European framework to decrease the burden of TB/HIV.

Tuberculosis (TB) in Europe is declining in countries in western and central Europe, but the burden is still high and increasing in eastern Europe. HIV/AIDS is increasing dramatically in eastern Europe. HIV-related tuberculosis (TB/HIV) morbidity and mortality are expected to accelerate significantly in the future. This framework aims to guide European countries in developing their national plan for reducing TB/HIV morbidity and mortality. It results from an extensive consultation process undertaken by the World Health Organization Regional Office for Europe and by those responsible for HIV/AIDS and TB programmes and their partners. It builds on strategies developed globally and in Europe for TB control and for HIV/AIDS prevention and care. This framework sets out the rationale for effective collaboration between HIV/AIDS and tuberculosis national programmes. It identifies five strategic components (political commitment, collaborative prevention, intensified case-finding, coordinated treatment and strengthened surveillance) and eight key operations (central coordination, policy development, surveillance, training, supply management, service delivery, health promotion and research).

Cost-effectiveness analysis of the russian treatment scheme for tuberculosis versus short-course chemotherapy: results from Tomsk, Siberia.

SETTING: Tomsk Oblast, Siberia. OBJECTIVE: To assess the cost-effectiveness of individualised Russian treatment and short-course chemotherapy (SCC) regimens for new WHO Category I tuberculosis patients. DESIGN: Analysis of costs incurred by the provider, the household and society as a whole for both treatment approaches, and a sensitivity analysis for SCC with hospitalisation for 2 weeks (patients theoretically at low risk of defaulting) and 2 months (patients theoretically at risk of defaulting). Outcomes were measured as cost per case cured and year of life saved, with cure rates based on a locally conducted trial. RESULTS: The cost per cure using the individualised Russian treatment was US $2,295, vs. US $1,901 when using SCC. The costs per year of life saved were respectively US $123 and US $103. The cost per cure was US $1,457 for SCC with 2 months hospitalisation and US $556 for SCC with 2 weeks hospitalisation, with costs per year of life saved of US $79 and US $30, respectively. CONCLUSION: Major financial savings for both the provider and the household, with cure rates similar to those obtained with the Russian treatment scheme, can be achieved in Tomsk when embarking on SCC with 2 weeks and 2 months hospitalisation.

Comparison of the effectiveness of WHO short-course chemotherapy and standard Russian antituberculous regimens in Tomsk, western Siberia.

BACKGROUND: There has been a resurgence of tuberculosis in Russia in the past decade. Traditional Russian services for treatment of tuberculosis are very different from those in the west. We aimed to compare the effects of WHO short-course chemotherapy with standard Russian antituberculous regimens. METHODS: New tuberculosis patients aged 18 years or older were included in a trial and systematically allocated to traditional Russian tuberculosis treatments or WHO short-course chemotherapy in the two largest tuberculosis diagnostic and treatment centres of Tomsk Oblast, western Siberia. Standard WHO tuberculosis outcomes and rates of sputum conversion were used as primary outcomes. Analyses were by intention-to-treat. FINDINGS: 646 new cases were enrolled into the trial, of which 356 patients were given Russian tuberculosis treatment (155 smear positive) and 290 were given WHO short-course chemotherapy (155 smear positive). There was no statistical difference between the proportion cured or completing treatment (63% for both groups [difference in proportion=0%, 95% CI -11 to 11%]); or dying (short-course chemotherapy, 8% vs Russian, 11% [difference in proportion=-3%, 95% CI -9 to 4%]). There was no statistical difference with respect to sputum conversion rate at 6 months (91% vs 85% [difference in proportion=6%, 95% CI -2 to 13%]). Overall, outcomes were worse among patients with multidrug resistant isolates than non-resistant isolates. INTERPRETATIONS: WHO short-course chemotherapy treatment for tuberculosis can work well in Russia.

The United States National Prospective Hemolytic Uremic Syndrome Study: microbiologic, serologic, clinical, and epidemiologic findings.

The frequency of Shiga toxin-producing Escherichia coli (STEC) serotypes associated with postdiarrheal hemolytic uremic syndrome (HUS) cases among children and adults in the United States and the proportion with IgM or IgG lipopolysaccharide antibodies to E. coli O157 were determined by use of a nationwide sample from January 1987 through December 1991. Among 83 patients, STEC were isolated from 30 (43%) of 70 whose stool cultures yielded bacterial growth (25 E. coli O157 isolates and 5 non-O157 STEC isolates). Fifty-three (80%) of 66 patients with serum samples had positive O157 lipopolysaccharide antibody titers. Of the 83 patients, 60 (72%) had evidence of STEC infection, including 6 of 8 adults whose illnesses also met criteria for thrombotic thrombocytopenic purpura. Data from a subset of patients suggest that E. coli O157 was the cause of > or = 80% of the STEC infections. All 3 women who were postpartum had evidence of E. coli O157 infection. STEC infection should be considered the likely cause for all persons with postdiarrheal HUS.

Developing nursing practice as part of the collaborative TB control programme, Tomsk, Siberia.

