Indian Subcontinent Ethnic Origin Research Articles

Peripheral tuberculous lymphadenopathy: a review of 67 cases.

Peripheral tuberculous lymphadenopathy is the commonest form of extrapulmonary tuberculosis. Sixty-seven patients with peripheral tuberculous lymphadenopathy who presented to general surgeons and underwent lymph node biopsy between 1979 and 1989 are reviewed. Fifty-four patients (81 per cent) were of Indian subcontinent ethnic origin and 13 (19 per cent) were of white ethnic origin. The sites most commonly affected were the cervical lymph nodes. Biopsy specimens obtained by open operation were sent for microbiological examination in all but 13 cases, of whom seven were patients of white ethnic origin. Tuberculous lymphadenopathy remains an important differential diagnosis of cervical lymphadenopathy and it is essential that peripheral lymph node biopsies are examined both histologically and microbiologically.

A case control study in the Indian subcontinent ethnic population on the effect of return visits and the subsequent development of tuberculosis

A local government area in North West England with a significant population of Indian subcontinent (ISC) ethnic origin and a high incidence of tuberculosis. To assess whether return visits to the ISC are associated with an increased risk of developing clinical tuberculosis. Analysis of data prospectively obtained from ISC patients diagnosed with TB in 1998-2002 (cases) and age and sex matched ISC patients in two local GP practices (controls). There is at best weak evidence of association between case status and whether individuals have had a repeat visit to the subcontinent within 3 years of notification in this cohort; odds ratio 1.26 (95% CI (0.95, 1.76)); Fishers exact test P=0.09.

Outcome of the treatment of culture negative tuberculosis (respiratory and non-respiratory): Blackburn 1996-2000.

To determine the outcome of treating patients without culture confirmation of tuberculosis, with a regimen of two months of isoniazid, rifampicin, pyrazinamide and ethambutol followed by four months of isoniazid and rifampicin (2HRZE/4HR) in a setting with a rate of isoniazid resistance of 7.5% in culture confirmed cases. Tuberculosis patients treated in the Blackburn, Hyndburn and Ribble Valley districts of the UK between 1996 and 2000 inclusive. Patients from a detailed prospective clinical and epidemiological data base for all tuberculosis patients were studied for the years 1996-2000. One hundred and fourteen cases, all but two of Indian subcontinent ethnic origin, without culture confirmation had received 2HRZE/4HR. Twenty had pulmonary, 55 other respiratory and 39 non-respiratory tuberculosis. There was no bacteriologically confirmed relapse, 1 case was retreated as a clinical relapse. The treatment of tuberculosis cases without culture confirmation with a regimen of 2HRZE/4HR gives highly acceptable results. The clinical relapse rate was 0.85% (1/114), and the cure rate 99.15%.

Are There Still Effects on Indian Subcontinent Ethnic Tuberculosis of Return Visits?: A Longitudinal Study 1978–97

Objective: To assess whether return visits to the Indian Subcontinent (ISC) are associated with increased risks of developing clinical tuberculosis.Methods: Descriptive analysis of epidemiological records over a period of 1978–97 inclusive in Blackburn, Hyndburn and Ribble Valley for individuals of ISC ethnic origin notified with tuberculosis. Those cases diagnosed through local contact tracing exercises were excluded.Results: Of 1032 eligible individuals notified with tuberculosis, 228 (22.1%) reported prior visits to the ISC. Of these 151 (66%) reported having visits within 3 years of that notification, including 60% of the United Kingdom (U.K.) born without prior exposure to the ISC.Conclusion: The clinical observations are consistent with the hypothesis that return visits to the ISC carry a risk of acquiring tuberculosis. This cannot be confirmed, however, without information about the return visits in the ISC population as a whole. A case-control study may be required to confirm the hypothesis.

Obstetric practice and faecal incontinence three months after delivery.

