Increasing resistance of M. tuberculosis to anti-TB drugs in Saudi Arabia

Drug Resistance to Anti-Tuberculosis Drugs: A Cross-Sectional Study From Makkah, Saudi Arabia

Aim

The aim of this study was to investigate the patterns and determinants of drug resistance to tuberculosis (TB) in a large population from Makkah, Saudi Arabia.

Methods

A retrospective, cross-sectional cohort study was conducted on all patients with TB who were referred to the National Tuberculosis Prevention Program in Makkah, Saudi Arabia, between January 2016 and September 2020. For each TB case, demographic data were collected in addition to the results of drug susceptibility testing (DST) for anti-TB drugs. The Statistical Package for Social Sciences (SPSS) software for Windows, version 23 (IBM Corporation, Armonk, NY, USA), was used for the statistical analysis.

Results

A total of 472 TB-confirmed cases were included in the analysis. The mean ± standard deviation of the age was 38.5 ± 17.7 years. The vast majority of patients were male (62.7%) and had pulmonary TB (91.7%). Only a small proportion of the patients with TB had diabetes mellitus (8.5%). Overall, the prevalence of monodrug-resistant TB ranged from 2.1% to 3.4%. Specifically, the prevalence of monodrug-resistant TB to isoniazid and streptomycin was ranked first and was equal to 3.4%. Pyrazinamide had the lowest prevalence of monodrug-resistant TB (2.1%). The prevalence of polydrug-resistant TB (PDR-TB) and multidrug-resistant TB (MDR-TB) was 1.5%. In the univariate analysis, sex (male) was the only sociodemographic factor that significantly correlated with a higher prevalence of MDR-TB.

Conclusions

This is the second study from Makkah to analyze the prevalence and associated risk factors of MDR-TB among patients from Makkah. Our data demonstrated that the prevalence of monodrug-resistant TB and MDR-TB was low (2.1%-3.4% and 1.5%, respectively). Diabetes mellitus was not a substantial factor correlated with a higher occurrence of MDR-TB. Additional epidemiologic studies are required to validate our results.

A retrospective study of tuberculosis prevalence amongst patients attending a tertiary hospital in Riyadh, Saudi Arabia

Tuberculosis (TB) is a public health challenge that affects all genders and age groups and is a single leading infectious disease killer globally. We retrospectively investigated the prevalence of TB and anti-TB drug resistance among patients treated at the Prince Sultan Military Medical City (PSMMC) between the years 2000 and 2017. Patient demographic variables and drug susceptibility test results were obtained from TB notification records located in the TB laboratory at PSMMC. A total of 58,141 records were reviewed of which 1123 (2%) specimens were positive for Mycobacterium tuberculosis. Of the positive, 621 (55%) were from pulmonary specimens. Males over the age of 15 years accounted for 60% of the positive specimens. Drug resistance to at least one drug was detected in 90 (8%) of which 60 (5.3%), 24 (2%) 6 (0.5%) patients were mono-drug-resistant, poly-drug resistant and multidrug resistant (MDR-TB) respectively. Resistance to isoniazid and streptomycin were the most frequently found among first-line tuberculosis drugs, accounting for 4.5% and 3.8% of drug resistance cases respectively. Our findings show low prevalence of tuberculosis and multidrug resistant TB among patients treated at PSMMC over a 17-year period. Nationwide assessment is needed to get a clear picture of the TB burden across Saudi Arabia and inform national policies for eradication of TB.

Health Education Intervention as an Effective Means for Prevention of Respiratory Infections Among Hajj Pilgrims: A Review

The prevalence of respiratory illness has continued to surge among Hajj pilgrims from different countries despite having some practices of preventive measures. Respiratory illnesses during Hajj could be due to many reasons and many factors that promote disease spread. These factors include overcrowding, cigarette smoking, and direct contact with infectious agents particularly viruses promote the spread of respiratory infections. However, due to the longer duration of the pilgrimage, there are high chances of pilgrims contracting various respiratory illnesses due to exposure to respiratory pathogens. Hajj pilgrims' knowledge, attitudes, and practices toward respiratory tract infections are used as the determinant of the effectiveness of the health education interventions. Knowledge and application of basic hygiene principles, use of face masks, following cough etiquettes, engaging in social distancing, and engaging in other measures are highly important. In this paper, we reviewed the various effective intervention strategies implemented to help prevent respiratory tract infections during Hajj.

Hajj-associated infections

BACKGROUND

The Hajj is the largest annual mass gathering event in the world, thus favoring the transmission of various infections: 183 different nationalities, high temperatures, coincidence with the start of the flu season in the Northern hemisphere, a long barefoot walk, tent-type accommodation, communal toilet facilities, absence of food control, and sharing of razors. Infections are the first cause of hospital admission, which often occurs in the home country of pilgrims.

