The association between common mental disorders and tuberculosis: a case-control study from Guinea-Bissau.

OBJECTIVE: The aim of the study was to explore the association between tuberculosis (TB) and common mental disorders (CMD), in an area with high prevalence of TB. METHODS: We performed a case-control study of TB patients and unmatched healthy controls, from a demographic surveillance site in Guinea-Bissau. Screening for CMD was performed once for controls and at inclusion and follow-up for TB patients. Kessler 10 (K-10) and a brief version of Hopkins Symptom Checklist 25 (SCL-8d) were used as screening instruments. RESULTS: 571 controls were interviewed and 416 interviews were performed for 215 TB cases. Estimated CMD prevalence at the time of diagnosis of TB was 33.6 % (SCL-8d) and 46.2 % (K-10), compared with 6.8 % (SCL-8d) and 6.7 % (K-10) among controls; adjusted OR 7.18 (95 % CI 4.07 to 12.67) and 14.52 (95 % CI 8.15 to 25.84), respectively. No significant difference in CMD prevalence rates was observed between TB patients, after 6 months of treatment, and controls. CONCLUSION: Psychological distress and common mental disorders were more prevalent among TB patients at the time of diagnosis compared with the background population, but after completion of TB treatment no increased prevalence of psychological distress was found.

Neonatal BCG vaccination and child survival in TB-exposed and TB-unexposed children: a prospective cohort study.

OBJECTIVES: To assess the association between neonatal BCG vaccination and mortality between 28 days and 3 years of age among tuberculosis (TB)-exposed and TB-unexposed children. DESIGN: Prospective cohort study. SETTING: Bandim Health Project runs an urban Health and Demographic Surveillance site in Guinea-Bissau with registration of mortality, vaccination status and TB cases. PARTICIPANTS: Children entered the analysis when their vaccination card was inspected after 28 days of age and remained under surveillance to 3 years of age. Children residing in the same house as a TB case were classified as TB-exposed from 3 months prior to case registration to the end of follow-up. METHODS: Using Cox-proportional hazards models with age as underlying time scale, we compared mortality of children with and without neonatal BCG between October 2003 and September 2017. MAIN OUTCOME MEASURE: HR for neonatal BCG compared with no neonatal BCG by TB-exposure status. RESULTS: Among the 39 421 children who entered the analyses, 3022 (8%) had observation time as TB-exposed. In total, 84% of children received neonatal BCG. Children with neonatal BCG had lower mortality both in TB-exposed (adjusted HR: 0.57 (0.26 to 1.27)) and in TB-unexposed children (HR: 0.57 (95% CI 0.47 to 0.69)) than children without neonatal BCG. Children exposed to TB had higher mortality than TB-unexposed children if they had not received neonatal BCG. CONCLUSION: Neonatal BCG vaccination was associated with lower mortality among both TB-exposed and TB-unexposed children, consistent with neonatal BCG vaccination having beneficial non-specific effects. Interventions to increase timely BCG vaccination are urgently warranted.

Dietary intake in undernourished adults living in Guinea-Bissau; a cross-sectional study.

BACKGROUND: Data on dietary intake in Guinea-Bissau is limited. The main purpose of this study was to compare mean daily energy intake (EI) with mean daily energy expenditure (EE) for a moderately active lifestyle in health-seeking individuals with a body mass index < 20.0 kg/m2. Furthermore, dietary composition was evaluated by estimates of macronutrient energy distribution, individual dietary diversity scores, and the identification of frequently consumed food items, stratified by sex. METHODS: A cross-sectional dietary survey was conducted at the suburban health- and demographic surveillance site in Guinea-Bissau, West Africa, from May 2014-February 2015. Each participant answered one interviewer-administered 24-h dietary recall at baseline, from which dietary intake was assessed. Differences in dietary intake between men and women were analysed using the X 2 test or Fisher's Exact test for categorical outcomes, and the Student's t-test for continuous variables. RESULTS: Forty-three men and forty-eight women were included. Mean EI for men was 6326 kJ/d (sd 2104) and for women 6822 kJ/d (sd 2210). Mean EE for a moderately active lifestyle with a physical activity level of 1.75 was 10,479 kJ/d (sd 658) for men and 8729 kJ/d (sd 731) for women. Both men and women had a significantly lower mean EI compared with mean EE (p-values both < 0.001). Dietary diversity was low with a score of 3.5 (sd 1.0) for men and 4.0 (sd 1.3) for women, p-value 0.046. Macronutrient energy was distributed as 66% (sd 11) carbohydrate, 15% (sd 5) protein, and 19% (sd 9) fat, with no significant difference in distribution between men and women. Consumption of starchy and sugary carbohydrates accounted for two thirds of mean EI. Cereals were the main source of protein, in place of animal protein. CONCLUSIONS: Both men and women in this study had low mean EI compared with mean EE for a moderately active lifestyle. Dietary intake was characterized by a seemingly low dietary diversity and imbalanced macronutrient energy distribution, comprising insufficient fat intake and excess carbohydrate intake. Cereals were the main source of protein. TRIAL REGISTRATION: PACTR2009110001673419. Registered 22 Oct 2009.

