Relapse and mortality among HIV-infected and uninfected patients with tuberculosis successfully treated with twice weekly directly observed therapy in rural South Africa

Objective: To determine post-treatment relapse and mortality rates among HIV-infected and uninfected patients with tuberculosis treated with a twice-weekly drug regimen under direct observation (DOT). Setting: Hlabisa, South Africa. Patients: A group of 403 patients with tuberculosis (53% HIV infected) cured following treatment with isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E) given in hospital (median 17 days), followed by HRZE twice weekly to 2 months and HR twice weekly to 6 months in the community under DOT. Methods: Relapses were identified through hospital readmission and 6-monthly home visits. Relapse (culture for Mycobacterium tuberculosis) and mortality given as rates per 100 person-years observation (PYO) stratified by HIV status and history of previous tuberculosis treatment. Results: Mean (SD) post-treatment follow-up was 1.2 (0.4) years (total PYO = 499); 78 patients (19%) left the area, 58 (14%) died, 248 (62%) remained well and 19 (5%) relapsed. Relapse rates in HIV-infected and uninfected patients were 3.9 [95% confidence interval (CI) 1.5-6.3] and 3.6 (95% CI 1.1-6.1) per 100 PYO (P = 0.7). Probability of relapse at 18 months was estimated as 5% in each group. Mortality was four-fold higher among HIV-infected patients (17.8 and 4.4 deaths per 100 PYO for HIV-infected and uninfected patients, respectively; P < 0.0001). Probability of survival at 24 months was estimated as 59% and 81%, respectively. We observed no increase in relapse or mortality among previously treated patients compared with new patients. A positive smear at 2 months did not predict relapse or mortality. Conclusion: Relapse rates are acceptably low following successful DOT with a twice weekly rifampifin-containing regimen, irrespective of HIV status and previous treatment history. Mortality is substantially increased among HIV-infected patients even following successful DOT and this requires further attention. (C) 1999 Lippincott Williams & Wilkins.

Women's health Australia: On the progress of the main cohort studies

More than 41,000 women aged 18-23, 45-50, and 70-75 years in 1996 are participating in the Australian Longitudinal Study on Women's Health (Women's Health Australia). Baseline surveys were conducted for all three cohorts in 1996, and the first follow-up survey of the mid-age group in 1998 has achieved a response rate exceeding 90%. The main findings so far reflect the large differences in the life experiences of the three cohorts. The young women report high levels of stress. The physical and mental health of those with young children is worse than for those without children, but confounding by sociodemographic characteristics may account for the differences. Two thirds of young women in the healthy weight or underweight range would like to weigh less, and early onset of dieting is associated with poorer physical and mental health. Most of the women in the mid-age group have multiple roles-in paid work, home duties, and caring for children and other dependents. The potential of the study to investigate the long-term impact of such busy lives on health outcomes is considerable. At this stage, the main health issues for these women relate to tiredness, weight gain, and menopause. The older cohort presents a picture of positive aging. These women are heavier users of health services than the mid-age and younger women, and they are also more satisfied with these services. Although their physical health is poorer, their mental health is better, and they report less stress than women in the other two cohorts. The follow-up survey of this group, planned for 1999, will focus on the coping strategies used by these women. An overall goal of the project is to understand the interactions among social roles, life events, and women's health in order to provide a basis for improved health policies and services. Analysis of these interactions, which relies on both quantitative and qualitative data, poses many challenges that will be addressed as the longitudinal data become available.

Emergence of multidrug-resistant tuberculosis in a community-based directly observed treatment programme in rural South Africa

OBJECTIVE: Although little studied in developing countries, multidrug-resistant tuberculosis (MDR-TB) is considered a major threat. We report the molecular epidemiology, clinical features and outcome of an emerging MDR-TB epidemic. METHODS: In 1996 all tuberculosis suspects in the rural Hlabisa district, South Africa, had sputum cultured, and drug susceptibility patterns of mycobacterial isolates were determined. Isolates with MDR-TB (resistant to both isoniazid and rifampicin) were DNA fingerprinted by restriction fragment length polymorphism (RFLP) using IS6110 and polymorphic guanine-cytosine-rich sequence-based (PGRS) probes. Patients with MDR-TB were traced to determine outcome. Data were compared with results from a survey of drug susceptibility done in 1994. RESULTS: The rate of MDR-TB among smear-positive patients increased six-fold from 0.36% (1/275) in 1994 to 2.3% (13/561) in 1996 (P = 0.04). A further eight smear-negative cases were identified in 1996 from culture, six of whom had not been diagnosed with tuberculosis. MDR disease was clinically suspected in only five of the 21 cases (24%). Prevalence of primary and acquired MDR-TB was 1.8% and 4.1%, respectively. Twelve MDR-TB cases (67%) were in five RFLP-defined clusters. Among 20 traced patients, 10 (50%) had died, five had active disease (25%) and five (25%) were apparently cured. CONCLUSIONS: The rate of MDR-TB has risen rapidly in Hlabisa, apparently due to both reactivation disease and recent transmission. Many patients were not diagnosed with tuberculosis and many were not suspected of drug-resistant disease, and outcome was poor.

