Comparing HIV prevalence estimates from prevention of mother-to-child HIV transmission programme and the antenatal HIV surveillance in Addis Ababa.

BACKGROUND: In the absence of reliable data, antenatal HIV surveillance has been used to monitor the HIV epidemic since the late 1980s. Currently, routine data from Prevention of Mother-to-child HIV transmission (PMTCT) programmes are increasingly available. Evaluating whether the PMTCT programme reports provide comparable HIV prevalence estimates with the antenatal surveillance reports is important. In this study, we compared HIV prevalence estimates from routine PMTCT programme and antenatal surveillance in Addis Ababa with the aim to come up with evidence based recommendation. METHODS: Summary data were collected from PMTCT programmes and antenatal surveillance reports within the catchment of Addis Ababa. The PMTCT programme data were obtained from routine monthly reports from 2004 to 2009 and from published antenatal HIV surveillance reports from 2003 to 2009. Data were analysed using descriptive statistics. RESULTS: In Addis Ababa, PMTCT sites had increased from six in 2004 to 54 in 2009. The site expansion was accompanied by an increased number of women testing. There were marked increases in the rate of HIV testing following the introduction of routine opt-out HIV testing approach. Paralleling these increases, the HIV prevalence showed a steady decline from 10.0% in 2004 to 4.5% in 2009. There were five antenatal surveillance sites from 2003 to 2007 in Addis Ababa and they increased to seven by 2009. Four rounds of surveillance data from five sites showed a declining trend in HIV prevalence over the years. The overall antenatal surveillance data also showed that the HIV prevalence among antenatal attendees had declined from 12.4% in 2003 to 5.5% in 2009. The HIV prevalence estimates from PMTCT programme were 6.2% and 4.5% and from antenatal surveillance 6.1 and 5.5% in 2008 and 2009 respectively. CONCLUSIONS: There were consistent HIV prevalence estimates from PMTCT programme and from antenatal surveillance reports. Both data sources showed a marked decline in HIV prevalence among antenatal care attendees in Addis Ababa. This study concludes that the routine data from the PMTCT programmes in Addis Ababa provides comparable HIV prevalence estimates with antenatal HIV surveillance data and could be used for monitoring trends.

Childhood tuberculosis deskguide and monitoring: an intervention to improve case management in Pakistan.

BACKGROUND: Childhood tuberculosis (TB) has been a neglected area in national TB control programme (NTCP) in high burden countries. The NTP Pakistan adapted the global approaches by developing and piloting its policy guideline on childhood TB in ten districts of the country. We developed an intervention package including a deskguide and a monitoring tool and tested with the ongoing childhood TB care in a district. The objective of our study was to measure effectiveness of intervention package with deskguide and monitoring tool by comparing TB case finding and treatment outcomes among districts in 2008, and performance assessment in intervention district. METHOD: An intervention study with cohort design within a routine TB control programme comparing case findings and treatment outcomes before and after the intervention, and in districts with and without intervention. We enrolled all children below 15 years registered at all nine public sector hospitals in three districts of Pakistan. The data was collected from hospital TB records. RESULTS: In eight months during 2007 there were 164 childhood TB cases notified, and after intervention in 2008 a total of 194 cases were notified. In intervention district case finding doubled (110% increase) and correct treatment practice significantly increased in eight months. Successful outcomes were significantly higher in intervention district (37,100%) compared to control district A (18, 18%, p < 0.05) and control district B (41, 72%, p < 0.05). CONCLUSION: Childhood TB deskguide and structured monitoring was associated with improved case management and it augmented NTP policy. More development and implementation in all health services of the district are indicated.

Tuberculosis: a review of current concepts and control programme in Nigeria.

