High rate of latent tuberculosis treatment completion in immigrants seeking asylum in Sweden.

BACKGROUND/AIM: Treatment of latently infected individuals at increased risk of reactivation is a cornerstone in tuberculosis control. Although asylum seekers without residence permit in Sweden are offered screening for both active tuberculosis and latent tuberculosis infection (LTBI), treatment for LTBI is often not initiated due to anticipated low rates of treatment completion. We aimed to compare completion rates for LTBI treatment between asylum seekers and other patients, and between asylum seekers with and without residence permit. METHODS: Data were collected retrospectively from tuberculosis clinic registers and medical records. For comparison of treatment completion rates, relative risks (RR) and confidence intervals (CI) were calculated. Predictors of completion were assessed by logistic regression multivariate analysis. RESULTS: Treatment completion was achieved in 506/606 subjects (83%). RR of non-completion for asylum seekers (n = 297) compared to other subjects (n = 309) was 1.13 (95% CI: 0.79-1.61; p = .51), and 0.91 (95% CI: 0.53-1.56; p = .72) for asylum seekers without residence permit (n = 217) compared to asylum seekers with residence permit (n = 80). Completion rates increased from 53% in 2008 to 92% in 2015-2016. The following factors were associated with completion: scheduled interpreter-assisted appointments throughout the course of therapy, shorter treatment duration (6 vs. 9 months), and being treated in connection with immunosuppressive therapy. CONCLUSION: Treatment completion rates were similar between asylum seekers and other subjects, supporting initiation of latent tuberculosis treatment in immigrants with recent arrival to low-endemic countries.

A Clinical Scoring Algorithm for Determination of the Risk of Tuberculosis in HIV-Infected Adults: A Cohort Study Performed at Ethiopian Health Centers.

BACKGROUND: The World Health Organization (WHO) tuberculosis (TB) symptom screening instrument (WHO-TB) can identify human immunodeficiency virus (HIV)-infected individuals at low risk of tuberculosis (TB); however, many patients report WHO-TB symptoms and require further TB investigations. We hypothesized that further clinical scoring could classify subjects with a positive WHO-TB screening result (WHO-TB(+)) for the likelihood of TB. METHODS: HIV-infected adults eligible to initiate antiretroviral therapy (ART) were recruited and prospectively followed at 5 Ethiopian health centers. Irrespective of symptoms, all participants underwent sputum bacteriological testing for TB. Symptoms, physical findings, hemoglobin, and CD4 cell count results were compared between subjects with and those without bacteriologically confirmed TB. Variables associated with TB in WHO-TB(+) individuals were used to construct a scoring algorithm with multiple logistic regression analysis. RESULTS: Among 812 participants, 137 (16.9%) had TB. One hundred fifty-nine persons (20%) had a negative WHO-TB screen, 10 of whom had TB (negative predictive value [NPV], 94% [95% confidence interval {CI}, 90%-97.5%]). For WHO-TB(+) subjects, the following variables were independently associated with TB, and were assigned 1 point each in the clinical scoring algorithm: cough, Karnofsky score ≤80, mid-upper arm circumference <20 cm, lymphadenopathy, and hemoglobin <10 g/dL. Among subjects with 0-1 points, 20 of 255 had TB (NPV, 92% [95% CI, 89%-95%]), vs 19 of 34 participants with ≥4 points (positive predictive value, 56% [95% CI, 39%-73%]). The use of WHO-TB alone identified 159 of 784 (20%) with a low risk of TB, vs 414 of 784 (53%) using WHO-TB followed by clinical scoring (P< .001). The difference in proportions of confirmed TB in these subsets was nonsignificant (6.3% vs 7.2%; P= .69). CONCLUSIONS: Clinical scoring can further classify HIV-infected adults with positive WHO-TB screen to assess the risk of TB, and would reduce the number of patients in need of further TB investigations before starting ART. CLINICAL TRIALS REGISTRATION: NCT01433796.

Long-term course of Mycobacterium tuberculosis infection in Swedish birth cohorts during the twentieth century.

