Proportion Of Tuberculosis Cases Research Articles

Impact of the COVID-19 pandemic on contact tracing of patients with pulmonary tuberculosis.

BackgroundThe COVID-19 pandemic could have negative effects on tuberculosis (TB) control. The objective was to assess the impact of the pandemic in contact tracing, TB and latent tuberculosis infection (LTBI) in contacts of patients with pulmonary TB in Catalonia (Spain).MethodsContact tracing was carried out in cases of pulmonary TB detected during 14 months in the pre-pandemic period (1 January 2019 to 28 February 2020) and 14 months in the pandemic period (1 March 2020 to 30 April 2021). Contacts received the tuberculin skin test and/or interferon gamma release assay and it was determined whether they had TB or LTBI. Variables associated with TB or LTBI in contacts (study period and sociodemographic variables) were analyzed using adjusted odds ratio (aOR) and the 95% confidence intervals (95% CI).ResultsThe pre-pandemic and pandemic periods showed, respectively: 503 and 255 pulmonary TB reported cases (reduction of 50.7%); and 4676 and 1687 contacts studied (reduction of 36.1%). In these periods, the proportion of TB cases among the contacts was 1.9% (84/4307) and 2.2% (30/1381) (P = 0.608); and the proportion of LTBI was 25.3% (1090/4307) and 29.2% (403/1381) (P < 0.001). The pandemic period was associated to higher LTBI proportion (aOR = 1.3; 95% CI 1.1–1.5), taking into account the effect on LTBI of the other variables studied as sex, age, household contact and migrant status.ConclusionsCOVID-19 is affecting TB control due to less exhaustive TB and LTBI case detection. An increase in LTBI was observed during the pandemic period. Efforts should be made to improve detection of TB and LTBI among contacts of TB cases.

Prevalence and associated risk factors of drug-resistant tuberculosis in Thailand: results from the fifth national anti-tuberculosis drug resistance survey.

To assess the prevalence and risk factors of drug-resistant tuberculosis (TB), the fifth national anti-TB drug resistance survey was conducted in Thailand. A cross-sectional study was conducted by stratified cluster sampling with probability proportional to size of TB cases from public health facilities in 100 clusters throughout Thailand from August 2017 to August 2018. Susceptibility testing of TB isolates to first- and second-line anti-TB drugs was performed on Löwenstein-Jensen medium using the indirect proportion method. Multiple imputation was done for handling missing data using Stata 16. The proportion of TB cases with drug resistance was determined. The odds ratio was used to evaluate risk factors associated with drug-resistant TB. Among 1501 new TB and 69 previously treated TB cases, 14.0% [95% confidence interval (CI): 12.1-16.1] and 33.4% (95% CI: 23.6-44.8), respectively, had resistance to any anti-TB drug. Multidrug-resistant TB accounted for 0.8% (95% CI: 0.5-1.4) of new TB cases and 13.0% (95% CI: 6.5-24.4) of previously treated TB cases. Drug-resistant TB was associated with prior TB treatment [odds ratio (OR), 2.9; 95% CI: 1.6-5.0], age at 45-54years (OR, 1.6; 95% CI: 1.0-2.4), male (OR, 1.5; 95% CI: 1.0-2.1) and human immunodeficiency virus (HIV) infection (OR, 1.6; 95% CI: 1.0-2.4). The burden of drug-resistant TB remains high in Thailand. Intensified prevention and control measures should be implemented to reduce the risks of drug-resistant TB in high-risk groups previously treated, especially individuals of late middle age, males and those with coinfection of TB and HIV.

