Characteristics, risk factors, and outcomes related to Zika virus infection during pregnancy in Northeastern Thailand: A prospective pregnancy cohort study, 2018-2020.

BACKGROUND: In response to the 2015-2016 Zika virus (ZIKV) outbreak and the causal relationship established between maternal ZIKV infection and adverse infant outcomes, we conducted a cohort study to estimate the incidence of ZIKV infection in pregnancy and assess its impacts in women and infants. METHODOLOGY/PRINCIPAL FINDINGS: From May 2018-January 2020, we prospectively followed pregnant women recruited from 134 participating hospitals in two non-adjacent provinces in northeastern Thailand. We collected demographic, clinical, and epidemiologic data and blood and urine at routine antenatal care visits until delivery. ZIKV infections were confirmed by real-time reverse transcriptase polymerase chain reaction (rRT-PCR). Specimens with confirmed ZIKV underwent whole genome sequencing. Among 3,312 women enrolled, 12 (0.36%) had ZIKV infections, of which two (17%) were detected at enrollment. Ten (83%, 3 in 2nd and 7 in 3rd trimester) ZIKV infections were detected during study follow-up, resulting in an infection rate of 0.15 per 1,000 person-weeks (95% CI: 0.07-0.28). The majority (11/12, 91.7%) of infections occurred in one province. Persistent ZIKV viremia (42 days) was found in only one woman. Six women with confirmed ZIKV infections were asymptomatic until delivery. Sequencing of 8 ZIKV isolates revealed all were of Asian lineage. All 12 ZIKV infected women gave birth to live, full-term infants; the only observed adverse birth outcome was low birth weight in one (8%) infant. Pregnancies in 3,300 ZIKV-rRT-PCR-negative women were complicated by 101 (3%) fetal deaths, of which 67 (66%) had miscarriages and 34 (34%) had stillbirths. There were no differences between adverse fetal or birth outcomes of live infants born to ZIKV-rRT-PCR-positive mothers compared to live infants born to ZIKV-rRT-PCR-negative mothers. CONCLUSIONS/SIGNIFICANCE: Confirmed ZIKV infections occurred infrequently in this large pregnancy cohort and observed adverse maternal and birth outcomes did not differ between mothers with and without confirmed infections.

Underdiagnosis in clinical documentation of community-acquired sepsis among children admitted to hospitals in two rural provinces: Thailand, October-December 2017.

Paediatric sepsis prevalence data from low-income and middle-income countries are lacking. In a cross-sectional study, we assessed clinician recognition and documentation of non-neonatal community-acquired paediatric sepsis in two rural border provinces in Thailand among children admitted between October and December 2017. Of the 152 children meeting sepsis criteria (26.9 paediatric sepsis patients per 1000 admissions), 15 (9.9%) had a clinician-documented admission diagnosis of sepsis or septic shock and 18 (11.8%) had a discharge diagnosis with International Classification of Diseases-10 codes related to sepsis. Clinician underdocumentation may cause challenges in global paediatric sepsis surveillance.

Case-Control Study of Use of Personal Protective Measures and Risk for SARS-CoV 2 Infection, Thailand.

We evaluated effectiveness of personal protective measures against severe acute respiratory disease coronavirus 2 (SARS-CoV-2) infection. Our case-control study included 211 cases of coronavirus disease (COVID-19) and 839 controls in Thailand. Cases were defined as asymptomatic contacts of COVID-19 patients who later tested positive for SARS-CoV-2; controls were asymptomatic contacts who never tested positive. Wearing masks all the time during contact was independently associated with lower risk for SARS-CoV-2 infection compared with not wearing masks; wearing a mask sometimes during contact did not lower infection risk. We found the type of mask worn was not independently associated with infection and that contacts who always wore masks were more likely to practice social distancing. Maintaining >1 m distance from a person with COVID-19, having close contact for <15 minutes, and frequent handwashing were independently associated with lower risk for infection. Our findings support consistent wearing of masks, handwashing, and social distancing to protect against COVID-19.

HIV incidence among men who have sex with men and transgender women in four provinces in Thailand.

