Integration and decentralisation of TB-HIV services increases HIV testing of TB cases in Rajasthan, India.

The proportion of tuberculosis (TB) patients tested for the human immunodeficiency virus (HIV) in the state of Ra-jasthan, India, is limited by the availability of HIV testing facilities. Rajasthan implemented a policy of initiating TB-HIV diagnosis at all health institutions in July 2013. The number of TB diagnostic facilities increased from 33 to 63 in Banswara District and from 22 to 68 in Jhunjhunu District, while the number of HIV testing facilities in these districts increased from 1 to 53 and from 10 to 81, respectively, after the policy implementation. The proportion of TB patients tested for HIV increased by respectively 27% and 19%.

La proportion de patients tuberculeux (TB) testés pour le virus de l'immunodéficience humaine (VIH) dans l'état du Rajasthan, Inde, est limitée par la disponibilité de lieux de tests du VIH. Le Rajasthan a mis en œuvre une politique d'initiation du diagnostic TB dans toutes les structures de santé en juillet 2013. Le nombre de lieux de diagnostic TB a augmenté de 33 à 63 dans le district de Banswara et de 22 à 68 dans le district de Jhunjhunu, tandis que le nombre de lieux de test du VIH a augmenté de 1 à 53 et de 10 à 81, respectivement, après la mise en œuvre de cette politique. La proportion de patients TB testés pour le VIH a augmenté de 27% et 19%, respectivement, dans les deux districts.

La proporción de pacientes con tuberculosis (TB) que cuentan con la prueba del virus de la inmunodeficiencia humana (VIH) en el estado de Rajastán en la India se ve limitada por la escasez de establecimientos que la practican. En julio del 2013 se introdujo en Rajastán una política de iniciar el diagnóstico de la TB y el VIH en todos los establecimientos de atención de salud. Después de la introducción de la política, el número de centros de diagnóstico de la TB en el distrito de Banswara aumentó de 33 a 63 y en el distrito Jhunjhunu aumentó de 22 a 68 y la progresión de centros con diagnóstico de la infección por el VIH en Banswazra fue de 1 a 53 centros y en Jhunjhunu de 10 a 81. La proporción de pacientes con TB que cuentan con una prueba del VIH en estos distritos aumentó un 27% y un 19%, respectivamente.

Clinical and bacteriological characteristics associated with clustering of multidrug-resistant tuberculosis.

SETTING: The impact of the genetic characteristics of Mycobacterium tuberculosis on the clustering of multidrug-resistant tuberculosis (MDR-TB) has not been analyzed together with clinical and demographic characteristics. OBJECTIVE: To determine factors associated with genotypic clustering of MDR-TB in a community-based study. DESIGN: We measured the proportion of clustered cases among MDR-TB patients and determined the impact of clinical and demographic characteristics and that of three M. tuberculosis genetic characteristics: lineage, drug resistance-associated mutations, and rpoA and rpoC compensatory mutations. RESULTS: Of 174 patients from California and Texas included in the study, the number infected by East-Asian, Euro-American, Indo-Oceanic and East-African-Indian M. tuberculosis lineages were respectively 70 (40.2%), 69 (39.7%), 33 (19.0%) and 2 (1.1%). The most common mutations associated with isoniazid and rifampin resistance were respectively katG S315T and rpoB S531L. Potential compensatory mutations in rpoA and rpoC were found in 35 isolates (20.1%). Hispanic ethnicity (OR 26.50, 95%CI 3.73-386.80), infection with an East-Asian M. tuberculosis lineage (OR 30.00, 95%CI 4.20-462.40) and rpoB mutation S531L (OR 4.03, 95%CI 1.05-23.10) were independent factors associated with genotypic clustering. CONCLUSION: Among the bacterial factors studied, East-Asian lineage and rpoB S531L mutation were independently associated with genotypic clustering, suggesting that bacterial factors have an impact on the ability of M. tuberculosis to cause secondary cases.

Protocol for a population-based molecular epidemiology study of tuberculosis transmission in a high HIV-burden setting: the Botswana Kopanyo study.

