Integration of HIV Testing in a Community Intervention for Tuberculosis Screening Among Household Contacts of Patients with Tuberculosis in Cameroon and Uganda

INTRODUCTION

People living with HIV are considered at higher risk of developing severe forms of tuberculosis (TB) disease. Providing HIV testing to TB-exposed people is therefore critical. We present the results of integrating HIV testing into a community-based intervention for household TB contact management in Cameroon and Uganda.

METHODS

Trained community health workers visited the households of index patients with TB identified in 3 urban/semiurban and 6 rural districts or subdistricts as part of a cluster-randomized trial and provided TB screening to all household contacts. Voluntary HIV counseling and testing were offered to contacts aged 5 years or older with unknown HIV status. We describe the cascade of care for HIV testing and the factors associated with the acceptance of HIV testing.

RESULTS

Overall, 1983 household contacts aged 5 years or older were screened for TB. Of these contacts, 1652 (83.3%) did not know their HIV status, 1457 (88.2%) accepted HIV testing, and 1439 (98.8%) received testing. HIV testing acceptance was lower among adults than children [adjusted odds ratio (aOR) = 0.35, 95% confidence interval (CI): 0.22 to 0.55], those living in household of an HIV-positive vs HIV-negative index case (aOR = 0.56, 95% CI: 0.38 to 0.83), and contacts requiring a reassessment visit after the initial TB screening visit vs asymptomatic contacts (aOR = 0.20, 95% CI: 0.06 to 0.67) and was higher if living in Uganda vs Cameroon (aOR = 4.54, 95% CI: 1.17 to 17.62) or if another contact of the same index case was tested for HIV (aOR = 9.22, 95% CI: 5.25 to 16.18).

CONCLUSION

HIV testing can be integrated into community-based household TB contact screening and is well-accepted.

Performance of a stool-based quantitative PCR assay for the diagnosis of tuberculosis in adolescents and adults: a multinational, prospective diagnostic accuracy study

BACKGROUND

Despite increasing availability of rapid molecular tests for the diagnosis of tuberculosis in high-burden settings, many people with tuberculosis are undiagnosed. Reliance on sputum as the primary specimen for tuberculosis diagnostics contributes to this diagnostic gap. We evaluated the diagnostic accuracy and additive yield of a novel stool quantitative PCR (qPCR) assay for the diagnosis of tuberculosis in three countries in Africa with high tuberculosis burdens.

METHODS

We undertook a prospective diagnostic accuracy study in Eswatini, Mozambique, and Tanzania from Sept 21, 2020, to Feb 2, 2023, to compare the diagnostic accuracy for tuberculosis of a novel stool qPCR test with the current diagnostic standard for Mycobacterium tuberculosis DNA detection from sputum and stool, Xpert-MTB/RIF Ultra (Xpert Ultra). Sputum, stool, and urine samples were provided by a cohort of participants, aged 10 years or older, diagnosed with tuberculosis. Participants with tuberculosis (cases) were enrolled within 72 h of treatment initiation for tuberculosis diagnosed clinically or following laboratory confirmation. Participants without tuberculosis (controls) consisted of household contacts of the cases who did not develop tuberculosis during a 6-month follow-up. The performance was compared with a robust composite microbiological reference standard (CMRS).

FINDINGS

The cohort of adolescents and adults (n=408) included 268 participants with confirmed or clinical tuberculosis (cases), 147 (55%) of whom were living with HIV, and 140 participants (controls) without tuberculosis. The sensitivity of the novel stool qPCR was 93·7% (95% CI 87·4-97·4) compared with participants with detectable growth on M tuberculosis culture, and 88·1% (81·3-93·0) compared with sputum Xpert Ultra. The stool qPCR had an equivalent sensitivity as sputum Xpert Ultra (94·8%, 89·1-98·1) compared with culture. Compared with the CMRS, the sensitivity of the stool qPCR was higher than the current standard for tuberculosis diagnostics on stool, Xpert Ultra (80·4%, 73·4-86·2 vs 73·5%, 66·0-80·1; p=0·025 on paired comparison). The qPCR also identified 17-21% additional tuberculosis cases compared to sputum Xpert Ultra or sputum culture. In controls without tuberculosis, the specificity of the stool qPCR was 96·9% (92·2-99·1).

