Multidrug-resistant tuberculosis. Recommendations for reducing risk during travel for healthcare and humanitarian work.

Healthcare and humanitarian workers who travel to work where the incidence of multidrug-resistant tuberculosis (MDR TB) is high and potential transmission may occur are at risk of infection and disease due to these resistant strains. Transmission occurs due to inadequate transmission control practices and the inability to provide timely and accurate diagnosis and treatment of persons with MDR TB. Patients risk exposure if active TB is unrecognized in workers after they return to lower-risk settings. Guidance for risk reduction measures for workers in high-risk areas is limited, and no studies confirm the efficacy of treatment regimens for latent TB infection due to MDR TB. Bacille Calmette-Guérin (BCG) vaccination decreases the risk of active TB and possibly latent infection. IFN-γ release assays differentiate TB infection from BCG vaccination effect. A series of risk reduction measures are provided as a potential strategy. These measures include risk reductions before travel, including risk assessment, TB screening, education, respirator fit testing, and BCG vaccination. Measures during travel include use of respirators in settings where this may not be common practice, transmission control practices, triaging of patients with consistent symptoms, providing education for good cough etiquette, and provision of care in well-ventilated areas, including open air areas. Risk reduction measures after return include TB screening 8 to 10 weeks later and recommendations for management of latent TB infection in areas where the likelihood of MDR TB exposure is high.

Bacterial vaginosis, gonorrhea, and chlamydial infection among women attending a sexually transmitted disease clinic: a longitudinal analysis of possible causal links.

PURPOSE: Interactions between bacterial vaginosis (BV) and inflammatory sexually transmitted infections, such as gonorrhea and chlamydial infection, are not well understood. Furthermore, evidence regarding the sexual transmission of BV is equivocal. METHODS: We assessed associations between incident BV and incidences of gonorrhea and/or chlamydial infection ("gonorrhea/chlamydia"), as well as similarities in associations for the two processes, among 645 female patients at a sexually transmitted disease clinic in Alabama followed prospectively for 6 months from 1995 to 1998. We identified predictors of both incident BV and gonorrhea/chlamydia and used bivariate logistic regression to determine whether these predictors differed. RESULTS: Participants completed 3188 monthly, follow-up visits. Several factors associated with incident BV involved sexual intercourse: young age (<16 years) at first intercourse (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.1-1.9), recent drug use during sex (aOR, 1.7; 95% CI, 1.2-2.5), prevalent trichomoniasis (aOR, 2.8; 95% CI, 1.7-4.6) and incident syphilis (aOR, 9.7; 95% CI, 1.9-48.4). Few statistical differences between potential factors for BV and gonorrhea/chlamydia emerged. BV appeared to precede the acquisition of gonorrhea/chlamydia (pairwise odds ratio, 1.6; 95% CI, 1.1-2.3), and vice versa (pairwise odds ratio, 2.4; 95% CI, 1.7-3.5). CONCLUSIONS: Findings are consistent with a causal role of sexual behavior in the acquisition of BV and confirm that BV facilitates acquisition of gonorrhea/chlamydia and vice versa independently from other risk factors.

Risk factors for incident herpes simplex type 2 virus infection among women attending a sexually transmitted disease clinic.

OBJECTIVES: To estimate the incidence of herpes simplex type 2 virus (HSV-2) infection, to identify risk factors for its acquisition, and to assess the protective effect of condoms. STUDY DESIGN: Prospective study of 293 HSV-2 seronegative women, aged 18 to 35 years, attending a sexually transmitted disease clinic in Alabama from 1992 to 1995. RESULTS: Incidence of HSV-2 infection was 20.5 per 100 woman-years [95% confidence interval (CI), 13.1-30.5]. Young women (18-20 years) had a significantly higher risk of incident HSV-2 infection [adjusted hazard ratio (HR), 2.8; 95% CI, 1.3-6.4] than older women. Women diagnosed with prevalent or incident bacterial vaginosis had a higher incidence of HSV-2 infection than those who were not so diagnosed (adjusted HR, 2.4; 95% CI, 1.1-5.6). No significant protective effect was observed for consistent (100%) condom use without breakage and slippage against HSV-2 acquisition (adjusted HR, 0.8; 95% CI, 0.2-2.3). CONCLUSION: Acquisition of HSV-2 infection among study participants was higher than previous estimates for adult female sexually transmitted disease clinic attendees, and no protective effect for condoms was demonstrated. The high incidence of HSV-2 infection with its potential for adverse health consequences emphasizes the need for better prevention strategies.

