Cost of Tuberculosis Treatment: Evidence from Iran’s Health System

OBJECTIVES: This study aimed to estimate the cost of smear-positive drug-susceptible pulmonary tuberculosis (TB) treatment of the patients in the Azadshahr district, Golestan Province, Iran. METHODS: In this retrospective study, all new smear positive pulmonary TB patients who had been registered at the district’s health network between April, 2013 and December, 2015 and had successfully completed their treatment were entered into the study (45 patients). Treatment costs were estimated from the provider’s perspective using an activity-based costing (ABC) method. RESULTS: The cost of treating a new smear-positive pulmonary TB patient was US dollar (USD) 1,409.00 (Iranian Rial, 39,438,260), which can be divided into direct and indirect costs (USD 1,226.00 [87%] and USD 183.00 [13%], respectively). The highest cost (58.1%) was related to care and management of TB patients (including 46.1% human resources costs and 12% directly-observed treatment, short course implementation) and then respectively related to hospitalization (12.1%), supportive activity centers (11.4%), transportation (6.5%), medicines (5.3%), and laboratory tests and radiography (3.2%). CONCLUSION: Using disease-specific cost studies can help the healthcare system management to have correct insight into the financial burden created by the disease. This can subsequently be used in prioritization, planning, operational budgeting, economic evaluation of programs, interventions, and ultimately in disease management.

Acute Epstein - Barr virus hepatitis without mononucleosis syndrome: a case report

Elevated liver enzymes accompanied by Infectious Mononucleosis syndrome are widely seen in primary Epstein-Barr virus infection while acute symptomatic hepatitis without typical presentations of EBV is extremely rare. In the following report, we present a patient with acute isolated hepatitis due to laboratory confirmed Epstein-Barr virus

Evaluation of hepatoprotective effect of silymarin among under treatment tuberculosis patients: a randomized clinical trial

Hepatic toxicity is the most serious adverse effect of anti tuberculosis drugs. This study was performed to evaluate efficacy of silymarin as a hepatoprotective herbal agent. In a randomized double blind clinical trial 70 new cases of pulmonary tuberculosis were divided into two groups. The intervention group was assigned to receive silymarin and the control group received placebo. Tuberculosis was treated by classic regimen consisting isoniazid, rifampin, pyrazinamide and ethambutol. No statistically significant difference was found between the two groups concerning the frequency of drug induced liver injury or mild elevation of liver enzymes. Silymarin was safe without any major side effect. Our results showed no significant hepatoprotective effect of silymarin among patients on tuberculosis treatment

H1N1 influenza patient saved by extracorporeal membrane oxygenation: first report from Iran

Respiratory failure is a serious complication of H1N1 influenza that, if not properly managed, can cause death. When mechanical ventilation is not effective, the only way to save the patient's life is extracorporeal membrane oxygenation [ECMO]. A prolonged type of cardiopulmonary bypass, ECMO is a high-cost management modality compared to other conventional types and its maintenance requires skilled personnel. Such staff usually comprises the members of open-heart surgical teams. Herein, we describe a patient with H1N1 influenza and severe respiratory failure not improved by mechanical ventilation who was admitted to Masih Daneshvari Medical Center in March 2015. She was placed on ECMO, from which she was successfully weaned 9 days later. The patient was discharged from the hospital after 52 days. Follow-up till 11 months after discharge revealed completely active life with no problem. There should be a close collaboration among infectious disease specialists, cardiac anesthetists, cardiac surgeons, and intensivists for the correct timing of ECMO placement, subsequent weaning, and care of the patient. This team work was the key to our success story. This is the first patient to survive H1N1 with the use of ECMO in Iran

Radiologic manifestations of pulmonary tuberculosis in patients of intensive care units

