Tuberculosis outbreaks in schools: Experiences from the Western Pacific Region

@#Reports of tuberculosis (TB) outbreaks among schoolchildren have increased in recent years in countries across the Western Pacific Region. Cases from China, Japan, Mongolia and the Republic of Korea were studied to derive lessons from the challenges and responses to TB outbreaks in schools. Despite differences in the TB burden and outbreak preparedness, the four countries reported similar challenges. These included delayed diagnosis of index cases, lack of experienced health professionals and sustained financial support, and difficulty in responding to intensified media and community attention. Early detection of outbreaks, established resource mobilization networks, coordination among stakeholders and proactive communication were highlights of successful outbreak responses. These principles could be adapted to each context for responses to future TB outbreaks in schools.

Characteristics of Drug Resistant Tuberculosis in Sanatoria of North Korea

Although several reports about drug-resistant tuberculosis (TB) in North Korea have been published, a nationwide surveillance on this disease remains to be performed. This study aims to analyze the drug resistance patterns of Mycobacterium tuberculosis among the patients in the sanatoria of North Korea, especially during the period when second-line drugs (SLDs) had not yet been officially supplied to this country. The Eugene Bell Foundation (EBF) transferred 947 sputum specimens obtained from 667 patients from 2007 to 2009 to the Clinical Research Center, Masan National Tuberculosis Hospital (MNTH), South Korea. Four hundred ninety-two patients were culture positive for TB (73.8%). Drug susceptibility test (DST) was performed for the bacilli isolated from 489 patients. Over 3 quarters of the cases (76.9%) were multidrug-resistant (MDR)-TB. Additionally, 2 patients had extremely drug-resistant (XDR)-TB. Very high resistance to first-line drugs and low resistance to fluoroquinolones (FQs) and injectable drugs (IDs) except for streptomycin (S) were detected. A small but significant regional variation in resistance pattern was observed. Big city regions had higher rate of MDR-TB, higher resistance to FQs and IDs than relatively isolated regions. In conclusion, significant number of drug-resistant TB was detected in North Korean sanatoria, and small but significant regional variations in resistance pattern were noticeable. However, the data in this study do not represent the nationwide drug resistance pattern in North Korea. Further large-scale evaluations are necessary to estimate the resistance pattern of TB in North Korea.

Evaluation of Reverse Hybridization Assay for Detecting Fluoroquinolone and Kanamycin Resistance in Multidrug-Resistance Mycobacterium tuberculosis Clinical Isolates / 결핵및호흡기질환

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) is an increasing public health problem and poses a serious threat to global TB control. Fluoroquinolone (FQ) and aminoglycoside (AG) are essential anti-TB drugs for MDR-TB treatment. REBA MTB-FQ(R) and REBA MTB-KM(R) (M&D, Wonju, Korea) were evaluated for rapid detection of FQ and kanamycin (KM) resistance in MDR-TB clinical isolates. METHODS: M. tuberculosis (n=67) were isolated and cultured from the sputum samples of MDR-TB patients for extracting DNA of the bacilli. Mutations in genes, gyrA and rrs, that have been known to be associated with resistance to FQ and KM were analyzed using both REBA MTB-FQ(R) and REBA MTB-KM(R), respectively. The isolates were also utilized for a conventional phenotypic drug susceptibility test (DST) as the gold standard of FQ and KM resistance. The molecular and phenotypic DST results were compared. RESULTS: Sensitivity and specificity of REBA MTB-FQ(R) were 77 and 100%, respectively. Positive predictive value and negative predictive value of the assay were 100 and 95%, respectively, for FQ resistance. Sensitivity, specificity, positive predictive value and negative predictive value of REBA MTB-KM(R) for detecting KM resistance were 66%, 94%, 70%, and 95%, respectively. CONCLUSION: REBA MTB-FQ(R) and REBA MTB-KM(R) evaluated in this study showed excellent specificities as 100 and 94%, respectively. However, sensitivities of the assays were low. It is essential to increase sensitivity of the rapid drug resistance assays for appropriate MDR-TB treatment, suggesting further investigation to detect new or other mutation sites of the associated genes in M. tuberculosis is required.

