Tuberculosis Treatment Programs Research Articles

The Impact of Tuberculosis on Zambia and the Zambian Nursing Workforce

In Zambia, the incidence of tuberculosis (TB) has greatly increased in the last 10 years. This article describes Zambia and highlights the country’s use of the United Nations Millennium Development Goals as a framework to guide TB treatment programmes. An overview of TB in Zambia is provided. Data related to TB cases at the county’s main referral hospital, the University Teaching Hospital (UTH), is discussed. Treatment policies and barriers are described. Zambian nurses have been greatly affected by the rise in the morbidity and mortality of nurses with TB. This article explains the impact of TB on the Zambian nursing workforce. Review of Zambian government programmes designed to address this health crisis and targeted interventions to reduce TB among nurses are offered.

Using GIS technology to identify areas of tuberculosis transmission and incidence.

BackgroundCurrently in the U.S. it is recommended that tuberculosis screening and treatment programs be targeted at high-risk populations. While a strategy of targeted testing and treatment of persons most likely to develop tuberculosis is attractive, it is uncertain how best to accomplish this goal. In this study we seek to identify geographical areas where on-going tuberculosis transmission is occurring by linking Geographic Information Systems (GIS) technology with molecular surveillance.MethodsThis cross-sectional analysis was performed on data collected on persons newly diagnosed with culture positive tuberculosis at the Tarrant County Health Department (TCHD) between January 1, 1993 and December 31, 2000. Clinical isolates were molecularly characterized using IS6110-based RFLP analysis and spoligotyping methods to identify patients infected with the same strain. Residential addresses at the time of diagnosis of tuberculosis were geocoded and mapped according to strain characterization. Generalized estimating equations (GEE) analysis models were used to identify risk factors involved in clustering.ResultsEvaluation of the spatial distribution of cases within zip-code boundaries identified distinct areas of geographical distribution of same strain disease. We identified these geographical areas as having increased likelihood of on-going transmission. Based on this evidence we plan to perform geographically based screening and treatment programs.ConclusionUsing GIS analysis combined with molecular epidemiological surveillance may be an effective method for identifying instances of local transmission. These methods can be used to enhance targeted screening and control efforts, with the goal of interruption of disease transmission and ultimately incidence reduction.

Cost effectiveness of tuberculosis treatment programmes

Cost effectiveness of tuberculosis treatment programmes

Cost effectiveness of tuberculosis treatment programmes

Cost effectiveness of tuberculosis treatment programmes

Tuberculosis – a missed opportunity?

The recent publicity surrounding tuberculosis (TB) in both the medical and the lay press, particularly in reference to a number of outbreaks of the disease in British schools, is a timely reminder of a ‘forgotten' disease that has never really gone away. Following a marked decrease in notification rates in developed counties in the 1960s and 1970s, TB control and treatment programmes were downgraded in the West, and soon both medical professionals and the lay public ceased to be able to identify early symptoms of the infection. Meanwhile, poorer countries continued to struggle to provide even basic medical resources, and death and sickness from TB continued unchecked. More recently, however, there has been a rise in the number of new cases of TB in industrialised nations, together with the emergence of multi-drug-resistant strains of the bacillus. This article reviews these and other aspects of the effectiveness of both UK and international TB control programmes.

