Tackling the spread of drug-resistant tuberculosis in Europe

Altered resting-state functional connectivity and dynamic network properties in cognitive impairment: an independent component and dominant-coactivation pattern analyses study

Introduction

Cognitive impairment (CI) due to Alzheimer's disease (AD) encompasses a decline in cognitive abilities and can significantly impact an individual's quality of life. Early detection and intervention are crucial in managing CI, both in the preclinical and prodromal stages of AD prior to dementia.

Methods

In this preliminary study, we investigated differences in resting-state functional connectivity and dynamic network properties between 23 individual with CI due to AD based on clinical assessment and 15 healthy controls (HC) using Independent Component Analysis (ICA) and Dominant-Coactivation Pattern (d-CAP) analysis. The cognitive status of the two groups was also compared, and correlations between cognitive scores and d-CAP switching probability were examined.

Results

Results showed comparable numbers of d-CAPs in the Default Mode Network (DMN), Executive Control Network (ECN), and Frontoparietal Network (FPN) between HC and CI groups. However, the Visual Network (VN) exhibited fewer d-CAPs in the CI group, suggesting altered dynamic properties of this network for the CI group. Additionally, ICA revealed significant connectivity differences for all networks. Spatial maps and effect size analyses indicated increased coactivation and more synchronized activity within the DMN in HC compared to CI. Furthermore, reduced switching probabilities were observed for the CI group in DMN, VN, and FPN networks, indicating less dynamic and flexible functional interactions.

Discussion

The findings highlight altered connectivity patterns within the DMN, VN, ECN, and FPN, suggesting the involvement of multiple functional networks in CI. Understanding these brain processes may contribute to developing targeted diagnostic and therapeutic strategies for CI due to AD.

An SVEIRE Model of Tuberculosis to Assess the Effect of an Imperfect Vaccine and Other Exogenous Factors

This study extends a deterministic mathematical model for the dynamics of tuberculosis transmission to examine the impact of an imperfect vaccine and other exogenous factors, such as re-infection among treated individuals and exogenous re-infection. The qualitative behaviors of the model are investigated, covering many distinct aspects of the transmission of the disease. The proposed model is observed to show a backward bifurcation, even when Rv<1. As such, we assume that diminishing Rv to less than unity is not effective for the elimination of tuberculosis. Furthermore, the results reveal that an imperfect tuberculosis vaccine is always effective at reducing the spread of infectious diseases within the population, though the general effect increases with the increase in effectiveness and coverage. In particular, it is shown that a limited portion of people being vaccinated at steady-state and vaccine efficacy assume a equivalent role in decreasing disease burden. From the numerical simulation, it is shown that using an imperfect vaccine lead to effective control of tuberculosis in a population, provided that the efficacy of the vaccine and its coverage are reasonably high.

The impact of a computerised decision support system on antibiotic usage in an English hospital

Background Antimicrobial resistance is correlated with the inappropriate use of antibiotics. Computerised decision support systems may help practitioners to make evidence-based decisions when prescribing antibiotics. Objective This study aimed to evaluate the impact of computerized decision support systems on the volume of antibiotics used. Setting A very large 1200-bed teaching hospital in Birmingham, England. Main outcome measure The primary outcome measure was the defined daily doses/1000 occupied bed-days. Method A retrospective longitudinal study was conducted to examine the impact of computerised decision support systems on the volume of antibiotic use. The study compared two periods: one with computerised decision support systems, which lasted for 2 years versus one without which lasted for 2 years after the withdrawal of computerised decision support systems. Antibiotic use data from June 2012 to June 2016 were analysed (comprising 2 years with computerised decision support systems immediately followed by 2 years where computerised decision support systems had been withdrawn). Regression analysis was applied to assess the change in antibiotic consumption through the period of the study. Result From June 2012 to June 2016, total antibiotic usage increased by 13.1% from 1436 to 1625 defined daily doses/1000 bed-days: this trend of increased antibiotic prescribing was more pronounced following the withdrawal of structured prescribing (computerised decision support systems). There was a difference of means of - 110.14 defined daily doses/1000 bed days of the total usage of antibiotics in the period with and without structured prescribing, and this was statistically significant (p = 0.026). From June 2012 to June 2016, the dominant antibiotic class used was penicillins. The trends for the total consumption of all antibiotics demonstrated an increase of use for all antibiotic classes except for tetracyclines, quinolones, and anti-mycobacterial drugs, whereas aminoglycoside usage remained stable. Conclusion The implementation of computerised decision support systems appears to influence the use of antibiotics by reducing their consumption. Further research is required to determine the specific features of computerised decision support systems, which influence increased higher adoption and uptake of this technology.