INTERPRETATION

In this study, a novel qPCR for the diagnosis of tuberculosis from stool specimens had a higher accuracy in adolescents and adults than the current diagnostic PCR gold standard on stool, Xpert-MTB/RIF Ultra, and equivalent sensitivity to Xpert-MTB/RIF Ultra on sputum.

FUNDING

National Institutes of Health (NIH) Allergy and Infectious Diseases, and NIH Fogarty International Center.

Tuberculosis in people of Ukrainian origin in the European Union and the European Economic Area, 2019 to 2022

Approximately five million Ukrainians were displaced to the EU/EEA following the Russian invasion of Ukraine. While tuberculosis (TB) notification rates per 100,000 Ukrainians in the EU/EEA remained stable, the number of notified TB cases in Ukrainians increased almost fourfold (mean 2019-2021: 201; 2022: 780). In 2022, 71% cases were notified in three countries, and almost 20% of drug-resistant TB cases were of Ukrainian origin. Targeted healthcare services for Ukrainians are vital for early diagnosis and treatment, and preventing transmission.

Effectiveness of a community-based approach for the investigation and management of children with household tuberculosis contact in Cameroon and Uganda: a cluster-randomised trial

BACKGROUND

Globally, the uptake of tuberculosis-preventive treatment (TPT) among children with household tuberculosis contact remains low, partly due to the necessity of bringing children to health facilities for investigations. This study aimed to evaluate the effect on TPT initiation and completion of community-based approaches to tuberculosis contact investigations in Cameroon and Uganda.

METHODS

We did a parallel, cluster-randomised, controlled trial across 20 clusters (consisting of 25 district hospitals and primary health centres) in Cameroon and Uganda, which were randomised (1:1) to receive a community-based approach (intervention group) or standard-of-care facility-based approach to contact screening and management (control group). The community-based approach consisted of symptom-based tuberculosis screening of all household contacts by community health workers at the household, with referral of symptomatic contacts to local facilities for investigations. Initiation of TPT (3-month course of rifampicin-isoniazid) was done by a nurse in the household, and home visits for TPT follow-up were done by community health workers. Index patients were people aged 15 years or older with bacteriologically confirmed, drug-susceptible, pulmonary tuberculosis diagnosed less than 1 month before inclusion and who declared at least one child or young adolescent (aged 0-14 years) household contact. The primary endpoint was the proportion of declared child contacts in the TPT target group (those aged <5 years irrespective of HIV status, and children aged 5-14 years living with HIV) who commenced and completed TPT, assessed in the modified intention-to-treat population (excluding enrolled index patients and their contacts who did not fit the eligibility criteria). Descriptive cascade of care assessment and generalised linear mixed modelling were used for comparison. This study is registered with ClinicalTrials.gov (NCT03832023).

FINDINGS

The study included nine clusters in the intervention group (after excluding one cluster that did not enrol any index patients for >2 months) and ten in the control group. Between Oct 14, 2019 and Jan 13, 2022, 2894 child contacts were declared by 899 index patients with bacteriologically confirmed tuberculosis. Among all child contacts declared, 1548 (81·9%) of 1889 in the intervention group and 475 (47·3%) of 1005 in the control group were screened for tuberculosis. 1400 (48·4%) child contacts were considered to be in the TPT target group: 941 (49·8%) of 1889 in the intervention group and 459 (45·7%) of 1005 in the control group. In the TPT target group, TPT was commenced and completed in 752 (79·9%) of 941 child contacts in the intervention group and 283 (61·7%) of 459 in the control group (odds ratio 3·06 [95% CI 1·24-7·53]).

INTERPRETATION

A community-based approach using community health workers can significantly increase contact investigation coverage and TPT completion among eligible child contacts in a tuberculosis-endemic setting.

FUNDING

Unitaid.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.