TBscore II: refining and validating a simple clinical score for treatment monitoring of patients with pulmonary tuberculosis.

BACKGROUND: The TBscore, based on simple signs and symptoms, was introduced to predict unsuccessful outcome in tuberculosis patients on treatment. A recent inter-observer variation study showed profound variation in some variables. Further, some variables depend on a physician assessing them, making the score less applicable. The aim of the present study was to simplify the TBscore. METHODS: Inter-observer variation assessment and exploratory factor analysis were combined to develop a simplified score, the TBscore II. To validate TBscore II we assessed the association between start score and failure (i.e. death or treatment failure), responsiveness using Cohen's effect size, and the relationship between severity class at treatment start and a decrease < 25% in score from the start until the end of the second treatment month and subsequent mortality. RESULTS: We analyzed data from 1070 Guinean (2003-2012) and 432 Ethiopian (2007-2012) pulmonary tuberculosis patients. For the refined score, items with less than substantial agreement (κ ≤ 0.6) and/or not associated with the underlying constructs were excluded. Items kept were: cough, dyspnea, chest pain, anemia, body mass index (BMI) < 18 kg/m(2), BMI < 16 kg/m(2), mid upper arm circumference (MUAC) < 220 mm, and MUAC < 200 mm. The effect sizes for the change between the start of treatment and the 2-month follow-up were 0.51 in Guinea-Bissau and 0.68 in Ethiopia, and for the change between the start of treatment and the end of treatment were 0.68 in Guinea-Bissau and 0.74 in Ethiopia. Severity class placement at treatment start predicted failure (p < 0.001 Guinea-Bissau, p = 0.208 Ethiopia). Inability to decrease at least 25% in score was associated with a higher failure rate during the remaining 4 months of treatment (p = 0.063 Guinea-Bissau, p = 0.008 Ethiopia). CONCLUSION: The TBscore II could be a useful monitoring tool, aiding triage at the beginning of treatment and during treatment.

Impact of isoniazid preventive therapy on mortality among children less than 5 years old following exposure to tuberculosis at home in Guinea-Bissau: a prospective cohort study.

OBJECTIVE: In a cohort of children less than 5 years old exposed to adult intrathoracic tuberculosis (TB) in 1996-1998, we found 66% increased mortality compared with community controls. In 2005, we implemented isoniazid preventive therapy (IPT) for children exposed to TB at home, and the present study evaluates the effect of this intervention on mortality. SETTING: This prospective cohort study was conducted in six suburban areas included in the demographic surveillance system of the Bandim Health Project in Bissau, the capital city of Guinea-Bissau. PARTICIPANTS: All children less than 5 years of age and living in the same house as an adult with intrathoracic TB registered for treatment in the study area between 2005 and 2007 were evaluated for inclusion in the IPT programme. MAIN OUTCOME MEASURES (END POINTS): The all-cause mortality rate ratio (MRR) between exposed children on IPT, exposed without IPT and unexposed community control children. RESULTS: A total of 1396 children were identified as living in the same houses as 416 adult TB cases; of those, 691 were enrolled in the IPT programme. Compared with community controls, the IPT children had an MRR of 0.30 (95%CI 0.1 to 1.2). The MRR comparing exposed children with and without IPT was 0.21 (0.0 to 1.1). The relative mortality in IPT children compared with community controls in 2005-2008 differed significantly from the relative mortality of exposed untreated children compared with the community controls in 1996-1998 (test of interaction, p=0.01). CONCLUSIONS: In 2005-2008, exposed children on IPT had 70% lower mortality than the community control children, though not significantly. Relative to the community control children, the mortality among TB-exposed children on IPT in 2005-2008 was significantly lower than the mortality among TB-exposed children not on IPT in 1996-1998.

