Applying the zero-inflated Poisson model with random effects to detect abnormal rises in school absenteeism indicating infectious diseases outbreak

Records of absenteeism from primary schools are valuable data for infectious diseases surveillance. However, the analysis of the absenteeism is complicated by the data features of clustering at zero, non-independence and overdispersion. This study aimed to generate an appropriate model to handle the absenteeism data collected in a European Commission granted project for infectious disease surveillance in rural China and to evaluate the validity and timeliness of the resulting model for early warnings of infectious disease outbreak. Four steps were taken: (1) building a 'well-fitting' model by the zero-inflated Poisson model with random effects (ZIP-RE) using the absenteeism data from the first implementation year; (2) applying the resulting model to predict the 'expected' number of absenteeism events in the second implementation year; (3) computing the differences between the observations and the expected values (O-E values) to generate an alternative series of data; (4) evaluating the early warning validity and timeliness of the observational data and model-based O-E values via the EARS-3C algorithms with regard to the detection of real cluster events. The results indicate that ZIP-RE and its corresponding O-E values could improve the detection of aberrations, reduce the false-positive signals and are applicable to the zero-inflated data.

Community perceptions of tuberculosis: A qualitative exploration from a gender perspective

OBJECTIVE

To explore community laypersons' perspective on tuberculosis (TB)-related illness experiences, meanings, behaviours and impact with reference to gender.

STUDY DESIGN

Qualitative, conducted in rural Bangladesh.

METHODS

Eleven focus group discussions (FGDs) were conducted (six female and five male) in five subdistricts where the non-governmental organization BRAC operates. On average, seven purposively chosen poor, illiterate, non-TB patients participated in each FGD. Discussions were audiotaped, translated verbatim into English and analysed using MAXQDA software for qualitative data analysis, used it to assign codes to text segments to identify themes from participants' narratives.

RESULTS

TB was recognized as a deadly disease that could affect anyone. The discussants were fairly aware of the psychological, financial and social impacts of TB. Women faced with adverse consequences more often than men, such as trouble in ongoing and prospective marital affairs. Coughing up sputum in public by women is culturally frowned upon, resulting in enormous suffering. Women tended to describe the clinical features more vaguely than men, and often specified fewer characteristic symptoms such as blood in sputum.

CONCLUSIONS

The gender differences in the health and socio-economic impact of TB included perceived causality, curability, stigma, family and community support, fear of disclosure, and use of self-help or home remedies. Interactive health education covering various consequences of TB could be indispensable to changing negative beliefs.

A snapshot of the biodiversity and clustering of Mycobacterium tuberculosis in Oman using spoligotyping

SETTINGS

National Tuberculosis Reference Laboratory, Central Public Health Laboratory, Ministry of Health, Oman.

OBJECTIVE

To use spoligotyping to explore the genetic population structure and clustering of Mycobacterium tuberculosis isolates among nationals and immigrants in Oman.

METHODS

Using spoligotyping, we characterised all available isolates from 2007, and randomly selected isolates from 2005 and 2006. A total of 312 clinical isolates from the same number of patients diagnosed with tuberculosis (TB) in 2005-2007 were included in the study.

RESULTS

Of 312 isolates, 69% were in clusters ranging from 2 to 38 isolates. The proportion of clustering was 58% among 2005-2006 samples and 67% among 2007 samples, with higher clustering among Omanis than among immigrants. The study showed that M. tuberculosis Indian family lineages, CAS1_Delhi, CAS and EAI5 were the predominant strains. Around 50% of the immigrants shared strains with Omanis. Twelve of the 19 INH-monoresistant strains and the two multidrug-resistant strains were in clusters (P = 0.81).

CONCLUSION

This study demonstrates the predominance in Oman of the strain family commonly found on the Indian sub-continent. A high proportion of immigrant strains were in the same clusters as Omani strains. To better ascertain the transmission dynamics of M. tuberculosis, we recommend that stringent molecular and conventional epidemiological methods be applied.

Female-male differences at various clinical steps of tuberculosis management in rural Bangladesh

A registry data-based study of 3,600 patients systematically drawn from out-patient clinic, laboratory and tuberculosis (TB) treatment registers (1200 from each) examined female-male differences at various clinical steps of TB management and compared selective indicators with published results. Female-to-male ratios (FMR) declined at the following clinical steps: respiratory patients seeking out-patient care (0.81), TB suspects submitting sputum for testing (0.52) and smear-positive test results (0.38), but the decline ceased at treatment initiation (0.41). Compared to 1997, the FMR in 2000 had decreased for out-patient clinics and sputum submission for testing, but had increased for smear-positive test results and treatment initiation. More female than male patients who underwent treatment achieved cure (93% vs. 89%). Lower female representation at the different clinical steps of TB management persists.

PPM: 'public-private' or 'private-public' mix? The case of Ujjain District, India

The World Health Organization and the Revised National TB Control Programme (RNTCP) in India have advocated public-private mix as essential for tuberculosis (TB) control. We conducted a cross-sectional sample survey of private providers (with various qualifications) in Ujjain District, India, to study willingness and motivation to collaborate. Most providers were aware of the RNTCP and had referred patients there. All were willing to collaborate, although the areas for collaboration varied between urban and rural providers. General altruism and an opportunity to collaborate with the government were the main motivations. None of the providers had ever been contacted by the RNTCP. Enthusiasm in the private sector has not been effectively exploited by the RNTCP.

Managing with maps? The development and institutionalization of a map-based health management information system in Madhya Pradesh, India

Aims: This paper presents the development of a map-based health management information system (mHMIS) in the central Indian province of Madhya Pradesh. Sample outputs and statistics from the system for one district are presented. The implementation dynamics and the preliminary performance of the system are discussed. Methods: The development of the mHMIS was a collaborative effort between the provincial Department of Health, the medical university and the Danidasupported Madhya Pradesh Basic Health Services project. One of India's most socioeconomically backward provinces, Madhya Pradesh is spread over an area of 304,000 km2, and has a population of 60.4 million distributed in its 55,392 villages and 394 towns. A primary survey of all healthcare providers (public and private) in the province was done to map these. Secondary data sources for sociodemographic information (census of India), vital statistics and health program indicators (health worker records) were used in developing the system. The process of mapping from obtaining hand-drawn maps of the villages from the commissioner, land records, to final digitizing is also described. Conclusions: Sample outputs and statistics for one district (Chindwara) from the system are presented. There were 20.35 trained doctors in rural areas and 72.78 in urban areas per 100,000 population. Preliminary experience after a year, advantages, constraints (both systemic limitations and weakness in the mHMIS) to optimal usage, and future prospects for use in this setting are discussed.

