MDR-TB Cases Research Articles

Factors Associated with Acid Fast Bacilli and Sputum Culture Conversion in Patients with Multidrug-Resistant Tuberculosis in Surabaya

Introduction: Indonesia is a high incidence country of multidrug-resistant tuberculosis. There are approximately 11,000 MDR TB cases, 2.8% of them are new cases and 16% of them are relapse cases. Although guidelines for MDR-TB are frequently designed, medication freely provided, and centers for treatment duly expanded, studies on time to sputum culture conversion have been very limited in Indonesia. Therefore the aim of the study is to identify risk factors that effect on sputum and culture conversion.Methods: Data on short-term regimen for MDR TB in Dr. Soetomo General Hospital from January 1st – December 31st, 2018 were collected with a total sampling approach, and fulfill the inclusion and exclusion. Data were analyzed by computer software IBM SPSS Statistic 24 for windows. Results: Male is more likely to have delayed sputum conversion and culture conversion but no statistical difference is observed (p>0.05). Smoking history is more likely to have delayed sputum and culture conversion but only in sputum smear test shows a significant difference (p≤ 0.05). Alcohol consumption has delay effect on sputum and culture conversion but there is statistically difference in only culture conversion (p<0.05). The high baseline smear test also affects delay the sputum and culture conversion but only in sputum smear reveals a significant effect (p<0.05).Conclusion: In this present study, we identified sex, smoking history, high bacillary loads as significant factors on sputum conversion. In addition, we revealed that alcohol-consumption history is a significant factor affecting on culture conversion.

Transmission of multidrug-resistant tuberculosis in Shimen community in Shanghai, China: a molecular epidemiology study

BackgroundMultidrug-resistant tuberculosis (MDR-TB) has become a major public health problem in China, with mounting evidence suggesting that recent transmission accounts for the majority of MDR-TB. Here we aimed to reveal the transmission pattern of an MDR-TB outbreak in the Jing'an District of Shanghai between 2010 and 2015.MethodsWe used whole-genome sequencing (WGS) to conduct genomic clustering analysis along with field epidemiological investigation to determine the transmission pattern and drug resistance profile of a cluster with ten MDR-TB patients in combining field epidemiological investigation.ResultsThe ten MDR-TB patients with genotypically clustered Beijing lineage strains lived in a densely populated, old alley with direct or indirect contact history. The analysis of genomic data showed that the genetic distances of the ten strains (excluding drug-resistant mutations) were 0–20 single nucleotide polymorphisms (SNPs), with an average distance of 9 SNPs, suggesting that the ten MDR-TB patients were infected and developed the onset of illness by the recent transmission of M. tuberculosis. The genetic analysis confirmed definite epidemiological links between the clustered cases.ConclusionsThe integration of the genotyping tool in routine tuberculosis surveillance can play a substantial role in the detection of MDR-TB transmission events. The leverage of genomic analysis in combination with the epidemiological investigation could further elucidate transmission patterns. Whole-genome sequencing could be integrated into intensive case-finding strategies to identify missed cases of MDR-TB and strengthen efforts to interrupt transmission.

STUDY OF DRUG SUSPECTIBILITY AND RESISTANCE PATTERN OF MULTI-DRUG RESISTANT TUBERCULOSIS PATIENTS AT A TERTIARY CARE CENTRE-A RETROSPECTIVE STUDY

OBJECTIVE: To study the sensitivity and resistance pattern of multi-drug resistant tuberculosis patients at a tertiary care centre. METHODS: Retrospective study will be conducted at tertiary care centre in Aurangabad from which data of patients will be collected who have registered under RNTCP from Jan 2018 to Jan 2020.Drug resistant patterns will be studied over a span of 3 years. RESULTS: In this study most of the patients of MDR-TB patients were of female gender with maximum involvement of pulmonary origin. Rifampicin resistance was most common. CONCLUSION: The present study emphasizes on the need for strengthening of laboratory services in diagnosis of MDR-TB, adequate and strict drug regimes to be followed in order to curtain the MDR-TB cases.

