Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Ergonomics in the anaesthetic workplace: Guideline from the Association of Anaesthetists

Ergonomics in relation to anaesthesia is the scientific study of the interaction between anaesthetists and their workspace environment in order to promote safety, performance and well-being. The foundation for avoiding pain or discomfort at work is to adopt and maintain a good posture, whether sitting or standing. Anaesthetists should aim to keep their posture as natural and neutral as possible. The successful practice of anaesthesia relies on optimisation of ergonomics and lack of attention to detail in this area is associated with impaired performance. The anaesthetic team should wear comfortable clothing, including appropriately-sized personal protective equipment where necessary. Temperature, humidity and light should be adequate at all times. The team should comply with infection prevention and control guidelines and monitoring as recommended by the Association of Anaesthetists. Any equipment or machinery that is mobile should be positioned where it is easy to view or reach without having to change the body or head position significantly when interacting with it. Patients who are supine should, whenever possible, be raised upwards to limit the need to lean towards them. Any item required during a procedure should be positioned on trays or trolleys that are close to the dominant hand. Pregnancy affects the requirements for standing, manually handling, applying force when operating equipment or moving machines and the period over which the individual might have to work without a break. Employers have a duty to make reasonable adjustments to accommodate disability in the workplace. Any member of staff with a physical impairment needs to be accommodated and this includes making provision for a wheelchair user who needs to enter the operating theatre and perform their work.

Tuberculosis chemotherapy centre - The beginning

OBJECTIVE

Establishment of a TB research centre with the aim of studying the feasibility of domiciliary treatment for the masses.

METHODS

In-depth case study of the TB chemotherapy Centres's initial activities and development.

RESULTS

Successful setting up of a research centre in 1956 at Madras.

CONCLUSION

Four agencies collaborated successfully to demonstrate that domiciliary treatment for the masses is feasible.

Pharmacovigilance of biosimilars - Why is it different from generics and innovator biologics?

Biosimilars are being marketed in India since 2000. Like biologics, biosimilars have a large size, complex structure, and complicated manufacturing process, and they are produced in a living organism. It requires specialized delivery devices for administration and needs tighter temperature control to prevent degradation. As biosimilar development follows abbreviated pathway, adverse events (AEs) previously unknown during a clinical trial may be detected postmarketing. In India, the awareness on pharmacovigilance has increased significantly after implementation of the pharmacovigilance guidance in January 2018. However, biologics require tighter monitoring to ensure their safety and efficacy. This review article discusses the importance of pharmacovigilance for biosimilars, how it is different from generics, and provides recommendations to sensitize clinicians and researchers about the requirement of a different approach to improve pharmacovigilance for biosimilars. Pharmacovigilance for biosimilars is as important as it is for innovator biologics and more important than that for generics.

Role of bacille Calmette-Guérin in preventing tuberculous infection

SETTING

Rural community in South India.

OBJECTIVE

To determine the role of bacille Calmette-Guérin (BCG) in preventing tuberculous infection in children.

DESIGN

A prevalence survey was undertaken in 1999-2001 in a representative rural population in Tiruvallur District in South India using cluster sampling. Tuberculin testing was performed among all children aged <15 years, and all adults aged 15 years were questioned about chest symptoms and underwent radiography, followed by sputum examinations, if indicated.

RESULTS

In children living in households with a tuberculosis case, the proportion with evidence of tuberculous infection was 35.5% of 200 in the absence of a BCG scar and 27.0% of 100 in its presence, a reduction of 24% (P = 0.14). In very young children (age <5 years), the corresponding proportions were 29.1% of 55 and 11.9% of 42, a reduction of 59%; the difference was statistically significant (P = 0.048).

CONCLUSION

There is a possible role for BCG in preventing tuberculous infection in very young children.

