Adult Tuberculosis Cases Research Articles

Identifying locations of recent TB transmission in rural Uganda: a multidisciplinary approach.

Targeting high Tuberculosis (TB) transmission sites may offer a novel approach to TB prevention in sub-Saharan Africa. We sought to characterise TB transmission sites in a rural Ugandan township. We recruited adults starting TB treatment in Tororo, Uganda, over 1year. Fifty four TB cases provided names of frequent contacts, sites of residence, health care, work and social activities, and two sputum samples. Mycobacterium tuberculosis (MTB) culture-positive specimens underwent spoligotyping to identify strains with shared genotypes. We visualised TB case social networks, and obtained, mapped and geo-coded global positioning system measures for every location that cases reported frequenting 1month before treatment. Locations of spatial overlap among genotype-clustered cases were considered potential transmission sites. Six distinct genotypic clusters were identified involving 21 of 33 (64%) MTB culture-positive, genotyped cases; none shared a home. Although 18 of 54 (33%) TB cases shared social network ties, none of the genotype-clustered cases shared social ties. Using spatial analysis, we identified potential sites of within-cluster TB transmission for five of six genotypic clusters. All sites but one were healthcare and social venues, including sites of drinking, worship and marketplaces. Cases reported spending the largest proportion of pre-treatment person-time (22.4%) at drinking venues. Using molecular epidemiology, geospatial and social network data from adult TB cases identified at clinics, we quantified person-time spent at high-risk locations across a rural Ugandan community and determined the most likely sites of recent TB transmission to be healthcare and social venues. These sites may not have been identified using contact investigation alone.

Survival analysis of adult tuberculosis disease.

BackgroundWe conducted a survival analysis of all the confirmed cases of Adult Tuberculosis (TB) patients treated in Cork-City, Ireland. The aim of this study was to estimate Survival time (ST), including median time of survival and to assess the association and impact of covariates (TB risk factors) to event status and ST. The outcome of the survival analysis is reported in this paper.MethodsWe used a retrospective cohort study research design to review data of 647 bacteriologically confirmed TB patients from the medical record of two teaching hospitals. Mean age 49 years (Range 18–112). We collected information on potential risk factors of all confirmed cases of TB treated between 2008–2012. For the survival analysis, the outcome of interest was ‘treatment failure’ or ‘death’ (whichever came first). A univariate descriptive statistics analysis was conducted using a non- parametric procedure, Kaplan -Meier (KM) method to estimate overall survival (OS), while the Cox proportional hazard model was used for the multivariate analysis to determine possible association of predictor variables and to obtain adjusted hazard ratio. P value was set at <0.05, log likelihood ratio test at >0.10. Data were analysed using SPSS version 15.0.ResultsThere was no significant difference in the survival curves of male and female patients. (Log rank statistic = 0.194, df = 1, p = 0.66) and among different age group (Log rank statistic = 1.337, df = 3, p = 0.72). The mean overall survival (OS) was 209 days (95%CI: 92–346) while the median was 51 days (95% CI: 35.7–66). The mean ST for women was 385 days (95%CI: 76.6–694) and for men was 69 days (95%CI: 48.8–88.5). Multivariate Cox regression showed that patient who had history of drug misuse had 2.2 times hazard than those who do not have drug misuse. Smokers and alcohol drinkers had hazard of 1.8 while patients born in country of high endemicity (BICHE) had hazard of 6.3 and HIV co-infection hazard was 1.2.ConclusionThere was no significant difference in survival curves of male and female and among age group. Women had a higher ST compared to men. But men had a higher hazard rate compared to women. Anti-TNF, immunosuppressive medication and diabetes were found to be associated with longer ST, while alcohol, smoking, RICHE, BICHE was associated with shorter ST.

