Escalating threat from tuberculosis: the third epidemic

Risk Factors for Tuberculosis in an Urban Setting in Indonesia: A Case-control Study in Umbulharjo I, Yogyakarta

The rate of incidence of Tuberculosis (TB) in Indonesia is the ninth highest in the world. Poor environmental conditions, mainly related to air circulation and improper behaviour, were recognized as the risk factors in this country. A case-control study of 69 participants was conducted in the Umbulharjo I Public Health Centre of Yogyakarta during January-August 2019. Data collection was conducted using a tested questionnaire. Analysis was performed using Chi-square and Logistic regression. Three variables were identified as potential risk factors for TB: family history of TB, smoking behaviour, and ventilation condition. The results of the logistic regression test revealed that people who smoke have the greatest risk of TB infection. Health promotion needs to be enforced to educate both patients and their family to prevent the transmission of TB.

Diabetes Mellitus among Adult Tuberculosis Patients Attending Tuberculosis Clinics in Eastern Ethiopia

BACKGROUND

Developing countries are suffering from the previously existing infectious diseases and alarmingly growing burden of noncommunicable diseases like diabetes mellitus. There is increased speculation that diabetes mellitus might attribute to high infectious diseases burden, such as tuberculosis. The global importance of diabetes mellitus as a tuberculosis-risk factor is still not a well-established fact. Thus, we conducted this study to determine the prevalence of diabetes mellitus and its associated factors among adult tuberculosis patients attending tuberculosis clinics.

METHODOLOGY

We conducted a cross-sectional survey, from March 10 to April 15, 2017, among 421 tuberculosis patients receiving tuberculosis treatment in health facilities of Dire Dawa City Administration Council, Eastern Ethiopia. Study participants were selected using systematic random technique, and data were collected using a structured questionnaire. Fasting blood sugar and anthropometric measurements were carried out for all participants. A logistic regression analysis was performed to identify factors associated with diabetes mellitus.

RESULT

The prevalence of diabetes mellitus in this study was 13.5%. Age 26-40 (AOR = 6, 95% CI: (1.28, 27.5)), age ≥41(AOR = 9, 95% CI: (1.9, 44.4)), and family history of diabetes (AOR = 3.14, 95% CI: (1.23, 8.02)) were found to have a significant association with diabetes mellitus.

CONCLUSION

This study found that the magnitude of diabetes mellitus among tuberculosis patients was higher than the national estimated prevalence of diabetes mellitus in Ethiopia. This study suggests the need for screening each tuberculosis patient for diabetes.

Multidrug-resistant tuberculosis treatment adherence in migrants: a systematic review and meta-analysis

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is a growing concern in meeting global targets for TB control. In high-income low-TB-incidence countries, a disproportionate number of MDR-TB cases occur in migrant (foreign-born) populations, with concerns about low adherence rates in these patients compared to the host non-migrant population. Tackling MDR-TB in this context may, therefore, require unique approaches. We conducted a systematic review and meta-analysis to identify and synthesise data on MDR-TB treatment adherence in migrant patients to inform evidence-based strategies to improve care pathways and health outcomes in this group.

METHODS

This systematic review and meta-analysis was conducted in line with PRISMA guidelines (PROSPERO 42017070756). The databases Embase, MEDLINE, Global Health and PubMed were searched to 24 May 2017 for primary research reporting MDR-TB treatment adherence and outcomes in migrant populations, with no restrictions on dates or language. A meta-analysis was conducted using random-effects models.

RESULTS

From 413 papers identified in the database search, 15 studies reporting on MDR-TB treatment outcomes for 258 migrants and 174 non-migrants were included in the systematic review and meta-analysis. The estimated rate of adherence to MDR-TB treatment across migrant patients was 71% [95% confidence interval (CI) = 58-84%], with non-adherence reported among 20% (95% CI = 4-37%) of migrant patients. A key finding was that there were no differences in estimated rates of adherence [risk ratio (RR) = 1.05; 95% CI = 0.82-1.34] or non-adherence (RR = 0.97; 95% CI = 0.79-1.36) between migrants and non-migrants.

