Adverse events among persons with TB using in-person vs. electronic directly observed therapy.

BACKGROUND: We evaluated patient safety within a randomized crossover trial comparing electronic directly observed therapy (eDOT) to in-person DOT (ipDOT) in persons undergoing TB treatment in New York City, NY, USA.METHODS: Participant symptoms, symptom severity, and clinical management were documented. We assessed adverse event reports (AERs) by DOT method during the two-period crossover. Using Cox proportional-hazards mixed-effects models, we estimated the adjusted hazard ratio (aHR) of participants reporting an adverse event (AE) vs. not reporting an AE.RESULTS: Of 211 participants, 57 (27.0%) reported AEs during the two-period crossover; of these, 54.4% (31/57) were reported while using eDOT vs. 45.6% (26/57) while using ipDOT. Controlling for study group and period, the aHR for eDOT vs. ipDOT was 0.98 (95% CI 0.49-1.93). Although statistically not significant, the wide confidence intervals suggest that a significant association cannot be entirely ruled out. Gastrointestinal symptoms were most frequently reported (42.1%, 24/57). AER types and severity did not differ significantly by DOT method. Days from symptom onset to medical attention was similar across DOT methods (median: 1.0 day, IQR 0.0-2.0). No participants switched DOT methods due to AERs or monitoring concerns.CONCLUSION: Further evaluation to ascertain whether AERs differ when patients use eDOT vs. ipDOT is warranted.

Tuberculosis prevention and control activities in the United States: an overview of the organization of tuberculosis services.

After a 20% increase in tuberculosis (TB) cases between 1986 and 1992, TB cases in the United States have declined from 1993 through 1997, an average of 5 to 7 per cent per year. In this paper, we review trends and the current epidemiology of TB in the US, present a brief history of TB control efforts in the country, and present the key strategies for TB control in the US. We describe the current organizational structure of TB services in the US, the role of the private sector in TB control, and how TB control is funded. Finally we discuss the mechanisms by which TB policy is developed. The US model represents a categorical disease program that combines a centralized role of the national government in development of policy, funding, and in the maintenance of national surveillance, and a decentralized role of state and local jurisdictions, which adapt and implement national guidelines and which are responsible for day-to-day program activities. Given the relative success of this combined approach, other countries facing the challenge of maintaining an effective TB control program in the face of increased decentralization of health services may find this description useful.

Measles control in Kinshasa, Zaire improved with high coverage and use of medium titre Edmonston Zagreb vaccine at age 6 months.

BACKGROUND: To improve measles control in Kinshasa, Zaire, a project to increase vaccine coverage was begun in 1988, and in 1989, the city vaccination programme changed measles vaccination policy from Schwartz vaccine at age 9 months to medium titre Edmonston Zagreb (EZ) vaccine at age 6 months. We report the impact of the programme on measles incidence and mortality. METHODS: Data on vaccine coverage were obtained from cluster sample surveys conducted every 1-2 years and from routine reports of vaccine doses administered. Data on measles incidence and mortality were obtained from sentinel surveillance sites. The serological response to EZ measles vaccine was evaluated at a health centre in 1989 and in a community survey in 1990. RESULTS: Measles vaccine coverage estimated in cluster surveys increased from 50% of the 1984 birth cohort to 89% of the 1989 birth cohort, accepting either a home-based record or a verbal history of vaccination. Reported measles incidence per 10,000 [corrected] population decreased by over 90%, from 37.5 in 1980 (early vaccination years) to 1.6 in 1991. There was a relative decrease in the proportion of cases aged < 9 months (32% of cases in 1986-1987 and 23% of cases in 1990-1991) and an increase in the proportion aged > 23 months (29% of cases in 1986-1987 and 43% in 1990-1991). According to ELISA assays, 74-76% of children seroresponded to EZ vaccine administered at age 6-7 months under routine programme conditions. CONCLUSIONS: Measles can be controlled in urban areas, although it is difficult to determine how great a contribution vaccination at age 6 months makes over and above the achievement of high coverage.

