Rates of drug resistance and risk factor analysis in civilian and prison patients with tuberculosis in Samara Region, Russia

Multi-drug-resistant tuberculosis and its associated factors among pulmonary tuberculosis patients linked to first-line anti-tuberculosis drugs in north-west Ethiopia

Introduction. Multi-drug-resistant tuberculosis (MDR-TB) is an emerging global challenge. Ethiopia is one of the 20 top countries with the highest estimated numbers of incidents of MDR-TB. Recently, the World Health Organization warned that drug-resistant TB is escalating and called for concerted action to reduce the spread of drug resistance.Hypothesis. The current study investigated MDR-TB in patients receiving first-line anti-TB drug treatment and associated factors.Aim. The study aimed to determine the prevalence of MDR-TB and its associated factors among smear-positive pulmonary TB patients receiving first-line anti-TB drug treatment.Methodology. An institution-based cross-sectional study was employed. All data were collected from laboratory result log books and information via a questionnaire. Samples from 205 smear-positive pulmonary TB patients were selected among first-line drug treatment by a systematic sampling method. Specimens were transported to Felege Hiwot referral hospital laboratory for GeneXpert testing. Factors associated with an outcome variable in binary multi-variable logistic regression analysis at P<0.05 were considered statistically significant variables. An ethical approval letter was taken to the respective health facility and written consent was obtained from each participant.Results. The overall prevalence of MDR-TB was 9.3 % (95 % CI, 5.4 13.7 %). Sign and symptom experience of anti-TB drug side effects [adjusted odds ratio (AOR)=0.18, 95 % CI=0.03-0.99, P=0.049] and co-morbidity (AOR=0.03, 95 % CI=0.01-0.55, P=0.02) were statistically associated with the development of MDR-TB infectionConclusion. The prevalence of MDR-TB was high (9.3 %) and contributed highly to new cases (8.3 %). Factors associated with MDR-TB were previous treatment, co-morbidity and laboratory diagnosis method prior to TB treatment. Therefore, this finding aims to maximize early detection and treatment, strengthening TB infection control, and proper implementation of directly observed therapy short course recommendations to reduce the burden of MDR-TB.

Prevalence, drug-susceptibility pattern and associated factors of Mycobacterium tuberculosis infection among prisoners in western Arsi zonal prisons, Oromia, South West Ethiopia

Objectives

Each year, tuberculosis (TB) in prisons is a major worldwide health concern that results in millions of diseases. It is particularly prevalent in low socio-economic countries like Ethiopia because of the poverty, overcrowding, starvation, lack of access to basic healthcare services, and high prevalence of HIV infection in these countries.

Methods

A cross-sectional study with 259 prisoners was carried out in the western Arsi zonal prison from November to January 2021. The sputum samples were taken from suspected TB patients and evaluated using the Gene Xpert Mycobacterium tuberculosis/rifampcine test. Line probe assay was used to assess the molecular drug susceptibility of isolates from positive sputum. A bivariate and multivariate logistic regression was analyzed using SPSS version 24 packages. Odds ratio (OR) and corresponding 95% CI were used to quantify the degrees of association between target potential risk factors and Mycobacterium tuberculosis positivity. P-value of less than 0.05 was considered statistically significant.

Results

The prevalence of undiagnosed pulmonary TB (PTB) verified positive cases was 5.4% (95% CI 2.7, 8.5) out of 259 research participants that were recruited in this study. One (0.38%) occurrence of mono-drug resistance to isoniazid was found among them. In this study, variables that were significantly linked with PTB positive were age ≥30 years, smoking (adjusted OR [AOR] = 0.087, 95% CI = 0.01-0.93, P = 0.043), body mass index 18.5 kg/m2, cough duration 4 weeks (AOR = 0.03, 95% CI = 0.1-0.13 P = 0.001), and coughing before incarceration (AOR = 6.2, 95% CI = 3.6-10.59, P = 0.004).

Conclusion

In West Arsi zonal prisons, PTB and mono-drug resistance for isoniazid were found to be more common than in the general population.

Planning and development of an antimicrobial stewardship program in penitentiary facilities: strategies to optimize therapeutic prescribing and reduce the incidence of antibiotic resistance

Introduction

In correctional facilities, due to the high incidence of bacterial infections, antibiotics are widely prescribed. As a result, it may occur a massive and improper use of antibiotics, which promotes the development of antibiotic-resistant bacteria. However, in literature, specific experiences, interventions or guidelines aimed to optimize their prescription within prisons are sporadic.

Objectives

In an Italian hospital where belong patients from four penitentiary institutions, a multidisciplinary team has implemented an antimicrobial stewardship project. The aim of the project was to reduce the incidence of antibiotic resistance in penitentiary institutions by optimizing and rationalizing antibiotic prescribing.

Methods

Following the analysis of microbiological prevalence and antibiotic consumption data within correctional facilities, the Antimicrobial Stewardship Team developed operational tools to support prison healthcare staff to manage properly antibiotic therapies.

Results

The analysis showed a gradual increase in antibiotic resistance: in 2021 the prevalence of resistant microorganisms was 1.75%, four times higher than in 2019. In contrast, between 2019 and 2021, antibiotic consumption decreased by 24%. Based on consumption data, pharmacy has drafted an antibiotic formulary for correctional facilities, supplemented with guidelines and data sheets, and also developed a prescription form for critical antibiotics.

Conclusion

Results showed an increasing incidence of antibiotic resistance within prisons, highlighting the need to establish a dedicated antimicrobial stewardship program. This project may impact positively not only on prisoners, but also for the entire community, as prisons can be considered as places of health education and promotion.

Tuberculosis Notification Trends and Treatment Outcomes in Penitentiary and Civilian Health Care Sectors in the WHO European Region

SETTING

Tuberculosis (TB) morbidity in penitentiary sectors is one of the major barriers to ending TB in the World Health Organization (WHO) European Region.

OBJECTIVES AND DESIGN

a comparative analysis of TB notification rates during 2014-2018 and of treatment outcomes in the civilian and penitentiary sectors in the WHO European Region, with an assessment of risks of developing TB among people experience incarceration.

RESULTS

in the WHO European Region, incident TB rates in inmates were 4-24 times higher than in the civilian population. In 12 eastern Europe and central Asia (EECA) countries, inmates compared to civilians had higher relative risks of developing TB (RR = 25) than in the rest of the region (RR = 11), with the highest rates reported in inmates in Azerbaijan, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, and Ukraine. The average annual change in TB notification rates between 2014 and 2018 was -7.0% in the civilian sector and -10.9% in the penitentiary sector. A total of 15 countries achieved treatment success rates of over 85% for new penitentiary sector TB patients, the target for the WHO European Region. In 10 countries, there were no significant differences in treatment outcomes between civilian and penitentiary sectors.

CONCLUSION

42 out of 53 (79%) WHO European Region countries reported TB data for the selected time periods. Most countries in the region achieved a substantial decline in TB burden in prisons, which indicates the effectiveness of recent interventions in correctional institutions. Nevertheless, people who experience incarceration remain an at-risk population for acquiring infection, developing active disease and unfavourable treatment outcomes. Therefore, TB prevention and care practices in inmates need to be improved.

Effects of cigarette smoke on the administration of isoniazid and rifampicin to macrophages infected with Mycobacterium tuberculosis

BACKGROUND

Smoking is a cause behind many diseases, including tuberculosis, and it is a risk factor for tuberculosis infection and mortality. Moreover, smoking is associated with a poor tuberculosis treatment outcome.

OBJECTIVES

In this study, we focus on the effects of cigarette smoke on an infected cell culture treated with anti-tuberculosis drugs.

MATERIALS AND METHODS

Cytotoxicity on THP-1, J774A.1 and MH-S cell lines and growth of Mycobacterium tuberculosis exposed to a reference or a commercial cigarette was evaluated. THP-1 cell line was exposed to cigarette smoke, infected with Mycobacterium tuberculosis and treated with anti-tuberculosis drugs. Apoptosis and death cell were also tested on M. bovis BCG infected cells. Minimal inhibitory concentrations of anti-tuberculosis drugs were analyzed.

RESULTS

All cells lines showed viability values higher than 80% when exposed to cigarette smoke extract. However, THP-1 cell line infected with M. bovis BCG and exposed to Marlboro cigarette smoke showed up to a 54% reduction of apoptotic cells than cells unexposed to smoke. M. tuberculosis exposed to Marlboro cigarette smoke for 11 days had an optical density 16% lower than unexposed bacteria. When cells were infected with M. tuberculosis, the intracellular recovery of CFUs showed up to a 0.66 log reduction in cells exposed to cigarette smoke extract because of a potential impairment in the phagocytosis. Macrophages treated with drugs showed up to a 2.55 log reduction in the intracellular load burden compared with non-treated ones. Despite poor treatment outcome on TB smoker patients, minimal inhibitory concentration of rifampicin increased only 2-fold in M. tuberculosis exposed to cigarette smoke.

CONCLUSION

Smoking interferes with tuberculosis treatment impairing the immunity of the host.

Prevalence and Determinants of Multidrug-Resistant Tuberculosis in Makkah, Saudi Arabia

Background and Objectives

Tuberculosis (TB) is a global public health issue. The emergence of multidrug-resistant (MDR) TB has further complicated the situation in the form of poor treatment outcomes and costs to individuals and health-care systems. We therefore aimed to measure the prevalence and associated risk factors of MDR TB among TB patients in Makkah city.

