The diagnosis of latent tuberculosis infection (LTBI): currently available tests,future developments,and perspectives to eliminate tuberculosis (TB)

Introduction:Despite great efforts, tuberculosis (TB) is still a major public health threat worldwide. For decades, TB control programs have focused almost exclusively on infectious TB active cases. However, it is evident that this strategy alone cannot achieve TB elimination. To achieve this objective a comprehensive strategy directed toward integrated latent tuberculosis infection (LTBI) management is needed. Recently it has been recognized that LTBI is not a stable condition but rather a spectrum of infections (e.g., intermittent, transient or progressive) which may lead to incipient, then subclinical, and finally active TB disease.Aim:Provide an overview of current available LTBI diagnostic test including updates, future developments and perspectives.Results:There is currently no test for the direct identification of live MT infection in humans. The diagnosis of LTBI is indirect and relies on the detection of an immune response against MT antigens, assuming that the immune response has developed after a contact with the biological agent. Tuberculin skin test (TST) and interferon gamma release assays (IGRAs) are the main diagnostic tools for LTBI, however, both present strengths and limitations. The most ancient diagnostic test (TST) can be associated with several technical errors, has limited positive predictive value, is being influenced by BCG vaccination and several conditions can reduce the skin reactivity. Notwithstanding these limitations, prompt identification of TST conversion, should orientate indications for preventive therapy of LTBI. IGRAs have superior specificity, are not affected by M. bovis, BCG vaccination and other environmental mycobacteria. However, they present some logistical and organisational constraints and are more expensive. Currently, the WHO guidelines recommend that either a TST or an IGRA can be used to detect LTBI in high-income and upper middle-income countries with estimated TB incidences less than 100 per 100,000 population. Two skin tests (C-TB and Diaskintest), using only two specific M. tuberculosis antigens (ESAT-6 and CFP-10) instead of the tuberculin solution, have recently been developed but, to date, none of these tests is available on the European market.Conclusion:Early identification and treatment of individuals with LTBI is an important priority for TB control in specific groups at risk within the population: this is of crucial meaning in recently infected cases both at the community level and in some occupational settings. Currently there is no gold standard test for LTBI: an improved understanding of the available tests is needed to develop better tools for diagnosing LTBI and predicting progression to clinical active disease.Key words: Tuberculosis, TB, latent tuberculosis infection, LTBI, diagnostic tests, elimination, occupational health, public health     

Switching health insurers: the role of price,quality and consumer information search

We examine the impact of price, service quality and information search on people’s propensity to switch health insurers in the competitive Dutch health insurance market. Using panel data from annual household surveys and data on health insurers’ premiums and quality ratings over the period 2006–2012, we estimate a random effects logit model of people’s switching decisions. We find that switching propensities depend on health plan price and quality, and on people’s age, health, education and having supplementary or group insurance. Young people (18–35 years) are more sensitive to price, whereas older people are more sensitive to quality. Searching for health plan information has a much stronger impact on peoples’ sensitivity to price than to service quality. In addition, searching for health plan information has a stronger impact on the switching propensity of higher than lower educated people, suggesting that higher educated people make better use of available health plan information. Finally, having supplementary insurance significantly reduces older people’s switching propensity.     

Qualitative study of health information needs, flow, and use in Senegal

Many health professionals and policymakers in Africa lack access to the information needed to make evidence-based decisions for effective health care. This study collected qualitative data from 75 key informants and members of two focus groups in Senegal on various aspects of health information needs, particularly in family planning and reproductive health, including information sources, strategies, and systems to transfer and share information; and barriers to accessing, sharing, and using health information. Respondents reported needing information on ways to motivate men's involvement in reproductive health and to address rumors and religious barriers to family planning. Results identified mobile phones as one scalable platform to improve health knowledge. Nevertheless, a nearly universal and persistent need for paper-based information exists, and many health personnel prefer interpersonal communication as a method for information sharing, knowledge synthesis, and learning. Hierarchy and social organization play a crucial role in the flow of communication and in knowledge exchange. The study also identified the importance of political support for a comprehensive knowledge management strategy for the health sector, including the need for strategies to empower and better support the knowledge role of health coordinators and supervisors.     

