Presence of tuberculosis symptoms among HIV-positive men who have sex with men (MSM) in Zimbabwe

We conducted secondary data analysis using a biobehavioral survey dataset of 1538 MSM from Zimbabwe. Survey participants were screened for the four symptoms suggestive of tuberculosis infection using the WHO TB screening algorithm. Results: All participants experienced at least one symptom suggestive of tuberculosis. 40% of HIV-positive MSM reported having had a cough in the last month and 13% of them experienced unexpected weight loss. The prevalence of experiencing any of the four TB symptoms amongst HIV-positive MSM was 23%. Contribution There is an urgent need for active TB case finding and treatment amongst HIV-positive MSM in Zimbabwe. Clinicians will need to ensure that MSM who need TB testing receive it timeously.

Missed opportunities in the prevention and diagnosis of pediatric tuberculosis: a scoping review

OBJECTIVES

Identify potential barriers, delays, and missed opportunities in the prevention and diagnosis of childhood TB.

METHODS

Scoping review according to the PRISMA extension. The definitions considered for the selection followed the acronym PCC where the population (P) is children under 18 years of age with TB disease, the concept (C) refers to missed opportunities for prevention and diagnosis, and context (C) is defined as a diagnosis of TB disease. The authors searched systematically in the databases; VHL/Lilacs, Medline via PubMed, Cochrane, Scopus, and Web of Science, without date or language limitation.

RESULTS

Seven studies were included. In developed countries, with low disease burden, the main shortcoming is the delay in diagnosing bacilliferous adults in contact with young children. This problem is concentrated in the portion of the population with socioeconomic vulnerability. In underdeveloped countries, with a high burden of disease, the biggest challenge is tracking children who come into contact with bacilliferous patients.

CONCLUSIONS

There are still many missed opportunities in the prevention and diagnosis of childhood TB. The positive legacy of the COVID-19 pandemic should be taken advantage of and the encouragement of scientific development in the management of infectious diseases should be taken.

Using Electronic Health Record System to Establish a National Patient's Registry : Lessons learned from the Cancer Registry in Iran

BACKGROUND

In Iran, the Integrated Electronic Health Record system, called SEPAS, has been established to store all patient encounters of individuals referring to healthcare facilities.

OBJECTIVE

We aimed to develop a model for cleaning SEPAS and applying its data in other databases.

METHODS

We used cancer data from SEPAS as the sample. We developed a guideline to identify codes for cancer-related diagnoses and services in the database. Furthermore, we searched the SEPAS database based on ICD-10 and the diagnosis description in English and Farsi in an Excel sheet. We added codes and descriptions of pharmaceuticals and procedures to the list. We applied the above database and linked it to the patient records to identify cancer patients. A dashboard was designed based on this information for every cancer patient.

RESULTS

We selected 5,841 diagnostic codes and phrases, 9,300 cancer pharmaceutics codes, and 452 codes from cancer-specific items related to the diagnostic procedures and treatment methods. Linkage of this list to the patient list generated a database of about 197,164 cancer patients for linkage in the registry database.

CONCLUSIONS

Patient registries are one of the most important sources of information in healthcare systems. Data linkage between Electronic Health Record Systems (EHRs) and registries, despite its challenges, is profitable. EHRs can be used for case finding in any patient registry to reduce the time and cost of case finding.

An economic evaluation of universal and targeted case-finding strategies for identifying antenatal depression: a model-based analysis comparing common case-finding instruments

Half of women with depression in the perinatal period are not identified in routine care, and missed cases reflect inequalities in other areas of maternity care. Case finding (screening) for depression in pregnant women may be a cost-effective strategy to improve identification, and targeted case finding directs finite resources towards the greatest need. We compared the cost-effectiveness of three case-finding strategies: no case finding, universal (all pregnant women), and targeted (only pregnant women with risk factors for antenatal depression, i.e. history of anxiety/depression, age < 20 years, and adverse life events). A decision tree model was developed to represent case finding (at around 20 weeks gestation) and subsequent treatment for antenatal depression (up to 40 weeks gestation). Costs include case finding and treatment. Health benefits are measured as quality-adjusted life years (QALYs). The sensitivity and specificity of case-finding instruments and prevalence and severity of antenatal depression were estimated from a cohort study of pregnant women. Other model parameters were derived from published literature and expert consultation. The most cost-effective case-finding strategy was a two-stage strategy comprising the Whooley questions followed by the PHQ-9. The mean costs were £52 (universal), £61 (no case finding), and £62 (targeted case finding). Both case-finding strategies improve health compared with no case finding. Universal case finding is cost-saving. Costs associated with targeted case finding are similar to no case finding, with greater health gains, although targeted case finding is not cost-effective compared with universal case finding. Universal case finding for antenatal depression is cost-saving compared to no case finding and more cost-effective than targeted case finding.

Burns Depression Scale Today (BDST): A validation study of BDST against the reference standard of PHQ-9

Background

Case finding for low mood is essential in primary care, but it is time-consuming using current depression inventories. The Burns Depression Scale Today (BDST) is a short, simple inventory which assesses mood for today, and we aimed to validate it in this study.

Materials and Methods

Consecutive patients with emotional distress seen in a single primary care clinic by one of the authors over 22 months were eligible for this retrospective audit (N = 160). Multiple visits (N = 421) from the same patient were included in the study. The index test was BDST, which assesses the patient's mood for today. The reference standard was the 9-item Patient Health Questionnaire (PHQ-9), which assesses mood over the past 2 weeks. PHQ-9 had a cut-off point of ≥10 and BDST had a cut-off point of ≥6 for a significant mood issue.

Results

The median age of patients was 35 years, and 63% of the cohort were women. The median BDST score was 8, indicative of moderately low mood, and the median PHQ-9 score was 15, indicative of moderately severe depression. For patients with a BDST score ≥6, the likelihood ratio of a positive test was 2.67. The sensitivity was 85% (95% confidence interval [CI]: 89%-96%) and the specificity was 68% (95% CI: 60%-76%). The area under the curve was 84% (95% CI: 80%-87%).

Conclusion

This audit validates BDST against PHQ-9 and finds it an excellent case-finding tool compared to PHQ-9. This is the first validation study of BDST.

Prevalence and detection rate of celiac disease in Italy: Results of a SIGENP multicenter screening in school-age children

BACKGROUND

Celiac disease is a common lifelong disorder. Recent studies indicate that the number of clinically detected cases has increased over the last decades, however little is known about changes in the prevalence and the detection rate of celiac disease.

AIM

To evaluate the current prevalence and detection rate of celiac disease in Italy by a multicenter, mass screening study on a large sample of school-age children.

METHODS

children aged 5-11 years were screened at school by HLA-DQ2 and -DQ8 determination on a drop of blood in six Italian cities; total serum IgA and IgA anti-transglutaminase were determined in children showing HLA-DQ2 and/or -DQ8 positivity. Diagnosis of celiac disease was confirmed according to the European guidelines.

RESULTS

5994 children were eligible, 4438 participated and 1873 showed predisposing haplotypes (42.2%, 95% CI=40.7-43.7). The overall prevalence of celiac disease was 1.65% (95% CI, 1.34%-2.01%). Only 40% of celiac children had been diagnosed prior to the school screening. Symptoms evoking celiac disease were as common in celiac children as in controls.

CONCLUSION

In this multicenter study the prevalence of celiac disease in school-age Italian children was one of the highest in the world. Determination of HLA predisposing genotypes is an easy and fast first-level screening test for celiac disease. Without a mass screening strategy, 60% of celiac patients remain currently undiagnosed in Italy.

HIV matters when diagnosing TB in young children: an ancillary analysis in children enrolled in the INPUT stepped wedge cluster randomized study

BACKGROUND

Children under age five years, particularly those living with HIV (CLHIV), are at risk for rapid progression of tuberculosis (TB). We aimed to describe TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV compared to children without HIV in Cameroon and Kenya.

METHODS

This sub-analysis of a cluster-randomized trial evaluating the integration of pediatric TB services from May 2019 to March 2021 enrolled children age < 5 years with TB. We estimated the HIV infection rate with 95% confidence interval (CI). We compared TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV and children without HIV. Finally, we investigated whether HIV infection was associated with a shorter time to TB diagnosis (≤ 3 months from symptoms onset) after adjusting for covariates. Univariable and multivariable logistic regression analysis were performed with adjusted odds ratios (AORs) presented as measures of the association of covariates with HIV status and with shorter time to TB diagnosis.

RESULTS

We enrolled 157 children with TB (mean age was 1.5 years) and 22/157 (14.0% [9.0-20.4%]) were co-infected with HIV. CLHIV were more likely to initially present with acute malnutrition (AOR 3.16 [1.14-8.71], p = 0.027). Most TB diagnoses (140/157, 89%) were made clinically with pulmonary TB being the most common presentation; however, there was weak evidence of more frequent bacteriologic confirmation of TB in CLHIV, 18% vs. 9% (p = 0.067), due to the contribution of lateral-flow urine lipoarabinomannan to the diagnosis. HIV positivity (AOR: 6.10 [1.32-28.17], p = 0.021) was independently associated with a shorter time to TB diagnosis as well as fatigue (AOR: 6.58 [2.28-18.96], p = 0.0005), and existence of a household contact diagnosed with TB (AOR: 5.60 [1.58-19.83], p = 0.0075), whereas older age (AOR: 0.35 [0.15-0.85], p = 0.020 for age 2-5 years), night sweats (AOR: 0.24 [0.10-0.60], p = 0.0022) and acute malnutrition (AOR: 0.36 [0.14-0.92], p = 0.034) were associated with a delayed diagnosis. The case fatality rate was 9% (2/22) in CLHIV and 4% (6/135) in children without HIV, p = 0.31.

CONCLUSIONS

These results altogether advocate for better integration of TB services into all pediatric entry points with a special focus on nutrition services, and illustrate the importance of non-sputum-based TB diagnostics especially in CLHIV.