Risk factors associated with large clusters of tuberculosis patients determined by whole-genome sequencing in a high-tuberculosis-burden country

Whole-genome sequencing (WGS) analysis has great discriminative power for detecting similar molecular fingerprints of suspected tuberculosis (TB) clusters. The proportion of TB cases within clusters and the associated risk factors are important epidemiological parameters guiding appropriate outbreak control strategies in endemic settings.We conducted a hospital-based TB case-cohort study between 2003 and 2011 in the northernmost province of Thailand. We identified TB clusters by Mycobacterium tuberculosis WGS and analysed the risks of TB clustering and the characteristics of large clusters compared with small clusters.Among 1146 TB isolates, we identified 77 clusters with 251 isolates defined by a 5-single-nucleotide variant (SNV) cutoff and 112 clusters with 431 isolates defined by a 12-SNV cutoff. Twelve large clusters with 6 isolates or more in each cluster were identified by a 12-SNV cutoff. Sublineage 2.2.1 (both Ancestral and Modern) strains and imprisonment were independently associated with large clusters. Furthermore, although large clusters of Lineage 2.2.1/Ancestral strains included a high number of prisoners, Lineage 2.2.1/Modern strain clusters were only associated with treatment failures and drug resistance. Heterogeneity among lineage strains was observed with respect to large-cluster characteristics. Patients with an increased TB-transmission tendency should be priority targets for contact investigations and outbreak interventions to prevent ongoing transmission.

Extrapulmonary tuberculosis among migrants in the EU/EFTA: Implications for policy and practice

Abstract Background The proportion of tuberculosis (TB) cases in the European Union/European Free Trade Association (EU/EFTA) that occur in migrants is increasing. Extrapulmonary TB poses challenges in diagnosis and treatment and causes serious morbidity and mortality. To date, there has been no in-depth exploration of extrapulmonary TB in migrants across Europe. Methods We analysed 22 years of data from the European Centre for Disease Prevention and Control's European Surveillance System (TESSy) for 32 EU/EFTA countries between 1995 and 2017. We investigated whether the proportion of TB cases that were extrapulmonary varied between migrants and non-migrants, and whether this varied by a) country/region of origin, b) reporting country/region, and c) site of disease. Results 1,270,896 TB cases were included in the analysis, comprising 326,987 (25.7%) migrants, and 943,909 (74.3%) non-migrants. The proportion of TB that is extrapulmonary is significantly higher in migrants than in non-migrants: 45.2% (n = 147,814) of cases in migrants were extrapulmonary, compared to 21.7% (n = 204,613) in non-migrants (χ2=6.7x104, p &amp;lt; 0.001). A relatively low proportion of extrapulmonary TB was seen in Eastern (17.4%) and Southern (29.6%) Europe compared with Western (35.7%) and Northern (41.8%) Europe, with migrants having a greater proportion of extrapulmonary TB only in Northern/Western Europe. Migrants from South-East Asia and Sub-Saharan Africa were at highest risk of extrapulmonary TB, with over half of all cases being extrapulmonary (62.0% and 54.5% respectively). Conclusions Among TB cases in the EU/EFTA, extrapulmonary disease is significantly more common in migrants than non-migrants, which has clinical and policy implications for patient detection and management. There is a need to improve clinical awareness of extrapulmonary TB, integrate detection of extrapulmonary TB into latent TB infection screening programmes, and harmonise data collection on migrant status in health systems. Key messages Migrants in the EU/EFTA are disproportionately affected by extrapulmonary TB compared to non-migrants. This has clinical and policy implications for diagnosis, screening, and data collection.

Increase of tuberculosis incidence in Ile-de-France region and the role of recent migration