The quality of nutritional information available on popular websites: a content analysis

The overall purpose of this study was to increase knowledge and understanding of the new informational landscape that is emerging on the Internet in relation to nutritional health content in order to provide policy makers with better communication and health promotion tools. We identified the sites most used by Canadians to access nutrition information and conducted content analyses to identify the sources of this nutritional information as well as its quality by systematic comparison with the main guidelines published in the Canada Food Guide. We found that commercial websites accounted for 80% of visits and time spent on seeking health and nutrition information. We also found uneven messaging about fruit and vegetable intake as well as consistent messaging undermining the 'eat a variety of foods' message, which is a central component of the Canada Food Guide. On the positive side, inappropriate or incongruent advice about salt, coffee and alcohol intake was virtually non-existent and advice congruent with the guide was found three times more often than incongruent advice. Finally, the site offering the best advice was a non-commercial government-based site. This site differed from the commercial sites not so much in its ability to deliver the 'right' advice but more in its ability to exclude articles with poor and misleading advice on their sites.     

Drug treatment program patients' hepatitis C virus (HCV) education needs and their use of available HCV education services

Background  

In spite of the disproportionate prevalence of hepatitis C virus (HCV) infection among drug users, many remain uninformed or misinformed about the virus. Drug treatment programs are important sites of opportunity for providing HCV education to their patients, and many programs do, in fact, offer this education in a variety of formats. Little is known, however, about the level of HCV knowledge among drug treatment program patients, and the extent to which they utilize their programs' HCV education services.     

Health care information sources for adolescents: age and gender differences on use, concerns, and needs.

OBJECTIVES: To assess adolescents' sources of health care information, explore beliefs about topics which health care providers should address and about those which have been addressed, and identify topics that are embarrassing for adolescents to discuss with providers. METHODS: Participants included a nationally representative sample of 3153 boys and 3575 girls in 5th through 12th grades who completed the Commonwealth Fund survey. Data were analysed by inspection of percentages and bivariate associations. RESULTS: Boys (41.7%) and girls (58.4%) identified their mother as the primary resource for health care information. Younger boys and girls (grades five and six) were more likely than older boys and girls (grades 10 to 12) to ask their mother first about health issues (boys 54.4% vs. 35.2%; girls 71.7% vs. 46.4%). Doctors, nurses, or school nurses were also frequently identified as the first person asked about health issues (boys 23.9%, girls 18.2%). Most adolescents indicated that providers should address the following topics: drugs (65.0%); smoking (58.5%); sexually transmitted diseases (61.4%); alcohol use (56.2%); and good eating behaviors (56.8%). However, fewer adolescents reported that providers have actually discussed these issues with them; only 23.1% to 34.2% of adolescents reported having discussed the first four topics with them. Many youth noted that it would be embarrassing for them to discuss these issues with their providers. CONCLUSIONS: Adolescents report that parents and health care providers are key sources of health-related information. Although adolescents may be embarrass having discussions with their health care providers, adolescents do believe that these topics should be addressed. Adolescents' embarrassment about discussing sensitive health topics highlights the importance of providers initiating and facilitating these discussions.     

Soup kitchen consumer perspectives on the quality and frequency of health service interactions.

OBJECTIVE: Whilst previous research has repeatedly documented premature mortality and high morbidity among seriously disadvantaged and homeless populations, far less is known of the extent and nature of their interactions with health services. DESIGN AND SETTING: This cross-sectional case study describes health service utilization patterns and explores participant-reported difficulties in accessing health care, adhering to prescribed treatment and maintaining continuity of care amongst 100 users of a charity-run soup kitchen in urban Sydney. Participants and results. The study describes a largely welfare-dependent population sample with poor health who are frequent users of the health system (85% had seen a general practitioner in the preceding 6 months). The homeless were more likely to report difficulties accessing health care when needed [odds-ratio 3.15; 95% confidence interval (CI) 1.04-9.62]. One in three respondents reported difficulty adhering to prescribed treatment following their last health care visit. Affordability (P < 0.0001), not understanding instructions (P = 0.007), and not agreeing with advice (P < 0.0001) were the main factors associated with adherence difficulties. One in four failed to return for follow-up visits as advised, largely associated with attitudinal barriers such as a history of not believing problems would be addressed (P = 0.05), not trusting health professionals (P = 0.04), and not knowing where to get help in the past (P = 0.05). CONCLUSION: These results reinforce the important role of free primary care in reducing access barriers for the disadvantaged, but also highlight possible reasons for service interactions being ineffective in a substantial proportion of cases.     

