Tuberculosis deaths averted by implementation of the DOTS strategy in Kazakhstan.

SETTING: Kazakhstan began implementing the DOTS strategy for tuberculosis (TB) in 1998. OBJECTIVE: Data were analyzed 1) to determine if changes in TB mortality rate (MR) and case fatality rate (CFR) in Kazakhstan for 1998-2003 differed from those of Uzbekistan and four adjacent Russian Federation (RF) oblasts that had not yet implemented DOTS, and 2) to estimate the number of deaths averted in Kazakhstan as a result of DOTS. DESIGN: Observed MRs were calculated, and predicted MRs for Kazakhstan were approximated by linear regression based on average slope of MRs from 1998 through 2003 in adjacent non-DOTS-implementing territories. Deaths averted were calculated by comparing predicted MRs to actual MRs by converting rate differences to numbers of deaths. RESULTS: TB MRs in Kazakhstan decreased markedly, but remained stable or increased in the neighboring territories. CFRs decreased markedly in Kazakhstan and marginally in Uzbekistan, and increased in the neighboring RF oblasts. From 1998 to 2004, DOTS appears to have helped avert approximately 17,800 deaths in Kazakhstan. CONCLUSION: DOTS has contributed markedly to a decrease in TB mortality in Kazakhstan. In settings where mortality data are relatively complete, deaths averted can be another indicator of DOTS effectiveness.

Non-typhoidal Salmonella rates in febrile children at sites in five Asian countries.

There is increased recognition of non-typhoidal Salmonella (NTS) as a major cause of severe febrile illness in sub-Saharan Africa. However, little is known about community-based incidence of NTS in Asia. In a multicentre, community-based prospective Salmonella surveillance study, we identified a total of six NTS cases: three in Karachi, Pakistan, one in Kolkata, India, and two in North Jakarta, Indonesia. No NTS cases were identified in Hechi, People's Republic of China, and Hue, Viet Nam. Three cases were in children under 3 years, and one case was in a child aged 10 years and one in a child aged 15 years. Only one case was an adult (29 years). The highest incidence of NTS infection was in Karachi (7.2 culture-proven NTS cases per 100,000 person years in age group of 2-15 years). However, in comparison with sub-Saharan Africa, the NTS burden in Asia appears rather limited.

[Detection of tuberculosis in the countries of Central Asia by the electronic monitoring system data].

The basic stages of putting into practice of tuberculosis monitoring systems in the Central Asian Region (CAC) (Uzbekistan, Kazakhstan, Kyrghyz, and Tajikistan) with the assistance of the USA Centers for Disease Control and Prevention, Central Asian Region Programs (CDC/CAR), and the USA Agency for International Development in 2000-2006 are considered. These stages comprised: 1) modification of accounting and reporting forms in accordance with the requirements of the uniform statistical tuberculosis registration system; 2) development, adaptation, and introduction of an electronic tuberculosis monitoring and management system (ETMMS) in the regions and countries of Central Asia; 3) epidemiological analysis of information of tuberculosis monitoring systems, by using the elements of evidence-based medicine. At present, policy electronic tuberculosis monitoring systems entirely cover the areas of three countries of the region. The quality of entries and their processing and analysis is assured by a wide training system set up by the CDC/CAR jointly with the leading national tuberculosis facilities of CAR with the support of the Global Fund for AIDS, Tuberculosis, and Malaria Control. The information obtained by ETMMS has permitted a detail comparative analysis of the structure of tuberculosis at the level of individual regions to identify characteristic groups of areas in the demographic and sociooccupational characteristics of new tuberculosis cases.

Progress toward tuberculosis control and determinants of treatment outcomes--Kazakhstan, 2000-2002.

