Intensified pulmonary tuberculosis case finding among HIV-infected new entrants of a prison in Malaysia: implications for a holistic approach to control tuberculosis in prisons.

PURPOSE: This intensified case finding study aimed to evaluate the prevalence of tuberculosis (TB) disease among people with HIV entering the largest prison in Malaysia. DESIGN/METHODOLOGY/APPROACH: The study was conducted in Kajang prison, starting in July 2013 in the men's prison and June 2015 in the women's prison. Individuals tested positive for HIV infection, during the mandatory HIV testing at the prison entry, were consecutively recruited over five months at each prison. Consented participants were interviewed using a structured questionnaire and asked to submit two sputum samples that were assessed using GeneXpert MTB/RIF (Xpert) and culture, irrespective of clinical presentation. Factors associated with active TB (defined as a positive result on either Xpert or culture) were assessed using regression analyses. FINDINGS: Overall, 214 incarcerated people with HIV were recruited. Most were men (84.6%), Malaysians (84.1%) and people who inject drugs (67.8%). The mean age was 37.5 (SD 8.2) years, and median CD4 lymphocyte count was 376 cells/mL (IQR 232-526). Overall, 27 (12.6%) TB cases were identified, which was independently associated with scores of five or more on the World Health Organization clinical scoring system for prisons (ARR 2.90 [95% CI 1.48-5.68]). ORIGINALITY/VALUE: Limited data exists about the prevalence of TB disease at prison entry, globally and none from Malaysia. The reported high prevalence of TB disease in the study adds an important and highly needed information to design comprehensive TB control programmes in prisons.

Impact of the COVID-19 pandemic situation on HIV care in Liège, Belgium.

BACKGROUND: Background: The COVID-19 pandemic and associated containment measures dramatically affected the health care systems including the screening of human immunodeficiency virus and the management people living with HIV around the world by making the access to preventive care services and specific medical monitoring more difficult. OBJECTIVE: Objective: To study the impact of the COVID-19 pandemic on the holistic care of people living with HIV in Liège (Belgium). METHODS: Methods: In this retrospective observational study conducted in Liège University Hospital, we compared the out-patient follow-up of HIV-infected individuals as well as the number of new HIV diagnoses between 2019 and 2020 and between the different waves of the COVID-19 pandemic in 2020. RESULTS: Results: In 2020, when compared to 2019, we observed a significant decrease in the number of new HIV diagnoses, especially during the first wave of the pandemic, and in the number of consultations undertaken by sexual health services, psychologists and specialists in infectious diseases at our HIV clinic. We also observed a decrease in the number of viral load assays and blood CD4 + T-cells count analyses performed, although we found less patients with HIV plasma viral load above 400 copies per mL in 2020. Finally, we noted a significant reduction in terms of screening of our HIV-infected patients for hepatitis C, syphilis, colorectal and anal cancers and hypercholesterolemia. CONCLUSIONS: Conclusions: Our experience exhibits the deleterious impact of the COVID-19 pandemic on the HIV care and the need to implement new strategies to guarantee its continuum.

Antibiotic utilization in hospitalized children under 2 years of age with influenza or respiratory syncytial virus infection - a comparative, retrospective analysis.

BACKGROUND: Infections due to Respiratory Syncytial Virus (RSV) and Influenza virus (FLU) are leading causes of hospitalization in young children. Yet, there is little data on factors associated with antibiotic use in these patients. METHODS: We conducted a retrospective, single-center study of all patients below 2 years of age hospitalized between 2014 and 2018. We compared children with RSV infection to children with FLU infection analyzing clinical characteristics and factors contributing to an increased rate of antimicrobial utilization. RESULTS: RSV infection was diagnosed in 476/573 (83.1%), FLU in 95/573 (16.6%), and RSV-FLU-co-infection in 2/573 (0.3%) patients. Median age was lower for RSV compared to FLU (4 vs. 12 months; p < 0.0001). Children with RSV had longer hospitalization (5 vs. 4 days; p = 0.0023) and needed oxygen more frequently (314/476 vs. 23/95; p < 0.0001) than FLU patients. There was no significant difference in the overall antibiotic utilization between RSV and FLU patients (136/476 vs. 21/95; p = 0.2107). Logistic regression analyses revealed that septic appearance on admission (odds ratio [OR] 8.95, 95% confidence interval [CI] 1.5-54.1), acute otitis media (OR 4.5, 95% CI 2.1-9.4), a longer oxygen therapy (OR 1.40; 95% CI 1.13-1.74) and a higher C-reactive protein (CRP) (OR 1.7, 95% CI 1.5-2.0) were significantly associated with antibiotic use in both groups, but not age or pneumonia. CONCLUSIONS: In our cohort, the rate of antibiotic utilization was comparable between RSV and FLU patients, while for both groups distinct clinical presentation and a high CRP value were associated with higher antibiotic use.