Abstract Background In metropolitan France and in the Ile-de-France region, the incidence of tuberculosis has globally decreased since the year 2000 and has stabilized from 2011 to 2015. This study analysed the evolution of tuberculosis in the Ile-de-France region between 2015 and 2017. Methods We analysed tuberculosis cases reported in Ile-de-France from 2015 to 2017; 2015 was considered as the baseline year. Incidence rates of reported tuberculosis cases were estimated using French census data for the corresponding year for the denominator. Age-standardized rates were estimated for each of the 8 departments of the region based on the Ile-de-France region population. Foreigners’ population was based on the 2015 French census data. Differences in incidence and proportions were tested with the CHI2 statistic (STATA® v14.0). Results The incidence of tuberculosis increased in the Ile-de-France region from 14.6 to 15.8/100 000 pop. between 2015 and 2017 (+8.2%, p &amp;lt; 0.01). In this region, all department’s incidence were above 10/100 000 pop. in 2017. Sub-regional disparities were observed, with an important increase of the incidence in Paris, from 13,5 to 16.8/100 000 pop. between 2015 and 2017 (p &amp;lt; 0,01). The incidence rates among foreigners increased from 44.6 to 51.7/100 000 pop. (p &amp;lt; 0.01) and the proportion of tuberculosis cases among foreigners who arrived in France less than 2 years ago increased from 23% to 32% (p &amp;lt; 0.01), between 2015 and 2017. The incidence rates of tuberculosis cases increased particularly in men, foreigners, and recent migrants. Conclusions The incidence of tuberculosis increased in the Ile-de-France region in 2016 and 2017, particularly in newly arrived migrants. This situation requires actions to better detect and manage tuberculosis in this specific population. Key messages The incidence of tuberculosis increased in the Ile-de-France region. The incidence of tuberculosis increased in vulnerable population in relation with recent migration.

Worsening situation of tuberculosis in Chile

Recent data suggest an increase in tuberculosis (TB) incidence in Chile. To evaluate recent epidemiological trends, geographic extension and potential factors associated with TB reemergence in Chile. Data analysis from official sources and trend analysis. TB incidence rate increased from 12.3 (2014) to 14.7 (2017) per 100,000 inhabitants. Morbidity rates also increased in nine out of 15 regions. The proportion of TB cases in specific groups has also increased in the last six years: HIV/AIDS (68%), immigrants (118%), drug users/alcoholics (267%) and homeless people (370%). Several indicators of the national TB program performance have deteriorated including TB case detection, HIV co-infection study and contact tracing activities. Overall results indicate a higher than expected case-fatality ratio (> 3%), high rates of loss from follow-up (> 5%), and low percentage of cohort healing rate (< 90%). This decline is associated with a Control Program with scarce human resources whose central budget decreased by 90% from 2008 to 2014. New molecular diagnostic tools and liquid media culture were only recently implemented. TB trends and overall program performance indicators have deteriorated in recent years in Chile and several factors appear to be involved. Multiple strategies will be required to rectify this situation.

Yield of tuberculosis among household contacts of tuberculosis patients in Accra, Ghana

BackgroundThe End TB Strategy calls for systematic screening of selected high-risk groups including contacts of tuberculosis (TB) cases to facilitate early TB case detection. Contact investigation is not usually routinely practiced in low TB burden countries, such as Ghana, with consequent paucity of data on the yield of TB case detection from such interventions. This study’s objective was to document the outcomes and feasibility of implementing contact investigation activities under programmatic conditions in Ghana.MethodsRetrospective analyses were conducted of abstracted data from the National TB Program, following a contact investigation intervention for TB cases diagnosed in 10 facilities in Accra from June 2010 to December 2014. Various proportions and yield from number of contacts needed to screen (NNS) and number needed to test (NNT) to detect a TB case were assessed.ResultsOverall, out of the 8519 listed contacts of 3267 index cases, 8166 (96%) were screened and 614 (7.5%) were identified as presumptive TB. Out of these, 438 (71%) underwent sputum smear microscopy/evaluation and 53 TB cases were diagnosed. Of these, 56.6% were males, and 49% had sputum smear-positive TB, 38% had sputum smear-negative TB, and 7% had extra-pulmonary TB. The NNS and NNT to detect a TB case of all forms were 154 and 8, respectively. The proportion of TB cases with contacts listed and proportion of contacts screened annually were 88–96% and 83–100%, respectively. The proportion of presumptive TB cases tested and proportion of TB cases diagnosed among contacts tested that were 100% and 36%, respectively, in 2010 dropped to 40% and 14%, respectively, by 2014.ConclusionsThe study demonstrates that contact identification and prioritization components of a contact investigation were feasible, but overall yield of TB cases may have been lower due to the declining rate of clinical evaluation of presumptive TB contacts over time. Addressing barriers to accessing appropriate diagnostic tests may enhance yield from contact investigation in Ghana.

