Tuberculosis in Saudi Arabia: can we change the way we deal with the disease?

Pulmonary tuberculosis in a cohort of forensic autopsies: a preliminary study from Saudi Arabia

Aims

The purpose of this study was to identify any cases of previously undiagnosed pulmonary tuberculosis during autopsy.

Methods

This prospective study investigated a cohort of deceased individuals that underwent a full external and internal postmortem examination at the Forensic Medicine Centre, Dammam, Saudi Arabia. Gross pathology, histopathology and molecular pathology were used to identify pulmonary tuberculosis in forensic autopsy samples from the lungs.

Results

A total of 82 cases autopsied were included in the study. The mean ± SD age of the study cohort was 35.5 ± 10.3 years (range, 20–80 years). Males (n = 70; 85.37%) outnumbered females. The deceased were from 15 different countries. The number of Saudis was 16 (19.51%). The maximum number of non-Saudis was from India with 26 cases (31.71%). There were no cases of undiagnosed pulmonary tuberculosis detected for the first time at autopsy.

Conclusions

Although the prevalence of pulmonary tuberculosis in forensic autopsy cases in this preliminary study was nil, we recommend further studies to be conducted on a larger scale and in different autopsy centres throughout Saudi Arabia to get an insight into the burden of clinically undiagnosed tuberculosis in the entire country.

Study on Genotyping Polymorphism and Sequencing of N-Acetyltransferase 2 (NAT2) among Al-Ahsa Population

One of the well-studied phase II drug metabolizing enzymes is N-acetyltransferase 2 (NAT2) which has an essential role in the detoxification and metabolism of several environmental toxicants and many therapeutic drugs like isoniazid (antituberculosis, TB) and antimicrobial sulfonamides. According to the variability in the acetylation rate among different ethnic groups, individuals could be classified into slow, intermediate, and fast acetylators; these variabilities in the acetylation rate are a result of single nucleotide polymorphisms (SNPs) in the coding sequence of NAT2. The variety of NAT2 acetylation status is associated with some diseases such as bladder cancer, colorectal cancer, rheumatoid arthritis, and diabetes mellitus. The main objectives of this research are to describe the genetic profile of NAT2 gene among the people of the Al-Ahsa region, to detect the significant SNPs of this gene, to determine the frequency of major NAT2 alleles and genotypes, and then categorize them into fast, intermediate, and slow acetylators. Blood samples were randomly collected from 96 unrelated people from Al-Ahsa population, followed by DNA extraction then amplifying the NAT2 gene by polymerase chain reaction (PCR); finally, functional NAT2 gene (exon 2) was sequenced using the Sanger sequencing method. The well-known seven genetic variants of NAT2 gene are 191G>A, 282C>T, 341T>C, 481C>T, 590G>A, 803A>G, and 857G>A were detected with allele frequencies 1%, 35.4%, 42.7%, 41.1%, 29.2%, 51%, and 5.7%, respectively. The most common NAT2 genetic variant among Al-Ahsa population was 803A>G with a high frequency 0.510 (95% confidence interval 0.44-0.581) followed by 341T>C 0.427 (95% confidence interval 0.357-0.497). The most frequent two haplotypes of NAT2 were NAT2∗6C (25.00%) and NAT2∗5A (22.92%) which were classified as a slow acetylators. According to trimodal distribution of acetylation activity, the predicted phenotype of Al-Ahsa population was found to be 5.21% rapid acetylators, 34.38% intermediate acetylators, and 60.42% were slow acetylators. In addition, this study found four novel haplotypes NAT2∗5TB, NAT2∗5AB, NAT2∗5ZA, and NAT2∗6W which were slow acetylators. This study revealed a high frequency of the NAT2 gene with slow acetylators (60.42%) in Al-Ahsa population, which might alter the drug's efficacy and vulnerability to some diseases.

Six Years Trend Analysis of Tuberculosis in Northwestern Tigrai, Ethiopia; 2019: A Retrospective Study

BACKGROUND

Ethiopia is one of the 22 high tuberculosis burden countries. In our country. there are limited published data to show the trend analysis of tuberculosis. Hence, we designed this trend analysis to fill the information gap in our study area. Institutional based retrospective cross-sectional study was employed from 2013 to 2018 to determine the trend analysis of tuberculosis among tuberculosis presumptive clients in Northwestern Tigrai. We have used a standard checklist to extract the data. There were some missing data from the logbooks which are then excluded from the analysis.

