Patients direct costs to undergo TB diagnosis.

BACKGROUND: A major impediment to the treatment of TB is a diagnostic process that requires multiple visits. Descriptions of patient costs associated with diagnosis use different protocols and are not comparable. METHODS: We aimed to describe the direct costs incurred by adults attending TB diagnostic centres in four countries and factors associated with expenditure for diagnosis. Surveys of 2225 adults attending smear-microscopy centres in Nigeria, Nepal, Ethiopia and Yemen. Adults >18 years with cough >2 weeks were enrolled prospectively. Direct costs were quantified using structured questionnaires. Patients with costs >75(th) quartile were considered to have high expenditure (cases) and compared with patients with costs <75(th) quartile to identify factors associated with high expenditure. RESULTS: The most significant expenses were due to clinic fees and transport. Most participants attended the centres with companions. High expenditure was associated with attending with company, residing in rural areas/other towns and illiteracy. CONCLUSIONS: The costs incurred by patients are substantial and share common patterns across countries. Removing user fees, transparent charging policies and reimbursing clinic expenses would reduce the poverty-inducing effects of direct diagnostic costs. In locations with limited resources, support could be prioritised for those most at risk of high expenditure; those who are illiterate, attend the service with company and rural residents.

Use of tuberculin skin test, IFN-γ release assays and IFN-γ-induced protein-10 to identify children with TB infection.

Current tests of tuberculosis (TB) infection (tuberculin skin test (TST), interferon (IFN)-γ-release assays (IGRAs) and IFN-γ-induced protein (IP)-10) have limitations and their value when used consecutively to identify infected children has not been explored. This study describes TST, IGRA and IP-10 responses in children in contact with adults with TB, the agreement of the tests and whether using multiple tests indentifies more infected children. 330 children (aged 1-15 yrs) in contact with adults with pulmonary TB and 156 controls were studied in Ethiopia. Children exposed to adults with high bacilli grades in sputum were more likely to have positive TST, IFN-γ and IP-10 than controls. The agreement of positive tests was directly associated with the sputum bacilli grades (p<0.001 for all). The agreement of negative tests was higher in control children. The consecutive use of the tests increased the number of children classified as having at least one positive test. Using three tests increases the number of children classified as infected. This increase is associated with the bacilli load of the adults. Using only one test may underestimate the proportion of infected children, but the interpretation of the data is difficult due to the lack of reference standards.

Unusual norovirus and rotavirus genotypes in Ethiopia.

BACKGROUND: Gastro-enteritis is associated with significant mortality in low- and middle-income countries, and rotavirus and norovirus are the principal viral agents implicated. AIMS: To investigate the molecular epidemiology and burden of disease associated with rotavirus and norovirus in children attending a health centre in Ethiopia. METHODS: A cross-sectional study was conducted in children attending a health centre in Awassa, southern Ethiopia. Children with diarrhoea (cases) and without diarrhoea (controls) were recruited over a 6-month period from December 2008 to May 2009. Rotavirus was detected by ELISA and genotyped by RT-PCR, and norovirus was amplified by RT-PCR with genotyping by sequence analysis of RT-PCR products. RESULTS: Rotavirus was detected in 44/200 (22%) cases and in none of the controls, with genotypes G3P[6] (48%), G1P[8] (27%) and G2P[4] (7%) being the strains most commonly identified. Norovirus was detected in 16 (8%) of 200 cases and in 4 (7%) of 57 controls. Norovirus GII.3 was the strain most commonly detected (40%: 8/20) and ten other genotypes were also detected. CONCLUSION: Rotavirus is a common cause of severe gastro-enteritis in children in Ethiopia; however, norovirus occurred with a similar frequency in cases and controls. A globally uncommon strain type, G3P[6], predominated within the rotavirus strains detected.

Can interferon-gamma or interferon-gamma-induced-protein-10 differentiate tuberculosis infection and disease in children of high endemic areas?