SETTING: Review of nursing practice, identification of training needs and implementation of training for nurses working in the Tomsk Oblast' Tuberculosis Services (TOTBS), Russia. OBJECTIVE: Preparation of TOTBS nurses for the implementation of a WHO-style TB control programme in January 1997. METHODS: Nursing services and training needs were assessed through observation visits to a number of institutions providing care for TB patients, semi-structured interviews, and discussions at staff meetings. Training sessions focused on the WHO DOTS strategy, patient education and default tracing. An evaluation visit focused on nurses' attitudes and levels of treatment completion. RESULTS: Out of a total of 165 TB cases notified in Tomsk Oblast' between January and March 1997, 53 were started on DOTS on an ambulatory basis. Five patients who defaulted returned to treatment within five days (range 2-5) and no patients were lost to follow up. Improved compliance was attributed to better patient education offered by nurses and a reliable supply of medication. Quarterly reports continue to show satisfactory levels of treatment completion. CONCLUSIONS: Obstacles to the development of nursing practice included resistance to change and low morale due to enormous workloads, no pay and staff shortages. Motivation improved through the setting of achievable targets.

Comparison of the effects of anaerobic and micro-aerophilic incubation on resistance of Helicobacter pylori to metronidazole.

To assess the influence of incubation conditions on the resistance of Helicobacter pylori this study compared the effect of micro-aerophilic and anaerobic incubation followed by micro-aerophilic incubation on the measurement of metronidazole resistance of 102 H. pylori isolates, by both disk diffusion and Epsilometer (E)-tests. Anaerobic incubation for 24 h before micro-aerophilic incubation for 48 h consistently increased metronidazole activity in both assay methods. Although statistically significant, this was microbiologically less significant, as only 4 of 102 isolates gave discrepant readings (all four were resistant in micro-aerophilic conditions but susceptible in anaerobic/micro-aerophilic conditions). In all four cases variation was by a few millimeters in zone size (i.e., all were close to the cut-off point). There was 100% agreement between disk diffusion and E-test results. Of 104 observations (52 duplicate assays: 13 strains, two atmospheric conditions, two methods of determining resistance) there was 100% intra-observer and inter-observer agreement with regard to susceptibility and resistance status for both E-test and disk diffusion methods. Anaerobic incubation followed by micro-aerophilic incubation had little effect on the estimation of prevalence of metronidazole resistance and seemed to add little, if any, significant advantage over micro-aerophilic incubation alone.

Salmonellosis in North Thames (East), UK: associated risk factors.

We assessed the rate of salmonella infections and risk factors associated with infection in North East Thames in 1993. Cases of culture confirmed infection were identified through microbiology laboratories and environmental health officers in the North East Thames. A total of 1730 cases were reported and 209 of these individuals (those who could be contacted within a 3-week interval after onset of symptoms) and matched controls were interviewed by telephone. In addition randomly selected controls were interviewed over a 4-month period about recent gastric acid lowering medication and antimicrobial ingestion. Sixty-six serotypes were identified: S. enteritidis was isolated from 1179 (69%) cases, S. typhimurium from 221 (13%), S. virchow from 77 (4%) and S. newport 25 (1%). Infections were more frequent in summer months. Highest rates were documented in children under 2 years of age for S. enteritidis (108/100,000) and under 1 year for S. typhimurium (36/100,000). Using the Townsend score, highest isolation rates of S. enteritidis were in more prosperous areas (36/100,000 vs. 27/100,000; odds ratio (OR) 1.3, 95% confidence intervals (CIs) 1.2-1.6, P < 0.0001), while for S. typhimurium, there was no relation between deprivation index and isolation rates areas (6.4/100,000 vs. 6.1/100,000; OR 1.1, 95% CIs 0.8-1.5, P = 0.77). The case control study showed a significant association between ingestion of products containing raw eggs and S. enteritidis infection (8/111 cases vs. 0/110 controls; OR undefined, lower 95% CIs 3.4). Individuals with salmonella infection were significantly more likely to have travelled abroad in the week before the onset of illness [42/186 (23%) vs. 1/182 (0.5%); OR 40, 95% CIs = 5.5-291, P < 0.001] and to report gastroduodenal disease [11/143 (7%) vs. 3/143 (2%); OR 5.0, 95% CIs = 1.1-23, P = 0.04]. There was an association between illness and gastric acid-lowering medications [unmatched controls OR 22.3 (95% CIs 1.5-3.7, P = 0.0002), matched controls OR 3.7 (95% CIs 1.0-3.8, P = 0.07)], but no association with antimicrobial ingestion.

Mortality and morbidity among Rwandan refugees repatriated from Zaire, November, 1996.