RESULTS

A total of 7793 tuberculosis presumptive clients were requested for laboratory diagnosis of which about 7639 results had a valid result for X-pert MTB/Rif assay. The overall detection rate of tuberculosis was found to be 9.9% (756/7639). Of the total tuberculosis cases, 8.7 % (66/756) were rifampicin-resistant. The trend of tuberculosis across the six years was fluctuating with a declining trend in the recent three years. HIV infection and being presumptive to drug resistance were associated with tuberculosis detection.

CONCLUSION

Although there was a cumulative declining trend of tuberculosis within the last six years, prevention and control strategies still need to be improved to achieve the stop tuberculosis strategy. To create a world free of tuberculosis, there should be quality service provision regarding tuberculosis case detection and treatment.

Emergence of Heteroresistance Mycobacterium Tuberculosis in Saudi Arabia

PURPOSE

Heteroresistant Mycobacterium tuberculosis (MTB) is defined as a group of drug-susceptible and resistant bacteria in a single clinical specimen from tuberculosis (TB) patients. Heteroresistance of MTB is considered a preliminary stage to full resistance. The present study aimed to determine the heteroresistance in Mycobacterium tuberculosis in Tabuk province, in the north of the Kingdom of Saudi Arabia.

METHOD

GenoType MTBDRplus assay was used to determine mutations associated with isoniazid and rifampicin resistance.

RESULTS

A total number of 46 confirmed M. tuberculosis positive sputum samples were scanned for heteroresistance. The present study revealed 3 (6.5%) heteroresistant mutations to either rpoB gene alone, 2 (4.4%) to rpoB and 1 (2.2%) to inhA genes.

CONCLUSION

The detection of heteroresistant mutations could guide the initiation of an appropriate regimen of treatment.

The use of Quantiferon-TB gold in-tube test in screening latent tuberculosis among Saudi Arabia dialysis patients

BACKGROUND AND AIM

Screening for tuberculosis (TB) is a key strategy for controlling infection. This study aimed to detect latent TB among dialysis patients.

METHODS

This is a prospective study conducted in King Saud University, Riyadh involving hemodialysis (HD) and peritoneal dialysis (PD) patients aged ≥18 years. Patients were screened for latent TB infection (LTBI) using both TBskin test (TST) and QuantiFERONTB Gold In-Tube test (QFT-GIT). All participants were followed-up clinically and radiologically every 3 months for 2 years.

RESULTS

A total of 243 (181 HD and 62 PD) patients were included and 112(46.1%) were males. 45.3% showed positive QFT in HD patients with sensitivity of 91.7%, specificity of 71.4%, positive predictive value (PPV) of 19.5%, and negative predictive value (NPV) of 91.1%. TST results in HD showed that positive TST was 17.4%, sensitivity was 63.2%, specificity was 95.5%, PPV was 51.5%, and NPV was 91.1%. Five (8.1%) showed positive QFT in PD patients with sensitivity of 7.7%, specificity of 91.8%, PPV of 6.6%, and NPV of 92.3%. TST results in PD showed that positive TST was 9.8%, sensitivity was 35.7%, specificity was 97.9%, PPV was 55.8%, and NPV was 93.3%. Previous TB infection was significantly correlated with QFT only in HD patients, but significantly associated with TST in both HD and PD patients. Also in HD, QFT was significantly associated with TST (P = 0.043).

CONCLUSIONS

Due to high variability of QFT-GIT sensitivity, we recommend its use for its NPV and to use either TST or QFT in screening latent TB.

