Treatment-seeking behaviors and improvement in adherence to treatment regimen of tuberculosis patients using intensive triad-model program, Thailand.

The aims of this study were to determine tuberculosis patients' treatment-seeking behaviors, to describe knowledge of TB among TB patients, how that knowledge affected their treatment-seeking behaviors, and to develop an appropriate model to strengthen the existing DOTS program. A cross-sectional study was conducted in all government TB clinics in Samut Prakan Province, Thailand during November 2005-May 2006. The triad model, which emphasizes the role of a triad of persons (the healthcare provider, the TB patient, and his/her treatment supporter), can improve patient adherence to TB treatment regimen. The results showed that only about a quarter (27.7%) of TB patients chose the hospitals with TB clinic for first treatment, while others chose alternative healthcare modes, including self-care and purchasing drugs from drugstores. The rate of successful treatment was higher for the experimental group (96.0%) than the control group (84.9%) (p = 0.057). The confirmed cure rate was also significantly higher in the experimental group (95.3% vs 78.9%, p = 0.02). The program could be utilized to strengthen the existing DOTS program.

Concurrent salmonella bacteremia in P. vivax infection--a report of 2 cases at the Hospital for Tropical Diseases, Thailand.

Malaria and concurrent bacteremia has been described in many reports, most of them with P. falciparum. Concurrent bacteremia with P. vivax infected patients is very rare. We reported 2 cases of salmonella bacteremia with P. vivax infection. Both patients presented with fever and the diagnosis of P. vivax was confirmed microscopically. The first patient presented with fever, jaundice, shock and renal failure which rarely occurs with P. vivax infection. The second patient had no clinical response after receiving standard antimalarial drugs. Hemoculture was positive for Salmonella spp in both cases. They recovered completely after appropriate antibiotics and antimalarial treatment.

Efficacy of ivermectin treatment of cutaneous gnathostomiasis evaluated by placebo-controlled trial.

Previous studies have revealed that ivermectin treatment for gnathostomiasis can reduce parasitic loads in animals and make recurrent subcutaneous swelling subside in 76% of patients. Our study aimed to evaluate the efficacy of ivermectin for cutaneous gnathostomiasis treatment in a placebo-controlled trial. This study was a prospective randomized placebo-controlled study performed at The Bangkok Hospital for Tropical Diseases, Mahidol University, Thailand. Thirty patients with a serologically confirmed diagnosis of cutaneous gnathostomiasis were enrolled. Seventeen patients in the ivermectin treated group received a single dose of 12 mg ivermectin (200 microg/kg bodyweight), while 13 patients in the control group received a single dose of 40 mg of vitamin B1. The follow-up period was 1 year. Of the 17 patients, 7 (41.2%) responded to ivermectin, while no patient responded to placebo. The mean (95% Cl) time to the first recurrence of subcutaneous swelling with ivermectin and in the placebo groups were 257 (184-331) and 146 (42-250) days, respectively, (p=0.102). Although this study revealed no significant difference in the mean time to first recurrence of swelling between the ivermectin and placebo groups, there was a trend towards ivermectin efficacy against gnathostomiasis in previous animal and human studies. Further studies with different doses of ivermectin and larger sample sizes, and close monitoring for ivermectin tolerability and treatment response are necessary to confirm an efficacy of ivermectin.

The association between environmental factors and tuberculosis infection among household contacts.

A cross-sectional study was conducted to determine the association between environmental factors and tuberculosis infection among household contacts aged less than 15 years in Bangkok, Thailand, between May and December 2003. During the study period, 480 household contacts aged under 15 years were identified. The prevalence of tuberculosis infection among household contacts was 47.08% (95% CI = 42.60-51.56). A generalized estimating equation (GEE) indicated that the risk of positive tuberculin skin testing in household contacst was found to increase with household crowding. Children living in a crowded household were five times more likely to have tuberculosis infection (OR = 5.19, 95% CI = 2.65-8.69). The association between environmental factors and tuberculosis infection assists community tuberculosis staff in understanding the risks for tuberculosis infection in the community and planning appropriate preventive actions based on this risk.

Tolerability of ivermectin in gnathostomiasis.

