Impact of SMS Text Messaging Reminders on Helmet Use Among Motorcycle Drivers in Dar es Salaam, Tanzania: Randomized Controlled Trial

Background

Road traffic injury is a pressing public health issue in Tanzania. Increasing helmet use among motorcycle drivers can help reduce the burden due to road traffic injuries in the country. Helmet adherence can be supported through mobile health interventions.

Objective

The aim of this study is to evaluate the comparative impact of two different types of SMS text messaging reminders on motorcycle helmet use.

Methods

Participants were 391 commercial motorcycle taxi drivers in Dar es Salaam, Tanzania. Participants were randomized into three groups, each receiving a different set of messages: (1) social norming messages aimed at emphasizing society’s positive stance on helmet wearing, (2) fear appeal messages that emphasized the dangers of riding without a helmet, and (3) control group messages, which included basic road safety messages unrelated to helmet use. Every participant received the control messages. Adherence to helmet use was evaluated by self-report through surveys conducted at baseline, 3 weeks, and 6 weeks.

Results

At 6 weeks, the odds of self-reporting consistent helmet use were estimated to be 1.58 times higher in the social norming group than in the control group (P=.04), though this difference was not significant after accounting for multiple testing. There was little difference between fear appeal and control group recipients (odds ratio 1.03, P=.47). Subgroup analysis suggests that both fear appeal and social norming message types might have been associated with increased helmet use among participants who did not consistently wear helmets at baseline (odds ratio 1.66 and odds ratio 1.84, respectively), but this was not significant (P=.11 and P=.07, respectively). Among those who were consistent wearers at baseline, the social norming messages performed better than the fear appeal messages, and this difference reached traditional significance (P=.03), but was not significant after accounting for multiple testing.

Conclusions

The use of SMS text messaging reminders may improve helmet use among motorcycle drivers when framed as social norming messages. Given that nearly half of the drivers in our sample did not consistently wear their helmets on every trip, strategies to increase consistent usage could greatly benefit public safety.

Trial Registration

ClinicalTrials.gov NCT02120742; https://clinicaltrials.gov/ct2/show/NCT02120742

Last mile research: a conceptual map

Background: The term 'last mile' has been used across disciplines to refer to populations who are farthest away, most difficult to reach, or last to benefit from a program or service. However, last mile research lacks a shared understanding around its conceptualization.Objectives: This project used a concept mapping process to answer the questions: what is last mile research in global health and, how can it be used to make positive change for health equity in the last mile?Methods: Between July and December 2019, a five-stage concept mapping exercise was undertaken using online concept mapping software and an in-person consensus meeting. The stages were: establishment of an expert group and focus prompt; idea generation; sorting and rating; initial analysis and final consensus meeting.Results: A group of 15 health researchers with experience working with populations in last mile contexts and who were based at the Matariki Network institutions of Queen's University, CAN and Dartmouth College, USA took part. The resulting concept map had 64 unique idea statements and the process resulted in a map with five clusters. These included: (1) Last mile populations; (2) Research methods and approaches; (3) Structural and systemic factors; (4) Health system factors, and (5) Broader environmental factors. Central to the map were the ideas of equity, human rights, health systems, and contextual sensitivity.Conclusion: This is the first time 'last mile research' has been the focus of a formal concept mapping exercise. The resulting map showed consensus about who last mile populations are, how research should be undertaken in the last mile and why last mile health disparities exist. The map can be used to inform research training programs, however, repeating this process with researchers and members from different last mile populations would also add further insight.

Telehealth's New Horizon: Providing Smart Hospital-Level Care in the Home

During the COVID-19 pandemic, medical providers have expanded telehealth into daily practice, with many medical and behavioral health care visits provided remotely over video or through phone. The telehealth market was already facilitating home health care with increasing levels of sophistication before COVID-19. Among the emerging telehealth practices, telephysical therapy; teleneurology; telemental health; chronic care management of congestive heart failure, chronic obstructive pulmonary disease, diabetes; home hospice; home mechanical ventilation; and home dialysis are some of the most prominent. Home telehealth helps streamline hospital/clinic operations and ensure the safety of health care workers and patients. The authors recommend that we expand home telehealth to a comprehensive delivery of medical care across a distributed network of hospitals and homes, linking patients to health care workers through the Internet of Medical Things using in-home equipment, including smart medical monitoring devices to create a "medical smart home." This expanded telehealth capability will help doctors care for patients flexibly, remotely, and safely as a part of standard operations and during emergencies such as a pandemic. This model of "telehomecare" is already being implemented, as shown herein with examples. The authors envision a future in which providers and hospitals transition medical care delivery to the home just as, during the COVID-19 pandemic, students adapted to distance learning and adults transitioned to remote work from home. Many of our homes in the future may have a "smart medical suite" as well as a "smart home office."

