Prevention of bronchial fistulas after pneumonectomies for selected cavitary drug resistant lung tuberculosis.

Background: The World Health Organization guidelines for management drug resistant tuberculosis include surgery as an additional method in selected cases. Pneumonectomies have higher risk of morbidity such as bronchial fistulas which may be prevented by bronchial stump covering. We compare two methods of bronchial stump reinforcement. Methods and materials: A retrospective single center follow-up study was done in 52 patients who underwent pneumonectomy for drug resistant pulmonary tuberculosis. Between 2000 and 2017 we performed pneumonectomies with pericardial fat reinforcement of bronchial stump in group 1 (n = 42), and between 2017 and 2021 in group 2 with pedicled muscle flap reinforcement group 2 (n = 10). Results: Bronchial fistulas occurred in 17/42 (41%) of patients group 1 and there was no fistula in group 2, and this was statistically different (Fisher's test p = 0.02). Post-operative complications were seen in 24/42 (57%) of the patients in Group 1, and 4/10 (40%) patients in Group 2 (Fischer's test p = 0.53). In group 1 positive bacteriology decreased from 74% to 24% just after surgery, and in group 2 it decreased from 90% to 10%, but this was not statistically different (Fisher's test p = 0.63). In group 1 no-one died the first month, but 8/42 (19%) died within a year; in group 2 one died within a month, and only this death (10%) within a year. This difference in case fatality was not statistically significant. Conclusions: The use of pedicle muscle flap for bronchial stump coverage during the pneumonectomies for destructive drug resistant tuberculosis can prevent severe postoperative fistulas and improve postoperative life.

Are patients with pulmonary tuberculosis identified by active and by passive case detection different? A cross-sectional study in Pakistan.

OBJECTIVES: Our objective was to compare the characteristics of patients with pulmonary tuberculosis (TB) identified through "extended contact screening" (ECS) with those of patients identified through routine passive case finding (PCF). METHODS: Active TB case finding by ECS was tested from 2013-2015. This was a cross-sectional study based on data collected from ECS and routine program data from Lahore, Faisalabad, and Rawalpindi districts, and Islamabad in 2015. Characteristics of patients identified through ECS and PCF were compared. RESULTS: Of the 12,114 patients with pulmonary TB in the study, 4604 (38%) were identified through ECS, of whom 4052 (88%) had bacteriological confirmation. Male patients comprised 56.2% (95% confidence interval [CI] 54.8-57.6) of patients with pulmonary TB identified through ECS and 49.7% (95% CI 48.6-50.8) of those identified through PCF. The proportion of bacteriologically confirmed cases was 88.0% (95% CI 87.1-88.9) in the ECS group and 50.3% (95% CI 49.2-51.4) in the PCF group. By regression analysis we found that compared with patients aged 15-44 years, children aged <15 years had higher chances of being identified through ECS (adjusted odds ratio 2.69; 95% CI 2.21-3.28). There was a higher chance of cases being detected by ECS in Faisalabad (adjusted odds ratio 2.57; 95% CI 2.01-3.29) than in Islamabad. CONCLUSION: ECS identified a higher proportion of male and child patients with pulmonary TB than routine case finding; both of these groups are more often unidentified through routine TB control.

Extending contact screening within a 50-m radius of an index tuberculosis patient using Xpert MTB/RIF in urban Pakistan: Did it impact treatment outcomes?