Trends in the prevalence of pulmonary tuberculosis over a period of seven and half years in a rural community in south India with DOTS

SETTING

Tiruvallur district In Tamil Nadu where DOTS was implemented by the State Government as the tuberculosis control measure in 1999, and monitored by the National Institute for Research in Tuberculosis for over five years.

OBJECTIVE

To estimate trends in TB prevalence in a rural community with DOTS.

DESIGN

Surveys of pulmonary tuberculosis were undertaken in representative samples of subjects aged > or =15 years (N = 83,000 - 92,000), initially and after two and half, five and seven and half years of implementation of DOTS. Sputa were collected from those with abnormal radiograph and/or presence of chest symptoms, and examined by direct smear and culture.

RESULTS

The prevalence of culture-positive tuberculosis was 607, 454, 309 and 388 per 100,000 in the four surveys, and that of smear-positive tuberculosis was 326, 259, 168 and 180. In the first five years; annual decrease was 12.4% (95% CI 10.4 - 14.4%) for culture-positive tuberculosis, and 12.2% (95% CI 8.0-16.2) for smear-positive tuberculosis. This was, however, followed by a significant increase in the next two and half years. The average new smear-positive case-notification rate was 75 per 100,000 during first four years but declined to 49 in subsequent years. There were no methodological differences during this period and information on changes in socio-economic indicators and nutritional standards was unavailable.

CONCLUSION

Despite the average annual success rate (78%) in this tuberculosis unit being lower than the expected rate of 85%, the implementation of DOTS was followed by a substantial decrease in the prevalence of pulmonary tuberculosis over the seven and half year period. Our findings suggest that sustaining the high effectiveness of DOTS programme needs vigilant supervision.

Significant decline in the tuberculosis burden in the Philippines ten years after initiating DOTS

BACKGROUND

The Philippines ranks ninth among the 22 high-burden countries for tuberculosis (TB).

OBJECTIVE

To measure the burden of pulmonary tuberculosis (PTB) in the Philippines and determine the impact of the DOTS strategy.

MATERIALS AND METHODS

The 2007 nationwide TB prevalence survey covered 50 clusters selected by multi-stage stratified random sampling from Metro Manila and other urban and rural areas. Subjects aged >or=10 years were screened radiographically for PTB to identify subjects for sputum examination and determine the prevalence of bacteriologically confirmed PTB, i.e., smear- and/or culture-positive PTB.

RESULTS

In subjects aged >or=10 years, the 2007 prevalence of radiographic PTB was 6.3% (95%CI 5.5-7.1), bacteriologically confirmed PTB was 6.6 per 1000 (95%CI 5.1-8.1) and sputum smear-positive PTB was 2.6/1000 (95%CI 1.7-3.6). For the total population, the corresponding estimates were respectively 4.7%, 4.9/1000 and 2.0/1000. Between 1997 and 2007, there was a 31% reduction in bacteriologically confirmed PTB (P < 0.02) and a 27% reduction in smear-positive PTB (P = 0.18). This decline occurred despite the increasing poverty in the population.

CONCLUSION

The survey demonstrated a significant decline in the TB burden 10 years after the implementation of DOTS, facilitated by a strategic public-private partnership.

Rapid decline in prevalence of pulmonary tuberculosis after DOTS implementation in a rural area of South India

SETTING

Tiruvallur District in Tamilnadu, South India, where the World Health Organization-recommended DOTS strategy was implemented as a tuberculosis (TB) control measure in 1999.

OBJECTIVE

To assess the epidemiological impact of the DOTS strategy on the prevalence of pulmonary tuberculosis (PTB).

DESIGN

Surveys of PTB were undertaken on representative population samples aged > or =15 years (n = 83000-90000), before and at 2.5 and 5 years after the implementation of the DOTS strategy. The prevalence of PTB (smear-positive/culture-positive) was estimated.

