Real-time recombinase-aided amplification assay for rapid amplification of the IS1081 gene of Mycobacterium tuberculosis.

Mycobacterium tuberculosis (MTB), the etiological agent of tuberculosis (TB), is the leading cause of death due to a single infectious agent worldwide. Rapid and accurate diagnosis of MTB is critical for controlling TB especially in resource-limited countries, since any diagnosis delay increases the chances of transmission. Here, a real-time recombinase-aided amplification (RAA) assay targeting conserved positions in IS1081 gene of MTB, is successfully established to detect MTB. The intact workflow was completed within 30 min at 42 °C with no cross-reactivity observed for non-tuberculous mycobacteria and other clinical bacteria, and the detection limit for recombinant plasmid of MTB IS1081 was 163 copies/reaction at 95% probability, which was approximately 1.5-fold increase in analytical sensitivity for the detection of MTB, compared to conventional quantitative real-time PCR (qPCR; 244 copies/reaction). Furthermore, the result of clinical performance evaluation revealed an increased sensitivity of RAA assay relative to qPCR was majorly noted in the specimens with low bacteria loads. Our results demonstrate that the developed real-time RAA assay is a convenient, sensitive, and low-cost diagnostic tool for the rapid detection of MTB.

Efficacy of ultra-short course chemotherapy for new smear positive drug susceptible pulmonary tuberculosis: study protocol of a multicenter randomized controlled clinical trial.

BACKGROUND: Shortening the standard 6-month treatment for drug-susceptible pulmonary tuberculosis (DS-PTB) would be a major improvement for TB case management and disease control. METHODS: We are conducting a randomized, open-label, controlled, non-inferiority trial involving patients with smear-positive, newly diagnosed DS-PTB cases nationwide to assess the efficacy and safety of two 4.5- month regimens in comparison to the standard 6-month WHO recommended regimen. The regimen used in one experiment group is a 4.5-month fluoroquinolone-containing regimen, which consists of full course of levofloxacin, isoniazid (H), rifampin (R), parazinamid (Z) and ethambutol (E). Regimen used in the second experiment group includes 4.5-month full course of H, R, Z, E with levofloxacin removed. Patients in the control group, receive H, R, Z and E for 2 months, followed by 4 months of H and R. The primary endpoint is treatment failure or relapse within 24 month after treatment completion. DISCUSSION: Results from this trial along with other studies will contribute to the science of constructing a shorter, effective and safe regiment for TB patients. TRIAL REGISTRATION: The protocol has been registered on ClinicalTrials.gov on 2 September,2016 with identifier NCT02901288 .

Prevalence of tuberculosis among health care workers in tuberculosis specialized hospitals in China.

OBJECTIVES: Tuberculosis (TB) specialized hospitals are playing an increasingly important role in the diagnosis and treatment of patients with TB in China. This study aimed to investigate the prevalence of TB among health care workers (HCWs) in TB specialized hospitals in China. METHODS: We conducted a cross-sectional survey to collect longitudinal information on the number of HCWs and patients with TB from HCWs among 203 TB hospitals in China. RESULTS: Overall, these 186 TB cases accounted for the incidence of 985 per 100,000 population. The prevalence ratios among medical professionals (PR = 2.40) and laboratory technicians (PR = 2.17) were significantly higher than other hospital staff (PR = 1.04). In addition, general hospitals with TB clinics had the highest prevalence ratio of TB (PR = 5.15), while designated TB hospitals had the lowest prevalence ratio (PR = 1.48). CONCLUSION: Our findings demonstrated that HCWs are suffering from an increased risk of infection with TB in China, and medical professionals (physicians and nurses) and general hospitals with TB clinics have the highest prevalence ratio of TB.

Tuberculosis Hospitalization Fees and Bed Utilization in China from 1999 to 2009: The Results of a National Survey of Tuberculosis Specialized Hospitals.

BACKGROUND: China is transitioning towards concentrating tuberculosis (TB) diagnostic and treatment services in hospitals, while the Centers of Disease Control and Prevention (CDC) system will retain important public health functions. Patient expenditure incurred through hospitalization may lead to barriers to TB care or interruption of treatment. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a national survey of TB specialized hospitals to determine hospitalization fees and hospital bed utilization in 1999, 2004, and 2009. Hospitalization of TB patients increased 185.3% from 1999 to 2009. While the average hospitalization fees also increased, the proportion of those fees in relation to GDP per capita decreased. Hospitalization fees differed across the three regions (eastern, central, and western). Using a least standard difference (LSD) paired analysis, in 2004, the difference in hospitalization fees was significant when comparing eastern and central provinces (p<0.001) as well as to western provinces (p<0.001). In 2009, the difference remained statistically significant when comparing eastern province hospitalization fees with central provinces (p<0.001) and western provinces (p = 0.008). In 2004 and 2009, the cost associated with hospitalization as a proportion of GDP per capita was highest in the western region. The average in-patient stay decreased from 33 days in 1999 to 26 and 27 days in 2004 and 2009 respectively. Finally, hospital bed utilization in all three regions increased over this period. CONCLUSIONS/SIGNIFICANCE: Our findings show that both the total number of in-patients and hospitalization fees increased from 1999 to 2009, though the proportion of hospitalization fees to GDP per capita decreased. As diagnostic services move to hospitals, regulatory and monitoring mechanisms should be established, and hospitals should make use of the experience garnered by the CDC system through continued strong collaborations. Infrastructure and social protection mechanisms in high burden areas, such as in the western region, should be strengthened.

