Tuberculosis control in Sweden

Sweden is a low tuberculosis (TB) incidence country with an incidence of 5.3 cases per 100 000 inhabitants 2017. The majority of new TB cases in Sweden are diagnosed among migrants from high TB incidence countries. Data from TB surveillance is analysed to identify risk groups, follow trends, discover new risk groups or outbreaks and update policies and guidelines, with the ultimate goal of reducing the number of new cases. Today all isolates from TB cases diagnosed in Sweden are genotyped to detect clustering which may reveal unknown links between cases and risk of transmission that has been overlooked. The methods of molecular genotyping have improved over time and reduced the risk of false clustering. In paper I we compared two different methods of molecular genotyping, Restriction fragment length polymorphism (RFLP) and Mycobacterial interspersed repetitive units – variable number of tandem repeats (MIRU-VNTR). There was an 82 percent concordance between the two methods. Compared to epidemiological data, around 50 percent of the clusters were judged as being false with both methods. As turn-around time for MIRU-VNTR is much faster than for RFLP it was the preferred method. Latent tuberculosis infection (LTBI) is defined as having a detectable immune response towards TB but no signs or symptoms of active disease. The tuberculin skin test has gradually been replaced by Interferon Gamma Release Assays (IGRA’s) to detect immune response towards the Mycobacterium tuberculosis (M.tb) specific antigens ESAT-6 and CFP-10. With QuantiFERON Gold In tube, the most widely used IGRA, there are challenges in interpreting results close to cut-off (0.35 IU/mL) due to the variability of the test method. In paper II we investigated the effect of a borderline range (0.20–0.99 IU/mL) around cut-off where repeated testing was recommended. Of negative (0.20–0.34 IU/mL) and positive (0.35–0.99 IU/mL) results in the borderline range, 66.1 percent and 42.5 percent respectively were negative below the borderline range (< 0.20 IU/mL) when retested. None of the subjects with initial result in the borderline range and a negative second test, developed incident active TB during a period of minimum two years of follow-up. We recommend re-testing of individuals with a result in the borderline range for a more reliable result. Multidrug resistant TB (MDR-TB) is an increasing problem worldwide and also in Sweden but on a smaller scale. In paper III we analysed a Swedish cohort of 158 MDR-TB cases diagnosed from 1992–2014. Treatment outcome was successful in 83.5 percent which is similar to treatment outcome for susceptible TB in Sweden. Treatment with pyrazinamide (PZA) in cases with PZA susceptible M.tb strains, shortened time to sputum culture conversion (aHR 2.25 (95% CI 1.27–3.99) p=0.005) (median difference 30 days). Increasing minimum inhibitory concentration of levofloxacin was correlated to unfavourable outcome (aHR 1.77 95% CI 1.15–2.71 p=0.009), as was diabetes (aHR 5.52 (95%CI 1.42–21.55) p= 0.014) and increasing age (age >40 years, aHR 4.51 (95% CI 1.74–11.67) p=0.002). The majority of people with LTBI will not develop active TB but there are factors increasing this risk, like for example human immunodeficiency virus or any other condition affecting the normal immune response. As pregnancy temporarily alters the immune response, we wanted to investigate if the risk of active TB increases during pregnancy and postpartum. In paper IV, a retrospective register-based cohort study of all women who gave birth in Sweden during the study period 2005–2013, we showed an incidence rate ratio of 3.0 (95% CI 2.3–3.9) and 4.2 (95% CI 3.2–5.5) of active TB during pregnancy and postpartum respectively compared to outside these risk periods. The increased risk was concentrated to women from high TB incidence countries. We recommend that women from high TB incidence settings should be screened for both active and latent TB when pregnant