Strategies to Decrease Tuberculosis in US Homeless Populations

The rate of tuberculosis (TB) among US homeless persons may be 20 times that of the general adult population. Studies suggest that the majority of urban homeless TB cases are attributable to ongoing transmission of TB. Optimal TB-control strategies in both chronically and transiently homeless populations are not known. To examine the effects of TB-control strategies on projected TB cases and deaths in US homeless populations using a computer-based simulation model. The US general population and a theoretical population of 2 million homeless individuals in 1995 were divided into 18 clinical states based on the risk for or presence of TB and human immunodeficiency virus (HIV) infection in a semi-Markov model. Prevalence of transiently and chronically homeless individuals with active TB and deaths from TB as a function of public health measures taken to control and eliminate TB, including improvement of treatment effectiveness, improvement in access to treatment, and vaccination with BCG. A 10% increase in access to treatment among homeless persons with active TB produced larger declines in predicted TB cases and deaths after 10 years (cases and deaths among chronically homeless persons decreased 12.5% and 19.8% and among transiently homeless persons dropped 35.9% and 32.4%, respectively) than improvements in the effectiveness of treatment programs (cases and deaths among chronically homeless persons declined 7.2% and 3.1% and among transiently homeless persons dropped 10.9% and 4.1%, respectively). A 10% increase in access to treatment among homeless persons with latent TB infection led to a 6.7% decline in TB among chronically homeless persons and a 5.7% decline among transiently homeless persons, while a 10% improvement in effectiveness of treatment for latent TB infection was associated with declines of 3.0% and 3.3%, respectively. When treatment for latent TB infection was modeled to be the same in vaccinated and nonvaccinated populations, BCG vaccination led to TB case declines of 15.4% and 21.5% in chronically and transiently homeless populations, respectively. Overcoming barriers faced by homeless individuals in accessing TB treatment programs will be crucial to reducing the burden of TB in this high-risk group. Increased treatment access, improvement in the effectiveness of treatment programs, and BCG vaccination of HIV-negative homeless individuals have the best chance to markedly decrease TB morbidity and mortality.

Drug-resistant tuberculosis in Taipei, 1996-1999

Objectives: To determine the trends, patterns, and risk factors associated with drug-resistant tuberculosis, we conducted a hospital-based retrospective study in Taipei. Methods: Clinical and bacteriologic data were routinely collected from 453 patients with a diagnosis of tuberculosis who were treated at Taipei Municipal Chronic Disease Hospital from January 1996 through December 1999 for whom drug-susceptibility testing was done. Results: Resistance to at least one drug was identified in 154 (34%) out of the 453 patients, and 34 (7.5%) patients were resistant to at least isoniazid and rifampin. Among the 199 patients with recurrent tuberculosis, 98 (49.2%) had isolates that showed resistance to at least one drug. Among the 254 new patients, 56 (22.0%) had isolates that were drug resistant. For all 453 patients, resistance to rifampin was most common (17.4%), followed by resistance to isoniazid (13.9%), streptomycin (13.7%), ethambutol (8.2%), and kanamycin (3.5%). A history of previous tuberculosis therapy (odds ratio = 9.4; 95% CI, 2.9-28) and being born outside of Taiwan (odds ratio 3.3; 95% CI, 1.1-34) were significant risk factors for multidrug resistance. Conclusions: Our data suggest that the Taipei tuberculosis control program should be rapidly strengthened by expanded use of directly observed therapy and more careful bacteriologic and clinical follow-up, particularly in cases of recurrence and in persons born outside of Taiwan in tuberculosis endemic areas. Our results also indicate that the regular measuring of rates of drug resistance and the monitoring and guiding of tuberculosis treatment programs could increase the therapeutic response rate and prevent the appearance of newly acquired resistance in patients with tuberculosis. In addition, with high rifampin resistance (17.4%), the regulated market for rifampin is essential in Taiwan. (AJIC Am J Infect Control 2001;29:41-7)

Microbiological confirmation of tuberculosis cases at diagnosis and at the end of treatment in Italy.

Microbiological findings at diagnosis and at the end of treatment are relevant for evaluating tuberculosis (TB) treatment programmes. The objectives of this study were to describe the microbiological findings at diagnosis and at the end of treatment in pulmonary and extrapulmonary TB patients treated under programme conditions in Italy. The study was a prospective monitoring activity based on the collection of standard recording and reporting forms from a representative sample of Italian TB Units. The forms with individual data were reviewed and analysed on a quarterly basis, 9 months after enrolment. The complete bacteriological profile of patients was analysed at diagnosis and at the completion of treatment. Individual data on 992 patients were analysed. At diagnosis 320 (32.2%) of cases were pulmonary sputum smear positive, 361 (36.4%) pulmonary smear negative or not done and 311 (33.4%) extrapulmonary; 424 (42.7%) of all TB cases were culture confirmed at diagnosis (368, 50.2%, of pulmonary cases); 575 (84.4%) of pulmonary cases had a culture done at diagnosis and 156 (22.9%) at the end of treatment (p < 0.001); 572 (84%) had a sputum smear done at diagnosis and 164 (24.1%) at the end of treatment (p < 0.001). Although the rate of bacteriologically confirmed cases is similar to that of other European countries, the bacteriological confirmation at diagnosis and, particularly, at the end of treatment, is sub-optimal. The importance of further disseminating national guidelines among physicians managing TB is emphasized, in order to achieve a higher proportion of TB cases bacteriologically confirmed at diagnosis and monitored at the end of treatment.

