Prevalence of drug-resistant pulmonary tuberculosis in India: systematic review and meta-analysis

Genotypic analysis of drug-resistant tuberculosis in Ghana: Insights into pre-XDR and XDR-TB

BACKGROUND

The emergence of Extensively Drug Resistant (XDR) and Pre-extensively drug resistant (Pre-XDR) tuberculosis (TB) threatens the management of multidrug-resistant tuberculosis (MDR) patients and impacts negatively on TB control programs, especially in developing countries like Ghana. The first case of XDR-TB in Ghana was reported in 2018. There is however inadequate data on the burden of XDR-TB and pre-XDR-TB and their associated resistant mutations in Ghana. The study sought to provide baseline data on the burden of pre-XDR-TB and XDR-TB among MDR TB cases in Ghana. It also determined the mutations responsible for pre-XDR/ XDR-TB, for clinical and programmatic management of pre-XDR/ XDR-TB in Ghana.

METHODS

One hundred and seventy-one (171) archived clinical MDR isolates obtained from TB patients across Ghana between January 2016 and December 2020 were retrieved. The isolates were retested to confirm their phenotypic and genotypic susceptibility to the first and second-line anti-TB drugs using the BACTEC MGIT system and Genotype MTBDRplus, MTBDRsl, line probe assays respectively.

RESULTS

Most of the 171 isolates came from 7 regions; the highest (39.5%) from Eastern, followed by Greater Accra region (19.8%). Most of the isolates were from male TB patients (78.9%). Of the 171 archived isolates, 81 (47.4%) were confirmed to be MDR, 6 (7.4%) were Pre-XDR-TB but no XDR-TB was detected. The katG S315T1 (33, 73.3%) and rpoB S531L (31, 42.5%) were the predominant mutations observed among isoniazid and rifampicin resistant isolates respectively. Many of the mutations and amino acid changes that caused pre-XDR-TB were gyrAWT3 + gyrAMUT3A and gyrAMUT3A (D94A) (50%) for fluoroquinolone. The other detected mutations with their amino acid changes were gyrA MUT1 (A90V), gyrAWT3 + gyrA MUT3C (D94G) and gyrA MUT2 (S91P) (16.7%) for fluoroquinolones and rrWT2 (position 1484) (33.3%) and rrs MUT2 (G1484T) (16.7%) for aminoglycosides.

CONCLUSION

The predominant mutations associated with pre-XDR-TB were D94A and C1402T for fluoroquinolone and aminoglycosides resistance respectively. The proportion of pre-XDR-TB among MDR-TB patients in Ghana was 7.4%; however, no XDR-TB was detected. A sustained surveillance of pre-XDR-TB and XDR-TB is recommended.

Evaluating Tuberculosis and Drug Resistance in Serbia: A Ten-Year Experience from a Tertiary Center

BACKGROUND

Tuberculosis (TB) remains a leading cause of mortality worldwide, particularly in low- and middle-income countries. The rise of multidrug-resistant TB (MDR-TB) poses significant challenges to global health. This study reviews the experience of the largest pulmonology center in Serbia, a country with low MDR-TB incidence, focusing on TB prevalence, resistance detection, and treatment strategies between 2012 and 2021.

METHODS

We retrospectively analyzed a total of 1239 patients who were diagnosed and treated for TB in the period from 2012 to 2021 at University Clinical Center of Serbia.

RESULTS

Drug resistance was identified in 21 patients (1.7%), with the highest resistance to rifampicin (1.4%) and isoniazid (1.3%). Pyrazinamide and streptomycin resistance were detected in only a few cases. Patients with resistant TB were younger on average, though the difference was not statistically significant (46.4 ± 19.1 vs. 53.6 ± 18.4, p = 0.079). Prior TB history was more frequent in the resistant group, almost reaching statistical significance (4 vs. 82, p = 0.052).

CONCLUSIONS

These findings underscore the critical importance of sustained surveillance, particularly of latent and drug-resistant TB forms, in alignment with the World Health Organization's (WHO) TB control strategy to preserve Serbia's low-incidence status. Moreover, given Serbia's strategic location on a major migration route, there is an elevated risk of new TB cases emerging and potential shifts in TB-drug-resistance patterns developing in the future.

Prevalence and epidemic pattern of ecdemic multidrug-resistant tuberculosis during 2012-2022 in Hangzhou, China: implication for public health strategies

BACKGROUND

To assess the prevalence and epidemic pattern of multidrug-resistant tuberculosis in Hangzhou City, Zhejiang Province, China during 2012-2022.

METHODS

All the tuberculosis cases undergoing drug susceptibility testing during 2012-2022 were included in this study. De-identified information was extracted from the electronic database Tuberculosis Information Management System for analysis of drug resistance prevalence in Hangzhou and ecdemic multidrug-resistant tuberculosis which originated from other regions. Chi-square tests were used to compare drug resistance rates between different groups, while Chi-square tests for trend were used to evaluate the change of drug resistance rates over the years of 2012-2022. The sources and destinations of ecdemic multidrug-resistant tuberculosis were illustrated using a Sankey diagram.

RESULTS

Of 21,127 cases included in this study, 1119 (5.3%) were multidrug-resistant tuberculosis. A significant decline in multidrug-resistant tuberculosis rates was observed during 2012-2022. There was a significant difference in multidrug-resistant tuberculosis rates among immigrant population and local residents in Hangzhou City. Of 1119 multidrug-resistant tuberculosis cases, 515(46%) were ecdemic multidrug-resistant tuberculosis cases, of which 277(53.8%) were from other parts of Zhejiang Province and 238(46.2%) were from other provinces in China. Anhui, Jiangxi and Sichuan were among top three provinces which were the source of ecdemic multidrug-resistant tuberculosis cases. Three districts including Xiaoshan, Shangcheng and Linping districts had the most cases in Hangzhou. The proportion of ecdemic multidrug-resistant tuberculosis cases in Binjiang, Xiaoshan, Qiantang and Linping districtalso exceeded 30% of total cases.

CONCLUSIONS

Multidrug-resistant tuberculosis prevalence has been declining in Hangzhou. Migrant population contributed to a significant potion of cases in Hangzhou. Interventions should be tailed to local and migrant residents.

Quantitative Study of Physical, Social, Psychological, and Environmental Challenges Faced by Patients With Drug-Resistant Tuberculosis

Background This study chronicles the socioeconomic and emotional challenges experienced by patients suffering from drug-resistant tuberculosis (DR-TB) in India, the country with the highest tuberculosis (TB) burden globally. Current government measures under the National TB Elimination Programme (NTEP) that include widely available molecular diagnostic methods, well-defined DR-TB regimens, free drug distribution, treatment adherence strategies, etc. need to expand to cover socioeconomic and emotional aspects of the disease. Objective The objective of this study was to assess the effects of DR-TB and its treatment on the quality of life of patients in the psychological, social, environmental, and physical domains using validated scales. Method Conducted at a tertiary care center in Pune, this quantitative study utilized the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire to objectively assess the quality of life of 64 DR-TB patients. The questionnaire was self-administered but assisted by the investigator to understand the meaning of the questions, and it covered four domains: psychological, social, environmental, and physical. Results The results indicated significant psychological distress, with the psychological domain scoring the lowest mean (33.41), followed by social (35.52), environmental (41.27), and physical domains (41.88). These findings underscore the profound impact of DR-TB on the mental health, social interactions, and overall well-being of these patients. Furthermore, substantial employment challenges, financial constraints, and fears of disease transmission were prevalent among patients, highlighting socioeconomic disparities. Conclusion The study emphasizes the necessity of holistic interventions that include psychological support, socioeconomic empowerment, and public health campaigns to improve the quality of life and treatment adherence for DR-TB patients. Future research should explore integrated care models that address both the clinical and psychosocial needs of patients. The insights from this study suggest a need for policy enhancements and resource allocation to better support this vulnerable population, ultimately aiming for more comprehensive and sustainable DR-TB management, thus focusing not only on the outcome but also on morbidity.