Cost-effectiveness of community-based household tuberculosis contact management for children in Cameroon and Uganda: a modelling analysis of a cluster-randomised trial

BACKGROUND

WHO recommends household contact management (HCM) including contact screening and tuberculosis-preventive treatment (TPT) for eligible children. The CONTACT trial found increased TPT initiation and completion rates when community health workers were used for HCM in Cameroon and Uganda.

METHODS

We did a cost-utility analysis of the CONTACT trial using a health-system perspective to estimate the health impact, health-system costs, and cost-effectiveness of community-based versus facility-based HCM models of care. A decision-analytical modelling approach was used to evaluate the cost-effectiveness of the intervention compared with the standard of care using trial data on cascade of care, intervention effects, and resource use. Health outcomes were based on modelled progression to tuberculosis, mortality, and discounted disability-adjusted life-years (DALYs) averted. Health-care resource use, outcomes, costs (2021 US$), and cost-effectiveness are presented.

FINDINGS

For every 1000 index patients diagnosed with tuberculosis, the intervention increased the number of TPT courses by 1110 (95% uncertainty interval 894 to 1227) in Cameroon and by 1078 (796 to 1220) in Uganda compared with the control model. The intervention prevented 15 (-3 to 49) tuberculosis deaths in Cameroon and 10 (-20 to 33) in Uganda. The incremental cost-effectiveness ratio was $620 per DALY averted in Cameroon and $970 per DALY averted in Uganda.

INTERPRETATION

Community-based HCM approaches can substantially reduce child tuberculosis deaths and in our case would be considered cost-effective at willingness-to-pay thresholds of $1000 per DALY averted. Their impact and cost-effectiveness are likely to be greatest where baseline HCM coverage is lowest.

FUNDING

Unitaid and UK Medical Research Council.

Tuberculosis prevention: current strategies and future directions

BACKGROUND

An estimated one fourth of the world's population is infected with Mycobacterium tuberculosis, and 5-10% of those infected develop tuberculosis in their lifetime. Preventing tuberculosis is one of the most underutilized but essential components of curtailing the tuberculosis epidemic. Moreover, current evidence illustrates that tuberculosis manifestations occur along a dynamic spectrum from infection to disease rather than a binary state as historically conceptualized. Elucidating determinants of transition between these states is crucial to decreasing the tuberculosis burden and reaching the END-TB Strategy goals as defined by the WHO. Vaccination, detection of infection, and provision of preventive treatment are key elements of tuberculosis prevention.

OBJECTIVES

This review provides a comprehensive summary of recent evidence and state-of-the-art updates on advancements to prevent tuberculosis in various settings and high-risk populations.

SOURCES

We identified relevant studies in the literature and synthesized the findings to provide an overview of the current state of tuberculosis prevention strategies and latest research developments.

CONTENT

We present the current knowledge and recommendations regarding tuberculosis prevention, with a focus on M. bovis Bacille-Calmette-Guérin vaccination and novel vaccine candidates, tests for latent infection with M. tuberculosis, regimens available for tuberculosis preventive treatment and recommendations in low- and high-burden settings.

IMPLICATIONS

Effective tuberculosis prevention worldwide requires a multipronged approach that addresses social determinants, and improves access to tuberculosis detection and to new short tuberculosis preventive treatment regimens. Robust collaboration and innovative research are needed to reduce the global burden of tuberculosis and develop new detection tools, vaccines, and preventive treatments that serve all populations and ages.

Tuberculosis incidence in foreign-born people residing in European countries in 2020

