Traditional healers' role in the detection of active tuberculosis cases in a pastoralist community in Ethiopia: a pilot interventional study

Background

Pastoralists rely on traditional healers (THs) for general health problems. However, some studies indicate that such practices result in delays in the diagnosis and treatment of tuberculosis (TB) cases. This study aims to assess the role of traditional healers in the detection and referral of active TB cases in a pastoralist community.

Methods

We identified 22 traditional healers from 7 villages of Kereyu pastoralist community in the Fentale district in Ethiopia in January 2015. We trained these THs in identifying presumptive TB symptoms and early referral to the nearby healthcare facilities. The training was held during a 1 week period that included a visit to their villages and follow-up. A 1 day meeting was held with the traditional healers, the district TB care and prevention coordinator and health extension workers from the selected sub-district to discuss the referral link between THs and the nearby healthcare facilities. Health providers working at the TB units in the selected healthcare facilities were oriented about the training given and planned involvement of THs in referring presumptive TB case. In addition, documentation of the presumptive TB cases was discussed.

Results

We succeeded in tracing and interviewing 8 of the 22 THs. The rest were on seasonal migration. According to the THs report for the 1 year period, these 8 THs had referred 24 TB suspects to the healthcare facilities. Sputum smear microscopy confirmed 13 of the 24 suspects as having TB cases. Among those confirmed, 10 completed treatment and three were on treatment. Five presumptive TB cases were confirmed non TB cases through further evaluation at the healthcare facilities and six of the presumptive TB cases were lost to follow up by the THs. Whereas, four of the presumptive TB cases were lost to follow up to the healthcare facility.

Conclusions

Results of the present study indicate that THs can contribute to the detection of undiagnosed active TB cases in a pastoralist community, provided they are given appropriate training and support.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7074-9) contains supplementary material, which is available to authorized users.

Can a galacto-oligosaccharide reduce the risk of traveller's diarrhoea? A placebo-controlled, randomized, double-blind study

BACKGROUND

Diarrhoea is a common medical problem affecting travellers to Asia, Africa and Latin America. The use of prophylactic antimicrobial agents may increase the risk of contracting resistant bacteria. Findings indicate that oligosaccharides, i.e. carbohydrate chains of 3-10 monosaccharides, reduce the risk of diarrhoea.

METHODS

We performed a placebo-controlled, double-blind study of a galacto-oligosaccharide, B-GOS (Bimuno®, Clasado Ltd, Milton Keynes UK), vs placebo for participants travelling to countries with a high/intermediate risk of diarrhoea for 7-15 days. The participants ingested 2.7g of B-GOS daily from 5 days prior to departure throughout the travel period, and returned a questionnaire, with a diarrhoea log, after their return. The case definition of diarrhoea was three or more loose stools per day.

RESULTS

Of 523 enrolled subjects, 334 travellers managed to comply per protocol (PP), 349 followed the protocol at least until the onset of diarrhoea (conditionally evaluable, CE), and 408 followed the protocol with fewer than 5 days of deviance from the protocol (intention to treat, ITT). There was a significant reduction of diarrhoea incidence in the PP group (odds ratio = 0.56, P  =   0.03), while the effect in the CE group was non-significant (OR = 0.65, P  =   0.08). No significant effect was found during the first 7 days after starting with B-GOS, but from day 8 there was a significant effect in both the PP and CE groups (OR = 0.47, P  =   0.02 and OR = 0.53, P  =   0.03, respectively). The entire effect was seen in 1-day (i.e. self-limiting) diarrhoea (PP: OR = 0.25, P  =   0.004). There was no effect on duration or the number of bowel movements during diarrhoea. The severity of diarrhoea was not affected.

CONCLUSIONS

B-GOS reduces the risk of diarrhoea lasting 1 day. The protection seemed to start after a week of treatment with B-GOS. Strict compliance is crucial. The treatment is environmentally friendly and without adverse effects.

Chronic respiratory disease in adults treated for tuberculosis in Khartoum, Sudan

Background: Chronic respiratory disease (CRD) causes substantial morbidity and mortality. Although the global CRD epidemic collides with the tuberculosis (TB) epidemic in many low- and middle-income country settings, the risk of TB-associated CRD is not well described in countries with a high burden of TB. Methods: We recruited 136 patients with a history of sputum smear-positive pulmonary TB (PTB) from the TB clinic at Omdurman Teaching Hospital in Khartoum, Sudan, and 136 age- and sex-matched community controls, between 28 July 2013 and 30 December 2013. Data were collected using standardised questionnaires and spirometry was performed before and after bronchodilator. Results: The mean age of the subjects with previous PTB and controls was respectively 44.0 years (SD 8.5) and 44.5 years (SD 8.6), with 27.2% females in both groups. Chronic respiratory symptoms such as chronic cough (OR 6.67, 95%CI 2.98-14.90, P < 0.001) and the presence of chronic airflow obstruction (OR 12.4, 95%CI 1.56-98.40, P = 0.02) were both strongly associated with a past history of PTB after adjusting for potential confounders. Conclusion: The clinical features of CRDs are strongly associated with past history of PTB. An integrated approach to improve the management of these common conditions should be considered. Contexte : Les maladies respiratoires chroniques (MRC) sont à l'origine d'une morbidité et d'une mortalité considérables dans le monde. Bien que l'épidémie mondiale des MRC entre en conflit avec l'épidémie de tuberculose (TB) dans de nombreux pays à revenu faible ou moyen, le risque de MRC associée à la TB n'est pas bien décrit dans les pays durement frappés par la TB. Méthodes : Nous avons recruté 136 patients ayant des antécédents de tuberculose pulmonaire (TBP) à frottis positif dans le service de pneumologie du Centre Hospitalier Universitaire Omdurman à Khartoum, Soudan, et 136 témoins de la communauté, appariés sur l'âge et le sexe, entre le 28 juillet 2013 et le 30 décembre 2013. Les données ont été recueillies grâce à des questionnaires standardisés ainsi qu'à une spirométrie avant et après bronchodilatateur. Résultats : L'âge moyen des cas et des témoins a été de 44,0 ans (DS 8,5) et 44,5 ans (DS 8,61), respectivement, avec 27,2% de femmes dans les deux groupes. Des symptômes respiratoires chroniques comme une toux chronique (OR 6,67 ; IC95% 2,98-14,90 ; P < 0,001) et la présence d'une obstruction chronique des voies aériennes (OR 12,39 ; IC%95 1,56-98,40 ; P = 0,02) ont été tous deux fortement associés à des antécédents de TBP après ajustement sur les facteurs de confusion potentiels. Conclusion : Les caractéristiques cliniques des MRC sont fortement associées à des antécédents de TBP. Une approche intégrée visant à améliorer la prise en charge de ces pathologies fréquentes devrait être envisagée. Marco de referencia: La enfermedad pulmonar crónica (EPC) es una causa importante de morbilidad y mortalidad. Aunque la epidemia mundial de EPC rivaliza con la epidemia de tuberculosis (TB) en muchos entornos de países con bajos y medianos recursos, el riesgo de aparición de EPC asociado con la TB se ha descrito cabalmente en los países con una alta carga de morbilidad por TB. Métodos: Entre el 28 de julio y el 30 de diciembre del 2013, participaron en el estudio 136 pacientes con antecedente de tuberculosis pulmonar (TBP) y baciloscopia positiva del esputo que habían recibido tratamiento en el consultorio de neumología del Hospital Universitario Omdurman de Jartún, en Sudán, y 136 testigos sanos de la comunidad, emparejados en función de la edad y el sexo. Se recogieron datos mediante cuestionarios normalizados y se practicó una espirometría antes y despuès una prueba de broncodilatación. Resultados: El promedio de la edad en el grupo de los casos fue 44,0 (desviación estándar 8,5 años) y en el grupo de testigos fue 44,5 años (8,6 años); la proporción de mujeres en ambos grupos fue 27,2%. Se observó una fuerte asociación entre la presencia de síntomas respiratorios crónicos como la tos (OR 6,67; IC95% 2,98-14,90; P < 0,001) y la presencia de obstrucción crónica al flujo en las vías respiratorias (OR 12,39; IC95% 1,56-98,40; P = 0,02) en las personas con antecedente de TBP, una vez corregidos los posibles factores de confusión. Conclusión: La presencia de rasgos clínicos de EPC exhibe una fuerte correlación con el antecedente de TBP. Es preciso considerar la posibilidad de aplicar un enfoque integrado con el fin de mejorar la atención de ambas enfermedades tan frecuentes.

Prevalence of tuberculosis, HIV, and TB-HIV co-infection among pulmonary tuberculosis suspects in a predominantly pastoralist area, northeast Ethiopia

BACKGROUND

TB-HIV co-infection is one of the biggest public health challenges in sub-Saharan Africa. Although there is a wealth of information on TB-HIV co-infection among settled populations in Africa and elsewhere, to our knowledge, there are no published reports on TB-HIV co-infection from pastoral communities. In this study, we report the prevalence of TB, HIV and TB-HIV co-infection among pulmonary TB suspects in the Afar Regional State of Ethiopia.