TRIAL REGISTRATION

NCT03862261, first registration 05/03/2019.

Relative role of border restrictions, case finding and contact tracing in controlling SARS-CoV-2 in the presence of undetected transmission: a mathematical modelling study

BACKGROUND

Understanding the overall effectiveness of non-pharmaceutical interventions to control the COVID-19 pandemic and reduce the burden of disease is crucial for future pandemic planning. However, quantifying the effectiveness of specific control measures and the extent of missed infections, in the absence of early large-scale serological surveys or random community testing, has remained challenging.

METHODS

Combining data on notified local COVID-19 cases with known and unknown sources of infections in Singapore with a branching process model, we reconstructed the incidence of missed infections during the early phase of the wild-type SARS-CoV-2 and Delta variant transmission. We then estimated the relative effectiveness of border control measures, case finding and contact tracing when there was no or low vaccine coverage in the population. We compared the risk of ICU admission and death between the wild-type SARS-CoV-2 and the Delta variant in notified cases and all infections.

RESULTS

We estimated strict border control measures were associated with 0.2 (95% credible intervals, CrI 0.04-0.8) missed imported infections per notified case between July and December 2020, a decline from around 1 missed imported infection per notified case in the early phases of the pandemic. Contact tracing was estimated to identify 78% (95% CrI 62-93%) of the secondary infections generated by notified cases before the partial lockdown in Apr 2020, but this declined to 63% (95% CrI 56-71%) during the lockdown and rebounded to 78% (95% CrI 58-94%) during reopening in Jul 2020. The contribution of contact tracing towards overall outbreak control also hinges on ability to find cases with unknown sources of infection: 42% (95% CrI 12-84%) of such cases were found prior to the lockdown; 10% (95% CrI 7-15%) during the lockdown; 47% (95% CrI 17-85%) during reopening, due to increased testing capacity and health-seeking behaviour. We estimated around 63% (95% CrI 49-78%) of the wild-type SARS-CoV-2 infections were undetected during 2020 and around 70% (95% CrI 49-91%) for the Delta variant in 2021.

CONCLUSIONS

Combining models with case linkage data enables evaluation of the effectiveness of different components of outbreak control measures, and provides more reliable situational awareness when some cases are missed. Using such approaches for early identification of the weakest link in containment efforts could help policy makers to better redirect limited resources to strengthen outbreak control.

The role of serology in the diagnosis of coeliac disease

Serology has significantly revolutionized the knowledge of celiac disease (CD), leading to the identification of unsuspected patients in at-risk CD groups, thereby increasing the number of CD diagnoses compared to the pre-screening era. Several markers for CD with a progressive diagnostic accuracy have been identified over the years, but only three of them, i.e. anti-tissue transglutaminase (anti-tTG), anti-endomysial (EmA) and anti-deamidated gliadin antibodies (DGP) are currently assessed in the daily clinical practice. A thorough review of the literature identified 44 original studies published between 1998 to 2022 for a total of 5098 pediatric and adult CD patients (without selective IgA deficiency) and 11930 disease controls. The results highlighted that anti-tTG IgA exhibited a higher sensitivity for CD (93.4%) than EmA IgA (92.8%), DGP IgG (81.8%) and DGP IgA (83.8%). The specificity of EmA IgA (99%) resulted to be higher than those of anti-tTG IgA (95.8%), DGP IgG (96.4%) and DGP IgA (92.1%). In patients with selective IgA deficiency, a condition closely related to CD, serological screening should include one of the three antibodies of IgG class, since anti-tTG, DGP and EmA have a very similar diagnostic accuracy in this clinical setting. According to age, there are two main diagnostic strategies for CD detection. In children, the revised ESPGHAN 2020 guidelines established that CD could be diagnosed in both symptomatic and asymptomatic children by high anti-tTG IgA titers (>10 times the cut-off) and EmA positivity with no need to obtain duodenal biopsy and HLA typing. In adult patients, although high tTG IgA titers (confirmed by EmA IgA positivity) correlate with villous atrophy, an intestinal biopsy is still considered mandatory for confirming CD diagnosis. Currently, a case finding approach in at-risk groups is preferred to mass screening for CD detection.

Risk of Missed Diagnosis of Primary Open-Angle Glaucoma by Eye Care Providers

Purpose

To evaluate the efficacy of opportunistic case finding in glaucoma detection and to determine factors associated with failure of glaucoma detection by eye health providers.

Methods

This study was conducted on 154 new definite primary open-angle glaucoma (POAG) patients presenting to our glaucoma clinic. A questionnaire was prepared to determine if these subjects had sought eye care up to 12 months before presentation. The type of eye care provider and the principal reason for the visit were probed. The primary outcome measure was the frequency of a correct glaucoma diagnosis in their index visit. The secondary outcomes were factors associated with missed POAG diagnosis.

Results

The great majority of study subjects (132 cases, 85.7%) had sought at least one ocular examination within 1 year before presentation. Among these patients, 73 cases (55.3%) had remained undiagnosed after the examination. Among the probed variables, age, gender, visual acuity, visual field defects, intraocular pressure, cup/disc ratio, nerve fiber layer thickness of the worse eye at presentation, and family history of glaucoma were comparable between correctly diagnosed and missed POAGs. The only factors significantly associated with missed POAG diagnosis were lack of significant refractive errors and visiting an optometrist rather than an ophthalmologist.

Conclusions

The efficacy of opportunistic case finding for POAG seems to be less than ideal in our settings. Lack of a significant refractive error and visiting an optometrist rather than an ophthalmologist were associated with a missed diagnosis of POAG. These observations reflect the need to adopt policies to improve glaucoma screening by eye care providers.

Barriers to tuberculosis case finding in primary and secondary health facilities in Ghana: perceptions, experiences and practices of healthcare workers

BACKGROUND

Ghana's national tuberculosis (TB) prevalence survey conducted in 2013 showed higher than expected TB prevalence indicating that many people with TB were not being identified and treated. Responding to this, we assessed barriers to TB case finding from the perspective, experiences and practices of healthcare workers (HCWs) in rural and urban health facilities in the Volta region, Ghana.

METHODS

We conducted structured clinic observations and in-depth interviews with 12 HCWs (including five trained in TB case detection) in four rural health facilities and a municipal hospital. Interview transcripts and clinic observation data were manually organised, triangulated and analysed into health system-related and HCW-related barriers.

RESULTS

The key health system barriers identified included lack of TB diagnostic laboratories in rural health facilities and no standard referral system to the municipal hospital for further assessment and TB testing. In addition, missed opportunities for early diagnosis of TB were driven by suboptimal screening practices of HCWs whose application of the national standard operating procedures (SOP) for TB case detection was inconsistent. Further, infection prevention and control measures in health facilities were not implemented as recommended by the SOP. HCW-related barriers were mainly lack of training on case detection guidelines, fear of infection (exacerbated by lack of appropriate personal protective equipment [PPE]) and lack of motivation among HCWs for TB work. Solutions to these barriers suggested by HCWs included provision of at least one diagnostic facility in each sub-municipality, provision of transport subsidies to enable patients' travel for testing, training of newly-recruited staff on case detection guidelines, and provision of appropriate PPE.

CONCLUSION

TB case finding was undermined by few diagnostic facilities; inconsistent referral mechanisms; poor implementation, training and quality control of a screening tool and guidelines; and HCWs fearing infection and not being motivated. We recommend training for and quality monitoring of TB diagnosis and treatment with a focus on patient-centred care, an effective sputum transport system, provision of the TB symptom screening tool and consistent referral pathways from peripheral health facilities.

Methods and Approaches for Buruli Ulcer Surveillance in Africa: Lessons Learnt and Future Directions

Over 95% of the global burden of Buruli ulcer disease (BU) caused by Mycobacterium ulcerans occurs in equatorial Africa. National and sub-national programs have implemented various approaches to improve detection and reporting of incident cases over recent decades. Regional incidence rates are currently in decline; however, surveillance targets outlined in 2012 by WHO have been missed and detection bias may contribute to these trends. In light of the new 2030 NTD roadmap and disease-specific targets, BU programs are required to strengthen case detection and begin a transition towards integration with other skin-NTDs. This transition comes with new opportunities to enhance existing BU surveillance systems and develop novel approaches for implementation and evaluation.In this review, we present a breakdown and assessment of the methods and approaches that have been the pillars of BU surveillance systems in Africa: (1) Passive case detection, (2) Data systems, (3) Clinical training, (4) Active case finding, (5) Burden estimation, and (6) Laboratory confirmation pathways. We discuss successes, challenges, and relevant case studies before highlighting opportunities for future development and evaluation including novel data collection tools, risk-based surveillance, and integrated skin-NTD surveillance. We draw on both experience and available literature to critically evaluate methods of BU surveillance in Africa and highlight new approaches to help achieve 2030 roadmap targets.

Novel tools and strategies for breaking schistosomiasis transmission: study protocol for an intervention study

Background

Global elimination of schistosomiasis as a public health problem is set as target in the new World Health Organization’s Neglected Tropical Diseases Roadmap for 2030. Due to a long history of interventions, the Zanzibar islands of Tanzania have reached this goal since 2017. However, challenges occur on the last mile towards interruption of transmission. Our study will investigate new tools and strategies for breaking schistosomiasis transmission.

Methods

The study is designed as an intervention study, documented through repeated cross-sectional surveys (2020–2024). The primary endpoint will be the sensitivity of a surveillance-response approach to detect and react to outbreaks of urogenital schistosomiasis over three years of implementation. The surveys and multi-disciplinary interventions will be implemented in 20 communities in the north of Pemba island. In low-prevalence areas, surveillance-response will consist of active, passive and reactive case detection, treatment of positive individuals, and focal snail control. In hotspot areas, mass drug administration, snail control and behaviour change interventions will be implemented. Parasitological cross-sectional surveys in 20 communities and their main primary schools will serve to adapt the intervention approach annually and to monitor the performance of the surveillance-response approach and impact of interventions. Schistosoma haematobium infections will be diagnosed using reagent strips and urine filtration microscopy, and by exploring novel point-of-care diagnostic tests.