CONCLUSIONS

MDR-TB treatment adherence rates among migrants in high-income low-TB-incidence countries are approaching global targets for treatment success (75%), and are comparable to rates in non-migrants. The findings highlight that only just over 70% of migrant and non-migrant patients adhere to MDR-TB treatment. The results point to the importance of increasing adherence in all patient groups, including migrants, with an emphasis on tailoring care based on social risk factors for poor adherence. We believe that MDR-TB treatment targets are not ambitious enough.

Tuberculosis vaccine development: Shifting focus amid increasing development challenges

A new tuberculosis vaccine is needed to replace or enhance BCG, which induces variable protection against Mycobacterium tuberculosis pulmonary infections in adults. Development of new TB vaccine candidates is severely hampered by the lack of a correlate of immunity, unproven animal models, and limited funding opportunities. One candidate, MVA85A, recently failed to meet its efficacy endpoint goals despite promising early-phase trial data. As a result, some in the field believe we should now shift our focus away from product development and toward a research-oriented approach. Here, we outline our suggestions for this research-oriented strategy including diversification of the candidate pipeline, expanding measurements of immunity, improving pre-clinical animal models, and investing in combination pre-clinical/experimental medicine studies. As with any evolution, this change in strategy comes at a cost but may also represent an opportunity for advancing the field.

A Comparative Study of Induced Sputum and Bronchial Washings in Diagnosing Sputum Smear Negative Pulmonary Tuberculosis

INTRODUCTION

Tuberculosis is one of the most important public health problem worldwide. Detecting patients with active pulmonary Koch's disease is an important component of tuberculosis control programs. However, at times in patients even with a compatible clinical picture, sputum smears do not reveal acid-fast bacilli and smear-negative pulmonary tuberculosis remains a common problem.

AIM

The present study is aimed to compare the results of induced sputum and bronchial washings smear in patients suspected to have sputum smear negative pulmonary tuberculosis.

MATERIALS AND METHODS

A prospective study conducted from August 2014 to July 2015, comprising 120 patients fulfilling study criteria. Patients with respiratory symptoms and chest roentgenogram suspicious of pulmonary tuberculosis with no previous history of anti-tuberculosis treatment and two spontaneous sputum smear samples negative for acid fast bacilli were included. Patients with active haemoptysis and sputum positive were excluded from the study. Sputum induction was done by using 5-10 ml of 3% hypertonic saline through ultrasonic nebulizer taking safety precautions. All the patient underwent fibreoptic bronchoscopy after six hours fasting on the same day. About 20 ml of normal saline instilled into the suspected pathology area and washings were taken with gentle suction. The sample processing and fluorescent staining for acid fast bacilli was done in a designated microscopy lab.

RESULTS

Out of 120 sputum smear negative pulmonary tuberculosis patients, induced sputum smear examination detected acid fast bacilli in 76 patients (63.3%) and acid fast bacilli detected from bronchial washings in 94 patients (78.3%). Smear positivity was higher in cavitary and infiltrative lesions as compared to consolidation and infrahilar pattern disease.

CONCLUSION

Even though both induced sputum and bronchial washings procedures were valuable for the diagnosis of sputum smear negative, sputum induction with hypertonic saline should be the initial procedure of choice, which can be repeated twice / thrice in a day or two consecutive days. If the patient still remains induced sputum smear negative and if the clinical probability of tuberculosis is high, starting anti-tuberculosis treatment and closely monitoring patient and reserving bronchoscopy to those patients who do not improve and to exclude alternative diagnosis seems to be a practically useful approach.