DESIGN

In a cross-sectional study design, 325 pulmonary TB suspects were included from five health facilities. Three sputum samples (spot-morning-spot) were collected from each participant. Sputum samples were examined for the presence of acid fast bacilli using Ziehl-Neelsen staining method, and culture was done on the remaining sputum samples. Participants were interviewed and HIV tested.

RESULTS

Of the 325 pulmonary TB suspects, 44 (13.5%) were smear positive, and 105 (32.3%) were culture positive. Among smear-positive patients, five were culture negative and, therefore, a total of 110 (33.8%) suspects were bacteriologically confirmed pulmonary TB patients. Out of 287 pulmonary TB suspects who were tested for HIV infection, 82 (28.6%) were HIV positive. A significantly higher proportion of bacteriologically confirmed pulmonary TB patients [40 (40.4%)] were HIV co-infected compared with patients without bacteriological evidence for pulmonary TB [42 (22.3%)]. However, among ethnic Afar pastoralists, HIV infections in smear- and/or culture-negative pulmonary TB suspects [7 (7.6%)] and bacteriologically confirmed pulmonary TB patients [4 (11.8%)] were comparable. On multivariable logistic regression analysis, Afar ethnicity was independently associated with low HIV infection [OR=0.16 (95% CI: 0.07-0.37)], whereas literacy was independently associated with higher HIV infection [OR=2.21 (95% CI: 1.05-4.64)].

CONCLUSIONS

Although the overall prevalence of TB-HIV co-infection in the current study is high, ethnic Afars had significantly lower HIV infection both in suspects as well as TB patients. The data suggest that the prevalence of HIV infection among Afar pastoralists is probably low. However, population-based prevalence studies are needed to substantiate our findings.

Lipoarabinomannan-specific TNF-α and IFN-γ as markers of protective immunity against tuberculosis: a cohort study in an endemic setting

Lipoarabinomannan (LAM) is a virulent factor used for entry and survival of Mycobacterium tuberculosis (Mtb) in macrophages. Although the role of LAM for the diagnosis of tuberculosis (TB) has been extensively investigated, its cytokine response during natural Mtb infection in humans is largely unknown. In this study, LAM-specific IFN-γ, TNF-α, and IL-10 levels following whole blood assay were measured in untreated pulmonary TB patients, their contacts and community controls at baseline. In treated patients and contacts, cytokines were also measured at 6 and 12 months. At entry, 52.8% and 74.8% of controls and contacts were QFT-GIT positive, respectively. At baseline, untreated TB patients and contacts had significantly lower IFN-γ and TNF-α response compared to community controls (p < 0.0001). Besides, untreated patients had significantly higher TNF-α and IL-10 response compared to their contacts (p < 0.0001). At 6 months, contacts and treated TB patients had significantly increased INF-γ and TNF-α response (p < 0.0001). In TB patients, IFN-γ increased 10-fold following chemotherapy suggesting its potential role for treatment monitoring. The data suggests that LAM might have an anti-inflammatory effect during clinical TB and early Mtb infection. The data also suggests that LAM-induced IFN-γ and TNF-α could be used as biomarkers of protective immunity.

Pro- and anti-inflammatory cytokines against Rv2031 are elevated during latent tuberculosis: a study in cohorts of tuberculosis patients, household contacts and community controls in an endemic setting

Tuberculosis (TB) is among the leading causes of morbidity and mortality. The causative agent, Mycobacterium tuberculosis (Mtb), has evolved virulent factors for entry, survival, multiplication and immune evasion. Rv2031 (also called alpha crystallin, hspX, 16-kDa antigen), one of the most immunogenic latency antigens, is believed to play a key role in long-term viability of Mtb. Here, we report the dynamics of pro-inflammatory (IFN-γ, TNF-α) and anti-inflammatory (IL-10) cytokines against Rv2031 using whole blood assay in human cohorts in a TB endemic setting. Cytokine responses to ESAT-6-CFP-10 were also measured for comparison. Blood samples were collected from smear positive pulmonary TB patients and their contacts at baseline, 6 and 12 months, and from community controls at entry. At baseline, 54.4% of controls and 73.2% of contacts were QFT-GIT test positive. Baseline IFN-γ, TNF-α and IL-10 responses to Rv2031 were significantly higher in controls compared to contacts and untreated patients (p<0.001). Furthermore, untreated patients had significantly higher TNF-α and IL-10 responses to Rv2031 compared to contacts (p<0.001). In contacts and treated patients, IFN-γ, TNF-α and IL-10 responses to Rv2031 significantly increased over 12 months (p<0.0001) and became comparable with the corresponding levels in controls. There was a positive and significant correlation between Rv2031 and ESAT-6-CFP-10 specific cytokine responses in each study group. The fact that the levels of IFN-γ, TNF-α and IL-10 against Rv2031 were highest during latent TB infection may indicate their potential as markers of protection against TB. Taken together, the findings of this study suggest the potential of IFN-γ, TNF-α and IL-10 against Rv2031 as biomarkers of the host response to Mtb during convalescence from, and the absence of, active tuberculosis.

QuantiFERON-TB Gold In-Tube test conversions and reversions among tuberculosis patients and their household contacts in Addis Ababa: a one year follow-up study

Background

QuantiFERON-TB Gold In-Tube® (QFT-GIT) test is used for the diagnosis of latent tuberculosis (TB) infection. Besides, QFT-GIT test could allow tracking changes in immune response among TB patients and their contacts. In high TB burden settings, reports on QFT-GIT conversions and reversions among TB patients and their contacts are limited. As part of a major project to study immune responses to TB infection, we investigated QFT-GIT test conversions and reversions among smear positive pulmonary TB patients and their household contacts over 12 months.

Methods

We followed a total of 107 HIV negative participants (33 patients and 74 contacts) in Addis Ababa. We did QFT-GIT test at baseline and 12 months later according to the manufacturer’s instructions.

Results

At baseline, 25/33 (75.8%) of the patients and 50/74 (67.6%) of the contacts were QFT-GIT positive. At 12 months, 2 more patients (1 test negative and 1 indeterminate) became test positive. Besides, 11/24 (45.8%) test negative contacts became positive. Only one patient and one contact who were test positive at baseline became test negative 12 months later. At 12 months, the proportions of QFT-GIT test positives for patients and contacts were, therefore, 78.8% and 81.1%, respectively. Among contacts, the proportion of QFT-GIT test positives at 12 months was significantly higher compared to the corresponding proportion at baseline (McNemar, p = 0.006); similarly, the median IFN-γ response significantly increased at 12 months compared with the baseline level (Wilcoxon matched-pairs signed rank test, p = 0.01). Patients, however, had comparable median IFN-γ levels at baseline and 12 months later (p = 0.56).

Conclusion

Nearly half of QFT-GIT negative household contacts at baseline became positive at 12 months. This suggests that repeated screening of QFT-GIT negative contacts may be needed for epidemiological studies and interventions of latent TB in an endemic setting. A large longitudinal study may be needed to confirm our observations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0654-5) contains supplementary material, which is available to authorized users.

IgA response to ESAT-6/CFP-10 and Rv2031 antigens varies in patients with culture-confirmed pulmonary tuberculosis, healthy Mycobacterium tuberculosis-infected and non-infected individuals in a tuberculosis endemic setting, Ethiopia

Little attention has been given to the role of antibodies against Mycobacterium tuberculosis (Mtb) infection. We have compared the levels of IgA and IgG against ESAT-6/CFP-10 and Rv2031c antigens in sera of patients with culture-confirmed pulmonary tuberculosis (PTB), healthy Mtb-infected and non-infected individuals in endemic TB settings. Venous blood samples were collected from 166 study participants; sera were separated and assayed by an enzyme-linked immunosorbent assay (ELISA). QuantiFERON-TB Gold In-Tube (QFTGIT) assay was used for the screening of latent TB infection. The mean optical density (OD) values of IgA against ESAT-6/CFP-10 and Rv2031 were significantly higher in sera of patients with culture-confirmed PTB compared with healthy Mtb-infected and non-infected individuals (P < 0.001). The mean OD values of IgG against ESAT-6/CFP-10 and Rv2031 were also significantly higher in sera of patients with culture-confirmed PTB compared with healthy Mtb-infected and non-infected individuals (P < 0.05). The mean OD values of IgA against both antigens were also higher in sera of healthy Mtb-infected cases compared with non-infected individuals. There were positive correlations (P < 0.05) between the level of IFN-γ induced in QFTGIT assay and the OD values of serum IgA against both antigens in healthy Mtb-infected subjects. This study shows the potential of IgA response against ESAT-6/CFP-10 and Rv2031 antigens in discriminating clinical TB from healthy Mtb-infected and non-infected cases. Nevertheless, further well-designed cohort study is needed to fully realize the full potential of this diagnostic marker.