Utilization of Molecular Quick Test as an Effort to Accelerate Case Findings of Multi Drug Resistant Tuberculosis in South Sulawesi Province

The discovery of TB and MDR TB cases increases every year along with the addition of TCM machines, which currently number 46 machines and have spread across 24 districts/cities in the roadmap towards TB elimination in 2030. This study aims to determine the effectiveness of the use of Molecular Rapid Tests to accelerate the diagnosis of TB and MDR TB in South Sulawesi and to evaluate the utilization of TCM examinations for examination of TB and MDR TB during the Covid 19 pandemic. The method used in collecting TB and MDR TB data is to compile secondary data from several data sources, namely eTB Manager, TCM monthly reports, SITT and SITB. The data that has been collected will be processed and analyzed descriptively and presented in the form of tables and trend charts for 3 years. The number of case discoveries between 2018 and 2019 showed an increase in cases as more suspects were referred for TCM examination. In 2020 the discovery of TB cases has decreased, namely TB RO cases as many as 483 and TB SO cases as many as 7,736 cases. The decline in cases in 2020 was due to the Covid 19 pandemic where many suspects did not want to visit health facilities. The addition of the number of TCM can increase the case finding of TB SO and TB RO which is accompanied by strengthening the specimen referral network system, especially in areas with difficult transportation or remote areas so that the diagnosis of TB, especially TB with Rifampicin resistance can be found early. Keywords: Molecular Quick Test, Case Findings of Multi-Drug Resistant Tuberculosis.

Gambaran Riwayat Pengobatan Tuberkulosis pada Pasien Multi Drug Resistant Tuberculosis di RSUP Dr. M. Djamil Padang

Background. The incidence of MDR-TB becomes a health issue that must be addressed immediately. According to a 2014 WHO report, the incidence of deaths from MDR-TB reached 190,000 cases. In 2015 there were 250,000 deaths and in 2016 there were 240,000 deaths. The incidence of MDR-TB cases in Indonesia has been reported in 2013 reaching 1,094 cases. In 2014 there were 1,752 cases and in 2015 there were 1,860. MDR-TB events can occur due to failure in the treatment of previous TB.
 Objective. This research aim to know overview of tuberculosis treatment history in patient with multy drug resistant (MDR-TB) in RSUP Dr. M. Djamil Padang
 Methods.This research an descriptive study with cros sectional designed, based on medical record of MDR-TB patient in RSUP Dr. M. Djamil Padang in 2018-2019, a sample of 37 people sample using total sampling and it was analyzed by univariate analysis.
 Result. The result of this research showed the characteristics of MDR-TB were found most in the age group of 35-44 years(27%), male gender (64,9%), self imployed (35,1%). with the most history of treatment in the form of relapsing cases (32,4%).
 Conclusion. the conclusion of this study is the patient with MR-TB in RSUP Dr. M. Djamil Padang dominated by age of 35-44 years old, male and self imployed and the history of TB treatment in MDR-TB patients founnd the most cases of relaps

Evaluasi Pelaksanaan Program TBC MDR di Dinas Kesehatan Provinsi Sumatera Selatan

MDR TB is a man-made phenomenon that occurs as a result of inadequate treatment of TB patients as well as direct transmission from MDR TB patients. The existence of cases that have not been detected and managed by the MDR TB control program makes this a new challenge in overcoming it. The purpose of this study was to determine how the implementation of the MDR TB control program in South Sumatra using theevaluation model Context, Input, Process, Product (CIPP). This study uses descriptive qualitative research methods, by conducting in- depth interviews. From the results of the research on the Context Evaluation which consisted of the background, objectives and program opportunities in accordance with the Tuberculosis technical rules and guidelines (Permenkes No. 67/2016). In the evaluation of the input of the provision of human resources, program managers, funds and infrastructure are in accordance with the needs of the program in both the province and district / city. In the evaluation process for MDR TB program planning, it has been carried out by involving cross-sector and cross-program and other related agencies, the program target is clear, but there are obstacles to Human Resources at first-level and advanced level health facilities. In the Product Evaluation, the detection and treatment rates for MDR TB cases (obtained, Enrollment rate) werenamely in 2017: 46%, 2018: 36%, 2019: 41%. In general, the implementation of the MDR TB Control Program in South Sumatra Province from context, input, process, has been going well but still needs improvement / improvement, to be able to produce products as expected by Permenkes Number 67 of 2016.