Epidemiology of first- and second-line drugs-resistant pulmonary tuberculosis in Iran: Systematic review and meta-analysis

Drug resistance among Mycobacterium tuberculosis (MTB) strains is a growing concern in developing countries. We conducted a comprehensive search for relevant studies in Iran on PubMed, Scopus, and Embase until June 12, 2020. Our study focused on determining the prevalence of antibiotic resistance in MTB isolates, with subgroup analyses based on year, location, and drug susceptibility testing (DST) methods. Statistical analyses were performed using STATA software. Our meta-analysis included a total of 47 articles. Among new TB cases, we found the following prevalence rates: Any-resistance to first-line drugs: 31 % (95 % CI, 24-38), mono-drug resistance: 15 % (95 % CI, 10-22), and multidrug resistance to first-line drugs: 6 % (95 % CI, 4-8). There was a significant variation in the rate of MDR among new TB cases based on the year of publication, location, and DST methods (P < 0.0001). We observed substantial variability in multidrug-resistant TB rates among new cases across the studies. Stratified analyses revealed that publication years and DST methods significantly affected resistance rates. Studies from southern and central Iran reported higher any-drug resistance rates, suggesting regional differences. Among retreatment cases, the prevalence rates were as follows: Any resistance: 68 % (95 % CI 58-78), mono-resistance: 19 % (95 % CI 7-34), multidrug resistance: 28 % (95 % CI 15-43). Our study revealed that the prevalence of drug-resistant TB (DR-TB) among TB cases in Iran is higher than the global average. Particularly, MDR-TB among retreatment TB cases is a significant public health issue.

Factors Associated with Non-Adherence to Treatment Among Migrants with MDR-TB in Wuhan, China: A Cross-Sectional Study

Background

Multidrug resistant tuberculosis (MDR-TB) has attracted increasing attention in achieving the global goal of tuberculosis (TB) control. China has the second largest TB burden worldwide and has been experiencing large-scale domestic migration. This study aims to explore the effect of migrants on non-adherence to MDR-TB treatment.

Materials and Methods

A cross-sectional study was carried out in Wuhan, China. The exposure cases were migrants who were not locally registered in the residence registration system. The control cases were local residents. Non-adherence cases were patients who were lost follow-up or refused treatment. Chi-square and t-test were used to compare variables between migrants and local residents. Logistic regression models using enter method were used to determine the relationship between migration and non-adherence to treatment. Moderation and medication effects on the association between migrant status and non-adherence were also explored.

Results

We studied 73 migrants and 219 local residents. The migrants, who did not to adhere to treatment (55, 75.3%), was far higher than that of local residents (89, 40.6%). Migrants with MDR-TB had 10.38-times higher difficulty in adhering to treatment (adjusted OR = 10.38, 95% CI 4.62-25.28) than local residents. This additional likelihood was moderated by age and treatment registration group. Migration had an indirect association with non-adherence to treatment via social medial insurance (adjusted OR = 1.05, 95% CI 1.01-1.13).

Conclusion

There a significant increased likelihood of non-adherence to treatment among migrants with MDR-TB, highlighting the importance of improving treatment adherence in this population. Migration prevented migrants from gaining access to social medical insurance and indirectly reduced their likelihood of adherence to treatment.

NEAT1 in inflammatory infectious diseases: An integrated perspective on molecular modulation

The long non-coding RNA (lncRNA), NEAT1, has emerged as a central figure in the intricate network of molecular regulators in inflammatory infectious diseases (IIDs). The review initiates a comprehensive exploration of NEAT1's multifaceted roles and molecular interactions in the context of these complex diseases. The study begins by acknowledging the global health burden of IIDs, underscoring the urgency for innovative insights into their pathogenesis and therapeutic avenues. NEAT1 is introduced as a pivotal lncRNA with growing relevance in immune responses and inflammatory processes. The core of this review unravels the NEAT1 landscape, elucidating its involvement in the modulation of immune signalling pathways, regulation of inflammatory cytokines, and interactions with various immune cells during infection. It explores NEAT1's role in orchestrating immune responses and balancing host defence mechanisms with the risk of immunopathology. Furthermore, the review underscores the clinical significance of NEAT1 in infectious diseases, discussing its associations with disease severity, prognosis, and potential as a diagnostic and therapeutic target. It provides insights into ongoing research endeavours aimed at harnessing NEAT1 for innovative disease management strategies, including developing RNA-based therapeutics. Concluding on a forward-looking note, the review highlights the broader implications of NEAT1 in the context of emerging infectious diseases and the possibility for precision medicine approaches that leverage NEAT1's regulatory capacities. In summary, this review illuminates the pivotal role of NEAT1 in IIDs by navigating its complex landscape, offering profound insights into its implications for disease pathogenesis and the development of targeted therapies.

Improving treatment adherence among tuberculosis patients through evening DOTS in Chennai, India

Background Fixed days and timings of service are challenges in the care of patients with tuberculosis (TB). We assessed whether provision of evening DOTS (directly observed treatment, short course) improves treatment outcomes in a city with a working population. Methods We enrolled new adult patients with TB from seven tuberculous units (TUs) in this prospective cohort study. Participants were offered the option of DOTS during the day (8 a.m. to 3:30 p.m.) or evening (4 p.m. to 8 p.m.) and assigned accordingly. Results Of 127 patients enrolled between April and July 2017, 19 (15%) opted for evening DOTS. The number varied between the seven TUs (p=0.002). On an average, antitubercular therapy (ATT) was taken at 9:41 a.m. in the routine and 5:14 p.m. in the evening DOTS centres. Patients who were employed, left residence and returned back at 9:05 a.m. and 6:40 p.m., respectively. Around 96% (104/108) opted for day-time DOTS due to closeness of the centre to their residence. Around 74% (14/19) chose evening DOTS because of time convenience. Around 15% of patients on routine DOTS (16) had unfavourable treatment outcomes. All had favourable outcomes in the evening DOTS. Men were less likely and those withut alcohol disorders were more likely to have treatment success. Conclusion Provision of time convenient services might improve adherence and treatment outcome.

A Retrospective Analysis of Clinico-Demographic and Genetic Characteristics and Treatment Outcomes in Isoniazid Mono-Resistant Tuberculosis Patients: A Single-Center Study

INTRODUCTION

Treatment failure and relapse rates are more likely to occur when there is isoniazid (INH) resistance. So, we can no longer ignore the problem of isoniazid mono-resistance. It is pertinent to control the spread of primary INH resistance and prevent secondary resistance.

AIM

This study aims to evaluate subjects' clinical, demographic, and genetic characteristics and explore their treatment outcomes.

METHODS

All data of isoniazid mono-resistant tuberculosis (TB) patients, which were maintained in the electronic database of mandatory notifications (NIKSHAY Portal) between 2017 and 2022, were reviewed. A total of 54 patients were included after excluding five patients with ongoing treatment.

RESULTS

Of 54 patients, 41 (75.9%) were cured, which was classified under favorable outcome, and the rest were classified under unfavorable outcome. Phenotypic, high-level mutation (katG) was found in 48 (88.9%) patients. Kaplan-Meier curves show that survival probabilities increase in weeks with regular intake of drugs.

CONCLUSION

Our study found that those with younger ages and males were more affected. We found favorable outcomes in the majority of patients.

