient une unité mobile intégrée offrant un dépistage pour des conditions multiples, une attention accélérée au centre de santé et un dépistage à domicile. Ces stratégies ont été fortement préférées par 42%, 25% et 27% des participants, respectivement, et 80% des participants ont fortement préféré au moins l'une des trois. L'attention accélérée au centre de santé a obtenu un score plus élevé chez les personnes ayant subi un retard de diagnostic de la TB de plus de 2 mois que chez celles ayant subi un diagnostic plus rapide (0,37 ± 0,06 contre 0,17 ± 0,06 ; P = 0,031). CONCLUSION: La fourniture de services de diagnostic de la TB centrés sur la personne à divers points d'accès pourrait permettre d'atteindre différentes populations, ce qui pourrait favoriser un diagnostic précoce et contribuer à combler le fossé en matière de diagnostic.

Implementing 3HP vs. IPT as TB preventive treatment in Pakistan.

BACKGROUND: We assessed treatment uptake and completion for 6 months of isoniazid (6H) and 3 months of isoniazid plus rifapentine weekly (3HP) in a programmatic setting in Pakistan.METHODS: All household contacts were clinically evaluated to rule out TB disease. 6H was used for TB preventive treatment (TPT) from October 2016 to April 2017; from May to September 2017, 3HP was used for contacts aged ≥2 years. We compared clinical evaluation, TPT uptake and completion rates between contacts aged ≥2 years in the 6H period and in the 3HP period.RESULTS: We identified 3,442 contacts for the 6H regimen. After clinical evaluation, 744/1,036 (72%) started treatment, while 46% completed treatment. In contrast, 3,722 contacts were identified for 3HP. After clinical evaluation, 990/1,366 (72%) started treatment, while 67% completed treatment. Uptake of TPT did not differ significantly between the 6H and 3HP groups (OR 1.03, 95%CI 0.86-1.24). However, people who initiated 3HP had 2.3 times greater odds (95% CI 1.9-2.8) of completing treatment than those who initiated 6H after adjusting for age and sex.CONCLUSION: In programmatic settings in a high-burden country, household contacts of all ages were more likely to complete TPT with shorter weekly regimens, although treatment uptake rate for the two regimens was similar.

A structured community engagement strategy to support uptake of TB active case-finding.

BACKGROUND: In Lima, Peru, a mobile TB screening program ("TB Móvil") was implemented in high TB prevalence districts to increase TB screening. Community engagement activities to promote TB Móvil were simultaneously conducted. OBJECTIVE: To describe a structured, theory-driven community engagement strategy to support the uptake of TB Móvil. METHODS: We adapted Popular Opinion Leader (POL), an evidence-based social networking intervention previously used in Peru to promote HIV testing, for TB Móvil. Community health workers, women who run soup kitchens, and motorcycle taxi drivers served as "popular opinion leaders" who disseminated information about TB Móvil in everyday conversations, aided by a multi-media campaign. Performance indicators of POL included the number/characteristics of persons screened; number of multimedia elements; and proportion of persons with abnormal radiographs hearing about TB Móvil before attending. RESULTS: Between February 2019 and January 2020, 63,899 people attended the TB Móvil program at 210 sites; 60.1% were female. The multimedia campaign included 36 videos, 16 audio vignettes, flyers, posters, community murals and "jingles." Among attendees receiving an abnormal chest X-ray suggestive of TB, 48% (6,935/14,563) reported hearing about TB Móvil before attending. CONCLUSIONS: POL promotes the uptake of TB Móvil and should be considered as a strategy for increasing TB screening uptake.