The HIV epidemic in Thailand is concentrated in key populations, with the highest rates in men who have sex with men (MSM) and transgender women (TG). Previous studies of HIV incidence in these groups have been limited mostly to Bangkok. We measured HIV incidence in MSM and TG in four provinces and evaluated factors associated with incident infections to inform public health prevention efforts. An analysis was conducted using data collected during a prospective observational cohort study during April 2015-May 2018 in outpatient clinics in five hospitals across four provinces in Thailand. MSM and TG aged ≥18 years, who were not known to be HIV-infected, and who reported anal intercourse with a male or TG without a condom in the past six months were enrolled. Participants were followed-up every 6 months for 18 months with questionnaires and HIV testing. A total of 40 HIV seroconversions occurred during follow-up, resulting in an HIV incidence of 3.5 per 100 person-years (95% CI 2.5, 4.8). Multivariate analyses indicated that identifying as gay (adjusted hazard ratio [AHR] 4.9; 95% CI 1.7-14.2), having receptive anal sex in the past six months (AHR 3.6; 95% CI 1.4-9.5), using alcohol (AHR 3.3; 95% CI 1.3-8.3), and taking alkyl nitrites (AHR 4.4; 95% CI 1.7-11.2) in the past six months were all independently associated with HIV infection. Overall this study found a lower HIV incidence in the highest risk population in Thailand compared with similar studies in Bangkok. Accelerated prevention efforts are needed to make the goal of 'zero new infections' possible in Thailand.

Evaluating a framework for tuberculosis screening among healthcare workers in clinical settings, Inner Mongolia, China.

BACKGROUND: Health care workers are at high risk for tuberculosis (TB). China, a high burden TB country, has no policy on medical surveillance for TB among healthcare workers. In this paper, we evaluate whether China's national TB diagnostic guidelines could be used as a framework to screen healthcare workers for pulmonary TB disease in a clinical setting in China. METHODS: Between April-August 2010, healthcare workers from 28 facilities in Inner Mongolia Autonomous Region, China were eligible for TB screening, comprised of symptom check, chest X-ray and tuberculin skin testing. Healthcare workers were categorized as having presumptive, confirmed, or clinically-diagnosed pulmonary TB, using Chinese national guidelines. RESULTS: All healthcare workers (N=4347) were eligible for TB screening, of which 4285 (99%) participated in at least one TB screening test. Of the healthcare workers screened, 2% had cough for ≥ 14 days, 3% had a chest X-ray consistent with TB, and 10% had a tuberculin skin test induration ≥ 20 mm. Of these, 124 healthcare workers were identified with presumptive TB (i.e., cough for ≥ 14 days in the past 4 weeks or x-ray consistent with TB). Twelve healthcare workers met the case definition for clinically-diagnosed pulmonary TB, but none were diagnosed with TB during the study period. CONCLUSION: A substantial proportion of healthcare workers in Inner Mongolia had signs, symptoms, or test results suggestive of TB disease that could have been identified using national TB diagnostic guidelines as a screening framework. However, achieving medical surveillance in China will require a framework that increases the ease, accuracy, and acceptance of TB screening in the medical community. Routine screening with improved diagnostics should be considered to detect tuberculosis disease among healthcare workers and reduce transmission in health care settings in China.

Tuberculosis Caused by Mycobacterium africanum, United States, 2004-2013.

Mycobacterium africanum is endemic to West Africa and causes tuberculosis (TB). We reviewed reported cases of TB in the United States during 2004-2013 that had lineage assigned by genotype (spoligotype and mycobacterial interspersed repetitive unit variable number tandem repeats). M. africanum caused 315 (0.4%) of 73,290 TB cases with lineage assigned by genotype. TB caused by M. africanum was associated more with persons from West Africa (adjusted odds ratio [aOR] 253.8, 95% CI 59.9-1,076.1) and US-born black persons (aOR 5.7, 95% CI 1.2-25.9) than with US-born white persons. TB caused by M. africanum did not show differences in clinical characteristics when compared with TB caused by M. tuberculosis. Clustered cases defined as >2 cases in a county with identical 24-locus mycobacterial interspersed repetitive unit genotypes, were less likely for M. africanum (aOR 0.1, 95% CI 0.1-0.4), which suggests that M. africanum is not commonly transmitted in the United States.

Implementation and evaluation of an isoniazid preventive therapy pilot program among HIV-infected patients in Vietnam, 2008-2010.

