High TB burden and low notification rates in the Philippines: The 2016 national TB prevalence survey.

SETTING: The 3rd national tuberculosis (TB) survey in the Philippines in 2007 reported a significant decline in the prevalence of TB. Since then, more significant investments for TB control have been made, yet TB burden estimates from routine surveillance data remain relatively stable. OBJECTIVE: To estimate the prevalence of bacteriologically confirmed pulmonary TB in the Philippines amongst individuals aged ≥15 years in 2016. DESIGN: In March-December 2016, we conducted a population-based survey with stratified, multi-stage cluster sampling of residents in 106 clusters aged ≥15 years. Survey participants were screened for TB by symptom-based interview and digital chest X-ray. Those with cough ≥2 weeks and/or haemoptysis and/or chest X-ray suggestive of TB were requested to submit 2 sputum specimens for Xpert MTB/RIF, direct sputum smear microscopy using LED fluorescent microscopy, and mycobacterial solid culture (Ogawa method). Bacteriologically confirmed pulmonary TB was defined as MTB culture positive and/or Xpert positive. RESULTS: There were 46,689 individuals interviewed, and 41,444 (88.8%) consented to a chest X-ray. There were 18,597 (39.8%) eligible for sputum examination and 16,242 (87.3%) submitted at least one specimen. Out of 16,058 sputum-eligible participants, 183 (1.1%) were smear-positive. There were 466 bacteriologically confirmed TB cases: 238 (51.1%) Xpert positive, 69 (14.8%) culture positive, and 159 (34.1%) positive by both Xpert and culture. The estimated TB prevalence per 100,000 population aged ≥15 years was 434 (95% CI: 350-518) for smear-positive TB, and 1,159 (95% CI: 1,016-1,301) for bacteriologically confirmed TB. CONCLUSION: This nationally representative survey found that the TB burden in the Philippines in 2016 was higher than estimated from routine TB surveillance data. There was no evidence of a decline in smear and culture positive TB from the 2007 survey despite significant investments in TB control. New strategies for case-finding and patient-centered care must be intensified and expanded.

Leptospirosis outbreak after a heavy rainfall typhoon in the Philippines: Clinical features, outcome and prognostic factors for mortality

@#<p style="text-align: justify;"><strong>BACKGROUND AND OBJECTIVES:</strong> In September 2009, Metro Manila was hit by a heavy rainfall typhoon Ketsana inundating several cities of Metro Manila causing an outbreak of leptospirosis. We analyzed the prognostic factors associated with mortality among leptospirosis patients admitted after the typhoon at nine tertiary hospitals from September to November 2009.<br /><strong>METHODS:</strong> We reviewed the charts of patients with probable and confirmed leptospirosis. Confirmed leptospirosis was based on any of the following: positive leptospiral culture of blood or urine, single high leptospira microagglutination titer (MAT) of 1:1600 or a fourfold rise in MAT antibody titers or seroconversion. Patients with negative serology or cultures but with history of wading in floodwaters plus any of the following signs and symptons: fever, headache, myalgia, conjunctival suffusion, diarrhea and abdominal pain, jaundice, oliguria and changes in sensorium were considered probable cases. <br /><strong>RESULTS:</strong> We analyzed 332 probable and 259 confirmed leptospirosis patients. Mean age was 37.95± 14.09, mostly males (80.2%). Almost all patients (98%) waded in floodwaters. Majority had moderate to severe form of leptospirosis (83%). Acute renal failure was the most common complication (87.1%). Mortality was 11.3% mostly due to pulmonary hemorrhage. On multivariate analysis of confirmed and probable cases, the factors independently associated with mortality were pulmonary hemorrhage (OR 2.75, 95% CI 1.46 to 5.20), severity of the disease (OR 3.85, 95% CI 1.60 to 9.26), thrombocytopenia (OR 3.16, 95% CI 1.22-8.16), duration of illness before admission (OR 0.88, 95% CI 0.78-0.99) and age (OR 1.03, 95% CI 1.00-1.06).<br /><strong>CONCLUSION:</strong> Pulmonary hemorrhage remains a poor prognostic factor and strong predictor of mortality among patients with severe leptospirosis. Early consult through heightened awareness of the public and prompt recognition of leptospirosis among clinicians can decrease the risk for progression to complications of leptospirosis and mortality. <br /><br /> </p>

The incidence, clinical characteristics and risk factors of tuberculosis among renal allograft recipients at National Kidney and Transplant Institute

OBJECTIVE: Renal allograft recipients are at higher risk of developing tuberculosis (TB) as compared to the general population. The infection also carries with it a significant morbidity and mortality. However, data is limited regarding its incidence and risk factor analysis in our setting. This study determined the incidence, characteristics and risk factors of post-transplant TB in National Kidney and Transplant Institute (NKTI).METHODS: This is a retrospective study involving chart review of 1,621 renal allograft recipients from 2003-2009. We recorded demographic information, transplant characteristics, median time to diagnosis of TB and forms of TB.RESULTS: The incidence of TB in renal allograft recipients is 2.6%. Median time to diagnosis of TB after transplant is 21 months (one to 105 months). Risk factors identified in this study were previous history of TB (OR 4.15, 95% CI 1.4-12.2), one episode of rejection (OR 2.33, 95% CI 1.2-4.6) and subsequent use of methylprednisolone as antirejection therapy (OR 2.36, 95% CI 1.3-4.4). Patients given a tacrolimus based regimen (OR 0.5, 95% CI 0.24-1.03) and those without episode of rejection (OR 0.43, 95% CI 0.22-0.84) had less tendency to develop post-transplant TB. There were no sufficient evidence to prove association between onset of TB and use of isoniazid prophylaxis, use of induction immunosuppression and type of immunosuppression. Eighty one percent (81%) had pulmonary and 19% had extrapulmonary forms of TB.CONCLUSION: Incidence of TB among renal allograft recipients is lower as compared to other high TB burden countries but is still higher as compared to the general Filipino population. The study identified multiple risk factors for post-transplant TB. Prevention of these diseases and identification of patients at risk are as important as early diagnosis and treatment of post-transplant TB.