BACKGROUND: Pakistan implemented initiatives to detect tuberculosis (TB) patients through extended contact screening (ECS); it improved case detection but treatment outcomes need assessment. OBJECTIVES: To compare treatment outcomes of pulmonary TB (PTB) patients detected by ECS with those detected by routine passive case finding (PCF). METHODS: A cohort study using secondary program data conducted in Lahore, Faisalabad and Rawalpindi districts and Islamabad in 2013-15. We used log binomial regression models to assess if ECS was associated with unfavorable treatment outcomes (death, loss-to-follow-up, failure, not evaluated) after adjusting for potential confounders. RESULTS: We included 79,431 people with PTB; 4604 (5.8%) were detected by ECS with 4052 (88%) bacteriologically confirmed. In all PTB patients the proportion with unfavorable outcomes was not significantly different in ECS group (9.6%) compared to PCF (9.9%), however, among bacteriologically confirmed patients unfavorable outcomes were significantly lower in ECS (9.9%) than PCF group (11.6%, P = 0.001). ECS was associated with a lower risk of unfavorable outcomes (adjusted relative risk (aRR) 0.90; 95% CI 0.82-0.99) among 'all PTB' patients and bacteriologically confirmed PTB patients (aRR 0.91; 95% CI 0.82-1.00). CONCLUSION: In PTB patients detected by ECS the treatment outcomes were not inferior to those detected by PCF.

Determinants of early child development in rural Tanzania.

BACKGROUND: It has been estimated that more than 200 million children under the age of five do not reach their full potential in cognitive development. Much of what we know about brain development is based on research from high-income countries. There is limited evidence on the determinants of early child development in low-income countries, especially rural sub-Saharan Africa. The present study aimed to identify the determinants of cognitive development in children living in villages surrounding Haydom, a rural area in north-central Tanzania. METHODS: This cohort study is part of the MAL-ED (The Interactions of Malnutrition & Enteric Infections: Consequences for Child Health and Development) multi-country consortium studying risk factors for ill health and poor development in children. Descriptive analysis and linear regression analyses were performed. Associations between nutritional status, socio-economic status, and home environment at 6 months of age and cognitive outcomes at 15 months of age were studied. The third edition of the Bayley Scales for Infant and Toddler Development was used to assess cognitive, language and motor development. RESULTS: There were 262 children enrolled into the study, and this present analysis included the 137 children with data for 15-month Bayley scores. Univariate regression analysis, weight-for-age and weight-for-length z-scores at 6 months were significantly associated with 15-month Bayley gross motor score, but not with other 15-month Bayley scores. Length-for-age z-scores at 6 months were not significantly associated with 15-month Bayley scores. The socio-economic status, measured by a set of assets and monthly income was significantly associated with 15-month Bayley cognitive score, but not with language, motor, nor total 15-month Bayley scores. Other socio-economic variables were not significantly associated with 15-month Bayley scores. No significant associations were found between the home environment and 15-month Bayley scores. In multivariate regression analyses we found higher Bayley scores for girls and higher Bayley scores in families with more assets. Adjusted R-squared of this model was 8%. CONCLUSION: We conclude that poverty is associated with a slower cognitive development in children and malnutrition is associated with slower gross motor development. This information should encourage authorities and other stakeholders to invest in improved welfare and nutrition programmes for children from early infancy.

Making progress towards food security: evidence from an intervention in three rural districts of Rwanda.

OBJECTIVE: Determining interventions to address food insecurity and poverty, as well as setting targets to be achieved in a specific time period have been a persistent challenge for development practitioners and decision makers. The present study aimed to assess the changes in food access and consumption at the household level after one-year implementation of an integrated food security intervention in three rural districts of Rwanda. DESIGN: A before-and-after intervention study comparing Household Food Insecurity Access Scale (HFIAS) scores and household Food Consumption Scores (FCS) at baseline and after one year of programme implementation. SETTING: Three rural districts of Rwanda (Kayonza, Kirehe and Burera) where the Partners In Health Food Security and Livelihoods Program (FSLP) has been implemented since July 2013. SUBJECTS: All 600 households enrolled in the FSLP were included in the study. RESULTS: There were significant improvements (P<0·001) in HFIAS and FCS. The median decrease in HFIAS was 8 units (interquartile range (IQR) -13·0, -3·0) and the median increase for FCS was 4·5 units (IQR -6·0, 18·0). Severe food insecurity decreased from 78% to 49%, while acceptable food consumption improved from 48% to 64%. The change in HFIAS was significantly higher (P=0·019) for the poorest households. CONCLUSIONS: Our study demonstrated that an integrated programme, implemented in a setting of extreme poverty, was associated with considerable improvements towards household food security. Other government and non-government organizations' projects should consider a similar holistic approach when designing structural interventions to address food insecurity and extreme poverty.

