Health care worker perspectives on TB case finding and HIV services among pediatric TB patients in Tanzania

BACKGROUND: Tuberculosis (TB) and human immunodeficiency virus (HIV) infection in children are of concern due to the high morbidity and mortality they engender. Tanzania is working to improve TB and HIV case identification and treatment, as well as linkage of TB and HIV care in pediatric patients.METHODS: In-depth interviews were conducted in March 2016 at 10 high TB burden clinics in five districts of Tanzania to identify the barriers to pediatric TB diagnosis and HIV care. Health care workers (HCWs) at TB clinics who provided informed consent were administered interviews which were analyzed.RESULTS: Of 41 HCWs interviewed, 26 reported receiving pediatric TB training. Barriers to TB diagnosis included low community awareness, stigma and late presentation to the clinic. Barriers to HIV testing included children attending the TB clinic with someone who was not their parent/guardian and shortages of HIV rapid test kits. HCWs stressed the need for improved community education because it was perceived that some caregivers did not understand the importance of prompt TB and HIV treatment in children (although most were eager for a resolution of their child's illness).CONCLUSIONS: Efforts are needed to ensure effective TB and HIV diagnosis and treatment of children, provision of broader HCW and community education, enhanced TB-HIV contact tracing, and ensuring a continuous supply of HIV rapid test kits.

Improving sputum collection processes to increase tuberculosis case finding among HIV-positive persons in Botswana

SETTING

Twenty-two human immunodeficiency virus (HIV) clinics in Botswana.

OBJECTIVE

To compare sputum collection rates, sputum quality and volume, and tuberculosis (TB) diagnosis rates before and after field efforts to improve sputum collection among individuals newly diagnosed with HIV with TB symptoms.

DESIGN

Newly diagnosed individuals living with HIV attending 22 HIV clinics in Botswana were screened for TB from August 2012 to March 2014. Starting in May 2013, a field intervention composed of the introduction of a tracking log for presumed TB patients, and patient instructions and sputum induction to improve sputum collection rates was implemented.

RESULTS

Prior to the intervention, sputum collection rates were 44.1% (384/870). Subsequently, sputum collection increased to 58.3% (579/993) (P < 0.001). Sputum quality and volume also improved. Although rates of TB diagnosis increased from 9.7% (84/870) to 12.5% (120/993), this difference was not significant (P = 0.143).

CONCLUSION

Sputum collection rates among presumptive TB cases, as well as sputum quality and volume improved after implementation of the field intervention. To improve sputum collection rates, efforts at the program level should be ongoing.

Assessment of routine screening of pediatric contacts of adults with tuberculosis disease in Tanzania

Setting

Ten selected healthcare facilities in Tanzania, March-April 2016.

Objective

To assess the implementation of screening among pediatric contacts of adults with tuberculosis (TB) disease.

Design

Using a mixed-methods approach, we conducted a questionnaire study among sputum smear-positive adult TB patients and abstracted data from their patient cards to assess the implementation of a child contact management (CCM) intervention. We also conducted in-depth interviews with healthcare workers (HCWs) to solicit their views on clinical practices and challenges in CCM.

Results

A total of 141 adult smear-positive TB patients reported 396 children living in households; detailed information on 346 (87.4%) was available. Only 37 (10.7%) children were clinically assessed for TB, 5 (13.5%) were diagnosed with TB, and 22 started on isoniazid preventive therapy (IPT) (59.0%). Of the 320 children whose caregivers responded to whether their children had undergone human immunodeficiency virus (HIV) testing, 55 (17.2%) had been tested and one (1.8%) was HIV-positive. Forty-one HCWs described passive CCM without use of contact or IPT registers.

Conclusion

We identified gaps in the implementation of TB screening, IPT provision, and HIV testing in pediatric contacts of adults with sputum smear-positive TB. Systematic efforts, including increasing HCW training and educating the community, may improve implementation.

Abstract 3374: CRISPR/Cas9 mediated genome editing induces exon skipping by alternative splicing or exon deletion

CRISPR is widely used to disrupt gene function by inducing small insertions and deletions. Here, we show that some single-guide RNAs (sgRNAs) can induce exon skipping or large genomic deletions that delete exons. For example, CRISPR-mediated editing of β-catenin exon 3, which encodes an autoinhibitory domain, induces partial skipping of the in-frame exon and nuclear accumulation of β-catenin. A single sgRNA can induce small insertions or deletions that partially alter splicing or unexpected larger deletions that remove exons. Exon skipping adds to the unexpected outcomes that must be accounted for, and perhaps taken advantage of, in CRISPR experiments.

