BackgroundLymphatic filariasis (LF) infects approximately 120 million people worldwide. As many as 40 million have symptoms of LF disease, including lymphedema, elephantiasis, and hydrocele. India constitutes approximately 45% of the world's burden of LF. The Indian NGO Church's Auxiliary for Social Action (CASA) has been conducting a community-based lymphedema management program in Orissa State since 2007 that aims to reduce the morbidity associated with lymphedema and elephantiasis. The objective of this analysis is to evaluate the effects of this program on lymphedema patients' perceived disability.Methodology/Principal FindingsFor this prospective cohort study, 370 patients ≥14 years of age, who reported lymphedema lasting more than three months in one or both legs, were recruited from villages in the Bolagarh sub-district, Khurda District, Orissa, India. The World Health Organization Disability Assessment Schedule II was administered to participants at baseline (July, 2009), and then at regular intervals through 24 months (July, 2011), to assess patients' perceived disability. Disability scores decreased significantly (p<0.0001) from baseline to 24 months. Multivariable analysis using mixed effects modeling found that employment and time in the program were significantly associated with lower disability scores after two years of program involvement. Older age, female gender, the presence of other chronic health conditions, moderate (Stage 3) or advanced (Stage 4–7) lymphedema, reporting an adenolymphangitis (ADL) episode during the previous 30 days, and the presence of inter-digital lesions were associated with higher disability scores. Patients with moderate or advanced lymphedema experienced greater improvements in perceived disability over time. Patients participating in the program for at least 12 months also reported losing 2.5 fewer work days per month (p<0.001) due to their lymphedema, compared to baseline.SignificanceThese results indicate that community-based lymphedema management programs can reduce disability and prevent days of work lost. These effects were sustained over a 24 month period.

BackgroundEfficient and effective strategies for identifying cases of active tuberculosis (TB) in rural sub-Saharan Africa are lacking. Household contact tracing offers a potential approach to diagnose more TB cases, and to do so earlier in the disease course.MethodsAdults newly diagnosed with active TB were recruited from public clinics in Vhembe District, South Africa. Study staff visited index case households and collected sputum specimens for TB testing via smear microscopy and culture. We calculated the yield and the number of households needed to screen (NHNS) to find one additional case. Predictors of new TB among household contacts were evaluated using multilevel logistic regression.ResultsWe recruited 130 index cases and 282 household contacts. We identified 11 previously undiagnosed cases of bacteriologically-confirmed TB, giving a prevalence of 3.9% (95% CI: 2.0–6.9%) among contacts, a yield of 8.5 per 100 (95% CI: 4.2–15.1) index cases traced, and NHNS of 12 (95% CI: 7–24). The majority of new TB cases (10/11, 90.9%) were smear negative, culture positive. The presence of TB symptoms was not associated with an increased odds of active TB (aOR: 0.3, 95% CI: 0.1–1.4).ConclusionsHousehold contacts of recently diagnosed TB patients in rural South Africa have high prevalence of TB and can be feasibly detected through contact tracing, but more sensitive tests than sputum smear are required. Symptom screening among household contacts had low sensitivity and specificity for active TB in this study.

SUMMARY Setting Initial cost-effectiveness evaluations of Xpert MTB/RIF (Xpert) for tuberculosis (TB) diagnosis have not fully accounted for realities of implementation in peripheral settings. Objective We evaluated costs and diagnostic outcomes of Xpert testing implemented at various healthcare levels in Uganda. Design We collected empirical cost data from five health centers utilizing Xpert for TB diagnosis, employing an ingredients approach. We reviewed laboratory and patient records to assess outcomes in these sites and ten sites without Xpert. We also estimated incremental cost-effectiveness of Xpert testing; our primary outcome was incremental cost of Xpert testing per newly detected TB case. Results The mean unit cost of an Xpert test was US$21 based on a mean monthly volume of 54 tests per site, though unit cost varied widely (US$16–58) and was primarily determined by testing volume. Total diagnostic costs were 2.4-fold higher in Xpert clinics compared to non-Xpert clinics, though Xpert only increased diagnoses by 12%. Diagnostic costs of Xpert averaged US$119 per newly detected TB case but were as high as US$885 in the lowest-volume center. Conclusion Xpert testing can detect TB cases at reasonable cost but may double diagnostic budgets for relatively small gains, with cost-effectiveness deteriorating with lower testing volumes.