Discussion

Our study will shed light on the field applicability and performance of novel adaptive intervention strategies, and standard and new diagnostic tools for schistosomiasis elimination. The evidence and experiences generated by micro-mapping of S. haematobium infections at community level, micro-targeting of new adaptive intervention approaches, and application of novel diagnostic tools can guide future strategic plans for schistosomiasis elimination in Zanzibar and inform other countries aiming for interruption of transmission.

Trial registration ISRCTN, ISCRCTN91431493. Registered 11 February 2020, https://www.isrctn.com/ISRCTN91431493

Staged reflexive artificial intelligence driven testing algorithms for early diagnosis of pituitary disorders

BACKGROUND

Sellar masses (SM) frequently present with insidious hormonal dysfunction. We previously showed that, by utilizing a combined reflex/reflecting approach involving a laboratory clinician (LC) on common endocrine test results requested by non-specialists, and subsequently adding further warranted tests, previously undiagnosed pituitary disorders can be identified. However, manually employing these strategies by an LC is not feasible for wider screening of pituitary disorders.

OBJECTIVE

The aim of this study was to compare the accuracy and financial impact of an Artificial Intelligence (AI) based, fully computerized reflex protocol with manual reflex/reflective intervention protocol led by an LC.

METHODS

We developed a proof-of-concept AI-based framework to fully computerize multi-stage reflex testing protocols for pituitary dysfunction using automated reasoning methods. We compared the efficacy of this AI-based protocol with a reflex/reflective protocol based on manually curated retrospective data in identifying pituitary dysfunction based on 12 months of laboratory testing.

RESULTS

The AI-based reflex protocol, as compared with the manual protocol, would have identified laboratory tests for add-on that either directly matched or included all manual add-on tests in 92% of cases, and recommended a similar specialist referral in 90% of the cases. The AI-based protocol would have issued 2.8 times the total number of manual add-on laboratory tests at an 85% lower operation cost than the manual protocol when considering marginal test costs, technical staff and specialist salary.

CONCLUSION/DISCUSSION

Our AI-based reflex protocol can successfully identify patients with pituitary dysfunction, with lower estimated laboratory cost. Future research will focus on enhancing the protocol's accuracy and incorporating the AI-based reflex protocol into institutional laboratory and hospital information systems for the detection of undiagnosed pituitary disorders.

Paramedics assessing patients with complex comorbidities in community settings: results from the CARPE study

Objectives

The aim for this study was to provide information about how community paramedicine home visit programs best “navigate” their role delivering preventative care to frequent 9-1-1 users by describing demographic and clinical characteristics of their patients and comparing them to existing community care populations.

Methods

Our study used secondary data from standardized assessment instruments used in the delivery of home care, community support services, and community paramedicine home visit programs in Ontario. Identical assessment items from each instrument enabled comparisons of demographic, clinical, and social characteristics of community-dwelling older adults using descriptive statistics and z-tests.

Results

Data were analyzed for 29,938 home care clients, 13,782 community support services clients, and 136 community paramedicine patients. Differences were observed in proportions of individuals living alone between community paramedicine patients versus home care clients and community support clients (47.8%, 33.8%, and 59.9% respectively). We found higher proportions of community paramedicine patients with multiple chronic disease (87%, compared to 63% and 42%) and mental health-related conditions (43.4%, compared to 26.2% and 18.8% for depression, as an example).

Conclusion

When using existing community care populations as a reference group, it appears that patients seen in community paramedicine home visit programs are a distinct sub-group of the community-dwelling older adult population with more complex comorbidities, possibly exacerbated by mental illness and social isolation from living alone. Community paramedicine programs may serve as a sentinel support opportunity for patients whose health conditions are not being addressed through timely access to other existing care providers.

Protocol registration

ISRCTN 58273216.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43678-021-00153-4.

The effect of a case-finding app on the detection rate of atrial fibrillation compared with opportunistic screening in primary care patients: protocol for a cluster randomized trial

Background

Atrial fibrillation is a cardiac arrhythmia commonly encountered in a primary care setting. Current screening is limited to pulse palpation and ECG confirmation when an irregular pulse is found. Paroxysmal atrial fibrillation will, however, still be difficult to pick up. With the advent of smartphones, screening could be more cost-efficient by making use of simple applications, lowering the need for intensive screening to discover (paroxysmal) atrial fibrillation.

Methods/design

This cluster randomized trial will examine the effect of using a smartphone-based application such as FibriCheck® on the detection rate of atrial fibrillation in a Flemish general practice population. This study will be conducted in 22 primary care practices across the Flanders region of Belgium and will last 12 months. Patients above 65 years of age will be divided in control and intervention groups on the practice level. The control group will be subjected to standard opportunistic screening only, while the intervention group will be prescribed the FibriCheck® app on top of this opportunistic screening. The difference in detection rate between control and intervention groups will be calculated at the end of the study.

We will use the online platform INTEGO for pseudonymized data collection and analysis, and risk calculation.

Discussion

Smartphone applications might offer a way to cost-effectively screen for (paroxysmal) atrial fibrillation in a primary care setting. This could open the door for the update of future screening guidelines.

Trial registration

ClinicalTrials.gov NCT04545723. Registered on September 10, 2020.

Protocol Summary of the COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) Validation in Primary Care Study

Chronic obstructive pulmonary disease (COPD) often remains undiagnosed and untreated. To date, COPD screening/case finding has not been designed to identify clinically significant COPD, disease ready for therapies beyond smoking cessation. Herein, we describe the ongoing prospective, pragmatic cluster-randomized controlled trial to assess specificity and sensitivity of the COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk (CAPTURE) tool consisting of 5 questions and peak expiratory flow. The tool is designed to identify clinically significant COPD (forced expiratory volume in 1 second [FEV₁] to forced vital capacity [FVC] ratio <.70 plus FEV₁% predicted <60% or increased risk for exacerbation) and the trial will explore the impact of CAPTURE-based screening on COPD diagnosis and treatment rates in primary care patients. Of a total planned enrollment of 5000 English- or Spanish-speaking patients 45 to 80 years of age without a prior COPD diagnosis from 100 primary care practices, a total of 68 practices and 3064 patients have been enrolled in the study. Practices are centrally randomized to either usual care or clinician receipt of patient-level CAPTURE results. All clinicians receive basic COPD education with those in intervention practices also receiving CAPTURE interpretation education. In a single visit, patient participants complete a CAPTURE screening, pre- and post-bronchodilator spirometry and baseline demographic and health questionnaires to validate CAPTURE sensitivity, specificity, and predictive value of identifying undiagnosed, clinically significant COPD. One-year follow-up chart reviews and participant surveys assess the impact of sharing versus not sharing CAPTURE results with clinicians on clinical outcomes including level of respiratory symptoms and events and clinicians' initiation of recommendation-concordant COPD care. This is one of the first U.S. studies to validate and assess impact of a simple COPD screening tool in primary care.

Clinical management of emotions in patients with cancer: introducing the approach "emotional support and case finding"

The current approach to the management of emotions in patients with cancer is “distress screening and referral for the provision of psychosocial care.” Although this approach may have certain beneficial effects, screening and referral programs have shown a limited effect on patient psychological well-being. We argue that this limited effect is due to a mismatch between patient needs and the provision of care, and that a fundamental reconceptualization of the clinical management of emotions in patients with cancer is needed. We describe the rationale and characteristics of “emotional support and case finding” as the approach to the management of emotions in patients with cancer. The two main principles of the approach are: (1) Emotional support: (a) The treating team, consisting of doctors, nurses, and allied health staff, is responsive to the emotional needs of patients with cancer and provides emotional support. (b) The treating team provides information on external sources of emotional support. (2) Case finding: The treating team identifies patients in need of mental health care by means of case finding, and provides a referral to mental health care as indicated. We present a novel perspective on how to organize the clinical management of emotions in patients with cancer. This is intended to contribute to a fruitful discussion and to inform an innovative research agenda on how to manage emotions in patients with cancer.

Management of Distress in Patients with Cancer-Are We Doing the Right Thing?

BACKGROUND

Screening for distress and referral for the provision of psychosocial care is currently the preferred approach to the management of distress in patients with cancer. To date, this approach has shown a limited effect on the reduction of distress. Recent commentaries have argued that the implementation of distress screening should be improved. On the other hand, the underlying assumption that a referral for psychosocial care is required for distressed patients can be questioned. This has led to the development of an alternative approach, called emotional support and case finding.

PURPOSE

In the context of finding innovative solutions to tomorrow's health challenges, we explore ways to optimize distress management in patients with cancer.

METHODS AND RESULTS

We discuss three different approaches: (i) optimization of screening and referral, (ii) provision of emotional support and case finding, and (iii) a hybrid approach with multiple assessments, using mobile technology.

CONCLUSIONS

We suggest continued research on the screening and referral approach, to broaden the evidence-base on improving emotional support and case finding, and to evaluate the utility of multiple assessments of distress with new interactive mobile tools. Lessons learned from these efforts can be applied to other disease areas, such as cardiovascular disease or diabetes.

Clinical Ontologies Improve Case Finding of Primary Biliary Cholangitis in UK Primary and Secondary Care

INTRODUCTION

PBC registries in the UK focus on data from secondary care without clear coordinated contribution from primary care. The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) receives data from > 500 primary care practices (PCPs). Notably, the Lancet commissioning group is extracting data from the RCGP RSC database to shape UK policy on liver disease.

AIMS

To create a novel ontology to facilitate PBC case finding from primary care provider (PCP) records.

METHODS

RCGP RSC data were collected from participating PCPs in the county of Surrey, UK. PBC diagnostic criteria of the AASLD and EASL guidelines were used to develop 725 data codes to facilitate patient record searches. A scoring system built into the ontology allowed categorization of cases as PBC definite, PBC probable, and PBC unlikely.

