Phylogeographic Analysis of Mycobacterium kansasii Isolates from Patients with M. kansasii Lung Disease in Industrialized City, Taiwan.

Little is known about environmental transmission of Mycobacterium kansasii. We retrospectively investigated potential environmental acquisition, primarily water sources, of M. kansasii among 216 patients with pulmonary disease from an industrial city in Taiwan during 2015-2017. We analyzed sputum mycobacterial cultures using whole-genome sequencing and used hierarchical Bayesian spatial network methods to evaluate risk factors for genetic relatedness of M. kansasii strains. The mean age of participants was 67 years; 24.1% had previously had tuberculosis. We found that persons from districts served by 2 water purification plants were at higher risk of being infected with genetically related M. kansasii isolates. The adjusted odds ratios were 1.81 (1.25-2.60) for the Weng Park plant and 1.39 (1.12-1.71) for the Fongshan plant. Those findings unveiled the association between water purification plants and M. kansasii pulmonary disease, highlighting the need for further environmental investigations to evaluate the risk for M. kansasii transmission.

Cardiovascular Disease Burden Attributable to High Body Mass Index in Taiwan.

Background: Studies on disease burden in Taiwan are lacking. We aimed to quantify the burden of cardiovascular disease (CVD) attributable to high body mass index (BMI) in Taiwan. Methods: Using a comparative risk assessment approach from the Global Burden of Disease study, we estimated the population attributable fraction (PAF), attributable CVD burden, and disability-adjusted life years (DALYs) according to sex, age, and area of residence in Taiwan. The BMI distribution for the population was obtained from the National Health Interview Survey in 2013. CVD was defined as an ischemic heart disease or stroke. Results: The attributable PAF for CVD from high BMI was 18.0% (19.6% in men and 15.6% in women), and it was highest (42.7%) in those aged 25-30 years. Adults aged 60-65 years had the highest absolute DALYs (11,546). The average relative age-standardized attributable burden was 314 DALYs per 100,000 person-years, and it was highest in those aged 75-80 years (1,407 DALYs per 100,000 person-years). Those living in Taitung County had the highest PAF of 21.9% and the highest age-standardized attributable burden (412 DALYs). Conclusions: In Taiwan, an 18% reduction in CVDs could be achieved if obesity/overweight was prevented. Prevention was most effective in early adulthood. The absolute CVD burden from obesity/overweight was highest in middle-aged men, and the relative burden was highest in older adults. Resource allocation in targeted populations and specific areas to eliminate CVD and health inequities is urgently required.

Transmission Dynamics and Effectiveness of Control Measures during COVID-19 Surge, Taiwan, April-August 2021.

An unprecedented surge of COVID-19 cases in Taiwan in May 2021 led the government to implement strict nationwide control measures beginning May 15. During the surge, the government was able to bring the epidemic under control without a complete lockdown despite the cumulative case count reaching >14,400 and >780 deaths. We investigated the effectiveness of the public health and social measures instituted by the Taiwan government by quantifying the change in the effective reproduction number, which is a summary measure of the ability of the pathogen to spread through the population. The control measures that were instituted reduced the effective reproduction number from 2.0-3.3 to 0.6-0.7. This decrease was correlated with changes in mobility patterns in Taiwan, demonstrating that public compliance, active case finding, and contact tracing were effective measures in preventing further spread of the disease.

Mortality, morbidity, and risk factors in Taiwan, 1990-2017: findings from the Global Burden of Disease Study 2017.

BACKGROUND: Taiwan has implemented a national health insurance system since 1995 with high coverage and utilization rate. However, the health care system in Taiwan is facing immense challenges due to rapid population ageing. We have evaluated the landscape of population health by revisiting the results of GBD 2017 study. METHODS: Taiwan vital registration data (1980-2016) and Taiwan national health insurance database (2016) were used. We also conducted benchmarking comparisons with selected countries in East Asia from 1990 to 2017. RESULTS: The age-standardized disability-adjusted life-year (DALY) rates decreased by one-quarter from 1990 to 2017; however, progress was relatively slow compared to the comparator countries and has been stagnant recently. The Social-demographic Index (SDI) level in Taiwan in 2017 was 0.86, which is similar to Japan, Singapore, and South Korea in 2017, while the SDI level of China in 2017 was similar to that of Taiwan (0.69) in 1990. Although Taiwan's SDI reached the same level as those in Japan, Singapore, and South Korea in 2017, modifiable risk factors still contributed to nearly half of Taiwan's total disease burden. Five leading risk factors (high fasting plasma glucose, high body-mass index, alcohol use, illicit drug use, and impaired kidney function) accounted for a higher DALY rate in Taiwan than comparator countries in 2017. CONCLUSION: Taiwan made marked progress in health from 1990 to 2017. However, interventions targeted on major modifiable disease risk factors should be prioritized to realize the full potential of heath improvement in the process of rapid socioeconomic development.

