Treatment default amongst patients with tuberculosis in urban Morocco: predicting and explaining default and post-default sputum smear and drug susceptibility results.

SETTING: Public tuberculosis (TB) clinics in urban Morocco. OBJECTIVE: Explore risk factors for TB treatment default and develop a prediction tool. Assess consequences of default, specifically risk for transmission or development of drug resistance. DESIGN: Case-control study comparing patients who defaulted from TB treatment and patients who completed it using quantitative methods and open-ended questions. Results were interpreted in light of health professionals' perspectives from a parallel study. A predictive model and simple tool to identify patients at high risk of default were developed. Sputum from cases with pulmonary TB was collected for smear and drug susceptibility testing. RESULTS: 91 cases and 186 controls enrolled. Independent risk factors for default included current smoking, retreatment, work interference with adherence, daily directly observed therapy, side effects, quick symptom resolution, and not knowing one's treatment duration. Age >50 years, never smoking, and having friends who knew one's diagnosis were protective. A simple scoring tool incorporating these factors was 82.4% sensitive and 87.6% specific for predicting default in this population. Clinicians and patients described additional contributors to default and suggested locally-relevant intervention targets. Among 89 cases with pulmonary TB, 71% had sputum that was smear positive for TB. Drug resistance was rare. CONCLUSION: The causes of default from TB treatment were explored through synthesis of qualitative and quantitative data from patients and health professionals. A scoring tool with high sensitivity and specificity to predict default was developed. Prospective evaluation of this tool coupled with targeted interventions based on our findings is warranted. Of note, the risk of TB transmission from patients who default treatment to others is likely to be high. The commonly-feared risk of drug resistance, though, may be low; a larger study is required to confirm these findings.

Monitoring of rotavirus vaccination in Morocco: establishing the baseline burden of rotavirus disease.

BACKGROUND: Rotavirus is a leading cause of childhood morbidity and mortality worldwide. Clinical trials for two rotavirus vaccines recommended by the WHO for global use since 2009 have successfully demonstrated the safety and efficacy of these vaccines in a wide range of countries. To control the burden of severe and fatal diarrheal disease, the Ministry of Health of Morocco introduced the single strain rotavirus vaccine into their national immunization program in 2010. METHODS: We employed a standard WHO case definition to identify children under 5 hospitalized with AGE at four hospitals from June 2006 to May 2010 to establish baseline burden of rotavirus disease before introduction of vaccine. Stool samples were collected and tested for rotavirus using a standard enzyme immunoassay. RESULTS: Overall, 40% (741 of 1841) of the children hospitalized with AGE tested positive for rotavirus, making it the single most common cause of severe gastroenteritis among children in Morocco. Applying this prevalence to the estimates of diarrheal hospitalizations and deaths in Morocco, we estimate that rotavirus annually causes 19,646 hospitalizations and 1604 deaths in children under 5 years of age. DISCUSSION: On the basis of these surveillance data, we estimate that 1 in 389 Moroccan children died and 1 in 32 was hospitalized due to rotavirus before their fifth birthday. A considerable proportion of these deaths and hospitalizations should be preventable through vaccination, and the 4 years of stable prevaccine surveillance in Morocco will be a tremendously useful platform for assessing potential changes in the epidemiology of rotavirus disease and measuring impact of the new rotavirus vaccine program in Morocco.

HIV-1 Subtype distribution in morocco based on national sentinel surveillance data 2004-2005.

BACKGROUND: Little is known about HIV-1 subtype distribution in Morocco. Some data suggest an emergence of new HIV subtypes. We conducted phylogenetic analysis on a nationally representative sample of 60 HIV-1 viral specimens collected during 2004-2005 through the Morocco national HIV sentinel surveillance survey. RESULTS: While subtype B is still the most prevalent, 23.3% of samples represented non-B subtypes, the majority of which were classified as CRF02_AG (15%). Molecular clock analysis confirmed that the initial introduction of HIV-1B in Morocco probably came from Europe in the early 1980s. In contrast, the CRF02_AG strain appeared to be introduced from sub-Saharan Africa in two separate events in the 1990s. CONCLUSIONS: Subtype CRF02_AG has been emerging in Morocco since the 1990s. More information about the factors introducing HIV subtype-specific transmission will inform the prevention strategy in the region.

Evaluation of a dry format reagent alternative for CD4 T-cell enumeration for the FACSCount system: a report on a Moroccan-Canadian study.

BACKGROUND: Efforts to improve alternative CD4 T-cell counting methods are critical to accelerate the implementation of HIV antiretroviral therapy in resources limited regions. Substituting liquid format reagents to eliminate cold-chain transportation and refrigerated storage with dry format reagents contributes to higher efficiency supply management solution especially for laboratories at remote locations. ReaMetrix has developed dry format reagent kits compatible with the FACSCount system, a dedicated flow cytometer for T-cell subset enumeration widely used in resource limited settings. A dual site collaborative study was designed to compare T-cell subsets using both the new dry format ReaMetrix reagent and the original BD Biosciences liquid reagents. METHOD: A total of 167 HIV positive samples prepared with Rea T Count (ReaMetrix) and FACSCount (BD Biosciences) reagents were analyzed using FACSCount Systems. To compare both methods, Bland-Altman, Pollock, Scott % similarity and correlation coefficient statistical analysis was applied. Immuno-Trol served as an assay processing control and quality indicator of interlaboratory and intralaboratory variation. RESULTS: The mean bias and limits of agreement for CD4 T-cell measurements between Rea T Count and FACSCount reagents were -16 cells/microl (-4.6%) and -74 to +43, respectively. The correlation obtained was 0.988 with a similarity of 97.9%. Between laboratory variation data was very good with %CV below 10%. CONCLUSION: The introduction of dry reagents permits the elimination of cold-chain transportation and the on-site refrigerated storage without compromise to assay quality. The substitution of dry reagents facilitates easier supply management practice that will assure wider access to quality HIV treatment.