BackgroundEuropean-specific policies for tuberculosis (TB) elimination require identification of key populations that benefit from TB screening.AimWe aimed to identify groups of foreign-born individuals residing in European countries that benefit most from targeted TB prevention screening.MethodsThe Tuberculosis Network European Trials group collected, by cross-sectional survey, numbers of foreign-born TB patients residing in European Union (EU) countries, Iceland, Norway, Switzerland and the United Kingdom (UK) in 2020 from the 10 highest ranked countries of origin in terms of TB cases in each country of residence. Tuberculosis incidence rates (IRs) in countries of residence were compared with countries of origin.ResultsData on 9,116 foreign-born TB patients in 30 countries of residence were collected. Main countries of origin were Eritrea, India, Pakistan, Morocco, Romania and Somalia. Tuberculosis IRs were highest in patients of Eritrean and Somali origin in Greece and Malta (both > 1,000/100,000) and lowest among Ukrainian patients in Poland (3.6/100,000). They were mainly lower in countries of residence than countries of origin. However, IRs among Eritreans and Somalis in Greece and Malta were five times higher than in Eritrea and Somalia. Similarly, IRs among Eritreans in Germany, the Netherlands and the UK were four times higher than in Eritrea.ConclusionsCountry of origin TB IR is an insufficient indicator when targeting foreign-born populations for active case finding or TB prevention policies in the countries covered here. Elimination strategies should be informed by regularly collected country-specific data to address rapidly changing epidemiology and associated risks.

Impact of the COVID pandemic on mental health and training opportunities of Public Health Residents from 4 European countries: A cross-sectional study

Objectives

There is little evidence on the impact of the COVID-19 pandemic on Public Health Residents' (PHR) mental health (MH). This study aims at assessing prevalence and risk factors for depression, anxiety and stress in European PHR during the COVID-19 pandemic.

Methods

Between March and April 2021, an online survey was administered to PHR from France, Italy, Portugal and Spain. The survey assessed COVID-19 related changes in working conditions, training opportunities and evaluated MH outcomes using the Depression Anxiety Stress Scales-21. Multivariable logistic regressions were applied to identify risk factors.

Results

Among the 443 respondents, many showed symptoms of depression (60.5%), anxiety (43.1%) and stress (61.2%). The main outcome predictors were: female gender for depression (adjOR = 1.59, 95%CI [1.05-2.42]), anxiety (adjOR = 2.03, 95%CI [1.33-3.08]), and stress (adjOR = 2.35, 95%CI [1.53-3.61]); loss of research opportunities for anxiety (adjOR = 1.94, 95%CI [1.28-2.93]) and stress (adjOR = 1.98, 95%CI [1.26-3.11]); and COVID-19 impact on training (adjOR = 1.78, 95%CI [1.12-2.80]) for depression.

Conclusions

The pandemic had a significant impact on PHR in terms of depression, anxiety and stress, especially for women and who lost work-related opportunities. Training programs should offer PHR appropriate MH support and training opportunities.

Implementing molecular tuberculosis diagnostic methods in limited-resource and high-burden countries

Tuberculosis (TB) is one of the deadliest infectious diseases in the world with more than a million people dying of TB each year. Accurate and timely TB diagnosis has the potential to alleviate the global TB burden; therefore, one of the pillars of the End TB Strategy developed by the World Health Organization (WHO) is the early diagnosis of TB, including universal drug-susceptibility testing (DST). The WHO emphasises the importance of DST before treatment initiation, using molecular WHO-recommended rapid diagnostic tests (mWRDs). Currently available mWRDs are nucleic acid amplification tests, line probe assays, whole genome sequencing, and targeted next-generation sequencing. However, implementing the sequencing mWRDs in routine laboratories in low-income countries is constrained by the existing infrastructure, high cost, the specialised skills needed, data storage, and the current delay in results compared with other routine methods. These limitations are pronounced in resource-limited settings, which often have a high TB burden and need for innovative TB diagnostic technologies. In this article we propose several possible solutions, like adapting infrastructure capacity to needs, advocating for lowering costs, building bioinformatics and laboratory capacity, and increasing the use of open-access resources for software and publications.

Feasibility of a randomized clinical trial evaluating a community intervention for household tuberculosis child contact management in Cameroon and Uganda

Background

One of the main barriers of the management of household tuberculosis child contacts is the necessity for parents to bring healthy children to the facility. We assessed the feasibility of a community intervention for tuberculosis (TB) household child contact management and the conditions for its evaluation in a cluster randomized controlled trial in Cameroon and Uganda.

Methods

We assessed three dimensions of feasibility using a mixed method approach: (1) recruitment capability using retrospective aggregated data from facility registers; (2) acceptability of the intervention using focus group discussions with TB patients and in-depth interviews with healthcare providers and community leaders; and (3) adaptation, integration, and resources of the intervention in existing TB services using a survey and discussions with stakeholders.

