Impact of malnutrition on clinical presentation, clinical course, and mortality in MDR-TB patients.

Despite the adoption of strategies to prevent and treat multidrug-resistant tuberculosis (MDR-TB) over the past decade, Latvia continues to have one of the highest rates of MDR-TB in the world. It is important to identify modifiable factors that may impact on MDR-TB patient outcomes. A study was conducted to elucidate the association between nutritional status and clinical presentation, clinical course, and mortality in 995 adult patients treated for MDR-TB from 2000 to 2004. Twenty percent of patients were underweight, defined as a body mass index <18·5, at the time of diagnosis. These patients were significantly more likely to have clinical evidence of advanced disease, and had a greater risk of experiencing ≥3 side-effects [adjusted odds ratio 1·5, 95% confidence interval (CI) 1·1-2·1] and death (adjusted hazard ratio 1·9, 95% CI 1·1-3·5) compared to patients who were normal or overweight. Interventions aimed at these high-risk patients, including nutritional supplementation as an adjunct to anti-TB therapy, should be considered and evaluated by TB programmes.

Prevalence and risk factors of tuberculosis disease in South African correctional facilities in 2015.

SETTING: Sixteen South African correctional facilities.OBJECTIVE: To determine the prevalence of and risk factors for tuberculosis (TB) in South African correctional facilities using data collected during a TB screening program in South African correctional facilities in 2015.DESIGN: Inmates in 16 South African correctional facilities were screened for TB from January to December 2015. Inmates reporting ≥1 TB symptom or having an abnormal computer-assisted digital chest X-ray (CXR) provided sputum. Abnormal CXRs were interpreted by a radiologist. Sputum was tested for Mycobacterium tuberculosis using Xpert® MTB/RIF. Data from 16 South African correctional facilities were used in regression analysis, and prevalence estimates calculated for 12 South African correctional facilities with >30% screening coverage.RESULTS: In 12 South African correctional facilities included in the prevalence estimates, 837 inmates had TB disease (2653/100 000) as indicated by current TB treatment or screening-identified TB by radiologist or Xpert. Previous TB was associated with increased odds of screening-identified TB in HIV-positive inmates (OR 4.3, 95%CI 2.5-7.3). For HIV-negative inmates, previous TB (adjusted OR [aOR] 4.9, 95%CI 1.7-14.1) and self-reported symptoms vs. none (1 symptom, aOR 8.8, 95%CI 1.2-67.7; >2 symptoms, aOR 21.7, 95%CI 3.0-158.8) were independently associated with increased odds of screening-identified TB.CONCLUSIONS: Routine TB screening, including CXR, is needed in South African correctional facilities to identify and refer inmates with active TB.

The other side of surveillance: Monitoring, application, and integration of tuberculosis data to guide and evaluate programme activities in South Africa.

BACKGROUND: The importance of using surveillance data to monitor and evaluate programme activities has been emphasised in international policies for tuberculosis (TB) control. OBJECTIVES: A survey was conducted to assess the use of TB surveillance data to monitor and guide TB programme activities in South Africa (SA). METHODS: As part of an evaluation of the SA national TB surveillance system, semi-structured interviews were conducted among TB staff at health facilities and offices in three provinces. At each site, all persons involved with TB care, management and surveillance were invited to participate. RESULTS: At least one person (range 1 - 4) was interviewed at 47/54 health facilities (87.0%), 11/13 subdistrict and district TB offices (84.6%), 2/3 provincial TB offices (66.7%), and at the national level (1/1, 100.0%). Of 119 TB staff, 64.7% recognised the purpose of TB surveillance as guiding programme planning, implementation and evaluation. However, only 16.0% reported using data to measure disease burden, 8.4% to monitor trends, and 9.2% to inform resource allocation. The majority reported using TB management tools provided by the national programme, but 44.5% also described using additional tools. Personnel mentioned the need for dedicated surveillance staff, training on recording and reporting, improved computer access, and methods to apply information from surveillance data to the programme. CONCLUSIONS: The majority of TB staff understood the purpose of surveillance but did not routinely use data to guide programme planning, implementation and evaluation. Training and supporting TB staff to utilise surveillance data will help improve the TB surveillance system.

