Low BMI increases all-cause mortality rates in patients with drug-resistant TB.

BACKGROUND: Loss to follow-up (LTFU) is common among patients with drug-resistant TB (DR-TB) receiving second-line TB treatment; however, little is known about outcomes after LTFU, including mortality.OBJECTIVE: To determine rates of and factors associated with all-cause mortality among patients with DR-TB who were LTFU.METHODS: Retrospective cohort study of adult patients with DR-TB in Georgia who initiated second-line TB treatment during 2011-2014 and were LTFU. Survival analyses were used to estimate all-cause mortality rates and adjusted hazard ratios (aHR).RESULTS: During 2011-2014, 2,437 second-line treatment episodes occurred and 695 patients were LTFU. Among 695 LTFU patients, 143 (21%) died during 2,686 person-years (PY) post-LTFU (all-cause mortality rate 5.1%, 95% CI 4.3-6.0 per 100 PY). In multivariable analysis, low weight (BMI < 18.5 kg/m²) at treatment initiation (aHR 3.2, 95% CI 2.2-4.7), return to treatment after LTFU (aHR 3.1, 95% CI 2.2-4.4), <12 months of treatment (aHR 2.4, 95% CI 1.4-4.1) and a pre-LTFU positive culture (aHR 3.3, 95% CI 2.2-4.9) were associated with all-cause mortality.CONCLUSION: High all-cause mortality occurred among patients with DR-TB after LTFU despite a low HIV prevalence. Providing additional assistance for patients during DR-TB treatment to prevent LTFU and use of new and shorter treatment regimens may reduce mortality among LTFU.

The burden and epidemiology of hepatitis B and hepatitis D in Georgia: findings from the national seroprevalence survey.

OBJECTIVES: The burden of hepatitis B virus (HBV) and hepatitis D virus (HDV) infections is unknown in Georgia. This analysis describes the prevalence of hepatitis B and coinfection with HDV and the demographic characteristics and risk factors for persons with HBV infection in Georgia. STUDY DESIGN: This is a cross-sectional seroprevalence study. METHODS: A cross-sectional, nationwide survey to assess hepatitis B prevalence among the general adult Georgian population (age ≥18 years) was conducted in 2015. Demographic and risk behavior data were collected. Blood specimens were screened for anti-hepatitis B core total antibody (anti-HBc). Anti-HBc-positive specimens were tested for hepatitis B surface antigen (HBsAg). HBsAg-positive specimens were tested for HBV and HDV nucleic acid. Nationally weighted prevalence estimates and adjusted odds ratios (aORs) for potential risk factors were determined for anti-HBc and HBsAg positivity. RESULTS: The national prevalence of anti-HBc and HBsAg positivity among adults were 25.9% and 2.9%, respectively. Persons aged ≥70 years had the highest anti-HBc positivity (32.7%), but the lowest HBsAg positivity prevalence (1.3%). Anti-HBc positivity was associated with injection drug use (aOR = 2.34; 95% confidence interval [CI] = 1.46-3.74), receipt of a blood transfusion (aOR = 1.68; 95% CI = 1.32-2.15), and sex with a commercial sex worker (aOR = 1.46; 95% CI = 1.06-2.01). HBsAg positivity was associated with receipt of a blood transfusion (aOR = 2.72; 95% CI = 1.54-4.80) and past incarceration (aOR = 2.72; 95% CI = 1.25-5.93). Among HBsAg-positive persons, 0.9% (95% CI = 0.0-2.0) were HDV coinfected. CONCLUSIONS: Georgia has an intermediate to high burden of hepatitis B, and the prevalence of HDV coinfection among HBV-infected persons is low. Existing infrastructure for hepatitis C elimination could be leveraged to promote hepatitis B elimination.

Rates and risk factors for nephrotoxicity and ototoxicity among tuberculosis patients in Tbilisi, Georgia.