The impact on incident tuberculosis by kidney function impairment status: analysis of severity relationship.

BACKGROUND: The risk of tuberculosis (TB) in patients with impaired kidney function remains unclear by different stages of renal function impairment. METHODS: We retrospectively recruited all patients with kidney function in a tertiary-care referral center from January 2008 to December 2013 and followed them till December 2016. We defined the primary outcome as active TB development and analyzed the impact of kidney function impairment. RESULTS: During the study period, a total of 289,579 patients were enrolled for analysis, and of them, 1012 patients had active TB events in an average of 4.13 years of follow-up. According to kidney function impairment, the incidence rate of TB was similar in patients with no chronic kidney disease (CKD) or stage 1 and stage 2, and it increased apparently at stage 3a (167.68 per 100,000 person-years) to stage 3b, stage 4 and stage 5 (229.25, 304.95 and 349.29 per 100,000 person-years, respectively). In a Cox proportional hazard regression model, the dose response of TB risk among different stages of kidney function impairment increased significantly from CKD stage 3a to stage 5. Patients with long-term dialysis had a hazard ratio of 2.041 (1.092-3.815, p = 0.0254), which is similar to that of stage 4 CKD but lower than that of stage 5. CONCLUSION: In patients with impaired kidney function, the risk of TB increases from CKD stage 3, and in stage 5, the risk is even higher than that of those receiving dialysis. Further strategies of TB control need to consider this high-risk group.

Improving the Use of Mortality Data in Public Health: A Comparison of Garbage Code Redistribution Models.

Objectives. To describe and compare 3 garbage code (GC) redistribution models: naïve Bayes classifier (NB), coarsened exact matching (CEM), and multinomial logistic regression (MLR).Methods. We analyzed Taiwan Vital Registration data (2008-2016) using a 2-step approach. First, we used non-GC death records to evaluate 3 different prediction models (NB, CEM, and MLR), incorporating individual-level information on multiple causes of death (MCDs) and demographic characteristics. Second, we applied the best-performing model to GC death records to predict the underlying causes of death. We conducted additional simulation analyses for evaluating the predictive performance of models.Results. When we did not account for MCDs, all 3 models presented high average misclassification rates in GC assignment (NB, 81%; CEM, 86%; MLR, 81%). In the presence of MCD information, NB and MLR exhibited significant improvement in assignment accuracy (19% and 17% misclassification rate, respectively). Furthermore, CEM without a variable selection procedure resulted in a substantially higher misclassification rate (40%).Conclusions. Comparing potential GC redistribution approaches provides guidance for obtaining better estimates of cause-of-death distribution and highlights the significance of MCD information for vital registration system reform.

Explaining age disparities in tuberculosis burden in Taiwan: a modelling study.

BACKGROUND: Tuberculosis (TB) burden shows wide disparities across ages in Taiwan. In 2016, the age-specific notification rate in those older than 65 years old was about 100 times as much as in those younger than 15 years old (185.0 vs 1.6 per 100,000 population). Similar patterns are observed in other intermediate TB burden settings. However, driving mechanisms for such age disparities are not clear and may have importance for TB control efforts. METHODS: We hypothesised three mechanisms for the age disparity in TB burden: (i) older age groups bear a higher risk of TB progression due to immune senescence, (ii) elderly cases acquired TB infection during a past period of high transmission, which has since rapidly declined and thus contributes to little recent infections, and (iii) assortative mixing by age allows elders to maintain a higher risk of TB infection, while limiting spillover transmission to younger age groups. We developed a series of dynamic compartmental models to incorporate these mechanisms, individually and in combination. The models were calibrated to the TB notification rates in Taiwan over 1997-2016 and evaluated by goodness-of-fit to the age disparities and the temporal trend in the TB burden, as well as the deviance information criterion (DIC). According to the model performance, we compared contributions of the hypothesised mechanisms. RESULTS: The 'full' model including all the three hypothesised mechanisms best captured the age disparities and temporal trend of the TB notification rates. However, dropping individual mechanisms from the full model in turn, we found that excluding the mechanism of assortative mixing yielded the least change in goodness-of-fit. In terms of their influence on the TB dynamics, the major contribution of the 'immune senescence' and 'assortative mixing' mechanisms was to create disparate burden among age groups, while the 'declining transmission' mechanism served to capture the temporal trend of notification rates. CONCLUSIONS: In settings such as Taiwan, the current TB burden in the elderly may be impacted more by prevention of active disease following latent infection, than by case-finding for blocking transmission. Further studies on these mechanisms are needed to disentangle their impacts on the TB epidemic and develop corresponding control strategies.

