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van Cutsem G, Isaakidis P, Farley J, Nardell E, Volchenkov G, Cox H. Infection Control for Drug-Resistant Tuberculosis: Early Diagnosis and Treatment Is the Key. Clin Infect Dis 2016; 62 Suppl 3:S238-43. [PMID: 27118853 PMCID: PMC4845888 DOI: 10.1093/cid/ciw012] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Multidrug-resistant (MDR) tuberculosis, "Ebola with wings," is a significant threat to tuberculosis control efforts. Previous prevailing views that resistance was mainly acquired through poor treatment led to decades of focus on drug-sensitive rather than drug-resistant (DR) tuberculosis, driven by the World Health Organization's directly observed therapy, short course strategy. The paradigm has shifted toward recognition that most DR tuberculosis is transmitted and that there is a need for increased efforts to control DR tuberculosis. Yet most people with DR tuberculosis are untested and untreated, driving transmission in the community and in health systems in high-burden settings. The risk of nosocomial transmission is high for patients and staff alike. Lowering transmission risk for MDR tuberculosis requires a combination approach centered on rapid identification of active tuberculosis disease and tuberculosis drug resistance, followed by rapid initiation of appropriate treatment and adherence support, complemented by universal tuberculosis infection control measures in healthcare facilities. It also requires a second paradigm shift, from the classic infection control hierarchy to a novel, decentralized approach across the continuum from early diagnosis and treatment to community awareness and support. A massive scale-up of rapid diagnosis and treatment is necessary to control the MDR tuberculosis epidemic. This will not be possible without intense efforts toward the implementation of decentralized, ambulatory models of care. Increasing political will and resources need to be accompanied by a paradigm shift. Instead of focusing on diagnosed cases, recognition that transmission is driven largely by undiagnosed, untreated cases, both in the community and in healthcare settings, is necessary. This article discusses this comprehensive approach, strategies available, and associated challenges.
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Affiliation(s)
- Gilles van Cutsem
- Médecins Sans Frontières Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa
| | | | - Jason Farley
- School of Nursing, Johns Hopkins University, Baltimore, Maryland
| | - Ed Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Grigory Volchenkov
- Department of Tuberculosis Control, Vladimir Oblast Tuberculosis Dispensary, Russian Federation
| | - Helen Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, South Africa Division of Medical Microbiology and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa
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Cadosch D, Abel zur Wiesch P, Kouyos R, Bonhoeffer S. The Role of Adherence and Retreatment in De Novo Emergence of MDR-TB. PLoS Comput Biol 2016; 12:e1004749. [PMID: 26967493 PMCID: PMC4788301 DOI: 10.1371/journal.pcbi.1004749] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 01/12/2016] [Indexed: 11/19/2022] Open
Abstract
Treatment failure after therapy of pulmonary tuberculosis (TB) infections is an important challenge, especially when it coincides with de novo emergence of multi-drug-resistant TB (MDR-TB). We seek to explore possible causes why MDR-TB has been found to occur much more often in patients with a history of previous treatment. We develop a mathematical model of the replication of Mycobacterium tuberculosis within a patient reflecting the compartments of macrophages, granulomas, and open cavities as well as parameterizing the effects of drugs on the pathogen dynamics in these compartments. We use this model to study the influence of patient adherence to therapy and of common retreatment regimens on treatment outcome. As expected, the simulations show that treatment success increases with increasing adherence. However, treatment occasionally fails even under perfect adherence due to interpatient variability in pharmacological parameters. The risk of generating MDR de novo is highest between 40% and 80% adherence. Importantly, our simulations highlight the double-edged effect of retreatment: On the one hand, the recommended retreatment regimen increases the overall success rate compared to re-treating with the initial regimen. On the other hand, it increases the probability to accumulate more resistant genotypes. We conclude that treatment adherence is a key factor for a positive outcome, and that screening for resistant strains is advisable after treatment failure or relapse.
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Affiliation(s)
| | - Pia Abel zur Wiesch
- Division of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Department of Pharmacy, Faculty of Health Sciences, Norwegian Arctic University (UiT), Tromsø, Norway
| | - Roger Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland & Institute of Medical Virology, Swiss National Center for Retroviruses, University of Zurich, Zurich, Switzerland
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The trials and tribulations of repurposing metformin and other generic drugs for tuberculosis. Pharm Pat Anal 2016; 5:101-5. [PMID: 26889918 DOI: 10.4155/ppa.15.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are a number of generic drugs that might be useful in treating tuberculosis, but will they ever get to the patients who need them? They might, but not without a lot of help. There are intellectual property issues, endpoint issues, cost of research issues, economic incentive issues, preclinical validation issues, "who is in charge" issues and many more. It is clear that repurposed generic drugs have the potential to make a safe, effective, quick and affordable impact on a global disease of poverty such as tuberculosis. But without the economic incentives that are usually in place for drug development, can we muster the scientific, economic and governmental support to bring them to the patients?
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Nardell EA. Indoor environmental control of tuberculosis and other airborne infections. INDOOR AIR 2016; 26:79-87. [PMID: 26178270 DOI: 10.1111/ina.12232] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 07/03/2015] [Indexed: 05/22/2023]
Abstract
Tuberculosis (TB) remains the airborne infection of global importance, although many environmental interventions to control TB apply to influenza and other infections with airborne potential. This review focuses on the global problem and the current state of available environmental interventions. TB transmission is facilitated in overcrowded, poorly ventilated congregate settings, such as hospitals, clinics, prisons, jails, and refugee camps. The best means of TB transmission control is source control- to identify unsuspected infectious cases and to promptly begin effective therapy. However, even with active case finding and rapid diagnostics, not every unsuspected case will be identified, and environmental control measures remain the next intervention of choice. Natural ventilation is the main means of air disinfection and has the advantage of wide availability, low cost, and high efficacy-under optimal conditions. It is usually not applicable all year in colder climates and may not be effective when windows are closed on cold nights in warm climates, for security, and for pest control. In warm climates, windows may be closed when air conditioning is installed for thermal comfort. Although mechanical ventilation, if properly installed and maintained, can provide adequate air disinfection, it is expensive to install, maintain, and operate. The most cost-effective way to achieve high levels of air disinfection is upper room germicidal irradiation. The safe and effective application of this poorly defined intervention is now well understood, and recently published evidence-based application guidelines will make implementation easier.
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Affiliation(s)
- E A Nardell
- Harvard Medical School, Harvard School of Public Health, Brigham & Women's Hospital, Boston, MA, USA
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Rockwood N, Abdullahi LH, Wilkinson RJ, Meintjes G. Risk Factors for Acquired Rifamycin and Isoniazid Resistance: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0139017. [PMID: 26406228 PMCID: PMC4583446 DOI: 10.1371/journal.pone.0139017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/07/2015] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Studies looking at acquired drug resistance (ADR) are diverse with respect to geographical distribution, HIV co-infection rates, retreatment status and programmatic factors such as regimens administered and directly observed therapy. Our objective was to examine and consolidate evidence from clinical studies of the multifactorial aetiology of acquired rifamycin and/or isoniazid resistance within the scope of a single systematic review. This is important to inform policy and identify key areas for further studies. METHODS Case-control and cohort studies and randomised controlled trials that reported ADR as an outcome during antitubercular treatment regimens including a rifamycin and examined the association of at least 1 risk factor were included. Post hoc, we carried out random effects Mantel-Haenszel weighted meta-analyses of the impact of 2 key risk factors 1) HIV and 2) baseline drug resistance on the binary outcome of ADR. Heterogeneity was assessed used I2 statistic. As a secondary outcome, we calculated median cumulative incidence of ADR, weighted by the sample size of the studies. RESULTS Meta-analysis of 15 studies showed increased risk of ADR with baseline mono- or polyresistance (RR 4.85 95% CI 3.26 to 7.23, heterogeneity I2 58%, 95% CI 26 to 76%). Meta-analysis of 8 studies showed that HIV co-infection was associated with increased risk of ADR (RR 3.02, 95% CI 1.28 to 7.11); there was considerable heterogeneity amongst these studies (I2 81%, 95% CI 64 to 90%). Non-adherence, extrapulmonary/disseminated disease and advanced immunosuppression in HIV co-infection were other risk factors noted. The weighted median cumulative incidence of acquired multi drug resistance calculated in 24 studies (assuming whole cohort as denominator, regardless of follow up DST) was 0.1% (5th to 95th percentile 0.07 to 3.2%). CONCLUSION Baseline drug resistance and HIV co-infection were significant risk factors for ADR. There was a trend of positive association with non-adherence which is likely to contribute to the outcome of ADR. The multifactorial aetiology of ADR in a programmatic setting should be further evaluated via appropriately designed studies.
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Affiliation(s)
- Neesha Rockwood
- Department of Medicine, Imperial College, London W2 1PG, United Kingdom
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Leila H. Abdullahi
- Vaccines for Africa Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Department of Medicine, Imperial College, London W2 1PG, United Kingdom
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Francis Crick Institute Mill Hill Laboratory, London, United Kingdom
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Imperial College, London W2 1PG, United Kingdom
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Deshmukh RD, Dhande DJ, Sachdeva KS, Sreenivas A, Kumar AMV, Satyanarayana S, Parmar M, Moonan PK, Lo TQ. Patient and Provider Reported Reasons for Lost to Follow Up in MDRTB Treatment: A Qualitative Study from a Drug Resistant TB Centre in India. PLoS One 2015; 10:e0135802. [PMID: 26301748 PMCID: PMC4547708 DOI: 10.1371/journal.pone.0135802] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/27/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Multidrug-resistant Tuberculosis (MDR TB) is emerging public health concern globally. Lost to follow-up (LTFU) is one of the key challenge in MDRTB treatment. In 2013, 18% of MDR TB patients were reported LTFU in India. A qualitative study was conducted to obtain better understanding of both patient and provider related factors for LTFU among MDR TB treatment. METHODS Qualitative semi-structured personal interviews were conducted with 20 MDRTB patients reported as LTFU and 10 treatment providers in seven districts linked to Nagpur Drug resistant TB Centre (DRTBC) during August 2012-February 2013. Interviews were transcribed and inductive content analysis was performed to derive emergent themes. RESULTS We found multiple factors influencing MDR TB treatment adherence. Barriers to treatment adherence included drug side effects, a perceived lack of provider support, patient financial constraints, conflicts with the timing of treatment services, alcoholism and social stigma. CONCLUSIONS Patient adherence to treatment is multi-factorial and involves individual patient factors, provider factors, and community factors. Addressing issue of LTFU during MDRTB treatment requires enhanced efforts towards resolving medical problems like adverse drug effects, developing short duration treatment regimens, reducing pill burden, motivational counselling, flexible timings for DOT services, social, family support for patients & improving awareness about disease.