Screening of patients with diabetes mellitus for tuberculosis in community health settings in China.

OBJECTIVE: To assess the feasibility and results of screening of patients with DM for TB in routine community health services in China. METHOD: Agreement on how to screen patients with DM for TB and monitor and record the results was obtained at a stakeholders meeting. Subsequent training was carried out for staff at 10 community health centres, with activities implemented from June 2013 to April 2014. Patients with DM were screened for TB at each clinical visit using a symptom-based enquiry, and those positive to any symptom were referred to the TB clinic for TB investigation. RESULTS: A total of 2942 patients with DM visited these ten clinics. All patients received at least one screening for TB. Two patients were identified as already known to have TB. In total, 278 (9.5% of those screened) who had positive TB symptoms were referred for TB investigations and 209 arrived at the TB centre or underwent a chest radiograph for TB investigation. One patient (0.5% of those investigated) was newly diagnosed with active TB and was started on anti-TB treatment. The TB case notification rate of those screened was 102/100,000. CONCLUSION: This pilot project shows it is feasible to carry out TB screening among patients with DM in community settings, but further work is needed to better characterise patients with DM at higher risk of TB. This may require a more targeted approach focused on high-risk groups such as those with untreated DM or poorly controlled hyperglycaemia.

Survey of tuberculosis hospitals in China: current status and challenges.

BACKGROUND: Hospitals will play an increasingly important role in delivering TB services in China, however little is known in terms of the current landscape of the hospital system that delivers TB care. METHODOLOGY/PRINCIPAL FINDINGS: In order to examine the status of TB hospitals we performed a study in which a total of 203 TB hospitals, with 30 beds or more, were enrolled from 31 provinces and Xinjiang Production and Construction Corps. Of the 203 hospitals, 93 (45.8%) were located in the eastern region of China, 84 (41.4%) in the central region, and 26 (12.8%) in the western region, while there were 34.6 million TB patients in western China, accounting for 34.6% of the TB burden nationwide. The total number of staff in these 203 hospitals was 83,011, of which 18,899 (22.8%) provided health services for TB patients, (physicians, nurses, lab technicians, etc). Although both the overall number of the health care workers and TB staff in the 203 hospitals increased from the year 1999 to 2009, the former increased by 52%, while the latter increased only by 34%, showing that the percentage of TB staff declined significantly (χ2 = 181.7, P<0.01). The total annual income of the 203 hospitals increased 5.5 fold from 1999 to 2009, while that from TB care increased 3.8 fold during the same period. TB care and control experienced a relatively slower development during this period as shown by the lower percentage of TB staff and the lesser increase in income from TB care in the hospitals. CONCLUSIONS/SIGNIFICANCE: In conclusion, our findings demonstrated that hospital resources are scarcer in western China as compared with eastern China. In view of the current findings, policymakers are urged to address the uneven distribution of medical resources between the underdeveloped west and the more affluent eastern provinces.

Is resistance to anti-tuberculosis drugs associated with type 2 diabetes mellitus? A register review in Beijing, China.

BACKGROUND: China has a high burden of drug-resistant tuberculosis (TB) and diabetes mellitus (DM). OBJECTIVE: The objectives of this study were to determine the following in patients with culture-confirmed TB: 1) demographic characteristics and disease patterns in relation to the presence or absence of type 2 diabetes and 2) presence or absence of drug resistance to isoniazid (INH), rifampicin (RMP) or both in relation to duration of diabetes and control of diabetes. DESIGN: This is a cross-sectional and retrospective study involving record reviews. RESULTS: There were 621 patients with culture-positive TB, of whom 187 (30%) had previously known or new type 2 diabetes. In those with diabetes, there was a significantly higher proportion of males, persons aged ≥35 years and patients registered with new TB (p<0.05). Prevalence of multidrug-resistant TB (MDR-TB) was 6.2% in new patients (N=422) and 62.3% in previously treated patients (N=199), with no significant differences between those with and without diabetes. In patients with diabetes, there was no association of drug resistance with diabetes duration or disease control [assessed by fasting blood glucose (FBG) at 1 week]. CONCLUSION: A high proportion of patients with TB in a tertiary health facility, Beijing, China, had diabetes, but there was no association between type 2 diabetes and drug-resistant TB. Further prospective studies are needed to confirm these findings.