METHODS

Literature review on PubMed from 1952 to November 2015 on the epidemiology and prevention of infections contracted during the Hajj, using the keywords "Hajj" and "infections".

RESULTS

Respiratory tract infections, ENT infections, influenza, pyogenic pneumonia, whooping cough, and tuberculosis are most frequently observed during the Hajj. Outbreaks of meningococcal meningitis have been reported in pilgrims and their contacts. Waterborne infections such as gastroenteritis and hepatitis A are common, despite the improvement of health conditions. Pyoderma and furuncles are also frequently observed. Recently, dengue fever, Alkhumra hemorrhagic fever, and Rift Valley fever have emerged but no case of MERS-coronavirus, appeared in Saudi Arabia in 2012, have yet been observed during the 2012-2014 Hajj.

CONCLUSION

Prevention is based on compulsory meningococcal vaccination, vaccination against seasonal influenza and pneumococcal infections for pilgrims at high risk of contracting the infection, and on vaccination against hepatitis A. Updating immunization for diphtheria/tetanus/poliomyelitis/pertussis and measles/mumps is also crucial and pilgrims must comply with hygiene precautions.

A Global Perspective on Pyrazinamide Resistance: Systematic Review and Meta-Analysis

Background

Pyrazinamide (PZA) is crucial for tuberculosis (TB) treatment, given its unique ability to eradicate persister bacilli. The worldwide burden of PZA resistance remains poorly described.

Methods

Systematic PubMed, Science Direct and Scopus searches for articles reporting phenotypic (liquid culture drug susceptibility testing or pyrazinamidase activity assays) and/or genotypic (polymerase chain reaction or DNA sequencing) PZA resistance. Global and regional summary estimates were obtained from random-effects meta-analysis, stratified by presence or risk of multidrug resistant TB (MDR-TB). Regional summary estimates were combined with regional WHO TB incidence estimates to determine the annual burden of PZA resistance. Information on single nucleotide polymorphisms (SNPs) in the pncA gene was aggregated to obtain a global summary.

Results

Pooled PZA resistance prevalence estimate was 16.2% (95% CI 11.2-21.2) among all TB cases, 41.3% (29.0-53.7) among patients at high MDR-TB risk, and 60.5% (52.3-68.6) among MDR-TB cases. The estimated global burden is 1.4 million new PZA resistant TB cases annually, about 270,000 in MDR-TB patients. Among 1,815 phenotypically resistant isolates, 608 unique SNPs occurred at 397 distinct positions throughout the pncA gene.

Interpretation

PZA resistance is ubiquitous, with an estimated one in six incident TB cases and more than half of all MDR-TB cases resistant to PZA globally. The diversity of SNPs across the pncA gene complicates the development of rapid molecular diagnostics. These findings caution against relying on PZA in current and future TB drug regimens, especially in MDR-TB patients.

Systematic review of the prevalence of Mycobacterium tuberculosis resistance in Saudi Arabia

AIM

To quantitatively estimate the prevalence of resistance of Mycobacterium tuberculosis (TB) to first line agents in Saudi Arabia.

METHODS

The overall prevalence of M. tuberculosis resistance was calculated using meta-analysis.

RESULTS

We included 22 studies from Saudi Arabia that were published from 1979 to 2013.A high degree of heterogeneity among studies was observed. Based on random effect methodology, the prevalence (and 95% CI) of the resistance rates were: INH 10.13 (8.13-12.11), rifampicin 5.41 (4.21-6.61), ethambutol 1.29 (1.83-2.37) and streptomycin 6.5 (4.9-8.1), and multi-drug resistant was 6.7 (5.1-8.3).

CONCLUSION

The prevalence of resistance to anti-tuberculous agents was highest for INH followed by streptomycin and rifampicin. Multi-drug resistant tuberculosis remains at 6.7%. The data support the recommendations to use four anti-tuberculous agents as empiric therapy.

Methicillin-Resistant Staphylococcus aureus: A 5-Year Review of Surveillance Data in a Tertiary Care Hospital in Saudi Arabia

Background.

Staphylococcus aureus is an important pathogen that leads to serious infections in the community and in hospitals. Evidence has shown that the prevalence of infection and colonization with drug-resistant S. aureus, such as methicillin-resistant S. aureus (MRSA) and glycopeptide intermediately susceptible S. aureus, is increasing. Authorities must be aware of the prevalence of MRSA infection and colonization in their country in order to implement and monitor infection control policies that help curtail further emergence of this pathogen.

Objectives.