Trends of Drug Resistance Tuberculosis from 2014 to 2018, Bale Zone, Oromia Region, Ethiopia.

PurposeMultidrug-resistant tuberculosis threatens global tuberculosis care and prevention and remains a major public health concern in many countries. In 2016, there were an estimated 490,000 cases of MDR and 110,000 more cases resistant to rifampicin (RR TB). Ethiopia is among the highest MDR TB burden countries according to the WHO. This study aims to describe the magnitude, trends, and geographical distribution of the drug-resistant TB in Bale Zone during study period.Materials and MethodsA descriptive study was conducted. We reviewed secondary data of MDR and RR TB cases from July 2014 to June 2018. Data were extracted from the Bale zone health management information system database, checked for completeness, and then analyzed for trends over time.ResultsA total of 43 cases (67.4% female) of drug-resistant TB were reviewed, with 30.2% MDR and 69.8% RR TB. The prevalence of drug-resistant tuberculosis cases declined from 0.81% to 0.62% (trend χ2=2.18; P=0.14) during study period. Among drug-resistant TB cases, RR TB increased from 52.6% to 81% (trend χ2=6.5; P=0.01).ConclusionDrug-resistant TB decreased over the period studied, although the trend did not reach statistical significance. These trends may reflect the efficacy of TB control programs to reduce drug-resistant TB transmission, as well as improved RR TB detection due to increased use of molecular diagnostic platforms like GeneXpert MTB/RIF.

Evaluation of drug-resistant tuberculosis treatment outcome in Portugal, 2000-2016.

Treatment of drug-resistant tuberculosis (TB), which is usually less successful than that of drug-susceptible TB, represents a challenge for TB control and elimination. We aimed to evaluate treatment outcomes and to identify the factors associated with death among patients with MDR and XDR-TB in Portugal. We assessed MDR-TB cases reported for the period 2000–2016, using the national TB Surveillance System. Treatment outcomes were defined according to WHO recommendations. We identified the factors associated with death using logistic regression. We evaluated treatment outcomes of 294 MDR- and 142 XDR-TB patients. The treatment success rate was 73.8% among MDR- and 62.7% among XDR-TB patients (p = 0.023). The case-fatality rate was 18.4% among MDR- and 23.9% among XDR-TB patients. HIV infection (OR 4.55; 95% CI 2.31–8.99; p < 0.001) and resistance to one or more second-line injectable drugs (OR 2.73; 95% CI 1.26–5.92; p = 0.011) were independently associated with death among MDR-TB patients. HIV infection, injectable drug use, past imprisonment, comorbidities, and alcohol abuse are conditions that were associated with death early on and during treatment. Early diagnosis of MDR-TB and further monitoring of these patients are necessary to improve treatment outcome.

Is deployement of diagnostic test alone enough? Comprehensive package of interventions to strengthen TB laboratory network: three years of experience in Burkina Faso

BackgroundsThe laboratory plays a critical role in tuberculosis (TB) control by providing testing for diagnosis, treatment monitoring, and surveillance at each level of the health care system. Weak accessibility to TB diagnosric services still represents a big concern in many limited resources’ countries. Here we report the experience of Burkina Faso in implementing a comprehensive intervention packages to strengthen TB laboratory capacity and diagnostic accessibility.MethodsThe intervention lasted from October 2016 to December 2018 and focused on two main areas: i) development of strategic documents and policies; ii) implementation of TB diagnostic technology.National TB laboratory data were collected between 2016 and 2018 and evaluated according to five programmatic TB laboratory indicators: i) Percentage of notified new and relapse TB cases with bacteriological confirmation; ii) Percentage of notified new and relapse TB cases tested by Xpert MTB/RIF; iii) Percentage of notified, bacteriologically confirmed TB cases with a drug susceptibility testing (DST) result for rifampin; iv) Percentage of notified MDR-TB cases on the estimated number of MDR-TB cases; v) The ration between the number of smear microscopy and Xpert MTB/RIF tests. We compared these indicators between a 1 year (2016–2017) and 2 years (2016–2018) timeframe.ResultsFrom 2016 to 2018, the percentage of bacteriologically confirmed cases increased from 67 to 71%. The percentage of new and relapse TB cases notified tested by Xpert MTB/RIF increased from 18% in 2016 to 46% in 2018 and the percentage of bacteriologically confirmed cases with an available DST result for rifampicin increased from 27% in 2016 to 66% in 2018.. The percentage of notified MDR-TB cases on the estimated number of MDR-TB cases in 2018 increased from 43% in 2016 to 78% in 2018. In 2018, the ratio between the number of smear microscopy and Xpert MTB/RIF tests decreased from 53% in 2016 to 21% in 2018.ConclusionWe demonstrated that the implementation of a comprehensive package of laboratory strengthening interventions led to a significant improvement of all indicators. External technical assistance played a key role in speeding up the TB laboratory system improvement process.