CONTEXTE: À Lima, Pérou, un programme mobile de dépistage de la TB (« TB Móvil ¼) a été mis en place dans les quartiers à forte prévalence de TB afin d'accroître le dépistage de la maladie. Des activités de mobilisation communautaire visant à promouvoir TB Móvil ont été menées en parallèle. L'objectif de ce rapport est de décrire une stratégie structurée de mobilisation communautaire, fondée sur des principes théoriques, afin de soutenir le recours au programme TB Móvil. MÉTHODES: Nous avons adapté à TB Móvil l'intervention factuelle de réseautage social appelée « Popular Opinion Leader (POL; leader d'opinion) ¼, précédemment utilisée au Pérou pour promouvoir le dépistage du VIH. Les agents de santé communautaires, les femmes responsables de la soupe populaire et les chauffeurs de mototaxis étaient des leaders d'opinion. Ils communiquaient des informations sur TB Móvil lors de leurs conversations quotidiennes, qui étaient étayées par une campagne multimédia. Les indicateurs de performance des POL comprenaient le nombre/les caractéristiques des personnes dépistées, le nombre d'éléments multimédias et le pourcentage de personnes avec cliché radiographique anormal qui avaient entendu parler de TB Móvil avant de se faire dépister. RÉSULTATS: Entre février 2019 et janvier 2020, 63 899 personnes ont pris part au programme TB Móvil dans 210 sites ; 60,1% étaient des femmes. La campagne multimédia reposait sur 36 vidéos, 16 vignettes audio, des prospectus, des posters, des peintures murales dans la communauté et des « jingles ¼. Parmi les personnes dont la radiographie pulmonaire était anormale et évocatrice de TB, 48% (6 935/14 563) ont rapporté avoir entendu parler de TB Móvil avant de venir consulter. CONCLUSIONS: L'intervention POL, qui semblait renforcer le recours au programme TB Móvil, peut donc servir d'une stratégie de promotion du dépistage de la TB.

Integrated screening and testing for TB and COVID-19 in Peru.

We describe the experience of integrating COVID-19 screening and testing into a mobile TB screening unit in Lima, Peru. All attendees received chest radiographs, which were analysed using CAD4TB and CAD4COVID; Xpert MTB/RIF Ultra was used to test for TB, and antibody and polymerase chain reaction (PCR) for SARS-CoV-2. One Xpert-positive TB case was diagnosed per 168 people screened, one person with SARS-CoV-2 antibodies per 3 people screened, and one PCR-confirmed SARS-CoV-2 infection per 8 people screened. Integrated screening can help to avoid delays in the diagnosis of both TB and COVID-19.

Nous décrivons l'expérience de l'intégration du dépistage et du test COVID-19 dans une unité mobile de dépistage de la TB à Lima, au Pérou. Toutes les personnes présentes ont reçu des radiographies pulmonaires, qui ont été analysées à l'aide de CAD4TB et CAD4COVID ; Xpert® MTB/RIF Ultra a été utilisé pour le dépistage de la TB, et les anticorps et la réaction en chaîne par polymérase (PCR) pour le SARS-CoV-2. Un cas de TB Xpert-positif a été diagnostiqué pour 168 personnes dépistées, une personne présentant des anticorps du SARS-CoV-2 pour 3 personnes dépistées et une infection du SARS-CoV-2 confirmée par PCR pour 8 personnes dépistées. Le dépistage intégré peut contribuer à éviter les retards dans le diagnostic de la TB et du COVID-19.

Conquering unwanted habits at the workplace: Day-level processes and longer term change in habit strength.

Although habits are a well-researched topic within psychology, habits enacted at the workplace received limited attention in the organizational literature. In this article we examine habits that employees show at the workplace. Because workplace habits are not always functional for performance or affective outcomes, and because employees themselves may regard specific habits as undesirable, it is important to identify ways of how employees can abandon such unwanted habits. We report findings from a daily-survey study (N = 145 persons) in which we examined if self-regulatory processes predict disengagement from undesirable habits and engagement in more desirable alternative behaviors. Multilevel path analysis showed that day-specific implementation intentions and day-specific vigilant monitoring were negatively related to day-specific habitual behavior and positively related to day-specific alternative behaviors, both in the morning and in the afternoon. Analysis of follow-up data (N = 126 persons) showed that change in habit strength was stable over a 2-month period, suggesting that implementation intentions, vigilant monitoring, and the associated enactment of alternative behavior indeed may help to disengage from unwanted habits, particularly with respect to task-related habits and when consistency in vigilant monitoring is high. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Caregivers' knowledge and perceptions are associated with children's TB preventive treatment completion.