Induced sputum versus bronchial washings in the diagnosis of sputum negative pulmonary tuberculosis

Introduction:

Tuberculosis (TB) is one of the most important public health problems worldwide. Detecting patients with active pulmonary TB (PT) is an important component of TB control programs. However, at times in patients even with a compatible clinical picture, sputum smears do not reveal acid-fast bacilli (AFB) and smear-negative PT remains a common problem. This study compares the results of induced sputum (IS) and bronchial washings (BWs) in detecting sputum negative PT.

Materials and Methods:

A prospective study conducted from June 2014 to June 2015, comprising 120 patients fulfilling study criteria. Patients with respiratory symptoms and chest roentgenogram suspicious of PT with no previous history of antiTB treatment (ATT) and two spontaneous sputum smear samples negative for AFB were included in the study. Patients with active hemoptysis and sputum positive were excluded from the study. Sputum induction was done using 5–10 ml of 3% hypertonic saline through ultrasonic nebulizer taking safety precautions. All the patients underwent fiberoptic bronchoscopy after 6 h fasting on the same day. About 20 ml of normal saline instilled into the suspected pathology area and washings were taken with gentle suction. The sample processing and fluorescent staining for AFB were done in a designated microscopy laboratory.

Results:

Of 120 smear-negative PT patients, IS smear examination detected AFB in 76 patients (63.3%) and AFB detected from BWs in 94 patients (78.5%). Smear positivity higher in cavitary and infiltrative lesions compared to consolidation and infrahilar pattern disease.

Conclusions:

Even though both IS and BWs procedures were valuable for the diagnosis of smear-negative TB, sputum induction with hypertonic saline should be the initial procedure of choice, which can be repeated twice/thrice in a day or 2 consecutive days. If the patient remains IS smear-negative and if the clinical probability of TB is high, starting ATT and closely monitoring patient and reserving bronchoscopy to those patients who do not improve and to exclude alternative diagnosis seems to be a practically useful approach.

Association between tuberculosis and smoking

Background

The association between smoking and tuberculosis (TB), which has been proven in multiple studies with different study population ethnicity, has not yet received sufficient attention in terms of TB control.

Objectives

The aim of the present study was to determine the association between TB and cigarette smoking in southeastern Iran, an endemic area for tuberculosis.

Patients and Methods

This prospective case-control study conducted at a University-Affiliated Hospital (Boo-Ali Hospital, Zahedan, and Southeastern Iran) from March 2007 to March 2012 enrolled 253 TB patients and 312 healthy controls. Factors including history of cigarette smoking, duration of smoking, number of cigarettes smoked per day, consumption of other drugs (parenteral and non-parenteral), and family history of tuberculosis and smoking, were evaluated in both cases and controls. Univarate and multivariate logistic regressions were performed to compare TB cases and controls. The odds ratio (OR) and 95% confidence intervals (CI) were also estimated.

Results

The results of the study revealed a significant difference between TB and control groups in relation to smoking (P < 0.0001). In multivariate logistic regression, cigarette smokers were 3.1 (95% CI: 1.4-10.3) times more frequent in TB patients compared with controls. Other factors that showed significant differences between TB patients and controls were the use of non-parenteral drugs (OR = 3.6, 95% CI: 2.2-21.4), family history of TB (OR = 6.6, 95% CI: 2.3-18.2), family history of smoking (OR = 2.8, 95% CI: 1.1-8.4), and smoking history of more than 10 years (OR = 1.6, 95% CI: 1.2-9.8).

Conclusions

The present study evidenced the association between TB and smoking. It is therefore recommended to include interventions for smoking cessation in the current TB control practice.

Is alcohol use associated with cavitary disease in tuberculosis?

BACKGROUND

Alcohol mediates detrimental alterations in the immune response to Mycobacterium tuberculosis. The association between quantity and frequency of alcohol use and the prevalence of cavitary disease in tuberculosis (TB) has not been analyzed. To investigate the relationship of alcohol use and the prevalence of cavitary disease in a 6-year population-based data set of individuals with TB.