Patients and Methods

This was a cross-sectional study conducted at Al-Noor Specialist Hospital, a public-sector hospital in Makkah. We included records of 158 confirmed TB patients from the list of all patients admitted in the hospital from January 2009 to January 2019 by systematic random sampling. Data were collected on socio-demographics, clinical profile and drug resistance patterns. Analysis was done in SPSS version 21.0.

Results

The mean age of the participants was 43.4 ± 18.7 years, and two-thirds (66.5%) were male. About 40% of the patients had chronic disease while lung disease other than TB was present in 5% patients. About 13% of cases were extrapulmonary infections. Prevalence of drug resistance was found to be 17.1% among TB patients. Among the resistant cases, streptomycin (25.9%) and isoniazid (11.1%) were the drugs most commonly affected by resistance. Prevalence of MDR TB was 5% among TB patients. Age, smoking, lung disease and previous TB were significant factors associated with MDR TB.

Conclusion

Prevalence of MDR TB, although comparable to current national estimates, is higher compared to previous reports. There is a need to reduce this burden through strengthening TB control programs to prevent further emergence of a public health threat of MDR TB. History of previous TB was the strongest risk factor in this study. This calls physicians, program managers and policy makers to focus on counselling and support of TB patients for compliance with the regimen to complete treatment without interruption.

Strategies for smoking cessation (pharmacologic intervention versus enhanced motivation vs. standard motivation) in TB patients under treatment in the RNTCP, India - A cluster - Randomized trial

BACKGROUND

Tuberculosis burden is still high and smoking prevalence among males has increased in India. It is found that increased morbidity, mortality and relapse among TB smokers.

METHOD

Setting: Patients from two Revised National Tuberculosis Control Program Centres of Tamilnadu form the study population.

OBJECTIVE

To compare the effectiveness of Bupropion therapy along with standard counselling versus enhanced counseling versus standard counseling for smoking cessation among TB patients.

STUDY DESIGN

Cluster randomized effectiveness trial.

PROCEDURE

Patients from each of the thirty-six Designated Microscopic Centres were randomly allocated to receive one of the three interventions using cluster randomization. Smoking cessation was assessed by self-reporting and confirmed by Carbon monoxide(CO) monitors, done at three-time points and TB treatment outcome at the end of ATT.

RESULTS

Out of 517 male patients enrolled to the study, the smoking status is available only to 381 subjects. The proportion of patients who have quit smoking in drug, enhanced and standard arms at the end of treatment was 67%, 83% and 52% (P= < 0.001). There was no statistical significance in response to TB treatment between those who quit and those who did not (Favourable response 99.2% vs 97.6%).

CONCLUSION

Both enhanced counselling arm and drug arm are effective strategies for smoking cessation among TB patients and their implementation in the TB programs are recommended.

Molecular characteristics of Mycobacterium tuberculosis in the "closed" Russian town with limited population migration

The aim of this study was to perform a molecular characterization of Mycobacterium tuberculosis strains circulating in one of the "closed" Russian cities under conditions of the limited population migration and high HIV coinfection rate. We analyzed 109 M. tuberculosis isolates recovered from TB patients in the Novouralsk municipality in the Ural area of Russia; 38.5% were from HIV coinfected TB patients and 19.3% patients were former prison inmates. The Beijing genotype was predominant (78.9%) while 57.8% and 17.4% of isolates belonged to the Beijing B0/W148 and Beijing 94-32-clusters, respectively. An atypical allele of the QUB26 VNTR locus (2 repeat units) was detected in 11 of 63 Beijing B0/W148 isolates. The non-Beijing isolates were subdivided into nine spoligotypes of the four genetic families (Ural, LAM, Haarlem, T), SIT35/Ural being the largest group (n = 9; 8.3%). Multidrug resistance (MDR) was detected in 63.6% and 83.7% of isolates from newly diagnosed and previously treated patients, respectively. Almost all isolates of the B0/W148-cluster were MDR (92.1%) compared to the Beijing 94-32-cluster (47.4%). No association was found between HIV status of patients and MDR-TB or particular genetic cluster. A combined contact and molecular investigation confirmed three family foci; in two of them, Ural SIT35 and Beijing B0/W148 strains were transmitted from HIV-infected sons to their fathers. To conclude, M. tuberculosis population in Novouralsk features an exceptionally high prevalence of the strongly MDR Beijing B0/W148-cluster and emergence of the B0/W148 substrain with unusual QUB26 allele. This situation was likely synergistically shaped by the limited population migration, high prevalence of the HIV coinfection and high proportion of the former prisoners. The existing organizational approaches to prevent TB transmission are insufficient and require a serious revision.

ImPROving TB outcomes by modifying LIFE-style behaviours through a brief motivational intervention followed by short text messages (ProLife): study protocol for a randomised controlled trial

Background

South Africa is among the seven highest tuberculosis (TB) burden countries. Harmful lifestyle behaviours, such as smoking and alcohol, and poor adherence to medication can affect clinical outcomes. Modification of these behaviours is likely to improve TB treatment outcomes and has proven possible using motivational interviewing (MI) techniques or use of short message service (SMS) text messaging. There have been no studies assessing the effect of combined MI and SMS interventions on multiple lifestyle factors and TB treatment outcomes.

Methods

This is a prospective, multicentre, two-arm individual randomised controlled trial looking at the effectiveness and cost-effectiveness of a complex behavioural intervention (the ProLife programme) on improving TB and lifestyle-related outcomes in three provinces of South Africa. The ProLife programme consists of an MI counselling strategy, delivered by lay health workers, augmented with subsequent SMS. We aim to recruit 696 adult participants (aged 18 years and over) with drug-sensitive pulmonary TB who are current smokers and/or report harmful or hazardous alcohol use. Patients will be consecutively enrolled at 27 clinics in three different health districts in South Africa. Participants randomised individually to the intervention arm will receive three MI counselling sessions one month apart. Each MI session will be followed by twice-weekly SMS messages targeting treatment adherence, alcohol use and tobacco smoking, as appropriate. We will assess the effect on TB treatment success, using standard World Health Organization (WHO) treatment outcome definitions (primary outcome), as well as on a range of secondary outcomes including smoking cessation, reduction in alcohol use, and TB medication and anti-retroviral therapy adherence. Secondary outcomes will be measured at the three-month and six-month follow-ups.

Discussion

This trial aligns with the WHO agenda of integrating TB care with the care for chronic diseases of lifestyle, such as provision of smoking cessation treatments, and with the use of digital technologies. If the ProLife programme is found to be effective and cost-effective, the programme could have significant implications for TB treatment globally and could be successfully implemented in a wide range of TB treatment settings.

Trial registration

ISRCTN Registry, ISRCTN62728852. Registered on 13 April 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3551-9) contains supplementary material, which is available to authorized users.

Advances in the understanding of Mycobacterium tuberculosis transmission in HIV-endemic settings

Tuberculosis claims more human lives than any other infectious disease. This alarming epidemic has fuelled the development of novel antimicrobials and diagnostics. However, public health interventions that interrupt transmission have been slow to emerge, particularly in HIV-endemic settings. Transmission of tuberculosis is complex, involving various environmental, bacteriological, and host factors, among which concomitant HIV infection is important. Preventing person-to-person spread is central to halting the epidemic and, consequently, tuberculosis transmission is now being studied with renewed interest. In this Series paper, we review recent advances in the understanding of tuberculosis transmission, from the view of source-case infectiousness, inherent susceptibility of exposed individuals, appending tools for predicting risk of disease progression, the biophysical nature of the contagion, and the environments in which transmission occurs and is sustained in populations. We focus specifically on how HIV infection affects these features with a view to describing novel transmission blocking strategies in HIV-endemic settings.

Investigating spillover of multidrug-resistant tuberculosis from a prison: a spatial and molecular epidemiological analysis

BACKGROUND

Congregate settings may serve as institutional amplifiers of tuberculosis (TB) and multidrug-resistant tuberculosis (MDR-TB). We analyze spatial, epidemiological, and pathogen genetic data prospectively collected from neighborhoods surrounding a prison in Lima, Peru, where inmates experience a high risk of MDR-TB, to investigate the risk of spillover into the surrounding community.

METHODS

Using hierarchical Bayesian statistical modeling, we address three questions regarding the MDR-TB risk: (i) Does the excess risk observed among prisoners also extend outside the prison? (ii) If so, what is the magnitude, shape, and spatial range of this spillover effect? (iii) Is there evidence of additional transmission across the region?

RESULTS

The region of spillover risk extends for 5.47 km outside of the prison (95% credible interval: 1.38, 9.63 km). Within this spillover region, we find that nine of the 467 non-inmate patients (35 with MDR-TB) have MDR-TB strains that are genetic matches to strains collected from current inmates with MDR-TB, compared to seven out of 1080 patients (89 with MDR-TB) outside the spillover region (p values: 0.022 and 0.008). We also identify eight spatially aggregated genetic clusters of MDR-TB, four within the spillover region, consistent with local transmission among individuals living close to the prison.

CONCLUSIONS

We demonstrate a clear prison spillover effect in this population, which suggests that interventions in the prison may have benefits that extend to the surrounding community.

Association between tobacco smoking and drug-resistant tuberculosis

Background

Tobacco smoking is a risk factor for tuberculosis but little is known about the relationship between tobacco smoking and drug-resistant tuberculosis (DR-TB). We undertook a systematic review and meta-analysis to quantitatively assess the association between DR-TB and tobacco smoking.

