Is there an increased risk of TB relapse in patients treated with fixed-dose combination drugs in Indonesia?

SETTING

South Sulawesi Province, Republic of Indonesia.

OBJECTIVE

To compare relapse rates among tuberculosis (TB) patients treated with fixed-dose combination drugs (FDCs) and patients treated with the same regimen using loose drugs.

METHODOLOGY

Between 1999 and 2001, new smear-positive TB patients were randomly allocated to treatment with four-drug FDCs or loose drugs to study differences in treatment outcomes. Although it was not in the original study design, in 2004-2005 we performed a follow-up study by home visit of cured patients. We conducted an interview and tried to collect a sputum sample from each patient. If the patient was absent or had died, a proxy interview was conducted. The sputum samples were examined by microscopy and culture.

RESULTS

The overall relapse rate was 7.0% in patients who were able to produce a sputum sample. Relapse appeared to be more frequent in the FDC group compared to the loose drug group (10.1% vs. 2.7%, P = 0.074).

CONCLUSION

This is the first documented long-term follow-up study of patients treated with four-drug FDCs. There is an indication that treatment of new sputum smear-positive TB patients with FDCs provides an increased risk of relapse compared to treatment with loose drugs. The long-term results of treatment with FDCs should be carefully evaluated in other settings.

High cure rates in smear-positive tuberculosis patients using ambulatory treatment with once-weekly supervision during the intensive phase in Sulawesi, Republic of Indonesia

SETTING

The four provinces of Sulawesi, Republic of Indonesia.

OBJECTIVE

Treatment of smear-positive pulmonary tuberculosis patients using ambulatory treatment with supervision once weekly during the intensive phase and once fortnightly during the continuation phase.

DESIGN

Pilot projects with gradual expansion of activities according to defined quantitative criteria.

RESULTS

During the period January 1993-December 1997, 11,879 new smear-positive and 320 smear-positive previously treated patients, of whom 259 were relapses, were placed on short-course chemotherapy. At the end of the intensive phase, 87.5% of new patients and 80.0% of retreatment patients had become sputum smear-negative. During the period January 1993-December 1996, of 7,251 new smear-positive patients placed on treatment 85.2% were cured and an additional 7.9% had completed treatment, giving a total success rate of 93.1%. For 239 patients placed on retreatment the total success rate was 86.6%.

CONCLUSION

The treatment results show that the policy introduced in Sulawesi is effective. In two provinces priority will now be given to increasing case detection, while in the other two provinces the emphasis will be on reaching full coverage. The reasons for the success of the projects are discussed, as are the prerequisites for introducing the policy in other areas.

Choosing the decolourizer and its strength to stain Mycobacterium leprae. Does it actually matter?

Leprosy bacilli are more easily decolourized during staining than tuberculosis bacilli, so a weaker concentration of decolourizer is usually recommended. In Indonesia, the same 'strong' decolourizer is used for identifying both organisms. In a study to compare the results using different concentrations of different decolourizers, no difference could be found in the bacterial index (BI). It is suggested that the same staining technique can be used for tuberculosis and leprosy.

Paralysis of facial muscles in leprosy patients with lagophthalmos

The objective of the study was to determine the pattern of involvement of facial muscles in lagophthalmos. Fifty-seven patients with lagophthalmos were examined to assess the degree of paralysis of facial muscles. Eighty-one percent of the patients with lagophthalmos had involvement of at least one other muscle group. In patients with lagophthalmos with a gap at mild closure of 5 mm or more, 27 of 30 (90%) had involvement of at least one other facial muscle. In lepromatous leprosy the pattern of involvement was symmetrical and "patchy," the right and left sides being affected equally. In tuberculoid leprosy, the ipsilateral muscles were more often involved, which is the pattern of involvement of a nerve trunk. The upper and lower facial muscles were affected in the same proportion. Hence, on clinical grounds, there is little support for the often postulated statement that the superficial course of the facial nerve above the zygomatic bone is decisive for exclusive paralysis of the zygomatic branch of the facial nerve.

