Tuberculosis in Suriname: trends in epidemiology, diagnostics and treatment

This thesis describes the epidemiology of tuberculosis in multi-ethnic Suriname, as well as progress in diagnosis and treatment trends of tuberculosis(TB) in Suriname.

Tuberculosis – patients’ knowledge, attitudes and practices regarding their illness

OBJECTIVE: To determine tuberculosis (TB) patients’ knowledge, attitudes and practices with respect to their illness. DESIGN AND METHODS: A cross sectional study was conducted. 208 tuberculosis patients > 18 years of age who were currently receiving treatment were included. The study sample was selected from two major regional chest clinics in Trinidad. A pilot tested questionnaire was interviewer administered to each patient. RESULTS: Out of the 208 patients interviewed (response rate 65.0%), 129 were male, and 79 were female. The majority of patients had either secondary or tertiary level of education (54.8%), whereas only 43.8% had either primary level of education or none at all. Analysis revealed that TB knowledge was affected by a patient’s level of education, where persons with secondary/tertiary levels of education had a greater knowledge about TB (p<0.005). The majority (78.4%) of patients believed that they were not stigmatized; however, 191 (91.8%) patients urged for increased public awareness about TB in order to change perceptions toward the disease. The majority of patients were compliant towards their management advice, as well as taking their prescribed medications, however non- compliance was noted to be more likely in the under 50 year age group (9.8%), rather than the over 50 year age group (1.1%). CONCLUSION: Patients with at least secondary level education had better knowledge about tuberculosis than those with primary level education. Patients indicated the need for more public awareness about TB. Compliance with management (medication and attendance at clinics) was good among the majority of the patients.

The relationship between nutritional and sociodemographic factors and the likelihood of children in the Dominican Republic having a BCG scar

OBJECTIVE: To critically assess the prevalence among schoolchildren 6 to 9 years of age throughout the Dominican Republic of a bacille Calmette-Guerin (BCG) vaccination scar, and to examine the relationship between nutritional and sociodemographic factors and the likelihood of having a BCG scar. METHODS: This correlational study used the database of the Second National Census on Height and Weight of Elementary School First Grade Students, which was conducted in the Dominican Republic August 2001-May 2002, to provide a critical assessment of BCG coverage nationwide. The Census information for the children included the presence of BCG scar, their nutritional status, and basic demographic data. We developed a new sociodemographic indicator, the "Rosa Index", to examine the potential influence of poverty and other environmental characteristics on scar presence. We used logistic regression models to predict the presence of a BCG scar. RESULTS: An overall BCG scar prevalence of 55.3 percent (85 644/154 887)was found. Malnourished children were less likely to have a BCG scar than were children with adequate nutritional status (odds ratio = 0.91; 95 percent confidence interval: 0.87, 0.95, P<0.05). Children who were 7-9 years old were less likely to have a BCG scar than were children 6 years old. Children in the areas of the country more than two hours' driving distance from the capital city of Santo Domingo more often exhibited lower BCG scar prevalence levels than did children in Santo Domingo. A higher Rosa Index (better level of socioeconomic characteristics) was correlated with higher BCG scar prevalence values (r=0.54, P<0.05). CONCLUSIONS: Our study findings indicate that BCG coverage appears to be inadequate for schoolchildren in the Dominican Republic. Nevertheless, the presence of a scar in a higher proportion of younger children suggests that coverage has improved in recent years. More programmatic and economic emphasis needs to be placed on extending early BCG vaccination coverage to the areas of the country where vaccination coverage is lower, and on examining the potential role that poverty may have on vaccination effectiveness (AU)

High frequency of multidrug-resistant Mycobacterium tuberculosis isolates in Georgetown, Guyana

Emergence of multi-drug resistance (MDR) Mycobacterium tuberculosis isolates constitutes a threat to public health worldwide. This study aimed at acquiring first epidemiological data for Guyana. Thirty-six M. tuberculosis isolates from patients of the Georgetown Chest Clinic were subjected to susceptibility testing on solid agar and in broth media. Resistance to at least one first-line drug was observed in 8 (22.2 percent, 95 percent confidence interval 8.3 -36.1 percent) and simultaneous resistance to rifampicin and isoniazid (MDR) in 4 (11.1 percent, 95 percent confidence interval 0.6-21.6 percent) of the 36 isolates. The risk of infection with resistant isolates was significantly related to earlier antituberculosis therapy (P=0.040). These data indicate a high proportion of resistant M.tuberculosis isolates in Guyana and call for the implementation of control strategies based on an improved laboratory diagnosis of TB(AU)

