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The zoonotic origin of the SARS-CoV-2 pandemic is still unknown. Animal experiments have shown that non-human primates, cats, ferrets, hamsters, rabbits and bats can be infected by SARS-CoV-2. In addition, SARS-CoV-2 RNA has been detected in felids, mink and dogs in the field. Here, we describe an in-depth investigation of outbreaks on 16 mink farms and humans living or working on these farms, using whole genome sequencing. We conclude that the virus was initially introduced from humans and has evolved, most likely reflecting widespread circulation among mink in the beginning of the infection period several weeks prior to detection. At the moment, despite enhanced biosecurity, early warning surveillance and immediate culling of infected farms, there is ongoing transmission between mink farms with three big transmission clusters with unknown modes of transmission. We also describe the first animal to human transmissions of SARS-CoV-2 in mink farms.One sentence summarySARS-CoV-2 transmission on mink farms.

ObjectiveTo quantify the prediagnostic loss to follow-up (PDLFU) in an active case finding tuberculosis (TB) programme and identify the barriers and enablers in undergoing diagnostic evaluation.DesignExplanatory mixed-methods design.SettingA rural population of 1.02 million in the Samastipur district of Bihar, India.ParticipantsBased on their knowledge of health status of families, community health workers or CHWs (called accredited social health activist or locally) and informal providers referred people to the programme. The field coordinators (FCs) in the programme screened the referrals for TB symptoms to identify presumptive TB cases. CHWs accompanied the presumptive TB patients to free diagnostic evaluation, and a transport allowance was given to the patients. Thereafter, CHWs initiated and supported the treatment of confirmed cases. We included 13 395 community referrals received between January and December 2018. To understand the reasons of the PDLFU, we conducted in-depth interviews with patients who were evaluated (n=3), patients who were not evaluated (n=4) and focus group discussions with the CHWs (n=2) and FCs (n=1).Outcome measuresProportion and characteristics of PDLFU and association of demographic and symptom characteristics with diagnostic evaluation.ResultsA total of 11 146 presumptive TB cases were identified between January and December 2018, out of which 4912 (44.1%) underwent diagnostic evaluation. In addition to the free TB services in the public sector, the key enablers were CHW accompaniment and support. The major barriers identified were misinformation and stigma, deficient family and health provider support, transport challenges and poor services in the public health system.ConclusionFinding the missing cases will require patient-centric diagnostic services and urgent reform in the health system. A community-oriented intervention focusing on stigma, misinformation and patient support will be critical to its success.

backgroundDespite active case-finding (ACF) identifying more presumptive and confirmed TB cases, high pre-diagnostic loss to follow-up (PDLFU) among presumptive TB cases referred for diagnostic test remains a concern. We aimed to quantify the PDLFU, and identify the barriers and enablers in undergoing a diagnostic evaluation in an ACF program implemented in 1.02 million rural population in the Samastipur district of Bihar, India.methodsDuring their routine work, Accredited Social Health Activists (ASHA, a community health worker or CHW), informal providers, and community laypersons identified people at risk of TB, and referred them to the program. A field coordinator (FC) screened them for TB symptoms at the patient’s home. The identified presumptive TB cases were accompanied by the CHW to a designated government facility for diagnostics. Those with a confirmed TB diagnosis were put on treatment by the CHW and followed-up till treatment completion. All services were provided free of cost and patients were supported throughout the care pathway, including a transport allowance. We analyzed programmatically collected data, conducted in-depth interviews with patients, and focus group discussions with the CHWs and FCs in an explanatory mixed-methods design.resultsA total of 11146 presumptive TB cases were identified from January 2018 to December 2018, out of which 4912 (44.1%) underwent a diagnostic evaluation. The key enablers were CHW accompaniment and support in addition to the free TB services in the public sector. The major barriers identified were transport challenges, deficient family and health provider support, and poor services in the public system.conclusionIf we are to find missing cases, the health system needs urgent reform, and diagnostic services need to be patient-centric. A strong patient support system engaging all stakeholders and involvement of CHWs in routine TB care is an effective solution.STRENGTHS AND LIMITATIONS OF THIS STUDYFirst such study to explore the reasons for pre-diagnostic loss to follow-upA mixed-method design including the views of both patients and community health workersUses operational data from a routine programmatic setting at an NGO siteNo record of the actual number of people screened intuitively before being referred to the program.No record of patients accessing diagnostics in private sector and those completing the diagnostic process.