BACKGROUND: The burden of tuberculosis in Nigeria is the highest in Africa. Therefore, improved knowledge of health workers on the current issues concerning the disease, including the National guideline, is important for effective disease control. METHODS: An in-depth search of relevant literature on the subject area. This includes texts and operational documents of the Nigerian national tuberculosis programme, as well as online searches using Pubmed, Africanjournal online (Ajol), and Google scholar. RESULTS: About one third of the world population is infected with tuberculous bacilli with up to 10% lifetime risk of developing the disease. Pulmonary tuberculosis (PTB) especially the reactivated latent infection is the major source of the infection in communities. In an effort to increase case detection, a single acid fast bacillus in at least one of two sputum smears is currently adequate to diagnose PTB. Furthermore, there is a global effort to eliminate the disease by the year 2050 and these efforts are coordinated in Nigeria by the National tuberculosis controlprogramme. CONCLUSION: Tuberculosis is an impediment to human development in developing countries, especially in this era of HIV pandemic. Continuing education of health professional on tuberculosis and its accessible treatment, will improve patients' education, proper management and appropriate referral.

Smear microscopy and culture conversion rates among smear positive pulmonary tuberculosis patients by HIV status in Dar es Salaam, Tanzania.

BACKGROUND: Tanzania ranks 15th among the world's 22 countries with the largest tuberculosis burden and tuberculosis has continued to be among the major public health problems in the country. Limited data, especially in patients co infected with HIV, are available to predict the duration of time required for a smear positive pulmonary tuberculosis patient to achieve sputum conversion after starting effective treatment. In this study we assessed the sputum smear and culture conversion rates among HIV positive and HIV negative smear positive pulmonary tuberculosis patients in Dar es Salaam METHODS: The study was a prospective cohort study which lasted for nine months, from April to December 2008 RESULTS: A total of 502 smear positive pulmonary tuberculosis patients were recruited. HIV test results were obtained for 498 patients, of which 33.7% were HIV positive. After two weeks of treatment the conversion rate by standard sputum microscopy was higher in HIV positive(72.8%) than HIV negative(63.3%) patients by univariate analysis(P = 0.046), but not in multivariate analysis. Also after two weeks of treatment the conversion rate by fluorescence microscopy was higher in HIV positive (72.8%) than in HIV negative(63.2%) patients by univariate analysis (P = 0.043) but not in the multivariate analysis. The conversion rates by both methods during the rest of the treatment period (8, 12, and 20 weeks) were not significantly different between HIV positive and HIV negative patients.With regards to culture, the conversion rate during the whole period of the treatment (2, 8, 12 and 20 weeks) were not significantly different between HIV positive and HIV negative patients. CONCLUSION: Conversion rates of standard smear microscopy, fluorescence microscopy and culture did not differ between HIV positive and HIV negative pulmonary tuberculosis patients.

Diagnosis and follow-up of treatment of latent tuberculosis; the utility of the QuantiFERON-TB Gold In-tube assay in outpatients from a tuberculosis low-endemic country.

BACKGROUND: Interferon-gamma (IFN-gamma) Release Assays (IGRA) are more specific than the tuberculosis skin test (TST) in the diagnosis of latent tuberculosis (TB) infection (LTBI). We present the performance of the QuantiFERON-TB Gold In-tube (QFT-TB) assay as diagnostic test and during follow-up of preventive TB therapy in outpatients from a TB low-endemic country. METHODS: 481 persons with suspected TB infection were tested with QFT-TB. Thoracic X-ray and sputum samples were performed and a questionnaire concerning risk factors for TB was filled. Three months of isoniazid and rifampicin were given to patients with LTBI and QFT-TB tests were performed after three and 15 months. RESULTS: The QFT-TB test was positive in 30.8% (148/481) of the total, in 66.9% (111/166) of persons with origin from a TB endemic country, in 71.4% (20/28) previously treated for TB and in 100% (15/15) of those diagnosed with active TB with no inconclusive results. The QFT-TB test was more frequently positive in those with TST > or = 15 mm (47.5%) compared to TST 11-14 mm (21.3%) and TST 6-10 mm (10.5%), (p < 0.001). Origin from a TB endemic country (OR 6.82, 95% CI 1.73-26.82), recent stay in a TB endemic country (OR 1.32, 95% CI 1.09-1.59), duration of TB exposure (OR 1.59, 95% CI 1.14-2.22) and previous TB disease (OR 11.60, 95% CI 2.02-66.73) were all independently associated with a positive QFT-TB test. After preventive therapy, 35/40 (87.5%) and 22/26 (84.6%) were still QFT-TB positive after three and 15 months, respectively. IFN-gamma responses were comparable at start (mean 6.13 IU/ml +/- SD 3.99) and after three months (mean 5.65 IU/ml +/- SD 3.66) and 15 months (mean 5.65 IU/ml +/- SD 4.14), (p > 0.05). CONCLUSION: Only one third of those with suspected TB infection had a positive QFT-TB test. Recent immigration from TB endemic countries and long duration of exposure are risk factors for a positive QFT-TB test and these groups should be targeted through screening. Since most patients remained QFT-TB positive after therapy, the test should not be used to monitor the effect of preventive therapy. Prospective studies are needed in order to determine the usefulness of IGRA tests during therapy.