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Affiliation(s)
- Rajesh D. Deshmukh
- World Health Organisation, Country Office for India, New Delhi, India
- * E-mail:
| | - D. J. Dhande
- Department of Pulmonary Medicine, Drug Resistant TB centre, Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
| | | | | | - A. M. V. Kumar
- International Union against Tuberculosis and Lung Disease, South East Asia Office, New Delhi, India
| | | | - Malik Parmar
- World Health Organisation, Country Office for India, New Delhi, India
| | - Patrick K. Moonan
- Division of TB Elimination, International Research Programs Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georiga, United States of America
| | - Terrence Q. Lo
- Division of TB Elimination, International Research Programs Branch, U.S. Centers for Disease Control and Prevention, Atlanta, Georiga, United States of America
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Seung KJ, Keshavjee S, Rich ML. Multidrug-Resistant Tuberculosis and Extensively Drug-Resistant Tuberculosis. Cold Spring Harb Perspect Med 2015; 5:a017863. [PMID: 25918181 PMCID: PMC4561400 DOI: 10.1101/cshperspect.a017863] [Citation(s) in RCA: 281] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The continuing spread of drug-resistant tuberculosis (TB) is one of the most urgent and difficult challenges facing global TB control. Patients who are infected with strains resistant to isoniazid and rifampicin, called multidrug-resistant (MDR) TB, are practically incurable by standard first-line treatment. In 2012, there were approximately 450,000 new cases and 170,000 deaths because of MDR-TB. Extensively drug-resistant (XDR) TB refers to MDR-TB strains that are resistant to fluoroquinolones and second-line injectable drugs. The main causes of the spread of resistant TB are weak medical systems, amplification of resistance patterns through incorrect treatment, and transmission in communities and facilities. Although patients harboring MDR and XDR strains present a formidable challenge for treatment, cure is often possible with early identification of resistance and use of a properly designed regimen. Community-based programs can improve treatment outcomes by allowing patients to be treated in their homes and addressing socioeconomic barriers to adherence.
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Affiliation(s)
- Kwonjune J Seung
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts 02115 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts 02115 Partners In Health, Boston, Massachusetts 02215
| | - Salmaan Keshavjee
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts 02115 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts 02115 Partners In Health, Boston, Massachusetts 02215
| | - Michael L Rich
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts 02115 Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts 02115 Partners In Health, Boston, Massachusetts 02215
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TOLA HH, TOL A, SHOJAEIZADEH D, GARMAROUDI G. Tuberculosis Treatment Non-Adherence and Lost to Follow Up among TB Patients with or without HIV in Developing Countries: A Systematic Review. IRANIAN JOURNAL OF PUBLIC HEALTH 2015; 44:1-11. [PMID: 26060770 PMCID: PMC4449995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 11/11/2014] [Indexed: 11/05/2022]
Abstract
This systematic review intended to combine factors associated with tuberculosis treatment non-adherence and lost to follow up among TB patients with/without HIV in developing countries. Comprehensive remote electronic databases (MEDLINE, (PMC, Pub Med Central), Google scholar and Web of science) search was conducted using the following keywords: Tuberculosis, treatment, compliance, adherence, default, behavioural factors and socioeconomic factors. All types of studies intended to assess TB treatment non-adherence and lost to follow up in developing countries among adult TB patient from 2008 to data extraction date were included. Twenty-six original and one-reviewed articles, which meet inclusion criteria, were reviewed. TB treatment non-adherence and lost to follow up were continued across developing countries. The main factors associated with TB treatment non-adherence and lost to follow up were socioeconomic factors: lack of transportation cost, lack of social support, and patients-health care worker poor communication. Behavioural factors were Feeling better after few weeks of treatments, tobacco and alcohol use, knowledge deficit about duration of treatment and consequences of non-adherence and lost to follow up. TB treatment non-adherence and lost to follow up were continued across developing countries throughout the publication years of reviewed articles. Numerous, socioeconomic and behavioural factors were influencing TB treatment adherence and lost to follow up. Therefore, well understanding and minimizing of the effect of these associated factors is very important to enhance treatment adherence and follow up completion in developing countries.
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Kuchukhidze G, Kumar AMV, de Colombani P, Khogali M, Nanava U, Blumberg HM, Kempker RR. Risk factors associated with loss to follow-up among multidrug-resistant tuberculosis patients in Georgia. Public Health Action 2014; 4:S41-6. [PMID: 26393097 PMCID: PMC4547510 DOI: 10.5588/pha.14.0048] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 08/22/2014] [Indexed: 11/10/2022] Open
Abstract
SETTING Georgia, a country with a high-burden of multi-drug-resistant tuberculosis (MDR-TB). OBJECTIVE To determine the proportion of loss to follow-up (LFU) among MDR-TB patients treated nationwide from 2009 to 2011, and associated risk factors. DESIGN Retrospective cohort study involving a review of the National Tuberculosis Programme electronic surveillance database. A Cox proportional hazards model was used to assess risk factors for time to LFU. RESULTS Among 1593 patients, 458 (29%) were lost to follow-up. A total of 1240 MDR-TB patients were included in the final analysis (845 treatment success, 395 LFU). Over 40% of LFU occurred during the first 8 months of MDR-TB treatment; 40% of patients had not achieved culture conversion at the time of LFU. In multivariate analysis, the factors associated with LFU included male sex, illicit drug use, tobacco use, history of previous anti-tuberculosis treatment, site of TB disease, and place and year of initiating treatment. CONCLUSION LFU was high among MDR-TB patients in Georgia and posed a significant public health risk, as many were culture-positive at the time of LFU. A multi-pronged approach is needed to address the various patient- and treatment-related characteristics associated with LFU.
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Affiliation(s)
- G. Kuchukhidze
- National Centre for Disease Control and Public Health, Tbilisi, Georgia
| | - A. M. V. Kumar
- International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India
| | - P. de Colombani
- World Health Organization Regional Office for Europe, Copenhagen, Denmark
| | - M. Khogali
- Department of Epidemiology, Operational Center of Brussels, Médecins Sans Frontières (MSF), MSF-Belgium, Addis Ababa, Ethiopia
| | - U. Nanava
- Department of Epidemiology, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - H. M. Blumberg
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - R. R. Kempker
- Emory University School of Medicine, Atlanta, Georgia, USA
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A close-up on the epidemiology and transmission of multidrug-resistant tuberculosis in Poland. Eur J Clin Microbiol Infect Dis 2014; 34:41-53. [PMID: 25037868 DOI: 10.1007/s10096-014-2202-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 06/27/2014] [Indexed: 10/25/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) poses a serious challenge to the global control of the disease. The purpose of this study was to characterize MDR-TB patients from Poland and to determine the extent of MDR-TB disease attributable to recent transmission. The study included all 46 patients diagnosed with MDR-TB in Poland in 2004 and followed up for 6 years (until 2011). For each patient, sociodemographic and clinical characteristics, treatment outcomes, and bacteriological data were collected by the review of medical and laboratory records. Mycobacterium tuberculosis isolates from all patients were characterized using spoligotyping, mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) typing, IS6110 restriction fragment length polymorphism (RFLP) analysis, and sequencing analysis of drug resistance-associated loci (katG, mabA-inhA, rpoβ, rpsL, and embB). The majority of patients were male (86.9%), 40-64 years of age (60.8%), with a history of TB treatment (84.8%), and producing smear-positive sputa (86.9%). Twenty-two (47.8%) patients suffered from concomitant diseases and 28 (60.8%) were alcohol abusers. Treatment outcome assessment revealed that 8 (17.4%) patients were cured or completed therapy, while 15 (32.6%) died of TB, 11 (23.9%) defaulted, 8 (17.4%) failed, and 1 (2.2%) was transferred and lost to follow-up. Upon genotyping, 10 (21.7%) isolates were allocated in four clusters. These were further subdivided by mutational profiling. Overall, in 6 (13%) patients, MDR-TB was a result of recent transmission. For 4 (8.7%) of these patients, a direct epidemiological link was established. The study shows that the transmission of MDR-TB occurs at a low rate in Poland. Of urgent need is the implementation of a policy of enforced treatment of MDR-TB patients in Poland.
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Cherkaoui I, Sabouni R, Ghali I, Kizub D, Billioux AC, Bennani K, Bourkadi JE, Benmamoun A, Lahlou O, Aouad RE, Dooley KE. Treatment default amongst patients with tuberculosis in urban Morocco: predicting and explaining default and post-default sputum smear and drug susceptibility results. PLoS One 2014; 9:e93574. [PMID: 24699682 PMCID: PMC3974736 DOI: 10.1371/journal.pone.0093574] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 03/06/2014] [Indexed: 11/18/2022] Open
Abstract
Setting Public tuberculosis (TB) clinics in urban Morocco. Objective Explore risk factors for TB treatment default and develop a prediction tool. Assess consequences of default, specifically risk for transmission or development of drug resistance. Design Case-control study comparing patients who defaulted from TB treatment and patients who completed it using quantitative methods and open-ended questions. Results were interpreted in light of health professionals’ perspectives from a parallel study. A predictive model and simple tool to identify patients at high risk of default were developed. Sputum from cases with pulmonary TB was collected for smear and drug susceptibility testing. Results 91 cases and 186 controls enrolled. Independent risk factors for default included current smoking, retreatment, work interference with adherence, daily directly observed therapy, side effects, quick symptom resolution, and not knowing one’s treatment duration. Age >50 years, never smoking, and having friends who knew one’s diagnosis were protective. A simple scoring tool incorporating these factors was 82.4% sensitive and 87.6% specific for predicting default in this population. Clinicians and patients described additional contributors to default and suggested locally-relevant intervention targets. Among 89 cases with pulmonary TB, 71% had sputum that was smear positive for TB. Drug resistance was rare. Conclusion The causes of default from TB treatment were explored through synthesis of qualitative and quantitative data from patients and health professionals. A scoring tool with high sensitivity and specificity to predict default was developed. Prospective evaluation of this tool coupled with targeted interventions based on our findings is warranted. Of note, the risk of TB transmission from patients who default treatment to others is likely to be high. The commonly-feared risk of drug resistance, though, may be low; a larger study is required to confirm these findings.
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Affiliation(s)
- Imad Cherkaoui
- Directorate of Epidemiology and Disease Control, Ministry of Health, Rabat, Morocco
| | - Radia Sabouni
- National Institute of Hygiene, Ministry of Health, Rabat, Morocco
| | - Iraqi Ghali
- Moulay Youssef University Hospital, CHU Ibn Sina, Rabat, Morocco
| | - Darya Kizub
- University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Alexander C. Billioux
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Kenza Bennani
- National TB Control Program, Directorate of Epidemiology and Disease Control, Ministry of Health, Rabat, Morocco
| | | | - Abderrahmane Benmamoun
- National TB Control Program, Directorate of Epidemiology and Disease Control, Ministry of Health, Rabat, Morocco
| | - Ouafae Lahlou
- National Institute of Hygiene, Ministry of Health, Rabat, Morocco
| | - Rajae El Aouad
- National Institute of Hygiene, Ministry of Health, Rabat, Morocco
| | - Kelly E. Dooley
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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Jenkins HE, Crudu V, Soltan V, Ciobanu A, Domente L, Cohen T. High risk and rapid appearance of multidrug resistance during tuberculosis treatment in Moldova. Eur Respir J 2014; 43:1132-41. [PMID: 24558181 PMCID: PMC4005038 DOI: 10.1183/09031936.00203613] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is a serious problem in the former Soviet Union and may appear during TB treatment. We aimed to estimate the prevalence of, timing of and factors associated with MDR-TB diagnosis during TB treatment in Moldova, which was part of the former Soviet Union. We analysed data on 3 754 confirmed non-MDR-TB cases (between January 1, 2007 and December 31, 2010) in the Moldovan TB surveillance database, where patients provided sputum specimens for drug-susceptibility testing, multiple times, during treatment. We estimated the percentage of individuals with confirmed baseline non-MDR-TB that were diagnosed with MDR-TB during treatment, documented the time at which MDR-TB was diagnosed, and used a failure-time model to identify factors associated with MDR-TB diagnosis. Between 7.2% and 9.2% of initially non-MDR-TB cases were diagnosed with MDR-TB during treatment. Half of these MDR-TB diagnoses occurred with 3 months of the initial diagnosis. An increased MDR-TB risk during treatment was associated with baseline resistance to first-line TB drugs (linear increase in risk per additional drug), previous incarceration and HIV co-infection. MDR can appear rapidly during TB treatment. Policy considerations should emphasise management during early treatment by increasing ambulatory TB treatment to prevent nosocomial transmission, and ensuring universal rapid diagnostics access to prevent acquisition and transmission of drug resistance.