Application of the case-crossover design to reduce unmeasured confounding in studies of condom effectiveness.

This analysis examined how unmeasured confounding affects estimates of the effectiveness of condoms in preventing sexually transmitted infections. Data were analyzed from a prospective cohort study of 1,122 female sexually transmitted disease clinic patients in Alabama (1992-1995), wherein participants were evaluated for sexually transmitted infections at six 1-month intervals. Associations between condom use and incident gonorrhea and chlamydia infection were compared between case-crossover and cohort analyses. In a case-crossover analysis of 228 follow-up visits ending in gonorrhea/chlamydia ("case intervals") and 743 self-matched follow-up visits not ending in gonorrhea/chlamydia ("noncase intervals") (183 women), consistent condom use without breakage or slippage was associated with significantly reduced risk of infection relative to nonuse (adjusted risk odds ratio = 0.49, 95% confidence interval: 0.26, 0.92). Conversely, a cohort analysis of 245 case intervals and 3,896 noncase intervals (919 women) revealed no significant reduction in infection risk from consistent use of condoms (adjusted risk odds ratio = 0.79, 95% confidence interval: 0.53, 1.17). Dose-response relations between the number of unprotected sex acts and infection were stronger in the case-crossover analysis (p for trend = 0.009) than in the cohort analysis (p for trend = 0.18). These findings suggest that epidemiologic studies confounded by unmeasured differences between condom users and nonusers underestimate condom effectiveness against these infections. The case-crossover method provides an additional technique for reducing unmeasured confounding in studies of condom effectiveness.

Female condom and male condom failure among women at high risk of sexually transmitted diseases.

OBJECTIVE: The objective of this study was to study the frequency and determinants of breakage and slippage during female and male condom use. GOAL: The goal of this study was to determine condom breakage and slippage rate. STUDY: We conducted a 6-month prospective follow-up study of women attending 2 sexually transmitted disease clinics. Breakage and slippage rates were computed. Logistic regression was used to evaluate baseline characteristics and time-dependent behaviors. RESULTS: A total of 869 women used condoms in 20,148 acts of intercourse. Breakage was less common for female condoms (0.1%; 95% confidence interval [CI], 0.05-0.21) than for male condoms (3.1%; 95% CI, 2.80-3.42). Slippage was more common for female condoms (5.6%; 95% CI, 5.10-6.13) than for male condoms (1.1%; 95% CI, 0.90-1.28). Rates significantly decreased with use and increased with number of previous failures. From first use to >15 uses, combined failure rate fell from 20% to 1.2% for female condoms (P < 0.0001) and 9% to 2.3% for male condoms (P < 0.01). CONCLUSIONS: Both condoms may provide good protection against sexually transmitted diseases. Experience determines success with either condom.

Same-day scheduling in a public health clinic: a pilot study.

Same-day scheduling, is built on the premise that today's work should be done today. Ensuring patients access to providers on the same day that they call their providers challenges a cherished assumption of medical practice management. Increasing dissatisfaction on the part of both patients and providers has made same-day scheduling increasingly popular for medical practices in both the for-profit and not-for-profit sectors. The study described in this article reports the results of an experimental introduction of same-day scheduling in a public health clinic. Same-day scheduling resulted in shorter waiting times, lower no-show rates (or alternatively higher show rates), more new patients, and increased provider productivity. The results of this pilot study were sufficient to convince the local health department to expand same-day scheduling to all its clinics and illustrate the gains that can be achieved in doing today's work today.