Mandated tuberculosis screening in a community of homeless people

Background: To examine the effects of a community program on tuberculosis incidence, prevalence, and transmission requiring users of public facilities to carry cards certifying their compliance with a tuberculosis screening, prophylaxis, and treatment program. Community knowledge of tuberculosis and costs and benefits of the program are described. Setting: A West Coast “skid row” community with historically high rates of tuberculosis, homelessness, poverty, and use of drugs and alcohol. Design: Analysis of tuberculosis activity in communities in Oregon using Oregon Health Division Tuberculosis Data Bank data. Description of community response and cost considerations. Main Outcome Measures: Rates of active disease, mortality, and skin-test response. Compliance with card use and understanding of tuberculosis control measures. Program expenditures. Results: An 89% drop in active disease in the highest-risk community in Oregon occurred over the first 10 years of the program. Compliance with the program permitting the use of public facilities, based on cooperation with skin testing, radiology, sputum collection, and therapy has been between 33% of converters completing prophylaxis in the worst year to 100% of active cases completing 4-drug therapy in the best. Facilities that provide services have been almost universal in requiring cooperation for participants. Costs have been reduced. Conclusion: A program of mandated compliance with tuberculosis skin testing, radiologic and sputum examination and treatment, coupled with education and outreach, succeeded in drastically reducing active tuberculosis, transmission, deaths, and cost in a homeless community.

GIS/GPS to document increased access to community-based treatment for tuberculosis in Africa

Application of geographic information system (GIS) and global positioning system (GPS) technology in the Hlabisa community-based tuberculosis treatment programme documents the increase in accessibility to treatment after the expansion of the service from health facilities to include community workers and volunteers.

PID17: DETERMINATION OF THE COST-EFFECTIVENESS OF A TUBERCULOSIS PREVENTION PROGRAM ALONG THE US/ MEXICO BORDER USING MARKOV PROCESS MODELING WITHIN A PREVENTION EFFECTIVENESS FRAMEWORK

A prevention effectiveness analysis framework was used to estimate the costefifectiveness of a county administered tuberculosis prevention program along the U.S. / Mexico border. The tuberculosis prevention program under study used prophylactic isoniazid therapy in patients who have tested positive for tuberculosis infection. This analysis determined the cost-effectiveness of the current program versus no program from the perspective of the county government and was modeled for two time periods; five years and 15 years post preventive therapy initiation. Costs were calculated using actual data from tuberculosis prevention and active tuberculosis treatment programs as well as hospital discharge data. The outcome of interest, cases of active tuberculosis averted, was calculated through a Monte Carlo simulated Markov process model. Average and incremental cost-effectiveness ratios were then calculated for the tuberculosis prevention program scenario. The cost-effectiveness ratios were calculated separately with the inclusion or exclusion of the tuberculosis contagion costs. The results of the cost-effectiveness ratio calculations established that the prevention of active tuberculosis cases with the tuberculosis prevention program is considerably cost-effective. Every baseline incremental cost-effectiveness ratio, across the five and 15 year analysis periods (irrespective of contagion costs) determined in this prevention effectiveness study demonstrated cost savings. Additionally, the cost savings were substantial. The results indicate that rather than incurring costs to avert active

Drug resistant tuberculosis in prisons in Azerbaijan: case study

Objectives: To document the existence of drug resistance in a tuberculosis treatment programme that adheres strictly to the DOTS principles (directly observed treatment, short course) and to determine the extent...