SETTING: Forty-six health centers in south Lima, Peru. OBJECTIVE: To assess the association between caregivers' knowledge and perceptions around isoniazid preventive therapy (IPT) and whether their children complete IPT. DESIGN: We conducted a retrospective medical record review of children who initiated IPT during 2017-2018. We administered structured surveys to caregivers of the children about their knowledge about and perceptions of IPT. We used a modified Poisson regression to determine factors associated with IPT completion. RESULTS: We included 550 children, of whom 31% did not complete IPT. Independent factors associated with not completing IPT were low caregiver knowledge about TB and IPT (adjusted risk ratio [aRR] 1.41, 95% CI 1.06-1.78), low caregiver perception of the importance of IPT (aRR 1.76, 95% CI 1.30-2.39), low caregiver satisfaction with the health services (aRR 1.57, 95% CI 1.14-2.16), experience of adverse events (aRR 2.08, 95% CI 1.51-2.87), and living in a household with moderate or severe family dysfunction (aRR 1.53, 95% CI 1.07-2.19). CONCLUSION: IPT completion among children was associated with the knowledge and perceptions of their caregivers, as well as the experience of adverse events. To improve IPT completion among children, health care providers should prioritize education and counseling for caregivers, promote positive interpersonal relationships with them, and monitor adverse events.

CONTEXTE: Quarante-six centres de santé au Sud de Lima, Pérou. OBJECTIF: Evaluer l'association entre les connaissances et les perceptions relatives au traitement préventif par l'isoniazide (TPI) des responsables des enfants et le fait que leurs enfants aient achevé le TPI. SCHÉMA: Nous avons réalisé une revue rétrospective des dossiers médicaux des enfants qui ont démarré le TPI entre 2017 et 2018. Nous avons administré aux responsables des enfants des questionnaires structurés relatifs à leurs connaissances et perceptions du TPI. Nous avons utilisé une régression de Poisson modifiée afin de déterminer les facteurs associés à l'achèvement du TPI. RÉSULTATS: Nous avons inclus 500 enfants dont 31% n'ont pas achevé le TPI. Les facteurs indépendants associés au non achèvement étaient faibles connaissances relatives à la TB et au TPI (risque relatif ajusté [RRa] 1,41 ; IC 95% 1,06­1,78), faibles perception par les responsables de l'importance du TPI (RRa 1,76 ; IC 95% 1,30­2,39), faible taux de satisfaction des responsables par rapport aux services de santé (RRa 1,57 ; IC 95% 1,14­2,16), survenue d'effets secondaires (RR 2,08 ; IC 95% 1,51­2,87) et dysfonction familiale modérée ou grave (RRa 1,53 ; IC 95% 1,07­2,19). CONCLUSION: L'achèvement du TPI chez les enfants a été associé aux connaissances et perceptions de leurs responsables, ainsi qu'à la survenue d'effets secondaires. Pour améliorer l'achèvement du TPI chez les enfants, les prestataires de soins de santé devraient accorder la priorité à l'éducation des responsables, promouvoir des relations inter personnelles positives avec eux et surveiller les effets secondaires.

The association of socioeconomic deprivation and paediatric open tibia fractures.