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Lange C, Abubakar I, Alffenaar JWC, Bothamley G, Caminero JA, Carvalho ACC, Chang KC, Codecasa L, Correia A, Crudu V, Davies P, Dedicoat M, Drobniewski F, Duarte R, Ehlers C, Erkens C, Goletti D, Günther G, Ibraim E, Kampmann B, Kuksa L, de Lange W, van Leth F, van Lunzen J, Matteelli A, Menzies D, Monedero I, Richter E, Rüsch-Gerdes S, Sandgren A, Scardigli A, Skrahina A, Tortoli E, Volchenkov G, Wagner D, van der Werf MJ, Williams B, Yew WW, Zellweger JP, Cirillo DM. Management of patients with multidrug-resistant/extensively drug-resistant tuberculosis in Europe: a TBNET consensus statement. Eur Respir J 2014; 44:23-63. [PMID: 24659544 PMCID: PMC4076529 DOI: 10.1183/09031936.00188313] [Citation(s) in RCA: 189] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) substantially challenges TB control, especially in the European Region of the World Health Organization, where the highest prevalence of MDR/XDR cases is reported. The current management of patients with MDR/XDR-TB is extremely complex for medical, social and public health systems. The treatment with currently available anti-TB therapies to achieve relapse-free cure is long and undermined by a high frequency of adverse drug events, suboptimal treatment adherence, high costs and low treatment success rates. Availability of optimal management for patients with MDR/XDR-TB is limited even in the European Region. In the absence of a preventive vaccine, more effective diagnostic tools and novel therapeutic interventions the control of MDR/XDR-TB will be extremely difficult. Despite recent scientific advances in MDR/XDR-TB care, decisions for the management of patients with MDR/XDR-TB and their contacts often rely on expert opinions, rather than on clinical evidence. This document summarises the current knowledge on the prevention, diagnosis and treatment of adults and children with MDR/XDR-TB and their contacts, and provides expert consensus recommendations on questions where scientific evidence is still lacking. TBNET consensus statement on the management of patients with MDR/XDR-TB has been released in theEur Respir Jhttp://ow.ly/uizRD
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Affiliation(s)
- Christoph Lange
- For the authors' affiliations see the Acknowledgements section
| | | | | | | | - Jose A Caminero
- For the authors' affiliations see the Acknowledgements section
| | | | - Kwok-Chiu Chang
- For the authors' affiliations see the Acknowledgements section
| | - Luigi Codecasa
- For the authors' affiliations see the Acknowledgements section
| | - Ana Correia
- For the authors' affiliations see the Acknowledgements section
| | - Valeriu Crudu
- For the authors' affiliations see the Acknowledgements section
| | - Peter Davies
- For the authors' affiliations see the Acknowledgements section
| | - Martin Dedicoat
- For the authors' affiliations see the Acknowledgements section
| | | | - Raquel Duarte
- For the authors' affiliations see the Acknowledgements section
| | - Cordula Ehlers
- For the authors' affiliations see the Acknowledgements section
| | - Connie Erkens
- For the authors' affiliations see the Acknowledgements section
| | - Delia Goletti
- For the authors' affiliations see the Acknowledgements section
| | - Gunar Günther
- For the authors' affiliations see the Acknowledgements section
| | - Elmira Ibraim
- For the authors' affiliations see the Acknowledgements section
| | - Beate Kampmann
- For the authors' affiliations see the Acknowledgements section
| | - Liga Kuksa
- For the authors' affiliations see the Acknowledgements section
| | - Wiel de Lange
- For the authors' affiliations see the Acknowledgements section
| | - Frank van Leth
- For the authors' affiliations see the Acknowledgements section
| | - Jan van Lunzen
- For the authors' affiliations see the Acknowledgements section
| | | | - Dick Menzies
- For the authors' affiliations see the Acknowledgements section
| | | | - Elvira Richter
- For the authors' affiliations see the Acknowledgements section
| | | | | | - Anna Scardigli
- For the authors' affiliations see the Acknowledgements section
| | - Alena Skrahina
- For the authors' affiliations see the Acknowledgements section
| | - Enrico Tortoli
- For the authors' affiliations see the Acknowledgements section
| | | | - Dirk Wagner
- For the authors' affiliations see the Acknowledgements section
| | | | - Bhanu Williams
- For the authors' affiliations see the Acknowledgements section
| | - Wing-Wai Yew
- For the authors' affiliations see the Acknowledgements section
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Abstract
The association between alcohol abuse and pneumonia has been recognized for more than two centuries and represents an enormous health burden worldwide. The first published notation of alcohol as a clinical risk factor for the development of pneumonia is now over 200 years old, and since then there have been over a 1,000 references in the medical literature confirming these observations. Even in this modern era of medicine pneumonia remains a common infection that afflicts over 450 million persons worldwide annually and causes 7 % of all deaths. When one considers that alcohol is the most commonly abused substance in the world, the enormous excessive burden that alcohol contributes to the morbidity and mortality of pneumonia represents a major public health consideration. In this chapter we review the foundational literature that has chronicled the evolution of our understanding of the association between pneumonia and alcohol abuse over the past century. In addition, we discuss some of the specific pathogens that are particularly associated with serious lung infections in individuals with alcohol use disorders. Finally, we consider some of the specific guidelines for the treatment and prevention of pneumonia in the setting of alcohol abuse.
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Affiliation(s)
- David M. Guidot
- Division of Pulmonary, Allergy and Critical Care Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, Georgia USA
| | - Ashish J. Mehta
- Division of Pulmonary, Allergy and Critical Care Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Decatur, Georgia USA
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Acosta CD, Rusovich V, Harries AD, Ahmedov S, van den Boom M, Dara M. A new roadmap for childhood tuberculosis. LANCET GLOBAL HEALTH 2013; 2:e15-7. [PMID: 25104625 DOI: 10.1016/s2214-109x(13)70153-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Colleen D Acosta
- WHO Regional Office for Europe, Tuberculosis and Multidrug-resistant Tuberculosis Programme, UN City, 2100 Copenhagen, Denmark
| | | | - Anthony D Harries
- International Union against Tuberculosis and Lung Disease, Paris, France; London School of Hygiene and Tropical Medicine, Department of Clinical Research, London, UK
| | - Sevim Ahmedov
- USAID, Health Infectious Diseases and Nutrition Division, Washington, DC, USA
| | - Martin van den Boom
- WHO Regional Office for Europe, Tuberculosis and Multidrug-resistant Tuberculosis Programme, UN City, 2100 Copenhagen, Denmark
| | - Masoud Dara
- WHO Regional Office for Europe, Tuberculosis and Multidrug-resistant Tuberculosis Programme, UN City, 2100 Copenhagen, Denmark.
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Bassili A, Fitzpatrick C, Qadeer E, Fatima R, Floyd K, Jaramillo E. A systematic review of the effectiveness of hospital- and ambulatory-based management of multidrug-resistant tuberculosis. Am J Trop Med Hyg 2013; 89:271-80. [PMID: 23926140 DOI: 10.4269/ajtmh.13-0004] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A systematic review of the literature was conducted on the effectiveness of MDR-TB management. A meta-analysis of treatment outcomes of patients treated in hospitals versus ambulatory-based models was performed in accordance with PRISMA guidelines. The pooled treatment success rate was 66.4% (95% confidence interval [CI] 61.4-71.1%), with no statistical difference between ambulatory (65.5%; 55.1-74.6%) and hospital-based models (66.7%; 61.0-72.0%). The pooled death rate was 10.4% (6.3-16.5%), the pooled treatment failure rate was 9.5% (7.3-12.4%), and the defaulter rate was 14.3% (10.5-19.1%). None of the differences between the two models were statistically significant for any of the outcomes considered. This work improves the quality of the evidence available supporting the World Health Organizations (WHO) recommendation that patients be treated using mainly ambulatory care, conditional on infection control measures in the home and clinic, clinical condition of the patient, availability of treatment support to facilitate adherence to treatment, and provisions for backup facility to manage patients who need inpatient treatment care.
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Affiliation(s)
- Amal Bassili
- Stop Tuberculosis Unit, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt.
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67
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Jenkins HE, Ciobanu A, Plesca V, Crudu V, Galusca I, Soltan V, Cohen T. Risk factors and timing of default from treatment for non-multidrug-resistant tuberculosis in Moldova. Int J Tuberc Lung Dis 2013; 17:373-80. [PMID: 23407226 DOI: 10.5588/ijtld.12.0464] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING The Republic of Moldova, in Eastern Europe, has among the highest reported nationwide proportions of tuberculosis (TB) patients with multidrug-resistant tuberculosis (MDR-TB) worldwide. Default has been associated with increased mortality and amplification of drug resistance, and may contribute to the high MDR-TB rates in Moldova. OBJECTIVE To assess risk factors and timing of default from treatment for non-MDR-TB from 2007 to 2010. DESIGN A retrospective analysis of routine surveillance data on all non-MDR-TB patients reported. RESULTS A total of 14.7% of non-MDR-TB patients defaulted from treatment during the study period. Independent risk factors for default included sociodemographic factors, such as homelessness, living alone, less formal education and spending substantial time outside Moldova in the year prior to diagnosis; and health-related factors such as human immunodeficiency virus co-infection, greater lung pathology and increasing TB drug resistance. Anti-tuberculosis treatment is usually initiated within an institutional setting in Moldova, and the default risk was highest in the month following the phase of hospitalized treatment (among civilians) and after leaving prison (among those diagnosed while incarcerated). CONCLUSIONS Targeted interventions to increase treatment adherence for patients at highest risk of default, and improving the continuity of care for patients transitioning from institutional to community care may substantially reduce risk of default.
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Affiliation(s)
- H E Jenkins
- Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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68
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Abstract
Multidrug-resistant tuberculosis (MDR-TB) threatens to become the dominant form of tuberculosis in many parts of the world because of decades of inappropriate treatment on a global scale. Infection with MDR-TB is associated with poor outcomes because of delays in treatment and the need for complex, toxic, and long medication regimens. Most cases are undetected because of technological and economic barriers to diagnosing tuberculosis and the availability of assays to test for drug resistance. Experience in treating MDR-TB is scarce. Tuberculosis was once curable, but could become a potentially untreatable infectious disease unless efforts are made to control it.
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Affiliation(s)
- John B Lynch
- Division of Allergy and Infectious Diseases, Department of Medicine, Harborview Medical Center, University of Washington, 325 9th Avenue, Box 359930, Seattle, WA, USA.
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69
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Ford CB, Shah RR, Maeda MK, Gagneux S, Murray MB, Cohen T, Johnston JC, Gardy J, Lipsitch M, Fortune SM. Mycobacterium tuberculosis mutation rate estimates from different lineages predict substantial differences in the emergence of drug-resistant tuberculosis. Nat Genet 2013; 45:784-90. [PMID: 23749189 PMCID: PMC3777616 DOI: 10.1038/ng.2656] [Citation(s) in RCA: 315] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 05/06/2013] [Indexed: 11/30/2022]
Abstract
A critical question in tuberculosis control is why some strains of Mycobacterium tuberculosis are preferentially associated with multiple drug resistances. We demonstrate that M. tuberculosis strains from Lineage 2 (East Asian lineage and Beijing sublineage) acquire drug resistances in vitro more rapidly than M. tuberculosis strains from Lineage 4 (Euro-American lineage) and that this higher rate can be attributed to a higher mutation rate. Moreover, the in vitro mutation rate correlates well with the bacterial mutation rate in humans as determined by whole genome sequencing of clinical isolates. Finally, using a stochastic mathematical model, we demonstrate that the observed differences in mutation rate predict a substantially higher probability that patients infected with a drug susceptible Lineage 2 strain will harbor multidrug resistant bacteria at the time of diagnosis. These data suggest that interventions to prevent the emergence of drug resistant tuberculosis should target bacterial as well as treatment-related risk factors.