Decolonizing Global Health Education: Rethinking Institutional Partnerships and Approaches

Global health often entails partnerships between institutions in low- and middle-income countries (LMICs) that were previously colonized and high-income countries (HICs) that were colonizers. Little attention has been paid to the legacy of former colonial relationships and the influence they have on global health initiatives. There have been recent calls for the decolonization of global health education and the reexamination of assumptions and practices under pinning global health partnerships. Medicine's role in colonialism cannot be ignored and requires critical review. There is a growing awareness of how knowledge generated in HICs defines practices and informs thinking to the detriment of knowledge systems in LMICs. Additionally, research partnerships often benefit the better-resourced partner. In this article, the authors offer a brief analysis of the intersections between colonialism, medicine, and global health education and explore the lingering impact of colonialist legacies on current global health programs and partnerships. They describe how "decolonized" perspectives have not gained sufficient traction and how inequitable power dynamics and neocolonialist assumptions continue to dominate. They discuss 5 approaches, and highlight resources, that challenge colonial paradigms in the global health arena. Furthermore, they argue for the inclusion of more transfor mative learning approaches to promote change in attitudes and practice. They call for critical reflection and concomitant action to shift colonial paradigms toward more equitable partnerships in global education.

The adverse health effects of punitive immigrant policies in the United States: A systematic review

BACKGROUND

Immigrants in the United States (US) today are facing a dynamic policy landscape. The Trump administration has threatened or curtailed access to basic services for 10.5 million undocumented immigrants currently in the US. We sought to examine the historical effects that punitive laws have had on health outcomes in US immigrant communities.

METHODS

In this systematic review, we searched the following databases from inception-May 2020 for original research articles with no language restrictions: Ovid MEDLINE, Ovid EMBASE, Cochrane Library (Wiley), Web of Science Core Collection (Clarivate), CINAHL (EBSCO), and Social Work Abstracts (Ovid). This study is registered with PROSPERO, CRD42019138817. Articles with cohort sizes >10 that directly evaluated the health-related effects of a punitive immigrant law or policy within the US were included.

FINDINGS

6,357 studies were screened for eligibility. Of these, 32 studies were selected for inclusion and qualitatively synthesized based upon four themes that appeared throughout our analysis: (1) impact on healthcare utilization, (2) impact on women's and children's health, (3) impact on mental health services, and (4) impact on public health. The impact of each law, policy, mandate, and directive since 1990 is briefly discussed, as are the limitations and risk of bias of each study.

INTERPRETATION

Many punitive immigrant policies have decreased immigrant access to and utilization of basic healthcare services, while instilling fear, confusion, and anxiety in these communities. The federal government should preserve and expand access for undocumented individuals without threat of deportation to improve health outcomes for US citizens and noncitizens.

Correction to: Successful implementation of isoniazid preventive therapy at a pediatric HIV clinic in Tanzania

An amendment to this paper has been published and can be accessed via the original article.

Successful implementation of isoniazid preventive therapy at a pediatric HIV clinic in Tanzania

BACKGROUND

In accordance with international guidance for tuberculosis (TB) prevention, the Tanzanian Ministry of Health recommends isoniazid preventive therapy (IPT) for children aged 12 months and older who are living with HIV. Concerns about tolerability, adherence, and potential mistreatment of undiagnosed TB with monotherapy have limited uptake of IPT globally, especially among children, in whom diagnostic confirmation is challenging. We assessed IPT implementation and adherence at a pediatric HIV clinic in Tanzania.

METHODS

In this prospective cohort study, eligible children living with HIV aged 1-15 years receiving care at the DarDar Pediatric Program in Dar es Salaam who screened negative for TB disease were offered a 6-month regimen of daily isoniazid. Patients could choose to receive IPT via facility- or community-based care. Parents/caregivers and children provided informed consent and verbal assent respectively. Isoniazid was dispensed with the child's antiretroviral therapy every 1-3 months. IPT adherence and treatment completion was determined by pill counts, appointment attendance, and self-report. Patients underwent TB symptom screening at every visit.

RESULTS

We enrolled 66 children between July and December 2017. No patients/caregivers declined IPT. Most participants were female (n = 43, 65.1%) and the median age was 11 years (interquartile range [IQR] 8, 13). 63 (95.5%) participants chose the facility-based model; due to the small number of participants who chose the community-based model, valid comparisons between the two groups could not be made. Forty-nine participants (74.2%) completed IPT within 10 months. Among the remaining 17, 11 had IPT discontinued by their provider due to adverse drug reactions, 5 lacked documentation of completion, and 1 had unknown outcomes due to missing paperwork. Of those who completed IPT, the average monthly adherence was 98.0%. None of the participants were diagnosed with TB while taking IPT or during a median of 4 months of follow-up.

