Macha, Zambia. To assess the benefits of auramine-O staining fluorescence microscopy and Mycobacterial Growth Indicator Tube (MGIT) liquid culture with molecular identification in tuberculosis (TB) diagnostics. One hundred patients suspected of TB were subjected to three sputum sample examinations applying Ziehl-Neelsen (ZN) and auramine-O staining and MGIT culture. Positive cultures were identified using the GenoType CM assay; cultures identified as Mycobacterium tuberculosis complex were the gold standard for a diagnosis of TB. The 100 patients produced 271 sputum samples; of these, 30 patients had positive cultures. M. tuberculosis complex bacilli were isolated in 17 (56.7%) patients, non-tuberculous mycobacteria (NTM) in 11 (36.7%) and other acid-fast bacilli in two. Forty-eight samples (17.7%) were contaminated. Auramine-O detected 16 (57.1%) patients culture-positive for mycobacteria and 12 patients with culture-proven TB, vs. respectively 8 (28.6%, P = 0.008) and 7 (41.2%, P = 0.044) for ZN. Three of eight auramine-positive/ZN-negative patients were culture-positive for NTM only. The auramine-O method significantly increases sensitivity, although the higher NTM detection rate implies that this does not in itself lead to a more accurate diagnosis of TB. MGIT culture is highly sensitive, although contamination rates were a drawback; the high frequency of NTM isolation warrants a robust identification method.

Author(s): Garfein, RS; Catanzaro, DG; Rodwell, TC; Avalos, E; Jackson, RL; Kaping, J; Evasco, H; Rodrigues, C; Crudu, V; Lin, S-Y; Groessl, E; Hillery, N; Trollip, A; Ganiats, T; Victor, TC; Eisenach, K; Valafar, F; Channick, J; Qian, L; Catanzaro, A

We report the efficiency and cost-effectiveness of p-nitrobenzoic acid (PNB) testing in Middlebrook 7H10 agar medium for the identification of Mycobacterium tuberculosis complex (MTC). PNB-7H10 was compared with PNB-MGIT and BACTEC-NAP using 200 clinical mycobacterial isolates. PNB-7H10 showed 100% agreement with PNB-MGIT and BACTEC-NAP tests, and reduced the cost of PNB-MGIT test by 80%. PNB-7H10 agar is therefore an effective alternative to the costly PNB-MGIT and BACTEC-NAP tests, especially in resource-poor settings.

This quasi-experimental cohort study aimed to evaluate World Health Organization (WHO) defined tuberculosis (TB) treatment outcomes for patients under directly observed treatment at a health facility (clinic DOT) or at home (family DOT) in urban Pakistan. We enrolled 582 sputum smear-positive TB patients being treated by either clinic DOT (n = 295) or family DOT (n = 287) in 11 treatment centres. Patients and/or family members were interviewed for baseline measurements. WHO-defined treatment outcomes were evaluated at the end of treatment. Proportions of 'cured' patients were computed. A log-binomial model was used to evaluate the associations of various factors with 'cured' status. The proportion of 'cured' patients was respectively 66% and 34% in the clinic DOT and family DOT groups (risk difference 0.32; 95%CI 0.24-0.39). Patients on clinic DOT were more likely to achieve cure (adjusted relative risk [RR(adj)] 1.85; 95%CI 1.43-2.39) than those on family DOT, as were patients satisfied with their health care worker's attitude (RR(adj) 5.73; 95%CI 2.54-12.96). Clinic DOT nearly doubled the proportion of cured patients compared to family DOT. Efforts to improve care-provider attitudes to enhance patient satisfaction, and effective implementation of the WHO's public-private mix approach, may enhance TB control in this and similar settings.

Tobacco prevention studies show that graphic health warnings are more effective than text warnings, but there are no data on the effectiveness of different types of graphic health warnings in a Pakistani population. Even marginal differences in the effectiveness of genres can be of potential significance for public health. To study the effectiveness of different types of graphic tobacco warnings in a Pakistani population. We presented ten anti-smoking warnings to randomly selected volunteers (n = 170) and recorded their opinion on the effectiveness of each warning. The warnings were based on a range of images aimed at the diverse population interviewed. A grading scale based on appeal, application, educational potential and motivation towards cessation was used to produce a composite grade of perceived effectiveness of the warning. Our results indicate that graphic warnings reach a greater proportion of the population than text warnings. Those appealing to logic, and those inculcating a sense of fear by showing a deleterious outcome of smoking, were judged likely to be most effective in motivating smokers to quit and preventing experimental smokers from forming a habit.

