A systematic review of the effectiveness of hospital- and ambulatory-based management of multidrug-resistant tuberculosis.

A systematic review of the literature was conducted on the effectiveness of MDR-TB management. A meta-analysis of treatment outcomes of patients treated in hospitals versus ambulatory-based models was performed in accordance with PRISMA guidelines. The pooled treatment success rate was 66.4% (95% confidence interval [CI] 61.4-71.1%), with no statistical difference between ambulatory (65.5%; 55.1-74.6%) and hospital-based models (66.7%; 61.0-72.0%). The pooled death rate was 10.4% (6.3-16.5%), the pooled treatment failure rate was 9.5% (7.3-12.4%), and the defaulter rate was 14.3% (10.5-19.1%). None of the differences between the two models were statistically significant for any of the outcomes considered. This work improves the quality of the evidence available supporting the World Health Organizations (WHO) recommendation that patients be treated using mainly ambulatory care, conditional on infection control measures in the home and clinic, clinical condition of the patient, availability of treatment support to facilitate adherence to treatment, and provisions for backup facility to manage patients who need inpatient treatment care.

Influenza research in the Eastern Mediterranean Region: the current state and the way forward.

We searched published literature, surveillance data sources, and sequence databases to analyze the state of influenza virus research and to identify research gaps in the World Health Organization (WHO) Eastern Mediterranean Region. PubMed, Scopus, and other databases were searched for influenza publications and nucleotide sequences. WHO's FluNet was searched to determine virologic reporting from each country. We found that influenza research has increased in recent years with the emergence of H5N1 and pandemic H1N1. In some countries, influenza research is growing and is diversified, covering epidemiologic, veterinary, and basic science aspects. However, the volume and diversity of influenza research is low, especially in light of the burden of influenza in the region. To have contemporary and advanced research in the region, systematic surveillance in humans and animals, as well as at the human-animal interface, needs to be boosted. Surveillance data should then be used to answer more important epidemiologic, virologic, immunologic, and basic science questions.

Occult hepatitis B virus infection among Egyptian blood donors.

AIM: To identify blood donors with occult hepatitis B virus (HBV) infection (OBI) to promote safe blood donation. METHODS: Descriptive cross sectional study was conducted on 3167 blood donors negative for hepatitis B surface antigen (HBsAg), hepatitis C antibody (HCV Ab) and human immunodeficiency virus Ab. They were subjected to the detection of alanine aminotransferase (ALT) and aspartate transaminase (AST) and screening for anti-HBV core antibodies (total) by two different techniques; [Monoliza antibodies to hepatitis B core (Anti-HBc) Plus-Bio-Rad] and (ARC-HBc total-ABBOT). Positive samples were subjected to quantitative detection of antibodies to hepatitis B surface (anti-HBs) (ETI-AB-AUK-3, Dia Sorin-Italy). Serum anti-HBs titers > 10 IU/L was considered positive. Quantitative HBV DNA by real time polymerase chain reaction (PCR) (QIAGEN-Germany) with 3.8 IU/mL detection limit was estimated for blood units with negative serum anti-HBs and also for 32 whose anti-HBs serum titers were > 1000 IU/L. Also, 265 recipients were included, 34 of whom were followed up for 3-6 mo. Recipients were investigated for ALT and AST, HBV serological markers: HBsAg (ETI-MAK-4, Dia Sorin-Italy), anti-HBc, quantitative detection of anti-HBs and HBV-DNA. RESULTS: 525/3167 (16.6%) of blood units were positive for total anti-HBc, 64% of those were anti-HBs positive. Confirmation by ARCHITECT anti-HBc assay were carried out for 498/525 anti-HBc positive samples, where 451 (90.6%) confirmed positive. Reactivity for anti-HBc was considered confirmed only if two positive results were obtained for each sample, giving an overall prevalence of 451/3167 (14.2%) for total anti-HBc. HBV DNA was quantified by real time PCR in 52/303 (17.2%) of anti-HBc positive blood donors (viral load range: 5 to 3.5 x 10(5) IU/mL) with a median of 200 IU/mL (mean: 1.8 x 10(4) ± 5.1 x 10(4) IU/mL). Anti-HBc was the only marker in 68.6% of donors. Univariate and multivariate logistic analysis for identifying risk factors associated with anti-HBc and HBV-DNA positivity among blood donors showed that age above thirty and marriage were the most significant risk factors for prediction of anti-HBc positivity with AOR 1.8 (1.4-2.4) and 1.4 (1.0-1.9) respectively. Other risk factors as gender, history of blood transfusion, diabetes mellitus, frequent injections, tattooing, previous surgery, hospitalization, Bilharziasis or positive family history of HBV or HCV infections were not found to be associated with positive anti-HBc antibodies. Among anti-HBc positive blood donors, age below thirty was the most significant risk factor for prediction of HBV-DNA positivity with AOR 3.8 (1.8-7.9). According to HBV-DNA concentration, positive samples were divided in two groups; group one with HBV-DNA ≥ 200 IU/mL (n = 27) and group two with HBV-DNA < 200 IU/mL (n = 26). No significant difference was detected between both groups as regards mean age, gender, liver enzymes or HBV markers. Serological profiles of all followed up blood recipients showed that, all were negative for the studied HBV markers. Also, HBV DNA was not detected among studied recipients, none developed post-transfusion hepatitis (PTH) and the clinical outcome was good. CONCLUSION: OBI is prevalent among blood donors. Nucleic acid amplification/HBV anti core screening should be considered for high risk recipients to eliminate risk of unsafe blood donation.