Results

Reaching the sample size is feasible in all clusters in 15 months with the condition of regrouping 2 facilities in the same cluster in Uganda due to decentralization of TB services. Community health worker (CHW) selection and training and simplified tools for contact screening, tolerability, and adherence of preventive therapy were key elements for the implementation of the community intervention. Healthcare providers and patients found the intervention of child contact investigations and TB preventive treatment management in the household acceptable in both countries due to its benefits (competing priorities, transport cost) as compared to facility-based management. TB stigma was present, but not a barrier for the community intervention. Visit schedule and team conduct were identified as key facilitators for the intervention.

Conclusions

This study shows that evaluating a community intervention for TB child contact management in a cluster randomized trial is feasible in Cameroon and Uganda.

Trial registration

Clini calTr ials. gov NCT03832023. Registered on February 6^th 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-00996-3.

Assessing COVID-19-related depression, anxiety and stress among European public health residents

Background

In Europe, Public Health Residents (PHR) have participated in the response against COVID-19.The pandemic has had a profound mental health (MH) impact on healthcare workers, but little evidence has been accrued about the Public Health (PH) workforce.The current study aims at assessing prevalence and risk factors for pandemic-related depression (D), anxiety (A) and stress (S).

Methods

Between March 22 and April 11, 2021 we administered an online survey to PHR from France, Italy, Portugal and Spain, recruited through the national associations of PHR.We collected socio-demographic data and assessed changes in the working conditions due to COVID-19.We used the Depression Anxiety Stress Scales-21.Cut-off scores for D, A and S were: 9, 7, and 14.Multivariable logistic regression models were applied to determine risk factors for pandemic-related MH outcomes.Data analysis was performed with SPSS version 27.

Results

443 out of approximately 2000 PHR completed the survey, response rate: 22.15%. Most responders (n = 226; 51%) were from Italy, 87 (19.6%) from Portugal, 74 (16.47%) from Spain and 56 (12.6%) from France. Median age: 29 years (IQR 25 - 33). Female/male ratio: 1.6. PHR above the cut-offs for D, A and S were: 60.5%, 43.1%, 61.2%.DASS-21 scores were 13.3 (± 10.27), 8.13 (± 7.79), 19.06 (± 9.71), respectively.Across the multivariable logistic regression models, the main identified predictors were: for D - the COVID-19 impact on PH training (OR 1.78, 95% CI [1.12-2.80], p = 0.014); for A - the loss of research opportunities (OR 1.94, 95% CI [1.28-2.93], p = 0.002) and for psychological S - the year of residency (last year vs other years of residency: OR 2.3, 95% CI [1.20-4.38], p = 0.012).

Conclusions

Our sample featured mild-to-moderate levels of prevalent D, A and moderate levels of psychological stress.Overall, the main risk factors associated with negative psychometric outcomes were training challenges, loss of research opportunities and residency seniority.

Key messages

During the pandemic it is vital to increase knowledge and awareness about the impact of the health emergency on mental health in the Public Health workforce. It is important to deploy concrete efforts into building healthy work environments, guarantee adequate training and research opportunities for Public Health Residents.

Community intervention for child tuberculosis active contact investigation and management: study protocol for a parallel cluster randomized controlled trial

Background

There are major gaps in the management of pediatric tuberculosis (TB) contact investigation for rapid identification of active tuberculosis and initiation of preventive therapy. This study aims to evaluate the impact of a community-based intervention as compared to facility-based model for the management of children in contact with bacteriologically confirmed pulmonary TB adults in low-resource high-burden settings.