To examine the trend of hospital-acquired MRSA infection and colonization in a tertiary care institution in Saudi Arabia during a 5-year period in order to identify specific areas at high risk for MRSA transmission, and to review our MRSA decolonization procedure and outcomes.

Methods.

Surveillance data prospectively collected from January 1, 2000, through December 31, 2004, on hospital-acquired (HA) MRSA were analyzed, with an emphasis on the trend of HA-MRSA infection and colonization, areas of high transmission, risk factors, and effectiveness of the implemented decolonization policy.

Results.

During the study period, 442 cases of HA-MRSA infection and colonization were identified. Of these, 51.2% were infections, and 48.8% were colonizations. An increasing trend in the incidence rates of infection and colonization was noticed during the study period, and most cases were identified on the surgical ward (33.3%) and medical ward (32.1%). Of the 34 infected patients who underwent systematic decolonization, 35.3% were successfully decolonized, and of the 11 who underwent topical decolonization, 63.6% were successfully decolonized.

Conclusion.

The increasing trend of HA-MRSA infections has been a noticeable global problem. We identified a gradual increase in the rates of MRSA colonization and infection in a tertiary care center Saudi Arabia and recognize the importance of abiding by strict infection control policies, including hand hygiene and proper isolation practices. Continued surveillance for MRSA and other emerging multidrug-resistant pathogens is also needed.

Potential risk for drug resistance globalization at the Hajj

Antibiotics were once considered the miracle cure for infectious diseases. The tragedy would be the loss of these miracles as we witness increased antibiotic resistance throughout the world. One of the concerns during mass gatherings is the transmission of antibiotic resistance. Hajj is one of the most common recurring mass gatherings, attracting millions of people from around the world. The transmission of drug-resistant organisms during the Hajj is not well described. In the current review, we summarize the available literature on the transmission and acquisition of antibiotic resistance during the Hajj and present possible solutions.

Epidemiology of antituberculosis drug resistance in Saudi Arabia: findings of the first national survey

The real magnitude of antituberculosis (anti-TB) drug resistance in Saudi Arabia is still unknown because the available data are based on retrospective laboratory studies that were limited to hospitals or cities. A representative national survey was therefore conducted to investigate the levels and patterns of anti-TB drug resistance and explore risk factors. Between August 2009 and July 2010, all culture-positive TB patients diagnosed in any of the tuberculosis reference laboratories of the country were enrolled. Isolates obtained from each patient were tested for susceptibility to first-line anti-TB drugs by the automated Bactec MGIT 960 method. Of the 2,235 patients enrolled, 75 cases (3.4%) were lost due to culture contamination and 256 (11.5%) yielded nontuberculous mycobacteria (NTM). Finally, 1,904 patients (85.2% of those enrolled) had available drug susceptibility testing results. Monoresistance to streptomycin (8.1%; 95% confidence interval [CI], 7.2 to 9.1), isoniazid (5.4%; 95% CI, 4.7 to 6.2), rifampin (1%; 95% CI, 0.7 to 1.3) and ethambutol (0.8%; 95% CI, 0.5 to 1.2) were observed. Multidrug-resistant TB (MDR-TB) was found in 1.8% (95% CI, 1.4 to 2.4) and 15.9% (95% CI, 15.4 to 16.5) of new and previously treated TB cases, respectively. A treatment history of active TB, being foreign-born, having pulmonary TB, and living in the Western part of the country were the strongest independent predictors of MDR-TB. Results from the first representative national anti-TB drug resistance survey in Saudi Arabia suggest that the proportion of MDR-TB is relatively low, though there is a higher primary drug resistance. A strengthened continuous surveillance system to monitor trends over time and second-line anti-TB drug resistance as well as implementation of innovative control measures, particularly among immigrants, is warranted.

Infectious diseases in the Arabian Peninsula and Egypt

Infectious diseases are important causes of morbidity and mortality globally. Epidemiologically, differences in the patterns of infectious diseases and antimicrobial resistance exist across diverse geographical regions. In this review on infectious diseases in the Arabian Peninsula and Egypt, the epidemiology of tuberculosis, malaria and human immunodeficiency virus (HIV) infections will be addressed. The challenges of the hepatitis C epidemic in Egypt and the epidemiology of this infection across the region will be reviewed. In recent years, we have seen dengue endemicity become established, with major outbreaks in parts of the region. Emerging data also indicate that, across the region, there is an increasing burden of antibiotic resistance, with endemicity in healthcare settings and dissemination into the community. New challenges include the emergence of the Alkhurma haemorrhagic fever virus in Saudi Arabia. The annual Hajj pilgrimage in Saudi Arabia serves as a model for the control of infectious disease in mass gatherings. As most of these countries constantly experience a uniquely dynamic population influx in the form of expatriate workers, tourists, or pilgrims, concerted regional and international collaboration to address these public health concerns in a region that lies at the crossroads for the global spread of infectious pathogens is imperative.

