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OBJECTIVES Describe the causes of death among infants and children

ImportanceAlthough child mortality trends have decreased worldwide, deaths among children younger than 5 years of age remain high and disproportionately circumscribed to sub-Saharan Africa and Southern Asia. Tailored and innovative approaches are needed to increase access, coverage, and quality of child health care services to reduce mortality, but an understanding of health system deficiencies that may have the greatest impact on mortality among children younger than 5 years is lacking.ObjectiveTo investigate which health care and public health improvements could have prevented the most stillbirths and deaths in children younger than 5 years using data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network.Design, Setting, and ParticipantsThis cross-sectional study used longitudinal, population-based, and mortality surveillance data collected by CHAMPS to understand preventable causes of death. Overall, 3390 eligible deaths across all 7 CHAMPS sites (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa) between December 9, 2016, and December 31, 2021 (1190 stillbirths, 1340 neonatal deaths, 860 infant and child deaths), were included. Deaths were investigated using minimally invasive tissue sampling (MITS), a postmortem approach using biopsy needles for sampling key organs and fluids.Main Outcomes and MeasuresFor each death, an expert multidisciplinary panel reviewed case data to determine the plausible pathway and causes of death. If the death was deemed preventable, the panel identified which of 10 predetermined health system gaps could have prevented the death. The health system improvements that could have prevented the most deaths were evaluated for each age group: stillbirths, neonatal deaths (aged ResultsOf 3390 deaths, 1505 (44.4%) were female and 1880 (55.5%) were male; sex was not recorded for 5 deaths. Of all deaths, 3045 (89.8%) occurred in a healthcare facility and 344 (11.9%) in the community. Overall, 2607 (76.9%) were deemed potentially preventable: 883 of 1190 stillbirths (74.2%), 1010 of 1340 neonatal deaths (75.4%), and 714 of 860 infant and child deaths (83.0%). Recommended measures to prevent deaths were improvements in antenatal and obstetric care (recommended for 588 of 1190 stillbirths [49.4%], 496 of 1340 neonatal deaths [37.0%]), clinical management and quality of care (stillbirths, 280 [23.5%]; neonates, 498 [37.2%]; infants and children, 393 of 860 [45.7%]), health-seeking behavior (infants and children, 237 [27.6%]), and health education (infants and children, 262 [30.5%]).Conclusions and RelevanceIn this cross-sectional study, interventions prioritizing antenatal, intrapartum, and postnatal care could have prevented the most deaths among children younger than 5 years because 75% of deaths among children younger than 5 were stillbirths and neonatal deaths. Measures to reduce mortality in this population should prioritize improving existing systems, such as better access to antenatal care, implementation of standardized clinical protocols, and public education campaigns.

Background The current burden of >5 million deaths yearly is the focus of the Sustainable Development Goal (SDG) to end preventable deaths of newborns and children under 5 years old by 2030. To accelerate progression toward this goal, data are needed that accurately quantify the leading causes of death, so that interventions can target the common causes. By adding postmortem pathology and microbiology studies to other available data, the Child Health and Mortality Prevention Surveillance (CHAMPS) network provides comprehensive evaluations of conditions leading to death, in contrast to standard methods that rely on data from medical records and verbal autopsy and report only a single underlying condition. We analyzed CHAMPS data to characterize the value of considering multiple causes of death. Methods and findings We examined deaths identified from December 2016 through November 2020 from 7 CHAMPS sites (in Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa), including 741 neonatal, 278 infant, and 241 child, In an analysis of data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network, Robert Breiman, Dianna Blau, and colleagues investigate how considering all conditions in the causal chain leading to death informs the identification of deaths attributable to various diagnoses., Author summary Why was this study done? More than 5 million deaths occur annually in children