Health impact assessment of PM2.5 from a planned coal-fired power plant in Taiwan.

PURPOSE: To investigate the impact of a planned coal-fired power plant (CFPPT) in Shenao on air quality and health at subnational levels in Taiwan. METHODS: We applied the Gaussian trajectory transfer-coefficient (GTx) model to estimate annual average PM2.5 (particulate matter with aerodynamic diameter less than 2.5 µm) increments in 19 Taiwanese cities and counties caused by CFPPT operation. A population health risk assessment was performed by incorporating evidence of the health effects of PM2.5 provided by prospective studies and estimating long-term PM2.5 exposure. Additionally, we considered ischemic heart disease, stroke, lung cancer, and chronic obstruct pulmonary disease as the primary outcomes. The population-attributable fraction was used to estimate the county-level mortality burden attributable to CFPPT-generated PM2.5 in 2025. RESULTS: The estimated annual PM2.5 increments ranged from 0.004 µg/m3 (Taitung County) to 0.28 µg/m3 (Hsinchu County) due to the Shenao CFPPT. The total and premature deaths attributable to PM2.5 from Shenao CFPPT operation in Taiwan during 2025-2040 would be 576 (95% confidence interval [CI]: 537-619) and 145 (95% CI: 136-155), respectively. Notably, we estimated 198 (95% CI: 169-234) deaths and 58 (95% CI: 51-66) premature deaths, respectively, in New Taipei City, which accounted for over a quarter of the total deaths. Overall, the mortality rate attributable to the Shenao CFPPT in Taiwan was 6 per 10,000. CONCLUSION: A scientific approach should be adopted for assessing the impacts of CFPPT operation on population health, which can serve as a valuable policymaking reference for the government.

Association of Obesity, Diabetes, and Risk of Tuberculosis: Two Population-Based Cohorts.

Background: Mounting data have revealed that body mass index (BMI) is inversely associated with risk of active tuberculosis. The inverse association presents a "paradox" with regard to diabetes, because obesity is a major determinant of diabetes, and diabetes is a well-known risk factor for tuberculosis. Methods: We conducted 2 population-based cohort studies involving 167392 participants. The main exposure was BMI and diabetes ascertained at baseline. Occurrence of incident tuberculosis was ascertained from Taiwan's National Tuberculosis Registry. We conducted a causal mediation analysis and a joint effects analysis to characterize the relationship between BMI, diabetes, and tuberculosis. Results: During a median of >7 years of follow-up, 491 individuals developed incident tuberculosis. Compared with normal-weight individuals, obese individuals (>30 kg/m2) had a 67% (95% confidence interval [CI], -3% to -90%) and 64% (31%-81%) reduction in tuberculosis hazard in the 2 cohorts. In the causal mediation analysis, obesity had a harmful effect on tuberculosis mediated through diabetes (0.8% and 2.7% increased odds in the 2 cohorts, respectively) but had a strongly protective effect not mediated through diabetes (72% and 67% decreased odds, respectively). Individuals who were simultaneously obese and diabetic had a lower but statistically insignificant risk of tuberculosis (adjusted hazard ratio, 0.30; 95% CI, .08-1.22) compared with nondiabetic normal-weight individuals. Conclusions: Our analyses revealed that the relationship between obesity, diabetes, and risk of tuberculosis was complex and nonlinear. Better understanding of the interplay between host metabolism and tuberculosis immunology may lead to novel therapeutic or preventive strategies.

