Extensive Mycobacterium tuberculosis circulation in a highly endemic prison and the need for urgent environmental interventions.

Aimed at assessing the circulation of Mycobacterium tuberculosis in a highly endemic prison, this 13-month prospective study was performed on strains isolated from tuberculosis (TB) cases detected passively and actively. We used X-ray screening of newly admitted inmates and mass screening at the beginning of the study and again 1 year later. Of the 94 strains genotyped by restriction fragment-length polymorphism, 79 (84·0%) belonged to one of the 12 identified clusters (2-21 strains each), including two main clusters (18 and 21 cases, respectively). A history of TB treatment was reported in 22/79 (27·8%) clustered cases. Time-space distribution of clustered cases was predominantly consistent with transmission, in micro-epidemics. Given the dominant pattern of exogenous infection and the extensive strain circulation, effective TB control should emphasize reduction of overcrowding and improvement of environmental measures as a complement to detection and treatment of cases.

International institutions, global health initiatives and the challenge of sustainability: lessons from the Brazilian AIDS programme.

The sustainability of successful public health programmes remains a challenge in low and middle income settings. These programmes are often subjected to mobilization-demobilization cycle. Indeed, political and organizational factors are of major importance to ensure this sustainability. The cooperation between the World Bank and the Brazilian AIDS programme highlights the role of international institutions and global health initiatives (GHI), not only to scale up programmes but also to guarantee their stability and sustainability, at a time when advocacy is diminishing and vertical programmes are integrated within health systems. This role is critical at the local level, particularly when economic crisis may hamper the future of public health programmes. Political and organizational evolution should be monitored and warnings should trigger interventions of GHI before the decline of these programmes.

Screening for tuberculosis on admission to highly endemic prisons? The case of Rio de Janeiro State prisons.

SETTING: Rio de Janeiro (RJ) State prisons, where tuberculosis (TB) is highly endemic. OBJECTIVE: To measure TB prevalence, identify risk factors and ascertain the most appropriate screening method among inmates of the RJ prisons. DESIGN: Systematic chest X-rays (CXRs) were performed in 1696 male inmates of three RJ prisons. Inmates were selected for sputum examination and culture if their CXRs showed evidence of any pulmonary, pleural or mediastinal abnormality. TB diagnosis was based on bacteriological results or, if bacteriological results were negative, on response to TB treatment. RESULTS: TB prevalence was 2.7% (46/1696), and 32/46 cases (69%) were bacteriologically confirmed, including 19 smear-positive cases. CXR lesions were extensive in 43% of cases. In the logistic regression model, TB-associated variables were being illiterate (adjusted OR 2.10, 95%CI 1.02-4.34), cough >or=3 weeks (aOR 2.85, 95%CI 1.54-5.27), history of TB treatment (aOR 3.61, 95%CI 1.76-7.39), and living in Rio City suburbs (aOR 4.54, 95%CI 1.02-20.07) and in Rio City (aOR 5.48, 95%CI 1.29-23.33). A screening based on cough >or=3 weeks followed by sputum smear examination would have identified only 9 of the 46 cases. CONCLUSION: These results call for screening on admission to prison based, if feasible, on CXR, and demonstrate the urgent need to improve detention conditions and medical assistance in police remand cells.

Malaria risk perception, knowledge and prophylaxis practices among travellers of African ethnicity living in Paris and visiting their country of origin in sub-Saharan Africa.

An observational prospective cohort study assessed malaria risk perception, knowledge and prophylaxis practices among individuals of African ethnicity living in Paris and travelling to their country of origin to visit friends or relatives (VFR). The study compared two groups of VFR who had visited a travel clinic (TC; n=122) or a travel agency (TA; n=69) before departure. Of the 47% of VFR citing malaria as a health concern, 75% knew that malaria is mosquito-borne and that bed nets are an effective preventive measure. Perception of high malaria risk was greater in the TA group (33%) than in the TC group (7%). The availability of a malaria vaccine was mentioned by 35% of VFR, with frequent confusion between yellow fever vaccine and malaria prevention. Twenty-nine percent took adequate chemoprophylaxis with complete adherence, which was higher among the TC group (41%) than the TA group (12%). Effective antivector protection measures used were bed nets (16%), wearing long clothes at night (14%) and air conditioning (8%), with no differences between the study groups except in the use of impregnated bed nets (11% of the TC group and none of the TA group). Media coverage, malaria chemoprophylaxis repayment and cultural adaptation of preventive messages should be improved to reduce the high rate of inadequate malaria prophylaxis in VFR.

