We identified risk factors associated with increased yearly incidence rates of leprosy in five island populations. Age, sex, household size and Mycobacterium leprae-specific antibodies as well as contact factors were studied. Of 94 index patients (patients diagnosed in 2000), 43 (46%) were classified as multibacillary (MB), 17 (19%) were seropositive for PGOL antibodies and 6 (7%) had M. leprae DNA in nasal swabs as determined by polymerase chain reaction (PCR) testing. All PCR positive patients were also seropositive. Forty-four of 4903 initially symptom free persons developed leprosy within 4 years, giving an incidence rate of 2.98 per 1000 person-years. Men had a 2.2 times higher risk [95% confidence interval (CI): 1.2–4.1] of developing leprosy than women. People living in households with more than 7 members had a 3.1 times higher risk (95% CI: 1.3–7.3) than households of 1–4 members. Persons who were seropositive in 2000 had a 3.8 times higher risk (95% CI: 1.1–12.6) than seronegative persons. Household contacts of MB patients had an adjusted hazard ratio (aHR) of 4.6 (95% CI: 1.6–12.9) and household contacts of PCR positive patients an aHR of 9.36 (95% CI: 2.5–34.9) compared with non-contacts. Patients with PCR positive nasal swabs, suggesting nasal excretion of M. leprae, are probably the patients with the highest transmission potential. Since all index patients who were PCR positive were also seropositive, serology seems an adequate tool to identify these patients. Preventing seropositive persons from becoming seropositive and infectious patients might break the chain of transmission.

An intervention study was implemented on five Indonesian islands highly endemic for leprosy to determine whether rifampicin can be used as chemoprophylaxis to prevent leprosy. The population was actively screened before the intervention and subsequently once a year for three years. In the control group, no chemoprophylaxis was given. In the contact group, chemoprophylaxis was only given to contacts of leprosy patients and in the blanket group to all eligible persons. The cohort consisted of 3,965 persons. The yearly incidence rate in the control group was 39/10,000; the cumulative incidence after three years was significantly lower in the blanket group (P = 0.031). No difference was found between the contact and the control groups (P = 0.93). Whether this apparent reduced leprosy incidence in the first three years in the blanket group is due to a delayed development of leprosy or a complete clearance of infection needs to be determined.

Background: Data on active TB case finding activities among artisanal gold mining communities (AMC) is limited. The study assessed the yield of TB cases from the TB screening activities among AMC in Ghana, the factors associated with TB in these communities and the correlation between the screening methods and a diagnosis of TB. Methods: We conducted secondary data analyses of NTP program data collected from TB case finding activities using symptom screening and mobile X-ray implemented in hard to reach AMC. Yield of TB cases, number needed to screen (NNS) and the number needed to test (NNT) to detect a TB case were assessed and logistic regression were conducted to assess factors associated with TB. The performance of screening methods chest X-ray and symptoms in the detection of TB cases was also evaluated. Results: In total 10,441 people from 78 communities in 24 districts were screened, 55% were female and 60% (6,296) were in the aged 25 to 54 years. Ninety-five TB cases were identified, 910 TB cases per 100,000 population screened; 5.6% of the TB cases were rifampicin resistant. Being male (aOR 5.96, 95% CI 3.25–10.92, P < 0.001), a miner (aOR 2.70, 95% CI 1.47–4.96, P = 0.001) and age group 35 to 54 years (aOR 2.27, 95% CI 1.35–3.84, P = 0.002) were risk factors for TB. NNS and NNT were 110 and 24 respectively.; Cough of any duration had the strongest association with X-ray suggestive of TB with a correlation coefficient of 0.48. Cough was most sensitive for a diagnosis of TB; sensitivity of 86.3% (95% CI 79.4–93.2) followed by X-ray, sensitivity 81.1% (95% CI 71.7–88.4). The specificities of the symptoms and X-rays ranged from 80.2% (cough) to 97.3% (sputum). Conclusion: The high risk of TB in the artisanal mining communities and in miners in this study reinforces the need to target these populations with outreach programs particularly in hard to reach areas. The diagnostic value of cough highlights the usefulness of symptom screening in this population that may be harnessed even in the absence of X-ray to identify those suspected to have TB for further evaluation.

