Tuberculosis preventive treatment opportunities at antiretroviral therapy initiation and follow-up visits.

SETTING: Twenty-two clinics providing HIV care and treatment in Botswana where tuberculosis (TB) and HIV comorbidity is as high as 49%. OBJECTIVES: To assess eligibility of TB preventive treatment (TPT) at antiretroviral therapy (ART) initiation and at four follow-up visits (FUVs), and to describe the TB prevalence and associated factors at baseline and yield of TB diagnoses at each FUV. DESIGN: A prospective study of routinely collected data on people living with HIV (PLHIV) enrolled into care for the Xpert® MTB/RIF Package Rollout Evaluation Study between 2012 and 2015. RESULTS: Of 6041 PLHIV initiating ART, eligibility for TPT was 69% (4177/6041) at baseline and 93% (5408/5815); 95% (5234/5514); 96% (4869/5079); and 97% (3925/4055) at FUV1, FUV2, FUV3, and FUV4, respectively. TB prevalence at baseline was 11% and 2%, 3%, 3% and 6% at each subsequent FUV. At baseline, independent risk factors for prevalent TB were CD4 <200 cells/mm3 (aOR = 1.4, P = 0.030); anemia (aOR = 2.39, P < 0.001); cough (aOR = 11.21, P < 0.001); fever (aOR = 2.15, P = 0.001); and weight loss (aOR = 2.60, P = 0.002). CONCLUSION: Eligibility for TPT initiation is higher at visits post-ART initiation, while most cases of active TB were identified at ART initiation. Missed opportunities for TB further compromises TB control effort among PLHIV in Botswana.

MARCO DE REFERENCIA: Veintidós consultorios que prestan atención y tratamiento relacionados con la infección por el virus de la inmunodeficiencia humana (VIH) en Botswana, donde la comorbilidad por tuberculosis (TB) e infección por el VIH puede alcanzar 49%. OBJETIVOS: Evaluar los criterios para recibir el tratamiento preventivo de la TB (TPT) durante las consultas de iniciación y seguimiento del tratamiento antirretrovírico (TAR) y describir la prevalencia de TB y los factores asociados en el momento del inicio y el rendimiento del diagnóstico de TB en cada cita de seguimiento del TAR. MÉTODO: Fue este un estudio prospectivo de los datos obtenidos sistemáticamente en las personas con infección por el VIH (PLHIV), inscritas en la atención para el estudio de evaluación del despliegue de la prueba Xpert® MTB/RIF del 2012 al 2015. RESULTADOS: De los 6041 PLHIV que iniciaron el TAR, 69% (4177/6041) cumplía los criterios para recibir el TPT al comienzo; 93% (5408/5815) en la primera consulta de seguimiento; 95% (5234/5514) en la segunda; 96% (4869/5079) en la tercera; y 97% (3925/4075) en la cuarta cita de seguimiento. La prevalencia inicial de TB fue 11% y durante el seguimiento fue 2%, 3%, 3% y 6%, respectivamente. Al comienzo del TAR, los factores de riesgo independientes de diagnóstico de TB fueron una cifra de linfocitos CD4 <200 células/mm3 (aOR 1,4; P = 0,030), la anemia (aOR 2,39; P < 0,001), la tos (aOR 11,21; P = <0,001), la fiebre (aOR 2,15; P = 0,001) y la pérdida de peso (aOR 2,60; P = 0,002). CONCLUSIÓN: Los pacientes cumplen las condiciones para recibir el TPT con mayor frecuencia en las consultas posteriores al comienzo del TAR, pero la mayoría de los casos de TB activa se detecta al iniciarlo. Las oportunidades desaprovechadas para detectar casos de TB dificultan aún más el control de esta enfermedad en las PLHIV en Botswana.

Integration and decentralisation of TB-HIV services increases HIV testing of TB cases in Rajasthan, India.

The proportion of tuberculosis (TB) patients tested for the human immunodeficiency virus (HIV) in the state of Ra-jasthan, India, is limited by the availability of HIV testing facilities. Rajasthan implemented a policy of initiating TB-HIV diagnosis at all health institutions in July 2013. The number of TB diagnostic facilities increased from 33 to 63 in Banswara District and from 22 to 68 in Jhunjhunu District, while the number of HIV testing facilities in these districts increased from 1 to 53 and from 10 to 81, respectively, after the policy implementation. The proportion of TB patients tested for HIV increased by respectively 27% and 19%.

La proportion de patients tuberculeux (TB) testés pour le virus de l'immunodéficience humaine (VIH) dans l'état du Rajasthan, Inde, est limitée par la disponibilité de lieux de tests du VIH. Le Rajasthan a mis en œuvre une politique d'initiation du diagnostic TB dans toutes les structures de santé en juillet 2013. Le nombre de lieux de diagnostic TB a augmenté de 33 à 63 dans le district de Banswara et de 22 à 68 dans le district de Jhunjhunu, tandis que le nombre de lieux de test du VIH a augmenté de 1 à 53 et de 10 à 81, respectivement, après la mise en œuvre de cette politique. La proportion de patients TB testés pour le VIH a augmenté de 27% et 19%, respectivement, dans les deux districts.