Improving public health information: a data quality intervention in KwaZulu-Natal, South Africa

Objective

To evaluate the effect of an intervention to improve the quality of data used to monitor the prevention of mother-to-child transmission (PMTCT) of the human immunodeficiency virus in South Africa.

Methods

The study involved 58 antenatal clinics and 20 delivery wards (37 urban, 21 rural and 20 semi-urban) in KwaZulu-Natal province that provided PMTCT services and reported data to the District Health Information System. The data improvement intervention, which was implemented between May 2008 and March 2009, involved training on data collection and feedback for health information personnel and programme managers, monthly data reviews and data audits at health-care facilities. Data on six data elements used to monitor PMTCT services and recorded in the information system were compared with source data from health facility registers before, during and after the intervention. Data completeness (i.e. their presence in the system) and accuracy (i.e. being within 10% of their true value) were evaluated.

Findings

The level of data completeness increased from 26% before to 64% after the intervention. Similarly, the proportion of data in the information system considered accurate increased from 37% to 65% (P < 0.0001). Moreover, the correlation between data in the information system and those from facility registers rose from 0.54 to 0.92.

Conclusion

A simple, practical data improvement intervention significantly increased the completeness and accuracy of the data used to monitor PMTCT services in South Africa.     

Perceived relevance and information needs regarding food topics and preferred information sources among Dutch adults: results of a quantitative consumer study

OBJECTIVE: For more effective nutrition communication, it is crucial to identify sources from which consumers seek information. Our purpose was to assess perceived relevance and information needs regarding food topics, and preferred information sources by means of quantitative consumer research. DESIGN: Based on qualitative studies, a quantitative questionnaire was developed and administered in face-to-face interviews. SUBJECTS: The study population consisted of Dutch adults aged 18-80 y. A stratified sample of 923 adults was taken from the GfK ScriptPanel; 603 respondents completed the questionnaire. RESULTS: Despite high perceived relevance of food topics regarding dietary guidelines (55-78%), most respondents indicated that they did not want more information about these topics (71-74%). Furthermore, our study revealed information needs regarding safety- and health-related food topics (up to 77% in some subgroups). Differences in perceived relevance and information needs were found in subgroups based on gender, age, perceived weight and socioeconomic status. Education offices of the food sector and the family doctor were mentioned for most food topics, who ranked among the highest regarding perceived reliability, perceived expertise, clearness and accessibility. CONCLUSIONS: With respect to five food topics (losing weight, sports and nutrition, lowering cholesterol, carbohydrates and food composition), interested subgroups should receive tailored information. For other groups and food topics, a population-wide strategy should suffice, utilising the preferred information source. If people who are not yet interested become interested through a life event, information on demand can be put into action. SPONSORSHIP: Dutch Dairy Association.     

The medical consequences of narghile (hookah, shisha) use in the world

BACKGROUND: Hookah (narghile, shisha) smoking is growing worldwide and particularly in France. The main reasons for this are: first, the arrival on the market of new highly flavored tobacco-based mixtures; second, a new type of charcoal used as a quick heating source; third, the pleasure to experiment with an exotic orientalist practice or the desire to return to the corresponding tradition; fourth, the belief that water filtration would lower the risk of smoking. METHODS AND RESULTS: Long-term epidemiological data on complications are scarce. Little is known about qualitative and quantitative transformations occurring when hookah is smoked (in particular regarding carcinogenic agents). Such information will be difficult to collect due to the lack of standardization for this mode of tobacco use. The only current consensus on this issue is that a significant amount of carbon monoxide is produced by the charcoal used to heat and distil the tobacco-molasses mixture. Apart from direct inhalation, concentrations measured in some fashionable hookah lounges and bars are particularly high. Moreover, the additives contained in the widely used quick-lighting charcoals and their harmlessness remain unknown. CONCLUSION: This study sets out the available scientific knowledge regarding the real medical consequences related to the growing use of hookah and focuses on the best known and urgent issue, i.e. concern related to carbon monoxide intoxication in a very peculiar context.     