The primary aim of this study is to test the association of open tibial fractures (OTF), in a paediatric age group, with socioeconomic deprivation. The secondary objectives are to more clearly define the epidemiological characteristics of these high-energy injuries. A consecutive series of patients with OTF presenting to a major trauma centre at a children's hospital in Liverpool had age, gender, fracture pattern, mechanism, timing of the injury and their postcode of residence recorded. Those cases outside Liverpool, Sefton and Knowsley local authorities were excluded from incidence calculations. Postcodes were used to generate deprivation scores (Index of Multiple Deprivation, 2010) based on census data (2011). Cases were ranked and allocated to deprivation quintiles. A comparison to the normal population within Merseyside was undertaken using regression analysis. There were 71 cases over a 9-year period. Fifty cases resided within the geographical limits of Merseyside and were included in the incidence calculations. The annual incidence of paediatric OTF is 3.09 per 100 000 children (0-16 years). The median age at injury was 11 years (range 2-16) and this occurred most usually during term-time between 3 and 5 p.m. from road traffic collisions. Paediatric OTFs are strongly associated with socioeconomic deprivation. The association with deprivation reflects an exposure to unsafe roads in busy urban areas with limited access to safe playing spaces. Socioeconomically deprived men are most at risk from this injury. The links between deprivation and outcomes of treatment or long-term prospects are unclear.

Lessons learned from community-based tuberculosis case-finding in western Kenya.

SETTING: Although Kenya has a high burden of tuberculosis (TB), only 46% of cases were diagnosed in 2016. OBJECTIVE: To identify strategies for increasing attendance at community-based mobile screening units. DESIGN: We analysed operational data from a cluster-randomised trial, which included community-based mobile screening implemented during February 2015-April 2016. Community health volunteers (CHVs) recruited individuals with symptoms from the community, who were offered testing for human immunodeficiency virus (HIV) and sputum collection for Xpert® MTB/RIF testing. We compared attendance across different mobile unit sites using Wilcoxon rank-sum test. RESULTS: A total of 1424 adults with symptoms were screened at 25 mobile unit sites. The median total attendance among sites was 54 (range 6-134, interquartile range [IQR] 24-84). The median yields of TB diagnoses and new HIV diagnoses were respectively 2.4% (range 0.0-16.7, IQR 0.0-5.3) and 2.5% (range 0.0-33.3, IQR 1.2-4.2). Attendance at urban sites was variable; attendance at rural sites where CHVs were paid a daily minimum wage was significantly higher than at rural sites where CHVs were paid a nominal monthly stipend (P < 0.001). CONCLUSION: Mobile units were most effective and efficient when implemented as a single event with community health workers who are paid a daily wage.

Optimizing the efficiency of tuberculosis active case-finding in health facilities and communities.

SETTING: Efficient tuberculosis (TB) active case-finding strategies are important in settings with high TB burdens and limited resources, such as those in western Kenya.OBJECTIVE: To guide efforts to optimize screening efficiency, we identified the predictors of TB among people screened in health facilities and communities.DESIGN: During February 2015-June 2016, adults aged ≥15 years reporting any TB symptom were identified in health facilities and community mobile screening units, and evaluated for TB. We assessed the predictors of TB using a modified Poisson regression with generalized estimating equations to account for clustering according to screening site.RESULTS: TB was diagnosed in 484 (20.3%) of 2394 symptomatic adults in health facilities and 39 (3.4%) of 1424 in communities. In health facilities, >10% of symptomatic adults in all demographic groups had TB, and no predictors were associated with a ≥2-fold increased risk. In communities, the independent predictors of TB were male sex (adjusted prevalence ratio [aPR] = 4.26, 95%CI 2.43-7.45), HIV infection (aPR 2.37, 95%CI 1.18-4.77), and household TB contact in the last 2 years (aPR 2.84, 95%CI 1.62-4.96).CONCLUSION: Our findings support the notion of general TB screening in health facilities and evaluation of the adult household contacts of TB patients.

The burden of multidrug-resistant tuberculosis in children.

BACKGROUND: Childhood tuberculosis (TB) has historically been neglected, although in recent years there has been increased focus on this problem. In particular, there have been two efforts to estimate the burden of pediatric multidrug-resistant TB (MDR-TB). METHODS: We review current estimates of the global incidence of pediatric MDR-TB disease. We then combine pediatric MDR-TB treatment data from the World Health Organization and recently published case fatality ratio estimates for children with TB to produce mortality estimates for children with MDR-TB. Finally, we combine treatment data and estimates of household size and disease risk to estimate how many children could be treated for probable or confirmed MDR-TB by carrying out household contact investigations around adult MDR-TB patients. RESULTS: Between 25 000 and 32 000 children develop MDR-TB disease annually, accounting for around 3% of all pediatric TB cases. Only 3-4% of these children are likely to receive MDR-TB treatment. We estimate that around 21% of children who develop MDR-TB disease will die. Carrying out household contact investigations around adult MDR-TB patients could find an estimated 12 times as many pediatric MDR-TB cases as are currently being identified. DISCUSSION: The diagnosis and treatment of children with MDR-TB needs to be prioritized by TB programs.