Towards the elimination of tuberculosis in a developing country: 25 years of tuberculosis control in Oman

OBJECTIVE

To analyse trends of tuberculosis (TB) in Oman (1981-2005) in relation to the socio-economic development of the country.

METHODS

Data were used from the National Tuberculosis Control Programme (NTP). Information on TB cases' age, sex and type were obtained from the national book (1981-1991) and the computer database (1992-2005).

RESULTS

TB notification rates among Omani nationals declined by more than 85% from 1981 to 1995. During the period 1981-1993, the TB notification rate declined by around 15% per year, compared to only 3.6% per year in subsequent years. Males and the age group > or = 50 years have higher rates than females and younger age groups, respectively. Non-nationals contributed 21% of all TB cases notified and 40% of all smear-positive cases. Of cases among nationals notified between 2004 and 2005, 95% had a family income lower than the national average.

CONCLUSION

Although TB notification in Oman has declined by more than 85% over the last 25 years, the decline has slowed down over the last 10 years, requiring a detailed analysis of existing TB control measures and implementation of additional measures for TB elimination.

Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India

SETTING

Ujjain district, Madhya Pradesh, India.

OBJECTIVE

To describe and compare health care seeking among men and women with cough of >3 weeks, with special focus on the utilisation of private and public health care.

DESIGN

A population-based cross-sectional survey including 45 719 individuals aged > or = 15 years.

RESULTS

The prevalence of cough was respectively 2.8% and 1.2% among men and women. The majority of men and women reported seeking health care for their symptoms (69% vs. 71%), but only 23% visited a public provider at some point during their illness. A similar health care seeking pattern was found for patients diagnosed with tuberculosis (TB) in our survey. No significant differences in health care seeking were found between men and women. Only 13% of those seeking care reported having had a sputum smear examination since the onset of cough. Factors associated with sputum examination were history of TB, haemoptysis and visiting a public provider.

CONCLUSION

The low utilisation of public health care services and the few sputum examinations reported in this rural Indian setting illustrate the need for improved diagnostic practices as well as involvement of private providers in TB control activities.

Diagnostic delays in access to tuberculosis care in counties with or without the National Tuberculosis Control Programme in rural China

SETTING

A county covered by the National Tuberculosis Control Programme (NTP) (Jianhu) and a nonprogramme county (Funing) in Jiangsu Province, China.

OBJECTIVE

To compare diagnostic delays among tuberculosis (TB) patients between counties with and without the NTP, and to study the impact of demographic, socioeconomic and policy factors on the delays.

DESIGN

A cohort study of 493 newly diagnosed TB patients registered in the study sites during 2002 was conducted using a structured questionnaire interview.

RESULT

The median total diagnostic delay was longer in Jianhu County, 31 (14-68) days, compared to Funing County, 19 (12-34) days, with a shorter patient's delay (10 vs. 16 days, P < 0.05) but a longer doctor's delay (6 vs. 0 days, P < 0.01) in Jianhu than in Funing. Smear-positive TB accounted for 86% of patients in Jianhu, compared to 37% in Funing. Less educated and uninsured patients had longer patient's or doctor's delays in Jianhu, while in Funing poor patients and farmers had both longer patient's and doctor's delays.

CONCLUSION

The subsidised NTP leads to a shorter patient's delay, but a longer doctor's delay, with a substantially higher proportion of smear-positive TB diagnosis. Education, medical insurance, poverty and the system of TB control can influence patients' access to TB care.

Lay health worker intervention with choice of DOT superior to standard TB care for farm dwellers in South Africa: a cluster randomised control trial

SETTING

Farms in the Boland health district, Western Cape Province, South Africa.

OBJECTIVE

To evaluate the effect of lay health workers (LHWs) on tuberculosis (TB) control among permanent farm workers and farm dwellers in an area with particularly high TB prevalence.

DESIGN

Pragmatic, unblinded cluster randomised control trial.

METHODS

This trial measured successful treatment completion rates among new smear-positive (NSP) adult TB patients on 106 intervention farms, and compared them with outcomes in patients on 105 control farms. Farms were the unit of randomisation, and analysis was by intention to treat.

RESULTS

A total of 164 adult TB patients were recruited into the study, 89 of whom were NSP. The successful treatment completion rate in NSP adult TB patients was 18.7% higher (P = 0.042, 95%CI 0.9-36.4) on farms in the intervention group than on farms in the control group. Case finding for adult NSP TB cases was 8% higher (P = 0.2671) on farms in the intervention group compared to the control group.

CONCLUSION

Trained LHWs were able to improve the successful TB treatment rate among adult NSP TB patients in a well-established health service, despite reduction of services.

Should the 'bleach microscopy method' be recommended for improved case detection of tuberculosis? Literature review and key person analysis

SETTING

It has been proposed that the sensitivity of direct sputum smear microscopy can be improved if sputum is liquefied with sodium hypochlorite (NaOCl or household bleach), and concentrated by centrifugation before acid-fast staining.

OBJECTIVE

To summarise the results of the studies of the bleach method for improved sensitivity of sputum microscopy and to describe the opinions and knowledge of key persons in National Tuberculosis Control Programmes (NTPs) about this method.

DESIGN

We searched Medline, EMBASE and Web of Science for studies comparing the bleach method to direct sputum smear microscopy in low- or middle-income countries. Each study was assessed regarding methodology and field applicability. We also sent out questionnaires concerning the bleach method to key persons in NTPs in 85 countries.

RESULTS

In 15 of the 19 studies identified there was a statistically significant improvement in the proportion of positive tests or sensitivity ranging from 7-253%. The majority (73%) of the key persons had heard of the bleach method. Forty-four per cent thought it could improve case detection in their countries, while 49% did not know; 93% of them would promote the bleach method; the most common reasons for doing so would be recommendations from the WHO or the IUATLD, or favourable studies performed in their own country. The bleach method was used routinely in only three countries.

CONCLUSION

There is enough evidence to recommend the evaluation and introduction of the bleach method in most settings where mycobacterial culture is not performed routinely.

Knowledge about tuberculosis and its treatment among new pulmonary TB patients in the north and central regions of Vietnam

SETTING

Tuberculosis (TB) units in 42 districts in north and central Vietnam were included in the study.

OBJECTIVES

To describe patients' knowledge of TB and to evaluate the impact of the National Tuberculosis Programme's health education.