Prediction of Under-Detection of Paediatric Tuberculosis in the Democratic Republic of Congo: Experience of Six Years in the South-Kivu Province.

IntroductionIn the field of tuberculosis (TB), and particularly in regard to paediatric TB (PedTB), clinical skills of health professionals play an important role in determining quality of care. In an era where novel diagnostic technologies and efficient treatment regimens are being made available for the poorest, we must not divert our attention from the importance of clinical skills, as this deliverable remains the cornerstone of individualized patient care and ultimately the best assurance for optimal use of resources. The aim of our work was to study the epidemiology of PedTB and the determinants of PedTB under-detection in the South-Kivu Province of the Democratic Republic of Congo (DRC), a setting with nearly no technical resources allowing to support the clinical diagnosis of PedTB, i.e. chest X-rays, rapid molecular tests or culture laboratories.MethodsWe collected TB notification data from 2010 to 2015 and analysed the space-time variations in notification for the different forms of TB among the 113 health facilities (HF) the South-Kivu Province, a region with a low HIV incidence. The different forms of TB notified were: smear positive pulmonary TB (SS+PTB), smear negative pulmonary TB (SS-PTB) and extra-pulmonary TB (EPTB). We further analysed the distribution of these different forms of the disease per age group and explored the possibility to predict the detection of PedTB.ResultsSignificant differences were observed between HF in regard to the proportion of paediatric TB and the proportion of SS-TB among adults. We found a strong correlation between the proportion of PedTB and three major factors: the proportion of TB cases with no bacteriological confirmation (SS-TB) among adults, the number of TB cases notified by the HF and the fact that the HF was supported or not by Médecins Sans Frontières (MSF). The proportion of SS-TB among adults was found to be a valid indicator for predicting the level of detection of PedTB at the same HF.ConclusionOur observations strongly suggest that under-detection of PedTB is associated with insufficient clinical skills and technical resources at the HF level which similarly affects other forms of the disease, in particular SS-TB. We demonstrated that, in the specific context of South-Kivu, under-detection of PedTB can be predicted by a low SS-TB/SS+PTB ratio in the adult population. In the context of severely under-resourced settings, this ratio could be used to rapidly identify HF that should benefit in priority from deeper evaluation, and eventually targeted interventions.

Is systematic screening and treatment for latent tuberculosis infection in HIV patients useful in a low endemic setting?

Objectives: A decreasing incidence of tuberculosis (TB) among HIV patients has been documented in high-income settings and screening for tuberculosis is not systematically performed in many clinics (such as ours). Our objectives are to evaluate whether a same decline of incidence was seen in our Belgian tertiary center and to evaluate whether systematic screening and prophylaxis of tuberculosis should remain part of routine practice.Methods: Between 2005 and 2012, the annual incidence of tuberculosis among adult HIV patients was measured. The impact of demographic characteristics and CD4 nadir on the incidence of active TB was evaluated.Results: Among the 1167 patients who entered the cohort, 42 developed active TB with a significant decrease of annual incidence from 28/1000 patient-years in 2005 to 3/1000 patient-years in 2012. Among the 42 cases, 83% were of sub-Saharan origin. Median CD4 cell count upon HIV diagnosis was significantly lower in TB cases and 60% had a nadir CD4 below 200/μl. Thirty-six percent of incident TB occurred within 14 days after HIV diagnosis.Conclusion: A significant decline of TB incidence in HIV patients was observed. Incident TB occurred mainly in African patients, with low CD4 upon HIV diagnosis. A significant proportion of TB cases were discovered early in follow-up which probably reflects TB already present upon HIV diagnosis. In a low endemic setting, exclusion of active TB upon HIV diagnosis remains a priority and screening for LTBI should focus on HIV patients from high risk groups such as migrants from endemic regions, especially in patients with low CD4 nadir.