La proporción de pacientes con tuberculosis (TB) que cuentan con la prueba del virus de la inmunodeficiencia humana (VIH) en el estado de Rajastán en la India se ve limitada por la escasez de establecimientos que la practican. En julio del 2013 se introdujo en Rajastán una política de iniciar el diagnóstico de la TB y el VIH en todos los establecimientos de atención de salud. Después de la introducción de la política, el número de centros de diagnóstico de la TB en el distrito de Banswara aumentó de 33 a 63 y en el distrito Jhunjhunu aumentó de 22 a 68 y la progresión de centros con diagnóstico de la infección por el VIH en Banswazra fue de 1 a 53 centros y en Jhunjhunu de 10 a 81. La proporción de pacientes con TB que cuentan con una prueba del VIH en estos distritos aumentó un 27% y un 19%, respectivamente.

Engaging private providers and Ayurvedic practitioners in Bilaspur, India: did it increase TB case detection?

To find 'missing' tuberculosis (TB) cases, in November 2014 we trained private practitioners (PPs) and Ayurvedic practitioners (APs; Indian system of medicine) in Bilaspur district, India, to identify patients with presumptive TB and refer them to sputum microscopy centres. To reinforce this training, we sent weekly text message reminders during January-March 2015. All 50 APs and 23 of 29 PPs participated. The number of patients with presumptive TB referred by the PPs and APs increased from 38 (January-March 2014) to 104 (January-March 2015), and the number of smear-positive TB patients diagnosed increased from 5 to 16, a 220% increase. While the intervention increased the number of referrals, it did not impact case detection at district level, due to the short duration of the intervention and the non-dominant private sector.

Dans le but de trouver des cas de tuberculose (TB) « manquants ¼, nous avons formé des praticiens privés (PP) et des praticiens ayurvédiques (AP ; médecine indienne) du district de Bilaspur, Inde, en novembre 2014 afin d'identifier des patients avec une TB présumée et de les référer dans des centres de microscopie de crachats. Pour renforcer cette formation, nous avons envoyé des messages sous forme de texto chaque semaine comme aide-mémoire de janvier à mars 2015. Tous les 50 AP et 23 des 29 PP ont participé. Le nombre de patients présumés TB référés par les PP et AP a augmenté de 38 (janvier­mars 2014) à 104 (janvier­mars 2015) et le nombre de patients à frottis de TB positifs diagnostiqués a augmenté de 5 à 16 (augmentation de 220%). Si l'intervention a augmenté la référence de patients au laboratoire, elle n'a pas eu d'impact sur la détection des cas au niveau du district à cause de sa durée brève et du fait que le secteur privé n'est pas dominant dans la région.

Con el propósito de detectar los casos de tuberculosis (TB) que 'se pasan por alto', se llevó a cabo una capacitación de los médicos del sector privado (PP) y los médicos del sistema Ayurveda (AP) de medicina tradicional de la India; la formación, realizada en el distrito de Bilaspur en noviembre del 2014, buscó mejorar el reconocimiento de los pacientes con presunción clínica de TB y su remisión a los centros de examen microscópico del esputo. Con el objeto de reforzar la capacitación, se enviaron mensajes recordatorios por SMS de enero a marzo del 2015. Participaron en el estudio todos los 50 AP y 23 de los 29 PP del distrito. El cociente del número de pacientes con presunción de TB remitidos por los PP y los AP de 38 (entre enero y marzo del 2014) a 104 (entre enero y marzo del 2015) y el número de casos diagnosticados de TB con baciloscopia positiva aumentó de cinco a 16 (incremento del 220%). Si bien la intervención aumentó el número de remisiones, la detección de casos a escala del distrito no se modificó, debido a la corta duración de la intervención y a que el sector privado no es predominante en este distrito.

Protocol for a population-based molecular epidemiology study of tuberculosis transmission in a high HIV-burden setting: the Botswana Kopanyo study.