Community-based prevalence of undiagnosed mycobacterial diseases in the Afar Region, north-east Ethiopia

BACKGROUND

Information on the community-based prevalence of tuberculosis (TB) in different settings is vital for planning, execution and evaluation of strategies to control the disease.

OBJECTIVE

To assess community-based prevalence of undetected active pulmonary TB (PTB) in pastoralists of the Amibara District.

METHODS

Between March and April 2010, a community-based cross-sectional survey of undiagnosed active PTB was conducted in the pastoralists of the Amibara District of the Afar Region, north-east Ethiopia. The study participants were interviewed for symptoms suggestive of PTB using a structured questionnaire. Sputum samples were collected and processed for smear microscopy and culture. Mycobacterium genus typing was performed using a multiplex polymerase chain reaction (PCR).

RESULTS

Out of 222 individuals who had symptoms suggestive of PTB, 4 (1.8%) were found positive by smear microscopy, while mycobacterial growth was observed on 62 (27.9%) samples. Mycobacterium genus typing was carried out for 42 of these 62 samples; 39 (92.9%) gave a positive signal for the genus Mycobacterium. Of these, 23 (59%) isolates proved to be members of the Mycobacterium tuberculosis (Mtb) complex, while the remaining 16 (41.0%) were found to be members of non-tuberculous Mycobacteria (NTM) species.

CONCLUSION

Sputum culture is highly sensitive, and it is the gold standard for the bacteriological diagnosis of PTB, while smear microscopy is less sensitive to detect acid fast bacilli (AFB) in stained sputum smears. The findings of the present study warrant the strengthening of culture facility services in the study area. The study also provides important preliminary information on the status of NTM infection in the pastoral setting. Nevertheless, further investigations into the species identification of the NTM infections would be useful in the study area.

Why some women fail to give birth at health facilities: a qualitative study of women's perceptions of perinatal care from rural Southern Malawi

BACKGROUND

Despite Malawi government's policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care.

OBJECTIVE

The study explores the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care.

METHODS

A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using a semi- structured interview guide that collected information on women's perception on perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. The women were asked how they perceived the care they received from health workers before, during, and after delivery. Data were manually analyzed using thematic analysis.

RESULTS

Onset of labor at night, rainy season, rapid labor, socio-cultural factors and health workers' attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbors. Two women delivered alone. Most women went to the health facility the same day after delivery.

CONCLUSIONS

This study reveals beliefs about labor and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. Even though, it is not easy to change cultural beliefs to convince women to use health facilities for deliveries. There is a need for further exploration of barriers that prevent women from accessing health care for better understanding and subsequently identification of optimal solutions with involvement of the communities themselves.

Do Malawian women critically assess the quality of care? A qualitative study on women's perceptions of perinatal care at a district hospital in Malawi

Background

Malawi has a high perinatal mortality rate of 40 deaths per 1,000 births. To promote neonatal health, the Government of Malawi has identified essential health care packages for improving maternal and neonatal health in health care facilities. However, regardless of the availability of health services, women’s perceptions of the care is important as it influences whether the women will or will not use the services. In Malawi 95% of pregnant women receive antenatal care from skilled attendants, but the number is reduced to 71% deliveries being conducted by skilled attendants. The objective of this study was to describe women’s perceptions on perinatal care among the women delivered at a district hospital.

Methods

A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using semi-structured interview guides collecting information on women’s perceptions on perinatal care. A total of 14 in depth interviews were conducted with women delivering at Chiradzulu District Hospital from February to March 2011. The women were asked how they perceived the care they received from health workers during antepartum, intrapartum and postpartum. They were also asked about the information they received during provision of care. Data were manually analyzed using thematic analysis.

Results

Two themes from the study were good care and unsatisfactory care. Subthemes under good care were: respect, confidentiality, privacy and normal delivery. Providers’ attitude, delay in providing care, inadequate care, and unavailability of delivery attendants were subthemes under unsatisfactory care.

Conclusions

Although the results show that women wanted to be well received at health facilities, respected, treated with kindness, dignity and not shouted at, they were not critical of the care they received. The women did not know the quality of care to expect because they were not well informed. The women were not critical of the care they received because they were not aware of the standard of care. Instead they had low expectations. Health workers have a responsibility to inform women and their families about the care that women should expect. There is also a need for standardization of the antenatal information that is provided.

Diagnostic and treatment delay among Tuberculosis patients in Afar Region, Ethiopia: a cross-sectional study

Background

TB is a major public health problem globally and Ethiopia is 8^th among the 22 high burden countries. Early detection and effective treatment are pre-requisites for a successful TB control programme. In this regard, early health seeking action from patients’ side and prompt diagnosis as well as initiation of treatment from the health system’s side are essential steps. The aim of this study was to assess delay in the diagnosis and treatment of TB in a predominantly pastoralist area in Ethiopia.

Methods

On a cross-sectional study, two hundred sixteen TB patients who visited DOTS clinics of two health facilities in Afar Region were included consecutively. Time from onset of symptoms till first consultation of formal health providers (patients’ delay) and time from first consultation till initiation of treatment (health system’s delay) were analyzed.

Results

The median patients’ and health system’s delay were 20 and 33.5 days, respectively. The median total delay was 70.5 days with a median treatment delay of 1 day. On multivariate logistic regression, self-treatment (aOR. 3.99, CI 1.50-10.59) and first visit to non-formal health providers (aOR. 6.18, CI 1.84-20.76) were observed to be independent predictors of patients’ delay. On the other hand, having extra-pulmonary TB (aOR. 2.08, CI 1.08- 4.04), and a first visit to health posts/clinics (aOR. 19.70, CI 6.18-62.79), health centres (aOR. 4.83, CI 2.23-10.43) and private health facilities (aOR. 2.49, CI 1.07-5.84) were found to be independent predictors of health system’s delay.

Conclusions

There is a long delay in the diagnosis and initiation of treatment and this was mainly attributable to the health system. Health system strengthening towards improved diagnosis of TB could reduce the long health system’s delay in the management of TB in the study area.

Association of the level of IFN-γ produced by T cells in response to Mycobacterium tuberculosis-specific antigens with the size of skin test indurations among individuals with latent tuberculosis in a highly tuberculosis-endemic setting

There is growing evidence showing the potential of T-cell-based gamma interferon (IFN-γ) release assays (IGRAs) for predicting the risk of progression of Mycobacterium tuberculosis (Mtb) infection, though there is little information from tuberculosis (TB)-endemic settings. In this study, we assessed the association between the level of IFN-γ produced by T cells in response to Mtb-specific antigens and the size of skin test indurations in 505 adult individuals who were screened for latent tuberculosis infection (LTBI) using the QuantiFERON-TB Gold In Tube (QFTGIT) assay and tuberculin skin test (TST). There was a strong positive correlation between the level of IFN-γ induced by the specific antigens and the diameter of the skin indurations (Spearman's rho = 0.6, P < 0.001). Body mass index and parasitic infection were not associated with the level of IFN-γ production or the TST reaction. In linear regression analysis, the size of the skin test indurations was significantly associated with the mean level of IFN-γ [coefficient, 0.65; 95% confidence interval (CI), 0.47 to 0.82, P < 0.001]. Similarly, results from logistic regression analysis demonstrated that individuals who had skin test indurations ≥ 10 mm were 6.82 times more likely than individuals who had skin test indurations < 10 mm to have high levels of IFN-γ (i.e. positive QFTGIT result) (adjusted odd ratio = 6.82; 95% CI, 3.67 to 12.69, P < 0.001). In conclusion, the results of this study could provide indirect evidence for the prognostic use of the QFTGIT assay for progression of Mtb infection, though prospective follow-up studies are needed to provide direct evidence.

Assessment of knowledge and practice of private practitioners regarding tuberculosis control in Ethiopia

INTRODUCTION

Ethiopia has a growing private health sector. In recent years, the directly observed treatment short course (DOTS) strategy was initiated in selected private health facilities in the country. The objective of the present study was to assess knowledge and practice of private practitioners in tuberculosis (TB) control in Amhara Region, Ethiopia.

METHODOLOGY

An institution-based cross-sectional study was conducted among 112 private practitioners selected from all private health facilities in the region. The study was conducted between May and August 2008 and data was collected using a semi-structured questionnaire. Group differences were analyzed using the chi-square test.

RESULTS

Fifty-nine (52.7%) of the private practitioners suspected TB in patients with three weeks' duration of cough. Only 37 (33.0%) of the private practitioners were able to precisely list the correct treatment regimens for all categories as recommended in the National Tuberculosis and Leprosy Control Program guidelines. The correct frequency of TB treatment monitoring was provided by 44 (50%) of the respondents. Overall 44 (39.3%) of the private practitioners did not have satisfactory knowledge about the directly observed treatment short course (DOTS) strategy. Those who attended DOTS training during the two years prior to the survey were more likely to have satisfactory knowledge compared to those who did not receive training (OR 4.45, 95% CI: 1.33, 14.87, p < 0.02).