Methods/design

This multicenter parallel open-label cluster randomized controlled trial is composed of three phases: I, baseline phase in which retrospective data are collected, quality of data recording in facility registers is checked, and expected acceptability and feasibility of the intervention is assessed; II, intervention phase with enrolment of index cases and contact cases in either facility- or community-based models; and III, explanatory phase including endpoint data analysis, cost-effectiveness analysis, and post-intervention acceptability assessment by healthcare providers and beneficiaries. The study uses both quantitative and qualitative analysis methods. The community-based intervention includes identification and screening of all household contacts, referral of contacts with TB-suggestive symptoms to the facility for investigation, and household initiation of preventive therapy with follow-up of eligible child contacts by community healthcare workers, i.e., all young (< 5 years) child contacts or older (5–14 years) child contacts living with HIV, and with no evidence of TB disease. Twenty clusters representing TB diagnostic and treatment facilities with their catchment areas are randomized in a 1:1 ratio to either the community-based intervention arm or the facility-based standard of care arm in Cameroon and Uganda. Randomization was stratified by country and constrained on the number of index cases per cluster. The primary endpoint is the proportion of eligible child contacts who initiate and complete the preventive therapy. The sample size is of 1500 child contacts to identify a 10% difference between the arms with the assumption that 60% of children will complete the preventive therapy in the standard of care arm.

Discussion

This study will provide evidence of the impact of a community-based intervention on household child contact screening and management of TB preventive therapy in order to improve care and prevention of childhood TB in low-resource high-burden settings.

Trial registration

ClinicalTrials.gov NCT03832023. Registered on 6 February 2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05124-9.

Lack of effect of a poster-based intervention to reduce the number of blood culture samples collected

OBJECTIVE

To reduce the number of blood culture samples collected.

PATIENTS AND METHOD

We performed a cluster randomized controlled trial in adult acute care, and subacute care and rehabilitation wards in a university hospital in France. A poster associating an image of eyes looking at the reader with a summary of blood culture sampling guidelines was displayed in hospital wards in the intervention group. The incidence rate of blood cultures per 1000 days during pre- and post-intervention periods was calculated.

RESULTS

Thirty-one wards participated in the study. The median difference in blood cultures/1000 days between periods was -1.863 [-11.941; 1.007] in the intervention group and -5.824 [-14.763; -2.217] in the control group (P=0.27).

CONCLUSION

The intervention did not show the expected effect, possibly due to the choice of blood cultures as a target of good practice, but also to confounding factors such as the stringent policy of decreasing unnecessary costly testing.

Seasonal influenza vaccination coverage and its determinants among nursing homes personnel in western France

BACKGROUND

Influenza-associated deaths is an important risk for the elderly in nursing homes (NHs) worldwide. Vaccination coverage among residents is high but poorly effective due to immunosenescence. Hence, vaccination of personnel is an efficient way to protect residents. Our objective was to quantify the seasonal influenza vaccination (IV) coverage among NH for elderly workers and identify its determinants in France.

METHODS

We conducted a cross-sectional study in March 2016 in a randomized sample of NHs of the Ille-et-Vilaine department of Brittany, in western France. A standardized questionnaire was administered to a randomized sample of NH workers for face-to-face interviews. General data about the establishment was also collected.

RESULTS

Among the 33 NHs surveyed, IV coverage for the 2015-2016 season among permanent workers was estimated at 20% (95% Confidence Interval (CI) 15.3%-26.4%) ranging from 0% to 69% depending on the establishments surveyed. Moreover, IV was associated with having previously experienced a "severe" influenza episode in the past (Prevalence Ratio 1.48, 95% CI 1.01-2.17), and varied by professional categories (p < 0.004) with better coverage among administrative staff. Better knowledge about influenza prevention tools was also correlated (p < 0.001) with a higher IV coverage. Individual perceptions of vaccination benefits had a significant influence on the IV coverage (p < 0.001). Although IV coverage did not reach a high rate, our study showed that personnel considered themselves sufficiently informed about IV.

CONCLUSIONS

IV coverage remains low in the NH worker population in Ille-et-Vilaine and also possibly in France. Strong variations of IV coverage among NHs suggest that management and working environment play an important role. To overcome vaccine "hesitancy", specific communication tools may be required to be adapted to the various NH professionals to improve influenza prevention.

Patterns of electronic cigarette use in current and ever users among college students in France: a cross-sectional study

OBJECTIVE

There is sparse information on electronic cigarette use and health behaviours among college student populations. Our objectives were to identify the patterns of electronic cigarette use in current and ever users among college students in France.

DESIGN

Cross-sectional study.