RESULTS

TB prevalence declined by about 50% in 5 years, from 609 to 311 per 100000 population for culture-positive TB and from 326 to 169/100000 for smear-positive TB. The annual rate of decline was 12.6% (95%CI 11.2-14.0) for culture-positive TB and 12.3% (95%CI 8.6-15.8) for smear-positive TB. The decline was similar at all ages and for both sexes.

CONCLUSION

With an efficient case detection programme and the DOTS strategy, it is feasible to bring about a substantial reduction in the burden of TB in the community.

Special considerations in the design, conduct and analysis of prophylaxis trials

Methodological considerations in clinical trials apply to prophylaxis studies also. In addition, there are certain aspects that need special attention. These are the identification of a valid group of controls, the choice of the unit of randomization and its impact on subsequent analyses, the specificity and the sensitivity of case diagnosis and their impact on estimated efficacy and its reliability. The ethical aspects of the trial also need special consideration, bearing in mind that the intervention is on healthy individuals, and not patients with disease. These are discussed in the context of community prophylaxis trials of tuberculosis and leprosy undertaken in south India.

Additional risk of developing TB for household members with a TB case at home at intake: a 15-year study

OBJECTIVE

To assess the additional risk to household contacts from an infectious case of tuberculosis (TB) at home in a rural community in south India.

METHODS

In all, 3506 contacts of smear-positive (S+C+) and 2910 contacts of smear-negative TB cases (S-C+) and 246 845 persons with no TB case at home were followed for 15 years, with a repeat survey every 2.5 years consisting of radiographic and sputum examination, selective follow-up of high-risk individuals and passive surveillance. If a case developed during follow-up, all household members were subsequently considered as contacts. Cox's proportional hazards model (multivariate) was employed to compare incidences.

RESULTS

The annual incidence of culture-positive TB was respectively 526 and 271 per 100000 population for contacts of smear-positive and smear-negative patients, and 198/100000 in non-contacts. The adjusted hazard rate was 3.4 for contacts of smear-positive patients (95% CI 3.0-3.9) and 1.7 for contacts of smear-negative patients (95% CI 1.4-2.0) as compared to non-contacts. Of 3942 incident cases, 337 (8.5%) came from households with a TB case.

CONCLUSION

Although family contacts had a significantly higher incidence, their contribution to total new caseload was meagre. Contact chemoprophylaxis as a public health measure would therefore have limited impact on community TB incidence.

Active community surveillance of the impact of different tuberculosis control measures, Tiruvallur, South India, 1968-2001

BACKGROUND

Tuberculosis is curable, but community surveys documenting epidemiological impact of the WHO-recommended DOTS strategy on tuberculosis prevalence have not been published. We used active community surveillance to compare the impact of DOTS with earlier programmes.

METHODS

We conducted tuberculosis disease surveys using random cluster sampling of a rural population in South India approximately every 2.5 years from 1968 to 1986, using radiography as a screening tool for sputum examination. In 1999, DOTS was implemented in the area. Prevalence surveys using radiography and symptom screening were conducted at the start of DOTS implementation and after 2.5 years.

RESULTS

From 1968 to 1999, culture-positive and smear-positive tuberculosis declined by 2.3 and 2.5% per annum compared with 11.9 and 5.6% after DOTS implementation. The 2.5 year period of DOTS implementation accounted for one-fourth of the decline in prevalence of culture-positive tuberculosis over 33 years. Multivariate analysis showed that prevalence of culture-positive tuberculosis decreased substantially (10.0% per annum, 95% CI: 2.8-16.6%) owing to DOTS after only slight declines related to temporal trends (2.1% annual decline, 95% CI: 1.1-3.2%) and short-course chemotherapy (1.5% annual decline, 95% CI: -9.7% to 11.5%). Under DOTS, the proportion of total cases identified through clinical care increased from 81 to 92%.

CONCLUSIONS

Following DOTS implementation, prevalence of culture-positive tuberculosis decreased rapidly following a gradual decline for the previous 30 years. In the absence of a large HIV epidemic and with relatively low levels of rifampicin resistance, DOTS was associated with rapid reduction of tuberculosis prevalence.