MDRTB Then, XMDRTB Now and Then ……… Totally

Multi drug resistant tuberculosis has come up as a separate disease meriting different diagnostic and therapeutic options from conventional tuberculosis. Worldwide there has been considerable increase in MDRTB cases to 60,000 and less than 5% of them get management as desired by various infectious disease bodies. Another entity titled XMDRTB has of late assumed significant proportion of tuberculosis cases which is steaming into a new health related inferno. Some sporadic cases of tuberculosis have come up which are completely resistant to all anti-tubercular drugs, that should be an area of concern for all healthcare givers. JMS 2016; 19(1):12-17

Rapid improvement in passive tuberculosis case detection and tuberculosis treatment outcomes after implementation of a bundled laboratory diagnostic and on-site training intervention targeting mid-level providers.

Background. Tuberculosis (TB) control is a public health priority with 3 million cases unrecognized by the public health system each year. We assessed the impact of improved TB diagnostics and on-site training on TB case detection and treatment outcomes in rural healthcare facilities.Methods. Fluorescence microscopy, Xpert MTB/RIF, and on-site training were introduced at 10 healthcare facilities. Using quasi-experimental methods, these 10 intervention healthcare facilities were compared with 2 controls and their own performance the previous year.Results. From January to October 2012, 186 357 and 32 886 outpatients were seen in the 10 intervention and 2 control facilities, respectively. The intervention facilities had a 52.04% higher proportion of presumptive TB cases with a sputum examination (odds ratio [OR] = 12.65; 95% confidence interval [CI], 5.60–28.55). After adjusting for age group and gender, the proportion of smear-positive patients initiated on treatment was 37.76% higher in the intervention than in the control facilities (adjusted OR [AOR], 7.59; 95% CI, 2.19–26.33). After adjusting for the factors above, as well as human immunodeficiency virus and TB retreatment status, the proportion of TB cases who completed treatment was 29.16% higher (AOR, 4.89; 95% CI, 2.24–10.67) and the proportion of TB cases who were lost to follow-up was 66.98% lower (AOR, 0.04; 95% CI, 0.01–0.09). When compared with baseline performance, the intervention facilities had a significantly higher proportion of presumptive TB cases with a sputum examination (64.70% vs 3.44%; OR, 23.95; 95% CI, 12.96–44.25), and these facilities started 56.25% more smear-positive TB cases on treatment during the project period (AOR, 15.36; 95% CI, 6.57–35.91).Conclusions. Optimizing the existing healthcare workforce through a bundled diagnostics and on-site training intervention for nonphysician healthcare workers will rapidly improve TB case detection and outcomes towards global targets.

S78 Do Tuberculosis Cases Managed By Clinicians With Average Annual Caseloads Below 10 Have Poorer Treatment Outcomes?

Introduction and objectives The 2007 Department of Health Tuberculosis Toolkit advises that clinicians should not be solely managing tuberculosis (TB) cases if their average caseload is less than 10 per year. A systematic evaluation of whether these guidelines are being followed, and how effective such a threshold is, has not been undertaken in the UK. Methods All UK TB cases notified 2003–2011 were extracted from Public Health England’s Enhanced Tuberculosis Surveillance system. Mean caseload for each clinician was calculated over the preceding year and three years by using case notification date. 12 month TB treatment outcomes were categorised as unfavourable or good/neutral.1,2 Cases without clinician information and resistant to rifampicin were excluded, the latter due to UK recommendations on the length of treatment. The proportion of cases managed by clinicians with a caseload under 10 was analysed, then random effects logistic regression utilised to determine the relationship between caseload and treatment outcomes, adjusting for clustering by clinician and confounding. Results 74,550 TB cases were notified 2003–11. The proportion of TB cases seen by a clinician who had a low caseload (less than 10) in the preceding year declined gradually 2004–11 (42 to 28%), with no apparent acceleration post-Toolkit. Univariate modelling demonstrated very strong evidence of increased odds of an unfavourable treatment outcome among cases seen by a clinician who had a low caseload over the preceding three years (cluster-specific odds ratio 1.23 (95% confidence interval 1.14–1.33), p-value Conclusions Our analysis indicates that TB cases managed by clinicians with a mean caseload of under 10 over the preceding three years have increased odds of an unfavourable treatment outcome. However other factors, such as the number of clinicians managing TB cases in the hospital overall, should potentially be taken into account for policy recommendations. References Ditah, Thorax 2008;63:440–446 Anderson, Euro Surveill. 2013;18(40):pii=20601