Promising outcomes of a national programme for the prevention of Mother-to-Child HIV transmission in Addis Ababa: a retrospective study.

BACKGROUND: Prevention of Mother-to-Child HIV Transmission (PMTCT) is still the most effective intervention in combating new HIV infections. In 2008, revised national PMTCT guidelines that incorporated new policies on HIV counselling and testing, antiretroviral prophylaxis regimen and infant HIV diagnosis came into effect in Ethiopia. In the present study we have examined trends in PMTCT service utilization and assessed the rate of MTCT in relation to policy changes in the national PMTCT programme. METHODS: Reports from February 2004 to August 2009 were reviewed in 10 sub-cities in Addis Ababa, Ethiopia. The data was collected from May to October 2009. RESULTS: The proportion of women who received HIV counselling and testing among new antenatal care attendees increased from 50.7% (95% CI 50.2-51.2) in 2007 to 84.5% (95% CI 84.1-84.9) in 2009 following the shift to routine opt-out testing. Nevertheless, in 2009 only 53.7% of the positive women and 40.7% of their infants received antiretroviral prophylaxis. The HIV prevalence among antenatal attendees decreased significantly from 10.5% in 2004 to 4.6% in 2009 in parallel to the increased number of women being tested. The HIV positive women were over 18 times (RR 18.5, p < 0.0001) more likely to be referred for treatment, care and support in 2009 than in 2004. The proportion of partners tested for HIV decreased by 14% in 2009 compared to 2004, although the absolute number was increasing year by year. Only 10.6% (95% CI 9.9-11.2) of the HIV positive women completed their follow up to infant HIV testing. The cumulative probability of HIV infection among babies on single dose nevirapine regimen who were tested at >=18 months was 15.0% (95% CI 9.8-22.1) in 2007, whereas it was 8.2% (95% CI 5.55-11.97) among babies on Zidovudine regimen who were tested at >=45 days in 2009. CONCLUSION: The paper demonstrates trends in PMTCT service utilization in relation to changing policy. There is marked improvement in HIV counselling and testing service utilization, especially after the policy shift to routine opt-out testing. However, despite policy changes, the ARV prophylaxis uptake, the loss to follow up and the partner testing have remained unchanged across the years. This should be a matter of immediate concern and a topic for further research.

Immunohaematological reference values in human immunodeficiency virus-negative adolescent and adults in rural northern Tanzania.