After many years of TB ‘control’ and incremental progress, the TB community is talking about ending the disease, yet this will only be possible with a shift in the way we approach the TB response. While the Asia-Pacific region has the highest TB burden worldwide, it also has the opportunity to lead the quest to end TB by embracing the four areas laid out in this series: using data to target hotspots, initiating active case finding, provisioning preventive TB treatment, and employing a biosocial approach. The Stop TB Partnership’s TB REACH initiative provides a platform to support partners in the development, evaluation and scale-up of new and innovative technologies and approaches to advance TB programs. We present several approaches TB REACH is taking to support its partners in the Asia-Pacific and globally to advance our collective response to end TB.

Background No guidelines exist on assessing ventilation through air changes per hour (ACH) using a vaneometer. The objective of the study was to evaluate the position and frequency for measuring air velocity using a vaneometer to assess ventilation with ACH; and to assess influence of ambient temperature and weather on ACH. Methods Cross-sectional survey in six urban health facilities in Kampala, Uganda. Measurements consisted of taking air velocity on nine separate moments in five positions in each opening of the TB clinic, laboratory, outpatient consultation and outpatient waiting room using a vaneometer. We assessed in addition the ventilation with the “20% rule”, and compared this estimation with the ventilation in ACH assessed using the vaneometer. Results A total of 189 measurements showed no influence on air velocity of the position and moment of the measurement. No significant influence existed of ambient temperature and a small but significant influence of sunny weather. Ventilation was adequate in 17/24 (71%) of all measurements. Using the “20% rule”, ventilation was adequate in 50% of rooms assessed. Agreement between both methods existed in 13/23 (56%) of the rooms assessed. Conclusion Most rooms had adequate ventilation when assessed using a vaneometer for measuring air velocity. A single vaneometer measurement of air velocity is adequate to assess ventilation in this setting. These findings provide practical input for clear guidelines on assessing ventilation using a vaneometer. Assessing ventilation with a vaneometer differs substantially from applying the “20% rule”.

Background Many of the countries in sub-Saharan Africa are still largely dependent on microscopy as the mainstay for diagnosis of tuberculosis (TB) including patients with previous history of TB treatment. The available guidance in management of TB retreatment cases is focused on bacteriologically confirmed TB retreatment cases leaving out those classified as retreatment ‘others’. Retreatment ‘others’ refer to all TB cases who were previously treated but with unknown outcome of that previous treatment or who have returned to treatment with bacteriologically negative pulmonary or extra-pulmonary TB. This study was conducted in 11 regional referral hospitals (RRHs) serving high burden TB districts in Uganda to determine the profile and treatment success of TB retreatment ‘others’ in comparison with the classical retreatment cases. Methods A retrospective cohort review of routinely collected National TB and Leprosy Program (NTLP) facility data from 1 January to 31 December 2010. This study uses the term classical retreatment cases to refer to a combined group of bacteriologically confirmed relapse, return after failure and return after loss to follow-up cases as a distinct group from retreatment ‘others’. Distribution of categorical characteristics were compared using Chi-squared test for difference between proportions. The log likelihood ratio test was used to assess the independent contribution of type of retreatment, human immunodeficiency virus (HIV) status, age group and sex to the models. Results Of the 6244 TB cases registered at the study sites, 733 (11.7 %) were retreatment cases. Retreatment ‘others’ constituted 45.5 % of retreatment cases. Co-infection with HIV was higher among retreatment ‘others’ (70.9 %) than classical retreatment cases (53.5 %). Treatment was successful in 410 (56.2 %) retreatment cases. Retreatment ‘others’ were associated with reduced odds of success (AOR = 0.44, 95 % CI 0.22,0.88) compared to classical cases. Lost to follow up was the commonest adverse outcome (38 % of adverse outcomes) in all retreatment cases. Type of retreatment case, HIV status, and age were independently associated with treatment success. Conclusion TB retreatment ‘others’ constitute a significant proportion of retreatment cases, with higher HIV prevalence and worse treatment success. There is need to review the diagnosis and management of retreatment ‘others’.