Tuberculosis and health sector reform: experience of integrating tuberculosis services into the district health system in rural South Africa

SETTING: Hlabisa health district, South Africa. OBJECTIVE: To describe the integration of a vertical tuberculosis control programme into an emerging 'horizontal' district health system, within the context of health sector reform. DESIGN: Descriptive account of the process of integration of the programme into the health system. RESULTS: A highly 'vertical' system of delivering tuberculosis treatment (with poor programme outcomes) was converted into a (horizontal' team, integrated within the district health system, that used available resources such as village clinics and community health workers, with improved programme outcomes. CONCLUSIONS: In some settings at least, integration of tuberculosis 'programmes' into the district health system as tuberculosis 'teams' is feasible, and may produce highly cost-effective outcomes.

Sedimentologic, petrographic, and sulfur isotope constraints on fine-grained pyrite formation at Mount Isa Mine and environs, Northwest Queensland, Australia

Fine-grained pyrite is the earliest generation of pyrite and the most abundant sulfide within the Urquhart Shale at Mount Isa, northwest Queensland. The pyrite is intimately interbanded with ore-grade Pb-Zn miner alization at the Mount Isa mine but is also abundant north and south of the mine at several stratigraphic horizons within the Urquhart Shale. Detailed sedimentologic, petrographic, and sulfur isotope studies of the Urquhart Shale, mostly north of the mine, reveal that the fine-grained pyrite (delta(34)S = -3.3 to +26.3 parts per thousand) formed by thermochemical sulfate reduction during diagenesis. The sulfate source was local sulfate evaporites, pseudo morphs of which are present throughout the Urquhart Shale (i.e., gypsum, anhydrite, and barite). Deep-burial diagenetic replacement of these evaporites resulted in sulfate-bearing ground waters which migrated parallel to bedding. Fine-grained pyrite formed where these fluids infiltrated and then interacted with carbon-rich laminated siltstones. Comparison of the sulfur isotope systematics of fine-grained pyrite and spatially associated base metal sulfides from the Mount Isa Pb-Zn and Cu orebodies indicates a common sulfur source of ultimately marine origin for all sulfide types. Different sulfur isotope ratio distributions for the various sulfides are the result of contrasting formation mechanisms and/or depositional conditions rather than differing sulfur sources. The sulfur isotope systematics of the base metal and associated iron sulfide generations are consistent with mineralization by reduced hydrothermal fluids, perhaps generated by bulk reduction of evaporite-sourced sulfate-bearing waters generated deeper in the Mount Isa Group, the sedimentary sequence which contains the Urquhart Shale. The available sulfur isotope data from the Mount Isa orebodies are consistent with either a chemically and thermally zoned, evolving Cu-Pb-Zn system, or discrete Cu and Pb-Zn mineralizing events linked by a common sulfur source.

Comparison of calcaneal ultrasound and DXA in young women

Purpose: The purpose of the study was to assess quantitative ultrasound (QUS) parameters in collegiate female gymnasts, a population whose training incorporates high-impact loading, which is particularly osteogenic, and to determine the discriminative capacity of this relatively new radiation-free technique compared with bone densitometry in a young healthy population. Methods: We studied 19 collegiate gymnasts and 23 healthy controls undergoing regular weight-bearing activity, matched for age (gymnasts 19.2 +/- 1.2, controls 19.9 +/- 1.6 yr) and body weight (gymnasts 56.7 +/- 3.7, controls 57.7 +/- 7.8 kg). QUS parameters of the calcaneus (broadband ultrasound attenuation (BUA), bone velocity (BV), and speed of sound (SOS)) were measured by a Walker Sonix UBA 575+. Bone mineral density (BMD; g.cm(-2)) of the lumbar spine, hip (Femoral neck, trochanter. Ward's triangle) and whole body was assessed by dual energy x-ray absorptiometry (DXA, Hologic QDR 1000/W). Data analysis included unpaired two-tailed Student's t-tests, analysis of variance, Pearson product-moment, and Spearman rank-order correlations. Results: Regional and whole body BMD of gymnasts was greater than controls (P < 0.001), with the difference being 7-28%. Average QUS parameters of the right and left calcaneus were also higher (P < 0.001) in the gymnasts. BUA, BV, and SOS were significantly (P < 0.001) correlated to each bone site with r = 0.54-0.79. Analysis of receiver operating characteristic (ROC) curves indicated no significant difference in sensitivity and specificity for QUS and DXA measures. Conclusions: These results indicate that QUS parameters of the calcaneus are higher in young women gymnasts compared to individuals who undergo regular weight-bearing activity and that QUS parameters are able to discriminate between these two groups in a similar manner as does regional and whole body BMD.

