Yersinia pestis infection in Vietnam. II. Quantiative blood cultures and detection of endotoxin in the cerebrospinal fluid of patients with meningitis

Quantitative blood cultures were obtained from 42 patients with acute Yersinia pestis infection to determine whether the concentration of bacteria in blood influenced the clinical severity and outcome of illness. In 17 bacteremic patients, colony counts in blood cultures ranged from less than 10 to 4 X 10(7)/ml. Three of five patients with colony counts of greater than 10(2)/ml died, and two patients survived episodes of hypotension. Results from plasma limulus tests were positive at the time of admission in three of 10 patients tested, and these three patients had bacteremia with colony counts of greater than 10(2)/ml. Meningitis developed in three patients and pneumonia in two patients; these five patients a-l had buboes in the axillary region. Endotoxin was detected with the limulus test in the cerebrospinal fluid in the three patients with meningitis. Ten patients randomly assigned to receive streptomycin or trimethoprim-sulfamethoxazole survived. Those treated with streptomycin had a shorter median duration of fever and a lower incidence of complications than did the patients treated with trimethoprim-sulfamethoxazole.

Typhoid fever. Studies of blood coagulation, bacteremia, and endotoxemia

Patients with typhoid fever were studied to determine whether disseminated intravascular coagulation (DIC), circulating bacteria, and endotoxemia were responsible for the signs and symptoms of their illnesses. Coagulation tests in 28 patients detected thrombocytopenia in 17, hypofibrinogenemia in nine, and elevated titers of fibrinogen-related antigens in 20. Repeated testing during convalescence showed a return toward normal values. Intestinal bleeding, however, did not correlate with abnormalities of coagulation tests. Thus, DIC occurred commonly but appeared to be a subclinical event in these patients. In 25 patients with positive blood cultures for Salmonella typhi, quantitative cultures detected from less than 10 to 9 x 10(2) bacteria/ml. Limulus tests for endotoxin in plasma were negative in all 21 patients tested. These results indicated that the concentrations of circulating bacteria and endotoxin in typhoid fever are lower than in other Gram-negative bacterial infections and suggested that circulating bacteria and endotoxin do not play a major role in the pathogenesis of typhoid fever.

Therapy of antimicrobial-resistant typhoid fever

Antimicrobial-resistant typhoid fever in Saigon was studied by examining in vitro antimicrobial susceptibilities of Salmonella typhi strains and conducting a randomized clinical trial of ampicillin and trimethoprim-sulfamethoxazole (TMP-SMZ). Isolates of S. typhi were obtained from blood or stool cultures of 90 patients. Of 87 isolates tested for antimicrobial susceptibility, 65 (75%) were resistant (R) to chloramphenicol, streptomycin, sulfonamide, and tetracycline, and 22 (25%) were susceptible (S). The drug resistance was transferable to Escherichia coli and was found in 11 different Vi-phage types. All isolates were susceptible to ampicillin and to TMP-SMZ. Agar dilution studies of TMP and SMZ showed synergistic inhibition of growth in all 18 S isolates and in 12 of 48 R isolates tested. The clinical trial of ampicillin and TMP-SMZ showed that both drugs were equally effective. Treatment failure with both drugs was more frequent in patients with S isolates than in patients with R isolates. Therefore, in an area where antimicrobial-resistant typhoid fever exists, patients with R isolates should receive either ampicillin or TMP-SMZ, but patients with S isolates should be treated with chloramphenicol.

Building operational research capacity in the Pacific

Operational research (OR) in public health aims to investigate strategies, interventions, tools or knowledge that can enhance the quality, coverage, effectiveness or performance of health systems. Attention has recently been drawn to the lack of OR capacity in public health programmes throughout the Pacific Islands, despite considerable investment in implementation. This lack of ongoing and critical reflection may prevent health programme staff from understanding why programme objectives are not being fully achieved, and hinder long-term gains in public health. The International Union Against Tuberculosis and Lung Disease (The Union) has been collaborating with Pacific agencies to conduct OR courses based on the training model developed by The Union and Médecins Sans Frontières Brussels-Luxembourg in 2009. The first of these commenced in 2011 in collaboration with the Fiji National University, the Fiji Ministry of Health, the World Health Organization and other partners. The Union and the Secretariat of the Pacific Community organised a second course for participants from other Pacific Island countries and territories in 2012, and an additional course for Fijian participants commenced in 2013. Twelve participants enrolled in each of the three courses. Of the two courses completed by end 2013, 18 of 24 participants completed their OR and submitted papers by the course deadline, and 17 papers have been published to date. This article describes the context, process and outputs of the Pacific courses, as well as innovations, adaptations and challenges.