INTRODUCTION: Mycobacterium tuberculosis (Mtb) is transmitted from person to person via airborne droplet nuclei. At the community level, Mtb transmission depends on the exposure venue, infectiousness of the tuberculosis (TB) index case and the susceptibility of the index case's social network. People living with HIV infection are at high risk of TB, yet the factors associated with TB transmission within communities with high rates of TB and HIV are largely undocumented. The primary aim of the Kopanyo study is to better understand the demographic, clinical, social and geospatial factors associated with TB and multidrug-resistant TB transmission in 2 communities in Botswana, a country where 60% of all patients with TB are also infected with HIV. This manuscript describes the methods used in the Kopanyo study. METHODS AND ANALYSIS: The study will be conducted in greater Gaborone, which has high rates of HIV and a mobile population; and in Ghanzi, a rural community with lower prevalence of HIV infection and home to the native San population. Kopanyo aims to enrol all persons diagnosed with TB during a 4-year study period. From each participant, sputum will be cultured, and for all Mtb isolates, molecular genotyping (24-locus mycobacterial interspersed repetitive units-variable number of tandem repeats) will be performed. Patients with matching genotype results will be considered members of a genotype cluster, a proxy for recent transmission. Demographic, behavioural, clinical and social information will be collected by interview. Participant residence, work place, healthcare facilities visited and social gathering venues will be geocoded. We will assess relationships between these factors and cluster involvement to better plan interventions for reducing TB transmission. ETHICS: Ethical approval from the Independent Review Boards at the University of Pennsylvania, US Centers for Disease Control and Prevention, Botswana Ministry of Health and University of Botswana has been obtained.

Evaluation of the integrated clinic model for HIV/AIDS services in Ho Chi Minh City, Viet Nam, 2013-2014.

Setting: Ho Chi Minh City (HCMC), Viet Nam. Objective: To evaluate a new integrated service model for human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS) care. Design: In HCMC, co-located services, including voluntary HIV counseling and testing (VCT), HIV treatment at out-patient clinics (OPC), and methadone maintenance therapy (MMT) for persons who inject drugs, have operated under different administrative structures. In the context of decreasing international financial support, integration of these services into one administrative structure with reduced staff occurred in seven districts in HCMC between October 2013 and June 2014. We used a pre-post study design to compare service-related outcomes from routinely collected data at health facilities 6 months before and 6 months after integration. Results: The proportion of HIV-infected persons linked from VCT to OPCs was unchanged or increased following integration. A higher percentage of patients eligible for antiretroviral therapy (ART) were started on ART. The proportion of ART patients lost to follow-up remained unchanged. The proportions of MMT patients who tested positive for heroin or other substances decreased or were unchanged. Conclusions: VCT, OPC and MMT service delivery quality remained the same or improved during the 6 months following the integration. Expansion of the integrated model should be considered for HIV-related services.

Contexte : Ho Chi Minh City (HCMC), Viet Nam.Objective : Evaluer un nouveau modèle intégré de services pour la prise en charge du virus de l'immunodéficience humaine (VIH) et syndrome de l'immunodéficience acquise (SIDA).Schéma : A HCMC, des services installés au même endroit, incluant le test et conseil volontaire du VIH (VCT), le traitement du VIH en consultation externe (OPC) et le traitement de substitution par méthadone (MMT) pour les utilisateurs de drogues injectables, ont fonctionné sous différentes structures administratives. Dans le cadre de la réduction du soutien financier international, l'intégration de ces services dans une seule structure administrative avec un personnel réduit a eu lieu dans sept districts de HCMC entre octobre 2013 et juin 2014. Nous avons utilisé un schéma d'étude avant-après afin de comparer les résultats liés à ces services à partir de données recueillies en routine dans des structures de santé 6 mois avant et 6 mois après l'intégration.Résultats : La proportion de patients VIH positifs envoyés du VCT vers les OPC n'a pas été modifiée ou a augmenté après l'intégration. Un pourcentage plus élevé de patients éligibles à les traitements antirétroviraux ont mis en route ce traitement. La proportion de patients sous ART perdus de vue est restée sans changement. Les proportions de patients MMT, chez qui la recherche d'héroïne ou d'autres substances a été positive, ont diminué ou sont restées inchangées.Conclusions: La qualité des services de VCT, OPC et MMT est restée la même ou s'est améliorée pendant les 6 mois suivant l'intégration. L'expansion du modèle intégré devrait être envisagée pour les services relatifs au VIH.

Marco de referencia: La Ciudad de Ho Chi Min.Objetivo: Evaluar un nuevo modelo de servicios integrados de atención de la infección por el virus de la inmunodeficiencia humana (VIH) y síndrome de inmunodeficiencia adquirida (SIDA).Método: En la Ciudad de Ho Chi Min, los servicios simultáneos de pruebas voluntarias y orientación sobre el VIH (VCT), de tratamiento en consulta externa de la infección por el VIH (OPC) y de tratamiento de mantenimiento con metadona a los consumidores de drogas inyectables (MMT) han funcionado en estructuras administrativas diferentes. En el contexto de una disminución del apoyo económico internacional, de octubre del 2013 a junio del 2014, se integraron estos servicios en una estructura administrativa única en siete distritos de la ciudad. En un estudio con análisis anterior y posterior a la intervención se compararon los resultados de estos servicios, a partir de los datos corrientes recogidos en los establecimientos de salud 6 meses antes de la integración y 6 meses después de la misma.Resultados: Después de la integración, la proporción de personas infectadas por el VIH vinculadas por los centros de VCT a los OPC permaneció invariable o aumentó; un porcentaje más alto de pacientes aptos para recibir el tratamiento antirretrovírico (TAR) lo iniciaron; la proporción de los pacientes en TAR que se perdieron durante el seguimiento permaneció estable; y las proporciones de los pacientes que recibían MMT que obtuvieron un resultado positivo para la heroína u otras sustancias disminuyeron o no se modificaron.Conclusión: Seis meses después de su integración, la calidad de la prestación de servicios de VCT, OPC y MMT permaneció estable o se mejoró. Se recomienda considerar la posibilidad de ampliar la escala de aplicación del modelo integrado de servicios relacionados con el VIH.