To compare the prevalence of tuberculosis infection and disease in household contacts of patients with bacteriologically confirmed tuberculosis disease and contacts of non-bacteriologically confirmed disease in western Kenya.We enrolled newly diagnosed index patients and their household contacts from March 2014 to June 2016. All contacts were evaluated with a symptom questionnaire, tuberculin skin test (TST) and HIV test. Clinical evaluation and sputum testing were performed for those with symptoms, positive TST result or HIV infection.We enrolled 1155 contacts of 330 index patients with bacteriologically confirmed tuberculosis and 192 contacts of 55 index patients with non-bacteriologically confirmed tuberculosis. 3.5% of contacts of patients with bacteriologically confirmed tuberculosis were diagnosed with tuberculosis, whereas no contacts of index patients with non-bacteriologically confirmed tuberculosis were. Of those diagnosed with tuberculosis disease, 58.5% reported symptoms, 34.1% reported no symptoms but had positive TST results, and 7.3% had neither symptoms nor positive TST but were HIV-positive. Among 872 contacts with a TST result, 50.9% of contacts of index patients with bacteriologically confirmed tuberculosis and 41.0% of contacts of index patients with non-bacteriologically confirmed tuberculosis had a positive result (prevalence ratio = 1.16, 95% confidence interval 0.92-1.48).In a high-burden setting, tuberculosis disease was more prevalent among contacts of patients with bacteriologically confirmed tuberculosis than contacts of patients with non-bacteriologically confirmed disease. TST was feasible to perform and helped to detect cases that would have been missed had only symptomatic contacts been evaluated.Comparer la prévalence de l'infection et de la maladie tuberculeuses chez les contacts familiaux des patients atteints de tuberculose confirmée bactériologiquement et les contacts de maladies non bactériologiquement confirmées dans l'ouest du Kenya. MÉTHODES: Nous avons recruté des patients indice nouvellement diagnostiqués et leurs contacts familiaux de mars 2014 à juin 2016. Tous les contacts ont été évalués à l'aide d'un questionnaire sur les symptômes, le test cutané à la tuberculine (TCT) et le test VIH. Une évaluation clinique et des tests d'expectoration ont été effectués pour les personnes présentant des symptômes, un résultat positif au TCT ou une infection par le VIH. RÉSULTATS: Nous avons recruté 1.155 contacts de 330 patients index avec une tuberculose confirmée bactériologiquement et 192 contacts de 55 patients indice avec une tuberculose non confirmée bactériologiquement. 3,5% des contacts des patients atteints de tuberculose confirmée bactériologiquement ont été diagnostiqués avec la tuberculose, alors qu'aucun contact des patients indice avec une tuberculose non bactériologiquement confirmée ne l'a été. Parmi les personnes diagnostiquées avec une tuberculose, 58,5% ont signalé des symptômes, 34,1% n'ont signalé aucun symptôme mais avaient des résultats positifs au TCT, et 7,3% n'avaient ni symptômes ni TCT positifs mais étaient VIH positifs. Parmi 872 contacts avec un résultat TCT, 50,9% des contacts des patients indice avec une tuberculose confirmée bactériologiquement et 41,0% des contacts des patients indice avec une tuberculose non bactériologiquement confirmée avaient un résultat positif (rapport de prévalence = 1,16, intervalle de confiance à 95%: 0,92-1,48 ).Dans un contexte de charge élevée, la maladie tuberculose était plus fréquente chez les contacts des patients atteints de tuberculose confirmée bactériologiquement que chez les contacts des patients atteints de la maladie non bactériologiquement confirmée. Le TCT était réalisable et a aidé à détecter les cas qui auraient été ratés si seuls les contacts symptomatiques avaient été évalués.

SETTING: Efficient tuberculosis (TB) active case-finding strategies are important in settings with high TB burdens and limited resources, such as those in western Kenya.OBJECTIVE: To guide efforts to optimize screening efficiency, we identified the predictors of TB among people screened in health facilities and communities.DESIGN: During February 2015-June 2016, adults aged ≥15 years reporting any TB symptom were identified in health facilities and community mobile screening units, and evaluated for TB. We assessed the predictors of TB using a modified Poisson regression with generalized estimating equations to account for clustering according to screening site.RESULTS: TB was diagnosed in 484 (20.3%) of 2394 symptomatic adults in health facilities and 39 (3.4%) of 1424 in communities. In health facilities, >10% of symptomatic adults in all demographic groups had TB, and no predictors were associated with a ≥2-fold increased risk. In communities, the independent predictors of TB were male sex (adjusted prevalence ratio [aPR] = 4.26, 95%CI 2.43-7.45), HIV infection (aPR 2.37, 95%CI 1.18-4.77), and household TB contact in the last 2 years (aPR 2.84, 95%CI 1.62-4.96).CONCLUSION: Our findings support the notion of general TB screening in health facilities and evaluation of the adult household contacts of TB patients.