Tuberculosis Monitoring Encouragement Adherence Drive (TMEAD): Toward improving the adherence of the patients with drug-sensitive tuberculosis in Nashik, Maharashtra

Introduction

Adherence to tuberculosis (TB) medication is one of the critical challenges to tuberculosis elimination in India. Digital adherence technologies (DAT) have the potential to facilitate medication adherence and monitor it remotely. Tuberculosis Monitoring Encouragement Adherence Drive (TMEAD) is one such DAT piloted in Nasik, Maharashtra, from April 2020 to December 2021. The study aims to assess the adherence and cost-effectiveness of TMEAD compared to the standard of care among patients with drug-sensitive tuberculosis (DSTB) residing in the urban areas of Nasik, Maharashtra, India.

Methods

A quasi-experimental study was conducted among new cases of TB as per the National TB Elimination Programme (NTEP) residing in the urban geography of Nasik. The intervention and control arms were purposively selected from non-contaminating TB units (TUs). A total of 400 DSTB patients (200 in the intervention group and 200 in the control group) were enrolled. After enrolment, patients in the intervention arm were provided with the TMEAD device and followed for 24 weeks to assess treatment outcomes. Adherence was measured as those patients who have completed 80% of prescribed doses, as reported during patient follow-up, and further validated by analyzing the trace of rifampicin in urine among 20% of patients from both arms. A budget impact analysis was done to assess the impact of the TMEAD program on the overall state health budget.

Results

Out of 400 enrolled DSTB patients, 261 patients completed treatment, 108 patients were on treatment, 15 patients died, and 16 patients were defaulters over the study period. The study reported overall treatment adherence of 94% among those who completed treatment. Patient reports indicated high levels of treatment adherence in the intervention group (99%) as compared to the control group (90%). Adherence assessed through analyzing trace of rifampicin in the urine sample for the intervention arm was 84% compared to the control arm (80%). Per beneficiary (discounted) cost for TMEAD was Indian rupees (INR) 6,573 (USD 83). The incremental cost-effectiveness ratio of the intervention is INR 11,599 (USD 146), which shows that the intervention is highly cost-effective.

Conclusion

This study revealed that patient-reported treatment adherence was high in TMEAD when compared to standard therapy of care for DSTB patients and the intervention is cost-effective. TMEAD could complement the national strategy to end TB by improving adherence to the treatment regimen in India.

A Global Bibliometric Analysis on Antibiotic-Resistant Active Pulmonary Tuberculosis over the Last 25 Years (1996-2020)

BACKGROUND

Tuberculosis (TB) is still a leading global cause of mortality and an increasingly crucial problem in fighting TB is antibiotic resistance. We aimed to conduct a bibliometric analysis on the articles of the past 25 years on antibiotic-resistant active pulmonary TB.

METHODS

Appropriate keywords were combined using the Boolean and wildcard operators and searched in Scopus database for articles published between 1996 and 2020 in English language. For all the bibliometric analyses, the Bibliometrix package in RStudio and Biblioshiny web apps were used. We identified the publication and citation trends, topmost cited documents, most productive authors, countries and institutions and most influential journals and funding agencies. We constructed collaborative networks of countries and co-citations. In addition, we developed a Three-Fields plot and a Thematic Map to explore different publication themes.

RESULTS

We included 7024 articles (88.9% research articles) and a persistently increasing publication and citation trends were evident throughout the past 25 years. Boehme 2010 was the most cited paper (1609 times cited), Stefan Niemann was the most productive author (86 papers), and 'International Journal of Tuberculosis and Lung Disease' was the leading journal. Centers for Disease Control and Prevention was the top contributing institution (3.7% papers) and both US- and UK-based funders were leading. The most productive countries were the USA, India, the UK, South Africa, and China and most of the collaborations took place between the USA, the UK, and South Africa.

CONCLUSION

Undoubtedly, researchers and funders from the USA dominated followed by the UK in most of the fields in antibiotic-resistant TB research. The outcomes of antibiotic-resistant TB research would be more productive and translational if researchers from low- or middle-income countries (especially from Africa, South America and Asia) with high research productivity and TB burden could be in collaboration with high-income countries exhibiting low TB burden.

Starting an All-Oral Longer Regimen in a Primary Multidrug-Resistant Pulmonary Tuberculosis Patient at a District Tuberculosis Center for the First Time: A Rare Case

Tuberculosis (TB) is a disease known to mankind for ages. The situation due to this infection in low- and middle-income countries is grave. The coronavirus disease 2019 (COVID-19) pandemic has only added up to the woes. The situation is alarming due to the isolation of drug-resistant Mycobacterium strains in patients with no history of TB. With the inclusion of new drugs for the management of TB, such as bedaquiline (Bdq), prompt diagnosis and management are feasible. The author herein presents the first case of a primary multidrug-resistant pulmonary TB patient managed on an all-oral longer regimen with Bdq started at a district TB center (DTC) for the first time in the pandemic of COVID-19. This case is unique as during the COVID-19 pandemic, healthcare facilities were saturated, and thus starting treatment after admission was very difficult. Also, the chances of cross-infection in TB patients were present due to weak immunity. This case is very important as this novel management at a DTC would help immensely in resource-limited countries where hospital admissions are difficult due to the COVID-19 pandemic and the burden of TB is very high.

Clinical spectrum of active tuberculosis in patients with systemic lupus erythematosus

INTRODUCTION

There is paucity of data on tuberculosis in Indian patients with systemic lupus erythematosus (SLE). We retrospectively studied clinical features and outcome of tuberculosis in SLE.

METHODS

Medical records of patients who developed tuberculosis simultaneous or after the diagnosis of SLE were retrospectively reviewed. All patients fulfilled 1997 ACR and/or SLICC 2012 classification criteria for SLE. A diagnosis of tuberculosis required bacteriological, histopathological or CT/MRI suggestive of tuberculosis and initiation of four drug antituberculous therapy. Baseline parameters were compared with the rest of cohort to identify predictors of tuberculosis.

RESULTS

In our cohort of 1335 SLE patients, 48 (3.6%) developed tuberculosis. Incidence of tuberculosis was calculated to be 733 per 100,000 patient years and occurred after a mean disease duration of 3.0 ± 4.1 years. Extrapulmonary tuberculosis (n = 37) was commoner than pulmonary tuberculosis (n =11). Most common radiological pattern in pulmonary tuberculosis was miliary and musculoskeletal TB was most common extrapulmonary TB. A microbiological diagnosis was obtained in 52.1% patients. Male gender was associated with higher risk of tuberculosis [OR 3.30 (1.55-7.05)]. Mortality was 14.5% and all patients who died had either disseminated (n = 5) or central nervous system (CNS) tuberculosis (n = 2).

CONCLUSION

Incidence of tuberculosis in SLE is higher than general population and is associated with different phenotype and higher mortality. Male gender was associated with increased risk of tuberculosis in SLE.

Outcome of drug resistant tuberculosis in Indian children

We aimed to determine the outcome of bacteriologically confirmed drug-resistant (DR) tuberculosis (TB) in 174 children. We found that DR-TB infected children have nonetheless a high treatment completion rate with a low incidence of fatality and treatment failure. Reversible adverse drug reactions are common during therapy.

Prevalence of depression and anxiety among drug resistant tuberculosis: A study in North India

BACKGROUND

Drug Resistant Tuberculosis (DR-TB) is an emergent issue in the recent decades. Multidrug resistant (MDR-TB) and Extensive drug resistant (XDR-TB) tuberculosis are the common type of DR-TB. Psychological issues like depression and anxiety are common among the chronic illnesses like tuberculosis. This study aimed at estimating the prevalence of depression and anxiety among these patients.

METHODS

Our study is conducted in a tertiary care teaching hospital in North India. This study aimed at identifying the prevalence of depression and anxiety among the drug resistant tuberculosis patients attending DOTS clinic. The depression and anxiety were screened using PHQ-9 and HAM-A inventories. Binomial and multinomial regression analysis were done to identifying the predictors of depression and anxiety.