TEENS, TOTS &amp; CONDOMS: HIV PREVENTION AND CULTURAL IDENTITY AMONG YOUNG ADOLESCENT MOTHERS

We evaluated the treatment results of 239 patients with sputum positive pulmonary tuberculosis (TB) and describe potential factors associated with reduced programme performance in a TB treatment programme in Ethiopia. The TB registry was incomplete and 64 (26.8%) patients were not recorded in the control programme. Of the 239 patients 34.3% received short-course chemotherapy (SCC) as a first treatment 5.9% received SCC having previously been treated with standard long-course chemotherapy (LCC) and 54.4% were initially put on LCC. After excluding the 75 patients (31.4%) who were transferred to other health institutions outside the control area 100 (61.0% 95% CI 53.0-68.4) were cured (22.6%) or completed the treatment (38.4%) falling short of the target of 85%. Five months or later during treatment 1.8% remained smear-positive 7.3% died and 29.9% interrupted their treatment. Sputum tests were done in 78% of the eligible patients at 2 months in 20% at 5 months and in 60.2% at the expected time of treatment completion. By July 1998 5.4% of the patients initially on LCC had relapsed and were retreated with SCC. None of those initially cured with SCC needed to be retreated. Compared with patients in the TB registry non-registered patients had lower treatment completed and cure rates (42.3% versus 65.2% P=0.047) more patients were transferred out of the TB programme (59.4% versus 21.1% P<0.001) and the defaulter rate was higher (57.7% versus 24.6% P=0.002). Weaknesses in the programme performance include organizational issues such as the under use of the TB registry deficient follow-up procedures the common usage of LCC and unsatisfactory rates of defaulting. (authors)

Directly observed therapy for tuberculosis in rural South Africa, 1991 through 1994.

This paper describes an audit of a community-based tuberculosis treatment program involving directly observed therapy in South Africa. A program audit of 2473 consecutive tuberculosis patients in Hlabisa Health District, KwaZulu/Natal, South Africa, was conducted between 1991 and 1994. Monthly admissions increased from 34 per month in 1991 to 66 in 1994. Of 2186 patients managed in Hlabisa, 1903 (87%) received directly observed therapy. Of those receiving directly observed therapy, 1034 (55%) were supervised by volunteers; 743 (72%) of these were supervised by storekeepers. Among those patients managed locally, 1679 (85%) of 1967 surviving patients completed treatment. Completion rates for patients supervised by health workers and non-health workers were the same. Completion fell from a high of 90% in 1992 to 78% in 1994. Mortality increased from 5% in 1991 to 10% in 1994. Community-based directly observed therapy that uses an intermittent drug regime and volunteers as supervisors can achieve high treatment completion rates for tuberculosis, even in resource-poor settings.

Unresolved Issues in Controlling the Tuberculosis Epidemic Among the Foreign-Born in the United States

Tuberculosis (TB), “the world’s most neglected health crisis,” has returned after decades of decline, but has only gradually caught the attention of governments as a formidable threat to public health. By 1984, when TB cases hit an all-time low, federal and state governments stopped supporting the medical infrastructure that once served to contain the disease. State officials around the nation began dismantling laboratory research programs and closing TB clinics and sanitoria. Since 1985, however, TB rates have steadily increased to 26,673 reported cases in 1992, and some have estimated that by the year 2000, there could be a twenty percent increase. By 1993, Congress, realizing that TB could pose a major public health threat, allocated over $100 million to the Department of Health and Human Services for TB prevention and treatment programs. Those funds, however, were sorely needed years before and amounted to only a fraction of what public health officials believe necessary to control TB today.

Trend of initial drug resistance of tubercle bacilli isolated from new patients with pulmonary tuberculosis and its correlation with the tuberculosis programme in Beijing

Setting: The tuberculosis control programme of Beijing. Objective: To observe the trend of initial drug resistance of tubercle bacilli and to try to correlate it with the Beijing tuberculosis control programme. Design: Susceptibility testing of randomly collected isolates of positive sputum culture from new patients with pulmonary tuberculosis without a history of prior antituberculosis therapy, in 1962 and continuously since 1978. Collection of treatment data from the Beijing tuberculosis control programme. Results: The trend of initial drug resistance in Beijing began to decline in 1978. The Beijing tuberculosis treatment programme has been very successful, resulting in rapid reduction of prevalence of smear-positive cases. Conclusion: It appears that the trend of initial drug resistance correlates with progress made in the implementation of the successful tuberculosis programme in Beijing. It is recommended that continuous observation of initial drug resistance be one of the indices of tuberculosis surveillance.