Background In informal settlements, the benefits of urban dwelling are diminished by conditions of poverty that exacerbate child undernutrition. The Child Health and Mortality Prevention Surveillance (CHAMPS) project has identified malnutrition as the leading underlying cause of death in children under 5 in the Manyatta urban informal settlement in Kisumu County, Kenya. Objective This qualitative study, nested within the CHAMPS project, aimed to understand community perspectives on complementary feeding practices in this settlement. Methods In-depth interviews were conducted with 20 mothers who lived in the urban informal settlement and had a child 6–23 months old. Two focus group discussions were conducted, 1 with mothers and 1 with community health workers (CHWs), to further explore themes related to complementary feeding. Results Mothers were knowledgeable about globally recommended feeding practices, but such practices were often not implemented due to 1) the community/household water and sanitation environment, 2) the community/household food environment, 3) a lack of income and employment opportunities for women, and 4) sociocultural factors. Together, these create an environment that is not conducive to optimal child feeding practices. Conclusions To improve complementary feeding practices and child nutritional outcomes in Kenya's informal urban settings, both community- and individual-level factors should be addressed. Possible interventions include investment in water infrastructure and social protection programs, such as cash transfers.

Background HIV testing efficiency could be improved by focusing on high yield populations and identifying types of health facilities where people with undiagnosed HIV infection are more likely to attend. Methods A retrospective cohort analysis of data collected during an integrated TB/HIV active case-finding intervention in Western Kenya. Data were analyzed from health facilities’ registers on individuals who reported TB-suggestive symptoms between 1 July and 31 December 2018 and who had an HIV test result within one month following symptom screening. We used logistic regression with general estimating equations adjusting for sub-county level data to identify health facility-level predictors of new HIV diagnoses. Results Of 11,376 adults with presumptive TB identified in 143 health facilities, 1038 (9%) tested HIV positive. The median HIV positivity per health facility was 6% (IQR = 2–15%). Patients with TB symptoms were over three times as likely to have a new HIV diagnosis in private not-for-profit facilities compared to those in government facilities (adjusted odds ratio (aOR) 3.40; 95% CI = 1.96–5.90). Patients tested in hospitals were over two times as likely to have a new HIV diagnosis as those tested in smaller facilities (i.e., health centers and dispensaries) (aOR 2.26; 95% CI = 1.60–3.21). Conclusion Individuals with presumptive TB who attended larger health facilities and private not-for-profit facilities had a higher likelihood of being newly diagnosed with HIV. Strengthening HIV services at these facilities and outreach to populations that use them could help to close the HIV diagnosis gap.

OBJECTIVE: To evaluate the utility of a broad and nonspecific symptom screen for identifying people with undiagnosed HIV infection. DESIGN: Secondary analysis of operational data collected during implementation of a cluster-randomized trial for tuberculosis case detection. METHODS: As part of the trial, adults reporting cough, fever, night sweats, weight loss, or difficulty breathing for any duration in the past month were identified in health facilities and community-based mobile screening units in western Kenya. Adults reporting any symptom were offered HIV testing. We analysed the HIV testing data from this study, using modified Poisson regression, to identify predictors of new HIV diagnoses among adults with symptoms and initially unknown HIV status. RESULTS: We identified 3818 symptomatic adults, referred 1424 (37%) for testing, of whom 1065 (75%) accepted, and 107 (10%) were newly diagnosed with HIV. The prevalence of new HIV diagnoses was 21% [95% confidence interval (CI) 17–25%] among those tested in health facilities and 5% (95% CI 4–7%) among those tested in mobile units. More men were diagnosed with HIV than women, despite fewer men being screened. People who reported 4–5 symptoms were over twice as likely to be diagnosed with HIV compared to those reporting 1–3 symptoms (adjusted prevalence ratio in health facilities = 2.58, 95% CI 1.65–4.05; adjusted prevalence ratio in mobile units = 2.63, 95% CI 1.37–5.03). CONCLUSION: We observed a high yield of new HIV diagnoses among adults identified by active application of a broad symptom screen. Use of integrated tuberculosis and HIV screening could help close the detection gap for both conditions.

