Barriers in accessing to tuberculosis care among non-residents in Shanghai: a descriptive study of delays in diagnosis

OBJECTIVES: To describe accessibility to tuberculosis (TB) diagnosis in non-resident TB patients in Shanghai, China, and to identify factors associated with delay in diagnosis. METHODS: A face-to-face interview of 222 newly diagnosed, non-resident TB patients registered in two districts of Shanghai: Changning District and Putuo District, was conducted using a structured questionnaire. RESULTS: Among the 222 non-resident TB patients, median patient's delay was 21 days and median doctor's delay was 8 days. The duration of doctor's delay was significantly longer in Changning District than Putuo District (13 vs. 5 days, P < 0.001). One-fourth of the subjects had a patient's delay longer than 42 days and a doctor's delay longer than 15 days. Logistic regression model shows that patients at lower income level, and who did not have haemoptysis symptom were more likely to have longer patient's delay. Patients who registered in Changning were more likely to have a longer doctor's delay. The proportion of diagnosis or consideration as suspected TB for referral was significantly higher in hospitals than non-hospitals. CONCLUSION: The results of this study indicate that patient- and doctor-related factors contribute significantly to delays in the diagnosis of non-resident TB patients in Chinese cities. Non-resident's poor economic status, clinical status, complexities in referral and diagnostic procedure at different districts accounted for delayed TB care-seeking and diagnosis.     

Integration of alcohol use disorders identification and management in the tuberculosis programme in Tomsk Oblast, Russia

Alcohol use disorders (AUDs) among tuberculosis (TB) patientsare associated with nonadherence and poor treatment outcomes.We developed a multidisciplinary model to manage AUDs amongTB patients in Tomsk, Russia. First, we assessed current standardsof care through stakeholder meetings and ethnographic work.The Alcohol Use Disorders Identification Test (AUDIT) was incorporatedinto routine assessment of all patients starting TB treatment.We established treatment algorithms based on AUDIT scores. Wethen hired specialists and addressed licensing requirementsto provide on-site addictions care. Our experience offers asuccessful model in the management of co-occurring AUDs amongpatients with chronic medical problems.     

From contact investigation to tuberculosis screening of drug addicts and homeless persons in Rotterdam

BACKGROUND: In early 2001 there were indications that tuberculosis (TB) was increasingly becoming a problem among drug addicts and homeless persons in Rotterdam, after a periodical screening was discontinued in 1997. A contact investigation around a homeless drug addicted man in Rotterdam with infectious pulmonary TB is described. Contact investigation: A total of 507 drug addicts, homeless persons, and staff of facilities for these risk groups were examined with tuberculin skin testing (TST) and chest radiography. DNA fingerprinting of mycobacteriological cultures through Restricted Fragment Length Polymorphism methodology and molecular epidemiology investigation through cluster analysis were performed. Outcome: TST showed an infection prevalence of 29%, especially among staff of services for drug addicts and homeless persons. Six persons with active intrathoracic TB were identified. Cluster analysis demonstrated no relation with the initial case but showed intense transmission of TB among drug addicts and homeless persons in Rotterdam by multiple sources. As a consequence of the findings, a proposal to the Council of the City of Rotterdam resulted in the re-introduction of a comprehensive TB screening programme among these risk groups with mobile digital X-ray units (MXUs). CONCLUSION: This contact investigation gradually obtained the characteristics of a screening of drug addicts and homeless persons. Novel technologies, such as MXUs, facilitate appropriate and efficient outreach approaches to TB control among difficult-to-reach groups. This method and knowledge of individual fingerprints and clusters of TB patients are indispensable for underpinning proposals for change of local TB control strategies and convincing local authorities of the rationale.     

Compulsory detention of recalcitrant tuberculosis patients in the context of a new tuberculosis control programme in Israel

OBJECTIVE: To analyse the use of compulsory detention in the context of a new national tuberculosis (TB) control programme launched in 1997. METHODS: A retrospective review was made of the use of compulsory detention in the management of infectious TB before and after the initiation of a new TB control programme, using data from the central TB registry in the Ministry of Health and the charts of each patient. RESULTS: Between 1994 and 2001, 13 recalcitrant patients out of 3056 (0.43%) cases of pulmonary TB were brought to trial. Eleven patients were detained. All were either hospitalized under a court order and, when failing to comply with the order, hospitalized in prison, or referred directly to a prison hospital. Twelve of 13 (92%) patients were new immigrants. After the new programme was launched, proportionately fewer patients were brought to trial [6/943 (0.64%) in 1994-1996 compared with 7/2113 (0.33%) in 1997-2001]. CONCLUSION: The reduction in the number of individuals detained could be viewed as an improvement in TB control due to the new TB control programme. It remains to be shown whether these individuals, most of whom had drug-resistant strains of TB, posed a sufficient threat to public health to justify detention.     

