Can tuberculosis be controlled?

Can Oral TB develop in susceptible individuals after an oral surgical procedure? 3 case reports

As opposed to the popular assumption, there have been an increase in the cases of Oral Tuberculosis as of late. Owing to increased drug resistance, there has been a change in the disease pattern leading to an upsurge in the Extra-pulmonary Oral Tuberculosis. According to the WHO, Diagnosis is the first step in the control of TB; but due to the lack of pathognomonic signs associated with Oral Tuberculosis and the rarity of these lesions, diagnosis is often difficult. So, to enable a timely diagnosis, we point out the occurrence of such lesions in the post-operative refractory lesions in susceptible individuals. However, a thorough search of literature did not yield any conclusive results. In this paper we present the clinical, radiographic and histopathological findings of three cases between the ages of 5 and 50 years old who were diagnosed of Oral Tuberculosis. These patients have undergone a recent oral surgical procedure prior to the development of Oral TB lesions. More research is required to increase the awareness of the pattern of this disease and to enable a quicker diagnosis so that the overall morbidity and mortality is reduced.

The boomerang effect of tuberculosis knowledge and self-efficacy on Chinese parents' intention to seek timely treatment and adhere to doctors' regimens

OBJECTIVE

The present study tested the level of tuberculosis (TB) knowledge of Chinese parents whose children attended kindergarten, primary school, and middle school, and examined whether their TB knowledge and self-efficacy in TB management exhibited a curvilinear relationship with their intention to seek timely TB treatment and adhere to doctors' regimens if their children are infected with TB.

METHODS

An online cross-sectional survey (N = 1129) was conducted. TB knowledge was assessed based on the manual provided by the Chinese Center for Disease Control and Prevention (CDC). Hierarchical polynomial regression was conducted to test the proposed curvilinear relationships.

RESULTS

Chinese parents lacked knowledge about risks of TB and how to prevent TB. TB knowledge and self-efficacy in TB management motivated Chinese parents to seek timely TB treatment and adhere to doctors' regimens, but too much knowledge and self-efficacy predicted both intentions negatively.

CONCLUSION

Excessive levels of self-efficacy in self-management and health knowledge could backfire.

PRACTICE IMPLICATION

Practitioners should elevate Chinese parents' perceptions of severity of TB and susceptibility to TB. Additionally, health education should not be limited to providing medical facts but offer guidance on how to access professional medical resources. Self-efficacy in self-management should not be elevated.

Tuberculosis management practices by private practitioners in Andhra Pradesh, India

Setting

Private medical practitioners in Visakhapatnam district, Andhra Pradesh, India.

Objectives

To evaluate self-reported TB diagnostic and treatment practices amongst private medical practitioners against benchmark practices articulated in the International Standards of Tuberculosis Care (ISTC), and factors associated with compliance with ISTC.

Design

Cross- sectional survey using semi-structured interviews.

Results

Of 296 randomly selected private practitioners, 201 (68%) were assessed for compliance to ISTC diagnostic and treatment standards in TB management. Only 11 (6%) followed a combination of 6 diagnostic standards together and only 1 followed a combination of all seven treatment standards together. There were 28 (14%) private practitioners who complied with a combination of three core ISTC (cough for tuberculosis suspects, sputum smear examination and use of standardized treatment). Higher ISTC compliance was associated with caring for more than 20 TB patients annually, prior sensitization to TB control guidelines, and practice of alternate systems of medicine.

Conclusion

Few private practitioners in Visakhapatnam, India reported TB diagnostic and treatment practices that met ISTC. Better engagement of the private sector is urgently required to improve TB management practices and to prevent diagnostic delay and drug resistance.

