Tuberculosis control in a socially vulnerable area: a community intervention beyond DOT in a Brazilian favela.

OBJECTIVES: To evaluate the population-based impact of a comprehensive intervention to strengthen tuberculosis (TB) control in Rocinha, the largest urban slum in Rio de Janeiro, Brazil. DESIGN: In July 2003, 40 lay persons were hired and trained as community health workers to supervise treatment, implement educational activities and establish a supportive social network for anti-tuberculosis treatment. Between July 2005 and June 2008, a door-to-door active case finding campaign was conducted. Data were obtained from the Brazilian National Reporting System, which collects information from the TB notification form for every reported case. RESULTS: Between January 2001 and December 2008, 2623 TB cases were reported, 852 before and 1771 after the start of the program. Following the intervention, treatment success rates increased (67.6% vs. 83.2%, P < 0.001) and default rates dropped (17.8% vs. 5.5%, P < 0.001). Compared to the pre-intervention period, the TB case rate declined by an average of 39 cases per 100,000 population per 6 months (P = 0.003) in the post-intervention period, although this may have been due to secular trends already in place at the start of the intervention. Case rates declined from 591/100,000 in 2001 to 496/100,000 in 2008. CONCLUSION: With proper planning and effective community involvement, a successful intervention can lead to high cure rates and may contribute to a decrease in TB notification rates.

CPAP and survival in moderate-to-severe obstructive sleep apnoea syndrome and hypoxaemic COPD.

Obstructive sleep apnoea syndrome (OSAS) often coexists in patients with chronic obstructive pulmonary disease (COPD). The present prospective cohort study tested the effect of OSAS treatment with continuous positive airway pressure (CPAP) on the survival of hypoxaemic COPD patients. It was hypothesised that CPAP treatment would be associated with higher survival in patients with moderate-to-severe OSAS and hypoxaemic COPD receiving long-term oxygen therapy (LTOT). Prospective study participants attended two outpatient advanced lung disease LTOT clinics in São Paulo, Brazil, between January 1996 and July 2006. Of 603 hypoxaemic COPD patients receiving LTOT, 95 were diagnosed with moderate-to-severe OSAS. Of this OSAS group, 61 (64%) patients accepted and were adherent to CPAP treatment, and 34 did not accept or were not adherent and were considered not treated. The 5-yr survival estimate was 71% (95% confidence interval 53-83%) and 26% (12-43%) in the CPAP-treated and nontreated groups, respectively (p<0.01). After adjusting for several confounders, patients treated with CPAP showed a significantly lower risk of death (hazard ratio of death versus nontreated 0.19 (0.08-0.48)). The present study found that CPAP treatment was associated with higher survival in patients with moderate-to-severe OSAS and hypoxaemic COPD receiving LTOT.

Adolescent smokers are at greater risk for current asthma and rhinitis.

BACKGROUND: The association of tobacco smoke with the prevalence of asthma and rhinitis has not been well-characterized in adolescents. METHODS: As part of the International Study of Asthma and Allergies in Childhood (ISAAC), we conducted a cross-sectional survey of 3000 adolescents aged 13-14 years in northern Argentina. Data included questions about asthma and rhinitis symptoms and about parental and personal smoking. Logistic regression and Pearson chi(2) statistics were used to estimate these associations. RESULTS: Over 13% of respondents described themselves as current smokers, and half indicated that at least one parent smoked at home. Active smoking was associated with both asthma (OR 1.83, 95%CI 1.42-2.35) and rhinitis (OR 1.61, 95%CI 1.33-1.92) in unadjusted analysis. These associations persisted after adjusting for parental smoking status, mother's educational level and sex. Boys were significantly less likely than girls to report current asthma or rhinitis. CONCLUSIONS: Active and passive smoking are both risk factors for asthma and rhinitis in adolescents. Assuming that some children with asthma never started smoking due to symptoms, then the true risk could be higher than reported here. These results reinforce the need to develop better strategies for primary and secondary prevention of tobacco exposure in children.

Can a normal peak expiratory flow exclude severe chronic obstructive pulmonary disease?

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is underdiagnosed. One barrier to diagnosis is the limited availability of spirometry testing, but in adults at risk for COPD, a normal pre-bronchodilator (pre-BD) peak expiratory flow (PEF) may rule out clinically significant COPD. OBJECTIVE: To identify post-BD airway obstruction using data from 13 708 individuals aged >or=40 years from the PLATINO and BOLD studies. METHODS: We evaluated different cut-off points of pre-BD. The PEF was obtained from a diagnostic-quality spirometer (not a mechanical PEF meter). At least one of the following COPD risk factors was present in 77% of the subjects: chronic respiratory symptoms; exposure to tobacco smoke, biomass smoke or dust in the workplace; or a previous diagnosis of asthma, COPD, emphysema or chronic bronchitis. RESULTS: Although the positive predictive value was low as expected, a pre-BD PEF of >or=70% predicted effectively ruled out Stages III and IV COPD of the Global Initiative for Chronic Obstructive Lung Disease. Among those with at least one risk factor, only 12% would require confirmatory spirometry using this criterion. CONCLUSIONS: Adding PEF measurement to a screening questionnaire may rule out severe to very severe COPD without the need for pre- and post-BD spirometry testing. Confirmation is needed from a study using inexpensive PEF meters or pocket spirometers with a staged screening protocol.