Multidrug-resistant tuberculosis, Somalia, 2010-2011.

In a nationwide survey in 2011, multidrug-resistant tuberculosis (MDR TB) was found in 5.2% and 40.8% of patients with new and previously treated TB, respectively. These levels of drug resistance are among the highest ever documented in Africa and the Middle East. This finding presents a serious challenge for TB control in Somalia.

Zoonoses and marginalised infectious diseases of poverty: where do we stand?

Despite growing awareness of the importance of controlling neglected tropical diseases as a contribution to poverty alleviation and achieving the Millennium Development Goals, there is a need to up-scale programmes to achieve wider public health benefits. This implementation deficit is attributable to several factors but one often overlooked is the specific difficulty in tackling diseases that involve both people and animals - the zoonoses. A Disease Reference Group on Zoonoses and Marginalised Infectious Diseases (DRG6) was convened by the Special Programme for Research and Training in Tropical Diseases (TDR), a programme executed by the World Health Organization and co-sponsored by UNICEF, UNDP, the World Bank and WHO. The key considerations included: (a) the general lack of reliable quantitative data on their public health burden; (b) the need to evaluate livestock production losses and their additional impacts on health and poverty; (c) the relevance of cross-sectoral issues essential to designing and implementing public health interventions for zoonotic diseases; and (d) identifying priority areas for research and interventions to harness resources most effectively. Beyond disease specific research issues, a set of common macro-priorities and interventions were identified which, if implemented through a more integrated approach by countries, would have a significant impact on human health of the most marginalised populations characteristically dependent on livestock.

Prevalence of tuberculosis suspects and their healthcare-seeking behavior in urban and rural Jordan.

To determine the prevalence and healthcare-seeking behavior of tuberculosis (TB) suspects in Middle and South Jordan. A community-based survey was carried out between June-September 2005, whereby 61,730 adult household members were inquired about the presence of persistent cough for more than three weeks to identify TB suspects. These adults were then interviewed and referred to the nearest health center for clinical and sputum smear examination. Of the 61,730 surveyed household members, 1,544 (2.51%) were identified as TB suspects, of these two were sputum smear positive pulmonary TB. The first action with the onset of symptoms was to visit the health centers. Reasons for timely seeking care were accessibility of the facilities and confidence in obtaining a cure, and obstacles were belief that symptoms would resolve and economic constraints in rural residents. Females, rural residents, expatriates, and using private means of transportation were predictors of delay in seeking care for more than three weeks. This study has set the baseline information about the prevalence of TB suspects in Jordan and their healthcare-seeking behavior that shows community preference to seek care at health centers. These should be upgraded and the health workers trained on suspect management to enhance the TB elimination efforts.

The quality of antimalarials available in Yemen.