Screening difficult-to-reach populations for tuberculosis using a mobile medical unit, Punjab India.

BACKGROUND: In India, the National Health Mission has provided one mobile medical unit (MMU) per district in the state of Punjab to provide primary health care services for difficult-to-reach populations. OBJECTIVES: To determine the number of patients with presumptive tuberculosis (TB) and the number of TB cases detected and treated among patients who used the MMU services from May to December 2012 in Mohali district, Punjab, India. METHODS: A cross-sectional study was conducted and registers of the out-patient, laboratory, radiology, and TB departments of the MMU were reviewed to determine the number of persons presumed to have TB and the number of persons diagnosed with TB. RESULTS: Of 8346 patients who attended the MMUs, 663 (8%) had symptoms suggestive of TB. Among those with TB symptoms, 540 (81%) were evaluated for pulmonary TB using sputum examination or chest X-ray. In total, 58 (11%) patients had clinical or laboratory evidence of pulmonary TB, of whom 21 (36%) started anti-tuberculosis treatment. CONCLUSION: As MMUs are an integral part of the general public health system, these units have the potential to detect TB cases among difficult-to-reach populations. Additional research is required to optimise the diagnosis of TB at MMUs and to increase rates of TB treatment initiation.

Contexte : En Inde, la Mission nationale santé a fourni une unité médicale mobile (MMU) par district dans l'état du Penjab afin d'offrir des services de soins de santé primaires aux populations difficilement accessibles.Objectifs : Déterminer le nombre de patients présumés atteints de la tuberculose (TB) et le nombre de cas de TB détectés et traités parmi les patients qui ont utilisé les services de la MMU de mai à décembre 2012 dans le district de Mohali de l'état du Penjab, Inde.Méthodes : Une étude transversale a été réalisée et l'étude des registres des consultations, du laboratoire, de la radiologie et des services de TB de la MMU a permis de compter le nombre de personnes présumées atteintes de TB et le nombre de personnes ayant eu un diagnostic de TB.Résultats : Un total de 8346 patients ont fréquenté la MMU, dont 663 (8%) avaient des symptômes suggérant une TB. Parmi ces derniers, 540 (81%) ont bénéficié d'une recherche de TB pulmonaire grâce à un examen de l'expectoration ou à une radiographie pulmonaire. Au total, 58 (11%) patients ont eu des preuves cliniques ou biologiques de TB pulmonaire, dont 21 (36%) ont mis en route un traitement de la tuberculose.Conclusion : Comme les MMU font partie intégrante du système de santé publique général, ces unités ont le potentiel de détecter les cas de TB parmi les populations « difficiles à atteindre ¼. De plus amples recherches sont requises afin d'optimiser le diagnostic de la TB dans les MMU pour accélérer la mise en route du traitement de la TB.

Marco de referencia: En la India, la National Health Mission ha suministrado una unidad médica móvil (MMU) a cada distrito del estado del Punjab, con el objeto de prestar servicios de atención primaria de salud a las poblaciones de difícil acceso.Objetivos: Determinar el número de pacientes con presunción clínica de tuberculosis (TB) y el número de casos de TB diagnosticados y tratados en el grupo de pacientes que acudieron a las MMU de mayo a diciembre del 2012 en el distrito de Mohali del estado del Punjab, en la India.Métodos: Se llevó a cabo un estudio transversal, en el cual se examinaron los registros de los servicios de consulta externa, laboratorio, radiología y los departamentos de TB de las MMU, con el propósito de calcular el número de personas con presunción de TB y el número de casos de TB diagnosticados.Resultados: Durante el período del estudio acudieron a las MMU 8346 personas, de las cuales 663 refirieron síntomas indicativos de TB (8%). Se investigaron 540 personas por TB pulmonar (81%) mediante la baciloscopia del esputo o la radiografía de tórax. Se encontraron pruebas clínicas o de laboratorio de TB pulmonar en 58 pacientes (11%) y se inició el tratamiento antituberculoso en 21 de ellos (36%).Conclusión: Puesto que las MMU forman parte integrante del sistema general de salud pública, estas estructuras pueden detectar los casos de TB en las poblaciones de difícil acceso. Se precisan nuevas investigaciones que contribuyan a optimizar el diagnóstico de la TB en estas unidades y a conseguir que una mayor proporción de pacientes inicie el tratamiento antituberculoso.