DESIGN

New pulmonary TB patients who had received TB treatment for a minimum of 1 month were interviewed using a structured questionnaire.

RESULTS

A total of 364 patients were interviewed; 93% of respondents reported receiving TB information from the health staff. Apart from health education, many patients reported TB information from the TV. This was more common among men than women (71.4% vs. 51.3%). The average knowledge score was 7.07 +/- 2.02 (maxium 10). This was significantly associated with level of education and receiving health education. More than half of the patients expressed fear of being known as TB patients in the community.

CONCLUSIONS

Knowledge about TB and its treatment was generally high. Marginalised groups with limited access to media and low education levels may benefit from specially targeted educational interventions. To reduce stigma and the impact of social consequences of TB, an ongoing health education programme designed to increase the knowledge level in the whole population appears warranted.

An economic analysis of persons with prolonged cough in rural northern Vietnam

SETTING

Epidemiological surveillance in the Bavi district, northern Vietnam.

OBJECTIVE

To compare the prevalences of prolonged cough across socio-economic groups defined by income, expenditure and official classification. To investigate inequalities using the Illness Concentration Index.

DESIGN

Interviews in 11,547 randomly selected households with 35,832 persons aged 15 years or more. Prolonged cough was identified in 559 persons (1.5%).

RESULTS

Differences between cough prevalences were found for all socio-economic indicators, but were less clear for expenditure. Lower economic groups reported higher prevalences than higher groups, and prevalences were higher among the elderly. Male was similar to female prevalence. The illness gap between the poor and rich was wider for men. The Illness Concentration Index confirmed these findings.

CONCLUSION

Inequalities were found when using both different socio-economic indicators and different analysis approaches.

Do women with tuberculosis have a lower likelihood of getting diagnosed?

OBJECTIVE

The aim was to estimate the gender-specific prevalence of tuberculosis (TB) through screening. A further aim was to calculate case detection within the Vietnamese National TB program.

STUDY DESIGN AND SETTING

A population-based survey of 35,832 adults was performed within an existing sociodemographic longitudinal study in Bavi district, northern Vietnam. Cases were identified by a screening question about prolonged cough and further diagnosed with sputum examination and a chest X-ray.

RESULTS

The estimated prevalence of pulmonary TB among men was 90/100,000 (95% CI 45-135/100,000) and among women 110/100,000 (95% CI 63-157/100,000). Case detection in the district was estimated to 39% (95% CI 20-76%) among men and 12% (95% CI 6-26%) among women.

CONCLUSION

TB prevalence was similar among men and women. Case detection among men and women was significantly lower than the reported national case detection of 80%, and there was a significant underdetection of female cases. These findings warrant actions, and emphasize the need to perform similar studies in different contexts.

Private tuberculosis care provision associated with poor treatment outcome: comparative study of a semi-private lung clinic and the NTP in two urban districts in Ho Chi Minh City, Vietnam. National Tuberculosis Programme

SETTING

Ho Chi Minh City, Vietnam.

OBJECTIVE

To compare tuberculosis case management and treatment outcome between a semi-private chest clinic and a publicly run national tuberculosis programme (NTP).

METHOD

Prospective, non-randomised, comparative cohort study. Case-management and treatment outcome was determined for 176 patients treated in the semi-private clinic and 326 patients treated in the NTP.

RESULTS

In the semi-private clinic cohort, significantly fewer patients completed treatment and/or were cured than in the NTP cohort (48.9% vs. 85.0%, P < 0.001). Among patients with sputum-positive pulmonary TB, significantly fewer were cured in the semi-private clinic cohort compared to the NTP cohort (22.2% vs. 79.2%, P < 0.001), and treatment success was significantly lower (35.2% vs. 79.7%. P < 0.001). Adjustment for a number of potential confounders did not change these findings significantly.

CONCLUSIONS

Treatment outcome was considerably better in the NTP than in the semi-private clinic. The difference is not likely to be due to differences in patient characteristics or in provider knowledge. Different financial incentives for the providers in the two settings and ways of paying for services by patients are possible reasons for the observed difference in the quality of case management and treatment outcome.

Primary health concept revisited: where do people seek health care in a rural area of Vietnam?

The government of Vietnam is committed to promote and secure equity in access to health care for all citizens. The current rapid changes towards a market economy may challenge the government's wish for maintaining equity, especially for low income and vulnerable groups. The aim of this study was to investigate aspects of access and utilisation of health care of rural people. The study included a random sample of 1075 out of the 11,547 households in the Field Laboratory in Bavi district, northern Vietnam and a structured questionnaire was used. The results indicate that self-treatment is common practice and private providers are an important source of health services not only for those who are better off but also for poor households. The costs for health care are substantial for households, and lower income groups spent a significantly higher proportion of their income on health care than the rich did. The poor are deterred from seeking health care more often than the rich and for financial reason. As regards sources for payments, the poor relied much more on borrowing money to pay for their health care needs, while those who are better off relied mostly on household savings. A burden of high cost for treatment implies high risks for families to fall into a 'medical poverty trap'. Our findings suggest a need for developing risk-sharing schemes (co-payment, pre-payment and insurance), and appropriate allocation of scarce public resources. We suggest that the private health care sector needs both support and regulations to improve the quality and access to health care by the poor.

Fear and social isolation as consequences of tuberculosis in VietNam: a gender analysis

SETTING

The study was conducted in four districts in different regions of Vietnam.

OBJECTIVE

To describe the socio-economic consequences of tuberculosis (TB) in Vietnam with special reference to gender differentials concerning social stigma and isolation.

DESIGN

Sixteen focus group discussions were carried out with men and women, TB patients and non-TB participants. Data was analysed using modified grounded theory technique.

RESULTS

Generally, the participants had good knowledge about TB. However, knowledge and practice were not closely related in the sense that most non-TB participants perceived that TB can be successfully cured, while patients were seriously shocked when they were told that they had TB. Male patients often worried about economic-related problems, while female patients worried about social consequences of the disease. Both in the family and the community, isolation could be subtle, but it could also be obvious and had a tendency to continue much longer than medically justified.

CONCLUSION

Information on stigma and isolation due to TB and gender differences is important for understanding patient dynamics and its effects on the disease. Tuberculosis control programmes need better understanding of the gender differences in attitudes and beliefs to improve case-detection and treatment outcome.