INTRODUCTION: Mycobacterium tuberculosis (Mtb) is transmitted from person to person via airborne droplet nuclei. At the community level, Mtb transmission depends on the exposure venue, infectiousness of the tuberculosis (TB) index case and the susceptibility of the index case's social network. People living with HIV infection are at high risk of TB, yet the factors associated with TB transmission within communities with high rates of TB and HIV are largely undocumented. The primary aim of the Kopanyo study is to better understand the demographic, clinical, social and geospatial factors associated with TB and multidrug-resistant TB transmission in 2 communities in Botswana, a country where 60% of all patients with TB are also infected with HIV. This manuscript describes the methods used in the Kopanyo study. METHODS AND ANALYSIS: The study will be conducted in greater Gaborone, which has high rates of HIV and a mobile population; and in Ghanzi, a rural community with lower prevalence of HIV infection and home to the native San population. Kopanyo aims to enrol all persons diagnosed with TB during a 4-year study period. From each participant, sputum will be cultured, and for all Mtb isolates, molecular genotyping (24-locus mycobacterial interspersed repetitive units-variable number of tandem repeats) will be performed. Patients with matching genotype results will be considered members of a genotype cluster, a proxy for recent transmission. Demographic, behavioural, clinical and social information will be collected by interview. Participant residence, work place, healthcare facilities visited and social gathering venues will be geocoded. We will assess relationships between these factors and cluster involvement to better plan interventions for reducing TB transmission. ETHICS: Ethical approval from the Independent Review Boards at the University of Pennsylvania, US Centers for Disease Control and Prevention, Botswana Ministry of Health and University of Botswana has been obtained.

What a difference a day makes: same-day vs. 2-day sputum smear microscopy for diagnosing tuberculosis.

Setting: Nine district-level microscopy centres in Assam and Tripura, India. Objective: Same-day sputum microscopy is now recommended for tuberculosis (TB) diagnosis. We compared this method against the conventional 2-day approach in routine programmatic settings. Methods: During October-December 2012, all adult presumptive TB patients were requested to provide three sputum samples (one at the initial visit, the second 1 h after the first sample, and the third the next morning) for examination by Ziehl-Neelsen smear microscopy. Detection of acid-fast bacilli with any sample was diagnostic. The first and second spot sample comprised the same-day approach, and the first spot sample and next-day sample comprised the 2-day approach. Results: Of 2168 presumptive TB patients, 403 (18.6%) were smear-positive according to the same-day method compared to 427 (19.7%) by the 2-day method (McNemar's test, P < 0.001). Of the total 429 TB patients, 26 (6.1%) were missed by the same-day method and 2 (0.5%) by the 2-day method. Conclusion: Same-day specimen collection for microscopy missed more TB than 2-day collection. In India, missing cases by using same-day microscopy would translate into a considerable absolute number, hindering TB control efforts. We question the indiscriminate switch to same-day diagnosis in settings where patients reliably return for testing the next day.

Contexte : Neuf centres de microscopie de district dans les états d'Assam et de Tripura, Inde.Objectif : On recommande maintenant une microscopie de frottis le même jour pour le diagnostic de la tuberculose (TB). Nous avons comparé cette méthode par rapport à l'approche conventionnelle en 2 jours dans un contexte de programme de routine.Méthodes : Entre octobre et décembre 2012, tous les patients adultes présumés atteints de TB ont été invités à fournir trois échantillons de crachats (lors de la visite initiale, 1 heure après le premier échantillon et le matin suivant) pour un examen par microscopie de frottis selon Ziehl-Neelsen. La détection de bacilles acido-alcoolo-résistants dans un quelconque échantillon constituait le diagnostic. Les premier et deuxième échantillons ont constitué l'approche du même jour et le premier échantillon plus celui du matin suivant constituaient l'approche en 2 jours.Résultats : Sur les 2168 patients présumés TB, 403 (18,6%) étaient frottis-positifs selon la méthode du même jour comparés à 427 (19,7%) par la méthode en 2 jours (test de McNemar P < 0,001). Sur ce total de 429 patients TB, 26 (6,1%) ont été manqués par la méthode du même jour et 2 (0,5%) par la méthode en 2 jours.Conclusion : Le recueil d'échantillons le même jour pour une microscopie a manqué plus de cas de TB que le recueil en 2 jours. En Inde, une stratégie de microscopie le même jour à ce taux se traduirait par un grand nombre absolu de cas manqués, entravant les efforts de lutte contre la TB. Nous remettons en question le fait de passer sans discrimination au diagnostic du jour même dans des contextes où les patients reviennent de manière fiable pour un test le jour suivant.

