SUMMARY Conclusion:Despite decreasing tuberculosis notifications overall, notifications of MDRTB and proportions of episodes with MDR increased in the larger company. Cure must be ensured in first episodes to prevent acquired resistance. Improved coverage of culture, drug susceptibility testing and HIV testing is required to allow treatment to be optimised.

SUMMARYBACKGROUND: Mycobacterium tuberculosis infection in children acts as a sentinel for infectious tuberculosis.OBJECTIVE: To assess risk factors associated with tuberculous infection in pre-school children.METHOD: We conducted a population-wide tuberculin skin test (TST) survey from January to December 2012 in Malawi. All children aged 2–4 years residing in a demographic surveillance area were eligible. Detailed demographic data, including adult human immunodeficiency virus (HIV) status, and clinical and sociodemographic data on all diagnosed tuberculosis (TB) patients were available.RESULTS: The prevalence of M. tuberculosis infection was 1.1% using a TST induration cut-off of 15 mm (estimated annual risk of infection of 0.3%). The main identifiable risk factors were maternal HIV infection at birth (adjusted OR [aOR] 3.6, 95%CI 1.1–12.2), having three or more adult members in the household over a lifetime (aOR 2.4, 95%CI 1.2–4.8) and living in close proximity to a known case of infectious TB (aOR 1.6, 95%CI 1.1–2.4), modelled as a linear variable across categories (>200 m, 100–200 m, <100 m, within household). Less than 20% of the infected children lived within 200 m of a known diagnosed case.CONCLUSION: Household and community risk factors identified do not explain the majority of M. tuberculosis infections in children in our setting.

Use of odds ratio in calculation of number needed to treat was inappropriateEditor-Christopher Del Mar and colleagues' meta-analysis of antibiotics in acute otitis media in children raises some questions. 1 The authors included only six studies in the analysis, but an earlier meta-analysis by Rosenfeld et al included 33 studies. 2 The authors report that 60% of patients given placebo were pain free within 24 hours but that, two to seven days after presentation, only 14% in the control group still had pain. We would have expected 40% (100% minus 60%) still to have pain.The number needed to treat, based on pain at two to seven days, was 17 in the meta-analysis. In a Cochrane review of the same trials, however, this number was 12. 3 It seems that the authors used the odds ratio for the calculation, which is inappropriate, since it is calculated as the inverse of the risk difference. Using the risk difference, according to figure 1 with a fixed effects model, as the authors also used, we arrived at 23. Furthermore, the use of the number needed to treat does not eliminate the importance of confidence intervals; the confidence interval we calculated was 15 to 56, which is more meaningful than a point estimate. Finally, the authors mention that the number needed to treat was of the same order as that in the meta-analysis by Rosenfeld et al. 2 This begs the question of why the authors did a new meta-analysis so soon after the first one, especially since the earlier meta-analysis was published in 1994 and Del Mar and colleagues did not search Medline beyond August 1994.The authors report that there was a trend for antibiotics to confer benefit in terms of deafness at three months. However, there must be an error in figure 1, since the total numbers affected in the two studies shown add up to 38 v 49, whereas the subtotals are 64 v 66.The authors state in the text and in the abstract that "antibiotics were associated with a near doubling of the risk of vomiting, diarrhoea, or rashes." However, this finding relates to just one study, of the broad spectrum penicillin amoxycillin, which contributes 90% to the weight in their meta-analysis. The statement is therefore irrelevant for small spectrum penicillins, which most clinicians would probably prefer for treatment of acute otitis media if they choose to treat at all. 3

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