Development and evaluation of tuberculosis screening scores in Brazilian prisons.

BACKGROUND: Tuberculosis (TB) is highly endemic in Rio de Janeiro State prisons. In addition to TB screening at entry and passive case detection, active case identification may be warranted. OBJECTIVES: To develop and evaluate performances of scores aimed at identifying "tuberculosis suspects" in order to target TB screening among inmates. METHODS: Systematic chest X-ray screening was carried out in two prisons (n=1910). TB was diagnosed among individuals with X-ray abnormalities by sputum microscopic examination and culture or, if bacteriological results were negative, by response to TB treatment. Using this strategy as a reference, the clinical score proposed in WHO guidelines "TB Control in Prisons" was evaluated. Using the same variables in a logistic regression comparing TB and non-TB cases, another score was developed and evaluated. Finally, a 'new score', based on socio-demographic and clinical variables was developed and evaluated. RESULTS: When applied to our study population (prevalence of active TB: 4.6%), these scores missed many TB cases (sensitivities: 56%, 72%, 74%, respectively). Among the "TB suspects", the probability of finding TB cases was low (positive predictive value: 10%). The scores had high negative predictive values (>97%); specificities (75%, 60%, 67%) were low. Performances were similarly poor for smear-negative and smear-positive cases. CONCLUSION: The scores investigated performed poorly and would be unhelpful to target TB screening. Therefore, systematic X-ray screening may be considered, at least during the initial stages of the reinforced TB programme, in order to reduce the impressive burden of TB.

Benefit of amoxicillin in differentiating between TB suspects whose initial AFB sputum smears are negative.

SETTING: Out-patient dispensary in Conakry, Guinea, West Africa. OBJECTIVE: To differentiate between pulmonary tuberculosis (PTB) and non-PTB diseases among 204 acid-fast bacilli (AFB) smear-negative adult TB suspects. DESIGN: We derived scores from clinical, serological and radiological findings among PTB suspects aged > or = 15 years who, after having had three AFB-negative smears, were treated for 10 days with amoxicillin (AMX, 1.5 g/day). RESULTS: At the selected cut-off score from model 1 (clinical), sensitivity for PTB was 95%, specificity 40%, negative predictive value (NPV) 84%, and positive predictive value (PPV) 69%. Comparable values from model 2 (clinical + serological + radiological) were: sensitivity 99%, specificity 45%, NPV 97%, and PPV 71%. Results from AMX were better: sensitivity 92%, specificity 93%, NPV 94%, and PPV 91%. Of the 117 suspects who failed to respond clinically and radiographically to AMX and remained AFB smear-negative, 110 (94%) had PTB, confirmed either by positive culture (73 patients) or response to anti-tuberculosis treatment (37 patients). CONCLUSION: The clinical and radiographic response to AMX is better than derived scores at differentiating between PTB and non-PTB in TB suspects presenting to a dispensary in Guinea, a low HIV-seroprevalence country.

Prevalence of pulmonary tuberculosis and comparative evaluation of screening strategies in a Brazilian prison.

SETTING: A prison (1171 male inmates) in Rio de Janeiro, Brazil. OBJECTIVES: To determine the prevalence of active pulmonary tuberculosis (TB) and to assess the performance of several screening strategies. DESIGN: In a cross-sectional study, all inmates underwent chest radiographic screening. Subjects with abnormal findings underwent sputum smear examination and sputum culture. Taking this strategy as the reference, we assessed three targeted screening strategies to identify TB suspects: Strategy 1: cough >3 weeks; Strategy 2: WHO score > or = 5; Strategy 3: presence of at least one potentially TB-related symptom. RESULTS: The prevalence of TB cases was 4.6% (48/1052) and 2.7% for definite TB cases. If TB suspects identified by targeted screening had sputum smear examination alone, 37 (86.0%) of the 43 cases would have been missed by Strategy 1, 34/43 (79.1%) by Strategy 2 and 34/43 (79.1%) by Strategy 3. If TB suspects had both sputum smear examination and, for smear-negative subjects, chest radiography, respectively 28/43 (65.1%), 18/43 (41.9%) and 13/43 (30.2%) of cases would have been missed. CONCLUSION: All three targeted screening strategies were unreliable. Given the importance of early TB diagnosis in overcrowded and highly endemic settings, routine radiography-based screening may be warranted.