Methods

We searched for relevant studies in the Ovid MEDLINE, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, WANFANG, and WEIPU data-bases from inception to September 1, 2017. Results were expressed as odds ratios (ORs) with accompanying 95% CIs, and subgroup analyses were performed by study design, smoking type, DR-TB type, and multivariate analysis.

Results

Thirty-three studies related to tobacco smoking and DR-TB were included. We found substantial evidence that tobacco smoking is associated with an increased risk of DR-TB (OR 1.57, 95% CI 1.33–1.86). Associations were also found in subgroup analyses: for multidrug-resistant tuberculosis (OR 1.49, 95% CI 1.19–1.86) and for any DR-TB (OR 1.70, 95% CI 1.3–2.23); the pooled OR was 1.45 (95% CI 1.11–1.90) for current smoking, 2.25 (95% CI 1.46–3.47) for past smoking, and 1.56 (95% CI 1.22–1.98) for smoking history; and similar ORs were also observed in study design and multivariate analysis subgroup analysis.

Conclusion

This study demonstrated that tobacco smoking is an independent risk factor for DR-TB.

Risk factors associated with multidrug-resistant tuberculosis (MDR-TB) in a tertiary armed force referral and teaching hospital, Ethiopia

Background

Ethiopia is one of the world health organization defined higher tuberculosis (TB) burden countries where the disease remains a massive public health threat. This study aimed to identify the prevalence and associated factors of multidrug-resistant tuberculosis (MDR-TB) using all armed force and civilian TB attendants in a tertiary level armed force hospital, where data for MDR-TB are previously unpublished.

Methods

Cross-sectional study was conducted from September 2014 to August 2015 in a tertiary level Armed Force Referral and Teaching Hospital (AFRTH), Ethiopia. Armed force members (n = 251) and civilians (n = 130) which has been undergone TB diagnosis at AFRTH were included. All the specimens collected were subjected to microscopic smear observation, culture growth and drug susceptibility testing. Data were analyzed using statistical package for social sciences following binary logistic regression and Chi-square. P-values < 0.05 were considered statistically significant.

Results

Among 381 TB patients, 355 (93.2%) new and 26 (6.8%) retreatment cases were identified. Culture and smear positive TB cases were identified in 297 (77.9%) and 252 (66.1%) patients, respectively. The overall prevalence of MDR-TB in AFRTH was found 1.8% (1.3% for armed force members and 0.5% for civilian patients) all of which were previously TB treated cases. The entire treatment success rates were 92.6% achieved highest in the armed force (active and pension) than the civilian patients. The failure and dead cases were also found 2.5 and 4.6%, respectively. Using bivariate analysis, category of attendants and TB contact history were strong predictors of MDR-TB in armed force and civilian patients. Moreover, human immunodeficiency virus (HIV) infection also identified a significant (OR = 14.6; 95% CI = 2.3–92.1; p = 0.004) predicting factor for MDR-TB in armed force members. However, sex, age and body mass index were not associated factor for MDR-TB.

Conclusions

In AFRTH, lower prevalence of MDR-TB was identified in armed force and civilian patients that were significantly associated with category of attendants, HIV infection and TB contact history. Considering armed force society as one segment of population significantly helps to plan a better MDR-TB control management, especially for countries classified as TB high burden country.

[Clinical and microbiological profile of patients experiencing relapses of tuberculosis in Tunisia]

INTRODUCTION

Relapse of tuberculosis (TB) is known to be as one of the major risk factors for resistant TB. The aim of this study is to focus on clinical, radiological and bacteriological features of patients with pulmonary TB relapse.

METHODS

We performed a retrospective survey in the respiratory department of the teaching hospital La Rabta in Tunis between January 2000 and December 2014. Data of patients with a pulmonary TB relapse were analyzed.

RESULTS

During the study period, among 1250 patients hospitalized for pulmonary TB, 44 had a TB relapse. The TB relapse rate was estimated to be at 3.5%. The average age was 43.95±16.7 years. Sex ratio was 5,2. Eighty one percent of patients were current smokers. Alcoholism was found in 40.9% of cases. The mean time to relapse was 6.37±3.7 years. The radiological lesions were moderately extended at least in 54.6% of cases. A resistant TB was found in 33% of cases (mono-resistance: 33.3%, multi-drug resistance (TB-MR): 11,1%, poly-resistance: 55.5%). The most incriminated drugs were isoniazid, rifampicin and pyrazinamide. One patient received TB-MR treatment regimen for 18 months. In the other cases, the duration of treatment was prolonged. Recovery was obtained in 72.7% of cases, two patients died and 22.7% of patients were lost to follow up.

CONCLUSION

In Tunisia, TB relapse usually affects young male patients who are often alcoholic and smokers. Resistant TB is frequent among these patients. These findings lead us to emphasize the need of rapid diagnosis tools and adapted treatment regimen in these patients.

[Multidrug-resistant tuberculosis (MDR-TB) in a black African carceral area: Experience of Mali]

INTRODUCTION

Prison constitutes a risk factor for the emergence of multi-drug resistance of tuberculosis (MDR-TB). The aim of this work was to study MDR-TB in a black African carceral center.

MATERIAL AND METHODS

Prospective study from January to December 2016 at the central house of arrest for men, Bamako. The study population was composed of tuberculous detainee. The suspicion of MDR-TB was done in any tuberculosis case remained positive in the second month of first-line treatment or in contact with an MDR-TB case.

RESULT

Among 1622 detainee, 21 cases of pulmonary tuberculosis were notified (1.29%), with an annual incidence of 13 cases/1000 detainee, they were 16 cases of SP-PTB (microscopy smear positive tuberculosis) and five cases of microscopy smear negative tuberculosis. The mean age was 28±7 years, extremes of 18 and 46 years. A negative association was found between the notion of smoking and occupation in the occurrence of tuberculosis (OR=0.036, [95% CI: 0.03-0.04], P=0.03. Among the 21 tuberculosis cases notified, one confirmed case of MDR-TB was detected (4.7%). In the first semester of 2016 cohort, we notified a cure rate of 87.5% (7/8 SP-PTB cases), and the confirmed MDR-TB case on treatment (21-month regimen), evolution enameled of pulmonary and hearing sequelae at seven months treatment.

CONCLUSION

It was the first case of MDR-TB detected in a prison in Mali. Late diagnosis, evolution is enameled of sequelae and side effects.

Drug resistant tuberculosis in Saudi Arabia: an analysis of surveillance data 2014-2015

Background

There is limited data that investigates the national rates of drug-resistant tuberculosis (TB) in Saudi Arabia.

This study aimed to estimate the rates of multi-drug-resistant tuberculosis (MDR-TB), rifampicin-resistant tuberculosis (RR-TB), and monoresistance (MR) in Saudi Arabia.

Methods

A retrospective cohort study was conducted on all TB cases reported to the National TB Control and Prevention Program (NTCPP) registry at the Saudi Ministry of Health between January 1, 2014 and December 31, 2015. A total of 2098 TB patients with positive TB cultures were included in the study. Subgroup analyses and multivariate binary logistic regression models were performed with IBM SPSS 23.0.

Results

Of the total TB cases, 4.4% (95% CI: 3.59%–5.40%) were found to have MDR-TB. The rates of MR were 3.8% (95% CI: 2.99%–4.67%) for ethambutol, 5.4% (95% CI: 4.50%–6.49%) for pyrazinamide, 10.2% (95% CI: 5.89%–11.52%) for isoniazid, 11% (95% CI: 9.70%–12.43%) for streptomycin, and 5.9% (95% CI: 4.90%–6.96%) for rifampicin. The high rates of MDR and RR-TB were found among the younger age group, female gender, and those who had a previous history of TB. We also discovered that renal failure tends to increase the risk of rifampicin resistance.

Conclusions

National TB data in Saudi Arabia shows that the rate of MDR-TB was similar to the global rate reported by the World Health Organization (WHO). It is a relatively high rate as compared to Western countries. The proportion of MDR/RR-TB patients tends to be higher in the younger age group, female gender, and in patients with a previous history of TB treatment. Effective strategies for prevention of all multi-drug-resistant TB cases are warranted.

Prevalence and Associated Factors of Tuberculosis in Prisons Settings of East Gojjam Zone, Northwest Ethiopia

Background

Tuberculosis, mainly in prisoners, is a major public health problem in Ethiopia where there is no medical screening during prison admission. This creates scarcity of TB data in such settings.

Objective

To determine prevalence and associated factors of TB in prisons in East Gojjam Zone, Northwest Ethiopia.

Methods

A cross-sectional study was conducted from February to May 2016 among 265 prisoners in three prison sites. Sputum was processed using GeneXpert MTB/RIF. Data were analyzed using SPSS version 20.0. Multivariable logistic regression was used; p values = 0.05 were considered statistically significant.

Results

Of 265 prisoners, 9 (3.4%) were TB positive (males); 77.8%, 55.6%, and 55.6% of cases were rural dwellers, married, and farmers, respectively. Seven (2.6%) prisoners were HIV positive, and 3 (1.13%) had TB/HIV coinfection. One (0.4%) TB case was rifampicin resistant. Marriage (AOR = 1.5; 95% CI: 1.7, 13.03), HIV (AOR = 0.14; 95% CI: 0.001, 0.17), and sharing of rooms (AOR = 1.62; 95% CI: 2.6, 10.20) were predictors for TB.

Conclusion

Nine prisoners were TB positive. One case showed rifampicin resistance and three had TB/HIV coinfection. Marriage, HIV, and sharing of rooms were predictors for TB. Prevention/control and monitoring are mandatory in such settings.