To determine whether obstetric and maternal factors relate to faecal incontinence at three months postpartum. Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). All women who delivered during one year in the three maternity units. Postal questionnaire at three months postpartum, to obtain information on faecal incontinence, linked to obstetric casenote data. Prevalence of faecal incontinence. 7879 questionnaires were returned, a 71.7% response rate. The prevalence of faecal incontinence was 9.6%, with 4.2% reporting this more often than rarely. Logistic regression, confined to primiparae, showed that forceps delivery was a predictor of an increased risk of symptoms (OR = 1.94, 95% CI 1.30 to 2.89) while vacuum extraction was not associated. Caesarean section was marginally associated with a reduced risk (OR = 0.58, 95% CI 0.35 to 0.97). Older maternal age, Indian sub-continent ethnic origin and body mass index 'not known' also showed significant associations. No associations were found for induced labour, duration of second stage labour, episiotomy, laceration or birthweight. Women delivered by forceps had almost twice the risk of developing faecal incontinence, whereas vacuum extraction was not associated with faecal incontinence at three months postpartum. Caesarean section appears to offer some protection.

Obstetric practice and faecal incontinence three months after delivery

Objective To determine whether obstetric and maternal factors relate to faecal incontinence at three months postpartum. Setting Maternity units in Aberdeen (Scotland), Birmingham (England) and Dunedin (New Zealand). Population All women who delivered during one year in the three maternity units. Methods Postal questionnaire at three months postpartum, to obtain information on faecal incontinence, linked to obstetric casenote data. Main outcome measures Prevalence of faecal incontinence. Results 7879 questionnaires were returned, a 71.7% response rate. The prevalence of faecal incontinence was 9.6%, with 4.2% reporting this more often than rarely. Logistic regression, confined to primiparae, showed that forceps delivery was a predictor of an increased risk of symptoms (OR=1.94, 95% CI 1.30 to 2.89) while vacuum extraction was not associated. Caesarean section was marginally associated with a reduced risk (OR=0.58, 95% CI 0.35 to 0.97). Older maternal age, Indian sub-continent ethnic origin and body mass index ‘not known’ also showed significant associations. No associations were found for induced labour, duration of second stage labour, episiotomy, laceration or birthweight. Conclusions Women delivered by forceps had almost twice the risk of developing faecal incontinence, whereas vacuum extraction was not associated with faecal incontinence at three months postpartum. Caesarean section appears to offer some protection.

Tuberculosis and the kidney.

Tuberculosis of the kidney and urinary tract is, like other forms of the disease, caused by members of the Mycobacte- rium tuberculosis complex. By far the most common causative organism is the human tubercle bacillus, M. tuberculosis, but the bovine tubercle bacillus, M. bovis, occasionally can be responsible. The vaccine strain, Bacille Calmette-Guerin (BCG), also has been the cause of renal lesions as a compli- cation of intravesical instillation of BCG for the treatment of superficial bladder cancer. The members of the M. tuberculosis complex are obligate pathogens and, together with M. leprae, differ from the many other species within the genus Mycobacterium, which are free-living environmental saprophytes and are commonly found in water, including piped water supplies. Some of these so-called environmental mycobacteria occasionally cause hu- man disease, particularly in immunosuppressed individuals, including recipients of renal transplants (1). The kidney may be involved when environmental mycobacteria cause dissemi- nated disease, such as that caused by M. avium in AIDS patients. Renal disease caused by environmental mycobacteria in nonimmunosuppressed individuals is exceedingly rare (2). However, because they occur in water, environmental myco- bacteria readily contaminate the lower urethra and external genitalia and, thus, often are isolated from urine samples. Globally, tuberculosis is a common disease, with 8 to 10 million new cases annually and a rising incidence, particularly in regions with a high incidence of HIV infection. Most often the lung is affected, but, after lymphadenopathy, the most common form of nonpulmonary tuberculosis is genitourinary disease, accounting for 27% (range, 14 to 41%) of nonpulmo- nary cases in several surveys in the United States, Canada, and United Kingdom (3). In developed countries, nonpulmonary tuberculosis is rela- tively more common in patients from ethnic minority groups, the exception being genitourinary tuberculosis, which is un- common in these groups. In the United Kingdom, the latter accounts for 5% of cases of nonpulmonary tuberculosis in ethnic minorities, mostly those of Indian subcontinent ethnic origin, compared with 27% of such cases in the European (white) population. This is, to some extent, age related: when patients of white and of Indian subcontinent ethnic origin were stratified by age, the incidence of genitourinary tuberculosis was similar in the two groups in each age band (4). Tuberculosis caused by M. bovis is now uncommon in industrially developed nations, accounting for fewer than 1% of all cases of tuberculosis. It is usually due to reactivation of old, dormant disease, although cases have occurred in younger, HIV-positive patients (5). In approximately 25% of cases caused by reactivation in older persons, the genitourinary sys- tem is involved (6). Such disease has a somewhat bizarre veterinary health significance because a number of farmers have infected cattle by urinating on hay in cowsheds (7).