Clinical profile of patients diagnosed with leptospirosis after a typhoon: a multicenter study.

This study described the clinical features and complications of leptospirosis among patients seen at nine tertiary hospitals from September 28 to November 30, 2009 after a heavy rainfall typhoon. The clinical findings of the confirmed cases were compared with the previous clinical studies on seasonal leptospirosis in the Philippines. Risk factors for complicated disease were also identified. Confirmed cases were based on any of the following: positive leptospiral cultures of blood or urine, single high leptospira microscopic agglutination test (MAT) titer of 1:1,600, a fourfold rise in MAT, and/or seroconversion. Of 670 patients with possible leptospirosis, 591 were probable by the WHO criteria, 259 (44%) were confirmed. Diagnosis was confirmed by MAT 176 (68%), by culture 57 (22%), and by MAT and culture 26 (10%). The mean age of the confirmed cases was 38.9 years (SD 14.3). The majority were males (82%) and had a history of wading in floodwaters (98%). The majority of the patients presented with nonspecific signs, with fever as the most common (98.5%). Other findings were myalgia (78.1%), malaise (74.9%), conjunctival suffusion (59.3%), oliguria (56.6%), diarrhea (39%), and jaundice (38%). Most of the patients presented with a moderate-to-severe form of leptospirosis (83%). Complications identified were renal failure (82%), pulmonary hemorrhage (8%), meningitis (5%), and myocarditis (4%). Mortality rate was 5%, mostly due to pulmonary hemorrhage. This study emphasizes the importance of public awareness and high index of suspicion among clinicians of leptospirosis during the monsoon months when flooding is common. Early recognition and detection of the disease should decrease morbidity and mortality.

Detection and characterization of mutations of multidrug-resistant tuberculosis isolates of the Philippine General Hospital

Background. Emergence of multidrug-resistant tuberculosis (MDR-TB) poses a major challenge to prevailing disease management. MDR-TB arises from mutations in several genes comprising the resistance determining regions, including rpoB, katG and gyrA. Objective. To detect and characterize mutations in rpoB, katG and gyrA. Methods. Thirty selected Mycobacterium tuberculosis isolates from the IDS-PGH were subjected to PCR amplification and sequencing. Sequences were compared to the wild type strain H37Rv. Results. Mutations were detected in codons 512, 513, 516, 522, 526, 531 and 533 of rpoB, codons 280, 281, 315 and 333 of katG, and codons 90 and 94 of gyrA sequences. The most frequently mutating codons for rpoB, katG and gyrA were 531, 315 and 94, respectively. A clustering analysis of the sequences showed occurrence of seven, four and three clusters for the genes rpoB, katG and gyrA, respectively. The eight clusters obtained from the concatenated sequences of the three genes represent the eight potential genotypes of local strains. One cluster represents the wild type strain genotype, another cluster represents the XDR strain genotype, and six clusters represent the MDR strain genotypes. Conclusion. These findings indicate the utility of multiple RDR sequence analysis in both identifying specific drug resistance mutation and genotyping of various M. tuberculosis isolates.

Detection and characterization of mutations of multidrug-resistant tuberculosis isolates of the Philippine General Hospital

BACKGROUND: Emergence of multidrug-resistant tuberculosis (MDR-TB) poses a major challenge to prevailing disease management. MDR-TB arises from mutations in several genes comprising the resistance determining regions, including rpoB, katG and gyrA. OBJECTIVE: To detect and characterize mutations in rpoB, katG and gyrA. METHODS: Thirty selected Mycobacterium tuberculosis isolates from the IDS-PGH were subjected to PCR amplification and sequencing. Sequences were compared to the wild type strain H37Rv. RESULTS: Mutations were detected in codons 512, 513, 516, 522, 526, 531 and 533 of rpoB, codons 280, 281, 315 and 333 of katG, and codons 90 and 94 of gyrA sequences. The most frequently mutating codons for rpoB, katG and gyrA were 531, 315 and 94, respectively. A clustering analysis of the sequences showed occurrence of seven, four and three clusters for the genes rpoB, katG and gyrA, respectively. The eight clusters obtained from the concatenated sequences of the three genes represent the eight potential genotypes of local strains. One cluster represents the wild type strain genotype, another cluster represents the XDR strain genotype, and six clusters represent the MDR strain genotypes. CONCLUSION: These findings indicate the utility of multiple RDR sequence analysis in both identifying specific drug resistance mutation and genotyping of various M. tuberculosis isolates.