BACKGROUND: The amount of CD4 T cells is used for monitoring HIV progression and improvement, and to make decisions to start antiretroviral therapy and prophylactic drugs for opportunistic infections. The aim of this study was to determine normal reference values for CD4 T cells, lymphocytes, leucocytes and haemoglobin level in healthy, HIV negative adolescents and adults in rural northern Tanzania. METHODS: A cross sectional study was conducted from September 2006 to March 2007 in rural northern Tanzania. Participants were recruited from voluntary HIV counselling and testing clinics. Patients were counselled for HIV test and those who consented were tested for HIV. Clinical screening was done, and blood samples were collected for CD4 T cell counts and complete blood cell counts. RESULTS: We enrolled 102 participants, forty two (41.2%) males and 60 (58.8%) females. The mean age was 32.6 +/- 95% CI 30.2-35.0. The mean absolute CD4 T cell count was 745.8 +/- 95% CI 695.5-796.3, absolute CD8 T cells 504.6 +/- 95% CI 461.7-547.5, absolute leukocyte count 5.1 +/- 95% CI 4.8-5.4, absolute lymphocyte count 1.8 +/- 95% CI 1.7-1.9, and haemoglobin level 13.2 +/- 95% CI 12.7-13.7. Females had significantly higher mean absolute CD4 T cell count (p = 0.008), mean absolute CD8 T cell count (p = 0.009) and significantly lower mean haemoglobin level than males (p = 0.003) CONCLUSION: Immunohaematological values found in this study were different from standard values for western countries. Females had significantly higher mean CD4 T cell counts and lower mean haemoglobin levels than males. This raises the issue of the appropriateness of the present reference values and guidelines for monitoring HIV/AIDS patients in Tanzania.

Delay in the diagnosis of tuberculosis in Nepal.

BACKGROUND: Identifying reasons for delay in diagnosis and treatment of tuberculosis is important for the health system to find ways to treat patients as early as possible, and hence reduce the suffering of patients and transmission of the disease. The objectives of this study was to assess the duration of delay in the diagnosis of tuberculosis and to investigate its determinants. METHODS: A cross-sectional survey was conducted using a structured questionnaire in 307 new tuberculosis patients registered by the National Tuberculosis Programme (NTP) in all DOTS centres in Banke district of Nepal. RESULTS: The median patient delay was 50 days, the median health system delay was 18 days, and the median total delay was 60 days. Sputum smear negative participants had significantly lower risk of patient delay. Smokers using >5 cigarettes per day had higher risk of patient delay and health system delay. CONCLUSION: Total delay in the diagnosis of tuberculosis in Banke district is shorter compared to other places in Nepal and neighbouring countries. The shorter delay for smear negative pulmonary tuberculosis raises suspicion that many of these patients are not examined according to the NTP manual before being diagnosed. Increasing public awareness of the disease and expansion of the facilities with assured quality could be helpful to reduce the delay in the diagnosis of tuberculosis.

Pulmonary tuberculosis among women with cough attending clinics for family planning and maternal and child health in Dar Es Salaam, Tanzania.

BACKGROUND: Tuberculosis (TB) case detection in women has remained low in developing world. This study was conducted to determine the proportion of smear positive TB among women with cough regardless of the duration attending family Planning (FP) and Maternal and child health (MCH) clinics in Dar es Salaam. METHODS: We conducted a cross sectional study in all three municipal hospitals of Dar es Salaam, between October 2007 and June 2008. All women with cough attending FP and MCH clinics were screened for TB by smear microscopy. Pearson chi-square was used to compare group difference for categorical variables. Risk factors for smear positive were estimated by logistics regression with 95% confidence intervals (CI) given for odds ratios indicating statistically significant relationship if the CI did not include one. RESULTS: We enrolled a total of 749 TB suspects. Five hundred and twenty nine patients (70.6%) were from MCH clinics. Mean (SD) age was 27.6 (5.2) years. A total of 616 (82.2%) patients were coughing for less than two weeks as compared to 133 (17.8%), who coughed for two or more weeks. Among 616 TB suspects, 14 (2.3%) were smear positive TB patients, and of the 133 who had coughed for two or more weeks, 13 (9.8%) were smear positive TB patients. Risk factors associated with smear positive results were having attended more than one visit to any facility prior to diagnosis (OR = 6.8; 95%CI 2.57-18.0) and having HIV/AIDS (OR = 4.4; 95%CI 1.65-11.96). Long duration of cough was not a risk factor for being smear positive (OR = 1.6; 95%CI 0.59-4.49). CONCLUSION: The proportion of smear positive TB patients among women with cough attending MCH and FP was 3.8%. Visits to any health facility prior to Diagnosis and HIV infection were risk for having a smear positive TB.

Delay in tuberculosis case detection in Pwani region, Tanzania. A cross sectional study.