First-line tuberculosis drug resistance patterns and associated risk factors in Germany, 2008-2017

Background

Drug-resistant tuberculosis (TB), especially multidrug-resistant TB (MDR-TB), poses a threat to public health. While standard surveillance focuses on Rifampicin and/or Isoniazid resistance, little is known about other resistance patterns. This study aims to identify predominant drug resistance (DR) patterns in Germany and risk factors associated with them in order to inform diagnostic and treatment strategies.

Methods

Case-based TB surveillance data notified in Germany from 2008–2017 were utilized to investigate DR and MDR-TB patterns for Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), and Streptomycin (S). Predominant patterns were further analyzed stratified by sex, age, country of birth, prior TB, and disease site. Multivariable logistic regression was conducted to determine risk factors associated with any resistance, MDR-TB, and complete HRZES resistance.

Results

26,228 cases with complete DST results were included in the study, among which 3,324 cases had any DR (12.7%). Four patterns were predominant, representing about ¾ of all cases with any resistance (S: 814 [3.1%]; H: 768 [2.9%]; HS: 552 [2.1%]; Z: 412 [1.6%]). High proportions of S and H resistances were found among both German and foreign-born populations, especially those born in Eastern Europe, and were unexpectedly high among children (H: 4.3%; S: 4.6%). Foreign-born cases had significantly higher proportion of any resistance (16.0%) and MDR-TB (3.3%) compared to German-born cases (8.3% and 0.6%). Of 556 MDR-TB cases, 39.2% showed complete HRZES resistance. Logistic regression revealed having prior TB and being foreign-born as consistently strong risk factors for any DR, MDR-TB, and complete HRZES resistance.

Conclusions

DR patterns observed in Germany, particularly for MDR-TB were more complex than expected, highlighting the fact that detailed drug-testing results are crucial before incorporating HRZES drugs in MDR-TB treatment. Furthermore, the relatively high rate of H-resistance in Germany provides strong rationale against the use of only H-based preventive therapy for LTBI.

The perfect storm: incarceration and the high-risk environment perpetuating transmission of HIV, hepatitis C virus, and tuberculosis in Eastern Europe and Central Asia

Despite global reductions in HIV incidence and mortality, the 15 UNAIDS-designated countries of Eastern Europe and Central Asia (EECA) that gained independence from the Soviet Union in 1991 constitute the only region where both continue to rise. HIV transmission in EECA is fuelled primarily by injection of opioids, with harsh criminalisation of drug use that has resulted in extraordinarily high levels of incarceration. Consequently, people who inject drugs, including those with HIV, hepatitis C virus, and tuberculosis, are concentrated within prisons. Evidence-based primary and secondary prevention of HIV using opioid agonist therapies such as methadone and buprenorphine is available in prisons in only a handful of EECA countries (methadone or buprenorphine in five countries and needle and syringe programmes in three countries), with none of them meeting recommended coverage levels. Similarly, antiretroviral therapy coverage, especially among people who inject drugs, is markedly under-scaled. Russia completely bans opioid agonist therapies and does not support needle and syringe programmes-with neither available in prisons-despite the country's high incarceration rate and having the largest burden of people with HIV who inject drugs in the region. Mathematical modelling for Ukraine suggests that high levels of incarceration in EECA countries facilitate HIV transmission among people who inject drugs, with 28-55% of all new HIV infections over the next 15 years predicted to be attributable to heightened HIV transmission risk among currently or previously incarcerated people who inject drugs. Scaling up of opioid agonist therapies within prisons and maintaining treatment after release would yield the greatest HIV transmission reduction in people who inject drugs. Additional analyses also suggest that at least 6% of all incident tuberculosis cases, and 75% of incident tuberculosis cases in people who inject drugs are due to incarceration. Interventions that reduce incarceration itself and effectively intervene with prisoners to screen, diagnose, and treat addiction and HIV, hepatitis C virus, and tuberculosis are urgently needed to stem the multiple overlapping epidemics concentrated in prisons.