Citation Format: Haiwei Mou, Jordan Smith, Lingtao Peng, Hao Yin, Jill Moore, Xiao-Ou Zhang, Chunqing Song, Ankur Sheel, Qiongqiong Wu, Deniz Ozata, Yingxiang Li, Daniel Anderson, Charles Emerson, Melissa Moore, Zhiping Weng, Wen Xue. CRISPR/Cas9 mediated genome editing induces exon skipping by alternative splicing or exon deletion [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3374.

Evaluation of a TB infection control implementation initiative in out-patient HIV clinics in Zambia and Botswana

SETTING

Out-patient human immunodeficiency virus (HIV) care and treatment clinics in Zambia and Botswana, countries with a high burden of HIV and TB infection.

OBJECTIVE

To develop a tuberculosis infection control (TB IC) training and implementation package and evaluate the implementation of TB IC activities in facilities implementing the package.

DESIGN

Prospective program evaluation of a TB IC training and implementation package using a standardized facility risk assessment tool, qualitative interviews with facility health care workers and measures of pre- and post-test performance.

RESULTS

A composite measure of facility performance in TB IC improved from 32% at baseline to 50% at 1 year among eight facilities in Zambia, and from 27% to 80% at 6 months among 10 facilities in Botswana. Although there was marked improvement in indicators of managerial, administrative and environmental controls, key ongoing challenges remained in ensuring access to personal protective equipment and implementing TB screening in health care workers.

CONCLUSION

TB IC activities at out-patient HIV clinics in Zambia and Botswana improved after training using the implementation package. Continued infrastructure support, as well as monitoring and evaluation, are needed to support the scale-up and sustainability of TB IC programs in facilities in low-resource countries.

Contemporary changes to herding systems in China and effects on pasture quality: a case study in Gansu Province, 2000-2012

Post-2000 efforts to protect China's pastoral areas are distinct from earlier efforts in that funding for the most recent round of policies and programs is commensurate with the task. Even with appropriate funding, however, effective methods of mitigating pasture degradation are widely disputed. The most controversial of the current policies include herding family resettlement, pasture fallow programs (herding "bans"), and the promotion of confined animal feeding operations (CAFOs). Ideally, the policies are intended to protect grassland ecological systems while assuring acceptable revenues to affected families and regions. This article presents a case study of 49 townships in three counties in central Gansu investigating the interactions among changes in mean interpolated annual precipitation and livestock density and pasture quality. Pasture quality is assessed using mean township values of the enhanced vegetation index (EVI) from 2000 to 2012 obtained by the MODerate-resolution Imaging Spectroradiometer (MODIS) sensor of the Terra satellite. The research joins remotely sensed environmental data, interpolated annual precipitation estimates, and livestock counts at the township scale for the years from 2000 to 2012 but is also informed by in-depth interviews with herding families and husbandry officials. Joining biophysical analyses of changes in pasture with archived data and in-depth interviews, we adopt a synthetic approach to determine changes to pasture quality under post-2000 policy interventions and possible reasons for these changes. Pasture quality has improved as CAFO livestock have increased; however, herders and local officials report that some of the new policies and programs may have important unanticipated negative impacts related to pasture ecology and water consumption.

Highlighting the need for more infection control practitioners in low- and middle-income countries

Background: Many low- and middle-income countries struggle to implement, monitor and evaluate the efficacy of infection control (IC) measures within health care facilities. This hampers their ability to prevent nosocomial infections, identify emerging pathogens and rapidly alert officials to possible outbreaks. The lack of dedicated and trained IC practitioners (ICPs) is a serious deficit in the health care workforce, and is worsened by the lack of institutions that offer IC training. Discussion: While no single individual can entirely eliminate the risk of nosocomial transmission, there is literature to support the value of designated IC persons. Recommendations from the World Health Organization in 2008 and 2009 describe the need for this specialized cadre of workers, but many countries lack the national regulations to authorize, train and manage such professionals at the national or local level. This article provides an overview of how ICPs are trained and credentialed in several countries, and discusses approaches countries can use to train ICPs. Conclusion: Trained ICPs can help prevent future outbreaks and control nosocomial transmission of diseases in health care facilities. For this to occur, supportive national policies, availability of training institutions and local administrative support will be required.

