Are global tuberculosis control targets overlooking an essential indicator? Prolonged delays to diagnosis despite high case detection rates in Yunnan, China.

Delay in treating active tuberculosis (TB) impedes disease control by allowing ongoing transmission, and may explain the unexpectedly modest declines in global TB incidence. Even though China has achieved TB control targets under the global Directly Observed Treatment, Short course (DOTS) strategy, TB prevalence in western provinces, including Yunnan, is not decreasing. This cross-sectional study investigates whether prolonged delay in identifying and correctly treating TB patients, which is not routinely monitored, persists even when there is a well-functioning TB control programme and global targets are being met. Records of adult smear-positive pulmonary TB patients diagnosed with between 2006 and 2013 were extracted from the Yunnan Centre for Disease Control electronic database, which contains information on the entire population of TB patients managed across 129 diagnostic centres. Delay was investigated at three stages: delay to DOTS facility (period between symptom onset and first visit to at a CDC unit providing standardized treatment); delay to TB confirmation (period between reaching a CDC unit and confirmation of smear-positive TB) and delay to treatment (period between confirmation of TB and initiation of treatment). Data from 76 486 patients was analysed. Delay to reaching a DOTS facility was by far the largest contributor to total delay to treatment initiation. The median delay to reaching a DOTS facility, to TB confirmation and to treatment was 57 days (IQR 25-112), 2 days (IQR 1-6) and 1 day (IQR 0-1) respectively. Prolonged delays to reaching a facility providing standardized TB care occurred in a substantial subset of the population despite all TB control targets being met; overall, 32% (24 676) of patients experienced a delay of more than 90 days to reaching a DOTS facility. Policies that focus on reducing delays in accessing appropriate health services, rather than only on increasing overall case-detection rates, may result in greater progress towards reducing TB incidence.

Phylogenetic characterisation of circulating, clinical influenza isolates from Bali, Indonesia: preliminary report from the BaliMEI project.

BACKGROUND: Human influenza represents a major public health concern, especially in south-east Asia where the risk of emergence and spread of novel influenza viruses is particularly high. The BaliMEI study aims to conduct a five year active surveillance and characterisation of influenza viruses in Bali using an extensive network of participating healthcare facilities. METHODS: Samples were collected during routine diagnostic treatment in healthcare facilities. In addition to standard clinical and molecular methods for influenza typing, next generation sequencing and subsequent de novo genome assembly were performed to investigate the phylogeny of the collected patient samples. RESULTS: The samples collected are characteristic of the seasonally circulating influenza viruses with indications of phylogenetic links to other samples characterised in neighbouring countries during the same time period. CONCLUSIONS: There were some strong phylogenetic links with sequences from samples collected in geographically proximal regions, with some of the samples from the same time-period resulting to small clusters at the tree-end points. However this work, which is the first of its kind completely performed within Indonesia, supports the view that the circulating seasonal influenza in Bali reflects the strains circulating in geographically neighbouring areas as would be expected to occur within a busy regional transit centre.

Financial barriers and coping strategies: a qualitative study of accessing multidrug-resistant tuberculosis and tuberculosis care in Yunnan, China.

BACKGROUND: Tuberculosis (TB) and multidrug-resistance tuberculosis (MDR-TB) pose serious challenges to global health, particularly in China, which has the second highest case burden in the world. Disparities in access to care for the poorest, rural TB patients may be exacerbated for MDR-TB patients, although this has not been investigated widely. We examine whether certain patient groups experience different barriers to accessing TB services, whether there are added challenges for patients with MDR-TB, and how patients and health providers cope in Yunnan, a mountainous province in China with a largely rural population and high TB burden. METHODS: Using a qualitative study design, we conducted five focus group discussions and 47 in-depth interviews with purposively sampled TB and MDR-TB patients and healthcare providers in Mandarin, between August 2014 and May 2015. Field-notes and interview transcripts were analysed via a combination of open and thematic coding. RESULTS: Patients and healthcare providers consistently cited financial constraints as the most common barriers to accessing care. Rural residents, farmers and ethnic minorities were the most vulnerable to these barriers, and patients with MDR-TB reported a higher financial burden owing to the centralisation and longer duration of treatment. Support in the form of free or subsidised treatment and medical insurance, was deemed essential but inadequate for alleviating financial barriers to patients. Most patients coped by selling their assets or borrowing money from family members, which often strained relationships. Notably, some healthcare providers themselves reported making financial and other contributions to assist patients, but recognised these practices as unsustainable. CONCLUSIONS: Financial constraints were identified by TB and MDR-TB patients and health care professionals as the most pervasive barrier to care. Barriers appeared to be magnified for ethnic minorities and patients coming from rural areas, especially those with MDR-TB. To reduce financial barriers and improve treatment outcomes, there is a need for further research into the total costs of seeking and accessing TB and MDR-TB care. This will enable better assessment and targeting of appropriate financial support for identified vulnerable groups and geographic development of relevant services.

Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey.

BACKGROUND: Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34% of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women. METHODS: From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres. RESULTS: Overall, only 514 (30%) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21% to 37%, p = 0.0172), month of diagnosis (37% in February 2015 and 23% in March 2015 p = 0.0004) and age group (26% in 25-64 years and 49% in 18-25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36% from 30%. CONCLUSIONS: Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.

Effect of X-ray treatments on Escherichia coli O157:H7, Listeria monocytogenes, Shigella flexneri, Salmonella enterica and inherent microbiota on whole mangoes.

UNLABELLED: The aims of this investigation were to; (i) study the effect of X-ray treatments in reducing Escherichia coli O157:H7, Listeria monocytogenes, Salmonella enterica and Shigella flexneri on whole mangoes, and (ii) study the effect of X-ray treatments on microflora counts (mesophilic counts, psychrotrophic counts and yeast and mould counts) of whole mangoes during storage at ambient temperature (22°C) for 30 days. A mixture of three strains of each test organism was spot inoculated (100 µl; approx. 8-9 log CFU ml(-1) ), separately, onto the surface (5 cm(2) ) of whole mangoes, air-dried (30 min), and then treated with different doses of X-ray (0, 0·1, 0·5, 1·0, and 1·5 kGy). Approximately 2·9, 1·8, 2·1 and 5·2 log CFU cm(-2) reduction of E. coli O157:H7, L. monocytogenes, Sh. flexneri and Salm. enterica were achieved by treatment with 0·5 kGy X-ray respectively. Furthermore, the populations of E. coli O157:H7, L. monocytogenes, Sh. flexneri and Salm. enterica were reduced to less than the detectable limit (2·0 log CFU cm(-2) ) by treatment with 1·5 kGy X-ray. Treatment with 1·5 kGy X-ray significantly reduced the initial inherent microflora on skin of whole mangoes and inherent levels were significantly (P < 0·05) lower than the control sample throughout storage at 22°C for 30 days. SIGNIFICANCE AND IMPACT OF THE STUDY: Fresh produce was associated with 770 outbreaks between 1990 and 2005, resulting in 35 060 cases of illness that costs the US $39 billion annually. The food industry is looking for new preservation methods. This investigation indicated that X-ray treatment was very effective against Escherichia coli O157:H7, Listeria monocytogenes, Shigella flexneri and Salmonella enterica and inherent microflora on whole mangoes which could offer an applicable approach to control pathogens and spoilage bacteria for the mango industry.

Two cases of culture proven Mycobacterium tuberculosis presenting with a broad-complex tachycardia and non-caseating granulomas.

Tuberculosis is a leading cause of death worldwide. It affects pulmonary and extra-pulmonary sites with a multitude of differing presentations. In this report, we describe two cases in which TB causes myopericarditis and presents with a broad-complex tachycardia that did not respond typically to standard anti-arrhythmic therapy; a very rare presentation with limited description in the literature. Both patients required extensive investigation culminating in identifying lymph nodes amenable to biopsy under endobronchial ultrasound guidance. It was not until both patients received anti-tuberculous chemotherapy alongside anti-arrhythmic management that any improvement to their condition was witnessed. Therefore, we recommend that the clinician should have a high index of suspicion for TB in any patient presenting with a broad-complex tachycardia that is not responding to standard first line management, especially if the patient is from a high risk background. We recommend an active diagnostic pursuit, and lymph node biopsy under endobronchial ultrasound guidance.

Assessing the effects of HIV/AIDS and TB disease control programmes on health systems in low- and middle-income countries of Southeast Asia: a semi-systematic review of the literature.

OBJECTIVE: To systematically review the literature on if and how HIV/AIDS and TB programmes have impacted on general healthcare systems in Association of Southeast Asian Nations (ASEAN) countries. METHODS: Medline, Embase, Global Health and CINHAL were searched for English language literature published between 1st January 2003 and 31st March 2011. Papers included had to focus on: HIV and/or TB control programmes; the low- and-middle-income ASEAN countries; and factors related to any health systems functions. The effects were examined along six system functions: Stewardship and Governance; Financing; Planning; Service Delivery; Monitoring and Evaluation; and Demand Generation. A comprehensive thematic analytical tool aligned with the above six health systems functions was developed to support data extraction and analysis. FINDINGS: 88 papers met the inclusion criteria. Most programme effects highlighted were related with health service delivery. The other five health system functions were seldom scrutinized, and each covered by less than a quarter of papers. Overall 69% of effects highlighted were positive effects whereas 31% were negative. CONCLUSION: There was a paucity of robust evidence. Effects on health systems were rarely a focus of research protocols but more often a minor component in the Results/Discussion sections. Particular attention should be paid by Global Health Initiatives to the negative effects that emerged from this study, such as the development of parallel systems, specific incentives not available to the general health systems, and lack of integration of services with private healthcare providers.