SETTINGS

A multicentre cross-sectional study was conducted on two major campuses in France. Students filled in an anonymous questionnaire on their use of electronic cigarettes and on targeted behaviours such as smoking, alcohol consumption, binge drinking, use of cannabis, practice of sport and eating disorders. Ever use of electronic cigarettes was defined as use but not during the previous 30 days, and current use of electronic cigarettes as any use in the previous 30 days. The opinions and motivations of electronic cigarette users were also sought and collected.

PARTICIPANTS

1134 college students between October 2014 and February 2015.

RESULTS

The 1134 students included had a mean age of 20.8 years. The prevalence of ever use and current use of electronic cigarettes was 23.0% (95% CI (20.5% to 25.3%)) and 5.7% (95% CI (4.4% to 7.1%)), respectively. The prevalence of the combined use of conventional cigarettes and electronic cigarettes was 14.5%. Almost half (45.8%) of the ever users of electronic cigarettes had never smoked conventional cigarettes. Behaviours associated with ever use of electronic cigarettes were current cigarette smoking (adjusted OR (AOR)=3.97, 95% CI 2.71 to 5.83), former smoking (AOR=2.56, 95% CI 1.42 to 4.61), cannabis use (AOR=2.44, 95% CI 1.70 to 3.51) and occasional binge drinking (AOR=1.83, 95% CI 1.28 to 2.64). The only behaviour associated with current use of electronic cigarettes was conventional smoking, either previously (AOR=4.85, 95% CI 1.53 to 15.34) or currently (AOR=14.53, 95% CI 6.81 to 31.02).

CONCLUSIONS

The ever users have an experimenter's profile with sensation-seeking while the current users are mostly smokers with intention to quit smoking. Our findings are crucial for the accurate targeting of student populations at risk and to implement appropriate awareness campaigns and health education programmes.

Long-term influence of aeration on arsenic trapping in a ZVI/sand bed reactor

High influence of dissolved oxygen on ZVI support capacity to remove arsenic in bed reactor.

Studies concerning chronic and acute effects of L-carnitina in elite athletes

Chronic and acute effects of L-Carnitina (vials of 1 g L-Carnitina endovenous; per orally administered vials of 1 g L-Carnitina; tablets of 1 g L-Carnitina) were recorded in 110 top athletes (rowing, kayak-canoe, swimming, weightlifting medium and long-distance runners), 47 girls and 63 boys, by six double blind placebo trials and cross over. Significant changes were registered after L-Carnitina treatment (both for a single dose or after 3 weeks of treatment) compared to placebo, for FFA, triglycenides, lactic acid after exercise, evoked muscular potential, plasma carnitine (free and acetyl-carnitine), urine carnitine (free carnitine) and others. The authors explain these changes by the increase of free carnitine, which permits a larger quantity of FFA to enter the mitochondria and to be more extensively used as energy source in endurance and strength efforts. Based on these results the authors recommend L-Carnitina as an ergogenic aid in elite athletes, especially in endurance and strength sports.

Studies concerning chronic and acute effects of L-carnitine on some biological parameters in elite athletes

Chronic and acute effects of L-carnitine have been recorded in a group of elite athletes by a prospective double blind placebo controlled trial. Forty top athletes (20 boys, kayak-canoë, 10 weightlifters and 10 girls, rowers) received orall 3 g L-carnitine daily for 3 weeks while 38 top athletes (20 kayak-canoë, 8 weightlifters and 10 rowers) received the same medicine as placebo. Significant changes were registered in the treated group concerning FFA and triglycerides, strength index, VO2max., urinary mucoproteins and in the control group concerning Ld (distal latency). All athletes were under medical supervision and had a controlled training program and food. The effects of a single oral dose (4 g L-carnitine were recorded in a group of 18 top weightlifters under basal conditions and 90' after L-carnitine ingestion. Significant changes in the treated group were registered for the FFA, triglycerides, urinary mucoproteins and distal latency of the right and left median nerve. Based on these data the authors recommend this aminoacid both for chronic and acute effects as a physiological mean for the biological preparation of elite athletes during hard training and competitions.