Factors involved in patient compliance with anti-tuberculosis treatment in Jamaica

The worldwide resurgence of tuberculosis that took place in the 1990's did not unduly affect Jamaica's National Tuberculosis Programme. The case detection rate over the past ten years has remained steady, even in light of increase HIV/AIDS infection. The major problem affecting the National Tuberculosis Programme (NTP) is in the area of drug compliance, which has peaked at a cure/completion rate of 82 percent in 1998 (MOH, 1998). This rate is still 3 percent below the recommended WHO standards of 85 percent for NTP. The aim of the study was to determine the factors relating to drug compliance within the Jamaican context. Data was collected using data extraction forms administered to a study population of 180 respondents. Qualitative data was collected from a focus group interview, which assisted in the design of questions for the data extraction forms. Some data was was obtained from the national TB register and from records ar the National Chest Hospital. ... The study found that the support given to family members during the period of illness definitely influenced the level of compliance. The gender and age distribution of respondents were similar to worldwide trends although it was found that males on the average were infected at an older age. The ability to procure medication is still an important component of drug compliance; 47 percent of completers were always able to purchase thier drugs, which is 4 times greater than the defaulters. Respondents indicated their preference for treatment in hospital despite the relatively high cost of hospitalization although there was no statistically significant difference in compliance level. Most respondents had fair scores in response to the attitude questions. Except for gender (P<0.01), there was no significant relationship between attitude and demographic variables. The study also found that respondents' knowledge about DOTS was limited however those who knew about it, indicated, in thier responses that it probably was the best method for treating TB cases. Recommendations concerning the factors relating to patient compliance will be documented so that the Ministry of Health and other related agencies can access it for policy development (AU)

A study of the Knowledge, attitudes and practices of primary health care workers in the South-East region of Jamaica concerning the DOTS strategy for the control of tuberculosis

Tuberculosis is an infectious disease caused by the micro-organism Mycobacterium tuberculosis. This micro-organism can be found in about one third of the world population and causes more deaths than any other infectious agent globally. To control this deadly disease, persons ill witH TB need to take a combination of medications for a period of 6 to 8 months. Most of those suffering from TB find this difficult, and to aid in the adequate treatment of persons with the disease and protect others from it, the World Health Organisation along with others concerned about the situation, developed the directly observed treatment, short-course (DOTS) strategy. This cost effective method of treatment requires that health workers world wide observe infected persons while they take their tablets. The aim of this study was to assess the knowledge, attitudes and practices of primary health care workers about the treatment and control of TB using the directly observed treatment, short-course (DOTS) strategy. Data were collected using a questionnaire administered to a sample of selected categories of health workers in the study area. Additionally, three selected key informants from the Jamaican health services were interviewed. One hundred and seventy respondents from five categories, (medical officers, nurses, public health inspectors, community health aids and contact investigators) completed questionnaires. The study found that primary health care workers in Jamaica are very willing to participate in this global effort. They feel confident that once they are given the right tools to work with they can contribute ... The study recommends a review of the progress of the implementation program, preparation of a revised plan of action will all involved in TB control activities and institution of training programs throughout the health service on this "health breakthrough of the 1990's" (AU)

A study of the knowledge, attitudes and practices of primary health care workers in the south-east region of Jamaica concerning the DOTS strategy for the control of tuberculosis

Tuberculosis is an infectious disease caused by the micro-organism Mycobacterium tuberculosis. This micro-organism can be found in about one third of the world population and cause more deaths than any other infectious agent globally. To control this deadly disease, persons ill with TB need to take a combination of medications for a period of 6 to 8 months. Most of those suffering from TB find this difficult, and to aid in the adequate treatment of persons with the disease and protect others from it, the World Health Organization along with others concerned about the situation, developed the directly observed treatment, short-course (DOTS) strategy. This cost effective method of treatment requires that health workers world wide observe infected persons while they take their tablets. The aim of this study was to assess the knowledge, attitudes and practices of primary health workers about the treatment and control of TB using the directly observed treatment, short-course (DOTS) strategy. Data were collected using a questionnaire administered to a sample of selected categories of health workers in the study area. Additionally, three selected key informants from the Jamaican health services were interviewed. One hundred and seventy respondents from five categories, (medical officers, nurses, public health inspectors, community health aids and contact investigators) completed questionnaires. The study found that primary health care workers in Jamaica are very willing to participate in this global effort. They feel confident that once they are given the right tools to work with they can contribute in some way to ridding the world of this ancient killer. The most important workers in the execution of the activities of the strategy in the South East Region of Jamaica, where the study was done were the community health aids, contact investigators and the nurses. Their basic knowledge about TB and DOTS was very limited despite the fact that the Ministry of Health has implemented the strategy about four years ago. The in-depth interviews, however, revealed that there are some challenges in the implementation of the strategy and questioned its usefulness in Jamaica presently. The study recommends a review of the progress of the implementation program, preparation of a revised plan of action with all involved in TB control activities and institution of training programs throughout the health service on this "health breakthrough of the 1990's".(Au)