Diabetes Mellitus and Latent Tuberculosis Infection: A Systematic Review and Metaanalysis.

Background: Despite the well-documented association between diabetes and active tuberculosis, evidence of the association between diabetes and latent tuberculosis infection (LTBI) remains limited and inconsistent. Methods: We included observational studies that applied either the tuberculin skin test or the interferon gamma release assay for diagnosis of LTBI and that provided adjusted effect estimate for the association between diabetes and LTBI. We searched PubMed and EMBASE through 31 January 2016. The risk of bias of included studies was assessed using a quality assessment tool modified from the Newcastle-Ottawa scale. Results: Thirteen studies (1 cohort study and 12 cross-sectional studies) were included, involving 38263 participants. The cohort study revealed an increased but nonsignificant risk of LTBI among diabetics (risk ratio, 4.40; 95% confidence interval [CI], 0.50-38.55). For the cross-sectional studies, the pooled odds ratio from the random-effects model was 1.18 (95% CI, 1.06-1.30), with a small statistical heterogeneity across studies (I2, 3.5%). The risk of bias assessment revealed several methodological issues, but the overall direction of biases would reduce the positive causal association between diabetes and LTBI. Conclusions: Diabetes was associated with a small but statistically significant risk for LTBI. Findings from this review could be used to inform future cost-effectiveness analysis on the impact of LTBI screening programs among diabetics.

Adult mortality of diseases and injuries attributable to selected metabolic, lifestyle, environmental, and infectious risk factors in Taiwan: a comparative risk assessment.

BACKGROUND: To facilitate priority-setting in health policymaking, we compiled the best available information to estimate the adult mortality (>30 years) burden attributable to 13 metabolic, lifestyle, infectious, and environmental risk factors in Taiwan. METHODS: We obtained data on risk factor exposure from nationally representative health surveys, cause-specific mortality from the National Death Registry, and relative risks from epidemiological studies and meta-analyses. We applied the comparative risk assessment framework to estimate mortality burden attributable to individual risk factors or risk factor clusters. RESULTS: In 2009, high blood glucose accounted for 14,900 deaths (95% UI: 11,850-17,960), or 10.4% of all deaths in that year. It was followed by tobacco smoking (13,340 deaths, 95% UI: 10,330-16,450), high blood pressure (11,190 deaths, 95% UI: 8,190-14,190), ambient particulate matter pollution (8,600 deaths, 95% UI: 7,370-9,840), and dietary risks (high sodium intake and low intake of fruits and vegetables, 7,890 deaths, 95% UI: 5,970-9,810). Overweight-obesity and physical inactivity accounted for 7,620 deaths (95% UI: 6,040-9,190), and 7,400 deaths (95% UI: 6,670-8,130), respectively. The cardiometabolic risk factors of high blood pressure, high blood glucose, high cholesterol, and overweight-obesity jointly accounted for 12,120 deaths (95% UI: 11,220-13,020) from cardiovascular diseases. For domestic risk factors, infections from hepatitis B virus (HBV) and hepatitis C virus (HCV) were responsible for 6,300 deaths (95% UI: 5,610-6,980) and 3,170 deaths (95% UI: 1,860-4,490), respectively, and betel nut use was associated with 1,780 deaths from oral, laryngeal, and esophageal cancer (95% UI: 1,190-2,360). The leading risk factors for years of life lost were similar, but the impact of tobacco smoking and alcohol use became larger because the attributable deaths from these risk factors occurred among young adults aged less than 60 years. CONCLUSIONS: High blood glucose, tobacco smoking, and high blood pressure are the major risk factors for deaths from diseases and injuries among Taiwanese adults. A large number of years of life would be gained if the 13 modifiable risk factors could be removed or reduced to the optimal level.

Burden of disease attributable to ambient fine particulate matter exposure in Taiwan.

