Tuberculosis infection control in primary health clinics in eThekwini, KwaZulu-Natal, South Africa.

SETTING: Primary health clinics in KwaZulu-Natal, South Africa. OBJECTIVE: To assess and describe current practices in infection control at local government primary health clinics. DESIGN: A descriptive study using a standardised tool to assess adherence to recommended infection control policies in 51 primary health clinics in 2009-2010. Administrative policies, engineering controls and personal respiratory protection were assessed by observations and interviews at the clinics. RESULTS: Of 51 clinics, 11 (22%) had infection control policies, 13 (26%) triaged coughing patients and 16 (31%) had a dedicated nurse and a dedicated consulting room for treating tuberculosis (TB) patients. Study clinics treated a median of 99 patients (range 3-331) daily and a median of 15 TB patients (range 2-73) monthly. Of the rooms in the clinics, all of which rely on natural ventilation, half (149/284) had ≤12 air changes per hour. Eleven (22%) of 51 clinics had N95 masks available for staff use. CONCLUSION: Limited infection control practices exist in clinics in a high TB burden setting in KwaZulu-Natal, South Africa. These practices need to be implemented more widely to minimise the spread of TB to non-infected patients and health care workers in primary health clinics.

Changes in healthcare workers' knowledge about tuberculosis following a tuberculosis training programme.

BACKGROUND: In resource-limited countries, health policy makers and practitioners need to know whether healthcare workers have sufficient knowledge of tuberculosis and its management. OBJECTIVES: We conducted a study to: (1) measure knowledge changes among healthcare workers who participated in a tuberculosis training programme; and (2) make recommendations about future tuberculosis training for healthcare workers in the KwaZulu-Natal Department of Health. METHODS: A cross-sectional study conducted in 2007 measured changes in tuberculosis knowledge of doctors, nurses and other healthcare workers after a training programme based on World Health Organization tuberculosis training modules. Data were collected before and after training using a self-administered, 98-item questionnaire covering eight components. RESULTS: A total of 267 healthcare workers, mean age 40.7 years, answered both pre- and post-training questionnaires. Mean total knowledge scores were low despite significant changes (p<0.001) from a pre-training score of 59.5% to a post-training score of 66.5%. Nurses showed significant improvements in mean total knowledge scores (p<0.001) but had the lowest mean total knowledge score post-training, 63.2%. Doctors had significantly better pre-training (p<0.001) and post-training (p<0.001) mean total knowledge scores compared to nurses. CONCLUSIONS: Improvement in healthcare workers' overall knowledge of tuberculosis during a training programme was not clinically significant. Periodic field training and supervision should be considered to ensure tuberculosis knowledge improvements.

Ukraine set to act on high suicide burden.

Having survived multiple catastrophes in the 20th century, newly independent Ukraine now has some of the highest injury death rates in Europe. The nation's most common type of injury death is suicide, and its rate is one of Europe's and the world's highest. Alcohol abuse occurs in 20% of men, and major depression in 20% of women. Suicide is the leading cause of death in the Ukrainian Army, which has begun to recognize and address the problem. Mental health is one of three current priorities of the Ukrainian Ministry of Public Health. The government is developing a mental health policy and plan, with potential for prevention of suicide. A national university in the capital has created a graduate school of public health to build human capacity to prevent and control disease and injury.

Identification of risk factors for non-fatal child injury in a rural area: Keokuk County Rural Health Study.