Assessment of the impact of the HIV epidemic on the incidence of tuberculosis in Trinidad and Tobago

We reviewed and assessed 987 reported cases of tuberculosis (TB) from 1990 to 1996. There were 602 (70 percent) males 263 (30 percent) females. The number of cases reported annually rose from 118 to 199 (81 percent) from 1990 to 1996. East Indians comprised 335 (34 percent) and Africans 503 (52 percent) of all cases. 122 of these patients (12.4 percent) were positive for the human immunodeficiency virus (HIV). However, of these, Africans made up 80 percent, (98/122) as compared to only 11 percent (13/122) who were of East Indian origin. Paediatric cases of TB rose by 600 percent from 4 cases in 1990 to 28 cases in 1996. Of a total of 74 paediatric cases 6 (8 percent) were HIV/TB was the 25-45 years group and of those with HIV/TB, 36 percent dies within 6-8 months of being diagnosed. This HIV/TB co-infection will cause a tremendous waste of youthful lives if strategies are not put in place to combat these epidemics.(AU)

Re-emergence of tuberculosis in the Caribbean: how ready are the Caribbean laboratories in 1997?

The incidence of tuberculosis is increasing in the English speaking Caribbean and multiple drug resistant M. tuberculosis has been reported. Twenty-one laboratories in the Caribbean were surveyed to assess their current practices and capabilities for the detection, isolation and drug susceptibility testing of M. tuberculosis. Sixteen laboratories perform laboratory diagnosis of tuberculosis, most commonly by the Kinyoun technique (10/16). Microscopic examination of sputum for acid fast bacilli (AFB) was being performed in 12 laboratories by the direct method. Only one laboratory used fluorochrome methods for the rapid detection of AFB in sputum and other clinical specimens. Only five laboratories culture for mycobacteria. None of the laboratories perform either nucleic acid probes of BACTEC NAP for the identification of mycobacteria other than tuberculosis (MOTT). Only three laboratories performed antimicrobial susceptibility testing in the Caribbean. Centrifuges with safety carriers were being used in only 13 percent of laboratories. Eight laboratories (50 percent) used level 2 containment biological safety cabinets while processing all specimens for mycobacterial infections. Reporting of smear results to hospital, physician or the ministry of health/public health department was mainly done by telephone. The time taken to report AFB smear microscopy results averaged over 48 hrs in 75 percent of laboratories. Implementation of CDC recommendations and laboratory quality standards for the control of tuberculosis are urgently needed in the Caribbean.(AU)

Quality assurance in relation to mycobacterial sputum samples received and processed at the National Public Health Laboratory, Jamaica, 1st August 1997-31st January 1998, and the effects on patients' treatment

There has been a global increase in the incidence of mycobacterial cases since the advent of HIV and AIDS. This increase has not been seen in Jamaica. This study was done to determine the quality of samples received, at the National Public Health Laboratory, in terms of sputum/saliva and time submitted after collection, and to evaluate if this affected case treatment. Data was retrospectively extracted from bench records at the laboratory and analyzed. Cross checking of laboratory negative and positive cases was done using patients' records ar the National Chest Hospital, to validate laboratory results with clinical diagnosis. Evaluation of treatment of positive cases with respect to sensitivity results was done. Results showed that of the 925 sputum samples submitted 86.6 percent were true sputum samples, submitted mainly from the urban region. Sputum samples were five times more likely to yield positive TB culture results than saliva. There was no statistically significant difference in mycobacteria other than tuberculosis (MOTT)or contamination results between sputum and saliva. With respect to time of arrival, only 412 samples were analyzed due to lack of data. Of these, 56.1 percent of these arrival within one day. Positive TB cultures were no different among sputum (14.3 percent) and saliva (13.3 percent) sample with respect to time of arrival. Contamination rate was slightly higher in samples received >1 day (4.4 percent), to those received within one day (2.2 percent). The treatment of 22 TB positive cases evalusted, corresponded with the sensitivity results, but only one of the three MOTT cases corresponded. The quality of sputum samples received was generally good, and did not significantly affect culture results and patients' treatment. A further study however, needs to be done to evaluate quality assurance and quality control measures in the laboratory (AU)