Reduction in Listeria monocytogenes and spoilage bacteria on smoked catfish using X-ray treatments.

AIMS: To determine the efficacy of X-ray processes in inactivating L. monocytogenes levels in smoked catfish during storage at 5°C and to determine the effects of X-ray doses on controlling the growth of spoilage bacteria on smoked catfish during storage at 5°C for up to 5 weeks. METHODS AND RESULTS: Smoked catfish fillets inoculated with L. monocytogenes were treated with 0.0-2.0 kGy X-ray and stored at 5°C for 5 weeks. The negative controls (uninoculated/untreated) and uninoculated samples treated with the lowest (0.1 kGy) and highest (2.0 kGy) doses were stored at 5°C and tested for psychrotrophs count during the 5 weeks of storage. The initial L. monocytogenes population on smoked catfish was significantly (P < 0.05) reduced to undetectable level by a treatment of 1.0 kGy or higher. The initial psychrotrophs count on smoked catfish was significantly reduced from 4.7 CFU g(-1) to below the detectable level by a treatment with 2.0 kGy. CONCLUSIONS: Smoked catfish treated with 2.0 kGy X-ray had no detectable L. monocytogenes throughout 35 days of storage at 5°C. A treatment with 2.0 kGy X-ray also kept the levels of psychrotrophs in the smoked catfish within the acceptable level until 35 days. SIGNIFICANCE AND IMPACT OF THE STUDY: The results of this investigation indicate that X-ray at 2.0 kGy can eliminate L. monocytogenes and extend the shelf life of smoked catfish stored at refrigeration temperature.

Health service resource needs for pandemic influenza in developing countries: a linked transmission dynamics, interventions and resource demand model.

We used a mathematical model to describe a regional outbreak and extrapolate the underlying health-service resource needs. This model was designed to (i) estimate resource gaps and quantities of resources needed, (ii) show the effect of resource gaps, and (iii) highlight which particular resources should be improved. We ran the model, parameterized with data from the 2009 H1N1v pandemic, for two provinces in Thailand. The predicted number of preventable deaths due to resource shortcomings and the actual resource needs are presented for two provinces and for Thailand as a whole. The model highlights the potentially huge impact of health-system resource availability and of resource gaps on health outcomes during a pandemic and provides a means to indicate where efforts should be concentrated to effectively improve pandemic response programmes.

Late diagnosis of HIV in Europe: definitional and public health challenges.

With universal access to antiretroviral therapy (ART), people can access effective treatment but are only able to benefit from these advances if they are aware of their status and are effectively accessing testing services. Although it was anticipated in the mid-1990s that the availability of ART would lead to earlier testing, this trend has not been observed in practice, with stagnant or even increasing rates of late diagnosis in Europe. Ahead of a gathering of key European stakeholders in Brussels in November 2007, we reviewed definitions of late diagnosis and approaches to surveillance of late HIV diagnosis in Europe. We found that there is no common or consistent reporting of late diagnosis across Europe and that the multiplicity of definitions for late diagnosis is likely proving a hindrance to providing information on the magnitude of the problem, determining trends, and informing understanding of reasons for changes in trends. We also show that existing evidence points to high rates of late diagnosis across Europe - between 15 and 38% of all HIV cases - and concur that trends that are increasing or at best stagnant. We identify risk factors that are associated with individuals being more likely to present late and we explore the reasons for late presentation. We reflect on the need to review surveillance and testing policies, notably in relation for population groups that are heavily represented in late presenters and make recommendations for a coherent, cross-European approach to surveillance and monitoring in order to support improvements in service provision and, ultimately, public health.

HIV testing strategies across European countries.

With universal access to effective combination antiretroviral therapy (ART), people in need can gain effective treatment but are only able to benefit from these advances if they are aware of their serostatus and have effectively accessed testing services. Despite the expectation that ART would lead individuals to seek earlier testing, this trend has not been observed in practice, with stable or even increasing rates of late diagnosis in Europe being witnessed. Ahead of a gathering of key European stakeholders in Brussels in November 2007, we reviewed testing strategies across European countries. We show differences in policy and practices. Moreover, HIV testing strategies are changing, in line with new global guidelines issued by World Health Organization headquarters, and a number of countries are promoting an expansion of routine and opt-out testing. However, gaps in our understanding of effective testing strategies remain and, as a consequence, national policies across Europe remain incoherent and often lack an evidence base. This is likely to have serious public health implications.

A rapid situation assessment of sexual risk behaviour of alcohol users in Lagos, Nigeria.