BACKGROUND: Delay in Tuberculosis (TB) case detection may worsen the disease and increase TB transmission. It is also a challenge to the National TB and Leprosy control Program (NTLP). METHODS: We conducted a cross sectional study in four out of six districts in Pwani region to estimate the extent and factors responsible for delay in TB case detection in Pwani region. Delays were divided into patient, health facility and total delay. RESULTS: We enrolled a total of 226 smear positive TB patients. Out of 226 patient's results were available for 206. The majority (66.5%) of the patients were males. Mean age for males and females were 37.3 and 33.7 years respectively. Mean (SD) total delay was 125.5 (98.5) days (median 90). Out of 206 patients, 79 (38.35%) delayed to seek TB health care. Health facility delay was observed among 121 (58.7%) patients.Risk factors for delay was poor knowledge that chest pain may be a TB symptom (OR = 2.9; 95%CI 1.20- 7.03) and the belief that TB is always associated with HIV/AIDS (OR = 2.7; 95%CI 1.39-5.23). Risk for delay was low among patients who first presented to a government health facility (OR = 0.3; 95%CI 0.12- 0.71) and those presenting with chest pain (OR = 0.2; 95%CI 0.10-0.61). CONCLUSION: There is a considerable delay in TB case detection in Pwani mainly contributed by patients. Risk factors for delay include misconception about TB/HIV and poor knowledge of TB symptoms.

Detection of pulmonary tuberculosis among patients with cough attending outpatient departments in Dar Es Salaam, Tanzania: does duration of cough matter?

BACKGROUND: According to WHO estimates, tuberculosis case detection rate in Tanzania is less than 50% and this poses a major challenge to control tuberculosis in the country. Currently, one of the defining criteria for suspecting tuberculosis is cough for two weeks or more. We wanted to find out whether the prevalence of tuberculosis was different in patients who reported cough for two weeks or more, compared to patients with cough for less than two weeks. METHODS: We conducted a cross sectional study in six health facilities in Dar es Salaam, between September and October 2007. All patients aged five years and above with cough were screened for pulmonary tuberculosis (PTB) by smear microscopy. Patients were divided into two groups, those who coughed for less than two weeks (<2 wks) and those who coughed for two weeks or more (> or = 2 wks). RESULTS: A total of 65,530 patients attended outpatients department (OPD). Out of these, 2274 (3.5%) patients reported cough. Among patients who reported cough, 2214 (97.4%) remembered their cough duration. One thousand nine hundred and seventy three patients (89.1%) coughed for >/= 2 wks as compared to 241 (10.9%) patients who coughed for <2 wks. Of those who coughed for two weeks or more, 250 (12.7%) had smear positive PTB, and of those who had coughed for less than two weeks, 21 (8.7%) had smear positive PTB. There was no statistically significant difference in prevalence of smear positive tuberculosis among the two groups (Pearson Chi-Square 3.2; p = 0.074). CONCLUSION: Detection of smear positive PTB among patients who coughed for less than two weeks was as high as for those who coughed for two weeks or more.

Differential expression of mycobacterial antigen MPT64, apoptosis and inflammatory markers in multinucleated giant cells and epithelioid cells in granulomas caused by Mycobacterium tuberculosis.

The development of granulomas is a major histopathological feature of tuberculosis. Very little information is available concerning the physiology and functions of different cell types in the tuberculous granulomas. The aim of this study was to compare the epithelioid cells (ECs) and multinucleated giant cells (MGCs) in the granulomas caused by Mycobacterium tuberculosis complex organisms. Lymph node biopsies from 30 cases of lymphadenitis were studied for expression of the secreted mycobacterial protein MPT64, caspase 3 as a marker of apoptosis, apoptosis-related proteins (Fas Ligand, Fas and Bax) and inflammatory cytokines (interleukin-10, transforming growth factor-beta (TGF-beta), tumour necrosis factor-alpha and interferon-gamma) by immunohistochemistry. MGCs more often contained M. tuberculosis secretory antigen MPT64 (p < 0.001) and expressed more TGF-beta (p = 0.004) than ECs. The total number of apoptotic MGCs was higher than the number of apoptotic ECs (p = 0.04). Interestingly, there was a significant negative correlation between apoptosis and MPT64 expression in MGCs (r = -0.569, p = 0.003), but not in ECs, implying that the heavy antigen load would lead to inhibition of apoptosis in these cells. When compared with ECs, higher percentage of MGCs expressed Fas Ligand and Fas (p < 0.004). The role of MGCs may thus be different from surrounding ECs and these cells by virtue of higher mycobacterial antigen load, more TGF-beta and reduced apoptosis may contribute towards persistence of infection.