Tuberculosis and excess alcohol use in the United States, 1997-2012.

BACKGROUND: Excess alcohol use among tuberculosis (TB) patients complicates TB control strategies. OBJECTIVES: To characterize the role of excess alcohol use in TB control, we describe the epidemiology of excess alcohol use and TB in the United States among those aged ⩾15 years. DESIGN: Using data reported to the National Tuberculosis Surveillance System, 1997-2012, we examined associations between excess alcohol use and TB treatment outcomes and markers for increased transmission (involvement in a local genotype cluster of cases) using multivariate logistic regression. We used Cox proportional hazards regression analysis to examine the relationship between excess alcohol use and the rate of conversion from positive to negative in sputum culture results. RESULTS: Excess alcohol use was documented for 31 207 (15.1%) of 207 307 patients. Prevalence of excess alcohol use was greater among male patients (20.6%) and US-born patients (24.6%). Excess alcohol use was associated with a positive sputum smear result (aOR 1.23, 95%CI 1.18-1.28) and death during treatment (vs. completion of treatment) (aOR 1.16, 95%CI 1.10-1.22). The rate of culture conversion was higher among patients without excess alcohol use (adjusted hazard ratio 1.20, 95%CI 1.18-1.23). CONCLUSIONS: Excess alcohol use was common among patients with TB, and was associated with TB transmission, lower rates of sputum culture conversion, and greater mortality.

The disconnect between a national tuberculosis drug resistance survey and treatment outcomes: a lost opportunity.

We linked results from the Fourth Botswana National Drug Resistance Survey (DRS), 2007-2008, to patient records from the national Electronic Tuberculosis Registry to determine treatment outcomes. Of 915 new patients, 651 (71%) had treatment data available. Completion or cure was achieved for 10/15 (67%, 95%CI 42-85) with isoniazid monoresistance, (6/16, 38%, 95%CI 18-61) with multidrug resistance, while 73% (391/537, 95%CI 69-76) were susceptible to first-line drugs. The analysis was limited because of unavailable treatment records and undocumented outcomes. Prospective analyses following DRSs should be considered to ensure adequate outcome data.

Impact of awareness drives and community-based active tuberculosis case finding in Odisha, India.

India's Revised National Tuberculosis Control programme employs passive case detection. The new sputum smear-positive case detection rate is less than 70% in Odisha State. During April-June 2012, active case finding (ACF) was conducted through awareness drives and field-based tuberculosis (TB) screening in select communities with the lowest case detection rates. During the campaign, 240 sputum smear-positive TB cases were detected. The number of smear-positive cases detected increased by 11% relative to April-June 2011 in intervention communities compared to an 0.8% increase in non-intervention communities. ACF brought TB services closer to the community and increased TB case detection.

Using tuberculosis patient characteristics to predict future cases with matching genotype results.

SETTING: United States. BACKGROUND: It is unknown whether tuberculosis (TB) case or patient characteristics can predict the likelihood of future related TB cases. OBJECTIVE: To estimate the likelihood for future related cases, i.e., cases with matching TB genotypes within the same county diagnosed within the 2 years following the year of reporting of each included case. DESIGN: We considered all TB cases with genotyping results reported in the United States during 2004-2010. Predictive scores were calculated based on patient characteristics by dividing the number of patients who were not the last case in a county-level TB genotype cluster by the total number of patients. RESULTS: Overall, there was a 30.8% chance that a future related case would be detected during the 2 years following the report year of any given case. Future related cases were detected in 34.7% of instances following the diagnosis of smear-positive cases, 51.9% of instances following the diagnosis of a homeless patient and 45.2% of instances following the diagnosis of a patient who reported substance abuse. Predictive scores ranged by race (White 13.9%, Native Hawaiian 43.8%) and age group (⩾65 years 13.1%, 0-4 years 43%), and were higher for US-born patients. CONCLUSIONS: Behavioral and sociodemographic factors can help predict the likelihood of future related cases and can be used to prioritize contact investigations.