Helicobacter pylori Reinfection Rate and Its Related Factors after Successful Eradication: 4-year Follow-up in a Korean Rural Community / 대한소화기학회지

BACKGROUND/AIMS: Recurrence of peptic ulcer after successful eradication of Helicobacter pylori is closely associated with reinfection. The aim of this study was to measure the rate and related factors of H. pylori reinfection through a 4-year follow-up excluding recrudescence. METHODS: Triple therapy was administered to H. pylori-positive 204 people in April 1998 in Gyeongju, Korea. The urea breath test was performed in April 1999. Eighty-seven subjects were regarded as negative for H. pylori, and they were followed up for 4 years to analyze the trends of reinfection rate and its related factors. Sixty-seven subjects completed the 4-year follow-up. During the follow-up period the urea breath test and questionnaire surveys were performed in April 2000, October 2001, and April 2003. RESULTS: The cumulative reinfection rate was 16.4% for 4 years, and the yearly reinfection rate was 4.1%. The reinfection rate of subjects having postprandial fullness and epigastric bloating was significantly high (p<0.05), and that of the subjects with high dyspepsia symptom scores (4 or 5) was also significantly higher than those with low dyspepsia symptom scores (3 or below)(p=0.016). According to the multiple logistic regression analysis to predict the factors related with H. pylori reinfection, the dyspepsia symptom score was the only significant variable with the odds ratio of 1.688. CONCLUSIONS: The cumulative reinfection rate for 4 years was 16.4% in a Korean rural community. The dyspepsia symptom score can be used to predict H. pylori reinfection in community population.

Trends & Evaluation of K-ADL in Sorokdo / 나학회지

Background : Korean Activities of Daily Living(K-ADL) scale and Korean Instrumental Activities of Daily Living(K-IADL) scale were developed to measure the function of the old. The evaluation through K-ADL and K-IADL is important for the optimal medical service to the disabled old people on the Sorokdo. This study was conducted to assess the functional disability of them and to find out the suitable medical service. Method : This research was collected from 731 Sorokdo residents in Oct, 2003. The data were compared by chi-square test, independent t-test and ANOVA test using SPSS(ver 10.0) with alpha-error=0.05. Result : Bathing-points and clothing-points on ADL scale are comparatively low: points of the women lower than those of the men; the group over 65 years than group under that age; the patients who have combined disease than the patients who have not; and the patients who have been hospitalized more than once than those who have not been. Besides, the points of the not-disabled are lower than those of disability, the lower one`s points on ADL scale. It is due to the fact that there are many not-disabled persons over 65 years old. Preparing-a-meal points and washing-points on IADL scale are comparatively low: points of the women lower than those of the men; the group over 65 years than group under that age; the patients who have combined disease than the patients who have not; the patients who have been hospitalized than those who have not been one a more; and the seriously- disabled and the slightly-disabled. The points on Barthel ADL scale are dwindling annually by 0.3 to 0.5, the decrease of the women being greater than that of the men. Conclusion : Special medical programs for the old patients and a rehabilitation health service will improve the reliability of medical service on Sorokdo hospital and increase quality of life.