Tuberculosis in Saudi Arabia: prevalence and antimicrobial resistance

Tuberculosis is a serious contagious disease caused by Mycobacterium tuberculosis and is endemic in many countries. Over the past two decades, there has been an increase in the number of multidrug-resistant TB and extensively drug-resistant TB cases around the world. As in many countries, TB is common in Saudi Arabia. The disease is particularly relevant in the Kingdom because of its population dynamics including a large number of resident expatriates mainly from TB endemic regions and the influx of millions of pilgrims to the country each year during the Hajj and Umrah seasons. This review investigates the prevalence and antimicrobial resistance among M. tuberculosis isolates from Saudi Arabia, highlighting the variations in rates in different geographical areas with particularly high rates in the main cities and regions hosting the annual pilgrimage. The review also refers to the measures needed to prevent and control TB transmission in the country.

Primary anti-tuberculous drugs resistance of pulmonary tuberculosis in Southwestern Saudi Arabia

The emergence of drug-resistant tuberculosis (TB) is an increasing problem which adversely affects patient care and public health. This study aimed to determine the rates and patterns of primary anti-TB drugs resistance in Najran, Southwestern Saudi Arabia. The study included 80 smear-positive new pulmonary TB patients. Sputum samples were cultured on Lowenstein-Jensen and Middle-Brook 7H10 media. Mycobacterium tuberculosis susceptibility testing was done by the conventional agar proportion method for isoniazide (INH), rifampicin (RIF), streptomycin (SPM) and ethambutol (EMB). Out of the 68 M. tuberculosis isolates, 42 (61.8%) were sensitive to all 4 drugs and 26 (38.2%) were resistant to one or more drugs. The most common resistance was found to INH (33.8%), followed by RIF (23.5%), SPM (13.2%) and EMB (2.9%). Eight (11.8%) isolates were resistant to one drug, 14 (20.6%) were resistant to 2 drugs, 3 (4.4%) were resistant to 3 drugs and one (1.5%) was resistant to 4 drugs. Multi-drug resistant (MDR) isolates were found in 14 (20.6%) cases. In conclusion, the primary resistance rate to four first-line anti-tuberculous drugs and MDR-TB rate are worryingly high, representing an alarming situation in Najran. Further studies are necessary for continuous surveillance of M. tuberculosis resistance patterns.

New insight into the molecular characterization of isoniazid and rifampicin resistant Mycobacterium tuberculosis strains from Saudi Arabia

Data on the genetic variation of isolates of Mycobacterium tuberculosis and spectrum of mutations determining resistance to principal anti-tuberculosis drugs isoniazid (INH) and rifampicin (RIF) have not yet been studied in Saudi Arabia. One hundred and fifty-one clinical isolates of M. tuberculosis from different regions in the country showing resistance to RIF and INH were subjected to drug susceptibility testing, characterization of mutations conferring drug resistance and genotyping. Phenotypically 17 (11.3%) isolates were resistance to RIF, 75 (49.6%) were resistant to INH and 59 (39.1%) were resistant to both RIF and INH, respectively. Sixteen (10.6%), 74 (49%) and 56 (37.1%) were determined as resistant to RIF, INH and to both by line probe assay. High frequency of rpoB 531 mutations (67.1%) in RIF resistant strains and katG 315 mutations (65.2%) in INH resistant strains were found. Mutations responsible for INH resistance, katG 315 (P value<0.001, odds ratio: 1.81, 95% CI [1.51, 2.18]) and inhA-15 (P value - 0.004, odds ratio: 1.48, 95% CI [1.22, 1.8]) were predominant among the newly diagnosed cases. Beijing strains were significantly associated with multi drug resistance and mutations in combination of rpoB531 and katG315 (P value - <0.001, odds ratio: 6.83, 95% CI [2.65, 17.58]). In addition multi drug resistance was significantly associated with treatment history (P value<0.001, odds ratio: 3.16, 95% CI [2.14, 4.67]). Furthermore, a higher rate (39.3%) of clustering among the multidrug resistant strains particularly with Beijing family (52.9%) was observed. Saudi Arabia harbors highly diverse drug resistant M. tuberculosis population with an ongoing transmission which needs to be immediately managed.

Patterns of antituberculous drug resistance in Eastern Saudi Arabia: a 7-year surveillance study from 1/2003 to 6/2010

OBJECTIVE

To examine the patterns of antituberculous drug resistance of Mycobacterium tuberculosis in patients with pulmonary and extra-pulmonary tuberculosis in the Eastern province of the Kingdom of Saudi Arabia.