Effects of a population-based smoking cessation programme on smoking in pregnancy.

A controlled study was conducted to evaluate the effects of a low-intensity population-based smoking cessation programme in maternity care clinics. Quitting smoking during pregnancy was assessed by a self-administered questionnaire and verified by hair nicotine concentration. In the intervention area, 58/306 women (19.0%) reported quitting smoking during pregnancy whereas in the reference area the numbers were 22/152 (14.5%) (difference = 4.5%, 95% confidence interval: -2.6%-11.6%). The intervention group indicated that they received more information on adverse effects of smoking, studied the material more actively, and felt that material from maternity care influenced their smoking behaviour more than the reference group.     

Evaluating the effect of policies and interventions to address inequalities in health: lessons from a Dutch programme

OBJECTIVES: Many initiatives have been taken in European countries that are designed to reduce inequalities in health. However, the effects of only a very few of these initiatives have been assessed. The main aim of a Dutch research and development programme was to systematically investigate and evaluate interventions aimed at reducing inequalities in health. In this paper, we report on this investigation, and draw lessons from the methodology used to evaluate such interventions. APPROACH: The programme included 12 evaluation studies, focusing on the wider determinants of inequalities in health (n = 2), behavioural determinants (n = 4), working conditions (n = 3) and health care (n = 3). RESULTS: An experimental design was applied in two evaluation studies. The studies provided evidence of a positive effect. A quasi-experimental design appeared to be the only attainable option in seven studies. Five of these provided sufficient evidence for a positive effect, but two interventions appeared not to be successful. In three studies, no experimental or quasi-experimental design could be applied. CONCLUSIONS: The programme showed that it is possible to apply experimental or quasi-experimental studies to complex public health interventions. The Programme Committee steering the programme considered that the evidence generated by the experimental and quasi-experimental studies justified the implementation of the interventions on a wider scale, accompanied by further evaluation studies. Further development of the methodology of public health interventions is necessary. These include non-experimental designs such as international comparisons and time trend studies, especially in order to be able to evaluate broader policy measures.     

A socio-epidemiological study of out-patients attending a city tuberculosis clinic in India to judge the place of specialized centres in a tuberculosis control programme

In India, specialized tuberculosis clinics exist mostly in cities. These clinics treat mainly persons with an awareness of symptoms who present themselves of their own accord. The few persons without symptoms are those who have been advised to have an examination. The urge to attend a specialized centre, presumably motivated by suffering or discomfort from symptoms and by awareness that specialized services exist, does not appear to be strong enough to overcome all the ”obstacles” that lie between the patient and the tuberculosis clinic. A distance of 4 miles (6.4 km) or more is a major obstacle, irrespective of where the town limits lie. The socio-economic value of the patient to his family also appears to influence attendance. There is evidence that most patients first approach treatment sources, without regard to the nature of the service, whether specialized or general. It has been observed that if the quality of service rendered by a centre is unsatisfactory, the patient may constantly search for ”better” treatment. Social considerations, other than suffering, which influence attendance could be termed ”social preference”. The justification for strengthening general health institutions (with adequate means for the diagnosis and treatment of tuberculosis), without taking urban or rural factors into consideration, is discussed in the light of the findings of this study.     

East-west differences in reported preventive practices. A comparative study of six European areas of the WHO-CINDI programme.

BACKGROUND: Differences have been reported in life expectancy and mortality between Eastern and Western European countries. Also, disparities have been found among different European countries or populations concerning the implementation of preventive practices by health professionals. This study analysed the patterns of reported preventive practices in three Eastern European areas and three Western ones. METHODS: Health surveys were carried out in particular geographical area of six countries participating in the project (three Eastern European countries; Russia, Poland and Hungary and three Western European countries; Finland, Germany and Spain). All of them are partners in the WHO-CINDI (Countrywide Integration Non-communicable Diseases Intervention) Programme. Three preventive practices are analysed: reported blood pressure and blood cholesterol measurements and reported antismoking counseling during the last year. Data are presented separately for the general population and for people reporting specific chronic conditions (cardiovascular disease, respiratory disease and/or diabetes mellitus). RESULTS: Blood pressure measurement and antismoking counseling are more frequently reported to be carried out by primary health care physicians in the Eastern European areas while blood cholesterol measurement is more frequently reported in Western European countries. All these preventive activities are more frequently reported to be done among people with chronic conditions than in the population as a whole. CONCLUSIONS: Major differences have been found in reported preventive practices between Eastern and Western European countries. Great potential exists for chronic disease prevention among them.     