Although Kenya has a high burden of tuberculosis (TB), only 46% of cases were diagnosed in 2016.To identify strategies for increasing attendance at community-based mobile screening units.We analysed operational data from a cluster-randomised trial, which included community-based mobile screening implemented during February 2015-April 2016. Community health volunteers (CHVs) recruited individuals with symptoms from the community, who were offered testing for human immunodeficiency virus (HIV) and sputum collection for XpertA total of 1424 adults with symptoms were screened at 25 mobile unit sites. The median total attendance among sites was 54 (range 6-134, interquartile range [IQR] 24-84). The median yields of TB diagnoses and new HIV diagnoses were respectively 2.4% (range 0.0-16.7, IQR 0.0-5.3) and 2.5% (range 0.0-33.3, IQR 1.2-4.2). Attendance at urban sites was variable; attendance at rural sites where CHVs were paid a daily minimum wage was significantly higher than at rural sites where CHVs were paid a nominal monthly stipend (Mobile units were most effective and efficient when implemented as a single event with community health workers who are paid a daily wage.Bien que le Kenya soit lourdement affecté par la tuberculose (TB), seulement 46% des cas ont été diagnostiqués en 2016.Identifier les stratégies visant à augmenter la fréquentation des unités mobiles de dépistage en communauté.Nous avons analysé les données opérationnelles d'un essai randomisé en grappes, qui a inclus les unités mobiles de dépistage dans les communautés mises en œuvre entre février 2015 et avril 2016. Les travailleurs de santé communautaire (CHV) ont recruté des individus symptomatiques de la communauté, à qui ont été proposés un test de virus de l'immunodéficience humaine (VIH) et un recueil de crachats pour un test XpertAu total, 1424 adultes symptomatiques ont été dépistés dans 25 sites d'unités mobiles. La fréquentation médiane totale dans les sites a été de 54 (fourchette : 6–134; intervalle interquartile [IQR]: 24–84). Le rendement médian de diagnostic de TB et de nouveaux diagnostics de VIH a été de 2,4% (fourchette 0,0–16,7 ; IQR 0,0–5,3) et de 2,5% (fourchette 0,0–33,3 ; IQR 1,2–4,2), respectivement. La fréquentation dans les sites urbains a été variable ; la fréquentation dans les sites ruraux où les CHV ont reçu un salaire minimum journalier a été significativement plus élevée que dans les sites ruraux où les CHV ont reçu une compensation mensuelle modeste (Les unités mobiles ont été les plus efficaces et rentables quand elles ont été mises en œuvre sous forme d'un évènement unique avec les CHV qui sont payés chaque jour.A pesar de que Kenya tenga una carga de morbilidad por tuberculosis (TB) alta, en el 2016 solo se diagnosticaron 46% de los casos.Definir estrategias que aumenten la asistencia a las unidades móviles comunitarias de detección sistemática.Se analizaron los datos operativos de un ensayo clínico aleatorizado en conglomerados, que incluyó unidades móviles comunitarias de detección activa de la TB de febrero del 2015 a abril del 2016. Los agentes de salud comunitarios voluntarios (CHV) incorporaron a las personas sintomáticas de la comunidad, a quienes se ofreció la prueba diagnóstica del virus de la inmunodeficiencia humana (VIH) y el examen de muestras de esputo con la prueba XpertSe examinaron 1424 adultos sintomáticos en 25 puestos de unidades móviles. La mediana de la asistencia global en todos los puestos fue 54 (entre 6 y 134; amplitud intercuartil [IQR] 24–84). La mediana del rendimiento diagnóstico de TB fue 2,4% (entre 0,0 y 16,7; IQR 0,0–5,3) y la de diagnósticos nuevos de infección por el VIH fue 2,5% (entre 0,0 y 33,3; IQR 1,2–4,2). La asistencia a los puestos urbanos fue variable; en los puestos rurales, donde los CHV recibían un salario mínimo diario, la asistencia fue significativamente más alta que en los puestos donde los voluntarios recibían una remuneración nominal mensual (Las unidades móviles fueron más eficaces y eficientes cuando los CHV operaban en un evento único, con remuneración diaria.