RESULTS

A total of 218,099 records were searched from participating PCPs. Of these, there were 58 PBC definite, 2317 PBC probable, and 215,724 PBC unlikely patients. There were 32 PBC definite patients who did not match to our regional PBC database and were henceforth included as new-found cases. Two of these cases were not labeled as PBC by the PCP. From the PBC unlikely group, 7/215,724 (0.003%) patients were labeled as PBC in secondary care records; however, none of them were coded as having PBC by their PCPs.

CONCLUSIONS

Utilization of the UK National RCGP RSC database supported by novel ontology score has successfully helped us identify (i) new cases of PBC not known to local/regional secondary care providers and (ii) de novo PBC cases. There are many PBC probable cases whose data merit further careful evaluation.

Prevalence of sarcopenia in pre-frail community dwelling older adult and utility of SARC-F, SARC-CalF and calf circumference in case finding

OBJECTIVE

To determine the prevalence of sarcopenia in the pre-frail community dwelling older adults based on the Asian Workgroup for Sarcopenia (AWGS 2019) criteria. In addition, the utility of case finding using the SARC-F, SARC-CalF and calf circumference on impact of prevalence was explored.

METHODS

75 older adults ≥65 years old were recruited between October 2019 and March 2020. The algorithms of AWGS 2019 was applied retrospectively to pre-frail participants recruited for an intervention study in primary care setting. In addition to demographics, SARC-F, calf circumference (CC), muscle mass, grip strength, gait speed, 5-time chair stand timing and short physical performance battery test (SPPB) were measured, to determine sarcopenia using AWGS 2019. SARC-CalF was determined using SARC-F and CC.

RESULTS

The prevalence of sarcopenia based on AWGS 2019 algorithm was 16.0%, possible sarcopenia 73.3% and severe sarcopenia 12.0%. Using SARC-F for case finding reduced the overall prevalence of sarcopenia to 4.0%, possible sarcopenia to 12.0% and severe sarcopenia to 4.0%. Positive percentage agreement of case finding criteria of SARC-F, SARC-CaIF and calf circumference for sarcopenia was 33%, 42% and 58% respectively.

CONCLUSIONS

Using the AWGS 2019 without case finding, the prevalence of sarcopenia was 16%. However, using SARC-F for case finding underestimated prevalence in this group by 75%. Utility of SARC-F for case finding in pre-frail requires further evaluation.

Yield of household contact investigation of patients with pulmonary tuberculosis in southern Ethiopia

BACKGROUND

Household Contacts (HHCs) of patients with pulmonary tuberculosis (PTB) have a higher risk of developing TB. Contact investigation is recommended to reach this group and identify undiagnosed cases. In this study, we have determined the yield of contact investigation among HHCs of patients with smear-positive PTB, and estimated TB burden.

METHODS

We conducted retrospective record review for the occurrence of TB among HHCs of Index PTB+ cases treated between November 2010 and April 2013 in 12 public health facilities in Boricha district. HHCs were followed up monthly and revisited between March and June 2015. Information on additional TB cases diagnosed and treated among HHCs were documented. HHCs who were diagnosed as having TB after the index cases were diagnosed and treated were considered as 'incident cases'. Presumptive TB case was defined as those having cough for ≥2 weeks or enlarged lymph node. Diagnosis of TB among HHCs were made using smear-microscopy and/or X-rays, and clinically for Extra-pulmonary TB (EPTB).

RESULTS

One thousand five hundred and seventeenth HHCs of 344 index cases were visited and screened for TB and followed up for a median of 37 months. 77 (5.1% - 72 with PTB and 5 with EPTB) HHCs developed TB during 4713 person-years of follow-up with an estimated incidence of 1634 (95% CI: 1370-2043) per 100,000 person-years follow-up which is much higher than the estimated TB incidence for the general population in Ethiopia of 210/100,000. Half (41/77) of incident TB cases were diagnosed within the first year of diagnosis of the index cases and 88% (68/77) were adults (Hazard Ratio: 4.03; 95% CI: 2.00-8.12).

CONCLUSION

HHCs of index PTB+ cases have high risk of developing active TB. Long term follow-up of HHCs could help improve TB case finding depending on country contexts. Further studies on effectiveness and feasibility of the approach and integration in routine settings are needed.

Are Treatment Outcomes of Patients with Tuberculosis Detected by Active Case Finding Different From Those Detected by Passive Case Finding?

Context

India has adopted active case finding (ACF) as an additional strategy to find its missing tuberculosis (TB) cases since 2017. Treatment outcomes of patients identified through ACF may be similar or different from those detected through routine passive case finding (PCF); currently, there are limited studies on this in India.

Aim

The aim of this study was to assess differences in treatment outcomes of patients detected through ACF and PCF under the national TB program.

Study Design

A study was conducted in six TB units of Haridwar district where ACF campaigns were conducted in 2017-2018.

Methods

Data from patients detected by ACF (n = 72) and PCF (n = 184) were extracted from program records.

Results

Of 72 patients detected by ACF, only 54 (75%) were initiated on treatment. A high proportion of initial loss to follow-up (25% vs. 0%) and delay in treatment initiation (4 days vs. 0 days) was observed in ACF patients as compared to PCF. The proportion of unsuccessful treatment outcome was 33% (n = 18) among ACF patients compared to 14% (n = 25) among PCF patients (adjusted relative risk: 2.6, 95% confidence interval: 1.7-4.0).

Conclusion

High initial loss to follow-up, delay in treatment initiation, and poor treatment outcome among ACF patients are a major concern. The study results call for active follow-up after diagnosis and close monitoring during treatment for patients detected by ACF.

Risk of infection and disease progression in children exposed to tuberculosis at home, Colombia

Aim:

To assess the risk of tuberculosis (infection and disease) in children less than 15 years’ old who are household contacts of pulmonary tuberculosis patients in three Colombian cities (Medellín, Cali, and Popayán).

Methods:

A cohort of 1,040 children household contacts of 380 adults with smear-positive pulmonary tuberculosis was followed up for 24 months. Study period 2005-2009.

Results:

Tuberculin skin test was positive (≥10 mm) in 43.7% (95% CI: 39.2-48.2). Tuberculin skin test positivity was associated with age 10-14 years (Prevalence Ratio -PR= 1.43, 95% CI: 1.1-1.9), having a BCG vaccine scar (PR= 1.52, 95% CI: 1.1-2.1), underweight, closer proximity to the index case and exposure time >3 months. The annual risk of infection (tuberculin skin test induration increase of 6 mm or more per year) was 17% (95% CI: 11.8-22.2) and was associated with a bacillary load of the adult index case (Relative Risk -RR= 2.12, 95% CI: 1.0-4.3). The incidence rate of active tuberculosis was 12.4 cases per 1,000 persons-year. Children <5 years without BCG vaccine scar had a greater risk of developing active disease (Hazard Ratio -HR= 6.00, 95% CI: 1.3-28.3) than those with scar (HR= 1.33, 95% CI: 0.5-3.4). The risk of developing active tuberculosis augmented along with the increase from initial tuberculin skin test (tuberculin skin test 5-9 mm HR= 8.55, 95% CI: 2.5-29.2; tuberculin skin test ≥10 mm HR= 8.16, 95% CI: 2.0-32.9).

Conclusions:

There is a need for prompt interruption of adult-to-children tuberculosis transmission within households. Conducting proper contact investigation and offering chemoprophylaxis to infected children could reduce tuberculosis transmission.

Active and adaptive case finding to estimate therapeutic program coverage for severe acute malnutrition: a capture-recapture study

Background

Coverage is an important indicator to assess both the performance and effectiveness of public health programs. Recommended methods for coverage estimation for the treatment of severe acute malnutrition (SAM) can involve active and adaptive case finding (AACF), an informant-driven sampling procedure, for the identification of cases. However, as this procedure can yield a non-representative sample, exhaustive or near exhaustive case identification is needed for valid coverage estimation with AACF. Important uncertainty remains as to whether an adequate level of exhaustivity for valid coverage estimation can be ensured by AACF.

Methods

We assessed the sensitivity of AACF and a census method using a capture-recapture design in northwestern Nigeria. Program coverage was estimated for each case finding procedure.

Results

The sensitivity of AACF was 69.5% (95% CI: 59.8, 79.2) and 91.9% (95% CI: 85.1, 98.8) with census case finding. Program coverage was estimated to be 40.3% (95% CI 28.6, 52.0) using AACF, compared to 34.9% (95% CI 24.7, 45.2) using the census. Depending on the distribution of coverage among missed cases, AACF sensitivity of at least ≥70% was generally required for coverage estimation to remain within ±10% of the census estimate.

Conclusion

Given the impact incomplete case finding and low sensitivity can have on coverage estimation in potentially non-representative samples, adequate attention and resources should be committed to ensure exhaustive or near exhaustive case finding.

Trial registration

ClinicalTrials.gov ID NCT03140904. Registered on May 3, 2017.

The role of active case finding in reducing patient incurred catastrophic costs for tuberculosis in Nepal

BACKGROUND

The World Health Organization (WHO) End TB Strategy has established a milestone to reduce the number of tuberculosis (TB)- affected households facing catastrophic costs to zero by 2020. The role of active case finding (ACF) in reducing patient costs has not been determined globally. This study therefore aimed to compare costs incurred by TB patients diagnosed through ACF and passive case finding (PCF), and to determine the prevalence and intensity of patient-incurred catastrophic costs in Nepal.