BACKGROUND: Diagnosis of childhood tuberculosis (TB) is difficult in high TB burden settings. Interferon-gamma-induced protein 10 (IP10) has been suggested as a marker of TB infection and disease, but its ability to differentiate the two conditions remains uncertain. OBJECTIVES: To describe Interferon-gamma (INFγ) and IP10 expression in children with TB infection and disease and controls to assess their potential to differentiate latent and active TB. METHODS: This was a cross sectional study of 322 1-15 years old children with symptoms of TB (28 confirmed, 136 probable and 131 unlikely TB), 335 children in contact with adults with pulmonary TB and 156 community controls in Southern Ethiopia. The Tuberculin Skin Test (TST) and Quantiferon-In-Tube (QFT-IT) were performed. INFγ and IP10 were measured in plasma supernatants. RESULTS AND INTERPRETATION: Children with confirmed and probable TB and contacts were more likely to have TST+ (78.6%, 59.3% and 54.1%, respectively) than children with unlikely TB (28.7%) and controls (12.8%) (p<0.001). Children with confirmed TB (59.3%) and contacts (44.7%) were more likely to have INFγ+ than children with probable (37.6%) or unlikely TB (28.1%) and controls (13.1%) (p<0.001). IP10 concentrations were higher in INFγ+ children independently of TST (p<0.001). There was no difference between IP10 concentrations of children with confirmed TB and contacts (p = 0.8) and children with and without HIV (p>0.1). INFγ and IP10 can identify children with TB infection and disease, but cannot differentiate between the two conditions. HIV status did not affect the expression of IP10.

A multi-country non-inferiority cluster randomized trial of frontloaded smear microscopy for the diagnosis of pulmonary tuberculosis.

BACKGROUND: More than 50 million people around the world are investigated for tuberculosis using sputum smear microscopy annually. This process requires repeated visits and patients often drop out. METHODS AND FINDINGS: This clinical trial of adults with cough ≥2 wk duration (in Ethiopia, Nepal, Nigeria, and Yemen) compared the sensitivity/specificity of two sputum samples collected "on the spot" during the first visit plus one sputum sample collected the following morning (spot-spot-morning [SSM]) versus the standard spot-morning-spot (SMS) scheme. Analyses were per protocol analysis (PPA) and intention to treat (ITT). A sub-analysis compared just the first two smears of each scheme, spot-spot and spot-morning. In total, 6,627 patients (3,052 SSM/3,575 SMS) were enrolled; 6,466 had culture and 1,526 were culture-positive. The sensitivity of SSM (ITT, 70.2%, 95% CI 66.5%-73.9%) was non-inferior to the sensitivity of SMS (PPA, 65.9%, 95% CI 62.3%-69.5%). Similarly, the specificity of SSM (ITT, 96.9%, 95% CI 93.2%-99.9%) was non-inferior to the specificity of SMS (ITT, 97.6%, 95% CI 94.0%-99.9%). The sensitivity of spot-spot (ITT, 63.6%, 95% CI 59.7%-67.5%) was also non-inferior to spot-morning (ITT, 64.8%, 95% CI 61.3%-68.3%), as the difference was within the selected -5% non-inferiority limit (difference ITT = 1.4%, 95% CI -3.7% to 6.6%). Patients screened using the SSM scheme were more likely to provide the first two specimens than patients screened with the SMS scheme (98% versus 94.2%, p<0.01). The PPA and ITT analysis resulted in similar results. CONCLUSIONS: The sensitivity and specificity of SSM are non-inferior to those of SMS, with a higher proportion of patients submitting specimens. The scheme identifies most smear-positive patients on the first day of consultation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN53339491. Please see later in the article for the Editors' Summary.

LED fluorescence microscopy for the diagnosis of pulmonary tuberculosis: a multi-country cross-sectional evaluation.

