Correspondence

analysis plan (tables were included Reversing the tide of the 180

in the online appendix). Household

socioeconomic position was
UK tuberculosis 160

measured by housing constr u c- epidemic 140

tion, water source and sanitation, 120

Number of patients
and asset possession. Differences Dominik Zenner and colleagues
100
were recorded by trial group, which (Oct 19, p 1311) 1 suggest that a
accounted for some of the between- quality-assured, primary care based 80

community variation in tuberculosis screening programme for latent 60

prevalence and had a small
confounding effect on estimates
of intervention effect. ZAMSTAR
was not powered to ascertain
whether intervention effects differed
tuberculosis infection for individuals
40
aged 16–35 years, who entered the UK
in the past 5 years from a country with 20
a tuberculosis incidence of 150 cases
0
per 100 000 population or higher,

5
10

0
0–

–1

–2

–3

–4

–5

–6
–2

–3

–4

–5

–6

–7
6–
11

21

31

51

66
16

26

46
41

61
36

according to household or individual
socioeconomic position.
The associations between incidence
of tuberculosis infection and
incidence and prevalence of tuber-
culosis disease, and the effect of HIV,
health-service factors, and novel
methods and approaches on these
associations, are complex. ZAMSTAR
shows that a simple, feasible, and
affordable household-based inter-
vention has a useful effect on the
overall burden of tuberculosis in the
commun ity and should stimulate
policy makers to include integrated
tuberculosis and HIV activities within
broader efforts to move health
care beyond the clinic and into
communities.
We declare that we have no conflicts of interest.
*Helen Ayles, Sian Floyd, Nulda Beyers,
Peter Godfrey-Faussett, on behalf of
the ZAMSTAR team
helen@zambart.org.zm
Department of Clinical Research, Faculty of
Infectious and Tropical Diseases, London School of
Hygiene and Tropical Medicine, London WC1E 7HT,
UK (HA, SF, PG-F); and ZAMBART Project,
University of Zambia, Lusaka, Zambia
(HA, SF, NB, PG-F)
1 Ayles H, Muyoyeta M, Du Toit E, et al. Effect of
household and community interventions on
the burden of tuberculosis in southern Africa:
the ZAMSTAR community-randomised trial.
Lancet 2013; 382: 1183–94.
2 Lonnroth K, Corbett E, Golub J, et al.
Systematic screening for active tuberculosis:
rationale, definitions and key considerations.
Int J Tuberc Lung Dis 2013; 17: 289–98.
3 Ayles H, Schaap A, Nota A, et al. Prevalence of
tuberculosis, HIV and respiratory symptoms in
two Zambian communities: implications for
tuberculosis control in the era of HIV. PLoS One
2009; 4: e5602.
could provide a solution to the UK
tuberculosis epidemic. We are strongly
supportive of such a primary care led
initiative.
The North West London NHS Trust,
London, UK, receives the highest
number of cases of tuberculosis in the
UK. Using data from 564 patients with
tuberculosis diagnosed at Northwick
Park Hospital, between Jan 1, 2011,
and Oct 31, 2013, we looked at those
who were from countries with a
tuberculosis incidence of 150 cases per
100 000, and compared age of entry to
the UK (figure).2 We found that should
we limit the screening programme
to those who enter the country aged
16–35 years we would miss out 25·5%
of patients who develop tuberculosis.
17·7% of these patients are older
than 35 years. Although the risk of
drug-induced hepatitis is greater in
this population, countries such as the
USA, Canada, and Australia have no
age restriction for treatment of latent
tuberculosis infection.3–5
If we want to solve the tuberculosis
epidemic in London, we propose to
screen a wider range of individuals.
We declare that we have no conflicts of interest.
Nikita Shah, *Sarah Young,
Rohma Ghani, Laurence John,
Robert N Davidson
sarahrachaelyoung@yahoo.co.uk
Imperial College London, School of Medicine,
London SW7 2AZ, UK (NS, SY); and Northwick Park
Hospital, Harrow, UK (RG, LJ, RND)
1 Zenner D, Zumla A, Gill P, et al. Reversing the
tide of the UK tuberculosis epidemic. Lancet
2013; 382: 1311–12.
56
Age (years)
Figure: Age on entry in the UK* of patients treated for tuberculosis at Northwick
Park Hospital (January, 2011–October, 2013)
*Only patients entering the UK from areas where incidence of tuberculosis is
>150 cases per 100 000 are included.
2 Public Health England. WHO estimates of
tuberculosis incidence by rate, 2011. http://
www.hpa.org.uk/web/HPAweb&HPA
webStandard/HPAweb_C/1195733837507
(accessed Nov 7, 2013).
3 American Thoracic Society, CDC, and the
Infectious Diseases Society of America.
Treatment of Tuberculosis, Recommendations
and Reports, June 2003. http://www.cdc.gov/
mmwr/preview/mmwrhtml/rr5211a1.htm
(accessed Nov 8, 2013).
4 Fisher D, Elwood K. Canadian Tuberculosis
Standards, 7th edn. 2013. http://www.
respiratoryguidelines.ca/sites/all/files/
Chapter%207.pdf (accessed Nov 8, 2013).
5 Victorian Government Department of Human
Services. Management, Control and
Prevention of Tuberculosis: Guidelines for
Health Care Providers (2002–2005). http://
docs.health.vic.gov.au/docs/doc/5F156B8265
6B85F9CA2578A700146FC1/$FILE/tb_
mgmt_guide.pdf (accessed Nov 8, 2013).
Mozambique faces
challenges in the fight
against tuberculosis
The 2013 Global Tuberculosis Report1
provides an up-to-date snapshot of
the tuberculosis epidemic across the
world. In their Comment, Alimuddin
Zumla and colleagues (Nov 30,
p 1765) 2 summarise the major
achievements in tuberculosis control.
However, most of these successes have
not been seen in some high-burden
countries such as Mozambique and
specific issues need to be highlighted.