Marco de referencia: Nueve centros distritales de microscopia de Assam y Tripura en la India.Objetivo: Actualmente se recomienda en el diagnóstico de la tuberculosis (TB) practicar la baciloscopia del esputo el mismo día de la consulta. En el presente estudio se comparó este método con la estrategia corriente de baciloscopia en dos días que se aplica en las prácticas programáticas.Métodos: De octubre a diciembre del 2012 se solicitó a todos los adultos con presunción diagnóstica de TB que aportaran tres muestras de esputo (en el momento de la consulta inicial, una hora después y a la mañana siguiente), con el fin de practicar el examen microscópico con la coloración de Ziehl-Neelsen. El criterio diagnóstico fue la detección de bacilos acidorresistentes en cualquiera de las muestras. La primera y la segunda muestras inmediatas constituyeron la estrategia del mismo día y la primera muestra inmediata y la muestra del día siguiente constituyeron la estrategia de 2 días.Resultados: En los 2168 pacientes con presunción de TB, se confirmó el diagnóstico en 403 casos (18,6%) con el método del mismo día y en 427 (19,7%) con la estrategia de 2 días (prueba de McNemar P < 0,001). Del total de 429 pacientes con diagnóstico de TB, se pasaron por alto 26 casos cuando se recogieron las muestras el mismo día (6,1%) y 2 casos cuando se recogieron durante 2 días (0,5%).Conclusión: La recogida de muestras destinadas a la baciloscopia en el mismo día omitió el diagnóstico de más casos de TB que la recogida de muestras en 2 días. En la India, pasar por alto el diagnóstico de casos con el examen microscópico realizado el mismo día tendría como consecuencia omitir una cifra absoluta de pacientes muy alta, que entorpecería los resultados de las iniciativas de control de la TB. En el presente artículo se pone en duda la utilidad de un cambio indiscriminado hacia el método de diagnóstico en el mismo día, en los entornos donde se puede confiar en que los pacientes regresarán al día siguiente para completar las muestras de esputo.

Factors associated with recurrent tuberculosis more than 12 months after treatment completion.

SETTING: Even among persons who have completed a course of treatment for their first tuberculosis (TB) episode, patients with a history of TB are at higher risk for having TB. OBJECTIVE: To describe factors from the initial TB episode associated with recurrent TB among patients who completed treatment and remained free of TB for at least 12 months. DESIGN: During 1993-2006, US TB cases stratified by birth origin were examined. Cox proportional hazards regression was used to assess the association of factors during the initial episode with recurrence at least 12 months after treatment completion. RESULTS: Among 632 US-born patients, TB recurrence was associated with age 25-44 years (adjusted hazard ratio [aHR] 1.77, 99% confidence interval [CI] 1.02-3.09, attributable fraction [AF] 1-34%), substance use (aHR 1.57, 99%CI 1.23-2.02, AF 8-22%), and treatment supervised by health departments (aHR 1.42, 99%CI 1.03-1.97, AF 2-28%). Among 211 foreign-born patients, recurrence was associated with human immunodeficiency virus infection (aHR 2.24, 99%CI 1.27-3.98, AF 2-9%) and smear-positive TB (aHR 1.56, 99%CI 1.06-2.30, AF 3-33%). CONCLUSION: Factors associated with recurrence differed by origin of birth, and might be useful for anticipating greater risk for recurrent TB among certain patients with a history of TB.

Screening difficult-to-reach populations for tuberculosis using a mobile medical unit, Punjab India.