BACKGROUND: WHO recommends screening for TB and evaluation for isoniazid preventive therapy (IPT) based on evidence that they reduce TB-related morbidity and mortality among HIV-infected persons. In Vietnam, an IPT pilot was implemented in two provinces; TB screening, treatment and outcomes were evaluated to inform the adoption and scale-up of IPT. METHODS: During April 2008 to March 2010, eligible HIV-infected persons aged >15 years, with no previous or current TB treatment, alcohol abuse or liver disease were screened for TB. If TB disease was ruled out based on symptoms, chest x-rays and sputum smears, isoniazid was administered for 9 months. RESULTS: Among 1281 HIV-infected persons who received initial eligibility screening, 520 were referred to and evaluated at district TB clinics for TB disease or IPT eligibility. Active TB was diagnosed in 17 patients and all were started on treatment. Of 520 patients evaluated, 416 (80.0%) initiated IPT: 382 (91.8%) completed IPT, 17 (4.1%) stopped treatment, 8 (1.9%) died, 3 (0.7%) developed TB during IPT and 6 (1.4%) had unknown outcomes. No severe adverse events were reported. CONCLUSIONS: IPT treatment completion was high; no serious complications occurred. Improving and expanding intensified case-finding and IPT should be considered in Vietnam.

A review of data quality of an electronic tuberculosis surveillance system for case-based reporting in Kenya.

BACKGROUND: Kenya recently transitioned from a paper to an electronic system for recording and reporting of tuberculosis (TB) data. METHODS: During September-October 2013, the data quality of the new system was evaluated through an audit of data in paper source documents and in the national electronic system, and an analysis of all 99 281 cases reported in 2012. RESULTS: While the new electronic system overall is robust, this assessment demonstrated limitations in the concordance and completeness of data reaching the national level. CONCLUSIONS: Additional oversight and training in data entry are needed to strengthen TB surveillance data quality in Kenya.

Quality of Sputum Specimen Samples Submitted for Culture and Drug Susceptibility Testing at the National Tuberculosis Reference Laboratory-Uganda, July-October 2013.

Setting: The Uganda National Tuberculosis Reference Laboratory (NTRL) in Kampala. Objective: The proportion of poor quality specimens received for drug susceptibility testing (DST) at the NTRL and factors contributing to poor specimen quality were assessed. Design: A cross-sectional study was conducted of sputum samples received at the NTRL from patients at high risk for multidrug-resistant tuberculosis (MDR TB) during July-October 2013. Demographic, clinical, and bacteriological data were abstracted from laboratory records. A poor quality sample failed to meet any one of four criteria: ≥3 milliliter (ml) volume, delivered within 72 hours, triple packaged, and non-salivary appearance. Results: Overall, 365 (64%) of 556 samples were of poor quality; 89 (16%) were not triple packaged, 44 (8%) were <3 mls, 164 (30%) were not delivered on time, and 215 (39%) were salivary in appearance. Poor quality specimens were more likely to be collected during the eighth month of TB treatment (OR = 2.5, CI = 1.2 - 5.1), from the East or Northeast zones (OR = 2.2, CI = 1.1 - 4.8), and from patients who previously defaulted from treatment (OR = 1.9, CI = 1.1 - 3.2). Conclusion: The majority of sputum samples had poor quality. Additional efforts are needed to improve quality of samples collected at the end of treatment, from East and Northeast zones, and from patients who had previously defaulted.

Death rates from human immunodeficiency virus and tuberculosis among American Indians/Alaska Natives in the United States, 1990-2009.

OBJECTIVES: We used race-corrected data and comprehensive diagnostic codes to better compare HIV and tuberculosis (TB) mortality from 1999 to 2009 between American Indian/Alaska Natives (AI/ANs) and Whites. METHODS: National Vital Statistics Surveillance System mortality data were adjusted for AI/AN racial misclassification through linkage with Indian Health Service registration records. We compared average annual 1990 to 2009 HIV and TB death rates (per 100,000 people) for AI/AN persons with those for Whites; Hispanics were excluded. RESULTS: Although death rates from HIV in AI/AN persons were significantly lower than those in Whites from 1990 to 1998 (4.2 vs 7.0), they were significantly higher than those in Whites from 1999 to 2009 (3.6 vs 2.0). Death rates from TB in AI/AN persons were significantly higher than those in Whites, with a significant disparity during both 1990 to 1998 (3.3 vs 0.3) and 1999 to 2009 (1.5 vs 0.1). CONCLUSIONS: The decrease in death rates from HIV and TB was greater among Whites, and death rates remained significantly higher among AI/AN individuals. Public health interventions need to be prioritized to reduce the TB and HIV burden and mortality in AI/AN populations.