Are we missing mumps epididymo-orchitis?

Mumps epididymo-orchitis has not been recorded as a cause of testicular symptoms without systemic features (including parotitis). The aim of the present study was to assess if we were missing cases in the genitourinary clinic during a previous outbreak of mumps in the community. During a prospective pilot study from November 2005 to February 2006, all patients presenting with symptoms or signs of epididymo-orchitis were studied. These patients were assessed for previous exposure to mumps virus or vaccine, and any current evidence of systemic illness. All patients included had a full sexual health screen (loop test, chlamydia polymerase chain reaction [PCR], gonorrhoea culture, HIV and Venereal Disease Research Laboratory [test]/ Treponema pallidum particle agglutination assay), urinary tract infection excluded by urinalysis and mid-stream specimen of urine (MSSU) and mumps serology (Immunoglobulin M [IgM] and Immunoglobulin G [IgG]) performed.

Twenty-three patients met inclusion criteria. Their ages ranged from 16 to 50 years, average 30.8 years. All had symptoms of these, 18 had testicular pain, eight swelling, (four had both pain and swelling) and three also had dysuria. On examination, 12 had tenderness, seven swelling, (two both tenderness and swelling) and six had no signs. Seventeen denied history of mumps, one patient had a record of vaccination and five described fever. None had parotid swelling. Three patients were chlamydia PCR positive, two had candida cultured, three had non-specific urethritis (>10 polymorphonuclear leucocyte/high powered field) and 13 had negative sexually transmitted infection screen (one known HIV-positive). Three had positive IgM mumps serology and two were IgG-positive.

It is important to include mumps in the differential of epididymo-orchitis and to be aware of outbreaks in the community that may present with genital symptoms, as the management and partner notification will be different.

The effects of China's environmental protection policies on pasture quality and the activities of small-scale herders in Songpan County, Western Sichuan

Since 2000, there has been an ambitious governmental effort to protect China's grassland resources through new, often controversial, policies and programs backed up by massive capital investments and subsidies. The policies are intended to protect pastoral ecological systems while allowing the pasture-based husbandry sector to continue to evolve in ways that assure acceptable revenues to affected families and regions. This article reports results of a case study conducted in Songpan County of western Sichuan during the fall of 2013 specifically focused on these issues and interactions. The mixed-method research combines remotely sensed MODIS vegetation indices (EVI), livestock counts by type, and grassland area estimates at the township scale from 2000-2012, with depth interviews with local herding families and husbandry officials to determine how the husbandry sector has changed in the past 12 years under post-2000 policy interventions. Results for Songpan indicate that pasture coverage has improved slightly as grazing livestock density per hectare declined, but herders and local officials report that some of the new laws and programs have important unanticipated negative impacts on pasture quality, pasture ecology, and economic returns from herding for some families.

Finding fossils in new ways: an artificial neural network approach to predicting the location of productive fossil localities

Chance and serendipity have long played a role in the location of productive fossil localities by vertebrate paleontologists and paleoanthropologists. We offer an alternative approach, informed by methods borrowed from the geographic information sciences and using recent advances in computer science, to more efficiently predict where fossil localities might be found. Our model uses an artificial neural network (ANN) that is trained to recognize the spectral characteristics of known productive localities and other land cover classes, such as forest, wetlands, and scrubland, within a study area based on the analysis of remotely sensed (RS) imagery. Using these spectral signatures, the model then classifies other pixels throughout the study area. The results of the neural network classification can be examined and further manipulated within a geographic information systems (GIS) software package. While we have developed and tested this model on fossil mammal localities in deposits of Paleocene and Eocene age in the Great Divide Basin of southwestern Wyoming, a similar analytical approach can be easily applied to fossil-bearing sedimentary deposits of any age in any part of the world. We suggest that new analytical tools and methods of the geographic sciences, including remote sensing and geographic information systems, are poised to greatly enrich paleoanthropological investigations, and that these new methods should be embraced by field workers in the search for, and geospatial analysis of, fossil primates and hominins.