Validation of sputum smear results in the Electronic TB Register for the management of tuberculosis, South Africa.

BACKGROUND: The accuracy of tuberculosis (TB) surveillance systems is paramount in TB control. In South Africa, information from the laboratory is not directly linked to the Electronic TB Register (ETR). OBJECTIVE: To validate smear results recorded in the ETR with those recorded in the laboratory. METHODS: A retrospective evaluation was conducted among all sputum smear-positive TB patients recorded in the ETR during the fourth quarter of 2009 in KwaZulu-Natal Province. RESULTS: Of 1036 smear-positive patients recorded in the ETR, 683 (65.9%) had positive results recorded in the laboratory register. Only 364 (53.2%) had their smear results recorded in the ETR at the end of the intensive phase of treatment; of 326 (89.6%) recorded as converted to smear-negative, 224 (61.5%) were confirmed as smear-negative in the laboratory. Of 331 patients with end-of-treatment results in the ETR, 302 (91.2%) were recorded as cured, but only 105 (34.8%) were confirmed in the laboratory. CONCLUSIONS: Over a third of TB patients registered as smear-positive in the ETR could not be confirmed based on laboratory results. Many patients did not have a laboratory record, lending to uncertainty as to the validity of the smear results and treatment outcomes recorded in the ETR.

Completeness and concordance of TB and HIV surveillance systems for TB-HIV co-infected patients in South Africa.

SETTING: South Africa currently maintains separate surveillance systems for tuberculosis (TB) and human immunodeficiency virus (HIV). There are future plans for integration of these systems; however, the consistency of information across the existing systems has not previously been assessed. OBJECTIVE: To determine the completeness and concordance of data in the TB and HIV surveillance systems for TB-HIV co-infected patients. DESIGN: In a retrospective cohort evaluation of the records of TB-HIV co-infected patients in the Eden District of the Western Cape, data were abstracted from paper-based and electronic TB and HIV surveillance sources. Concordance was measured using Fleiss' kappa coefficient. RESULTS: Demographic variables had high completeness and concordance across the TB and HIV systems. Completeness and concordance for clinical variables was somewhat lower, particularly for TB variables in the HIV systems and HIV variables in the TB systems. CONCLUSION: Varying levels of completeness and concordance of surveillance data for TB-HIV co-infected patients highlight challenges in the current TB and HIV surveillance systems. Future integration of TB and HIV programs in this region will need to support more accurate data collection at all levels.

Impact of patient and program factors on default during treatment of multidrug-resistant tuberculosis.

SETTING: In the Philippines, programmatic treatment of drug-resistant tuberculosis (TB) was initiated by the Tropical Disease Foundation in 1999 and transitioned to the National TB Program in 2006. OBJECTIVE: To determine patient and socio-demographic characteristics associated with default, and the impact of patient support measures on default. DESIGN: Retrospective cohort analysis of 583 MDR-TB patients treated from 1999 to 2006. RESULTS: A total of 88 (15%) patients defaulted from treatment. The median follow-up time for patients who defaulted was 289 days (range 1-846). In multivariate analysis adjusted for age, sex and previous TB treatment, receiving a greater number of treatment drugs (≥ 5 vs. 2-3 drugs, HR 7.2, 95%CI 3.3-16.0, P < 0.001) was significantly associated with an increased risk of default, while decentralization reduced the risk of default (HR 0.3, 95%CI 0.2-0.7, P < 0.001). CONCLUSION: Improving access to treatment for MDR-TB through decentralization of care to centers near the patient's residence reduced the risk of default. Further research is needed to evaluate the feasibility, impact and cost-effectiveness of decentralized care models for MDR-TB treatment.

Concordance of programmatic and laboratory-based multidrug-resistant tuberculosis treatment outcomes in Peru.