RESULTS

The prevalence rate of depression in MDR-TB and XDR-TB is 68% and 78% respectively. The prevalence of anxiety is 54% in MDR-TB and 66% in XDR-TB respectively in our study. Duration of illness and literacy were the significant predictors of depression and anxiety.

CONCLUSION

Patients with DR-TB faces huge psychological burden and this study highlighted the toll of depression and anxiety among them. Adequate screening, identification and treatment for these disorders among DR-TB patients at their earlier treatment stage helps in improving the adherence to treatment and functionality.

Upward trends in new, rifampicin-resistant and concurrent extrapulmonary tuberculosis cases in northern Guizhou Province of China

Similar to global trends, the incidence rate of tuberculosis (TB) in China declined from 2000 to 2018. In this study, we aimed to evaluate TB trends in northern Guizhou Province and identify risk factors associated with rifampicin-resistant (RR) and concurrent extrapulmonary TB (EPTB). We analyzed data of TB patients hospitalized in Affiliated Hospital of Zunyi Medical University from 2011 to 2018, and assessed correlations between demographic characteristics of patients and RR-TB as well as concurrent EPTB. Our results showed that numbers of new, retreated, RR-TB and concurrent EPTB cases increased gradually from 2011 to 2018. Retreated patients had the highest odds of RR-TB but a lower likelihood of concurrent EPTB compared to new patients. Patients between 21 and 40 years of age had a higher likelihood of RR-TB compared to those 20 years and younger. Female patients and patients from Bijie city as well as the Miao ethnic minority had higher odds of concurrent EPTB. In summary, our data demonstrate upward trends in new, rifampicin-resistant and concurrent extrapulmonary TB cases in northern Guizhou Province of China, which should not be overlooked especially during and post the COVID-19 pandemic because TB is a greater long-term global health threat than COVID-19.

Prevalence of Drug-Resistant Tuberculosis in Sudan: A Systematic Review and Meta-Analysis

Drug-resistant tuberculosis (DR-TB) is still one of the most critical issues impeding worldwide TB control efforts. The aim of this systematic review and meta-analysis was to give an updated picture of the prevalence of DR-TB in Sudan. A comprehensive systematic search was performed on four electronic databases (PubMed, Scopus, Web of Science and Google Scholar) to identify all published studies reporting prevalence data of DR-TB in Sudan. Sixteen eligible studies published during 2002-2020 were included. Using meta-analysis of proportions, the pooled prevalence of TB cases with resistance to any anti-TB drugs was 47.0% (95% CI: 35.5-58.6%). The overall prevalence of mono, multi, poly and extensive drug resistance were estimated to be 16.2% (95% CI: 9.0-23.4%), 22.8% (95% CI: 16.0-29.7%), 6.8% (95% CI: 0.5-13.0%) and 0.7% (95% CI: 0-2.1%), respectively. Considering any first-line anti-TB drugs, the resistance prevalence was highest for isoniazid (32.3%) and streptomycin (31.7%), followed by rifampicin (29.2%). In contrast, resistance against second-line drugs was reported for only two antibiotics, namely, ofloxacin (2.1%) and kanamycin (0.7%). Of note, the resistance profile of the previously treated patients was found to be remarkably high compared with the newly diagnosed TB patients. The relatively high prevalence estimation of anti-TB drug resistance warrants strengthening TB control and treatment strategies in Sudan.

Epidemiological profile of patients with rifampicin-resistant tuberculosis: an analysis of the Uganda National Tuberculosis Reference Laboratory Surveillance Data, 2014-2018

BACKGROUND

Drug-resistant tuberculosis (DR-TB), including rifampicin-resistant tuberculosis (RR-TB) and multidrug-resistant tuberculosis (MDR-TB, or RR-TB with additional isoniazid resistance), presents challenges to TB control. In Uganda, the GeneXpert test provides point-of-care testing for TB and rifampicin resistance. Patients identified with RR-TB receive culture-based drug susceptibility testing (DST) to identify additional resistance, if any. There are few data on the epidemiological profiles of current DR-TB patients in Uganda. We described patients with RR-TB in Uganda and assessed the trends of RR-TB to inform TB control interventions.

METHODS

We identified patients with RR-TB whose samples were referred for culture and DST during 2014-2018 from routinely-generated laboratory surveillance data at the Uganda National Tuberculosis Reference Laboratory. Data on patient demographics and drug sensitivity profile of Mycobacterium tuberculosis isolates were abstracted. Population data were obtained from the Uganda Bureau of Statistics to calculate incidence. Descriptive epidemiology was performed, and logistic regression used to assess trends.

RESULTS

We identified 1474 patients whose mean age was 36 ± 17 years. Overall incidence was 3.8/100,000 population. Males were more affected by RR-TB than females (4.9 vs. 2.7/100,000, p ≤ 0.01). Geographically, Northern Uganda was the most affected region (IR = 6.9/100,000) followed by the Central region (IR = 5.01/100,000). The overall population incidence of RR-TB increased by 20% over the evaluation period (OR = 1.2; 95% CI 1.15-1.23); RR-TB in new TB cases increased by 35% (OR = 1.35; 95% CI 1.3-1.4) and by 7% in previously-treated cases (OR = 1.07; 95% CI 1.0-1.1). Of the 1474 patients with RR-TB, 923 (63%) were culture-positive of whom 670 (72%) had full DST available. Based on the DST results, 522/670 (78%) had MDR-TB.

CONCLUSION

Between 2014 and 2018, the incidence of RR-TB increased especially among newly-diagnosed TB patients. We recommend intensified efforts and screening for early diagnosis especially among previously treated patients. Mechanisms should be in put to ensure that all patients with RR-TB obtain DST.

Assessment of burden of drug-resistant tuberculosis at a tertiary care centre in northern India: a prospective single centre cohort study

OBJECTIVES

We aim to define the burden of rifampicin monoresistant tuberculosis (TB) at a tertiary care centre in northern India as well as determine the second-line drug susceptibilities (SL-DST) in a subset of patients.

METHODS

A total of 3045 pulmonary (n=1883) and extrapulmonary (n=1162) samples from likely patients with TB were subjected to microscopy, culture and the Xpert MTB/RIF assay from March 2017 to June 2019. SL-DST testing by line probe assay version 2 for fluoroquinolones (FQs) and second-line injectable drugs were performed on 62 samples.

RESULTS

Out of 3045 samples processed in our laboratory during the study period, 36.1% (1101/3045) were positive for Mycobacterium tuberculosis complex (MTBC) and 21.6% were rifampicin monoresistant (223/1032). The rate of rifampicin resistance in pulmonary samples was 23.5% (166/706) and in extrapulmonary cases, it was 17.4% (57/326). Out of 62 cases included for second-line testing, 48 were resistant to FQs (77.4%) while 11 were extensively drug resistant.

CONCLUSIONS

India urgently needs to arrest an emerging multidrug-resistant TB epidemic with associated resistance to FQs. A robust surveillance system is needed to execute the National Strategic Plan for 2017-2025.