Disputed rpoB Mutations in Mycobacterium tuberculosis and Tuberculosis Treatment Outcomes.

Discordant results between genotypic drug susceptibility testing (gDST) and phenotypic DST (pDST) for Mycobacterium tuberculosis isolates with disputed (discordance between gDST and pDST results) mutations affect rifampin (RIF)-resistant (RR) and multidrug-resistant (MDR) tuberculosis (TB) treatments due to a lack of practical clinical guidelines. To investigate the role of disputed rpoB mutations in M. tuberculosis and TB treatment outcomes, initial isolates of 837 clinical RR- or MDR-TB cases confirmed during 2014 to 2018 were retested using agar-based RIF pDST and rpoB gene sequencing. MICs were determined for isolates with disputed rpoB mutations. Disputed rpoB mutations were identified in 77 (9.2%) M. tuberculosis isolates, including 50 (64.9%) and 14 (18.2%) phenotypically RIF- and rifabutin (RFB)-resistant isolates, respectively. The predominant single mutations were those encoding L533P (a change of L to P at position 533) (44.2%) and L511P (20.8%). Most of the isolates harboring mutations encoding L511P (87.5%), H526N (100%), D516Y (70.0%), and L533P (63.6%) had MICs of ≤1 mg/liter, whereas isolates harboring the mutation encoding H526L (75%) had a MIC of >1 mg/liter. Of the 63 cases with treatment outcomes available, 11 (17.5%) cases died, 1 (1.6%) case transferred out, and 51 (81%) cases had favorable outcomes, including 8 and 20 cases treated with standard-dose RIF- and RFB-containing regimens, respectively. Excluding cases that transferred out or received no or 1-day treatment, we observed statistically significant differences between the outcomes using active and inactive fluoroquinolones (FQs) (P = 0.008, odds ratio = 0.05 [95% confidence interval, 0.01 to 0.38]) in 57 cases (where active means a case susceptible to the drug and inactive means a case resistant to the drug or drug not used). We concluded that disputed rpoB mutations are not rare. Depending on the resources available, sequencing and/or MIC testing is recommended for better management of RR- and MDR-TB cases.

A Mathematical Model for the Study of Effectiveness in Therapy in Tuberculosis Taking into Account Associated Diseases

Tuberculosis (TB) remains a major global health problem. We present a deterministic mathematical model for the study of the effectiveness of therapy in TB to determine the impact of HIV/AIDS and diabetes in the spread of the disease and drug resistance. Our model takes into account the relationships between TB, HIV/AIDS, and diabetes and we also study the behavior of multidrug-resistance (MDR-TB) and extensively drug-resistant (XDR-TB). The main mathematical and epidemiology features of the model are investigated. The basic reproduction number (R0) in the different sub-populations (diabetics, HIV/AIDS, and those who do not suffer from these diseases) was studied. Conditions were obtained on the model parameters to know when the growth of the parameters associated with resistance to TB treatment has a negative impact on the transmission of TB in the population based on the R0 study. It is concluded that MDR-TB and XDR-TB have a negative impact on TB control. Computational simulations show that a greater number of drug-sensitive TB cases with respect to MDR-TB and XDR-TB cases are reported in the infected compartments, and MDR-TB cases surpass XDR-TB cases, except in the diabetes sub-population, which has a growth of XDR-TB cases that surpasses the other compartments of infected of all the sub-populations. It was shown when comparing the sub-populations of diabetes and HIV/AIDS, that although the diabetes sub-population reports a higher number of XDR-TB cases, a lower number of drug-sensitive TB and MDR-TB cases, have a greater number of recovered cases with respect to HIV/AIDS sub-population at the end of the study period. Also, when the XDR-TB cases in the diabetes sub-population exceed the other infected compartments, there is a growth of recovered TB in this subpopulation. The results suggest that it is necessary to increase the attention to the diabetic population, which include improved glucose control, increase the number of specialized medical consultations to achieve permanence in TB treatment and control the entry of individuals to the diabetic compartments by tests of diabetes.