Contexte : Etats-Unis.Cadre : On ne sait pas si les caractéristiques d'un cas de tuberculose (TB) ou du patient permettent de prévoir la probabilité de contamination dans l'avenir.Objectif : Estimer la probabilité de cas présentant un génotype similaire dans le même conté et dans une période de 2 ans suivant le cas index.Schéma : Nous avons étudié tous les cas de TB avec génotypage déclarés aux Etats-Unis entre 2004 et 2010. Les scores prédictifs ont été calculés en fonction des caractéristiques du patient en divisant le nombre de patients qui n'étaient pas le dernier cas d'un groupement de génotypes au niveau d'un conté par le nombre total de patients.Résultats : Le risque global de nouveau cas lié à un autre cas était de 30,8% pendant les 2 années suivant l'année de déclaration de tout nouveau cas. Ces contaminations ont été détectées dans 34,7% des circonstances après diagnostic d'un cas à frottis positif, 51,9%, après diagnostic d'un patient sans domicile fixe et 45,2%, après diagnostic d'un patient toxicomane. Les scores prédictifs variaient en fonction de l'ethnie (Blancs 13,9% ; Amérindiens/Hawaïens 43,8%), l'âge (>65 ans 13,1% ; 0­4 ans 43%) et étaient plus élevé chez les patients nés aux Etats-Unis.Conclusion: Les facteurs comportementaux et socio-démographiques peuvent contribuer à prévoir la probabilité d'infection de cas dans le futur et peuvent servir à prioriser les recherches de sujets contacts.

Marco de referencia: En los Estados Unidos de América se desconoce si las características clínicas de un caso de tuberculosis (TB) o las características del paciente permiten pronosticar la probabilidad de aparición de futuros casos de TB relacionados.Objectivo: Evaluar la probabilidad de aparición en el futuro de casos relacionados ­ es decir, casos con genotipos equivalentes, diagnosticados en el mismo condado, durante los 2 primeros años después del año de notificación de cada caso incluido.Métodos: Se consideraron en el estudio todos los casos de TB notificados en los Estados Unidos que contaban con resultados de genotipificación entre el 2004 y el 2010. Se calcularon las puntuaciones pronósticas en función de las características del paciente, al dividir el número de pacientes que no fueron el último caso de un conglomerado genotípico de TB a escala del condado, por el número total de pacientes.Resultados: En general, se observó una probabilidad de 30,8% de aparición de un caso relacionado, durante los 2 años que siguieron al año de notificación de cualquier caso dado. Se observaron casos relacionados en el 34,7% de las veces después del diagnóstico de casos con baciloscopia positiva; el 51,9% de las veces después del diagnóstico de una persona sin domicilio; y en el 45,2% de las veces tras el diagnóstico de un paciente que refería consumo de drogas. Las puntuaciones pronósticas oscilaron, con respecto a la etnia, entre 13,9% en la etnia blanca y 43,8% en los nativos de Hawái); con respecto al grupo de edad, entre 13,1% a partir de los 65 años y 43% en el grupo entre 0 años y 4 años; y el índice pronóstico fue más alto en los pacientes nacidos en los Estados Unidos.Conclusión: Los factores comportamentales y sociodemográficos contribuyen a predecir la probabilidad de aparición de casos futuros relacionados con un caso de TB y se pueden utilizar con el propósito de priorizar las investigaciones de contactos.

Association between Mycobacterium tuberculosis lineage and time to sputum culture conversion.

SETTING: Mycobacterium tuberculosis comprises four principal genetic lineages: one evolutionarily ancestral (Indo-Oceanic) and three modern. Whether response to tuberculosis (TB) treatment differs among the lineages is unknown. OBJECTIVE: To examine the association between M. tuberculosis lineage and time to sputum culture conversion in response to standard first-line drug therapy. DESIGN: We conducted an exploratory retrospective cohort analysis of time to sputum culture conversion among pulmonary tuberculosis (PTB) cases reported in the United States from 2004 to 2007. RESULTS: The analysis included 13,170 PTB cases with no documented resistance to first-line drugs who received a standard four-drug treatment regimen. Among cases with baseline positive sputum smear results, relative to cases with Euro-American lineage, cases with Indo-Oceanic lineage had higher adjusted hazards of sputum culture conversion (aHR 1.32, 95%CI 1.20-1.45), whereas cases with East-African-Indian or East-Asian lineage did not differ (aHR 1.05, 95%CI 0.88-1.25 and aHR 0.99, 95%CI 0.91-1.07, respectively). Among cases with baseline negative sputum smear results, time to sputum culture conversion did not differ by lineage. CONCLUSION: Although these results are exploratory, they suggest that the eradication of viable bacteria may occur sooner among cases with Indo-Oceanic lineage than among those with one of the three modern lineages. Prospective studies of time to sputum culture conversion by lineage are required.

Alcohol use, drunkenness and tobacco smoking in rural western Kenya.