Correlation between Resistin, Tuberculosis and Khat Addiction: A Study from South Western Province of Saudi Arabia

Tuberculosis(TB) is a disease of global significance, which accounts for a death in every 15 seconds. Recent studies shows TB is rising in certain parts of the world, and Saudi Arabia is one of them. Several factor contribute in predisposing the subjects for infection including but not limited to addiction to various compounds which have immune modulation properties, such as amphetamines and Heroin etc. Khat a plant whose leaves are chewed for its euphoric effect in east Africa and Arabian Peninsula including Saudi Arabia, is considered as mildly addictive, and its principle compound, Cathinone shares structural and functional similarity with amphetamine a known immunomodulator. Tuberculosis being a disease of immune modulation has a varied spectrum of complex interplay of proinflammatory molecules, resistin is one of them. In the present study, we try to explore the trinity of khat addiction, serum resistin level and tuberculosis by correlating the serum resistin level in non khat addicted healthy subjects, khat addicted healthy subjects, and in patients, both khat addicted and non khat addicted, with active tuberculosis. We observed significantly higher resistin level among the apparently healthy khat addicted subjects as compared to non addicted healthy controls. Thereafter, when we compare the resistin levels between khat addicted and non khat addicted TB patients we did not found significant difference between the two groups. However bacillary load was observe to be significantly higher among the khat addicted TB patient as compare to non addicted one. Validation of above results in animal model revealed dose dependant increase in bacillary growth in the Wistar rats treated with khat. Taken together these results suggest the role of khat in immune modulation albeit in the limited frame of resistin level.

Low rate of non-compliance to antituberculous therapy under the banner of directly observed treatment short course (DOTS) strategy and well organized retrieval system: a call for implementation of this strategy at all DOTS centers in Saudi Arabia

Introduction

The objective of this study was to show the effectiveness of revised retrieval system on non-compliance.

Methods

We retrospectively evaluated the effectiveness of a revised retrieval system on non-compliance during continuous phase of antituberculous treatment (Jan-2005 to Dec-2010) compared to baseline non-compliance (Jan-2002 to Dec-2004).

Results

In the baseline period, 141 of 501 (28%) patients did not attend their first appointment. Of these 141 patients, 63 (45%) patients could be brought back to treatment while 78 patients (16%) dropped out and could not be retrieved. During the 2nd phase after launching a revised retrieval system, 98 of 835 (13%) patients did not attend their first appointment. Using the retrieval system, 79 (81%) patients were brought back for regular follow up, and 19 patients could not be retrieved, a dropout rate of 2.27%. By virtue of revised retrieval system, there was a significant drop in non-compliance by 15% and a decline in net dropout rate by 14%. The number of those brought back to treatment by revised retrieval system almost doubled (81%) compared to 44% retrieval in initial period.

Conclusion

The revised retrieval system had a significant impact on the reduction of dropout rate and significant improvement in the retrieval of those patients.

Systematic review of the prevalence of Mycobacterium tuberculosis resistance in Saudi Arabia

AIM

To quantitatively estimate the prevalence of resistance of Mycobacterium tuberculosis (TB) to first line agents in Saudi Arabia.

METHODS

The overall prevalence of M. tuberculosis resistance was calculated using meta-analysis.

RESULTS

We included 22 studies from Saudi Arabia that were published from 1979 to 2013.A high degree of heterogeneity among studies was observed. Based on random effect methodology, the prevalence (and 95% CI) of the resistance rates were: INH 10.13 (8.13-12.11), rifampicin 5.41 (4.21-6.61), ethambutol 1.29 (1.83-2.37) and streptomycin 6.5 (4.9-8.1), and multi-drug resistant was 6.7 (5.1-8.3).

CONCLUSION

The prevalence of resistance to anti-tuberculous agents was highest for INH followed by streptomycin and rifampicin. Multi-drug resistant tuberculosis remains at 6.7%. The data support the recommendations to use four anti-tuberculous agents as empiric therapy.

Evaluation of tuberculosis public health surveillance, Al-Madinah province, Kingdom of Saudi Arabia, 2012

The objective of the study is to evaluate the quality of the data, the sensitivity of the surveillance, and the completeness of identification and investigation of tuberculosis (TB) patient's contacts. The study covered the TB surveillance program in Al-Madinah province in 2011. First, we reviewed all the notifications, treatment cards, and register books, as well as monthly and quarterly reports, for completeness and accuracy of data. Then, we searched for the missed cases that were not reported. Finally, we reviewed all the patients' household contacts' reports to assess the degree of completion of identification and investigation. There were 444 cases detected during the study period; only 200 cases were reported. The sensitivity of the TB surveillance system was 45%. Among the 200 reported cases, the results revealed high completeness rates for demographic and disease data and low completeness rates for the test result fields. The contact identification and investigation showed that 34.4% of smear-positive cases' contacts were not identified. Only 67% of identified contacts were investigated. The review of hospital records and lab registers showed that 244 cases were not reported. In conclusion, the TB surveillance system has several areas that need improvement.