Analysis of tuberculosis prevalence surveys: new guidance on best-practice methods.

BACKGROUND: An unprecedented number of nationwide tuberculosis (TB) prevalence surveys will be implemented between 2010 and 2015, to better estimate the burden of disease caused by TB and assess whether global targets for TB control set for 2015 are achieved. It is crucial that results are analysed using best-practice methods. OBJECTIVE: To provide new theoretical and practical guidance on best-practice methods for the analysis of TB prevalence surveys, including analyses at the individual as well as cluster level and correction for biases arising from missing data. ANALYTIC METHODS: TB prevalence surveys have a cluster sample survey design; typically 50-100 clusters are selected, with 400-1000 eligible individuals in each cluster. The strategy recommended by the World Health Organization (WHO) for diagnosing pulmonary TB in a nationwide survey is symptom and chest X-ray screening, followed by smear microscopy and culture examinations for those with an abnormal X-ray and/or TB symptoms. Three possible methods of analysis are described and explained. Method 1 is restricted to participants, and individuals with missing data on smear and/or culture results are excluded. Method 2 includes all eligible individuals irrespective of participation, through multiple missing value imputation. Method 3 is restricted to participants, with multiple missing value imputation for individuals with missing smear and/or culture results, and inverse probability weighting to represent all eligible individuals. The results for each method are then compared and illustrated using data from the 2007 national TB prevalence survey in the Philippines. Simulation studies are used to investigate the performance of each method. KEY FINDINGS: A cluster-level analysis, and Methods 1 and 2, gave similar prevalence estimates (660 per 100,000 aged ≥ 10 years old), with a higher estimate using Method 3 (680 per 100,000). Simulation studies for each of 4 plausible scenarios show that Method 3 performs best, with Method 1 systematically underestimating TB prevalence by around 10%. CONCLUSION: Both cluster-level and individual-level analyses should be conducted, and individual-level analyses should be conducted both with and without multiple missing value imputation. Method 3 is the safest approach to correct the bias introduced by missing data and provides the single best estimate of TB prevalence at the population level.

Challenges and opportunities in a tuberculosis outbreak investigation in southern Mississippi, 2005-2007.

OBJECTIVE: Between December 2005 and November 2007, a cluster of 11 tuberculosis (TB) cases emerged in Jackson County, Mississippi. We investigated the potential sources of disease transmission and epidemiologic links in this cluster to prevent future transmission in the community. MATERIALS AND METHODS: Cases of TB reported in Jackson County from December 2005 to November 2007 having matching genotypes or social links to patients with matching genotypes were included in the investigation. We interviewed patients, reviewed medical records, and performed contact investigations. RESULTS: The combined genotyping and epidemiologic data pointed to ongoing TB transmission in this rural community. A combination of patient-specific and programmatic factors, including substance use, delays in TB diagnosis, nonadherence, and TB program staffing cuts, contributed to this outbreak in the context of the 2004 and 2005 Atlantic hurricane seasons. CONCLUSIONS: To eliminate Mycobacterium tuberculosis transmission in this setting, recommendations for the TB program include enhanced coordination with substance abuse programs, community and provider education, and increased outreach capacity.

Tuberculosis in indigenous peoples in the U.S., 2003-2008.