Pulmonary tuberculosis among people living with HIV/AIDS attending care and treatment in rural northern Tanzania.

BACKGROUND: Tuberculosis is the commonest opportunistic infection and the number one cause of death in HIV/AIDS patients in developing countries. To address the extent of the tuberculosis HIV coinfection in rural Tanzania we conducted a cross sectional study including HIV/AIDS patients attending care and treatment clinic from September 2006 to March 2007. METHODS: Sputum samples were collected for microscopy, culture and drug susceptibility testing. Chest X-ray was done for those patients who consented. Blood samples were collected for CD4+ T cells count. RESULTS: The prevalence of tuberculosis was 20/233 (8.5%). Twenty (8.5%) sputum samples were culture positive. Eight of the culture positive samples (40%) were smear positive. Fifteen (75%) of these patients neither had clinical symptoms nor chest X-ray findings suggestive of tuberculosis. Nineteen isolates (95%) were susceptible to rifampicin, isoniazid, streptomycin and ethambutol (the first line tuberculosis drugs). One isolate (5%) from HIV/tuberculosis coinfected patients was resistant to isoniazid. No cases of multi- drug resistant tuberculosis were identified. CONCLUSION: We found high prevalence of tuberculosis disease in this setting. Chest radiograph suggestive of tuberculosis and clinical symptoms of fever and cough were uncommon findings in HIV/tuberculosis coinfected patients. Tuberculosis can occur at any stage of CD4+T cells depletion.

Patient and health system delays: health-care seeking behaviour among pulmonary tuberculosis patients in Pakistan.

OBJECTIVE: To determine the time taken for diagnosis and treatment of pulmonary TB and the factors responsible for delay, by studying the level of awareness regarding TB in the patients, and the extent of social stigmatization associated with TB in Punjab (Multan and Sialkot), Pakistan. METHODS: It was a hospital based cross-sectional study using a pre-structured questionnaire. The study was done in two areas Multan (Nishtar Hospital) and Sialkot (Bethania Hospital) in the province of Punjab, Pakistan from May - July 2006. The sample (n = 301) consisted of all the TB patients coming to the hospitals during the study period. The data was analyzed using SPSS version 14.0. RESULTS: The median patient delay was 33 days (range 2-90). The median health system delay was 60 days (range 4-365). The median total delay was 90 days (range 23-365). The percentage of patients aware about TB was 37%. The number of patients who perceived stigmatization was 27%. CONCLUSION: The major portion of the delay is contributed by the health system, rather than the patient. The awareness about TB is low and emphasis should be given to increasing the awareness of TB among the community.

Acceptability of community and health facility-based directly observed treatment of tuberculosis in Tanzanian urban setting.

SETTING: An urban district in Dar es Salaam, Tanzania. OBJECTIVE: To assess the acceptability of community and health facility-based direct observation of treatment (DOT) of tuberculosis (TB) patients in Temeke district. DESIGN: Both quantitative and qualitative study methodologies were used. Eight focus group discussions were carried out with TB patients, treatment supporters, health workers and community members. Quantitative study was also carried out among TB patients and treatment supporters. RESULTS: A total of 268 patients and 103 treatment supporters were enrolled in the study. The majority of the patients (75%) were satisfied with the DOT options they received. Males were more satisfied with community-based DOT (84%) than females (67%) (OR 4.96, 95% CI 1.38-17.86). The majority (81%) were willing to supervise another TB patient. The results of the qualitative study demonstrated that community-based DOT was preferred because it was found to be convenient, reduced costs, saved time of the patients and reduced workload in health services. The main challenge of community-based DOT was to ensure effective supervision and monitoring of patients and treatment supporters in the community. CONCLUSION: The results from the quantitative and qualitative studies indicate that both DOT options were acceptable. The study has also identified key challenges and opportunities for effective implementation of community-based DOT interventions that are relevant, sensitive and acceptable to the population. Community-based DOT is a viable option and can complement and strengthen the existing health facility-based DOT, especially in countries like Tanzania where the health system is overwhelmed with increasing number of TB and HIV/AIDS patients.