Tuberculosis in HIV-infected infants, children, and adolescents in Latin America

ObjectiveTo evaluate the occurrence, clinical presentations and diagnostic methods for tuberculosis in a cohort of HIV-infected infants, children and adolescents from Latin America. MethodsA retrospective analysis of children with tuberculosis and HIV was performed within a prospective observational cohort study conducted at multiple clinical sites in Latin America. ResultsOf 1114 HIV-infected infants, children, and adolescents followed from 2002 to 2011, 69 that could be classified as having confirmed or presumed tuberculosis were included in this case series; 52.2% (95% CI: 39.8–64.4%) had laboratory-confirmed tuberculosis, 15.9% (95% CI: 8.2–26.7%) had clinically confirmed disease and 31.9% (95% CI: 21.2–44.2%) had presumed tuberculosis. Sixty-six were perinatally HIV-infected. Thirty-two (61.5%) children had a history of contact with an adult tuberculosis case; however information on exposure to active tuberculosis was missing for 17 participants. At the time of tuberculosis diagnosis, 39 were receiving antiretroviral therapy. Sixteen of these cases may have represented immune reconstitution inflammatory syndrome. ConclusionsOur study emphasizes the need for adequate contact tracing of adult tuberculosis cases and screening for HIV or tuberculosis in Latin American children diagnosed with either condition. Preventive strategies in tuberculosis-exposed, HIV-infected children should be optimized.

Assessment of children exposed to adult pulmonary tuberculosis in Cali, Colombia

Background:There is a lack of uniform criteria for the diagnosis and management of tuberculosis (TB) in children in Cali, Colombia. Addressing TB in children is a challenge in this setting, under both programmatic and research conditions.Objectives:To facilitate the diagnostic assessment of TB in a paediatric cohort of TB household contacts.Methods:A diagnostic and management algorithm (DMA) was used to assess children exposed to adult TB cases, according to clinical and epidemiological findings and under programmatic conditions. On the basis of diagnostic tests, cases were classified as TB exposure, TB infection, suspected TB, possible TB or confirmed TB and then submitted to a management plan. This was a prospective pilot study nested within a national cohort study of the transmission dynamics of Mycobacterium tuberculosis, undertaken in Colombia during 2005–2008.Results:During 24 months of follow-up, 54 of 217 children met the criteria for assessment by DMA, 18 of whom (33%) were considered to be TB incident cases (new TB cases among household contacts). The main clinical findings were failure to thrive and cough lasting >21 days. Only one case was smear-positive and culture-confirmed TB. TB treatment was given to 16 children and they demonstrated clinical and radiographic resolution at follow-up. Conducting the study under programmatic conditions demonstrated barriers to accessing competent radiological evaluation, correct interpretation of the tuberculin skin test, and proper specimen collection.Conclusion:Structured assessment using DMA facilitated the detection of incident TB cases. The study identified potential barriers to addressing childhood TB in Cali.

HIV Testing of Tuberculosis Patients by Public and Private Providers in New York City

Thirty percent of tuberculosis (TB) patients in New York City in 2007 were not tested for HIV, which may be attributable to differential testing behaviors between private and public TB providers. Adult TB cases in New York City from 2001 to 2007 (n = 5,172) were evaluated for an association between TB provider type (private or public) and HIV testing. Outcomes examined were offers of HIV tests and patient refusal of HIV testing, using multivariate logistic and binomial regression, respectively. HIV test offers were less frequent among patients who visited only private providers than patients who visited only public providers [males: adjusted odds ratio (aOR) 0.33, 95% confidence interval (CI) 0.15-0.74; females: aOR 0.26, 95% CI 0.12-0.57]. Changing from private to public providers was associated with an increase in HIV tests offered among male patients (aOR 1.96, 95% CI 1.04-3.70). Among patients who did not use substances, those who visited only private providers were more likely to refuse HIV testing than those who visited only public providers [males: adjusted prevalence ratio (aPR) 1.26, 95% CI 0.99-1.60; females: aPR 1.78, 95% CI 1.43-2.22]. Patients of private providers were less likely to have an HIV test performed during their TB treatment. Education of TB providers should emphasize HIV testing of all TB patients, especially among patients who are traditionally considered low-risk.

Are routine tuberculosis programme data suitable to report on antiretroviral therapy use of HIV-infected tuberculosis patients?