Sociodemographic correlates of HIV drug resistance and access to drug resistance testing in British Columbia, Canada

Sociodemographic correlates of engagement in human immunodeficiency virus (HIV) care are well studied, however the association with accessing drug resistance testing (DRT) and the development of drug resistance have not been characterized. Between 1996-2014, 11 801 HIV patients accessing therapy in British Columbia were observed longitudinally. A subset of 9456 patients had testable viral load; of these 8398 were linked to census data. Sociodemographic (census tract-level) and clinical (individual-level) correlates of DRT were assessed using multivariable General Estimating Equation logistic regression adjusted odds ratios (aOR). The mean number of tests per patient was 2.1 (Q1-Q3; 0-3). Separately, any drug resistance was determined using IAS-USA (2013) list for 5703 initially treatment naïve patients without baseline resistance; 5175 were census-linked (mean of 1.5 protease-reverse transcriptase sequences/patient, Q1-Q3; 0-2). Correlates of detecting drug resistance in this subset were analyzed using Cox PH regression adjusted hazard ratios (aHR). Our results indicate baseline CD4 <200 cells/μL (aOR: 1.5, 1.3-1.6), nRTI-only baseline regimens (aOR: 1.4, 1.3-1.6), and unknown (therapy initiation before routine pVL in BC) baseline pVL (aOR: 1.8, 1.5-2.1) were among individual-level clinical covariates strongly associated with having accessed DRT; while imperfect adherence (aHR: 2.2, 1.9-2.5), low baseline CD4 count (aHR: 1.9, 1.6-2.3), and high baseline pVL (aHR: 2.0, 1.6-2.6) were associated with a higher likelihood of developing drug resistance. A higher median income (aOR: 0.83, 0.77-0.89) and higher percentage of those with aboriginal ancestry (aOR: 0.85, 0.76-0.95) were census tract-level sociodemographic covariates associated with decreased access to DRT. Similarly, aboriginal ancestry (aHR: 1.2, 1.1-1.5) was associated with development of drug resistance. In conclusion, clinical covariates continue to be the strongest correlates of development of drug resistance and access to DRT for individuals. Regions of high median income and high aboriginal ancestry were weak census-level sociodemographic indicators of reduced DRT uptake, however high aboriginal ancestry was the only sociodemographic indicator for development of drug resistance.

Outcomes from patients with presumed drug resistant tuberculosis in five reference centers in Brazil

Background

The implementation of rapid drug susceptibility testing (DST) is a current global priority for TB control. However, data are scarce on patient-relevant outcomes for presumptive diagnosis of drug-resistant tuberculosis (pDR-TB) evaluated under field conditions in high burden countries.

Methods

Observational study of pDR-TB patients referred by primary and secondary health units. TB reference centers addressing DR-TB in five cities in Brazil. Patients age 18 years and older were eligible if pDR-TB, culture positive results for Mycobacterium tuberculosis and, if no prior DST results from another laboratory were used by a physician to start anti-TB treatment. The outcome measures were median time from triage to initiating appropriate anti-TB treatment, empirical treatment and, the treatment outcomes.

Results

Between February,16th, 2011 and February, 15th, 2012, among 175 pDR TB cases, 110 (63.0%) confirmed TB cases with DST results were enrolled. Among study participants, 72 (65.5%) were male and 62 (56.4%) aged 26 to 45 years. At triage, empirical treatment was given to 106 (96.0%) subjects. Among those, 85 were treated with first line drugs and 21 with second line. Median time for DST results was 69.5 [interquartile - IQR: 35.7–111.0] days and, for initiating appropriate anti-TB treatment, the median time was 1.0 (IQR: 0–41.2) days. Among 95 patients that were followed-up during the first 6 month period, 24 (25.3%; IC: 17.5%–34.9%) changed or initiated the treatment after DST results: 16/29 MDRTB, 5/21 DR-TB and 3/45 DS-TB cases. Comparing the treatment outcome to DS-TB cases, MDRTB had higher proportions changing or initiating treatment after DST results (p = 0.01) and favorable outcomes (p = 0.07).

Conclusions

This study shows a high rate of empirical treatment and long delay for DST results. Strategies to speed up the detection and early treatment of drug resistant TB should be prioritized.

Multidrug resistant tuberculosis in prisons located in former Soviet countries: A systematic review

Background

A systematic literature review was performed to investigate the occurrence of multidrug-resistant tuberculosis (MDR TB) in prisons located in countries formerly part of the Soviet Union.

Methods

A systematic search of published studies reporting MDR TB occurrence in prisons located in former Soviet countries was conducted by probing PubMed and Cumulative Index Nursing and Allied Health Literature for articles that met predetermined inclusion criteria.

Results

Seventeen studies were identified for systematic review. Studies were conducted in six different countries. Overall, prevalence of MDR TB among prisoners varied greatly between studies. Our findings suggest a high prevalence of MDR TB in prisons of Post-Soviet states with percentages as high as 16 times more than the worldwide prevalence estimated by the WHO in 2014.

Conclusion

All studies suggested a high prevalence of MDR TB in prison populations in Post-Soviet states.

The epidemiology, pathogenesis, transmission, diagnosis, and management of multidrug-resistant, extensively drug-resistant, and incurable tuberculosis

Global tuberculosis incidence has declined marginally over the past decade, and tuberculosis remains out of control in several parts of the world including Africa and Asia. Although tuberculosis control has been effective in some regions of the world, these gains are threatened by the increasing burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. XDR tuberculosis has evolved in several tuberculosis-endemic countries to drug-incurable or programmatically incurable tuberculosis (totally drug-resistant tuberculosis). This poses several challenges similar to those encountered in the pre-chemotherapy era, including the inability to cure tuberculosis, high mortality, and the need for alternative methods to prevent disease transmission. This phenomenon mirrors the worldwide increase in antimicrobial resistance and the emergence of other MDR pathogens, such as malaria, HIV, and Gram-negative bacteria. MDR and XDR tuberculosis are associated with high morbidity and substantial mortality, are a threat to health-care workers, prohibitively expensive to treat, and are therefore a serious public health problem. In this Commission, we examine several aspects of drug-resistant tuberculosis. The traditional view that acquired resistance to antituberculous drugs is driven by poor compliance and programmatic failure is now being questioned, and several lines of evidence suggest that alternative mechanisms-including pharmacokinetic variability, induction of efflux pumps that transport the drug out of cells, and suboptimal drug penetration into tuberculosis lesions-are likely crucial to the pathogenesis of drug-resistant tuberculosis. These factors have implications for the design of new interventions, drug delivery and dosing mechanisms, and public health policy. We discuss epidemiology and transmission dynamics, including new insights into the fundamental biology of transmission, and we review the utility of newer diagnostic tools, including molecular tests and next-generation whole-genome sequencing, and their potential for clinical effectiveness. Relevant research priorities are highlighted, including optimal medical and surgical management, the role of newer and repurposed drugs (including bedaquiline, delamanid, and linezolid), pharmacokinetic and pharmacodynamic considerations, preventive strategies (such as prophylaxis in MDR and XDR contacts), palliative and patient-orientated care aspects, and medicolegal and ethical issues.

Profile of drug-resistant tuberculosis in Western Maharashtra

CONTEXT

Drug-resistant tuberculosis (TB) strains have evolved mainly due to incomplete or improper treatment of TB patients and are one of the hurdles in controlling TB problem. It is better to understand the magnitude and comorbidities associated with drug-resistant TB.

AIM AND OBJECTIVES

(1) To study some of the sociodemographic profile and history of TB treatment of drug-resistant TB cases. (2) To study their drug-resistance pattern and their comorbidity profile.

SETTINGS AND DESIGN

It was a record-based study descriptive, cross-sectional study of drug-resistant TB cases that were referred to State TB Training and Demonstration Centre (STDC).

MATERIALS AND METHODS

The data were collected by means of use of TB patient treatment register of those tested at STDC during first two quarters of the year 2012 (from January to June 2012). Sputum samples of all the cases were subjected to concentrated microscopy, and all positive samples were tested by GeneXpert and Line Probe Assay for drug susceptibility testing (DST) for isoniazid and rifampicin.

STATISTICAL ANALYSIS

The findings were analyzed with Epi info7, using the mean, standard deviation, Chi-square test.

RESULTS

The mean age of the patients was 35.65 ± 13.59 years, majority 71.87% were males. The majority of patients 72.91% had the previous history of TB. A majority 68.75% of the patients had acquired drug resistance, and 73.95% of cases were suffering from multidrug-resistant TB. A total of 28.13% patients had self-reported comorbidity. A majority 62.5% had failure as the treatment outcome for the current episode of TB and mortality was seen in 12.5% cases.

CONCLUSIONS

Majority had failure as a treatment outcome due to advanced disease status or late diagnosis. Rapid diagnosis and DST for first- and second-line drugs will greatly improve the clinical outcome.

Prisoners co-infected with tuberculosis and HIV: a systematic review

INTRODUCTION

Almost from the beginning of the HIV epidemic in 1981, an association with tuberculosis (TB) was recognized. This association between HIV and TB co-infection has been particularly evident amongst prisoners. However, despite this, few studies of TB in prisons have stratified results by HIV status. Given the high prevalence of HIV-positive persons and TB-infected persons in prisons and the documented risk of TB in those infected with HIV, it is of interest to determine how co-infection varies amongst prison populations worldwide. For this reason we have undertaken a systematic review of studies of co-infected prisoners to determine the incidence and/or prevalence of HIV/TB co-infection in prisons, as well as outcomes in this group, measured as treatment success or death.