Screening of benzodiazepines in thirty European rivers

Pharmaceuticals as environmental contaminants have received a lot of interest over the past decade but, for several pharmaceuticals, relatively little is known about their occurrence in European surface waters. Benzodiazepines, a class of pharmaceuticals with anxiolytic properties, have received interest due to their behavioral modifying effect on exposed biota. In this study, our results show the presence of one or more benzodiazepine(s) in 86% of the analyzed surface water samples (n = 138) from 30 rivers, representing seven larger European catchments. Of the 13 benzodiazepines included in the study, we detected 9, which together showed median and mean concentrations (of the results above limit of quantification) of 5.4 and 9.6 ng L−1, respectively. Four benzodiazepines (oxazepam, temazepam, clobazam, and bromazepam) were the most commonly detected. In particular, oxazepam had the highest frequency of detection (85%) and a maximum concentration of 61 ng L−1. Temazepam and clobazam were found in 26% (maximum concentration of 39 ng L−1) and 14% (maximum concentration of 11 ng L−1) of the samples analyzed, respectively. Finally, bromazepam was found only in Germany and in 16 out of total 138 samples (12%), with a maximum concentration of 320 ng L−1. This study clearly shows that benzodiazepines are common micro-contaminants of the largest European river systems at ng L−1 levels. Although these concentrations are more than a magnitude lower than those reported to have effective effects on exposed biota, environmental effects cannot be excluded considering the possibility of additive and sub-lethal effects

Social differentiation and embodied dispositions: a qualitative study of maternal care-seeking behaviour for near-miss morbidity in Bolivia

<p>Abstract</p> <p>Background</p> <p>Use of maternal health care in low-income countries has been associated with several socioeconomic and demographic factors, although contextual analyses of the latter have been few. A previous study showed that 75% of women with severe obstetric morbidity (near-miss) identified at hospitals in La Paz, Bolivia were in critical conditions upon arrival, underscoring the significance of pre-hospital barriers also in this setting with free and accessible maternal health care. The present study explores how health care-seeking behaviour for near-miss morbidity is conditioned in La Paz, Bolivia.</p> <p>Methods</p> <p>Thematic interviews with 30 women with a near-miss event upon arrival at hospital. Near-miss was defined based on clinical and management criteria. Modified analytic induction was applied in the analysis that was further influenced by theoretical views that care-seeking behaviour is formed by predisposing characteristics, enabling factors, and perceived need, as well as by socially shaped habitual behaviours.</p> <p>Results</p> <p>The self-perception of being fundamentally separated from "others", meaning those who utilise health care, was typical for women who customarily delivered at home and who delayed seeking medical assistance for obstetric emergencies. Other explanations given by these women were distrust of authority, mistreatment by staff, such as not being kept informed about their condition or the course of their treatment, all of which reinforced their dissociation from the health-care system.</p> <p>Conclusion</p> <p>The findings illustrate health care-seeking behaviour as a practise that is substantially conditioned by social differentiation. Social marginalization and the role health institutions play in shaping care-seeking behaviour have been de-emphasised by focusing solely on endogenous cultural factors in Bolivia.</p

Knowledge collaboration and proximity - The spatial organization of biotech innovation projects

This article addresses the role of proximity for knowledge collaboration between dedicated biotechnology firms (DBFs) and related actors. Innovation projects managed by a selection of eight Swedish DBFs are analysed in detail and classified with regard to their specific knowledge characteristics. Based on this classification, explanations to the relative importance of functional and relational proximity to collaborators are sought. The findings indicate that knowledge collaboration in projects characterized by embodied knowledge are more sensitive to functional proximity than projects characterized by embrained and encoded knowledge. The findings also indicate that even though functional proximity is facilitative, global knowledge collaboration is indispensable for most DBFs. The convenience of local collaboration can never replace the extreme requirements of specialized knowledge, which forces them to seek collaborators on a global arena despite the impediments they face in these situations. Policy resources aimed at promoting bioregions are therefore better used to enhance local resources and to provide conditions for DBFs to link up with global sources of knowledge rather than to boost the formation of 'second best' local networks