Applying the zero-inflated Poisson model with random effects to detect abnormal rises in school absenteeism indicating infectious diseases outbreak.

Records of absenteeism from primary schools are valuable data for infectious diseases surveillance. However, the analysis of the absenteeism is complicated by the data features of clustering at zero, non-independence and overdispersion. This study aimed to generate an appropriate model to handle the absenteeism data collected in a European Commission granted project for infectious disease surveillance in rural China and to evaluate the validity and timeliness of the resulting model for early warnings of infectious disease outbreak. Four steps were taken: (1) building a 'well-fitting' model by the zero-inflated Poisson model with random effects (ZIP-RE) using the absenteeism data from the first implementation year; (2) applying the resulting model to predict the 'expected' number of absenteeism events in the second implementation year; (3) computing the differences between the observations and the expected values (O-E values) to generate an alternative series of data; (4) evaluating the early warning validity and timeliness of the observational data and model-based O-E values via the EARS-3C algorithms with regard to the detection of real cluster events. The results indicate that ZIP-RE and its corresponding O-E values could improve the detection of aberrations, reduce the false-positive signals and are applicable to the zero-inflated data.

Screening diabetes in tuberculosis patients in eastern rural China: a community-based cross-sectional study.

OBJECTIVES: To understand the prevalence of diabetes mellitus (DM) and tuberculosis (TB) comorbidity in rural China and to identify factors associated with TB-DM comorbidity and screening efficacy. METHODS: A community-based cross-sectional study was carried out in four counties in eastern rural China. All TB patients newly registered from April 2013 to March 2014 were screened for DM using fasting blood glucose (FBG). Screening-positive patients were further examined using glycosylated haemoglobin A1C (HbA1c). RESULTS: Ninety-seven (7.7%) of the 1252 recruited TB patients had DM, 44 (45.4%) of whom were newly diagnosed. The DM-TB patients were significantly older than non-diabetics (mean age 57 ± 13 years vs. 49 ± 19 years, P < 0.001). The risk of DM-TB was higher in patients aged >40 years (OR 3.039) and in overweight patients (OR 2.595). The number needed to screen (NNS) among TB patients to identify one case of DM was 12.97. The NNS to identify one new DM patient (27.4) was lower in participants aged >40 years (20.5), those who were illiterate (19.9), those with a family history of DM (9.3), those with missing bacille Calmette-Guérin vaccination (11.3), current smokers (14.2) and those with body mass index >24 (11.4). CONCLUSION: Regular DM screening in TB patients is practical in rural China. Better efficacy of DM-TB detection could be obtained by screening high-risk populations, such as overweight TB patients or those with a family history of DM.

Using daily syndrome-specific absence data for early detection of school outbreaks: a pilot study in rural China.

OBJECTIVES: This paper describes and preliminarily evaluates the usefulness of the daily syndrome-specific absenteeism surveillance system (DSSASS) as an early warning system of school outbreaks in rural China. STUDY DESIGN: We conducted an experimental study in rural areas of Hubei Province from September 19, 2011 to December 31, 2011. METHODS: Nine public elementary schools from two counties were selected as pilot sentinel schools. Daily monitoring data of the absent date and reason, sex, age and class of each absent student was collected and entered into a web database. Reported data were checked daily and field investigation was carried out when there was abnormal absentee aggregation. Descriptive analysis and preliminary evaluation were then conducted after the pilot study. RESULTS: The findings showed that the total average of daily absenteeism rate was 3%, and the absenteeism rate differed by county, school level and grade level. The daily absenteeism rate in illness absentees was highest (2.74%), followed by business absentees (0.13%) and injury absentees (0.09%). The total timeliness report rate was 64.84% and the total incident report rate was 29.22%. One varicella outbreak and one influenza B outbreak were identified, but neither of them was detected by China Information System for Diseases Control and Prevention (CISDCP). The study shows syndrome-specific absenteeism data would be useful for early detection of unusual public health events or outbreaks in school. However, more efforts are needed to enhance the quality of surveillance data, and longer follow-up and more analysis are required to evaluate the system comprehensively. Our study might provide useful experience and evidence for other developing regions or counties establishing similar systems.