SETTING: Treatment of multidrug-resistant tuberculosis (MDR-TB) is lengthy and utilizes second-line anti-TB drugs associated with frequent adverse drug reactions (ADRs).OBJECTIVE: To evaluate the prevalence of and risk factors for ADRs among patients with MDR- and extensively drug-resistant TB (XDR-TB).DESIGN: A retrospective chart review of patients initiating treatment for M/XDR-TB in 2010-2012 in Tbilisi, Georgia.RESULTS: Eighty (54%) and 38 (26%) of 147 patients developed nephrotoxicity per RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification and ototoxicity, respectively. Twenty-five (17%) patients required permanent interruption of injectables due to an ADR. Median hospital stay, total treatment duration and number of regimen changes were higher among those with nephrotoxicity and/or ototoxicity, compared to those without (P < 0.01). Multinomial logistic regression analysis identified increasing age (per year) as a risk factor for nephrotoxicity (aOR 1.08, 95%CI 1.03-1.12) and for both, nephro- and ototoxicity (aOR 1.11, 95%CI 1.05-1.17). Low baseline creatinine clearance (CrCl) was a significant risk factor for developing nephrotoxicity (aOR 1.05, 95%CI 1.02-1.07).CONCLUSION: Second-line injectable drug-related ADRs are common among M/XDR-TB patients. Patients with increasing age and low baseline CrCl should be monitored closely for injectable-related ADRs. Notably, our findings support WHO's latest recommendations on introduction of injectable free anti-TB treatment regimens.

A population-based tuberculosis contact investigation in the country of Georgia.

Setting: Identification and screening of contacts of patients with active tuberculosis (TB) is infrequent in low- and middle-income countries. Objective: To estimate the incidence, prevalence and risk factors of latent tuberculous infection (LTBI) and active TB among contacts of newly reported smear-positive TB patients. Design: A population-based contact investigation of sputum smear-positive pulmonary TB (PTB) cases diagnosed between April and December 2012 in Georgia was conducted. LTBI was assessed using the tuberculin skin test (TST). Contacts with active TB were identified from the National TB Program surveillance database. Results: Among 896 index patients with active TB, 3133 contacts were identified and 1157 (37%) underwent a TST, 34% of whom were positive. Most contacts were household contacts (86%) and female (58%). Among contacts, the 1-year period prevalence of active TB was 3.3% (95%CI 2.70-3.98); the incidence rate was 1101 per 100 000 person-years (95%CI 822-1443). In multivariable analysis, household contacts were more likely to have LTBI (adjusted OR [aOR] 2.28, 95%CI 1.49-3.49) than close contacts. Conclusions: A high prevalence of both LTBI and active TB was identified among contacts of PTB cases. Efforts aimed at active case finding among TB contacts should improve early case detection and enhance TB control efforts.

Contexte : Identifier et dépister les contacts des patients atteints de tuberculose (TB) active n'est pas souvent réalisé dans les pays à revenu faible et moyen.Objectif : Estimer l'incidence, la prévalence et les facteurs de risque d'infection tuberculeuse latente (LTBI) et de TB active parmi les contacts de patients TB nouveaux à frottis positif.Schéma : Une investigation en population a été réalisée à la recherche des contacts de cas de TB pulmonaire à frottis positif diagnostiqués entre avril et décembre 2012 en Géorgie ; la LTBI a été évaluée grâce à un test cutané à la tuberculine (TST). Les contacts atteints de TB active ont été identifiés à partir de la base de données de surveillance du Programme National TB.Résultats : Parmi 896 patients index atteints de TB active, 3133 contacts ont été identifiés et 1157 (37%) ont eu un TST, dont 34% ont été positifs. La majorité des contacts ont été des contacts domiciliaires (86%) et des femmes (58%). Parmi les contacts, la prévalence sur un an de la TB active a été de 3,3% (IC95% 2,70­3,98) tandis que le taux d'incidence a été de 1101 par 100 000 années-personne (IC95% 822­1443). En analyse multivariée, les contacts domiciliaires ont été plus susceptibles d'avoir une LTBI (OR ajusté [ORa] 2,28 ; IC95% 1,49­3,49) comparés aux contacts étroits.Conclusion : Une prévalence élevée à la fois de LTBI et de TB active a été identifiée parmi les contacts des cas de TB pulmonaire. Les efforts visant à une recherche active de cas parmi les contacts de TB devraient améliorer une détection précoce des cas et renforcer les efforts de lutte contre la TB.