BACKGROUND: The diagnosis of tuberculosis (TB) in resource-limited settings relies on Ziehl-Neelsen (ZN) smear microscopy. LED fluorescence microscopy (LED-FM) has many potential advantages over ZN smear microscopy, but requires evaluation in the field. The aim of this study was to assess the sensitivity/specificity of LED-FM for the diagnosis of pulmonary TB and whether its performance varies with the timing of specimen collection. METHODS AND FINDINGS: Adults with cough ≥2 wk were enrolled consecutively in Ethiopia, Nepal, Nigeria, and Yemen. Sputum specimens were examined by ZN smear microscopy and LED-FM and compared with culture as the reference standard. Specimens were collected using a spot-morning-spot (SMS) or spot-spot-morning (SSM) scheme to explore whether the collection of the first two smears at the health care facility (i.e., "on the spot") the first day of consultation followed by a morning sample the next day (SSM) would identify similar numbers of smear-positive patients as smears collected via the SMS scheme (i.e., one on-the-spot-smear the first day, followed by a morning specimen collected at home and a second on-the-spot sample the second day). In total, 529 (21.6%) culture-positive and 1,826 (74.6%) culture-negative patients were enrolled, of which 1,156 (49%) submitted SSM specimens and 1,199 (51%) submitted SMS specimens. Single LED-FM smears had higher sensitivity but lower specificity than single ZN smears. Using two LED-FM or two ZN smears per patient was 72.8% (385/529, 95% CI 68.8%-76.5%) and 65.8% (348/529, 95% CI 61.6%-69.8%) sensitive (p<0.001) and 90.9% (1,660/1,826, 95% CI 89.5%-92.2%) and 98% (1,790/1,826, 95% CI 97.3%-98.6%) specific (p<0.001). Using three LED-FM or three ZN smears per patient was 77% (408/529, 95% CI 73.3%-80.6%) and 70.5% (373/529, 95% CI 66.4%-74.4%, p<0.001) sensitive and 88.1% (95% CI 86.5%-89.6%) and 96.5% (95% CI 96.8%-98.2%, p<0.001) specific. The sensitivity/specificity of ZN smear microscopy and LED-FM did not vary between SMS and SSM. CONCLUSIONS: LED-FM had higher sensitivity but, in this study, lower specificity than ZN smear microscopy for diagnosis of pulmonary TB. Performance was independent of the scheme used for collecting specimens. The introduction of LED-FM needs to be accompanied by appropriate training, quality management, and monitoring of performance in the field. TRIAL REGISTRATION: Current Controlled Trials ISRCTN53339491. Please see later in the article for the Editors' Summary.

Inadequate feeding practices and impaired growth among children from subsistence farming households in Sidama, Southern Ethiopia.

Whether current child feeding practices and behaviours among rural households in Sidama, Southern Ethiopia conform to the World Health Organization (WHO) guiding principles for complementary feeding is uncertain. We assessed socio-demographic status, anthropometry, breastfeeding, complementary feeding practices and behaviours, and motor development milestones in a convenience sample of 97 breastfed children aged 6-23 months from three rural Sidama communities. Energy and nutrient intakes from complementary foods were also calculated from 1-day in-home weighed records. Prevalence of stunting ranged from 25% for infants aged 6-8 months to 52% for children aged 12-23 months, whereas for wasting, the corresponding prevalence was 10% and 14%, respectively. Very few children were exclusively breastfed up to 6 months of age (n = 2), or received solids/semi-solids for the recommended minimum number of times containing the recommended number of food groups. Responsive feeding was not practised and no cellular animal products were consumed. Median intakes of energy, and intakes and densities of micronutrients from complementary foods (but not protein) were below WHO recommendations, assuming average breast milk intakes; greatest shortfalls were for retinol, vitamin C and calcium densities. Mothers of stunted children were shorter and lighter, and from households of lower socio-economic status than non-stunted children (P < 0.05). Acquisition of some motor development milestones was delayed in stunted infants compared with their non-stunted counter-parts. In conclusion, interventions that address the WHO guiding principles for complementary feeding practices and behaviours, as well as prenatal influences on growth, are urgently required in this setting.

Inadequate intakes of dietary zinc among pregnant women from subsistence households in Sidama, Southern Ethiopia.