Persistent 'hotspots' of lymphatic filariasis microfilaraemia despite 14 years of mass drug administration in Ghana.

Background: Among the 216 districts in Ghana, 98 were declared endemic for lymphatic filariasis in 1999 after mapping. Pursuing the goal of elimination, WHO recommends annual treatment using mass drugs administration (MDA) for at least 5 years. MDA was started in the country in 2001 and reached national coverage in 2006. By 2014, 69 districts had 'stopped-MDA' (after passing the transmission assessment survey) while 29 others remained with persistent microfilaraemia (mf) prevalence (≥1%) despite more than 11 years of MDA and were classified as 'hotspots'. Methods: An ecological study was carried out to compare baseline mf prevalence and anti-microfilaria interventions between hotspot and stopped-MDA districts. Results: Baseline mf prevalence was significantly higher in hotspots than stopped-MDA districts (p<0.001). After three years of MDA, there was a significant decrease in mf prevalence in hotspot districts, but it was still higher than in stopped-MDA districts. The number of MDA rounds was slightly higher in hotspot districts (p<0.001), but there were no differences in coverage of MDA or long-lasting-insecticide-treated nets. Conclusions: The main difference in hotspots and stopped-MDA districts was a high baseline mf prevalence. This finding indicates that the recommended 5-6 rounds annual treatment may not achieve interruption of transmission.

Burden of isolation for multidrug-resistant organisms in a tertiary public hospital in Southern Brazil.

We aimed to describe the use of isolation beds between September 2011 and August 2013 at a tertiary hospital located in Southern Brazil. The main cause for isolation was gram-negative carbapenem-resistant bacteria. Huge costs were associated with isolation practices. Considering the high burden on the isolation ward, practice of surveillance cultures and contact isolation should be balanced with other infection control practices.

High attrition among HIV-infected patients with advanced disease treated in an intermediary referral center in Maputo, Mozambique.

BACKGROUND: In Mozambique, antiretroviral therapy (ART) scale-up has been successfully implemented. However, attrition in care remains a major programmatic challenge. In 2009, an intermediary-level HIV referral center was created in Maputo to ensure access to specialized care for HIV-infected patients with complications (advanced clinical-immunological stage, Kaposi sarcoma, or suspected ART failure). OBJECTIVE: To determine the attrition from care and to identify risk factors that lead to high attrition among patients referred to an intermediary-level HIV referral center. DESIGN: This was a retrospective cohort study from 2009 to 2011. RESULTS: A total of 1,657 patients were enrolled, 847 (51%) were men, the mean age was 36 years (standard deviation: 11), the mean CD4 count was 27 cells/µl (interquartile range: 11-44), and one-third were severely malnourished. The main reasons for referral were advanced clinical stages (WHO stages 3 and 4, and CD4 count <50 cells/µl) in 70% of the cases, and 19% had Kaposi sarcoma. The overall attrition rate was 28.7 per 100 person-years (PYs) - the mortality rate was 5.0 (95% confidence interval [CI]: 4.2-5.9) per 100 PYs, and the loss-to-follow-up rate was 23.7 (95% CI: 21.9-25.6) per 100 PYs. There were 793 attritions - 137 deaths and 656 lost to follow-up (LTFU); 77% of all attrition happened within the first year. The factors independently associated with attrition were male sex (adjusted hazard ratio [aHR]: 1.15, 95% CI: 1.0-1.3), low body mass index (aHR: 1.51, 95% CI: 1.2-1.8), WHO clinical stage 3 or 4 (aHR: 1.30, 95% CI: 1.0-1.6; and aHR: 1.91, 95% CI: 1.4-2.5), later year of enrollment (aHR 1.61, 95% CI 1.3-1.9), and 'being already on ART' at enrollment (aHR 13.71, 95% CI 11.4-16.4). CONCLUSIONS: Attrition rates among HIV-infected patients enrolled in an intermediary referral center were high, mainly related to advanced stage of clinical disease. Measures are required to address this, including innovative strategies for HIV-testing uptake, earlier ART initiation and nutritional supplementation, and special attention to men and those who are already on ART at enrolment. Qualitative research is required to understand the reasons for being LTFU and design informed evidence-based interventions.