Clinical Finding of MDR Tuberculosis and Frequency of MOTT / 결핵

BACKGROUND: The frequency of MOTT has risen as the prevalence of tuberculosis has been declining. Our country has been also. The most of MOTT was resistant to the major anti-tuberculous drugs. METHOD: To compare clinical characteristics and frequencies of MDR tuverculosis with MOTT, the author studied 65 patients showing AFB culture positive with sputum. The data were collected from 176 patients who had been admitted at the National Masan Tuberculosis Hospital from May to June, 1997 to April, 1998. RESULTS: The frequency of MDR tuberculosis was 43.1% and that of MOTT was 9.2%. Among 65 isolated my-cobacteria, 3 cases were M. intracellulare, 2 cases were M. fortuitum, and 1 case was unidentified MOTT. The most frequent age group in 65 culture positive patients was 4th decade and the mean age was 44. The mean age was 61 in MOTT and 42 in M. tuberculosis and bad significant difference(p<0.01). The numbers with past history of treatment were 2.3 in MDR tuberculosis and 1.7 in non-MDR tuberculosis and had significant difference(p<0.05). At the time of admisson, the most frequent regiment for the theatment of MDR tuberculosis was 24 months regimen(85.7%) with the 2nd line anti-tuberculosis drugs. For non-MDR tuberculosis, 9 or 12 months regimen (72.9%) with the 1st line anti-tuberculosis drugs and had significant difference(p<0.01). At the time of admission, the symptom of weight loss was shown in 84.7% of M. tuberculosis and 50.0% in MOTT and there was significant difference(p<0.05) between them. All of the MOTT were identified to be resistant against INH and PAS. Drug resistane rates to INH, OFX(p<0.01) and PAS(p<0.05) in MOTT were higher than in MDR. All of three M. intracellulare strains were resistant to INH, RFP, PAS and OFX. All of two M. fortuitum strains were resistant to most anti-tuberculosis drugs. And the other MOTT was resistant to INH, EMB and PAS. CONCLUSION: MOTT was more common in elderly patients than M. tuberculosis. MOTT cases should be considered to be the probability of multiple drug resistance and treatment failure during the 1st treatment because they showed more resistance to anti-tuberculosis drugs than M. tuberculosis cases. Therefore, there should be more careful investigations for clinical characteristics, natural history of disease, and efficient management for MOTT.

Clinical Study of Pulmonary Tuberculosis for Admitted Patients at National Masan Tuberculosis Hospital / 결핵

OBJECTIVE: Although the prevalence of pulmonary tuberculosis has decreased progressively after the national control program for tuberculosis began, nowadays the number of MDRTB is increasing seriously. MDRTB tends to be poor responsive to current antituberculosis regimens. It is mainly due to poor compliance, high rate of side reaction of secondary drugs, and limitation in number of available drugs. The purpose of present study is to evaluate the clinical features of pulmonary tuberculosis patients admitted in one national tuberculosis hospital and to expose the problems pertaining to current remedies, to increase the treatment efficacy for pulmonary tuberculosis including MDRTB in the end. METHOD: Retrospective analysis of 336 pulmonary tuberculosis patients admitted in National Masan Tuberculosis Hospital was done. Contents of analysis were patients profile, the first diagnosed time and medical institutes, family history, residence, previous treatment history, chief complaints at the time of admission, lesion site on chest X-ray film, combined deseases, side reaction to antibuberculosis drugs, used drugs before admission and the results of drug sensitivity test. RESULTS: The ratio between male and female was 4:1. Age showed relatively even distribution from 3rd to 6 th decades. 64.6% of the patients was diagnosed at public health center. Weight loss was the most common complaint at admission. Bilateral lesions on chest X-ray films were 59.8%. 1 30patients had combined desease, of which DM was the most common(37.7%). 95patients had family history, of which parents were the most common(41.7%). According to the time of first diagnosis, 31 patients were diagnosed before 1980, and after then the number of patients was increased by degrees Residence overwhelmed in pusan and gyung-nam province. 258 patients got previous treatment history, of which 112 patients(43.4%) had more than 3 times and only 133 patients(51.6%) got regular medication. 97 patients used more than other 3 drugs in addition to INH, EMB, RFP and PZA before admission. 154 patients were informed with the results of drug sensitivity test. of which 77 patients had resistance to more than 5 drugs. Gastrointestinal problem was the most common in side reaction to drugs. CONCLUSION: In the case of weigt loss of unknown cause, tuberculosis should be suspected. In first treatment, sufficient and satisfactory explanation for tuberculosis is necessary and treatment period should not be stict to 6 month-short term therapy. In retreatment, new drugs should not be added to used drugs enen though drug sensitivity restlts show sensitivity to some of them. Proper time for surgical intervention should not be delayed.