METHODS

This is a retrospective study of antibiotic susceptibility of 1681 non-repetitive M. tuberculosis isolates from 1/2003 to 6/2010.

RESULTS

Of the total patients, 41% (n=687) were Saudis and 59% (n=994) were non-Saudis. The pulmonary and extra-pulmonary specimens constituted 68% (n=1148) and 32% (n=533), respectively. The incidence of resistance was 15.5% to one or more of anti-tuberculosis drugs. The resistance rates to first-line drugs were as follows: streptomycin (10.4%), INH (9.8%), rifampicin (1.5%) and ethambutol (1.0%). Multi-drug resistant tuberculosis was present in 1.4% (n=24) of the sample.

CONCLUSION

INH resistance in this study was relatively high, whereas the rate of MDR-TB was low. A rate of MDR-TB observed in this study was 1.4%. Thus, an empiric four-drug therapy is required to treat patients with tuberculosis in this area of Saudi Arabia.

Ethambutol resistance of indigenous Mycobacterium tuberculosis isolated from human patients

The present study was conducted to find out the ethambutol resistance pattern of indigenous isolates of Mycobacterium tuberculosis from Tuberculosis diagnosed human patients. A total of 172 specimens were collected from six different sources and comprised of 84.9% sputum, 10.5% pus and 4.7% bronchial washings. There were 70.9% males and 29.1% females with 84.30% pulmonary and 15.69% extra-pulmonary tuberculosis. The Mycobacterium tuberculosis isolates collected from primary culture were further studied to determine their pattern and level of resistance. The inoculums were prepared using 0.5 Mac Farland turbidity standards. Five different concentration of ethambutol were used in Lowenstein Jensen (LJ) medium i.e. 2µg/ml, 4µg/ml, 6µg/ml, 8µg/ml and 10µg/ml for sensitivity testing. Data showed 10 (5.8%) resistant and 162 (94.2%) sensitive Mycobacterium tuberculosis out of total 172 clinical isolates. The growth was not inhibited at 1^st (2µg/ml) and 2^nd (4µg/ml) drug levels, while growth of 50% isolates inhibited at 3^rd level (6µg/ml), 30% inhibited at 4^th level (8µg/ml) and 20% at 5^th level (10µg/ml). The last three levels are above the therapeutic index and not recommended in actual clinical practice. It is thus conceivable to explore some other more effective chemotherapeutic agents, modify combinations or find more effective procedures to stop morbidity and mortality due to ethambutol resistant Mycobacterium tuberculosis.

Susceptibility Pattern and Epidemiology of Mycobacterium tuberculosis in United Emirati Hospital

Objective:

Human tuberculosis (TB) has re-emerged at an alarming rate as one of the deadliest contagious diseases; not only in the developing world, but also in the developed countries. Its re-emergence indicates failure to control its transmission. What causes part of the alarm is the growing number of isolates displaying resistance to the first line drugs used in its control. The very high volume of travel to the United Arab Emirates (UAE) is yet another reason for concern over the spread of the disease. This study reports on the pattern of multiple drug (MDR) resistance exhibited by Mycobacterium tuberculosis (MTB) isolates from a major hospital in the UAE.

Methods:

All pulmonary and extrapulmonary tuberculosis patients with positive culture results from January 2001 to December 2008 were included in the study. Cultures were performed at the mycobacteriology laboratory of the Emirati Hospital, Abu Dhabi, UAE, using the conventional Lewes-Johnson media. M. tuberculosis was isolated by standard procedures. M. tuberculosis complex was identified by conventional biochemical tests. Anti-mycobacterial sensitivity testing was done by the disk method as described by Wayne & Krasnow.

Results:

From 2002 to 2008, 43 nonrepetitive culture-positive cases were identified. The resistance rates of M. tuberculosis to tested first-line agents were as follows: isoniazid, 34.5%; pyrazinamide, 34.8%; rifampin, 32.5%; streptomycin, 25.6%; and ethambutol, 20.9%. The resistance rate to isoniazid, rifampin and pyrazinamide was 7%; to isoniazid, rifampin and streptomycin was 2.3%; and to isoniazid, rifampin, streptomycin and pyrazinamide was 2.3%. The resistance rate to all the five agents together was 4.6%.

Conclusion:

This study is the first in the UAE to report such high levels of resistance to anti-TB drugs; 27.7% for anti-tuberculosis Drugs such as isoniazid and pyrazinamide are of great significance to achieve proper treatment in M. tuberculosis infections in future. Indeed, isoniazid and rifampicin are important components of any regimen for the treatment of drug susceptible TB.