CONCLUSION

A significant proportion of private practitioners did not have satisfactory knowledge and practice about DOTS. The provision of regular DOTS refresher courses improves TB management for patients in the region.

Prevalence of pulmonary tuberculosis and associated risk factors in Eastern Ethiopian prisons

OBJECTIVES

To determine the prevalence of pulmonary tuberculosis (PTB) and associated risk factors among inmates in three major prison settings of Eastern Ethiopia.

DESIGN

Between July and November, 2008, 371 prisoners with a history of cough of ≥ 2 weeks were screened for PTB using direct smear microscopy and culture. Data were analysed using descriptive statistics and multivariable logistic regression.

RESULTS

Of 371 PTB suspects identified by active screening, 33 (8.9%) were confirmed as smear- or culture-positive PTB. Together with the 11 PTB patients already on treatment, the point prevalence of PTB was 1913 per 100,000 (95%CI 1410-2580), about seven times higher than that of the general population. Eleven newly diagnosed PTB patients were sharing a cell with known TB patients. Factors significantly associated with PTB were young age (15-44 years of age) (OR 3.73), urban residence (OR 3.59), having a cough >4 weeks (OR 3.15), and sharing a cell with a TB patient (OR 3.39) or a prisoner with chronic cough (OR 4.5).

CONCLUSIONS

The study documented a high prevalence of PTB among Ethiopian prisoners. Socio-demographic and TB management factors were identified to be underlying causes of the high transmission rate and the acquisition of new cases. Active surveillance of TB and implementing prevention and control guidelines are imperative.

Community-based cross-sectional survey of latent tuberculosis infection in Afar pastoralists, Ethiopia, using QuantiFERON-TB Gold In-Tube and tuberculin skin test

Background

There is little information concerning community-based prevalence of latent tuberculosis infection (LTBI) using T-cell based interferon-γ (IFN-γ) release assays (IGRAs), particularly in TB endemic settings. In this study, the prevalence of LTBI in the Afar pastoral community was assessed using QuantiFERON-TB Gold In-Tube (QFTGIT) and tuberculin skin tests (TST).

Methods

A community-based cross-sectional survey of LTBI involving 652 apparently healthy adult pastoralists was undertaken in the pastoral community of Amibara District of the Afar Region between April and June 2010.

Results

The prevalence of LTBI was estimated as 63.7% (363/570) using QFTGIT at the cut-off point recommended by the manufacturer (≥ 0.35 IU/ml IFN-γ), while it was 74.9% (427/570) using a cut-off point ≥ 0.1 IU/ml IFN-γ. The QFTGIT-based prevalence of LTBI was not significantly associated with the gender or age of the study participants. However, the prevalence of LTBI was 31.2% (183/587) using TST at a cut-off point ≥ 10 mm of skin indurations, and it was higher in males than females (36.8% vs. 23.5%, X² = 11.76; p < 0.001). There was poor agreement between the results of the tests (k = 0.098, 95% CI, 0.08 - 0.13). However, there was a positive trend between QFTGIT and TST positivity (X² = 96.76, P < 0.001). Furthermore, individuals with skin indurations ≥ 10 mm were 13.6 times more likely to have positive results using QFTGIT than individuals with skin indurations of 0 mm (adjusted OR = 13.6; 95%CI, 7.5 to 24.7, p < 0.001).

Conclusions

There is currently no agreed gold standard for diagnosis of LTBI. However, the higher prevalence of LTBI detected using QFTGIT rather than TST suggests that QFTGIT could be used for epidemiological studies concerning LTBI at the community level, even in a population unreactive to TST. Further studies of adults and children will be required to assess the effects of factors such as malnutrition, non-tuberculosis mycobacterial infections, HIV and parasitic infections on the performance of QFTGIT.

Knowledge of cervical tuberculosis lymphadenitis and its treatment in pastoral communities of the Afar region, Ethiopia

Background

Infection with Mycobacterium bovis (Mb) predominantly causes cervical TB lymphadenitis (TBL). Raw milk is considered the main source of Mb infection and raw milk is a major food source for Afar pastoralists. The aim of this study was to assess Afar pastoralists' knowledge concerning cervical TBL and its treatment.

Methods

A community-based cross-sectional survey involving 818 interviewees was conducted in two districts of the Afar Region, Ethiopia. In addition, two focus group discussions (FGDs) were conducted in each of the study areas, one with men and the other with women.

Results

Of the 818 interviewees [357 (43.6%) females and 461 (56.4%) males], 742 (90.7%) reported that they had knowledge of cervical TBL, mentioning that swelling(s) on the neck resulting in a lesion and scar are common symptoms. However, only 11 (1.5%) individuals mentioned that bacteria or germs are the causative agents of TBL. Three interviewees and a male discussant mentioned drinking raw milk as the cause of TBL. A considerable proportion (34.2%) of the interviewees and almost all the discussants suggested herbal medicine as an effective treatment. Male study participants were 1.82 times more likely to have overall knowledge of TBL than female study participants (adjusted OR, 1.82; 95% CI, 1.32 to 2.51, p < 0.001).

Conclusion

The pastoral community members in the study areas had little biomedical knowledge of the cause, the source of infection and the transmission route of cervical TBL. Furthermore, most community members believed that herbal medicines are the most effective treatment for TBL. Therefore, TB control programs in the Afar Region require the incorporation of public health education introducing current biomedical knowledge of the disease. In addition, further studies are important to elucidate which medicinal plants are used by Afar pastoralists to treat TBL.

Assessment of knowledge and practice about tuberculosis among eastern Ethiopian prisoners

OBJECTIVE

To assess the level of knowledge and practice related to TB and identify predictive factors in three prisons in eastern Ethiopia: Dire Dawa, Jijiga and Harar.

DESIGN

Between July and November 2008, 382 TB patients and suspects were interviewed using a structured questionnaire. Data were analysed using descriptive statistics and ordinal logistic regression.

RESULTS

Only six (1.6%) prisoners described the cause of TB as being bacterial, while a wind locally known as 'nefas' was frequently mentioned (36.1%); nearly 75% of the prisoners correctly described breath as a mode of TB transmission; 116 (30.7%) did not know any measures for TB prevention and control; and half of the participants did not know that anti-tuberculosis drugs were provided free of charge. Significant predictors of TB knowledge were: incarceration in the Jijiga (OR 9.62, P < 0.001) and Dire Dawa (OR 2.14, P = 0.016) prisons, those who did not consult and receive treatment for TB symptoms (OR 2.46, P < 0.001), and prisoners without a past history of TB (OR 2.72, P = 0.002).

CONCLUSION

The study demonstrates that prisoners have a modest level of biomedical knowledge. As part of the National TB Programme, health education programmes need to be implemented to enhance prisoners' knowledge of TB.

Performance of QuantiFERON-TB Gold In-Tube (QFTGIT) for the diagnosis of Mycobacterium tuberculosis (Mtb) infection in Afar Pastoralists, Ethiopia

BACKGROUND

Currently, T-cell based gamma interferon (IFNγ) release assays (IGRAs) are acknowledged as the best methods available for the screening of latent tuberculosis infection (LTBI) and also as aid for the diagnosis of active tuberculosis (TB). To our information, the performance of these diagnostic tests has not been evaluated in Ethiopia. Therefore, the intent of this study was to evaluate the performance of QuantiFERON-TB Gold In-Tube (QFTGIT) in patients clinically suspected of active pulmonary TB (PTB) as well as in healthy subjects prior to its utilization for the epidemiological study of active TB and LTBI in Afar pastoralists.

METHODS

The sensitivity of QFTGIT was evaluated in 140 subjects who were clinically suspected of PTB using the cut-off value recommended by the manufacturer (≥ 0.35 IU/ml) and disease-specific cut-off value. Sputum culture result was used as a gold standard. The specificity of the test was evaluated both in patients and in 55 tuberculin skin test (TST) negative healthy subjects.

RESULTS

Out of the 140 study participants, 37 (26.4%) were positive for active PTB by culture. Out of the 37 subjects who had positive results by culture, 6 individuals were HIV-seropositive. Out of the 103 subjects who were negative by culture, 6 subjects had indeterminate results and 21 were HIV-seropositive. The performance of the test was assessed using data from 107 (31 culture positive and 76 culture negative) individuals who were clinically suspected of PTB and HIV-seronegatives. Using the manufacturer recommended cut-off value, the sensitivity of the test was 64.5% (20/31), while its specificity was 36.8% (28/76). The sensitivity of the test was increased to 77.4%, while the specificity was reduced to 23.7% using a cut-off value ≥ 0.1 IU/ml of IFNγ as disease-specific cut-off value. In TST negative healthy subjects, the specificity of the test was 58.2%.