[Prevalence of hepatitis B and C virus, HTLV-1 and HIV in type B lymphoproliferative syndromes in Gabon]. / Prévalences des virus des hépatites B et C, de l'HTLV-1 et du VIH dans les syndromes lymphoprolifératifs de type B au Gabon.

B lymphoproliferative disorders (B-LPD) are the most frequent types of lymphoid malignancies encountered in Gabon where HCV, HBV, HTLV-I and HIV are highly prevalent and all known for lymphotropism. Prevalences of HBs Ag, antibodies to HCV, HTLV-I and HIV were compared in 40 patients (21 men, 19 women; 17 < age < 75 years) with newly diagnosed B-LPD (low grade lymphoma = 6, intermediate grade = 21, high grade = 8: chronic lymphocytic leukaemia = 5) and 160 age and sex-matched controls. None of the B-LPD patients had got transfusion or parenteral care from the onset of symptoms to the inclusion day. In the B-LPD group, 13 patients had HBs Ag and antibodies to HCV, HIV and HTLV-1 were detected in 11, 6 and 10 subjects. In monovariate analysis, HBs Ag, antibodies to HIV or HTLV-1 were risk factors for B-LPD but antibodies to HCV were not associated with such diseases. Multivariate analysis showed only a relationship between HBs Ag and B-LPD (OR = 3.86; IC: 1.11-13.48). In such patients, reactivation of B hepatitis by treatment of B-LBD may be an important concern. If a background poor immune system could explain both susceptibility to long standing virus carriage and lymphoma development, a participating action of the HBV in lymphomagenesis could not be excluded.

Useful clues to the presence of smear-negative pulmonary tuberculosis in a West African city.

OBJECTIVE: Tuberculosis suspects with negative sputum smears for acid-fast bacilli (AFB) may have either pulmonary tuberculosis (PTB) or some other pulmonary disease (non-PTB). The aim of this study was to improve the differentiation between PTB and non-PTB. DESIGN: We enrolled 396 tuberculosis suspects 15 years of age or older who had cough of 21 days or longer and three negative AFB smears. Non-PTB was diagnosed by clinical and radiographic responses to amoxicillin; smear-negative PTB was diagnosed by positive culture for Mycobacterium tuberculosis or response to antituberculosis chemotherapy. RESULTS: Multivariate analysis, without X-ray variables, of 79 patients with a final diagnosis of non-PTB and 110 patients with smear-negative PTB indicated that age less than 37 years, family contact with TB, never having been married, loss of weight, lack of expectoration, human immunodeficiency virus (HIV) seropositivity, and tuberculin reactivity were significantly associated with PTB. When the initial X-ray findings were included, age younger than 37 years, lack of expectoration, HIV seropositivity, and tuberculin reactivity remained in the model, and cavitation and patchy densities were significantly associated. CONCLUSION: The response to 10 days of amoxicillin and certain demographic, clinical and radiographic characteristics are useful in separating non-PTB from PTB in tuberculosis suspects with negative AFB smears.

A simple clinical and paraclinical score predictive of CD4 cells counts below 400/mm3 in HIV-infected adults in Dakar University Hospital, Senegal.