SETTING: Tuberculosis (TB) stigma is thought to delay or prevent the decision to seek health care, but the strength of this association and the prevalence of anticipated TB stigma in the general population in most countries is unknown. OBJECTIVE: To examine epidemiological, cultural and sociodemographic factors associated with TB courtesy stigma in 15 surveys across 13 countries, and its link to health seeking for cough in children under five. DESIGN: A multilevel survey weighted logistic regression model was used to analyse how individual characteristics and social contexts affect the occurrence of TB courtesy stigma. The same modelling approach was used to analyse associations between TB courtesy stigma and individual-level predictors of health-seeking behaviour of mothers for children with cough. RESULTS: TB courtesy stigma varies greatly among countries. TB courtesy stigma was negatively correlated with knowledge of TB's curability (adjusted OR [aOR] 0.82; 95%CI 0.78–0.86) and human immunodeficiency virus (HIV) accepting attitudes (proxy for HIV stigma) (aOR 0.15, 95%CI 0.15–0.16). Mothers' health-seeking behaviour for children under five with cough was found to be positively correlated with HIV accepting attitudes (OR 1.16, 95%CI 1.08–1.25), but was marginally affected by TB courtesy stigma (OR 0.99, 95%CI 0.98–1.00). CONCLUSION: Improving the general awareness of the effectiveness of anti-tuberculosis treatment will help to diminish TB courtesy stigma, and should be prioritised over expanding knowledge of mode of transmission. Efforts to reduce HIV and TB stigma may increase care seeking for childhood TB symptoms.

Background: Staff shortages could harm the provision and quality of health care in Uganda, so staff retention and motivation are crucial. Understanding the impact of HIV/AIDS on staff contributes to designing appropriate retention and motivation strategies. This research aimed 'to identify the influence of HIV/AIDS on staff working in general hospitals at district level in rural areas and to explore support required and offered to deal with HIV/AIDS in the workplace'. Its results were to inform strategies to mitigate the impact of HIV/AIDS on hospital staff. Methods: A cross-sectional study with qualitative and quantitative components was implemented during two weeks in September 2005. Data were collected in two government and two faith-based private not-for-profit hospitals purposively selected in rural districts in Uganda's Central Region. Researchers interviewed 237 people using a structured questionnaire and held four focus group discussions and 44 in-depth interviews. Results: HIV/AIDS places both physical and, to some extent, emotional demands on health workers. Eighty-six per cent of respondents reported an increased workload, with 48 per cent regularly working overtime, while 83 per cent feared infection at work, and 36 per cent reported suffering an injury in the previous year. HIV-positive staff remained in hiding, and most staff did not want to get tested as they feared stigmatization. Organizational responses were implemented haphazardly and were limited to providing protective materials and the HIV/AIDS-related services offered to patients. Although most staff felt motivated to work, not being motivated was associated with a lack of daily supervision, a lack of awareness on the availability of HIV/AIDS counselling, using antiretrovirals and working overtime. The specific hospital context influenced staff perceptions and experiences. Conclusion: HIV/AIDS is a crucially important contextual factor, impacting on working conditions in various ways. Therefore, organizational responses should be integrated into responses to other problematic working conditions and adapted to the local context. Opportunities already exist, such as better use of supervision, educational sessions and staff meetings. However, exchanges on interventions to improve staff motivation and address HIV/AIDS in the health sector are urgently required, including information on results and details of the context and implementation process.

In Rwanda tuberculosis (TB) is one of the major health problems. To contribute to an improved performance of the Rwandan National TB Control Program, we conducted a study with the following objectives: (1) to assess the completion rate of sputum smear examinations at the end of the intensive phase of TB treatment; (2) to assess the sputum conversion rate (SCR); (3) to assess associations between smear completion rate or SCR with key health facility characteristics.