Diabetes mellitus and tuberculosis: pattern of tuberculosis, two-month smear conversion and treatment outcomes in Guangzhou, China.

OBJECTIVE: There is a high burden of both diabetes (DM) and tuberculosis (TB) in China. We evaluated the association between DM and the pattern of disease, 2-month sputum smear conversion and treatment outcomes of patients with TB in Guangzhou, China. METHOD: All patients registered with TB from September 2011 to June 2012 were screened for DM and assessed for treatment outcomes in relation to presence or absence of DM and quality of DM control using patient registers, treatment cards and electronic record systems. RESULTS: There were 1589 patients with TB of whom 189 (12%) had DM. Among those with DM, there was a significantly higher proportion of men, persons aged 35 years and older and persons with smear-positive pulmonary tuberculosis (PTB) (P < 0.01). In patients with DM and new smear-positive PTB, there was a higher proportion who had positive sputum smears at 2 months (21.7% vs. 5.6%, RR 3.85, 95%CI 2.24-6.63), who were lost-to-follow-up (5.2% vs. 1.7%, RR 3.23, 95%CI 1.08-9.63) and who failed treatment (10.3% vs. 2.3%, RR 4.46, 95%CI 1.96-10.18) compared with patients who had no DM. There was no significant association between these adverse outcomes and DM control as measured by 2 and 6-month fasting blood glucose. CONCLUSION: Diabetes mellitus in new smear-positive patients with PTB was associated with failure to sputum smear convert at 2 months and adverse treatment outcomes of loss-to-follow-up and failure. Further research is needed to understand the reasons for these findings and to determine whether the current length of treatment of 6 months is adequate.

High prevalence of tuberculosis diagnosed during autopsy examination at Muhimbili National Hospital in Dar es Salaam, Tanzania.

The primary aims of tuberculosis (TB) control programmes is early diagnosis and prompt treatment of infectious cases to limit transmission. Failure to diagnose and adequately treat TB could lead to premature death and unrecognized transmission of Mycobacterium tuberculosis. The proportion of missed TB cases has not been reported in Tanzania. The objective of this study was to quantify the number of cases of TB identified by autopsy. Deceased morbid bodies from Muhimbili National Hospital were involved. Retrieval of admission, diagnostic and other important records used to manage the patient after admission was done. Demographic information, site and type of disease, past medical history, chest x-ray report, clinical diagnosis and cause of death reported upon death certification were recorded. Lung tissues, lymphnodes and blood clots for HIV testing were collected. Biopsy tissues were processed through Ziehl Nielsen staining and examined by microscopy. The study involved 74 deceased individuals where 56 (75.7%) were males. Information for duration of seeking health care before death was available for 41 (55.4%) subjects. Thirty-four (45.9%) cases received diagnosis before death. The main diagnoses were pneumonia 10 (13.5%), heart failure 6 (8.1%), AIDS-related illnesses 6 (6.8%) and malaria 5 (6.8%). The main clinical findings were wasting (51/74 (68.9%)) and abnormal fluid collection in different body cavities, 61 (50.8%). In 24 out of 71 (33.8%) biopsies acid fast bacilli (AFB) were detected. Records of lymphnodes examination were available in 63 cases and 22 of them had AFB. Twenty-two (34.9%) from the paratracheal and hilar lymphnodes were observed to have AFB. HIV was detected by ELISA in 19 (33.3%) out of 57 deceased, and 12 (63.2%) of the HIV positive deceased were co-infected with TB. Out of the 22 cases positive for AFB on tissue-biopsies 12 (54.5%) were HIV positive. There is a high number of TB cases diagnosed after death that could not be detected before they died. There is a need for increased awareness and to include post-mortem data in the annual statistics of TB for precise reporting of the magnitude of the TB burden in the country.