METHODS

A literature search was undertaken using the online databases PubMed, Embase, IBSS, Scopus, Web of Science, Global Health and CINAHL Plus. No restrictions were set on language or publication date for article retrieval, with articles included if indexed up to 18 October 2015. A total of 1975 non-duplicate papers were identified. For treatment and outcome data all eligible papers were appraised for inclusion; for incidence/prevalence estimates papers published prior to 2000 were excluded from full text review. After full text appraisal, 46 papers were selected for inclusion in the review, 41 for incidence/prevalence estimates and nine for outcomes data, with four papers providing evidence for both outcomes and prevalence/incidence.

RESULTS

Very few studies estimated the incidence of TB in HIV positive prisoners, with most simply reporting prevalence of co-infection. Co-infection is rarely explicitly measured, with studies simply reporting HIV status in prisoners with TB, or a cross-sectional survey of TB prevalence amongst prisoners with HIV. Estimates of co-infection prevalence ranged from 2.4 to 73.1% and relative risks for one, given the other, ranged from 2.0 to 10.75, although some studies reported no significant association between HIV and TB. Few studies provided a comparison with the risk of co-infection in the general population.

CONCLUSIONS

Prisoners infected with HIV are at high risk of developing TB. However, the magnitude of risk varies between different prisons and countries. There is little evidence on treatment outcomes in co-infected prisoners, and the existing evidence is conflicting in regards to HIV status influence on prisoner treatment outcomes.PROSPERO Number: CRD42016034068.

Smear positive pulmonary tuberculosis and HIV co-infection in prison settings of North Gondar Zone, Northwest Ethiopia

BACKGROUND

In correctional settings tuberculosis is a public health concern. The incarcerated population is at greater risk for tuberculosis (TB) than the general population. The aim of this study was to determine the prevalence of smear positive pulmonary tuberculosis (PTB) and associated risk factors in prison settings.

METHODS

A cross-sectional study was conducted among prisoners of North Gondar zone where all inmates with a history of cough for ≥ 2 weeks were included. Socio-demographic characteristics and potential risk factors were assessed using a structured questionnaire. Spot-morning-spot sputum samples were collected, smears were prepared and stained with Auramine O stain and examined through light emitting diode- fluorescence microscope. All samples positive for acid-fast bacilli were further examined by GeneXpert MTB/RIF assay. Data was analyzed using SPSS version 20 and a P-value < 0.05 was taken as statistically significant. The multivariable logistic regression analysis was used to determine the association between risk factors and prison tuberculosis.

RESULTS

A total of 282 prison inmates suspected of PTB were enrolled in the study. The overall prevalence of smear positive PTB infection was 5.3 % (15/282), but none of the smear positive TB cases were resistant to rifampicin. The prevalence of HIV infection among TB suspected prisoners and smear positive PTB cases was 6 and 27 %, respectively. Moreover, smear positive PTB disease was significantly associated with smoking status, malnutrition, number of prison inmates per cell, poor cell ventilation, and a history of contact with TB patients.

CONCLUSION

The prevalence of smear positive pulmonary tuberculosis among north Gondar prison inmates was still high although lower than previous reports. There was a high prevalence of HIV among smear positive PTB cases. Reducing the burden of prison inmates in a particular cell, preventing malnutrition, establishing ventilation system can possibly minimize the transmission of tuberculosis among prisoners.

Pattern of Drug Resistance and Risk Factors Associated with Development of Drug Resistant Mycobacterium tuberculosis in Pakistan

Background

Drug resistant tuberculosis (DR-TB) is a major public health problem in developing countries such as Pakistan.

Objective

The current study was conducted to assess the frequency of drug resistant tuberculosis including multi drug resistance (MDR- TB) as well as risk factors for development of DR-TB, in Punjab, Pakistan.

Methodology

Drug susceptibility testing (DST) was performed, using proportion method, for 2367 culture positive Mycobacterium tuberculosis (MTB) cases that were enrolled from January 2012 to December 2013 in the province of Punjab, Pakistan, against first-line anti-tuberculosis drugs. The data was analyzed using statistical software; SPSS version 18.

Results

Out of 2367 isolates, 273 (11.5%) were resistant to at least one anti-TB drug, while 221 (9.3%) showed MDR- TB. Risk factors for development of MDR-TB were early age (ranges between 10–25 years) and previously treated TB patients.

Conclusion

DR-TB is a considerable problem in Pakistan. Major risk factors are previous history of TB treatment and younger age group. It emphasizes the need for effective TB control Program in the country.

Status of multidrug resistant tuberculosis (MDR-TB) among the Sahariya tribe of North Central India

BACKGROUND

The incidence/prevalence of tuberculosis (TB) is reported to be high in the Sahariya tribe of North Central India. The outbreaks of different drug-resistant isolates of Mycobacterium tuberculosis emphasized the need for continuous monitoring of resistance to anti-tuberculosis drugs. This study aimed to assess the profile of multidrug resistant TB among the Sahariya tribe and their non-tribal neighbors for first line drugs through field-based investigations.

METHODOLOGY

A total of 274 sputum positive pulmonary TB individuals were enrolled and studied for their drug susceptibility profile by the proportion method.

RESULTS

A total of 21 cases from Sahariya and 6 from non-tribes were identified with MDR-TB. Thus Sahariya tribe showed a 1.95-fold increased risk of developing drug resistance than non-tribes. Significant differences were observed for developing drug sensitivity between Sahariya males and females when analyzed for resistance developed to any drug and overall drug resistance vs. sensitive isolates, respectively. A 4.46-fold risk was found for MDR-TB among the smokers of Sahariya tribe, whereas, the non-tribes did not show any significant association.

CONCLUSION

The drug susceptibility profile developed in the present study indicates that drug-resistant tuberculosis is emerging as a serious public health concern in Sahariya tribe. Urgent and effective control measures and better management policies are needed for the prevention of MDR-TB in the tribe.

A smoking cessation intervention among tuberculosis patients in rural China

OBJECTIVE

To assess the integration of a smoking cessation intervention into routine tuberculosis (TB) services.

METHOD

Consecutive TB patients registered from 1 March to 31 August 2010 were enrolled in an intervention for self-reported smoking to promote tobacco cessation during treatment for TB. Information on the harmful health effects of tobacco smoke and smoking and TB were provided to TB patients who self-reported as current smokers. Smoking status was reassessed at every follow-up visit during anti-tuberculosis treatment with reinforced health messages and advice to quit.

RESULTS

Of 800 TB patients enrolled, 572 (71.5%) were male and 244 (30.5%) were current smokers. Females were more likely to be non-smokers (100% vs. 35.8%, P < 0.001). Of the 244 current smokers, 144 (59.0%) started smoking at <20 years, 197 (80.7%) consumed ⩾20 cigarettes per day, 211 (86.5%) had perceived smoking dependence and 199 (81.6%) had made no attempt to quit before the diagnosis of TB. Of the 244 current smokers, 234 (95.9%) were willing to quit, and 156 (66.7%) reported abstinence at month 6. Challenges to implementing smoking cessation intervention were identified.

CONCLUSION

The majority of current smokers among TB patients were willing to quit and remained abstinent at the end of anti-tuberculosis treatment. This intervention should be scaled up nationwide.

First national survey of anti-tuberculosis drug resistance in Azerbaijan and risk factors analysis

SETTING

Civilian population of the Republic of Azerbaijan.

OBJECTIVES

To determine patterns of anti-tuberculosis drug resistance among new and previously treated pulmonary tuberculosis (TB) cases, and explore their association with socio-demographic and clinical characteristics.

DESIGN

National cross-sectional survey conducted in 2012-2013.

RESULTS

Of 789 patients (549 new and 240 previously treated) who met the enrolment criteria, 231 (42%) new and 146 (61%) previously treated patients were resistant to any anti-tuberculosis drug; 72 (13%) new and 66 (28%) previously treated patients had multidrug-resistant TB (MDR-TB). Among MDR-TB cases, 38% of new and 46% of previously treated cases had pre-extensively drug-resistant TB (pre-XDR-TB) or XDR-TB. In previously treated cases, 51% of those who had failed treatment had MDR-TB, which was 15 times higher than in relapse cases (OR 15.2, 95%CI 6-39). The only characteristic significantly associated with MDR-TB was a history of previous treatment (OR 3.1, 95%CI 2.1-4.7); for this group, history of incarceration was an additional risk factor for MDR-TB (OR 2.8, 95%CI 1.1-7.4).

CONCLUSION

Azerbaijan remains a high MDR-TB burden country. There is a need to implement countrywide control and innovative measures to accelerate early diagnosis of drug resistance in individual patients, improve treatment adherence and strengthen routine surveillance of drug resistance.