BACKGROUND: Malaria has always been a major public health problem in Yemen. Several studies in developing countries have demonstrated ineffective and poor quality drugs including antimalarials. Therefore, quality assessment of antimalarial drugs is of crucial importance. This study aimed to assess the quality of antimalarials (chloroquine and sulfadoxine/pyrimethamine) available in Yemen and to determine whether the quality of these products was related to the level of the distribution chain at which the samples were collected or related to the manufacturers. METHODS: Four samples from each antimalarial product were collected from each of the various levels of the distribution chain. One sample was kept with the research team. Two were tested at Sana'a and Aden Drug Quality Control Laboratories. The fourth was sent to the Centre for Quality Assurance of Medicines in Potchefstroom, South Africa, for analysis. Quality indicators measured were the content of the active ingredient and dissolution rate (for tablets only) in comparison to standard specifications for these products in the relevant pharmacopoeia. RESULTS: The results identified several problems of sub-standard products within the drug distribution chain. They included high and low failures in ingredient content for chloroquine tablets and chloroquine syrup. There was some dissolution failure for chloroquine tablets, and high sulfadoxine/pyrimethamine tablets dissolution failures. Failures with the dissolution of the pyrimethamine were found at most of the collection points. No clear relationship neither between the quality products and the level of the distribution chain, nor between locally manufactured and imported products was observed. CONCLUSION: There are sub-standard antimalarial products circulating within the drug distribution chains in the country, which will have serious implications on the reduced therapeutic effectiveness and on the development of drug resistance. This appears to be due to non-compliance with Good Manufacturing Practice guidelines by manufacturers in the production of the antimalarials.

Morbidity of schistosomiasis mansoni in rural Alexandria, Egypt.

A parasitological survey of stool and urine of 2577 from 3281 individuals living in Abis villages, Alexandria was undertaken in 1998 in order to investigate the prevalence of schistosomiasis in this area and risk factors for hepatic morbidity. A random sample of 1082 individuals was interviewed using a questionnaire regarding risk factors for liver morbidity. All interviewed adults (total: 728) were clinically examined for evidence of organomegally (hepatomegally and/or splenomegally). Individuals with clinically detected organomegally were referred for detailed investigations (total: 65). The criteria for severe hepatic morbidity were AST/ALT ratio higher than 1, prothrombin activity < 70%, and evidence of portal hypertension. The results revealed that prevalence of S. mansoni accounted for 20.5%, with low intensity of infection and increased with age to reach a maximum of 40-46.3% at 15-30 years of age. Intensity of infection followed the same pattern. All tested urine samples were negative for S. haemato-bium. The prevalence of clinically detected organomegally was 10.3% among adults (75/728). Significant risk factors for developing organomegally were age > or = 35 years (2.2 folds), farming occupation (1.7 fold), history of parenteral anti-schisto-somal treatment (PAT) with or without tablets (2.03 folds), and heavy water canal exposure (2.85 folds). Detailed morbidity study on 65 individuals with clinically detected organomegally showed that 52.3% reported heavy score for water canal exposure, 33.8% were positive for HCV antibodies, and 7.7% for HBV antibodies. Procollagen level was higher than 5.5 microg/l in 26.2% of this group. The results of Doppler ultrasonography showed that 33.3% recorded a portal vein diameter > or = 13 mm, 26.2% periportal fibrosis more than grade 2 (> 5 mm), 19% hepatofugal direction of portal blood flow, 30.2% collaterals, 28.6% splenomegaly, and 17.5% hepatofugal direction of splenic blood flow. The burden of severe hepatic morbidity was alarming among this group: 33.8% with portal hypertension, 24.6% with prothrombin activity < 70, and 13.8% with AST/ALT ratio > 1. There was a 4.44 and 3.7 fold increased risk for portal hypertension with elevated levels of PIIIP and positive serologic tests for HCV and/or HBV infections, respectively. Similarly, a 4.58 and 18.35 fold increased risk for AST/ALT more than one was attributed to these two factors, respectively. Elevated procollagen level was significantly associated with viral infection (HCV and/or HbsAG). Seropositivity for HCV antibodies was found strikingly high in adults above 35 years (positive HCV antibodies in 45.9% of individuals). This indicates a high level of endemicity in the study area which is also endemic for S. mansoni. So, a heavy burden of severe liver disease exist in rural Alexandria is attributed to combined infection of S. mansoni and hepatitis viruses. This emphasizes the need for intervenetion strategies targeting these two main liver offenders.