Antituberculosis IgG antibodies as a marker of active Mycobacterium tuberculosis disease

Anti-Mycobacterium tuberculosis IgG antibodies may aid in the diagnosis of active M. tuberculosis disease. We studied whether anti-M. tuberculosis IgG antibodies are elevated in active M. tuberculosis disease and assessed factors contributing to false-positive and -negative results. A retrospective study of 2,150 individuals tested by the QuantiFERON-TB Gold In-Tube (QFT-GIT) assay was conducted at the University of Utah, ARUP Laboratories, November 2008 to December 2010. All samples were tested with the InBios Active TbDetect antituberculosis (anti-TB) IgG antibody assay. Of 1,044 patients with a positive QFT-GIT, 59 (5.7%) were positive for M. tuberculosis antibodies. Fourteen of 1,106 (1.3%) with a negative or indeterminate QFT-GIT were positive for M. tuberculosis antibodies. M. tuberculosis antibody tests were positive in 61.5% with confirmed active M. tuberculosis disease and other mycobacterial infections. Over half of the false-negative M. tuberculosis antibody tests occurred in patients ≥ 90 years of age. False positives were seen in 12.9% of autoimmune patients. The odds ratio of being positive by the QFT-GIT and the InBios TB IgG assay increased with confirmed M. tuberculosis disease or highly suspected M. tuberculosis disease and was 86.7 (95% confidence interval [CI], 34.4 to 218.5) in these two groups compared to patients negative by both tests. Although anti-M. tuberculosis antibodies can be detected in patients with active M. tuberculosis disease, caution should be used with patients where immunoglobulin levels may be decreased or patients with autoantibodies.

Natural history of tuberculosis: duration and fatality of untreated pulmonary tuberculosis in HIV negative patients: a systematic review

BACKGROUND

The prognosis, specifically the case fatality and duration, of untreated tuberculosis is important as many patients are not correctly diagnosed and therefore receive inadequate or no treatment. Furthermore, duration and case fatality of tuberculosis are key parameters in interpreting epidemiological data.

METHODOLOGY AND PRINCIPAL FINDINGS

To estimate the duration and case fatality of untreated pulmonary tuberculosis in HIV negative patients we reviewed studies from the pre-chemotherapy era. Untreated smear-positive tuberculosis among HIV negative individuals has a 10-year case fatality variously reported between 53% and 86%, with a weighted mean of 70%. Ten-year case fatality of culture-positive smear-negative tuberculosis was nowhere reported directly but can be indirectly estimated to be approximately 20%. The duration of tuberculosis from onset to cure or death is approximately 3 years and appears to be similar for smear-positive and smear-negative tuberculosis.

CONCLUSIONS

Current models of untreated tuberculosis that assume a total duration of 2 years until self-cure or death underestimate the duration of disease by about one year, but their case fatality estimates of 70% for smear-positive and 20% for culture-positive smear-negative tuberculosis appear to be satisfactory.

Survival after spinal cord injury: a systematic review

Spinal cord injury (SCI) leading to neurological deficits produces long-term effects that persist over a lifetime. Survival analysis of patients with SCI, at individual and population level, is important for public health management and the assessment of treatment achievements. The current study evaluated survival following traumatic and non-traumatic SCI worldwide. A systematic review was conducted, and all included papers were assessed for quality using a purposely designed assessment form. Survival data were presented in Kaplan-Meier curves and compared using the log-rank test. Sixteen studies were included of which 11 concerned traumatic SCI, four non-traumatic SCI, and one both. Crude standard mortality rates (SMRs) revealed that overall mortality in SCI is up to three times higher than in the general population. Survival rates were statistically significantly lower in non-traumatic SCI than in traumatic SCI (log-rank p = 0.000). Age at injury, neurological level, extent of lesion, and year of injury have been described as predictors of survival. Causes of death stem from secondary complications, with failure of the respiratory system being the leading cause. This is the first systematic literature review on survival analysis following SCI worldwide. An increase in survival over time was found. However, the SMRs of individuals with SCI still exceed those of an age-matched non-disabled population, mainly due to secondary complications. Lower survival rates were observed in non-traumatic SCI compared with traumatic SCI.

Factors associated with mortality in HIV-infected and uninfected patients with pulmonary tuberculosis

Background

HIV has fuelled the TB epidemic in sub-Saharan Africa. Mortality in patients co-infected with TB and HIV is high. Managing factors influencing mortality in TB patients might help reducing it. This study investigates factors associated with mortality including patients' HIV sero-status, CD4 cell count, laboratory, nutritional and demographic characteristics in AFB smear positive pulmonary TB patients.

Methods

We studied 887 sputum smear positive PTB patients, between 18 and 65 years of age receiving standard 8 months anti-TB treatment. Demographic, anthropometric and laboratory data including HIV, CD4 and other tests were collected at baseline and at regular intervals. Patients were followed for a median period of 2.5 years.

