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Introduction: Tuberculosis contacts are candidates for active and latent tuberculosis infection screening and eventual treatment. However, many losses occur in the different steps of the contacts' cascade of care. Reasons for this are poorly understood., Objective: To describe the different steps where losses in the contact cascade occur and to explore knowledge and attitudes regarding tuberculosis transmission/prevention and perceptions about tuberculosis services in order to understand the reasons for losses from the tuberculosis service users' perspective., Design: We collected routine data from the index case and contact registry books and from patients' records to build the cascade of care of contacts in 12 health facilities in three Brazilian cities with high tuberculosis incidence rates. During a knowledge, attitudes and practices (KAP) survey, trained interviewers administered a semi-structured questionnaire to 138 index cases and 98 contacts., Results: Most of the losses in the cascade occurred in the first two steps (contact identification, 43% and tuberculin skin testing placement, 91% of the identified contacts). Among KAP-interviewed contacts, 67% knew how tuberculosis is transmitted, 87% knew its key symptoms and 81% declared they would take preventive therapy if prescribed. Among KAP-interviewed index cases, 67% knew they could spread tuberculosis, 70% feared for the health of their families and 88% would like their family to be evaluated in the same services., Conclusion: Only a small proportion of contacts are evaluated for active and latent tuberculosis, despite their-and their index cases'-reasonable knowledge, positive attitudes towards prevention and satisfaction with tuberculosis services. In these services, education of service users would not be a sufficient solution. Healthcare workers' and managers' perspective, not explored in this study, may bring more light to this subject.

Background: Children with latent tuberculous infection (LTBI) are particularly vulnerable to progression to active tuberculosis (TB), and are thus a priority target for isoniazid preventive therapy (IPT). However, adherence to IPT is poor. We hypothesised that children from poorer families, with reduced access to health care and lack of understanding about the disease are more likely to default from IPT., Methods: A questionnaire was administered to close child contacts or their parents at the time of prescribing IPT in three cities in Rio de Janeiro State. The children were followed prospectively. Treatment adherence was defined as taking 80% of prescribed doses., Results: Among 1078 children screened for LTBI, 97 (8.9%) did not return for tuberculin skin test (TST) reading; 332 (30.8%) were TST-positive; 115/332 (34.6%) were prescribed IPT, 6 of whom did not initiate treatment and 11 did not adhere during the first 2 months; 25 additional children did not complete IPT. Overall non-completion was four times more frequent among those with lower income. Health care access and knowledge did not improve treatment completion., Conclusions: Substantial losses to follow-up occurred before IPT prescription; this should be further investigated. Among the children who started isoniazid, low income, but not difficult access or poor knowledge, increased the risk of treatment non-completion.

Setting: Randomised trial comparing 9 months of isoniazid with 4 months of rifampicin for the treatment of high-risk tuberculin skin test positive subjects in Rio de Janeiro, Brazil., Objectives: To compare QuantiFERON®-TB Gold In-Tube (QFT-GIT) responses before and 1, 4 and 9 months after starting treatment for latent tuberculous infection (LTBI) according to adherence to one of the two regimens., Design: Participants in the trial were invited to undergo serial QFT-GIT. Within-subject differences at different time points were analysed as quantitative responses and categorised as positive or negative using different cut-off points., Results: Of 215 participants, 118 completed treatment, of whom 58 underwent all three tests; and 97 did not complete treatment, of whom 10 underwent all tests. After 1 month of treatment, there was no significant difference in QFT-GIT response between the groups. After 4 and 9 months, reversions were more frequent in non-adherent subjects. Marked within-subject fluctuations were observed. No cut-off point could be established at which QFT-GIT responses were consistently positive or associated with adherence or type of treatment., Conclusion: Frequent within-subject variability in QFT-GIT responses, not associated with LTBI treatment, makes it difficult for clinicians to interpret QFT-GIT conversions and reversions.

A prospective study was conducted to evaluate tuberculosis treatment outcomes according to socio-economic status (SES) using different classification criteria. Patients aged ≥18 years under treatment for ≤8 weeks were interviewed. Outcomes were classified as successful (cure/completed) or unsuccessful (default/failure/death). The overall treatment default ratio was 20.9% and the unsuccessful outcome rate was 24.1%. Unsuccessful treatment was associated with SES according to any criteria used, except for the definition of poverty line. Poverty seems to be hampering the achievement of the World Health Organization targeted 90% cure rate in developing settings.

The objective of this study was to compare gender differences among tuberculosis patients in a city with a high incidence of tuberculosis. This was a cross-sectional questionnaire-based study involving 560 tuberculosis patients (373 males and 187 females). Sociodemographic and clinical data, as well as data related to diagnostic criteria and treatment outcome, were collected (from the questionnaires and medical records) and subsequently compared between the genders. The median time from symptom onset to diagnosis was 90 days. There were no differences between the genders regarding the clinical presentation, diagnostic criteria, previous noncompliance with treatment, time from symptom onset, number of medical appointments prior to diagnosis, or treatment outcome. Gender-specific approaches are not a priority in Brazil. However, regardless of patient gender, the delay in diagnosis is a major concern.