Quality of sexually transmitted disease services in Jamaica: evaluation of a clinic-based approach. Collaborative Working Group on Indicators of STD Case Management

As part of a larger strategy to develop global indicators of HIV (human immunodeficiency virus) infection prevention programmes, a clinic-based method for the assessment of sexually transmitted disease (STD) service quality was developed and field tested by trained observers who visited a random sample of public-sector clinics in Jamaica in October 1991. The assessment included an inventory of equiptment and drugs, interview with clinic staff, and observations of 27 health workers in 15 clinics as they provided services to 115 patients presented for STD care. This observation-based method provided Jamaican programme managers with descriptive data on STD case management in public clinics within a one-month study period at an approximate local cost of US$ 5000. Based on weighted estimates, 91 percent of public-sector STD patients in Jamaica were seen in clinics whose staff had received some training in STD case management during the preceding 12 months. The correct treatment rate was estimated to be 82 percent for those diagnosed with gonorrhoea, and 70 percent for those diagnosed with syphilis. Based on 98 observed encounters for first-time-for-episode patients, counselling included sex partner referral (57 percent), partner reduction (48 percent), and condom use (59 percent). Although 61 percent of STD patients were seen in clinics with condoms in stock on the day of the assessment, only 23 percent were offered condoms during their visit. The clinic-based assessment method can be adapted to the programme management and reporting needs of the countries at all stages of STD service development, and can provide data needed to improve programme operations and meet international reporting standards (AU)

The role of applied research in donor-supported public health programmes in developing countries - abstract

The basic goal of scientific inquiry, whether in individual patient care or in health practice, is to replace intuitive thinking or ad hoc decision-making with methodological tools for appropriate decision-making. Two objectives of the USAID-supported African Child Survival Initiative - Combatting Childhood Communicable Disease (ACSI-CCCD) have been to provide data necessary for programmatic needs and to develop indigenous research capability among African counterparts and institutions. The twelve-year experience of applied research in ACSI-CCCD was reviewed through project documents, research reports and proposals, and focus groups, individual interviews and on-site visits with African investigators and programme managers. Research undertaken with CCCD support was compared to the typology of Feachem et al which classifies the priorities for developing country research in hiearchical fashion. Particular attention was paid to evaluating programme or policy impact or research findings, benefits to local institutions or individual researchers, and perceived value of the research proces or results to local, national or regional health objectives. Over 250 research activities in 18 countries received CCCD support from the project's inception. Significant accomplishments were achieved in strengthening research capacity as well as advancing programmatic objectives, despite the conflicting nature of these goals. Identified strengths of the CCCD research component were its close links to local programmes and programme managers, responsiveness to local priorities, availability of local review and funding mechanisms, policy relevance, and flexibility in the face of changing circumstances. Skills transfer and availability of technical assistance were also highlighted. Weaknesses identified included inadequate monitoring and supervision of research activities (particularly in remote or widespread geographical locations), absence of a clear agenda or priorities for indigenous research, sometimes conflicting objectives of donors and local programme managers, and relatively small achievements in institutional strengthening. Long-term benefits in donor-sponsored applied research will require acknowledging a clear distinction between "promoting research" and "developing researchers". Both short-term training, such as workshops and mentoring relationships, and formal postgraduate training are necessary to establish an acceptable and sustainable research infrastructure for health services in developing countries (AU)

Changes in use of health services in a rural health zone in Zaire.

As part of the Combatting Childhood Communicable Diseases (CCCD) project funded by the US Agency for International Development (USAID), the Zairian CCCD programme conducted surveys in the rural health zones of Kingandu and Pai-Kongila, Zaire, in 1984-1985 and 1988-1989 to determine whether a strategy of selective primary health care would affect childhood mortality. This paper describes the changes in the medical care infrastructure and the increasing coverage of selected services. The strategies evaluated were vaccination, oral rehydration therapy, and treatment of febrile episodes with antimalarial drugs for children; and tetanus vaccination and malaria prophylaxis for pregnant women. The health infrastructure in the Kingandu and Pai-Kongila Health Zones expanded considerably from 1984 to 1989, with health centres increasing from 7 to 18. During this period, economic conditions deteriorated moderately, with the nation experiencing nearly 700% inflation. Medical care costs remained stable because of external subsidies. Use of health services was assessed in 1984, 1988, and 1989. Between 1984 and 1989, the proportion of children aged 12-23 months vaccinated against measles increased from 22% to 71%. Coverage with other vaccine antigens increased similarly. Women's knowledge of the correct recipe for the preparation of sugar-salt solution increased from 0% to 61%. Reported treatment at home with sugar-salt or oral rehydration solution increased from 6% to 53%. The proportion of children with febrile episodes who were treated presumptively for malaria with chloroquine remained unchanged (47% in 1984; 44% in 1988). We conclude that, despite a moderate deterioration in economic conditions, Kingandu and Pai-Kongila Health Zones achieved remarkable increases in use of selected health services between 1984 and 1989, especially in vaccination coverage.