OBJECTIVES: To describe the prevalence of smoking and alcohol use and abuse in an impoverished rural region of western Kenya. METHODS: Picked from a population-based longitudinal database of demographic and health census data, 72 292 adults (≥18 years) were asked to self-report their recent (within the past 30 days) and lifetime use of tobacco and alcohol and frequency of recent 'drunkenness'. RESULTS: Overall prevalence of ever smoking was 11.2% (11.0-11.5) and of ever drinking, 20.7% (20.4-21.0). The prevalence of current smoking was 6.3% (6.1-6.5); 5.7% (5.5-5.9) smoked daily. 7.3% (7.1-7.5) reported drinking alcohol within the past 30 days. Of these, 60.3% (58.9-61.6) reported being drunk on half or more of all drinking occasions. The percentage of current smokers rose with the number of drinking days in a month (P < 0.0001). Tobacco and alcohol use increased with decreasing socio-economic status and amongst women in the oldest age group (P < 0.0001). CONCLUSIONS: Tobacco and alcohol use are prevalent in this rural region of Kenya. Abuse of alcohol is common and likely influenced by the availability of cheap, home-manufactured alcohol. Appropriate evidence-based policies to reduce alcohol and tobacco use should be widely implemented and complemented by public health efforts to increase awareness of their harmful effects.

Lessons learned during tuberculosis screening in public medical clinics in Francistown, Botswana.

In Botswana, where one quarter of the adult population is infected with the human immunodeficiency virus and the annual tuberculosis (TB) incidence is among the highest globally, intensified TB case finding is needed in health care facilities to detect and treat TB cases early and prevent transmission. During August-December 2009, TB screening was implemented among adults at patient intake in five clinics in Francistown. Among 11 779 TB screenings at intake, 926 were positive. Nineteen patients were diagnosed with TB. Routine TB screening at intake was operationally feasible, but had low yield. Innovative case-finding strategies are needed in Botswana.

Prevalence and risk factors for tuberculosis infection among personnel in two hospitals in Viet Nam.

SETTING: Two general hospitals in Viet Nam. OBJECTIVE: To assess the risk of tuberculosis (TB) infection associated with hospital employment. DESIGN: During October-December 2009, we performed a cross-sectional study of hospital personnel and, for community comparison groups, staff from nearby schools. We tested for TB infection using the tuberculin skin test; an induration ≥ 10 mm indicated TB infection. RESULTS: Of 956 hospital personnel, 380 (40%) had TB infection compared to 40 (26%) of 155 school personnel. Hospital personnel had twice the odds of TB infection compared with school personnel (OR 2.0, 95%CI 1.3-3.0) after adjustment for age and sex. Compared to hospital administrative staff, the odds of TB infection were similar among clinical staff (OR 1.0, 95%CI 0.6- 1.3), clinical support staff (OR 0.9, 95%CI 0.5-1.6) and auxiliary staff (OR 1.1, 95%CI 0.6-2.0) at the hospitals. No additional infection risk was detected in high-risk departments (OR 1.1, 95%CI 0.6-2.0). CONCLUSIONS: Hospital personnel are at increased risk of TB infection. Among hospital personnel, risk was independent of job or department, suggesting that personnel are commonly at risk and that improvements in infection control are needed throughout hospitals.

South Carolina tuberculosis genotype cluster investigation: a tale of substance abuse and recurrent disease.

The South Carolina Tuberculosis (TB) Control Division ranked all the TB genotype clusters (two or more cases with matching genotypes) in the state based on the number of cases. The largest cluster, PCR00002, was investigated to determine if the cluster represented recent Mycobacterium tuberculosis transmission, and if so, to identify associated risk factors. The PCR0002 cluster, which included pediatric cases, clearly represented recent M. tuberculosis transmission. The two primary factors contributing to cluster growth were substance abuse and recurrent TB disease. Elimination of ongoing M. tuberculosis transmission in this population will require concurrent treatment for TB disease and substance abuse.

Tuberculosis risk among staff of a large public hospital in Kenya.

SETTING: In sub-Saharan Africa, high rates of tuberculosis (TB) and human immunodeficiency virus (HIV) infection pose a serious threat for occupationally acquired TB among health care workers. OBJECTIVE: To identify factors associated with TB disease among staff of an 1800-bed hospital in Kenya. DESIGN: We calculated TB incidence among staff and conducted a case-control study where cases (n = 65) were staff diagnosed with TB and controls (n = 316) were randomly selected staff without recent TB. RESULTS: The annual incidence of TB from 2001 to 2005 ranged from 645 to 1115 per 100000 population. Factors associated with TB disease were additional daily hours spent in rooms with patients (adjusted odds ratio [aOR] 1.3, 95%CI 1.2-1.5), working in areas where TB patients received care (aOR 2.1, 95%CI 1.1-4.2), HIV infection (aOR 29.1, 95%CI 5.1-167) and living in a slum (aOR 4.7, 95%CI 1.8-12.5) or hospital-provided low-income housing (aOR 2.6, 95%CI 1.2-5.6). CONCLUSION: Hospital exposures were associated with TB disease among staff at this hospital regardless of their job designation, even after controlling for living conditions, suggesting transmission from patients. Health care facilities should improve infection control practices, provide quality occupational health services and encourage staff testing for HIV infection to address the TB burden in hospital staff.