METHODS

We assessed quantity and frequency of alcohol use (daily alcohol use, years of alcohol use, and lifetime alcohol use) with a standardized questionnaire. The study group consisted of 1,250 patients analyzed for cavitary disease (HIV sero-negative subjects that were 18 years or older). Significant covariates for cavitary disease were entered into multiple logistic regression models.

RESULTS

Although daily alcohol use, years of alcohol use, and alcohol use 30 days or 6 months before symptom onset were significant predictors of cavitary disease in univariate analysis, no independent associations were found between alcohol use and cavitary disease in the multivariate analysis. Only diabetes mellitus was independently associated with cavitary disease at any level or frequency of alcohol use.

CONCLUSION

Alcohol use is not independently associated with increased prevalence of cavitary disease in adult patients with TB.

Industry, innovation and social values

Remaining important tasks in finding and developing new drugs and vaccines for HIV/AIDS, malaria, cancer and other diseases require continued industry research and development. Industry's research and development pipeline has produced drugs that have saved AIDS victims previously facing certain death, but still no cure nor vaccine is yet available. Experience with the process of research and development indicates that it requires more than a decade of development to produce a new drug with costs in the hundreds of millions of dollars. Intellectual property protection is critically important in assuring that drug development continues. Partnerships between industry and the public sector have increased access to new therapies in developing countries and promise to enhance access to both patented and generic medicines in the future.

Evaluation of young children in household contact with adult multidrug-resistant pulmonary tuberculosis cases

BACKGROUND

The prevention and management of multidrug-resistant (MDR) tuberculosis has received much attention, but little attention has been given to children with MDR tuberculosis or children in contact with adults with MDR tuberculosis. The aim of this study was to determine the prevalence of tuberculous infection and disease in childhood contacts of adults with MDR pulmonary tuberculosis.

METHOD

All children <5 years of age in household contact with 75 recently diagnosed adults with MDR pulmonary tuberculosis were evaluated. Evaluation included clinical examination, tuberculin skin test, chest radiography and culture for Mycobacterium tuberculosis from gastric aspirates.

RESULTS

One hundred twenty-eight children, median age 27 months, were evaluated. Fifty children had recent contact with other adult tuberculosis cases. Sixty-six children previously had chemoprophylaxis or treatment of whom 36 defaulted treatment or received insufficient chemoprophylaxis. One child had HIV infection. Forty-seven children were classified as noninfected, 66 were considered infected only (Mantoux test, > or = 15 mm) and 15 had disease. Three children, who had not previously received antituberculosis drugs, had positive cultures for M. tuberculosis; all were multidrug-resistant.

CONCLUSION

This study documents the transmission of multidrug-resistant M. tuberculosis to childhood contacts, the development of disease in these contacts and the importance of knowing the index case's M. tuberculosis susceptibility pattern in choosing a proper treatment regimen for the childhood contact.

EMERGING AND RE-EMERGING INFECTIOUS DISEASES: The Third Epidemiologic Transition

▪ Abstract  We use an expanded framework of multiple epidemiologic transitions to review the issues of re/emerging infection. The first epidemiologic transition was associated with a rise in infectious diseases that accompanied the Neolithic Revolution. The second epidemiologic transition involved the shift from infectious to chronic disease mortality associated with industrialization. The recent resurgence of infectious disease mortality marks a third epidemiologic transition characterized by newly emerging, re- emerging, and antibiotic resistant pathogens in the context of an accelerated globalization of human disease ecologies. These transitions illustrate recurring sociohistorical and ecological themes in human–disease relationships from the Paleolithic Age to the present day.

Tuberculosis in the hospice--a cause for concern?

Open pulmonary tuberculosis has been increasingly seen in HIV-infected patients in this hospice. Multidrug-resistant tuberculosis is a new and serious threat and two cases have occurred in our hospice in the past two years. This infection poses a health risk to staff, patients, relatives and volunteers. Palliative care teams in the hospice and community must have an index of suspicion for this infection, take active measures to ensure patient compliance with tuberculosis treatment and be prepared to implement infection control guidelines when needed.