CONCLUSIONS

High adherence and treatment completion rates can be achieved when IPT is integrated into routine, self-selected facility-based pediatric HIV care. Improved record-keeping may yield even higher completion rates. IPT was well tolerated and no cases of TB were detected. IPT for children living with HIV is feasible and should be implemented throughout Tanzania.

Integrated and patient-selected care facilitates completion of isoniazid preventive therapy in Eswatini

Setting

Five human immunodeficiency virus (HIV) care facilities in Eswatini.

Objective

To identify critical factors that enabled persons living with HIV to successfully complete a 6-month course of isoniazid preventive therapy (IPT) provided through a choice of facility-based or community-based delivery, coordinated with antiretroviral therapy (ART) refills.

Design

This was a mixed methods, retrospective cross-sectional study.

Results

Between June and October 2017, we interviewed 150 participants who had completed IPT in the previous year. Fourteen participants did not recall being offered a choice, and were excluded from the analysis. Of the remaining 136, 56.6% were female and 64.7% chose facility-based care; the median age was 42.5 years. Most participants reported that having a choice was important to their treatment completion (87.7%) and that linking IPT and ART refills facilitated undergoing IPT (98.5%). Participants were knowledgeable about the benefits of IPT and valued the education received from their providers. Participants also reported a high rate of IPT disclosure (95%) to friends and family members.

Conclusion

Offering patients a choice of IPT delivery, linking IPT with ART refills, emphasizing patient education and engagement with healthcare workers, and supporting disclosure of IPT are critical factors to enabling IPT completion. These interventions should be incorporated throughout Eswatini and in similar high tuberculosis and HIV burden settings.

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda

BACKGROUND

The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda.

METHODS

The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors.

RESULTS

In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions.

CONCLUSION

The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.

High completion rates of isoniazid preventive therapy among persons living with HIV in Swaziland

SETTING

Five human immunodeficiency virus (HIV) care facilities in Swaziland.

OBJECTIVE

To assess adherence and treatment completion of a 6-month course of isoniazid preventive therapy (IPT) provided to HIV-infected patients through a self-selected model of facility-based, community-based or peer-supported IPT delivery coordinated with antiretroviral refills.

DESIGN

Prospective cohort study.

RESULTS

Between February and August 2015, we enrolled 908 patients, with follow-up until February 2016. Most were female (66.2%), with a median age of 38 years (interquartile range 31-45). Most (n = 797, 87.8%) chose facility-based delivery, 111 (12.2%) selected community-based delivery, and none selected peer-supported delivery. Adherence was high in both cohorts; among those with available data, 794 (94.8%) reported taking at least 80% of their IPT (P > 0.05). Twenty-two patients screened positive for tuberculosis (TB) at any visit; all had TB excluded and most continued IPT. In total, 812 (89.4%) patients completed treatment: 711 (89.2%) were on facility-based and 111 (91.0%) on community-based IPT (P > 0.05). No confirmed treatment failures occurred. Few patients discontinued IPT (6.3%) or were lost to follow-up (4.1%).

CONCLUSION

Self-selected IPT delivery aligned with HIV care achieved high rates of adherence and treatment completion. This model may improve outcomes by simplifying clinic visits and conferring agency to the patient, and may be readily implemented in similar high TB-HIV burden settings.

Barriers to tuberculosis care delivery among miners and their families in South Africa: an ethnographic study

SETTING

South African miners suffer the highest tuberculosis (TB) rates in the world. Current efforts to stem the epidemic are insufficient. Historical legacies and persistent disease burden demand innovative approaches to reshape health care delivery to better serve this population.

OBJECTIVE

To characterize social and behavioral health determinants for successful TB care delivery and treatment from the perspective of miners/ex-miners, health care workers and policy makers/managers.

DESIGN

We conducted applied ethnography with 30 miners/ex-miners, 13 family/community members, 14 health care providers, and 47 local policy makers/managers in South Africa.

RESULTS

Miners/ex-miners felt health care delivery systems failed to meet their needs. Many had experienced unnecessary physical and psychological harm due to limited health education about TB, minimal engagement in their own care, lack of trust in providers, and a system that did not value their experience. Stigma and fear associated with TB result in denial of symptoms and delays in care seeking. Health care providers and policy makers/managers felt discouraged by system constraints in providing optimal care.

CONCLUSION

Our findings describe long-term effects of perpetual TB misinformation and stigma resulting from fear and disempowerment among miners and their families/communities. To reduce the TB burden, there is an urgent need to co-design a care delivery system with miners to better meet their needs.