Hepatitis A outbreak predominantly affecting men who have sex with men in Northern Ireland, October 2008 to July 2009

We describe an outbreak of hepatitis A which evolved in Northern Ireland between October 2008 and July 2009, against a background of large concurrent hepatitis A outbreaks in various parts of Europe. Thirty-eight cases were defined as outbreak cases using a stratified case definition; 36 were males with a median age of 29 years and of the 28 males whose sexual orientation was known, 26 were men who have sex with men(MSM). Detailed descriptive epidemiology data collected through standardised questionnaires, together with sequencing of a 289 bp fragment of the VP1/2PA region of the virus, significantly aided the understanding of the spread of the outbreak when non-MSM cases occurred. The sequence of the outbreak strain, genotype IA, was indistinguishable from that involved in a large outbreak in the Czech Republic. Although seeded in a generally susceptible Northern Ireland population, the outbreak remained mostly contained in MSM, showing this sub-population to be the most vulnerable despite ongoing hepatitis A vaccination programmes in genito-urinary medicine clinics.

Hepatitis A outbreak predominantly affecting men who have sex with men in Northern Ireland, October 2008 to July 2009

We describe an outbreak of hepatitis A which evolved in Northern Ireland between October 2008 and July 2009, against a background of large concurrent hepatitis A outbreaks in various parts of Europe. Thirty-eight cases were defined as outbreak cases using a stratified case definition; 36 were males with a median age of 29 years and of the 28 males whose sexual orientation was known, 26 were men who have sex with men (MSM). Detailed descriptive epidemiology data collected through standardised questionnaires, together with sequencing of a 289 bp fragment of the VP1/2PA region of the virus, significantly aided the understanding of the spread of the outbreak when non-MSM cases occurred. The sequence of the outbreak strain, genotype IA, was indistinguishable from that involved in a large outbreak in the Czech Republic. Although seeded in a generally susceptible Northern Ireland population, the outbreak remained mostly contained in MSM, showing this sub-population to be the most vulnerable despite ongoing hepatitis A vaccination programmes in genito-urinary medicine clinics.

Assessing training in sexual dysfunction for genitourinary medicine registrars

The training programme for specialist registrars in genitourinary medicine (GU) lists sexual dysfunction (SD) as ‘beyond essential, core curriculum’ despite many GU medicine clinics offering this service. A cross-sectional study was performed of all trainees on the British Association for Sexual Health and HIV mailing list. Data collected included frequency of clinics attended and involvement, any training and interest in future training. A total of 39/76 (51%) responses were received. In total, 20/39 (51%) work in departments with no SD clinic provision, and 12/39 have had some training in SD. In routine GU medicine consultation, 85% trainees are consulted regarding SD at least monthly. In all, 19/39 (49%) work in areas with weekly SD clinics; however, only three trainees were involved. Thirty-four out of 39 (87%) expressed interest in training and 31/39 (79%) respondents would like to see SD training added to the SpR curriculum. Fifty-one percent of juniors work in units without SD provision. Even when SD clinics occur, only three trainees are routinely involved and a large training opportunity is being missed. Despite this, 12/39 trainees have sought out extra training in the form of seminars, courses and meetings. Eighty-five percent wished to have SD as part of the core curriculum as they may ultimately work in an area where these skills are required.

Access to medical records for research purposes: varying perceptions across research ethics boards

INTRODUCTION

Variation across research ethics boards (REBs) in conditions placed on access to medical records for research purposes raises concerns around negative impacts on research quality and on human subject protection, including privacy.

AIM

To study variation in REB consent requirements for retrospective chart review and who may have access to the medical record for data abstraction.

METHODS

Thirty 90-min face-to-face interviews were conducted with REB chairs and administrators affiliated with faculties of medicine in Canadian universities, using structured questions around a case study with open-ended responses. Interviews were recorded, transcribed and coded manually.