Analysis of Causes for Primary Treatment Failure of Pulmonary Tuberculosis / 결핵

BACKGROUND: Nowadays drug resistant tuberculosis is making problems in the treatment of pulmonary tuberculosis and its number is increasing. Several reasons for this are considered including irregular medication, poor drug compliance and wrong regimens. But there are treatment failure cases in spite of regular medication with short-term standard regimens. We reviewed clinical data of 50 patients to find out possible causes of this. METHODS: Subject of this study was 50 patients who failed in the primary treatment of pulmonary tuberculosis in spite of regular medication with short-term standard regimens. All of them were under treatment with secondary regimens in National Masan Tuberculosis Hospital on Oct. 1996. The patient's records were analyzed retrospectively and direct interviews with patients were done. RESULTS: There were relatively more patients in the age of 20th. Male overwhelmed in number. There were smoking in 22 patients and drinking in 24 patients during medication. 17(34%) patients had family history of tuberculosis. Public health center was the most common site for the initial diagnosis among medical institutes. 42 patients had subjective symptoms for pulmonary tuberculosis. 38 patients got sufficient explanation from medical institute about tuberculosis and medication courses. 24 patients had bilateral lesions on chest X-ray film and 43 patients had cavitary lesions. 29 patients had past history for pulmonary tuberculosis with regular medication. The results of drug sensitivity test showed resistance in 41 patients of whom we could get the results CONCLUISON: Main cause of treatment failure of pulmonary tuberculosis in spite of regular medication with short-term standard regimens was drug resistance. Several factors were considered to be related to high prevalence of drug resistance, including age of 20th, male, family history for tuberculosis, bilateral lesions or remaining cavitary lesion on chest X-ray film.

Factors Influencing Compliance with Anti-Tuberculosis Therapy / 예방의학회지

The purpose of the study was to determine factors influencing compliance with anti-tuberculosis therapy. The study subjects were 104 tuberculosis patients who have received the initial treatment in 3 health centers of Kyongju-city, Dalseong-Gun in Teagu and Kumi-city. Data were collected between september and october 1995. The patients were classified into the improved group and the non-improved group according to outcomes of 3 month treatment with short-term therapeutic regimen. To find factors influencing compliance with anti-tuberculosis therapy, multiple logistic regression was made. There was no significant differences between the improved group and the non-improved group in sex, age, education level, occupation, family pattern, and habitual change regarding smoking and drinking. The level of knowledge about anti-tuberculosis therapy in the improved group was significantly higher than the non-improved group(p<0.01). Multiple logistic regression analysis revealed that family support for not forgetting medication(p<0.05) was a predictor of improvement and knowledge about anti-tuberculosis therapy (p=0.054), regularity of medication(p=0.062), and consultation to family, doctor and nurse(p=0.075)were marginal predictors of improvement. Treatment must be given to every patient confirmed as having tuberculosis and must be given free of charge to the patients. The requirements for adequate chemotherapy are prescribed in the correct dosage and taken regularly by the patient for a sufficient period to prevent relapse of the disease after cure. It is suggested that education to the patients should be reinforced and connectedness between patients and tuberculosis control workers and family should be solidated.