High maternal mortality estimated by the sisterhood method in a rural area of Mali.

BACKGROUND: Maternal mortality is high in Mali. Nevertheless, there are few studies on this topic from rural areas, and current estimates are mostly based on studies from urban settings. Our objective was to estimate the maternal mortality ratio in Kita, rural Mali. METHODS: Using the "sisterhood method", we interviewed participants aged 15-50 years from 20 villages in Kita, Mali, and thereby created a retrospective cohort of their sisters in reproductive age. Based on population and fertility estimates, we calculated the lifetime risk of maternal death, and from that the estimated approximate maternal mortality ratio. RESULTS: The 2,039 respondents reported 4,628 sisters who had reached reproductive age. Of these 4,628 sisters, almost a third (1,233; 27%) had died, and 429 (9%) had died during pregnancy or childbirth. This corresponded to a lifetime risk of maternal death of 20% and a maternal mortality ratio of 3,131 per 100,000 live births (95% confidence interval 2,967-3,296), with a time reference around 1999. CONCLUSIONS: We found a very high maternal mortality in rural Mali and this highlights the urgent need for obstetric services in the remote rural areas.

Avoidable stillbirths and neonatal deaths in rural Tanzania.

OBJECTIVE: To determine the causes of stillbirths and neonatal deaths in the community in rural Tanzania and to evaluate whether the deaths were avoidable under the prevailing circumstances. DESIGN: Review of stillbirths and neonatal deaths. SETTING: Rural northern Tanzania, Mbulu and Hanang districts. SAMPLE: One hundred and nineteen stillbirth and neonatal deaths identified in a prospective cohort of antenatal attendees and 21 stillbirths and neonatal deaths identified retrospectively in a household survey in seven rural communities. METHODS: Verbal autopsy was done to reach a diagnosis, in many cases supplemented with information from antenatal records and hospital records. The avoidability of deaths under the prevailing circumstances was assessed for each case. An account of risk factors detectable at antenatal clinic was done and compared with the woman's recall of the risk assessment and recall of being referred. MAIN OUTCOME MEASURES: Avoidability of stillbirths and neonatal deaths. RESULTS: There were 60 stillbirths, 49 early neonatal deaths and 27 late neonatal deaths. Infection-related deaths were most common (n = 53), followed by asphyxia-related deaths (n = 32) and immaturity-related deaths (n = 20). Malaria was the most common infectious agent observed (21 children and 20 mothers). Twenty-one deaths (15%) were probably avoidable and 13 (10%) were possibly avoidable. A patient-oriented avoidable factor was identified in 17 (51%) and a provider-oriented avoidable factor was identified in 22 cases (65%). Twenty-six of the 34 avoidable deaths had risk factors, but only two of the women were aware of it and only one recalled being referred to a hospital for the risk factor. There were eight deaths among the 133 mothers who experienced a perinatal death. CONCLUSION: Our data indicate that prevention and adequate treatment of infections and asphyxia in the newborn should have high priority in low-income settings. The relatively low proportion of avoidable stillbirths and neonatal deaths may be partly due to accessible emergency obstetric care in the area. Future efforts should emphasise improving the communication between midwife and women at the antenatal clinics, preparing the women-and their families-for the delivery and to be ready for complications.

Perinatal mortality in northern rural Tanzania.