Value of dual testing for identifying tuberculous infection

SETTING

A rural community in Chingleput district in Tamil Nadu state in south India.

OBJECTIVE

To determine the value of dual testing with PPD-S and PPD-B for identifying subjects with a tuberculous infection.

DESIGN

About 240,000 subjects in rural south India, all of whom were tested initially with PPD-S and PPD-B, were followed up for 15 years, mainly by total population survey once in every 212 years. The incidence of culture-positive tuberculosis was estimated using life-table technique.

RESULTS

Among 17,530 subjects with an intermediate reaction (8-11 mm) to PPD-S at intake, 285 with an induration to PPD-S exceeding the induration to PPD-B by at least 2mm, had a significantly higher incidence of culture-positive tuberculosis than the remaining (154 and 93 per 100,000), and similarly 481 who had an induration of <10mm to PPD-B compared to those with >or=10 mm (131 and 93 per 100,000). These subjects may be regarded as having a tuberculous infection. Infection with non-tuberculous mycobacteria conferred protection of about 30% against the development of tuberculosis over a 15-year period.

CONCLUSION

In subjects with an intermediate reaction (8-11 mm) to PPD-S, dual testing with PPD-B enabled identification of those with a tuberculous infection. Most of the reactions were due to non-tuberculous mycobacteria.

A baseline survey of the prevalence of tuberculosis in a community in south India at the commencement of a DOTS programme

OBJECTIVE

To determine the baseline prevalence of culture-positive and smear-positive tuberculosis and the annual risk of tuberculous infection (ARTI) in a community in south India where DOTS is being implemented.

METHODS

Using cluster sampling, 50 rural panchayats (villages) and three urban units in Tiruvallur district were selected randomly. All adults aged > or = 15 years underwent symptom and radiographic examination, and those with abnormal shadows and/or chest symptoms had sputum smear and culture examination. In another cluster sample of 73 villages and three urban units, all children aged < 10 years were tuberculin tested.

RESULTS

The prevalence of culture-positive and smear-positive tuberculosis was respectively 605 and 323/100,000. Both increased appreciably with age, and were substantially higher in males than in females at all ages; the overall male:female ratio was 5.5 for culture-positive and 6.5 for smear-positive tuberculosis. The ARTI in children aged under 10 years was 1.6%, and was unaffected by sex. Over three decades there was an overall decline of 1.8% per annum in the prevalence of culture-positive and 2.1% for smear-positive tuberculosis.

CONCLUSION

Tuberculosis is a major problem in this rural community in south India, with a prevalence of 605/100,000 for culture-positive tuberculosis and 323/100,000 for smear-positive tuberculosis.

Association of initial tuberculin sensitivity, age and sex with the incidence of tuberculosis in south India: a 15-year follow-up

OBJECTIVE

To determine the association of initial tuberculin sensitivity, age and sex with the development of tuberculosis.

METHODS

A 15-year follow-up of 280000 subjects in south India, where new cases of tuberculosis were detected mainly by periodic population surveys. Life-table technique was employed to estimate tuberculosis incidence and disease risk in survivors. The independent effect of tuberculin sensitivity, sex and age at intake was determined using Cox's proportional hazard model.

RESULTS

Taking subjects with reaction size 0-7 mm to 3 IU PPD-S as reference group, the adjusted relative risk (RR) for developing culture-positive tuberculosis was 1.1, 1.9, 2.9, 3.6 and 3.3 for those with indurations of 8-11, 12-15, 16-19, 20-24 and > or = 25 mm (P < 0.01). Considering subjects aged 0-4 years as reference group, the adjusted RR for the other groups increased from 1.7 to 10.8 (P < 0.01). Males had a substantially higher incidence (adjusted RR 3.0, P < 0.001). The risk of culture-positive tuberculosis over 15 years in survivors was 3.3% (5.0% in males and 1.6% in females), and increased substantially with tuberculin sensitivity at intake. In those with > or = 12 mm at intake, the approximate lifetime risk was 6.1% (8.6% in males and 3.1% in females).