MDR tuberculosis and HIV infection in the North-Western Federal District

The objective of the study : to study changes in MDR tuberculosis incidence and prevalence among patients with HIV infection in the North-Western Federal District and its regions in 2007-2018. Subjects and methods . The data from FSN Form No. 61 on Information on HIV Infected Patients Contingents for 2007-2018, materials of Federal Research Institute for Health Organization and Informatics by the Russian Ministry of Health, information from tables additionally developed by the authors were used. Epidemiological and statistical methods were applied; the differences between the variables were established by the Fisher coefficient based on the Statistica software. Results . The increase in the incidence of TB/HIV co-infection is the highest in regions with the low cumulation of HIV infection: Arkhangelsk, Pskov Regions and the Komi Republic. In 2018, MDR TB among HIV patients with HIV was the most prevalent in Leningrad Region (37.7%), the Komi Republic (32.2%) and Novgorod Region (29.3%), while in the Republic of Karelia, there was not a single case of MDR TB detected among HIV patients, in Pskov Region - 2.4% of cases. The efficacy of tuberculosis chemotherapy by regimens IV-V among the MDR TB/HIV cohort was statistically significantly lower than that of the entire MDR TB cohort: 41.4% versus 61.5% (p &lt; 0.04).

Ethnographic Study of Tuberculosis Treatment Seeker Behavior on the Island of Buru, Maluku, Indonesia

Background: Tuberculosis (TB) is reported as a world health problem, especially in developing countries. It is estimated that one third of the world's population has been infected by Mycobacterium tuberculosis. WHO has stated that tuberculosis has now become a global threat. Indonesia is one of the 27 countries in the world with MDR-TB cases.&#x0D; Methods: A qualitative study with an ethnography design was conducted to determine and reveal the meaning of treatment-seeking behavior in “Batu Balender” or TB patients in Buru Island, Maluku, Indonesia. The research data was collected through interviews with 15 informants from all risk groups that are directly related to TB. Observations were made to ensure the validity of the data.&#x0D; Results: This study revealed that from generation to generation, the Alifuru tribe believes that diseases are grouped into three categories: natural diseases, sick submissions, and ancestral curse. Indigenous people have believed that TB is an incurable ancestral curse disease. They know the "Kaygosa" who is believed to be the holder of natural medicinal plants to treat TB, such as leaves and bark.&#x0D; Conclusions: Alifuru tribal people who access health services to obtain Directly Observed Treatment Short-Course (DOTS) have experienced failure in treatment due to local customary rules that prohibit taking medicine if a tribal community has died and believes that a community health center or hospital is "house died". This study suggest that education and counseling for TB treatment should be optimized in efforts to improve the health of local tribal communities.

Comparison of N-acetyl-L-cysteine-sodium hydroxide and Modified Petroff's Decontamination Methods for Mycobacterium tuberculosis Culture