Results

Of the 887 participants, 155 (17.5%) died, of whom 90.3% (140/155) were HIV-infected, a fatality of 29.7% (140/471) compared to 3.6% (15/416) among HIV-uninfected. HIV infection, age, low Karnofsky score, CD4 cell counts and hemoglobin, high viral load, and oral thrush were significantly associated with high mortality in all patients.

Conclusion

Mortality among HIV-infected TB patients is high despite the use of effective anti-TB therapy. Most deaths occur after successful completion of therapy, an indication that patients die from causes other than TB. HIV infection is the strongest independent predictor of mortality in this cohort.

Profile of tuberculosis patients progressing to death, city of São Paulo, Brazil, 2002

OBJECTIVE

To profile adult patients dying of tuberculosis in the city of São Paulo with respect to biological, environmental and institutional factors.

METHODS

Descriptive study covering all tuberculosis deaths (N=416) among individuals aged over 15 years in 2002. Data were obtained from hospital records, the local Mortality Information System, Coroner's Service, and tuberculosis Surveillance System. The estimates of relative risk and 95% confidence intervals (95% CI) were based on the reference group, i.e., females aged 15 to 29 years, originally from the State of São Paulo (Brazil). A comparative analysis was conducted using Pearson's chi-square test and Fisher's exact test for categorical variables and Kruskal-Wallis test for continuous variables.

RESULTS

Of all tuberculosis deaths identified, 78% had pulmonary form. Tuberculosis diagnosis was made after death in 30% and in primary health care units in 14%. Of them, 44% had not started treatment; 49% were not notified; and 76% were men. The median age was 51 years; 52% had up to four years of schooling; 4% were probably living in the streets. Mortality rate increased with age; it was 5.0/100,000 for the entire city, ranging between zero to 35 according to the district. Previous treatment was reported for 82 out of 232 patients, and of them, 41 defaulted treatment. Diabetes (16%), chronic obstructive pulmonary disease (19%), HIV infection (11%), smoking (71%), and alcohol abuse (64%) were also reported.

CONCLUSIONS

Adult males over 50, migrants and living in lower Human Development Index districts were more likely to die of tuberculosis. Low schooling and comorbidities are relevant characteristics. Low involvement of primary care units in tuberculosis diagnosis and high underreporting of cases were also seen.

Tuberculosis incidence in Portugal: spatiotemporal clustering

BACKGROUND

The statistics of disease clustering is one of the most important tools for epidemiologists to detect and monitor public health disease patterns. Nowadays, tuberculosis (TB)--an infectious disease caused by the Mycobacterium tuberculosis--presents different (development in populations and antibiotics resistance) patterns and specialists are very concerned with it and its association to several other diseases and factors. Each year, tuberculosis kills about three million people in the world. In particular, it is responsible for the death of more than one-third of HIV-infected people, who prove particularly susceptible due to a decline in their immune defences. The purpose of this study is to determine if there are spatiotemporal tuberculosis incidence clusters in continental Portugal. The presented case study is based on the notification of new tuberculosis cases (disease incidence), between 2000 and 2004. In methodological terms, the spatial scan statistic, used to identify spatiotemporal clusters, was improved by including two new approaches: definition of window sizes in the cluster scanning processes considering empirical mean spatial semivariograms and an independent and posterior validation of identified clusters (based on geostatistical simulations).

RESULTS

Continental Portugal is organized in 18 districts with 278 sub-districts. For this case study, the number of new notified cases of TB, per sub-district and per year (2000-2004) was available. TB incidence presents clear spatial patterns: a semivariogram consistent with 40% of nugget effect and 60% of spatial contribution, following an exponential model with a range of 143 kilometres. Temporal semivariograms were not conclusive, as only 5 years of data were available. The spatial and temporal persistence of clusters were analyzed considering different models. Significant high incidence rate space-time clusters were identified in three areas of Portugal (between 2000 and 2004) and a purely temporal cluster was identified covering the whole country, during 2002.