Reliable DST against second-line anti-tuberculosis drugs (SLDs) is crucial for the management of the increasing burden of patients affected by multidrug- and extensively drug-resistant TB. This study utilizes 252 clinical isolates of Mycobacterium tuberculosis from five countries (Hong Kong Special Administrative Region, Korea, Latvia, Peru, Philippines) with documented treatment histories to establish clinically and microbiologically relevant critical concentrations (CCs) of six SLDs for three routine testing methods: the absolute concentration method using Löwenstein-Jensen (LJ) medium, the 1% proportion method using Middlebrook 7H10 agar medium, and the radiometric BACTEC 460 system. In LJ medium, CCs of capreomycin, ethionamide, kanamycin, ofloxacin, rho-aminosalicylic acid and cycloserine (CS) were respectively 40.0, 40.0, 30.0, 3.0, 1.0 and 30.0 mg/l. In 7H10 agar medium, the respective CCs for the first five antibiotics (except CS) were 8.0, 2.0-3.0, 3.0-5.0, 1.0-1.5 and 0.5-1.0 mg/l. In BACTEC 460 broth, the respective CCs were 1.5-2.0, 1.0-1.5, 2.0-3.0, 0.5-1.0 and 0.5-1.0 mg/l. Precautions in DST interpretation was also discussed. By adopting this set of CCs as a global standard to define second-line drug susceptibility and resistance, as well as precautions in result interpretation, the screening, diagnosis and management of patients with drug-resistant TB can be greatly improved.

Vitamin D deficiency (VDD) is associated with impaired mycobacterial immunity and susceptibility to tuberculosis (TB). We measured 25 hydroxy vitamin D levels in 161 adult TB patients at a central hospital in Malawi, of whom 120 (74.5%) had ≤75 nmol/l (hypovitaminosis D), 68 (42%) had ≤50 nmol/l (VDD) and 13.6% of in-patients and 6.8% of out-patients had ≤25 nmol/l (severe VDD). In-patients had lower body mass index (BMI; 19.0 vs. 20.5, P < 0.004), and vitamin D levels were lower in those with BMI < 20. However, on multiple regression analysis in-patient status and BMI were not associated with vitamin D level. We conclude that VDD is common in adult TB patients in Malawi. In this small sample, it was not possible to identify any independent associations of VDD.

Batibo District Hospital (BDH), North-West Cameroon. To assess the outcome of the implementation of the Global Fund (GF) Grant Round 3 for tuberculosis (TB) control at the district level. A retrospective study for the period 2003-2008 comparing TB programme outcome indicators before (2003-2005) and after (2006-2008) the GF grant. During the study period 293 TB cases were enrolled on treatment. Comparing the cumulative outcome indicators for smear-positive pulmonary TB cases 3 years before and after the grant, case notification increased by >50%, case detection by almost 50% and treatment success by nearly 20% during the grant period. The case detection rate for smear-positive pulmonary TB nearly doubled, while the treatment success rate reached 100% in 2006. Default and mortality rates dropped to zero in 2006 and 2007 from maximum values of respectively 15% and 23% in 2004 and 2005. However, in 2008, there was a decline across all programme indicators, probably due to staff turnover. Outcome indicators of the TB programme in BDH increased markedly following the implementation of the GF grant. Nevertheless, if not tackled appropriately, staff turnover might impede the sustainability of this positive outcome.

Household air pollution from burning biomass fuel is increasingly recognised as a major global health concern. Biomass smoke is associated with chronic obstructive pulmonary disease (COPD) in Asian and Central American countries, but there are few data from Africa. We hypothesised that reported wood smoke as compared to charcoal smoke exposure would be associated with a reduction in forced expiratory volume in 1 second in Malawian adults. Volunteers from urban and rural locations performed spirometry and completed a questionnaire assessing lifestyle, including smoke exposure and symptoms. In total, 374 adults were recruited; 61% were female; 160 cooked using charcoal and 174 used wood. Individuals who used wood as their main domestic fuel had significantly worse lung function than those who used charcoal. Significant factors associated with impaired lung function in the multivariate model were age, sex, height, wood smoke exposure, poverty, smoking and previous tuberculosis. Our data suggest that wood smoke and poverty contribute to reduced lung function in rural Africans and that COPD is common in this population. The use of charcoal in rural populations may be relatively protective, and this idea merits further study. The risk factors for impaired lung function in Malawi are multiple and require more detailed characterisation to plan appropriate health interventions.