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1.
PLoS One ; 16(1): e0245328, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33481816

RESUMO

One principle of tuberculosis control is to prevent the development of tuberculosis disease by treating individuals with latent tuberculosis infection. The diagnosis of latent infection using the tuberculin skin test is not straightforward because of concerns about immunologic cross reactivity with the Bacille Calmette-Guerin (BCG) vaccine and environmental mycobacteria. To parse the effects of BCG vaccine and environmental mycobacteria on the tuberculin skin test, we estimated the frequency distribution of skin test results in two divisions of Kampala, Uganda, ten years apart. We then used mixture models to estimate parameters for underlying distributions and defined clinically meaningful criteria for latent infection, including an indeterminate category. Using percentiles of two underlying normal distributions, we defined two skin test readings to demarcate three ranges. Values of 10 mm or greater contained 90% of individuals with latent infection; values less than 7.2 mm contained 80% of individuals without infection. Contacts with values between 7.2 and 10 mm fell into an indeterminate zone where it was not possible to assign infection. We conclude that systematic tuberculin skin test surveys within populations at risk, combined with mixture model analysis, may be a reproducible, evidence-based approach to define meaningful criteria for latent tuberculosis infection.

3.
Clin Infect Dis ; 2020 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-33064142

RESUMO

RATIONALE: Although households of tuberculosis cases represent a setting for intense transmission of M. tuberculosis, household exposure accounts for less than 20% of transmission within a community. OBJECTIVES: To estimate excess risk of M. tuberculosis infection among household and extra-household contacts of index cases. METHODS: We performed a cross-sectional study in Kampala, Uganda, to delineate social networks of tuberculosis cases and matched controls without tuberculosis. We estimated the age-stratified prevalence difference of tuberculous infection between case and control networks, partitioned as household and extra-household contacts. RESULTS: We enrolled 123 index cases, 124 index controls, and 2415 first-degree network contacts. The prevalence of infection was highest among household contacts of cases (61.5%), lowest among household contacts of controls (25.2%), and intermediary among extra-household tuberculosis contacts (44.9%) and extra-household control contacts (41.2%). The age-adjusted prevalence difference between extra-household contacts of cases and their controls was 5.4%. The prevalence of infection was similar among the majority of extra-household case contacts and corresponding controls (47%). CONCLUSIONS: Most first-degree social network members of tuberculosis cases do not have adequate contact with the index case to experience additional risk for infection but appear instead to acquire infection through unrecognized exposures with infectious cases in the community.

4.
JMIR Res Protoc ; 2020 Sep 16.
Artigo em Inglês | MEDLINE | ID: mdl-32990629

RESUMO

BACKGROUND: The End TB Strategy envisions a world free of tuberculosis (TB)-zero deaths, disease, and suffering due to TB by 2035. Non-adherence reduces cure rates, prolongs infectiousness, and contributes to the emergence of multi-drug resistant TB (MDR-TB). Moreover, MDR-TB is a growing, complex, and costly problem that presents a major obstacle to TB control. Directly observed therapy (DOT) for treatment adherence monitoring is the recommended standard, however, it is challenging to implement at scale because it is labor-intensive. Mobile health interventions can facilitate remote adherence monitoring and minimize the costs and inconveniences associated with standard DOT. OBJECTIVE: The DOT Selfie study aims to evaluate the effectiveness of using Video Directly Observed Treatment (VDOT) plus incentives to improve medication adherence in TB treatment versus usual care DOT in an African context. METHODS: The DOT Selfie study is an open-label, randomized controlled trial (RCT) with two parallel groups, in which 144 adult TB patients aged 18-65 years will be randomly assigned to receive the usual care DOT monitoring or VDOT as the intervention. The intervention will consist of a smartphone App, a weekly internet subscription, translated text message reminders, and incentives for those who adhere. The participant will use a smartphone to record and send time-stamped encrypted videos showing his/her daily medication ingestion. This video component will directly substitute the need for daily face-to-face meetings between the health provider and patients. We hypothesize that the VDOT intervention will be more effective because it allows patients to swallow their pills anywhere, anytime. Moreover, patients will receive mobile-phone-based 'social bundle' incentives to motivate adherence to continued daily submission of videos to the health system. The health providers will log into a secured computer system to verify treatment adherence, document missed doses, investigate the reasons for missed doses, and follow pre-specified protocol measures to reestablish medication adherence. The primary endpoint is the adherence level as measured by the fraction of expected doses observed over the treatment period. The main secondary outcome will be time-to-treatment completion in both groups. RESULTS: This study was funded in 2019, enrollment began in July and is expected to be complete by November 2020. Data collection and follow-up are expected to be completed by June 2021. Results from the analyses based on the primary endpoint are expected to be submitted for publication by December 2021. CONCLUSIONS: This RCT will be among the first to evaluate the effectiveness of VDOT within an African setting. The results will provide robust scientific evidence on the implementation and adoption of mobile Health (mHealth) tools coupled with incentives to motivate TB medication adherence. If successful, VDOT will be applicable to other low-income settings and a range of chronic diseases with lifelong treatment such as HIV/AIDs. CLINICALTRIAL: ClinicalTrials.gov NCT04134689; http://clinicaltrials.gov/ct2/show/NCT04134689.