Increasing prevalence of resistance to second-line drugs among multidrug-resistant Mycobacterium tuberculosis isolates in Kuwait

Molecular methods detect genetic mutations associated with drug resistance. This study detected resistance-conferring mutations in gyrA/gyrB for fluoroquinolones and rrs/eis genes for second-line injectable drugs (SLIDs) among multidrug-resistant Mycobacterium tuberculosis (MDR-TB) isolates in Kuwait. Fifty pansusceptible M. tuberculosis and 102 MDR-TB strains were tested. Phenotypic susceptibility testing was performed by MGIT 960 system using SIRE drug kit. GenoType MTBDRsl version 1 (gMTBDRslv1) and GenoType MTBDRsl version 2 (gMTBDRslv2) tests were used for mutation detection. Results were validated by PCR-sequencing of respective genes. Fingerprinting was performed by spoligotyping. No mutations were detected in pansusceptible isolates. gMTBDRslv1 detected gyrA mutations in 12 and rrs mutations in 8 MDR-TB isolates. gMTBDRsl2 additionally detected gyrB mutations in 2 and eis mutation in 1 isolate. Mutations in both gyrA/gyrB and rrs/eis were not detected. gMTBDRslv1 also detected ethambutol resistance-conferring embB mutations in 59 isolates. Although XDR-TB was not detected, frequency of resistance-conferring mutations for fluoroquinolones or SLIDs was significantly higher among isolates collected during 2013–2019 versus 2006–2012. Application of both tests is warranted for proper management of MDR-TB patients in Kuwait as gMTBDRslv2 detected resistance to fluoroquinolones and/or SLIDs in 3 additional isolates while gMTBDRslv1 additionally detected resistance to ethambutol in 58% of MDR-TB isolates.

"It Takes Two to Tango": Role of Neglected Macrophage Manipulators Coronin 1 and Protein Kinase G in Mycobacterial Pathogenesis

Macrophages being the connecting link between innate and adaptive immune system plays a crucial role in microbial antigen presentation and orchestrates the subsequent clearance of microorganisms. Microbial invasion of macrophages trigger a plethora of signaling cascades, which interact among them to generate a dynamically altered hostile environment, that ultimately leads to disruption of microbial pathogenesis. Paradoxically, Mycobacterium sp. exploits macrophage proteins such as Coronin 1, Calcineurin, LRG47, SOCS1, CISH, Gbp5 etc. and secretes virulence proteins such as PknG, PtpA, SapM, Eis etc. to hijack these intra-macrophage, signaling cascades and thereby develop its own niche. Coronin 1, being a cortical protein is transiently recruited to all mycobacteria containing phagosomes, but only pathogenic mycobacteria can retain it on the phagosome, to hinder its maturation. Additionally, mycobacterial infection linked secretion of virulence factor Protein Kinase G through its phosphorylation, manipulates several macrophage signaling pathways and thus promotes pathogenesis at various stages, form early infection to latency to granuloma formation. Here we discuss the present status of mycobacteria engaged Coronin 1-dependent signaling cascades and secreted PknG related sequence of events promoting mycobacterial pathogenesis. Current knowledge about these two proteins in context of macrophage signaling manipulation encompassing diverse mechanisms like calcium-calcineurin signaling, reduced proinflamtory cytokine secretion, cytoskeletal changes, and adaptation in acidic environment, which ultimately converge toward mycobacterial survival inside the macrophages has been discussed.

Prevalence of Antibiotic-Resistant Pulmonary Tuberculosis in Bangladesh: A Systematic Review and Meta-Analysis

Resistance to anti-tuberculosis (anti-TB) antibiotics is a major public health concern for many high-TB burden countries in Asia, including Bangladesh. Therefore, to represent the overall drug-resistance pattern against TB in Bangladesh, a systematic review and meta-analysis was conducted. Databases such as PubMed, Scopus, and Google Scholar were searched to identify studies related to antibiotic-resistant TB. A total of 24 studies covering 13,336 patients with TB were secured and included. The random-effects model was used to calculate the summary estimates. The pooled prevalence of any, mono, multi, poly, and extensive anti-TB antibiotic-resistances were 45.3% [95% CI: 33.5–57.1], 14.3% [95% CI: 11.4–17.2], 22.2% [95% CI: 18.8–25.7], 7.7% [95% CI: 5.6–9.7], and 0.3% [95% CI: 0.0–1.0], respectively. Among any first and second-line anti-TB drugs, isoniazid (35.0%) and cycloserine (44.6%) resistances were the highest, followed by ethambutol (16.2%) and gatifloxacin (0.2%). Any, multi, and poly drug-resistances were higher in retreatment cases compared to the newly diagnosed cases, although mono drug-resistance tended to be higher in newly diagnosed cases (15.7%) than that in retreatment cases (12.5%). The majority (82.6%) of the included studies were of high quality, with most not exhibiting publication bias. Sensitivity analyses confirmed that all outcomes are robust and reliable. It is concluded that resistance to anti-TB drugs in Bangladesh is rampant and fast growing. Therefore, the implementation of a nationwide surveillance system to detect suspected and drug-resistant TB cases, as well as to ensure a more encompassing treatment management by national TB control program, is highly recommended.

Prevalence and patterns of drug resistant pulmonary tuberculosis in India-A systematic review and meta-analysis

OBJECTIVE

Drug-resistant tuberculosis (DR-TB) is a major global public health threat. India, as it shares a large fraction of the world's TB burden, is currently at a critical phase due to the rise of drug resistance. Monitoring the prevalence and patterns of drug resistance is essential to measure the progress of TB control programmes. We aimed to systematically review Indian studies on the prevalence and patterns of DR-TB among various treatment types and risk groups.

METHODS

A systematic search was conducted on PubMed, Google Scholar, IndMed, major TB journals and other databases for English language articles published till March 2018 that estimated the prevalence of DR TB in new, previously treated, presumptive multidrug resistance (MDR), paediatric and HIV co-infected pulmonary TB patients. Two authors independently conducted the search, assessed study quality, and extracted the relevant data. Pooled prevalence of DR-TB and its types were calculated by DerSimonian-Laird random effects meta-analysis. Heterogeneity was investigated by sub-group and sensitivity analyses.

RESULTS

Ninety non-duplicate studies were included. The prevalence of MDR, any drug resistance and extensive drug resistance was 3.5%, 24.9% and 0.06% (among new) and 26.7%, 58.4% and 1.3% (among previously treated), respectively. MDR prevalence among presumptive MDR, paediatric and HIV co-infected TB patients was 23.3%, 5.1% and 18.8%, respectively. MDR prevalence among new TB patients was highest in Maharashtra and lowest in Telangana. There was high heterogeneity between the studies. Study period, place of study and zone were significantly associated with MDR prevalence.

CONCLUSIONS

India suffers from a significant burden of DR-TB. Its patterns and prevalence are very heterogeneous across time, region and setting. Implementation of universal drug susceptibility testing in all districts and continuous DR-TB surveillance is crucial to ensure programmatic success.

Understanding the gaps in elimination of tuberculosis in India

Tuberculosis (TB) is a highly infectious disease, and it has the highest global burden on India with 21% prevalence rate and 27% of patients who do not receive pertinent medical treatment. Although India spends 23 billion dollars annually towards medical expenses for TB, India still ranks among the top 2 countries with the highest incidence and prevalence rates with more than 300,000 deaths excluding the patients with HIV and TB calling for prompt consideration. India faces a great challenge socially and economically. They lack a uniform health care system, making it burdensome to use effective surveillance techniques for prevention of TB. Currently, India is working on resolving the issue meticulously through the web-based application program 'Nikshay' with other strategies like Revised National Tuberculosis Control Program (RNTCP) and World Health Organization's The End TB Strategy. India's cardinal goal is to make advanced diagnostic tools made available and public-private healthcare sector collaboration. India needs to focus more on primary prevention by effective policy formation and campaign which promote proper sanitation and vaccine administration while educating the layman.

Prevalence of multidrug-resistant tuberculosis in Latin America and the Caribbean: a systematic review and meta-analysis

OBJECTIVES

To evaluate the prevalence of multidrug-resistant tuberculosis (MDR-TB) in individuals living in Latin America and the Caribbean (LAC).

METHODS

We searched the MEDLINE, Embase and Literatura Latino Americana e do Caribe em Ciências da Saúde (Lilacs) databases until 08 August 2019 for all studies on the subject, without time or language restrictions. Original studies reporting the prevalence of infection with Mycobacterium tuberculosis resistant to isoniazid and rifampicin simultaneously (MDR) in LAC, the prevalence of resistance in cases with no previous treatment (new cases) and the prevalence of resistance in previously treated cases were selected. Considering the expected heterogeneity between studies, all analyses were performed using the random effects model, and heterogeneity was assessed using the I² statistic.

