Evaluating the use of educational videos to support the tuberculosis care cascade in remote Madagascar.

SETTING: Access to information about tuberculosis (TB) is vital to ensure timely diagnosis, treatment, and control among vulnerable communities. Improved approaches for distributing health education materials to remote populations are needed.OBJECTIVE: To evaluate the impact of two comprehensive video training curricula in improving patient, community member, and community health worker knowledge of TB in a remote area of Madagascar.DESIGN: A pre-test/post-test design was used to measure knowledge acquisition. Educational videos were short, culturally appropriate films presented at critical moments in the TB cascade of care.RESULTS: Of the total 146 participants, 86 (58.9%) improved their score on the post-test, 50 (34.2%) obtained the same score, and 10 (6.8%) received a worse score. A statistically significant difference was observed between the pre- and post-test scores, wherein scores increased by a median of 10.0% (interquartile range 0.0-20.0) after viewing the videos (P < 0.001). There was a significant difference between the number of correct answers on the pre-test and the number of correct answers on the post-test (P < 0.001).CONCLUSION: Educational videos were found to significantly improve TB knowledge among a low-literacy, remote population in Madagascar. Our findings suggest educational videos could be a powerful, low-cost, and sustainable tool to improve access to TB education materials globally.

'It makes the patient's spirit weaker': tuberculosis stigma and gender interaction in Dar es Salaam, Tanzania.

SETTING: Dar es Salaam, Tanzania. OBJECTIVES: To describe tuberculosis (TB) related stigma and to understand how it interacts with gender to affect access to care. DESIGN: Eight focus group discussions were held among 48 TB patients and their household members, and a thematic content analysis was carried out. RESULTS: The main components of stigma were fear, self-isolation, ostracization, loss of status in the community, and discrimination by providers. Participants described the cultural context in which stigma operated as characterized by a general lack of health knowledge, cultural beliefs about TB, and engendered beliefs about disease in general. Both genders described some similar effects of stigma, including relationship difficulties and specifically challenges forming new relationships, but many effects of stigma were distinct by gender: women described challenges including assumptions about promiscuity and infidelity, as well as rejection by partners, while men described survival challenges. Stigma acted as a barrier to care through a cyclical pattern of stigma and fear, leading to health-seeking delays, with resulting continued transmission and poor health outcomes that further reinforced stigma. CONCLUSION: TB-related stigma is prevalent in this setting and operates differently for men and women. Interventions designed to increase case detection must address stigma and its interaction with gender.

Tuberculosis contact investigation in low- and middle-income countries: standardized definitions and indicators.

There is a need for better utilization of program data for global tuberculosis (TB) control. Significant information could be gained from data collected by TB programs that could supplement traditional sources of evidence and contribute to policy development. For this operational information to be useful, it must be collected in a uniform manner, using standardized definitions and approaches to evaluation. As an example of an approach to uniformity in generating useful program data, we present recommendations for the standardization of definitions and indicators for the investigation of contacts of persons with infectious TB in low- and middle-income countries.

Molecular epidemiologic investigation of tuberculosis in an area of increasing incidence in inner-city Dublin.

In 2002 the tuberculosis (TB) incidence in Dublin was 13.1 cases per 100,000 persons. In inner city Dublin, the TB incidence was > 20 per 100,000 persons. TB notification rates have remained elevated. The objective of the study is to characterize the population affected in this inner city area and to investigate transmission patterns and potential risk factors for TB disease. This hospital-based molecular epidemiologic study included all culture positive cases of TB between January 1, 1998 and December 31, 2002 from the Mater Misericordiae University Hospital. 142 cases were analyzed. 84 (59%) had clustered Mycobacterium tuberculosis (Mtb) isolates, 58 (41%) had unique isolates by molecular typing. There were 13 clusters; the largest two clusters had 26 cases each, one linked to pubs, the other linked through family contact. In multivariate logistic regression analysis, birth in Ireland, pulmonary TB, and younger age were significantly associated with recent transmission. Dublin is a developed city with persistent areas of high rates of TB in the native population. Despite a functioning public health system and lack of predisposing risk factors such as HIV, immigration, and extreme poverty, TB can persist in pockets of the younger, native population.

Intussusception among infants given an oral rotavirus vaccine.