Comparative Study on the Regimens with Pyrazinamide orOfloxacin in the retreatment of pulmonary tuberculosis / 결핵

Objective: In the early short-term therapy of pulmonary tuberculosis, PZA is used for the first two months on 6EHRZ therapy but PZA is not effective in the case of long-term use PZA for retreatment in the sensitive relapse or acquired drug resistance for PZA. But in the endemic area as Korea, if we can't use PZA in the retreatment of pulmonary tuberculosis, we can't expect the success for retreatment of pulmonary tuberculosis, therefore we need new drugs substituting for PZA. In these days, 4-fluoroquinolone derivatives were investigated and only ofloxacin and ciprofloxacin of derivatives were known to be effective but the effectiveness was also not certain because the result was experimental or combined with other bacteriocidal drugs and datas on effectiveness of pulmonary tuberculosis were so little. Therefore these drugs should be use with other two or three strong-acting drugs in the last period of retreatment of pulmonary tuberculosis. The ofloxacin or ciprofloxacin is used in some area in Korea but randomly and needed more study. We did this study for proving the effectiveness of these drugs and establishment of retreatment regimen for pulmonary tuberculosis. Methods: Retrospective cohort study of 83 drug-resistant pulmonary tuberculosis patients at National Masan Tuberculosis Hospital from Jan. 1994 to dec. 1995 was made. All the patients taken medicine for 2nd anti-tuberculosis regimens for the first time. We separated the patients by two groups.(Group I: OFX+PTA+CS+PAS + Injection, Group II: PZA+PTA+CS+PAS+Injection). We compared the difference between two groups and tested the confidence limit about results after treatment by chi2-test and T-test. Results: 1. The age distribution was most frequent in fourth decade(29.2% in Group I, 37.1% in Group II) and the mean age was 43.9 year in Group I, and 39.0 year in Group II, but had no significant difference between two groups. The sex distribution was more frequent in the males(68.8% in Group I, 85.7% in Group II), but had no significant difference. 2. Family history was 29.2% in Group I, 28.6% in Group II, but had no significant difference. 3. In the respect of extent of disease, far-advanced state was 60.4% in Group I, 74.3% in Group II, but had no significant difference. 4. The side effects for drugs showed in 58.3% in Group I and 65.7% in Group II, and the gastrointestinal trouble showed 25.0% in Group I and arthralgia 34.3% in Group II predominantly respectively and had the significant difference(p<0.05). 5. The negative conversion rate on sputum AFB smear was 87.5% in Group I and 80.0% in Group II, but had no significant difference. But the negative conversion rate on sputum AFB culture was 83.3% in Group I and 57.1% in Group II and had the significant difference(p<0.05). 6. The success rate of treatment was 87.5% in Group I and 83.3% in Group II but had no significant difference. Conclusion: In the retreatment of pulmonary tuberculosis, ofloxacin is useful drug for the patients who are not available to use PZA and can be use effectively substituting for PZA.

Effect of Long-Term Noise Exposure on the Blood Pressure in Factory Workers / 대한산업의학회지

The question of an association between occupational noise exposure and blood pressure has important public health implications. The harmful effects of hypertension are well known and noise is considered the mosts pervasive problem of all occupational exposures in Taegu City, Korea. A cross-sectional study on the effect of long-term noise exposure on blood pressure was done for 276 noise exposed workers (203 male workers, 73 female workers). Long-term noise exposure was measured by cumulative noise exposure level and noise-induced hearing loss. Hearing loss=(500Hz+2x1,000Hz+2x2,000Hz+4,000Hz)/6 Questionaire was administered to the workers, which includes age, sex, occupational history on the noise exposure, habits on alcohol drinking and smoking, practice of regular exercise, family history of hypertension. Type A behavior, question on stress, height, weight and blood pressure were measured. Serum triglyceride and low density lipoprotein (LDL) were also measured. Audiometry was done in the closed booth at 1,000, 2,000, 3,000, 4,000, 6,000, 8,000, 1,000 and 500Hz in order. Mutiple logistic regression analysis revealed that cumulative noise exposure level(p<0.05), serum triglyceride(p<0.01), age(p<0.01) and family history of hypertension (p<0.05) predict hypertension (systolic blood pressure: 160mmHg or above, or diastolic blood pressure: 95mmHg or above) in male workers. In female workers, serum triglyceride (p<0.01), LDL (p<0.01) and family history of hypertension(p<0.05) were predictors of hypertension (systolic blood pressure: 160mmHg or above, or diastolic blood pressure: 95mmHg or above). As the number of female workers with hypertension was too small, the multiple logistic regression was done according to hypertension criteria of systolic blood pressure greater than or equal to 140mmHg, or diastolic blood pressure greater than or equal to 90mmHg. Based on this criteria, cumulative noise exposure level (p=0.055) and age (p=0.057) predict hypertension. It is suggested that long-term noise exposure which was calculated by cumulative noise exposure level was a significant predictor of hypertension in noise exposed workers.