INTRODUCTION: In Kazakhstan, during 1995-2002, the annual notification rate per 100,000 population for new cases of tuberculosis (TB) increased from 67.1 to 165.1. Beginning in 1998, public health authorities have used the national case management strategy (DOTS) promulgated by the World Health Organization (WHO) to control TB. Intended goals of DOTS include achieving a cure rate of >85% for persons with newly detected pulmonary TB sputum-smear-positive (PTB+) cases and having PTB+ represent >65% of all PTB cases among adults. Surveillance data collected during 2000-2002 were analyzed to evaluate progress toward achieving these goals and identify factors associated with specific treatment outcomes. METHODS: Surveillance data included the following nonidentifiable information on persons with newly reported cases of PTB: dates of disease onset and treatment initiation; methods of diagnosis; treatment outcomes; HIV status; and selected demographic, socioeconomic, and behavioral characteristics. Cure rates and proportions of PTB+ cases were calculated on the basis of the TB case definition and treatment outcome classification format outlined in DOTS guidelines issued by WHO. Denominator data to calculate rates were obtained from the National Census Office of Kazakhstan. Logistic regression was employed to investigate factors associated with treatment outcomes using Epi Info version 3.2. RESULTS: During 2000-2002, a total of 65,011 new cases of PTB were detected in Kazakhstan. The average annual countrywide notification rate per 100,000 population was 146.0; provincial notification rates varied (range: 65.1-274.0). The countrywide cure rate for newly detected PTB+ was 72.2%; provincial rates varied (range: 65%-81%). Of 59,905 cases of PTB among adults during 2000-2002, a total of 26,804 (44.7%) were PTB+. Unfavorable treatment outcome of new PTB+ cases was associated with alcohol abuse, homelessness, and previous incarceration. CONCLUSION: The cure rate for new PTB+ cases and the proportion of cases of PTB+ among all adults with PTB were below targeted goals. This might, in part, be explained by the 1998 adoption of DOTS. Improving program indicators requires evaluation of detection efforts, laboratory diagnostic capabilities, and adherence to treatment regimens, especially in provinces in which rates are high and among persons at high risk for unfavorable treatment outcomes.

Risk factors for brucellosis--Leylek and Kadamjay districts, Batken Oblast, Kyrgyzstan, January-November, 2003.

INTRODUCTION: Brucellosis is a zoonotic disease that is associated with chronic serious sequelae in humans. During 1997-2002, the reported incidence of human brucellosis in Kyrgyzstan increased nearly twofold, from 20 to 36 per 100,000 population. In 2002, the highest incidence of brucellosis was reported in two rural districts of Batkan Oblast: Leylek (106 per 100,000 population) and Kadamjay (80 per 100,000 population). During January-November 2003, trainees from the Applied Epidemiology Training program in Central Asia conducted a matched, hospital-based, case-control study to identify risk factors for brucellosis and describe the epidemiology of disease in these two districts. METHODS: Brucellosis cases were defined on the basis of epidemiologic, clinical, and laboratory criteria. During January-November 2003, a total of 100 persons with confirmed brucellosis were identified in the infectious disease wards of the two district hospitals; these persons were matched by age and date of admission to 100 controls who were admitted to other hospital wards for unrelated conditions. Data on socioeconomic and occupational factors and history of exposure to animals and animal products were collected by using a structured questionnaire. Conditional logistic regression was used to study the association between exposure variables and brucellosis. RESULTS: Among the 100 persons with confirmed brucellosis during the study period, 86 (86%) owned farm animals, and 45 (45%) became ill during April-May, the birthing season for farm animals. Multivariate analysis indicated that brucellosis was associated with exposure to aborted farm animals in the household (odds ratio [OR] = 29.8; 95% confidence interval [CI] = 4.4-203.4) and consumption of home-made milk products obtained from bazaars or neighbors (OR = 11.4; CI = 1.6-83.9). Knowledge of the mode of brucellosis transmission appeared to be protective against disease transmission (OR = 0.2; CI = 0.03-0.8). DISCUSSION: Exposure to aborted home-owned animals and consumption of home-made milk products obtained from bazaars or neighbors were identified as probable sources of human brucellosis infections in the study districts. This finding suggests that brucellosis spreads among farm animals in the area and that home-made milk products are not adequately pasteurized. CONCLUSION: To reduce the burden of brucellosis in Batken Oblast, veterinary services should be improved, and health education programs should be increased. Implementing these measures should minimize exposure to farm animals and reduce the risk for infection from locally produced milk products.

The increasing prominence of household transmission of hepatitis A in an area undergoing a shift in endemicity.