Leveraging an existing community health strategy, a contact tracing intervention was piloted under routine programmatic conditions at three facilities in Kisumu County, Kenya. Data collected during a 6-month period were compared to existing programmatic data. After implementation of the intervention, we found enhanced programmatic contact tracing practices, noting an increase in the proportions of index cases traced, symptomatic contacts referred, referred contacts presenting to a facility for tuberculosis screening, and eligible contacts started on isoniazid preventive therapy. As contact tracing is scaled up, health ministries should consider the adoption of similar contact tracing interventions to improve contact tracing practices.En s'appuyant sur la stratégie de santé communautaire existante, une intervention de recherche des contacts a été pilotée dans des conditions de routine des programmes dans trois structures du comté de Kisumu, Kenya. Les données recueillies sur une période de 6 mois ont été comparées aux données de programme existantes. Après la mise en œuvre de l'intervention, nous avons trouvé des pratiques améliorées de recherche des contacts dans les programmes, notant une augmentation des proportions de recherche des cas index, de référence des contacts symptomatiques, de présentation des contacts référés vers une structure de dépistage de la tuberculose et de mise en route des contacts éligibles sous traitement préventif par isoniazide. A mesure que la recherche des contacts est accrue, les ministres de la santé devraient envisager l'adoption d'interventions similaires de recherche des contacts afin d'améliorer les pratiques de recherche des contacts.A partir de una estrategia de salud comunitaria existente, se puso a prueba una intervención de investigación de contactos de los pacientes tuberculosos (TB) en las condiciones programáticas corrientes, en tres establecimientos del condado de Kisumu en Kenia. Los datos recogidos durante un período de 6 meses se compararon con los datos existentes del programa. Después de la ejecución de la intervención se observó una intensificación de las prácticas programáticas de seguimiento de los contactos, con un aumento de la proporción de casos iniciales localizados, la remisión de los contactos sintomáticos, la remisión de los contactos que acudían a un centro con el fin de practicar la detección de la TB y un aumento del número de pacientes idóneos que comenzaban el tratamiento preventivo con isoniazida. Al ampliar la escala del seguimiento de los contactos, los ministerios de salud deberían considerar la adopción de intervenciones de investigación de contactos semejantes a la que se ensayó en el presente estudio, con el fin de mejorar las prácticas de localización de contactos.

Objective To assess prevalence and occupational risk factors of latent TB infection and history of TB disease ascribed to work in a healthcare setting in western Kenya. Methods We conducted a cross-sectional survey among healthcare workers in western Kenya in 2013. They were recruited from dispensaries, health centres and hospitals that offer both TB and HIV services. School workers from the health facilities' catchment communities were randomly selected to serve as the community comparison group. Latent TB infection was diagnosed by tuberculin skin testing. HIV status of participants was assessed. Using a logistic regression model, we determined the adjusted odds of latent TB infection among healthcare workers compared to school workers; and among healthcare workers only, we assessed work-related risk factors for latent TB infection. Results We enrolled 1005 healthcare workers and 411 school workers. Approximately 60% of both groups were female. A total of 22% of 958 healthcare workers and 12% of 392 school workers tested HIV positive. Prevalence of self-reported history of TB disease was 7.4% among healthcare workers and 3.6% among school workers. Prevalence of latent TB infection was 60% among healthcare workers and 48% among school workers. Adjusted odds of latent TB infection were 1.5 times higher among healthcare workers than school workers (95% confidence interval 1.2–2.0). Healthcare workers at all three facility types had similar prevalence of latent TB infection (P = 0.72), but increasing years of employment was associated with increased odds of LTBI (P < 0.01). Conclusion Healthcare workers at facilities in western Kenya which offer TB and HIV services are at increased risk of latent TB infection, and the risk is similar across facility types. Implementation of WHO-recommended TB infection control measures are urgently needed in health facilities to protect healthcare workers.