BackgroundAntiretroviral therapy (ART) is lifesaving for HIV-infected tuberculosis (TB) patients. ART-use by these patients lag behind compared to HIV-testing and co-trimoxazole preventive therapy. TB programmes provide the data on ART-use by HIV-infected TB patients, however often the HIV services provide the ART. We evaluated whether the data on ART-use in the TB register were complete and correct. The timing of ART initiation was evaluated to assess whether reporting on ART-use could have happened with the TB case finding reporting. We collected data on TB treatment, HIV testing and ART for adult TB cases in 2007 from three TB clinics in Manica Province, Mozambique. These data on use of ART from TB registers were compared with those from the HIV services.FindingsOf 628 patients included, 504 (81%) were tested and of these 356 (71%) were HIV-infected. Of the co-infected patients, 81% registered with the HIV services in the same facility. The TB register was correct on ART-use in 73% of co-infected cases and complete in 74%. Information on ART-use could have been reported with the TB case finding reports in 56% of co-infected patients.ConclusionThe TB register is reasonably correct and complete on ART-use. However, the HIV patient record seems a much better source to provide this information. Reporting on ART-use at the end of the quarter in which TB treatment starts provides the programme with timely but incomplete information. A more complete but less timely picture is available after a year.

Impact of isoniazid preventive therapy on mortality among children less than 5 years old following exposure to tuberculosis at home in Guinea-Bissau: a prospective cohort study

ObjectiveIn a cohort of children less than 5 years old exposed to adult intrathoracic tuberculosis (TB) in 1996–1998, we found 66% increased mortality compared with community controls. In 2005, we...

The effect of tuberculosis and antiretroviral treatment on CD4+ cell count response in HIV-positive tuberculosis patients in Mozambique

BackgroundTuberculosis (TB) presents a serious problem in Mozambique. HIV prevalence among TB patients is estimated at 47%. A delay in having their first CD4+ cell count could lead to a missed opportunity for ART initiation due to a CD4+ cell increase above the cut-off caused by TB treatment. The objective is to describe CD4+ cell response during TB treatment and quantify the effect of TB treatment and ART on this response.MethodsAll new HIV + adult TB cases in 2007 from three TB clinics in Mozambique were included. Data on TB diagnosis and treatment and HIV parameters were collected. A general mixed model was used for CD4+ cell count response.Results338 HIV + patients were notified and 252 (75%) were included in the analysis. Using TB medication was not independently associated with the CD4+ count response (19 cells/mm3; 95% CI: -40 to 79; p = 0.529). ART-use was associated with statistically significantly higher CD4+ cells compared to no ART-use (81 cells/mm3; 95% confidence interval (CI): 12 to 151; p = 0.022).ConclusionIn this study, no independent effect of TB treatment on CD4+ cell count was found. HIV-infected TB patients on ART had a significantly higher CD4+ cell count than those not receiving ART. CD4+ cell counts for patients not on ART at TB treatment start, remained below the cut off for initiating ART during the first three months of TB treatment; therefore some delay in getting the first CD4+ cell count would not lead to missing the opportunity to start ART.

Adherence to and outcome of isoniazid chemoprophylaxis among household contact children of adults having pulmonary tuberculosis in Alexandria, Egypt