Beyond Visas and Vaccines: Preparing Students for Domestic and Global Health Engagement

At campuses across the United States, scores of students are embarking on global health experiences in low- and middle-income countries. The desire to improve the health of poor communities while preparing for future health careers is often the main driver. The spotlight on domestic health issues also has fueled a resurgence of interest in underserved communities in the United States. Regardless of the destination, rigorous preparation is needed to ensure that the students' presence benefits the communities they aim to serve. Development of mutually beneficial programs with host communities coupled with thoughtful preparation of students is essential to the future of these university programs but, more importantly, to achieve the goal of shared learning and capacity building across borders. US program leaders may not fully consider the potential risks that can occur to their programs from involving poorly prepared students, or these risks may appear largely theoretical. However, many experienced practitioners and their international collaborators can relate examples of damaged partnerships, adverse consequences on community structures, dangers to patient safety, and harmed professional reputations and credibility. Domestic health experiences do not require a visa or vaccines but bring students in contact with many of the same ethical, professional, and cross-cultural challenges as overseas endeavors. Fortunately, best practices for preparing students to confront these challenges have emerged from years of experience in domestic and global contexts alike. It all begins with establishing institutional partnerships built on principles of reciprocity and respect. Through careful program design, universities can align missions, goals, and expectations to best serve all invested parties: local partners, students, faculty, staff, and the communities where they will be working. A second critical component is appropriate student selection. Matching student skills with partner needs can optimize benefits for both the host organization and student. Finally, universities can prepare students to navigate in cross-cultural settings in a professional and ethical manner through careful training. Just as negative experiences can have lasting negative consequences, the best ones can lead to strengthened partnerships; durable benefits for local and global communities; and optimal learning for students, their supervisors, and hosts.

Safety and immunogenicity of an inactivated whole cell tuberculosis vaccine booster in adults primed with BCG: A randomized, controlled trial of DAR-901

BACKGROUND

Development of a tuberculosis vaccine to boost BCG is a major international health priority. SRL172, an inactivated whole cell booster derived from a non-tuberculous mycobacterium, is the only new vaccine against tuberculosis to have demonstrated efficacy in a Phase 3 trial. In the present study we sought to determine if a three-dose series of DAR-901 manufactured from the SRL172 master cell bank by a new, scalable method was safe and immunogenic.

METHODS

We performed a single site, randomized, double-blind, controlled, Phase 1 dose escalation trial of DAR-901 at Dartmouth-Hitchcock Medical Center in the United States. Healthy adult subjects age 18-65 with prior BCG immunization and a negative interferon-gamma release assay (IGRA) were enrolled in cohorts of 16 subjects and randomized to three injections of DAR-901 (n = 10 per cohort), or saline placebo (n = 3 per cohort), or two injections of saline followed by an injection of BCG (n = 3 per cohort; 1-8 x 106 CFU). Three successive cohorts were enrolled representing DAR-901 at 0.1, 0.3, and 1 mg per dose. Randomization was performed centrally and treatments were masked from staff and volunteers. Subsequent open label cohorts of HIV-negative/IGRA-positive subjects (n = 5) and HIV-positive subjects (n = 6) received three doses of 1 mg DAR-901. All subjects received three immunizations at 0, 2 and 4 months administered as 0.1 mL injections over the deltoid muscle alternating between right and left arms. The primary outcomes were safety and immunogenicity. Subjects were followed for 6 months after dose 3 for safety and had phlebotomy performed for safety studies and immune assays before and after each injection. Immune assays using peripheral blood mononuclear cells included cell-mediated IFN-γ responses to DAR-901 lysate and to Mycobacterium tuberculosis (MTB) lysate; serum antibody to M. tuberculosis lipoarabinomannan was assayed by ELISA.

RESULTS

DAR-901 had an acceptable safety profile and was well-tolerated at all dose levels in all treated subjects. No serious adverse events were reported. Median (range) 7-day erythema and induration at the injection site for 1 mg DAR-901 were 10 (4-20) mm and 10 (4-16) mm, respectively, and for BCG, 30 (10-107) mm and 38 (15-55) mm, respectively. Three mild AEs, all headaches, were considered possibly related to DAR-901. No laboratory or vital signs abnormalities were related to immunization. Compared to pre-vaccination responses, three 1 mg doses of DAR-901 induced statistically significant increases in IFN-γ response to DAR-901 lysate and MTB lysate, and in antibody responses to M. tuberculosis lipoarabinomannan. Ten subjects who received 1 mg DAR-901 remained IFN-γ release assay (IGRA) negative after three doses of vaccine.

CONCLUSIONS

A three-injection series of DAR-901 was well-tolerated, had an acceptable safety profile, and induced cellular and humoral immune responses to mycobacterial antigens. DAR-901 is advancing to efficacy trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02063555.

The future of global health education: training for equity in global health

BACKGROUND

Among academic institutions in the United States, interest in global health has grown substantially: by the number of students seeking global health opportunities at all stages of training, and by the increase in institutional partnerships and newly established centers, institutes, and initiatives to house global health programs at undergraduate, public health and medical schools. Witnessing this remarkable growth should compel health educators to question whether the training and guidance that we provide to students today is appropriate, and whether it will be applicable in the next decade and beyond. Given that "global health" did not exist as an academic discipline in the United States 20 years ago, what can we expect it will look like 20 years from now and how can we prepare for that future?