5.
Clin Infect Dis ; 2020 Aug 08.
Artigo em Inglês | MEDLINE | ID: mdl-32770236

RESUMO

BACKGROUND: There are large knowledge gaps on the transmission dynamics of Mycobacterium tuberculosis in settings where both tuberculosis and HIV are endemic. We aimed to assess the infectiousness of tuberculosis patients coinfected with HIV. METHODS: We systematically searched for studies of contacts of both HIV-positive and negative tuberculosis index cases. Our primary outcome was Mycobacterium tuberculosis infection in contacts. Data on sputum smear and lung cavitation status of index cases was extracted from each study to assess effect modification. Secondary outcomes included prevalent tuberculosis and HIV in contacts of HIV-positive and negative index cases. RESULTS: Of 5,255 original citations identified, 32 studies met inclusion criteria including 25 studies investigating M. tuberculosis infection (Nparticipants=36,893), 13 on tuberculosis (Nparticipants=18,853), and 12 on HIV positivity (Nparticipants=18,424). Risk of M. tuberculosis infection was lower in contacts of HIV-positive index cases (Odds Ratio [OR], 0.67, 95% CI, 0.58-0.77) but was heterogeneous (I2=75.1%). Two factors modified this relationship: the lung cavitary status of the index case and immunosuppression (measured through CD4 counts or HIV or AIDS diagnoses) among index patients living with HIV. Rates of HIV were consistently higher in contacts of coinfected index cases (OR, 4.9, 95% CI, 3.0-8.0). This was modified by whether the study was in sub-Saharan Africa (OR, 2.8, 1.6-4.9) or in another global region (OR, 9.8, 5.9-16.3). CONCLUSIONS: Tuberculosis patients coinfected with HIV are less infectious than HIV-uninfected cases when they have severe immunosuppression or paucibacillary disease. Contacts of coinfected index cases are almost five times more likely to also have HIV.

6.
BMC Public Health ; 20(1): 892, 2020 Jun 09.
Artigo em Inglês | MEDLINE | ID: mdl-32517672

RESUMO

BACKGROUND: The risk of infection from respiratory pathogens increases according to the contact rate between the infectious case and susceptible contact, but the definition of adequate contact for transmission is not standard. In this study we aimed to identify factors that can explain the level of contact between tuberculosis cases and their social networks in an African urban environment. METHODS: This was a cross-sectional study conducted in Kampala, Uganda from 2013 to 2017. We carried out an exploratory factor analysis (EFA) in social network data from tuberculosis cases and their contacts. We evaluated the factorability of the data to EFA using the Kaiser-Meyer-Olkin Measure of Sampling Adequacy (KMO). We used principal axis factoring with oblique rotation to extract and rotate the factors, then we calculated factor scores for each using the weighted sum scores method. We assessed construct validity of the factors by associating the factors with other variables related to social mixing. RESULTS: Tuberculosis cases (N = 120) listed their encounters with 1154 members of their social networks. Two factors were identified, the first named "Setting" captured 61% of the variance whereas the second, named 'Relationship' captured 21%. Median scores for the setting and relationship factors were 10.2 (IQR 7.0, 13.6) and 7.7 (IQR 6.4, 10.1) respectively. Setting and Relationship scores varied according to the age, gender, and nature of the relationship among tuberculosis cases and their contacts. Family members had a higher median setting score (13.8, IQR 11.6, 15.7) than non-family members (7.2, IQR 6.2, 9.4). The median relationship score in family members (9.9, IQR 7.6, 11.5) was also higher than in non-family members (6.9, IQR 5.6, 8.1). For both factors, household contacts had higher scores than extra-household contacts (p < .0001). Contacts of male cases had a lower setting score as opposed to contacts of female cases. In contrast, contacts of male and female cases had similar relationship scores. CONCLUSIONS: In this large cross-sectional study from an urban African setting, we identified two factors that can assess adequate contact between tuberculosis cases and their social network members. These findings also confirm the complexity and heterogeneity of social mixing.