Beijing clades of Mycobacterium tuberculosis are associated with differential survival in HIV-negative Russian patients

We conducted a prospective study to establish factors associated with survival in tuberculosis patients in Russia including social, clinical and pathogen-related genetic parameters. Specifically we wished to determine whether different strains/clades of the Beijing lineage exerted a differential effect of survival. HIV-negative culture-confirmed cases were recruited during 2008-2010 across Samara Oblast and censored in December 2011. Molecular characterization was performed by a combination of spoligotyping, multilocus VNTR typing and whole genome sequencing (WGS). We analyzed 2602 strains and detected a high prevalence of Beijing family (n=1933; 74%) represented largely by two highly homogenous dominant clades A (n=794) and B (n=402) and non-A/non-B (n=737). Multivariable analysis of 1366 patients with full clinical and genotyping data showed that multi- and extensive drug resistance (HR=1.86; 95%CI: 1.52, 2.28 and HR=2.19; 95%CI: 1.55, 3.11) had the largest impact on survival. In addition older age, extensive lung damage, shortness of breath, treatment in the past and alcohol abuse reduced survival time. After adjustment for clinical and demographic predictors there was evidence that clades A and B combined were associated with poorer survival than other Beijing strains (HR=0.48; 95%CI 0.34, 0.67). All other pathogen-related factors (polymorphisms in genes plcA, plcB, plcC, lipR, dosT and pks15/1) had no effect on survival. In conclusion, drug resistance exerted the greatest effect on survival of TB patients. Nevertheless we provide evidence for the independent biological effect on survival of different Beijing family strains even within the same defined geographical population. Better understanding of the role of different strain factors in active disease and their influence on outcome is essential.

Multidrug-Resistant Tuberculosis in Patients with Chronic Obstructive Pulmonary Disease in China

BACKGROUND

Relatively little is known about the specific relationship and impact from chronic obstructive pulmonary disease (COPD) on multidrug-resistant tuberculsosis (MDR-TB).

METHODS

We conducted a retrospective study included patients aged ≥40 years with a confirmed pulmonary TB at three tertiary hospitals (Shandong, China) between January 2011 and October 2014. Univariable and multivariable analyses were performed to identify the relationship of MDR-TB and COPD.

RESULTS

A total of 2164 patients aged ≥ 40 years with available results of drug susceptibility test (DST) and medical records were screened for this study: 268 patients with discharge diagnosis of COPD and 1896 patients without COPD. Overall, 14.2% of patients with COPD and 8.5% patients without COPD were MDR-TB. The rate of MDR-TB were significantly higher in patients with COPD (P<0.05). Migrant (odds ratios (OR) 1.32, 95% confidence interval (CI) 1.02-1.72), previous anti-TB treatment (OR 4.58, 95% CI 1.69-12.42), cavity (OR 2.33, 95% CI 1.14-4.75), and GOLD stage (OR 1.86, 95% CI 1.01-2.93) were the independent predictors for MDR-TB among patients with COPD.

CONCLUSIONS

MDR-TB occurs more frequently in patients with underlying COPD, especially those with being migrant, previous anti-TB therapy, cavity and severe airway obstruction.

Resistance profile and risk factors of drug resistant tuberculosis in the Baltic countries

The rates of multi- and extensively drug-resistant tuberculosis (X/MDRTB) in the Baltic countries are the highest within the European Union hampering recent achievements of national TB control programmes. We included all consecutive culture-confirmed X/MDRTB patients registered for treatment in 2009 in Latvia, Lithuania and Estonia into this multicenter case-control study. Cases were compared with randomly selected controls with non-MDRTB registered for treatment in the same year across these sites. Of 495 MDRTB patients, 243 (49.7%) showed resistance to at least one second-line drug, 206 (42.1%) had pre-XDRTB (i.e. MDRTB with additional resistance to a second-line injectable or fluoroquinolones) and 64 (13.1%) had XDRTB. Younger age, male gender and known contact with an MDRTB case were associated with increased risk of primary infection with X/MDRTB strains. Previous treatment and alcohol abuse were strong predictors for MDRTB acquisition; defaults and failures in the past triggered XDRTB development. All patients received appropriate therapy; less than half of the patients were fully adherent. An erroneous treatment strategy is unlikely to drive resistance development. Increasing patients' compliance, addressing issues of social support, rapid detection of drug resistance and improving infection control is crucial for prevention of further spread of X/MDRTB and achieving higher cure rates.

Review of the prevalence and drug resistance of tuberculosis in prisons: a hidden epidemic

SUMMARY The prison setting has been often cited as a possible reservoir of tuberculosis (TB) including multidrug-resistant (MDR)-TB. This is particularly true in low-income, high TB prevalence countries in Sub-Saharan Africa. A systemic literature review was done to assess the prevalence, drug resistance and risk factors for acquiring TB in the prison population. Our review indicated a high prevalence of TB in prisons which is reported to be 3- to 1000-fold higher than that found in the civilian population, indicating evidence and the need for public health policy formulation. In addition, high levels of MDR and extensively drug-resistant (XDR)-TB have been reported from prisons, which is a warning call to review prison TB control strategy. Multiple risk factors such as overcrowding, poor ventilation, malnutrition, human immunodeficiency virus (HIV), and others have fuelled the spread of TB in prisons. Furthermore, the impact extends beyond the prison walls; it affects the civilian population, because family visits, prison staff, and members of the judiciary system could be potential portals of exit for TB transmission. The health of prisoners is a neglected political and scientific issue. Within these background conditions, it is suggested that political leaders and scientific communities should work together and give special attention to the control of TB and MDR-TB in prisons. If not, TB in prisons will remain a neglected global problem and threatens national and international TB control programmes. Further researches are required on the prevalence and drug resistance of smear-negative TB in prisons. In addition, evidence of the circulating strains and transmission dynamics inside prisons is also warranted.

Efficacy of brief motivational interviewing on smoking cessation at tuberculosis clinics in Tshwane, South Africa: a randomized controlled trial

BACKGROUND AND AIMS

Tuberculosis (TB) patients who smoke risk adverse TB outcomes and other long-term health effects of smoking. This study aimed to determine the efficacy of brief motivational interviewing by lay health-care workers (LHCWs) in assisting TB patients to quit smoking.

DESIGN

Multi-centre two-group parallel individual randomized controlled trial.

SETTING

Six primary care tuberculosis clinics in a South African township.

PARTICIPANTS

Newly diagnosed adult TB patients identified as current smokers were randomized to brief motivational interviewing by a LHCW (intervention group, n = 205) or brief smoking cessation advice from a TB nurse (control group, n = 204).

MEASUREMENTS

The primary outcome was self-reported sustained 6-month smoking abstinence. Exhaled carbon monoxide (CO) testing was offered to about half the participants. Secondary outcomes were sustained abstinence at 3 months; 7-day point prevalence abstinence at 1, 3 and 6 months; and quit attempts. Allocation was concealed. Primary analysis relied on intention to treat. Multi-level analysis accounted for site heterogeneity of effect.

FINDINGS

Self-reported 6-month sustained abstinence was 21.5% for the intervention group versus 9.3% for the control group [relative risk (RR) = 2.29, 95% confidence interval (CI) = 1.34, 3.92]. Biochemically verified 6-month sustained abstinence was also higher in the intervention group (RR 2.21, 95% CI = 1.08, 4.51) for the 166 participants who were offered carbon monoxide testing. Self-reported 3-month sustained abstinence was 25.4% for the intervention group and 12.8% for the control group (RR = 1.98, 95% CI = 1.24, 3.18).

CONCLUSIONS

Motivational interviewing by lay counsellors to promote smoking cessation in tuberculosis patients in South Africa approximately doubled sustained smoking abstinence for at least 6 months compared with brief advice alone.

Geographical heterogeneity of multidrug-resistant tuberculosis in Georgia, January 2009 to June 2011

In 2011, Georgia, in the Caucasus, reported that 11% of new and 32% of previously treated tuberculosis (TB) cases nationally had multidrug-resistant TB (MDR-TB). To help understand the mechanisms driving these high risks of drug-resistance and plan for targeted interventions, we identified geographical variability in the MDR-TB burden in Georgia and patient-level MDR-TB risk factors. We used routinely collected surveillance data on notified TB cases to estimate the MDR-TB incidence/100,000 people and the percentage of TB cases with MDR-TB for each of 65 districts and regression modelling to identify patient-level MDR-TB risk factors. 1,795 MDR-TB cases were reported (January 2009–June 2011); the nationwide notified MDR-TB incidence was 16.2/100,000 but far higher (837/100,000) in the penitentiary system. We found substantial geographical heterogeneity between districts in the average annual MDR-TB incidence/100,000 (range: 0.0–5.0 among new and 0.0–18.9 among previously treated TB cases) and the percentage of TB cases with MDR-TB (range: 0.0%–33.3% among new and 0.0%–75.0% among previously treated TB cases). Among treatment-naïve individuals, those in cities had greater MDR-TB risk than those in rural areas (increased odds: 43%; 95% confidence interval: 20%–72%). These results suggest that interventions for interrupting MDR-TB transmission are urgently needed in prisons and urban areas.

Drug resistance among tuberculosis cases in the European Union and European Economic Area, 2007 to 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

Prevalence, risk factors and social context of active pulmonary tuberculosis among prison inmates in Tajikistan

SETTING

Tuberculosis (TB) is highly prevalent in prisons of the former Soviet Union.

OBJECTIVE

To understand the behavioral, demographic and biological factors placing inmates in Tajikistan at risk for active TB.

DESIGN

We administered a behavioral and demographic survey to 1317 inmates in two prison facilities in Sughd province, Tajikistan along with radiographic screening for pulmonary TB. Suspected cases were confirmed bacteriologically. Inmates undergoing TB treatment were also surveyed. In-depth interviews were conducted with former prisoners to elicit relevant social and behavioral characteristics.