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Affiliation(s)
- Christopher B Ford
- Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA, USA
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Chirwa T, Nyasulu P, Chirwa E, Ketlogetswe A, Bello G, Dambe I, Ndalama D, Joshua M. Levels of tuberculosis treatment adherence among sputum smear positive pulmonary tuberculosis patients attending care at Zomba Central hospital, southern Malawi, 2007-2008. PLoS One 2013; 8:e63050. [PMID: 23723972 PMCID: PMC3665834 DOI: 10.1371/journal.pone.0063050] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 03/28/2013] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite great efforts to control Tuberculosis (TB), progress is compromised by low adherence to medication, leading to prolonged duration of infectiousness and continued transmission. Investigating low adherence is of high importance from TB programmatic perspective. Though data on actual days of missed treatment exist, the effect of such on TB cure rates has not been investigated. METHODS TB operational research data were extracted for smear-positive pulmonary TB patients registered at Zomba Central hospital, Malawi from January 2007 to December 2008. RESULTS Of the 524 patients, 302 (57.6%) were males and 340 (64.9%) fully adhered to treatment. Excluding 5 individuals with missing data on cure, four hundred and eighty-one (92.7%) were cured of TB, and of these 162 (33.7%) missed at least one day of treatment. Respectively, 49/64 (76.6%) and 71/76 (93.4%) of those who missed treatment in the intensive and continuation phases were cured of TB (p = 0.005). The adjusted logistic regression analysis showed that those who missed 15-29 days of treatment (OR = 0.04, 95% CI: 0.01, 0.14) were less likely to be cured of TB compared with those who fully adhered. CONCLUSION Treatment non-adherence was high and was observed even within the first 2 months of treatment. Thus, even at an earlier critical stage of treatment, simple algorithms need to be developed to identify and monitor patients at higher risk of non-adherence. Efforts on treatment compliance counselling should focus on enhanced counselling to improve adherence during the intensive treatment phase.
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Affiliation(s)
- Tobias Chirwa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand (Wits), Johannesburg, South Africa.
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71
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Pachi A, Bratis D, Moussas G, Tselebis A. Psychiatric morbidity and other factors affecting treatment adherence in pulmonary tuberculosis patients. Tuberc Res Treat 2013; 2013:489865. [PMID: 23691305 PMCID: PMC3649695 DOI: 10.1155/2013/489865] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 01/03/2013] [Accepted: 02/07/2013] [Indexed: 12/11/2022] Open
Abstract
As the overall prevalence of TB remains high among certain population groups, there is growing awareness of psychiatric comorbidity, especially depression and its role in the outcome of the disease. The paper attempts a holistic approach to the effects of psychiatric comorbidity to the natural history of tuberculosis. In order to investigate factors associated with medication nonadherence among patients suffering from tuberculosis, with emphasis on psychopathology as a major barrier to treatment adherence, we performed a systematic review of the literature on epidemiological data and past medical reviews from an historical perspective, followed by theoretical considerations upon the relationship between psychiatric disorders and tuberculosis. Studies reporting high prevalence rates of psychiatric comorbidity, especially depression, as well as specific psychological reactions and disease perceptions and reviews indicating psychiatric complications as adverse effects of anti-TB medication were included. In sum, data concerning factors affecting medication nonadherence among TB patients suggested that better management of comorbid conditions, especially depression, could improve the adherence rates, serving as a framework for the effective control of tuberculosis, but further studies are necessary to identify the optimal way to address such issues among these patients.
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Affiliation(s)
- Argiro Pachi
- Psychiatric Department, Sotiria General Hospital of Chest Disease, Athens, Greece
| | - Dionisios Bratis
- Psychiatric Department, Sotiria General Hospital of Chest Disease, Athens, Greece
| | - Georgios Moussas
- Psychiatric Department, Sotiria General Hospital of Chest Disease, Athens, Greece
| | - Athanasios Tselebis
- Psychiatric Department, Sotiria General Hospital of Chest Disease, Athens, Greece
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Liu Q, Luo T, Li J, Mei J, Gao Q. Triplex real-time PCR melting curve analysis for detecting Mycobacterium tuberculosis mutations associated with resistance to second-line drugs in a single reaction. J Antimicrob Chemother 2013; 68:1097-103. [PMID: 23288402 DOI: 10.1093/jac/dks509] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Resistance to anti-tuberculosis (TB) drugs has been a great challenge for global TB control. Limited tools have been developed to detect resistance to second-line drugs that are associated with extensively drug-resistant (XDR) TB. In this study we aimed to develop a simple and widely applicable assay for detecting mutations associated with second-line drug resistance in Mycobacterium tuberculosis. METHODS Three dually labelled probes targeting gyrA, rrs and the promoter of eis were designed to detect resistance to fluoroquinolones and second-line injectable agents (capreomycin, amikacin and kanamycin). A triplex reaction with all three probes and corresponding primers was first tested against 13 isolates with different mutations in the targeted regions. Then, the triplex assay was applied to 109 second-line drug-resistant isolates in a blind manner and the results were compared with the sequencing data. RESULTS All mutations in the targeted regions of 13 representative isolates could be detected through significant Tm reductions of the corresponding probe compared with the wild-type control. The detection results with 109 isolates were 100% concordant with sequencing data. Twelve ofloxacin-resistant isolates were detected as heteroresistant, indicating the coexistence of mutant and wild-type strains or the existence of different gyrA mutations. CONCLUSIONS We have developed a simple and widely applicable assay to detect second-line drug resistance of M. tuberculosis. This method, combined with assays for detecting first-line drug resistance, provides an efficient and reliable tool to diagnose multidrug-resistant TB and XDR-TB.
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Affiliation(s)
- Qingyun Liu
- Key Laboratory of Medical Molecular Virology, Institutes of Biomedical Sciences and Institute of Medical Microbiology, Fudan University, Shanghai 200032, People's Republic of China
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Anaam MS, Ibrahim MIM, Al Serouri AW, Bassili A, Aldobhani A. A nested case-control study on relapse predictors among tuberculosis patients treated in Yemen's NTCP. Public Health Action 2012; 2:168-73. [PMID: 26392978 PMCID: PMC4463052 DOI: 10.5588/pha.12.0044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 10/10/2012] [Indexed: 11/10/2022] Open
Abstract
SETTING The National Tuberculosis (TB) Control Programme in Yemen. OBJECTIVE To identify risk factors associated with TB relapse. METHODS In a prospective nested case-control study, relapse cases were recruited from a cohort of pulmonary TB patients registered between July 2007 and June 2008. Four controls per case were randomly selected from the list of non-relapse patients. Three forms were used for data collection, which included interviews with the participants and review of their medical cards and TB registers. Multivariate logistic regression analysis was performed to identify independent risk factors for relapse. RESULTS A relapse rate of 5.7% was found. Multivariate logistic regression analysis showed that unemployment, smoking, presence of cavitations, weight gain, weight loss, non-adherence during the continuation phase and diabetes were significantly associated with relapse (P < 0.05). CONCLUSION Relapse rates can be reduced by ensuring that patients take their treatment regularly and are counselled effectively to stop smoking. Reinforcing the implementation of the DOTS strategy and strengthening the anti-smoking campaigns are important actions. Action to help unemployed patients, including free services and the creation of new job opportunities, should be adopted. Using rifampicin-based regimens in the treatment of cavitary TB and bi-directional screening in TB and diabetes patients are recommended.
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Affiliation(s)
- M S Anaam
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | | | - A W Al Serouri
- Community Health Department, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen
| | - A Bassili
- Stop Tuberculosis Unit, Communicable Disease Research, Eastern Mediterranean Regional Office, World Health Organization, Cairo, Egypt
| | - A Aldobhani
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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Sarang A, Rhodes T, Sheon N. Systemic barriers accessing HIV treatment among people who inject drugs in Russia: a qualitative study. Health Policy Plan 2012. [PMID: 23197431 DOI: 10.1093/heapol/czs107] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Achieving 'universal access' to antiretroviral HIV treatment (ART) in lower income and transitional settings is a global target. Yet, access to ART is shaped by local social condition and is by no means universal. Qualitative studies are ideally suited to describing how access to ART is socially situated. We explored systemic barriers to accessing ART among people who inject drugs (PWID) in a Russian city (Ekaterinburg) with a large burden of HIV treatment demand. We undertook 42 in-depth qualitative interviews with people living with HIV with current or recent experience of injecting drug use. Accounts were analysed thematically, and supplemented here with an illustrative case study. Three core themes were identified: 'labyrinthine bureaucracy' governing access to ART; a 'system Catch 22' created by an expectation that access to ART was conditional upon treated drug use in a setting of limited drug treatment opportunity; and 'system verticalization', where a lack of integration across HIV, tuberculosis (TB) and drug treatment compromised access to ART. Taken together, we find that systemic factors play a key role in shaping access to ART with the potential adverse effects of reproducing treatment initiation delay and disengagement from treatment. We argue that meso-level systemic factors affecting access to ART for PWID interact with wider macro-level structural forces, including those related to drug treatment policy and the social marginalization of PWID. We note the urgent need for systemic and structural changes to improve access to ART for PWID in this setting, including to simplify bureaucratic procedures, foster integrated HIV, TB and drug treatment services, and advocate for drug treatment policy reform.
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Affiliation(s)
- Anya Sarang
- Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, London, UK. E-mail:
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75
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Zetola NM, Modongo C, Kip EC, Gross R, Bisson GP, Collman RG. Alcohol use and abuse among patients with multidrug-resistant tuberculosis in Botswana. Int J Tuberc Lung Dis 2012; 16:1529-34. [PMID: 22963934 DOI: 10.5588/ijtld.12.0026] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Data on alcohol abuse as a risk factor for the development of multidrug-resistant tuberculosis (MDR-TB) are scarce. OBJECTIVE To describe the patterns of alcohol use in MDR-TB patients and to determine whether alcohol use is associated with the development of MDR-TB in Botswana. METHODS We compared the level of alcohol use among MDR-TB patients against three control groups: 1) non-MDR-TB patients, 2) human immunodeficiency virus (HIV) infected patients without a history of TB, and 3) the general population. Alcohol use and abuse was measured with the Alcohol Use Disorders Identification Test 10 (AUDIT) questionnaire. RESULTS Of a total national population of 164 MDR-TB cases, 114 (70%) were interviewed. MDR-TB cases had a lifetime prevalence of alcohol use of 35.1%, which was lower than that of all control groups (P < 0.001). MDR-TB cases had higher 1-month prevalence of alcohol dependence symptoms and a lower 1-year period prevalence of alcohol dependence symptoms (P < 0.01 and P = 0.01 respectively). Among patients with TB, alcohol abuse was found to be a risk factor for the development of MDR-TB. CONCLUSION MDR-TB patients in Botswana have high rates of alcohol use and abuse. Among TB patients, alcohol abuse is associated with the diagnosis of MDR-TB, and could be an important modifiable factor.