Background: Tuberculosis (TB) treatment default is a major constraint of TB control, resulting in continued disease transmission and possibly the emergence of multidrug resistance. Marginalized populations may abandon treatment before being cured. The objective of this study was to evaluate the socioeconomic status (SES) of TB patients and identify potential incentives for improving treatment compliance by SES., Material and Methods: A cross-sectional survey was conducted in a public health unit in Duque de Caxias, a county with one of the lowest per capita incomes in Rio de Janeiro state. From November 2003 to March 2004, 305 TB patients answered an anonymous questionnaire on socio-demographic aspects, household items and family income, history of previous treatment default, and on incentives for improving treatment adherence. Incentives were classified as economic, administrative, health service support, and habits, and scored as fundamental (3), important (2), desirable (1), or irrelevant (0)., Results: Health service support incentives had the highest scores overall. The aggregate economic incentive score correlated with SES (r = -0.191, p = 0.001). Among the 20% poorest patients, 16.7% had a previous history of default vs. 1.6% among the wealthiest (p = 0.004). Patients with a history of treatment default were significantly more likely to choose health service support incentives than other patients (r = -0.263, p = 0.039)., Conclusions: Professional commitment will be needed to effect the necessary changes in health service support. Financial support for food and transportation subsidies may be required to improve treatment compliance among the poorest TB patients, i.e. those most likely to have previously defaulted from treatment.

Setting: Five medical schools in three cities with different tuberculosis (TB) incidence rates in Rio de Janeiro State, Brazil., Objective: To estimate prevalence of and associated factors for latent tuberculosis infection (LTBI) among medical students., Design: A cross-sectional survey was conducted among undergraduate students in pre-clinical, early and late clinical years from schools in cities with low (28/100,000), intermediate (63/100,000) and high (114/100,000) TB incidence rates. Information on socio-demographic profile, previous BCG vaccination, potential TB exposure, co-morbidity and use of respiratory protective masks was obtained. A tuberculin skin test (TST) was performed using the Mantoux technique by an experienced professional. A positive TST, defined as induration > or = 10 mm, was considered LTBI., Results: LTBI prevalence was 6.9% (95%CI 5.4-8.6). In multivariate analysis, male sex (adjusted odds ratio [aOR] 1.8; 95% CI 1.1-3.0), late clinical years (aOR 1.9; 95% CI 1.01-3.5), intermediate TB incidence (aOR 4.3; 95% CI 1.3-14.6) and high TB incidence in the city of medical school (aOR 5.1; 95% CI 1.6-16.8) were significantly associated with LTBI., Conclusions: The higher prevalence of LTBI in late clinical years suggests that medical students are at increased risk for nosocomial Mycobacterium tuberculosis infection. The implementation of a TB control program may be necessary in medical schools, particularly in cities with higher TB incidence.

Fetus-in-fetu (FIF) is a rare pathological condition, which presents as a congenital tumor, usually in the abdomen or retroperitoneum. A few cases have been reported in the cranial cavity, cervical spine, ovarium, scrotum and liver. We presently report a case of intrapulmonary FIF in a 12-year-old girl who was on treatment for pulmonary tuberculosis and had no symptoms related to the tumor. To our knowledge this is the first reported case of FIF with pulmonary presentation.

Setting: Two tuberculosis (TB) reference hospitals and three general hospitals in Rio de Janeiro (RJ)., Objective: To analyze TB-attributed deaths as a tool for evaluating the TB control program in RJ., Design: Retrospective study based on 302 medical records selected from the 1998 death database., Results: Of 1146 registered adult (>14 years) TB-attributed deaths in RJ, 328 occurred in five hospitals, and 302 records were analyzed. Median age was 47.5 (17-89) years; 237 (78.5%) were male. Median time elapsed from onset of symptoms until diagnosis was 60 (7-730) days; median hospitalization was 60 (0-517) days. Acid-fast bacilli sputum smears were performed in 200 (69%) of 290 cases of pulmonary disease. Among 32 (36%) smear-negative patients, culture was done in only one. The recommended regimen (RHZ) was used in 175 (58%). Among 125 re-treatment patients, 55 (44%) were on RHZ instead of RHZE. Notification to health authorities was recorded in 131 (43.4%) cases., Conclusion: In RJ, young people die from TB. Major issues identified in the public health system were poor detection and notification and a high default rate, perpetuating the spread of TB. Treating professionals do not follow guidelines, and political commitment is needed to ensure TB control in the state and in the country.