METHODS

The study was conducted in two districts of Nepal: Bardiya and Pyuthan (Province No. 5) between June and August 2018. One hundred patients were included in this study in a 1:1 ratio (PCF: ACF, 25 consecutive ACF and 25 consecutive PCF patients in each district). The WHO TB patient costing tool was applied to collect information from patients or a member of their family regarding indirect and direct medical and non-medical costs. Catastrophic costs were calculated based on the proportion of patients with total costs exceeding 20% of their annual household income. The intensity of catastrophic costs was calculated using the positive overshoot method. The chi-square and Wilcoxon-Mann-Whitney tests were used to compare proportions and costs. Meanwhile, the Mantel Haenszel test was performed to assess the association between catastrophic costs and type of diagnosis.

RESULTS

Ninety-nine patients were interviewed (50 ACF and 49 PCF). Patients diagnosed through ACF incurred lower costs during the pre-treatment period (direct medical: USD 14 vs USD 32, P = 0.001; direct non-medical: USD 3 vs USD 10, P = 0.004; indirect, time loss: USD 4 vs USD 13, P <  0.001). The cost of the pre-treatment and intensive phases combined was also lower for direct medical (USD 15 vs USD 34, P = 0.002) and non-medical (USD 30 vs USD 54, P = 0.022) costs among ACF patients. The prevalence of catastrophic direct costs was lower for ACF patients for all thresholds. A lower intensity of catastrophic costs was also documented for ACF patients, although the difference was not statistically significant.

CONCLUSIONS

ACF can reduce patient-incurred costs substantially, contributing to the End TB Strategy target. Other synergistic policies, such as social protection, will also need to be implemented to reduce catastrophic costs to zero among TB-affected households.

Algorithms to identify COPD in health systems with and without access to ICD coding: a systematic review

Background

Chronic obstructive pulmonary disease (COPD) causes significant morbidity and mortality worldwide. Estimation of incidence, prevalence and disease burden through routine insurance data is challenging because of under-diagnosis and under-treatment, particularly for early stage disease in health care systems where outpatient International Classification of Diseases (ICD) diagnoses are not collected. This poses the question of which criteria are commonly applied to identify COPD patients in claims datasets in the absence of ICD diagnoses, and which information can be used as a substitute. The aim of this systematic review is to summarize previously reported methodological approaches for the identification of COPD patients through routine data and to compile potential criteria for the identification of COPD patients if ICD codes are not available.

Methods

A systematic literature review was performed in Medline via PubMed and Google Scholar from January 2000 through October 2018, followed by a manual review of the included studies by at least two independent raters. Study characteristics and all identifying criteria used in the studies were systematically extracted from the publications, categorized, and compiled in evidence tables.

Results

In total, the systematic search yielded 151 publications. After title and abstract screening, 38 publications were included into the systematic assessment. In these studies, the most frequently used (22/38) criteria set to identify COPD patients included ICD codes, hospitalization, and ambulatory visits. Only four out of 38 studies used methods other than ICD coding. In a significant proportion of studies, the age range of the target population (33/38) and hospitalization (30/38) were provided. Ambulatory data were included in 24, physician claims in 22, and pharmaceutical data in 18 studies. Only five studies used spirometry, two used surgery and one used oxygen therapy.

Conclusions

A variety of different criteria is used for the identification of COPD from routine data. The most promising criteria set in data environments where ambulatory diagnosis codes are lacking is the consideration of additional illness-related information with special attention to pharmacotherapy data. Further health services research should focus on the application of more systematic internal and/or external validation approaches.

Tuberculosis case finding: Supplement intensified case finding among acute lower respiratory infection (ALRI) hospitalized patients in Sa Kaeo province, Thailand

BACKGROUND AND PURPOSE

We aimed to estimate TB prevalence among in-patients hospitalized with acute lower respiratory infection (ALRI) through a routine TB case finding approach (Patient-Initiated-Pathway, PIP) and among those without initial TB detection by PIP using a supplementary-Intensified-Case-Finding (supplementary-ICF) approach to determine the extent of active TB infection in patients enrolled in population-based surveillance in Sa Keao, Thailand. We also investigated secondary TB transmission through household contacts (HHCs).

METHODS

This was a prospective cross-sectional study. Data for hospitalized patients with ALRI were obtained from population-based pneumonia surveillance. PIP was provided in ALRI patients with suspected TB infection; those without initial suspicion of TB infection were evaluated for TB by the supplementary-ICF approach. For each active TB case finding approach, index cases were identified by acid-fast-bacillus testing and the TB prevalence was estimated. HHCs of each TB index case were followed to identify the extent of secondary TB infection.

RESULTS

TB prevalence among ALRI hospitalized patients was 12.2% among those undergoing PIP and 6.8% among those undergoing supplementary-ICF. The total number of active TB cases was doubled after implementing the supplementary-ICF method. Secondary TB infection among HHCs was 3.5 times more common for contacts of index cases identified by routine active TB case finding compared to supplementary-ICF TB.

CONCLUSION

Supplementary-ICF among ALRI hospitalizations would be expected to result in improved active TB case detection compared to the current policy of PIP. The supplementary-ICF also enhanced early case detection and showed lower prevalence of secondary infection.

Health care-associated infection surveillance system in Iran: Reporting and accuracy

BACKGROUND

Valid data are a crucial aspect of infection prevention and control programs. The aim of this study was to examine the accuracy of routine reporting in the Iranian Nosocomial Infection Surveillance System in intensive care units.

METHODS

A blinded retrospective review of general intensive care unit medical records was performed with a standard case-finding form. Infection control nurses (ICNs) were also interviewed to explore possible reasons for differences.

RESULTS

The results of 951 events in 856 medical records were assessed. Sensitivity, specificity, and positive and negative predictive values of routine surveillance were 27.5%, 97.2%, 69%, and 85.3%, respectively. The results indicate 82.2%, 68.4%, 62.7%, and 57.3% under-reporting of surgical site infections, urinary tract infections, bloodstream infections, and pneumonia, respectively. Over-reporting of approximately 8%-15% was detected in 4 types of health care-associated infections (HAIs). Misinterpretation of HAI definition, high ICN workload, and inactivity of infection control link nurses were the main causes of inaccurate reporting.

CONCLUSIONS

Under and over-reporting of HAIs are main challenges of HAIs reporting in Iran. Developing guidelines, empowering ICNs through specialized training and activating infection control link nurses are necessary to achieve more accurate data in the Iranian Nosocomial Infection Surveillance System.

CONTROVERSIES AND LIMITATIONS IN THE DIAGNOSIS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality worldwide. While the cut-off point to define airflow obstruction has been controversial, it is widely accepted that the spirometry test is vital, as well as performing it after using a bronchodilator. The 6-second spirometry and the forced expiratory volume in 1 second/forced expiratory volume in 6 seconds (FEV₁/FEV₆) have demonstrated validity for defining obstruction, and it would be advisable to incorporate them in the definitions of obstruction. Another relevant issue is that spirometry with borderline obstruction can vary over time, changing to above or below the cut-off point. Thus, surveillance should be considered over time, repeating the spirometry to have a greater certainty in the diagnosis. The objective of this article was to conduct an in-depth review of the controversies in the diagnosis of COPD. During the past years, COPD definition has been updated in different times; however, it is now considered more as a complex syndrome with systemic participation, requiring a multidimensional assessment, and not only a spirometry.

High Yield of Active Tuberculosis Case Finding Among HIV-Infected Patients Using Xpert MTB/RIF Testing

Objective

Conduct an active case finding study in Tbilisi, Georgia, for pulmonary tuberculosis (TB) among people living with HIV (PLWH).

Methods

Newly diagnosed HIV patients were assessed for symptoms and asked to submit sputum samples for smear microscopy, culture, and molecular diagnostic testing (Xpert MTB/RIF).

Results

Among 276 PLWH, 131 agreed to participate and 103 submitted sputum samples. Most participants were male (70%) and mean age of 43 years. There were high rates of a positive hepatitis C virus (HCV) antibody test (46%) and the median CD4 count was 122 cells/mm³. A total of 15 (11.5%) persons were diagnosed with pulmonary TB, including 1 each with multidrug-resistant and isoniazid-resistant disease. Twelve had a positive culture for Mycobacterium tuberculosis and Xpert TB/RIF assay, and 4 had positive smear microscopy. Patients with pulmonary TB were more likely to use injection drugs (67% vs 36%, P = .02) and have a positive HCV antibody (73% vs 42%, P = .02). The presence and absence of any TB symptom had a sensitivity and negative predictive value for TB of 93% and 98%, respectively.

Conclusion

Our findings highlight the high prevalence of TB among newly diagnosed HIV-infected patients in an area with high rates of drug-resistant TB and the utility of an active case finding strategy for TB diagnosis.

Chronic obstructive pulmonary disease (COPD) among opioid-dependent patients in agonist treatment. A diagnostic study

AIMS

To estimate the prevalence of chronic obstructive pulmonary disease (COPD) and related risk factors in people in opioid agonist treatment (OAT), to compare airflow limitation severity and age-specific COPD prevalence rates with those in the general population, and to assess the OAT patients' willingness to adopt life-style changes and to use therapeutic offers for COPD management.

DESIGN

Cross-sectional study in a random sample of OAT patients.

SETTING

Out-patient centres for substance addiction medicine in Zurich, Switzerland.

PARTICIPANTS

A total of 125 participants, recruited from November 2016 to April 2017 through invitation letters followed by phone or personal contact.

MEASUREMENTS

Standardized questionnaires about drug use, smoking habits and medical history, completed during face-to-face interviews or from medical records. Spirometry without and-depending on the result-with bronchodilation.

FINDINGS

Almost one-third [30.3%; 95% confidence interval (CI) = 22.6-39.0%] of the 119 participants with valid spirometry tests were diagnosed with COPD. Among males aged 30-59 years, the age-adjusted prevalence of at least moderate airflow limitation (GOLD grade ≥ 2) was 2.4 (95% CI = 1.3-4.4) times as high as in the ever-smoking Swiss population in the same age group. Smoking tobacco (92.0%) and substance inhalation (cannabis = 97.6%, cocaine = 69.6%, heroin = 68.0%) were highly prevalent among all participants. The participants expressed considerable interest in life-style changes and use of therapeutic offers for COPD management, with smoking cessation being least (20.2% of tobacco smokers interested) and pharmacological treatment to alleviate COPD symptoms most popular.