Tuberculosis in end-stage renal disease patients on hemodialysis

Recent studies have shown that there is an increase in the incidence of mycobacterium tuberculosis (MBT). This is more prevalent among immune compromised patients (those on dialysis) and recipients of organ transplants. Furthermore, extra-pulmonary presentation appears to be more common and difficult to diagnose. We aimed in this study to assess and evaluate the presentation of MBT in a retrospective study conducted among 256 hemodialysis (HD) patients where 18 of them were diagnosed and managed for tuberculosis over a 10-year period between 1990 and 2000. The mean age of the patients was 38 years (21-75 years). The mean interval between the onset of HD and the time of diagnosis was about 24 months (1-120 months). The diagnosis of tuberculosis was made either by isolation of acid-fast bacilli (AFB), the typical caseating granuloma on biopsy, or by recovery of tubercle bacilli from the culture of the biopsy material. Extra-pulmonary tuberculosis was more common (77.8%) than pulmonary tuberculosis (22.2%). The various extra-pulmonary tuberculosis sites noted were cervical lymphadenitis (16.7%), gastrointestinal (16.7%), genitourinary (11.1%), peritonitis (11.1%), pleural effusion (5.6%), pericardial effusion (5.6%), miliary tuberculosis (5.6%), and pyrexia of unknown origin (5.6%). None of the patients with extra-pulmonary tuberculosis had evidence of pulmonary tuberculosis. The atypical presentation with insidious onset was quite common. Anergy to tuberculin skin test was noticed in 56% of cases. All of our patients received modified antituberculosis treatment for 1 year with adequate response, and without undue side effects. We conclude that a high index of suspicion is required especially in the diagnosis of extra-pulmonary tuberculosis, and when there is a high percentage of anergy to tuberculin skin test. Tissue biopsy both for characteristic histology and demonstration of MTB, either by staining or culture, remains the main criteria for the diagnosis of extra-pulmonary tuberculosis.

Health risks at the Hajj

Annually, millions of Muslims embark on a religious pilgrimage called the "Hajj" to Mecca in Saudi Arabia. The mass migration during the Hajj is unparalleled in scale, and pilgrims face numerous health hazards. The extreme congestion of people and vehicles during this time amplifies health risks, such as those from infectious diseases, that vary each year. Since the Hajj is dictated by the lunar calendar, which is shorter than the Gregorian calendar, it presents public-health policy planners with a moving target, demanding constant preparedness. We review the communicable and non-communicable hazards that pilgrims face. With the rise in global travel, preventing disease transmission has become paramount to avoid the spread of infectious diseases, including SARS (severe acute respiratory syndrome), avian influenza, and haemorrhagic fever. We examine the response of clinicians, the Saudi Ministry of Health, and Hajj authorities to these unique problems, and list health recommendations for prospective pilgrims.

Susceptibility Pattern and Epidemiology of Mycobacterium tuberculosis in a Saudi Arabian Hospital

OBJECTIVES

The objective of this study was to examine the prevalence and trends of drug resistance of Mycobacterium tuberculosis at the Saudi Aramco Medical Services Organization.

METHODS

We retrospectively identified M tuberculosis isolates from January 1989 to December 2003. Antimicrobial susceptibility and clinical data were collected and analyzed.

RESULTS

From 1989 to 2003, 276 nonrepetitive culture-positive cases were identified. There were 236 Saudis (84.6%), and the remainder were non-Saudis (15.4%). M tuberculosis isolates were obtained from pulmonary specimens (49%) and extrapulmonary sites (51%). The resistance rates of M tuberculosis to tested first-line agents were as follows: isoniazid, 12.5%; ethambutol, 7.5%; streptomycin; 6.9%; and rifampin, 1.1%. The resistance rate to isoniazid and streptomycin was 1.8%, the rate to isoniazid and rifampin was 0.7%, and the rate to isoniazid and ethambutol was 2.5%. The resistance rate to isoniazid, ethambutol, and streptomycin was 0.7%

CONCLUSION

M tuberculosis resistance to isoniazid showed a decreased rate over the study period from 20 to 5.7%. The rate of multidrug-resistant M tuberculosis remained low.

Demographic pattern and clinical characteristics of patients with smear- positive pulmonary tuberculosis in kuwait

OBJECTIVE

The aim of this study was to document various clinical factors that are likely to be of help in the control of tuberculosis in Kuwait.

SUBJECTS AND METHODS

Details of patients with sputum positive for acid-fast bacilli in the period from January 1998 to December 2000 were collected retrospectively from the case records and population statistics from government sources. The data were then tabulated and analyzed.