Bundled HIV and Hepatitis C Testing in the Emergency Department: A Randomized Controlled Trial.

Introduction: An estimated 25% of the 1.2 million individuals living with human immunodeficiency virus (HIV) in the U.S. are co-infected with hepatitis C (HCV). The Centers for Disease Control and Prevention recommends HCV testing for high-risk groups. Our goal was to measure the impact of bundled HIV and HCV testing vs. HIV testing alone on test acceptance and identification of HCV and HIV. Methods: We conducted a two-armed, randomized controlled trial on a convenience sample of 478 adult patients in the Jacobi Medical Center emergency department from December 2012 to May 2013. Participants were randomized to receive either an offer of bundled HIV/HCV testing or HIV testing alone. We compared the primary outcome, HIV test acceptance, between the two groups. Secondary outcomes included HIV and HCV prevalence, and HCV test acceptance, refusal, risk, and knowledge. Results: We found no significant difference in HIV test acceptance between the bundled HCV/HIV (91.8%) and HIV-only (90.6%) groups (p=0.642). There were also no significant differences in test acceptance based on gender, race, or ethnicity. A majority of participants (76.6%) reported at least one HCV risk factor. No participants tested positive for HIV, and one (0.5%) tested positive for HCV. Conclusion: Integrating bundled, rapid HCV/HIV testing into an established HIV testing program did not significantly impact HIV test acceptance. Future screening efforts for HCV could be integrated into current HIV testing models to target high-risk cohorts.

Nurses' Knowledge of Tuberculosis, HIV, and Integrated HIV/TB Care Policies in Rural Western Cape, South Africa.

HIV and tuberculosis (TB) co-infection remain the leading causes of mortality in many developing countries. Several policies for their prevention and management exist; however, progress to meet the World Health Organization's indicators is slow. As nurses in rural areas are the main health care professionals responsible for the implementation of policies, questions arose about nursing knowledge regarding TB and HIV policies. A concurrent mixed method research approach was used to investigate this issue in a rural area of the Western Cape in South Africa. After a two-step sampling process, data were collected through 44 questionnaires and 12 interviews. We used descriptive and inferential statistics as well as content analysis methods. We found that most of the nurses had insufficient knowledge on certain aspects of policy guidelines that included medications, intensive case findings, and management of multidrug-resistant TB. It is recommended that training be intensified to improve implementation of policies.

Household contact non-attendance of clinical evaluation for tuberculosis: a pilot study in a high burden district in South Africa.

BACKGROUND: In 2012, the World Health Organization launched guidelines for systematically investigating contacts of persons with infectious tuberculosis (TB) in low- and middle-income countries. As such, it is necessary to understand factors that would influence successful scale-up. This study targeted household contacts of newly-diagnosed infectious TB patients in the Mangaung Metropolitan district to explore factors associated with non-attendance of clinical evaluation. METHOD: In September-October 2016, a pilot study of household contacts was conducted. At each of the 40 primary health care (PHC) facilities in the district, at least one out of four types of TB index cases were purposefully selected. These included children <5 years, smear-positive cases, HIV co-infected cases, and multidrug-resistant TB (MDR-TB) cases. Trained fieldworkers administered questionnaires and screened contacts for TB symptoms. Those with TB symptoms as well as children <5 years were referred for clinical evaluation at the nearest PHC facility. Contacts' socio-demographic and clinical characteristics, TB knowledge and perception about TB-related discrimination are described. Logistic regression analysis was used to investigate factors associated with non-attendance of clinical evaluation. RESULTS: Out of the 259 participants, approximately three in every five (59.5%) were female. The median age was 20 (interquartile range: 8-41) years. While the large majority (87.3%) of adult contacts correctly described TB aetiology, almost three in every five (59.9%) thought that it was hereditary, and almost two-thirds (65.5%) believed that it could be cured by herbal medicine. About one-fifth (22.9%) of contacts believed that TB patients were subjected to discrimination. Two in every five (39.4%) contacts were referred for clinical evaluation of whom more than half (52.9%) did not attend the clinic. Non-attendance was significantly associated with inter alia male gender (AOR: 3.4; CI: 1.11-10.24), prior TB diagnosis (AOR: 5.6; CI: 1.13-27.90) and sharing of a bedroom with the index case (AOR: 3.4: CI: 1.07-10.59). CONCLUSION: The pilot study identified gaps in household contacts' knowledge of TB. Further research on important individual, clinical and structural factors that can influence and should be considered in the planning, implementation and scale-up of household contact TB investigation is warranted.