In industrialized countries the decision to start co-trimoxazole (CMX) prophylaxis of HIV-related opportunistic infections is based on the CD4+ cell count. The value of CMX prophylaxis has also been demonstrated in Africa, where CD4+ cell counts are rarely available. We therefore developed a simple score predictive of a threshold CD4+ cell count (400/mm3) below which CMX prophylaxis is indicated. In a retrospective cross-sectional study, we collected clinical and biological data on 211 HIV-infected patients recruited from January 1996 through January 1998 at Fann University Hospital in Dakar, Senegal. Several variables were identified as being predictive of a CD4+ cell count below 400/mm3 by stepwise logistic regression. Each variable was weighted according to its regression coefficient, as follows: male sex (+1), weight loss (+2), body mass index < 22 (+2), herpes zoster (+4), tuberculin induration < 5 mm (+3) and haemoglobin < or = 10 g/dL (+1). A score of > or = 4 (sum of weights) selected patients with CD4+ cell counts below 400/mm3 with a sensitivity of 98% and a negative predictive value of 83%. Such a score should be applicable in the African context and should facilitate the management of HIV-infected patients, especially the prescription of CMX prophylaxis.

Seroepidemiological survey of hepatitis C virus among commercial sex workers and pregnant women in Kinshasa, Democratic Republic of Congo.

BACKGROUND: Studies conducted mainly in industrialized countries have shown that the transmission of hepatitis C virus (HCV) is mainly parenteral, and have emphasized the role of nosocomial transmission. In Equatorial Africa, the respective contributions of parenteral and non-parenteral routes of transmission are unknown. The potential role of sexual transmission in this area of high HCV endemicity, where sexually transmitted infections (STI) are frequent, is suggested by the fact that HCV infection is rare in infants and young adolescents, but increases thereafter with age. The present study, conducted in Democratic Republic of Congo, was designed to determine the prevalence of HCV infection and associated sexual risk factors in two female populations with different sexual behaviour. METHODS: Cross-sectional studies conducted among commercial sex workers (CSW; n = 1144) and pregnant women (n = 1092) in the late 1980s in Kinshasa showed a high frequency of at-risk sexual behaviour, STI and human immunodeficiency virus (HIV) infection, particularly among CSW. We screened samples collected during these epidemiological studies for antibodies to HCV using a second-generation ELISA with confirmation by a third-generation LIA. We also assessed sociodemographic variables, medical history, STI markers and sexual behaviour, and their potential association with HCV infection. RESULTS: The overall prevalence of anti-HCV was 6.6% (95% CI : 5.2-8.2) among CSW and 4.3% (95% CI : 3.2-5.7) among pregnant women (age-adjusted OR = 1.5, 95% CI : 1.0-2.1, P = 0.05). Multivariate analysis showed that the presence of anti-HCV among CSW was independently associated with a previous history of blood transfusion (P < 0.001), age >30 years (P < 0.001) and the presence of at least one biological marker of STI (P < 0.03). No such links were found among pregnant women (although the history of blood transfusions was not investigated in this group). Anti-HCV was not associated with sociodemographic variables or sexual behaviour in either group, or with individual markers of STI. Despite the high-risk sexual behaviour and the higher prevalence of STI in CSW, the difference in HCV seroprevalence between CSW and pregnant women (6.6% versus 4.3%) was small, particularly when compared with the difference in the seroprevalence of HIV (34.1% versus 2.8%). CONCLUSION: The role of sexual transmission in the spread of HCV seems to be limited. Parenteral transmission (including blood transfusion and injections), possibly related to the treatment of STI, probably plays a major role.

Tuberculosis-associated severe CD4+ T-lymphocytopenia in HIV-seronegative patients from Dakar. SIDAK Research Group.

OBJECTIVES: To determine the frequency and associated features of severe CD4+ T-lymphocytopenia (<300 cells/mm(3)) in HIV-seronegative patients with tuberculosis. METHODS: Statistical analysis of 430 consecutively enrolled HIV-seronegative inpatients with tuberculosis in two teaching hospitals in Dakar, Senegal. RESULTS: The mean CD4 + cell count was 602+/-318.3 cells/mm(3). CD4 + cell counts were below 300 cells/mm(3)in 62 patients (14.4%). Patients with fewer than 300 CD4+ cells/mm(3)differed from those with higher counts in being less likely to have a positive smear for acid-fast bacilli; in having a higher frequency of extrapulmonary involvement (pleural effusion, adenopathy and miliary disease) and oral candidiasis; and in having smaller tuberculin reactions, lower haemoglobin levels, less cavitation and less patchy infiltration. After adjustment for gender and age, all differences remained except miliary disease. CONCLUSIONS: A substantial percentage (14.4%) of HIV-seronegative hospitalized patients for tuberculosis in a West African country presented with severe CD4 + T-lymphocyte depletion and had clinical and radiographic features indicative of more advanced disease and accompanying immunodepression. These results and those already published suggest that tuberculosis should be regarded as one of the diseases associated with a subgroup of patients with "idiopathic CD4 + T-lymphocytopenia".