The global tuberculosis situation and the inexorable rise of drug-resistant disease

The highly cost-effective DOTS strategy helped to bring the global tuberculosis (TB) epidemic under control in many parts of the world; however, the emergence and spread of drug-resistant strains pose a major threat to these gains. Molecular epidemiology studies, together with recent genomic evidence, provide proof that some drug-resistant strains are highly transmissible with documented epidemic spread. The potential for epidemic replacement of drug-susceptible with drug-resistant strains provides strong motivation for renewed emphasis on TB drug and vaccine development. It also reflects the need for enhanced infection control measures in health care and congregate settings, especially in TB endemic areas. The exploration of preventive therapy options for close contacts of patients with infectious drug-resistant TB also warrants further exploration, in an attempt to break the transmission cycle. Increased population mobility and large scale cross-border migration imply that the inexorable rise of drug-resistant TB is not geographically confined; it is a global concern that poses a very real threat to TB endemic and non-endemic settings. Failure to find new solutions will compromise traditional TB control efforts and derail momentum toward future TB elimination.

Improving Control of Tuberculosis in Low-Burden Countries: Insights from Mathematical Modeling

Tuberculosis control and elimination remains a challenge for public health even in low-burden countries. New technology and novel approaches to case-finding, diagnosis, and treatment are causes for optimism but they need to be used cost-effectively. This in turn requires improved understanding of the epidemiology of TB and analysis of the effectiveness and cost-effectiveness of different interventions. We describe the contribution that mathematical modeling can make to understanding epidemiology and control of TB in different groups, guiding improved approaches to public health interventions. We emphasize that modeling is not a substitute for collecting data but rather is complementary to empirical research, helping determine what are the key questions to address to maximize the public-health impact of research, helping to plan studies, and making maximal use of available data, particularly from surveillance, and observational studies. We provide examples of how modeling and related empirical research inform policy and discuss how a combination of these approaches can be used to address current questions of key importance, including use of whole-genome sequencing, screening and treatment for latent infection, and combating drug resistance.

Supporting clinical management of the difficult-to-treat TB cases: the ERS-WHO TB Consilium

Multi-drug and extensively drug-resistant tuberculosis (MDR/XDR-TB) are considered a serious threat for TB control and elimination. The outcome of these patients is still largely unsatisfactory as of today, with treatment success rates being consistently below 50% at global level. The World Health Organization (WHO) recommends that management of MDR-TB cases is supported by a specialized team, including complementary medical professionals able to cover several perspectives (clinical, both for adults and children; surgical; radiological; public health; psychological; nursing, among others). Implementation of such a body (known as Consilium in most of the former Soviet Union countries) is often a pre-requisite to apply for international TB control funding and concessionally priced medicines to treat M/XDR-TB cases. The primary objective of the ERS/WHO TB Consilium is to provide clinical consultation for drug-resistant TB and other difficult-to-treat TB cases, including co-infection with HIV and paediatric cases. Through technical guidance to clinicians managing complex TB cases, the main contribution and outcome of the initiative will be a public health response aimed at achieving correct treatment of affected patients and preventing further development of drug resistance. The Consilum's secondary objective is to ensure monitoring and evaluation of clinical practices on the ground (diagnosis, treatment and prevention).

[Fight against tuberculosis in the world]