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Affiliation(s)
- N M Zetola
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Peltzer K, Louw J, Mchunu G, Naidoo P, Matseke G, Tutshana B. Hazardous and harmful alcohol use and associated factors in tuberculosis public primary care patients in South Africa. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2012. [PMID: 23202681 PMCID: PMC3499864 DOI: 10.3390/ijerph9093245] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to assess the prevalence of hazardous and harmful alcohol use and associated factors among patients with tuberculosis in South Africa. In a cross-sectional survey new tuberculosis (TB) and TB retreatment patients were consecutively screened using the Alcohol Use Disorder Identification Test (AUDIT) within one month of anti-tuberculosis treatment. The sample included 4,900 (54.5% men and women 45.5%) tuberculosis patients from 42 primary care clinics in three districts. Results indicate that, overall 23.2% of the patients were hazardous or harmful alcohol drinkers, 31.8% of men and 13.0% of women were found to be hazardous drinkers, and 9.3% of men and 3.4% of women meet criteria for probable alcohol dependence (harmful drinking) as defined by the AUDIT. Men had significantly higher AUDIT scores than women. In multivariable analyses it was found that among men poor perceived health status, tobacco use, psychological distress, being a TB retreatment patient and not being on antiretroviral therapy (ART), and among women lower education, tobacco use and being a TB retreatment patient were associated with hazardous or harmful alcohol use. The study found a high prevalence of hazardous or harmful alcohol use among tuberculosis primary care patients. This calls for screening and brief intervention and a comprehensive alcohol treatment programme as a key component of TB management in South Africa.
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Affiliation(s)
- Karl Peltzer
- HIV/STI and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Durban and Cape Town 8000, South Africa; (J.L.); (G.M.); (P.N.); (G.M.); (B.T.)
- Department of Psychology, University of Limpopo, Turfloop 06854, South Africa
- Author to whom correspondence should be addressed; ; Tel.: +27-12-302-2000; Fax: +27-12-302-2067
| | - Julia Louw
- HIV/STI and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Durban and Cape Town 8000, South Africa; (J.L.); (G.M.); (P.N.); (G.M.); (B.T.)
| | - Gugu Mchunu
- HIV/STI and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Durban and Cape Town 8000, South Africa; (J.L.); (G.M.); (P.N.); (G.M.); (B.T.)
| | - Pamela Naidoo
- HIV/STI and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Durban and Cape Town 8000, South Africa; (J.L.); (G.M.); (P.N.); (G.M.); (B.T.)
- Department of Psychology, University of the Western Cape, Cape Town 8000, South Africa
| | - Gladys Matseke
- HIV/STI and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Durban and Cape Town 8000, South Africa; (J.L.); (G.M.); (P.N.); (G.M.); (B.T.)
| | - Bomkazi Tutshana
- HIV/STI and TB (HAST) Research Programme, Human Sciences Research Council, Pretoria, Durban and Cape Town 8000, South Africa; (J.L.); (G.M.); (P.N.); (G.M.); (B.T.)
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Garrido MDS, Penna ML, Perez-Porcuna TM, de Souza AB, Marreiro LDS, Albuquerque BC, Martínez-Espinosa FE, Bührer-Sékula S. Factors associated with tuberculosis treatment default in an endemic area of the Brazilian Amazon: a case control-study. PLoS One 2012; 7:e39134. [PMID: 22720052 PMCID: PMC3373579 DOI: 10.1371/journal.pone.0039134] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 05/16/2012] [Indexed: 11/18/2022] Open
Abstract
Setting Treatment default is a serious problem in tuberculosis control because it implies persistence of infection source, increased mortality, increased relapse rates and facilitates the development of resistant strains. Objective This study analyzed tuberculosis treatment default determinants in the Amazonas State to contribute in planning appropriate control interventions. Design Observational study with a retrospective cohort using Brazilian Disease Notification System data from 2005 to 2010. A nested case control study design was used. Patients defaulting from treatment were considered as ‘cases’ and those completing treatment as ‘controls’. In the analysis, 11,312 tuberculosis patients were included, 1,584 cases and 9,728 controls. Results Treatment default was observed to be associated to previous default (aOR 3.20; p<0.001), HIV positivity (aOR 1.62; p<0.001), alcoholism (aOR 1.51; p<0.001), low education level (aOR 1.35; p<0.001) and other co-morbidities (aOR 1.31; p = 0.05). Older patients (aOR 0.98; p = 0.001) and DOT (aOR 0,72; p<0.01) were considered as protective factor for default. Conclusions Associated factors should be considered in addressing care and policy actions to tuberculosis control. Information on disease and treatment should be intensified and appropriate to the level of education of the population, in order to promote adherence to treatment and counter the spread of multidrug resistance to anti-TB drugs.
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Affiliation(s)
- Marlucia da Silva Garrido
- Tropical Medicine Post-Graduate Program - Amazonas State University/Dr Heitor Vieira Dourado Tropical Medicine Foundation, Manaus, Amazonas, Brazil.
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Cavanaugh JS, Kazennyy BY, Nguyen ML, Kiryanova EV, Vitek E, Khorosheva TM, Nemtsova E, Cegielski JP. Outcomes and follow-up of patients treated for multidrug-resistant tuberculosis in Orel, Russia, 2002-2005. Int J Tuberc Lung Dis 2012; 16:1069-74. [PMID: 22691694 DOI: 10.5588/ijtld.11.0696] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Multidrug-resistant tuberculosis (MDR-TB) treatment facility, Orel Oblast, Russian Federation. OBJECTIVES To determine factors associated with poor outcome and to document status of patients after recording of TB outcomes. DESIGN Retrospective review of prospective single cohort. RESULTS Among 192 patients, factors significantly associated with poor outcome in multivariate analysis include three or more treatment interruptions during the intensive phase of therapy and alcohol or drug addiction (adjusted OR [aOR] 2.1, 95%CI 1.0-4.3 and aOR 1.9, 95%CI 1.0-3.7). Previous treatment was associated with poor outcome, but only among smear-positive patients (aOR 3.1, 95%CI 1.3-7.3). Ten patients (5%) developed extensively drug-resistant TB (XDR-TB) during treatment; of 115 patients with at least 6 months of follow-up data after outcomes were recorded, 13 (11%) developed XDR-TB. CONCLUSION Interventions focused on supporting patient adherence during the intensive phase of treatment; the management of drug and alcohol addiction should be developed and studied. A substantial proportion of patients developed XDR-TB during and after treatment. Longer term follow-up data of patients treated for MDR-TB are needed to better inform programmatic policy.
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Affiliation(s)
- J S Cavanaugh
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
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79
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Dharmadhikari AS, Mphahlele M, Stoltz A, Venter K, Mathebula R, Masotla T, Lubbe W, Pagano M, First M, Jensen PA, van der Walt M, Nardell EA. Surgical face masks worn by patients with multidrug-resistant tuberculosis: impact on infectivity of air on a hospital ward. Am J Respir Crit Care Med 2012; 185:1104-9. [PMID: 22323300 PMCID: PMC3359891 DOI: 10.1164/rccm.201107-1190oc] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 01/31/2012] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Drug-resistant tuberculosis transmission in hospitals threatens staff and patient health. Surgical face masks used by patients with tuberculosis (TB) are believed to reduce transmission but have not been rigorously tested. OBJECTIVES We sought to quantify the efficacy of surgical face masks when worn by patients with multidrug-resistant TB (MDR-TB). METHODS Over 3 months, 17 patients with pulmonary MDR-TB occupied an MDR-TB ward in South Africa and wore face masks on alternate days. Ward air was exhausted to two identical chambers, each housing 90 pathogen-free guinea pigs that breathed ward air either when patients wore surgical face masks (intervention group) or when patients did not wear masks (control group). Efficacy was based on differences in guinea pig infections in each chamber. MEASUREMENTS AND MAIN RESULTS Sixty-nine of 90 control guinea pigs (76.6%; 95% confidence interval [CI], 68-85%) became infected, compared with 36 of 90 intervention guinea pigs (40%; 95% CI, 31-51%), representing a 56% (95% CI, 33-70.5%) decreased risk of TB transmission when patients used masks. CONCLUSIONS Surgical face masks on patients with MDR-TB significantly reduced transmission and offer an adjunct measure for reducing TB transmission from infectious patients.
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Affiliation(s)
- Ashwin S Dharmadhikari
- Division of Pulmonary and Critical Care Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, 641 Huntington Avenue, Room 3A03, Boston, MA 02115, USA.
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Dharmadhikari AS, Mphahlele M, Stoltz A, Venter K, Mathebula R, Masotla T, Lubbe W, Pagano M, First M, Jensen PA, van der Walt M, Nardell EA. Surgical Face Masks Worn by Patients with Multidrug-Resistant Tuberculosis. Am J Respir Crit Care Med 2012. [DOI: 10.1164/rccm.201107-1190oc https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/coronavirus-disease-covid-19-masks] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ashwin S. Dharmadhikari
- Division of Pulmonary and Critical Care Medicine, and
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matsie Mphahlele
- South African Medical Research Council, Tuberculosis Epidemiology and Intervention Research Unit, Pretoria, South Africa
| | - Anton Stoltz
- Division of Infectious Diseases, University of Pretoria, Pretoria, South Africa
| | - Kobus Venter
- South African Medical Research Council, Tuberculosis Epidemiology and Intervention Research Unit, Pretoria, South Africa
| | - Rirhandzu Mathebula
- South African Medical Research Council, Tuberculosis Epidemiology and Intervention Research Unit, Pretoria, South Africa
| | - Thabiso Masotla
- South African Medical Research Council, Tuberculosis Epidemiology and Intervention Research Unit, Pretoria, South Africa
| | - Willem Lubbe
- South African Medical Research Council, Tuberculosis Epidemiology and Intervention Research Unit, Pretoria, South Africa
| | | | - Melvin First
- Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts; and
| | - Paul A. Jensen
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Martie van der Walt
- South African Medical Research Council, Tuberculosis Epidemiology and Intervention Research Unit, Pretoria, South Africa
| | - Edward A. Nardell
- Division of Pulmonary and Critical Care Medicine, and
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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81
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Miller AC, Gelmanova IY, Keshavjee S, Atwood S, Yanova G, Mishustin S, Furin JJ, Shin SS. Alcohol use and the management of multidrug-resistant tuberculosis in Tomsk, Russian Federation. Int J Tuberc Lung Dis 2012; 16:891-6. [PMID: 22507895 DOI: 10.5588/ijtld.11.0795] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Alcohol use increases the risk of multidrug-resistant tuberculosis (MDR-TB) and poses challenges for successful MDR-TB treatment, including the potential for additional adverse events. AIM To investigate the association between alcohol consumption during MDR-TB treatment and adverse events and treatment outcomes in a cohort of patients in Tomsk, Russia. DESIGN From 2000 to 2004, retrospective data were collected on 407 MDR-TB patients in Tomsk. Factors associated with treatment outcomes were assessed using logistic regression. RESULTS Of the 407 patients, 253 (62.2%) consumed alcohol during treatment ('drinkers'), and 367 (90.2%) had at least one documented adverse advent. No significant differences were noted in frequency of adverse events in drinkers vs. non-drinkers. Drinkers had less favourable treatment outcomes (OR 0.28, 95%CI 0.18-0.45). Among drinkers, favourable treatment outcome was associated with adherence to at least 80% of prescribed doses (OR 2.89, 95%CI 1.30-6.43) and the occurrence of an adverse event requiring treatment interruption (OR 2.49, 95%CI 1.11-5.59). CONCLUSIONS Alcohol use did not appear to increase the risk of adverse events during MDR-TB treatment; however, alcohol consumption was associated with poor outcome. Our findings suggest that individuals who drink alcohol should receive aggressive attention to optimise treatment adherence and manage adverse events.
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Affiliation(s)
- A C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts 02115, USA.