Indonesia is one of 22 countries with a high incidence of TB in the world, particularly related to TB-HIV and MDR-TB cases. Contamination of normal flora from nasopharyngeal tract is the main problem to isolate Mycobacterium tuberculosis (MTB) from sputum. It is needed a safe solution to decontaminate without killing MTB bacilli. N-acetyl-L-cysteine-sodium hydroxide (NALC-NaOH) is compared with modified Petroff’s which is widely used in laboratories, to get better outcome. Of the 110 sputum samples were collected from suspected cases of Pulmonary TB. Decontamination using 2% NALC-NaOH and Modifed Petroff (4% NaOH) was performed before AFB smear and culture on LJ medium. Each group was assessed for contamination and culture positive rate. The positive culture was validated using chromatography test for detected antigen MPT-64 and PNB. Result of this study showed that NALC-NaOH and modified Petroff’s methods did not significantly affect positivity rate of Acid-Fast Bacillus (AFB) smear, 71% and 66% respectively. Contamination on culture was significantly (p=0,034) higher in samples treated with NALC-NaOH (21%) compared to Modified Petroff methods(13%). Proportion of positive culture on samples treated with NALC-NaOH was lower than Modified Petroff, 65% and 70% respectively with p value=1. Conclusion of this study showed that sputum decontamination using Modified Petroff methods is still more effective than NALC-NaOH to increase positivity rate of MTB culture. However, the two methods were not significantly different to get positivity result on the microscopic examination of AFB.

In-depth analysis of multi- and extensively drug-resistant mycobacterium tuberculosis isolates in the capital of iran

Aims and objectives: The emergence and spread of multidrug resistant (MDR) Mycobacterium tuberculosis (M. tuberculosis) strains is a critical global health problem. In order to shorten the course of treatment and its effectiveness, it is essential to gain an in-depth insight into the genetic diversity, drug resistance mechanisms and host-pathogen interactions of drug resistant M. tuberculosis. Methods: Between 2014 and 2018, 606 MTBC strains were isolated from 13,892 suspected pulmonary tuberculosis (TB) patients in Tehran, Iran, including 16 MDR-TB cases. A combination of phenotypic (conventional drug susceptibility testing, MIC, Verapamil effectiveness) and genotypic methods (whole-genome sequencing and qPCR) was employed for the identification of additional drug resistances, the role of efflux pumps and strain-to-strain genetic distances as a marker for recent transmission events. Finally, the consequences of mutations in genes encoding the beta subunit of RNA polymerase (rpoB) for host-pathogen interactions was investigated by means of THP-1-derived macrophages infection and Cytokines and Chemokines Real-Time RT2 Profiler PCR Array. Results: MDR and extensively drug-resistant (XDR) TB cases were almost exclusively infected by lineage 2/Beijing strains (14/16, P &lt; 0.001). Out of the 16 MDR/pre-XDR/XDR isolates, 6 (37.5%) and 3 (18.8%) isolates demonstrated a significant decrease in rifampicin (RIF) MIC and isoniazid (INH) MIC due to the Verapamil exposure (64 μg/mL), respectively. More importantly, it was found that the administration of Verapamil profoundly decreased the MIC of Bedaquiline (BDQ) among most of the studied clinical isolates. Moreover, the efflux pump genes of Rv2938, Rv2936, Rv1145, Rv1146, Rv933, Rv1250, Rv876, Rv2333, Rv2459, Rv849, and Rv1819 were overexpressed in the presence of anti-TB drugs, showing the contribution of these efflux pumps to the overall resistance phenotype. Finally, the macrophages immune responses induced in response to infection with drug-resistant M. tuberculosis (RMR strain) may not be substantially different from drug susceptible M. tuberculosis (H37Rv strain), but the severity of the responses was different in some cases specially IL-6, IL-8, CNTF, IL-13, TNFSF10 and CD40LG in response to RMR and H37Rv strains. In addition, RMR strain showing significantly higher intracellular bacillary growth compared to H37Rv strain. Conclusions: The crucial finding is that almost all of our MDR/pre-XDR/XDR strains are of the Beijing lineage (14/16) and more than half of them are probably from recent transmission (8/14). Our results clearly showed that efflux systems, besides spontaneous mutations, play a role in the development of INH/RIF resistance. In addition, Verapamil was very successful at the phenotypic level specially in response to BDQ. Finally, the results initially demonstrate that the M. tuberculosis carrying the rpoB-S450L can modulate macrophage responses to mediate bacterial survival.