Gender inequalities in tuberculosis: aspects of infection, notification rates, and compliance

Tuberculosis (TB) kills approximately 1 million women per year and it is estimated that almost 1 billion women and girls are infected with TB worldwide. Gender aspects of TB have been neglected in the research, and little attention is given to gender in TB-control programs. This review brings together the most important publications on gender and TB during 1999 and 2000 and illuminates areas where gender has an impact on the disease and its control. Even though only a limited number of publications on gender aspects of TB are available, some interesting findings were presented during the past year. Studies from Vietnam have shown that women with pulmonary TB are diagnosed on average 2 weeks later than men because of delays from the health care provider. In a study of persons with cough it was found that men were given sputum examinations more often than women. These and other findings are discussed in relation to the hypothesis that women with TB are under-notified.

Utilization of private and public health-care providers for tuberculosis symptoms in Ho Chi Minh City, Vietnam

In Vietnam, as in many other countries, tuberculosis (TB) control has long been organized exclusively within the public health-care system. However, recently the private health-care sector has become more important and private health-care providers currently have a role in TB care delivery in Vietnam. Through a retrospective survey of patients at District Tuberculosis Units (DTUs) of the National Tuberculosis Programme in Ho Chi Minh City, we investigated utilization of private and public health-care providers among people with symptoms of TB. Eight hundred and one patients in eight DTUs were interviewed. For the current illness episode, about half of the patients had initially opted for a private health-care provider. Twenty-seven percent had been to a private physician and 31% to a private pharmacy at some time during their current illness. We found no significant association between socioeconomic status and use of private health-care providers. Utilization of private health-care providers among people with TB or symptoms of TB in Ho Chi Minh City seems to be similar to the general utilization of private providers in Vietnam, at least before TB is diagnosed. Since a large proportion of people with TB in Ho Chi Minh City across all economic and social strata consult private providers at some time during their illness, planners of TB control strategies need to consider both the health-care seeking behaviour of people with TB and the clinical behaviour of private providers, in order to secure early detection of TB, early initiation of appropriate treatment, and maintenance of appropriate treatment.

Private pharmacies and tuberculosis control: a survey of case detection skills and reported anti-tuberculosis drug dispensing in private pharmacies in Ho Chi Minh City, Vietnam

SETTING

Ho Chi Minh City (HCMC), Vietnam.

OBJECTIVES

To assess knowledge about tuberculosis, to describe self-reported dispensing practices and to estimate the magnitude of anti-tuberculosis drug dispensing in private pharmacies.

DESIGN

Survey of a random sample of 147 private pharmacies out of a total of 1814 registered pharmacies. Interviews were carried out based on a structured questionnaire.

RESULTS

Eighteen per cent of interviewees identified TB as a possible diagnosis for a fictitious case with fever and cough for 4 weeks. Fifty-eight per cent reported selling anti-tuberculosis drugs often or sometimes. Interviewees estimated that 1.3 persons on average (95%CI 0.6-1.9) had bought anti-tuberculosis drugs during the last 4-week period, and that 24% of them had bought anti-tuberculosis drugs without a prescription.

CONCLUSION

We have estimated that between 1100 and 3400 persons buy anti-tuberculosis drugs each month in the 1814 registered private pharmacies in HCMC, that about a quarter of them do so without a prescription, and that at least 40% of all anti-tuberculosis drug dispensing in HCMC occurs in the private sector. Regulations need to be put in place urgently and collaboration strengthened between the strong National Tuberculosis Programme and the unorganised private sector in HCMC.

Combining feedback from simulated cases and prescribing. Design and implementation of an educational intervention in primary care in Sweden

OBJECTIVES

To develop and evaluate a new model of continuing medical education (CME) for general practitioners (GPs). The study is part of the joint European Drug Education Project (DEP). This paper presents the Swedish part regarding the design of the evaluation study, the educational methodology, and the participants' evaluation.

METHODS

An educational model was developed. Two peer group discussions (facilitated by a GP/pharmacist team), including individual feedback on the GPs' judgments of written simulated cases and prescribing, were main components. The model was tested in a parallel randomized controlled study including 36 GP groups, allocated to education on asthma or urinary tract infections. Background and outcome data were knowledge and attitudes (K/A) assessed by a questionnaire and prescribing practices for actual and written simulated cases. The GPs' evaluation of the model was captured through a questionnaire.

RESULTS

All 36 groups completed the program. The mean participation rate in the group discussions was 75%. The response rates were 82-98% regarding outcome data K/A questionnaire and written cases), and 80% regarding the evaluation questionnaire. Prescribing data were captured for 99% of the GPs. Both group discussions were considered important by 84-89%. Eighty-seven percent wished to take part in similar CME activities for other conditions. About 80% reported that their purpose in participating had been fulfilled.

CONCLUSIONS

It was feasible to evaluate the developed educational model by using a two-armed parallel study design. The model was well received by the participants.

Gender and tuberculosis control: perspectives on health seeking behaviour among men and women in Vietnam

This study explores the perspectives of tuberculosis patients on which factors influenced their health seeking behaviour, with special reference to gender differentials in terms of delays in health seeking. In 1996, a multi-disciplinary research team carried out 16 focus group discussions. The study was done in four districts in Vietnam, both in the south and north of the country and in urban and rural areas. Qualitative analysis of data was performed following general principles of modified grounded theory technique. Participants in the focus groups described three main factors as contributing to delay in health seeking. These were fear of social isolation, economic constraints and inadequate staff attitudes and poor quality of health services. A model illustrating different factors influencing health seeking was elaborated and served as a basis for discussion of the findings. The main factor contributing to delay among women was described as fear of social isolation from the family or the community. Stigma was described as closely related to contextual factors such as gender-roles, socio-economic status and level of education and seemed to be mediated via denial and concealment of tuberculosis diagnosis and disease, thus causing delay. The main factor contributing to delay among men was described as fear of individual costs of diagnosis and treatment. Staff attitudes and quality of health service facilities were described as not always corresponding to people's expectations of appropriate health services. Women saw themselves and were seen by others as being more sensitive than men to poor service conditions and staff attitudes. A typical feature of the described health seeking behaviour of men was that they neglected symptoms until the disease reached a serious stage, by which time they tended to go directly to public health services without first visiting private health practitioners. Women, on the other hand, were described as having a tendency to seek out private services and practice self-medication before seeking care at public services. In conclusion, there is a need for better understanding of behavioural factors and for developing strategies, that take these into account. Health workers need to better understand gender and social aspects of tuberculosis control, particularly aspects that influence the likelihood for achieving equity in diagnosis and cure.

Delay and discontinuity--a survey of TB patients' search of a diagnosis in a diversified health care system

SETTING

Ho Chi Minh City (HCMC), Vietnam.

