Increasing Prevalence of Nontuberculous Mycobacteria in Respiratory Specimens from US-Affiliated Pacific Island Jurisdictions1.

Nontuberculous mycobacteria (NTM) respiratory infections represent a growing public health problem in many countries. However, there are limited published epidemiologic studies for the Western Pacific region. We reviewed respiratory specimens submitted to Diagnostic Laboratory Services in Hawaii, USA, for culture of Mycobacterium tuberculosis during August 2007-December 2011 to determine the NTM isolation rate. We observed a statistically significant increase in the rate of specimens with NTM isolated in respiratory culture (adjusted rate ratio per year 1.65, 95% CI 1.54-1.77; p<0.01). In contrast, the number of patients with respiratory cultures positive for M. tuberculosis showed no increase (adjusted rate ratio per year 0.98, 95% CI 0.94-1.01; p = 0.19). A 6-month subset of NTM isolates was identified by using a nucleic acid probe or 16S rRNA sequencing. M. avium complex and M. fortuitum were the most common NTM identified.

A tuberculosis outbreak fueled by cross-border travel and illicit substances: Nevada and Arizona.

OBJECTIVES: From May 2006 to August 2008, the Southern Nevada Health District identified eight tuberculosis (TB) cases in six adults and two children in a Hispanic community. We conducted an outbreak investigation to determine the extent of TB transmission and prevent additional cases. METHODS: We investigated TB cases in Nevada and Arizona with the outbreak genotype or cases with suspected epidemiologic links to this cluster but without genotyping data. We reviewed medical records and interviewed patients and contacts. Subsequently, genotype surveillance was conducted for approximately four years to monitor additional outbreak-related cases. RESULTS: Eight outbreak cases were identified among six adults and two children. All patients were Hispanic and five were U.S.-born. The index patient was diagnosed while detained in Immigration and Customs Enforcement custody but deported before treatment completion. He was lost to follow-up for two years, during which time he served as the source for six secondary TB cases, including his own child. Along with the index patient, five patients reportedly engaged in the sale or use of methamphetamine. Follow-up surveillance in the two states identified eight additional cases with the outbreak genotype; three had epidemiologic links to the index case. CONCLUSIONS: We found that incomplete TB treatment led to extensive TB transmission. We recommend thorough discharge planning and active measures to ensure continuity of care and TB treatment completion for people in custody at higher risk for loss to follow-up, which likely includes those engaged in the sale or use of illicit substances.

Molecular epidemiology of Mycobacterium tuberculosis in the United States-Affiliated Pacific Islands.

The United States-Affiliated Pacific Islands (USAPI) are part of the US National Tuberculosis (TB) Surveillance System and use laboratory services contracted through a cooperative agreement with the Centers for Disease Control and Prevention (CDC). In 2004, the CDC established the National Tuberculosis Genotyping Service, a system to genotype 1 isolate from each culture-confirmed case of TB. To describe the molecular epidemiology of TB in the region, we examined all Mycobacterium tuberculosis isolates submitted for genotyping from January 1, 2004, to December 31, 2008. Over this time period, the USAPI jurisdictions reported 1339 verified TB cases to the National Tuberculosis Surveillance System. Among 419 (31%) reported culture-confirmed TB cases, 352 (84%) had complete genotype results. Routine TB genotyping allowed, for the first time, an exploration of the molecular epidemiology of TB in the USAPI.

The impact of post-election violence on HIV and other clinical services and on mental health-Kenya, 2008.

INTRODUCTION: In December 2007, civil disruption and violence erupted in Kenya following national elections, displacing 350,000 people and affecting supply chains and services. The Kenyan government and partners were interested in assessing the extent of disruption in essential health services, especially HIV treatment. METHODS: A two-stage cluster sampling for patients taking antiretroviral therapy (ART) was implemented ten weeks after elections, March 10-21, 2008, at twelve health facilities providing ART randomly selected in each of the three provinces most affected by post-election disruption-Rift Valley, Nyanza, and Central Provinces. Convenience samples of patients with tuberculosis, hypertension, or diabetes were also interviewed from the same facilities. Finally, a convenience sampling of internally displaced persons (IDPs) in the three provinces was conducted. RESULTS: Three hundred thirty-six IDPs in nine camps and 1,294 patients in 35 health facilities were interviewed. Overall, nine percent of patients reported having not returned to their routine health care facility; 9%-25% (overall 16%) reported a temporary inability for themselves or their children to access care at some point during January-February 2008. Less than 15% of patients on long-term therapies for HIV, tuberculosis, diabetes, or hypertension had treatment interruptions compared with 2007. The proportion of tuberculosis patients receiving a ≥45-day supply of medication increased from five percent in November 2007 to 69% in December 2007. HIV testing decreased in January 2008 compared with November 2007 among women in labor wards and among persons tested through voluntary counseling and testing services in Nyanza and Rift Valley Provinces. Patients and their family members witnessed violence, especially in Nyanza and Rift Valley Provinces (54%-59%), but few patients (2.5%-14%, 10% overall) personally experienced violence. More IDPs reported witnessing (80%) or personally experiencing (38%) violence than did patients. About half of patients and three-quarters of IDPs interviewed had anxiety or depression symptoms during the four weeks before the assessment. There was no association among patients between the presence of HIV, tuberculosis, diabetes, and hypertension and the prevalence of anxiety or depression symptoms. CONCLUSION: More than 85% of patients in highly affected provinces avoided treatment interruptions; this may be in part related to practitioners anticipating potential disruption and providing patients with medications for an extended period. During periods of similar crisis, anticipating potential limitations on medication access and increased mental health needs could potentially prevent negative health impacts.