DISCUSSION

Most clinicians and trainees today recognize the importance of true partnership and capacity building in both directions for successful international collaborations. The challenge is in the execution of these practices. There are projects around the world where this is occurring and equitable partnerships have been established. Based on our experience and observations of the current landscape of academic global health, we share a perspective on principles of engagement, highlighting instances where partnerships have thrived, and examples of where we, as a global community, have fallen short.

CONCLUSIONS

As the world moves beyond the charity model of global health (and its colonial roots), it is evident that the issue underlying ethical global health practice is partnership and the pursuit of health equity. Thus, achieving equity in global health education and practice ought to be central to our mission as educators and advisors when preparing trainees for careers in this field. Seeking to eliminate health inequities wherever they are ingrained will reveal the injustices around the globe and in our own cities and towns.

Ending neglect: providing effective childhood tuberculosis training for health care workers in Tanzania

SETTING

Health care facilities in Dar es Salaam, Pwani, and Arusha, Tanzania.

OBJECTIVE

To assess health care worker (HCW) knowledge and practices 1 year after specialized training in childhood tuberculosis (TB).

DESIGN

Using a standardized survey, we interviewed a convenience sample of HCWs providing both general and specialized care to children.

RESULTS

We interviewed 117 HCWs in TB clinics, maternal and child health clinics, human immunodeficiency virus (HIV) clinics, out-patient departments, and pediatric in-patient wards at 12 facilities. A total of 81 HCWs (62% of nurses, 74% of clinicians) reported having attended the national childhood TB training course. Most HCWs responded correctly to questions on childhood TB diagnosis, treatment, and TB-HIV co-management, regardless of training history. Most HCWs reported that they routinely obtain chest radiographs, HIV testing, and a TB contact history when evaluating children for TB. Less than half of HCWs reported routinely obtaining sputum for mycobacterial culture or performing a tuberculin skin test. Three times as many trained as untrained HCWs reported having ever prescribed isoniazid preventive therapy (IPT) to a child (P < 0.05).

CONCLUSION

In general, levels of childhood TB knowledge were high and practices were in accordance with national guidance. Specific gaps in diagnosis, treatment and use of IPT were identified for future focused training.

Interventions to improve delivery of isoniazid preventive therapy: an overview of systematic reviews

Background

Uptake of isoniazid preventive therapy (IPT) to prevent tuberculosis has been poor, particularly in the highest risk populations. Interventions to improve IPT delivery could promote implementation. The large number of existing systematic reviews on treatment adherence has made drawing conclusions a challenge. To provide decision makers with the evidence they need, we performed an overview of systematic reviews to compare different organizational interventions to improve IPT delivery as measured by treatment completion among those at highest risk for the development of TB disease, namely child contacts or HIV-infected individuals.

Methods

We searched the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects (DARE), and MEDLINE up to August 15, 2012. Two authors used a standardized data extraction form and the AMSTAR instrument to independently assess each review.

Results

Six reviews met inclusion criteria. Interventions included changes in the setting/site of IPT delivery, use of quality monitoring mechanisms (e.g., directly observed therapy), IPT delivery integration into other healthcare services, and use of lay health workers. Most reviews reported a combination of outcomes related to IPT adherence and treatment completion rate but without a baseline or comparison rate. Generally, we found limited evidence to demonstrate that the studied interventions improved treatment completion.

Conclusions

While most of the interventions were not shown to improve IPT completion, integration of tuberculosis and HIV services yielded high treatment completion rates in some settings. The lack of data from high burden TB settings limits applicability. Further research to assess different IPT delivery interventions, including those that address barriers to care in at-risk populations, is urgently needed to identify the most effective practices for IPT delivery and TB control in high TB burden settings.

Nutritional Deficiencies and Food Insecurity Among HIV-infected Children in Tanzania

BACKGROUND

Poor nutrition has been associated with impaired immunity and accelerated disease progression in HIV-infected children. The aim of this study was to quantify the levels of nutrient intake in HIV-infected children and compare these to standard recommendations.

METHODS

We surveyed HIV-infected Tanzanian children enrolled in a pediatric care program that provided routine nutritional counseling and vitamin supplementation. We obtained anthropometric measurements and determined 24-hour macronutrient and micronutrient intakes and food insecurity. Values were compared to recommended nutrient intakes based on age and gender.