CONCLUSIONS

In Switzerland, COPD prevalence and multiple risk factors for COPD appear to be high among people in OAT compared with the general population. Individuals in OAT appear to develop COPD at a younger average age compared with the general population and are open to life-style changes and other COPD management approaches.

Identification of patients with recent-onset psychosis in KwaZulu Natal, South Africa: a pilot study with traditional health practitioners and diagnostic instruments

PURPOSE

There is considerable variation in epidemiology and clinical course of psychotic disorders across social and geographical contexts. To date, very little data are available from low- and middle-income countries. In sub-Saharan Africa, most people with psychoses remain undetected and untreated, partly due to lack of formal health care services. This study in rural South Africa aimed to investigate if it is possible to identify individuals with recent-onset psychosis in collaboration with traditional health practitioners (THPs).

METHODS

We developed a strategy to engage with THPs. Fifty THPs agreed to collaborate and were asked to refer help-seeking clients with recent-onset psychosis to the study. At referral, the THPs rated probability of psychosis ("maybe disturbed" or "disturbed"). A two-step diagnostic procedure was conducted, including the self-report Community Assessment of Psychic Experiences (CAPE) as screening instrument, and a semi-structured interview using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN). Accuracy of THP referrals, and test characteristics of the THP rating and the CAPE were calculated.

RESULTS

149 help-seeking clients were referred by THPs, of which 44 (29.5%) received a SCAN DSM-IV diagnosis of psychotic disorder. The positive predictive value of a THP "disturbed" rating was 53.8%. Test characteristics of the CAPE were poor.

CONCLUSION

THPs were open to identifying and referring individuals with possible psychosis. They recognized "being disturbed" as a condition for which collaboration with formal psychiatric services might be beneficial. By contrast, the CAPE performed poorly as a screening instrument. Collaboration with THPs is a promising approach to improve detection of individuals with recent-onset psychosis in rural South Africa.

Healthy shopper? Blood pressure testing in a shopping centre Pop-Up in England

BACKGROUND

Improving detection of elevated blood pressure (BP) remains a public health need. We present results from a Pop-Up health check stationed in shopping centres in England. We hypothesise the rate of case detection is related to measurable 'unhealthiness' of the shopping centres.

METHODS

A Pop-Up health check was sited in four and three shopping centres sampled from the top ten unhealthiest and top 15 healthiest shopping regions respectively, following a report ranking towns/cities based on their unhealthy and healthy retail outlets. On one day in each shopping centre, people were approached and consented to BP testing. Outcome measure was people flagged with BP ≥ 140/90 mmHg (cases).

RESULTS

We detected 45 (22.6%) and 20 (13.1%) cases from testing 199 and 152 adults in the unhealthy and healthy locations respectively (relative risk 1.72; 95% confidence interval: 1.06 to 2.78). A measure of unhealthy retail outlets (e.g. fast-food outlets) within each shopping centre was associated with detection rate (R2 = 0.61; p = 0.04).

CONCLUSION

An association exists between cases of suspect hypertension found in a health check Pop-Up and measured 'unhealthiness' of the shopping centre site. Results hint at strategies for public testing of BP, potentially in the context of reducing health inequalities.

Hepatitis C seropositivity among newly incarcerated prisoners in Estonia: data analysis of electronic health records from 2014 to 2015

Background

Hepatitis C virus (HCV) infection is a widespread problem in prisons. The present study aimed to assess the prevalence of HCV seropositivity, HCV genotypes, factors associated with HCV seropositivity in newly incarcerated prisoners and to report experiences of treatment with pegylated interferon/ribavirin for HCV-positive inmates.

Methods

Patient data were extracted from the Estonian prison medical information system (Vanglate meditsiiniline infosüsteem) databases.

Results

Among 1845 prisoners newly incarcerated from January 2014 to January 2015, the overall prevalence of HCV was 56.3% (95% CI: 54 to 59), and 25.5% (95% CI: 23.5 to 27.6%) had HIV (39.0% had neither). The all-inclusive HCV testing strategy identified 37.7% more HCV infected prisoners than the risk-based (drug use history, HIV status) case finding. Factors associated with HCV seropositivity included history of drug use (aOR 6.51 95%CI 5.12–8.28), HIV co-infection (aOR 2.56 95%CI 1.92–3.43), previous incarceration (aOR 3.61 95%CI 2.48–4.04), and increasing age. The main HCV genotypes were 3a (n = 172, 44.4%) and 1b (n = 135, 35.2%). Twenty-five prisoners received HCV treatment: 60% (n = 15) were cured, 16% (n = 4) relapsed (3 with genotype 3a, one with 1b), and 12% (n = 3) were unresponsive (all with genotype 3a).

Conclusions

HCV seropositivity rate is high and HCV tretment rate is very low in Estonian prisons. Optimizing case finding and scaling up treatment is critical to addressing the health needs of prisoners and meeting public health goals.

Optimal control analysis of a tuberculosis model

In this paper, we extend the model of Liu and Zhang (Math Comput Model 54:836-845, 2011) by incorporating three control terms and apply optimal control theory to the resulting model. Optimal control strategies are proposed to minimize both the disease burden and the intervention cost. We prove the existence and uniqueness of optimal control paths and obtain these optimal paths analytically using Pontryagin's Maximum Principle. We analyse our results numerically to compare various strategies of proposed controls. It is observed that implementation of three controls is most effective and less expensive among all the strategies. Thus, we conclude that in order to reduce tuberculosis threat all the three controls must be taken into consideration concurrently.

[Acceptability of the opportunistic search for human immunodeficiency virus infection by serology in patients recruited in Primary Care Centres in Spain]

Objetivo

Valorar la aceptabilidad de la prueba del virus de la inmunodeficiencia humana (VIH) mediante búsqueda oportunista.

Diseño

Estudio observacional, transversal.

Emplazamiento

Centros de atención primaria (CAP) del Sistema Nacional de Salud.

Participantes

Pacientes de 18 a 65 años a los que hubiese que realizar una analítica y que nunca antes se hubiesen realizado la prueba del VIH.

Mediciones principales

Edad, sexo, pareja estable, nivel de instrucción, consumo de tabaco/alcohol, motivo de la analítica, aceptabilidad de la prueba del VIH, motivo por el que no acepta o por el que no se le ha realizado antes. Se realizó un análisis estadístico descriptivo, bivariante y multivariante (regresión logística).

Resultados

Doscientos ocho médicos de 150 CAP captaron 3.314 pacientes. La aceptabilidad del test del VIH fue del 93,1% (IC 95%: 92,2-93,9). De estos, el 56,9% no se la habían realizado antes por no considerarse en riesgo, y el 34,8% por no habérsela ofertado su médico. Del 6,9% que rechazaron la serología, el 73,9% alegaron no considerarse en riesgo. Mediante análisis de regresión logística las variables que mostraron relación con la aceptabilidad de la prueba positivamente fueron: la edad (grupo de 26 a 35 años; OR = 1,79; IC 95%:1,10-2,91) y ser no fumador (OR = 1,39; IC 95%: 1,01-1,93). Los residentes en poblaciones entre 10.000 y 50.000 habitantes (OR = 0,57; IC 95%: 0,40-0,80) fueron los que en menor grado aceptaron la prueba. La prevalencia de VIH detectada fue del 0,24%.

Conclusiones

La prueba serológica del VIH tiene una alta aceptación entre los usuarios que acuden para hacerse un análisis de sangre a los CAP. La búsqueda oportunista es coste-efectiva.

The effect of a gerontology nurse specialist for high needs older people in the community on healthcare utilisation: a controlled before-after study

BACKGROUND

Nurse-led models of comprehensive geriatric assessment and care coordination can improve health management as well as reduce hospitalisations for high risk community dwelling older people. This study investigated the effect on healthcare utilisation of systematic case finding to identify high risk older people in the community with a subsequent comprehensive assessment and care coordination intervention by a Gerontology Nurse Specialist based in primary care.

METHODS

This was a controlled before-after study design located within primary healthcare practices in Auckland, New Zealand. An intervention model was initiated within two primary healthcare practices and involved a screening tool to identify high risk older people with succeeding gerontology nurse specialist assessment and care coordination. The comparison group included older people who received usual care at three comparable primary healthcare practices. The primary outcome measure was acute hospital admissions. Secondary outcomes included hospital re-admissions, length of stay, emergency department presentations, residential care admissions, and community contacts.

RESULTS

A total of 579 older people were posted the screening tool in the intervention group, with 517 completed screens (89% response rate) formulating the intervention group. A total of 101 older people were identified as high risk from these screens (20%). The comparison group comprised 883 older people. Comparing the intervention and comparison group, no statistical differences were found for hospital admissions, emergency department presentations, hospital re-admissions, length of stay, or residential care admission. Community physiotherapy showed a statistically significant increase for the intervention compared to the comparison group (p = 0.03). Non-significant findings revealed decreased risk of entering residential care and fewer frequent hospital re-admissions for the intervention group when compared with the comparison group.

CONCLUSIONS

This specialist nurse-led intervention involving comprehensive assessment and care coordination care did not appear superior to usual care, however, there is benefit to exploring a more robust randomised controlled trial design.

TRIAL REGISTRATION

Retrospectively registered on 18/09/2017 with the Australian New Zealand Clinical Trials Registry (ANZCTR). Registration number ACTRN12617001332314.

Provider initiated tuberculosis case finding in outpatient departments of health care facilities in Ghana: yield by screening strategy and target group

Background

Meticulous identification and investigation of patients presenting with tuberculosis (TB) suggestive symptoms rarely happen in crowded outpatient departments (OPDs). Making health providers in OPDs diligently follow screening procedures may help increase TB case detection. From July 2010 to December 2013, two symptom based TB screening approaches of varying cough duration were used to screen and test for TB among general outpatients, PLHIV, diabetics and contacts in Accra, Ghana.