In the rapidly developing city of Almaty, Kazakhstan, rates of hepatitis A have fallen, but no data on prevalence of antibody to hepatitis A virus (anti-HAV) exist with which to interpret incidence data. In the autumn of 2001, we determined the anti-HAV prevalence among household and school contacts of hepatitis A cases. For contacts aged 0-4 years, 5-9 years, 10-14 years, 15-19 years, or 20-30 years, immune prevalences were 9, 12, 33, 33 and 77% respectively, among immediate-family household contacts and 15, 28, 49, 52 and 77% respectively, among community contacts. Child community contacts were more likely to be immune than their immediate-family household counterparts (odds ratio 2.0, 95% confidence interval 1.3-3.2). Almaty is experiencing an epidemiological shift in hepatitis A incidence. Feasible and effective prevention strategies using hepatitis A vaccine should be explored.

Person-to-person transmission of hepatitis A virus in an urban area of intermediate endemicity: implications for vaccination strategies.

Developing countries with an increasing hepatitis A disease burden may target vaccination to specific groups, such as young children, as an initial control strategy. To better understand transmission of hepatitis A virus in such countries, the authors prospectively studied household and day-care/school contacts of cases in Almaty, Kazakhstan. Overall, by the time of identification of symptomatic index cases, half of transmission had already occurred, having been detected retrospectively. The odds of household contacts' becoming infected were 35.4 times those for day-care/school contacts (95% confidence interval (CI): 17.5, 71.7). Within households, younger age of either index cases or susceptible contacts elevated the odds of secondary infection among susceptible contacts: The presence of a case under 6 years of age raised the odds 4.7 times (95% CI: 1.2, 18.7); and compared with contacts aged 14 years or older, the odds of infection were increased to 7.7 (95% CI: 1.5, 40.3) and 7.0 (95% CI: 1.4, 34.3) among contacts aged 0-6 years and 7-13 years, respectively. Young children are appropriate targets for sustainable hepatitis A vaccination programs in areas undergoing hepatitis A epidemiologic transition. If vaccine is determined to be highly effective postexposure and if it is feasible, vaccinating household contacts could be a useful additional control strategy.

[Detection of antibodies to HIV virus in saliva by express-tests in Uzbekistan]. / Opredelenie antitel k virusu immunodefitsita cheloveka v sliune s pomoshch'iu ékspress-testa v Uzbekistane.

Saliva tests, when used in screening for antibodies to HIV virus (anti-HIV), makes testing safer, easy-to-fulfill (even outside clinic) and acceptable for a majority of examinees. The main quality parameters of express-test for the detection of anti-HIV in saliva were evaluated for the purpose of using the related approach in the HIV epidemiological supervision. Saliva samples and sera of 81 HIV-infected patients and of 99 presumably non-infected persons were investigated by the "OraQuick" express-test. The data obtained were compared with the results of ELISA-based serum testing. The sensitivity of "OraQuick" made 95% and its specificity was 100%. The test is appropriate for epidemiological investigations and HIV epidemiological supervision but it cannot be recommended for the blood transfusion service.

[Subtypes of HBsAg of the hepatitis B virus in Western Siberia]. / Subtipy HBsAg virusa gepatita B v Zapadnoi Sibiri.

HBs antigens were subtyped in blood samples of intravenous drug-addicts (IDA) and of donors from as many as 10 cities of Western Siberia by using the immune-enzyme assay with 6 high-specific monoclonal antibodies. Two HBsAg subtypes were found, in a ratio of 3% ayw2: 97% ayw3 (varA and varB), in IDA blood samples from Novosobirsk. Three HBsAg subtypes were found, in a ratio of 57% ayw2: 42% ayw3 (varA and varB): 1% adw2, in the donors' blood samples. The obtained data are sufficient for developing the first national sera panel containing different HBsAg subtypes of hepatitis B virus typical of Russia.

Hepatitis E virus antibody prevalence among persons who work with swine.