Impact of private funding on access to elective hospital treatment in the regions of England and Wales. National records survey.

BACKGROUND: The UK National Health Service aims to match access to health care to the level of need and to reduce inequalities in the health of sub-populations. One in ten persons have private medical insurance (PMI). This study describes the impact of private purchasing on access to hospital care in regions according to health need. METHOD: Details of admissions to NHS hospitals in one year and waiting times were obtained from the government's Hospital Episodes Statistics, and of patients in independent hospitals through weighted time samples of records. Data were combined into two groups, state funded and privately funded patients. The prevalence of limiting longstanding illness and the proportions of individuals covered by PMI in Wales and the eight English health regions were obtained from the General Household Survey. Correlation coefficients were calculated for inter-regional relationships between measures of need, provision of resources and levels of activity. RESULTS: Limiting, longstanding illness was significantly associated with NHS resource levels, NHS hospital activity, and total hospital activity, however funded; and inversely with PMI coverage, waiting times for NHS admission and levels of privately funded activity. Waiting times for admission were positively correlated with PMI coverage. CONCLUSIONS: Regionally, NHS resources and activity match need. Private hospital use complements lower levels of NHS service. Private consumption does not distort access according to need but in regions with lower levels of NHS activity those least deprived may make relatively more use of NHS hospitals, thus widening the health gap. Small area studies should explore this.     

Heroin-assisted treatment as a response to the public health problem of opiate dependence

Injection drug use (involving the injection of illicit opiates) poses serious public health problems in many countries. Research has indicated that injection drug users are at higher risk for morbidity in the form of HIV/AIDS and Hepatitis B and C, and drug-related mortality, as well as increased criminal activity. Methadone maintenance treatment is the most prominent form of pharmacotherapy treatment for illicit opiate dependence in several countries, and its application varies internationally with respect to treatment regulations and delivery modes. In order to effectively treat those patients who have previously been resistant to methadone maintenance treatment, several countries have been studying and/or considering heroin-assisted treatment as a complementary form of opiate pharmacotherapy treatment. This paper provides an overview of the prevalence of injection drug use and the opiate dependence problem internationally, the current opiate dependence treatment landscape in several countries, and the status of ongoing or planned heroin-assisted treatment trials in Australia, Canada and certain European countries.     

Population health and the health system: a comparative analysis of avoidable mortality in three nations and their world cities

BACKGROUND: Access to timely and effective medical services can reduce rates of premature mortality attributed to certain conditions. We investigate rates of total and avoidable mortality (AM) and the percentage of avoidable deaths in France, England and Wales and the United States, three wealthy nations with different health systems, and in the urban cores of their world cities, Paris, Inner London and Manhattan. We examine the association between AM and an income-related variable among neighbourhoods of the three cities. METHODS: We obtained mortality data from vital statistics sources for each geographic area. For two time-periods, 1988-90 and 1998-2000, we assess the correlation between area of residence and age- and gender-adjusted total and AM rates. In our comparison of world cities, regression models are employed to analyse the association of a neighbourhood income-related variable with AM. RESULTS: France has the lowest mortality rates. The US exhibits higher total, but similar AM rates compared to England and Wales. Rates of AM are lowest in Paris and highest in London. Avoidable mortality rates are higher in poor neighbourhoods of all three cities; only in Manhattan is there a correlation between the percentage of deaths that are avoidable and an income related variable. CONCLUSIONS: Beyond the well-known association of income and mortality, persistent disparities in AM exist, particularly in Manhattan and Inner London. These disparities are disturbing and should receive greater attention from policy makers.     

Patterns of suicidal behaviour in a metro subway system: a study of 306 cases injured by the Munich subway, 1980-1999

BACKGROUND: As a basis for preventive strategies to reduce subway suicides, an investigation was undertaken to determine if there was a distinct pattern of subway suicidal behaviour. METHODS: Data were taken from the Municipal Munich Subway System case registry (southern Germany) for all suicidal incidents on the track: purposely inflicted; date, time and location of incident, sex of victim, outcome. The analysis covered a 20 year observation period between 1980 and 1999, for which the Munich Municipal Office for Statistics also provided data of all deaths due to suicides within the city area of Munich. Suicide mortality was classified by the International Classification of Diseases, Ninth revision (codes E950-E959). RESULTS: A total of 306 incidents were documented with an annual mean of 16.5 cases. Case fatality was 66% (n=202). It was highest in winter and in higher aged groups. No significant time trend for incidences was observed. Median age of suicide attempters was 38 years. Most incidences (24.2%) were recorded for persons aged 20-29 years. The male: female ratio was 1.15 : 1. The peak time of day for incidences in women was during the late morning hours while significantly more men committed subway suicides during evening hours (p=0.001). No consistent seasonal variation was observed. CONCLUSIONS: In comparison to average suicide attempters, subjects committing subway suicides are markedly younger and they follow to a lesser extent established seasonal or circadian time patterns. More women are involved in subway suicides than would be expected. However, similarities to reports on behavioural patterns of subway suicides in other communities are striking.     