Assuntos
Família , Mycobacterium tuberculosis , Meio Social , Rede Social , Tuberculose/transmissão , Adolescente , Adulto , Criança , Pré-Escolar , Busca de Comunicante , Estudos Transversais , Características da Família , Feminino , Humanos , Lactente , Recém-Nascido , Relações Interpessoais , Masculino , Pessoa de Meia-Idade , Tuberculose/epidemiologia , Tuberculose/microbiologia , Uganda/epidemiologia , Adulto Jovem
7.
Am J Trop Med Hyg ; 103(1_Suppl): 36-41, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32400342

RESUMO

In 2010, the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) began the design of randomized controlled trials to compare different strategies for praziquantel mass drug administration, whether for gaining or sustaining control of schistosomiasis or for approaching local elimination of Schistosoma transmission. The goal of this operational research was to expand the evidence base for policy-making for regional and national control of schistosomiasis in sub-Saharan Africa. Over the 10-year period of its research programs, as SCORE operational research projects were implemented, their scope and scale posed important challenges in terms of research performance and the final interpretation of their results. The SCORE projects yielded valuable data on program-level effectiveness and strengths and weaknesses in performance, but in most of the trials, a greater-than-expected variation in community-level responses to assigned schedules of mass drug administration meant that identification of a dominant control strategy was not possible. This article critically reviews the impact of SCORE's cluster randomized study design on performance and interpretation of large-scale operational research such as ours.


Assuntos
Esquema de Medicação , Administração Massiva de Medicamentos , Esquistossomose/tratamento farmacológico , África ao Sul do Saara/epidemiologia , Animais , Anti-Helmínticos/uso terapêutico , Humanos , Praziquantel/uso terapêutico , Prevalência , Projetos de Pesquisa , Schistosoma haematobium/efeitos dos fármacos , Schistosoma mansoni/efeitos dos fármacos , Esquistossomose/epidemiologia , Esquistossomose/transmissão
8.
Am J Trop Med Hyg ; 103(1_Suppl): 30-35, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32400348

RESUMO

The Schistosomiasis Consortium for Operational Research (SCORE) was funded in 2008 to improve the evidence base for control and elimination of schistosomiasis-better understanding of the systemic morbidities experienced by children in schistosomiasis-endemic areas and the response of these morbidities to treatment, being essential for updating WHO guidelines for mass drug administration (MDA) in endemic areas. This article summarizes the SCORE studies that aimed to gauge the impact of MDA-based treatment on schistosomiasis-related morbidities. Morbidity cohort studies were embedded in the SCORE's larger field studies of gaining control of schistosomiasis in Kenya and Tanzania. Following MDA, cohort children had less undernutrition, less portal vein dilation, and increased quality of life in Year 5 compared with baseline. We also conducted a pilot study of the Behavioral Assessment System for Children (BASC-2) in conjunction with the Kenya gaining control study, which demonstrated beneficial effects of treatment on classroom behavior. In addition, the SCORE's Rapid Answers Project performed systematic reviews of previously available data, providing two meta-analyses related to morbidity. The first documented children's infection-related deficits in school attendance and achievement and in formal tests of learning and memory. The second showed that greater reductions in egg output following drug treatment correlates significantly with reduced odds of most morbidities. Overall, these SCORE morbidity studies provided convincing evidence to support the use of MDA to improve the health of school-aged children in endemic areas. However, study findings also support the need to use enhanced metrics to fully assess and better control schistosomiasis-associated morbidity.


Assuntos
Schistosoma/patogenicidade , Esquistossomose Urinária , Esquistossomose mansoni , Adolescente , Animais , Criança , Estudos de Coortes , Feminino , Humanos , Quênia/epidemiologia , Masculino , Administração Massiva de Medicamentos , Morbidade , Contagem de Ovos de Parasitas , Praziquantel/uso terapêutico , Prevalência , Schistosoma/efeitos dos fármacos , Schistosoma haematobium/efeitos dos fármacos , Schistosoma haematobium/patogenicidade , Schistosoma mansoni/efeitos dos fármacos , Schistosoma mansoni/patogenicidade , Esquistossomose Urinária/tratamento farmacológico , Esquistossomose Urinária/epidemiologia , Esquistossomose mansoni/tratamento farmacológico , Esquistossomose mansoni/epidemiologia , Instituições Acadêmicas , Tanzânia/epidemiologia
9.
Am J Trop Med Hyg ; 103(1_Suppl): 105-113, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32400352