The efficiency of tuberculosis treatment programme conducted by anti tuberculosis dispansaries in Turkey

To identify Mycobacterium tuberculosis (M. tuberculosis) and other acid fast organisms isolated from sputum of HIV positive adult patients with pulmonary disease in Jos, Nigeria.Acid fast organisms isolated from 80 acid fast bacilli (AFB) positive sputa of HIV positive adult patients suspected for tuberculosis in Jos, Nigeria were identified for members of M. tuberculosis complex (M. tuberculosis, Mycobacterium bovis, Mycobacterium africanum, Mycobacterium canetti, Mycobacterium microti and Mycobacterium caprae) by use of spoligootyping, Multiplex Gen Probe, Hain genotype assay and gene sequencing for spoligotype negative isolates.Seven different spoligotypes of M. tuberculosis complex were identified from 70/80 (87.5%) total number of isolates. Mycobacterium kansasii (1), Mycobacterium dulvalii (1) Nocardia species (1) and Tsukamurella species (2) were detected from 5/10 spoligotype negative isolates.Although M. tuberculosis is the dominant AFB associated with chronic pulmonary disease in Jos, Nigeria, other clinically relevant mycobacteria were also observed in the study. This suggests that other AFB positive microorganisms associated with tuberculosis-like symptoms might be misdiagnosed and incorrectly treated as M. tuberculosis. It is therefore necessary for laboratories in tuberculosis high burden countries to step up diagnostic procedures beyond routine smear microscopy.

The three year evolution of a continuous quality managed tuberculosis screening and treatment program at a V.A. dimiciliary

The three year evolution of a continuous quality managed tuberculosis screening and treatment program at a V.A. dimiciliary

High-compliance tuberculosis treatment programme in a rural community

The global tuberculosis epidemic is being fuelled by dual infection with human immunodeficiency virus type I. Short-course chemotherapy is effective but usually fails for operational reasons. A community-based treatment programme of twice-weekly fully-supervised treatment is described in which 89% of surviving patients completed treatment under programme conditions. Half the patients were successfully supervised by non-health workers. New approaches are needed to combat the global tuberculosis epidemic.

Genetics of tuberculosis

Molecular methods for identifying organisms, strain typing, and determining drug susceptibilities are extremely valuable for pathogens that are impossible to grow on artificial media, slow growing on artificial media, or exceptionally hazardous to grow in a clinical microbiology laboratory. DNA hybridization probes and RFLP analysis are currently being used to facilitate the diagnosis and evaluation of mycobacterial disease. PCR is rapidly progressing to the point at which it will become routine in the clinical microbiology laboratory. LCR clearly has a future role in mycobacteriology but requires further understanding of mycobacterial genetics and physiology. The mycobacteriophage reporter-gene assay is an exciting future option that may allow us to obtain critical treatment related information in a much more timely fashion. The technologies mentioned in this article do not include all of the possibilities for the future; however, it can already be imagined that the isolation, identification, and drug-resistance properties of mycobacteria can be determined directly from clinical specimens and the results made available in a matter of days rather than weeks to months. What about the cost? These are expensive methods currently; however, the cost of conventional culture, drug susceptibility determinations, unnecessary periods of isolation for infection control, delays in recognition of resistant isolates, and deaths before the availability of laboratory information are high prices to pay. Only through further investigation can we clarify the most efficient and cost-effective tuberculosis treatment and control program. The dual epidemics of the human immunodeficiency virus and TB will continue to press the scientific community to develop cost-effective approaches, both for developed and developing nations, to a wide array of pathogens. If we do not characterize existing and future organisms at the molecular level, we will be forced to deal with them on their terms and at their leisure.