Prevalence of antibody and risk factors to hepatitis E virus (HEV) infection were determined in a cross-sectional study of 2 group-matched populations: swine farmers (n=264) and persons without occupational exposure to swine (n=255) in Moldova, a country without reported cases of hepatitis E. The prevalence of HEV infection was higher among swine farmers than among the comparison group (51.1% vs. 24.7%; prevalence ratio, 2.07; 95% confidence interval [CI], 1.62-2.64). In multivariate analysis, HEV infection was associated with an occupational history of cleaning barns or assisting sows at birth (odds ratio [OR], 2.46; 95% CI, 1.52-4.01), years of occupational exposure (OR, 1.04 per year; 95% CI, 1.01-1.07), and a history of drinking raw milk (OR, 1.61; 95% CI, 1.08-2.40). HEV infection was not associated with civilian travel abroad or having piped water in the household. The increased prevalence of HEV infection among persons with occupational exposure to swine suggests animal-to-human transmission of this infection.

Hepatitis E virus infection in chimpanzees: a retrospective analysis.

Different patterns of disease were observed among 11 chimpanzees who were inoculated intravenously with hepatitis E virus (HEV) positive fecal specimens from four different outbreaks (Nepal 1981, Uzbekistan 1981, Pakistan 1985, and Mexico 1986). Five chimpanzees had marginal or no liver enzyme elevations within 70 days of inoculation. Two of the chimpanzees had limited viremia, but did not produce detectable antibody. The four remaining chimpanzees had liver enzyme elevations, viral shedding, viremia, seroconversion to anti-HEV, and detectable HEV antigen in liver biopsy specimens. These results may reflect the range of infection patterns that develop in humans after natural exposure to the HEV.

[Morbidity and mortality in acute viral hepatitides in a hyperendemic region. The role of viral hepatitis E]. / Zabolevaemost' i smertnost' pri ostrykh virusnykh gepatitakh v giperéndemichnom regione. Rol' virusnogo gepatita E.

Official annual statistical data on morbidity in acute viral hepatitides (AVH), including the number of lethal cases, for 1985-1995 were analyzed. Mortality rates per 100,000 of the population at the period of 11 years were calculated for different age groups, sex and the place of residence. 396 and 99 patients were examined for the presence of serological markers of hepatitides A, B and E, respectively, at the periods of epidemic rises in morbidity and satisfactory epidemic situation. In the course of 11 years AVH caused the death of 22,405 persons. In 1985-1987 the average mortality level (ML) reached 12.3-17.8 per 100,000 of the population (with morbidity being 1,200-1,400 and was essentially higher among the rural population in comparison with the urban population. During these years the highest ML, was registered among children aged 0-2 years (190-50 per 100,000) and, among adults, mainly among women aged 20-29 years (21.4-19.6 per 100,000). During the years when the epidemic of AVH was absent, ML among these groups was essentially lower: 40-20 among children aged 0-2 years and 4-5 among women aged 20-29 years. In 1987 in the Fergana Valley hepatitis E was detected in 72.2% of all examined patients, and in the southern areas of the country in 68.7%. A sharp rise on mortality among women of the productive age at the period of the epidemic rise of AVH morbidity in the endemic region indicated that this epidemic was linked with hepatitis E. High ML among young children may be indicative of a highly unfavorable course of hepatitis E in the group of infants, which had never been registered before. This newly established regularity may be used for the retrospective diagnostics of the outbreak of hepatitis E.

Prevalence of antibody to hepatitis E virus among rodents in the United States.

The recent identification of antibody to hepatitis E virus (HEV) in pigs, sheep, and cattle and characterization of an HEV isolated from domestic pigs suggest animal reservoirs for this virus. To investigate whether rodents might be a natural reservoir of HEV, the prevalence of anti-HEV was determined among a variety of species throughout the United States. Serum samples were obtained from 806 rodents of 26 species in 15 genera. Anti-HEV prevalence was assessed by 2 EIAs (mosaic protein- and 55-kDa protein-based), which gave concordant results. The highest prevalence of antibody was found in the genus Rattus (59.7%; 166/278). Overall, rodents from urban habitats had a significantly higher prevalence of anti-HEV than did animals captured from rural areas. A high prevalence of anti-HEV was found in animals captured on mainland versus barrier islands. The results from this study provide convincing evidence of widespread HEV or HEV-like infection in rodents of the United States.

Universal immunization: the diphtheria control strategy of choice in the Republic of Tajikistan, 1993-1997.