BACKGROUND: Confirmation of cure for multidrug-resistant tuberculosis (MDR-TB) patients requires laboratory tests for Mycobacterium tuberculosis growth on culture media. Outcome decisions dictate patient management, and inaccuracies place patients at an increased risk of morbidity and mortality, and may contribute to continued transmission of MDR-TB. OBJECTIVE: To examine concordance between programmatic and laboratory-based MDR-TB treatment outcomes. METHODS: The study population included 1658 MDR-TB patients in Peru treated between 1996 and 2002 with both program and laboratory-based outcomes. Laboratory-based outcomes were assigned according to international standards requiring at least five consecutive negative cultures in the last 12 months of treatment to confirm cure. RESULTS: Compared to the global culture-defined standard classification, only 1.1% of treatment successes, but 54.3% of failures, were misclassified programmatically. Overall, 10.4% of patients identified by a clinician as having a successful treatment outcome still had cultures positive for MDR-TB. CONCLUSION: Most patients with successful treatment outcomes by strict culture definitions were also classified by clinicians as having successful outcomes. However, many culture-confirmed failures were missed. In light of delays and incomplete access to culture in MDR-TB programs, efforts should be made to improve the accuracy of programmatically determined treatment outcomes.

The role of chronic hepatitis in isoniazid hepatotoxicity during treatment for latent tuberculosis infection.

BACKGROUND: To examine chronic viral hepatitis (CVH) as a risk factor for hepatotoxicity during isoniazid (INH) treatment for latent tuberculosis infection (LTBI). METHODS: A search of MEDLINE (1966-May 2008) was conducted using the terms 'tuberculosis', 'antitubercular', 'therapeutics', 'treatment', 'prevention', 'prophylaxis', 'hepatitis', 'toxic hepatitis', 'hepatotoxic', 'liver' and 'injury'. Peer-reviewed, English-language articles describing the relationship between a history of CVH and occurrence of hepatotoxicity during LTBI treatment were selected. We limited CVH diagnoses to reports with positive serological test or biopsy for hepatitis B or C. Risk ratios and 95% confidence intervals were abstracted or derived. RESULTS: We reviewed 486 abstracts, and 11 studies met the selection criteria. Populations included in the studies were the general population (n = 6) and transplant recipients (n = 5). The variability in study designs and case finding practices precluded performing a quantitative meta-analysis. Two studies of former or current drug users reported a consistent, positive association between chronic hepatitis C infection and INH hepatotoxicity. Other risk ratios did not significantly or consistently show any association between CVH in patients treated for LTBI and the development of INH hepatotoxicity. CONCLUSION: Owing to the limited number of published papers, CVH was not established as a risk factor for INH hepatotoxicity during LTBI treatment. Controlled studies are needed to define the safety and tolerability of LTBI treatment in those with CVH and to provide an evidence base for recommendations for LTBI treatment in persons with CVH.

Physical activity and white matter lesion progression: assessment using MRI.

We evaluated the association between physical activity and changes in white matter lesions (WMLs) on MRI in a sample of 179 older adults comprising 59 incident cases of Alzheimer disease, 60 persons with mild cognitive impairment, and 60 persons who remained cognitively stable over a median 5-year follow-up. Physical activity was not significantly associated with a decreased rate of periventricular or deep WML progression.

Outbreak of norovirus illness associated with a swimming pool.

On 3 February 2004, the Vermont Department of Health received reports of acute gastroenteritis in persons who had recently visited a swimming facility. A retrospective cohort study was conducted among persons attending the facility between 30 January and 2 February. Fifty-three of 189 (28%) persons interviewed developed vomiting or diarrhoea within 72 h after visiting the facility. Five specimens tested positive for norovirus and three specimen sequences were identical. Entering the smaller of the two pools at the facility was significantly associated with illness (RR 5.67, 95% CI 1.5-22.0, P=0.012). The investigation identified several maintenance system failures: chlorine equipment failure, poorly trained operators, inadequate maintenance checks, failure to alert management, and insufficient record keeping. This study demonstrates the vulnerability of recreational water to norovirus contamination, even in the absence of any obvious vomiting or faecal accident. Our findings also suggest that norovirus is not as resistant to chlorine as previously reported in experimental studies. Appropriate regulations and enforcement, with adequate staff training, are necessary to ensure recreational water safety.