How do patients who fail first-line TB treatment but who are not placed on an MDR-TB regimen fare in South India?

A systematic review of clinical outcomes on the WHO Category II retreatment regimen for tuberculosis

OBJECTIVE

To assess the clinical outcomes of patients prescribed the World Health Organization (WHO) Category II retreatment regimen for tuberculosis (TB).

DESIGN

A systematic review of the literature was performed by searching Medscape, Embase and Scopus databases for cohort studies and clinical trials reporting outcomes in adult patients on the Category II retreatment regimen.

RESULTS

The proportion of patients successfully completing the retreatment regimen varied from 27% to 92% in the 39 studies included in this review. In only 2/39 (5%) studies was the treatment success rate > 85%. There are very few data concerning outcomes in patients categorised as 'other', and outcomes in this subgroup are variable. Of the five studies reporting disaggregated outcomes in human immunodeficiency virus (HIV) positive people, four demonstrated worse outcomes than in HIV-negative people on the retreatment regimen. Only four studies reported disaggregated outcomes in patients with isoniazid (INH) resistance, and treatment success rates varied from 11% to 78%.

CONCLUSION

Clinical outcomes on the Category II retreatment regimen are poor across various populations. Improvements in management should consider the holistic treatment of comorbidity and comprehensive approaches to drug resistance in patients with recurrent TB, including a standardised approach for the management of INH resistance in patients who develop recurrent TB in settings without reliable access to comprehensive drug susceptibility testing.

Clinical Correlates and Drug Resistance in HIV-Infected and -Uninfected Pulmonary Tuberculosis Patients in South India

OBJECTIVES

To examine demographics, clinical correlates, sputum AFB (acid fast bacilli) smear grading DOTS (Directly Observed Therapy Short Course) uptake, and drug resistance in a cohort of newly-diagnosed, smear positive pulmonary tuberculosis (TB) patients with respect to HIV status at baseline, and compare smear conversion rates, side effects and mortality after two months.

DESIGN

A prospective study among 54 HIV positive and 41 HIV negative pulmonary TB patients. Data were collected via face-to-face interviews, review of medical records, and lab tests.

RESULTS

HIVTB co-infected patients, though more symptomatic at baseline, showed more improvement in their symptoms compared to HIV-uninfected TB patients at follow-up. The HIV co-infected group had more prevalent perceived side effects, and sputum smear positivity was marginally higher compared to the HIV negative group at follow-up. Mortality was higher among the HIV-infected group. Both groups had high rates of resistance to first-line anti-tubercular drugs, particularly isoniazid. There was no significant difference in the drug resistance patterns between the groups.

CONCLUSIONS

Prompt initiation and provision of daily regimens of ATT (Anti-Tubercular treatment) along with ART (Anti-Retroviral treatment) via ART centers is urgently needed in India. As resistance to ART and/or ATT is directly linked to medication non-adherence, the use of counseling, regular reinforcement, early detection and appropriate intervention strategies to tackle this complex issue could help prevent premature mortality and development of resistance in HIV-TB co-infected patients. The high rate of isoniazid resistance might preclude its use in India as prophylaxis for latent TB in HIV infected persons as per the World Health Organization (WHO) guideline.

Infectious Diseases and Livelihoods

Agriculture has been the most common form of livelihood for rural communities in developing countries for centuries. Apart from providing a livelihood, rural communities find food and nutrients necessary for their survival and well-being from their farms. Agriculture also brings risks to health through infectious diseases. Poor health leads to reduction in productivity, where individuals are not able to carry out their livelihoods due to ill health. This could lead to reduction in income through excess expenditure on treatments, thereby inhibiting economic development of the affected communities. Infectious diseases have both direct and indirect impact on livelihoods. The direct impact includes poor health and loss of lives, which leads to partial and complete loss of livelihoods. Indirectly, infectious diseases lead to loss of income through poor performance of livelihoods as well as diversion of resources that could have been used to improve livelihood to seek medical treatment. Due to the effects of disease, individuals become marginalized, socially affecting their businesses and ways of earning a livelihood.