Re-emergence of tuberculosis in the Caribbean: how ready are the Caribbean laboratories in 1997

WHO declared tuberculosis a "Global Emergency" in 1994. The incidence of tuberculosis is increasing in the English speaking Caribbean. Sporadic occurrence of multiple drug resistance M. tuberculosis has been reported in a few countries in this region. It is well recognized that the laboratory plays an important role in the control of tuberculosis through rapid detection, isolation, idenfification of and drug susceptibility testing of M. tuberculosis. Twenty one laboratories were surveyed to assess the current practices and capabilities that exist in laboratories for the detection isolation and drug susceptibility testing of M. tuberculosis in the Caribbean. Sixteen laboratories perform laboratory diagnosis of tuberculosis. Microscopic examination of sputum for acid fast bacilli (AFB) is being performed in 12 laboratories by the direct method. The most commonly used method is the Kinyoun technique (10/16). Only one laboratory is practising fluorochrome methods for the rapid detection of AFB in sputum and other clinical specimens. Only five laboratories culture for mycobacteria. None of the laboratories perform either nucleic acid probes or BACTEC NAP for the identification of mycobacteriae other than tuberculosis (MOTT). Only three laboratories perform antimicrobial susceptibility testing in the Caribbean. All susceptibility testing for M. tuberculosis is done on solid media (LJ slants). The major antibiotics test are rifampicin, isoniazid, ethambutol and stretomycin. Sixty three percent of laboratories do not have a policy on monitoring of laboratory personnel by tuberculosis testing. The use of disposable bacteriological loops and bacticinerator as a minimal safety procedure is 57 percent and 63 percent respectively. Centrifuges with safety carriers are being used in only 13 percent of laboratories. Eight laboratories (50 percent) use Level 2 containment biological safety cabinet while processing of all specimens for mycobacterial infections. Reporting of smear results to hospital, physician or the ministry of health/public health department is mainly done by telephone; but some laboratories report by writing and telephone. Thirty seven percent (6/16) laboratories do not report positive smear AFB results to the public health department. The time required to report AFB smear microscopy results take on an average of over 48 hrs in 75 percent of laboratories.

A retrospective study of tuberculosis in Trinidad and Tobago during 1985, 1990 and 1995

The aim of this study was to analyse the trend in the incidence of new and reactivated cases of tuberculosis in Trinidad and Tobago by comparing the years 1985, 1990 and 1995 with a view to scrutinizing the possible associations between Human Immune Deficiency Virus (HIV) infection and tuberculosis, ethnic drifts and possible emergence of resistant strains of tuberculosis. A data collecting tool was designed and used which enabled relevant data to be collected, using registration numbers of clients who attended the Thoracic Clinic at the Eric Williams Medical Sciences Complex, and the Chest Clinic at the General Hospital San Fernando, Trinidad. The study comprised 363 records which were all the cases diagnosed or reactivated during those years. All age groups were included. The incidence rates of tuberculosis for all three years were 8 per 100,000 population in 1985, 8.7 in 1990 and 13.2 in 1995. There were 17 reactivated cases, 13 (76.4 percent) which were in unemployed persons. Africans predominated among the infected persons in all three years. In 1985, 50.5 percent: 1990, 54.7 percent in 1995, 48.1 percent. The Indians followed with 43.3 percent in 1985 31.1 percent and 34.4 percent in 1995. The mixed group showed a significant rise from 6.2 precent in 1985. 12.3 percent in 1990 and a further rise to 16.9 percent in 1995. The predominant geographical areas of residence were the East-West corridor and South Trinidad with .03 percent of athe population in each of these areas infected with tuberculosis in the years 1985, 1990 and 1995. There were 28 cases of dual infection of HIV and tuberculosis, 14 in 1990 and 14 in 1995, most of occured in 35-39 age group. No cases of multi-drug resistant tuberculosis were discovered during the period under study. There was a significant relationship between employment status and tuberculosis in that 69.6 percent of the subject were unemployed (p=.001). The frequency distribution of tuberculosis showed three main peaks - children under 5 years of age, the 30-34 age group and the 65 and over age group. It also showed a trend in which infection increased with age. The male-female ratio was 2:1. This Public Health problem of tuberculosis must be dealt with in a cost-effective and efficient manner. To this end, continued case-finding and the use of specific treatment protocols are recommended.(Au)

A retrospective study of tuberculosis in Trinidad and Tobago during 1985, 1990 and 1995