At present, no universally-accepted effective treatment for cutaneous gnathostomiasis is available. At the Hospital for Tropical Diseases, Mahidol University, albendazole 400 mg twice a day for 14 days is commonly prescribed for patients diagnosed with cutaneous gnathostomiasis. The efficacy of albendazole to induce outward migration of the parasite was less than or around 20% in 2 studies. Research for alternative, more efficacious treatment, is needed. In this prospective open-labeled study, we assessed the safety of ivermectin in 20 Thai patients diagnosed with cutaneous gnathostomiasis. Ivermectin, one time only, at dosages of 50, 100, 150, or 200 microg/kg bodyweight, was given orally to 4 groups of patients, 5 patients each group. Adverse events were recorded and laboratory tests were obtained before and after treatment. No serious adverse events occurred in this study. Forty adverse events were possibly related to ivermectin. The adverse events were malaise (35%), myalgia (30%), drowsiness (30%), pruritus (20%), nausea/vomiting (20%), dizziness (15%), diarrhea (15%), feeling of shortness of breath (10%), feeling of palpitations (10%), constipation (5%), anorexia (5%), and headache (5%). These adverse events were self-limited and not dose-related. Laboratory abnormalities were found in 3 patients (15%). Transient microscopic hematuria, pyuria, and mildly elevated liver enzymes were found in 1 patient each. Ivermectin single dose, of 50,100, 150, and 200 microg/kg bodyweight, is considered safe in Thai patients. Future trials of ivermectin on human gnathostomiasis may be performed using dosages up to 200 microg/kg bodyweight.

Factors associated with the household contact screening adherence of tuberculosis patients.

A cross-sectional study was conducted to explore factors associated with the adherence of tuberculosis patients in bringing their household contacts to a TB clinic in Bangkok, Thailand. During the study period, May to December 2003, 325 sputum-smear-positive tuberculosis patients were recruited into the study. Of the 325 eligible tuberculosis patients, 169 (52.00%, 95% Cl = 47.00-57.00) brought their household contacts to the TB clinic. Psychosocial and cues to action factors were examined as indicators of the household contact screening adherence of tuberculosis patients. The results reveal that the household contact screening adherence of tuberculosis patients was significantly associated with a higher perceived susceptibility (Adjusted OR = 2.90, 95% Cl = 1.18-7.16), lower perceived barriers (Adjusted OR = 4.60, 95% CI = 1.99-10.60), a higher intention to bring the contacts to the TB clinic (Adjusted OR = 3.35, 95% Cl = 1.44-7.76), and a short distance from home to the TB clinic (Adjusted OR = 11.47, 95% Cl = 4.57-28.79). The results from this study provide information for TB clinic staff for developing an appropriate intervention program. Through effective intervention and active policy enforcement, a higher percentage of household contact screening adherences can be achieved.

Risk factors for tuberculosis infection among household contacts in Bangkok, Thailand.

A cross-sectional study was conducted to determine the prevalence of tuberculosis infection and risk factors for tuberculosis infection among household contacts aged less than 15 years in Bangkok, Thailand, between August 2002 and September 2003. During the study period, 342 index cases with sputum smear positive pulmonary tuberculosis patients were recruited into the study and their 500 household contacts aged under 15 years were identified. The prevalence of tuberculosis infection among household contacts was found to be 47.80% (95%CI = 43.41-52.19). In multivariate analysis, a generalized estimating equation (GEE) was used to determine the risk factors for tuberculosis infection among household contacts. The results indicated that the risk of tuberculosis infection was significantly associated with close contact (adjusted OR = 3.31, 95%CI = 1.46-7.45), exposure to female index case (adjusted OR = 2.75, 95%CI = 1.25-6.08), exposure to mother with tuberculosis (adjusted OR = 3.82, 95%CI = 1.44-10.14), exposure to father with tuberculosis (adjusted OR = 2.55, 95%CI = 1.19-5.46), exposure to index case with cavitation on chest radiograph (adjusted OR = 4.43, 95%CI = 2.43-8.05), exposure to index case with 3+ sputum smear grade (adjusted OR = 3.85, 95%CI = 1.92-7.70), and living in crowded household (adjusted OR = 2.63, 95%CI = 1.18-5.85). The distribution of tuberculosis infection and risk factors among contact cases are significant for health care staff in strengthening and implementing tuberculosis control programs in Thailand.

Association of intestinal helminths with decreased liver size and sCD23 concentration during falciparum malaria.

To determine if intestinal helminths and the CD23/nitric oxide pathway had an influence on liver size, we conducted a cross-sectional study on 438 patients with confirmed P. falciparum malaria admitted at the Hospital for Tropical Diseases in Bangkok. For all patients the liver size was measured as number of centimeters below the rib cage, a stool examination was conducted, and CD23 and reactive nitrogen intermediates were measured. The median liver size was smaller in helminth-infected patients than in helminth-free patients (chi2 for trend = 9.1, p = 0.003). Liver size significantly increased with the concentration of sCD23 (p < 0.0001). The median sCD23 concentration (OD) was significantly lower in helminth-infected patients than in helminth-free patients, respectively 0.33 (quartiles 0.24-0.57) and 0.45 (quartiles 0.27-0.59), (p = 0.01). There was a negative correlation between sCD23 concentrations and RNI (Spearman's rho = -0.40, p < 0.0001). All the above results remained significant after controlling for potential confounders. These results are compatible with a CD23/NO-mediated decrease in liver size in helminth-infected patients.