RESULTS

We included 91 studies from 16 countries. The estimated overall prevalence was 13.0% (95% CI 12.0-14.0%), and the heterogeneity between studies was substantial (I²  = 96.1%). In the subgroup analyses, it was observed that the prevalence of MDR-TB among new cases was 7.0% (95% CI 6.0-7.0%) and in previously treated cases was 26.0% (95% CI 24.0-28.0%).

CONCLUSIONS

This review highlights multidrug resistance to antituberculosis drugs in LAC, indicating that prevention strategies have not been effective. Government institutions should invest heavily in strategies for early diagnosis and the rapid availability of effective treatments and prioritise adequate protection for health professionals. In addition, screening programmes should be adopted to prevent secondary cases.

Yield of Systematic Longitudinal Screening of Household Contacts of Pre-Extensively Drug Resistant (PreXDR) and Extensively Drug Resistant (XDR) Tuberculosis Patients in Mumbai, India

While risk of tuberculosis (TB) is high among household contacts (HHCs) of pre-extensively drug resistant (pre-XDR) TB and XDR-TB, data on yield of systematic longitudinal screening are lacking. We aim to describe the yield of systematic longitudinal TB contact tracing among HHCs of patients with pre-XDR-TB and XDR-TB. At the Médecins Sans Frontières (MSF) clinic, Mumbai, India a cohort comprising 518 HHCs of 109 pre-XDR and XDR index cases was enrolled between January 2016 and June 2018. Regular HHC follow-ups were done till one year post treatment of index cases. Of 518 HHCs, 23 had TB (21 on TB treatment and two newly diagnosed) at the time of first visit. Of the rest, 19% HHCs had no follow-ups. Fourteen (3.5%) TB cases were identified among 400 HHCs; incidence rate: 2072/100,000 person-years (95% CI: 1227-3499). The overall yield of household contact tracing was 3% (16/518). Of 14 who were diagnosed with TB during follow-up, six had drug susceptible TB (DSTB); six had pre-XDR-TB and one had XDR-TB. Five of fourteen cases had resistance patterns concordant with their index case. In view of the high incidence of TB among HHCs of pre-XDR and XDR-TB cases, follow-up of HHCs for at least the duration of index cases' treatment should be considered.

Pattern of InhA and KatG mutations in isoniazid monoresistant Mycobacterium tuberculosis isolates

Aims and Objectives:

The aim of the study is to detect the pattern of genetic mutation, i.e., InhA or KatG or both (InhA and katG) in isoniazid (INH) monoresistant mycobacteria and to correlate with the pattern in multidrug-resistant (MDR) isolates.

Materials and Methods:

In this study, a quantitative research approach was used. The research design was descriptive observational study. The study was conducted at the Department of Respiratory Medicine, JLN Medical College, Ajmer, Rajasthan, and Intermediate Referral Laboratory, State TB Demonstration Centre, Ajmer. A total of 298 samples found to have resistant strains of Mycobacterium tuberculosis were enrolled with purposive sampling.

Results:

The mean age of patients was 40.27 ± 13.82 years. There were 250 (83.9%) males, while 48 (16.1%) were females. One hundred ninety-two (64.4%) were resistant for INH only, while the rest were resistant to both INH as well as rifampicin (MDR-tuberculosis). The most common mutation in INH monoresistance was katG (125; 65.1%) as compared to inhA (54; 28.1%) and both inhA and katG (13; 6.7%). Among katG mutations, the most common gene pattern was the absence of WT (S315T) and the presence of MUT1 (S315T1).

Conclusion:

Knowledge about mutation patterns of different INH resistant strains is important in the present era where there is a provision of separate regimens for INH monoresistant TB. Since these mutations are very closely related to high- or low-degree resistance to INH, the therapeutic regimens cannot be generalized.

Mendelian susceptibility to mycobacterial disease-Challenges in hematopoietic stem cell transplantation

We present our experience in the hematopoietic stem cell transplantation (HSCT) in two children diagnosed with Mendelian susceptibility to mycobacterial diseases. The first child underwent a haploidentical HSCT with posttransplant cyclophosphamide using a reduced intensity conditioning following which he had primary graft failure. He was subsequently found to have interferon-γ1 receptor deficiency. He had immune reconstitution and is on antitubercular therapy. The second child diagnosed with IL12RB1 gene mutation underwent matched sibling donor HSCT with myeloablative conditioning following pretransplant immunosuppression with fludarabine and dexamethasone. He is 13 months post-HSCT with complete and remains disease free.

A model-based investigation into urban-rural disparities in tuberculosis treatment outcomes under the Revised National Tuberculosis Control Programme in India

In this study, we investigate differences in tuberculosis (TB) treatment outcomes between urban and rural India and estimate their impact on epidemiological outcomes such as TB incidence, prevalence and mortality using a mathematical model of TB transmission dynamics. Publicly available district-level treatment outcomes data for new and previously treated TB cases was analyzed in conjunction with census data providing the proportion of urban population in each district to determine the effect of urbanity/rurality on treatment outcomes. Districts were grouped in clusters based on the proportion of urban population in each district, wherein the clusters were identified by applying machine learning methods. Regression analyses revealed that average treatment success rates among both new and previously treated cases decline with increase in the proportion of urban population in a district cluster, with substantially sharper declines in treatment success rates with degree of urbanity observed for previously treated cases. The impact of differences in treatment outcomes on epidemiological outcomes was estimated using a dynamic transmission model developed for this purpose. For example, the cluster with highest treatment success rates is projected to have an average of 3.2% fewer deaths per 100,000 population in comparison with the national average across 2019–24, and the cluster with the lowest treatment success rates has an average of 4.5% more deaths per 100,000 in comparison with the national average. We anticipate that these disparities in TB treatment outcomes and epidemiology between urban and rural India may motivate investigations into the associated causes and their redressal.

Prevalence of multidrug resistance tuberculosis in adult patients in India: A systematic review and meta-analysis

Background:

Multidrug resistance tuberculosis (MDR-TB) is an important public health problem for India but there is a paucity of data related to the prevalence of MDR-TB in India. This systematic review and meta-analysis was designed to synthesize evidence regarding the prevalence of MDR-TB in adult patients in India.

Methods:

PubMed and Google Scholar were searched to find different observational studies reporting MDR-TB prevalence in India. Data related to MDR-TB prevalence were pooled for the analysis. PubMed was searched by using different MeSH words. Prevalence was reported with 95% confidence interval (CI). A separate analysis was done for new cases and previously treated cases. Random effect model was used and heterogeneity was assessed by I² and Cochran Q test.

Results:

MDR-TB prevalence in new cases were 3% (95% CI 2%-5%, I² = 95.3%). There was difference in prevalence between different methods of measurement of MDR-TB and study designs. MDR-TB prevalence in previously treated cases was found to be 35% (95% CI 29%-41%, I² = 98.7%). Results vary with the method of measurement as well as the study design.

Conclusion:

MDR-TB prevalence in previously treated patients was found higher compared to the reported values in national surveys. There is a need for large scale cross-sectional study to verify the findings observed in this review.

Treatment outcome of multidrug-resistant tuberculosis with modified DOTS-plus strategy: A 2 years' experience

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is a global health problem with notoriously difficult and challenging treatment. This study determined treatment outcome in patients of MDR-TB with modified DOTS-Plus strategy.