CONCLUSION

Our findings revealed a low sensitivity of QFTGIT in the diagnosis of Mycobacterium tuberculosis (Mtb) infection in the present study area using the cut-off value recommended by the manufacturer. Nevertheless, the sensitivity increased from 64.5% to 77.4% by lowering the cut-off value recommended by the manufacturer to ≥ 0.1 IU/ml of IFNγ level. Hence, it is of practical importance to evaluate the performance of QFTGIT in population under different settings prior to its application either for the diagnosis of active TB or LTBI.

Knowledge and perception of pulmonary tuberculosis in pastoral communities in the middle and Lower Awash Valley of Afar region, Ethiopia

Background

Afar pastoralists live in the northeast of Ethiopia, confined to the most arid part of the country, where there is least access to educational, health and other social services. Tuberculosis (TB) is one of the major public health problems in Afar region. Lack of knowledge about TB could affect the health-seeking behaviour of patients and sustain the transmission of the disease within the community. In this study, we assessed the knowledge and perception of apparently healthy individuals about pulmonary tuberculosis (PTB) in pastoral communities of Afar.

Methods

Between March and May 2009, a community-based cross-sectional questionnaire survey involving 818 randomly selected healthy individuals was conducted in pastoral communities of Afar region. Moreover, two focus group discussions (FGDs), one with men and one with women, were conducted in each of the study area to supplement the quantitative study.

Results

The majority (95.6%) of the interviewees reported that they have heard about PTB (known locally as "Labadore"). However, the participants associated the cause of PTB with exposure to cold air (45.9%), starvation (38%), dust (21.8%) or smoking/chewing Khat (Catha edulis) (16.4%). The discussants also suggested these same factors as the cause of PTB. All the discussants and the majority (74.3%) of the interviewees reported that persistent cough as the main symptom of PTB. About 87.7% of the interviewees and all the discussants suggested that PTB is treatable with modern drugs. All the discussants and the majority (95%) of the interviewees mentioned that the disease can be transmitted from a patient to another person. Socio-cultural practices, e.g. sharing cups (87.6%), and house type (59.8%) were suggested as risk factors for exposure to PTB in the study areas, while shortage of food (69.7%) and chewing khat (53.8%) were mentioned as factors favouring disease development. Almost all discussants and a considerable number (20.4%) of the interviewees thought that men were the highest risk group to get PTB as well as playing a major role in the epidemiology of the disease.

Conclusion

The findings indicate that pastoral communities had basic awareness about the disease. Nevertheless, health education to transform their traditional beliefs and perceptions about the disease to biomedical knowledge is crucial.

Health care seeking among pulmonary tuberculosis suspects and patients in rural Ethiopia: a community-based study

BACKGROUND

Health care seeking is a dynamic process that is influenced by socio-demographic, cultural and other factors. In Ethiopia, there are limited studies regarding the health seeking behaviour of tuberculosis (TB) suspects and TB patients. However, a thorough understanding of patients' motivation and actions is crucial to understanding TB and the treatment of disease. Such insights would conceivably help to reduce delay in diagnosis, improve treatment adherence and thereby reduce transmission of TB in the community. The objective of this study was to describe and analyze health care seeking among TB suspects and pulmonary TB (PTB) cases in a rural district of the Amhara Region in Ethiopia.

METHODS

Study kebeles were randomly selected in a cross-sectional study design. House-to-house visits were conducted in which individuals aged 15 years and above in all households of the kebeles were included. Subjects with symptoms suggestive of TB were interviewed about their health seeking behaviour, socio-demographic and clinical factors using a semi-structured questionnaire. Logistics regression analysis was employed to assess associations between the independent and outcome variables.

RESULTS

The majority, 787 (78%), TB suspects and 33 (82.5%) PTB cases had taken health care actions for symptoms from sources outside their homes. The median delay before the first action was 30 days. In logistics regression, women (AOR 0.8, 95% CI 0.6, 0.9) were found to be less likely to visit a medical health provider than men. Those with a long duration of cough (AOR 1.5, 95% CI 1.03, 2.1) and those with a previous history of TB (AOR 1.5, 95% CI 1.03, 2.3) were more likely to visit a medical health provider compared to those with a shorter duration of cough and with no history of TB.

CONCLUSION

The majority of TB suspects and PTB cases had already taken health care actions for their symptoms at the time of the survey. The availability of a simple and rapid diagnostic TB test for use at the lowest level of health care and the involvement of all health providers in case finding activities are imperative for early TB case detection.

Evaluating an active case-finding strategy to identify smear-positive tuberculosis in rural Ethiopia

OBJECTIVE

To assess an active case-finding strategy for the identification of smear-positive pulmonary tuberculosis (TB) in a rural district of Amhara Region, Ethiopia.

METHODS

Study kebeles (smallest administrative units) were randomly selected in a cross-sectional study. House-to-house visits involving individuals aged >or=15 years in all households of the kebeles were conducted. The heads of households were asked to identify subjects with TB symptoms. Identified suspects were asked to provide three sputum samples for smear microscopy.

RESULTS

Among the 47,478 individuals living in households that were screened, 1006 TB suspects and 38 cases were detected. This resulted in 38 cases of smear-positive TB, i.e., 80 per 100,000 population, using cluster sampling. The ratio of active vs. passive case detection was 2.5:1, indicating 2.5 undetected TB cases in the community for every smear-positive TB case receiving treatment during the survey period. A higher proportion of female patients was detected by the survey.

CONCLUSION

The study revealed a very high proportion of undiagnosed TB. This indicates that the potential for a large infectious pool and significant transmission of TB in the community is high. The expansion of diagnostic facilities and the active involvement of health extension workers is necessary to expedite early detection, timely referral and treatment of TB.

Tuberculosis in the 21st century: an emerging pandemic?

Since the mid-1980ies the world has witnessed a dramatic increase in tuberculosis. Our knowledge of tuberculosis epidemiology was established during the previous epidemic that, at least in Europe, took two hundred years from rise to fall. It is difficult to understand the new epidemic if we assume that the genetics of the host-parasite relationship is unchanged from the previous epidemic.The paper discusses how both host and parasite genetics may have changed. Molecular epidemiology done in Archangel, Russia, where most of the classical reasons for increase in tuberculosis were absent, indicated that strains of Mycobacterium tuberculosis with changed biological properties could be responsible. Strains belonging to the so-called Beijing family were strongly associated with primary drug resistance and caused clusters ten times as big as “traditional” strains.The paper describes how the research consortium takes these observations further to explore the importance of “new” strains of tubercle bacilli in the on-going pandemic. What are the changes in biological properties and what genetic changes do they reflect? The previous epidemic may have changed the genetic susceptibility of the human host by selection, but what has constituted a selective pressure for the bacillary population? The two most dramatic changes in the environment of M. tuberculosis are mass introduction of chemotherapy and BCG vaccination. We explore further the nature of drug resistance in these strains and the possibility that BCG may fail to protect against bacilli of the new pandemic.Lastly the paper points at some action that can be taken instantly and that may have a major impact on transmission, even before the questions mentioned above are answered. The clue here is to shorten the time of transmission by a rapid test to secure early diagnosis and treatment. What is needed, however, is not a diagnostic test for tuberculosis, but a simple screening test with high sensitivity that could tell us whom among the numerous people who have a chronic cough and systemic symptoms who are the true “tuberculosis suspects” eligible for rapid examination of sputum by smear microscopy

The protective role of antibody responses during Mycobacterium tuberculosis infection

Tuberculosis (TB) caused by Mycobacterium tuberculosis (Mtb) is one of the most important infectious diseases globally. Immune effector mechanisms that lead to protection or development of clinical disease are not fully known. It is generally accepted that cell-mediated immunity (CMI) plays a pivotal role in controlling Mtb infection, whereas antibody responses are believed to have no protective role. This generalization is based mainly on early classical experiments that lacked standard protocols, and the T helper type 1 (Th1)/Th2 paradigm. According to the Th1/Th2 paradigm Th1 cells protect the host from intracellular pathogens, whereas Th2 cells protect form extracellular pathogens. During the last two decades, the Th1/Th2 paradigm has dominated not only our understanding of immunity to infectious pathogens but also our approach to vaccine design. However, the last few years have seen major discrepancies in this model. Convincing evidence for the protective role of antibodies against several intracellular pathogens has been established. Studies of B cell-deficient mice, severe combined immunodeficiency (SCID) mice, passive immunization using monoclonal (mAb) and polyclonal antibodies and immune responses against specific mycobacterial antigens in experimental animals reveal that, in addition to a significant immunomodulatory effect on CMI, antibodies play an essential protective role against mycobacterial infections. In this review, our current understanding of the essential role of antibodies during Mtb infections, limitations of the Th1/Th2 model and the unfolding interdependence and mutual regulatory relationships between the humoral and CMI will be presented and discussed.