OBJECTIVES

To describe delay to diagnosis; to compare diagnostic procedures and referral routines used by private and public health care providers; and to examine associations between contact with various types of providers and risk of delay to TB diagnosis.

DESIGN

Cross-sectional survey of new patients in the National Tuberculosis Programme (NTP). Retrospective assessment of health seeking and diagnostic procedures used by previously contacted health care providers.

RESULTS

Four weeks after first symptom, 81% of patients had sought help outside the household. Four weeks after first health care contact, 47% had been diagnosed with TB. Private physicians used X-rays, sputum smears, and referrals significantly less often than public health care providers. Patients who had turned first to a private pharmacy, a private physician or a public hospital were significantly more likely to have a long provider delay than those who turned first to the NTP.

CONCLUSION

Delay to diagnosis of TB in HCMC is due more to inability among health care providers to detect TB than to under-utilisation of health care services. Diagnostic procedures need to be improved and referral chains need to be strengthened in HCMC, particularly among private providers.

Attitudes to compliance with tuberculosis treatment among women and men in Vietnam

SETTING

A study carried out in 1996 in four districts representing south and north as well as urban and rural areas of Vietnam.

OBJECTIVE

To explore gender differences in knowledge, beliefs and attitudes towards tuberculosis and its treatment, and how these factors influence patients' compliance with treatment.

DESIGN

Sixteen focus group discussions were performed by a multi-disciplinary research team from Vietnam and Sweden. Analysis was performed using modified Grounded Theory technique, specifically evaluating gender differences.

RESULTS

Women were believed to be more compliant than men. Insufficient knowledge and individual cost during treatment were reported as main obstacles to compliance among men (poor patient compliance), while sensitivity to interaction with health staff and stigma in society (poor health staff and system compliance) were reported as the main obstacles among women.

CONCLUSIONS

It is time to adopt a more comprehensive and gender-sensitive approach to compliance, which incorporates patient compliance, doctor compliance and system compliance, in order to fully support individual patients in their efforts to comply with treatment.

Different tuberculosis in men and women: beliefs from focus groups in Vietnam

After decades in decline, tuberculosis (TB) has been increasing worldwide. In 1993, the World Health Organisation declared TB a global emergency. Passive case-finding is an important part of TB control programmes, and this is strongly affected by people's perceptions and beliefs of TB and society's behaviour towards TB sufferers. The aim of this study was to describe the perceptions and beliefs of Vietnamese people regarding TB and its risk factors with special reference to differences between men and women. Sixteen focus group discussions (FGDs) were organised in four districts representing different regions in Vietnam and consisting of men and women, TB patients and non-TB participants. In general, participants had good knowledge of TB being a dangerous, contagious and infectious disease, caused by germs. However, traditional beliefs in different types of TB still exist, mainly among older people in rural areas, but also resorted to by other people once ill. Four main types of TB were reported: (1) 'Lao truyen' (hereditary TB), handed down from older generations to latter ones through 'family blood', regardless of sexes; (2) 'Lao luc' (physical TB), caused by hard work, more men affected; (3) 'Lao tam' (mental TB), caused by too much worrying-more women affected; and (4) 'Lao phoi' (lung TB), dangerous and caused by TB germs, transmitted through the respiratory system-more men affected. Other general risk factors were also mentioned. Men were perceived to get TB more often than women, as they were more exposed to risk factors during both work and leisure time. These traditional beliefs may contribute to long delays to TB diagnosis and increased social stigma and isolation of TB patients and their families due to erroneous beliefs in transmission routes. Our findings demonstrate areas where TB control programmes may be improved.

Influencing prescribing for urinary tract infection and asthma in primary care in Sweden: a randomized controlled trial of an interactive educational intervention

Our aim was to evaluate effects on prescribing for urinary tract infection (UTI) and asthma, of an education with messages based on national guidelines, aimed at improving prescribing in primary care in Sweden. The study is part of the European Drug Education Project. A randomized controlled trial, with groups of general practitioners (GPs) allocated to education on UTI (18 groups, 104 GPs) or asthma (18 groups, 100 GPs), the two parallel intervention arms being controls for each other. Feedback was provided on the GP's judgments of simulated cases and prescribing. Prescribing indicators were developed and measured before and after the intervention. Analysis was performed by multi-level technique. Prescribing of first choice UTI drugs increased in the intervention arm from 52% to 70% and remained constant in the control arm (P < 0.001). The proportion of patients receiving an inhaled corticosteroid increased insignificantly in both study arms. The educational model can be used to improve prescribing. Further studies are needed to define when the model is effective.

Longer delays in tuberculosis diagnosis among women in Vietnam

SETTING

Study conducted in 23 randomly selected districts in four provinces of Vietnam.

OBJECTIVE

To describe and compare health seeking behaviour between men and women and to measure delays in tuberculosis (TB) diagnosis.

DESIGN

All patients (n = 1027) aged 15-49 years with new smear-positive pulmonary TB detected in the selected districts during 1996 were interviewed using a structured questionnaire.

RESULTS

Mean total delay to TB diagnosis was 13.3 weeks (95% confidence interval [CI] 11.5, 15.1) for women and 11.4 weeks (95% CI 10.6, 12.2) for men, including a patient's delay of 7.9 weeks (95% CI 6.5, 9.3) and 7.6 weeks (95% CI 6.9, 8.3) respectively. Doctor's delay was significantly longer among women (5.4 weeks, 95% CI 4.2, 6.6) than among men (3.8 weeks, 95% CI 3.3, 4.3). Women did not start seeking care later than men, nor did they have a different health seeking pattern. Women visited more health care providers than men (1.7 and 1.5 providers, respectively, P = 0.02).

CONCLUSION

Patient's delay is unacceptably long for both men and women. Women do not receive a diagnosis of TB by doctors or other health care providers as quickly as men once they seek health care. The reasons for this gender difference warrant further investigations.

Maternal and infant health problems after normal childbirth: a randomised controlled study in Zambia

STUDY OBJECTIVES

The main aim of the study was to discover if a midwife home visiting programme has a significant effect on the prevalence of health problems and breast feeding behaviour of mothers who delivered normally and their healthy fullterm newborn babies, during a period of 42 days after delivery. Another aim was to compare the mothers', the midwife's, and the doctor's findings of prevalence of health problems at the end of the puerperium period.

DESIGN

A randomised controlled trial was carried out. One group of mothers and their infants were randomly allocated to a home visiting group (Group A); the other group (Group B) was only visited at day 42.

SETTING

The study was carried out at the University Teaching Hospital (UTH) in Lusaka, the capital city of Zambia.