Isolation of bacteria from diabetic foot ulcers with special reference to anaerobe isolation by simple two-step combustion technique in candle jar.

BACKGROUND & OBJECTIVES: Although polymicrobial infections involving both aerobic and anaerobic bacteria are very common in diabetic foot ulcers, in many centres of developing countries, anaerobes are rarely isolated due to technical difficulties. This can be overcome by using a new simple, innovative technique of a combination of candle combustion and use of acidified copper-coated steel wool, as reported here. METHODS: In-house developed method was used in a prospective clinico-microbiological study for anaerobes from randomly selected 43 patients with diabetic foot ulcers along with conventional method of anaerobic culture in GasPak system and aerobic culture by standard laboratory procedures. For primary isolation of anaerobes, Brucella blood agar supplemented with hemin (5 µg/ml) and menadione (1 µg/ml) was used. Antibiotic sensitivity tests were performed by the standard disc diffusion method for aerobes and E-test method for anaerobes. RESULTS: All the 43 samples were culture positive, of which aerobic Gram-negative bacteria (GNB) predominated, followed by Staphylococcus aureus, Enterococcus and diphtheroids. Anaerobes isolated from 21 samples were Peptostreptococcus, Bacteroides, Porphyromonas, Veillonella spp. and Clostridium perfringens by both GasPak and in-house developed and modified candle jar techniques. Imipenem and metronidazole were most sensitive while clindamycin, penicillin and cefoxitin were least sensitive drugs for anaerobes. Aerobic GNB were found to be multidrug resistant, especially to penicillin and cephalosporins. The most sensitive drug was piperacillin-tazobactam. INTERPRETATION & CONCLUSIONS: For isolation of anaerobes from clinical specimens such as diabetic foot ulcers, modified candle jar technique was found to be as reliable as GasPak system. This modified technique needs to be tested for many other clinical materials which are not yet evaluated.

Tuberculosis Associated with HIV Infection.

Tuberculosis (TB) has recently surpassed HIV as the primary infectious disease killer worldwide, but the two diseases continue to display lethal synergy. The burden of TB is disproportionately borne by people living with HIV, particularly where HIV and poverty coexist. The impact of these diseases on one another is bidirectional, with HIV increasing risk of TB infection and disease progression and TB slowing CD4 recovery and increasing progression to AIDS and death among the HIV infected. Both antiretroviral therapy (ART) and latent TB infection (LTBI) treatment mitigate the impact of coinfection, and ART is now recommended for HIV-infected patients independent of CD4 count. LTBI screening should be performed for all HIV-positive people at the time of diagnosis, when their CD4 count rises above 200, and yearly if there is repeated exposure. Tuberculin skin tests (TSTs) may perform better with serial testing than interferon gamma release assays (IGRAs). Any patient with HIV and a TST induration of ≥5 mm should be evaluated for active TB disease and treated for LTBI if active disease is ruled out. Because HIV impairs multiple aspects of immune function, progressive HIV is associated with lower rates of cavitary pulmonary TB and higher rates of disseminated and extrapulmonary disease, so a high index of suspicion is important, and sputum should be obtained for evaluation even if chest radiographs are negative. TB diagnosis is similar in patients with and without TB, relying on smear, culture, and nucleic acid amplification tests, which are the initial tests of choice. TSTs and IGRAs should not be used in the evaluation of active TB disease since these tests are often negative with active disease. Though not always performed in resource-limited settings, drug susceptibility testing should be performed on all TB isolates from HIV-positive patients. Urine lipoarabinomannan testing may also be helpful in HIV-positive patients with disseminated disease. Treatment of TB in HIV-infected patients is similar to that of TB in HIV-negative patients except that daily therapy is required for all coinfected patients, vitamin B6 supplementation should be given to all coinfected patients receiving isoniazid to reduce peripheral neuropathy, and specific attention needs to be paid to drug-drug interactions between rifamycins and many classes of antiretrovirals. In patients requiring ART that contains ritonavir or cobicistat, this can be managed by the use of rifabutin at 150 mg daily in place of rifampin. For newly diagnosed coinfected patients, mortality is lower if treatment is provided in parallel, rather than serially, with treatment initiation within 2 weeks preferred for those with CD4 counts of <50 and within 8 to 12 weeks for those with higher CD4 counts. When TB immune reconstitution inflammatory syndrome occurs, patients can often be treated symptomatically with nonsteroidal anti-inflammatory drugs, but a minority will benefit from steroids. Generally, patients who do not have space-occupying lesions such as occurs in TB meningitis do not require cessation of therapy.