Tuberculosis [TB] is a serpent disease with various pulmonary manifestations, and timely diagnosis of the disease is paramount, since delayed treatment is associated with severe morbidity, particularly in intensive care units [ICU]. Therefore, it is imperative that intensivists understand the typical distribution, patterns, and imaging manifestations of TB. To describe different manifestations of pulmonary TB in patients in the ICU. In a retrospective study, all patients with a clinical and a laboratory-confirmed diagnosis of TB who were admitted to the ICU were entered in the study. All patients had a confirmatory laboratory diagnosis of TB including positive smears. The patterns of parenchymal lesions, involved segments and presence of cavity, bronchiectasis and bronchogenic spread of the lesions with computed tomography [CT] and chest/X-ray [CXR] were recorded and analyzed. Data of 146 patients with TB were entered in the study. The most common finding in CT was acute respiratory distress syndrome [ARDS]-like radiologic manifestations [17.1%], followed by parenchymal nodular infiltration [13.6%] and cavitation [10.9%], consolidation [10.2%], interstitial involvement [9.5%], calcified parenchymal mass [8.3%], ground-glass opacities [7.5%], and pleural effusion or thickening [6.9%]. Radiologic evidence of lymphadenopathy was seen in up to 43% of adults. Miliary TB was observed in 2.3% of patients, mostly in those older than 60 years of age. ARDS-like [64.5%] manifestations on CT and miliary TB [85.5%] had the highest mortality rates among other pulmonary manifestations. ARDS, interstitial involvement, and Parenchymal nodular infiltration are the most common manifestations of pulmonary TB. Various features of TB in ICU patients could be misleading for intensivists

effect of Garcin[registered sign] in preventing antiTB-induced hepatitis in newly diagnosed tuberculosis patients

Adverse effects of antituberculosis agents such as hepatotoxicity may reduce treatment effectiveness, because they significantly contribute to nonadherence and eventually result in treatment failure, relapse or the emergence of drug resistance. Garlic is an ancient herbal substance, which its effectiveness on isoniazid and rifampicin-induced hepatic injury in animal models has been demonstrated [1]. In the present study a randomized, double blind, placebo-controlled, parallel group clinical trial was designed to assess the effect[s] of garlic tablets [1000 mg daily] administered for two weeks orally. Fifty eight newly diagnosed, smear positive pulmonary tuberculosis patients, with age ranges between 18-65 years old, were randomly allocated into two groups. Each patient received either garlic or placebo tablets for the first two weeks of tuberculosis treatment. Of total 58 patients, 31 received garlic tablets while 27 received placebo. No significant difference was found between the two groups regarding age, sex, nationality, smoking, underlying diseases and opium usage. During 8 weeks of anti-TB [antituberculosis] treatment, 8 [13.0%] patients developed drug-induced hepatotoxicity [DIH]. Of them, 6 [75%] occurred in the first two weeks of treatment. Fifty percent of the patients who developed DIH were in garlic group. Results indicated no significant difference between groups in developing DIH [p=1.000]. We could not show a significant role in preventing DIH by 1000 mg daily garlic administration

Multidrug-resistant tubercular appendicitis: report of a case

Acute tubercular appendicitis has remained a rare disease despite frequent cases of tuberculosis. The following study reports a patient with multidrug-resistant [MDR] pulmonary tuberculosis that developed acute appendicitis. Histopathology of the appendix was compatible with tuberculosis. The patient had a good outcome after surgery and medical therapy

Disseminated Mycobacterium kansasii in an HIV-negative patient

Disseminated Mycobacterium kansasii infection is a rare infection in non-HIV patients. This research has uncovered a very rare manifestation of disseminated M. kansasii infection in a non-HIV patient with lung and pericardial involvement

Clinical and demographic characteristics of confirmed cases in H1N1 [2009] influenza

Presentation of pandemic H1N1 influenza [H1N1] is widely evolving as it continues to involve different geographic locations and populations. This study was conducted to improve the precision of clinical diagnosis of H1N1 [2009] influenza infection in an outpatient setting. A prospective cross-sectional study was conducted among adult patients [age >15 years] with influenza-like illnesses [ILI] from November 2009 to February 2010. Clinical, laboratory and epidemiological findings in the first week of illness were collected using a standardized datasheet. Influenza testing was performed by real-time reverse-transcriptase polymerase chain reaction [rRT-PCR]. Thirty nine [24%] patients were positive for H1N1 and 123 [76%] were negative for any subtype of influenza A virus. Whilst otalgia [14% vs. 0 p= 0.01] was more prevalent in non-influenza A cases, cough [90% vs. 72% p = 0.03] and shortness of breath [67% vs. 47% p = 0.02] were more often associated with H1N1-infection. Comparative analysis of coexisting conditions and demographic factors of patients revealed no other significant differences between the two groups. The clinical presentation of H1N1 [2009] infection is largely indistinguishable from other acute respiratory diseases. Although previous studies suggested significant differences in demographic and co-existing conditions of H1N1 infected patients, our study shows that as the pandemic spreads worldwide and affects the majority of the population, H1N1 diagnosis based on clinical presentation and demographic characteristics has become less practical and much more difficult in tertiary care centers