A Study on Preception and Attitudes of Health Workers Towards the Organization and Activies of Urban Health Centers / 영남의대학술지

A survey was conducted to study perception and attitudes of health workers towards health centers activities and organization of health services, from August 15 to September 30, 1994. The study population was 310 health workers engaged in seven urban health centers in Taegu City area. A questionnaire method was used to collect data and response rate was 81.3 percent or 252 respondents. The following are summaries of findings: Profiles of study population: Health workers were predomina1itly female(62.3%); had college education(60. 3%); 'and held medical and nursing positions(39.6%), technicians(30.6%) and. public health/administrativc positions(29.8%). Perceptions on health center's resources: Slightly more than a half(51.1%) of respondents expressed that physical facilities of the centers are inadequate; equipments needed are short(39.0%); human resource is inadequate(44.8%); and health budget allocated is insufficient(38.5%) to support the performance of health center's activities. Decentralization and health services: The majority revealed that the decentralization of government system would affect the future activities of health centers(51.9%) which may have to change. However, only one quarter of respondents(25.4%) seemed to view the decentralization positively as they expect that it would help perform health activities more effectively. The majority of the respondents(78.6%) insisted that the function and organization of the urban health centers should be changed. Target workload and job satisfaction: A large proportion (43.3%) of respondents felt that present target setting systems for various health activities are unrealistic in terms of community needs and health center's situation while only 11.1 percent responded it positively; the majority(57.5%) revealed that they need further training in professional fields to perform their job more effectively; more than one third(35.7%) expressed that they enjoy their professional autonomy in their job performance; and a considerable proportion (39.3%) said they are satisfied with their present work. Regarding the personnel management, more worker (47.3%) perceived it negatively than positive(11.5%) as most of workers seemed to think the personnel management practiced at the health centers is not fair or justly done. Health services rendered: Among health services rendered, health workers perceived the following services are most successfully delivered; they are, in order of importance, Th controi, curative services, and maternal and child health care. Such areas as health education, oral health, environmental sanitation, and integrated health services are needed to be strengthening. Regarding the community attitudes towards health workers, 41.3 percent of respondents think they are trusted by the community they serve. New areas of concern identified which must be included in future activities of health centers are, in order of priority, health care of elderly population, home health care, rehabilitation services, and such chronic diseases control programs as diabetes, hypertension, school health and mental health care. In conclusion, the study revealed that health workers seemed to have more negative perceptions and attitudes than positive ones towards organization and management of health services and activities performed by the .urban health centers where they are engaged. More specifically, the majority of health workers studied revealed to have the following areas of health center's organization and management inadequate or insufficient to support effective performance of their health activities: Namely, physical facilities and equipments required are inadequate; human and financial resources are insufficient; pefsonnel management is unsatisfactory; setting of service target system is unrealistic in terms of the community needs. However, respondents displayed a number of positive 'perceptions, particularly' to those areas as further training needs 'and implementation of decentralization of government system which will bring more autonomy of local government as they perceived these change would bring the necessary changes to future activities of the health center. They also displayed positive perceptions in their job autonomy and have job satisfactions.