Primary actinomycosis of the breast caused by Actinomyces turicensis with associated Peptoniphilus harei.

Actinomycosis of the breast is a rare disease which may mimic malignancy in presentation. Clinical presentation may make it difficult to distinguish primary actinomycosis from mastitis and inflammatory carcinoma. A 22-year-old lady presented with a 3-week history of right breast pain and greenish discharge through her nipple piercing. Physical examination revealed a palpable fluctuant lump in the upper inner quadrant of the right breast and a nipple jewelry in-situ in the upper inner quadrant of the right breast with an abscess at the edge of the areola. Needle aspiration was performed and microbiological examination of the aspirate isolated Actinomyces turicensis and Peptoniphilus harei. Actinomycosis of the breast is rare and the specie, Actinomyces turicensis, is even rarer especially in association with Peptoniphilus harei. Actinomyces is a difficult organism to treat due to its relative indolent course with potential scarring and disruption of local tissue. However, surgical intervention could be avoided with an intensive course of high-dose intravenous antibiotics and prolonged oral antibiotics afterwards.

Integration of HIV and tuberculosis in the community.

Current strategies are insufficient to contain the growing tuberculosis (TB) epidemic in areas of high HIV prevalence such as sub-Saharan Africa. Due to the increased risk of morbidity and mortality among those coinfected, early detection is critical. However,strategies dependent on passive, facility-based case finding have failed due to severe limitations in the HIV-positive population.There is growing evidence from multiple clinical trials that early initiation of antiretroviral therapy (ART) in patients coinfected with HIV and TB reduces mortality. Integration of community-based distribution of ART and TB medicines should be considered for coinfected patients to help improve retention in care and to off-load busy health systems. Several models of integration of HIV and TB care in sub-Saharan Africa have been successful. This review article examines the concepts of HIV and TB integration of testing and treatment at the community level.

Evaluation of how integrated HIV and TB programs are implemented in South Africa and the implications for rural-urban equity.

INTRODUCTION: In countries such as South Africa with a high prevalence of HIV and TB policy directives support program integration. Operational research suggests this is desirable, at least for increasing coverage of HIV and TB services, but warns that implementation models must take local health service infrastructure into account. METHODS: A program evaluation of HIV and TB prevention and therapeutic services was performed at facility level in two purposefully selected districts in South Africa - one deep rural and an urban district - in order to describe integration and how it is implemented. Twenty-six rural and 146 urban public primary-care facilities were evaluated using secondary data generated from two large evaluations of HIV/TB/Sexually Transmitted Infections (STI) programs conducted in December 2008 and May 2009. The data collection tools consisted of a review of data in the routine health information system, a facility manager interview, a checklist for equipment and supplies, register reviews and a series of patient folder (health record) reviews. Data were collected on extent to which clients receive integrated services, as well as the quality of care, and the availability of key resources and system capacity to support quality care. Data were entered into MS Excel spreadsheets and proportions calculated for all indicators, and confidence intervals for proportions. RESULTS: Evidence of integration was found across two dimensions - disease programs and the prevention-therapeutic axis. Integration was enabled in both the rural and urban districts because HIV and TB services were co-located in the extensive network of general primary-care services. Smaller rural facilities did not always have staff trained in all the required services, nurses worked without the support of a doctor and supervision was weaker, threatening quality of care. In the rural district there were instances of clients receiving more integrated services. The quality of care in the TB program was high in both districts. CONCLUSIONS: In both the districts evaluated, integration across programs and the prevention-care-rehabilitation axis of services was achieved through co-location at primary-care level. Coupled with health system strengthening, this has the potential to improve access across the HIV/TB/STI cluster of services. The benefit is likely to be greater in rural areas. Quality of care was maintained in the long established TB programs in both settings.