BACKGROUND: In India, the National Health Mission has provided one mobile medical unit (MMU) per district in the state of Punjab to provide primary health care services for difficult-to-reach populations. OBJECTIVES: To determine the number of patients with presumptive tuberculosis (TB) and the number of TB cases detected and treated among patients who used the MMU services from May to December 2012 in Mohali district, Punjab, India. METHODS: A cross-sectional study was conducted and registers of the out-patient, laboratory, radiology, and TB departments of the MMU were reviewed to determine the number of persons presumed to have TB and the number of persons diagnosed with TB. RESULTS: Of 8346 patients who attended the MMUs, 663 (8%) had symptoms suggestive of TB. Among those with TB symptoms, 540 (81%) were evaluated for pulmonary TB using sputum examination or chest X-ray. In total, 58 (11%) patients had clinical or laboratory evidence of pulmonary TB, of whom 21 (36%) started anti-tuberculosis treatment. CONCLUSION: As MMUs are an integral part of the general public health system, these units have the potential to detect TB cases among difficult-to-reach populations. Additional research is required to optimise the diagnosis of TB at MMUs and to increase rates of TB treatment initiation.

Contexte : En Inde, la Mission nationale santé a fourni une unité médicale mobile (MMU) par district dans l'état du Penjab afin d'offrir des services de soins de santé primaires aux populations difficilement accessibles.Objectifs : Déterminer le nombre de patients présumés atteints de la tuberculose (TB) et le nombre de cas de TB détectés et traités parmi les patients qui ont utilisé les services de la MMU de mai à décembre 2012 dans le district de Mohali de l'état du Penjab, Inde.Méthodes : Une étude transversale a été réalisée et l'étude des registres des consultations, du laboratoire, de la radiologie et des services de TB de la MMU a permis de compter le nombre de personnes présumées atteintes de TB et le nombre de personnes ayant eu un diagnostic de TB.Résultats : Un total de 8346 patients ont fréquenté la MMU, dont 663 (8%) avaient des symptômes suggérant une TB. Parmi ces derniers, 540 (81%) ont bénéficié d'une recherche de TB pulmonaire grâce à un examen de l'expectoration ou à une radiographie pulmonaire. Au total, 58 (11%) patients ont eu des preuves cliniques ou biologiques de TB pulmonaire, dont 21 (36%) ont mis en route un traitement de la tuberculose.Conclusion : Comme les MMU font partie intégrante du système de santé publique général, ces unités ont le potentiel de détecter les cas de TB parmi les populations « difficiles à atteindre ¼. De plus amples recherches sont requises afin d'optimiser le diagnostic de la TB dans les MMU pour accélérer la mise en route du traitement de la TB.

Marco de referencia: En la India, la National Health Mission ha suministrado una unidad médica móvil (MMU) a cada distrito del estado del Punjab, con el objeto de prestar servicios de atención primaria de salud a las poblaciones de difícil acceso.Objetivos: Determinar el número de pacientes con presunción clínica de tuberculosis (TB) y el número de casos de TB diagnosticados y tratados en el grupo de pacientes que acudieron a las MMU de mayo a diciembre del 2012 en el distrito de Mohali del estado del Punjab, en la India.Métodos: Se llevó a cabo un estudio transversal, en el cual se examinaron los registros de los servicios de consulta externa, laboratorio, radiología y los departamentos de TB de las MMU, con el propósito de calcular el número de personas con presunción de TB y el número de casos de TB diagnosticados.Resultados: Durante el período del estudio acudieron a las MMU 8346 personas, de las cuales 663 refirieron síntomas indicativos de TB (8%). Se investigaron 540 personas por TB pulmonar (81%) mediante la baciloscopia del esputo o la radiografía de tórax. Se encontraron pruebas clínicas o de laboratorio de TB pulmonar en 58 pacientes (11%) y se inició el tratamiento antituberculoso en 21 de ellos (36%).Conclusión: Puesto que las MMU forman parte integrante del sistema general de salud pública, estas estructuras pueden detectar los casos de TB en las poblaciones de difícil acceso. Se precisan nuevas investigaciones que contribuyan a optimizar el diagnóstico de la TB en estas unidades y a conseguir que una mayor proporción de pacientes inicie el tratamiento antituberculoso.