Respiratory symptoms and obstructive pulmonary disease in a population aged over 70 years.

STUDY QUESTION: What is the prevalence of respiratory symptoms and obstructive pulmonary disease by age, sex, and smoking history in a population aged 70 years and older? What is the association between selected comorbidities and obstructive pulmonary disease? PATIENTS AND METHODS: A questionnaire on respiratory symptoms and disease, selected comorbidities, and smoking history was mailed to a cross-sectional, sex- and age-stratified, random sample of the population 70 years and older of Bergen, Norway. RESULTS: About 11% of these elderly persons reported having at least one current obstructive pulmonary disease, 8% reported daily wheezing, and 12% reported significant dyspnea. The only respiratory symptom or disorder to show any clear age-related pattern was dyspnea, which increased through age 89 before declining. Dyspnea, current asthma, and current chronic bronchitis were about half as likely in males as females, after adjusting for smoking pack-years. Persons with obstructive pulmonary disease reported problems with walking, heart disease, and muscle/joint disease more frequently than those without. CONCLUSIONS: The prevalence of respiratory symptoms and obstructive pulmonary disease has been estimated. Only dyspnea was associated with age in this elderly population. Female sex was a predictor of dyspnea, current asthma, and current chronic bronchitis.

Cost and cost-effectiveness of community based and health facility based directly observed treatment of tuberculosis in Dar es Salaam, Tanzania.

BACKGROUND: Identifying new approaches to tuberculosis treatment that are effective and put less demand to meagre health resources is important. One such approach is community based direct observed treatment (DOT). The purpose of the study was to determine the cost and cost effectiveness of health facility and community based directly observed treatment of tuberculosis in an urban setting in Tanzania. METHODS: Two alternative strategies were compared: health facility based directly observed treatment by health personnel and community based directly observed treatment by treatment supervisors. Costs were analysed from the perspective of health services, patients and community in the year 2002 in USD using standard methods. Treatment outcomes were obtained from a randomised-controlled trial which was conducted alongside the cost study. Smear positive, smear negative and extra-pulmonary TB patients were included. Cost-effectiveness was calculated as the cost per patient successfully treated. RESULTS: The total cost of treating a patient with conventional health facility based DOT and community based DOT were 145 dollars and 94 dollars respectively. Community based DOT reduced cost by 35%. Cost fell by 27% for health services and 72% for patients. When smear positive and smear negative patients were considered separately, community DOT was associated with 45% and 19% reduction of the costs respectively. Patients used about 43 dollars to follow their medication to health facility which is equivalent to their monthly income. Indirect costs were as important as direct costs, contributing to about 49% of the total patient's cost. The main reason for reduced cost was fewer number of visits to the TB clinic. Community based DOT was more cost-effective at 128 dollars per patient successfully treated compared to 203 dollars for a patient successfully treated with health facility based DOT. CONCLUSION: Community based DOT presents an economically attractive option to complement health facility based DOT. This is particularly important in settings where TB clinics are working beyond capacity under limited resources.

Reference values for arterial blood gases in the elderly.