Heterogeneity of Mycobacterium tuberculosis isolates in Sunamganj District, Bangladesh

A total of 111 Mycobacterium tuberculosis isolates from new pulmonary tuberculosis patients, living in the rural Sunamganj district in northern Bangladesh were characterized with IS6110 restriction fragment length polymorphism analyses and spoligotyping. Only 3 of the isolates belonged to the W-Beijing genotype of M. tuberculosis. A high degree of diversity indicated that the spread of M. tuberculosis, in this rural area, was not caused by closely related genotypes. The tuberculosis cases in the current study were less likely to represent recent transmission than what is commonly observed in urban parts of south-east Asia. It was indicated that the tuberculosis cases of this isolated area, of a high-incidence country, represented those of an established epidemic, not yet influenced by recently disseminated strains.

Pastoralism and delay in diagnosis of TB in Ethiopia

BACKGROUND

Tuberculosis (TB) is a major public health problem in the Horn of Africa with Ethiopia being the most affected where TB cases increase at the rate of 2.6% each year. One of the main contributing factors for this rise is increasing transmission due to large number of untreated patients, serving as reservoirs of the infection within the communities. Reduction of the time between onset of TB symptoms to diagnosis is therefore a prerequisite to bring the TB epidemic under control. The aim of this study was to measure duration of delay among pastoralist TB patients at TB management units in Somali Regional State (SRS) of Ethiopia.

METHODS

A cross sectional study of 226 TB patients with pastoralist identity was conducted in SRS of Ethiopia from June to September 2007. Patients were interviewed using questionnaire based interview. Time between onset of TB symptoms and first visit to a professional health care provider (patient delay), and the time between first visits to the professional health care provider to the date of diagnosis (medical provider's delay) were analyzed. Both pulmonary and extrapulmonary TB patients were included in the study.

RESULT

A total of 226 pastoralist TB patients were included in this study; 93 (41.2%) were nomadic pastoralists and 133 (58.8%) were agro-pastoralists. Median patient delay was found to be 60 days with range of 10-1800 days (83 days for nomadic pastoralists and 57 days for agro-pastoralists). Median health care provider's delay was 6 days and median total delay was 70 days in this study. Patient delay constituted 86% of the total delay. In multivariate logistic regression analysis, nomadic pastoralism (aOR. 2.69, CI 1.47-4.91) and having low biomedical knowledge on TB (aOR. 2.02, CI 1.02-3.98) were significantly associated with prolonged patient delay. However, the only observed risk factor for very long patient delay >120 days was distance to health facility (aOR.4.23, CI 1.32-13.54). Extra-pulmonary TB was the only observed predictor for health care providers' delay (aOR. 3.39, CI 1.68-6.83).

CONCLUSION

Patient delay observed among pastoralist TB patients in SRS is one of the highest reported so far from developing countries, exceeding two years in some patients. This long patient delay appears to be associated with patient's inadequate knowledge of the disease and distance to health care facility with nomadic pastoralists being the most affected. Regional TB control programmes need to consider the exceptional circumstances of pastoralists, to maximise their access to TB services.

Assessment of measles immunity among infants in Maputo City, Mozambique

Background

The optimum age for measles vaccination varies from country to country and thus a standardized vaccination schedule is controversial. While the increase in measles vaccination coverage has produced significant changes in the epidemiology of infection, vaccination schedules have not been adjusted. Instead, measures to cut wild-type virus transmission through mass vaccination campaigns have been instituted. This study estimates the presence of measles antibodies among six- and nine-month-old children and assesses the current vaccination seroconversion by using a non invasive method in Maputo City, Mozambique.

Methods

Six- and nine-month old children and their mothers were screened in a cross-sectional study for measles-specific antibodies in oral fluid. All vaccinated children were invited for a follow-up visit 15 days after immunization to assess seroconversion.

Results

82.4% of the children lost maternal antibodies by six months. Most children were antibody-positive post-vaccination at nine months, although 30.5 % of nine month old children had antibodies in oral fluid before vaccination. We suggest that these pre-vaccination antibodies are due to contact with wild-type of measles virus. The observed seroconversion rate after vaccination was 84.2%.

Conclusion

These data indicate a need to re-evaluate the effectiveness of the measles immunization policy in the current epidemiological scenario.

Evolution of human immunodeficiency virus type 1 serotypes in northern Tanzania: a retrospective study

The HIV-1 epidemic in Tanzania is characterized by the circulation of heterogeneous virus subtypes. A retrospective study was conducted to determine the changing pattern of circulating HIV-1 subtypes in northern Tanzania. A peptide-binding enzyme immunoassay (PEIA) was employed to analyse 305 HIV-1 positive serum and plasma samples collected between 1985 and 2005. Samples were serotyped using synthetic peptides representing HIV-1 genotypes A-E derived from consensus gp120 V3 sequences. Plasma samples collected in 2005 were V3 genotyped for comparison with PEIA results. In 1985, serotypes A and D were co-circulating while serotype C was first detected in 1990. In 2001 and 2005, serotype C was the most prevalent, serotype A was stable, and serotype D was declining. PEIA is relatively rapid and simple to perform compared to molecular approaches, and is a valuable epidemiological tool in regions with limited resources. HIV-1 classification into serotypes based on antigenic V3 diversity may be a useful screening tool for the identification of HIV-1 variants with regard to diagnosis, treatment, disease progression and candidate vaccine development.

Prevalence of reverse transcriptase and protease mutations associated with antiretroviral drug resistance among drug-naïve HIV-1 infected pregnant women in Kagera and Kilimanjaro regions, Tanzania

BACKGROUND

Access to antiretroviral drugs for HIV-1 infection has increased in sub-Saharan Africa (SSA) during the past few years. Mutations in the HIV-1 genome are often associated with treatment failure as indicated by viral replication and elevated levels of virus in the blood. Mutations conferring resistance to antiretroviral drugs are based on comparing gene sequences with corresponding consensus sequences of HIV-1 subtype B that represents only 10% of the AIDS pandemic. The HIV pandemic in SSA is characterized by high viral genetic diversity. Before antiretroviral drugs become more widely available, it is important to characterize baseline naturally occurring genetic mutations and polymorphisms associated with antiretroviral drug resistance among circulating HIV-1 subtypes.

METHODS

The prevalence of mutations associated with antiretroviral drug resistance in protease (PR) and reverse transcriptase (RT) regions among antiretroviral treatment-naïve HIV-1 infected pregnant women was investigated in Bukoba (Kagera) and Moshi (Kilimanjaro) municipalities, Tanzania, between September and December 2005. The HIV-1 pol gene was amplified using primers recognizing conserved viral sequences and sequenced employing BigDye chemistry from 100 HIV-1 seropositive treatment-naïve pregnant women and 61 HIV-1 seropositive women who had received a single dose of Nevirapine (sdNVP). Positions 1-350 of the RT and 1-99 of the PR genes were analyzed for mutations based on the Stanford University HIV Drug Resistance Database.

RESULTS

HIV-1 subtypes A, C, D, CRF10_CD and Unique Recombinant Forms (URF) were detected. Primary mutations associated with NRTI and NNRTI resistance were detected among 3% and 4% of treatment-naïve strains, respectively. Primary mutations associated with NRTI and NNRTI resistance were detected in 1.6% and 11.5% of women who had received sdNVP, respectively. None of the primary mutations associated with PI resistance was found. Polymorphisms detected in RT and PR sequences were mainly mutations that are found in the consensus sequences of non-B subtypes

CONCLUSION

Based on the WHO HIV Drug Resistance Research Network Threshold of less than 5%, the baseline prevalence of primary mutations among treatment-naïve HIV-1 infected pregnant women in Kagera and Kilimanjaro regions was low. The significance of HIV-1 subtype B polymorphic positions with respect to antiretroviral resistance identified among the prevalent HIV-1 subtypes is unknown. More studies addressing the correlation between polymorphic mutations, antiretroviral resistance and clinical outcome are warranted in regions where non-B subtypes are prevalent.

Diversity of human immunodeficiency virus type 1 subtypes in Kagera and Kilimanjaro regions, Tanzania

A strategy to prevent the spread of HIV-1 worldwide is complicated by the high genetic diversity of the virus. To gain a better understanding of the HIV-1 genetic diversity in Tanzania, a molecular epidemiological investigation was conducted in Kagera and Kilimanjaro regions. While several studies have addressed HIV-1 subtypes in Tanzania, this is the first study to describe the virus subtypes circulating in Kagera. The Kagera region is the epicenter of the HIV-1 epidemic in Africa, and it was therefore of interest to compare the prevalence of HIV subtypes in this region and Kilimanjaro. Blood samples were obtained from 246 HIV-1-infected pregnant women attending antenatal clinics. Plasma HIV-1 RNA was extracted, amplified, and sequenced in the env C2V3 and/or pol regions from 209 samples. Based on the analysis of env C2V3 and pol sequences, 47.4% had concordant subtypes, 19.1% were discordant indicating recombination, and for 33.5% sequences were obtained for only one region. The distribution HIV-1 subtypes based on the phylogenetic analysis of paired env C2V3/ pol sequences in Kagera region was A/A (27.8%), C/C (29.6%), D/D (16.7%), and unique recombinant forms (25.9%), and in Kilimanjaro region was A/A (32.9%), C/C (25.9%), D/D (10.6%), CRF10_CD (1.2%), and unique recombinant forms (29.4%). The env C2V3 subsubtype A2 and env C2V3/pol CRF10_CD were also observed indicating that these recombinants are circulating in Tanzania. The high diversity of HIV-1 subtypes and the high prevalence of recombinants demonstrated in this study necessitate expanded and continuous monitoring of the epidemic in Tanzania. The trend may have implications for current national control strategies against the HIV-1 epidemic.