METHODS

Ninety-eight consecutive MDR-TB patients treated with standardized regimen according to modified DOTS-Plus strategy aligned to the existing national DOTS-Plus guidelines with relevant modifications proposed by Chennai consensus were analyzed prospectively. Treatment included monthly follow-up with clinical, radiological, and bacteriological assessment (sputum smear advised monthly till conversion then quarterly; culture for Mycobacterium tuberculosis at 0, 4, 6, 12, 18, and 24 months), ensuring adherence, intense health education, and monitoring of adverse events (AEs). Patients' outcome was considered as cure when at least two of the last three cultures (all three or last two) were negative and as failure when the same were positive.

RESULTS

Favorable and unfavorable outcomes in this cohort were reported to be 71/98 (72.4%) and 27/98 (27.6%) (failure - 10 [10.2%], default - 7 [7.1%], and expiry - 10 [10.2%]), respectively. Sputum smear and culture conversion rate were 75/81 (92.5%) and 71/81 (87.7%), respectively. Major AEs were experienced in only 17.4% of patients.

CONCLUSIONS

MDR-TB can be cured successfully with modified DOTS-Plus strategy and requires much effort from both the patients and health-care workers. It can be an alternative model for treating MDR-TB patients in private sector.

High prevalence of rifampin-resistant tuberculosis in mountainous districts of India

BACKGROUND

India accounts for quarter of global rifampin-resistant/multi-drug resistant-tuberculosis (RR/MDR-TB). Knowledge on risk-factors and distribution of MDR-TB at district level is limited.

OBJECTIVE

Study prevalence and risk factors of MDR-TB in tuberculosis patients in hilly districts of Himachal Pradesh, India.

METHODS

Between July 2012-June 2013, TB patients registered under the Revised National Tuberculosis Control Program in Kangra and Una districts suspected of MDR-TB were referred for Xpert® MTB/RIF testing at the Delek Hospital, Dharamsala by the district TB Office.

RESULTS

Of 378 patients enrolled (median age: 45 years; 85% males), 18% (n = 68) were rifampin-resistant. Among Xpert positives (n = 305), distributions of RR-TB were: 10% (n = 9/89) for recurrent cases who had received TB treatment for <2-months, 15% each for new (n = 9/59) or recurrent cases (n = 5/34) remaining smear positive between 2 and 4 months of treatment, 36% (n = 41/113) for treatment failures, and 40% (n = 2/5) for loss to follow-ups. Of the sputum-smear positives, 15% (n = 51/338) were Xpert negative. Seeking care in the private sector was associated with higher risk of RR-TB (OR:1.85; 95% CI:0.87-3.9).

CONCLUSION

Prevalence of RR-TB is generally high in patients suspected of MDR-TB in the hilly districts of Himachal Pradesh. High prevalence during early phase of treatment can suggest primary transmission of DR-TB. Universal drug susceptibility testing and innovative case finding strategies will benefit patients living in mountain districts with inadequate access to healthcare. The high proportion of sputum-smear positive but Xpert negative cases may be due to non-tubercular mycobacterial disease.

Structural dynamics behind variants in pyrazinamidase and pyrazinamide resistance

Pyrazinamide (PZA) is an important component of first-line anti-tuberculosis (anti-TB) drugs. The anti-TB agent is activated into an active form, pyrazinoic acid (POA), by Mycobacterium tuberculosis (MTB) pncA gene encoding pyrazinamidase (PZase). The major cause of PZA-resistance has been associated with mutations in the pncA gene. We have detected several novel mutations including V131F, Q141P, R154T, A170P, and V180F (GeneBank Accession No. MH461111) in the pncA gene of PZA-resistant isolates during PZA drug susceptibility testing followed by pncA gene sequencing. Here, we investigated molecular mechanism of PZA-resistance by comparing the results of experimental and molecular dynamics. The mutants (MTs) and wild type (WT) PZase structures in apo and complex with PZA were subjected to molecular dynamic simulations (MD) at the 40 ns. Multiple factors, including root mean square deviations (RMSD), binding pocket, total energy, dynamic cross correlation, and root mean square fluctuations (RMSF) of MTs and WT were compared. The MTs attained a high deviation and fluctuation compared to WT. Binding pocket volumes of the MTs, were found, lower than the WT, and the docking scores were high than WT while shape complementarity scores were lower than that of the WT. Residual motion in MTs are seemed to be dominant in anti-correlated motion. Mutations at locations, V131F, Q141P, R154T, A170P, and V180F, might be involved in the structural changes, possibly affecting the catalytic property of PZase to convert PZA into POA. Our study provides useful information that will enhance the understanding for better management of TB. AbbreviationsDSTdrug susceptibility testingΔelecelectrostatic energyLJLowenstein-Jensen mediumMGITmycobacterium growth indicator tubesMTsmutantsMDmolecular dynamic simulationsMTBMycobacterium tuberculosisNALC-NaOHN-acetyl-l-cysteine-sodium hydroxideNIHNational Institutes of HealthNPTamount of substance (N), pressure (P) temperature (T)NVTmoles (N), volume (V) temperature (T)PZasepyrazinamidaseΔpspolar solvation energyPTRLProvincial Tuberculosis Reference LaboratoryRMSDroot mean square deviationsRMSFroot mean square fluctuationsΔSASAsolvent accessible surface area energyTBtuberculosisGTotaltotal binding free energyΔvdWVan der Waals energyWTwild typeCommunicated by Ramaswamy H. Sarma.

Rapid, point-of-care diagnosis of tuberculosis with novel Truenat assay: Cost-effectiveness analysis for India's public sector

Background

Truenat is a novel molecular assay that rapidly detects tuberculosis (TB) and rifampicin-resistance. Due to the portability of its battery-powered testing platform, it may be valuable in peripheral healthcare settings in India.

Methods

Using a microsimulation model, we compared four TB diagnostic strategies for HIV-negative adults with presumptive TB: (1) sputum smear microscopy in designated microscopy centers (DMCs) (SSM); (2) Xpert MTB/RIF in DMCs (Xpert); (3) Truenat in DMCs (Truenat DMC); and (4) Truenat for point-of-care testing in primary healthcare facilities (Truenat POC). We projected life expectancy, costs, incremental cost-effectiveness ratios (ICERs), and 5-year budget impact of deploying Truenat POC in India’s public sector. We defined a strategy “cost-effective” if its ICER was <US$990/year-of-life saved (YLS). Model inputs included: TB prevalence, 15% (among those not previously treated for TB) and 27% (among those previously treated for TB); sensitivity for TB detection, 89% (Xpert) and 86% (Truenat); per test cost, $12.63 (Xpert) and $13.20 (Truenat); and linkage-to-care after diagnosis, 84% (DMC) and 95% (POC). We varied these parameters in sensitivity analyses.

Results

Compared to SSM, Truenat POC increased life expectancy by 0.39 years and was cost-effective (ICER $210/YLS). Compared to Xpert, Truenat POC increased life expectancy by 0.08 years due to improved linkage-to-care and was cost-effective (ICER $120/YLS). In sensitivity analysis, the cost-effectiveness of Truenat POC, relative to Xpert, depended on the diagnostic sensitivity of Truenat and linkage-to-care with Truenat. Deploying Truenat POC instead of Xpert increased 5-year expenditures by $270 million, due mostly to treatment costs. Limitations of our study include uncertainty in Truenat’s sensitivity for TB and not accounting for the “start-up” costs of implementing Truenat in the field.

Conclusions

Used at the point-of-care in India, Truenat for TB diagnosis should improve linkage-to-care, increase life expectancy, and be cost-effective compared with smear microscopy or Xpert.

Epidemiological and behavioural correlates of drug-resistant tuberculosis in a Tertiary Care Centre, Delhi, India

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is a major public health challenge in India. It is associated with poor treatment outcomes, multiple adverse effects to treatment and involves enormous social and economic losses. The objective of the study was to ascertain the epidemiological and behavioural correlates contributing to drug resistance among patients admitted in a tertiary hospital in Delhi with drug-resistant TB (DR-TB).