BACKGROUND: National sentinel surveys of HIV/AIDS among pregnant women in Nigeria have shown steady rise in prevalence from 1991 (1.8%) to 2001 (5.8%), which may reflect the pattern in the adult population in the country. The roles of known potential risk factors of the HIV/AIDS scourge in Nigeria deserve elucidation. This work aims to study the relationship between alcohol use and sexual risk behaviour. PATIENTS AND METHODS: Rapid assessment technique involving qualitative and quantitative methods was employed. A multi-site design which made it possible to compare samples recruited in high and low density settings was used. RESULTS: One hundred and nine of the alcohol users were recruited in the Low Density Area (LDA), while 130 were recruited in the High Density Area (HDA). In the HDA, 49 (53%) of the beer users used alcohol before sex either most or all of the time 21 (22.6%), or occasionally 28 (29.1%). Unlike the beer users less than half, 8 (42.1%), of Palm wine drinkers drank alcohol before sex. Beer users in the HDA used beer after sex with casual partners significantly more than the Palm wine drinkers (P = 0.036). Alcohol users in the LDA were more inclined to casual sex and they (54, 56.8%) believed that it had some or major role in their desire as well as performance of sex compared with users in the HDA (P = 0.005). CONCLUSION: Irrespective of their socioeconomic class, ethnicity, religion and educational attainment alcohol users in the country indulge in high risk sexual behaviours that predispose them to infection with HIV and other sexually transmitted diseases.

Is air travel safe for those with lung disease?

Airlines commonly report respiratory in-flight emergencies; flight outcomes have not been examined prospectively in large numbers of respiratory patients. The current authors conducted a prospective, observational study of flight outcomes in this group. UK respiratory specialists were invited to recruit patients planning air travel. Centres undertook their usual pre-flight assessment. Within 2 weeks of returning, patients completed a questionnaire documenting symptoms, in-flight oxygen use and unscheduled healthcare use. In total, 616 patients were recruited. Of these, 500 (81%) returned questionnaires. The most common diagnoses were airway (54%) and diffuse parenchymal lung disease (23%). In total, 12 patients died, seven before flying and five within 1 month. Pre-flight assessment included oximetry (96%), spirometry (95%), hypoxic challenge (45%) and walk test (10%). Of the patients, 11% did not fly. In those who flew, unscheduled respiratory healthcare use increased from 9% in the 4 weeks prior to travel to 19% in the 4 weeks after travel. However, when compared with self-reported data during the preceding year, medical consultations increased by just 2%. In patients flying after careful respiratory specialist assessment, commercial air travel appears generally safe.

Public health law and tuberculosis control in Europe.

BACKGROUND: Tuberculosis control is an important public health challenge in many European countries. Law is an important tool that policy-makers can draw upon to support control efforts and, according to the World Health Organization, represents a tangible expression of political commitment and will. Despite this, little national research, and even less cross-national comparative research, has been conducted to describe and analyse legislative approaches to tuberculosis control. METHODS: We conducted a survey of 14 European countries to identify, describe, map and analyse legislative tools used to support tuberculosis control. RESULTS: We found a wide range of legislative models. Legal measures available to nation states, such as compulsory examination, compulsory screening, compulsory detention, compulsory treatment and compulsory vaccination, vary widely in both scope and number. We identified a typology of legal frameworks, from the most authoritarian to the least restrictive. It seems likely that the application of some laws might not withstand scrutiny under the European Convention for the Protection of Human Rights and Fundamental Freedoms. CONCLUSIONS: Harmonization of legislative response to infectious diseases, based upon sound evidence, may be necessary if collaborative efforts in support of infectious disease control, as envisaged in the new International Health Regulations, are to be most effective and are to reflect more appropriately a globalized 21st century world.

Stigma and HIV infection in Russia.

Few studies have examined the personal and social consequences of stigma associated with HIV infection in Russia, a country with one of the most rapidly advancing HIV epidemics globally. By May 2005, Samara Oblast, Russia had 24,022 notified seropositive individuals. Focus-group discussions with randomly sampled seropositive and seronegative individuals, matched by age, gender and education were selected from the general population and used to provide an informal forum for discussion of attitudes to HIV and potentially stigmatizing behavior. The results demonstrated that the perception that HIV was associated with immoral behaviour underpinned stigma. Discriminating attitudes are strongly associated with misperceptions regarding transmission and frequent over-estimation of risks from casual contact. The general population was unforgiving to those who had become infected sexually or through drug use. Infection through a medical procedure or from an assault was perceived as a likely route of infection. Knowledge of population attitudes and perceptions, as well as those who are HIV-positive, is critical for successful interventions and to encourage people to come forward for HIV testing. This research offers insights into the distance that needs to be traveled if stigma is to be addressed in wider efforts to control HIV in Russia.