CONCLUSION

The incidence of tuberculosis increased steadily with tuberculin sensitivity to PPD-S and age at intake. Males had a significantly higher risk than females in every PPD-S group and the overall risk was three-fold higher.

Social behaviour of the slender Loris (Loris tardigradus lydekkerianus)

The social behaviour of the nocturnal prosimian Loris tardigradus lydekkerianus in its natural habitat was studied for 21 months in a scrub jungle in Dindigul, southern India. A total of 22834 scans were collected during 2656 hours of observation on identified and unidentified lorises. Social interactions were observed between individuals of all age-sex classes, both during the night and at dawn, when the animals met to sleep together. The majority of aggressive encounters between individuals occurred in territorial and mating contexts. Individuals also communicated with each other through chemical and vocal signals. Adults and sub-adults of both sexes were observed to immigrate into the study area, leading to social interactions with resident individuals.

Chitra heart valve: results of a multicenter clinical study

BACKGROUND AND AIM OF THE STUDY

The Chitra tilting disc valve was developed in India to meet the need for a low-cost cardiac valve. The valve has an integrally machined cobalt-based alloy cage, an ultra-high molecular-weight polyethylene disc, and a polyester suture ring. An important feature of this valve is its soft closing sound, by virtue of a plastic occluder.

METHODS

Between December 1990 and January 1995, 306 patients underwent isolated aortic (AVR, n = 101) or mitral valve replacement (MVR, n = 205) at six institutions in India. The early mortality rate was 6.9% (seven after AVR; 14 after MVR). A total of 285 survivors was followed up until September 1998; total follow up was 1212 patient-years (pt-yr) (AVR, 445 pt-yr; MVR, 767 pt-yr).

RESULTS

There were 52 late deaths (4.3%/pt-yr; AVR 2.2%/pt-yr; MVR 5.5%/pt-yr). Thirty-five deaths were valve-related (23 were due to unknown causes). One AVR patient (0.2%/pt-yr) and 12 MVR patients (1.6%/pt-yr) developed valve thrombosis, and embolic episodes occurred in 25 patients (seven after AVR, 1.6%/pt-yr; 18 after MVR, 2.4%/pt-yr). Bleeding events and infectious endocarditis occurred infrequently (AVR 0.9 and 0.7%/pt-yr; MVR 0.4 and 0.5%/pt-yr, respectively). There was no incidence of paravalvular leak or structural dysfunction of the valve. Actuarial survival rates at seven years were 82.4+/-4.0% for AVR and 65.2+/-5.0% for MVR. During the same interval, thrombus-free and embolism-free survival after AVR and MVR occurred in 98.9+/-1.1% and 94.1+/-1.9%, and 92.3+/-2.8% and 82.1+/-5.7% of patients, respectively. Freedom from all valve-related mortality and morbidity at seven years was 81.5+/-4.1% after AVR, and 64.2+/-5.1% after MVR.

CONCLUSION

The Chitra valve appears to be safe and to have performance comparable with that of other currently used tilting disc valves. This valve costs substantially less than other valves, and is therefore within reach of a larger subset of Indian patients.

Trends in the prevalence and incidence of tuberculosis in south India

OBJECTIVE

To study trends in the prevalence and incidence of tuberculosis in south India.

METHODS

In 1968-1970, about 100,000 subjects were surveyed for tuberculosis and followed thereafter for 15 years, mainly by repeat survey once every 2.5 years. New entrants were inducted at every repeat survey. Radiographic examination of subjects aged 5 years or more and sputum smear and culture examinations of those with an abnormal shadow were undertaken; tuberculin tests were done initially on all, and at 4, 10 and 15 years in selected samples of those aged 1-9 years.