Tuberculosis and excess alcohol use in the United States, 1997-2012.

BACKGROUND: Excess alcohol use among tuberculosis (TB) patients complicates TB control strategies. OBJECTIVES: To characterize the role of excess alcohol use in TB control, we describe the epidemiology of excess alcohol use and TB in the United States among those aged ⩾15 years. DESIGN: Using data reported to the National Tuberculosis Surveillance System, 1997-2012, we examined associations between excess alcohol use and TB treatment outcomes and markers for increased transmission (involvement in a local genotype cluster of cases) using multivariate logistic regression. We used Cox proportional hazards regression analysis to examine the relationship between excess alcohol use and the rate of conversion from positive to negative in sputum culture results. RESULTS: Excess alcohol use was documented for 31 207 (15.1%) of 207 307 patients. Prevalence of excess alcohol use was greater among male patients (20.6%) and US-born patients (24.6%). Excess alcohol use was associated with a positive sputum smear result (aOR 1.23, 95%CI 1.18-1.28) and death during treatment (vs. completion of treatment) (aOR 1.16, 95%CI 1.10-1.22). The rate of culture conversion was higher among patients without excess alcohol use (adjusted hazard ratio 1.20, 95%CI 1.18-1.23). CONCLUSIONS: Excess alcohol use was common among patients with TB, and was associated with TB transmission, lower rates of sputum culture conversion, and greater mortality.

Impact of awareness drives and community-based active tuberculosis case finding in Odisha, India.

India's Revised National Tuberculosis Control programme employs passive case detection. The new sputum smear-positive case detection rate is less than 70% in Odisha State. During April-June 2012, active case finding (ACF) was conducted through awareness drives and field-based tuberculosis (TB) screening in select communities with the lowest case detection rates. During the campaign, 240 sputum smear-positive TB cases were detected. The number of smear-positive cases detected increased by 11% relative to April-June 2011 in intervention communities compared to an 0.8% increase in non-intervention communities. ACF brought TB services closer to the community and increased TB case detection.

Isoniazid preventive treatment in children in two districts of South India: does practice follow policy?

SETTING: Two districts of Tamil Nadu, India OBJECTIVES: To determine the proportion of household contacts aged <6 years of patients with tuberculosis (TB) with positive sputum microscopy results who initiated and completed isoniazid preventive treatment (IPT), and to determine reasons for non-initiation and non-completion of IPT. DESIGN: Household visits were conducted on a random sample of adult patients registered during January-June 2012 to identify household contacts aged <6 years. RESULTS: Among 271 children living with 691 index patients, 218 (80%) were evaluated and 9 (4%) were diagnosed with TB. Of 209 remaining contacts, 70 (33%) started IPT and 16 (22.9%) completed a full course of IPT. Of 139 contacts who did not start IPT, five developed TB disease. Reasons for non-initiation of IPT included no home visit by the field staff (19%) and no education about IPT (61%). Reasons for non-completion included isoniazid not provided (52%) and long duration of treatment (28%). CONCLUSION: This study shows that Revised National TB Programme guidance was not being followed and IPT implementation was poor. Poor IPT uptake represents a missed opportunity to prevent future TB cases. Provision of IPT may be improved through training, improved logistics and enhanced supervision and monitoring.

Composite indicator: new tool for monitoring RNTCP performance in India.

India's Revised National Tuberculosis Control Programme (RNTCP) used the international benchmarks of 70% case detection rate and 85% treatment success rate among new smear-positive tuberculosis (TB) cases for assessing programme performance. This approach overemphasises outcomes and focuses on quantitative benchmarks without sufficient regard to developing systems to monitor appropriate programme practice to achieve a minimum standard of TB care services. The RNTCP has developed a novel composite indicator tool based on a logical framework pathway to move beyond narrow-focused outcome indicators such as case detection to encourage a broad-based analysis of programme implementation. The constituent indicators are from routinely monitored information, spanning input, process, output and outcome indicators across various thematic categories of the RNTCP.