Pattern of tobacco consumption among TB patients in a tuberculosis referral center

Tuberculosis [TB] is among the major causes of illness and death worldwide, especially in Asia and Africa. On the other hand, tobacco use is the most important preventable and the second biggest cause of death throughout the world. Smoking is associated with recurrent tuberculosis and its related mortality. Also, it could affect clinical manifestations, bacteriological conversion and outcome of treatment. This study aimed to evaluate the pattern of tobacco smoking, history of previous quit attempts, and attitude towards quitting in tuberculosis patients. It was a cross-sectional study done amongst pulmonary TB patients presented to Masih Daneshvari Hospital. Two hundred patients entered the study as [First Come First Serve]. Self-reported questionnaires were designed according to the standard questionnaires of smoking pattern. A total of 93.5% were males. The mean age was 39.8 +/- 1.73 yrs. Thirty-four percent of them were current smokers at the time of interview, 7.5% were occasional smokers and 28% of smoker patients had a history of at least one quit attempt. Considering the prevalence of smoking in TB patients, evaluation of tobacco smoking status in such patients and motivating them to quit smoking could be considered as important steps in their treatment process

Prevalence of oseltamivir-resistant 2009 H1N1 influenza virus among patients with pandemic 2009 H1N1 influenza infection in NRITLD, Tehran, Iran

Oseltamivir-resistant cases were reported during the 2009 pandemic influenza outbreak and therefore, widespread emergence of oseltamivir-resistant 2009 H1N1 virus is imaginable. Underlying medical conditions like immunosuppression increase the chance of oseltamivir resistance. In a retrospective cross-sectional study, respiratory tract specimens of confirmed cases of 2009 H1N1 influenza referred to the Masih Daneshvari Hospital were analyzed for presence of H275Y mutation. From November 2009 through March 2010, oseltamivir-resistant 2009 H1N1 infection was observed and confirmed in 4 patients [including 2 immunocompromised patients] by performing H275Y mutation molecular testing. Close monitoring of resistance to neuraminidase inhibitors is essential in tertiary care centers. The H275Y mutation [oseltamivir-resistant genotype] could appear in the absence or presence of selective drug pressure

Comparison of polymerase chain reaction single-strand conformation polymorphism with DNA sequencing to detect drug resistance of mycobacterium tuberculosis isolates

Advancements in molecular technology increased our understanding of genetic mechanism of drug resistance. Nowadays, the chance of rapid detection of resistant Mycobacterium tuberculosis [M. tuberculosis] strains is increased. In the present study, we aimed to investigate the sensitivity and specificity of PCR-SSCP for detecting susceptible and resistant strains of M. tuberculosis compared with DNA sequencing. To calculate the sensitivity and specificity of PCR-SSCP assay to detect drug resistance in M. tuberculosis, respiratory samples were collected from suspected patients referred to Mycobacteriology Research Center [Masieh Daneshvary Hosptial] since 2002. Susceptibility testing against first line drugs was performed on 74 culturepositive specimens. Consequently, PCR-SSCP and DNA sequencing were performed on katG, inhA, ahpC and rpoB genes. Drug-susceptibility testing by the proportional method in selected samples revealed 16 MDR [21.6%], 23 mono-drug resistant [31%] and 35 susceptible strains [47.3%]. In comparison with DNA sequencing as a gold standard for molecular methods, the sensitivity of PCR-SSCP assay for detecting of mutation in 315 codon of katG gene was 94.74% [CI=73.97%-99.87%] with 100% [CI=93.51%-100%] specificity. In contrast, the sensitivity and specificity of this assay in detecting of rpoB gene were 70.8% [CI=48.91%-87.38%] and 88% [CI=75.69%-95.47%], respectively. PCR-SSCP in combination with DNA sequencing can be used as screening method to detect MDR-TB and mono-drug resistant cases