A rapid review of treatment literacy materials for tuberculosis patients.

OBJECTIVE: To assess available treatment literacy materials for patients undergoing treatment for tuberculosis (TB). DESIGN: We conducted a rapid review by searching the US Centers for Disease Control's Find TB Resources website and the websites of health departments and TB-focused organizations. We included English-language documents intended to educate TB patients about anti-tuberculosis treatment. We evaluated the format, readability, and content of documents, and audience. We defined 12 essential content elements based on those previously identified as facilitating human immunodeficiency virus treatment literacy. RESULTS: Of the 205 documents obtained, 45 were included in our review. The median reading grade level was 7 (IQR 5-8). The median number of essential content elements present was 6 (IQR 4-8), with the most comprehensive document containing 11 of the 12 elements. Only two documents were written for children with TB or their care givers, and two for patients with drug-resistant TB. Many documents contained paternalistic and non-patient-centered language. CONCLUSION: We found few examples of comprehensive, patient-centered documents. Work is needed to achieve consensus as to the essential elements of TB treatment literacy and to create additional materials for children, patients with drug-resistant TB, and those with lower literacy levels.

A systematic review of national policies for the management of persons exposed to tuberculosis.

OBJECTIVE: To describe mandates and policy gaps in tuberculosis (TB) contact investigation and management. DESIGN: We conducted a systematic review of national TB policy documents obtained using a systematic internet search and by contacting national TB programs. We included policies published in English, Spanish, and French, and abstracted data using a standardized form. RESULTS: We reviewed policy documents for 68 of 216 (31%) countries and territories. All countries recommended performing contact investigations, but 40% did not specify how contacts enter the health system for evaluation or who was responsible for this process. All countries recommended preventive therapy for contacts, but in 14 (21%) countries only young children were eligible. While four preventive therapy regimens exist, 48 (71%) countries recommended only isoniazid monotherapy. In addition, 28 (41%) countries lacked guidance on whether to give preventive therapy to contacts exposed to drug-resistant TB. Policies in 28 (41%) countries lacked recommendations for managing contacts with the human immunodeficiency virus (HIV) after new TB exposure. CONCLUSION: Policies recommending contact investigation and preventive therapy for contacts are widespread, but policy gaps exist in the areas of ensuring accountability and the management of vulnerable populations such as people living with HIV and those exposed to drug-resistant TB.

Comparison of a commercial interferon-gamma release assay and tuberculin skin test for the detection of latent tuberculosis infection in Hong Kong arthritis patients who are candidates for biologic agents.