SETTING: Sweden under transition from high to low tuberculosis (TB) incidence from 1920 to 2009. OBJECTIVE: To correlate estimates of TB infection in birth cohorts with the longitudinal incidence of active TB to assess the long-term risk and time pattern of reactivated TB. DESIGN: Time trend analysis on TB incidence using age-cohort modelling. RESULTS: The overall TB incidence decreased from 700 per 100,000 population in 1920 to 1.4 in 2009 in the Sweden-born population. The estimated disease rate (number of cases divided by the estimated number of infected in 1967), for each birth cohort between 1920 and 1940, was stable on a level between 9.8% and 10.7%. The reactivation rate of latent TB infection (LTBI) was 2% after 1967, when indigenous transmission had disappeared. CONCLUSION: Although approximately 10% of persons with LTBI developed active TB, the majority of cases occurred shortly after infection, and the rates of reactivation declined over time. This indicates extensive spontaneous clearance of LTBI.

A case-control study of transmission routes for GB virus C/hepatitis G virus in Swedish blood donors lacking markers for hepatitis C virus infection.

BACKGROUND AND OBJECTIVES: The transmission routes for GB virus-C (GBV-C)/hepatitis G virus (HGV) in blood donors unexposed to hepatitis C virus (HCV) are unknown. We performed a case-control study of risk factors for GBV-C/HGV exposure in blood donors. MATERIALS AND METHODS: After testing stored sera from 458 HCV-negative blood donors for GBV-C/HGV RNA and GBV-C/HGV E2 antibodies, 66 donors with GBV-C/HGV markers and 125 age- and gender-matched controls were interviewed regarding risk factors for viral transmission. RESULTS: Exposure to GBV-C/HGV was strongly associated with previous treatment for a sexually transmitted disease (odds ratio [OR] 4.6; 95% confidence interval [CI] 2.2-9.8), with multiple sexual partners (OR 2.9; 95% CI 1.4-5.7) and with a past history of endoscopy (OR 7.0; 95% CI 3.0-16.4). CONCLUSIONS: In blood donors with GBV-C/HGV markers, sexual contacts and medical procedures appear to be the main transmission routes.

Three-year follow-up of patients with pulmonary tuberculosis in Guinea-Bissau, West Africa.

SETTING: Raoul Follereau Hospital, Bissau, Guinea-Bissau. OBJECTIVE: To study the long-term outcome of patients with bacteriologically verified tuberculosis (TB), with or without human immunodeficiency virus (HIV) co-infection. DESIGN: Sputum samples were collected from all patients referred to the hospital with clinical symptoms of pulmonary tuberculosis. Direct microscopy and culture was performed at the Health Laboratory. Patients with a culture positive for Mycobacterium tuberculosis were followed for 3 years, and underlying factors were analysed regarding the outcome of treatment. A group of sex and age-matched HIV-negative individuals was used as controls. RESULTS: Of 206 bacteriologically verified pulmonary TB patients, 168 were followed up. Antibodies to HIV-2 were found in 33 patients (19.6%); eight patients (4.8%) had antibodies to HIV-1 or showed dual reactivity. Of 149 patients discharged to follow ambulatory treatment, the survival rate of HIV-2-positive patients was 42.3% (11/26) and for HIV-negative patients it was 81.9% (95/116). The difference in survival between HIV-2-positive and HIV-negative patients was highly significant (P < 0.00001). HIV-negative TB patients had a significantly higher mortality than their controls (mortality ratio 3.75, 95% confidence interval 1.58-8.90). Most patients who survived, regardless of HIV status, also became free from symptoms compatible wtih pulmonary TB. CONCLUSION: Although the mortality rate among HIV-positive TB patients was very much higher than among HIV-negative patients, there are weighty arguments for active contact tracing and effective treatment of all TB patients.

Pulmonary tuberculosis in Guinea-Bissau: clinical and bacteriological findings, human immunodeficiency virus status and short term survival of hospitalized patients.