OBJECTIVE: To assess the prevalence of zinc inadequacy based on dietary intakes and plasma zinc concentrations and, simultaneously, the prevalence of inadequate intakes of energy, protein, calcium and iron. DESIGN: A cross-sectional study of a convenience sample of subsistence farming households in Sidama, Southern Ethiopia. SUBJECTS: Dietary intakes were calculated from 1-day weighed food records and 40 repeats from 99 pregnant women in the third trimester using analysed values of major staple foods for zinc, iron, calcium and phytate. The distribution of observed intakes was adjusted for usual intakes and the prevalence of inadequacy estimated using the estimated average requirement (EAR) cutpoint method. Prevalence of inadequacy for zinc, protein and iron intakes were compared with those based on biochemical measures. RESULTS: Prevalence of zinc inadequacy was very high: 99% for US FNB EAR and 100% for IZiNCG EAR compared to 72% based on low plasma zinc concentrations. Corresponding prevalence estimates for iron were much lower: 4% for inadequate intakes based on US FNB EAR vs. 8.7% for iron deficiency anaemia (haemoglobin < 110 g l-1; ferritin < 12 microg l-1) and 32.3% for low storage iron. Prevalence of inadequacy for protein was 100% for adjusted intakes and 91% for serum albumin < 32 g l-1. For calcium, 74% were at risk for inadequate intakes. CONCLUSION: The high prevalence of inadequate intakes of zinc and protein was reasonably consistent with those based on biochemical measures. Such dietary deficits could be overcome by regular consumption of cellular animal protein. In contrast, both dietary and biochemical measures of iron inadequacy were low.

Zinc absorption during late pregnancy in rural southern Ethiopia.

BACKGROUND: Little is yet known about zinc absorption in late pregnancy, and no information on absorption from the total diet is available. OBJECTIVE: The objective was to measure the fractional absorption of zinc (FAZ) and to estimate the total quantity of absorbed zinc (TAZ) each day during the third trimester of pregnancy in poor rural southern Ethiopian women. DESIGN: The participants (n = 17) were a convenience sample from a larger study population. The third stage of pregnancy was estimated from fundal height by the Bushulo Health Center prenatal outreach program. FAZ was determined with a dual-isotope tracer ratio technique that uses measurements of urine enrichment with zinc stable isotopes administered intravenously and orally, as an extrinsic label, with all meals in 1 d. Total dietary zinc (TDZ) was calculated from weighed diet records and Ethiopian food-composition tables supported by zinc and phytate analyses of major food items for individual meals. Plasma zinc and exchangeable zinc pool size were also estimated. RESULTS: Mean (+/-SD) FAZ was 0.35 +/- 0.11, TDZ was 6.0 +/- 3.2 mg/d, TAZ was 2.1 +/- 1.0 mg/d, phytate intake was 1033 +/- 843 mg/d, plasma zinc was 44.1 +/- 6.0 microg/dL, and the exchangeable zinc pool size was 142 +/- 39 mg. The molar ratio of phytate to zinc was 17:1. CONCLUSIONS: Women from a poor rural population who were dependent on a moderately high-phytate diet had low TDZ and low plasma zinc concentrations in the third trimester of pregnancy. TAZ was modestly higher than that predicted but did not meet physiologic requirements.

Rural poverty and delayed presentation to tuberculosis services in Ethiopia.

To measure time to initial presentation and assess factors influencing the decision to seek medical attention, we interviewed 243 patients undergoing sputum examination for the diagnosis of tuberculosis (TB) at a rural health centre near Awassa, Ethiopia. A structured questionnaire was used. Median (mean+SD) patient delay was 4.3 (9.8+12.4) weeks. Delays over 4 weeks were significantly associated with rural residence, transport time over 2 h, overnight travel, transport cost exceeding US $1.40, having sold personal assets prior to the visit, and use of traditional medicine. The majority of patients cited economic or logistical barriers to health care when asked directly about causes of delay. Case-finding strategies for TB must be sensitive to patient delay and health systems must become more accessible in rural areas.