Anti-tuberculous activity of treponemycin produced by a streptomyces strain MS-6-6 isolated from Saudi Arabia

A Streptomyces strain MS-6-6 with promising anti-tuberculous activity was isolated from soil samples in Saudi Arabia. The nucleotide sequence of its 16S rRNA gene (1426 bp) evidenced a 100% similarity to Streptomyces mutabilis. Through an anti-tuberculous activity-guided approach, a polyketide macrolide was isolated and identified as treponemycin (TP). The structure of the isolated compound was determined by comprehensive analyses of its 1D and 2D NMR as well as HRESI-MS. In addition to the promising anti-tuberculous activity (MIC = 13.3 µg/mL), TP showed broad spectrum of activity against the Gram positive, Gram negative strains, and Candida albicans. Improvement of TP productivity (150%) was achieved through modification in liquid starch nitrate medium by replacing KNO3 with corn steep liquor and yeast extract or tryptone, and removing CaCO3 and K2HPO4. The follow up of TP percentage as well as its metabolites profile for each media was assessed by LC/DAD/MS.

Does khat chewing increases the risk of Mycobacterium tuberculosis infection by macrophage immune modulation?

Drug abuse is a serious problem associated with different pathological outcomes including modulating the immune system. Drug abuse is rising in Saudi Arabia and so as TB, a disease of worldwide significance, caused by immunological modulation in the host system. Khat chewing is a common practice in Arabian Peninsula which is now gaining momentum in other parts of the world. It is considered as an addiction. It has been associated with different adverse outcomes such as periodontitis, oral leukoplakia and oral cancer and also has shown to promote apoptotic cell death through cysteine proteases. The active ingredient of khat, cathinone is shown to have immunomodulatory effect. In principle, this leads to enhanced susceptibility to various infections. The present study is designed to delineate the mechanism of immunomodulation produced by khat/cathinone in human/mouse macrophage. Further, this activity will be evaluated both in vivo and in vitro in response to infection with Mycobacterium smegmatis to get an insight if there exists a co relation between the Mycobacterium tuberculosis infection and khat chewing.

Molecular epidemiology and genotyping of Mycobacterium tuberculosis isolated in Baghdad

Tuberculosis (TB) remains a major health problem in Iraq but the strains responsible for the epidemic have been poorly characterized. Our aim was to characterize the TB strains circulating in Bagdad (Iraq). A total of 270 Mycobacterium tuberculosis complex (MTBC) strains isolated between 2010 and 2011 from TB patients attending the Center of Chest and Respiratory diseases in Baghdad were analyzed by Spoligotyping. The analysis indicated that 94.1% of the isolates belong to known genotype clades: CAS 39.6%, ill-defined T clade 29.6%, Manu 7.4%, Haarlem 7%, Ural 4.1%, LAM 3.3%, X 0.7%, LAM7-TUR 0.7%, EAI 0.7%, S 0.7%, and unknown 5.9%. Comparison with the international multimarker database SITVIT2 showed that SIT 309 (CAS1-Delhi) and SIT1144 (T1) were the most common types. In addition, 44 strains were included in SITVIT2 database under 16 new Spoligotype International Types (SITs); of these, 6 SITs (SIT3346, SIT3497, SIT3708, SIT3790, SIT3791, and SIT3800) (n = 32 strains) were created within the present study and 10 were created after a match with an orphan in the database. By using 24-loci MIRU-VNTR-typing on a subset of 110 samples we found a high recent transmission index (RTI) of 33.6%. In conclusion, we present the first unifying framework for both epidemiology and evolutionary analysis of M. tuberculosis in Iraq.

Population dynamics and tuberculosis: a cross sectional study of an overlooked disease in Saudi Arabia

BACKGROUND

International travel, migration and human population movements facilitate the spread of tuberculosis (TB).