Current international guidelines recommend 6-9 months of isoniazid (INH) preventive chemotherapy to prevent the development of active tuberculosis (TB) in susceptible children exposed to Mycobacterium tuberculosis. However, this is dependent on good adherence, as shown by previous studies. This study was conducted to describe the outcome of screening of contact children aged 5 years or less with household exposure to an adult pulmonary TB index case to determine the prevalence and possible risk factors of infection among contact children and to determine the extent and outcome of adherence of contact children to unsupervised INH chemoprophylaxis for 6 months. A descriptive facility-based cross-sectional study was conducted from March 2009 to August 2010. Research settings were three of the National TB control program chest dispensaries (primary care facilities) in Alexandria, Egypt. Facility-based TB treatment registers of the previous 3 months were used to identify all new adult pulmonary TB cases. All children aged 5 years or less living in the same house as the index cases were identified and screened for TB. The contact children were given unsupervised INH preventive chemotherapy once active TB was excluded. Adherence to and outcome of preventive chemotherapy were followed up. Preventive chemotherapy consisted of unsupervised INH monotherapy for 6 months with monthly collection of tablets from the clinic. Adherence was documented after completion of the 6-month preventive treatment period. Adherence was considered reasonable if tablets were collected for more than 4 months, poor if collected for 2-4 months, and very poor if collected for less than 2 months. (a) Prevalence of infection and disease and the possible risk factors among contacts. (b) The extent and outcome of adherence to unsupervised INH chemoprophylaxis among contact children. (c) Factors behind poor adherence. In total, 197 adult TB index cases from 187 households were identified. In all, 297 children aged 5 years or less experienced household exposure, of whom 252 (84.9%) were fully evaluated. Tuberculin test was positive in 136 of the 252 child contacts (54.0%), of whom 130 were contacts of sputum-positive patients and six were contacts of sputum-negative patients. The important risk factors for transmission of TB infection were younger age, male sex, severe malnutrition, absence of BCG vaccination, contact with a sputum-positive adult who was a source case, household overcrowding, and exposure to environmental tobacco smoke. Thirty-three children were diagnosed and treated for TB at the baseline screening and 217 received preventive INH chemotherapy. Of the children who received preventive chemotherapy, only 36 (16.6%) completed at least 4 months of unsupervised INH monotherapy. During the subsequent follow-up period, eight children developed TB (secondary attack rate for TB disease was 3.7%), of whom four received no preventive chemotherapy and four were poorly adherent. The prevalence of TB infection and clinical disease among children in household contact with adult patients is high, and risk is significantly increased because of child contact, index patients and environmental factors. Adherence to 6 months of unsupervised INH chemoprophylaxis was very poor.

Tuberculosis and alcohol misuse in Scotland: a population-based study using enhanced surveillance data

To identify for the first time in Scotland the epidemiological characteristics of tuberculosis (TB) patients who misuse alcohol. A retrospective cohort study using Enhanced Surveillance of Mycobacterial Infections (ESMI) scheme data for adult (aged ≥ 18 years) TB cases notified in Scotland, 2001-2007. Characteristics and treatment outcomes of TB cases with and without recorded alcohol misuse were compared. Of 2419 adult TB cases, alcohol misuse was recorded in 426 (18%). Alcohol misuse was associated with male sex, White ethnicity, birth in the United Kingdom, unemployment, urban residence and socio-economic deprivation. Alcohol misusers were more likely than other TB cases to have pulmonary TB (92% vs. 61%, P < 0.001), be sputum smear-positive (74% vs. 58%, P < 0.001) and be enrolled on directly observed treatment (30% vs. 3%, P < 0.001). Treatment completion rates were respectively 77% and 79% (P = 0.34) in alcohol misusers and other TB cases. We have identified epidemiological characteristics associated with alcohol misuse among TB patients in Scotland, notably socio-economic deprivation. We suggest improvements in data collection to allow more robust findings to inform policy decisions to assist the prevention and management of alcohol misuse and reduce the TB incidence in Scotland.

Adherence to isoniazid preventive therapy in children exposed to tuberculosis: a prospective study from Guinea-Bissau

To assess adherence to isoniazid preventive therapy (IPT) in children exposed to adult pulmonary tuberculosis (TB) at home. Children were enrolled on IPT if they were aged ≤ 5 years or 5-15 years and presented a tuberculin skin test induration of ≥ 10 mm. Children were included from the demographic surveillance system of the Bandim Health Project in Bissau, Guinea-Bissau. The main outcome measures were adherence, completion rates and side effects during 9 months of IPT. The main outcome was 6 consecutive months of at least 80% adherence. A total of 2631 children were identified as contacts of adult TB cases. Among the children identified, 1895 (72%) were evaluated for eligibility for IPT, and 820 were enrolled in the study: 609 were aged ≤ 5 years and 211 aged 5-15 years. A total of 79% of the prescribed doses were taken, with 65% of the children taking > 80% of their doses. In all, 51% completed more than 6 consecutive months of IPT. Overall adherence to IPT was better than previously reported from TB-endemic areas, with 76% of the children completing at least 6 months of treatment, with more than 80% adherence.