RESULTS

Fourteen sites (47%) required individual patient consent for the study to proceed as proposed. Three (10%) indicated that their response would depend on how potentially identifying variables would be managed. Eleven sites (38%) did not require consent. Two (7%) suggested a notification and opt-out process. Most stated that consent would be required if identifiable information was being abstracted from the record. Among those not requiring consent, there was substantial variation in recognising that the abstracted information could potentially indirectly re-identify individuals. Concern over access to medical records by an outside individual was also associated with requirement for consent. Eighteen sites (60%) required full committee review. Sixteen (53%) allowed an external research assistant to abstract information from the health record.

CONCLUSIONS

Large variation was found across sites in the requirement for consent for research involving access to medical records. REBs need training in best practices for protecting privacy and confidentiality in health research. A forum for REB chairs to confidentially share concerns and decisions about specific studies could also reduce variation in decisions.

Ventral neural progenitors switch toward an oligodendroglial fate in response to increased Sonic hedgehog (Shh) activity: involvement of Sulfatase 1 in modulating Shh signaling in the ventral spinal cord

In the embryonic chick ventral spinal cord, the initial emergence of oligodendrocytes is a relatively late event that depends on prolonged Sonic hedgehog (Shh) signaling. In this report, we show that specification of oligodendrocyte precursors (OLPs) from ventral Nkx2.2-expressing neural progenitors occurs precisely when these progenitors stop generating neurons, indicating that the mechanism of the neuronal/oligodendroglial switch is a common feature of ventral OLP specification. We further show that an experimental early increase in the concentration of Shh is sufficient to induce premature specification of OLPs at the expense of neuronal genesis indicating that the relative doses of Shh received by ventral progenitors determine whether they become neurons or glia. Accordingly, we observe that the Shh protein accumulates at the apical surface of Nkx2.2-expressing cells just before OLP specification, providing direct evidence that these cells are subjected to a higher concentration of the morphogen when they switch to an oligodendroglial fate. Finally, we show that this abrupt change in Shh distribution is most likely attributable to the timely activity of Sulfatase 1 (Sulf1), a secreted enzym that modulates the sulfation state of heparan sulfate proteoglycans. Sulf1 is expressed in the ventral neuroepithelium just before OLP specification, and we show that its experimental overexpression leads to apical concentration of Shh on neuroepithelial cells, a decisive event for the switch of ventral neural progenitors toward an oligodendroglial fate.

Lipopolysaccharide induces type 2 iodothyronine deiodinase in the mediobasal hypothalamus: implications for the nonthyroidal illness syndrome

To determine whether the type 2 iodothyronine deiodinase (D2), the principal central nervous system enzyme converting T(4) to biologically active T(3), is regulated in tanycytes by immune activation, D2 activity was measured in the mediobasal hypothalamus (MBH) 4, 12, and 24 h after administration of bacterial lipopolysaccharide (LPS) and compared with D2 levels in the cortex and anterior pituitary of rats. In contrast to D2 activity in the cortex and anterior pituitary that showed a steady linear increase over 24 h, which was coincident with a decline in thyroid hormone and TSH levels, D2 activity peaked in the MBH 12 h after LPS administration. By in situ hybridization, the increased D2 mRNA synthesis induced by LPS was specifically localized to tanycytes lining the third ventricle. In vitro assays in HC11 and HEK-293 cells demonstrated that the p65 subunit of nuclear factor-kappaB markedly increased both rat and human D2 genes (dio2) as analyzed by promoter assays. No activation of human dio2 was observed when an 83-bp minimal promoter was used. We propose that LPS or LPS-induced cytokines directly induce D2 mRNA in tanycytes. The ensuing MBH-specific D2-mediated local thyrotoxicosis may suppress the hypothalamus-pituitary-thyroid axis by local feedback inhibition of hypophysiotropic TRH and/or TSH and contribute to the mechanism of central hypothyroidism associated with infection.

A subtractive approach to characterize genes with regionalized expression in the gliogenic ventral neuroepithelium: identification of chick Sulfatase 1 as a new oligodendrocyte lineage gene

To address the question of the origin of glial cells and the mechanisms leading to their specification, we have sought to identify novel genes expressed in glial progenitors. We adopted suppression subtractive hybridization (SSH) to establish a chick cDNA library enriched for genes specifically expressed at 6 days of incubation (E6) in the ventral neuroepithelium, a tissue previously shown to contain glial progenitors. Screens were then undertaken to select differentially expressed cDNAs, and out of 82 unique SSH clones, 21 were confirmed to display a regionalized expression along the dorsoventral axis of the E6 ventral neuroepithelium. Among these, we identified a transcript coding for the chick orthologue of Sulf1, a recently identified cell surface sulfatase, as a new, early marker of oligodendrocyte (OL) precursors in the chick embryonic spinal cord. This study provides groundwork for the further identification of genes involved in glial specification.