Lack of training as a central barrier to the promotion of smoking cessation: a survey among general practitioners in Germany

BACKGROUND: General practitioners (GPs) can contribute substantially to the promotion of smoking cessation in the general population. However, engagement of GPs in helping their patients to quit remains very limited in many countries, including Germany. Therefore, new strategies to foster implementation of evidence-based methods in smoking cessation assistance have to be identified, and data for current practice of and barriers against smoking cessation promotion in general practice are needed. METHODS: A cross-sectional survey among all 657 general practitioners practising in the Rhein-Neckar Region of Germany was conducted in spring 2002 using a postal questionnaire (response rate 48%). RESULTS: The majority (54%) of GPs reported having treated less than 10 patients for smoking cessation (by any means including mere advice to quit) within the last three months, 23% of GPs never received any education or training in smoking cessation promotion, and only one-third of GPs rated their training as adequate. The factor most strongly associated with low activity in smoking cessation promotion (defined as having treated less than 10 patients within the last three months) was perceived lack of training (odds ratio 2.70, 95% confidence interval 1.68 - 4.32), followed by perceived lack of demonstration material (2.10, 1.31 - 3.39) and perceived lack of time (1.65, 1.02 - 2.66). Furthermore, there was a clear dose-response relationship between the time spent on training and the activity in smoking cessation promotion. CONCLUSION: Adequate training may be a key factor to enhance engagement of general practitioners in the promotion of smoking cessation.     

The relationship of household income to a range of health measures in three age cohorts from the West of Scotland

Background: The aim of this study was to determine the relationshipbetween household income and measures of health at differentpoints in the life course. Method: Analysis of second-wave datacollected in 1990–1991 in a longitudinal study of threeage cohorts (15, 35 and 55 years in 1987–1988) in theWest of Scotland was performed. The subjects were 851 18 yearolds, 801 39 year olds and 761 58 year olds on whom data onIncome and a range of health measures were available (92% ofthose interviewed in 1990–1991). Results: Blood pressurewas not significantly related to household income. Height, weight,waist:hip ratio, body mass index, pulse rate, long-standingillness and limiting long-standing illness showed linear associationswith household income and FEV₁/height², number of recent malaisesymptoms reported, number of checklist of 22 recent symptomsreported, GHQ scores and self-assessed health had curvillnearrelationships with household Income. There were interactionsbetween Income and sex for weight, waist:hip ratio, BMI andpulse rate and interactions between income and age for malaise,symptom checklist and self-assessed health. A threshold modelof the relationship between income and health was not supported.Conclusion: The relationship of income to health varies notonly according to the health measure chosen but by age and gender.     

The role of gender in long-term sickness absence and transition to permanent disability benefits. Results from a multiregister based,prospective study in Norway 1990-1995

BACKGROUND: The aim of the study was to identify predictors for the transition from long-term sickness absence into disability pension with a special focus on gender. METHODS: The study used data from a national database containing a 10% random sample of the Norwegian adult population (The KIRUT database). The study population were all individuals in the database who on 1 January 1990 were eligible for sick pay from the Norwegian National Insurance System: 83,398 men and 75,586 women. Individuals below 60 years with long-term sickness absence starting in 1990 and 1991 were identified, 6,434 men and 8,233 women, and followed up for three years. Background data were used as independent variables in a logistic regression of the probability for receiving disability pension during follow-up. RESULTS: Annual cumulative incidence of long-term sickness absence was 6.5% for women and 4.9% for men. During follow-up, 12.4% of the women and 12.6% of the men received disability pension. Among full-time employed women only 10.3% had become disability pensioners, while the corresponding proportion for women working part-time was 15.5%. For men the figures were 12.1% (full-time) and 18.1% (part-time). In the logistic regression of the whole sample the female odds ratio was insignificant. The dominant predictive factors for disability pension were age and duration of the sickness spells. Working part-time also increased the risk. Higher levels of education and having children below 7 years reduced the probability for disability pension. Separate regressions for men and women showed that the 'protective' effect of having small children only remained for women.     