Reported childhood tuberculosis treatment outcomes, Gaborone and Francistown, Botswana, 1998-2002.

SETTING: Botswana. OBJECTIVES: To estimate frequencies of tuberculosis (TB) treatment outcomes, assess the validity of reported treatment outcomes, and identify risk factors for death during TB treatment among children aged <15 years during 1998-2002. DESIGN: We examined TB treatment outcome frequencies using the national Electronic TB Registry (ETR) data. Treatment and medical records were reviewed to calculate predictive values (PV) for outcomes recorded in the ETR. We interviewed parents of children treated for TB and assessed risk factors for death during treatment via case-control study. RESULTS: Of 5483 patients, 3646 (67%) were cured or completed treatment and 577 (10.5%) died during treatment. The PV for ETR was 76% for death and 97% for cured or completed treatment. We interviewed parents of 91 children who died during treatment and 220 children who completed treatment. Human immunodeficiency virus (HIV) status was unknown for 76% of the children and 54% of the parents. Parent-reported adverse effects to anti-tuberculosis medication (adjusted odds ratio [aOR] 4.9, 95% confidence limit [CL] 2.2-9.2), and lower patient age (aOR 2.2, 95%CL 1.2-4.2) were associated with death during treatment. CONCLUSIONS: TB control programs in Botswana should assess for potential adverse effects of anti-tuberculosis medication and expand HIV testing among children with TB and their parents.

Relationship between perceived life satisfaction and adolescents' substance abuse.

PURPOSE: To explore the relationship between perceived global life satisfaction and selected substance use behaviors among 5032 public high school students. METHODS: The 1997 South Carolina Youth Risk Behavior Survey substance abuse and life satisfaction variables were used. An adjusted polychotomous logistic regression analysis utilizing SAS/SUDAAN, revealed a significant race/gender interaction. Subsequent multivariate models were constructed individually for four race/gender groups. Adjusted odds ratios and 95% confidence intervals were calculated to assess the magnitude of risk for selected substance abuse behaviors and their association with reduced global life satisfaction. RESULTS: Cigarette smoking, chewing tobacco, marijuana, cocaine, regular alcohol use, binge drinking, injection drug, and steroid use were significantly (p < .05) associated with reduced life satisfaction for specific race/gender groups (white males; black males; white females; and black females). In addition, age (< or = 13 years) of first alcohol drink, first marijuana use, first cocaine use, and first cigarette smoked were also significantly (p < .05) associated with reduced life satisfaction. CONCLUSION: Longitudinal studies are needed to determine whether dissatisfaction with life is a consequence or determinant of substance abuse behavior for adolescents.

Binge drinking among undergraduate college students in the United States: implications for other substance use.

The authors examined the relationship between binge drinking and other substance use among US college students, using nationally representative data from the 1995 National College Health Risk Behavior Survey implemented by the Centers for Disease Control and Prevention. Compared with nonbinge drinkers, current binge drinkers were significantly more likely to report "ever" using and current use of cigarettes, marijuana, cocaine, and other illegal drugs. The researchers also found that the more often students binge drank, the more likely they were to have ever used cigarettes, marijuana, cocaine, and other drugs, and the more likely they were to report current use of cigarettes and marijuana. Those who design programs to prevent binge drinking and use of other substances should take into account the reality that many students use more than one substance and that the more frequently students report binge drinking, the more likely they are to be using other substances as well.

Trends and subgroup differences in transportation-related injury risk and safety behaviors among high school students, 1991-1997.

PURPOSE: To examine national trends in transportation-related injury risk and safety behaviors among U.S. high school students. METHODS: To examine secular trends in riding with a driver who had been drinking, driving after drinking, and using seat belts, bicycle helmets, and motorcycle helmets, we used logistic regression to analyze data from national Youth Risk Behavior Surveys (YRBS) conducted in 1991, 1993, 1995, and 1997. The YRBS is a self-administered, anonymous survey that uses a national probability sample of U.S. students in public and private schools from grades 9-12 (N = 55,734 for all years combined). RESULTS: The percentages of students who rode with a driver who had been drinking (36.6% in 1997), drove after drinking alcohol (16.9% in 1997), always wore seat belts (33.2% in 1997), and always wore a motorcycle helmet when riding a motorcycle (45.0% in 1997) remained stable between 1991 and 1997. From 1991 to 1997, the percentage of bicycle riders who always wore a helmet when bicycling showed a small but statistically significant increase (1.1% in 1991 to 3.8% in 1997), but helmet use remained low. CONCLUSION: Many young people place themselves at unnecessary risk for motor vehicle- and bicycle-related crash injuries and fatalities. Improved motor vehicle- and bicycle-related injury prevention strategies are needed that specifically target adolescents.