PARTICIPANTS

A total of 408 mothers who had a normal delivery and gave birth to a healthy fullterm infant, as assessed by the attending midwife, were randomised to two groups. Group A consisted of 208 mother/infant dyads who were visited by a midwife in their homes at days 3, 7, 28, and 42 after delivery and Group B consisted of 200 mother/infant dyads who were only visited at day 42.

MAIN RESULTS

At day 42 an equal proportion (30%) of mothers in both groups perceived that they had health problems. The prevalence of infant health problems in Group B was significantly higher (p < 0.01) as perceived by mothers. There were more mothers in Group B (p < 0.01) perceiving insufficient milk production and giving supplementary feeding. At day 42, mothers in Group A (56%) took more actions than mothers in Group B (41%) to solve infant health problems (p < 0.03). In both groups the mothers' perceived own health problems, were significantly higher (p < 0.01) than those observed by the obstetrician and those observed by the midwife. The midwife found more infant health problems in Group B (p < 0.01) than in Group A and more infants with health problems in both groups compared with the paediatrician's findings (p < 0.01).

CONCLUSIONS

There was a significant difference between the mothers' reported health problems and the health problems identified by the midwife and the doctors. The study shows that a midwife home visit and individual health education to mothers, reduce the prevalence of infant health problems, and enables the mother to more often take action when an infant health problem is identified. There is a need to re-evaluate the midwifery training curriculums with the intention to include more infant management care.

Routine care of women experiencing normal deliveries in Zambian maternity wards: a pilot study

OBJECTIVE

To describe the routine care of women during normal labour and delivery, and the immediate care of newborn babies in Zambia at different levels of health care.

DESIGN

A descriptive survey carried out between July 1994 and January 1995.

SETTING

Eleven maternity facilities, one University teaching hospital, two urban health centres and eight rural hospitals in one province in Zambia.

PARTICIPANTS

Eighty-four women in normal childbirth and their babies studied from admission to the labour ward until time of discharge from the labour ward.

MEASUREMENTS AND FINDINGS

Observations related to the care of the women during normal labour and delivery, and the immediate care of the baby. The findings show that women were confined to bed during the whole labour and delivery period, food and drinks were withheld, and no gowns were provided. None of the women were allowed to have a companion present during labour. Fetal monitoring was inconsistent and the partograph was either not used or partly lacking. All women were delivered in a lithotomy position and primiparae were fixed in stirrups during the second and third stages of labour. There was general lack of support for early mother/baby contact, prevention of hypothermia in the babies and early initiation of breast feeding.

IMPLICATIONS FOR PRACTICE

Based on our findings we suggest that many present maternity ward routines, both physiological and psychological, should be carefully studied. It is also suggested that the midwives reorient their caring practices to more culturally and evidenced-based maternity care. Refresher courses for midwives who have been working for many years are recommended.

Practice-knowledge-attitudes-practice: an explorative study of information in primary care

Contemporary information programmes for health staff fail to give thorough consideration to the influence of situational factors on information transfer within health institutions. To study information transfer in Swedish primary care health centres, we have therefore used the participant observation method, to explore the influences of practice on knowledge and attitude formation, in turn giving rise to new practice. Management of hyperlipidaemia was used as an example. Our study suggests that the practice generates new information, which is added to or counteracts the acquisition and use of already existing information and is subsequently used in practice. Ongoing discussions between staff members give an opportunity to share practice experiences. Profession, professional hierarchy and gender are some of the factors influencing the use of information in this context. To improve the effectiveness of information programmes these factors and the professional roles of the health staff should be taken into consideration.

Chloroquine blood concentrations and malaria prophylaxis in Tanzanian women during the second and third trimesters of pregnancy

OBJECTIVE

Routine malaria prophylaxis with chloroquine (CQ) is recommended to pregnant semi-immune women in several countries in Africa. The dosage is empirically based. We investigated whether blood CQ concentrations and apparent oral blood clearance (CL/F) change during the course of pregnancy. We also studied whether malaria parasites could be detected together with low CQ blood levels.

METHODS

Forty nine semi-immune Tanzanian women were recruited in the 16th week of pregnancy. They were given 310 mg oral CQ base once per week as prophylaxis during the whole pregnancy. Capillary blood samples were taken for analysis of CQ before treatment and at weeks 26 and 36. Blood samples were dried on filter paper and analysed by HPLC. Blood was also drawn to detect occurrence of malaria parasites.

RESULTS

A total of 25 women fulfilled the sampling schedule. CL/F increased significantly from 160 ml.min-1 at week 26 to 180 ml.min-1 at week 36. In 7 of 25 women, CL/F increased > 20%. Trough blood CQ concentrations, determined on four occasions at week 26 and at week 36 varied between 200 and 900 nmol.l-1. No statistically significant differences between occasions were seen. Malaria parasites were seen in two individuals early in pregnancy.

CONCLUSION

Blood CQ CL/F showed a small increase during the course of pregnancy. The estimated mean blood CL/F values of 160 and 180 ml.min-1 (week 26 and 36, respectively) were higher than the mean CL/F of 125 ml.min-1 in non-pregnant individuals, published previously. Efficacy of higher dosages of CQ in malaria prophylaxis in pregnant women could, therefore, be evaluated in controlled trials in high-risk malaria areas.

Staff and patient attitudes to tuberculosis and compliance with treatment: an exploratory study in a district in Vietnam

SETTING

The study, a collaboration between the National Tuberculosis Institute, Hanoi, Vietnam and the Karolinska Institutet, Stockholm, Sweden, was carried out in a district of Quang Ninh Province in North Vietnam.

OBJECTIVES

To describe tuberculosis (TB) services, attitudes of staff, and attitudes of patients considered as defaulters to TB treatment.

DESIGN

Two focus group discussions were carried out with staff at the district hospital. Ten defaulter patients were interviewed in their homes.

RESULTS AND CONCLUSIONS

This exploratory study has revealed some important aspects of staff and patients' attitudes to TB and its treatment. Tuberculosis is considered a 'dirty' disease, which mainly affects poor people. There is a tendency to avoid telling others about it. Obvious symptoms are explained as 'being overworked'. A patient with TB feels 'less respected' by others. The social stigmatization leads to delays in seeking medical care, often only after self-medication: anti-tuberculosis drugs can be bought without prescription in various pharmacies. The patient's economic situation is also an important determinant of compliance and non-compliance. These factors need to be taken into consideration in TB control in Vietnam.