RESULTS

We identified 59 cases of active pulmonary TB (prevalence 4.5%). Factors independently associated with increased prevalence of active TB were: HIV-infection by self-report (PR 7.88; 95%CI 3.40-18.28), history of previous TB (PR 10.21; 95%CI 6.27-16.63) and infrequent supplemental nutrition beyond scheduled meals (PR 3.00; 95%CI 1.67-5.62). Access to supplemental nutrition was associated with frequency of visits from friends and family and ability to rely on other inmates for help.

CONCLUSION

In prison facilities of Tajikistan, HIV-infection, injection drug use and low access to supplemental nutrition were associated with prevalent cases of active pulmonary TB. Policies that reduce HIV transmission among injection drug users and improve the nutritional status of socially isolated inmates may alleviate the TB burden in Tajikistan's prisons.

Challenges in the development of an immunochromatographic interferon-gamma test for diagnosis of pleural tuberculosis

Existing diagnostic tests for pleural tuberculosis (TB) have inadequate accuracy and/or turnaround time. Interferon-gamma (IFNg) has been identified in many studies as a biomarker for pleural TB. Our objective was to develop a lateral flow, immunochromatographic test (ICT) based on this biomarker and to evaluate the test in a clinical cohort. Because IFNg is commonly present in non-TB pleural effusions in low amounts, a diagnostic IFNg-threshold was first defined with an enzyme-linked immunosorbent assay (ELISA) for IFNg in samples from 38 patients with a confirmed clinical diagnosis (cut-off of 300 pg/ml; 94% sensitivity and 93% specificity). The ICT was then designed; however, its achievable limit of detection (5000 pg/ml) was over 10-fold higher than that of the ELISA. After several iterations in development, the prototype ICT assay for IFNg had a sensitivity of 69% (95% confidence interval (CI): 50-83) and a specificity of 94% (95% CI: 81-99%) compared to ELISA on frozen samples. Evaluation of the prototype in a prospective clinical cohort (72 patients) on fresh pleural fluid samples, in comparison to a composite reference standard (including histopathological and microbiologic test results), showed that the prototype had 65% sensitivity (95% CI: 44-83) and 89% specificity (95% CI: 74-97). Discordant results were observed in 15% of samples if testing was repeated after one freezing and thawing step. Inter-rater variability was limited (3%; 1 out of 32). In conclusion, despite an iterative development and optimization process, the performance of the IFNg ICT remained lower than what could be expected from the published literature on IFNg as a biomarker in pleural fluid. Further improvements in the limit of detection of an ICT for IFNg, and possibly combination of IFNg with other biomarkers such as adenosine deaminase, are necessary for such a test to be of value in the evaluation of pleural tuberculosis.

Prevalence and clinical predictors of drug-resistant tuberculosis in three clinical settings in Calabar, Nigeria

BACKGROUND AND AIMS

Drug-resistant tuberculosis (TB) poses a serious challenge to global control of TB. This multicentre study was to identify risk factors for drug resistance to the first line anti-TB drugs among TB patients presenting for care in three health facilities in Calabar, Nigeria.

MATERIALS AND METHODS

A cohort of 100 consecutive TB patients were recruited. Demographic information such as age, sex, weight, height, occupation, previous TB diagnosis and treatment, smoking, alcohol dependence and substance abuse were obtained. Sputum samples were collected from participants and cultured on Lowenstein - Jensen (LJ) slopes. Drug susceptibility testing was then carried out for the isolates identified as Mycobacterium tuberculosis, using isoniazid, rifampicin, ethambutol and streptomycin.

RESULTS

Forty-two of the 100 participants evaluated were found to be resistant to at least one drug. Multi-drug-resistant TB was seen in four persons. Statistically significant differences were found with respect to three variables: younger age, abandonment of TB treatment and presence of cavitary lesions on chest radiograph. The variables sex, alcohol dependence, tobacco use and previous imprisonment were not significantly associated with TB drug resistance. Four variables were significant following the multivariate analysis with the following adjusted odds ratios: abandonment of TB treatment (9.34), cavitary lesions on chest radiograph (5.88), younger age (6.25) and male sex (3.25).

CONCLUSION

Thus, risk stratification of TB patients is advocated in clinical settings where diagnostic facilities for drug-resistant TB are scarce using the identified predictors. This group will benefit from close monitoring and early drug susceptibility testing.

Factors contributing to the high prevalence of multidrug-resistant tuberculosis among previously treated patients: a case-control study from China

SETTING

Multidrug-resistant tuberculosis (MDR-TB) has emerged as a serious global public health problem. In China, the risk factors for MDR-TB have not been systematically evaluated.

OBJECTIVE

To identify risk factors associated with MDR-TB among previously treated patients in China.

DESIGN

A case-control study was carried out. Cases were selected from previously treated MDR-TB patients who were resistant to both isoniazid and rifampin, and controls were selected from previously treated TB patients who were sensitive to isoniazid and rifampin (non-MDR-TB). Information was collected from the registration database and a structured questionnaire.

RESULTS

A total of 61 cases and 50 controls were recruited. A multivariate analysis showed that the family annual per-capita income ≤7,000 Yuan (odds ratio [OR]=3.238; 95% confidence interval [CI]: 1.270-8.252), no history of fixed dose combinations (FDCs) in anti-TB treatment (OR=4.027; 95% CI: 1.457-11.129), and adverse reactions in the course of TB treatment (OR=3.568; 95% CI: 1.402-9.085) were independent predictors of MDR-TB. Moreover, among the TB patients who had adverse reactions, quitting the treatment was shown as a risk factor for MDR-TB (p=0.009).

CONCLUSION

In the control of MDR-TB among previously treated patients, lower socioeconomic groups, the expanding use of FDCs, and improving adherence to treatment by implementing Directly Observed Therapy Short Course-Plus (DOTS-Plus), strictly should become a priority that requires strong commitment and collaboration among health organizations.

Using nursing practice guidelines for the prevention of multidrug-resistant tuberculosis among hospitalized adult patients in Bangladesh

Multidrug-resistant tuberculosis (MDR-TB) is one of the major public health concerns worldwide particularly in developing countries, including Bangladesh. Thus far, there are no well-validated clinical guidelines for the prevention of MDR-TB. This study aims to evaluate the improvement in nurses' practice using the newly developed Nursing Practice Guidelines for the Prevention of MDR-TB (NPG: MDR-TB) among hospitalized adult patients in Bangladesh. The guidelines were developed, disseminated and evaluated among 64 nurses by assessing nursing practice for the prevention of MDR-TB during pre- and postimplementation of the guidelines. Significant differences between pretest and post-test mean scores of nursing practice for the prevention of MDR-TB in case finding and case holding were found in three levels of wards, including Level 0 (non-TB), Level 1 (TB) and Level 2 (MDR-TB) (P < 0.001). This indicated that the guidelines might be applicable to reduce the development of MDR-TB in hospitals. However, this was a preliminary study with a limited time frame. Further evaluation is, therefore, needed.

Rapid diagnostics of tuberculosis and drug resistance in the industrialized world: clinical and public health benefits and barriers to implementation

In this article, we give an overview of new technologies for the diagnosis of tuberculosis (TB) and drug resistance, consider their advantages over existing methodologies, broad issues of cost, cost-effectiveness and programmatic implementation, and their clinical as well as public health impact, focusing on the industrialized world. Molecular nucleic-acid amplification diagnostic systems have high specificity for TB diagnosis (and rifampicin resistance) but sensitivity for TB detection is more variable. Nevertheless, it is possible to diagnose TB and rifampicin resistance within a day and commercial automated systems make this possible with minimal training. Although studies are limited, these systems appear to be cost-effective. Most of these tools are of value clinically and for public health use. For example, whole genome sequencing of Mycobacterium tuberculosis offers a powerful new approach to the identification of drug resistance and to map transmission at a community and population level.

Correlations between Income inequality and antimicrobial resistance

Objectives

The aim of this study is to investigate if correlations exist between income inequality and antimicrobial resistance. This study’s hypothesis is that income inequality at the national level is positively correlated with antimicrobial resistance within developed countries.

Data collection and analysis

Income inequality data were obtained from the Standardized World Income Inequality Database. Antimicrobial resistance data were obtained from the European antimicrobial Resistance Surveillance Network and outpatient antimicrobial consumption data, measured by Defined daily Doses per 1000 inhabitants per day, from the European Surveillance of antimicrobial Consumption group. Spearman’s correlation coefficient (r) defined strengths of correlations of: > 0.8 as strong, > 0.5 as moderate and > 0.2 as weak. Confidence intervals and p values were defined for all r values. Correlations were calculated for the time period 2003-10, for 15 European countries.

Results

Income inequality and antimicrobial resistance correlations which were moderate or strong, with 95% confidence intervals > 0, included the following. Enterococcus faecalis resistance to aminopenicillins, vancomycin and high level gentamicin was moderately associated with income inequality (r= ≥0.54 for all three antimicrobials). Escherichia coli resistance to aminoglycosides, aminopenicillins, third generation cephalosporins and fluoroquinolones was moderately-strongly associated with income inequality (r= ≥0.7 for all four antimicrobials). Klebsiella pneumoniae resistance to third generation cephalosporins, aminoglycosides and fluoroquinolones was moderately associated with income inequality (r= ≥0.5 for all three antimicrobials). Staphylococcus aureus methicillin resistance and income inequality were strongly associated (r=0.87).

Conclusion

As income inequality increases in European countries so do the rates of antimicrobial resistance for bacteria including E. faecalis, E. coli, K. pneumoniae and S. aureus. Further studies are needed to confirm these findings outside Europe and investigate the processes that could causally link income inequality and antimicrobial resistance.