Detection of carbapenem resistance genes and cephalosporin, and quinolone resistance genes along with oqxAB gene in Escherichia coli in hospital wastewater: a matter of concern.

AIMS: This study was performed to detect the presence of Escherichia coli resistant to cephalosporins, carbapenems and quinolones in hospital wastewater. METHODS AND RESULTS: Wastewaters from a rural (H1) and an urban (H2) hospital were tested for E. coli resistant to cephalosporins, carbapenem and quinolones. Genes coding for chromosomal and plasmid-mediated resistance and phylogenetic grouping was detected by multiplex polymerase chain reaction (PCR) and for genetic relatedness by rep-PCR. Of 190 (H1 = 94; H2 = 96) E. coli examined, 44% were resistant to both cephalosporins and quinolones and 3% to imipenem. ESBLs were detected phenotypically in 96% of the isolates, the gene blaCTX-M coding for 87% and blaTEM for 63%. Quinolone resistance was due to mutations in gyrA and parC genes in 97% and plasmid-coded aac-(6')-Ib-cr in 89% of isolates. Only in one carbapenem-resistant E. coli, NDM-1 was detected. Nearly 67% of the isolates belonged to phylogenetic group B2. There was no genetic relatedness among the isolates. CONCLUSIONS: Hospital wastewater contains genetically diverse multidrug-resistant E. coli. SIGNIFICANCE AND IMPACT OF THE STUDY: This study stresses the need for efficient water treatment plants in healthcare settings as a public health measure to minimize spread of multidrug-resistant bacteria into the environment.

Qualitative study on perceptions of hand hygiene among hospital staff in a rural teaching hospital in India.

BACKGROUND: Hand hygiene is a simple but underutilized measure to control healthcare-associated infections. AIM: To explore staff perceptions of hand hygiene using focus group discussions (FGDs) in a teaching hospital in India. METHODS: Qualitative study. The FGD guide included questions on transmission of infections, hand hygiene practices and problems with implementation, and ways to improve adherence to hand hygiene recommendations. The FGDs were recorded, transcribed verbatim, translated into English (when conducted in Hindi) and analysed using content analysis. FINDINGS: Two themes emerged: 'inter-relationship of knowledge, beliefs, motivation, practices and needs' and 'roles and responsibilities for sustainable and efficient implementation of context-relevant approaches and interventions'. Staff were generally aware of the importance of hand hygiene for the prevention of healthcare-associated infections, but perceived practical problems with implementation. CONCLUSIONS: The staff suggested various interventions and appeared to be prepared to follow hand hygiene guidelines if the hospital provided the necessary facilities.

Community perceptions of tuberculosis: A qualitative exploration from a gender perspective.

OBJECTIVE: To explore community laypersons' perspective on tuberculosis (TB)-related illness experiences, meanings, behaviours and impact with reference to gender. STUDY DESIGN: Qualitative, conducted in rural Bangladesh. METHODS: Eleven focus group discussions (FGDs) were conducted (six female and five male) in five subdistricts where the non-governmental organization BRAC operates. On average, seven purposively chosen poor, illiterate, non-TB patients participated in each FGD. Discussions were audiotaped, translated verbatim into English and analysed using MAXQDA software for qualitative data analysis, used it to assign codes to text segments to identify themes from participants' narratives. RESULTS: TB was recognized as a deadly disease that could affect anyone. The discussants were fairly aware of the psychological, financial and social impacts of TB. Women faced with adverse consequences more often than men, such as trouble in ongoing and prospective marital affairs. Coughing up sputum in public by women is culturally frowned upon, resulting in enormous suffering. Women tended to describe the clinical features more vaguely than men, and often specified fewer characteristic symptoms such as blood in sputum. CONCLUSIONS: The gender differences in the health and socio-economic impact of TB included perceived causality, curability, stigma, family and community support, fear of disclosure, and use of self-help or home remedies. Interactive health education covering various consequences of TB could be indispensable to changing negative beliefs.