During the 1993-1997 diphtheria epidemic in Tajikistan, the incidence rate was the highest observed throughout the Newly Independent States of the former Soviet Union (76.2 cases/100,000 population in 1995). Factors that contributed to this situation included an increase in the number of persons who were not fully immunized, a breakdown of health care services and disease surveillance, civil war, an increase in migration, shortages of qualified medical personnel, and shortages of products, resources, and services. The Ministry of Health and numerous international organizations have worked to address the needs of the republic, and in the fourth quarter of 1995, the number of reported cases began to decrease. It is believed that this decrease was largely the result of routine immunization, implementation of national immunization days, and use of a World Health Organization-recommended system for working with patients and contacts, and it underscores the importance of universal diphtheria immunization with special booster doses in such an epidemic setting.

Injections given in healthcare settings as a major source of acute hepatitis B in Moldova.

BACKGROUND: Reported rates of acute hepatitis B are high in many former Soviet Union republics and modes of transmission are not well defined. METHODS: Two case-control studies were undertaken in Moldova to identify risk factors for acute hepatitis B in people aged 2-15 years (children) and > or =15 years (adults). Serologically confirmed acute hepatitis B cases occurring between 1 January 1994 and 30 August 30 1995, were matched on age, sex, and district of residence to three potential controls who were tested for hepatitis B markers to exclude the immune. Stratified odds ratios (SOR) were calculated using bivariate and multivariate methods. RESULTS: In multivariate analysis, compared with the 175 controls, the 70 adult cases (mean age 25 years, 66% male) were more likely to report receiving injections in the 6 months before illness during a dental visit (SOR = 21; 95% CI: 3.7-120), a hospital visit (SOR = 35; 95% CI: 7.2-170), or a visit to the polyclinic (SOR = 13; 95% CI: 2.4-74). Among children, receiving injections during a hospital visit (SOR = 5.2; 95% CI: 1.2-23) was the only exposure reported significantly more often by the 19 cases (mean age 8 years, 68% male) compared with the 81 controls. CONCLUSION: These results, along with reported unsafe injection practices in Moldova, suggest that injections are a major source of hepatitis B virus transmission and highlight the importance of proper infection-control procedures in preventing transmission of blood-borne infections.

PIP: Two case-control studies were conducted between January 1994 and August 1995 to determine the relative importance of injections and other exposures as a source of acute hepatitis B in Moldova among adults (aged 15 years) and children (aged 2-15 years). Results showed that injections in various health care settings were associated with acute hepatitis B and showed a higher proportion among adults compared with children. Contact with an HBsAg-positive person was also associated with illnesses; however, there was no statistically significant association between acute hepatitis B and other exposures. The risk of HBV transmission following percutaneous exposure is high (at least 30%). Calculation of the population attributable to risk suggests that injections associated with acute hepatitis B cases occurred in adults (52%) and children (21%). Adverse effects of injections may not be apparent in causing chronic infections. Transmission of blood-borne pathogens through unsafe injection practices is a problem increasingly identified worldwide.

Prevalence of hepatitis B, D and C virus infections among children and pregnant women in Moldova: additional evidence supporting the need for routine hepatitis B vaccination of infants.

Rates of acute hepatitis B are high in Moldova, but the prevalence of chronic infection is unknown. In 1994, we surveyed children and pregnant women, collected demographic information, and drew blood for laboratory testing. Among the 439 children (mean age, 5 years), the prevalence of antibody to hepatitis B core antigen (anti-HBc) and hepatitis B surface antigen (HBsAg) were 17.1 and 6.8%, respectively. Among the 1098 pregnant women (mean age, 26 years), 52.4% were anti-HBc-positive and 9.7% were HBsAg-positive. Of the HBsAg-positive pregnant women, 35.6% were hepatitis B e antigen (HBeAg) positive and 18.3% had antibodies to hepatitis D virus. The prevalence of antibody to hepatitis C virus was 1.4% in children and 2.3% in pregnant women. The high HBeAg prevalence among HBsAg-positive pregnant women and the high anti-HBc prevalence among children indicate that both perinatal and early childhood transmission contribute to the high hepatitis B virus endemicity in Moldova.