OBJECTIVES: We examined trends and epidemiology of tuberculosis (TB) across racial/ethnic groups to better understand TB disparities in the United States, with particular focus on American Indians/Alaska Natives (AI/ANs) and Native Hawaiians/other Pacific Islanders (NH/PIs). METHODS: We analyzed cases in the U.S. National Tuberculosis Surveillance System and calculated TB case rates among all racial/ethnic groups from 2003 to 2008. Socioeconomic and health indicators for counties in which TB cases were reported came from the Health Resources and Services Administration Area Resource File. RESULTS: Among the 82,836 TB cases, 914 (1.1%) were in AI/ANs and 362 (0.4%) were in NH/PIs. In 2008, TB case rates for AI/ANs and NH/PIs were 5.9 and 14.7 per 100,000 population, respectively, rates that were more than five and 13 times greater than for non-Hispanic white people (1.1 per 100,000 population). From 2003 to 2008, AI/ANs had the largest percentage decline in TB case rates (-27.4%) for any racial/ethnic group, but NH/PIs had the smallest percentage decline (-3.5%). AI/ANs were more likely than other racial/ethnic groups to be homeless, excessively use alcohol, receive totally directly observed therapy, and come from counties with a greater proportion of people living in poverty and without health insurance. A greater proportion of NH/PIs had extrapulmonary disease and came from counties with a higher proportion of people with a high school diploma. CONCLUSIONS: There is a need to develop flexible TB-control strategies that address the social determinants of health and that are tailored to the specific needs of AI/ANs and NH/PIs in the U.S.

Alcohol brewing and the African tuberculosis epidemic.

Countries in much of Africa are struggling with large tuberculosis (TB) epidemics. Although the treatment programs are being implemented as well as the many constraints allow, more prevention of TB is needed. Based on literature on alcohol and TB, and observations and case studies, we consider one potential area for intervention might be the popular and ubiquitous small bars and beer huts in many towns and cities. In these usually poverty-ridden sites, with their densely packed clientele, large amounts of alcohol are consumed often by those with compromised immune systems who are at risk of acquiring the disease. The alcohol brewers-called Mama Pimas (from kupima, to measure, in Kiswahili) in Kenya-are the subject of this editorial. We look at the risks and potential benefits of reaching these women. Medical anthropologists are needed to help provide better evidence for TB prevention programs.

Tuberculosis services and treatment outcomes in private and public health care facilities in Thailand, 2004-2006.

BACKGROUND: The World Health Organization recommends that national tuberculosis (TB) programs encourage public and private providers to follow the 'International standards for tuberculosis care'. We assessed services and treatment outcomes in TB patients in public and private facilities to inform public-private mix scale-up in Thailand. METHODS: We prospectively collected data on TB patients in four provinces and the national infectious diseases hospital during 2004-2006. We analyzed services and outcomes among new pulmonary TB patients according to facility type. RESULTS: Of 7526 patients, 4539 (60%) were treated in small public facilities, 2275 (30%) in large public facilities and 712 (10%) in private facilities. Compared with the private sector, more public sector patients had at least two sputum smears examined, were prescribed a standard anti-tuberculosis regimen and received directly observed therapy; however, public sector facilities also performed suboptimally. Treatment outcomes were unsuccessful for 237 (33%) patients in private facilities, and for respectively 1018 (23%) and 655 (29%) patients in small and large public facilities. CONCLUSIONS: TB diagnostic and treatment services and outcomes should be enhanced in both public and private facilities in Thailand. Initiatives are needed to improve treatment outcomes and increase the use of microscopy, standardized TB regimens, and directly observed therapy in the public and private sectors.

Prevalence and predictors of underweight, stunting, and wasting among children aged 5 and under in western Kenya.

The health and nutritional status of children aged 5 and under was assessed in three villages in Siaya District of western Kenya. A cross-sectional survey was conducted among 121 adults and 175 children during July 2002. Primary caretakers were interviewed during home visits to assess agricultural and sanitation resources, child feeding practices, and the nutritional status of their children aged 5 years and under. Through anthropometry, the prevalence of underweight, stunting and wasting were determined: 30 per cent were underweight, 47 per cent were stunted, and 7 per cent were wasted. Predictors of undernutrition were analysed using logistic regression controlling for age, sex, and SES, and four major findings emerged. First, children in their second year of life were more likely to be underweight and stunted. Second, children who were introduced to foods early had an increased risk of being underweight. Third, up-to-date vaccinations were protective against stunting, while reports of having upper respiratory infections or other illness in the past month predicted underweight. Finally, living with non-biological parents significantly increased risk of stunting. Emphasis should be placed on current immunization, prolonging exclusive breastfeeding, and improving access to nutrient-rich foods among adopted children and their families via community-based nutrition interventions.