Longitudinal Analysis of QuantiFERON-TB Gold In-Tube in Children with Adult Household Tuberculosis Contact in South Africa: A Prospective Cohort Study

BackgroundQuantiFERON-TB Gold In Tube (QFT-GIT) is a tool for detecting M. tuberculosis infection. However, interpretation and utility of serial QFT-GIT testing of pediatric tuberculosis (TB) contacts is not well understood. We compared TB prevalence between baseline and 6 months follow-up using QFT-GIT and tuberculin skin testing (TST) in children who were household contacts of adults with pulmonary TB in South Africa, and explored factors associated with QFT-GIT conversions and reversions.MethodProspective study with six month longitudinal follow-up.ResultsAmong 270 enrolled pediatric contacts, 196 (73%) underwent 6-month follow-up testing. The 6-month prevalence estimate of MTB infection in pediatric contacts increased significantly from a baseline of 29% (79/270, 95%CI [24–35]) to 38% (103/270, 95% CI [32–44], p<0.001) using QFT-GIT; prevalence increased from a baseline of 28% (71/254, 95%CI [23–34]) to 33% (88/263, 95%CI [21–32], p = 0.002) using TST. Prevalence estimates were influenced by thresholds for positivity for TST, but not for QFT-GIT. Among 134 children with a negative or indeterminate baseline QFT-GIT, 24 (18%) converted to positive at follow-up; conversion rates did not differ significantly when using more stringent thresholds to define QFT-GIT conversion. Older age >10 years (AOR 8.9 95%CI [1.1–72]) and baseline TST positivity ≥5 mm (AOR 5.2 95%CI [1.2–23]) were associated with QFT-GIT conversion. Among 62 children with a positive baseline QFT-GIT, 9 (15%) reverted to negative; female gender (AOR 18.5 95%CI [1.1–321]; p = 0.04] was associated with reversion, while children with baseline positive TST were less likely to have QFT-GIT reversion (AOR 0.01 95%CI [0.001–0.24]).ConclusionAmong pediatric contacts of adult household TB cases in South Africa, prevalence estimates of TB infection increased significantly from baseline to 6 months. Conversions and reversions occurred among pediatric TB contacts using QFT-GIT, but QFT-GIT conversion rates were less influenced by thresholds used for conversions than were TST conversion rates.

Discussing the current situation of tuberculosis case-finding by mass miniature radiography in Japan

The system of tuberculosis (TB) case-finding by mass miniature radiography (MMR) was established and expanded for almost all Japanese citizens in the 1950s. And, as stipulated by the TB Prevention Law, periodic mass screenings for schools, inhabitants, employees and institutions have been carried out. Among those aged over 25 years, the proportion of people screened by MMR was estimated to be 60.3%. This means that about 54 million people aged over 25 years are receiving medical service with MMR every year. However, the detection rates of TB cases by MMR have declined markedly compared with those in 1950s. As of 1998, the detection rate was 0.03 per 1,000 for school children and students, 0.06 per 1,000 for employees, and 0.16 per 1,000 for inhabitants. The proportion of cases detected by MMR among newly notified TB cases was 12.8% in 1998, and this ratio has been almost constant for the last 10 years. This ratio was greater among young adult TB cases. Approximately 20% of notified TB cases aged 20-39 years were detected by MMR for employees. Although the purpose of MMR is to find the cases before discharging TB bacilli, 35.1% of the cases were bacteriologically confirmed, and this proportion was greater among elderly TB cases. The Japan Anti-Tuberculosis Association (JATA) has been carrying out MMR for a long time. Eight selected branches of JATA that has been doing high quality case-finding reported 228 TB cases out of 965,440 inhabitants aged over 40 years examined by MMR in 1996. Based on these results, the cost per TB case detected by MMR was calculated. The cost was 4.4 millions yen (yen) per case for all forms of TB, yen 2.3 millions for male, yen 8.4 millions for female, yen 7.3 millions for those aged 40-49 years and yen 1.8 millions for those aged over 80 years. TB detection rate by MMR for inhabitants was correlated with TB incidence rate in various areas, and based on this correlation, the cost was calculated for various incidence rates. For all forms of TB, the cost was yen 4.0 millions per case for an incidence rate of 30 per 100,000, and yen 6.7 millions for an incidence rate of 20 per 100,000. MMR is not economically cost-effective even among elderly people and in areas with incidence rate less than 50 per 100,000, because the medical expense for a TB patient treated under hospitalization for 2 months and outpatient's clinic for 4 months is approximately yen 0.9 millions in 1996. The decision making in continuation or abolition or limitation of MMR should be discussed from a wide range of cost-effectiveness analyses as well as from the view of public health service and willingness of people. For the purpose of decision making, this study provides the detection rates; the costs stratified by sex, age and incidence; and the proportion of cases detected by MMR among newly notified TB cases by age-group and bacteriological status.