The aim of this study was to analyse the trend in the incidence of new and reactivated cases of tuberculosis in Trinidad and Tobago by comparing the years 1985, 1990 and 1995 with a view to scruinizing the possible associations between Human Immune Deficiency Virus (HIV) infection and tuberculosis, ethnic drifts and possible emergence of resistant strains of tuberculosis. A data collecting tool was designed and used which enabled relevant data to be collected, using registration numbers of clients who attended the Thoracic Clinic at the Eric Williams Medical Sciences Complex, and the Chest Clinic at the General Hospital San Fernando, Trinidad. The study comprised 363 records which were all the cases diagnosed or reactivated during those years. All age groups were included. The incidence rates of tuberculosis of all three years were 8 per 100,000 population in 1985, 8.7 in 1990 and 13.2 in 1995. There were 17 reactivated cases, 13 (76.4 percent) of which were in unemployed persons. Africans predominated among the infected persons in all three years. In 1985, 50.5 percent; 1990, 54.7 percent and in 1995, 48.1 percent. The Indians followed with 43.3 percent in 1985, 31.1 percent in 1990 and 34.4 percent in 1995. The mixed group showed a significant rise from 6.2 percent in 1985, 12.3 percent and a further rise to 16.9 percent in 1995. The predominant geographical areas of residence were the East-West corridor and South Trinidad with .03 percent of the population in each of these areas infected with tuberculosis in the years 1985, 1990 and 1995. There were 28 cases of dual infection of HIV and tuberculosis, 14 in 1990 and 14 in 1995, most of the cases occurred in the 35-39 age group. No case of multi-drug resistant tuberculosis were discovered during the period under study. There was a significant relationship between employment status and tuberculosis in that 69.9 percent of the subjects were unemployed (P=.001). The frequency distribution of tuberculosis showed three main peaks - children under 5 years of age, the 30-34 age group and the 65 and over age group. It also showed a trend in which infection increased with age. The male-female ratio was 2:1. The Public Health problem of tuberculosis must be dealt with in a cost-effective and efficient manner. To this end, continued active case-finding and the use of specific treatment protocols are recommended (AU)

Creation of multiple drug-resistant mycobacterium tuberculosis in a patient failing to comply with chemotheraphy in Trinidad and Tobago - abstract

The presence of a multiple drug-resistant strain of Mycobacterium tuberculosis in Trinidad and Tobago was confirmed in 1996 in a sputum sample from a 36-year-old male. In September 1990 smear microscopy was positive for AFB3+. Three consecutive sputum samples taken on the 5th, 7th and 8th of July, 1993 from the same patient was positive for AFB3+ and M. tuberculosis, identified by culture, was resistant to isoniazid (28 percent). This was the first laboratory confirmed case of isoniazid resistant M. tuberculosis. In 1996, M. tuberculosis was cultured from the sputum of the same patient and bacilli were resistant to isoniazid (now 60.3 percent), rifampicin and streptomycin. Treatment records of the patients revealed habitual self-deferral with resumption coinciding with worsening of his clinical condition. The patient works in the mass transport industry and a large -part of the travelling public may have been exposed to a MDR M. tuberculosis strain. This has potentially perilous consequences for Trinidad and Tobago.(AU)

AIDS/Hepatitis, and tuberculosis: implications for the dentist and dental profession

Dentists worlwide treat and manage patients with a variety of oral and systemic complaints. Bacterial fungal and viral infections are commonly seen in dentist practice. Although primarily sexually transmissible, serious diseases such as hepatitis B, herpes, HIV/AIDS and tuberculosis are the major infections for which the dentist must reduce or eliminate the risk of transmission. The best approach to minimize cross-infection to, or from, a patient or other health care worker (HCW) is to use "Universal Precautions" that is, to treat every patient as if they were a carriers of some infection. However, unlike infection control strategies of developed countries, in developing countries these precautions may need to be modified to match the socioeconomic constraints of the region. Governments and HCWs should work together to make vaccinations against hepatitis B a national priority, and improve the education of patients and colleages concerning the risks from all STDs including HIV/AIDS, hepatitis B and tuberculosis. (AU)

The control of tuberculosis in the Caribbean

A survey of the Ministries of Health in the English-speaking Caribbean countries was conducted with the purpose of collecting information about current capacity in the prevention and control of tuberculosis. A response rate of 78.9 percent was achieved. The results of this survey indicate that tuberculosis control programmes in the English-speaking Caribbean are limited, and inadequately address issuse relating to multi-drug resistant disease and co-infection with human immunodeficiency virus (HIV). Limitations and implications of this survey are discussed. (AU)