BACKGROUND/PURPOSE: There is compelling epidemiological evidence that links air pollution to increased risk of mortality from cardiopulmonary disease and lung cancer. We quantified the burden of mortality attributable to ambient fine particulate matter (PM2.5) among the Taiwanese population in 2014 at the national and subnational levels. METHODS: Subnational PM2.5 exposure levels were obtained from Taiwan Air Quality Monitoring Network. Relative risks were derived from a previously developed exposure-response model. Population attributable fraction for cause-specific mortality was estimated at the county level using the estimated ambient PM2.5 concentrations and the relative risk functions. RESULTS: In 2014, PM2.5 accounted for 6282 deaths [95% confidence interval (CI), 5716-6847], from ischemic heart disease (2244 deaths; 95% CI, 2015-2473), stroke (2140 deaths; 95% CI, 1760-2520), lung cancer (1252 deaths; 95% CI, 995-1509), and chronic obstructive pulmonary disease (645 deaths; 95% CI, 418-872). Nationally, the population attributable mortality fraction of PM2.5 for the four disease causes was 18.6% (95% CI, 16.9-20.3%). Substantial geographic variation in PM2.5 attributable mortality fraction was found; the percentage of deaths attributable to PM2.5 ranged from 8.7% in Hualian County to 21.8% in Yunlin County. In terms of absolute number of deaths, New Taipei and Kaohsiung cities had the largest number of deaths associated with PM2.5 (874 and 829 deaths, respectively) among all cities and counties. CONCLUSION: Ambient PM2.5 pollution is a major mortality risk factor in Taiwan. Aggressive and multisectorial intervention strategies are urgently needed to bring down the impact of air pollution on environment and health.

Glycemic Control and the Risk of Tuberculosis: A Cohort Study.

BACKGROUND: Diabetes is a well-known risk factor for tuberculosis (TB) and is increasingly prevalent in low- and middle-income countries, where the burden of TB is high. Glycemic control has the potential to modify the risk of TB. However, there are few studies on the association between glycemic control and TB risk, and the results are inconsistent. METHODS AND FINDINGS: We assembled a cohort using 123,546 individuals who participated in a community-based health screening service in northern Taiwan from 5 March 2005 to 27 July 2008. Glycemic control was measured using fasting plasma glucose (FPG) at the time of screening. The cohort was followed up to 31 December 2012 for the occurrence of TB by cross-matching the screening database to the national health insurance database. Multiple imputation was used to handle missing information. During a median follow-up of 4.6 y, 327 cases of TB occurred. In the multivariable Cox regression model, diabetic patients with poor glycemic control (FPG > 130 mg/dl) had a significantly higher hazard of TB (adjusted hazard ratio [aHR] 2.21, 95% CI 1.63-2.99, p < 0.001) compared to those without diabetes. The hazard of TB in diabetic patients with good glycemic control (FPG ≤ 130 mg/dl) did not differ significantly from that in nondiabetic individuals (aHR 0.69, 95% CI 0.35-1.36, p = 0.281). In the linear dose-response analysis, the hazard of TB increased with FPG (aHR 1.06 per 10-mg/dl increase in FPG, 95% CI 1.03-1.08, p < 0.001). Assuming the observed association between glycemic control and TB was causal, an estimated 7.5% (95% CI 4.1%-11.5%) of incident TB in the study population could be attributed to poor glycemic control. Limitations of the study include one-time measurement of fasting glucose at baseline and voluntary participation in the health screening service. CONCLUSIONS: Good glycemic control could potentially modify the risk of TB among diabetic patients and may contribute to the control of TB in settings where diabetes and TB are prevalent.

Health Care Visits as a Risk Factor for Tuberculosis in Taiwan: A Population-Based Case-Control Study.

OBJECTIVES: To assess whether health care visits of nontuberculous patients are a risk factor for contracting tuberculosis. METHODS: We conducted a case-control study nested within the cohort of 1 million individuals from the health insurance database in Taiwan between 2003 and 2010. We identified incident cases of tuberculosis through International Classification of Diseases, Ninth Revision (ICD-9) codes and prescription of antituberculosis drugs. We identified 4202 case participants and 16 808 control participants matched by age, gender, and date of diagnosis to estimate the association between frequency of health care visits and incidence of tuberculosis. RESULTS: Frequency of health care visits was associated with increased risk of tuberculosis in a dose-dependent manner after adjustment for other medical comorbidities (P for trend < .001). Compared with individuals with fewer than 5 visits per year, those with more than 30 had a 77% increase in tuberculosis risk (adjusted odds ratio = 1.77; 95% confidence interval [CI] = 1.60, 1.97). CONCLUSIONS: Frequent health care visits of nontuberculous patients appear to be a risk factor for contracting tuberculosis. PUBLIC HEALTH IMPLICATIONS: Efforts should focus on educating the general population to avoid unnecessary hospital visits, strengthening active case finding, and intensifying infection control in all health care settings.