RESULTS

The prevalence of culture-positive tuberculosis decreased by 1.4% per annum to 694/100,000, while that of smear-positive tuberculosis showed no significant decrease from 457/100,000. The annual incidence of culture-positive tuberculosis decreased by 4.3%/annum to 189/100,000 and that of smear-positive tuberculosis decreased by 2.3%/annum to 113/100,000. Decreases in incidence occurred exclusively in those with abnormal radiographic findings suggestive of tuberculosis at the start of the period. The annual risk of tuberculosis infection (ARTI) was initially 2%, and showed no sign of decline over the period.

CONCLUSION

The prevalence of tuberculosis and ARTI showed little or no decrease over the 15-year period. A significant decrease in incidence occurred, but exclusively in those with abnormal radiograph suggestive of tuberculosis at the start of the period.

Bacillary disease and health seeking behavior among Filipinos with symptoms of tuberculosis: implications for control

SETTING

Urban and rural communities and urban poor settlements in the Philippines.

OBJECTIVE

To determine bacillary disease and action taking among individuals with symptoms of tuberculosis (TB), and to analyze their implications for TB control.

STUDY DESIGN AND METHOD

Subjects aged 20 years and older were interviewed in the 1997 nationwide stratified multi-cluster survey. Sputum acid-fast smears and cultures were done in subjects with abnormal screening chest radiographs.

RESULTS

Individuals with TB symptoms comprised 18.1% of the population studied. The prevalence of bacillary disease was 39/1000 in symptomatic subjects compared to 13/1000 in asymptomatic subjects. Symptom screening had a 14.3% positive predictive value and a 91.4% negative predictive value for bacillary disease. Significantly more symptomatic than asymptomatic subjects attended chest radiographic screening during the survey. However, in response to their symptoms, the majority (43.0%) took no action or self medicated (31.6%), while 11.8% consulted a private practitioner, 7.5% a public health center, 4.4% a hospital, and 1.7% a traditional healer.

CONCLUSION

Sputum smear examination after symptom screening was acceptable for case finding. The health seeking behavior of subjects with TB symptoms was inappropriate. A health education program and public-private collaboration in directly observed therapy, short course (DOTS) are essential for TB control in the Philippines.

BCG coverage and the annual risk of tuberculosis infection over a 14-year period in the Philippines assessed from the Nationwide Prevalence Surveys

SETTING

A prevalence survey of tuberculosis (TB) infection was undertaken in the Philippines, a developing country in the Western Pacific region.

OBJECTIVE

To determine the bacille Calmette Guerin (BCG) vaccination rate, the prevalence of TB infection and the annual risk of TB infection (ARTI).

METHODS

A nationwide stratified multi-stage cluster survey of 21,960 individuals. BCG scar verification and tuberculin test were performed on those aged > or =2 months. The ARTI was calculated using the prevalence rates of TB infection in children aged 5-9 years.

RESULTS

BCG scars were noted in 66% of the study population. The prevalence of TB infection was 63.4% among unvaccinated individuals. The prevalence rate was higher in males in both urban and rural areas. With both sexes combined, urban and rural communities had similar prevalence rates. In children aged 5-9 years, the prevalence rate was 16.1% (males 17.4%, females 14.9%), corresponding to an ARTI of 2.3% (males 2.5%, females 2.1%).

CONCLUSION

BCG coverage increased substantially between 1981-1983 and 1997. The ARTI, however, was virtually unchanged, indicating that morbidity due to TB continued to be high.

Direct drug susceptibility test for tubercle bacilli by the sputum swab culture method

OBJECTIVE

To develop a simple, inexpensive method for testing direct drug susceptibility of tubercle bacilli to isoniazid (INH) and streptomycin (SM) which can be adopted for use even in remote parts of the world.