RESULTS

We interviewed 48 pairs of children and their caregiver(s). The age of the child ranged from 2-14 years; median age 6 and 60% female. The median weight-for-height z-score for children ≤ 5 years was 0.69 and BMI-for-age z-scores for children >5 was -0.84. Macronutrient evaluation showed that 29 (60%) children were deficient in dietary intake of energy; deficiency was more common in older children (p=0.004). Micronutrient evaluation shows that over half of study subjects were deficient in dietary intake of vitamin A, vitamin D, vitamin E, thiamine, riboflavin, niacin, folate, vitamin B12, and calcium. Food insecurity was reported by 20 (58%) caregivers.

CONCLUSIONS AND PUBLIC HEALTH IMPLICATIONS

The diets of many HIV-infected children at a specialized treatment center in Tanzania do not meet recommended levels of macro-and micro-nutrients. Food insecurity was a contributory factor. Enhanced dietary counseling and provision of macro- and micro-nutrient supplements will be necessary to achieve optimal nutrition for most HIV-infected children in resource-poor regions.

Consensus Statement on Research Definitions for Drug-Resistant Tuberculosis in Children

Few children with drug-resistant (DR) tuberculosis (TB) are identified, diagnosed, and given an appropriate treatment. The few studies that have described this vulnerable population have used inconsistent definitions. The World Health Organization (WHO) definitions used for adults with DR-TB and for children with drug-susceptible TB are not always appropriate for children with DR-TB. The Sentinel Project on Pediatric Drug-Resistant Tuberculosis was formed in 2011 as a network of experts and stakeholders in childhood DR-TB. An early priority was to establish standardized definitions for key parameters in order to facilitate study comparisons and the development of an evidence base to guide future clinical management. This consensus statement proposes standardized definitions to be used in research. In particular, it suggests consistent terminology, as well as definitions for measures of exposure, drug resistance testing, previous episodes and treatment, certainty of diagnosis, site and severity of disease, adverse events, and treatment outcome.

Children's medicines in Tanzania: a national survey of administration practices and preferences

OBJECTIVE

The dearth of age-appropriate formulations of many medicines for children poses a major challenge to pediatric therapeutic practice, adherence, and health care delivery worldwide. We provide information on current administration practices of pediatric medicines and describe key stakeholder preferences for new formulation characteristics.

PATIENTS AND METHODS

We surveyed children aged 6-12 years, parents/caregivers over age 18 with children under age 12, and healthcare workers in 10 regions of Tanzania to determine current pediatric medicine prescription and administration practices as well as preferences for new formulations. Analyses were stratified by setting, pediatric age group, parent/caregiver education, and healthcare worker cadre.

RESULTS

Complete data were available for 206 children, 202 parents/caregivers, and 202 healthcare workers. Swallowing oral solid dosage forms whole or crushing/dissolving them and mixing with water were the two most frequently reported methods of administration. Children frequently reported disliking medication taste, and many had vomited doses. Healthcare workers reported medicine availability most significantly influences prescribing practices. Most parents/caregivers and children prefer sweet-tasting medicine. Parents/caregivers and healthcare workers prefer oral liquid dosage forms for young children, and had similar thresholds for the maximum number of oral solid dosage forms children at different ages can take.

CONCLUSIONS

There are many impediments to acceptable and accurate administration of medicines to children. Current practices are associated with poor tolerability and the potential for under- or over-dosing. Children, parents/caregivers, and healthcare workers in Tanzania have clear preferences for tastes and formulations, which should inform the development, manufacturing, and marketing of pediatric medications for resource-limited settings.

Specificity of the tuberculin skin test and the T-SPOT.TB assay among students in a low-tuberculosis incidence setting

OBJECTIVE

Interferon-γ release assays (IGRAs) are an important tool for detecting latent Mycobacterium tuberculosis infection (LTBI). Insufficient data exist about IGRA specificity in college health centers, most of which screen students for LTBI using the tuberculin skin test (TST).

PARTICIPANTS

Students at a low-TB incidence college health center.

METHODS

TST and T-SPOT.TB were performed on prospectively recruited students. TB exposure risk was assessed using a questionnaire: Those at low risk were assumed to not have LTBI in order to calculate test specificity.

RESULTS

Of 184 students enrolled, 143 had results available for both TST and T-SPOT.TB. Agreement of the tests was 97% (kappa statistic 0.717; 95% confidence interval, 0.399-1.00). Among 124 low-risk students, specificity for TST and T-SPOT.TB were 98.4% and 100%, respectively.

CONCLUSIONS

T-SPOT.TB specificity was high among low-risk students. Additional studies such as cost-effectiveness analyses using T-SPOT.TB as a single or confirmatory test to TST are needed to contribute to LTBI screening policy decisions.