Prevalence and genetic variants of hepatitis GB-C/HG and TT viruses in Gabon, equatorial Africa.

The distribution of Hepatitis GB-C/HG (GB-C/HG) and TT viruses (TTV) infections was investigated in selected populations from Gabon using Polymerase Chain Reaction (PCR) and Enzyme Linked Immunosorbent Assay (ELISA) for anti-Envelop 2 (anti-E2) GBV-C/HGV antibodies. Among pregnant women, 29 of 229 (12.6%) were Hepatitis GB virus-C and Hepatitis G virus (GBV-C/HGV) RNA positive (+) and 32 of 81 (39.5%) anti-E2 + versus 8 of 39 (20.5%) TTV DNA +. Among sickle cell anemia patients, 9.7% (3/31) were GBV-C/HGV RNA + versus 22.5% (7/31) TTV DNA +. For tuberculosis patients, the figures were 11.5% (4/35) and 0%. A study of hepatocellular carcinoma cases (n = 27) versus controls (n = 66) did not show significant differences for GBV-C/HGV RNA (10.7% versus 12.1%) and TTV DNA (44.4% versus 30.3%). According to phylogenetic analysis, the 15 GBV-C/HGV strains investigated clustered in group 1, the most common in sub-Saharan Africa whereas TTV sequences (n = 4) mostly clustered in genotypes G1 and one close to genotype G3. In the Gabonese populations investigated, GBV-C/HGV and TTV infections were highly endemic. These data are consistent with the low pathogenicity of these agents.

Comparison of methods for assessing nutritional status in HIV-infected adults.

Malnutrition is a frequent complication of human immunodeficiency virus (HIV) infection and is associated with a poor prognosis. To compare different measures of nutritional status in HIV-infected patients, we prospectively studied 88 outpatients seen at a Paris AIDS outpatient clinic for routine follow-up examinations. Nutritional status was assessed according to body weight loss (BWL, 4 classes), anthropometry, bioelectric impedance analysis (BIA), and subjective global assessment of nutritional status (SGA). Malnutrition was diagnosed in 22.4% of subjects using SGA, and 37.1% by BWL. SGA rapidly detected a worsening of nutritional status, while BWL detected malnutrition at an earlier stage. A good correlation was found between SGA class and body composition assessed by anthropometry and BIA. Deteriorating nutritional status diagnosed by SGA correlated with the CDC HIV disease class. SGA, a simple nutritional assessment, can serve as a basis for prescribing artificial nutrition, while BWL detects malnutrition at an earlier stage.

Nutritional status of adult inpatients in Bujumbura, Burundi (impact of HIV infection).