Prevalence of multidrug-resistant tuberculosis cases among HIV-positive and HIV-negative patients eligible for retreatment regimen in Togo using GeneXpert MTB/RIF

Drug-resistant tuberculosis (TB) is emerging as an important health problem in Togo. From sputum of previously treated TB patients, multidrug-resistant (MDR) TB was diagnosed in 24% (10/42) patients via GeneXpert MTB/RIF compared to 25% (6/24) patients via conventional drug susceptibility testing (BACTEC MGIT 960 system). The agreement between these two methods to detect MDR-TB is excellent. However, GeneXpert MTB/RIF offers the advantage of rapidly detecting Mycobacterium tuberculosis complex in sputum samples in instances where the cultures are negative (33%, 14/42) or contaminated (9.5%, 4/42). GeneXpert MTB/RIF permitted us to estimate the prevalence of MDR-TB in previously treated TB patients and to improve TB diagnostics among HIV-positive and -negative patients in Togo, where culturing M. tuberculosis complex from sputum samples is challenging.

Promoting operational research through fellowships: a case study from the South-East Asia Union Office

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) jointly developed a new paradigm for operational research (OR) capacity building and started a new process of appointing and supporting OR fellows in the field. This case study describes 1) the appointment of two OR fellows in The Union South-East Asia Office (USEA), New Delhi, India; 2) how this led to the development of an OR unit in that organisation; 3) achievements over the 5-year period from June 2009 to June 2014; and 4) challenges and lessons learnt. In June 2009, the first OR fellow in India was appointed on a full-time basis and the second was appointed in February 2012-both had limited previous experience in OR. From 2009 to 2014, annual research output and capacity building initiatives rose exponentially, and included 1) facilitation at 61 OR training courses/modules; 2) publication of 96 papers, several of which had a lasting impact on national policy and practice; 3) providing technical assistance in promoting OR; 4) building the capacity of medical college professionals in data management; 5) support to programme staff for disseminating their research findings; 6) reviewing 28 scientific papers for national or international peer-reviewed journals; and 7) developing 45 scientific abstracts for presentation at national and international conferences. The reasons for this success are highlighted along with ongoing challenges. This experience from India provides good evidence for promoting similar models elsewhere.

Prevalence of multidrug resistance among retreatment pulmonary tuberculosis cases in a tertiary care hospital, Hyderabad, India

Background:

India is one of the high tuberculosis (TB) burden countries in the world. India ranks second in harboring multi drug resistant (MDR)-TB cases. About 50,000 of MDR cases are recorded in retreatment pulmonary TB cases. This study was conducted in a tertiary care facility (Government General and Chest Hospital) in Hyderabad, India.

Objectives:

Toassess: Proportion of the TB patients having MDR-TB at the initiation of retreatment regimen; the prevalence of isoniazid (INH) resistance in this geographical area.

Materials and Methods:

An analytical, observational, prospective cohort study of patients attending the out-patient department from December 2010 to March 2011.

Results:

Sputum samples from 100 patients were subjected to acid fast bacilli (AFB) culture and drug sensitivity testing. Of these, 28 (28%) were MDR-TB, 42 (42%) were non-MDR-TB and 39% being INH resistance.

Conclusions:

In conclusion, one third of the retreatment pulmonary TB cases attending a tertiary care institute for TB will be MDR-TB at the initiation of treatment and there is a need to include ethambutol in the continuation phase of new TB case treatment in view of high INH resistance.

Isoniazid-resistant tuberculosis in children: a systematic review

BACKGROUND

Isoniazid resistance is an obstacle to the treatment of tuberculosis disease and latent tuberculosis infection in children. We aim to summarize the literature describing the risk of isoniazid-resistant tuberculosis among children with tuberculosis disease.

METHODS

We did a systematic review of published reports of children with tuberculosis disease who had isolates tested for susceptibility to isoniazid. We searched PubMed, Embase and LILACS online databases up to January 12, 2012.

RESULTS

Our search identified 3403 citations, of which 95 studies met inclusion criteria. These studies evaluated 8351 children with tuberculosis disease for resistance to isoniazid. The median proportion of children found to have isoniazid-resistant strains was 8%; the distribution was right-skewed (25th percentile: 0% and 75th percentile: 18%).

CONCLUSIONS

High proportions of isoniazid resistance among pediatric tuberculosis patients have been reported in many settings suggesting that diagnostics detecting only rifampin resistance are insufficient to guide appropriate treatment in this population. Many children are likely receiving substandard tuberculosis treatment with empirical isoniazid-based regimens, and treating latent tuberculosis infection with isoniazid may not be effective in large numbers of children. Work is needed urgently to identify effective regimens for the treatment of children sick with or exposed to isoniazid-resistant tuberculosis and to better understand the scope of this problem.