Effects of multimicronutrient home fortification on anemia and growth in Bhutanese refugee children.

BACKGROUND: Anemia remains a significant public health problem in refugee settings. Home fortification with micronutrient powders has been proposed as a feasible option to alleviate micronutrient deficiencies; its efficacy in reducing anemia in children aged 6 to 24 months has been demonstrated in several trials. OBJECTIVE: To evaluate the effectiveness of a large-scale micronutrient powder distribution program in reducing anemia prevalence and promoting growth in refugee children aged 6 to 59 months. METHODS: Four representative cross-sectional surveys were conducted 13 months before and 7, 14, and 26 months after initiation of the supplementation program. Data collected on children aged 6 to 59 months included hemoglobin concentration, anthropometric indicators, morbidity, feeding practices, and information on the micronutrient distribution program. The study had a pre-post design with no control group. RESULTS: The overall prevalence of anemia in children did not change significantly between baseline (43.3%) and endpoint (40.2%). The prevalence of moderate anemia decreased over the same period from 18.9% to 14.4% (p < .05). The levels of severe anemia were negligible (< 1%) in all surveys. The prevalence of stunting decreased significantly from 39.2% at baseline to 23.4% at endpoint (p < .001), a relative decrease of40%. Reported coverage, use, and acceptance of micronutrient supplements remained consistently high throughout the study. CONCLUSIONS: In the absence of a control group, changes in key outcomes should be interpreted with caution. The minor effect on hemoglobin status requires further investigation of underlying causes of anemia in this population. The large positive effect on linear growth may be a significant benefit of supplementation if confirmed by future studies.

Nutritional status of under-five children living in an informal urban settlement in Nairobi, Kenya.

Malnutrition in sub-Saharan Africa contributes to high rates of childhood morbidity and mortality. However, little information on the nutritional status of children is available from informal settlements. During the period of post-election violence in Kenya during December 2007-March 2008, food shortages were widespread within informal settlements in Nairobi. To investigate whether food insecurity due to post-election violence resulted in high prevalence of acute and chronic malnutrition in children, a nutritional survey was undertaken among children aged 6-59 months within two villages in Kibera, where the Kenya Medical Research Institute/Centers for Disease Control and Prevention conducts population-based surveillance for infectious disease syndromes. During 25 March-4 April 2008, a structured questionnaire was administered to caregivers of 1,310 children identified through surveillance system databases to obtain information on household demographics, food availability, and child-feeding practices. Anthropometric measurements were recorded on all participating children. Indices were reported in z-scores and compared with the World Health Organization (WHO) 2005 reference population to determine the nutritional status of children. Data were analyzed using the Anthro software of WHO and the SAS. Stunting was found in 47.0% of the children; 11.8% were underweight, and 2.6% were wasted. Severe stunting was found in 23.4% of the children; severe underweight in 3.1%, and severe wasting in 0.6%. Children aged 36-47 months had the highest prevalence (58.0%) of stunting while the highest prevalence (4.1%) of wasting was in children aged 6-11 months. Boys were more stunted than girls (p < 0.01), and older children were significantly (p < 0.0001) stunted compared to younger children. In the third year of life, girls were more likely than boys to be wasted (p < 0.01). The high prevalence of chronic malnutrition suggests that stunting is a sustained problem within this urban informal settlement, not specifically resulting from the relatively brief political crisis. The predominance of stunting in older children indicates failure in growth and development during the first two years of life. Food programmes in Kenya have traditionally focused on rural areas and refugee camps. The findings of the study suggest that tackling childhood stunting is a high priority, and there should be fostered efforts to ensure that malnutrition-prevention strategies include the urban poor.

Risk factors associated with sexual violence towards girls in Swaziland.