The incidence of AIDS and other sexually transmitted diseases (STDs) is increasing among adolescents. In order to better understand high-risk sexual behavior among students, a cross-sectional study based on a self-answered anonymous questionnaire was conducted in 10 public and private high schools in Rio de Janeiro, Brazil. Data were obtained on sociodemographics, knowledge of STD/AIDS, and sexual behavior. Among 945 students aged 13-21, 59% were sexually initiated, and the median age at first sexual intercourse was 15 years (range: 7-19). Although 94% reported being aware of the need for condom use for protection, only 34% informed always using condoms during sex. Low family income was associated with unsatisfactory knowledge (OR = 9.40; 95% CI = 6.05-14.60) and inconsistent condom use (OR = 11.60; 95% CI = 5.54-24.30). However, unsatisfactory knowledge was not associated with inconsistent condom use. School-based educational programs should focus on sexual behavior more than on transmission of knowledge, as well as targeting low-income students.

Three hundred and fifty two medical records of AIDS inpatients were analysed in a retrospective study to establish the frequency, clinical patterns and etiology of AIDS-related diarrhea. Diarrhea was observed in 58.8% of the patients, being a chronic symptom in 65.7%, and the first complaint in 24.6%. The most common cause of diarrhea was coccidea and the etiology remained unknown in 56.1% of the patients. Routine stool examination was the most sensitive method in the diagnosis of diarrhea. In countries with limited resources, the use of stool examinations seems to provide appropriate clinical management. The implementation of an objective protocol could improve the etiologic diagnosis of AIDS-related diarrhea without the burden of more complex and invasive technologies.

Setting: Department of internal medicine in a general hospital in Rio de Janeiro, Brazil, which provides secondary care to the poor population., Objective: The aim of this study was to evaluate the prevalence of human immunodeficiency virus (HIV) infection in patients with pleural tuberculosis (TB) and to compare its manifestations in HIV-negative and HIV-infected patients., Design: Cross-sectional study., Methods: Forty-three patients with a final diagnosis of pleural TB were submitted to HIV testing (ELISA), chest X-ray, and thoracentesis for biochemical, cytological and bacteriological analysis. Pleural tissue was obtained in 36 patients for histopathological examination. PPD testing was performed in 29 patients. Whenever productive cough was present, sputum acid-fast smears and culture for Mycobacterium tuberculosis were performed., Results: The HIV prevalence was high (30%). TB symptoms were similar in both groups. Atypical radiological aspects were observed in HIV-infected patients with concurrent pulmonary TB (P = 0.03). Pleural fluid, tissue aspects and PPD testing were comparable in both groups., Conclusion: Only atypical radiographic patterns in patients with concurrent pulmonary TB were indicative of HIV infection. Therefore, a high index of suspicion is necessary for the early recognition of HIV/TB co-infection. We suggest that all patients presenting with pleural TB should be screened for anti-HIV antibodies.

To evaluate the ability of different diagnostic methods for the detection of AIDS-related diarrhoeal pathogens in developing countries, we studied 40 HIV-infected patients with diarrhoea. All patients were subjected to stool examinations for parasites, stool culture and peroral jejunal biopsy. Jejunal specimens were processed for histological examination with several stains and for transmission electron microscopy (TEM). Jejunal juice and mucosa were cultured. An aetiologic agent was found in twenty patients. Eleven stool specimens were positive for parasites and stool culture was positive in three patients. The enteropathogens detected by these two methods included every microorganism amenable to treatment. Histological examination revealed four agents not previously identified. TEM added to diagnosis in only two patients. All cultures of jejunal mucosa and jejunal juice were negative, even when stool culture was positive. We conclude that a minimal investigation consisting of stool examination for parasites and stool culture is a cost-effective strategy in the management of AIDS-related diarrhoea in developing countries.

Forty-nine HIV-infected patients were submitted to peroral jejunal biopsy in order to evaluate the presence of microorganisms and the histomorphometric aspects of the enteric mucosa with subsequent correlation of these findings to the appropriate clinical stage of the disease. Thirty-seven patients fulfilled the CDC criteria for AIDS, of whom 23 presented with diarrhea. Of the 12 patients who had not yet been given an AIDS diagnosis. 3 had persistent generalized lymphadenopathy and 9 were asymptomatic carriers. Flat mucosa was observed in two patients (8.7%) with diarrhea and coccidea. Subtotal villous atrophy and severe lamina propria (LP) mononuclear infiltrate (13%) were found only in patients with diarrhea. Moderate to severe histologic changes were more frequently observed in this group, not always related to the presence of microorganisms. Crypt hyperregeneration was a constant finding. Intraepithelial lymphocyte (IEL) count was decreased in patients with diarrhea. Specific infectious agents were unexpectedly rare for the tropical developing country population studied. The organism most commonly associated with diarrhea was Cryptosporidium sp. (21.7%). The etiology of diarrhea in a significant number of patients remains unclear.