INTRODUCTION: It is universally agreed that screening for latent tuberculosis infection prior to biologic therapy is necessary, especially in endemic areas such as Hong Kong. There are still, however, controversies regarding how best to accomplish this task. The tuberculin skin test has been the routine screening tool for latent tuberculosis infection in Hong Kong for the past decade although accuracy is far from perfect, especially in patients who have been vaccinated with Bacillus Calmette-Guérin, who are immunocompromised, or who have atypical mycobacterium infection. The new interferon-gamma release assays have been shown to improve specificity and probably sensitivity. This study aimed to evaluate agreement between the interferon-gamma release assay and the tuberculin skin test in the diagnosis of latent tuberculosis infection in patients with arthritic diseases scheduled to receive biologic agents. METHODS: We reviewed 38 patients with rheumatoid arthritis, psoriatic arthritis, or spondyloarthritis at a local hospital in Hong Kong from August 2013 to April 2014. They were all considered candidates for biologic agents. The patients underwent both the interferon-gamma release assay (ASACIR.TB; A.TB) and the tuberculin skin test simultaneously. Concurrent medications were documented. Patients who tested positive for either test (ie A.TB+ or TST+) were prescribed treatment for latent tuberculosis if they were to be given biologic agents. All patients were followed up regularly for 1 year and the development of active tuberculosis infection was evaluated. RESULTS: Based on an induration of 10 mm in diameter as the cut-off value, 13 (34.2%) of 38 patients had a positive tuberculin skin test. Of the 38 patients, 11 (28.9%) also had a positive interferon-gamma release assay. The agreement between interferon-gamma release assay and tuberculin skin test was 73.7% (kappa=0.39). Six patients were TST+/A.TB- and four were TST-/A.TB+. When positive tuberculin skin test was defined as an induration of 5-mm diameter, the agreement between the two tests improved with a kappa value of 0.47. In that case, half of the patients had a positive tuberculin skin test; among them, nine were TST+/A.TB-. Only one was TST-/A.TB+. Subgroup analysis showed that the agreement between both tests improved further (kappa=0.69) in patients not taking a concurrent systemic steroid. For patients prescribed systemic steroid, the agreement was only slight with a kappa value of 0.066. Finally, none of the 38 patients, of whom 32 had an exposure to biologic agents, developed active tuberculosis during the 1-year follow-up period. CONCLUSION: In a tuberculosis-endemic population, although 10-mm diameter induration is the usual cut-off for a positive tuberculin skin test, the level of agreement between the interferon-gamma release assay and tuberculin skin test improved from fair to moderate when the cut-off was lowered to 5 mm. A dual testing strategy of tuberculin skin test and interferon-gamma release assays appeared to be effective and should be pursued especially in patients who are on systemic steroid therapy. Nonetheless, the issue of potential overtreatment is yet to be evaluated.

Two methods for setting child-focused tuberculosis care targets.

OBJECTIVE: To allocate resources for household contact investigations, tuberculosis (TB) programs need estimates of the numbers of child contacts requiring care. DESIGN: We developed two methods to estimate annual numbers of child contacts aged 0-14 years requiring evaluation and treatment. Method 1 combines local data using simple formulas. Using publicly available data, Method 2 uses a linear regression model based on Demographic and Health Survey and World Bank data to estimate the number of children per household, then combines these results with case notifications and risk estimates of disease and infection. RESULTS: Applying Method 1 to data from Malawi indicated that every year ~21 000 child contacts require evaluation and ~1900 should be diagnosed with TB. Applying Method 2 to all countries suggested that, globally, 2.41 million (95% uncertainty interval [UI] 2.36-2.46) children aged <5 years, and 5.07 million (95%UI 4.81-5.34) children aged 5-14 years live in households of adult patients with known TB. Of these, 239 014 (95%UI 118 649-478581) and 419 816 (95%UI 140600-1 268805), respectively, will have TB. An additional 848 453 (95%UI 705838-1 017551) and 2660 885 (95%UI 2080517-3 413 189), respectively, will be infected. CONCLUSION: It is feasible to use available data to set programmatic evaluation and treatment targets to improve care for child contacts of patients with TB.