Oxolinic acid in the treatment of typhoid fever due to chloramphenicol-resistant strains of Salmonella typhi

Of 28 strains of Salmonella typhosa collected in late 1972 in Vietnam, 4 had minimum inhibitory concentrations to chloramphenicol of >100 mug/ml. Median minimum inhibitory concentrations of all strains to oxolinic acid were 0.39 mug/ml; ampicillin, 6.25 mug/ml; amoxicillin, 0.39 mug/ml. Widespread typhoid fever appeared in mid-1973 with more than three-fourths of strains found to be resistant to chloramphenicol. Peak serum concentrations of oxolinic acid average 3.0 mug/ml after the oral ingestion of 1.0 g. In July 1974, a pilot study was begun to evaluate the efficacy of oxolinic acid in vivo, recognizing the discrepancy between in vitro and in vivo results with many agents evaluated in the treatment of typhoid fever. Seven patients with typhoid fever, six with positive blood cultures, were treated with oxolinic acid (1.5 g twice daily by mouth, a daily dose that averaged 75 mg/kg per day) for 5 to 12 days. In four of six patients, blood cultures became negative at 2 to 3 days, with another being negative at 6 days. Despite negative blood cultures, all but one patient remained clinically ill with temperatures of >39.5 C at 4 to 9 days. All strains were susceptible to 0.19 mug of oxolinic acid per ml, and resistant strains did not occur. One patient died after being changed to ampicillin, one left against advice, three responded to amoxicillin, and one died with pseudomonas bacteremia. Toxicity to oxolinic acid did not occur.

The trend of tuberculosis cases over 60 years in Fiji's largest treatment centre: 1950-2010

SETTING

P J Twomey Hospital, National Tuberculosis Programme, Fiji.

OBJECTIVES

To review the trend in numbers of tuberculosis (TB) cases registered each year from 1950 to 2010 at P J Twomey Hospital, Fiji's largest TB treatment centre and central TB unit, and to consider trends in the context of key TB control events in Fiji.

DESIGN

Descriptive study of data from medical records and TB registers, including age, sex, ethnicity, TB diagnosis and smear result.

RESULTS

Between 1950 and 2010, 14 616 cases were registered at P J Twomey Hospital. Of these, 58% were male, 70% were indigenous Fijians (i-taukei) and 64% were aged 15-49 years. The caseload dropped sharply in the 1960s, and has fallen steadily since 1990. Smear results were available for the majority of cases (91%). Between 1950 and 1985, smear-positive cases accounted for 19% of cases overall; this increased to 41% after 1985 following laboratory training. The numbers of sputum smear-positive cases recorded each year has been increasing in the last decade.

CONCLUSION

There have been marked changes in TB caseload over the last 60 years at Fiji's largest TB treatment centre. The recent increase in smear-positive cases while total TB cases have been falling needs further evaluation.

Is effective patient support missing in the global response to multidrug-resistant tuberculosis?

Multidrug-resistant tuberculosis (MDR-TB) is a threat to the achievement of the global targets to the World Health Organization (WHO) End TB by 2030 Strategy. The WHO consolidated guidelines for the treatment of drug-resistant TB emphasise the importance of addressing health systems issues, including supporting patients during treatment, contributing to improved adherence, reduced catastrophic costs and better treatment outcomes. The recently published results of the STREAM (Standardised Treatment Regimen of Anti-TB Drugs for Patients with MDR-TB) clinical trial and the Delamanid 213 Trial suggest that the implementation of a proper patient-centred approach to the clinical and programmatic management of MDR-TB as per the WHO guidelines is key to improving treatment outcomes in MDR-TB patients.

Nurses graduating in Fiji between 2001 and 2010: sufficient supply for Fiji's health service demands?

SETTING

Fiji's schools of nursing and government health services, 2001-2010.

OBJECTIVES

To report on 1) the number and characteristics of nurses who graduated in Fiji, 2) the proportion of vacant nursing positions in the government health services and 3) attrition among nurses.

DESIGN

Descriptive study involving a retrospective record review of Ministry of Health annual reports and nursing registers.

RESULTS

Over the period 2001-2010, a total of 1500 nurses graduated, with the overall trend being a gradual increase in newly qualified nurses year on year. Available data from 2007 onwards showed relatively low vacancy rates (range 0.4-2%), with a sharp rise to 15% in 2009. Complete data on nurse attrition were available only from 2007 onwards, with rates of attrition ranging from 4% to 10%; the most common reason for attrition was resignation.

CONCLUSION

While it was unable to directly assess whether Fiji's supply of nursing graduates has been meeting the country's health service demands, this study provides a series of baseline data on Fiji's nurse graduate and nursing workforce. In addition, it identifies some of the challenges and gaps that need to be considered to better assess and address nursing staff shortages.

Sputum smear examination and time to diagnosis in patients with smear-negative pulmonary tuberculosis in the Pacific

SETTING

National tuberculosis programmes (NTPs) in Kiribati and the Marshall Islands, 2006-2010.

OBJECTIVE

To determine the proportion of all tuberculosis (TB) cases that were pulmonary smear-negative, and for these patients to determine how many sputum smears were examined and the time from sputum smear examination to registration.

DESIGN

A retrospective cross-sectional study involving a record review of national TB and laboratory registers.