OBJECTIVE

To study the impact of poorly screened expatriates working in Saudi Arabia on the local incidence of TBs.

PATIENTS AND METHODS

This cross sectional study was carried out in the Chest Disease Hospital, Taif. All confirmed cases of TB from June 2009 to May 2010 admitted to the hospital were enrolled. Inclusion criteria were diagnosed cases of TB (pulmonary & extra-pulmonary) in patients between the ages of 14 to 65 years. Patients with HIV and coexistent malignancies were excluded. The age, gender and ethnic group of each patient was recorded, and patients were divided into two groups. Of the two groups, Group A consisted of Taif residents and group B of patients referred from other cities in the country.

RESULTS

Of the 686 cases studied, 370 (54%) were Saudi nationals (Group A = 80 & Group B = 290) and 316 (46%) cases were from other countries. Males outnumbered females and most of the patients were aged 20 to 29 years. The number of cases from the areas close to the pilgrimage sites, i.e. Makah (233) and Jeddah (275), outnumbered those in Taif (110).

CONCLUSIONS

Our study identifies an increased prevalence of TB cases in areas close to the pilgrimage (Group B). The higher proportion of non-Saudi TB patients in group B is most likely explained by the higher number of poorly screened illegal expatriates in the region.

Infectious diseases in the Arabian Peninsula and Egypt

Infectious diseases are important causes of morbidity and mortality globally. Epidemiologically, differences in the patterns of infectious diseases and antimicrobial resistance exist across diverse geographical regions. In this review on infectious diseases in the Arabian Peninsula and Egypt, the epidemiology of tuberculosis, malaria and human immunodeficiency virus (HIV) infections will be addressed. The challenges of the hepatitis C epidemic in Egypt and the epidemiology of this infection across the region will be reviewed. In recent years, we have seen dengue endemicity become established, with major outbreaks in parts of the region. Emerging data also indicate that, across the region, there is an increasing burden of antibiotic resistance, with endemicity in healthcare settings and dissemination into the community. New challenges include the emergence of the Alkhurma haemorrhagic fever virus in Saudi Arabia. The annual Hajj pilgrimage in Saudi Arabia serves as a model for the control of infectious disease in mass gatherings. As most of these countries constantly experience a uniquely dynamic population influx in the form of expatriate workers, tourists, or pilgrims, concerted regional and international collaboration to address these public health concerns in a region that lies at the crossroads for the global spread of infectious pathogens is imperative.

Tuberculosis in Saudi Arabia: prevalence and antimicrobial resistance

Tuberculosis is a serious contagious disease caused by Mycobacterium tuberculosis and is endemic in many countries. Over the past two decades, there has been an increase in the number of multidrug-resistant TB and extensively drug-resistant TB cases around the world. As in many countries, TB is common in Saudi Arabia. The disease is particularly relevant in the Kingdom because of its population dynamics including a large number of resident expatriates mainly from TB endemic regions and the influx of millions of pilgrims to the country each year during the Hajj and Umrah seasons. This review investigates the prevalence and antimicrobial resistance among M. tuberculosis isolates from Saudi Arabia, highlighting the variations in rates in different geographical areas with particularly high rates in the main cities and regions hosting the annual pilgrimage. The review also refers to the measures needed to prevent and control TB transmission in the country.

Tuberculosis trends in Saudis and non-Saudis in the Kingdom of Saudi Arabia--a 10 year retrospective study (2000-2009)

BACKGROUND

Tuberculosis (TB) remains a public health problem in the Kingdom of Saudi Arabia (KSA), which has a very large labour force from high TB endemic countries. Understanding the epidemiological and clinical features of the TB problem, and the TB burden in the immigrant workforce, is necessary for improved planning and implementation of TB services and prevention measures.

METHODS

A 10 year retrospective study of all TB cases reported in KSA covering the period 1st January 2000 to 31st December 2009. Data was obtained from TB reporting forms returned to the Ministry of Health. Data were then organised, tabulated and analysed for annual incidence rates by province, nationality, country of origin and gender.