Characterizing tuberculosis genotype clusters along the United States-Mexico border.

We examined the growth of tuberculosis (TB) genotype clusters during 2005-2010 in the United States, categorized by country of origin and ethnicity of the index case and geographic proximity to the US-Mexico border at the time of TB diagnosis. Nationwide, 38.9% of cases subsequent to Mexico-born index cases were US-born. Among clusters following US-born Hispanic and US-born non-Hispanic index cases, respectively 29.2% and 5.3% of subsequent cluster members were Mexico-born. In border areas, the majority of subsequent cases were Mexico-born following US-born Hispanic (56.4%) and US-born non-Hispanic (55.6%) index cases. These findings suggest that TB transmission commonly occurs between US-born and Mexico-born persons. Along the US-Mexico border, prioritizing TB genotype clusters following US-born index cases for investigation may prevent subsequent cases among both US-born and Mexico-born persons.

Using tuberculosis patient characteristics to predict future cases with matching genotype results.

SETTING: United States. BACKGROUND: It is unknown whether tuberculosis (TB) case or patient characteristics can predict the likelihood of future related TB cases. OBJECTIVE: To estimate the likelihood for future related cases, i.e., cases with matching TB genotypes within the same county diagnosed within the 2 years following the year of reporting of each included case. DESIGN: We considered all TB cases with genotyping results reported in the United States during 2004-2010. Predictive scores were calculated based on patient characteristics by dividing the number of patients who were not the last case in a county-level TB genotype cluster by the total number of patients. RESULTS: Overall, there was a 30.8% chance that a future related case would be detected during the 2 years following the report year of any given case. Future related cases were detected in 34.7% of instances following the diagnosis of smear-positive cases, 51.9% of instances following the diagnosis of a homeless patient and 45.2% of instances following the diagnosis of a patient who reported substance abuse. Predictive scores ranged by race (White 13.9%, Native Hawaiian 43.8%) and age group (⩾65 years 13.1%, 0-4 years 43%), and were higher for US-born patients. CONCLUSIONS: Behavioral and sociodemographic factors can help predict the likelihood of future related cases and can be used to prioritize contact investigations.

Contexte : Etats-Unis.Cadre : On ne sait pas si les caractéristiques d'un cas de tuberculose (TB) ou du patient permettent de prévoir la probabilité de contamination dans l'avenir.Objectif : Estimer la probabilité de cas présentant un génotype similaire dans le même conté et dans une période de 2 ans suivant le cas index.Schéma : Nous avons étudié tous les cas de TB avec génotypage déclarés aux Etats-Unis entre 2004 et 2010. Les scores prédictifs ont été calculés en fonction des caractéristiques du patient en divisant le nombre de patients qui n'étaient pas le dernier cas d'un groupement de génotypes au niveau d'un conté par le nombre total de patients.Résultats : Le risque global de nouveau cas lié à un autre cas était de 30,8% pendant les 2 années suivant l'année de déclaration de tout nouveau cas. Ces contaminations ont été détectées dans 34,7% des circonstances après diagnostic d'un cas à frottis positif, 51,9%, après diagnostic d'un patient sans domicile fixe et 45,2%, après diagnostic d'un patient toxicomane. Les scores prédictifs variaient en fonction de l'ethnie (Blancs 13,9% ; Amérindiens/Hawaïens 43,8%), l'âge (>65 ans 13,1% ; 0­4 ans 43%) et étaient plus élevé chez les patients nés aux Etats-Unis.Conclusion: Les facteurs comportementaux et socio-démographiques peuvent contribuer à prévoir la probabilité d'infection de cas dans le futur et peuvent servir à prioriser les recherches de sujets contacts.