OBJECTIVE: To identify risk factors for non-fatal injury among rural children. DESIGN: Cross sectional health interview survey, 1994-98. SETTING: A rural Iowa county, not adjacent to a metropolitan area. SUBJECTS: Stratified, random sample of households, including all resident children and adults. MAIN OUTCOME MEASURES: Injury episodes in the past 12 months among children aged 0-17 years and the parental and child characteristics associated with these episodes. RESULTS: Of the 621 children in participating households, 137 or 22.1% were injured during the past 12 months. Children age 5-17 on a sports team were 1.88 times (95% confidence interval (CI) 1.07 to 3.31) more likely than other children to be injured. Children age 12-17 who binge drink were 3.50 times (95% CI 1.31 to 9.50) more likely than other children to be injured. Compared with children not on sports teams, girls on teams were 2.26 times (95% CI 1.02 to 5.13) more likely while boys on teams were 1.60 times (95% CI 0.71 to 3.68) more likely to have an injury episode. Compared with children who did not binge drink, girls binge drinking were 8.11 times (95% CI 1.52 to 43.33) more likely while boys binge drinking were 2.19 times (95% CI 0.70 to 6.84) more likely to have an injury episode. CONCLUSIONS: Local studies such as this can provide useful clues regarding the etiology of injury. Some known and some new potential risk factors including behavioral aspects for childhood non-fatal injury in a very rural area were investigated. It is planned to address these cross sectional findings in future longitudinal follow up of this population.

Development of a life events/icon calendar questionnaire to ascertain occupational histories and other characteristics of migrant farmworkers.

BACKGROUND: Specialized methods are necessary to collect data from migrant farmworkers for epidemiologic research. METHODS: We developed a questionnaire that collected lifetime occupational histories and other lifestyle risk factors via a life events/icon calendar, and administered the questionnaire to a convenience sample of 162 migrant farmworkers in nine areas of the U.S. RESULTS: The average duration of the interviews was about 1 h 30 min, with an average of 45 min for the work history section. The occupational histories covered a median of 27.6 years per person for men and 20.8 years per person for women. The median number of years spent in farm jobs was 11.3 for men and 5.8 for women. The median number of farm jobs (crop/task combination) per person was 59 among men and 27 among women. Many farmworkers performed the same crop/task combinations at multiple times throughout their lives, yielding a median of 13 unique farm jobs and 8 unique crops among men and 7 jobs and 5 crops among women. CONCLUSIONS: The project demonstrated that it is feasible to collect detailed work histories and other risk factor data from farmworkers, documented the complexity of work histories encountered among farmworkers, and yielded recommendations for refining a questionnaire that will facilitate future epidemiologic research on farmworkers.

Ability to trace migrant farmworkers ten years after initial identification in a Northern State (Wisconsin).

BACKGROUND: Migrant farmworkers have rarely been included in epidemiologic studies. To assess the feasibility of following farmworkers over extended periods, a critical feature of many study designs, we attempted to trace a sample of Mexican-American farmworkers identified in a clinic in Wisconsin. METHODS: We randomly chose 100 farmworkers from a migrant health center registration list for 1984-85. In 1995, we searched recent clinic records, made telephone calls, and visited migrant camps to find these farmworkers in Wisconsin during the growing season. We also attempted to find 46 farmworkers at their homes in southwest Texas over a two-week period in 1996 using the address listed in the clinic records, local phone books, and conversations with next-door neighbors. RESULTS: Although 25 farmworkers had reregistered at the clinic in recent years, we found only 6 of them in Wisconsin in 1995. In southwest Texas, we either located or ascertained information about the vital status of 25 of the 46 farmworkers (54%). CONCLUSIONS: Tracing efforts must include extensive contacts in farmworkers' home states and must incorporate a variety of information sources. Tracing farmworkers in epidemiologic studies appears to be feasible but requires more intensive methods over longer periods of time than those used in this study.

Epidemiology of unintentional adult injury in a rural population.

BACKGROUND: The purpose of this study was to describe the frequency, characteristics, and risk factors of unintentional adult injury in a rural population. METHODS: We interviewed 1,644 adults representing an all-rural county in Iowa. Analyses used bivariate and multivariable logistic regression. RESULTS: Participants' mean age was 53 years, and 54% were women. Twenty-three percent (n = 380) of participants reported an injury during the past 12 months, of which four fifths were treated. Overexertion (25%) and falls (22%) caused nearly half the injuries. Women with high levels of depression symptoms had 1.57 times (95% confidence interval, 1.05-2.33) the prevalence of injury occurrence as did women with low levels of depression symptoms. Men with a CAGE score of 2 or more had between 0.98 and 2.56 times (according to the range of values of the relevant odds ratio 95% confidence interval) the prevalence of injury episode of men without this exposure. CONCLUSION: The association of injury occurrence with alcohol problems is consistent with prior research, but the increased prevalence of injury associated with high levels of symptoms of depression requires further study and explanation.