Epidemiological analyses of tuberculosis in Archangelsk, Russia and implementation of a rapid assay for detection of resistance in this high burden setting

BACKGROUND

Tuberculosis (TB) is a major problem in Russia, particularly regarding multidrug-resistant tuberculosis (MDR-TB). Rapid drug susceptibility testing methods are therefore needed.

OBJECTIVES

To perform epidemiological analyses of TB in the Archangelsk region and to evaluate the molecular method GenoType®MTBDRplus in this type of setting.

MATERIALS AND METHODS

Clinical and microbiological data of all TB patients in Archangelsk were collected in 2010. Smear-positive sputa were analysed by MTBDRplus and Bactec MGIT 960.

RESULTS

The number of TB cases was 812 (incidence 65/105) and among these patients, 151 cases were registered in the penitentiary system (incidence 1162/105). Most patients were men, 94% had pulmonary TB and 22% were relapses. Out of all cases, 341 (42%) were smear positive and thus contagious and 176 (22%) had MDR-TB, among which one had extensively drug resistant tuberculosis (XDR-TB). Furthermore, two TB patients had strains being resistant to rifampicin, but susceptible to isoniazid. The number of cases being both contagious and MDR-TB was 128 representing 15.8% of all TB cases (incidence 10.2/105). Among these 128 TB patients 37 were relapses representing 25.7% of all the relapse cases. The results of MTBDRplus and Bactec MGIT analyses corresponded in 98.8%.

CONCLUSIONS

In Archangelsk many TB patients had contagious MDR-TB thus being hazardous in society and relapsing pulmonary TB was common. The TB situation in the prisons was particularly severe. The analyses showed furthermore that MTBDRplus is of major value in this setting.

Prevalence of smear positive pulmonary tuberculosis among prisoners in North Gondar Zone Prison, northwest Ethiopia

BACKGROUND

People concentrated in congregated systems, such as prisons, are important but often neglected reservoirs for TB transmission, and threaten those in the outside community. Therefore, this study was conducted to determine the prevalence of tuberculosis in a prison system of North Gondar Zone.

METHODS

An active case-finding survey in North Gondar Prison was carried out from March to May 2011. All prison inmates who had history of cough for at least a week were included in the study. Three morning sputum samples were collected from suspected inmates and examined through fluorescence microscopy. Fine needle aspiration cytology was done for those having significant lymphadenopathy. Pre and post HIV test counseling was provided after written consent. Binary logistic and multivariable analysis was performed using SPSS version 16.

RESULTS

A total of 250 prisoners were included in the survey. Among these, 26 (10.4%) prisoners were found to have TB giving a point prevalence of 1482.3 per 100,000 populations of smear positive TB among the TB suspects. All the inmates who participated in the study volunteered for HIV testing and a total of 19(7.6%) inmates were found to be reactive for the HIV antibody test amongst of which 9(47.4%) had TB co-infection. The prevalence of HIV infection in the TB infected inmates was found to be 34.6% (9/26). From the 26 TB cases identified 12 (46.2%) were having under nutrition (BMI < 18.5kg/m(2)).

CONCLUSIONS

There is high prevalence of TB in North Gondar Prison with possible active transmission of TB within the prison. There was a high prevalence of HIV among the TB suspects. Strong cooperation between prison authorities and the national tuberculosis control programmes is urgently required to develop locally appropriate interventions to reduce transmission. The determinants for poor nutrition in the prison need also further investigation.

Multidrug-resistant tuberculosis in Belarus: the size of the problem and associated risk factors

OBJECTIVE

To assess the problem of multidrug-resistant tuberculosis (MDR-TB) throughout Belarus and investigate the associated risk factors.

METHODS

In a nationwide survey in 2010-2011, 1420 tuberculosis (TB) patients were screened and 934 new and 410 previously treated cases of TB were found to meet the inclusion criteria. Isolates of Mycobacterium tuberculosis from each eligible patient were tested for susceptibility to anti-TB drugs. Sociobehavioural information was gathered in interviews based on a structured questionnaire.

FINDINGS

MDR-TB was found in 32.3% and 75.6% of the new and previously treated patients, respectively, and, 11.9% of the 612 patients found to have MDR-TB had extensively drug-resistant TB (XDR-TB). A history of previous treatment for TB was the strongest independent risk factor for MDR-TB (odds ratio, OR: 6.1; 95% confidence interval, CI: 4.8-7.7). The other independent risk factors were human immunodeficiency virus (HIV) infection (OR: 2.2; 95% CI: 1.4-3.5), age < 35 years (OR: 1.4; 95% CI: 1.0-1.8), history of imprisonment (OR: 1.5; 95% CI: 1.1-2.0), disability sufficient to prevent work (OR: 1.9; 95% CI: 1.2-3.0), alcohol abuse (OR: 1.3; 95% CI: 1.0-1.8) and smoking (OR: 1.5; 95% CI: 1.1-2.0).

CONCLUSION

MDR-TB is very common among TB patients throughout Belarus. The numerous risk factors identified for MDR-TB and the convergence of the epidemics of MDR-TB and HIV infection call not only for stronger collaboration between TB and HIV control programmes, but also for the implementation of innovative measures to accelerate the detection of TB resistance and improve treatment adherence.

Assessing spatial heterogeneity of multidrug-resistant tuberculosis in a high-burden country

Multidrug-resistant tuberculosis (MDR-TB) is a major concern in countries of the former Soviet Union. The reported risk of resistance among tuberculosis (TB) cases in the Republic of Moldova is among the highest in the world. We aimed to produce high-resolution spatial maps of MDR-TB risk and burden in this setting. We analysed national TB surveillance data collected between 2007 and 2010 in Moldova. High drug susceptibility testing coverage and detailed location data permitted identification of subregional areas of higher MDR-TB risk. We investigated whether the distribution of cases with MDR-TB risk factors could explain this observed spatial variation in MDR-TB. 3447 MDR-TB cases were notified during this period; 24% of new and 62% of previously treated patients had MDR-TB. Nationally, the estimated annual MDR-TB incidence was 54 cases per 100 000 persons and >1000 cases per 100 000 persons within penitentiaries. We identified substantial geographical variation in MDR-TB burden and hotspots of MDR-TB. Locations with a higher percentage of previously incarcerated TB cases were at greater risk of being MDR-TB hotspots. Spatial analyses revealed striking geographical heterogeneity of MDR-TB. Methods to identify locations of high MDR-TB risk and burden should allow for better resource allocation and more appropriate targeting of studies to understand local mechanisms driving resistance.

[Treatment of recurrent pulmonary tuberculosis]

INTRODUCTION

Tuberculosis (TB) is a greatest public health problem of the world. This work aims to study the antituberculous treatment and the evolution of the patients with recurrent tuberculosis.

PATIENTS AND METHOD

The study is a retrospective study on 64 patients with recidivant pulmonary TB: A1 group: at the first TB attack; A2 group: at the time of recidivant TB, and 105 controls patients with confirmed TB without recidive.

RESULTS

Multidrug-resistant TB is more frequent with recidivant TB (21.1% vs 3%, P<0.05) and also extensively drug-resistant. Antituberculous treatment duration in group A1, A2 and T was respectively 8.63 months, 9.79 months, and 7.08 months. Antituberculous drug complications were more frequent in group A2 compared to group T (76.1% vs 41.2%; P<0.001).

CONCLUSION

All tuberculous patients, specially recidivant TB, should benefit of particular care and drug protocol adaptation.

Global fund financing of tuberculosis services delivery in prisons

INTRODUCTION

Despite concerted efforts to scale up tuberculosis control with large amounts of international financing in the last 2 decades, tuberculosis continues to be a social issue affecting the world's most marginalized and disadvantaged communities. This includes prisoners, estimated at about 10 million globally, for whom tuberculosis is a leading cause of mortality and morbidity. The Global Fund to Fight AIDS, Tuberculosis and Malaria has emerged as the single largest international donor for tuberculosis control, including funding support in delivering tuberculosis treatment for the confined population.

METHODS

The Global Fund grants database, with an aggregate approved investment of $21.7 billion in 150 countries by the end of 2010, was reviewed to identify tuberculosis and human immunodeficiency virus/tuberculosis grants and activities that monitored the delivery of tuberculosis treatment and support activities in penitentiary settings. The distribution and trend of number of countries with tuberculosis prison support was mapped by year, geographic region, tuberculosis or multidrug-resistant tuberculosis burden, and prison population rate. We examined the types of grant recipients managing program delivery, their performance, and the nature and range of services provided.

RESULTS

Fifty-three of the 105 countries (50%) with Global Fund-supported tuberculosis programs delivered services within prison settings. Thirty-two percent (73 of 228) of tuberculosis grants, representing $558 million of all disbursements of Global Fund tuberculosis support by the end of 2010, included output indicators related to tuberculosis services delivered in prisons. Nearly two-thirds (64%) of these grants were implemented by governments, with the remaining by civil society and other partners. In terms of services, half (36 of 73) of grants provided diagnosis and treatment and an additional 27% provided screening and monitoring of tuberculosis for prisoners. The range of services tracked was limited in scope and scale, with 69% offering only 1 type of service and less than one-fifth offering 2 types of service.

CONCLUSIONS

This study is a preliminary attempt to examine Global Fund investments in the fight against tuberculosis in prison settings. Tuberculosis services delivered in prisons have increased in the last decade, but systematic information on funding levels and gaps, services provided, and cost-effective delivery models for delivering tuberculosis services in prisons are lacking.