CONCLUSION

In terms of spatiotemporal clustering of tuberculosis disease, the proposed methodology allowed the identification of critical spatiotemporal areas. In Portugal there were 3 critical districts (Porto, Setúbal and Lisbon) with high rates of notified incidences between 2000 and 2004. In methodological terms, semivariogram parameters were successfully applied to define spatiotemporal scan window sizes and shapes (ellipsoidal cylinders), showing very good results and performances in the case study. After defining the clusters, these were authenticated through a validation method, based on geostatistical simulations.

International standards for tuberculosis care

Part of the reason for failing to bring about a more rapid reduction in tuberculosis incidence worldwide is the lack of effective involvement of all practitioners-public and private-in the provision of high quality tuberculosis care. While health-care providers who are part of national tuberculosis programmes have been trained and are expected to have adopted proper diagnosis, treatment, and public-health practices, the same is not likely to be true for non-programme providers. Studies of the performance of the private sector conducted in several different parts of the world suggest that poor quality care is common. The basic principles of care for people with, or suspected of having, tuberculosis are the same worldwide: a diagnosis should be established promptly; standardised treatment regimens should be used with appropriate treatment support and supervision; response to treatment should be monitored; and essential public-health responsibilities must be carried out. Prompt and accurate diagnosis, and effective treatment are essential for good patient care and tuberculosis control. All providers who undertake evaluation and treatment of patients with tuberculosis must recognise that not only are they delivering care to an individual, but they are also assuming an important public-health function. The International Standards for Tuberculosis Care (ISTC) describe a widely endorsed level of care that all practitioners should seek to achieve in managing individuals who have, or are suspected of having, tuberculosis. The document is intended to engage all care providers in delivering high quality care for patients of all ages, including those with smear-positive, smear-negative, and extra-pulmonary tuberculosis, tuberculosis caused by drug-resistant Mycobacterium tuberculosis complex, and tuberculosis combined with HIV infection.

Active community surveillance of the impact of different tuberculosis control measures, Tiruvallur, South India, 1968-2001

BACKGROUND

Tuberculosis is curable, but community surveys documenting epidemiological impact of the WHO-recommended DOTS strategy on tuberculosis prevalence have not been published. We used active community surveillance to compare the impact of DOTS with earlier programmes.

METHODS

We conducted tuberculosis disease surveys using random cluster sampling of a rural population in South India approximately every 2.5 years from 1968 to 1986, using radiography as a screening tool for sputum examination. In 1999, DOTS was implemented in the area. Prevalence surveys using radiography and symptom screening were conducted at the start of DOTS implementation and after 2.5 years.

RESULTS

From 1968 to 1999, culture-positive and smear-positive tuberculosis declined by 2.3 and 2.5% per annum compared with 11.9 and 5.6% after DOTS implementation. The 2.5 year period of DOTS implementation accounted for one-fourth of the decline in prevalence of culture-positive tuberculosis over 33 years. Multivariate analysis showed that prevalence of culture-positive tuberculosis decreased substantially (10.0% per annum, 95% CI: 2.8-16.6%) owing to DOTS after only slight declines related to temporal trends (2.1% annual decline, 95% CI: 1.1-3.2%) and short-course chemotherapy (1.5% annual decline, 95% CI: -9.7% to 11.5%). Under DOTS, the proportion of total cases identified through clinical care increased from 81 to 92%.

CONCLUSIONS

Following DOTS implementation, prevalence of culture-positive tuberculosis decreased rapidly following a gradual decline for the previous 30 years. In the absence of a large HIV epidemic and with relatively low levels of rifampicin resistance, DOTS was associated with rapid reduction of tuberculosis prevalence.

Evaluation of five antibody detection tests for diagnosis of bovine paratuberculosis