Cloning, sequencing, and expression of interferon-gamma from elk in North America

Eradication of Mycobacterium bovis relies on accurate detection of infected animals, including potential domestic and wildlife reservoirs. Available diagnostic tests lack the sensitivity and specificity necessary for accurate detection, particularly in infected wildlife populations. Recently, an in vitro diagnostic test for cattle which measures plasma interferon-gamma (IFN-gamma) levels in blood following in vitro incubation with M. bovis purified protein derivative has been enveloped. This test appears to have increased sensitivity over traditional testing. Unfortunately, it does not detect IFN-gamma from Cervidae. To begin to address this problem, the IFN-gamma gene from elk (Cervus elaphus) was cloned, sequenced, expressed, and characterized. cDNA was cloned from mitogen stimulated peripheral blood mononuclear cells. The predicted amino acid (aa) sequence was compared to known sequences from cattle, sheep, goats, red deer (Cervus elaphus), humans, and mice. Biological activity of the recombinant elk IFN-gamma (rElkIFN-gamma) was confirmed in a vesicular stomatitis virus cytopathic effect reduction assay. Production of monoclonal antibodies to IFN-gamma epitopes conserved between ruminant species could provide an important tool for the development of reliable, practical diagnostic assays for detection of a delayed type hypersensitivity response to a variety of persistent infectious agents in ruminants, including M. bovis and Brucella abortus. Moreover, development of these reagents will aid investigators in studies to explore immunological responses of elk that are associated with resistance to infectious diseases.

Tat-specific cytotoxic T lymphocytes select for SIV escape variants during resolution of primary viraemia

Human immunodeficiency virus (HIV) and simian immunodeficiency virus (SIV) infections are characterized by early peaks of viraemia that decline as strong cellular immune responses develop. Although it has been shown that virus-specific CD8-positive cytotoxic T lymphocytes (CTLs) exert selective pressure during HIV and SIV infection, the data have been controversial. Here we show that Tat-specific CD8-positive T-lymphocyte responses select for new viral escape variants during the acute phase of infection. We sequenced the entire virus immediately after the acute phase, and found that amino-acid replacements accumulated primarily in Tat CTL epitopes. This implies that Tat-specific CTLs may be significantly involved in controlling wild-type virus replication, and suggests that responses against viral proteins that are expressed early during the viral life cycle might be attractive targets for HIV vaccine development.

Effect of telephone followups on post vasectomy office visits

Vasectomies are considered minor outpatient procedures. Yet, many patients return to their urologist's office for rechecks because of complications or the need for reassurance of normal healing sequela. This study suggests that use of a tool for telephone followup can increase patient satisfaction and benefit urologic practice by curtailing the incidence of needless followup visits.

Ectopic expression of MyoD1 in mice causes prenatal lethalities

A variety of differentiated cell types can be converted to skeletal muscle following transfection with the myogenic regulatory gene MyoD1. To determine whether MyoD1 is a dominant muscle regulator in vivo, mouse fertilized eggs were microinjected with a beta-actin/MyoD1 gene. Ectopic expression of MyoD1 during mouse embryogenesis led to embryonic lethalities, the cause of which is not known. Transgenic embryos died before midgestation. The majority of tested embryos between 7.5 and 9.5 days, although retarded compared to control littermates, differentiated normally into tissues representative of all three germ layers. In most transgenic embryos there was no indication of myogenic conversion. The expression of the introduced gene was detected in all ectodermal and mesodermal tissues but was absent in all endodermal cells. Forced expression of MyoD1 was associated with the activation of myogenin and MLC2 (but not myf5 or MRF4) genes in non-muscle cell types, demonstrating the dominant regulatory function of MyoD1 during development. These results demonstrate that ectopic MyoD1 expression and activation of myogenin and MLC2 have no significant effects in the determination of cell lineages or the developmental fate of differentiated mesodermal and ectodermal cell lineages.