Cigarette smoking in Wisconsin: the influence of race, ethnicity, and socioeconomics.

A disparate burden of cigarette use has been demonstrated among demographic subgroups both in the United States and Wisconsin. We examined patterns of adult current smoking prevalence in Wisconsin by race, Hispanic ethnicity, household income, and education to assess whether differences exist among these subgroups. This analysis revealed a strong graded relationship between household income, education, and smoking prevalence, consistent among non-Hispanic whites and blacks, though not Hispanics. Respondents with less than a high school education had significantly higher smoking prevalence rates (41%) than those with a college degree or more (13%). Smoking prevalence rates did not significantly differ between the race and ethnicity subgroups overall, or by gender and education, although they differed in some age and income subgroups. Possible explanations for the socioeconomic gradient include differences in tobacco product marketing practices, indoor workplace smoking policies, and access to health information, resources, and consistent, high-quality health care.

Progress in reducing per capita cigarette sales in Wisconsin, 1985-1999.

Over the past several decades, initiatives have been undertaken both on a national and state level to reduce cigarette smoking and its resultant health consequences. We compared trends in per capita cigarette sales in Wisconsin versus other states from 1985-1999. During this time period, per capita cigarette sales declined 21% in Wisconsin, versus 26% in the United States. Although the average per capita sales in Wisconsin were less than sales in the United States in both 1985 (107 versus 122 packs per capita) and 1999 (84 versus 90 packs per capita), Wisconsin's sales have declined at a slower rate, narrowing the gap between Wisconsin and US sales. Other states, such as California and Massachusetts, with large statewide tobacco control programs had rates of decline in cigarette sales over twice the Wisconsin decline from 1985-1999. In 1985, only 10 states had lower per capita sales than Wisconsin. By 1999, 24 states had lower rates, indicating greater relative progress in reducing sales in other states. Possible explanations for the greater decline in per capita cigarette sales in other states include differences in tobacco control programs, tobacco excise tax increases, and other tobacco policy initiatives.

Rural population survey of behavioral and demographic risk factors for loaded firearms.

OBJECTIVES: In the United States, firearm deaths are almost as frequent as motor vehicle deaths. Firearm unintentional and suicide death rates are raised in rural areas. This study examines firearm prevalence and storage practices in three different types of rural households. METHODS: Adults from a stratified random sample of 983 households in a rural Iowa county were interviewed. The chi2 test of independence was used to assess association between loaded, unlocked firearms and seven behavioral and demographic risk factors. RESULTS: Nearly 67% of respondents reported firearms in their households. Nearly 7% of households had a loaded, unlocked gun. Prevalence of firearms at home was higher while prevalence of loaded, unlocked guns was lower than reported in other surveys. Prevalence of loaded, unlocked guns in farm households, 10.5%, was about twice the level in town households, 5.5% (chi2 test, p=0.033). Having taken a gun safety course was associated with more than double the prevalence of a loaded, unlocked gun, 13.5% v 5.1% (chi2 test, p=0.001). The prevalence of loaded, unlocked guns in households with a handgun, 19.3%, was four and one half times higher than in households with a long gun only, 4.2% (chi2 test, p=0.001). Households with someone with a lifetime prevalence of alcohol abuse or dependence were about twice as likely as other households, 13.0% v 6.6% (chi2 test, p=0.004), to report having loaded, unlocked firearms. CONCLUSIONS: Anyone interested in promoting safe storage of firearms in rural homes should consider these observations.

Risk factors for injury in rural Iowa: round one of the Keokuk County Rural Health Study.