Tuberculosis in Older Adults in the United States, 1993-2008

To describe older adults with tuberculosis (TB) and compare demographic, diagnostic, and disease characteristics and treatment outcomes between older and younger adults with TB. Descriptive analysis of all confirmed people with TB aged 21 and older. The National Tuberculosis Surveillance System (NTSS) for the 50 United States and the District of Columbia from 1993 to 2008. A total of 250,784 adult TB cases were reported, including 61,119 people with TB aged 65 and older. TB case count and rates and proportion of TB cases in older adults. Older adults had consistently higher incidence rates of TB than younger adults. In 2008, the rate of TB in older adults was 6.4 per 100,000, compared with 5.0 per 100,000 for younger adults. A lower percentage of older adults had TB diagnostic test results (tuberculin skin test, sputum smear, sputum culture) or human immunodeficiency virus (HIV) infection status reported. TB risk factors (substance use, homelessness, HIV infection) and multidrug-resistant TB were less prevalent in older than younger adults. Seven percent of older adults were dead at diagnosis, and 21% died during therapy, compared with 2% and 7%, respectively, of younger adults. Sputum culture conversion percentages were similar for people who did not die. Older adults also completed therapy in a timely manner, similar to younger adults. Although older adults had higher rates of TB and mortality, for older adults who survived therapy, successful treatment outcomes were similar to those of younger adults.

Antiretroviral Therapy and TB Notification Rates in a High HIV Prevalence South African Community

Antiretroviral therapy (ART) has been proposed as an intervention for reducing tuberculosis (TB) burdens in areas with high HIV prevalence. However, little data is available on the impact of ART on population-level TB. Trends in adult TB case fatality and notifications were assessed before and during increasing ART coverage in a well-defined periurban community, from 1997 to 2008. Mean changes in TB rates were measured using linear autoregression models. ART coverage increased from 1% in 2003 to 5%, 13%, and 21% of HIV-infected population in 2004, 2005, and 2008, respectively. From 1997 to end of 2004 TB notification rates increased by an average of 187 cases/100,000/year (P < 0.001), reaching a peak of 2536/100,000 in 2005. From 2005 to 2008, TB notification rates declined by approximately 202 cases/100,000/year (P < 0.001). TB rates were initially stable in HIV-uninfected individuals, but declined moderately from 2005. TB rates declined in HIV-infected adults from 6513/100,000 in 2005 to 4741/100,000 in 2008. The predominant decline in TB notifications occurred among HIV-infected patients receiving ART (1156 cases/100,000/year) and was less marked in those not receiving ART (416 cases/100,000/year). Similarly, TB case fatality was constant for HIV-uninfected individuals, but declined in HIV-infected individuals from 23% in 2002 to 8% in 2008 (P = 0.01). In this community heavily affected by both HIV and TB epidemics, rapid and high ART coverage was associated with significant reductions in TB notifications and TB-associated case fatality.