The study was conducted to investigate the association between perinatal mortalityand factors relating to nutrition and infections in a rural population in northern Tanzania. A cohort of 3,618 women attending antenatal clinics was registered with background information and the results of antenatal examinations, and followed up after delivery. Stillbirths and neonatal deaths were identified and traced for an interview with the closest relatives. No information on outcome of pregnancy was obtained for seven women, and incomplete information was obtained for 99. The perinatal mortality rate was 27/1,000 births [95% confidence interval (CI) 22/1,000-33/1,000]; 44% were early neonatal deaths; and 56% were stillborn. There was an increased risk of perinatal death among babies with low birth-weight [for babies weighing 2,000-2,499 g, adjusted odds ratio (AOR) 5.8, 95% CI 2.1-15.8, babies below 2,000 g AOR 45.7; 95% CI 18.3-114.1], babies of women with a small arm circumference (below 23 cm, AOR 5.3, 95% CI 1.3-22.2), babies of women with positive VDRL serology (AOR 5.1, 95% CI 1.0-25.7), babies of mothers who had previously lost a baby (AOR 1.9, 95% CI 1.1-3.2), and among babies of nulliparous women (AOR 1.7; 95% CI 1.0-3.0). Infections and nutritional deficiencies should be addressed at antenatal clinics.

Maternal mortality in northern rural Tanzania: assessing the completeness of various information sources.

BACKGROUND: To assess the completeness of various information sources and the subsequent estimates on maternal mortality. METHODS: Maternal deaths in the study area, rural northern Tanzania, in 1995 were identified from hospital records, health centers and dispensaries, registration by village leaders, follow up of an antenatal cohort, and a household survey. Data from some of these sources were also obtained in 1996. RESULTS: In 1995, 22 of a total of 26 maternal deaths were identified at the Haydom hospital. Three of the 15 deaths (20%) reported by the village leaders were not identified at any health facility. Four deaths were found in the antenatal cohort and one death in the household survey. Only two deaths were reported by the official statistics. Of the identified maternal deaths, 85% were found from health facility data. Including data from 1996, a total of 45 maternal deaths were identified; 13 of which were direct and 32 indirect obstetric deaths. The 1995 estimated maternal mortality ratio, based on reports from the multiple source registrations, was 382 (95% confidence interval 250-560) per 100 000 live births. The antenatal cohort yielded an estimate of 322 (95% confidence interval 160-580). The ratio based on official figures for 1995 and 1996 combined was 123 (95% confidence interval 70-200). CONCLUSIONS: Even a high quality routine registration of maternal deaths will miss a small proportion of cases. Investing in better registration of direct and indirect obstetric deaths will give better insight into this important health problem. Estimates based on official reports showed substantial underreporting.

Causes and characteristics of maternal deaths in rural northern Tanzania.

BACKGROUND: To assess causes and characteristics of maternal deaths in a poorly characterized area. METHODS: A health facility- and population-based study, with an audit of case series on maternal deaths, was done in two divisions with 42 villages (population 143 000), in Mbulu and Hanang districts, Arusha region, Tanzania. In 1995, all known deaths of women between 15 and 50 years, who were residents of the study area, were recorded from all the health facilities and villages in the study area. Supplementary data from the health facilities were collected in 1996. Verbal autopsies, health facility and antenatal records, and additional oral information were used to assess each maternal death. RESULTS: Forty-five maternal deaths were identified, 26 in 1995 and 19 in 1996. Thirteen of the deaths were direct, while 32 were indirect. Hemorrhage was the main cause of direct obstetric deaths and cerebral malaria of indirect death, accounting for 20 cases, with most of them occurring during an epidemic season. Twenty-four of the women, including 10 of those dying of malaria, died postpartum. Most of the deceased women sought help at a health facility as the first place of seeking help, and used the hospital ambulance. Fourteen of the deaths (31%) were considered possibly avoidable under the prevailing circumstances, with delay in seeking help being most common. CONCLUSIONS: Addressing malaria as a major cause of maternal death, both in pregnancy and postpartum, in epidemic-prone areas, and increased community and family awareness of when to seek help could be important factors in reducing maternal deaths.