BACKGROUND: Unintentional injuries represent a major cause of morbidity and mortality in rural communities. This study aimed to determine the distribution of injury risk factors in a rural Iowa community and to identify the rural subgroups at highest risk for injury. METHODS: We reported on 1583 participants, aged > or =25 years, from Round One of the Keokuk County Rural Health Study, a longitudinal panel study of a rural community. The self-reported data were collected during face-to-face interviews. RESULTS: Our data suggested that several risk factors for injury are not uniformly distributed among rural populations. Male farmers were significantly less likely to wear their seatbelts than townspeople or rural nonfarmers. However, farm women were as likely to wear seatbelts as other women. Both male and female farmers were more likely to use all-terrain vehicles than townspeople or rural nonfarmers. In contrast, townspeople were more likely to ride bicycles than either farmers or rural nonfarmers. Townspeople were less likely to have firearms in their homes than either farmers or rural nonfarmers. Farmers were most likely to have fired a gun in the last year. Male farmers aged <65 years were less than half as likely as other men the same age to report a history of alcohol abuse. Binge drinking was equally frequent among farmers, rural nonfarmers, and townspeople. CONCLUSIONS: These differences in risk behavior in a rural county suggest the possibility of targeting specific rural injury prevention interventions at those with the highest risk for dangerous behavior.

Comparison of self-reported and expert-observed physical activities at work in a general population.

Concerns about exposure assessment quality have impeded research to identify risk factors for ergonomic disorders. We compared self-reported and expert-observed estimates of work-related physical factors for participants in a study of carpal tunnel syndrome (CTS). We analyzed data from 61 subjects, including 28 CTS cases and 33 controls randomly samples from a case-control study with 417 participants. For 11 posture and manual materials handling factors, the median difference in mean exposure between self-reported and expert-observed exposure at work was less than 1/2 hour a day. Measurements by the two methods in this study agreed more often than expected by chance (median kappa 0.31 in cases and 0.28 in controls). Kappa differed significantly by case-control status for two factors: bending at the waist (kappa 0.79 in cases versus 0.28 in controls, P = 0.01) and twisting of the forearm (kappa 0.45 in cases versus -0.02 in controls, P = 0.02). Although imperfect, exposure information collected from workers' self-reports is useful for many ergonomic epidemiology studies.

Incidence of diagnosed carpal tunnel syndrome in a general population.

We sought to determine the incidence rate of carpal tunnel syndrome in the general population. Using three different case definitions, we conducted a prospective study to ascertain by medical record review all cases of incident disease in a defined population during a 2-year period. Newly diagnosed probable or definite carpal tunnel syndrome (N = 309) occurred at a rate of 3.46 cases per 1,000 person-years (95% confidence interval = 3.07-3.84). The incidence rate in our study was 3.5 times higher than the rate 20 years ago in a Minnesota city. The rate difference probably results from a combination of reasons, including a true rise in incidence.

Paroxysmal supraventricular tachycardia in the general population.

OBJECTIVES: We sought to determine the epidemiology and clinical significance of paroxysmal supraventricular tachycardia (PSVT) in the general population. BACKGROUND: Current knowledge of PSVT has been derived primarily from otherwise healthy patients referred to specialized centers. METHODS: We used the resources of the Marshfield Epidemiologic Study Area, a region covering practically all medical care received by its 50,000 residents. A review of 1,763 records identified prevalent cases as of July 1, 1991 and all new cases of PSVT diagnosed from that day until June 30, 1993. A mean follow-up period of 2 years was completed in all incident patients. Patients without other cardiovascular disease were labeled as having "lone PSVT." RESULTS: The prevalence was 2.25/1,000 persons and the incidence was 35/100,000 person-years (95% confidence interval, 23 to 47/100,000). Other cardiovascular disease was present in 90% of males and 48% of females (p = 0.0495). Compared with patients with other cardiovascular disease, those with lone PSVT were younger (mean 37 vs. 69 years, p = 0.0002), had a faster PSVT heart rate (mean 186 vs. 155 beats/min, p = 0.0006) and were more likely to have their condition first documented in the emergency room (69% vs. 30%, p = 0.0377). The onset of symptoms occurred during the childbearing years in 58% of females with lone PSVT versus 9% of females with other cardiovascular disease (p = 0.0272). CONCLUSIONS: There are approximately 89,000 new cases/year and 570,000 persons with PSVT in the United States. In the general population, there are two distinct subsets of patients with PSVT: those with other cardiovascular disease and those with lone PSVT. Our data suggest etiologic heterogeneity in the pathogenesis of PSVT and the need for more population-based research on this common condition.