RESULTS

Of 2420 TB cases identified, 709 (29%) were registered as smear-negative pulmonary TB. Of the 695 (98%) with information on smear examination, 222 (32%) had no smear recorded, 61 (9%) had one smear, 86 (12%) two smears and 326 (47%) three smears. Among the 473 patients who had at least one smear, 238 (50%) were registered before sputum examination, 131 (28%) within 1 week, 72 (15%) between 1 and 4 weeks, and 34 (7%) >4 weeks after sputum examination.

CONCLUSION

NTPs in Kiribati and the Marshall Islands are diagnosing 29% of all TB patients as smear-negative pulmonary TB. Many patients do not have smears done or are registered before undergoing smear examination. Corrective measures are needed.

An assessment of current tuberculosis patient care and support policies in high-burden countries

CONTEXT: Adherence to treatment for tuberculosis (TB) is an important predictor of treatment outcomes. The World Health Organization guidelines recommend a patient-centred approach to adherence support; however, the extent to which policies in high-burden countries facilitate this approach remains uncertain.DESIGN: A cross-sectional survey of current national patient care and support policies in high TB burden countries was performed.RESULT: Responses were provided by TB care programmes in 23 of the 30 high TB burden countries, comprising 77.4% of TB cases globally. Clinic-based and household adherence support and patient education were recommended in all countries, while policies for digital technologies and social supports have been adopted in a small minority of countries. Financial or material support (such as reimbursement for transportation) and psychological support to patients-if included in the policies-was mainly recommended only for specific sub-groups of patients.CONCLUSION: National policies in many countries have not yet fully adopted global recommendations for patient care and support. Further scale-up of evidence-based approaches to care is required to improve quality of care for patients in high TB burden settings.

Evaluation of sputum smear microscopy in the National Tuberculosis Control Programme in the north of Vietnam

OBJECTIVE

To assess the yield of sputum smear microscopy and sex differences in the National Tuberculosis Control Programme in the north of Vietnam.

METHODS

Review of registers of 30 randomly selected laboratories (26 district, 4 provincial level).

RESULTS

The average daily workload per technician was 4.4 examinations in district and 5.3 examinations in provincial laboratories. To find one smear-positive case, 9.7 suspects were examined and 29.3 smears done. The smear-positive rate (mean 10.3%) was higher among men (11.6%) than among women (8.4%, P < 0.001). There were more men than women among tuberculosis (TB) suspects (male:female ratio 1.36, 95%CI 1.19-1.54), but even more so among smear-positive patients (1.89, 95%CI 1.64-2.14), irrespective of specimen quality and number of smears examined. Three smears were examined for 18,055 suspects (61.7%). The incremental gain was 33.5% and 4.9% for the second and third smear examination, respectively; 186 (95%CI 160-221) smears needed to be examined to find one additional case of TB with a third serial examination.

CONCLUSION

The diagnostic process seemed generally efficient. The male:female ratios suggest higher TB incidence in men rather than lower access to TB facilities for women. The third smear examination could be omitted.

Radiographic predictors of subsequent reactivation of tuberculosis

SETTING

A cohort of migrants to Australia (n = 7265) selected to be at increased risk of tuberculosis (TB) were assessed at the Liverpool Chest Clinic, Sydney, between 1984 and 2003.

OBJECTIVE

To assess the reproducibility and predictive value of various radiographic criteria for predicting the subsequent development of TB.

METHODS

A nested case control study was conducted. Cases were those who had a confirmed diagnosis of TB during follow-up (n = 60). A random sample of 107 controls was selected. Initial chest X-rays were read independently and blinded to case vs. control status by two readers according to two classification systems. Agreement was quantified as weighted kappa (kappaw). Sensitivity and specificity for subsequent TB were estimated.

RESULTS

There was moderate agreement between readers for both classification systems (kappaw 0.67 and 0.60, respectively). The presence of calcified nodular densities or fibrosis together with non-calcified nodular densities in mid and/or upper lung zones or the presence of a pulmonary infiltrate typical of TB had a sensitivity of 66% for subsequent pulmonary TB and a specificity of 82%. Minor abnormalities or findings consistent with past primary TB infection alone were not predictive of subsequent TB.

CONCLUSIONS

Radiographic screening can be helpful in identifying individuals at increased risk of subsequent TB.

No universal access to drug-resistant tuberculosis care without engaging all health care providers

Should the engagement of all health care providers in all aspects of programmatic management of drug-resistant tuberculosis (PMDT) become a priority in the national strategic plans for tuberculosis (TB), progress towards universal access to diagnosis, treatment and care of drug-resistant tuberculosis (DR-TB) would accelerate. This would be especially crucial in countries where the private sector is a significant provider of health services. Proven successful interventions to engage all health care providers and partners in the cascade of prevention, diagnosis, treatment and care of DR-TB patients need to be urgently scaled up. Such engagement should not be limited to the diagnosis and treatment of DR-TB, but extended also to all the aspects of PMDT, including approaches ensuring that patient-centred care, social support, pharmacovigilance and surveillance. Integral to the End TB Strategy, PMDT should be embedded in all public-private mix initiatives for TB and vice versa.