Risk factors for incomplete vaccination and missed opportunity for immunization in rural Mozambique

Background

Inadequate levels of immunization against childhood diseases remain a significant public health problem in resource-poor areas of the globe. Nonetheless, the reasons for incomplete vaccination and non-uptake of immunization services are poorly understood. This study aimed at finding out the reasons for non-vaccination and the magnitude of missed opportunities for vaccination in children less than two years of age in a rural area in southern Mozambique.

Methods

Mothers of children under two years of age (N = 668) were interviewed in a cross-sectional study. The Road-to-Health card was utilized to check for completeness and correctness of vaccination schedule as well as for identifying the appropriate use of all available opportunities for vaccination. The chi-square test and the logistic regression were used for statistical analysis.

Results

We found that 28.2% of the children had not completed the vaccination program by two years of age, 25.7% had experienced a missed opportunity for vaccination and 14.9% were incorrectly vaccinated. Reasons for incomplete vaccination were associated with accessibility to the vaccination sites, no schooling of mothers and children born at home or outside Mozambique.

Conclusion

Efforts to increase vaccination coverage should take into account factors that contribute to the incomplete vaccination status of children. Missed opportunities for vaccination and incorrect vaccination need to be avoided in order to increase the vaccine coverage for those clients that reach the health facility, specially in those countries where health services do not have 100% of coverage.

Barriers and enablers in the management of tuberculosis treatment in Addis Ababa, Ethiopia: a qualitative study

Background

Non-adherence to tuberculosis (TB) treatment is an important barrier for TB control programs because incomplete treatment may result in prolonged infectiousness, drug resistance, relapse, and death. The aim of the present study is to explore enablers and barriers in the management of TB treatment during the first five months of treatment in Addis Ababa, Ethiopia.

Methods

Qualitative study which included 50 in-depth interviews and two focus groups with TB patients, their relatives and health personnel.

Results

We found that loss of employment or the possibility to work led to a chain of interrelated barriers for most TB patients. Daily treatment was time-consuming and physically demanding, and rigid routines at health clinics reinforced many of the emerging problems. Patients with limited access to financial or practical help from relatives or friends experienced that the total costs of attending treatment exceeded their available resources. This was a barrier to adherence already during early stages of treatment. A large group of patients still managed to continue treatment, mainly because relatives or community members provided food, encouragement and sometimes money for transport. Lack of income over time, combined with daily accumulating costs and other struggles, made patients vulnerable to interruption during later stages of treatment. Patients who were poor due to illness or slow progression, and who did not manage to restore their health and social status, were particularly vulnerable to non-adherence. Such patients lost access to essential financial and practical support over time, often because relatives and friends were financially and socially exhausted by supporting them.

Conclusion

Patients' ability to manage TB treatment is a product of dynamic processes, in which social and economic costs and other burdens change and interplay over time. Interventions to facilitate adherence to TB treatment needs to address both time-specific and local factors.

The politics of global immunization initiatives: Can we learn from research on global environmental issues?

The number of institutions, representing different groups of stakeholders and organizations, aiming to coordinate global health policy is on the rise. Yet, as each have distinct interests and priorities, the political dimension becomes an important factor in understanding how institutions work, and how the coordination at the global level affects implementation in countries. This is already a topic for research on global environmental cooperation, inciting the question if one can transfer their analytical framework to the health field. This paper combines a presentation of lessons from research on environmental regimes with a review of global immunization policies and initiatives in order to explore that possibility. The paper describes cooperation on vaccines and immunization according the concepts of institutions and regimes, as defined by international relations research. This description emphasizes efforts to fulfill transnational agreements on objectives, the different ways stakeholders organize and the dynamics of such arrangements. An account of the research practice on global environmental cooperation leads to a discussion of how one could adapt the analytical framework. The paper makes the case for the development of a research program, where the analytical approach is modified to account for the interaction between technology production and public-led institutions. The conclusion proposes a number of entry points to research that have already yielded policy-relevant knowledge in the environmental field. These include the formation of new institutions, the contribution of institutional design to effective implementation, and the interplay between vaccine initiatives and other global institutions.

Progress in serodiagnosis of Mycobacterium tuberculosis infection

One-third of the world population is estimated to have Mycobacterium tuberculosis infection. Accurate and timely identification of infected individuals is critical for treatment and control. The current diagnostic methods lack the desired sensitivity and specificity, require sophisticated equipment and skilled workforce or take weeks to yield results. Diagnosis of extrapulmonary TB, TB-HIV co-infection, childhood TB and sputum smear-negative pulmonary TB pose serious challenges. Interest in developing serodiagnostic methods is increasing because detection of antibody is rapid, simple and relatively inexpensive, and does not require a living cell for detection. Three types of tests, namely screening tests to overcome diagnostic delay, specific tests for diagnosis of extrapulmonary TB and other bacteriologically negative cases, and tests for vaccine-induced immunity need critical consideration. Several factors must be considered to develop serodiagnostic methods for TB. Antigen recognition by infected individuals is highly heterogeneous due to stage of disease, differences in HLA types, strain of the bacilli, health of the patient and bacillary load. With advances in molecular biological techniques, a number of novel antigens have been identified. Some of these antigens have proven valuable in detecting specific antibodies in some of the most challenging TB patients. The best example is a fusion protein containing several M. tuberculosis proteins (e.g. CFP-10, MTB8, MTB48, MTB81 and the 38-kDa protein) which showed encouraging results in detecting antibodies in sera of patients, including TB-HIV co-infection. This review presents progress made in the serodiagnosis of TB during the last decade.

Clonal reconquest of antibiotic-susceptible Salmonella enterica serotype Typhi in Son La Province, Vietnam

In the last three decades, high rates of resistance to common first-line antimicrobial agents have been reported in Salmonella enterica serotype Typhi (Typhi), the causative organism of typhoid fever (TF), in many regions of the world, especially in South East Asia. Analysis of Typhi strains isolated from outbreaks and sporadic cases of TF in Son La province, northwest Vietnam, in 2002 revealed that 94.5% (85/90) of the isolates were fully susceptible to amoxicillin, chloramphenicol, cotrimoxazole, tetracycline, and nalidixic acid. There was a clear decline in the occurrence of multi-drug resistant (MDR) Typhi isolates collected in this province in 2002 (4.4%) compared with the period 1995-1999 in the same province (30.8-100%). By using molecular (IS200 profiling, PstI-ribotyping, XbaI-pulsed-field gel electrophoresis, and haplotyping) and phage-typing methods, we showed that the Typhi isolates from Son La province in 2002 were genetically related; however, they were unrelated to the previous MDR clones established in Vietnam.

Drug resistance of Mycobacterium tuberculosis in the Sunamganj District of Bangladesh

Spread of drug-resistant tuberculosis (TB) threatens TB-control programmes, and all countries need to monitor the patterns and trends of anti-TB drug resistance. Such data assess the quality of control programmes and help forecast future trends of drug resistance. It will also help to establish guidelines for TB therapy. The aim of the current study was to describe the rate of drug-resistant Mycobacterium tuberculosis in the Sunamganj District of Bangladesh. Bacterial isolates were collected from sputum smear positive (ss+) patients who attended the National TB Programme from November 2003 to December 2004. A total of 95 isolates was tested for susceptibility to streptomycin (SM), isoniazid (INH), rifampicin (RMP) and ethambutol (EMB) at the National Reference Laboratory for Mycobacteria at the Norwegian Institute of Public Health (NIPH), Oslo. The total resistance among new cases to any drug was 31%. For SM it was 18%, INH 23%, RMP 2%, EMB 10% and 2% were multidrug-resistant (MDR). The National Tuberculosis Programme (NTP) in Sunamganj is still effective, although the high resistance to INH is alarming. An increased risk of treatment failure has been demonstrated in areas with high levels of INH resistance, and a high proportion of INH resistant cases may develop resistance to RMP during treatment.

The emergence of Beijing family genotypes of Mycobacterium tuberculosis and low-level protection by bacille Calmette-Guérin (BCG) vaccines: is there a link?