Risk factors for carpal tunnel syndrome in a general population.

OBJECTIVE: To determine the individual, physical, and psychosocial risk factors for carpal tunnel syndrome in a general population. METHODS: Population based case-control study in Marshfield epidemiological study area in Wisconsin, USA. Cases were men and women aged 18-69 with newly diagnosed carpal tunnel syndrome (n = 206 (83.1%) of 248 eligible). Controls were a random sample of residents of the study area who had no history of diagnosed carpal tunnel syndrome (n = 211 (81.5%) of 259 eligible). Cases and controls were matched by age. Telephone interviews and reviews of medical records obtained height and weight, medical history, average daily hours of exposure to selected physical and organisational work factors, and self ratings on psychosocial work scales. RESULTS: In the final logistic regression model, five work and three non-work variables were associated with risk of carpal tunnel syndrome, after adjusting for age. For each one unit of increase in body mass index (kg/m2), risk increased 8% (odds ratio (OR) 1.08; 95% confidence interval (95% CI) 1.03 to 1.14). Having a previous musculoskeletal condition was positively associated with carpal tunnel syndrome (OR 2.54; 95% CI 1.03 to 6.23). People reporting the least influence at work had 2.86 times the risk (95% CI, 1.10 to 7.14) than those with the most influence at work. CONCLUSIONS: Carpal tunnel syndrome is a work related disease, although some important measures of occupational exposure, including keyboard use, were not risk factors in this general population study. The mechanism whereby a weight gain of about six pounds increases the risk of disease 8% requires explanation.

Long-term symptom outcomes of carpal tunnel syndrome and its treatment.

A retrospective follow-up study of a population-based case series was conducted to determine the clinical course and outcomes of carpal tunnel syndrome (CTS). A total of 425 cases first diagnosed between 1979 and 1988 were followed through 1993. Among patients who did not have surgery, median duration of symptoms was between 6 and 9 months, but 22% had symptoms for 8 years or longer. Patients who had surgery were about 6 times more likely to have resolution of their symptoms than were patients who did not have surgery. Patients who had surgery 3 or more years after their initial diagnosis of CTS were less than half as likely to have symptom resolution than were patients who had surgery within 3 years of diagnosis. The results indicate that surgery is a highly effective treatment, but duration of CTS prior to surgery is a key determinant of surgical outcome.

Case-control study of agricultural injuries to women in central Wisconsin.

A small number of women are the owner/operators of farms and women often participate in the work of production agriculture. Estimates of the percentage of females involved in agricultural injuries range from 11-45% and it is not clear if the risk factors associated with injuries to women are different from those for men. In a two year case-control study of injuries to farm residents, there were 40 injuries involving adult women. Multivariable analysis revealed that the two major risk factors for agricultural injury to females were number of hours worked and the presence of bulls on the farm. Most (55%) of the women were injured while in a barn. A cow was the primary agent of injury in 17 (42.5%) of the cases. Efforts to reduce the rate of injuries to women in agriculture should be targeted to the particular risks they experience.

Representativeness of trauma center registries for farm injury surveillance.

Trauma center registries are the foundation for many surveillance systems that attempt to define the frequency and spectrum of various types of injuries. To assess the representativeness of trauma center-based farm injury surveillance, we evaluated data for 1986-1991 from the Marshfield Clinic/St Joseph's Hospital, a major trauma center located in Central Wisconsin. We compared the pattern of farm injuries seen in residents of the Marshfield Epidemiologic Surveillance Area (MESA), a geographically defined, population-based surveillance area, with those from outside MESA, a nonpopulation-based mix of primary care and referral patients typical of most trauma registries. The population-based and nonpopulation-based surveillance data suggested similar patterns with respect to seasonality, circumstances of injury, and source of injury. There were significant differences with respect to the body part injured, severity of injury, and selected aspects of acute medical care. While useful for many purposes, trauma center-based injury surveillance data should be interpreted cautiously.