www.thelancet.com Vol 383 January 18, 2014 215

 Correspondence
The target of reversal of the spread of
tuberculosis by 2015 is far from being
achieved at country level. Reported
tuberculosis figures in Mozambique
are still following an upward trend,
which are hardly explained by an
improved case detection rate which,
according to WHO estimates, remains
worryingly stable at only 34%, the
lowest among the high-burden
countries. Thus, the true magnitude
of the disease burden is unknown
and current estimates are far from
precise. Childhood tuberculosis
continues to be relatively neglected
and, in Mozambique, a country in
which almost 50% of the population
is younger than 15 years, the lack of
childhood tuberculosis estimates
only perpetuates and magnifies
the problem. Moreover, the current
surveillance system only detects
16% of the estimated total number
of multidrug-resistant tuberculosis
cases3 posing a dramatic challenge
for the near future. As a country
with one of the highest tuberculosis/
HIV co-infection rates, ensuring
prompt diagnosis and treatment of
tuberculosis through newly available
technology (ie, Gene Xpert) and
ensuring high antiretroviral therapy
coverage, is not a minor undertaking
and is regarded as a top health priority
by the government.
For countries such as Mozambique,
the Global TB report identifies the
need for targeted efforts to improve
the tuberculosis surveillance system,
which should be integrated with
Published Online HIV surveillance efforts. Within this
November 14, 2013 framework, operational research
http://dx.doi.org/10.1016/
S0140-6736(13)62223-0
needs cannot be overlooked since
they will provide improved estimates
of disease burden and identify
programme failures and priority areas
for action and improvement. Political
commitment to sustain and increase
national and international donors’
budget allocations to tuberculosis
control and research is crucial in order
to relieve this longstanding scourge.
We declare that we have no conflicts of interest.
216
*Alberto L García-Basteiro,
Elisa López-Varela, Ivan Manhiça,
Eusebio Macete, Pedro L Alonso
alberto.garcia-basteiro@manhica.net
Manhiça Health Research Center, Vila da Manhiça,
Maputo, Mozambique (ALG-B, EL-V, EM, PLA);
Barcelona Centre for International Health Research
CRESIB, Hospital Clínic-Universitat de Barcelona,
Barcelona, Spain (ALG-B, EL-V, PLA); and National
Tuberculosis Program, Ministry of Health, Maputo,
Mozambique (IM)
1 WHO. Global tuberculosis report 2013. Geneva:
World Health Organization, 2013. http://www.
who.int/tb/publications/global_report/en/
index.html (accessed Oct 23, 2013).
2 Zumla A, George A, Sharma V, Herbert N,
Baroness Masham of Ilton. WHO’s 2013 global
report on tuberculosis: successes, threats, and
opportunities. Lancet 2013; 382: 1765–67.
3 Falzon D, Jaramillo E, Wares F, Zignol M, Floyd K,
Raviglione MC. Universal access to care for
multidrug-resistant tuberculosis: an analysis of
surveillance data. Lancet Infect Dis 2013;
13: 690–97.
Calcium-based
phosphate binders and
chronic kidney disease
We have concerns regarding