DESIGN

Using 239 smear-positive sputum specimens obtained from an equal number of patients, a comparison was made between the direct swab susceptibility test and the standard indirect method for INH and SM using Löwenstein-Jensen (L-J) medium.

RESULTS

There was 95% agreement of results for INH by 6 weeks and 90% for SM by 8 weeks; 96% of INH-resistant cultures could be detected in 5 weeks and 91% of SM-resistant cultures by 8 weeks. The discrepancies in the two tests were virtually symmetrically distributed at 6 and 8 weeks. The speed and efficiency of detection of resistance by the swab method was also assessed in relation to the standard indirect method. For INH, 96% of the cultures were detected by the fifth week, while 66% were detected as early as 2 weeks and 93% by 4 weeks. With SM, 84% were detected by 4 weeks, 89% by 5 weeks and 91% by 8 weeks.

CONCLUSION

This study has indicated the usefulness of the swab method for testing the drug susceptibility of tubercle bacilli. As this method is simple and easy, and does not even require a centrifuge, it has the potential of application even in the remote parts of the world. The material used, Cetavlon (Cetrimide), is inexpensive and easily water soluble, and more importantly, aqueous solutions are self-sterilizing. It should be stressed, however, that the results obtained with this test take the same time as conventional methods, and it can therefore not be considered as a rapid test.

Tuberculosis in the urban poor settlements in the Philippines

SETTING

Urban poor settlements in the Philippines.

OBJECTIVE

To determine the magnitude of the tuberculosis problem in urban poor settlements in comparison with urban areas studied in the Nationwide Tuberculosis Prevalence Survey.

STUDY DESIGN AND METHOD

A multistage cluster survey of BCG scar, tuberculin test, chest radiography and sputum examination for bacillary disease, in urban poor areas.

RESULTS

The prevalences of culture-positive and smear-positive tuberculosis were 17.5 +/- 2.3 (95% CI 13.3-22.4) and 7.9 +/- 2.3 per thousand (95% CI 2.611.5), respectively. Extrapolated to the total population, the rates in the urban poor settlements were 12.4 +/- 1.7 (95% CI 9.6-16.2) and 5.6 +/- 1.6 per thousand population (95% CI 1.3-8.3), respectively. The prevalence of active pulmonary tuberculosis in subjects aged 10 years or more was 66 +/- 5.6/1000 (95% CI 55-77). The BCG vaccination rate was 72%. The overall prevalence of tuberculosis infection was 66%, and 39% in those aged 5-9 years, corresponding to an annual risk of infection (ARI) of 6.5%.

CONCLUSION

The problem of tuberculosis was substantial in the urban poor settlements, and was appreciably worse than that in the general urban population.

Syringe labels in anaesthetic induction rooms

A survey of 35 hospitals in the United Kingdom has uncovered a wide variety of syringe drug labels. Use of different systems in different hospitals may result in wrong drug administrations, particularly when trainees move from one hospital to another. There is an urgent need to standardise the colour coding of syringe labels in the United Kingdom. Such standards are already in place in Australia, New Zealand and in the United States of America. This survey of syringe drug labels highlights the existing risks and recommendations for change are made.

Lot quality assurance sampling for monitoring immunization coverage in Madras City

OBJECTIVE

To explore the usefulness of Lot Quality Assurance Sampling (LQAS) to identify divisions in a city that had immunization coverage levels of 80% for any of the four EPI vaccines.

METHODS

Only 43 divisions were considered for the study, the stratification factor being the death rate. The hypothesis that 80% coverage is 'unacceptable' was stipulated. Critical value (the number of unimmunized children) was chosen as 3. A simple random sample of 36 children in the age-group 12-23 months was taken from each selected division. Since sampling frames of children were not available, a simple random sample of 36 households was selected. Immunization status of each child was assessed by interviewing the child's mother/guardian. If the number of unimmunized children exceeded 3, then the division was regarded having coverage level 80% and rejected.