Objectif : Pour allouer des ressources aux recherches de contacts domiciliaires, les programmes de lutte contre la tuberculose (TB) ont besoin d'estimations du nombre d'enfants contacts nécessitant une prise en charge.Schéma : Nous avons élaboré deux méthodes afin d'estimer les nombres annuels d'enfants contacts âgés de 0­14 ans requérant une évaluation et un traitement. La Méthode 1 combine des données locales utilisant des formules simples. En utilisant les données disponibles publiquement, la Méthode 2 se sert d'un modèle de régression linéaire basé sur les données de l'Enquête Démographie et Santé et celles de la Banque Mondiale afin d'estimer le nombre d'enfants dans chaque famille, puis de combiner ces résultats avec ceux de la déclaration des cas et des estimations de risque de maladie et d'infection.Résultats : En appliquant la Méthode 1 aux données du Malawi, nous avons abouti à ce que ~21 000 enfants contacts par an requéraient une évaluation et ~1900 devraient avoir un diagnostic de TB. Appliquer la Méthode 2 à tous les pays a suggéré que, dans le monde, 2,41 millions d'enfants âgés de <5 ans (intervalle d'incertitude [II] à 95% 2,36­2,46 millions) et 5,07 millions (II95% 4,81­5,34 millions) d'enfants âgés de 5­14 ans vivent dans des foyers comprenant un patient adulte atteint de TB chaque année. Parmi eux, 239 014 (II95% 118 649­478 581) et 419 816 (II95% 140 600­1 268 805), respectivement, auront la TB et 848 453 autres enfants (II95% 705838­1017 551) et 2660 885 (II95% 2080 517­3413 189) seront infectés.Conclusion : Il est possible d'utiliser les données disponibles pour établir des objectifs d'évaluation programmatique et de traitement afin d'améliorer la prise en charge des enfants contacts de patients tuberculeux.

Objetivo: Para designar los recursos necesarios para la evaluación de contactos de pacientes con tuberculosis (TB), los programas necesitan estimados de cuántos contactos niños requieren atención.Diseño: Desarrollamos dos métodos de estimar cuántos contactos que tienen 0­14 años requieren evaluación y tratamiento cada año. Método 1 usa información local y fórmulas sencillos. Usando información pública, Método 2 usa un modelo de regresión lineal basado en datos de las Encuestas Demográficas y de Salud y del Banco Mundial para estimar el número de niños en cada domicilio, y luego combina estos resultados con números reportados de casos de TB y con estimados del riesgo de enfermedad e infección con TB.Resultados: Aplicando el Método 1 a datos de Malawi indica que cada año, ~21 000 contactos niños deben ser evaluados y ~1900 deben ser diagnosticados con TB. Aplicando el Método 2 a datos de todos los países del mundo indica que cada año, al nivel mundial, hay 2,41 millón (intervalo de incertidumbre [II] de 95% 2,36­2,46 millón) de niños de edad <5 años, y 5,07 millón (II95% 4,81­5,34 millón) de niños que tienen 5­14 años, quienes viven en domicilios de adultos que se sabe son pacientes con TB. De estos niños, 239 014 (II95% 118649­478 581) y 419816 (II95% 140600­1 268 805), respectivamente, estarán enfermos con TB. Además, 848 453 (II95% 705838­1 017551) y 2 660 885 (II95% 2080 517­3 413189) estarán infectados con TB pero no enfermos.Conclusión: Es factible usar datos disponibles para generar metas programáticas para la evaluación y el tratamiento, con el fin de mejorar la atención a los contactos niños de pacientes con TB.

Vertebral Fractures: Clinical Importance and Management.

Vertebral fractures are common and can result in acute and chronic pain, decreases in quality of life, and diminished lifespan. The identification of vertebral fractures is important because they are robust predictors of future fractures. The majority of vertebral fractures do not come to clinical attention. Numerous modalities exist for visualizing suspected vertebral fracture. Although differing definitions of vertebral fracture may present challenges in comparing data between different investigations, at least 1 in 5 men and women aged >50 years have one or more vertebral fractures. There is clinical guidance to target spine imaging to individuals with a high probability of vertebral fracture. Radiology reports of vertebral fracture need to clearly state that the patient has a "fracture," with further pertinent details such as the number, recency, and severity of vertebral fracture, each of which is associated with risk of future fractures. Patients with vertebral fracture should be considered for antifracture therapy. Physical and pharmacologic modalities of pain control and exercises or physiotherapy to maintain spinal movement and strength are important components in the care of vertebral fracture patients.

Map the gap: missing children with drug-resistant tuberculosis.