Marco de referencia: En los Estados Unidos de América se desconoce si las características clínicas de un caso de tuberculosis (TB) o las características del paciente permiten pronosticar la probabilidad de aparición de futuros casos de TB relacionados.Objectivo: Evaluar la probabilidad de aparición en el futuro de casos relacionados ­ es decir, casos con genotipos equivalentes, diagnosticados en el mismo condado, durante los 2 primeros años después del año de notificación de cada caso incluido.Métodos: Se consideraron en el estudio todos los casos de TB notificados en los Estados Unidos que contaban con resultados de genotipificación entre el 2004 y el 2010. Se calcularon las puntuaciones pronósticas en función de las características del paciente, al dividir el número de pacientes que no fueron el último caso de un conglomerado genotípico de TB a escala del condado, por el número total de pacientes.Resultados: En general, se observó una probabilidad de 30,8% de aparición de un caso relacionado, durante los 2 años que siguieron al año de notificación de cualquier caso dado. Se observaron casos relacionados en el 34,7% de las veces después del diagnóstico de casos con baciloscopia positiva; el 51,9% de las veces después del diagnóstico de una persona sin domicilio; y en el 45,2% de las veces tras el diagnóstico de un paciente que refería consumo de drogas. Las puntuaciones pronósticas oscilaron, con respecto a la etnia, entre 13,9% en la etnia blanca y 43,8% en los nativos de Hawái); con respecto al grupo de edad, entre 13,1% a partir de los 65 años y 43% en el grupo entre 0 años y 4 años; y el índice pronóstico fue más alto en los pacientes nacidos en los Estados Unidos.Conclusión: Los factores comportamentales y sociodemográficos contribuyen a predecir la probabilidad de aparición de casos futuros relacionados con un caso de TB y se pueden utilizar con el propósito de priorizar las investigaciones de contactos.

Association between Mycobacterium tuberculosis lineage and time to sputum culture conversion.

SETTING: Mycobacterium tuberculosis comprises four principal genetic lineages: one evolutionarily ancestral (Indo-Oceanic) and three modern. Whether response to tuberculosis (TB) treatment differs among the lineages is unknown. OBJECTIVE: To examine the association between M. tuberculosis lineage and time to sputum culture conversion in response to standard first-line drug therapy. DESIGN: We conducted an exploratory retrospective cohort analysis of time to sputum culture conversion among pulmonary tuberculosis (PTB) cases reported in the United States from 2004 to 2007. RESULTS: The analysis included 13,170 PTB cases with no documented resistance to first-line drugs who received a standard four-drug treatment regimen. Among cases with baseline positive sputum smear results, relative to cases with Euro-American lineage, cases with Indo-Oceanic lineage had higher adjusted hazards of sputum culture conversion (aHR 1.32, 95%CI 1.20-1.45), whereas cases with East-African-Indian or East-Asian lineage did not differ (aHR 1.05, 95%CI 0.88-1.25 and aHR 0.99, 95%CI 0.91-1.07, respectively). Among cases with baseline negative sputum smear results, time to sputum culture conversion did not differ by lineage. CONCLUSION: Although these results are exploratory, they suggest that the eradication of viable bacteria may occur sooner among cases with Indo-Oceanic lineage than among those with one of the three modern lineages. Prospective studies of time to sputum culture conversion by lineage are required.

Epidemiology of recurrent tuberculosis in the United States, 1993-2010.

Recurrent tuberculosis (TB) can result from reactivation of a previous TB episode or reinfection with a new Mycobacterium tuberculosis strain. A retrospective analysis of all recurrent TB cases reported in the United States during 1993-2010 was conducted. The proportion of recurrent cases remained stable during the study period (annual range 4.2-5.7%). Compared with persons without a previous diagnosis of TB, persons with recurrent TB experienced lower treatment completion within 12 months and higher mortality during the recurrent episode. Persons with recurrent TB have poorer outcomes, suggesting the need for targeted interventions to ensure treatment completion.

Is bleach-sedimented smear microscopy an alternative to direct microscopy under programme conditions in India?

This cross-sectional multi-centric study compared the yield of and potential benefit for detecting smear-positive pulmonary tuberculosis (PTB) by bleach sedimentation (2% sodium-hypochlorite) versus direct microscopy under programme conditions in India. Among 3168 PTB suspects, 684 (21.6%) were detected by bleach sedimentation vs. 625 (19.7%) by direct microscopy, with a proportional overall agreement of 96% (κ = 0.88). While 594 patients were smear-positive with both methods, 31 patients detected by direct microscopy were missed and an additional 90 patients were detected by bleach sedimentation. Overall, bleach sedimentation increased the yield of smear-positive TB detection; however; it also increased the time to results.