RESULTS

The coverage was classified as unacceptable(i. e., below 80%) in 19 divisions for Polio and DPT vaccines, in 26 divisions for Measles vaccine and in 4 divisions for BCG vaccine. The average time spent for undertaking the LQAS survey was 6 man-days per division.

CONCLUSION

This study demonstrated the utility of the LQAS technique in identifying 'unsatisfactory' pockets in Madras City, when the overall coverage was satisfactory. The technique will have greater application with an increase in the number of large units (cities/districts) having an overall coverage of 90% or more.

The 1997 Nationwide Tuberculosis Prevalence Survey in the Philippines

SETTING

The Philippines is a developing country where tuberculosis (TB) remains a significant public health problem.

OBJECTIVE

To determine the prevalence of TB as a basis for setting the targets of the National Tuberculosis Control Program.

STUDY POPULATION AND METHODS

A multi-stage cluster survey of a random sample of 21960 subjects from 36 clusters nationwide was undertaken from 2 April to 31 July 1997. BCG scar verification and tuberculin testing was performed for subjects aged 2 months and over, and chest radiography screening was done on subjects 10 years and older. Sputum samples were collected from individuals who were initially assessed to have abnormal chest radiographs to determine the prevalence of bacillary tuberculosis. Acid-fast smear by modified Kinyoun's technique and culture on Löwenstein Jensen were done to demonstrate Mycobacterium tuberculosis.

RESULTS

The prevalence of active pulmonary TB was 42/1000 population. The prevalence of culture-positive and smear-positive cases was 8.1 and 3.1/1000, respectively. The prevalence was similar in urban and rural areas.

CONCLUSION

Morbidity from TB remains high. Allowing for methodological differences from the survey in 1981-1983, the prevalence of active pulmonary TB was unchanged. There was only a minimal decrease, of 37% for smear-positive cases and 25% for culture-positive cases, in the 14-year interval.

Randomised controlled field trial of two antenatal care packages in rural south India

A randomised community intervention trial was undertaken in 12 subcentres in Karur health unit district, Tamil Nadu, to compare the efficacy of two antenatal care packages. A newly recommended 'high-risk' strategy package and a uniform package recommended by the Tamil Nadu Government were each implemented in 4 randomly selected subcentres by the study team, and the latter was also delivered by routine health services in the 4 remaining subcentres. Analyses were based on 294 pregnant women on the high-risk package (HR), 242 on the Tamil Nadu Government (TNG) package and 335 women in the control series. The HR package reduced the differences between the high-risk women and the others in mean haemoglobin and the percentages with preventable neonatal morbidity and low birth weight, and consequently the overall outcome was better in the HR series than in the TNG series. Finally, the results with the TNG package were better when it was implemented by the study team than by the routine health services, in terms of preventable maternal morbidity and preventable perinatal morbidity, but there was no impact on birth weight.

A concurrent comparison of a WHO-recommended 30-cluster survey and a modified version of it under Indian conditions in the estimation of immunization coverages

A concurrent comparison of the WHO 30-cluster sample survey method for estimating immunization coverages (DPT, Polio, BCG, Measles) and an Indian modification of (GOI) was undertaken in five districts in South India. The essential difference between the two methods is the manner in which the first household is selected in the chosen clusters. With the WHO method, it is chosen clusters. With the WHO method, it is chosen at random, whereas with the GOI method it is often close to the village centre. Estimates with the required degree of precision, i.e., 95% confidence limits of +/- 10 percentage points, were provided in 18 (90%) of 20 instances by the WHO method and in 19 (95%) by the GOI method, findings which are in accordance with expectation. The estimated coverages were, however, higher by the GOI method than by the WHO method in two districts, lower in one district, and in the remaining two districts there was no clear pattern. On the average, there was a suggestion that the GOI method yielded slightly higher coverages, but the differences were not statistically significant.