OBJECTIVE: To explore risk factors for sexual violence in childhood in a nationally representative sample of females aged 13 to 24 years in Swaziland. METHODS: During a household survey respondents were asked to report any experiences of sexual violence before the age of 18 years. The association between childhood sexual violence and several potential demographic and social risk factors was explored through bivariate and multivariate logistic regression. FINDINGS: Participants totalled 1244. Compared with respondents who had been close to their biological mothers as children, those who had not been close to her had higher odds of having experienced sexual violence (crude odds ratio, COR: 1.89; 95% CI: 1.14-3.14), as did those who had had no relationship with her at all (COR: 1.93; 95% CI: 1.34-2.80). In addition, greater odds of childhood sexual violence were noted among respondents who were not attending school at the time of the survey (COR: 2.26; 95% CI: 1.70-3.01); who were emotionally abused as children (COR: 2.04; 95% CI: 1.50-2.79); and who knew of another child who had been sexually assaulted (COR: 1.77; 95% CI: 1.31-2.40) or was having sex with a teacher (COR: 2.07; 95% CI: 1.59-2.69). Childhood sexual violence was positively associated with the number of people the respondent had lived with at any one time (COR: 1.03; 95% CI: 1.01-1.06). CONCLUSION: Inadequate supervision or guidance and an unstable environment put girls at risk of sexual violence. Greater educational opportunities and an improved mother-daughter relationship could help prevent it.

Islands of hope: building local capacity to manage an outbreak of multidrug-resistant tuberculosis in the Pacific.

A single case of multidrug-resistant tuberculosis (MDR-TB) can overwhelm the technical and financial capacity of small TB programs. In May 2008, the island state of Chuuk requested assistance for their first cases of MDR-TB. Second-line drugs and isolation rooms were unavailable, lab capacity was limited, and clinicians lacked experience. Delayed response caused prolonged transmission among household contacts. Several agencies responded with technical assistance and resources. Subsequent evaluations identified 16 additional MDR-TB cases and 124 infected contacts. Within six months, the local TB program gained remarkable capacity to manage MDR-TB cases and contacts, and greatly improve care for all TB patients. The Chuuk outbreak demonstrates the importance of establishing MDR-TB readiness in smaller jurisdictions and maintaining an essential TB control infrastructure.

Sexual violence and its health consequences for female children in Swaziland: a cluster survey study.

BACKGROUND: Despite concern, few studies have been done about sexual violence against girls younger than 18 years of age in sub-Saharan Africa. We report the prevalence and circumstances of sexual violence in girls in Swaziland, and assess the negative health consequences. METHODS: We obtained data from a nationally representative sample of girls and women aged 13-24 years from selected households in Swaziland between May 15, 2007, and June 16, 2007, with a two-stage cluster design. The questionnaire examined demographics, type of sexual violence that took place before the respondent was 18 years of age, circumstances of the incident, and health-related conditions. Information was gathered from 1244 women and girls (response rate 96.3%), of whom 1242 provided retrospective responses to questions about sexual violence. We used regression models adjusted for relevant demographics to estimate the odds ratios for the associations between sexual violence and health-related conditions. FINDINGS: 33.2% (95% CI 29.9-36.7) of respondents reported an incident of sexual violence before they reached 18 years of age. The most common perpetrators of the first incident were men or boys from the respondent's neighbourhood (32.3% [28.8-36.1]) and boyfriends or husbands (26.2% [22.2-30.7]). The first incident most often took place in the respondent's own home (26.1% [21.6-31.2]). Sexual violence was associated with reported lifetime experience of sexually transmitted diseases (adjusted OR 3.69 [95% CI 1.78-7.66]), pregnancy complications or miscarriages (3.54 [1.47-8.55]), unwanted pregnancy (2.92 [1.87-4.55]), and self-report of feeling depressed (2.30 [1.70-3.11]). INTERPRETATION: Knowledge of the high prevalence of sexual violence against girls in Swaziland and its associated serious health-related conditions and behaviours should be used to develop effective prevention strategies. FUNDING: UNICEF.

Comparison of altitude effect on Mycobacterium tuberculosis infection between rural and urban communities in Peru.

The mechanism of high altitude effect on tuberculosis (TB) infection has not been fully established. We previously reported a lower positive tuberculin skin test (TST) prevalence in high altitude villages compared with sea level communities in Peru. In this study, four additional communities were tested to assess whether decreased TB transmission was also in urban environments at high altitude. TST results from 3,629 individuals in nine communities were analyzed using generalized estimating equations to account for community clustering. Positive TST prevalence was not significantly different between the urban highland and the urban non-highland communities after adjusting for age, household contacts with a TST-positive person or a TB case, and presence of a Bacillus Calmette-Guérin vaccination scar. The effect of population concentration and increased contact with active TB overwhelmed the protective effect of altitude in urban highlands. Highland cities require the same preventive efforts against TB as non-highland communities.