Quality and use of consumer information provided with home test kits: room for improvement

Background

Diagnostic self‐tests (tests on body materials that are initiated by consumers with the aim of diagnosing a disorder or risk factor) are becoming increasingly available. Although the pros and cons of self‐testing are currently not clear, it is an existing phenomenon that is likely to gain further popularity.

Objective

To examine consumers'' use of and needs for information about self‐testing, and to assess the quality of consumer information provided with home test kits, as perceived by consumers and as assessed using a checklist of quality criteria.

Methods

A cross‐sectional Internet survey among 305 self‐testers assessed their use of and needs for information and their perception of the quality of consumer information provided with self‐test kits. A meta‐search engine was used to identify Dutch and English consumer information for home diagnostic tests available online at the time of the study. The quality of this consumer information was evaluated using a checklist of quality criteria.

Results

The consumers'' information needs were in line with the most frequently used information, and the information was perceived as being of moderate to good quality. The information was mostly in agreement with clinical practice guidelines, although information on reliability and follow‐up behaviour was limited. Approximately half of the instruction leaflets did not include information on the target group of the test.

Conclusions

Although generally of moderate to good quality, some aspects of the information provided were in many cases insufficient. European legislation concerning self‐tests and accompanying information needs to be adapted and adhered to more closely.     

DISCERN: an instrument for judging the quality of written consumer health information on treatment choices

OBJECTIVE: To develop a short instrument, called DISCERN, which will enable patients and information providers to judge the quality of written information about treatment choices. DISCERN will also facilitate the production of new, high quality, evidence-based consumer health information. DESIGN: An expert panel, representing a range of expertise in consumer health information, generated criteria from a random sample of information for three medical conditions with varying degrees of evidence: myocardial infarction, endometriosis, and chronic fatigue syndrome. A graft instrument, based on this analysis, was tested by the panel on a random sample of new material for the same three conditions. The panel re-drafted the instrument to take account of the results of the test. The DISCERN instrument was finally tested by a national sample of 15 information providers and 13 self help group members on a random sample of leaflets from 19 major national self help organisations. Participants also completed an 8 item questionnaire concerning the face and content validity of the instrument. RESULTS: Chance corrected agreement (weighted kappa) for the overall quality rating was kappa = 0.53 (95% CI kappa = 0.48 to kappa = 0.59) among the expert panel, kappa = 0.40 (95% CI kappa = 0.36 to kappa = 0.43) among information providers, and kappa = 0.23 (95% CI kappa = 0.19 to kappa = 0.27) among self help group members. Higher agreement levels were associated with experience of using the instrument and with professional knowledge of consumer health information. Levels of agreement varied across individual items on the instrument, reflecting the need for subjectivity in rating certain criteria. The trends in levels of agreement were similar among all groups. The final instrument consisted of 15 questions plus an overall quality rating. Responses to the questionnaire after the final testing revealed the instrument to have good face and content validity and to be generally applicable. CONCLUSIONS: DISCERN is a reliable and valid instrument for judging the quality of written consumer health information. While some subjectivity is required for rating certain criteria, the findings demonstrate that the instrument can be applied by experienced users and providers of health information to discriminate between publications of high and low quality. The instrument will also be of benefit to patients, though its use will be improved by training.     

Improving the use of research evidence in guideline development: 10. Integrating values and consumer involvement

Background  

The World Health Organization (WHO), like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the 10^th of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this.     