OBJECTIVES: We present reference values for arterial blood gas measurements for persons > 70 years old. At the same time, we wish to examine how different criteria for exclusion from the reference sample with regard to previous smoking and various comorbidities might influence reference values. METHODS: After first screening a random sample of the general elderly population by postal questionnaire, we selected 146 men and women without respiratory disease, significant dyspnea, symptomatic heart disease or hypertension, or current smoker status. Arterial blood samples were drawn from subjects while in the supine position. RESULTS: The mean (SD; lower limit of normal) PaO(2) and arterial oxygen saturation (SaO(2)) for men was 77.0 mm Hg (9.1; 62.0) and 95.3% (1.4; 93.0), respectively, and for women was 73.5 mm Hg (8.4; 59.6) and 94.8% (1.7; 92.0). Mean (SD; upper limit of normal) PaCO(2) was 39.4 mm Hg (3.3; 44.8) for both sexes. None of the blood gas variables were associated with age, smoking history, or presence of various comorbidities. CONCLUSIONS: The reference values for PaO(2) and SaO(2) in elderly persons are sex specific but age independent. Ex-smokers and persons with nonpulmonary comorbidities who do not have significant respiratory symptoms need not be excluded from the reference sample for arterial blood gases.

Injuries in Khartoum state, the Sudan: a household survey of incidence and risk factors.

Low- and middle-income countries have a higher burden of fatal and non-fatal injuries. The lack of evidence-based information hampers efforts for injury prevention. The aim of this study was to calculate non-fatal injury incidence rates and to investigate causes and risk factors for non-fatal injuries in Khartoum state. Information was gathered in a community-based survey using a stratified two-stage cluster sampling technique. Methods of data collection were face-to-face interviews during October and November 2010. The total number of individuals included was 5661, residing in 973 households. The overall injury incidence rate was 82.0/1000 person-years-at-risk. The three leading causes were falls, mechanical forces and road traffic crashes. Low socio-economic status was a risk factor for injuries in urban areas. Males had a significantly higher risk of being injured in both urban and rural areas. Our findings can contribute to the planning of prevention programmes.

Genetic profile of Mycobacterium tuberculosis and treatment outcomes in human pulmonary tuberculosis in Tanzania.

Information on the different spoligotype families of Mycobacterium tuberculosis in Tanzania is limited, and where available, restricted to small geographical areas. This article describes the genetic profile of M tuberculosis across Tanzania and suggests how spoligotype families might affect drug resistance and treatment outcomes for smear positive pulmonary tuberculosis patients in Tanzania. We conducted the study from 2006 to 2008, and the isolates were obtained from samples collected under the routine drug resistance surveillance system. The isolates were from specimens collected from 2001 to 2007, and stored at the Central and Reference Tuberculosis Laboratory. A total of 487 isolates from 23 regions in the country were spoligotyped. We were able to retrieve clinical information for 446 isolates only. Out of the 487 isolates spoligotyped, 195(40.0%) belonged to the Central Asian (CAS) family, 84 (17.5%) to the Latin American Mediterranean (LAM) family, 49 (10.1%) to the East-African Indian (EAI) family, and 33 (6.8%) to the Beijing family. Other isolates included 1 (0.2%) for H37Rv, 10 (2.1%) for Haarlem, 4 (0.8%) for S family, 58 (11.9%) for T family and 52 (10.7%) for unclassified. No spoligotype patterns were consistent with M bovis. Regarding treatment outcomes, the cure rate was 80% with no significant variation among the spoligotype families. The overall level of MDR TB was 2.5% (3/12 1), with no significant difference among the spoligotype families. All Beijing strains (11.8%, 30/254) originated from the Eastern and Southern zones of the country, of which 80% were from Dar es Salaam. Isolates from the CAS and T families were reported disproportionately from the Eastern-Southern zone, and EAI and LAM families from the Northern-Lake zones but the difference was not statistically significant. Five isolates were identified as non-tuberculous Mycobacteria. In conclusion, M. tuberculosis isolates from pulmonary tuberculosis cases in Tanzania were classified mostly within the CAS, LAM, and EAI and T families, while the Beijing family comprised about 7% isolates only. Consistently good treatment outcomes were recorded across these spoligotype families. The proportion of drug resistance strains was low. The findings also suggest variation of spoligotype families with varying geographical localities within the country, and identify this area for further research to confirm this finding.