Meningococcal disease among children of Indian subcontinent ethnic origin

The rate of meningococcal septicaemia and meningitis was significantly lower in children of Indian subcontinent ethnic origin than in children of other origins over 12 years in the Blackburn area of the UK.

Clusters of new tuberculosis cases in North-west London: a survey from three hospitals based on IS6110 RFLP typing

Objectives: The relative contributions of reactivation of latent infection and clusters of new infections to the overall incidence of tuberculosis in the U.K. is unknown. A study was carried out in North-West London to determine the feasibility of ISP6110 RFLP strain typing as a tool to investigate the relative contributions of these two sources.Methods: All available isolates of M. tuberculosis from specimens collected over a calendar year at three participating hospitals were typed by RFLP using an IS6110 probe. Isolates exhibiting a single band pattern were subject to further typing using an oligonucleotide direct repeat probe. Demographic and clinical information on cases was obtained from the National Survey of Tuberculosis Notifications in England and Wales and further information sought on clustered cases as identified by RFLP typing.Results: Twenty-seven (23%) of the 118 cases had shared IS6110 RFLP patterns. Strains from nine cases had single band patterns, but these were all distinguishable from each other when subjected to further typing by direct repeat probe. The remaining 18 cases belonged to eight clusters. Epidemiological links were established between all the patients in each cluster. The likelihood of being in a cluster was increased in cases with pulmonary smear-positive disease. It was lower in cases of Indian Sub-continent ethnic origin. For 10 of the 18 clustered cases epidemiological links had not been established by conventional contact tracing.Conclusions: Investigation of the relative contributions of reactivation of latent infection and new infection is feasible in a UK population, using IS6110 RFLP typing of M. tuberculosis isolates and epidemiological enquiries. This study in London identified clustered, presumably new cases, the majority of whom had not been linked epidemiologically. Comprehensive IS6110 RFLP typing of UK isolates would probably identify many clusters of incident tubercular infection.

Significance of an index of insulin resistance on admission in non-diabetic patients with acute coronary syndromes

BACKGROUNDInsulin resistance is associated with ischaemic heart disease and has been proposed as a risk factor for subsequent myocardial infarction.AIMTo investigate the potential use of a recently proposed insulin resistance...

Does vitamin d deficiency account for ethnic differences in tuberculosis seasonality in the UK?

Objectives. Notifications of tuberculosis in England and Wales are reported to peak in the summer season. The purpose of this study was to confirm that finding and to determine to what extent patients of Indian Subcontinent (ISC) ethnic origin contributed to the seasonality. The clinical presentation of the disease is presumed to occur some months following reactivation of the endogenous latent focus of tuberculosis infection. There arises the possibility of vitamin D deficiency producing immunological inadequacy at the end of winter and beginning of spring. Patients and methods. Monthly (or 4‐weekly) aggregated data over 7 years were collected from the three countries of mainland Britain, England, Wales, Scotland and from the city of Birmingham in England. The notifications from Birmingham were divided into those of ISC ethnic origin and ‘whites’. The presence or absence of seasonality was determined by fitting a sinusoidal curve by the technique called ‘cosinor analysis’. In this method amplitude gives a measure of the extent of the seasonal variation. Results. The summer peak of clinical diagnosis was confirmed in the UK series from England, Wales and Scotland. In England and Wales without Scotland a larger seasonal variation was present. Scotland, with a lower proportion of population of ISC ethnic origin, was examined separately and the results in Scotland alone failed to confirm seasonality. In the data from Birmingham, seasonality was confirmed with a greater amplitude, particularly in those over 60 years of age. The finding was influenced by those of ISC ethnic origin, seasonality not being present in the ‘white’ population. Conclusion. The results from Birmingham are very striking, but there were almost three times as many patients in the ISC ethnic group as in indigenous ‘white’ patients. A series with larger numbers of ‘white’ patients would be necessary to confirm the absence of seasonality in the ‘white’ population. The discussion reviews the evidence that vitamin D may have an important hormonal role in immunological defence in the prevention of tuberculosis.