Drug-resistance - a challenge for tuberculosis control in the European Union and European Economic Area

Worldwide resistance to antituberculosis drugs is jeopardising the control and eventually the elimination of tuberculosis (TB). Patients who are infected by Mycobacterium tuberculosis resistant to antituberculosis drugs, especially to both isoniazid and rifampicin and thus having multidrug-resistant (MDR) TB, need more complicated treatment that lasts longer and consists of a large number of drugs and frequently leads to side effects. In the European Union and European Economic Area (EU/EEA), treatment outcome results for all types of drug resistance were below the target of 85% set by the European Centre for Disease Prevention and Control (ECDC), for new pulmonary culture-positive cases and with 34% the reported treatment success rate of MDR-TB cases was substantially below the target of 70% [1, 2]. Of TB cases diagnosed with MDR-TB in 2009 in the EU/EEA, almost two-thirds died during treatment, failed their treatment or defaulted from treatment. This failure to ensure adequate MDR-TB treatment not only puts patients’ lives at risk but also paves the way for XDR TB, and further transmission of the disease. Analysis of the worldwide data for TB from 2007 to 2010, showed proportions of MDR-TB of 3.4% in new TB cases and 19.8% in those previously treated [3]. The proportions of TB cases with MDR-TB are similar in the EU/EEA with 2.6% of the new culture-confirmed TB cases diagnosed with MDR-TB and 18.8% of previously treated culture-confirmed TB cases [2]. In this issue of Eurosurveillance and in the 13 March issue, studies on surveillance of drug-resistant TB, including molecular surveillance, are published. These studies show that drug-resistant TB occurs in diverse settings in Europe and that there is ongoing transmission of drug-resistant TB also in countries with a low TB incidence.

Predicting U.S. Tuberculosis Case Counts through 2020

In 2010, foreign-born persons accounted for 60% of all tuberculosis (TB) cases in the United States. Understanding which national groups make up the highest proportion of TB cases will assist TB control programs in concentrating limited resources where they can provide the greatest impact on preventing transmission of TB disease. The objective of our study was to predict through 2020 the numbers of U.S. TB cases among U.S.-born, foreign-born and foreign-born persons from selected countries of birth. TB case counts reported through the National Tuberculosis Surveillance System from 2000–2010 were log-transformed, and linear regression was performed to calculate predicted annual case counts and 95% prediction intervals for 2011–2020. Data were analyzed in 2011 before 2011 case counts were known. Decreases were predicted between 2010 observed and 2020 predicted counts for total TB cases (11,182 to 8,117 [95% prediction interval 7,262–9,073]) as well as TB cases among foreign-born persons from Mexico (1,541 to 1,420 [1,066–1,892]), the Philippines (740 to 724 [569–922]), India (578 to 553 [455–672]), Vietnam (532 to 429 [367–502]) and China (364 to 328 [249–433]). TB cases among persons who are U.S.-born and foreign-born were predicted to decline 47% (4,393 to 2,338 [2,113–2,586]) and 6% (6,720 to 6,343 [5,382–7,476]), respectively. Assuming rates of declines observed from 2000–2010 continue until 2020, a widening gap between the numbers of U.S.-born and foreign-born TB cases was predicted. TB case count predictions will help TB control programs identify needs for cultural competency, such as languages and interpreters needed for translating materials or engaging in appropriate community outreach.