Smoking effects on clinical manifestations and drug resistance patterns in pulmonary TB patients

Considering the rising trend of tuberculosis [TB] and cigarette smoking, an evaluation of the clinical manifestations and drug resistance patterns in TB patients with regard to smoking status seemed beneficial. Clinical manifestations and drug resistance patterns were studied in 872 new pulmonary TB patients classified as non-smokers, ever-smokers, and passive smokers during 3 years at the National Research Institute of Tuberculosis and Lung Disease. Both univariate and multivariate analyses were performed. Ever-smokers were mostly male [p<0.001], Iranian [p<0.001], and drug and alcohol users [p<0.001]. They were found to have a longer patient delay [15.9 versus 8.7 and 6.3 days, p=0.008], shorter diagnostic delay [106.8 versus 132.6 and 156 days, p=0.01], greater weight loss [p=0.01], and higher sputum expectoration [p<0.001]. Notably, the degree of smear positivity was associated with smoking [p<0.001] in both univariate and multivariate analyses. No statistical significance was found for the aforementioned factors among non-smokers and passive smokers. Some of the clinical manifestations of TB are significantly different with regard to the patients' smoking status.The degree of sputum smear positivity for acid fast bacilli was higher and patient delay was longer in ever-smoker patients

Performance of QuantiFERON-TB Gold test compared to tuberculin skin test in detecting talent tuberculosis infection in HUV-positive individuals in IRAN

There is limited data about the performance of QuantiFERON-TB Gold [QFT-G] test in detecting latent tuberculosis infection [LTBI] in our region. We intended to determine the performance of QFT-G compared to conventional tuberculin skin test [TST] in detecting LTBI in HIV-positive individuals in Iran. This study was conducted in a HIV clinic in Tehran, Iran in April 2007. A total of 50 consecutive HIV-positive patients, not currently affected with active tuberculosis [TB], were recruited; 43 [86%] were male. The mean age was 38 +/- 7.2 years [21-53]. All had history of Bacillus Calmetta Guerin [BCG] vaccination. A TST with purified protein derivative [PPD] and whole-blood interferon-gamma release assay [IGRA] in reaction, to ESAT-6 and CFP-10 antigens was performed and measured by enzyme-linked immune-sorbent assay [ELISA]. The agreement between TST and QFT=G results were analyzed using Kappa test. A total of 36 [72%] patients had negative TST. For QFT-G, 20 [40%] tested positive, 19 [38%] tested negative, and the results in 11 cases [22%] were indeterminate. A total of 14 [28%] patients had a CD4 count of < 200 .Of the 14, TST + group, 12 had QFT-G +, only one case TST +/QFT-G-, and QFT-G was indeterminate in one TST positive case. Of the 36 patients with negative TST test, 8 [22%] had positive GFT-G and 10 [28%] yielded indeterminate results. There was no association between a positive TST and receiving highly active anti-retroviral therapy [HAART] or CD4 counts was not significant [P=0.06]. Although TST results were not significantly different in patients with CD <200 vs. CD4>200 [P=0.095], association between QFT-G results and CD4 cutoff of 200 reached statistical significance [P= 0.027]. Agreement Kappa coefficient between TST and QFT-G was 0.54 [Kappa = 0.54, 95% CI = 38.4-69.6, P < 0.001]. Detecting LTBI in HIV-positive individuals showed moderate agreement between QFT-G and LTBI in our study. Interestingly, our findings revealed that nontuberculous mycobacteria and prior BCG vaccination have minimal influence on TST results in HIV patients in Iran

Comparison of pulmonary TB patients with and without diabetes mellitus type II

There are several studies on the effect of diabetes mellitus [DM] on clinical symptoms and radiological findings of multi-drug resistant tuberculosis [MDR-TB] and bacteriological findings in pulmonary tuberculosis patients. Considering the contradictory results of these studies, this study was conducted for further investigation in this regard. This was a case-control study conducted in Masih-Daneshvari Hospital in Tehran. Forty-seven patients with tuberculosis infection and diabetes type II were selected as the case group and 102 TB cases without diabetes were considered as controls. There were significant differences in hemoptysis, dyspnea and loss of appetite between the two groups, but no significant difference was found in cough, sputum production, chest pain, night sweat, fever or weight loss. Also, there was no significant difference between the 2 groups in terms of MDR-TB and bacteriological findings. On CXR, diabetic patients had a higher prevalence of typical presentations along with cavitary lesion[s] but no significant difference was found between the 2 groups in terms of radiological presentation. In this study, diabetes type II did not have much influence on clinical symptoms and bacteriological findings of TB patients. However, PTB-DM type II cases may be considered more contagious due to the higher prevalence of cavitary lesions compared to those without DM. Prevalence of MDR-TB was the same in both groups