OBJECTIVE: To study tuberculosis patients in Guinea-Bissau with regard to clinical findings, bacteriologically verified diagnosis, human immunodeficiency virus (HIV) status and short term survival. DESIGN: 763 consecutive patients referred to the tuberculosis clinic with pulmonary symptoms underwent clinical examination and Ziehl-Neelsen sputum microscopy. Sputum for culture of mycobacteria on Löwenstein-Jensen medium was collected from all hospitalized patients, who were also screened by enzyme linked immunosorbent assay for the presence of HIV-1 and HIV-2 antibodies. HIV-positivity was confirmed by Western blot. RESULTS: 350 patients were diagnosed with tuberculosis and hospitalized. Adequate sputum samples were obtained from 301 patients, of whom 184 (61%) were positive on direct microscopy and the remaining 116 patients were diagnosed from clinical findings. Mycobacterium tuberculosis was cultured from 184 patients and M. avium in 16 patients, whereas in 101 patients the culture was negative. HIV-1 antibodies were found in 3.0%, HIV-2 antibodies in 16.4%, and dual infections in 2.0%. These figures, however, did not differ significantly from those of randomly selected age and sex matched controls. The prevalence of HIV-antibodies was statistically as common in patients with culture verified tuberculosis as in patients with clinically defined tuberculosis. Clinical acquired immunodeficiency syndrome was commonly diagnosed (80/301 patients) but significantly more often in HIV-positive, culture-positive tuberculosis patients, as were weight loss and lymphadenopathy. There was no statistical difference in short-time survival rate between the various patient groups. CONCLUSION: The diagnostic criteria applied, which are generally used in developing countries, identified most patients with pulmonary tuberculosis; however, a substantial number of patients are treated for tuberculosis without definite diagnostic criteria. The prevalence of HIV-infection was high but statistically no significant difference was demonstrated between the patient groups, controls and patients hospitalized for diseases other than tuberculosis.

Direct detection of Mycobacterium tuberculosis in sputum samples from Guinea Bissau by an rRNA target-amplified test system.

SETTING: There is a need for more sensitive and rapid methods for laboratory confirmation in the diagnosis of tuberculosis. OBJECTIVE: To investigate the applicability of a target rRNA amplified test system (AMTDT, Gen-Probe, CA) for rapid detection of Mycobacterium tuberculosis. DESIGN: The rRNA amplified test system was compared to standard methods for acid fast microscopy and mycobacterial culture for the demonstration of M. tuberculosis in sputum samples from 247 patients in Guinea Bissau with suspected tuberculosis. RESULTS: The highest incidence of positive samples was obtained with the AMTDT test. Out of 274 sputum samples 96 (35%) were positive by the AMTDT test, 82 (30%) were positive by culture and 38 (14%) by direct microscopy. Using culture as reference method the sensitivity of the test was 85% (after discrepancy analysis 87%), and the specificity was 86% (after discrepancy analysis 93%). CONCLUSION: The sensitivity and specificity of the AMTDT test used in this setting indicates that it may be a valuable complement for improving the laboratory diagnosis of tuberculosis.

Mycobacterium avium complex sputum isolates from patients with respiratory symptoms in Guinea-Bissau.

In total, 814 patients with clinically suspected tuberculosis were examined at the Raoul Follerau Hospital in Bissau, Guinea-Bissau. Sputum samples were collected, and cultures were grown on Löwenstein-Jensen medium. Isolates were further characterized by standard biochemical methods and nucleic acid probes for Mycobacterium tuberculosis and Mycobacterium avium complex (MAC). Serum samples were collected and analyzed for antibodies against human immunodeficiency virus (HIV) types 1 and 2. Of 17 patients who had MAC organisms in sputum, 2 were HIV-2-positive and none was HIV-1-positive. Of the total 814 patients, 189 had culture-verified tuberculosis; 36 (19%) of them were HIV-2-positive. Thus, of 206 patients with sputum culture positive for M. tuberculosis or MAC, 17 (8%) had MAC organisms in sputum. MAC infection may be the cause of some treatment failures in areas where MAC pulmonary infection is common.