Background Tuberculosis (TB) case finding is an important component of TB control because it can reduce transmission of Mycobacterium tuberculosis (MTB) through prompt detection and treatment of infectious patients. Methods Using population-based infectious disease surveillance (PBIDS) platforms with links to health facilities in Kenya we implemented intensified TB case finding in the community and at the health facilities, as an adjunct to routine passive case finding conducted by the national TB program. From 2011 to 2014, PBIDS participants ≥15 years were screened either at home or health facilities for possible TB symptoms which included cough, fever, night sweats or weight loss in the preceding 2 weeks. At home, participants with possible TB symptoms had expectorated sputum collected. At the clinic, HIV-infected participants with possible TB symptoms were invited to produce sputum. Those without HIV but with symptoms lasting 7 days including the visit day had chest radiographs performed, and had sputum collected if the radiographs were abnormal. Sputum samples were tested for the presence of MTB using the Xpert MTB/RIF assay. TB detection rates were calculated per 100,000 persons screened. Results Of 11,191 participants aged ≥15 years screened at home at both sites, 2695 (23.9%) reported possible TB symptoms, of whom 2258 (83.8%) produced sputum specimens. MTB was detected in 32 (1.4%) of the specimens resulting in a detection rate of 286/100,000 persons screened. At the health facilities, a total of 11,762 person were screened, 7500 (63.8%) had possible TB symptoms of whom 1282 (17.1%) produced sputum samples. MTB was detected in 69 (5.4%) of the samples, resulting in an overall detection rate of 587/100,000 persons screened. The TB detection rate was higher in persons with HIV compared to those without at both home (HIV-infected - 769/100,000, HIV-uninfected 141/100,000, rate ratio (RR) – 5.45, 95% CI 3.25–22.37), and health facilities (HIV-infected 3399/100,000, HIV-uninfected 294/100,000, RR 11.56, 95% CI 6.18–18.44). Conclusion Facility-based intensified TB case finding detected more TB cases per the number of specimens tested and the number of persons screened, including those with HIV, than home-based TB screening and should be further evaluated to determine its potential programmatic impact.

BackgroundDeveloping countries grapple with inadequate funding amidst high burden of diseases. Africa is home to 9 of the 22 countries with a high tuberculosis (TB) burden and to 29 of the 41 countries with a high TB-HIV burden. Kenya is among the high TB and high TB-HIV burden countries. The Western Kenya region has the highest burden of TB and HIV. North-South partnerships are pivotal in ameliorating funding gaps in clinical research.MethodsWhile optimising existing infrastructure and organising programme support (i.e sensitisation and awareness creation, leading to study participant recruitment), from 2005 to date we conducted with multiple North-South collaborators capacity strengthening, TB prevalence survey, observational studies, operational research, and vaccine and drug trials.ResultsTB prevalence survey showed 600 cases per 100,000 population, TB epidemiological studies among adolescents and infants yielded 680 and 900/100,000 population respectively while 2 TB vaccine trials among infants and adults were conducted in Siaya. Three TB drug trials and a TB patient observational cum bio-bank study were concluded in Kisumu. KEMRI TB laboratory was upgraded from BSL2 to BSL3, was ISO-accredited in 2013, renewed in 2015 and 2017 and supports TB programme health facilities with retreatment specimens, supervision and mentorship. Over 25 operational TB studies grouped into community and case detection (increasing case detection), diagnostic and molecular (new diagnostic methods) and epidemiology studies (testing and monitoring cohorts for epidemiological questions) were implemented. Five PhDs, 9 Master’s, 2 Postgraduate Diplomas, 6 Bachelor’s degrees and 10 Diplomas have been supported. Siaya clinical research center was built while in Kisumu an adolescent clinic was constructed. This work involved 18 northern and 26 southern partners. Over 35 publications have been published out of these collaborations.ConclusionNorth-South collaborations provided funding, expertise and resources to harness research capacity of KEMRI; hence the need to foster a global networking culture.

Rationale: Limited information exists on the prevalence of tuberculosis and adequacy of case finding in African populations with high rates of HIV. Objectives: To estimate the prevalence of bacteriologically confirmed pulmonary tuberculosis (PTB) and the fraction attributable to HIV, and to evaluate case detection. Methods: Residents aged 15 years and older, from 40 randomly sampled clusters, provided two sputum samples for microscopy; those with chest radiograph abnormalities or symptoms suggestive of PTB provided one additional sputum sample for culture. Measurements and Main Results: PTB was defined by a culture positive for Mycobacterium tuberculosis or two positive smears. Persons with PTB were offered HIV testing and interviewed on care-seeking behavior. We estimated the population-attributable fraction of HIV on prevalent and notified PTB, the patient diagnostic rate, and case detection rate using provincial TB notification data. Among 20,566 participants, 123 had PTB. TB prevalence was 6.0/1,000 (95% confidence interval, 4.6-7.4) for all PTB and 2.5/1,000 (1.6-3.4) for smear-positive PTB. Of 101 prevalent TB cases tested, 52 (51%) were HIV infected, and 58 (64%) of 91 cases who were not on treatment and were interviewed had not sought care. Forty-eight percent of prevalent and 65% of notified PTB cases were attributable to HIV. For smear-positive and smear-negative PTB combined, the patient diagnostic rate was 1.4 cases detected per person-year among HIV-infected persons having PTB and 0.6 for those who were HIV uninfected, corresponding to case detection rates of 56 and 65%, respectively. Conclusions: Undiagnosed PTB is common in this community. TB case finding needs improvement, for instance through intensified case finding with mobile smear microscopy services, rigorous HIV testing, and improved diagnosis of smear-negative TB