Five diagnostic tests based on enzyme-linked immunosorbent assay (ELISA) technology for bovine paratuberculosis were evaluated by using individual serum or milk samples from 359 dairy cattle in seven paratuberculosis-free herds and 2,094 dairy cattle in seven Mycobacterium paratuberculosis-infected dairy herds. Three independent laboratories using three different culture procedures completed fecal cultures for M. paratuberculosis on these cattle and found 417 cows to be shedding M. paratuberculosis in their feces. An animal that was fecal culture positive for M. paratuberculosis by any of the three laboratories was considered a confirmed case of infection. The specificity of three ELISAs (two on serum and one on milk) was > or =99.8%. The specificity of the remaining two ELISAs, both done on serum, was 94.9 and 84.7%. Four of the five ELISAs evaluated produced similar sensitivity in detecting fecal culture-positive cattle (27.8 to 28.9%). Serum ELISA "D" had the lowest specificity (84.7%) and the highest sensitivity (44.5%), but if the cutoff value defining a positive test was changed from 125 to 250% (of the positive control) the sensitivity and specificity, 31.8 and 97.5%, respectively, were comparable to those of the other four assays. If the case definition for M. paratuberculosis infection was based on the culture results of a single laboratory instead of the combined results of three laboratories, ELISA sensitivity estimates were 45.7 to 50.0%. With the exception of ELISA D, assay agreement was high (kappa 0.66 to 0.85) for categorical assay interpretations (positive or negative), but linear regression of quantitative results showed low correlation coefficients (r(2) = 0.40 to 0.68) due to the fact that ELISA results for some cows were high in one assay but low in another assay. Likelihood ratio analysis showed a direct relationship between the magnitude of ELISA result and the odds of a cow shedding M. paratuberculosis in its feces. If used judiciously and interpreted quantitatively, these ELISAs are useful tools in support of paratuberculosis control programs in dairy herds.

Tuberculosis control in resource-poor countries: have we reached the limits of the universal paradigm?

The aim of TB control is to break the cycle of transmission by treating TB cases as early and efficiently as possible. In its efforts to promote a model of worldwide TB control, WHO defined specific targets and launched the 'Directly Observed Therapy, Short-course' (DOTS) strategy as the main tool to reach them. However, the diversity of patients' attitudes towards the disease and the extreme variability of access to care, especially in resource-poor countries, are amongst the many factors of social context that profoundly affect the ability of control programmes to implement this policy effectively. There are multiple reports of TB control programmes using various types of intervention to promote adherence and enhance case-holding, but most of these interventions depend on external funding, which bring into question their long-term sustainability. In this paper, we address the problems related to operational variabilities in the implementation of the DOTS strategy in resource-poor countries and question the appropriateness of a universal paradigm for global TB control. This analysis is of particular importance as programmers consider using this model in the delivery of anti-retroviral therapies for the treatment of HIV in resource-limited settings.

Trends in tuberculosis and the influence of HIV infection in northern Malawi, 1988-2001

OBJECTIVE

To document the changing incidence and patterns of tuberculosis (TB) in rural Africa and the extent to which they are influenced by HIV.

METHODS

As part of longstanding epidemiological studies in Karonga District, Malawi, a series of case control studies of TB and HIV were conducted from 1988 onwards. Data from these studies, from a total population survey, and from the Malawi national census have been used to reconstruct the changes in the TB epidemic in the area from 1988 to 2001, examining the role of HIV.

RESULTS

The incidence of all confirmed TB, and of new smear-positive TB, in adults increased to peak in the late 1990s but appears to have decreased since. Two-thirds of cases are now HIV positive. The rise in incidence was greatest in the 30-44-year-old age group and was particularly marked for women, leading to a decrease in the male : female ratio for TB incidence from 1.3 to 0.8. The proportion of new smear-positive TB cases attributable to HIV increased from 17% in 1988-1990 to 57% in 2000-2001, but the estimated rate of smear-positive TB in the absence of HIV decreased from 0.78/1000 to 0.45/1000.

CONCLUSIONS

Without HIV the incidence of smear-positive TB would have fallen in this population. Instead it has risen and is predominantly affecting young adults and women. There is some evidence that the HIV-associated TB epidemic may have passed its peak.

Two young female patients with anorexia nervosa complicated by Mycobacterium tuberculosis infection

Patients with anorexia nervosa (AN) seldom present with infectious illness, despite malnutrition-induced immunodeficiency. We described two young women who had a long-standing history of severe emaciation and pulmonary or lymph node tuberculosis discovered during the treatment of AN. Both patients reported a positive history of BCG vaccination. Contact tracing failed to reveal sources of infection, although the tuberculosis was considered transferred. Since the decline of notification rates for tuberculosis have been stagnant and outbreaks in schools or hospitals have been increasing in Japan, special attention must be given to the possibility of opportunistic infections in AN patients.