RESULTS

Of the 526 cases, 83.5% were expatriates and 16.5% Kuwaiti; 373 (70.9%) were male. Of the expatriates, 66.7% were from Asia and the Far East, 5.7% were > or =60 years. The annual incidence was 8.34 per 100,000 population. The lowest incidence was observed in the Jahrah governorate with an overall incidence of 5 (2.0 among Kuwaitis and 6.4 among expatriates) per 100,000 population. The highest incidence overall (10.2) and among Kuwaitis (4.1) was observed in the Farwaniya governorate, while the highest incidence among expatriates was seen in the Capital governorate (13.4). Radiologically, 94 (19.5%) had minimal, 246 (51.5%) had moderately advanced and 141 (29.3%) far-advanced disease. The majority of the patients (72%) had only + status for AFB in the smear. Hypercalcemia (25.7%), hyponatremia (22.15%) and hyperglycemia (29.9%) were common in the patients. Mean serum albumin was low (28.7 +/- 5.5 g/l). Two hundred and forty-seven (47.2%) were declared cured while 116 (22.2%) completed treatment. Comparison between nationals and expatriates showed a significant difference only for age, smoking status, defaulter rate and place of residence.

CONCLUSION

The lowest regional incidence was found in the Jahrah governorate. Both biochemical abnormalities and radiologically advanced presentations were common. Disease pattern and response to treatment was purely individual and did not differ with respect to nationality or race.

Prevalence of resistance to antituberculosis drugs in Riyadh and a review of previous reports

BACKGROUND

Resistance to antituberculosis drugs is an important cause of treatment failure. We evaluated the prevalence and pattern of antituberculosis drug resistance in the central region of Saudi Arabia, and reviewed previous reports from Saudi Arabia.

MATERIALS AND METHODS

We retrospectively examined the records of sputum smear and culture-positive pulmonary tuberculosis patients admitted consecutively from 1998 through 1999 in a main referral hospital in Riyadh, and analyzed drug sensitivity reports. We also reviewed previous reports on antituberculosis drug resistance in Saudi Arabia.

RESULTS

Of 515 patients with pulmonary tuberculosis, 80 (15.5%) had resistance to at least one antituberculosis drug. Resistance to streptomycin was most frequent (9.7% ), followed by rifampicin (9.5%), isoniazid (4.3%), and ethambutol (0.2%). Resistance to one antituberculosis drug was found in 8.9%, resistance to two drugs in 5.2%, resistance to three drugs in 1.2%, and resistance to four drugs in 0.2%. Multidrug resistance (defined as resistance to at least isoniazid and rifampicin) was found in 1.9% of patients. A literature review including 6114 patients in Saudi Arabia showed that resistance against streptomycin was most common (8.8%), followed by rifampicin (8%), and isoniazid (7.2%). Of the 6114 patients, 6.8% patients were resistant to only one drug, 3.6% were resistant to two drugs, and 3.7% to three drugs.

CONCLUSION

The high prevalence of rifampicin resistance and resistance to multiple drugs in the Riyadh region and in other parts of Saudi Arabia is a major challenge to the control of tuberculosis in this country. Efforts should be made to prevent the emergence of further antituberculosis drug resistance.

Treatment outcome of tuberculosis among Saudi nationals: role of drug resistance and compliance

OBJECTIVE

Recent studies have demonstrated a high prevalence of multiresistant Mycobacterium tuberculosis (MDR-TB) in Saudi Arabia. In this study, we assessed the impact of this and other factors on the treatment outcome of tuberculosis among Saudi nationals.

METHODS

We studied all patients (147 patients) with a culture-proven diagnosis of tuberculosis seen at the King Khalid National Guard Hospital (KKNGH), Jeddah, Saudi Arabia from June 1993 to June 1999. Treatment outcome was classified as success or failure based on the clinical assessment, improvement or deterioration of chest X-rays, and results of follow-up sputum examination.

RESULTS

Of the 147 patients, only 126 completed the follow-up program. Treatment was found to be successful in 102 (81.0%) and unsuccessful in 24 (19.0%) of these 126 patients. However, treatment success is much less (102/147; 69.4%) and failure is much higher (45/147; 30.6%) if the 21 patients who were lost to follow-up are regarded as treatment failures. The prevalence of poor compliance and multiply drug-resistant Mycobacterium tuberculosis were found to be significantly higher among those with treatment failure than among those in whom treatment was successful. There was no significant difference in treatment outcome between the different age groups. However, failure of treatment was observed to be more common (P < 0.001) among males (35 patients; 46.7%) than among females (10 patients; 13.9%). This could be explained mainly by the significantly higher prevalence of non-compliance among males (44%) than among females (15.3%). There were no significant differences in the symptoms, radiologic findings, clinical presentation (pulmonary versus extrapulmonary), social background or drug resistance between genders.