Identification of clinical criteria for group A-beta hemolytic streptococcal pharyngitis in children living in a rheumatic fever endemic area.

A cross-sectional study was conducted over a 1-year period (1 January-31 December 2000) during which cases suffering from uncomplicated tonsillopharyngitis were recruited from the private and public health services in Alexandria. The objective was to determine the prevalence of group A-beta haemolytic streptococci (GABHS) among children suffering from tonsillopharyngitis and to identify the clinical criteria predicting GABHS pharyngitis in children. A total of 578 children aged between 1 and 15 years with a mean of 6.3 +/- 3.7 years, presenting with sore throat were enrolled in the study. Demographic data and presenting signs and symptoms for each patient were recorded on a standardized form and a throat swab was taken using the filter paper technique. The overall prevalence of GABHS was 17 per cent and the highest isolation rate was reported in children aged 10-15 years. Non-GABHS comprised 11.9 per cent of the total isolates. The most prevalent of them were group C and G streptococci. The highest frequency of both GABHS and non-GABHS was in early spring. Significant predictors of GABHS pharyngitis were: age 10-15 years, the presence of dysphagia, vomiting, pharyngeal exudate, and scarlatiniform rash. Watery eyes and/or rhinitis had a protective value against the diagnosis of GABHS pharyngitis, while fever was considered to be a non-specific finding in cases with GABHS pharyngitis. Antibiotic sensitivity test showed higher sensitivity to both penicillin and erythromycin. Only 1 per cent of the GABHS isolates showed resistance to cephadroxil. We concluded that a syndrome of signs and symptoms could be used as a clinical predictor for the diagnosis of GABHS pharyngitis.

Pattern of diagnostic and therapeutic care of childhood epilepsy in Alexandria, Egypt.

OBJECTIVES: To evaluate the quality of care delivered to children with epilepsy and study the predictors of seizure recurrence after initial control. DESIGN: A cross-sectional study was conducted during 4-month period (1 January to 30 April 1999). SETTING: Children's hospitals providing out-patient and in-patient services to the majority of children in Alexandria, Egypt. OUTCOME: Seizure recurrence after at least 6 months from anti-epileptic drug (AED) adjustment. RESULTS: Electroencephalogram was performed in 82.1% of cases, whereas plasma assay was performed in only 7% of cases. AEDs were initiated after the first seizure rather than the first recurrence of seizure. Carbamazepine was the most frequently prescribed drug, followed by valproate, except for generalized absence type, which was mainly managed by valproate. Suboptimal quality of care consisted mainly of poor diagnostic assessment of children with epilepsy, underuse of plasma monitoring for AED levels, unjustified use of oral AEDs during breakthrough fits, and defective health education to the caregivers of children with epilepsy that was manifested by non-compliance with AEDs in 30.1% of cases. The outcome of the current healthcare was a 71.6% recurrence of seizures after initial control. Continuous seizures before treatment, a polytherapy regimen, and non-compliance with management procedures were significant predictors for seizure recurrence. CONCLUSIONS: More specialized neurological care and health education programs for the caregivers of children with epilepsy are warranted. By exploring the details of medical practice, a foundation is provided upon which to build a quality improvement program, using the parameters in our study as an initial framework.

Genetic determinants of essential hypertension.

This study aimed at determining the role of genetic and environmental risk factors in the development of essential hypertension in Alexandria, Egypt. A case-control-study was conducted in the Main Health Insurance Hospital, (MHI) Alexandria, Egypt, whereby cases previously diagnosed as hypertensive were included in the study. A hospital-based control group visiting the hospital for other unrelated conditions and randomly selected in the same day as cases was also included in the study. Both cases and controls were subjected to a semi-structured questionnaire including information concerning socio-demographic data and risk factors for hypertension Only cases were subjected to segregation analysis. This study included 165 cases with history of essential hypertension, and 196 controls. Multivariate analysis of potential risk factors showed the following factors to be independently associated with an increased risk of essential hypertension: age over 40 years, elevated BMI, workers, ever smoker and stress. Education less than 6 years remained in the model as an independent protective effect. Segregation analysis proved that the disease is not inherited as single gene mode of inheritance. On the other hand, the heritability for 1st, 2nd and 3rd degree relative was 28.2%, 28.7% and 20.0%. These figures provide evidence to multifactorial mode of inheritance in essential hypertension.