RESUMO

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was created to conduct research that could inform programmatic decision-making related to schistosomiasis. SCORE included several large cluster randomized field studies involving mass drug administration (MDA) with praziquantel. The largest of these were studies of gaining or sustaining control of schistosomiasis, which were conducted in five African countries. To enhance relevance for routine practice, the MDA in these studies was coordinated by or closely aligned with national neglected tropical disease (NTD) control programs. The study protocol set minimum targets of at least 90% for coverage among children enrolled in schools and 75% for all school-age children. Over the 4 years of intervention, an estimated 3.5 million treatments were administered to study communities. By year 4, the median village coverage was at or above targets in all studies except that in Mozambique. However, there was often a wide variation behind these summary statistics, and all studies had several villages with very low or high coverage. In studies where coverage was estimated by comparing the number of people treated with the number eligible for treatment, denominator estimation was often problematic. The SCORE experiences in conducting these studies provide lessons for future efforts that attempt to implement strong research designs in real-world contexts. They also have potential applicability to country MDA campaigns against schistosomiasis and other NTDs, most of which are conducted with less logistical and financial support than was available for the SCORE study efforts.


Assuntos
Anti-Helmínticos/uso terapêutico , Administração Massiva de Medicamentos , Esquistossomose/tratamento farmacológico , África , Animais , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Moçambique , Doenças Negligenciadas/tratamento farmacológico , Doenças Negligenciadas/prevenção & controle , Praziquantel/uso terapêutico , Prevalência , Saúde Pública , População Rural , Schistosoma , Esquistossomose/prevenção & controle , Instituições Acadêmicas
10.
Glob Public Health ; 15(6): 877-888, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32027555

RESUMO

Identifying and reducing TB-related costs is necessary for achieving the End TB Strategy's goal that no family is burdened with catastrophic costs. This study explores costs during the pre-diagnosis period and assesses the potential for using coping costs as a proxy indicator for catastrophic costs when comprehensive surveys are not feasible. Detailed interviews about TB-related costs and productivity losses were conducted with 196 pulmonary TB patients in Kampala, Uganda. The threshold for catastrophic costs was defined as 20% of household income. Multivariable regression analyses were used to assess the influence of patient characteristics on economic burden, and the positive predictive value (PPV) of coping costs was estimated. Over 40% of patients experienced catastrophic costs, with average (median) pre-diagnosis costs making up 30.6% (14.1%) of household income. Low-income status (AOR = 2.91, 95% CI = 1.29, 6.72), hospitalisation (AOR = 8.66, 95% CI = 2.60; 39.54), and coping costs (AOR = 3.84, 95% CI = 1.81; 8.40) were significantly associated with the experience of catastrophic costs. The PPV of coping costs as an indicator for catastrophic costs was estimated to be 73% (95% CI = 58%, 84%). TB patients endure a substantial economic burden during the pre-diagnosis period, and identifying households that experience coping costs may be a useful proxy measure for identifying catastrophic costs.

11.
J Infect Dis ; 221(5): 796-803, 2020 02 18.
Artigo em Inglês | MEDLINE | ID: mdl-31621850

RESUMO

BACKGROUND: Some villages, labeled "persistent hotspots (PHS)," fail to respond adequately in regard to prevalence and intensity of infection to mass drug administration (MDA) for schistosomiasis. Early identification of PHS, for example, before initiating or after 1 or 2 years of MDA could help guide programmatic decision making. METHODS: In a study with multiple rounds of MDA, data collected before the third MDA were used to predict PHS. We assessed 6 predictive approaches using data from before MDA and after 2 rounds of annual MDA from Kenya and Tanzania. RESULTS: Generalized linear models with variable selection possessed relatively stable performance compared with tree-based methods. Models applied to Kenya data alone or combined data from Kenya and Tanzania could reach over 80% predictive accuracy, whereas predicting PHS for Tanzania was challenging. Models developed from one country and validated in another failed to achieve satisfactory performance. Several Year-3 variables were identified as key predictors. CONCLUSIONS: Statistical models applied to Year-3 data could help predict PHS and guide program decisions, with infection intensity, prevalence of heavy infections (≥400 eggs/gram of feces), and total prevalence being particularly important factors. Additional studies including more variables and locations could help in developing generalizable models.


Assuntos
Anti-Helmínticos/uso terapêutico , Administração Massiva de Medicamentos/métodos , Praziquantel/uso terapêutico , Schistosoma mansoni/isolamento & purificação , Esquistossomose mansoni/tratamento farmacológico , Esquistossomose mansoni/epidemiologia , Animais , Criança , Estudos de Viabilidade , Fezes/parasitologia , Feminino , Humanos , Quênia/epidemiologia , Masculino , Modelos Estatísticos , Doenças Negligenciadas/tratamento farmacológico , Doenças Negligenciadas/epidemiologia , Doenças Negligenciadas/parasitologia , Prevalência , Esquistossomose mansoni/parasitologia , Esquistossomose mansoni/prevenção & controle , Tanzânia/epidemiologia
12.
J Trop Pediatr ; 66(1): 56-65, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31089687