Use of whole genome sequencing to identify transmission of resistant tuberculosis strains in italy

Aims and objectives: In the present study, we report on the cross-border clusters involving Italian MDR-TB strains collected in the framework of the ECDC supported EUSeqMyTB project. This pilot study was conducted as retrospective/prospectic WGS-based surveillance project to monitor possible cross-border TB transmission involving strains isolated in Europe. Methods: Within the EUSeqMyTB study period (approximately 24 months) 2218 RR/MDR-TB strains from 25 EU countries were collected, including a total of 127 strains from Italy. Additional RR/MDR-TB strains were collected and sequenced in Italy as part of the national WGS-based surveillance. All strains were subjected to WGS according to standard protocol for the Ion torrent or Illumina platform. Sequencing of Italian strains was performed by Illumina. WGS data were subjected to quality check (See Tagliani et al ERJ 2020) and analysis was performed by SNP based pipeline and Core Genome MSLT (SeqSphere+ Redom GmbH, Germany) Results: The Euroamerican superlineage was the most represented in Italy (64% of cases). The Italian strains were included in the 3 major cross-border clusters identified in the study. The largest cluster comprised a total of 30 patients from 3 different countries, including 22 individuals born in the same European country. Italy contributed to this cluster with 12 cases isolated during the study period and with additional two cases after the end of the study in 2019. The clustered strains isolated in Italy were from both Italian born and foreign born TB cases, the majority of which were from another EU country. For the majority of the clustered cases isolated in Italy the epidemiological link was identified and the cluster was linked to a pub located in Milan, Italy. A subgroup of the MDR-TB cases showed additional resistance to 2nd line anti TB drugs as well as resistance to bedaquiline (linked to a large deletion in the rv0678 gene). One clustered case showed also a minimum inhibitory concentration for delamanid close to the drug critical concentration. For the additional two large cross-border clusters identified in the EUSeqMyTB pilot study, Italy contributed with respectively 2 and 5 cases. All of them were linked to migration from sub-Saharan Africa countries and no case of transmission to Italian born population was identified neither during the study timeframe nor afterwards. Conclusions: We documented that WGS-based surveillance of RR/MDR-TB strains highly support contact tracing investigation. The implementation of WGS in routine should require the performance of WGS as soon as the strain become available and not in batches with delay. Information exchange with neighboring countries should be facilitate. We report on an ongoing transmission of a pre-XDR strain linked to a larger EU cluster and that the transmitted strain is highly resistant to therapy with the current MDR recommended treatment.

Starting a newer shorter MDR regimen for MDR-TB at a district TB center for the first time- A case report from a heavy center in Western Delhi

Drug Resistant TB is a challenge for a country like India where there is highest prevalence of MDR cases in the world. With decentralizing and smooth accessibility of the Gene Xpert, it has become quick and easy to rule out the drug resistance. Unlike the conventional CAT-IV treatment of about 24 months, a newer shorter regimen of MDR TB treatment has been started in selected cases like pulmonary MDR-TB (when there is no resistance of FQs% or SLIs on the second line LPA). We herein, present a case of secondary pulmonary MDR-TB, who has been started on a newer shorter MDR regimen treatment for the first time at a very large and heavily burdened center in the Western part of the national capital of India. Keywords: Gene Xpert; LPA; MDR; SLI; TB.

Review of treatment outcome of multi-drug resistant tuberculosis

Introduction: Multidrug resistant tuberculosis (MDR TB) is essentially a man-made phenomenon and arises mainly due to inadequate treatment of drug-sensitive TB. Drug resistance is seen in 1-3% of new cases and 12% of re-treated tuberculosis. Material and Methods: We studied 291 cases of multidrug resistant tuberculosis registered at drug resistant tuberculosis (DRTB) center, Mysore. Patients were treated according to programmatic management of drug resistant tuberculosis (PMDT) guidelines by DRTB committee of the hospital. Results: Out of 291 treated cases of MDR TB, 41 were diagnosed when they were on Category I regimen of revised national tuberculosis control program. Thirty cases were treatment after lost to follow-up. Twenty-one cases were co-infected with tuberculosis and human immune deficiency virus. Conclusion: Treatment outcome was available in 275 patients. Out of which 16 cases completed treatment, 106 were cured, 55 cases stopped treatment, 84 died, treatment was stopped in 3 patients due to some reason and 11 cases were switched to extensively drug resistant tuberculosis (XDR) regimen. Our study concluded that despite adequate drugs with well-organized program the treatment outcome of MDR tuberculosis was still low. Keywords: Multidrug tuberculosis; Drug resistant tuberculosis center; Programmatic management of drug resistant tuberculosis; Extensively drug resistant tuberculosis.