RESULTS

There was an annual increase in the number of TB cases registered from 3,284 in 2000 to 3,964 in 2009. Non-Saudis had nearly twice the TB incidence rate compared to Saudis (P = <0.05). All but four provinces (Najran, Riyadh, Makkah, Tabuk) showed decreasing TB incidence rates. The highest rates were seen in the 65+ age group. In the 15-24 year age group the incidence rate increased from 15.7/100,000 in 2000 to 20.9/100,00 in 2009 (P = <0.05). The incidence of TB in Saudi males was higher than Saudi females. Conversely, for non-Saudis the TB incidence rates were significantly higher in females compared to males.

CONCLUSIONS

Despite significant investments in TB control over 15 years, TB remains an important public health problem in the KSA affecting all age groups, and Saudis and non-Saudis alike. Identification of the major risk factors associated with the persistently high TB rates in workers migrating to KSA is required. Further studies are warranted to delineate whether such patients re-activate latent Mycobacterium tuberculosis (M.tb) infection or acquire new M.tb infection after arrival in KSA. Appropriate interventions are required to reduce TB incidence rates as have been implemented by other countries.

Primary anti-tuberculous drugs resistance of pulmonary tuberculosis in Southwestern Saudi Arabia

The emergence of drug-resistant tuberculosis (TB) is an increasing problem which adversely affects patient care and public health. This study aimed to determine the rates and patterns of primary anti-TB drugs resistance in Najran, Southwestern Saudi Arabia. The study included 80 smear-positive new pulmonary TB patients. Sputum samples were cultured on Lowenstein-Jensen and Middle-Brook 7H10 media. Mycobacterium tuberculosis susceptibility testing was done by the conventional agar proportion method for isoniazide (INH), rifampicin (RIF), streptomycin (SPM) and ethambutol (EMB). Out of the 68 M. tuberculosis isolates, 42 (61.8%) were sensitive to all 4 drugs and 26 (38.2%) were resistant to one or more drugs. The most common resistance was found to INH (33.8%), followed by RIF (23.5%), SPM (13.2%) and EMB (2.9%). Eight (11.8%) isolates were resistant to one drug, 14 (20.6%) were resistant to 2 drugs, 3 (4.4%) were resistant to 3 drugs and one (1.5%) was resistant to 4 drugs. Multi-drug resistant (MDR) isolates were found in 14 (20.6%) cases. In conclusion, the primary resistance rate to four first-line anti-tuberculous drugs and MDR-TB rate are worryingly high, representing an alarming situation in Najran. Further studies are necessary for continuous surveillance of M. tuberculosis resistance patterns.

Outbreak of Bacille Calmette-Guérin-related lymphadenitis in Saudi children at a university hospital after a change in the strain of vaccine

BACKGROUND AND OBJECTIVES

Bacille Calmette-Guérin (BCG) vaccination is part of the expanded program of vaccination in Saudi Arabia. Lymphadenitis is the most common complication of the BCG vaccine. We observed an increase in the rate of BCG lymphadenitis that coincided with the introduction of a new strain of BCG vaccine. The aim of this study was to determine the incidence and the possible causes of BCG lymphadenitis at a university hospital in Riyadh, Saudi Arabia.

DESIGN AND SETTING

Retrospective chart review and prospective follow up of infants who received BCG vaccine.

METHODS

We studied all infants presenting with suppurative or nonsuppurative adenopathy with nodes age;2 cm seen at the infectious diseases clinic at KKUH. The study duration was divided into two periods. The first period reviewed infants who received different BCG vaccine strains between January 2002 and December 2007. The second study period was conducted after close evaluation of the BCG administration technique of the vaccinating staff and reviewed infants who received the BCG SSI Danish strain 1331 between January 2008 and December 2010.

RESULTS

During the study period from January 2002 to December 2007, 19 402 infants received four different BCG vaccine strains. Eight infants developed BCG lymphadenitis, and all were associated with the BCG SSI vaccine. The incidence rate in 2007 was 1.96 per 1000. In the second period, 66 of 9921 infants who received the BCG SSI vaccine developed BCG lymphadenitis between January 2008 and December 2010. The incidence rate was 10.14 per 1000 in 2010.

CONCLUSION

We conclude that receipt of the BCG SSI vaccine might have contributed to the increased incidence of lymphadenitis in these children. Hence, caution should be exercised in switching from one vaccine to another, as is often done in developing countries.