RESUMO

BACKGROUND: We carried out analyses of early infant testing results at Livingstone Central Hospital in Zambia to assess time of testing, linkages to care and availability of test results for clinical decision making. METHODS: We abstracted data from registers of HIV-exposed infants who had dried blood spots cards (DBS) collected for DNA-PCR from January 2009 to December 2017. Only those tested from 2014 to 2017 had additional data which were used to estimate risk factors for mother-to-child HIV transmission using logistic regression models. RESULTS: DBS were collected from 2630 children. The proportion of HIV-positive tests decreased from 21% in 2009 to 2% in 2016 and 2017. Median turnaround time for results was 9 weeks (IQR: 5, 15) for HIV-negative, 7 weeks (IQR: 5, 13) for HIV-positive children. Only 2% of infants whose mothers took antiretroviral therapy (ART) were HIV positive, while 18% of infants whose mothers took short course antiretroviral drugs (ARVs) were infected. Infants of mothers who did not take ARVs had 9 times the odds of an HIV positive test (OR = 8.9, 95% CI: 3.6, 22.6). Infants of mothers who received short course ARVs were 40% less likely to get an HIV test within the first 2 months of life (OR = 0.6, 95% CI: 0.4, 0.9) compared to infants of mothers who received ART. Only 52% had a third test at median age 52 weeks (IQR: 50, 54). CONCLUSIONS: Long turnaround time for test results and low retention in care after the initial HIV test were critical challenges to clinical decision making.


Assuntos
Antirretrovirais/uso terapêutico , Infecções por HIV/diagnóstico , Infecções por HIV/transmissão , Transmissão Vertical de Doença Infecciosa/prevenção & controle , DNA Viral/sangue , Feminino , HIV/genética , HIV/isolamento & purificação , Infecções por HIV/prevenção & controle , Humanos , Lactente , Recém-Nascido , Masculino , Reação em Cadeia da Polimerase , Profilaxia Pós-Exposição , Gravidez , Complicações Infecciosas na Gravidez , Sistema de Registros , Zâmbia
13.
PLoS One ; 14(10): e0223966, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31639145

RESUMO

Household contact studies of tuberculosis (TB) are a common way to study disease transmission dynamics. However these studies lack a mechanism for accounting for community transmission, which is known to be significant, particularly in high burden settings. We illustrate a statistical approach for estimating both the correlates with transmission of TB in a household setting and the probability of community transmission using a modified Bayesian mixed-effects model. This is applied to two household contact studies in Vitória, Brazil from 2008-2013 and Kampala, Uganda from 1995-2004 that enrolled households with an individual that was recently diagnosed with pulmonary TB. We estimate the probability of community transmission to be higher in Uganda (ranging from 0.21 to 0.69, depending on HHC age and HIV status of the index case) than in Brazil (ranging from 0.13 for young children to 0.50 in adults). These estimates are consistent with a higher overall burden of disease in Uganda compared to Brazil. Our method also estimates an increasing risk of community-acquired TB with age of the household contact, consistent with existing literature. This approach is a useful way to integrate the role of the community in understanding TB disease transmission dynamics in household contact studies.


Assuntos
Teorema de Bayes , Busca de Comunicante/métodos , Características da Família , Modelos Estatísticos , Mycobacterium tuberculosis/isolamento & purificação , Tuberculose Pulmonar/epidemiologia , Adolescente , Brasil/epidemiologia , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Fatores de Risco , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/microbiologia , Uganda/epidemiologia
14.
Am J Trop Med Hyg ; 101(6): 1336-1344, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31407653

RESUMO

The WHO recommends mass treatment with praziquantel as the primary approach for Schistosoma mansoni-related morbidity control in endemic populations. The Schistosomiasis Consortium for Operational Research and Evaluation implemented multi-country, cluster-randomized trials to compare effectiveness of community-wide and school-based treatment (SBT) regimens on prevalence and intensity of schistosomiasis. To assess the impact of two different treatment schedules on S. mansoni-associated morbidity in children, cohort studies were nested within the randomized trials conducted in villages in Kenya and Tanzania having baseline prevalence ≥ 25%. Children aged 7-8 years were enrolled at baseline and followed to ages 11-12 years. Infection intensity and odds of infection were reduced both in villages receiving four years of annual community-wide treatment (CWT) and those who received biennial SBT over 4 years. These regimens were also associated with reduced odds of undernutrition and reduced odds of portal vein dilation at follow-up. However, neither hemoglobin levels nor the prevalence of the rare abnormal pattern C liver scores on ultrasound improved. For the combined cohorts, growth stunting worsened in the areas receiving biennial SBT, and maximal oxygen uptake as estimated by fitness testing scores declined under both regimens. After adjusting for imbalance in starting prevalence between study arms, children in villages receiving annual CWT had significantly greater decreases in infection prevalence and intensity than those villages receiving biennial SBT. Although health-related quality-of-life scores improved in both study arms, children in the CWT villages gained significantly more. We conclude that programs using annual CWT are likely to achieve better overall S. mansoni morbidity control than those implementing only biennial SBT.