A snapshot of the biodiversity and clustering of Mycobacterium tuberculosis in Oman using spoligotyping.

SETTINGS: National Tuberculosis Reference Laboratory, Central Public Health Laboratory, Ministry of Health, Oman. OBJECTIVE: To use spoligotyping to explore the genetic population structure and clustering of Mycobacterium tuberculosis isolates among nationals and immigrants in Oman. METHODS: Using spoligotyping, we characterised all available isolates from 2007, and randomly selected isolates from 2005 and 2006. A total of 312 clinical isolates from the same number of patients diagnosed with tuberculosis (TB) in 2005-2007 were included in the study. RESULTS: Of 312 isolates, 69% were in clusters ranging from 2 to 38 isolates. The proportion of clustering was 58% among 2005-2006 samples and 67% among 2007 samples, with higher clustering among Omanis than among immigrants. The study showed that M. tuberculosis Indian family lineages, CAS1_Delhi, CAS and EAI5 were the predominant strains. Around 50% of the immigrants shared strains with Omanis. Twelve of the 19 INH-monoresistant strains and the two multidrug-resistant strains were in clusters (P = 0.81). CONCLUSION: This study demonstrates the predominance in Oman of the strain family commonly found on the Indian sub-continent. A high proportion of immigrant strains were in the same clusters as Omani strains. To better ascertain the transmission dynamics of M. tuberculosis, we recommend that stringent molecular and conventional epidemiological methods be applied.

[Postconditioning is a universal protective phenomenon].

The analysis of the data available in the literature shows that postconditioning enhances cardiac tolerance to the arrhythmogenic impact of reperfusion, prevents the occurrence of the no-reflow phenomenon, and eliminates cardiomyocytic necrosis and apoptosis during reperfusion. Independent clinical observations indicate the high clinical efficiency of postconditioning in patients with acute myocardial infarction. The literature data show that postconditioning enhances the tolerance of the brain, spinal cord, kidneys, liver, intestine, and skeletal muscles to reperfusion injury. The molecular mechanism of the protective action of postconditioning is discussed.

PPM: 'public-private' or 'private-public' mix? The case of Ujjain District, India.

The World Health Organization and the Revised National TB Control Programme (RNTCP) in India have advocated public-private mix as essential for tuberculosis (TB) control. We conducted a cross-sectional sample survey of private providers (with various qualifications) in Ujjain District, India, to study willingness and motivation to collaborate. Most providers were aware of the RNTCP and had referred patients there. All were willing to collaborate, although the areas for collaboration varied between urban and rural providers. General altruism and an opportunity to collaborate with the government were the main motivations. None of the providers had ever been contacted by the RNTCP. Enthusiasm in the private sector has not been effectively exploited by the RNTCP.

Female-male differences at various clinical steps of tuberculosis management in rural Bangladesh.

A registry data-based study of 3,600 patients systematically drawn from out-patient clinic, laboratory and tuberculosis (TB) treatment registers (1200 from each) examined female-male differences at various clinical steps of TB management and compared selective indicators with published results. Female-to-male ratios (FMR) declined at the following clinical steps: respiratory patients seeking out-patient care (0.81), TB suspects submitting sputum for testing (0.52) and smear-positive test results (0.38), but the decline ceased at treatment initiation (0.41). Compared to 1997, the FMR in 2000 had decreased for out-patient clinics and sputum submission for testing, but had increased for smear-positive test results and treatment initiation. More female than male patients who underwent treatment achieved cure (93% vs. 89%). Lower female representation at the different clinical steps of TB management persists.