Understanding Disparity on the Canadian Prairies: A Step toward Improving Tuburculosis Outcomes

Understanding Disparity on the Canadian Prairies: A Step toward Improving Tuburculosis Outcomes

Tuberculosis in an Urban Area in China: Differences between Urban Migrants and Local Residents

BackgroundThe increase in urban migrants is one of major challenges for tuberculosis control in China. The different characteristics of tuberculosis cases between urban migrants and local residents in China have not been investigated before.Methodology/Principal FindingsWe performed a retrospective study of all pulmonary tuberculosis patients reported in Songjiang district, Shanghai, to determine the demographic, clinical and microbiological characteristics of tuberculosis cases between urban migrants and local residents. We calculated the odds ratios (OR) and performed multivariate logistic regression to identify the characteristics that were independently associated with tuberculosis among urban migrants. A total of 1,348 pulmonary tuberculosis cases were reported during 2006–2008, among whom 440 (32.6%) were local residents and 908 (67.4%) were urban migrants. Urban migrant (38.9/100,000 population) had higher tuberculosis rates than local residents (27.8/100,000 population), and the rates among persons younger than age 35 years were 3 times higher among urban migrants than among local residents. Younger age (adjusted OR per additional year at risk = 0.92, 95% CI: 0.91–0.94, p<0.001), poor treatment outcome (adjusted OR = 4.12, 95% CI: 2.65–5.72, p<0.001), and lower frequency of any comorbidity at diagnosis (adjusted OR = 0.20, 95% CI: 0.13–0.26, p = 0.013) were significantly associated with tuberculosis patients among urban migrants. There were poor treatment outcomes among urban migrants, mainly from transfers to another jurisdiction (19.3% of all tuberculosis patients among urban migrants).Conclusions/SignificanceA considerable proportion of tuberculosis cases in Songjiang district, China, during 2006–2008 occurred among urban migrants. Our findings highlight the need to develop and implement specific tuberculosis control strategies for urban migrants, such as more exhaustive case finding, improved case management and follow-up, and use of directly observed therapy (DOT).

Coloring the white plague: a syndemic approach to immigrant tuberculosis in Canada

Objective. In this article, we adopt a syndemic approach to immigrant tuberculosis (TB) in Canada as a way of challenging contemporary epidemiological models of infectious diseases that tend to racialize and medicalize the risk of infections in socio-economically disadvantage populations and obscure the role of social conditions in sustaining the unequal distribution of diseases in these populations. Design. A syndemic approach unravels social and biological connections which shape the distribution of infections over space and time and is useful in de-racializing and de-medicalizing these epidemiologic models. The socio-historic framework allows us to examine social factors which, refracted through medical science, were central to the development of TB control in Canada at the beginning of twentieth century. Results. We expose the ideological assumptions about race, immigration, and social status which underpin current policies designed to control TB within the immigrant population. We argue that TB control policies which divert the attention from structural health determinants perpetuate health and social inequities of racialized populations in Canada. Medical screening and surveillance is an ineffective control policy because the proportion of TB cases attributed to immigrants increased from 18 to 66% between 1970 and 2007. Conclusion. More effective TB control policies require shifting the focus from the individual disease carriers toward social inequities which underlie the problem of immigrant TB in Canada. In addition, de-racialization and de-medicalization of the contemporary epidemiological models of infectious diseases entail an in-depth exploration of how the categories of ethnicity, culture, and immigration status are played out in everyday health-related experiences of racialized groups.

Increased prevalence of advanced tuberculosis in rural low tuberculosis caseload counties in North Carolina

Pulmonary tuberculosis (TB) patients reported in North Carolina (NC), USA, from 1996 to 2008 (inclusive). To compare prevalence of cavitary TB as a surrogate marker for advanced disease in low-caseload counties with high-caseload counties. A multivariate log binomial regression model was used to estimate prevalence ratios (PRs) for cavitary TB. The proportion of TB cases in low-caseload counties vs. the total number of TB cases in NC over the study period increased from 10% in 1996 to 20% in 2008. After adjusting for human immunodeficiency virus (HIV) status, excess alcohol use and report year, patients in rural areas of low-caseload counties had greater prevalence (PR 1.40, 95%CI 1.19-1.64) of cavitary disease compared with patients from rural areas of high-caseload counties. The prevalence of cavitary TB did not differ between urban residents of high- or low-caseload counties (PR 1.00, 95%CI 0.86-1.16) after adjusting for HIV status, excess alcohol use and report year. TB patients in rural areas of low-caseload counties presented with more advanced TB disease compared with patients from urban and/or high-caseload counties. Barriers to timely recognition of TB in rural low-caseload settings must be considered in TB control programs.