CONCLUSION

Successful treatment outcome among Saudi Nationals seen at the KKNGH in 1993-99 was below the rate recommended by the WHO, and failed treatment was associated with poor compliance, male gender and drug-resistant Mycobacterium tuberculosis. These results emphasize the importance of culture and sensitivity tests for Mycobacterium tuberculosis and close supervision of patients taking antituberculosis medications.

Travel epidemiology: the Saudi perspective

The Kingdom of Saudi Arabia occupies four-fifths of the Arabian Peninsula, with a land area of 2 million square kilometres. Saudi Arabia holds a unique position in the Islamic world, as the custodian of the two holiest places of Islam, in Mecca and Medina. Annually, some 2 million Muslims from over 140 countries embark on Hajj. This extraordinary en masse migration is a unique forum for the study of travel epidemiology since the Hajj carries various health risks, both communicable and non-communicable, often on a colossal scale. Non-communicable hazards of the Hajj include stampede and motor vehicle trauma, fire-related burn injuries and accidental hand injury during animal slaughter. Communicable hazards in the form of outbreaks of multiple infectious diseases have been reported repeatedly, during and following the Hajj. Meningococcal meningitis, gastroenteritis, hepatitis A, B and C, and various zoonotic diseases comprise some of the possible infectious hazards at the Hajj. Many of these infectious and non-infectious hazards can be avoided or averted by adopting appropriate prophylactic measures. Physicians and health personnel must be aware of these risks to appropriately educate, immunize and prepare these travellers facing the unique epidemiological challenges of Hajj in an effort to minimize untoward effects. Travel epidemiology related to the Hajj is a new and exciting area, which offers valuable insights to the travel specialist. The sheer scale of numbers affords a rare view of migration medicine in action. As data is continually gathered and both national and international policy making is tailored to vital insights gained through travel epidemiology, the Hajj will be continually safeguarded. Practitioners will gain from findings of travel related epidemiological changes in evolution at the Hajj: the impact of vaccinating policies, infection control policies and public health are afforded a real-world laboratory setting at each annual Hajj, allowing us to learn from this unique phenomenon of migration medicine.

Tuberculosis in association with travel

Throughout history, tuberculosis has been spread by the movement of human populations. Modern travel continues to be associated with risk of tuberculosis infection and disease. TB transmission has been documented on commercial aircraft, from personnel or passengers to other personnel and passengers, but the risk of transmission is low. As in other settings, the likelihood of transmission is proportional to duration and proximity of contact. Travellers from low incidence to high incidence countries have an appreciable risk of acquiring TB infection similar to that of the general populations in the countries they visit, but the risk is higher if they work in health care. Two-step tuberculin skin testing prior to departure, followed by single-step tuberculin testing after return, is recommended for all such travellers. For travellers from high incidence to low incidence countries the risk of acquiring new TB infection is low. Tuberculin screening is not beneficial and not recommended. Chest X-ray screening is expensive and complex but may be beneficial for long-term migrants. For short-term travellers, such as the pilgrims to Mecca in Saudi Arabia, there is no practical or feasible intervention to detect or prevent TB. Emphasis should be placed on public awareness and education campaigns to facilitate passive diagnosis of symptomatic cases. Mycobacterium tuberculosis (MTB) continues to be a common concern for the global traveller.

Infection control in Saudi Arabia: meeting the challenge

Hospital-acquired infection poses significant clinical and economic burden worldwide. In the Kingdom of Saudi Arabia, infection control is a young, rapidly growing specialty. An infrastructure to expedite the growth of this important discipline is fast being established. The kingdom faces unique challenges when addressing infection control, which are the subject of this review. Much of the policy-making in domestic infection control is driven by the preventive medicine concerns of the annual pilgrimage (Hajj) to Mecca, which are unparalleled. The Saudi Ministry of Health acts to contain and control public health risks at this gathering of 2 million. Infectious hazards at the Hajj include meningococcal meningitis, respiratory tract infections, bloodborne diseases, and zoonotic diseases, all of which have international ramifications as pilgrimaging Muslims return home. In the wake of the extraordinary pace of modernization in Saudi Arabia, deficiencies in infection control remain, which are slowly being redressed. This review examines the anatomy of infection control and its evolution in the kingdom. Future goals and infection control policy-making are given particular emphasis. Saudi Arabia seeks increasing international partnership in the area of infection control and preventive medicine. The Saudi health care system was formed on the basis of Western models to resounding success. Saudi Arabia is now in a position to provide experience and knowledge in return. International dialogue in the infection control arena is of mutual value. Important public health progress is afoot in this young kingdom, and these advances translate both regionally and on the international platform.