Is there a risk to contacts of patients with rabies?

The number of persons in the United States potentially in contact with rabid humans has increased in recent years because of labor-intensive medical care, longer survival times, and care in two or more hospitals. Many of these persons request rabies prophylaxis, and their physicians prescribe it because of their insecurity, a situation that is expensive and often unnecessary. Records of the Centers for Disease Control and the literature were reviewed to examine the current practice of prophylaxis of contacts and the actual need for it. Rabies virus is present in a variety of human fluids and tissues during the first five weeks of illness, but there are only four well-documented reports of human-to-human transmission--all in corneal transplant recipients. Prophylaxis of contacts of 14 rabid patients was predominantly for saliva exposure to open wounds or mucous membranes and was given most often to medical personnel having the greatest contact with the patient. Although it has never been documented, human-to-human transmission of rabies following saliva exposure remains a theoretical possibility. Virus shedding by rabid patients should be studied thoroughly in the future. Recommendations for managing contacts of rabid patients are presented.

Genetic and biochemical factors relevant to alcoholism.

Important biochemical clues from animal and human studies as well as epidemiologic studies of twins and adoptees suggest that genetic factors may predispose to alcohol addiction. This paper critically examines the epidemiology and biochemistry literature to assess the strength of the evidence supporting a genetic element in alcohol addiction. Then, a biochemical hypothesis is presented that involves the identification of specific metabolic pathways, pathway controls, and metabolites that may be unique to alcoholics, and which has been tested by experiment.

Sudden death among Southeast Asian refugees. An unexplained nocturnal phenomenon.

In the period July 15, 1977, through March 30, 1982, there were at least 51 sudden, unexplained deaths in the United States among refugees from Southeast Asia. These deaths involved relatively young (median age, 33 years), previously healthy persons. All except one were male, and all died at night. Available data from studies among young adults in this country suggest that this specific phenomenon has an unusually high incidence among Laotian and Kampuchean refugees and, furthermore, has not previously been observed in the United States. Interviews with families of the decedents and a case-control study have failed to establish causal factors, but emotional stress cannot be ruled out as a contributing element. While reviews of the forensic investigations have confirmed the absence of important common pathological or toxicological findings, preliminary findings of special postmortem cardiac studies, now in progress, suggest that at least some of these deaths may be associated with developmentally abnormal conduction system pathways. Further studies are required to confirm this association, to define the apparently sleep-induced mechanism that triggers these deaths, and to explain the male preponderance in this disorder.

2,3-butanediol: an unusual metabolite in the serum of severely alcoholic men during acute intoxication.

In a controlled experiment 15 (79%) of 19 severely alcoholic men but only 1 of 22 controls had a serum concentration of greater than or equal to 5 mumol/l 2,3-butanediol after ingestion of distilled spirits. Another diol, 1,2-propanediol, was found in a concentration of greater than or equal to 5 mumol/l in all patients' specimens after drinking; but it was also present in lower concentrations in the reference specimens of most of the patients. These data are consistent with the experimental evidence that ethanol can be metabolised in rats to produce 2,3-butanediol and with the epidemiological hypothesis that severely alcoholic men metabolise ethanol by a different pathway than do control subjects.

A large outbreak of hepatitis A in a day-care center: association with non-toilet-trained children and persistence of IgM antibody to hepatitis A virus.

In early summer, 1979, a large outbreak of hepatitis A occurred in an Oklahoma day-care center. A total of 41 cases were confirmed, all in adults. Of the 115 non-employee households represented by children in the center, 19 households (16.5%) had one or more cases of hepatitis. Hepatitis occurred in 29% of the households with at least one non-toilet-trained child, compared to 2% of the households without such a child (p = 0.00004). At least four (15%) of 27 center employees had hepatitis. Of 26 cases tested serologically, all were positive for hepatitis A antibody (anti-HAV), and 24 of these 26 were also positive for anti-HAV of immunoglobulin class M (anti-HAV IgM), at an average time after onset of illness of 80 days (range, 38-142 days). Three of ten persons remained anti-HAV IgM-positive 164 days after onset.