Inhaled nitric oxide and the risk of renal dysfunction in patients with acute respiratory distress syndrome: a propensity-matched cohort study.

BACKGROUND: Inhaled nitric oxide (iNO) is a rescue therapy for severe hypoxemia in patients with acute respiratory distress syndrome (ARDS). Pooled data from clinical trials have signaled a renal safety warning for iNO therapy, but the significance of these findings in daily clinical practice is unclear. We used primary data to evaluate the risk of iNO-associated renal dysfunction in patients with ARDS. METHODS: We conducted a cohort study using data from a tertiary teaching hospital to evaluate the risk of incident renal replacement therapy (RRT) in iNO users compared with that of non-users. Propensity score matching and competing-risks regression were used for data analysis. Residual confounding was assessed by means of a rule-out approach. We also evaluated effect modification by pre-specified factors using stratified analysis. RESULTS: We identified 547 patients with ARDS, including 216 iNO users and 331 non-users. At study entry, 313 (57.2%) patients had moderate ARDS and 234 (42.8%) had severe ARDS. The mean patient age was 63 ± 17 years. The crude hazard ratio of the need for RRT in iNO users compared with non-users was 2.23 (95% CI, 1.61-3.09, p < 0.001). After propensity score matching, there were 151 iNO users matched to 151 non-users. The adjusted hazard ratio was 1.59 (95% CI, 1.08-2.34, p = 0.02). In the stratified analysis, we found that older aged patients (≥65 years) were more susceptible to iNO-associated kidney injury than younger patients (p = 0.05). CONCLUSIONS: This study showed that iNO substantially increased the risk of renal dysfunction in patients with ARDS. Older aged patients were especially susceptible to this adverse event.

Diagnostic performance of CT and MRI on the detection of symptomatic intracranial dural arteriovenous fistula: a meta-analysis with indirect comparison.

INTRODUCTION: This study aims to review the diagnostic performance of computed tomography (CT) and magnetic resonance imaging (MRI) in symptomatic dural arteriovenous fistula (DAVF). METHODS: EMBASE, PubMed, and Cochrane Library were searched until April 2015 for studies which compared CT, MRI, or both with angiography for the detection of DAVF. The diagnostic performances of MRI and CT were indirectly compared using modality as a covariate in the analysis. RESULTS: Thirteen studies met our inclusion criteria. MRI had a sensitivity of 0.90 (95 % confidence interval (CI) = 0.83-0.94) and specificity of 0.94 (95 % CI = 0.90-0.96). CT had a sensitivity of 0.80 (95 % CI = 0.62-0.90) and specificity of 0.87 (95 % CI = 0.74-0.94). MRI showed better diagnostic performance than CT (p = 0.02). Contrast medium use and time-resolved MR angiography did not improve MRI diagnostic performance (p = 0.31 and 0.44, respectively). CONCLUSION: Both CT and MRI had good diagnostic performance. MRI was better than CT on the detection of symptomatic intracranial dural arteriovenous fistula in the indirect comparison.

Ambient air pollution and risk of tuberculosis: a cohort study.

OBJECTIVES: Several respirable hazards, including smoking and indoor air pollution from biomass, were suggested to increase the risk of tuberculosis. Few studies have been conducted on ambient air pollution and tuberculosis. We investigated the association between exposure to ambient air pollution and incidence of active tuberculosis. METHODS: We conducted a cohort study using 106,678 participants of a community-based screening service in Taiwan, 2005-2012. We estimated individual exposure to air pollution using data from the nearest air quality monitoring station and the road intensity within a 500 m buffer zone. The incidence of tuberculosis was ascertained from the national tuberculosis registry. RESULTS: After a median follow-up of 6.7 years, 418 cases of tuberculosis occurred. Exposure to fine particulate matter (PM2.5) was associated with increased risk of active tuberculosis (adjusted HR: 1.39/10 µg/m3 (95% CI 0.95 to 2.03)). In addition, traffic-related air pollution including nitrogen dioxide (adjusted HR: 1.33/10 ppb; 95% CI 1.04 to 1.70), nitrogen oxides (adjusted HR: 1.21/10 ppb; 95% CI 1.04 to 1.41) and carbon monoxide (adjusted HR: 1.89/ppm; 95% CI 0.78 to 4.58) was associated with tuberculosis risk. There was a non-significant trend between the length of major roads in the neighbourhood and culture-confirmed tuberculosis (adjusted HR: 1.04/km; 95% CI 0.995 to 1.09). CONCLUSIONS: Our study revealed a possible link between ambient air pollution and risk of active tuberculosis. Since people from developing countries continue to be exposed to high levels of ambient air pollution and to experience high rates of tuberculosis, the impact of worsening air pollution on global tuberculosis control warrants further investigation.