The world is confronted with major tuberculosis (TB) outbreaks at a time when the protection of bacillus Calmette-Guérin (BCG) vaccine has become inconsistent and controversial. Major TB outbreaks are caused by a group of genetically similar strains of Mycobacterium tuberculosis (Mtb) strains, including the Beijing family genotypes. The Beijing family genotypes exhibit important pathogenic features such high virulence, multi-drug resistance and exogenous reinfection. These family strains have developed mechanisms that modulate/suppress immune responses by the host, such as inhibition of apoptosis of infected macrophages, diminished production of interleukin (IL)-2, interferon (IFN)-gamma, tumour necrosis factor (TNF)-alpha and elevated levels of IL-10 and IL-18. They demonstrate distinct expression of proteins, such as several species of alpha-crystallin (a known Mtb virulence factor), but decreased expression of some antigens such as heat shock protein of 65 kDa, phosphate transport subunit S and a 47-kDa protein. In addition, the Beijing family strains specifically produce a highly bioactive lipid (a polyketide synthase)-derived phenolic glycolipid. This altered expression of proteins/glycolipids may be important factors underlying the success of the Beijing family strains. The Beijing family strains are speculated to have originated from South-east Asia, where BCG vaccination has been used for more than 60 years. The hypothesis that mass BCG vaccination may have been a selective factor that favoured genotypic and phenotypic characteristic acquired by the Beijing family strains is discussed.

[Tuberculosis vaccines]

Even though the BCG vaccine is one of the most used vaccines in the world, tuberculosis is still a major problem worldwide. Research aimed at developing new vaccines against tuberculosis has become more goal-directed during the last 10-15 years, and there are now several vaccine candidates in clinical study phases I and II, that should be in phase III in 2010. It will then still take several years before we know whether a new vaccine will reduce the occurrence of tuberculosis. There are several promising vaccine candidates, but there is uncertainty whether they will be successful in reducing tuberculosis, as we do not have sufficient knowledge about protective immunity in tuberculosis. Today's vaccine candidates have been developed to protect against a few laboratory strains of the bacteria and will not protect against all strains. Estimations show that an effective vaccine against latent tuberculosis will give a rapid and considerable reduction in tuberculosis. The current vaccine candidates are however developed to protect against primary tuberculosis and not against reactivated latent tuberculosis. It is important to ensure an optimal experimental basis for new tuberculosis vaccines and to compare them so the best can be selected.

Patient and health care system delays in the start of tuberculosis treatment in Norway

Background

Delay in start of tuberculosis (TB) treatment has an impact at both the individual level, by increasing the risk of morbidity and mortality, and at the community level, by increasing the risk of transmission. The aims of this study were to assess the delays in the start of treatment for TB patients in Oslo/Akershus region, Norway and to analyze risk factors for the delays.

Methods

This study was based on information from the National TB Registry, clinical case notes from hospitals and referral case notes from primary health care providers. Delays were divided into patient, health care system and total delays. The association with sex, birthplace, site of the disease and age group was analyzed by multiple linear regression.

Results

Among the 83 TB patients included in this study, 71 (86%) were born abroad. The median patient, health care system and total delays were 28, 33 and 63 days respectively, with a range of 1–434 days. In unadjusted analysis, patient delay and health care system delay did not vary significantly between men and women, according to birthplace or age group. Patients with extra-pulmonary TB had a significantly longer patient, health care system and total delay compared to patients with pulmonary TB. Median total delay was 81 and 56 days in the two groups of TB patients respectively. The health care system delay exceeded the patient delay for those born in Norway. The age group 60+ years had significantly shorter patient delay than the reference group aged 15–29 years when adjusted for multiple covariates. Also, in the multivariate analysis patients born in Norway had significantly longer health care system delay than patients born abroad.

Conclusion

A high proportion of patients had total delays in start of TB treatment exceeding two months. This study emphasizes the need of awareness of TB in the general population and among health personnel. Extra-pulmonary TB should be considered as a differential diagnosis in unresolved cases, especially for immigrants from high TB prevalence countries.

Assessment of routine surveillance data as a tool to investigate measles outbreaks in Mozambique

BACKGROUND

Measles remains a major public health problem in Mozambique despite significant efforts to control the disease. Currently, health authorities base their outbreak control on data from the routine surveillance system while vaccine coverage and efficacy are calculated based on mathematical projections of the target population. The aim of this work was to assess the quality of the measles reporting system during two outbreaks that occurred in Maputo City (1998) and in Manica Province (2002).

METHODS

Retrospectively, we collected data from the routine surveillance system, i.e. register books at health facilities and weekly provincial and national epidemiological reports. To test whether the provinces registered an outbreak, the distribution of measles cases was compared to an endemic level established based on cases reported in previous years.

RESULTS

There was a significant under-notification of measles cases from the health facilities to the province and national level. Register books, the primary sources of information for the measles surveillance system, were found to be incomplete for two main variables: "age" and "vaccination status".

CONCLUSION

The Mozambican surveillance system is based on poor quality records, receives the notification of only a fraction of the total number of measles in the country and may result in failures do detect epidemics. The measles reporting system does not provide the data needed by Expanded Program on Immunisation managers to make evidence-based decisions, nor does it allow in-depth analysis to monitor measles epidemiology in the country. The progress of Mozambique to the next stage of measles elimination will require an improvement of the routine surveillance system and a stronger Health Information System.

Risk factors associated with typhoid fever in Son La province, northern Vietnam

Between July and December 2002, we undertook a hospital-based case-control study to identify risk factors associated with typhoid fever in Son La province, northern Vietnam. Among 617 suspected cases, 90 cases of typhoid fever were confirmed by blood or stool culture. One hundred and eighty controls (neighbours of typhoid cases matched for gender and age) were chosen. Participants were interviewed at home using a standardized questionnaire. Seventy-five per cent of cases were aged 10-44 years. No cases in patients aged less than 5 years were recorded in this study. In a conditional logistic regression analysis recent contact with a typhoid patient (OR = 3.3, 95% CI 1.7-6.2, P < 0.001), no education (OR = 2.0, 95% CI 1.0-3.7, P = 0.03) and drinking untreated water (OR = 3.9, 95% CI 2.0-7.5, P < 0.001) were independently associated with typhoid fever. Improving quality of drinking water must be a priority and health education strategies targeted at individuals with no schooling, and contacts of patients, would be expected to decrease the burden of typhoid fever.

Immunization coverage in Mozambique: from concepts to decision-making

Immunization is an effective strategy to reduce morbidity and mortality among children. This recognition has led many countries to concentrate efforts in establishing desirable achievements in the form of immunization coverage figures. However, less focus has been placed on effort made by different countries to attain high immunization coverage. During August 2002, 14 district health directors in a remote province of Mozambique (Niassa) were interviewed. The objective was to ascertain the construction of immunization coverage and how they implement the desired program strategies in order to improve the health status of the region. We found that most managers regarded the immunization coverage as data and thus high coverage as an end in itself, rather than as a reflection of the reality. We also found that there are uncertainties in population data which makes it difficult to plan activities bellow the level of a district. We argue further that the innovative distinction between the views proposed on the immunization coverage, provided us with an insight of the different challenges that district health directors face as leaders of the district health management team in Niassa. Clues on the implications of certain views of immunization coverage for policy and local decision-making in the national and global pursuit of immunization targets are provided.

Diagnostic and treatment delay among pulmonary tuberculosis patients in Ethiopia: a cross sectional study

Background

Delayed diagnosis and treatment of tuberculosis (TB) results in severe disease and a higher mortality. It also leads to an increased period of infectivity in the community. The objective of this study was to determine the length of delays, and analyze the factors affecting the delay from onset of symptoms of pulmonary tuberculosis (PTB) until the commencement of treatment.

Methods

In randomly selected TB management units (TBMUs), i.e. government health institutions which have diagnosing and treatment facilities for TB in Amhara Region, we conducted a cross sectional study from September 1-December 31/2003. Delay was analyzed from two perspectives, 1. Period between onset of TB symptoms to first visit to any health provider (health seeking period), and from the first health provider visit to initiation of treatment (health providers' delay), and 2. Period between onset of TB symptoms to first visit to a medical provider (patients' delay), and from this visit to commencement of anti-TB treatment (health systems' delay). Patients were interviewed on the same date of diagnosis using a semi-structured questionnaire. Logistics regression analysis was applied to analyze the risk factors of delays.

Results

A total of 384 new smear positive PTB patients participated in the study. The median total delay was 80 days. The median health-seeking period and health providers' delays were 15 and 61 days, respectively. Conversely, the median patients' and health systems' delays were 30 and 21 days, respectively. Taking medical providers as a reference point, we found that forty eight percent of the subjects delayed for more than one month. Patients' delays were strongly associated with first visit to non-formal health providers and self treatment (P < 0.0001). Prior attendance to a health post/clinic was associated with increased health systems' delay (p < 0.0001).

Conclusion

Delay in the diagnosis and treatment of PTB is unacceptably high in Amhara region. Health providers' and health systems' delays represent the major portion of the total delay. Accessing a simple and rapid diagnostic test for TB at the lowest level of health care facility and encouraging a dialogue among all health providers are imperative interventions.