Impact of Xpert MTB/RIF scale up in improving Rifampicin resistance TB detection - Experience from 5 regions in Tanzania

Background: The WHO recommends the use of Xpert MTB/RIF technology rather than conventional microscopy, culture and DST as the initial diagnostic test for all presumptive TB cases. In 2017, there were an estimated 640 MDR/RR-TB cases, but only 200 cases of MDR-TB were identified in Tanzania, representing about 31% of the total estimated cases in the country. Tanzania has also revised the policy guideline to include Xpert MTB/RIF as primary diagnostic test among all presumptive TB cases although due to financial constraints the coverage of Xpert diagnostic facilities has remained low. USAID Boresha Afya Southern Zone program a comprehensive HIV Care project with support from USAID providing services in 5 regions has supported scale up of Gene X-pert machine in TB and RR-TB case detection. We document impact of Xpert scale up in improving RR-TB case detection. Methods and materials: The program mapped the number and location of Xpert machines available at all 35 district councils and only 11 councils had Xpert Machines. The program supported the efforts by the ministry to scale up Xpert machine availability by adding 27 new Xpert machines which increased a coverage to at least one Xpert machine per council. Furthermore, the program started supporting transport of sputum samples to X-pert sites by integrating sputum samples transportation with HIV Viral Load sample transportation system. Results: The number of RR-TB notifications increased by more than two folds from 21 cases in 2017 to 47 cases in 2018.Further more, the total number of TB cases notified increased from 8681 cases notified in 2017 to 9824 cases in 2018.Tabled 1PeriodJan-March 2017Apr-June 2017July-Sept 2017Oct -Dec 2017Jan-March 2018Apr-June 2018July-Sept 2018Oct- Dec 2018Number of RR-TB cases Detected44855101715 Open table in a new tab Conclusion: Use of Xpert MTB/RIF has demonstrated effectiveness in addressing the first pillar of the END TB Strategy; early diagnosis of TB including universal drug susceptibility testing. While there is a need to scale up Xpert machine to cover more sites, strengthening sputum sample transportation system to sites with Xpert machines will improve TB case detection in remote constrained settings.

Effectiveness of m-learning on knowledge and attitude of nurses about the prevention and control of MDR TB: A quasi-randomized study

BackgroundMultidrug-Resistant Tuberculosis is a fatal form because of high morbidity and poor recovery. Improper use of first line medicines and default treatment are the prime reasons of developing resistance of mycobacterium towards conventional anti- TB drugs. Nurses with refined knowledge, current evidence and positive attitude can prevent arising of MDR TB cases by ensuring adequate treatment, promoting treatment adherence and real time case monitoring. Because of paucity of data, present study was aimed to assess efficacy of m-learning in improving knowledge and attitude of nurses about the prevention and control of MDR-TB. MethodsIn this Quasi-randomized study, nurses working in the unit of pulmonary, emergency, respiratory ICU, general medicine of AIIMS Rishikesh during the months of August–October 2019 were involved. The number of participation was 190 (95 in each group; experimental and control) where m-learning intervention was available only for experimental group. There were structured questionnaire to measure knowledge and dichotomous checklist to evaluate attitude of nurses of both group before and one week after the provision of m-learning module. ResultsBoth the group was homogeneous and m-learning intervention was effective to improve knowledge, when compared post-test knowledge score between experimental and control group (18.2 ± 5.4 vs 12.4 ± 4.4; P < 0.001); however, this one-time social media based intervention could not improve attitude of participants (10.3 ± 1.8 vs. 9.9 ± 1.8; P = 0.175). ConclusionHence, m-learning is useful for knowledge development among large number of nurses within limited resource setting but frequent provision of technology based module is recommended to acquire positive attitude among nurses.