BACKGROUND: The lack of published information about children with multidrug-resistant tuberculosis (MDR-TB) is an obstacle to efforts to advocate for better diagnostics and treatment. OBJECTIVE: To describe the lack of recognition in the published literature of MDR-TB and extensively drug-resistant TB (XDR-TB) in children. DESIGN: We conducted a systematic search of the literature published in countries that reported any MDR- or XDR-TB case by 2012 to identify MDR- or XDR-TB cases in adults and in children. RESULTS: Of 184 countries and territories that reported any case of MDR-TB during 2005-2012, we identified adult MDR-TB cases in the published literature in 143 (78%) countries and pediatric MDR-TB cases in 78 (42%) countries. Of the 92 countries that reported any case of XDR-TB, we identified adult XDR-TB cases in the published literature in 55 (60%) countries and pediatric XDR-TB cases for 9 (10%) countries. CONCLUSION: The absence of publications documenting child MDR- and XDR-TB cases in settings where MDR- and XDR-TB in adults have been reported indicates both exclusion of childhood disease from the public discourse on drug-resistant TB and likely underdetection of sick children. Our results highlight a large-scale lack of awareness about children with MDR- and XDR-TB.

Cadre : La pénurie d'informations publiées sur la tuberculose multirésistante (TB-MDR) de l'enfant entrave les efforts visant à en améliorer le diagnostic et le traitement.Objectif : Décrire le manque de reconnaissance de la TB-MDR et de la TB ultra-résistante (TB-XDR) de l'enfant dans la littérature publiée.Schéma : Nous avons réalisé une recherche systématique de la littérature publiée dans les pays qui ont déclaré au moins un cas de TB-MDR ou -XDR avant 2012 afin d'identifier des cas de TB-MDR ou -XDR chez des adultes et des enfants.Résultats : Sur les 184 pays et territoires qui ont déclaré des cas de TB-MDR entre 2005 et 2012, nous avons identifié des cas de TB-MDR de l'adulte dans la littérature dans 143 (78%) pays et des cas de TB-MDR pédiatrique dans 78 (42%) pays. Sur les pays qui ont déclaré des cas de TB-XDR, nous avons identifié des cas adultes dans la littérature dans 55 (60%) pays et des cas pédiatriques dans 9 (10%) pays.Conclusion : L'absence de publications documentant les cas de TB-MDR et -XDR chez l'enfant dans des régions où la TB-MDR et la TB-XDR ont été déclarées chez les adultes témoigne à la fois d'une exclusion de la maladie de l'enfant du discours public sur la TB pharmacorésistante et probablement d'une sous-détection des enfants malades. Nos résultats mettent en évidence un manque de connaissance à grande échelle de la TB-MDR et de la TB-XDR de l'enfant.

Marco de referencia: La falta de información publicada sobre los niños con tuberculosis multidrogo-resistente (TB-MDR) es un obstáculo a los esfuerzos para abogar por mejores diagnósticos y tratamientos.Objetivos: Describir la falta de reconocimiento en la literatura publicada de la TB-MDR y la TB extremadamente resistente (TB-XDR) en los niños.Métodos: Para los países que hasta 2012 habían informado de algún caso de TB-MDR o TB-XDR, realizamos una búsqueda sistemática de la literatura publicada para identificar casos de TB-MDR o TB-XDR en adultos y en niños.Resultados: De los 184 países y territorios que informaron algún caso de TB-MDR durante 2005­2012, encontramos reportes de casos de TB-MDR en adultos en la literatura publicada para 143 (78%) países, y reportes de casos de TB-MDR pediátricos para 78 (42%) países. De los 92 países que informaron algún caso de TB-XDR, encontramos reportes de casos de TB-XDR en adultos en la literatura publicada para 55 (60%) países y reportes de casos de TB-XDR pediátricos para 9 (10%) países.Conclusión: La ausencia de publicaciones que documentan casos de TB-MDR y TB-XDR pediátricos en lugares donde casos de TB-MDR y TB-XDR en adultos han sido reportados indica tanto la exclusión de enfermedad infantil del discurso público sobre la TB drogo-resistente y la probable sub-detección de niños enfermos. Nuestros resultados recalcan la falta de reconocimiento a gran escala de los niños con TB-MDR y TB-XDR.