Factors determining household expenditure for tuberculosis and coping strategies in Tajikistan

To investigate factors influencing expenditure levels and the use of potentially detrimental coping strategies among tuberculosis (TB) patients. For the purpose of the present study, potentially detrimental coping strategies included borrowing money and selling assets. Questionnaire survey with an initial and a follow-up interview of each adult new pulmonary TB case registered over a period of 4 months, conducted in 12 districts with DOTS in Tajikistan, one of the poorest countries in the world. Patients and their households faced mean expenditures of US$ 396 related to a TB episode. In multivariate mixed-effect regression models, the main determinants of out-of-pocket payments-either over the whole course of the disease or after enrolment in DOTS treatment-were 'complimentary treatment' besides the anti-TB drugs, duration of hospitalization and treatment delay. Complimentary treatment mainly consisted of vitamins and rehydrating infusions. Sex showed no association with expenditure. To cope with the costs of illness, two-thirds of patients employed a potentially detrimental coping strategy. TB patients raised on average US$ 23 through loans with interest, US$ 57 through loans without interest and US$ 102 through selling assets. The catastrophic out-of-pocket payments faced by TB patients are correlated with receiving complimentary treatment, delay to treatment and duration of hospitalisation. The widespread use of potentially detrimental coping strategies illustrates that TB constitutes a substantial risk of impoverishment. More parsimonious use of complimentary treatment and hospitalisation could reduce illness-related costs for patients and should be carefully considered.

Household costs of illness during different phases of tuberculosis treatment in Central Asia: a patient survey in Tajikistan

BackgroundIllness-related costs incurred by patients constitute a severe economic burden for households especially in low-income countries. High household costs of illness lead to impoverishment; they impair affordability and equitable access to health care and consequently hamper tuberculosis (TB) control. So far, no study has investigated patient costs of TB in the former Soviet Union.MethodsAll adult new pulmonary TB cases enrolled into the DOTS program in 12 study districts during the study period were enrolled. Medical and non-medical expenditure as well as loss of income were quantified in two interviews covering separate time periods. Costs of different items were summed up to calculate total costs. For missing values, multiple imputation was applied.ResultsA cohort of 204 patients under DOTS, 114 men and 90 women, participated in the questionnaire survey. Total illness costs of a TB episode averaged $1053 (c. $4900 purchasing power parity, PPP), of which $292, $338 and $422 were encountered before the start of treatment, during intensive phase and in continuation phase, respectively. Costs per month were highest before the start of treatment ($145) and during intensive phase ($153) and lower during continuation phase ($95). These differences were highly significant (paired t-test, p < 0.0005 for both comparisons).ConclusionsThe illness-related costs of an episode of TB exceed the per capita GDP of $1600 PPP about two-and-a-half times. Hence, these costs are catastrophic for concerned households and suggest a high risk for impoverishment. Costs are not equally spread over time, but peak in early stages of treatment, exacerbating the problem of affordability. Mitigation strategies are needed in order to control TB in Tajikistan and may include social support to the patients as well as changes in the management of TB cases. These mitigation strategies should be timed early in treatment when the cost burden is highest.

Serodiagnostic Efficacy of Mycobacterium tuberculosis 30/32-kDa Mycolyl Transferase Complex, ESAT-6, and CFP-10 in Patients with Active Tuberculosis