Improving drug use through continuing education: a randomized controlled trial in Zambia

The objective of this study was to evaluate the impact of three continuing education seminars (within a period of 4 months) on the quality of patient management and rational drug use. The study was designed as a randomized controlled trial. Prescribers in 16 general health centers were allocated to an intervention (eight health centers) or a control (eight health centers) group. A total of 5,685 patient cards was analyzed for quality of case management and rational drug use. In the intervention health centers the average number of drugs per patient decreased from 2.3 to 1.9 (p = 0.005) and the proportion of patients managed with nonpharmacological treatment increased from 1 to 13.2%. Recorded history taking, examination, and diagnosis improved in the intervention health centers. More drugs were correctly chosen in the intervention health centers compared to control health centers (p = 0.03). The proportion of patients prescribed antibiotics decreased and the proportion of patients adequately managed increased in the intervention health centers. Our conclusion is that continuing education in the form of repeated seminars is effective in influencing prescribers and in promoting rational drug use in primary care.

Effects of "group detailing" on the prescribing of lipid-lowering drugs: a randomized controlled trial in Swedish primary care

The objective was to study the effect of "academic group detailing" on the prescribing of lipid-lowering drugs in Swedish primary care. A randomized controlled trial was conducted, randomization being by group. Groups of doctors at 134 community health centres were randomly allocated to an intervention and a control group. The 67 intervention health centres were offered four sessions, conducted by a pharmacist, with group information on guidelines for the management of hyperlipidaemia. The number of prescriptions of lipid-lowering drugs per month increased in the intervention health centres and the increase was statistically different from the corresponding change in the control health centres among women in the age group 30-65 years (p = 0.03). The prescription of first-line lipid-lowering drugs increased by 20% in the intervention health centres (p = 0.03). "Academic group detailing" by pharmacists to primary care doctors can be an effective method for influencing prescribing practices.

Respiratory infection with Chlamydia pneumoniae in middle-aged and older adult outpatients

This study was undertaken to characterize the epidemiology and clinical presentation of infection with Chlamydia pneumoniae in a population composed primarily of middle-aged and older adults. Pharyngeal swabs and acute and convalescent phase sera were obtained from outpatients presenting with signs and symptoms of an acute respiratory infection. Sera were examined using the micro-immunofluorescence (MIF) test to detect antibody to Chlamydia pneumoniae and complement fixation tests to detect Mycoplasma pneumoniae, influenza A virus, influenza B virus, respiratory syncytial virus and adenovirus. Pharyngeal swab specimens were cultured for Chlamydia pneumoniae and tested for Chlamydia pneumoniae by the polymerase chain reaction (PCR). A total of 743 patients with a mean age of 40.5 +/- 16.1 years were enrolled in the study. Twenty-one patients were serologically positive for acute Chlamydia pneumoniae infection in the MIF test. PCR was positive in 15 of the 20 serologically positive patients tested. Acute Chlamydia pneumoniae infection was identified in 3% (2/76) of subjects with pneumonia, 5% (12/247) of those with bronchitis, 5% (3/61) of those with sinusitis only and 2% (2/103) of those with pharyngitis only. Of the 21 patients with Chlamydia pneumoniae infection, seven (mean age of 33 years) had an antibody pattern suggesting a primary infection while 14 (mean age of 54 years) had a reinfection pattern. Patients with reinfection had milder disease than those with primary infection. PCR testing in the current study confirms the previously proposed serologic criteria of acute Chlamydia pneumoniae infection.

Protective effect of BCG against tuberculous meningitis and miliary tuberculosis: a meta-analysis

The protective effect of BCG against tuberculosis (TB) estimated in randomized controlled trials and observational studies ranges from negative to close to a 100%. One of the many explanations offered for this is that different immunological mechanisms may be associated with protective effect against different forms and sites of disease. In this investigation, we recalculated vaccine protective effect separately for pulmonary disease and for meningeal/miliary disease in randomized controlled trials and case-control studies, tested for heterogeneity in site-specific estimates of protective effect and calculated a summary measure when appropriate. We found protective effect against pulmonary disease to be heterogeneous to a statistically significant degree, and thus we did not calculate a summary measure of protection. Protective effect against meningeal and miliary TB was higher than against pulmonary disease and, except for a single study with two cases only, appeared to be homogenous. Summary BCG protective effect against miliary or meningeal TB in randomized controlled trials was 86% (95% confidence interval [CI] 65, 95) and in case-control studies 75% (95% CI: 61, 84). The fact that protective effect appeared to be homogeneous against meningitis and miliary TB but not against pulmonary disease may result from the fact that patients with meningitis are on average younger and thus less likely to have been exposed to atypical bacteria; to a waning of the protective effect of BCG; or from the diversity of mechanisms of pathogenesis of pulmonary disease, which can originate from reinfection, reactivation or primary progression.

HIV, BCG and TB in children: a case control study in Lusaka, Zambia

Even before the onset of the HIV epidemic, studies reported large variations in the protective effect of BCG against TB. The current HIV/AIDS epidemic has increased the incidence of tuberculosis in many countries in sub-Saharan Africa. Thus, local estimates of the effectiveness of BCG are needed which take prevalence of HIV into account for planning strategies for vaccination and TB control programmes. A case control study was conducted in Lusaka, Zambia. The study included 116 TB cases and 154 hospital controls. Eighty-eight per cent of controls had BCG scars compared to 77 per cent of the cases. BCG was not associated with TB in HIV positive children (OR 1.0, 95 per cent CI 0.2, 4.6). However, there was 59 per cent protective effect (OR 0.41, 95 per cent CI 0.18, 0.92) in HIV negative children. The results also suggest an eight times higher risk of TB in HIV positive children.

On the variation in conceptions among primary care physicians regarding hypercholesterolaemia: a phenomenographic analysis

Twenty primary care physicians at 12 health centres in Sweden were interviewed in a semi-structured way. Analysis was conducted using a phenomenographic method. Concerning the general attitude towards cardiovascular disease (CVD), there were two categories of answers; (A) CVD is a big threat to public health, and the health care system should play an active role in treatment and prevention, and (B) CVD is a symptom of normal aging with little or no need for active health care intervention. Questions on the management of hypercholesterolaemia showed a general acceptance of diet and lifestyle alterations, with a marked reluctance to use drugs except in cases of hereditary hypercholesterolaemia. The physicians were positive to non-commercial information from official sources. Critical opinions existed, however, questioning the adequacy and applicability of the national expert recommendations. There was a general acknowledgement of the importance of patient information, whereas a lack in communication skills was expressed. The description of attitudes and conceptions can assist in the understanding of mechanism underlying physicians' behaviour and provide a base for future information programmes.