Assuntos
Anti-Helmínticos/administração & dosagem , Administração Massiva de Medicamentos/estatística & dados numéricos , Esquistossomose mansoni/tratamento farmacológico , Esquistossomose mansoni/prevenção & controle , Criança , Estudos de Coortes , Esquema de Medicação , Fezes/parasitologia , Feminino , Geografia , Humanos , Quênia/epidemiologia , Masculino , Administração Massiva de Medicamentos/métodos , Praziquantel/administração & dosagem , Prevalência , Esquistossomose mansoni/epidemiologia , Instituições Acadêmicas/estatística & dados numéricos , Tanzânia/epidemiologia
15.
BMC Public Health ; 19(1): 1120, 2019 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-31416432

RESUMO

BACKGROUND: Retention in care is critical for children living with HIV taking antiretroviral therapy (ART). Loss to follow-up (LTFU) is high in HIV treatment programs in resource limited settings. We estimated the cumulative incidence of LTFU and identified associated risk factors among children on ART at Livingstone Central Hospital (LCH), Zambia. METHODS: Using a retrospective cohort study design, we abstracted data from medical records of children who received ART between 2003 and 2015. Loss to follow-up was defined as no clinical and pharmacy contact for at least 90 days after the child missed their last scheduled clinical visit. Non-parametric competing risks models were used to estimate the cumulative incidence of death, LTFU and transfer. Cause-specific Cox regression was used to estimate the hazard ratios of the risk factors of LTFU. RESULTS: A total of 1039 children aged 0-15 years commenced ART at LCH between 2003 and 2015. Median duration of follow-up was 3.8 years (95% CI: 1.2-6.5), median age at ART initiation was 3.6 years (IQR: 1.3-8.6), 179 (17%) started treatment during their first year of life. At least 167 (16%) were LTFU and we traced 151 (90%). Of those we traced, 39 (26%) had died, 71 (47%) defaulted, 20 (13%) continued ART at other clinics and 21 (14%) continued treatment with gaps. The cumulative incidence of LTFU for the entire cohort was 2.7% (95% CI: 1.9-3.9) at 3 months, 4.1% (95% CI: 2.9-5.4) at 6 months and 14.1% (95% CI: 12.4-16.9) after 5 years on ART. Associated risk factors were: 1) non-disclosure of HIV status at baseline, aHR = 1.9 (1.2-2.9), 2) No phone ownership, aHR = 2.1 (1.6-2.9), 3) starting treatment between 2013 to 2015, aHR = 5.6 (2.2-14.1). CONCLUSION: Among the children LTFU mortality and default were substantially high. Children who started treatment in recent years (2013-2015) had the highest hazard of LTFU. Lack of access to a phone and non-disclosure of HIV-status to the index child was associated with higher hazards of LTFU. We recommend re-enforcement of client counselling and focused follow-up strategies using modern technology such as mobile phones as adjunct to current approaches.


Assuntos
Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Perda de Seguimento , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Registros Médicos , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Zâmbia/epidemiologia
16.
PLoS One ; 14(5): e0217219, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31120965

RESUMO

Directly observed therapy (DOT) is almost universally used for the treatment of TB. Several meta-analyses using different methods have assessed the effectiveness of DOT compared to self-administered therapy (SAT). The results of these meta-analyses often conflict with some concluding DOT is superior and others that there is little or no difference. Meta-analyses can guide policymaking, but such analyses must be reliable. To assess the validity of a previous meta-analysis, we tried to reproduce it. We encountered problems with the previous analysis that did not allow for a meaningful reproduction. We describe the issues we encountered here. We then performed a new meta-analysis comparing the treatment outcomes of adults given treatment with SAT versus DOT. Outcomes in the new analysis are loss to follow-up, treatment failure, cure, treatment completed, and all-cause mortality. All data, documentation, and code used to generate our results is provided. Our new analysis included four randomized and three observational studies with 1603 and 1626 individuals respectively. The pooled relative risks (RR) are as follows: Lost to follow-up (RR = 1.2, 95% CI 0.9, 1.7), Treatment Failure (RR = 1.1, 95% CI 0.6, 2), Cure (RR = 0.9, 95% CI 0.8, 1.1), Treatment Completion (RR = 1, 95% CI 0.9, 1.1), Mortality (RR = 0.9, 95% CI 0.6, 1.3). Based on data from our new meta-analysis, the magnitude of the difference between DOT and SAT for all reported outcomes is small, and none of the differences are statistically significant.


