New methods for estimating the tuberculosis case detection rate in high-HIV prevalence countries: the example of Kenya

OBJECTIVE: To develop new methods for estimating the sputum smear-positive tuberculosis case detection rate (CDR) in a country where infection with HIV is prevalent. METHODS: We estimated the smear-positive tuberculosis CDR in HIV-negative and HIV-positive adults, and in all adults in Kenya. Data on time trends in tuberculosis case notification rates and on HIV infection prevalence in adults and in tuberculosis patients were used, along with data on tuberculosis control programme performance. FINDINGS: In 2006, the estimated smear-positive tuberculosis CDR in HIV-negative adults was 79% (95% confidence interval, CI: 64-94) and in HIV-positive adults, 57% (95% CI: 26-88), giving a weighted mean of 68% (95% CI: 49-87). The separate estimate for all smear-positive tuberculosis cases was 72% (95% CI: 53-91), giving an overall average for the three estimates of 70% (95% CI: 58-82). As the tuberculosis CDR in 1996 was 57% (95% CI: 47-67), the estimated increase by 2006 was 13 percentage points (95% CI: 6-20), or 23%. This increase was accompanied by a more than doubling of the resources devoted to tuberculosis control in Kenya, including facilities and staff. CONCLUSION: Using three approaches to estimate the tuberculosis CDR in a country where HIV infection is prevalent, we showed that expansion of the tuberculosis control programme in Kenya led to an increase of 23% in the CDR between 1996 and 2006. While the methods developed here can be applied in other countries with a high prevalence of HIV infection, they rely on precise data on trends in such prevalence in the general population and among tuberculosis patients

Incongruent HIV and tuberculosis co-dynamics in Kenya: interacting epidemics monitor each other

Kenya is heralded as an example of declining HIV in Africa, while its tuberculosis (TB) numbers continue rising. We conducted a comparative investigation of TB-HIV co-dynamics in Africa to determine the likelihood of reported trends. Our mathematical modeling analysis exposes the notable incongruence of reported trends in Kenya because TB-HIV co-dynamics, tightly knit worldwide and most dramatically in sub-Saharan Africa, suggest that declining HIV trends should trigger reductions in TB trends. Moreover, a continental-scale analysis of TB-HIV trends places Kenya as an outlier in eastern and southern Africa, and shows TB outpacing HIV in western central Africa. We further investigate which TB processes across HIV stages have greater potential to reduce TB incidence via a sensitivity analysis. There are two parsimonious explanations: an unaccounted improvement in TB case detection has occurred, or HIV is not declining as reported. The TB-HIV mismatch could be compounded by surveillance biases due to spatial heterogeneity in disease dynamics. Results highlight the need to re-evaluate trends of both diseases in Kenya, and identify the most critical epidemiological factors at play. Substantial demographic changes have occurred in Kenya, including rapid urbanization accompanied by poor living conditions, which could disproportionately increase TB incidence. Other possible contributors include immune reconstitution due to the recent delivery of antiretrovirals, and an increased presence of the virulent Beijing/W TB genotype. Results support the importance of integrating information from closely interacting epidemics, because this approach provides critical insights unobtainable when components of generalized epidemics are considered individuall

Cover Crops and Ecosystem Services: Insights from Studies in Temperate Soils

Cover crops (CCs) can provide multiple soil, agricultural production, and environmental benefits. However, a better understanding of such potential ecosystem services is needed. We summarized the current state of knowledge of CC effects on soil C stocks, soil erosion, physical properties, soil water, nutrients, microbial properties, weed control, crop yields, expanded uses, and economics and highlighted research needs. Our review indicates that CCs are multifunctional. Cover crops increase soil organic C stocks (0.1–1 Mg ha–1 yr–1) with the magnitude depending on biomass amount, years in CCs, and initial soil C level. Runoff loss can decrease by up to 80% and sediment loss from 40 to 96% with CCs. Wind erosion potential also decreases with CCs, but studies are few. Cover crops alleviate soil compaction, improve soil structural and hydraulic properties, moderate soil temperature, improve microbial properties, recycle nutrients, and suppress weeds. Cover crops increase or have no effect on crop yields but reduce yields in water-limited regions by reducing available water for the subsequent crops. Th e few available studies indicate that grazing and haying of CCs do not adversely affect soil and crop production, which suggests that CC biomass removal for livestock or biofuel production can be another benefit from CCs. Overall, CCs provide numerous ecosystem services (i.e., soil, crop–livestock systems, and environment), although the magnitude of benefits is highly site specific. More research data are needed on the (i) multi-functionality of CCs for different climates and management scenarios and (ii) short- and longterm economic return from CCs