BACKGROUND: Intussusception is a form of intestinal obstruction in which a segment of the bowel prolapses into a more distal segment. Our investigation began on May 27, 1999, after nine cases of infants who had intussusception after receiving the tetravalent rhesus-human reassortant rotavirus vaccine (RRV-TV) were reported to the Vaccine Adverse Event Reporting System. METHODS: In 19 states, we assessed the potential association between RRV-TV and intussusception among infants at least 1 but less than 12 months old. Infants hospitalized between November 1, 1998, and June 30, 1999, were identified by systematic reviews of medical and radiologic records. Each infant with intussusception was matched according to age with four healthy control infants who had been born at the same hospital as the infant with intussusception. Information on vaccinations was verified by the provider. RESULTS: Data were analyzed for 429 infants with intussusception and 1763 matched controls in a case-control analysis as well as for 432 infants with intussusception in a case-series analysis. Seventy-four of the 429 infants with intussusception (17.2 percent) and 226 of the 1763 controls (12.8 percent) had received RRV-TV (P=0.02). An increased risk of intussusception 3 to 14 days after the first dose of RRV-TV was found in the case-control analysis (adjusted odds ratio, 21.7; 95 percent confidence interval, 9.6 to 48.9). In the case-series analysis, the incidence-rate ratio was 29.4 (95 percent confidence interval, 16.1 to 53.6) for days 3 through 14 after a first dose. There was also an increase in the risk of intussusception after the second dose of the vaccine, but it was smaller than the increase in risk after the first dose. Assuming full implementation of a national program of vaccination with RRV-TV, we estimated that 1 case of intussusception attributable to the vaccine would occur for every 4670 to 9474 infants vaccinated. CONCLUSIONS: The strong association between vaccination with RRV-TV and intussusception among otherwise healthy infants supports the existence of a causal relation. Rotavirus vaccines with an improved safety profile are urgently needed.

A hemodynamic excitatory response to veratridine in the in utero lamb.

The inhibitory hemodynamic effects of the Bezold-Jarisch reflex in the adult animal, which play a role in the response to disease states, are elicited by veratridine and are mediated by vagal afferents. We tested whether the reported excitatory response to veratridine in the fetal animal may be caused by a maturational phase in the Bezold-Jarisch response. The effects of proprananol and atropine on the hemodynamic response to veratridine were examined at 124-141 d (mean, 133 d) of gestation in 11 fetal lambs instrumented long-term (instrumentation, 111-129 d of gestation). Seven lambs had intact vagal nerves, and four had bilateral cervical vagotomies. Veratridine injected into the superior vena cava (0.3 to 2.8 micrograms/kg) and the left atrium (0.2 to 0.8 microgram/kg) increased heart rate, arterial pressure, and left ventricular output, with the responses to left atrial injections occurring more rapidly. Propranolol markedly inhibited the increase in arterial pressure; atropine had no effect. Neither carbocaine, perfused around the cervical vagi, nor bilateral transection of the vagal nerves altered the hemodynamic excitatory response to veratridine. These findings demonstrate that the fetal excitatory response to veratridine is not mediated by vagal afferents, indicating the Bezold-Jarisch reflex does not undergo a maturational change from an excitatory reflex to an inhibitory one and suggesting the maturational loss of a sympathetically mediated hemodynamic reflex.

The in utero left ventricle of the fetal sheep: the effects of isoprenaline.

1. Isoprenaline was infused into in utero fetal lambs to examine the effect of this beta-adrenoceptor agonist on left ventricular stroke volume and left ventricular output and test the generally held assumption that the fetal ventricle is markedly limited in its ability to increase ventricular output. 2. Seven in utero lambs (121-133 days of gestation) were instrumented with left ventricular dimension transducers, an ascending aortic electromagnetic flow transducer, a brachiocephalic arterial catheter and electrocardiographic and atrial pacing electrodes. 3. On the day of study, 5-8 days following surgery and 129-137 days of gestation, each lamb received infusions of isoprenaline, via the superior vena cava or left atrium, at rates which ranged from 0.005-0.5 microgram kg-1 min-1. 4. Heart rate and left ventricular stroke volume, output and end-diastolic and end-systolic dimensions were measured under control conditions and during various levels of isoprenaline infusion, with and without controlling heart rate. 5. Analysis of variance was done using the mean cell model. Least-square means and standard errors of the least-square means are reported. F ratios were calculated from type III sums-of-squares; P less than 0.05 was considered significant. 6. The mean heart rate increased with isoprenaline (P less than 0.0001) from a mean control level of 169 +/- 8 to 281 +/- 9 beats min-1 (+/- S.E.M.). 7. Mean left ventricular end-diastolic and end-systolic minor axis dimensions decreased significantly with isoprenaline from 16.7 +/- 0.1 mm (control) to 15.7 +/- 0.2 mm (P less than 0.0004) and from 11.7 +/- 0.1 mm (control) to 10.4 +/- 0.2 mm (P less than 0.0001) respectively. When heart rate was controlled with atrial pacing, mean end-diastolic dimension increased significantly at the higher isoprenaline doses from 14.6 +/- 0.1 mm (control) to 15.3 +/- 0.2 mm (control) (P = 0.0002), while mean end-systolic dimension fell significantly from 10.9 +/- 0.1 to 10.5 +/- 0.1 mm (P less than 0.003). Inasmuch as stroke volume increased, the increase in end-diastolic dimension and the fall in end-systolic dimension indicate an increase in venous return to the left ventricle. 8. During spontaneous rhythm, isoprenaline increased stroke volume from 2.45 +/- 0.06 ml (control) to 2.63 +/- 0.09 ml, not statistically significant. When heart rate was controlled, stroke volume increased with isoprenaline dose from 1.68 +/- 0.06 ml (control) to 2.40 +/- 0.08 ml (P less than 0.0001).(ABSTRACT TRUNCATED AT 400 WORDS)