Barriers and solutions to finding rifampicin-resistant tuberculosis cases in older children and adolescents.

Little is known about the barriers to post-exposure management of rifampicin-resistant tuberculosis (RR-TB) in older children and adolescents. We report on implementation lessons from a pilot programme targeting household-exposed individuals aged 6-18 years in Khayelitsha, South Africa. Barriers included misperceptions regarding risk of exposure, multiple research and implementation stakeholders, additional workload for an overburdened healthcare system, logistical issues faced by families, and insufficient human and financial resources. Solutions to these barriers are possible, but creativity and persistence are required. Our experience can guide others looking to roll-out care for children and adolescents exposed to RR-TB.

On connaît mal les entraves à la prise en charge post-exposition de la tuberculose résistante à la rifampicine (RR-TB) chez les enfants plus âgés et les adolescents. Nous rapportons les leçons de la mise en œuvre d'un programme pilote ciblant les individus exposés dans leurs foyers, âgés de 6­18 ans, à Khayelitsha, Afrique du Sud. Les obstacles ont inclus des perceptions erronées à propos du risque d'exposition, la multiplicité des partenaires de recherche et de mise en œuvre, la charge de travail supplémentaire pour un système de santé déjà surchargé, les problèmes logistiques auxquels sont confrontées les familles, et l'insuffisance des ressources humaines et financières. Il y a des solutions possibles à ces obstacles mais elles demandent de la créativité et de la détermination. Notre expérience peut guider ceux qui veulent lancer la prise en charge des enfants et des adolescents exposés à la RR-TB.

Se conoce poco sobre los factores que obstaculizan la atención después de la exposición a un caso de tuberculosis resistente a rifampicina (RR-TB) en los niños mayores y los adolescentes. En el presente artículo se describen las enseñanzas aprendidas durante la ejecución de un programa piloto dirigido a los contactos domiciliarios expuestos entre los 6 y los 18 años de edad, en Khayelitsha, Suráfrica. Entre los obstáculos observados se pueden citar las percepciones equivocadas sobre el riesgo de exposición, la multiplicidad de interesados directos en la investigación y la ejecución, la carga de trabajo adicional en un sistema de salud sobresaturado, los problemas organizativos afrontados por las familias y la insuficiencia de recursos humanos y de financiamiento. Las soluciones a estos problemas son posibles, pero exigen creatividad y persistencia. Esta experiencia puede orientar a otros equipos que intenten poner en marcha la atención de los niños y los adolescentes expuestos a la RR-TB.

Arbovirus investigation in patients from Mato Grosso during Zika and Chikungunya virus introdution in Brazil, 2015-2016.

Arboviruses have become a major public health concern in Brazil, especially after Zika virus (ZIKV) and Chikungunya virus (CHIKV) introduction, leading to massive epidemics. We conducted an investigation of arboviruses in patients with acute febrile illness for less than five days in Mato Grosso state (MT) during the period of ZIKV and CHIKV dissemination in Brazil. To achieve that, 453 human serum samples of patients suspected of Dengue (DENV), Yellow Fever (YFV), ZIKV or CHIKV collected in health units of 31 cities of MT were subjected to RT-PCR protocols for 10 flaviviruses, 5 alphaviruses and orthobunyaviruses from Simbu serogroup, nucleotide sequencing and viral isolation. Regarding flaviviruses, five (1.1%) patients were infected with DENV-1 genotype V, 22 (4.4%) with DENV-4 genotype II, 3 (0.7%) with YFV South American genotype II and five (1.1%) with ZIKV Asian genotype. The first human case of ZIKV in MT was detected in this study during August, 2015 in Tapurah. Alphaviruses were detected in 2 (0.4%) patients infected with CHIKV genotype ECSA, 1 (0.2%) with Madariaga (EEEV) lineage III and 34 (7.5%) with Mayaro (MAYV) genotype L. Four (11.4%) patients presented dual infections with DENV-1/ZIKV, DENV-1/DENV4, DENV-4/MAYV and ZIKV/MAYV. The majority - 13/34 positive for MAYV, one for Madariaga virus - are residents in Várzea Grande (VG), metropolitan region of Cuiabá, capital of MT. The first CHIKV infection in MT was detected in this study in Mirassol D'Oeste, during July, 2015. In addition, 20 (4.4%) patients were positive for OROV Segment S genotype IA. These results reinforce the variation in arboviruses frequency and distribution during outbreaks, highlinghing the importance of differential diagnosis to identify agents silently co-circulating with major health problem arboviruses.

The experience of bedaquiline implementation at a decentralised clinic in South Africa.