Intranasal delivery of whole cell lysate of Mycobacterium tuberculosis induces protective immune responses to a modified live porcine reproductive and respiratory syndrome virus vaccine in pigs

Porcine reproductive and respiratory syndrome (PRRS) is an economically important disease to pork producers worldwide. Commercially, both live and killed PRRSV vaccines are available to control PRRS, but they are not always successful. Based on the results of mucosal immunization studies in other viral models, a good mucosal vaccine may be an effective way to elicit protective immunity to control PRRS outbreaks. In the present study, mucosal adjuvanticity of Mycobacterium tuberculosis whole cell lysate (Mtb WCL) was evaluated in pigs administered a modified live PRRS virus vaccine (PRRS-MLV) intranasally. A Mtb WCL mediated increase in the frequency of NK cells, CD8⁺and CD4⁺ T cells, and γδ T cells in pig lungs were detected. Importantly, an increased and early generation of PRRSV specific neutralizing antibodies were detected in PRRS-MLV+ Mtb WCL compared to pigs inoculated with vaccine alone. In addition, there was an increased secretion of Th1 cytokines (IFNγ and IL-12) that correlated with a reciprocal reduction in the production of immunosuppressive cytokines (IL-10 and TGFβ) as well as T-regulatory cells in pigs vaccinated with PRRS-MLV+ Mtb WCL. Further, a complete rescue in arginase levels in the lungs mediated through Mtb WCL was observed in pigs inoculated with PRRS-MLV. In conclusion, Mtb WCL may be a potent mucosal adjuvant for PRRS-MLV in order to potentiate the anti-PRRSV specific immune responses to control PRRS effectively.     

Incorporation of immunostimulatory motifs in the transcribed region of a plasmid DNA vaccine enhances Th1 immune responses and therapeutic effect against Mycobacterium tuberculosis in mice

T-helper type 1 (Th1) immune response is involved in the development of protective immunity against Mycobacterium tuberculosis. Thus, an increase in Th1 and cellular immune responses should lead to enhanced anti-mycobacterial activity. In this study, we aimed to improve Th1 immune responses to a DNA vaccine by adding potentially immunostimulatory nucleotide sequences into the transcribed region downstream of the antigen. The Mycobacterium leprae gene for hsp65, codon-optimized for expression in mammalian cells, was inserted into pVAX1 with and without 3′-sequences containing CpG and dsRNA motifs. When the plasmid contained both motifs, transfected murine macrophage-like RAW264.7 cells showed markedly increased levels of mRNA for immune molecules of Th1 (IFN-α, IL-12) and Th17 (IL-17, IL-23 and IL-6) responses and for T cell co-stimulatory molecules (CD80 and CD86) but not for a Th2 response (IL-4 and IL-10). Immunized mice showed substantially increased serum anti-Hsp65 IgG2a antibody levels and IFN-γ production by spleen cells, confirming enhancement of the Th1 response in vivo. Furthermore, when non-vaccinated mice were infected with H37Rv by low-dose aerosol challenge, and then 4 weeks later were treated with plasmids by intramuscular injection, the mice that had been treated with plasmids containing immunostimulatory motifs showed an enhanced reduction in mycobacterial loads in lung and spleen. We conclude that DNA vaccines may be made more highly immunogenic and more effective for treatment by including transcribed stimulatory sequences.     

Feasibility and performance of post-mortem examination to determine the aetiology of congenital anomalies in a population of 1019 foetal and perinatal deaths

We assess the feasibility and the performance of a post-mortemexamination protocol including Polaroid® photographs, radiographs,karyotyping, gross and microscopic necropsy, and genetic expertise.This protocol was applied to the 1019 consecutive foetal orperinatal deaths that occurred between January 1984 and June1987 in the Marseille district (France). The feasibility forthe routine use of such a protocol was low; all five componentsof the protocol were completed in only 9% of the cases. Grossautopsy was performed in 85% of the cases, histologic examinationin 48%, successful karyotyping in 17%, radiography in 52% andgenetic expertise in all the cases. Of the 1019 consecutivecases reviewed, 227 lethal congenital anomalies were detected(22.3%). Each element's contribution to the establishment ofthe aetiology of congenital anomalies was assessed. Alone orcombined with the information given by other elements of theprotocol, gross necropsy gave the cause of death in 58% of allcases, karyotyping in 38%, radiography in 3% and genetic expertisein 38%. If the protocol had been applied to malformed Infantsonly, it would have detected 86% of the aetiologies of congenitalanomalies.