Multi-drug resistant tuberculosis in migrants

Multidrug-resistant tuberculosis in Western Australia, 1998-2012

OBJECTIVE To describe the epidemiology, clinical features, health care resource use, treatment and outcomes of multidrug-resistant tuberculosis (MDR-TB) cases diagnosed in Western Australia, compared with matched controls with drug-susceptible TB.

DESIGN, SETTING AND PATIENTS

Retrospective case-control study of all MDR-TB cases notified in WA between 1 January 1998 and 31 December 2012, compared with matched controls. Cases were identified and managed through the Western Australia Tuberculosis Control Program, including specialist TB services, the Mycobacterium Reference Laboratory and affiliated secondary and tertiary outpatient and inpatient medical services in WA.

MAIN OUTCOME MEASURES

Demographic characteristics, clinical manifestations, treatment, outcomes and health care resource use.

RESULTS

Sixteen MDR-TB cases were notified during the study period (1.2% of all TB notifications). The median age of patients with MDR-TB was 26 years, and 15 were born outside Australia. Patients with MDR-TB were more likely to have received previous treatment (25% v 2%; P = 0.006) and had longer delays to effective therapy (median, 48 v 21 days; P = 0.002) than controls. MDR-TB patients more frequently required hospitalisation (100% v 35%; P < 0.001) and were treated for longer (mean, 597 v 229 days). Adverse effects were more commonly reported in MDR-TB patients than controls (81% v 33%; P < 0.001). Treatment success was not significantly different between patients with MDR-TB and controls (75% v 84%; P = 0.72). No treatment failures or deaths were identified in either group.

CONCLUSION

MDR-TB remains uncommon in WA but its challenges are increasingly recognised. Despite delays in commencing effective therapy, MDR-TB is usually associated with treatment success. Adverse effects of medications are common, and treatment courses are long and complex. Specialist TB services should continue to be involved in management and prevention of all cases of MDR-TB.

Migrant health in New Zealand: exploring issues concerning medicines access and use

Objectives

Every year a cohort of new migrants enters New Zealand (NZ), bringing challenges that impact on medicines use and health outcomes. The prescribing of medicines is a common therapeutic intervention and access to medicines and optimal use cannot be assumed for these populations. Internationally the literature exploring issues relating to medicines access and use by migrants in high-income countries is scarce. This study aims to explore attitudes, beliefs and perceptions of a cohort of migrants about medicines access and use in NZ.

Methods

A qualitative research methodology was employed with participants being recruited through snowballing techniques and interviewed (seven Indian and four Chinese). Following consent, a semi-structured guide was used for discussions. Themes were developed from codes based on the guide. These themes were developed by two members of the research team and reviewed by a third member.

Results

Emergent themes reflected the following dialogue: (a) financial barriers: paying doctor and pharmacist, lack of affordability of over-the-counter medicines, sharing medicines with family and friends; (b) information transfer and knowledge of rules, systems and initiatives, particularly regarding subsidies and brand switching; (c) misconceptions due to culture and language barriers, including not understanding information and lack of compliance in symptom-free disease; (d) perceptions of high quality in prescription medicines; (e) non-disclosure of traditional medicine use and (f) variability of community pharmacy service provision, especially counselling.

Conclusions

Significant barriers to access and optimal use of medicines by new migrants in NZ were identified. Policy change and educational interventions are likely to be required to improve medicines-related health care to migrant New Zealanders. Future research will need to quantify the extent of the issues and interventions should be developed and evaluated as ongoing research.

Culture-positive tuberculosis in Western Australia

Notifications of 485 patients with culture-positive tuberculosis (TB) in Western Australia from 1980 to 1989 inclusive have been analysed. In 478 (98.6%) the disease was caused by Mycobacterium tuberculosis hominis and in seven (1.4%) M. bovis. Most (78.5%) of the disease was pulmonary with 4.3% pleural and 17.2% extrapulmonary. The annual incidence decreased from 4.6 per 100,000 in 1980 to 2.5 in 1985 steadying thereafter around 3.3. The Aborigines had over four times the average incidence of the non-Aboriginal Australians but less than a quarter that of the Asians. In a total 297 migrants, 51% of 253 with data available had been in Australia for over five years. Initial drug resistance was found in 48 patients giving an overall rate of 9.9%. In 32 (66.7%), resistance was against a single drug, mainly isoniazid and in 11 (22.9%) against two drugs, predominantly isoniazid and streptomycin. The most disturbing finding was the occurrence of multiple-drug resistance including both isoniazid and rifampicin in five immigrants (10.4%). This study has provided useful baseline TB data, raised important issues such as chemoprophylaxis and drug resistance, and clearly indicates that the campaign against TB is far from over. Continual surveillance, monitoring and regular evaluation of existing policies should be maintained.