OBJECTIVE: To determine the prevalence and analyse the characteristics and causes of malnutrition among inpatients in an HIV highly endemic area. DESIGN: Prospective cross-sectional study. SETTING: Department of Internal Medicine, University Hospital, Bujumbura, Burundi. SUBJECTS: 226 adult inpatients. MAIN OUTCOMES MEASURES: Evaluation of nutritional status using anthropometry. Degree of malnutrition defined by the percentage of body weight loss (BWL), calculated by reference to the usual body weight. RESULTS: Among the 226 patients recruited (mean age: 34.4 +/- 11.9 y, M:F sex ratio: 1.72), 102 (45.1%) were HIV seropositive. 62 (60.8%) of these HIV seropositive were AIDS cases. The AIDS defining criterion was 'wasting syndrome' for 25 (40.3%) and opportunistic infection (OI) for 37 (59.7%) including 34 cases of tuberculosis (TB). The nutritional status of 119/226 patients (52.7%) was normal (BWL < or = 10%). Moderate malnutrition (10% < or = BWL < or = 20%) was observed in 47 (20.8%) and severe malnutrition (BWL > 20%) was observed in 60 (26.5%). HIV seroprevalence and, among HIV seropositive subjects, the percentage of AIDS cases increased according to decreasing level of nutrition (Chi2 for trends: P < 0.001 in both instances). The fat free mass mass of malnourished subjects was lower and the fat body mass was higher among HIV seropositive subjects than HIV seronegative subjects. Among HIV seropositive subjects, malnutrition was associated with TB (P < 0.001) and dysphagia (P < 0.05). Among HIV seronegative subjects, malnutrition was associated with decreased food availability (P < 0.003) and TB (P < 0.05). One week after admission, the mortality rate was higher among HIV seropositive subjects (10.8%) than seronegative subjects (2.4%, P=0.009). Other factors associated with death were decreased fat free mass (P < 0.01) and tricipital skinfold thickness (P < 0.04). CONCLUSIONS: The prevalence of malnutrition is high among the inpatients investigated. Main factors are HIV infection and TB. Strategies adapted to the African context should be developed to prevent, detect and treat malnutrition and associated factors, particularly among HIV seropositive subjects.

Hepatitis A among health workers in Paris hospitals. Occupational Health Physicians of Paris Hospital (AP-HP)

To design a vaccination strategy against hepatitis A among hospital employees, we carried out a serological survey against hepatitis A virus (HAV) infection in 10 university hospitals in the Paris area. Subjects under 60 years of age were consecutively enrolled by occupational health services and tested for IgG to HAV by ELISA. Of the 1,516 subjects recruited, 926 were health workers (HW), 322 clerks, and 268 cooks or kitchen employees. Among HW and clerks the HAV seroprevalence was 53.8 percent (95 percent CI: 44.0-65.6), increasing with age and being higher among Europe (83.6 percent vs 45.6 percent, P < .001). Age correlated closely with the duration of hospital work, so only age was taken into account for further analysis. The HAV seroprevalences among HW and clerks originating from Europe were close (48.8 percent vs 42.6 percent) and remained so after adjustment for age. HAV seroprevalences in HW caring for adults and those caring for children were also similar (45.2 percent vs 40.1 percent). Seroprevalence was higher in assistant nurses than in nurses (51.3 percent vs 39.8 percent, P < .02). Among cooks and kitchen employees, 53.4 percent were HAV-seropositive. This study shows that hospital employees need not routinely be vaccinated against HAV; the decision should be taken by the occupational physician according to the type of work, but should be routine for cooks and kitchen employees. The need for prevaccinal screening for anti-HAV should be assessed in the light of employees' geographical origin and age.(Au)

Hepatitis A among health workers in Paris hospitals. Occupational Health Physicians of Paris Hospital (AP-HP).

To design a vaccination strategy against hepatitis A among hospital employees, we carried out a serological survey of hepatitis A virus (HAV) infection in 10 university hospitals in the Paris area. Subjects under 60 years of age were consecutively enrolled by occupational health services and tested for IgG to HAV by ELISA. Of the 1,516 subjects recruited, 926 were health workers (HW), 322 clerks, and 268 cooks or kitchen employees. Among HW and clerks the HAV seroprevalence was 53.8% (95% CI: 44.0-65.6), increasing with age and being higher among employees of African or Caribbean origin than those from Europe (83.6% vs 45.6%, P < .001). Age correlated closely with the duration of hospital work, so only age was taken into account for further analysis. The HAV seroprevalences among HW and clerks originating from Europe were close (46.8% vs 42.6%) and remained so after adjustment for age. HAV seroprevalences in HW caring for adults and those caring for children were also similar (45.2% vs 40.1%). Seroprevalence was higher in assistant nurses than in nurses (51.3% vs. 39.8%, P < .02). Among cooks and kitchen employees, 53.4% were HAV-seropositive. This study shows that hospital employees need not routinely be vaccinated against HAV; the decision should be taken by the occupational physician according to the type of work, but should be routine for cooks and kitchen employees. The need for prevaccinal screening for anti-HAV should be assessed in the light of employees' geographical origin and age.