Methods

This study was a retrospective analysis comparing the yield of TB cases using two different screening approaches, allocated to selected public health facilities. In the first approach, the conventional 2 weeks cough duration with or without other TB suggestive symptoms was the criterion to test for TB in attendants of 7 general OPDs. In the second approach the screening criteria cough of >24 hours, as well as a history of at least one of the following symptoms: fever, weight loss and drenching night sweats were used to screen and test for TB among attendants of 3 general OPDs, 7 HIV clinics and 2 diabetes clinics. Contact investigation was initiated for index TB patients. The facilities documented the number of patients verbally screened, with presumptive TB, tested using smear microscopy and those diagnosed with TB in order to calculate the yield and number needed to screen (NNS) to find one TB case. Case notification trends in Accra were compared to those of a control area.

Results

In the approach using >24-hour cough, significantly more presumptive TB cases were identified among outpatients (0.82% versus 0.63%), more were tested (90.1% versus 86.7%), but less smear positive patients were identified among those tested (8.0% versus 9.4%). Overall, all forms of TB cases identified per 100,000 screened were significantly higher in the >24-hour cough approach at OPD (92.7 for cough >24 hour versus 82.7 for cough >2 weeks ), and even higher in diabetics (364), among contacts (693) and PLHIV (995). NNS (95% Confidence Interval) varied from 100 (93-109) for PLHIV, 144 (112-202) for contacts, 275 (197-451) for diabetics and 1144 (1101-1190) for OPD attendants. About 80% of the TB cases were detected in general OPDs. Despite the intervention, notifications trends were similar in the intervention and control areas.

Conclusion

The >24-hour cough approach yielded more TB cases though required TB testing for a larger number of patients. The yield of TB cases per 100,000 population screened was highest among PLHIV, contacts, and diabetics, but the majority of cases were detected in general OPDs. The intervention had no discernible impact on general case notification.

Pilot Evaluation of a Dementia Case Finding Clinical Service Using the Informant AD8 for At-Risk Older Adults in Primary Health Care: A Brief Report

BACKGROUND

An AD8 cut-off score of ≥4 has been reported to successfully detect 90% of dementia cases in elderly patients aged 75 years and above.

OBJECTIVE

We investigated the benefits of a pilot clinical service conducted in primary care that used the AD8 to identify patients with dementia in an at-risk population.

METHOD

Patients ≥75 years of age were recruited from a primary health care center in Singapore. Trained nurses administered the AD8 to informants of eligible patients. Patients screened positive (AD8 score ≥4) were referred to specialist memory clinics by primary health care physicians for further evaluation.

RESULTS

Of the 551 eligible patients in the primary health care center, 168 (30.5%) consented and the AD8 was administered to their informants. Among the recruited patients, 23 (13.7%) were screened positive and 7 (30.4%) of them accepted referrals to specialist memory clinics. The clinical diagnoses for these patients were as follows: no cognitive impairment (NCI) (n = 1), cognitive impairment no dementia (CIND) (n = 5), and dementia (n = 1). Most of the (98.8%) nurses found AD8 user-friendly and could track functional decline. Eighteen of the 23 (78.3%) primary health care physicians who referred patients to specialist memory clinics considered the AD8 useful for facilitating referrals. The remaining physicians (21.7%) preferred performance-based tests.

CONCLUSION

The AD8 is easily administered by nurses and useful to a majority of primary health care physicians to generate referrals. However, physician preference for performance-based tests and a lower prevalence of dementia in the at-risk population may indicate the need to consider a "2-pronged assessment approach" that combines both performance-based and informant-based brief tests to reduce false positive rates and better detect dementia.

Feasibility and Effectiveness of Tuberculosis Active Case-Finding among Children Living with Tuberculosis Relatives: a Cross-Sectional Study in Guinea-Bissau

Background and objectives

The World Health Organization End tuberculosis (TB) Strategy, approved in 2014, aims at a 90% reduction in TB deaths and an 80% reduction in TB incidence rate by 2030. One of the suggested interventions is the systematic screening of people with suspected TB, belonging to specific risk groups. The Hospital Raoul Follereau (HRF) in Bissau, Guinea-Bissau, is the National Reference Hospital for Tuberculosis and Lung Disease of the country. We performed an active case-finding program among pediatric age family members and cohabitants of admitted adult TB patients, from January to December 2013.

Methods

Newly admitted adult patients with a diagnosis of TB were invited to bring their family members or cohabitants in childhood age for clinical evaluation in a dedicated outpatient setting within the hospital compound. All the children brought to our attention underwent a medical examination and chest x-ray. In children with clinical and/or radiologic finding consistent with pulmonary TB, a sputum-smear was requested.

Results

All admitted adult patients accepted to bring their children cohabitants. In total, 287 children were examined in 2013. Forty-four patients (15%) were diagnosed with TB. The number needed to screen (NNS) to detect one case of TB was 7. 35 patients (80%) had pulmonary TB; 2 of them were sputum smear-positive. No adjunctive personnel cost was necessary for the intervention.

Conclusions

A hospital-based TB active case-finding program targeted to high-risk groups like children households of severely ill admitted patients with TB can successfully be implemented in a country with limited resources.

Tuberculosis active case finding in Cambodia: a pragmatic, cost-effectiveness comparison of three implementation models

BACKGROUND

Globally, almost 40% of tuberculosis (TB) patients remain undiagnosed, and those that are diagnosed often experience prolonged delays before initiating correct treatment, leading to ongoing transmission. While there is a push for active case finding (ACF) to improve early detection and treatment of TB, there is extremely limited evidence about the relative cost-effectiveness of different ACF implementation models. Cambodia presents a unique opportunity for addressing this gap in evidence as ACF has been implemented using different models, but no comparisons have been conducted. The objective of our study is to contribute to knowledge and methodology on comparing cost-effectiveness of alternative ACF implementation models from the health service perspective, using programmatic data, in order to inform national policy and practice.

METHODS

We retrospectively compared three distinct ACF implementation models - door to door symptom screening in urban slums, checking contacts of TB patients, and door to door symptom screening focusing on rural populations aged above 55 - in terms of the number of new bacteriologically-positive pulmonary TB cases diagnosed and the cost of implementation assuming activities are conducted by the national TB program of Cambodia. We calculated the cost per additional case detected using the alternative ACF models.

RESULTS

Our analysis, which is the first of its kind for TB, revealed that the ACF model based on door to door screening in poor urban areas of Phnom Penh was the most cost-effective (249 USD per case detected, 737 cases diagnosed), followed by the model based on testing contacts of TB patients (308 USD per case detected, 807 cases diagnosed), and symptomatic screening of older rural populations (316 USD per case detected, 397 cases diagnosed).

CONCLUSIONS

Our study provides new evidence on the relative effectiveness and economics of three implementation models for enhanced TB case finding, in line with calls for data from 'routine conditions' to be included in disease control program strategic planning. Such cost-effectiveness comparisons are essential to inform resource allocation decisions of national policy makers in resource constraint settings. We applied a novel, pragmatic methodological approach, which was designed to provide results that are directly relevant to policy makers, costing the interventions from Cambodia's national TB program's perspective and using case finding data from implementation activities, rather than experimental settings.

Effectiveness and cost-effectiveness of nationwide campaigns for awareness and case finding of hepatitis C targeted at people who inject drugs and the general population in the Netherlands

BACKGROUND

Hepatitis C virus infection (HCV) is a serious, but underdiagnosed disease that can generally be treated successfully. Therefore, a nationwide HCV awareness campaign was implemented in the Netherlands targeting people who inject drugs (PWID) in addiction care ('PWID intervention') and high-risk groups in the general population ('public intervention'). The objective of this study is to assess the effectiveness and cost-effectiveness of the interventions used in this campaign.

METHODS

For the 'PWID' intervention, all addiction care centres in the Netherlands provided proactive individual HCV consultation and testing. The 'public intervention' consisted of health education through mass media and instruction of health care professionals. A Markov chain model was used to estimate incremental cost-effectiveness ratios (ICER, cost per QALY gained). We included a 'DAA treatment' scenario to estimate the effect of these treatment strategies on cost-effectiveness.

RESULTS

The 'PWID intervention' identified 257 additional HCV-carriers. The ICER was €9056 (95% CI: €6043-€13,523) when compared to 'no intervention'. The 'public intervention' identified 38 additional HCV-carriers. The ICER was €18,421 (95% CI: €7376-€25,490,119) when compared to 'no intervention'. Probabilistic sensitivity analysis showed that the probability that the 'PWID intervention' was cost-effective was 100%. It also showed a probability of 34% that the 'public intervention' did not exceed the Dutch threshold for cost-effectiveness (€20,000). New treatment regimens are likely to improve cost-effectiveness of this strategy.

CONCLUSION

In a nationwide HCV awareness and case finding campaign, the intervention targeting PWID was effective and cost-effective. An intervention targeting risk groups in the general population showed only a modest effect and is therefore less likely to be cost-effective.

The challenge of identifying family medicine patients with obstructive sleep apnea: addressing the question of gender inequality

PURPOSE

The purpose of this study was to examine the sleep characteristics, metabolic syndrome disease and likelihood of obstructive sleep apnea in a sample of older, family medicine patients previously unsuspected for sleep apnea.

METHODS

A total of 295 participants, minimum age 45, 58.7% women, were recruited from two family medicine clinics. None previously had been referred for sleep apnea testing. All participants completed a sleep symptom questionnaire and were offered an overnight polysomnography study, regardless of questionnaire results. 171 followed through with the sleep laboratory component of the study. Health data regarding metabolic syndrome disease (hypertension, hyperlipidemia, diabetes and obesity) were gathered by chart review.