Cette étude transversale multicentrique a comparé, dans les conditions du programme en Inde, le rendement et les avantages potentiels de la détection des tuberculoses pulmonaires (TBP) à frottis positif par la sédimentation à l'eau de Javel (2% d'hypochlorite de sodium) par comparaison avec l'examen microscopique direct. Parmi 3168 sujets suspects de TBP, 684 (21,6%) ont été détectés par la sédimentation à l'eau de Javel par rapport à 625 (19,7%) par l'examen microscopique direct, avec donc une proportion de 96% de concordance globale (κ = 0,88). Alors que les résultats des frottis étaient positifs chez 594 patients par les deux méthodes, l'examen microscopique direct a raté la détection chez 31 patients et la sédimentation à l'eau de Javel a détecté 90 patients de plus. Au total, la sédimentation à l'eau de Javel a augmenté le rendement de la détection des TB à frottis positif, mais a prolongé la durée avant obtention des résultats.

En un estudio transversal multicéntrico se comparó el rendimiento y la posible utilidad de la detección de la tuberculosis (TB) con baciloscopia positiva mediante la concentración del esputo con hipoclorito de sodio (2%) y se comparó esta técnica con el examen microscópico directo, en las condiciones del programa nacional de la India. En los 3168 pacientes con presunción clínica de TB se detectaron 684 casos (21,6%) por el método de la sedimentación con lejía y 625 casos (19,7%) mediante la microscopia directa, lo cual ofrece una concordancia global del 96% (índice κ = 0,88). Quinientos noventa y cuatro pacientes presentaron baciloscopias positivas con ambas técnicas; con la técnica de sedimentación se pasaron por alto 31 de los pacientes diagnosticados por microscopia directa y la concentración con lejía permitió el diagnóstico de 90 pacientes suplementarios. En términos generales, la sedimentación con lejía aumentó el rendimiento de la detección de casos de tuberculosis con baciloscopia positiva, pero prolongó el lapso hasta la obtención de los resultados.

South Carolina tuberculosis genotype cluster investigation: a tale of substance abuse and recurrent disease.

The South Carolina Tuberculosis (TB) Control Division ranked all the TB genotype clusters (two or more cases with matching genotypes) in the state based on the number of cases. The largest cluster, PCR00002, was investigated to determine if the cluster represented recent Mycobacterium tuberculosis transmission, and if so, to identify associated risk factors. The PCR0002 cluster, which included pediatric cases, clearly represented recent M. tuberculosis transmission. The two primary factors contributing to cluster growth were substance abuse and recurrent TB disease. Elimination of ongoing M. tuberculosis transmission in this population will require concurrent treatment for TB disease and substance abuse.

Tuberculosis: what is the yield of associate investigations in non-BCG-immunized children with positive tuberculin skin tests?

SETTING: Urban county health department in Tarrant County, Texas, USA. OBJECTIVE: To determine the yield of associate investigations in non-bacille Calmette-Guerin (BCG) immunized children with positive tuberculin skin tests (TSTs). DESIGN: We compared the results of associate investigations of the contacts of 38 TST-positive, non-BCG-immunized pre-school children with the results of contact investigations of 290 culture-confirmed persons with tuberculosis (TB). RESULTS: Associate investigations were more likely than contact investigations to identify persons with culture-confirmed TB and positive TSTs. Contacts identified through associate investigation of non-BCG-immunized pre-school children were 9.4 (95%CI 4.2-22.5) times more likely to have culture-confirmed TB and 2.3 (95%CI 2.0-2.7) times more likely to have positive TSTs than contacts of persons with culture-confirmed TB. CONCLUSION: While conducting associate investigations is labor intensive, these data indicate that associate investigation of pre-school non-BCG-immunized children should be assigned priority in TB control activities, at least equal to the importance of investigating the contacts of culture-proven TB.