Tuberculosis control in China: use of modelling to develop targets and policies.

It is unclear if current programmes in China can achieve the post-2015 global targets for tuberculosis - 50% reduction in incidence and a 75% reduction in mortality by 2025. Chinese policy-makers need to maintain the recent decline in the prevalence of tuberculosis, while revising control policies to cope with an epidemic of drug-resistant tuberculosis and the effects of ongoing health reform. Health reforms are expected to shift patients from tuberculosis dispensaries to designated hospitals. We developed a mathematical model of tuberculosis control in China to help set appropriate targets and prioritize interventions that might be implemented in the next 10 years. This model indicates that, even under the most optimistic scenario - improved treatment in tuberculosis dispensaries, introduction of a new effective regimen for the treatment of drug-susceptible tuberculosis and optimal care of cases of multidrug-resistant tuberculosis - the current global targets for tuberculosis are unlikely to be reached. However, reductions in the incidence of multidrug-resistant tuberculosis should be feasible. We conclude that a shift of patients from tuberculosis dispensaries to designated hospitals is likely to hamper efforts at tuberculosis control if cure rates in the designated hospitals cannot be maintained at a high level. Our results can inform the planning of tuberculosis control in China.

Il est difficile de savoir si les programmes actuellement menés en Chine permettront d'atteindre les objectifs mondiaux pour l'après-2015 concernant la tuberculose, qui consistent à réduire l'incidence de 50% et la mortalité de 75% d'ici à 2025. Les dirigeants chinois doivent confirmer le récent déclin de la prévalence de la tuberculose, mais aussi revoir les politiques de lutte pour faire face à une épidémie de tuberculose pharmacorésistante et les effets de l'actuelle réforme de la santé. La réforme de la santé est censée prévoir le transfert des patients traités dans des dispensaires antituberculeux vers des hôpitaux expressément désignés. Nous avons élaboré un modèle mathématique de lutte contre la tuberculose en Chine qui aide à définir les objectifs appropriés et à hiérarchiser les interventions qui pourraient être réalisées au cours des dix prochaines années. Ce modèle indique que même dans le scénario le plus optimiste ­ amélioration du traitement dans les dispensaires antituberculeux, introduction d'un nouveau schéma thérapeutique efficace pour le traitement de la tuberculose sensible et traitement optimal des cas de tuberculose multirésistante ­, il paraît difficile d'atteindre les objectifs mondiaux actuels pour la tuberculose. Néanmoins, il devrait être possible de réduire l'incidence de la tuberculose multirésistante. Nous en concluons que le transfert des patients traités dans des dispensaires antituberculeux vers des hôpitaux expressément désignés est susceptible d'entraver les efforts de lutte contre la tuberculose s'il est impossible de maintenir des taux de guérison élevés dans ces hôpitaux. Nos résultats peuvent servir de base à la planification de la lutte contre la tuberculose en Chine.