Multidrug-resistant tuberculosis (MDR-TB) is a serious public health problem, but the new drugs bedaquiline (BDQ) and delamanid offer hope to improve outcomes and minimise toxicity. In Khayelitsha, South Africa, patients are routinely started on BDQ in the out-patient setting. This report from the field describes BDQ use in the out-patient setting at the Nolungile Clinic. The clinic staff overall report a positive experience using the drug. Challenges have been based largely on the logistics of drug supply and delivery. BDQ can be started successfully in the out-patient setting, and can be a positive experience for both patients and providers. La tuberculose multirésistante (TB-MDR) est un problème de santé publique grave, mais les nouveaux médicaments que sont la bédaquiline (BDQ) et le délamanide apportent un espoir d'améliorer les résultats tout en réduisant la toxicité. A Khayelitsha, Afrique du Sud, les patients démarrent leur traitement par BDQ en consultation externe en routine. Ce rapport du terrain décrit l'utilisation de la BDQ à la consultation externe du dispensaire Nolungile. Dans l'ensemble, le personnel du centre de santé exprime une expérience positive du médicament. Les défis ont surtout été liés à la logistique de l'approvisionnement et de la distribution du médicament. La BDQ peut être mise en route avec succès dans le cadre d'une consultation externe et peut constituer une expérience positive pour les patients et les prestataires de soins. La tuberculosis multirresistente (TB-MDR) representa un grave problema de salud pública, pero la utilización de nuevos medicamentos como la bedaquilina (BDQ) y el delamanid ofrece perspectivas de mejores desenlaces terapéuticos y disminución de la toxicidad asociada. En Khayelitsha, Suráfrica, se inicia de manera sistemática el tratamiento ambulatorio con BDQ. En el presente informe del terreno, se describe la utilización de BDQ en tratamiento antituberculoso ambulatorio en el centro de atención Nolungile. En general, los miembros del personal del centro refirieron una experiencia positiva con la administración del medicamento. Las dificultades surgieron en gran parte con respecto a aspectos logísticos del suministro y la administración del medicamento. Es posible iniciar un tratamiento eficaz con BDQ en condiciones ambulatorias, y represente una experiencia positiva para los pacientes y los profesionales de salud.

Diagnostic accuracy of tuberculin skin test self-reading by HIV patients in a low-resource setting.

BACKGROUND: The World Health Organization recommends tuberculin skin tests (TSTs) where feasible to identify individuals most likely to benefit from isoniazid preventive therapy (IPT). The requirement for TST reading after 48-72 h by a trained nurse is a barrier to implementation and increases loss to follow-up. METHODS: Patients with human immunodeficiency virus (HIV) infection were recruited from a primary care clinic in South Africa and trained by a lay counsellor to interpret their own TST. The TST was placed by a nurse, and the patient was asked to return 2 days later with their self-reading result, followed by blinded reading by a trained nurse (reference). RESULTS: Of 227 patients, 210 returned for TST reading; 78% interpreted their test correctly: those interpreting it as negative were more likely to be correct (negative predictive value 93%) than those interpreting it as positive (positive predictive value 42%); 10/36 (28%) positive TST results were read as negative by the patient. CONCLUSIONS: Patients with HIV in low-resource settings can be trained to interpret their own TST. Those interpreting it as positive should return to the clinic within 48-72 h for confirmatory reading and IPT initiation; those with a negative interpretation can return at their next scheduled visit and initiate IPT at that time if appropriate.

Microalbuminuria and renal morphology in the evaluation of subclinical lupus nephritis.

AIM AND METHOD: In an attempt to evaluate subclinical lupus nephropathy, we analyzed the clinical characteristics, determined the albumin excretion rate (AER) by radioimmunoassay and performed renal biopsy in 30 patients with systemic lupus erythematosus (SLE) who had no clinical signs of renal involvement (no urinary sediment abnormalities, absence of proteinuria, serum creatinine <1.3 mg/dl). All biopsies were classified according to a modified classification proposed by the WHO. RESULTS: Fifteen cases (50%) had mesangial glomerulonephritis (MGN) type IIb, 12 had MGN type IIa and 3 patients showed no changes on light microscopy (LM) or on immunofluorescence (IF) (type I). Anti-IgM-fluorescent deposits were found in 83% of the renal biopsies, being associated with less heavily stained deposits of IgG, IgA and C3. Patients with MGN type IIb showed lower mean age when compared to those of MGN type IIa (26.04 years vs. 36.3 years) (p<0.029); those patients also presented disease duration of 4.8 years and their mean AER was 39.9 microg/min. Six of the patients (6 of 15, 40%) showed positive anti-dsDNA antibodies, in contrast to patients with MGN type IIa who did not show positive anti-dsDNA antibodies (p<0.002). The group with abnormal AER presented lower mean age (p<0.029) and lower C3 levels (p<0.0098) when compared to the group with normal AER. CONCLUSION: The results suggest the high prevalence of MGN type IIb and IgM deposits on IF, despite the paucity of clinical and laboratory data on these patients. Furthermore, there is an association between MGN type IIb and positive anti-dsDNA antibodies and a relationship between abnormal AER and low C3 levels. The level of AER could not determine the presence or absence of renal disease on LM or IF in this population.