Effectiveness of a sports-based HIV prevention intervention in the Dominican Republic: a quasi-experimental study

Previous observational and quasi-experimental studies in sub-Saharan Africa have suggested the effectiveness of youth-targeted HIV prevention interventions using sport as an educational tool. No studies have yet assessed the effect of similar programs in the Caribbean. A quasi-experimental trial was conducted to assess the effectiveness of a sports-based intervention in six migrant settlements in the Puerto Plata Province of the Dominican Republic. A total of 397 structured interviews were conducted with 140 adolescents prior to, immediately following, and four months following 10-hour interventions using the Grassroot Soccer curriculum. Interview responses were coded, aggregated into composite scores, and analyzed using logistic regression, adjusting for baseline differences as well as age, sex, community, and descent. At post-intervention, significant differences were observed between groups in HIV-related knowledge (adjOR = 13.02, 95% CI = 8.26, 20.52), reported attitudes (adjOR = 12.01, 95% CI = 7.61, 18.94), and reported communication (adjOR = 3.13, 95% CI = 1.91, 5.12). These differences remained significant at four-month follow-up, though declines in post-intervention knowledge were observed in the Intervention group while gains in knowledge and reported attitudes were observed in the Control group. Results suggest that this sports-based intervention could play a valuable role in HIV prevention efforts in the Caribbean, particularly those targeting early adolescents. Further evaluation of sports-based interventions should include indicators assessing behavioral and biological outcomes, longer-term follow-up, a larger sample, randomization of study participants, and strenuous efforts to minimize loss-to-follow-up.

Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality

BACKGROUND

Disseminated tuberculosis (TB) is a major cause of death in patients with the acquired immune-deficiency syndrome (AIDS), but its pathogenesis and clinical features have not been defined prospectively.

METHODS

Human immunodeficiency virus (HIV) infected adults with a CD4 count ≥ 200 cells/μl and bacille Calmette-Guérin scar underwent immunologic evaluation and subsequent follow-up.

RESULTS

Among 20 subjects who developed disseminated TB, baseline tuberculin skin tests were ≥15 mm in 14 (70%) and lymphocyte proliferative responses to Mycobacterium tuberculosis were positive in 14 (70%). At the time of diagnosis, fever ≥2 weeks plus ≥5 kg weight loss was reported in 16 (80%) patients, abnormal chest X-rays in 7/17 (41%), and positive sputum cultures in 10 (50%); median CD4 count was 30 cells/μl (range 1-122). By insertion sequence (IS) 6110 analysis, 14 (70%) blood isolates were clustered and 3/8 (37%) concurrent sputum isolates represented a different strain (polyclonal disease). Empiric TB treatment was given to eight (40%) patients; 11 (55%) died within a month.

CONCLUSIONS

Disseminated TB in HIV occurs with cellular immune responses indicating prior mycobacterial infection, and IS6110 analysis suggests an often lethal combination of reactivation and newly acquired infection. Control will require effective prevention of both remotely and recently acquired infection, and wider use of empiric therapy in patients with advanced AIDS and prolonged fever.

Prevention of tuberculosis in Bacille Calmette-Guérin-primed, HIV-infected adults boosted with an inactivated whole-cell mycobacterial vaccine

OBJECTIVE

To determine whether a multiple-dose series of an inactivated whole cell mycobacterial vaccine, Mycobacterium vaccae, can prevent HIV-associated tuberculosis.

DESIGN AND METHODS

The DarDar trial was a randomized, placebo-controlled, double-blind trial. The study was carried in an outpatient facility in Dar es Salaam, Tanzania. HIV-infected patients with CD4 cell counts of at least 200 cells/microl and a Bacille Calmette-Guérin scar were chosen for the study. The intervention was carried out by random 1:1 assignment to five intradermal doses of M. vaccae or placebo. Tuberculin skin tests were performed, and patients with reactions of at least 5 mm were administered isoniazid for 6 months. The main outcome measures were disseminated (primary endpoint), definite, and probable tuberculosis (secondary endpoints).

RESULTS

Two thousand thirteen individuals were randomized (1006 to M. vaccae, 1007 to placebo) and followed every 3 months for a median of 3.3 years. The trial was terminated early because of slow accrual of cases of disseminated tuberculosis and significant protection against definite tuberculosis. Hazard ratios were disseminated tuberculosis 0.52 (95% confidence interval 0.21-1.34; seven cases in M. vaccae, 13 cases in placebo; log-rank P = 0.16), definite tuberculosis 0.61 (95% confidence interval 0.39-0.96; 33 cases in M. vaccae, 52 cases in placebo; P = 0.03), and probable tuberculosis 1.17 (95% confidence interval 0.76-1.80; 48 cases in M. vaccae, 40 cases in placebo; P = 0.46). Immunization was well tolerated, with no adverse effect on CD4 cell count or HIV viral load, and no increase in the rate of serious adverse events.

CONCLUSION

Administration of a multiple-dose series of M. vaccae to HIV-infected adults with childhood Bacille Calmette-Guérin immunization is safe and is associated with significant protection against definite tuberculosis. These results provide evidence that immunization with a whole cell mycobacterial vaccine is a viable strategy for the prevention of HIV-associated tuberculosis.