Background Tuberculosis (TB) is the leading opportunistic infection and cause of death among people living with HIV (PLHIV). HIV predisposes latently TB-infected people to developing TB disease. Current TB screening algorithms lack sensitivity and specificity. We sought to determine the sensitivity and specificity of conducting a two-step clinical screening and testing for latent TB infection (LTBI). Methods We enrolled 650 newly diagnosed HIV patients aged >7 years from HIV clinics in Kisumu County, Kenya. Study participants were screened for TB symptoms and sputum tested for smear microscopy, liquid culture and GeneXpert MTB/RIF (Xpert). Quantiferon (QFT) and tuberculin skin testing (TST) for LTBI. Positive results from liquid culture or Xpert defined a TB case. ‘Negative for TB’ was any participant with at least two negative Xpert or culture results from different specimens. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated and compared for one – and two – stage screening and stratified by QFT results. Results Females were 62% of participants. TST-positive were 88 of 592 (15%); 274 of 648 (42%) were QFT-positive. TB prevalence was 15%. Screening results for one stage and second stage: 75% and 97% sensitivity, 31% and 12%, specificity, 89% and 96% NPV and 14% and 15% PPV, respectively. Screening performance stratified by QFT for sensitivity, specificity, NPV and PPV was 96%, 11%, 91% and 24% among QFT-positive. Conclusions Two-step versus one-step screening increases sensitivity but reduces specificity. Positive QFT result increases the PPV of two-step screening.

Background HIV-infected people are at greatest risk of progression from latent tuberculosis infection (LTBI) to development of active tuberculosis (TB) disease. Accurate diagnosis and treatment of LTBI in this group is an essential component of the WHO TB control strategy. Interferon-gamma assays have emerged as novel alternatives to the tuberculin skin test (TST) for the diagnosis of LTBI. Comparable performance for these two tests is not fully evaluated in regions with high incidence of HIV and TB. We compared the performance of QuantiFERON TB-Gold In-tube® assay (QFT) and TST tests for LTBI. Methods Newly diagnosed HIV patients older than 7 years were enrolled from HIV clinics. Blood was drawn for QFT assay, thereafter TST was placed into the volar surface of the forearm. The TST was read at 48–72 hours and deemed positive at >or=5 mm. Statistical analyses were performed using SAS 9.2. Agreement evaluated using kappa (k) statistic. Results Of the 650 HIV-infected participants, 62% were females; median age (IQR) was 32 (26–39). Among 592 (91%) who received TST, 88 (17%) were positive; QFT positives were 274 (42%). Indeterminate QFT results were 22 (3%). Overall agreement between QFT and TST was 37% (95% CI: 30–45%). Agreement was 56% (95% CI: 30–45%) and 15% (95% CI: 30–45%) for negative and positive QFT and TST results. Conclusions Low prevalence of LTBI was found; however, agreement between the 2 tests was moderate. This lack of agreement calls for a search for a better diagnostic test for LTBI among HIV-infected persons in TB endemic regions since TST positivity is associated with better response to INH in LTBI patients.