Diabetes mellitus and tuberculosis: pattern of tuberculosis, two-month smear conversion and treatment outcomes in Guangzhou, China.

OBJECTIVE: There is a high burden of both diabetes (DM) and tuberculosis (TB) in China. We evaluated the association between DM and the pattern of disease, 2-month sputum smear conversion and treatment outcomes of patients with TB in Guangzhou, China. METHOD: All patients registered with TB from September 2011 to June 2012 were screened for DM and assessed for treatment outcomes in relation to presence or absence of DM and quality of DM control using patient registers, treatment cards and electronic record systems. RESULTS: There were 1589 patients with TB of whom 189 (12%) had DM. Among those with DM, there was a significantly higher proportion of men, persons aged 35 years and older and persons with smear-positive pulmonary tuberculosis (PTB) (P < 0.01). In patients with DM and new smear-positive PTB, there was a higher proportion who had positive sputum smears at 2 months (21.7% vs. 5.6%, RR 3.85, 95%CI 2.24-6.63), who were lost-to-follow-up (5.2% vs. 1.7%, RR 3.23, 95%CI 1.08-9.63) and who failed treatment (10.3% vs. 2.3%, RR 4.46, 95%CI 1.96-10.18) compared with patients who had no DM. There was no significant association between these adverse outcomes and DM control as measured by 2 and 6-month fasting blood glucose. CONCLUSION: Diabetes mellitus in new smear-positive patients with PTB was associated with failure to sputum smear convert at 2 months and adverse treatment outcomes of loss-to-follow-up and failure. Further research is needed to understand the reasons for these findings and to determine whether the current length of treatment of 6 months is adequate.

Screening of patients with tuberculosis for diabetes mellitus in China.

OBJECTIVE: There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and this study aimed to assess feasibility and results of screening patients with TB for DM within the routine healthcare setting of six health facilities. METHOD: Agreement on how to screen, monitor and record was reached in May 2011 at a stakeholders' meeting, and training was carried out for staff in the six facilities in July 2011. Implementation started in September 2011, and we report on 7 months of activities up to 31 March 2012. RESULTS: There were 8886 registered patients with TB. They were first asked whether they had DM. If the answer was no, they were screened with a random blood glucose (RBG) followed by fasting blood glucose (FBG) in those with RBG ≥ 6.1 mm (one facility) or with an initial FBG (five facilities). Those with FBG ≥ 7.0 mm were referred to DM clinics for diagnostic confirmation with a second FBG. Altogether, 1090 (12.4%) patients with DM were identified, of whom 863 (9.7%) had a known diagnosis of DM. Of 8023 patients who needed screening for DM, 7947 (99%) were screened. This resulted in a new diagnosis of DM in 227 patients (2.9% of screened patients), and of these, 226 were enrolled to DM care. In addition, 575 (7.8%) persons had impaired fasting glucose (FBG 6.1 to <7.0 mm). Prevalence of DM was significantly higher in patients in health facilities serving urban populations (14.0%) than rural populations (10.6%) and higher in hospital patients (13.5%) than those attending TB clinics (8.5%). CONCLUSION: This pilot project shows that it is feasible to screen patients with TB for DM in the routine setting, resulting in a high yield of patients with known and newly diagnosed disease. Free blood tests for glucose measurement and integration of TB and DM services may improve the diagnosis and management of dually affected patients.

Screening patients with diabetes mellitus for tuberculosis in China.

OBJECTIVE: There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and as DM increases the risk of TB and adversely affects TB treatment outcomes, there is a need for bidirectional screening of the two diseases. How this is best performed is not well determined. In this pilot project in China, we aimed to assess the feasibility and results of screening DM patients for TB within the routine healthcare setting of five DM clinics. METHOD: Agreement on how to screen, monitor and record was reached in May 2011 at a national stakeholders meeting, and training was carried out for staff in the five clinics in July 2011. Implementation started in September 2011, and we report on 7 months of activities up to 31 March 2012. DM patients were screened for TB at each clinic attendance using a symptom-based enquiry, and those positive to any symptom were referred for TB investigations. RESULTS: In the three quarters, 72% of 3174 patients, 79% of 7196 patients and 68% of 4972 patients were recorded as having been screened for TB, resulting in 7 patients found who were already known to have TB, 92 with a positive TB symptom screen and 48 of these newly diagnosed with TB as a result of referral and investigation. All patients except one were started on anti-TB treatment. TB case notification rates in screened DM patients were several times higher than those of the general population, were highest for the five sites combined in the final quarter (774/100 000) and were highest in one of the five clinics in the final quarter (804/100 000) where there was intensive in-house training, special assignment of staff for screening and colocation of services. CONCLUSION: This pilot project shows that it is feasible to carry out screening of DM patients for TB resulting in high detection rates of TB. This has major public health and patient-related implications.