RESULTS

Overall, more women than men enrolled in the study and pursued laboratory testing. Of those who underwent polysomnography testing, 75% of the women and 85% of the men were diagnosed with sleep apnea based on an apnea/hypopnea index of 10 or greater. Women and men had similar polysomnography indices, the majority being in the moderate to severe ranges. In those with OSA diagnosis, gender differences in sleep symptom severity were not significant.

CONCLUSIONS

We conclude that greater gender equality in sleep apnea rates can be achieved in family practice if sleep apnea assessments are widely offered to older patients.

Using Virtual Social Networks for Case Finding in Clinical Studies: An Experiment from Adolescence, Brain, Cognition, and Diabetes Study

BACKGROUND

One of the main usages of social networks in clinical studies is facilitating the process of sampling and case finding for scientists. The main focus of this study is on comparing two different methods of sampling through phone calls and using social network, for study purposes.

METHODS

One of the researchers started calling 214 families of children with diabetes during 90 days. After this period, phone calls stopped, and the team started communicating with families through telegram, a virtual social network for 30 days. The number of children who participated in the study was evaluated.

RESULTS

Although the telegram method was 60 days shorter than the phone call method, researchers found that the number of participants from telegram (17.6%) did not have any significant differences compared with the ones being phone called (12.9%).

CONCLUSIONS

Using social networks can be suggested as a beneficial method for local researchers who look for easier sampling methods, winning their samples' trust, following up with the procedure, and an easy-access database.

[Acceptability and feasibility among primary care doctors of the opportunistic search for HIV in Health Care centers in Spain]

Objetivo

Valorar la aceptabilidad y la factibilidad de la búsqueda oportunista del VIH por parte de los profesionales de atención primaria. Conocer el perfil del médico que participa en este tipo de estudio.

Diseño

Estudio observacional, transversal.

Emplazamiento

Centros de atención primaria del Sistema Nacional de Salud.

Participantes

Médicos de familia y residentes que participaron en el estudio VIH-AP para medir la aceptabilidad de la búsqueda oportunista del VIH por parte de los pacientes.

Mediciones principales

Mediante encuesta autocumplimentada se determinó: edad, sexo, cualidad de docente, años de investigación, tiempo trabajando con el mismo cupo, aceptabilidad y factibilidad de la búsqueda oportunista del VIH.

Resultados

Un total de 197 médicos con una media de edad de 45,2 ± 9,7 (DT) años. El 18,8% eran menores de 36 años, el 70,1% mujeres y el 62,4% docentes. El 55,8% trabajaban en localidades mayores de 100.000 habitantes y la media de años ocupando el mismo cupo fue de 6,4 ± 6,6. El 91,9% (IC 95%: 88,1-98,7) consideró la búsqueda oportunista del VIH aceptable, el 89,3% (IC 95%: 85,0-93,6), factible de realizar, mostrando el análisis multivariante relación positiva con el realizar actividad docente (OR: 2,74; IC 95%: 1,16-6,49). La aceptación de la prueba por parte de los pacientes fue del 93,1%, y esta se relacionó positivamente con el tiempo que el médico había trabajado en el mismo cupo, la cualidad de docente y los años dedicados a la investigación.

Conclusiones

La búsqueda oportunista del VIH es un método aceptable y factible para los profesionales de atención primaria.

Impact of mass-screening on tuberculosis incidence in a prospective cohort of Brazilian prisoners

BACKGROUND

Globally, prison inmates are a high-risk population for tuberculosis (TB), but the specific drivers of disease and impact of mass screening interventions are poorly understood.

METHODS

We performed a prospective cohort study to characterize the incidence and risk factors for tuberculosis infection and disease in 12 Brazilian prisons, and to investigate the effect of mass screening on subsequent disease risk. After recruiting a stratified random sample of inmates, we administered a questionnaire to ascertain symptoms and potential risk factors for tuberculosis; performed tuberculin skin testing (TST); collected sera for HIV testing; and obtained two sputum samples for smear microscopy and culture, from participants reporting a cough of any duration. We repeated the questionnaire and all tests for inmates who remained incarcerated after 1 year. TST conversion was defined as TST ≥10 mm and an induration increase of at least 6 mm in an individual with a baseline TST <10 mm. Cox proportional hazard models were performed to identify risk factors associated with active TB. To evaluate the impact of screening on subsequent risk of disease, we compared TB notifications over one year among individuals randomized to screening for active TB with those not randomized to screening.

RESULTS

Among 3,771 inmates recruited, 3,380 (89.6 %) were enrolled in the study, and 1,422 remained incarcerated after one year. Among 1,350 inmates (94.9 %) with paired TSTs at baseline and one-year follow-up, 25.7 % (272/1060) converted to positive. Among those incarcerated for the year, 10 (0.7 %) had TB at baseline and 25 (1.8 %) were diagnosed with TB over the subsequent year. Cases identified through active screening were less likely to be smear-positive than passively detected cases (10.0 % vs 50.9 %; p < 0.01), suggesting early case detection. However, there was no reduction in subsequent disease among individuals actively screened versus those not screened (1.3 % vs 1.7 %; p = 0.88). Drug use during the year (AHR 3.22; 95 % CI 1.05-9.89) and knows somebody with TB were (AHR 2.86; 95 % CI 1.01-8.10) associated with active TB during one year of follow up CONCLUSIONS: Mass screening in twelve Brazilian prisons did not reduce risk of subsequent disease in twelve Brazilian prisons, likely due to an extremely high force of infection. New approaches are needed to control TB in this high-transmission setting.

[Case finding in early prevention networks - a heuristic for ambulatory care settings]

BACKGROUND

One goal of early prevention is the support of families with small children up to three years who are exposed to psychosocial risks. The identification of these cases is often complex and not well-directed, especially in the ambulatory care setting.

OBJECTIVE

Development of a model of a feasible and empirical based strategy for case finding in ambulatory care.

METHODS

Based on the risk factors of postpartal depression, lack of maternal responsiveness, parental stress with regulation disorders and poverty a lexicographic and non-compensatory heuristic model with simple decision rules, will be constructed and empirically tested. Therefore the original data set from an evaluation of the pediatric documentary form on psychosocial issues of families with small children in well-child visits will be used and reanalyzed.

RESULTS

The first diagnostic step in the non-compensatory and hierarchical classification process is the assessment of postpartal depression followed by maternal responsiveness, parental stress and poverty. The classification model identifies 89.0 % cases from the original study. Compared to the original study the decision process becomes clearer and more concise.

CONCLUSIONS

The evidence-based and data-driven model exemplifies a strategy for the assessment of psychosocial risk factors in ambulatory care settings. It is based on four evidence-based risk factors and offers a quick and reliable classification. A further advantage of this model is that after a risk factor is identified the diagnostic procedure will be stopped and the counselling process can commence. For further validation of the model studies, in well suited early prevention networks are needed.

Buruli ulcer in Nigeria: results of a pilot case study in three rural districts

Background

Buruli ulcer (BU), also known as Mycobacterium ulcerans disease, is the third most common mycobacterial disease worldwide. Although BU disease has been diagnosed among Nigerians in neighbouring West African countries, data on the burden of the disease in Nigeria itself are scanty. This study aimed to assess the magnitude and epidemiology of BU in the South South region of Nigeria.

Methods

We conducted a cross-sectional survey in the Ogoja territory (comprising 31 communities). We undertook sensitisation programmes centred on BU in 10 of the communities. Participants were asked to identify community members with long-standing ulcers, who were then invited for evaluation. We also contacted traditional healers to refer their clients who had non-healing ulcers. All suspected cases had a full clinical evaluation and laboratory testing. Confirmed cases were given treatment in a referral hospital in the territory.

Results

We diagnosed 41 clinical BU cases; 36 (87.8 %) of which were confirmed by quantitative polymerase chain reaction (qPCR). These 36 PCR-confirmed cases were diagnosed in a total population of 192,169 inhabitants. Therefore, the estimated crude prevalence of BU was 18.7 per 100,000 population, varying from 6.0 to 41.4 per 100,000 in the districts surveyed. The majority (66.7 %) of the cases were females. About 92 % of the BU lesions were located on the patients’ extremities. No differences were observed between the sexes in terms of the location of the lesions. The age of the patients ranged from four to 60 years, with a median age of 17 years. All 35 (100 %) patients who consented to treatment completed chemotherapy as prescribed. Of the treated cases, 29 (82.9 %) needed and received surgery. All cases healed, but 29 (82.9 %) had some limitations in movement. Healing with limitations in movement occurred in 18/19 (94.7 %) and 8/10 (80.0 %) of patients with lesions >15 cm (Category III) and 6–15 cm in diameter (Category II), respectively. The median duration of treatment was 130 (87–164) days for children and 98 (56–134) days for adults (p = 0.15).

Conclusions

In Nigeria, BU is endemic but its severity is underestimated—at least in the study setting. There is a need to identify and map BU endemic regions in Nigeria. A comprehensive BU control programme is also urgently needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-016-0119-8) contains supplementary material, which is available to authorized users.

Optimal control application to an Ebola model

Ebola virus is a severe, frequently fatal illness, with a case fatality rate up to 90%. The outbreak of the disease has been acknowledged by World Health Organization as Public Health Emergency of International Concern. The threat of Ebola in West Africa is still a major setback to the socioeconomic development. Optimal control theory is applied to a system of ordinary differential equations which is modeling Ebola infection through three different routes including contact between humans and a dead body. In an attempt to reduce infection in susceptible population, a preventive control is put in the form of education and campaign and two treatment controls are applied to infected and late-stage infected (super) human population. The Pontryagins maximum principle is employed to characterize optimality control, which is then solved numerically. It is observed that time optimal control is existed in the model. The activation of each control showed a positive reduction of infection. The overall effect of activation of all the controls simultaneously reduced the effort required for the reduction of the infection quickly. The obtained results present a good framework for planning and designing cost-effective strategies for good interventions in dealing with Ebola disease. It is established that in order to reduce Ebola threat all the three controls must be taken into consideration concurrently.