HIV infection among women admitted to the gynaecology service of a district hospital in South Africa

Our objective was to determine the prevalence of HIV infection and disease-specific HIV prevalence among women admitted to the gynaecology service of a district hospital in South Africa over a 3-month period in 1997. This was done with the goal of developing HIV education and counselling services in this setting. HIV status was determined among 196 (96%) of 205 consecutive admissions; 82 (42%) tested HIV positive. The HIV-infected women were younger than the HIV uninfected women (mean age 27 vs 33 years, P=0.001). The disease-specific HIV prevalence was greater than or equal to 40% among women who had had abortions, pelvic inflammatory disease, or ectopic pregnancy. The length of hospital stay (mean 5.4 days) and mortality (1%) were similar in the 2 groups. Inpatient gynaecology services may be act important setting in Africa, within which to provide HIV education, counselling and care.

Leaking urine: Prevalence and associated factors in Australian women

The Women's Health Australia project provided the opportunity to examine the prevalence of leaking urine and associated variables in three large cohorts of Australian women 18-23 years of age (young N = 14,761), 45-50 (mid-age N = 14,070), and 70-75 (older N = 12,893). The proportion of women reporting leaking urine was 12.8% (95% CI: 12.2-13.3), 36.1% (35.2-37.0), and 35% (34.1-35.9) in each of the three cohorts, respectively. Logistic regression analysis showed significant associations between leaking urine and parity in the young and mid-age women, and between leaking urine and constipation, other bowel symptoms, body mass index, and urine that burns or stings in all three groups. in the mid-age and older cohorts, women who reported having both hysterectomy and prolapse repair, or prolapse repair alone, were also more likely to report leaking urine. Lower scores on the physical and mental component summary scores of the medical outcomes survey short form (36 items) questionnaire suggest lower quality of life among women who report leaking urine, compared with those who do not. (C) 1999 Wiley-Liss,Inc.

Who fails to complete tuberculosis treatment? Temporal trends and risk factors for treatment interruption in a community-based directly observed therapy programme in a rural district of South Africa

SETTING: Hlabisa Tuberculosis Programme, Hlabisa, South Africa. OBJECTIVE: To determine trends in and risk factors for interruption of tuberculosis treatment. METHODS: Data were extracted from the control programme database starting in 1991. Temporal trends in treatment interruption are described; independent risk factors for treatment interruption were determined with a multiple logistic regression model, and Kaplan-Meier survival curves for treatment interruption were constructed for patients treated in 1994-1995. RESULTS: Overall 629 of 3610 surviving patients (17%) failed to complete treatment; this proportion increased from 11% (n = 79) in 1991/1992 to 22% (n = 201) in 1996. Independent risk factors for treatment interruption were diagnosis between 1994-1996 compared with 1991-1393 (odds ratio [OR] 1.9, 95% confidence interval [CT] 1.6-2.4); human immunodeficiency virus (HIV) positivity compared with HIV negativity (OR 1.8, 95% CI 1.4-2.4); supervised by village clinic compared with community health worker (OR 1.9, 95% CI 1.4-2.6); and male versus female sex (OR 1.3, 95% CI 1.1-1.6). Few patients interrupted treatment during the first 2 weeks, and the treatment interruption rate thereafter was constant at 1% per 14 days. CONCLUSIONS: Frequency of treatment interruption from this programme has increased recently. The strongest risk factor was year of diagnosis, perhaps reflecting the impact of an increased caseload on programme performance. Ensuring adherence to therapy in communities with a high level of migration remains a challenge even within community-based directly observed therapy programmes.

Accessibility to general practitioners in rural South Australia - A case study using geographic information system technology

Objective: To demonstrate the potential of GIS (geographic information system) technology and ARIA (Accessibility/Remoteness Index for Australia) as tools for medical workforce and health service planning in Australia. Design: ARIA is an index of remoteness derived by measuring road distance between populated localities and service centres. A continuous variable of remoteness from 0 to 12 is generated for any location in Australia. We created a GIS, with data on location of general practitioner services in non-metropolitan South Australia derived from the database of HUMPS (Rural Undergraduate Medical Placement System), and estimated, for the 1170 populated localities in South Australia, the accessibility/inaccessibility of the 109 identified GP services. Main outcome measures: Distance from populated locality to GP services. Results: Distance from populated locality to GP service ranged from 0 to 677 km (mean, 58 km). In all, 513 localities (43%) had a GP service within 20 km (for the majority this meant located within the town). However, for 173 populated localities (15%), the nearest GP service was more than 80 km away. There was a strong correlation between distance to GP service and ARIA value for each locality (0.69; P<0.05). Conclusions: GP services are relatively inaccessible to many rural South Australian communities. There is potential for GIS and for ARIA to contribute to rational medical workforce and health service planning. Adding measures of health need and more detailed data on types and extent of GP services provided will allow more sophisticated planning.

Litterfall from two eucalypt woodlands in central Queensland

The mean annual litterfall at two dry woodland sites in central Queensland was 1129 kg ha(-1) for an open E. populnea F. Muell. woodland (n = 2 years), and 2318 kg ha(-1) for a woodland dominated by E. cambageana Maiden (n = 1 year). Leaves formed the largest component of total litterfall, which varied seasonally with a spring-summer maximum. Annual litterfall at these sites conformed with a pattern of decreasing litter production with declining annual rainfall, consistent with a range of eucalypt-dominated communities.