Elimination of tuberculosis (TB) largely depends upon definitive rapid diagnosis and treatment. Widely used diagnostic tests do not qualify for use in a developing country due to lack of either desired accuracy or their cost. In the present study an enzyme-linked immunosorbent assay was used to evaluate the diagnostic potential of an immuno-dominant 30/32-kDa mycolyl transferase complex (Ag85 complex) and Mycobacterium tuberculosis-specific proteins (ESAT-6 and CFP-10) of the RD1 region. Higher sensitivity (84.1%) with Ag85 complex was observed compared with ESAT-6 (64.9%) and CFP-10 (66%), with almost similar specificity (Ag85: 85.2%, ESAT-6: 88.9%, CFP-10: 85.2%), whereas the individual components of Ag85 complex, i.e. Ag85A, Ag85B, and Ag85C, showed sensitivities of 44.6, 34, and 80.9% and specificities of 55.6, 74.1, and 40.7% respectively. A cocktail of Ag85 complex, ESAT-6, CFP-10, Ag85A, Ag85B, and Ag85C antigens also could not help in increasing either sensitivity (51.1%) or specificity (85.2%). Furthermore, immunoblot analysis using clinical isolates as well as a standard strain (H37Rv) of M. tuberculosis also showed strong reactivity of sera from TB patients to Ag85 complex and, to a lesser extent, also to ESAT-6. To conclude, use of Ag85 complex along with ESAT-6 and CFP-10 seems to be promising in minimizing the heterogeneous sero-responses of adult TB cases.

Childhood tuberculosis infection and disease: a spatial and temporal transmission analysis in a South African township.

Tuberculosis (TB) remains a leading cause of mortality and morbidity in South Africa. While adult TB results from both recent and past infection, childhood TB results from recent infection and reflects ongoing transmission despite current TB control strategies. A South African community with high rates of TB and HIV disease. A Geographic Information System was used to spatially and temporally define the relationships between TB exposure, infection and disease in children < 15 years of age with exposure to adult HIV-positive and HIV-negative TB disease on residential plots between 1997 and 2007. During the study period the annual adult TB notification rate increased from 629 to 2 106/100 000 and the rate in children aged < 15 years ranged between 664/100 000 and 1 044/100 000. The mean number of exposures to adult TB for TB-uninfected children, latently TB-infected children and TB cases were 5.1%, 5.4% and 33% per annum and the mean number of adult smear-positive cases per exposed child was 1.0, 1.6 and 1.9, respectively. Acquisition of TB infection was not associated with HIV status of the adult TB case to which the child was exposed, and 36% of child TB cases were diagnosed before the temporally closest adult case on their plot. Childhood infection and disease were quantitatively linked to infectious adult TB prevalence in an immediate social network. Childhood infection should be monitored in high-burden settings as a marker of ongoing TB transmission. Improved knowledge of township childhood and adult social networks could also facilitate targeted active case finding, which may provide an adjunct to currently failing TB control strategies.

Tuberculosis and AIDS co-morbidity in Brazil: linkage of the tuberculosis and AIDS databases

This study evaluated differences in AIDS patients with and without tuberculosis (TB) in Espírito Santo State, Brazil. Standard regional AIDS (SINAN, SISCEL, SICLOM and SIM) and tuberculosis (SINAN) databases were used. TB and AIDS databases were linked using Reclink software, version 3, with SPSS software support to identify co-infected cases. Data from July 2000 to June 2006 in Espírito Santo State were linked. The results showed 3,523 adult AIDS cases and 9,958 adult TB cases resulted in 430 co-infected patients, who were compared to 1,290 AIDS patients who never developed TB. Among 430 co-infected patients, TB was diagnosed first in 223 (51.9%), AIDS was first in 44 (10.2%), and AIDS and TB were diagnosed concurrently in 163 (37.9%). Median age did not differ between co-infected cases (36 years (interquartile range [IQR] 29-43) and non-co-infected cases (34 years; IQR 28-42). Pulmonary tuberculosis was diagnosed in 239 (55.6%); 109 (25.3%) had extra-pulmonary TB and 82 (19.1%) had both presentations. In the final logistic regression model, living in a metropolitan area [Odds Ratio (OR)=1.43 (95% Confidence Interval (CI) 1.05-1.95)], education < 3 years [OR=3.03 (95%CI 1.56-5.88)] and CD4 counts < 200/mm(3) [OR=1.14 (95%CI 1.09-1.18)] were associated with co-infection. This report emphasizes the significance of tuberculosis among AIDS cases in Brazil, and highlights the importance of evaluating secondary data for purposes of improving data quality and developing public health interventions.