Pediatric therapeutics and medicine administration in resource-poor settings: a review of barriers and an agenda for interdisciplinary approaches to improving outcomes

The lack of affordable, available pediatric drug formulations presents serious global health challenges. This article argues that successful pharmacotherapy for children demands an interdisciplinary approach. There is a need to develop new medicines to address acute and chronic illnesses of children, but also to produce formulations of essential medicines to optimize stability, bioavailability, palatability, cost, accurate dosing and adherence. This, in turn, requires an understanding of the social ecologies in which treatment occurs. Understanding health worker, caregiver and patient practices, limitations, and expectations with regard to medicines is crucial to guiding effective drug development and administration. Using literature on pediatric tuberculosis as a reference, this review highlights sociocultural, pharmacological, and structural barriers that impede the delivery of medicines to children. It serves as a basis for the development of an intensive survey of patient, caregiver, and health care worker understandings of, and preferences for, pediatric formulations in three East African countries.

DOTS implementation in a post-war, United Nations-administered territory: Lessons from Kosovo

SETTING

The WHO-recommended strategy of tuberculosis control (DOTS strategy) has been shown to be effective in reducing tuberculosis incidence in a variety of countries/ settings. Little evidence exists on the implementation, and effectiveness of DOTS in a transitional, post-war setting

OBJECTIVE

To describe the process of establishing a National Tuberculosis Control Program (NTP) and implementing DOTS throughout Kosovo, and the outcomes achieved by this international collaboration in a post-war transitional setting during 1999-2005.

METHODS

In 1999, as part of the re-organization of health services, a DOTS-based NTP was established and operationalized through a collaboration of several international partners in Kosovo. Five key steps supported these activities.

RESULTS

Kosovo has reached the World Health Assembly targets, having achieved 75% case detection rate (sputum smear-positive cases) and 93% treatment success rate. During 2000-2005, new smear-positive tuberculosis case notifications decreased by 44.5% (median annual decrease for all cases: 7.6%).

CONCLUSIONS

Kosovo's success story is a collaborative tale, each partner involved playing a unique role in supporting NTP activities. The Kosovo example provides yet another setting in which DOTS implementation has resulted in successful patient outcomes. The international TB control community would be well-served by formal guidelines for implementing DOTS and the new STOP TB Strategy in these settings.

Health department costs of managing persons with suspected and noncounted tuberculosis in New York City, Three Texas counties, and Massachusetts

OBJECTIVES

To describe persons with suspected (did not meet the national tuberculosis [TB] surveillance case definition) and noncounted TB (met the TB case definition but transferred and were counted by another jurisdiction) and estimate costs incurred by public health departments for managing them.

METHODS

We reviewed TB registry, medical records, budgets, bills, salaries, organizational charts, and travel/activity logs from the year 2000 at health departments in New York City (NYC), three Texas (TX) counties (El Paso, Hidalgo, and Webb), and Massachusetts (MA). We also interviewed or observed personnel to estimate the time spent on activities for these patients.

RESULTS

In 2000, NYC and MA had more persons with suspected (n = 2,996) and noncounted (n = 163) TB than with counted (n = 1,595) TB. TX counties had more persons with counted TB (n = 179) than with suspected (n = 55) and noncounted (n = 15) TB. Demographic and clinical characteristics varied widely. For persons with suspected TB, NYC spent an estimated $1.7 million, with an average cost of $636 for each person; TX counties spent $60,928 ($1,108 per patient); and MA spent $1.1 million ($3,330 per patient). For persons with noncounted TB, NYC spent $303,148 ($2,180 per patient), TX counties spent $40,002 ($2,667 per patient), and MA spent $84,603 ($3,525 per patient).

CONCLUSIONS

Health departments incurred substantial costs in managing persons with suspected and noncounted TB. These costs should be considered when allocating TB program resources.

Childhood turberculosis in the developing world

Tuberculosis remains an important cause of childhood morbidity and mortality in many areas of the developing world. Published data on the epidemiology of TB in children are scarce, and research efforts focused on TB in children are too few. The diagnosis of TB in children is difficult, and too many children are not completing their prescribed courses of treatment. Controlling TB in all populations requires that attention be devoted to the issues of accurate surveillance and adequate diagnosis and treatment of TB in children.

Virilization during pregnancy with spontaneous resolution postpartum: a case report and review of the English literature

The incidence of gestational hyperandrogenism secondary to ovarian pathology is low. However, when the condition does exist, diagnosis should be made with minimally invasive modalities. It is important to provide appropriate medical/surgical intervention without disturbing the pregnancy iatrogenically or causing unnecessary maternal morbidity. This case report adds to the existing radiographic data concerning this rare obstetrical condition. Presented is a review of the English literature on virilizing ovarian tumors during pregnancy, and a discussion of an approach to managing these tumors when they occur during pregnancy.