Assuntos
Antituberculosos/administração & dosagem , Terapia Diretamente Observada/métodos , Adesão à Medicação/estatística & dados numéricos , Autoadministração/métodos , Tuberculose/tratamento farmacológico , Tuberculose/microbiologia , Ensaios Clínicos como Assunto , Humanos , Metanálise como Assunto , Resultado do Tratamento
17.
J Am Board Fam Med ; 32(2): 234-247, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30850460

RESUMO

BACKGROUND: A systematic review of clinical decision rules to identify patients at low risk for community-acquired pneumonia (CAP) has not been previously presented in the literature. METHODS: A systematic review of MEDLINE for prospective studies that used at least 2 signs, symptoms, or point-of-care tests to determine the likelihood of CAP. We included studies that enrolled adults and adolescents in the outpatient setting where all or a random sample of patients received a chest radiograph as the reference standard. We excluded retrospective studies and studies that recruited primarily patients with hospital-acquired CAP. RESULTS: Our search identified 974 articles, 12 of which were included in the final analysis. The simple heuristic of normal vital signs (temperature, respiratory rate, and heart rate) to identify patients at low risk for CAP was reported by 4 studies and had a summary estimate of the negative likelihood ratio (LR-) of 0.24 (95% CI, 0.17 to 0.34) and a sensitivity of 0.89 (95% CI, 0.79 to 0.94). The simple heuristic of normal vital signs combined with a normal pulmonary examination to identify patients at low risk for CAP was reported by 3 studies, and had a summary estimate of LR- of 0.10 (95% CI, 0.07 to 0.13) with an area under the receiver operating characteristic curve of 0.92. CONCLUSIONS: Adults with an acute respiratory infection who have normal vital signs and a normal pulmonary examination are very unlikely to have CAP. Given a baseline CAP risk of 4%, these patients have only a 0.4% likelihood of CAP.


Assuntos
Regras de Decisão Clínica , Pneumonia/diagnóstico , Testes de Função Respiratória , Sinais Vitais/fisiologia , Adolescente , Adulto , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/fisiopatologia , Feminino , Humanos , Masculino , Pneumonia/fisiopatologia , Estudos Prospectivos , Medição de Risco , Sensibilidade e Especificidade
18.
BMC Public Health ; 19(1): 115, 2019 Jan 28.
Artigo em Inglês | MEDLINE | ID: mdl-30691416

RESUMO

BACKGROUND: In 2017, 64% of children living with HIV in Zambia accessed Antiretroviral Therapy (ART). Despite expanded ART coverage, there is paucity of information on effectiveness of pediatric ART in reducing mortality. The aim of this research is to describe treatment outcomes, measure mortality rates and assess predictors of mortality among children receiving ART. METHODS: Using a retrospective cohort study design, we abstracted routinely collected clinical data from medical records of children from birth to 15 years old, who had received ART for at least 6 months at Livingstone Central Hospital in Southern Province Zambia, between January 2003 and June 2015. The primary outcome was death. Cause of death was ascertained from medical records and death certificates. Distribution of survival times according to baseline covariates were estimated using Kaplan Meier and Cox Proportional Hazards methods. RESULTS: Overall, 1039 children were commenced on ART during the study period. The median age at treatment initiation was 3.6 years (IQR: 1.3-8.6) and 520 (50%) children were female. Of these, 71 (7%) died, 164 (16%) were lost to follow-up, 210 (20%) transferred and 594 (56%) were actively on treatment. After 4450 person years, mortality rate was 1.6/100 (95% CI: 1.4-1.8). Mortality was highest during the first 3 months of treatment (11.7/100 (95% CI: 7.6-16.3). In multivariable proportional hazards regression, the adjusted hazards of death were highest among children aged < 1 year (aHR = 3.1 (95% CI: 1.3-6.4), compared to those aged 6-15 years, WHO stage 4 (aHR =4.8 (95% CI: 2.3-10), compared to WHO stage 1 and 2. In the sensitivity analysis to address bias due to loss to follow-up, mortality increased 5 times when we assumed that all the children who were lost to follow up died within 90 days of their last visit. CONCLUSION: We observed low attrition due to mortality among children on ART. Loss to follow-up was high (16%). Mortality was highest during the first 3 months of treatment. Children aged less than one year and those with advanced WHO disease stage had higher mortality. We recommend effective interventions to improve retention in care and early diagnosis of HIV in children.