Marco de referencia: La localización y la investigación de contactos de pacientes con tuberculosis (TB) activa rara vez se siguen en los países con ingresos bajos y medianos.Objetivo: Estimar la incidencia, la prevalencia y los factores de riesgo de contraer la infección tuberculosa latente (LTBI) y la TB activa en los contactos de los casos nuevos de TB con baciloscopia positiva notificados.Método: Se llevó a cabo una investigación de base poblacional de los contactos de casos de TB pulmonar con baciloscopia positiva diagnosticados de abril a diciembre del 2012 en Georgia; se investigó la LTBI mediante la prueba cutánea de la tuberculina (TST). Los contactos con TB activa se localizaron en la base de datos de vigilancia del Programa Nacional contra la Tuberculosis.Resultados: Se reconocieron 3133 contactos de los 896 casos iniciales con TB activa y se practicó la TST en 1157 (37%), de los cuales el 34% obtuvo un resultado positivo. La mayoría de los contactos fueron contactos domiciliarios (86%) y de sexo femenino (58%). En los contactos, la prevalencia a un año de TB activa fue 3,3% (IC95% 2,70­3,98) y la tasa de incidencia fue 1101 por 100 000 años-persona (IC95% 822­1443). El análisis multivariante reveló que la probabilidad de padecer la ITL era mayor en los contactos domiciliarios (cociente de posibilidades ajustado 2,28; IC95% 1,49­3,49) que los contactos directos (no domiciliarios).Conclusiones: Se encontró una alta prevalencia de LTBI y de TB activa en los contactos de los casos de TB pulmonar. Las iniciativas de búsqueda activa de casos en los contactos de los pacientes con TB deberían mejorar la detección temprana y reforzar los esfuerzos de control de la TB.

Tularemia transmission to humans: a multifaceted surveillance approach.

Tularemia has sustained seroprevalence in Eurasia, with estimates as high as 15% in endemic regions. The purpose of this report is to characterise the current epidemiology of Francisella tularensis subspecies holarctica in Georgia. Three surveillance activities are summarised: (1) acute infections captured in Georgia's notifiable disease surveillance system, (2) infectious disease seroprevalence study of military volunteers, and (3) a study of seroprevalence and risk factors in endemic regions. Descriptive analyses of demographic, exposure and clinical factors were conducted for the surveillance studies; bivariate analyses were computed to identify risk factors of seropositivity using likelihood ratio χ2 tests or Fisher's exact tests. Of the 19 incident cases reported between 2014 and August 2017, 10 were confirmed and nine met the presumptive definition; the estimated annual incidence was 0.12/100 000. The first cases of tularemia in Western Georgia were reported. Seroprevalences of antibodies for F. tularensis were 2.0% for military volunteers and 5.0% for residents in endemic regions. Exposures correlated with seropositivity included work with hay and contact with multiple types of animals. Seroprevalence studies conducted periodically may enhance our understanding of tularemia in countries with dramatically underestimated incidence rates.

ROTAVIRUS VACCINE IMPLEMENTATION IN GEORGIA - IMPACT OF KNOWLEDGE, APPROACH, AND PRACTICES OF HEALTH CARE WORKERS.

Rotavirus (RV) is the most common cause of severe gastroenteritis in infants and young children worldwide. RV causes approximately half a million deaths each year among children aged <5 years. According to WHO estimates for 2008, there were approximately 10 to 50 deaths annually in young children due to rotavirus diarrhea in Georgia. The purpose of this study was to assess the knowledge, attitudes, and practices related to rotavirus diarrhea and the rotavirus vaccine among health care workers (HCWs). The National Center for Disease Control and Public Health (NCDC) conducted a cross-sectional survey of HCWs involved in the expanded program of immunization (EPI). The HCWs were selected by simple random sampling using employee lists, and questionnaires were hand-delivered to selected HCWs during working hours. The majority of HCWs (67.9%) recognized diarrhea as a frequent health-related problem in children under 2 years of age. However, 53.9% partially disagreed with the statement that rotavirus is the most common cause of all forms of diarrhea. Multivariable analysis revealed that the following perceptions among HCWs more than doubled the likelihood that they would not support adoption of the RV vaccine: no perception of need for this vaccine in Georgia specifically (OR=2.54, CI: 1.46-4.42), no perception of need to address burden of disease in developing countries (OR=2.75, CI: 1.59-4.75), and concerns about the vaccine's safety (OR=2.51, CI: 1.56-4.02). Concerns about vaccine safety, low awareness about the RV disease burden and the effectiveness of the RV vaccine, combined with a lack of communication skills represented the main predictors of RV vaccine uptake among HCWs. Intensive vaccine promotion interventions that focus on the epidemiology of disease and vaccine effectiveness are urgently needed.