Implementation of tuberculosis infection control measures at HIV care and treatment sites in sub-Saharan Africa.

SETTING: A total of 663 human immunodeficiency virus (HIV) care and treatment sites in nine tuberculosis (TB) affected African countries, serving over 900,000 persons living with HIV. OBJECTIVE: To determine the implementation of infection control (IC) measures and whether program and facility characteristics were associated with implementation of these measures. DESIGN: A survey was conducted to assess the presence of a TB IC plan, triage practices for TB suspects, location of sputum collection and availability of particulate respirators. The association of facility characteristics with IC measures was examined using bivariate and multivariate methods. RESULTS: Forty-seven per cent (range across countries [RAC] 2-77%) of sites had written TB IC plans; 60% (RAC 5-93%) practiced triage; of those with access to microscopy, 83% (RAC 59-91%) performed sputum collection outdoors and 13% (RAC 0-36%) in ventilated indoor rooms; 16% (RAC 1-87%) had particulate respirators available. Sites providing anti-tuberculosis treatment were more likely to have written IC plans (54% vs. 12%, P < 0.0001) and particulate respirators (18% vs. 8%, P = 0.0126), and to perform TB triage (65% vs. 40%, P = 0.0001) than those without anti-tuberculosis treatment services. CONCLUSIONS: To protect HIV-infected patients and health care workers, there is an urgent need to scale up IC practices at HIV care and treatment sites, particularly at sites without anti-tuberculosis treatment services.

Refractory hypocalcemia precipitated by dual infection with typhoid fever and hepatitis A in a patient with congenital hypoparathyroidism.

We present this rare occurrence of a 17 yr old boy, a known case of congenital hypoparathyroidism, who presented with fever and jaundice for 8 days and 2 episodes of generalised tonic-clonic seizures. Premorbidly patient was on regular oral calcium supplementations with normal serum calcium levels. Investigations revealed severe hypocalcaemia (3.2 mg/dL), low 25 hydroxyvitamin D levels and hypomagnesaemia. The marked elevation of serum bilirubin was accompanied by derangement of liver enzymes. Microbiological investigations were confirmatory for both hepatitis A and typhoid fever. In spite of the aggressive management with intravenous calcium gluconate infusion, refractory hypocalcaemia persisted with recovery only after gradual decline in the bilirubin levels. We inferred that the cholestatic process produced by both acute viral hepatitis A and typhoid fever precipitated this state of refractory hypocalcaemia in the previously well preserved patient.

Evaluation of collaborative tuberculosis and human immunodeficiency virus activities in Phnom Penh, Cambodia.

SETTING: Phnom Penh, Cambodia. OBJECTIVES: 1) To monitor the number of tuberculosis (TB) patients undergoing human immunodeficiency (HIV) testing during TB treatment and trends of referral of TB-HIV patients to HIV services following the appointment of TB-HIV coordinators in TB wards, and 2) to investigate factors that influence undesirable TB treatment outcomes. DESIGN: Retrospective descriptive study based on a review of patient records and interviews with programme staff. RESULTS: Eighty-six per cent of newly registered TB patients underwent HIV testing. Most of the TB-HIV patients were referred to HIV services. Using logistic regression analysis, the risk of an undesirable treatment outcome in extra-pulmonary TB was significantly lower than in smear-positive pulmonary TB. Interviews revealed that patients in poor clinical condition at the start of TB treatment or who faced social problems, such as homelessness or foreign nationality, were at considerable risk for undesirable TB treatment outcomes. CONCLUSION: The appointment of TB-HIV coordinators to TB wards resulted in better HIV testing uptake and referral to HIV care and treatment services. To save TB-HIV patients' lives, it is important to continue this kind of study over a longer term to monitor these activities and to identify high-risk patients.