No está claro si los programas actuales en China pueden alcanzar los objetivos globales para la tuberculosis después de 2015, una reducción del 50% de la incidencia y una reducción del 75% de la mortalidad de aquí a 2025. Los responsables políticos de China necesitan mantener el reciente descenso en la prevalencia de la tuberculosis, al mismo tiempo que revisan las políticas de control para hacer frente a una epidemia de tuberculosis farmacorresistente y los efectos en la reforma sanitaria en curso. Se espera que las reformas sanitarias trasladen los pacientes de los dispensarios para tuberculosis a los hospitales designados. Se ha desarrollado un modelo matemático de control de la tuberculosis en China para ayudar a establecer los objetivos apropiados y priorizar las intervenciones que podrían implementarse en los próximos diez años. Este modelo indica que, incluso en el escenario más optimista (una mejora del tratamiento en los dispensarios para tuberculosis, la introducción de un nuevo y efectivo régimen para el tratamiento de la tuberculosis farmacosensible y la atención óptima en casos de la tuberculosis farmacorresistente), es muy poco probable que se cumplan los objetivos actuales globales para la tuberculosis. Sin embargo, las reducciones en la incidencia de la tuberculosis farmacorresistente deberían ser factibles. Se concluye que es posible que un cambio de los pacientes de los dispensarios para tuberculosis a los hospitales designados obstaculice los esfuerzos de un control para la tuberculosis si las tasas de cura en los hospitales designados no pueden mantenerse en un nivel alto. Nuestros resultados pueden dar información sobre la planificación del control de la tuberculosis en China.

Health system delay among patients with tuberculosis in Taiwan: 2003-2010.

BACKGROUND: Taiwan has integrated the previous vertical tuberculosis (TB) control system into the general health care system. With the phase out of the specialized TB care system and the declining TB incidence, it is likely that clinical workers become less familiar with the presentation of TB, resulting in delay in TB diagnosis and treatment. METHODS: We used the detailed information of health care visits in the Taiwan National Health Insurance database to analyze the temporal pattern of the health system delay (HSD) among 3,117 patients with TB between 2003 and 2010. RESULTS: The median HSD was 29 days (interquartile range 5-73 days), and the median delay increased from 26 days in 2003 to 33.5 days in 2008, thereafter slightly decreased to 32 days in 2010. Patient factors associated with a longer HSD included: aged 45-64 and ≧65 years (as compared to aged <30 years); females (as compared to males); an initial visit as an outpatient (as compared to an inpatient). Provider factors were an initial visit to a provider not specialized in TB (as compared to a TB-related provider), to a primary care clinic or to a medical center (as compared to a district hospital), and in Central region, Northern region, KaoPing region, Southern region and Taipei region (as compared to in Eastern region). Longer distances from the point of initial visit to that of treatment were associated with longer HSD. Patients who switched among different levels or different types of medical care services during their illness exhibited the longest HSD. CONCLUSIONS: In countries where the TB care systems are being restructured from a vertical to a horizontal system, it is critical to monitor HSD and be aware of its increase. The potential increase in the HSD from 2003 to 2008 observed in this study is concerning and the decline of HSD after 2008 might be attributed to the launch of contact investigation. Our results call for actions to improve the efficiency of TB diagnosis in the health care system and to increase the awareness of TB among physicians and the general public.

Impact of active screening for methicillin-resistant Staphylococcus aureus (MRSA) and decolonization on MRSA infections, mortality and medical cost: a quasi-experimental study in surgical intensive care unit.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) is a leading pathogen of healthcare-associated infections in intensive care units (ICUs). Prior studies have shown that decolonization of MRSA carriers is an effective method to reduce MRSA infections in ICU patients. However, there is currently a lack of data on its effect on mortality and medical cost. METHODS: Using a quasi-experimental, interrupted time-series design with re-introduction of intervention, we evaluated the impact of active screening and decolonization on MRSA infections, mortality and medical costs in the surgical ICU of a university hospital in Taiwan. Regression models were used to adjust for effects of confounding variables. RESULTS: MRSA infection rate decreased from 3.58 (baseline) to 0.42‰ (intervention period) (P <0.05), re-surged to 2.21‰ (interruption period) and decreased to 0.18‰ (re-introduction of intervention period) (P <0.05). Patients admitted to the surgical ICU during the intervention periods had a lower in-hospital mortality (13.5% (155 out of 1,147) versus 16.6% (203 out of 1,226), P = 0.038). After adjusting for effects of confounding variables, the active screening and decolonization program was independently associated with a decrease in in-hospital MRSA infections (adjusted odds ratio: 0.3; 95% CI: 0.1 to 0.8) and 90-day mortality (adjusted hazard ratio: 0.8; 95% CI: 0.7 to 0.99). Cost analysis showed that $22 medical costs can be saved for every $1 spent on the intervention. CONCLUSIONS: Active screening for MRSA and decolonization in ICU settings is associated with a decrease in MRSA infections, mortality and medical cost.