Tuberculosis (TB) in a major health problem in the world. WHO and its partners especially, the stop TB partnership launched numerous strategies against TB especially in the 1990. Strategy DOTS (directly observed therapy short course) was launched in 1995. One main key was the direct supervision of drug intake by patients. Progress was achieved but it was insufficient. A new strategy called "Stop TB Strategy 2006-2015" was launched in 2006 in the context of Millennium Development Goals (MDG) elaborated by United Nations. The common goals were to halt and start to reverse the incidence of TB, reduce the prevalence and death rate by 50% compared to their level in 1990 by 2015 to eliminate TB as a public health problem by 2050. The end of 2010 marks the mid-point of the Global Plan and is an obvious time to update it and take into account actual progress with a focus on the 2015 to reach goals. So an updated Global Plan to stop TB 2011-2015, was launched. Expected progress and targets were defined for 2015, in diagnosis and treatment, in co-infection TB/HIV, in drug-resistant TB and achievements expected in new tests for diagnosis, new medications, new vaccines and new regimens with shorter duration of treatment. WHO and partners have started discussions to define the new post 2015 strategy to TB control and elimination. Risk factors (diabetes, malnutrition, tobacco smoke…) and socioeconomic factors, which are associated with TB, should be included in the new strategy to eliminate TB in 2050.

Consolidated Action Plan to Prevent and Combat Multidrug- and Extensively Drug-resistant Tuberculosis in the WHO European Region 2011-2015: Cost-effectiveness analysis

Drug-resistant tuberculosis (TB) has increased at an alarming rate in the WHO European Region. Of the 27 countries worldwide with a high burden of multidrug resistant-TB (MDR-TB), 15 are in the European Region. An estimated 78,000 new cases of MDR-TB occur annually in the Region, of which approximately 10% are extensively drug-resistant (XDR)-TB. In response, the WHO Regional Office for Europe developed a Consolidated Action Plan to Prevent and Combat Multidrug- and Extensively Drug-resistant Tuberculosis (2011-2015). Our objective was to analyse the cost-effectiveness of implementing the plan, with the expected achievements of diagnosing 85% of estimated MDR-TB cases and treating at least 75% successfully. A transmission model, using epidemiological data reported to WHO was developed to calculate expected achievements. WHO-CHOICE database was used for cost analyses. The highly cost-effective plan is expected to prevent the emergence of 250,000 new MDR-TB and 13,000 XDR-TB patients respectively, saving US$7 billion and 120,000 lives. The plan and accompanying Resolution were fully endorsed by the sixty-first session of the WHO Regional Committee for Europe in 2011. Member States need to continuously improve health system performance and address TB determinants. Research and development of new medicines, tools and patient-friendly services are also crucial.

Epidemiology of tuberculosis in WHO European Region and public health response

PURPOSE

To provide an overview of the tuberculosis (TB) and multi-drug resistant tuberculosis (MDR-TB) in the WHO European Region and evolution of public health response with focus on extra-pulmonary tuberculosis and Pott's disease.

METHODS

Authors reviewed regional strategic documents related to TB. The epidemiologic data were reviewed and analyzed.

RESULTS

In the absence of associated pulmonary TB, Pott's disease is reported as extra-pulmonary TB (up to 47 % of all TB cases in some settings). Due to limitations of the surveillance system, the epidemiology of Pott's disease and its treatment success are unknown. The Stop TB Strategy and Consolidated Action Plan to Prevent and Combat M/XDR-TB provide comprehensive roadmaps to address all types of TB.

CONCLUSIONS

There is a need to further analyze country data to document the extent of Pott's disease and develop specific guidelines for timely diagnosis and treatment of Pott's disease.

European union standards for tuberculosis care

The European Centre for Disease Prevention and Control (ECDC) and the European Respiratory Society (ERS) jointly developed European Union Standards for Tuberculosis Care (ESTC) aimed at providing European Union (EU)-tailored standards for the diagnosis, treatment and prevention of tuberculosis (TB). The International Standards for TB Care (ISTC) were developed in the global context and are not always adapted to the EU setting and practices. The majority of EU countries have the resources and capacity to implement higher standards to further secure quality TB diagnosis, treatment and prevention. On this basis, the ESTC were developed as standards specifically tailored to the EU setting. A panel of 30 international experts, led by a writing group and the ERS and ECDC, identified and developed the 21 ESTC in the areas of diagnosis, treatment, HIV and comorbid conditions, and public health and prevention. The ISTCs formed the basis for the 21 standards, upon which additional EU adaptations and supplements were developed. These patient-centred standards are targeted to clinicians and public health workers, providing an easy-to-use resource, guiding through all required activities to ensure optimal diagnosis, treatment and prevention of TB. These will support EU health programmes to identify and develop optimal procedures for TB care, control and elimination.