The provider cost of treating tuberculosis in Bauchi State, Nigeria.

The study was aimed at assessing the economic cost shouldered by government, as providers, in the provision of free Tuberculosis (TB) diagnosis and treatment services in Bauchi State, northern Nigeria. A cost analysis study was designed and questionnaires administered by the principal investigators to officers in charge of 27 randomly sampled government TB services providers across the State of Bauchi. Seventeen of these centers were primary care centers, 9 secondary care providers and one was a tertiary care provider. Data was also collected from personnel and projects records in the State Ministry of Health, of Works as well as the Ministry of Budget and Planning. The cost of buildings, staff and equipment replacement, laboratory, radiology and drugs in facilities were assessed and costs attributable tuberculosis inpatient, outpatient and directly observed therapy (DOT) services were estimated from the total cost based on the proportion of TB cases in the total patient pool accessing those services. The average proportion of TB patients in facilities was 3.4% in overall, 3.3% among inpatients and 3.1% in the outpatient population. The average cost spent to treat a patient with TB was estimated at US $227.14. The cost of inpatient care averaged $16.95/patient; DOT and outpatient services was $133.34/patient, while the overhead cost per patient was $30.89.The overall cost and all computed cost elements, except for DOT services, were highest in the tertiary center and least expensive in the infectious diseases hospital partly due to the higher administrative and other overhead recurrent spending in the tertiary health facility while the lower overhead cost observed in the infectious diseases hospital could be due to the economy of scale as a result of the relative higher number of TB cases seen in the facility operating with relatively same level of resources as other facilities in the state.

Tuberculosis in the elderly in Germany

To the Editors: Germany has a low tuberculosis (TB) incidence with a decreasing trend [1]. However, the proportion of TB patients aged ≥60 yrs is increasing (1976: 26.5%; 1986: 30.9%; 1996: 33.7%; 2006: 34.8%. 1976 and 1986 figures are for the Federal Republic of Germany only), reflecting demographic changes. Age-related factors not only increase the risk of TB reactivation but also enhance susceptibility to TB infection, abetting outbreaks, e.g. in nursing homes [2, 3]. To optimise healthcare services and TB control in this subpopulation of growing impact, detailed knowledge of the epidemiological features of TB in the elderly is needed. National German TB notification data from 2002 to 2006 were analysed as a pooled 5-yr data set stratified into two age groups: TB patients 15–59 yrs (referred to as “younger adults”) and those aged ≥60 yrs (“the elderly”). For both groups, proportions of TB cases with reference to demographic factors, affected organs, drug resistance, case finding and treatment outcome were determined. Mortality (based on treatment outcome notification data), TB incidence, and age-specific TB incidence in 5-yr strata were calculated based on population data from regional statistical offices (time averaged 2002–2006). As the country of birth was unknown for the general population, origin-related TB incidence was derived from citizenship information. Proportion (%) and incidence (cases per 100,000 population) were compared between both groups using the Z-test. Odds ratios (ORs), 95% confidence intervals (CIs) and corresponding p-values were specified. Data were collected using the electronic reporting system SurvNet@rki (Robert Koch Institute, Berlin, Germany) and analysed using SPSS version 15 (SPSS Inc., Chicago, IL, USA), Excel (Microsoft Corporation, Redwood, CA, USA) and Stata version 11.0 (StataCorp LP, College Station, TX, USA). A total of 31,459 TB cases aged ≥15 yrs were identified. Details of the study set …