Update on 2009 pandemic influenza a [H1N1] virus

The pandemic influenza A [H1N1/2009] virus as a new challenge for health care providers has caused significant morbidity and mortality worldwide. Although many aspects of this virus are similar to other human influenza viruses, there are some disparities. This article reviews different aspects of influenza H1N1/2009 virus with focus on clinical features and management of patients

Risk factors associated with multidrug-resistant tuberculosis

Multi-drug resistant tuberculosis [MDR-TB], a form of TB resistant to isoniazid and rifampin, is considered as a major threat to TB control worldwide. Moreover, the infectivity of MDR-TB is similar to that of non-MDR TB. This study aims to find the risk factors associated with the development of MDR-TB among TB patients admitted to Masih Daneshvari Hospital, the national referral center for tuberculosis and lung diseases. The national referral institute for tuberculosis and lung diseases in Tehran [NRITLD] receives all the MDR-TB cases from all over the country. Based on this criterion alone, forty-eight pulmonary MDR-TB patients who were referred to this center between 2002 and 2005 were included in this study. For the purpose of comparison, 234 patients diagnosed with pulmonary TB were also selected randomly as the control group. The two groups were compared based on 102 demographic and clinical variables. These variables included age, sex, nationality, drug and opium use, method of referral, symptoms and etc. Immigration and refugee status as well as history of anti-TB medication were found to be the most significant among the risk factors associated with MDR-TB. Also, 95.8% of the MDR-TB cases reported a previous history of anti-TB medication. This number was 23.1% in the non-MDR group. MDR-TB was more prevalent among the Afghan patients; out of a total of 78 Afghan patients, 22 [46.8%] composed the MDR-TB category, whereas, 56 [23.9%] Afghan patients belonged to the non-TB category. All MDR-TB patients had positive smears whereas 13.2% of non-MDR-TB patients had negative smears. Dyspnea and weight loss were among other significant variables. History of close contact, diabetes, smoking, drug use, fever, and BCG scar in both MDR TB and non-MDR-TB groups were among the insignificant variables found in this study. The limited sample size and location of the study may have resulted in insignificant variables. However, based on the obtained data, patient's status as an immigrant or a refugee is an important risk factor for both MDR and non-MDR TB and is of particular concern in the growing trend of MDR-TB

Comparison of Nramp1 gene polymorphism among TB health care workers and recently infected cases; Assessment of host susceptibility

A link between polymorphisms in the natural resistance -associated macrophage protein gene 1 [Nramp] and susceptibility to tuberculosis [TB] has been demonstrated worldwide. This study aimed to investigate the Nramp1 gene variants among workers exposed to TB bacilli [1-2 hours per day for 1 to 20 years] who did not develop the diseases with those who developed the disease through recent transmission. The polymorphism of Nramp1 at INT4, D543 and 3'UTR was examined in 71 newly smear-positive TB cases and 39 healthcare workers exposed to TB. Polymerase chain reaction [PCR] and restriction fragment length polymorphism [RFLP] were used to genotype Nramp1 polymorphism. Patients' clinical and demographical data were collected. The heterozygote patterns of INT4 [G/C], D543 [G/A] and 3'UTR [+/del] occurred more frequently in control subjects than in patients [P =0.012], respectively [odds: 1.9 CI95%] [1.13-3.12]. Although, the homozygous patterns of INT4 [C/C; 8.5%], D543 [A/A; 1.4%] and 3'UTR [del/del; 1.4%] were only seen in patients [sensitivity 11% and specificity 100%]. The other risk factors like gender, age, resistance and PPD were not associated with Nramp1 gene polymorphism. Individuals with homozygous type mutation have an increased risk of developing tuberculosis. Therefore, we suggest detection of Nramp1 variants in high-risk groups i.e., health workers and close contact cases