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82
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Kipp AM, Pungrassami P, Stewart PW, Chongsuvivatwong V, Strauss RP, Van Rie A. Study of tuberculosis and AIDS stigma as barriers to tuberculosis treatment adherence using validated stigma scales. Int J Tuberc Lung Dis 2012; 15:1540-5, i. [PMID: 22008770 DOI: 10.5588/ijtld.10.0273] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adherence to tuberculosis (TB) treatment is important for TB control. The effect of stigma on adherence has not been well quantified. OBJECTIVE To identify the effects of TB and acquired immune-deficiency syndrome (AIDS) stigma on missed doses during TB treatment. DESIGN Validated TB and AIDS stigma scales assessing perceived and experienced/felt stigma were administered in a prospective cohort of 459 TB patients at TB treatment initiation and after 2 months. Repeated measures and multivariable models estimated the effects of stigma on the rate of missed doses. RESULTS Fifty-six per cent of patients missed no doses, and associations between stigma and missed doses were minimal. Heterogeneity of effects was observed, how- ever, with higher experienced and felt TB stigma increasing missed doses among women (adjusted RR 1.22, 95%CI 1.10-1.34) and human immunodeficiency virus (HIV) co-infected patients (aRR 1.39, 95%CI 1.13-1.72). Experienced and felt AIDS stigma also increased missed doses among HIV co-infected patients (aRR 1.43, 95%CI 1.31-1.56). CONCLUSION Stigma has a minimal effect in this population with good adherence. Among women and HIV co-infected patients, however, experienced and felt stigma, and not perceived stigma, increased the rate of missed doses. Further research is needed to determine if stigma or coping interventions among these subgroups would improve adherence.
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Affiliation(s)
- A M Kipp
- University of North Carolina, Chapel Hill, North Carolina, USA.
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83
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Finlay A, Lancaster J, Holtz TH, Weyer K, Miranda A, van der Walt M. Patient- and provider-level risk factors associated with default from tuberculosis treatment, South Africa, 2002: a case-control study. BMC Public Health 2012; 12:56. [PMID: 22264339 PMCID: PMC3306745 DOI: 10.1186/1471-2458-12-56] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 01/20/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Persons who default from tuberculosis treatment are at risk for clinical deterioration and complications including worsening drug resistance and death. Our objective was to identify risk factors associated with tuberculosis (TB) treatment default in South Africa. METHODS We conducted a national retrospective case control study to identify factors associated with treatment default using program data from 2002 and a standardized patient questionnaire. We defined default as interrupting TB treatment for two or more consecutive months during treatment. Cases were a sample of registered TB patients receiving treatment under DOTS that defaulted from treatment. Controls were those who began therapy and were cured, completed or failed treatment. Two respective multivariable models were constructed, stratified by history of TB treatment (new and re-treatment patients), to identify independent risk factors associated with default. RESULTS The sample included 3165 TB patients from 8 provinces; 1164 were traceable and interviewed (232 cases and 932 controls). Significant risk factors associated with default among both groups included poor health care worker attitude (new: AOR 2.1, 95% CI 1.1-4.4; re-treatment: AOR 12, 95% CI 2.2-66.0) and changing residence during TB treatment (new: AOR 2.0, 95% CI 1.1-3.7; re-treatment: AOR 3.4, 95% CI 1.1-9.9). Among new patients, cases were more likely than controls to report having no formal education (AOR 2.3, 95% CI 1.2-4.2), feeling ashamed to have TB (AOR 2.0, 95% CI 1.3-3.0), not receiving adequate counseling about their treatment (AOR 1.9, 95% CI 1.2-2.8), drinking any alcohol during TB treatment (AOR 1.9, 95% CI 1.2-3.0), and seeing a traditional healer during TB treatment (AOR 1.9, 95% CI 1.1-3.4). Among re-treatment patients, risk factors included stopping TB treatment because they felt better (AOR 21, 95% CI 5.2-84), having a previous history of TB treatment default (AOR 6.4, 95% CI 2.9-14), and feeling that food provisions might have helped them finish treatment (AOR 5.0, 95% CI 1.3-19). CONCLUSIONS Risk factors for default differ between new and re-treatment TB patients in South Africa. Addressing default in both populations with targeted interventions is critical to overall program success.
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Affiliation(s)
- Alyssa Finlay
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333, USA
| | - Joey Lancaster
- Tuberculosis Epidemiology and Intervention Research Unit, Medical Research Council, 1 Soutpansberg Road, Pretoria 0001, South Africa
| | - Timothy H Holtz
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333, USA
| | - Karin Weyer
- Stop TB Department, World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland
| | - Abe Miranda
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Atlanta, GA 30333, USA
| | - Martie van der Walt
- Tuberculosis Epidemiology and Intervention Research Unit, Medical Research Council, 1 Soutpansberg Road, Pretoria 0001, South Africa
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van der Werf MJ, Langendam MW, Huitric E, Manissero D. Multidrug resistance after inappropriate tuberculosis treatment: a meta-analysis. Eur Respir J 2011; 39:1511-9. [PMID: 22005918 PMCID: PMC3365250 DOI: 10.1183/09031936.00125711] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We conducted a systematic review and meta-analysis to assess the evidence for the postulation that inappropriate tuberculosis (TB) regimens are a risk for development of multidrug-resistant (MDR)-TB. MEDLINE, EMBASE and other databases were searched for relevant articles in January 2011. Cohort studies including TB patients who received treatment were selected and data on treatment regimen, drug susceptibility testing results and genotyping results before treatment and at failure or relapse were abstracted from the articles. Four studies were included in the systematic review and two were included in the meta-analysis. In these two studies the risk of developing MDR-TB in patients who failed treatment and used an inappropriate treatment regimen was increased 27-fold (RR 26.7, 95% CI 5.0-141.7) when compared with individuals who received an appropriate treatment regimen. This review provides evidence that supports the general opinion that the development of MDR-TB can be caused by inadequate treatment, given the drug susceptibility pattern of the Mycobacterium tuberculosis bacilli. It should be noted that only two studies provided data for the meta-analysis. The information can be used to advocate for adequate treatment for patients based on drug resistance profiles.
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85
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Natural infection of guinea pigs exposed to patients with highly drug-resistant tuberculosis. Tuberculosis (Edinb) 2011; 91:329-38. [PMID: 21478054 DOI: 10.1016/j.tube.2011.03.002] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 02/21/2011] [Accepted: 03/07/2011] [Indexed: 12/22/2022]
Abstract
A natural TB infection model using guinea pigs may provide useful information for investigating differences in transmission efficiency and establishment of active disease by clinical TB strains in a highly susceptible host under controlled environmental conditions. We sought to examine the capacity of naturally transmitted multidrug-resistant Mycobacterium tuberculosis to establish infection and produce active disease in guinea pigs. Guinea pigs were continuously exposed for 4 months to the exhaust air of a 6-bed multidrug-resistant tuberculosis inpatient hospital ward in South Africa. Serial tuberculin skin test reactions were measured to determine infection. All animals were subsequently evaluated for histologic disease progression at necropsy. Although 75% of the 362 exposed guinea pigs had positive skin test reactions [≥6 mm], only 12% had histopathologic evidence of active disease. Reversions (≥6 mm change) in skin test reactivity were seen in 22% of animals, exclusively among those with reactions of 6-13 mm. Only two of 86 guinea pigs with reversion had histological evidence of disease compared to 47% (31/66) of guinea pigs with large, non-reverting reactions. Immunosuppression of half the guinea pigs across all skin test categories did not significantly accelerate disease progression. In guinea pigs that reverted a skin test, a second positive reaction in 27 (33%) of them strongly suggested re-infection due to ongoing exposure. These results show that a large majority of guinea pigs naturally exposed to human-source strains of multidrug-resistant tuberculosis became infected, but that many resolved their infection and a large majority failed to progress to detectable disease.
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86
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Pefura Yone EW, Kengne AP, Kuaban C. Incidence, time and determinants of tuberculosis treatment default in Yaounde, Cameroon: a retrospective hospital register-based cohort study. BMJ Open 2011; 1:e000289. [PMID: 22116091 PMCID: PMC3225586 DOI: 10.1136/bmjopen-2011-000289] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objectives High rates of antituberculosis treatment discontinuation have been reported in some areas of Africa. The aim of this study was to determine the rate, time to and determinants of antituberculosis treatment default in Yaounde. Design This was a retrospective cohort study based on hospital registers. Tuberculosis treatment default or antituberculosis treatment discontinuation was defined as any interruption of treatment for at least 2 months following treatment initiation. Sociodemographic and clinical predictors of treatment discontinuation were investigated with the use of Cox regressions models. Setting This study was carried out in the tuberculosis diagnosis and treatment centre at Yaounde Jamot Hospital, which serves as a referral centre for tuberculosis and respiratory diseases for the capital city of Cameroon (Yaounde) and surrounding areas. Participants All (1688) patients started on antituberculosis treatment at the centre between January and December 2009 were enrolled. Outcome measures were antituberculosis treatment default and time to treatment default. Results Of the 1688 included patients, 337 (20%) defaulted from treatment, 86 (5.1%) died, treatment failed in 6 (0.4%) and 104 (6.2%) were transferred. Therefore, treatment was successfully completed in 1154 (68.4%) patients. Median duration to treatment discontinuation was 90 days (IQR 30-150), and 62% of treatment discontinuation occurred during the continuation phase. Hospitalisation during the intensive phase (adjusted HR 0.69; 95% CI 0.54 to 0.89) and non-consenting for HIV screening (1.65; 1.24 to 2.21) were the main determinants of defaulting from treatment in multivariable analysis. Conclusions The default incidence rate is relatively high in this centre and treatment discontinuation occurs frequently during the continuation phase of treatment. Action is needed to improve adherence to treatment when received on an ambulatory basis, to clarify the association between HIV testing and antituberculosis treatment default, and to identify other potential determinants of treatment discontinuation in this setting.
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Affiliation(s)
- Eric Walter Pefura Yone
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, The University of Yaounde I, Yaounde, Cameroon
- Chest Unit, Yaounde Jamot Hospital, Yaounde, Cameroon
| | - André Pascal Kengne
- South African Medical Research Council and University of Cape Town, Cape Town, South Africa
| | - Christopher Kuaban
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, The University of Yaounde I, Yaounde, Cameroon
- Chest Unit, Yaounde Jamot Hospital, Yaounde, Cameroon
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87
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Nardell E, Dharmadhikari A. Turning off the spigot: reducing drug-resistant tuberculosis transmission in resource-limited settings. Int J Tuberc Lung Dis 2010; 14:1233-1243. [PMID: 20843413 PMCID: PMC3709569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023] Open
Abstract
Ongoing transmission and re-infection, primarily in congregate settings, is a key factor fueling the global multidrug-resistant/extensively drug-resistant tuberculosis (MDR/XDR-TB) epidemic, especially in association with the human immunodeficiency virus. Even as efforts to broadly implement conventional TB transmission control measures begin, current strategies may be incompletely effective under the overcrowded conditions extant in high-burden, resource-limited settings. Longstanding evidence suggesting that TB patients on effective therapy rapidly become non-infectious and that unsuspected, untreated TB cases account for the most transmission makes a strong case for the implementation of rapid point-of-care diagnostics coupled with fully supervised effective treatment. Among the most important decisions affecting transmission, the choice of an MDR-TB treatment model that includes community-based treatment may offer important advantages over hospital or clinic-based care, not only in cost and effectiveness, but also in transmission control. In the community, too, rapid identification of infectious cases, especially drug-resistant cases, followed by effective, fully supervised treatment, is critical to stopping transmission. Among the conventional interventions available, we present a simple triage and separation strategy, point out that separation is intimately linked to the design and engineering of clinical space and call attention to the pros and cons of natural ventilation, simple mechanical ventilation systems, germicidal ultraviolet air disinfection, fit-tested respirators on health care workers and short-term use of masks on patients before treatment is initiated.