Sophie Jamal and colleagues’ Article
(Oct 12, p 1268)1 on the effect of
calcium-based versus non-calcium-
based phosphate binders on mortality
in patients with chronic kidney disease.
First, Suki and colleagues’ large
randomised controlled trial with 2103
patients and 542 events was a well done
negative trial and should be considered
while interpreting the present results.2
The forest plot (figure 2)1 strongly
suggests a small-study effect;3 indeed a
subgroup analysis of small (<50 events;
RR 0·54, 95% CI 0·37–0·79) versus
large (>50 events; RR 0·93, 95% CI
0·82–1·04) trials shows a significant
difference in effect size. This also
resolves the heterogeneity with I2 values
of 0. Second, we found that the Duval‘s
trim and fill analysis4 for publication
bias using the correct options does
add three studies with an adjusted
value of the RR being 0·82 (95% CI
0·64–1·04). Lastly, the trial by Di Iorio
and colleagues had a correction,5 it
was not registered, it was reported per
protocol (and not intention-to-treat
analysis) and patients were censored at
dialysis inception (thus mortality after
dialysis initiation was not reported)
despite all cause mortality being the
primary outcome. Neither the patients
nor the investigators were blinded, and
the categorisation of this trial5 as low
risk of bias is questionable. Exclusion of
this trial on sensitivity analysis leads to a
revised RR of 0·82 (95% CI 0·66–1·04).
On the basis of these issues, the
conclusion of the superiority of calcium-
based phosphate binders in reducing
mortality is not robust.
We declare that we have no conflicts of interest.
*Swapnil Hiremath, Ayub Akbari
shiremath@toh.on.ca
University of Ottawa, Ottawa, ON K1H 7W9, Canada
1 Jamal SA, Vandermeer B, Raggi P, et al. Effect
of calcium-based versus non-calcium-based
phosphate binders on mortality in patients
with chronic kidney disease: an updated
systematic review and meta-analysis. Lancet
2
2013; 382: 1268–77.
Suki WN. Effects of sevelamer and calcium-
based phosphate binders on mortality in
hemodialysis patients: results of a randomized
clinical trial. J Ren Nutr 2008; 18: 91–98.
3 Nuesch E, Trelle S, Reichenbach S, et al. Small
study effects in meta-analyses of osteo-
arthritis trials: meta-epidemiological study.
BMJ 2010; 341: c3515.
4 Duval S, Tweedie R. Trim and fill: a simple
funnel-plot-based method of testing and
adjusting for publication bias in meta-analysis.
Biometrics 2000; 56: 455-63.
5 Di Iorio D. Correction. http://cjasn.asnjournals.
org/content/7/8/1370 (accessed July 31, 2013).
Polio and the risk for the
European Union
Martin Eichner and Stefan Brockmann
warn that “Vaccinating only Syrian
refugees—as has been recommended
by the ECDC—must be judged as
insufficient; more comprehensive
measures should be taken into
consideration.”1
In response to the recent develop-
ments regarding wild-type polio
virus (WPV) circulation in Israel and
a cluster of poliomyelitis cases in
Syria, the European Centre for Disease
Prevention and Control (ECDC) has
published two risk assessments for
www.thelancet.com Vol 383 January 18, 2014