INTRODUCTION: Following renewed ethnic violence at the end of September 1996, conflict between Tutsi rebels and the Zairian army spread to North Kivu, Zaire where approximately 700,000 Rwandan Hutu refugees resided following the 1994 genocide. After a major rebel offensive against the camps' militia groups on 15 November, a massive movement of refugees towards Rwanda through Goma town, the capital of North Kivu, began. Massive population movements such as this are likely to be associated with substantial mortality and morbidity. OBJECTIVE: To study patterns of mortality, morbidity, and health care associated with the Rwandan refugee population repatriation during November 1996. METHODS: This study observed the functioning of the health-care facilities in the Gisenyi District in Rwanda and the Goma District in Zaire, and surveyed mortality and morbidity among Rwandan refugees returning from Zaire to Rwanda. Patterns of mortality, morbidity, and health care were measured mainly by mortality and health centre consultation rates. RESULTS: Between 15 and 21 November 1996, 553,000 refugees returned to Rwanda and 4,530 (8.2/1,000 refugees) consultations took place at the border dispensary (watery diarrhea, 63%; bloody diarrhea, 1%). There were 129 (0.2/1,000) surgical admissions (72% soft tissue trauma) to the Gisenyi hospital in the subsequent two weeks. The average number of consultations from the 13 health centres during the same period was 500/day. Overall, the recorded death rate was 0.5/10,000 (all associated with diarrhea). A total of 3,586 bodies were identified in the refugee camps and surrounding areas of Goma, almost all the result of trauma. Many had died in the weeks before the exodus. Health centres were overwhelmed and many of the deficiencies in provision of health care identified in 1994 again were evident. CONCLUSIONS: Non-violent death rates were low, a reflection of the population's health status prior to migration and immunity acquired from the 1994 cholera outbreak. Health facilities were over stretched, principally because of depleted numbers of local, health-care workers associated with the 1994 genocide. Health-care facilities running parallel to the existing health-care system functioned most effectively.

Vibrio vulnificus infection reporting on death certificates: the invisible impact of an often fatal infection.

This study assessed accuracy of (a) recording Vibrio vulnificus infection on death certificates and (b) International Classification of Disease (ICD)-9 codes for V. vulnificus. Patients with microbiologically confirmed V. vulnificus infection were identified as part of co-ordinated surveillance in four USA Gulf Coast states between 1989 and 1993. Of 60 deaths, 51 death certificates were reviewed and V. vulnificus was recorded as the immediate cause of death on 11 (22%). There was no ICD-9 code for V. vulnificus infection, thus no patients had an ICD-9 code indicating V. vulnificus infection. Of 23 certificates where V. vulnificus was recorded on the death certificate, only 5 (22%) were coded for Gram-negative, septicaemia. This study highlights the importance of teaching physicians how to provide epidemiologically meaningful data on death certificates and the need for accurate ICD mortality codes.

Helicobacter pylori acquisition in infancy after decline of maternal passive immunity.

We evaluated the natural history of Helicobacter pylori infection and the host immune response in 80 infants, and determined seroprevalence of H. pylori infection in their Taiwanese mothers. Decline in passively transferred maternal anti-H. pylori IgG antibodies and subsequent H. pylori infection was assessed in infants over 14 mo. A sensitive and specific, 96-well microtiter ELISA for the detection of H. pylori IgG antibodies was used to evaluate maternal serum (single specimen) and their infants (birth, 1, 2, 3, 6, 12, and 14 mo). Sera were also evaluated by ELISA for the presence of anti-H. pylori IgM antibodies in the infants. Maternal H. pylori IgG seroprevalence was 62.5% [50/80; 95% confidence intervals (CI), 51-73%]. All infants born to the 50 seropositive mothers passively acquired maternal H. pylori IgG. Transplacentally transferred maternal anti-H. pylori IgG lasted until about the 3rd mo of life, and disappeared in nearly all the infants by 6 mo of age. Seven and one-half percent of infants (6/80; 95% CI, 3-16%) acquired H. pylori infection; two were born to H. pylori-negative mothers. Among the six IgG seropositive infants, an IgM response specific for H. pylori antigens was detected and appeared to precede the rise in IgG in five. We conclude that maternal passive transfer of IgG antibodies occurs in the infant and disappears by 6 mo of age. H. pylori infection is acquired in infancy in this population; IgM antibodies against H. pylori are detectable, seem short-lived, and appear to precede IgG antibody development.

Shiga-like toxin-producing Escherichia coli O111 and associated hemolytic-uremic syndrome: a family outbreak.

OBJECTIVE: To describe a family cluster of Shiga toxin-producing Escherichia coli O111ac:NM infection. STUDY DESIGN: The index case was identified as part of a United States prospective study of hemolytic-uremic syndrome. Epidemiologic investigation was conducted through interviews. E. coli O111:NM infection was characterized through culture and serology. Shiga toxin 1 and 2 gene sequences were determined with oligonucleotide DNA probes. RESULTS: All three children and both parents had nonbloody diarrhea, vomiting and abdominal cramps, and one child developed hemolytic-uremic syndrome. Shiga toxin 1- and 2-producing E. coli O111ac:NM was isolated from two children. IgG antibodies to E. coli O111 were detected in all three children. CONCLUSIONS: To our knowledge this is the first reported cluster of O111 infection and only the second caused by non-O157 Shiga toxin-producing E. coli in North America.