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Affiliation(s)
- E Nardell
- Division of Global Health Equity, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Nathanson E, Nunn P, Uplekar M, Floyd K, Jaramillo E, Lönnroth K, Weil D, Raviglione M. MDR tuberculosis--critical steps for prevention and control. N Engl J Med 2010; 363:1050-8. [PMID: 20825317 DOI: 10.1056/nejmra0908076] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Eva Nathanson
- Stop TB Department, World Health Organization, Geneva, Switzerland
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89
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Carvalho ACC, Migliori GB, Cirillo DM. Tuberculosis in Europe: a problem of drug resistance or much more? Expert Rev Respir Med 2010; 4:189-200. [PMID: 20406085 DOI: 10.1586/ers.10.7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tuberculosis has re-emerged as a public health concern in high-income countries in the last few decades. The European region accounts for only 5% of world TB cases. The incidence of new TB cases in Europe varies from very low rates in Scandinavian countries (six to eight cases/100,000 population) to rates as high as 231 cases/100,000 population in Tajikistan; the Russian Federation is eleventh among the 22 high-burden TB countries. The estimated detection rate of new sputum smear-positive pulmonary cases and the treatment success rate in 2007 were poor compared with other WHO regions: 51% of cases were diagnosed and 70% of them completed a full course of anti-TB therapy, which is still a long way from the World Health Assembly targets (detection of 70% of infectious cases and successful treatment of 85% of them). The low success rate is largely attributable to the increasing number of drug-resistant TB cases: Eastern European countries are among those with the highest rates of multidrug-resistant (MDR)-TB (TB resistant to rifampicin and isoniazid) in the world. By the end of September 2009, at least one case of extensively drug-resistant TB (named XDR-TB and defined as a MDR-TB strain with additional resistance to any fluoroquinolone, and to at least one of three injectable drugs used in anti-TB treatment) had been reported by 25 countries in the WHO European Region. In Western Europe, TB continues to cause disease among elderly native-born individuals, although high-risk groups including immigrants, prisoners, HIV-infected persons and drug addicts significantly contribute to the overall burden. Improved TB control in Europe requires a large coordinated effort by all stakeholders, including governments, governmental and non-governmental institutions, as well as the academic and private sectors and affected communities.
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Affiliation(s)
- Anna C C Carvalho
- Institute of Infectious and Tropical Diseases, Università degli Studi di Brescia, Piazzale Spedali Civili 1, 25125 Brescia, Italy
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Shin SS, Keshavjee S, Gelmanova IY, Atwood S, Franke MF, Mishustin SP, Strelis AK, Andreev YG, Pasechnikov AD, Barnashov A, Tonkel TP, Cohen T. Development of extensively drug-resistant tuberculosis during multidrug-resistant tuberculosis treatment. Am J Respir Crit Care Med 2010; 182:426-32. [PMID: 20413630 DOI: 10.1164/rccm.200911-1768oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Extensively drug-resistant (XDR) tuberculosis (TB) may arise in individuals on treatment for multidrug-resistant (MDR) TB. Preventing this amplification of resistance will likely improve clinical outcomes and delay the secondary spread of XDR-TB. OBJECTIVES To measure the proportion of individuals that develops XDR-TB during the course of MDR-TB treatment, and to identify those factors associated with the development of XDR. METHODS We performed a retrospective analysis of 608 consecutive patients with documented MDR-TB who were started on MDR-TB treatment between September 10, 2000 and November 1, 2004 in the Tomsk Oblast TB Treatment Services in Western Siberia, Russian Federation. MEASUREMENTS AND MAIN RESULTS A total of 6% of patients were observed to develop XDR-TB while on MDR-TB treatment. These patients were significantly less likely to be cured or to complete treatment. Using Cox proportional hazard models, we found that the presence of bilateral and cavitary lesions was associated with a greater than threefold increase in hazard (adjusted hazard ratio [HR], 3.47; 95% confidence interval [CI], 1.32-9.14). Prior exposure to a second-line injectable antibiotic was associated with a greater than threefold increase in hazard (adjusted HR, 3.65; 95% CI, 1.81-7.37), and each additional month in which a patient failed to take at least 80% of their prescribed drugs was associated with nearly an additional 20% hazard of developing XDR-TB (adjusted HR, 1.17; 95% CI, 1.01-1.35). CONCLUSIONS Early and rapid diagnosis, timely initiation of appropriate therapy, and programmatic efforts to optimize treatment adherence during MDR-TB therapy are crucial to avoiding the generation of excess XDR-TB in MDR-TB treatment programs.
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Affiliation(s)
- Sonya S Shin
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA 02115, USA.
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91
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Greenfield SF, Shields A, Connery HS, Livchits V, Yanov SA, Lastimoso CS, Strelis AK, Mishustin SP, Fitzmaurice G, Mathew TA, Shin S. Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients: Design and Implementation. Alcohol Clin Exp Res 2010; 34:317-30. [PMID: 19930235 PMCID: PMC2898509 DOI: 10.1111/j.1530-0277.2009.01094.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND While the integration of alcohol screening, treatment, and referral in primary care and other medical settings in the U.S. and worldwide has been recognized as a key health care priority, it is not routinely done. In spite of the high co-occurrence and excess mortality associated with alcohol use disorders (AUDs) among individuals with tuberculosis (TB), there are no studies evaluating effectiveness of integrating alcohol care into routine treatment for this disorder. METHODS We designed and implemented a randomized controlled trial (RCT) to determine the effectiveness of integrating pharmacotherapy and behavioral treatments for AUDs into routine medical care for TB in the Tomsk Oblast Tuberculosis Service (TOTBS) in Tomsk, Russia. Eligible patients are diagnosed with alcohol abuse or dependence, are newly diagnosed with TB, and initiating treatment in the TOTBS with Directly Observed Therapy-Short Course (DOTS) for TB. Utilizing a factorial design, the Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients (IMPACT) study randomizes eligible patients who sign informed consent into 1 of 4 study arms: (1) Oral Naltrexone + Brief Behavioral Compliance Enhancement Therapy (BBCET) + treatment as usual (TAU), (2) Brief Counseling Intervention (BCI) + TAU, (3) Naltrexone + BBCET + BCI + TAU, or (4) TAU alone. RESULTS Utilizing an iterative, collaborative approach, a multi-disciplinary U.S. and Russian team has implemented a model of alcohol management that is culturally appropriate to the patient and TB physician community in Russia. Implementation to date has achieved the integration of routine alcohol screening into TB care in Tomsk; an ethnographic assessment of knowledge, attitudes, and practices of AUD management among TB physicians in Tomsk; translation and cultural adaptation of the BCI to Russia and the TB setting; and training and certification of TB physicians to deliver oral naltrexone and brief counseling interventions for alcohol abuse and dependence as part of routine TB care. The study is successfully enrolling eligible subjects in the RCT to evaluate the relationship of integrating effective pharmacotherapy and brief behavioral intervention on TB and alcohol outcomes, as well as reduction in HIV risk behaviors. CONCLUSIONS The IMPACT study utilizes an innovative approach to adapt 2 effective therapies for treatment of alcohol use disorders to the TB clinical services setting in the Tomsk Oblast, Siberia, Russia, and to train TB physicians to deliver state of the art alcohol pharmacotherapy and behavioral treatments as an integrated part of routine TB care. The proposed treatment strategy could be applied elsewhere in Russia and in other settings where TB control is jeopardized by AUDs. If demonstrated to be effective, this model of integrating alcohol interventions into routine TB care has the potential for expanded applicability to other chronic co-occurring infectious and other medical conditions seen in medical care settings.
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Affiliation(s)
- Shelly F Greenfield
- Alcohol and Drug Abuse Treatment Program, McLean Hospital, Belmont, MA 02478, USA.
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Jha UM, Satyanarayana S, Dewan PK, Chadha S, Wares F, Sahu S, Gupta D, Chauhan LS. Risk factors for treatment default among re-treatment tuberculosis patients in India, 2006. PLoS One 2010; 5:e8873. [PMID: 20111727 PMCID: PMC2810342 DOI: 10.1371/journal.pone.0008873] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2009] [Accepted: 01/04/2010] [Indexed: 11/19/2022] Open
Abstract
Setting Under India's Revised National Tuberculosis Control Programme (RNTCP), >15% of previously-treated patients in the reported 2006 patient cohort defaulted from anti-tuberculosis treatment. Objective To assess the timing, characteristics, and risk factors for default amongst re-treatment TB patients. Methodology For this case-control study, in 90 randomly-selected programme units treatment records were abstracted from all 2006 defaulters from the RNTCP re-treatment regimen (cases), with one consecutively-selected non-defaulter per case. Patients who interrupted anti-tuberculosis treatment for >2 months were classified as defaulters. Results 1,141 defaulters and 1,189 non-defaulters were included. The median duration of treatment prior to default was 81 days (25%–75% interquartile range 44–117 days) and documented retrieval efforts after treatment interruption were inadequate. Defaulters were more likely to have been male (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.2–1.7), have previously defaulted anti-tuberculosis treatment (aOR 1.3 95%CI 1.1–1.6], have previous treatment from non-RNTCP providers (AOR 1.3, 95%CI 1.0–1.6], or have public health facility-based treatment observation (aOR 1.3, 95%CI 1.1–1.6). Conclusions Amongst the large number of re-treatment patients in India, default occurs early and often. Improved pre-treatment counseling and community-based treatment provision may reduce default rates. Efforts to retrieve treatment interrupters prior to default require strengthening.
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Affiliation(s)
- Ugra Mohan Jha
- Central Tuberculosis Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Srinath Satyanarayana
- Centre for Operational Research, International Union Against Tuberculosis and Lung Diseases (The Union), New Delhi, India
- * E-mail:
| | | | | | - Fraser Wares
- Office of the WHO Representative to India, New Delhi, India
| | - Suvanand Sahu
- Office of the WHO Representative to India, New Delhi, India
| | - Devesh Gupta
- Central Tuberculosis Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - L. S. Chauhan
- Central Tuberculosis Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, New Delhi, India
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Rehm J, Samokhvalov AV, Neuman MG, Room R, Parry C, Lönnroth K, Patra J, Poznyak V, Popova S. The association between alcohol use, alcohol use disorders and tuberculosis (TB). A systematic review. BMC Public Health 2009; 9:450. [PMID: 19961618 PMCID: PMC2796667 DOI: 10.1186/1471-2458-9-450] [Citation(s) in RCA: 257] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 12/05/2009] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND In 2004, tuberculosis (TB) was responsible for 2.5% of global mortality (among men 3.1%; among women 1.8%) and 2.2% of global burden of disease (men 2.7%; women 1.7%). The present work portrays accumulated evidence on the association between alcohol consumption and TB with the aim to clarify the nature of the relationship. METHODS A systematic review of existing scientific data on the association between alcohol consumption and TB, and on studies relevant for clarification of causality was undertaken. RESULTS There is a strong association between heavy alcohol use/alcohol use disorders (AUD) and TB. A meta-analysis on the risk of TB for these factors yielded a pooled relative risk of 2.94 (95% CI: 1.89-4.59). Numerous studies show pathogenic impact of alcohol on the immune system causing susceptibility to TB among heavy drinkers. In addition, there are potential social pathways linking AUD and TB. Heavy alcohol use strongly influences both the incidence and the outcome of the disease and was found to be linked to altered pharmacokinetics of medicines used in treatment of TB, social marginalization and drift, higher rate of re-infection, higher rate of treatment defaults and development of drug-resistant forms of TB. Based on the available data, about 10% of the TB cases globally were estimated to be attributable to alcohol. CONCLUSION The epidemiological and other evidence presented indicates that heavy alcohol use/AUD constitute a risk factor for incidence and re-infection of TB. Consequences for prevention and clinical interventions are discussed.