Background The findings of a prevalence survey conducted in western Kenya, in a population with 14.9% HIV prevalence suggested inadequate case finding. We found a high burden of infectious and largely undiagnosed pulmonary tuberculosis (PTB), that a quarter of the prevalent cases had not yet sought care, and a low case detection rate. Objective and methods We aimed to identify factors associated with inadequate case finding among adults with PTB in this population by comparing characteristics of 194 PTB patients diagnosed in a health facility after self-report, i.e., through passive case detection, with 88 patients identified through active case detection during the prevalence survey. We examined associations between method of case detection and patient characteristics, including HIV-status, socio-demographic variables and disease severity in univariable and multivariable logistic regression analyses. Findings HIV-infection was associated with faster passive case detection in univariable analysis (crude OR 3.5, 95% confidence interval (CI) 2.0–5.9), but in multivariable logistic regression this was largely explained by the presence of cough, illness and clinically diagnosed smear-negative TB (adjusted OR (aOR) HIV 1.8, 95% CI 0.85–3.7). Among the HIV-uninfected passive case detection was less successful in older patients aOR 0.76, 95%CI 0.60–0.97 per 10 years increase), and women (aOR 0.27, 95%CI 0.10–0.73). Reported current or past alcohol use reduced passive case detection in both groups (0.42, 95% CI 0.23–0.79). Among smear-positive patients median durations of cough were 4.0 and 6.9 months in HIV-infected and uninfected patients, respectively. Conclusion HIV-uninfected patients with infectious TB who were older, female, relatively less ill, or had a cough of a shorter duration were less likely found through passive case detection. In addition to intensified case finding in HIV-infected persons, increasing the suspicion of TB among HIV-uninfected women and the elderly are needed to improve TB case detection in Kenya.

Background: We conducted a tuberculosis (TB) prevalence survey and evaluated the screening methods used in our survey, to assess if screening in TB prevalence surveys could be simplified, and to assess the accuracy of screening algorithms that may be applicable for active case finding. Methods: All participants with a positive screen on either a symptom questionnaire, chest radiography (CXR) and/or sputum smear microscopy submitted sputum for culture. HIV status was obtained from prevalent cases. We estimated the accuracy of modified screening strategies with bacteriologically confirmed TB as the gold standard, and compared these with other survey reports. We also assessed whether sequential rather than parallel application of symptom, CXR and HIV screening would substantially reduce the number of participants requiring CXR and/or sputum culture. Results: Presence of any abnormality on CXR had 94% (95%CI 88-98) sensitivity (92% in HIV-infected and 100% in HIV-uninfected) and 73% (95%CI 68-77) specificity. Symptom screening combinations had significantly lower sensitivity than CXR except for 'any TB symptom' which had 90% (95%CI 84-95) sensitivity (96% in HIV-infected and 82% in HIV-uninfected) and 32% (95%CI 30-34) specificity. Smear microscopy did not yield additional suspects, thus the combined symptom/CXR screen applied in the survey had 100% (95%CI 97-100) sensitivity. Specificity was 65% (95%CI 61-68). Sequential application of first a symptom screen for 'any symptom', followed by CXR-evaluation and different suspect criteria depending on HIV status would result in the largest reduction of the need for CXR and sputum culture, approximately 36%, but would underestimate prevalence by 11%. Conclusion: CXR screening alone had higher accuracy compared to symptom screening alone. Combined CXR and symptom screening had the highest sensitivity and remains important for suspect identification in TB prevalence surveys in settings where bacteriological sputum examination of all participants is not feasible

Background The two issues mostly affecting the success of tuberculosis (TB) control programmes are delay in presentation and non-adherence to treatment. It is important to understand the factors that contribute to these issues, particularly in resource limited settings, where rates of tuberculosis are high. The objective of this study is to assess health-seeking behaviour and health care experiences among persons with pulmonary tuberculosis, and identify the reasons patients might not complete their treatment. Methods We performed qualitative one-on-one in-depth interviews with pulmonary tuberculosis patients in nine health facilities in rural western Kenya. Thirty-one patients, 18 women and 13 men, participated in the study. All reside in an area of western Kenya with a Health and Demographic Surveillance System (HDSS). They had attended treatment for up to 4 weeks on scheduled TB clinic days in September and October 2005. The nine sites all provide diagnostic and treatment services. Eight of the facilities were public (3 hospitals and 5 health centres) and one was a mission health centre. Results Most patients initially self-treated with herbal remedies or drugs purchased from kiosks or pharmacies before seeking professional care. The reported time from initial symptoms to TB diagnosis ranged from 3 weeks to 9 years. Misinterpretation of early symptoms and financial constraints were the most common reasons reported for the delay. We also explored potential reasons that patients might discontinue their treatment before completing it. Reasons included being unaware of the duration of TB treatment, stopping treatment once symptoms subsided, and lack of family support. Conclusions This qualitative study highlighted important challenges to TB control in rural western Kenya, and provided useful information that was further validated in a quantitative study in the same area.