Assuntos
Antirretrovirais/uso terapêutico , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Sobreviventes de Longo Prazo ao HIV/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Feminino , Infecções por HIV/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Registros Médicos , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Zâmbia/epidemiologia
19.
BMC Infect Dis ; 19(1): 1087, 2019 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-31888518

RESUMO

BACKGROUND: At least 13-20% of all Tuberculosis (TB) cases are recurrent TB. Recurrent TB has critical public health importance because recurrent TB patients have high risk of Multi-Drug Resistant TB (MDR-TB). It is critical to understand variations in the prevalence and treatment outcomes of recurrent TB between different geographical settings. The objective of our study was to estimate the prevalence of recurrent TB among TB cases and compare risk of unfavorable treatment outcomes between rural and urban settings. METHODS: In a retrospective cohort study conducted in southern province of Zambia, we used mixed effects logistic regression to asses associations between explanatory and outcome variables. Primary outcome was all-cause mortality and exposure was setting (rural/urban). Data was abstracted from the facility TB registers. RESULTS: Overall 3566 recurrent TB cases were diagnosed among 25,533 TB patients. The prevalence of recurrent TB was 15.3% (95% CI: 14.8 15.9) in urban and 11.3% (95% CI: 10.7 12.0) in rural areas. Death occurred in 197 (5.5%), 103 (2.9%) were lost to follow-up, and 113 (3.2%) failed treatment. Rural settings had 70% higher risk of death (adjusted OR: 1.7; 95% CI: 1.2 2.7). Risk of lost to follow-up was twice higher in rural than urban (adjusted OR: 2.0 95% CI: 1.3 3.0). Compared to HIV-uninfected, HIV-infected individuals on Antiretroviral Treatment (ART) were 70% more likely to die (adjusted OR: 1.7; 95% CI: 1.2 3.1). CONCLUSION: Recurrent TB prevalence was generally high in both urban and rural settings. The risk of mortality and lost to follow-up was higher among rural patients. We recommend a well-organized Directly Observed Therapy strategy adapted to setting where heightened TB control activities are focused on areas with poor treatment outcomes.


Assuntos
Disparidades em Assistência à Saúde , População Rural , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , População Urbana , Adolescente , Adulto , Criança , Coinfecção/tratamento farmacológico , Feminino , HIV/imunologia , Infecções por HIV/tratamento farmacológico , Humanos , Modelos Logísticos , Perda de Seguimento , Masculino , Pessoa de Meia-Idade , Prevalência , Saúde Pública , Recidiva , Estudos Retrospectivos , Falha de Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/mortalidade , Adulto Jovem , Zâmbia/epidemiologia
20.
Am J Emerg Med ; 37(9): 1681-1685, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30553636

RESUMO

BACKGROUND: Uncomplicated episodes of prolonged acute cough are usually viral and self-limited, but despite evidence and recommendations to the contrary, they are often treated with antibiotics. METHODS: Mixed cross-sectional and prospective observational study of adults 18 years or older presenting to two urgent care centers with a cough of 7 to 56 days as their chief complaint. Factors associated with cough duration and clinical decisions were analyzed by univariate and multivariate logistic regression. RESULTS: Of the 125 enrolled patients, 118 (94%) received an antibiotic, 97 (78%) a cough suppressant, 87 (70%) a systemic corticosteroid, and 39 (31%) a chest X-ray (CXR). Longer duration of cough was associated with the presence of self-reported wheezing or noises (adjusted odds ratio 6.29, 95% CI 1.36-29.16) while the presence of both wheezing and crackles on a clinician chest exam was associated with shorter duration (aOR 0.03, 95% CI 0.00-0.27). A clinician was more likely to order a CXR in patients with dyspnea (aOR 3.01, 95% CI 1.21-7.49), less likely to prescribe a systemic corticosteroid in patients with crackles (aOR 0.27, 95% CI 0.09-0.82), and more likely to prescribe a cough suppressant to older patients (1.04 per additional year of age, 95% CI 1.01-1.07). CONCLUSIONS: Systemic corticosteroids and cough suppressants are being prescribed at high rates in patients with uncomplicated acute cough in the urgent care setting. Additional studies to determine if similar rates are seen in other urgent care centers, or in other contemporary ambulatory settings are warranted.


Assuntos
Corticosteroides/uso terapêutico , Antibacterianos/uso terapêutico , Antitussígenos/uso terapêutico , Bronquite/diagnóstico , Tomada de Decisão Clínica , Tosse/tratamento farmacológico , Adulto , Instituições de Assistência Ambulatorial , Auscultação , Bronquite/complicações , Bronquite/tratamento farmacológico , Tosse/diagnóstico por imagem , Tosse/etiologia , Dispneia/diagnóstico por imagem , Dispneia/etiologia , Feminino , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Radiografia Torácica , Sons Respiratórios , Fatores de Tempo
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