To the Editors: Tuberculosis (TB) remains a serious public health problem in many low- and middle-income countries in Africa, Asia and the former Soviet Union [1]. Mozambique is one of them. Despite the fact that in this country, detection of patients with TB has drastically increased during the past decade due to improved notification (from nearly 20,000 new TB cases notified in 1998 to nearly 40,000 in 2008), less than half of the cases of TB estimated to emerge annually are currently being detected. As in other southern African countries, the HIV epidemic is fuelling the TB epidemic in Mozambique, with 60% of patients with TB being co-infected with HIV [1]. Drug-resistant TB is thought to be a major problem, although the latest information available on the magnitude of resistance to anti-TB drugs is from 1998, when the first national drug resistance survey (DRS) was conducted. At that time, multidrug-resistant (MDR)-TB (defined as TB resistant to at least isoniazid and rifampicin, the two main first-line drugs in the treatment of TB) was found among 3.5 and 3.3% of new and previously treated TB cases, respectively [2]. Since then, there has been no further investigation of the magnitude of drug resistance in the country. Based on the latest available data, >3,500 MDR-TB cases are estimated to have emerged in Mozambique in 2008 [3]. Detecting and treating patients with MDR-TB is feasible but substantially more complex and costly than treating patients with fully susceptible Mycobacterium tuberculosis strains. Knowing the …

Objective Healthcare Workers (HCWs) have a higher frequency of TB exposure than the general population and have therefore an occupational TB risk that infection prevention and control (IPC) measures aim to reduce. HCWs are crucial in the implementation of these measures. The objective of the study was to investigate Mozambican HCWs' perceptions of their occupational TB risk and the measures they report using to reduce this risk. In addition, we explored the challenges HCWs encounter while using these TBIPC measures. Methods Focus group discussion. Analysis according content method. Participants Four categories of HCWs: auxiliary workers, medical (doctors and clinical officers), nurses and TB program staff. Results HCWs are aware of their occupational TB risk and use various measures to reduce their risk of infection. HCWs find it challenging to employ measures that minimize such risks and a lack of clear guidelines contributes to these challenges. HCWs' and patient behavior further complicate the use of TBIPC measures. Conclusion HCWs in Mozambique perceive a high occupational risk of TB infection. They report several challenges using measures to reduce this risk such as shortage of material, lack of clear guidelines, insufficient motivation and inadequate training. Robust training with motivational approaches, alongside supervision and support for HCWs could improve implementation of TBIPC measures. Healthcare management should address the areas for improvement that are beyond the individual HCW's control.

Background Antiretroviral therapy (ART) is lifesaving for HIV-infected tuberculosis (TB) patients. ART-use by these patients lag behind compared to HIV-testing and co-trimoxazole preventive therapy. TB programmes provide the data on ART-use by HIV-infected TB patients, however often the HIV services provide the ART. We evaluated whether the data on ART-use in the TB register were complete and correct. The timing of ART initiation was evaluated to assess whether reporting on ART-use could have happened with the TB case finding reporting. We collected data on TB treatment, HIV testing and ART for adult TB cases in 2007 from three TB clinics in Manica Province, Mozambique. These data on use of ART from TB registers were compared with those from the HIV services. Findings Of 628 patients included, 504 (81%) were tested and of these 356 (71%) were HIV-infected. Of the co-infected patients, 81% registered with the HIV services in the same facility. The TB register was correct on ART-use in 73% of co-infected cases and complete in 74%. Information on ART-use could have been reported with the TB case finding reports in 56% of co-infected patients. Conclusion The TB register is reasonably correct and complete on ART-use. However, the HIV patient record seems a much better source to provide this information. Reporting on ART-use at the end of the quarter in which TB treatment starts provides the programme with timely but incomplete information. A more complete but less timely picture is available after a year.