METHODOLOGY

A descriptive cross-sectional study was carried out during the period of July-November 2013 at the Rajan Babu Institute of Pulmonary Medicine and Tuberculosis (RBIPMT), Delhi. All patients admitted with DR-TB for treatment were interviewed regarding social, demographic, and treatment aspects, using a semi-structured questionnaire. Their medical records were also reviewed.

RESULTS

A total of 250 patients were included in the study; 198 (79.2%) with multidrug-resistant (MDR-TB) and 52 (20.8%) with extensively drug-resistant TB (XDR-TB). Of these, 66% patients were male and 46% came from poor socioeconomic background. All the patients had history of receiving anti-tubercular treatment (a mean of 2.3 times, range 1-6 times) before the current diagnosis of DR-TB. While 81 (32%) took treatment from private practitioner during the first episode of TB, 146 (58%) received treatment exclusively at government health facilities. Almost 87% of DR-TB patients were previously treated with category-II under RNTCP. Irregularity of treatment was reported by 88 (35%) patients.

CONCLUSION

The study explores the epidemiological and behavioural correlates among the patients with drug-resistant TB. History of previous treatments for TB was a common feature among all the enrolled patients. The fact that more than half of DR-TB patients received anti-tubercular treatment exclusively in government facilities is a matter of concern. There is an urgent need to ensure treatment adherence through improved quality in service delivery in public sector and strong linkage with the private sector. Health education and patient counseling is needed to address personal level risk factors and to ensure treatment adherence.

Feasibility of lung cancer screening in developing countries: challenges, opportunities and way forward

Lung cancer is the leading cause of all cancer deaths worldwide, comprising 18.4% of all cancer deaths. Low-dose computed tomography (LDCT) has shown mortality benefit in various trials and now a standard tool for lung cancer screening. Most researches have been carried out in developed countries where lung cancer incidence and mortality is very high. There is an increasing trend in lung cancer incidence in developing countries attributed to tobacco smoking and various environmental and occupational risk factors. Implementation of lung cancer screening is challenging, so organised lung cancer screening is practically non-existent. There are numerous challenges in implementing such programs ranging from infrastructure, trained human resources, referral algorithm to cost and psychological trauma due to over-diagnosis. Pulmonary tuberculosis and other chest infections are important issues to be addressed while planning for lung cancer screening in developing countries. Burden of these diseases is very high and can lead to over-diagnosis in view of cut off of lung nodule size in various studies. Assessment of high risk cases for lung cancer is difficult as various forms of smoking make quantification non-uniform and difficult. Lung cancer screening targets only high risk population unlike screening programs for other cancers where entire population is targeted. There is a need of lung cancer screening for high risk cases as it saves life. Tobacco control and smoking cessation remain the most important long term intervention to decrease morbidity and mortality from lung cancer in developing countries. There is no sufficient evidence supporting the introduction of population-based screening for lung cancer in public health services.

The goal to end TB- strategy: Public private partnership. Is it only private sector to blame?

National Strategic Plan for tuberculosis care and control, Nepal ( 2016-2021) envisions ambitious target of decreasing TB incidence by 20% by 2021.In achieving so it has to identify and manage 20,000 more cases by 2021 compared to 2015. Contribution of private sector which roughly accounts to 25% of all the burden of tuberculosis cases in Nepal will be vitally important along with effective public private partnership. In this review we discuss why blaming the private sector alone is not sufficient and much effective PPP collaboration needs to be done stepping on the positive results shown by the earlier collaboration.

Multi-drug resistant Mycobacterium tuberculosis in Port Harcourt, Nigeria

Background

In past years, much focus has been on tackling the scourge and spread of tuberculosis worldwide. The recent emergence of multi-drug resistant (MDR) tuberculosis has, however, negatively threatened progress made so far. Nigeria ranks fourth out of the 22 high tuberculosis burden countries in the world and has the highest burden of tuberculosis in Africa. It is therefore necessary to monitor the MDR tuberculosis situation in the country.

Objectives

This study set out to assess the proportions of MDR tuberculosis in patients attending six directly observed treatment short-course centres in Port Harcourt, Nigeria, from October 2015 to October 2016.

Methods

Six hundred and nine participants between the ages of 18 and 75 years were enrolled in this study and comprised suspected and newly diagnosed tuberculosis cases. Sputum samples obtained from the participants were screened for the presence of Mycobacterium tuberculosis using standard culture and phenotypic biochemical techniques, and drug susceptibility testing was carried out using the 1% proportion conventional method.

Results

Of the 609 participants enrolled, 30 (4.9%) were confirmed as M. tuberculosis-positive cases. A high prevalence of drug resistant tuberculosis was noted in this study (14/30, 46.7%), with 26.7% of isolates resistant to streptomycin. MDR tuberculosis, defined as being resistant to isoniazid and rifampicin, was detected in only one case (3.3%).

Conclusion

This study reports a low rate of MDR tuberculosis and contributes to the sparse data on drug resistant tuberculosis in Nigeria.

Prevalence and patterns of drug resistance among pulmonary tuberculosis patients in Hangzhou, China

Background

To evaluate prevalence and patterns of drug resistance among pulmonary tuberculosis (TB) patients in Hangzhou City, China.

Methods

Sputum samples of smear positive TB patients enrolled in 2011 and 2015 were collected and tested for drug susceptibility, and demographic and medical record data were extracted from the electronic database of China Information System for Disease Control and Prevention. Chi-square test was used to compare drug resistance prevalence between new and treated patients and between male and female patients, and Chi-square test for trend was used to compare the prevalence over calendar years 2011 and 2015.

Results

Of 1326 patients enrolled in 2015, 22.3% had resistance to any first-line anti-TB drugs and 8.0% had multi-drug resistance (MDR); drug resistance rates among previously treated cases were significantly higher than among new cases. Significant declines of resistance to isoniazid, rifampin, ethambutol and streptomycin, and MDR from 2011 to 2015 were observed among previously treated patients, while a significant decline of resistance to rifampin was observed among new cases.

Conclusions

While the prevalence of acquired drug resistance decreased due to due to implementation of DOTS-Plus program, the prevalence of primary drug resistance due to transmission remained high. Greater efforts should be made to screen drug resistance for case finding and to reduce transmission through improving the treatment and management of drug-resistant patients.

Prevalence of Multidrug-Resistant Tuberculosis and Associated Factors in Ethiopia: A Systematic Review

Background

Multidrug-resistant tuberculosis (MDR-TB) has continued to be a challenge for tuberculosis (TB) control globally. Ethiopia is one of the countries with high MDR-TB burden.

Objective

The main purpose of this study was to determine the prevalence of MDR-TB and associated factors in Ethiopia.

Methods

A systematic review of the literatures on prevalence of MDR-TB and associated factors was conducted in the country.

Results

In our electronic search, 546 citations were depicted. Among the total 546 citations described, a total of 22 articles met eligibility criteria and were included in the review article. According to our review, the prevalence of MDR-TB ranged from 0 to 46.3%. The average mean rate of MDR-TB in Ethiopia was found to be 12.6 ± 15.9%. The overall prevalence of MDR-TB in all TB cases was estimated to be 1.4%. From a total of 3849 patients studied, 527 had MDR-TB. Previous exposure to antituberculosis treatment was the most commonly identified risk factor of MDR-TB in Ethiopia.

Conclusion

Despite relative decline in incidence of MDR-TB, the distribution and prevalence of MDR-TB continued to be a serious challenge for TB control in Ethiopia. Previous exposure to antituberculosis treatment was also the most common risk factor for MDR-TB. Therefore, strong TB and MDR-TB treatment along with tight introduction of follow-up strategies should be applied for better TB control.