Geographical distribution of tuberculosis notifications in national surveys of England and Wales in 1988 and 1993: report of the Public Health Laboratory Service/British Thoracic Society/Department of Health Collaborative Group

BACKGROUNDThe geographical distribution of tuberculosis in England and Wales and changes since 1983 were examined using data from the 1988 and 1993 national surveys of tuberculosis notifications.METHODSNotification rates for England...

Cutaneous tuberculosis in Blackburn district (U.K.): a 15-year prospective series, 1981-95

Data collected prospectively on all 1065 cases of tuberculosis occurring in the Blackburn district, U.K. (population 265,000), over a 15-year period have been analysed, and from these 47 cases of cutaneous tuberculosis have been identified. The most common form was scrofuloderma, skin involvement with adjacent structural disease, of which there were 26 cases (55.3%). There was no ethnic bias in this group. The eight white patients with scrofuloderma were of average age 66 years, and are thought to represent reactivation disease. Six patients (12.8%) had lupus vulgaris, four (8.5%) had metastatic tuberculosis and 10 (21.3%) were diagnosed as having one of the tuberculides, of which Bazin's disease (erythema induratum) was the most common. In addition, one patient (2.2%) had orificial tuberculosis. In contrast to scrofuloderma, all other forms of cutaneous tuberculosis occurred almost exclusively in patients from the Indian Subcontinent (ISC). The high incidence of tuberculosis in Blackburn is mainly linked to its significant proportion of residents of ISC ethnic origin. There were no cases of HIV infection coexisting with either cutaneous or other forms of tuberculosis. Recommendations for the treatment of cutaneous tuberculosis are made.

Miliary tuberculosis in a high prevalence area of the U.K.: Blackburn 1978–1993

Thirty-nine cases of miliary tuberculosis treated between 1978–1993 in a district with a high incidence of tuberculosis are reported. Twenty-eight patients were of Indian Subcontinent (ISC) ethnic origin, 10 patients were Caucasian and one patient was Chinese. Mortality at 10% in both Caucasian (x 2 4·94; 0·05> P>0·01) and ISC patients (x 2 10·22; 0·001>P) were significantly lower than in a recently reported series from Edinburgh, as was the proportion of post mortem diagnoses of miliary tuberculosis (x 2 6·35; 0·02>P>0·01). Both the rate of miliary tuberculosis and the average age at diagnosis in Caucasian patients were lower than in the Edinburgh series suggesting that miliary tuberculosis could be under-diagnosed in the elderly Caucasian population in the Blackburn district. The better outcome of those diagnosed in life may be partly due to heightened awareness of tuberculosis locally and partly due to treatment by a centralized tuberculosis service.

Tuberculosis epidemiology in Croydon

A survey of tuberculosis in Croydon between 1988 and 1991, using Chest Clinic health visitor records, showed that the disease occurred most frequently in those of Indian Sub-Continent (ISC) ethnic origin. Of the 222 cases during the 4-year period, 65% were of ISC ethnic origin, 22% were Caucasian and 11% Afro-Caribbean. Non-Caucasian cases were younger (P < 0.0001), and more likely to be female (P = 0.064) or present with non-pulmonary disease (P = 0.064). One-quarter of ISC patients developed active tuberculosis more than 15 years after immigration into the UK. Only seven cases were children. The contact tracing procedure resulted in three additional cases, all of whom were contacts of smear-positive index cases. There were significantly fewer Heaf or radiologically positive contacts of non-smear positive pulmonary, or non-pulmonary index cases (P = 0.0002). The value of the current contact tracing system is discussed.

Mediastinal lymph node size in an Asian population.

There is a high incidence of respiratory tuberculosis in the British population of Indian subcontinent (Asian) ethnic origin. Granulomatous diseases can cause long term lymph node enlargement. Separate computed tomography (CT) criteria for normal nodal size could therefore be necessary when staging thoracic malignancy in Asian patients. The objective of this study was to measure mediastinal lymph node size in an Asian population, and to correlate nodal size with previous tuberculosis. Chest CT scans on all Asian patients over a 5 year period were reviewed and those with pulmonary disease, malignancy or grossly distorted anatomy were excluded. The study group consisted of 48 patients (26 male, 22 female) aged 10-75 years (mean 47 years). All nodes were measured and the site of those greater than 7 mm was recorded using the American Thoracic Society (ATS) lymph node map. 81.3% of patients had nodes less than or equal to 7 mm at all ATS stations, 10.4% had nodes of 8-10 mm and 8.3% had nodes greater than 10 mm. All nodes measuring more than 7 mm were in regions 4R, 10R and 7. Fourteen patients had signs of previous tuberculosis, and in this group 50% had nodes greater than 7 mm as compared with 6% in the group with no signs of previous tuberculosis (p < 0.001, X2 test). Despite these differences only four of the 48 patients (8.3%) had nodes greater than 10 mm, which is in keeping with other general population studies. Thus the generally accepted size criteria for mediastinal lymph node enlargement (greater than 10 mm) can reasonably be applied to all Asian patients when staging lymphoma or bronchogenic carcinoma.