Using publicly available information to create exposure and risk-based ranking of chemicals used in the workplace and consumer products

Mandates that require the estimation of exposure and human health risk posed by large numbers of chemicals present regulatory managers with a significant challenge. Although these issues have been around for some time, the estimation of human exposure to chemicals from use of products in the workplace and by the consumer has been generally hindered by the lack of good tools. Logically and in the interest of cost-effective resource allocation and regulation one would typically and naturally first attempt to rank-order or prioritize the chemicals according to the human exposure potential that each might pose. We have developed an approach and systematic modeling construct that accomplishes this critical task by providing a quantitative estimate of human exposure for as many as several hundred chemicals initially; however, it could ultimately do this for any number of regulated chemicals starting only with the identity (Chemical Abstract Service number) for each chemical under consideration. These exposure estimates can then be readily linked to toxicological benchmarks for each item to estimate and rank the human health risk for the chemicals under consideration in a "worst things first" listing. This modeling construct, entitled Complex Exposure Tool (ComET) was developed by The LifeLine Group as a proof of concept under the sponsorship of Health Canada. ComET considers multiple routes of exposure, multiple subpopulations and different possible durations of exposure. A beta-version of ComET was issued and demonstrated in which users can change the assumptions in the model and see the impacts of these changes and the quality of information as they relate to the predicted exposure potential. We have advanced the operational elements of ComET into a tool entitled the Chemical Exposure Priority Setting Tool (CEPST) designed to provide quantitative estimation of the exposure potential of large groups of chemicals with little data and possibly multiple exposure scenarios. A basic feature of this tool is the utilization of an internally consistent approach and assumptions that are completely transparent. It uses publicly available information as critical input and is specifically designed to be continually reviewed, refined, expanded and updated using scientific peer review and stakeholder input.     

Mercury in seafood: mechanisms of accumulation and consequences for consumer health

Mercury is a largely uncontrollable heavy metal contaminant in that it is globally ubiquitous, and environmentally persistent. The element has the potential for global mobilization following liberation from environmental stores, which can occur as a consequence of either anthropogenic activities or natural processes. Furthermore, organic forms like methylmercury accumulate in biological tissues with an exceptionally long biological half-life, facilitating the magnification of this toxin along trophic food chains. Bioaccumulation is particularly evident in aquatic environments, in which long-lived piscivorous fishes and marine mammals are reported with a mercury burden one-million times that of the surrounding water body, typically attaining mercury burdens exceeding 1 microg g(-1). Mercury levels in other seafood, however, are typically reported in the range of 0.1 to 0.2 microg g(-1) and usually less then 0.5 microg g(-1). The primary source of human exposure to environmental mercury is through seafood consumption. The dangers associated with the consumption of large amounts of methylmercury accumulated in seafood are well recognized from past poisoning incidents, in which fish with mercury burdens in the range of 9 to 24 microg g(-1) were consumed. Nevertheless, the toxicological consequence of chronic low-level mercury exposure from habitual seafood consumption is an area of contention. This review discusses the mechanisms of mercury accumulation and distribution in fish tissues and the toxicological consequences of mercury exposure from seafood consumption with regard to international safety guidelines.     

宫颈癌患者疾病信息需求及影响因素调查研究

目的 了解宫颈癌患者信息选择的需求状况及影响因素.方法 采用一般资料问卷、卡氏功能量表和癌症患者信息选择问卷对78例宫颈癌患者进行调查分析.结果 癌症患者信息选择问卷的总分、诊断、治疗、预后和其他维度均分分别为39.04±7.42、6.19±1.28、10.69±2.63、10.08±2.07和12.01±2.43."我很想知道"信息内容排名前3位为条目4、8、13、12(8和13并列),"我不想知道"信息内容排名前3位为条目14、16、10.卡氏评分在80分及以上(可进行正常活动)组的总分、诊断、治疗、预后和其它因子均分均低于卡氏评分在70分及以下(生活受到不同程度的影响)组(t值分别为3.431、2.125、2.047、3.571、2.319,均P<0.05).年轻妇女、文化程度较高及脑力工作的癌症患者信息选择问卷某些分值较高,希望获知的信息需求较多.结论 癌症患者信息选择问卷及各维度得分与年龄、受教育程度、职业和健康状态有关,医生在为癌症患者提供治疗时,应注意其需要的疾病相关医学信息和健康需求.     

The elderly healthcare consumer: a critical review of information source use and advertising recommendations.

A critical review of the literature is undertaken to examine the state of the art and degree of articulation of theories, methods, and findings between health care marketing and the traditional "generic" marketing literature as related to knowledge of information use by and advertising to the elderly consumer. Evaluative criteria suggestive of scientific rigor are applied to this domain as consistencies, discrepancies, and gaps are identified. Recommendations for future research are advanced.