Randomization by group in studying the effect of drug information in primary care

Drug information is a technology which is rarely evaluated. Practical and ethical considerations limit the use of a classical experimental method (a randomized controlled trial) in studying the effect of drug information in primary care. An alternative approach, randomization by group, is preferable for several reasons: it avoids contamination of the control group; the effect of information can be evaluated in the natural working environment; and the impact of information is increased via diffusion. This article describes the selection of a control group, the Hawthorne effect and 'blindness' in information experiments. Sample size tables and power calculations are presented when randomization by group is used. The study power is influenced by the number of health centres and the variance between them. The number of doctors per health centre plays a less important role, and the number of patients is relatively unimportant. There is also a need to use qualitative methods to prepare information and to understand factors influencing change of behaviour among prescribers.

Experimental evaluation of the effects of drug information on antibiotic prescribing: a study in outpatient care in an area of Sri lanka

The intervention level of epidemiology is useful for studying effects in health systems research. Due to practical and ethical reasons, it is often difficult to apply experimental methods such as classical randomized clinical trials in the field. However with alternative approaches such as 'randomization by group' some of these problems can be overcome. Drug information has since long been considered as an instrument to influence physicians, however evaluation of its effects is a new field of research. In the present study the impact of drug information on prescribing behaviour was evaluated in an outpatient setting in Sri Lanka. The study included 15 state health institutions (45 prescribers) with a common drug formulary. Groups of prescribers were randomized into two interventions; newsletters and newsletters reinforced by a group seminar, and one control group. The target topic was 'rational prescribing of antibiotics'. Some 18,766 randomly selected outpatient drug prescriptions were studied. Antibiotics (and sulphonamides) were prescribed to 33.2% of the patients. An overall trend towards a decrease in proportion of patients prescribed antibiotics in the two intervention groups was seen, although the difference was not significant (p greater than 0.05) compared to the control group. This is similar to the effect of written information on prescribing in other studies. A mean difference of -7.4% in written, -7.3% in written + seminar and -0.4% in the control group was shown. The general antibiotic prescribing pattern did not change in any of the three groups. Penicillin was the most commonly prescribed antibiotic and tetracycline was only rarely prescribed to children. This experiment indicates the feasibility of drug information intervention studies in developing countries.(ABSTRACT TRUNCATED AT 250 WORDS)

Operational evaluation of the efficacy of vaccines by the case control method

To maintain high efficacy and cost-effectiveness of health interventions, such as immunization programs and health information, systematic and careful evaluation is necessary. This is particularly relevant when health resources are scarce, as in most developing countries. Whereas vaccines used in immunization programs are generally evaluated for efficacy and safety prior to their application in routine health service, very little attention is paid to continuous or operational evaluation. Because of practical reasons (cost, time, feasibility, etc.) or ethical reasons (randomization), the most reliable method for evaluation, the classical RCT, cannot be applied for the operational evaluation of vaccine efficacy, and alternative methods such as the case control method are needed. This method is relatively cheap, quicker, poses fewer ethical problems, and can also provide continuous evaluation.

Drug use and the role of patients and prescribers

In order to move towards rational drug use in any national or local setting the methods of inquiry have to be expanded. Both the public and private sector have to be addressed. In the latter the pharmacists might be studied using a tracer, fictitious client. One important factor influencing prescribing, drug information, has rarely been assessed scientifically. Experimental studies using group randomization are, however feasible even in developing countries. The individual human being must be in the focus of drug studies and health care and health in the foreground. The combination of qualitative and quantitative methods will assist us to achieve rational drug use that is culturally acceptable, economically feasible and pharmacologically sound.

Maternity care routines in a teaching hospital in Zambia

At the University Teaching Hospital, Lusaka, Zambia, 59 uncomplicated, vaginally delivered mothers, were studied with regard to maternity care during the antenatal period and delivery. Information was collected from antenatal cards, labour records, observations during delivery and interviews with mothers. The average of more than five antenatal visits indicates that there was a sufficient demand for health care. The results suggest low application of the recommended maternity care routines, positive correlation between application of the maternity care and the mother's educational level and low staff encouragement of self-care among mothers. These findings suggest a need for systematic critical review and, if necessary, modification of current maternal care technologies and improved general and health education of women.

Maternal smoking in relation to the incidence of early neonatal jaundice

A case-control study was carried out to investigate the association between maternal smoking during pregnancy and the risk of early neonatal jaundice. A total of 1,569 cases of neonatal jaundice (2.7% of all singleton births) were identified from the 1984 Washington State birth certificates as having a bilirubin level greater than 10 mg/dl within the first 2 days of life. 2,336 nonjaundiced infants were randomly selected to serve as controls. Information regarding smoking during pregnancy was also obtained from the birth certificates. After excluding infants with known risk factors for neonatal jaundice, 912 cases and 1,752 controls were available for analyses. Infants whose mother smoked cigarettes during pregnancy were at lower risk of neonatal jaundice (odds ratio = 0.81; 95% confidence interval = 0.66-0.99) relative to infants of nonsmokers. This relative risk changed very little after adjusting separately for maternal age, infant's gender, number of prior pregnancies, number of prenatal visits, marital status and number of prior fetal deaths. There was suggestive evidence that this apparent protective effect may be operating only among normal and high-birth-weight infants.

Community- and hospital-acquired pneumonia associated with Chlamydia TWAR infection demonstrated serologically

Serum specimens from 198 patients with pneumonia hospitalized in Seattle between October 1980 and April 1981 were retrospectively tested for antibody against a recently described Chlamydia organism called TWAR. They had been previously tested for antibody for some viruses and Mycoplasma. Twenty (10%) had serologic evidence of recent TWAR infection. The hospital records of the patients with acute TWAR antibody and an equal number of matched controls were examined for clinical characteristics, laboratory tests, treatment, and course during the hospital stay. It was not possible clinically or roentgenographically to distinguish pneumonia associated with TWAR antibody from pneumonia in the controls. Nine of 20 patients with TWAR antibody acquired pneumonia during their hospital stay. The mode of transmission in the hospital was not determined. All the patients with hospital-acquired pneumonia had been intubated, and all had had some surgical procedure. Ten of 20 control patients had onset of their pneumonia in the hospital. Fifteen (11%) of 142 of the patients with pneumonia had evidence of influenza A virus infection. The clinical characteristics of their pneumonias were similar to those of the patients with acute TWAR antibody.