Factors determining ethnic differences in the incidence of bacteriologically confirmed genitourinary tuberculosis in South East England

In South East England, genitourinary (GU) tuberculosis is a much less common manifestation of non-respiratory tuberculosis in patients of Indian subcontinent (ISC) ethnic origin than in those of European ethnic origin. When considered in relation to all bacteriologically confirmed cases of tuberculosis, both respiratory and non-respiratory, the ethnic difference in the occurrence of GU tuberculosis is much less evident, while there is a highly significant excess of other forms of non-respiratory tuberculosis among the ethnic ISC patients. Unlike other forms of non-respiratory tuberculosis, GU disease tends to occur in an older age range in the ethnic ISC population and, when stratified for age, the ethnic difference in the occurrence of this form of tuberculosis is not significant while that of lymph node tuberculosis remains significantly high. Thus, after elimination of the confounding factor of age, the occurrence of GU tuberculosis is very similar in the two ethnic groups while other forms of non-respiratory tuberculosis differ considerably.

Tuberculosis in children: a national survey of notifications in England and Wales in 1988. Medical Research Council Cardiothoracic Epidemiology Group.

A survey of all notified cases of tuberculosis in England and Wales in children (less than 15 years old) in 1988 was undertaken to study changes in the frequency and distribution of disease in the population since similar surveys in 1978-9 and 1983. There were 294 children with newly notified previously untreated tuberculosis, an annual rate of 3.1/100,000. Children of Indian, Pakistani, and Bangladeshi (Indian subcontinent) ethnic origin formed the largest group (134 (46%)), but only 29 (22%) of these children were born outside the UK. The rate for children of Indian subcontinent ethnic origin born abroad (53/100,000) was twice that for those born in the UK (26/100,000), but the latter was 17 times higher than the rate for white children (1.5/100,000). These ratios have changed little since the first survey in 1978-9 and highlight the need for improvement in the prevention and control of tuberculosis in children known to be at increased risk.

Why does genitourinary tuberculosis occur less often than might be expected in the ethnic Indian subcontinent population living in the United Kingdom?

Genitourinary tuberculosis is the only non-respiratory form of the disease which occurs more often in the white ethnic group than in the Indian Subcontinent (ISC) ethnic group as shown by national tuberculosis surveys of England and Wales. Analysis of non-respiratory tuberculosis in a district where 70% of the notified cases were of ISC ethnic origin, showed that the ethnic distribution of genitourinary tuberculosis was different from all other forms of non-respiratory tuberculosis, in that > 80% cases were of white ethnic origin, whereas for all other sites 70% or greater were of ISC ethnic origin. Factors which may account for this difference are discussed.

Results of tuberculosis contact tracing: Blackburn 1982–1990

Between 1982 and 1990, 649 index cases of tuberculosis were seen of which 429 (66·1%) were of Indian Subcontinent (ISC) ethnic origin: 7017 close contacts of these cases were screened, 50 cases of tuberculosis were detected (7·7% of notifications) and 372 children given chemoprophylaxis. All cases of tuberculosis detected in the white ethnic group were contacts of smear-positive pulmonary disease, six (46%) found at initial screening, five (38%) at 1 year and one (8%) at 2 year follow-up. Of 37 cases detected in the ISC ethnic group, only 14 (38%) were contacts of smear-positive disease, 17 (46%) being contacts of other respiratory disease, and six (16%) contacts of non-respiratory disease. Eighteen (49%) of ISC cases detected were at initial screening, with six (16%), eight (22%) and three (8%), respectively, at 6 month, 1 year and 2 year follow-up. The results support the revised Joint Tuberculosis Committee advice on contact tracing, with differential contact programmes depending on type of disease and ethnic group of index cases.