The allocation of leprosy patients into paucibacillary and multibacillary groups for multidrug therapy, taking into account the number of body areas affected by skin, or skin and nerve lesions

In Nepal, the setting up and maintaining of reliable services for slit-skin smears has proven difficult. A clinical classification system for leprosy has therefore been developed to assist in the allocation of patients to either paucibacillary or multibacillary groups for the purpose of multiple drug therapy (MDT), using 9 body areas: head (1), arms (2), legs (2), trunk (4). Patients with more than two areas of the body affected are grouped as multibacillary (MB) and those with only one or two areas affected are paucibacillary (PB). Using a computer simulation model and the data of 53 patients registered at Green Pastures Hospital (GPH) in Pokhara and 703 field patients from the Western Region, different clinical classification systems were evaluated with regard to their sensitivity, specificity, and predictive value for MB or PB classification, as compared with the histological classification for the GPH cases and the bacteriological classification for the field patients. The sensitivity and specificity of the body area system in present use were 93% and 39%, respectively. The low specificity is due to MB overclassification. The sensitivity of the WHO classification system without skin smear facilities is 73% (the difference with the body area system is significant: p < 0.05, McNemar's test). Our histology findings confirm previous publications indicating that, while some borderline-tuberculoid (BT) patients may outwardly have a 'PB appearance' and be skin-smear negative, their nerve biopsy and sometimes skin biopsy may show a 'MB' picture. This is the first publication discussing a 'body area system' for the purpose described, including diagrams of the areas used. In Nepal it has proved easy to use and teach and its use may be justified in other control programmes which implement MDT, particularly if slit-skin smear services are unreliable or nonexistent.

Self-administered dapsone compliance of leprosy patients in eastern Nepal

Self-administered dapsone intake by leprosy patients in Eastern Nepal was monitored with a urine spot test. Of 341 outpatients 55 (16.1%) were found to be noncompliant. A significant relationship was found between noncompliance and age and between noncompliance and caste. Sex, disease classification, type of treatment, duration of treatment, history of leprosy reactions and travel time to the clinic did not influence the compliance. In remote areas the urine spot test can be useful in leprosy control programmes.

Specificity of lymphocytotoxic autoantibodies (LCAbs) found in the serum of leprosy patients: class I MHC antigens

Lymphocytotoxic autoantibodies (LCAbs) of the IgM class have been identified in patients with borderline tuberculoid (BT) and borderline lepromatous (BL) leprosy with Type I reactions (I) as well as lepromatous leprosy (LL) patients with erythema nodosum leprosum reactions (ENL). The observation that lymphocytotoxic activity (LCA) was reduced in the presence of platelets led us to determine whether LCAbs had specificities for Class I Major Histocompatibility Complex (MHC) determinants. Absorption of LCA positive sera with platelets, classically used to deplete Class I specific lymphocytotoxic antibodies, reduced LCA towards autologous as well as allogeneic target cells. This was true for LCA positive sera from all patient classifications (group BT in the autologous system, p less than 0.01; in all other patient groups, p less than 0.001). Introducing B-2m to cytotoxicity assays only marginally reduced LCA when added at high concentrations (5 mg/ml). An anti-Class I MHC antiserum which blocked the lytic activity. The data indicate that LCAbs while absorbed by platelets, are not specific for the Class I MHC antigens. The autoantigen recognized by these autoantibodies therefore remains to be identified.

Serum lymphocytotoxic activity in leprosy

Sera from 167 patients across the spectrum of leprosy and 46 endemic controls were screened for lymphocytotoxic activity (LCA). The Terasaki microdroplet lymphocytotoxicity assay was performed at 37 degrees C and 15 degrees C to test sera for LCA against a panel of lymphocytes from 50 donors which represented most known HLA-ABC antigens. Raised complement-dependent LCA at 15 degrees C was seen in leprosy patients with histories of erythema nodosum leprosum (ENL) or reversal/Type I (I) reactions. Eighty-six per cent of lepromatous (LL) patients with a history of ENL (n = 21, P less than 0.001), 83% of borderline lepromatous (BL) and 88% of borderline tuberculoid patients (BT) with a history of Type I reactions (n = 12, P less than 0.01 and n = 24, P less than 0.001 respectively) had LCA compared to 39% of endemic controls (n = 46). LCA was attributed to IgM on the basis of reduced activity when serum was treated with both dithiothreitol or absorbed with antiserum for IgM. Removal of immune complexes and rheumatoid factor did not influence LCA. LCA-positive sera reacted similarly with allogeneic lymphocytes from either healthy donors or leprosy patients. Moreover LCA-positive sera reacted with autologous lymphocytes. Specificities for HLA-ABC antigens were not identified. The potential role of these autoantibodies, manifested in leprosy patients with hypersensitivity reactions remains speculative.