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Affiliation(s)
- Jürgen Rehm
- Public Health and Regulatory Policies, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Canada
- Head WHO Collaboration Centre for Substance Abuse, Zurich, Switzerland
- Epidemiological Research Unit, Klinische Psychologie & Psychotherapie, Technische Universität Dresden, Germany
| | - Andriy V Samokhvalov
- Public Health and Regulatory Policies, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Manuela G Neuman
- In Vitro Drug Safety and Biotechnology, Department of Pharmacology, Institute of Drug Research, University of Toronto, Toronto, Canada
- Centre for International Health, University of Toronto, Toronto, Canada
| | - Robin Room
- School of Population Health, University of Melbourne, Melbourne, Australia
- AER Centre for Alcohol Policy Research, Turning Point Alcohol & Drug Centre, Fitzroy, Victoria, Australia
| | - Charles Parry
- Alcohol & Drug Abuse Research Unit, Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | - Knut Lönnroth
- Stop TB Department, World Health Organization, Geneva, Switzerland
| | - Jayadeep Patra
- Public Health and Regulatory Policies, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Vladimir Poznyak
- Management of Substance Abuse, Department of Mental Health and Substance Abuse, World Health Organization, Geneva, Switzerland
| | - Svetlana Popova
- Public Health and Regulatory Policies, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Canada
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Outcomes after chemotherapy with WHO category II regimen in a population with high prevalence of drug resistant tuberculosis. PLoS One 2009; 4:e7954. [PMID: 19956770 PMCID: PMC2776350 DOI: 10.1371/journal.pone.0007954] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 10/20/2009] [Indexed: 11/19/2022] Open
Abstract
Standard short course chemotherapy is recommended by the World Health Organization to control tuberculosis worldwide. However, in settings with high drug resistance, first line standard regimens are linked with high treatment failure. We evaluated treatment outcomes after standardized chemotherapy with the WHO recommended category II retreatment regimen in a prison with a high prevalence of drug resistant tuberculosis (TB). A cohort of 233 culture positive TB patients was followed through smear microscopy, culture, drug susceptibility testing and DNA fingerprinting at baseline, after 3 months and at the end of treatment. Overall 172 patients (74%) became culture negative, while 43 (18%) remained positive at the end of treatment. Among those 43 cases, 58% of failures were determined to be due to treatment with an inadequate drug regimen and 42% to either an initial mixed infection or re-infection while under treatment. Overall, drug resistance amplification during treatment occurred in 3.4% of the patient cohort. This study demonstrates that treatment failure is linked to initial drug resistance, that amplification of drug resistance occurs, and that mixed infection and re-infection during standard treatment contribute to treatment failure in confined settings with high prevalence of drug resistance.
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95
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Xu W, Lu W, Zhou Y, Zhu L, Shen H, Wang J. Adherence to anti-tuberculosis treatment among pulmonary tuberculosis patients: a qualitative and quantitative study. BMC Health Serv Res 2009; 9:169. [PMID: 19765290 PMCID: PMC2753329 DOI: 10.1186/1472-6963-9-169] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Accepted: 09/18/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) patients have difficulty following a long-term treatment regimen. Efforts to improve treatment outcomes require better understanding of adherence as a complex behavioral issue and of the particular barriers to and facilitators of patient adherence. METHODS This study was carried out in Jiangsu Province of China with both quantitative and qualitative approaches. For the quantitative study, 780 sputum-smear positive TB patients consecutively registered since 2006 in 13 counties (districts) were queried with a structured questionnaire. Patients who had missed 10% of their total prescribed doses of TB drugs were deemed as non-adherent. Risks for non-adherence were estimated by computing odds ratios (ORs) and their 95% confidence intervals (95% CIs) using a logistic regression model. We also invited 20 TB patients and 10 local health workers for in-depth interviews. We then used content analysis based on this qualitative study to explore factors associated with non-adherence. RESULTS The proportion of non-adherence among 670 patients was 12.2%. Univariate analysis showed that patients, who were illiterate, divorced/widowed, lacked health insurance and were migrants, were more likely to be non-adherent. The crude ORs(95%CIs) were 2.38(1.37-4.13), 2.42(1.30-4.52), 1.89(1.07-3.32) and 1.98(1.03-3.83), respectively. The risk of non-adherence was lower among patients whose treatment was given under direct observation by village doctors or regular home visits by health workers, with ORs (95% CIs) of 0.19(0.10-0.36) and 0.23(0.10-0.51), respectively. In multivariate analysis, factors associated with non-adherence included illiteracy (OR: 2.42; 95% CI: 1.25-4.67) and direct observation by village doctors (OR: 0.23; 95% CI: 0.11-0.45). The in-depth interviews indicated that financial burdens and extra medical expenditures, adverse drug reactions, and social stigma were additional potential factors accounted for non-adherence. CONCLUSION More importance should be given to treatment adherence under the current TB control program. Heavy financial burdens, lack of social support, adverse drug reactions and personal factors are associated with non-adherence. Direct observation and regular home visits by health workers appear to reduce the risk of non-adherence. More patient-centered interventions and greater attention to structural barriers are needed to improve treatment adherence.
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Affiliation(s)
- Weiguo Xu
- Jiangsu Provincial Center for Disease Prevention and Control, Nanjing, PR China.
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PARRY CHARLES, REHM JÜRGEN, POZNYAK VLADIMIR, ROOM ROBIN. Alcohol and infectious diseases: an overlooked causal linkage? Addiction 2009; 104:331-2. [PMID: 19207335 DOI: 10.1111/j.1360-0443.2008.02500.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- CHARLES PARRY
- Alcohol and Drug Abuse Research Unit, Medical Research Council and Department of Psychiatry, Stellenbosch University, PO Box 19070, Tygerberg (Cape Town), 7505, South Africa, E‐mail:
| | - JÜRGEN REHM
- Centre for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario, M55251, Canada
| | - VLADIMIR POZNYAK
- Management of Substance Abuse, Department of Mental Health and Substance Abuse, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
| | - ROBIN ROOM
- and School of Population Health, University of Melbourne, and, AER Centre for Alcohol Policy Research, Turning Point Alcohol and Drug Centre Inc, 54–62 Gertrude Street, Fitzroy, Vic. 3065, Australia
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Deiss RG, Rodwell TC, Garfein RS. Tuberculosis and illicit drug use: review and update. Clin Infect Dis 2009; 48:72-82. [PMID: 19046064 DOI: 10.1086/594126] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Illicit drug users continue to be a group at high risk for tuberculosis (TB). Here, we present an updated review of the relationship between TB and illicit drug use, and we summarize more than a decade of new research. Drug users, and injection drug users in particular, have driven TB epidemics in a number of countries. The successful identification and treatment of TB among illicit drug users remain important components of a comprehensive TB strategy, but illicit drug users present a unique set of challenges for TB diagnosis and control. New diagnostic modalities, including interferon-gamma-release assays, offer potential for improved diagnosis and surveillance among this group, along with proven treatment strategies that incorporate the use of directly observed therapy with treatment for drug abuse. Special considerations, including coinfection with viral hepatitis and the rifampin-methadone drug interaction, warrant clinical attention and are also updated here.
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Affiliation(s)
- Robert G Deiss
- University of California, San Diego, La Jolla, California, USA
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Suárez-García I, Rodríguez-Blanco A, Vidal-Pérez JL, García-Viejo MA, Jaras-Hernández MJ, López O, Noguerado-Asensio A. Risk factors for multidrug-resistant tuberculosis in a tuberculosis unit in Madrid, Spain. Eur J Clin Microbiol Infect Dis 2008; 28:325-30. [PMID: 18830725 DOI: 10.1007/s10096-008-0627-y] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Accepted: 08/27/2008] [Indexed: 11/29/2022]
Abstract
The setting for this retrospective cohort study was a specialised tuberculosis unit in Madrid, Spain. The objective was to describe the risk factors for multidrug-resistant tuberculosis (MDR-TB). The medical records of all patients admitted to the unit were reviewed retrospectively to identify factors associated with multidrug resistance. Patients with positive culture for M. tuberculosis and with available drug-susceptibility tests were included. The variables assessed were age, gender, country of origin, homelessness, alcohol consumption, intravenous drug use, methadone substitution therapy, contact with a tuberculosis patient, sputum smear, site of disease, previous tuberculosis treatment, HIV infection, history of imprisonment, diabetes mellitus and chronic obstructive pulmonary disease. Thirty patients with MDR-TB and 666 patients with non-MDR-TB were included from the years 1997 to 2006. The only factors associated with MDR-TB in multivariate analysis were previous tuberculosis treatment (OR: 3.44; 95% CI: 1.58-7.50; p = 0.003), age group 45-64 years (OR: 3.24; 95% CI: 1.34-7.81; p = 0.009) and alcohol abuse (OR: 0.12; 95% CI: 0.03 to 0.55; p = 0.003). In our study, patients who had had previous treatment for tuberculosis, who were 45-64 years of age or who had no history of alcohol abuse were more likely to have MDR-TB.
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Affiliation(s)
- I Suárez-García
- Department of Internal Medicine, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain.
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Sansone RA, Sansone LA. Alcohol/Substance misuse and treatment nonadherence: fatal attraction. PSYCHIATRY (EDGMONT (PA. : TOWNSHIP)) 2008; 5:43-46. [PMID: 19727260 PMCID: PMC2687090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Alcohol and substance misuse have a variety of potential ramifications. In this edition of The Interface, we discuss studies that relate to alcohol/substance misuse and medical treatment nonadherence. Despite illness type, population characteristics, or adherence measures, studies are fairly consistent-alcohol and substance misuse reduce patient adherence with medical treatment.This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care-two fields that are inexorably linked.
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Affiliation(s)
- Randy A Sansone
- Departments of Psychiatry and Internal Medicine, Wright State University School of Medicine in Dayton, Ohio; Psychiatry Education, Kettering Medical Center in Kettering, Ohio, USA.
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Hasker E, Khodjikhanov M, Usarova S, Asamidinov U, Yuldashova U, van der Werf MJ, Uzakova G, Veen J. Default from tuberculosis treatment in Tashkent, Uzbekistan; who are these defaulters and why do they default? BMC Infect Dis 2008; 8:97. [PMID: 18647400 PMCID: PMC2492865 DOI: 10.1186/1471-2334-8-97] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 07/22/2008] [Indexed: 11/17/2022] Open
Abstract
Background In Tashkent (Uzbekistan), TB treatment is provided in accordance with the DOTS strategy. Of 1087 pulmonary TB patients started on treatment in 2005, 228 (21%) defaulted. This study investigates who the defaulters in Tashkent are, when they default and why they default. Methods We reviewed the records of 126 defaulters (cases) and 132 controls and collected information on time of default, demographic factors, social factors, potential risk factors for default, characteristics of treatment and recorded reasons for default. Results Unemployment, being a pensioner, alcoholism and homelessness were associated with default. Patients defaulted mostly during the intensive phase, while they were hospitalized (61%), or just before they were to start the continuation phase (26%). Reasons for default listed in the records were various, 'Refusal of further treatment' (27%) and 'Violation of hospital rules' (18%) were most frequently recorded. One third of the recorded defaulters did not really default but continued treatment under 'non-DOTS' conditions. Conclusion Whereas patient factors such as unemployment, being a pensioner, alcoholism and homelessness play a role, there are also system factors that need to be addressed to reduce default. Such system factors include the obligatory admission in TB hospitals and the inadequately organized transition from hospitalized to ambulatory treatment.
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Affiliation(s)
- Epco Hasker
- Project HOPE Tuberculosis Control Program for the Central Asia Region, Almaty, Kazakhstan.
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