Utility of the plasma level of suPAR in monitoring risk of mortality during TB treatment.

OBJECTIVE: To investigate whether changes in the plasma level of soluble urokinase plasminogen activator receptor (suPAR) can be used to monitor tuberculosis (TB) treatment efficacy. DESIGN: This prospective cohort study included 278 patients diagnosed with active pulmonary TB and followed throughout the 8-month treatment period. RESULTS: Mortality during treatment was higher in the highest inclusion quartile of suPAR (23%) compared to the lowest three quartiles (7%), the risk ratio being 3.1 (95% CI 1.65-6.07). No association between early smear conversion and subsequent mortality or inclusion suPAR was observed. After 1 and 2 months of treatment, an increase in suPAR compared to at diagnosis was associated with a Mortality Rate Ratio (MRR) of 4.5 (95%CI: 1.45-14.1) and 2.1 (95%CI 0.62-6.82), respectively, for the remaining treatment period. CONCLUSIONS: The present study confirmed that elevated suPAR level at time of initiation of TB treatment is associated with increased risk of mortality. Furthermore, increased suPAR levels after one month of treatment was associated with increased risk of mortality during the remaining 7-month treatment period.

High mortality risk among individuals assumed to be TB-negative can be predicted using a simple test.

OBJECTIVES: To determine mortality among assumed TB negative (aTBneg) individuals in Guinea-Bissau and to investigate whether plasma levels of soluble urokinase receptor (suPAR) can be used to determine post-consultation mortality risk. METHODS: This prospective West-African cohort study included 1007 aTBneg individuals who were enrolled from 2004 to 2006; 4983 age-matched controls were followed for comparison. Plasma suPAR levels were measured using the suPARnostic ELISA. Survival was analysed using Cox regression, ROC curves and Kaplan-Meier analysis. RESULTS: After 3 months of follow-up, mortality was 21 per 100 person-year-observation (PYO) among aTBneg individuals and three per 100 PYO among the control population [mortality rate ratio (MRR) = 6.92 (95% CI 4.48-10.7)]. SuPAR values ranged between 0.9 and 45 ng/ml in aTBneg individuals. A log-linear relationship was found between suPAR levels <15 ng/ml and mortality. In the log-linear range, a 1 ng/ml increase was associated with a 46% increase in the mortality rate: MRR = 1.46 (95% CI 1.34-1.59). The area under the ROC curves was 0.88 for HIV-positive individuals and 0.79 for HIV-negative individuals. CONCLUSIONS: Our study showed a high mortality rate among aTBneg individuals and demonstrated that suPAR measurements can provide prognostic information on mortality among individuals without disease diagnosis. Measuring suPAR is a technically simple method for determining mortality risk in individuals that are assumed to be TB-negative.

TBscore: Signs and symptoms from tuberculosis patients in a low-resource setting have predictive value and may be used to assess clinical course.

We developed a clinical score to monitor tuberculosis patients in treatment and to assess clinical outcome. We used the WHO clinical manual to choose signs and symptoms, including cough, haemoptysis, dyspnoea, chest pain, night sweating, anaemia, tachycardia, lung-auscultation finding, fever, low body-mass index, low mid-upper arm circumference giving patients a TBscore from 0 to 13. We validated the score with data from a cohort of 698 TB patients, assessing sensitivity to change and ability to predict mortality. The TBscore declined for 96% of the surviving patients from initiation to end of treatment, and declined with a similar pattern in HIV-infected and HIV-uninfected patients, as well as in smear negative and smear positive patients. The risk of dying during treatment increased with higher TBscore at inclusion. For patients with a TBscore of >8 at inclusion, mortality during the 8 months treatment was 21% (45/218) versus 11% (55/480) for TBscore <8 (p< 0.001). TBscore assessed at end of treatment also strongly predicted subsequent mortality. The TBscore is a simple and low-cost tool for clinical monitoring of tuberculosis patients in low-resource settings and may be used to predict mortality risk. Low TBscore or fall in TBscore at treatment completion may be used as a measure of improvement.