Clinical experience with intravenous quinine, intramuscular artemether and intravenous artesunate for the treatment of severe malaria in Thailand.

We prospectively studied 803 Thai patients admitted to the Bangkok Hospital for Tropical Diseases to assess the safety, tolerability and effectiveness of treatments for strictly defined P. falciparum malaria. Patients were assigned to one of five treatment groups: (i) a 5-day course of intravenous artesunate in a total dose of 600 mg, Group Aiv; (ii) intravenous artesunate as in Group Aiv followed by mefloquine, 25 mg/kg, Group Aiv+M; (iii) a 3-day course of intramuscular artemether in a total dose of 480 mg, Group Aim; (iv) intramuscular artemether as in Group Aim followed by mefloquine, 25 mg/kg, Group Aim+M, and (v) intravenous quinine, 200 mg/kg given in divided doses over seven days followed by oral tetracylcine, 10 mg/kg, for 7 days. When patients could take oral medications, the parenteral antimalarials were administered as oral agents. There were no major adverse effects observed with any of the five treatment regimens. With all regimens, 95 to 100% of the patients survived. Mean parasite clearance times were more rapid with the artemisinin regimens (53 to 62 hours) than with quinine (92 hours). The mean fever clearance times with intravenous artesunate (80 to 82 hours) were about a day shorter than those with intramuscular artemether (108 hours) or intravenous quinine (107 hours). Mefloquine reduced the recrudescence rate from 24 to 5% with intravenous artesunate but from 45 to 20% with intramuscular artemether; recrudescence was 4% with quinine and tetracycline. A dose and duration of therapy greater than those in this study are needed for optimal therapy with intramuscular artemether. Effective therapy for severe falciparum malaria can be provided by either intravenous artesunate followed by mefloquine or by intravenous quinine followed by tetracycline.

Mycobacterium tuberculosis infection among HIV/AIDS patients in Thailand: clinical manifestations and outcomes.

A one year retrospective study, was conducted at Bamrasnaradura Hospital, Nonthaburi Province, Bangkok, Thailand, of 271 subjects with both TB and HIV/AIDS. Single males (median age group 31 to 40 years) were most likely to develop co-infection. The commonest clinical manifestations on initial presentation included a low grade fever, cough, weight loss, lymphadenopathy with pancytopenia, and lung infiltrates. Multi-drug resistant TB (MDR-TB) was found in 26.6% of the subjects which was significantly associated with a past history of anti-TB treatment (p = 0.005; OR=2.5); it was also significantly associated with disseminated TB (p = 0.022; OR=1.9) and mortality (p= 0.013; OR=2.8). Analysis of clinical outcomes showed that 46.7% were lost to follow-up and 13.3% had died by the time of follow-up. Among those who survived, only 11.4% had been successfully treated; the rest had not improved due to relapse (2.9%), therapeutic failure (8.8%), treatment in progress (5.9%), and failure to complete treatment (10.7%).

Management of Malaria in Thailand

The purpose of treatment for uncomplicated malaria is to produce a radical cure using the combination of: artesunate (4 mg/kg/day) plus mefloquine (8 mg/kg day) for 3 days; a fixed dose of artemether and lumefantrine (20/120 mg tablet) named Coartem (4 tablets twice a day for three days for adults weighing more than 35 kg); quinine 10 mg/kg 8-hourly plus tetracycline 250 mg 6-hourly for 7 days (or doxycycline 200 mg as an alternative to tetracycline once a day for 7 days) in patients aged 8 years and over; Malarone (in adult 4 tablets daily for 3 days). In treating severe malaria, early diagnosis and treatment with a potent antimalarial drug is recommended to save the patients life. The antimalarial drugs of choice are: intravenous quinine or a parenteral form of an artemisinin derivative (artesunate i.v./i.m. for 2.4 mg/kg followed by 1.2 mg/kg injection at 12 and 24 hr and then daily for 5 days; artemether i.m. 3.2 mg/kg injection followed by 1.6 mg/kg at 12 and 24 hrs and then daily for 5 days; arteether i.m. (Artemotil) with the same dose of artemether or artesunate suppository (5 mg/kg) given rectally 12 hourly for 3 days). Oral artemisinin derivatives (artesunate, artemether, and dihydroartemisinin with 4 mg/kg/day) could replace parenteral forms when patients can tolerate oral medication. Oral mefloquine (25 mg/kg divided into two doses 8 hrs apart) should be given at the end of the artemisinin treatment course to reduce recrudescence.