Impact of ethnic disparities on the treatment outcomes of HIV-negative drug-resistant tuberculosis patients in Kuala Lumpur, Malaysia: A call for a culturally-sensitive community intervention approach.

OBJECTIVE: Little is known about the treatment outcomes of HIV-negative drug-resistant tuberculosis (TB) patients in Malaysia. With respect to this issue, this study aimed to determine factors associated with unsuccessful treatment outcomes among drug-resistant TB patients at the Institute of Respiratory Medicine, Kuala Lumpur, Malaysia. METHODS: This retrospective cohort study involved laboratory-confirmed drug-resistant TB patients from January 2009 to June 2013. Multiple logistic regression was used to model the outcome, which was subsequently defined according to the recent definition by the WHO. Data were analysed using IBM SPSS Statistics for Windows version 22.0. RESULTS: Among the 403 patients who were analysed, 66.7% of them were found to have achieved successful outcomes (cured or completed treatment) while the remaining 33.3% had unsuccessful treatment outcomes (defaulted, treatment failure or died). Multivariable analysis showed that the type of resistance [polyresistant (aOR = 3.00, 95% CI 1.14-7.91), multidrug resistant (MDR) (aOR = 5.37, 95% CI 2.65-10.88)], ethnicity [Malay (aOR = 2.86, 95% CI 1.44-5.71), Indian (aOR = 3.04, 95% CI 1.20-7.70)], and treatment non-compliance (aOR = 26.93, 95% CI 14.47-50.10) were the independent risk factors for unsuccessful treatment outcomes among this group of patients. Notably, the odds of unsuccessful treatment outcome was also amplified among Malay MDR-TB patients in this study (aOR = 13.44, 95% CI 1.99-90.58). CONCLUSION: In order to achieve better treatment outcomes for TB, effective behavioural intervention and thorough investigation on ethnic disparities in TB treatment are needed to promote good compliance.

Beriberi Outbreak Among Unauthorised Immigrants in a Detention Camp in Malaysia.

In February 2012, a district health authority received three inmates with bilateral leg swelling and difficulty in breathing from a detention camp for unauthorized immigrants. A case control study was conducted. Fasting blood samples of case and control groups were collected according to instructions of the laboratory for determining thiamine level, and their 1 week dietary intake was analyzed. 9% (21/226) of inmates had bilateral leg swelling, and 75% (6/8) of them had low thiamine level (< 66 mmol/L). Their diet contained mainly polished rice and other items with low thiamine contents. Bilateral leg swelling was associated with history of no meat consumption during past 3 months (OR 8.4; CI 2.2-32.1). Patients were treated with 100 mg thiamine intravenously and 5 mg orally per day for 6 weeks. All patients responded well. The management was advised to provide vitamin B complex daily, and encouraged to provide thiamine rich foods.

Falciparum Malaria Outbreak in Sabah Linked to an Immigrant Rubber Tapper.

Sabah is a Malaysian state situated in the northern part of Borneo, and it is endemic for malaria. The incidence of malaria is the lowest (0.05/1,000 population) in Penampang districts of Sabah. In June 26, 2012, two Plasmodium falciparum malaria cases were notified to public health department from a village in Penampang. Immediate investigation was initiated to identify the risk factors and to institute control measures. We performed active case finding by asking household members of all houses in the village regarding malaria symptoms and by examining blood smears. Environmental investigation was performed by collecting samples to detect mosquito breeding sites and to identify malaria transmitting vector mosquitoes. A case-control study with a ratio of 1:4 (11 cases and 44 controls) was conducted using self-administered questionnaire. The microscopic examination of blood smear for malarial parasite and entomology sampling was carried out. The malarial attack rate was 2.3%, 6/11 smears have gametocyte, and the case fatality rate was 9.1%. One case was a migrant rubber tapper from Indonesia which happened to be the first case with gametocyte positive. Overall, the incidence of malaria was higher (6/11) among rubber tappers. The odds of cases for those living nearby stagnant water were 7.3 [95% confidence interval: 1.2-43.5] times higher. In conclusion, an outbreak of P. falciparum malaria was introduced into a malaria-free village by a migrant rubber tapper, by whom the imported parasite was introduced to the community via vector Anopheles balabacensis. Living near stagnant water bodies was the risk factor in this outbreak.

Surveillance Evaluation of the National Cancer Registry in Sabah, Malaysia.

BACKGROUND: Cancer is the fourth leading cause of death in Sabah Malaysia with a reported agestandardized incidence rate was 104.9 per 100,000 in 2007. The incidence rate depends on nonmandatory notification in the registry. Underreporting will provide the false picture of cancer control program effectiveness. The present study was to evaluate the performance of the cancer registry system in terms of representativeness, data quality, simplicity, acceptability and timeliness and provision of recommendations for improvement. MATERIALS AND METHODS: The evaluation was conducted among key informants in the National Cancer Registry (NCR) and reporting facilities from FebMay 2012 and was based on US CDC guidelines. Representativeness was assessed by matching cancer case in the Health Information System (HIS) and state pathology records with those in NCR. Data quality was measured through case finding and reabstracting of medical records by independent auditors. The reabstracting portion comprised 15 data items. Selfadministered questionnaires were used to assess simplicity and acceptability. Timeliness was measured from date of diagnosis to date of notification received and data dissemination. RESULTS: Of 4613 cancer cases reported in HIS, 83.3% were matched with cancer registry. In the state pathology centre, 99.8% was notified to registry. Duplication of notification was 3%. Data completeness calculated for 104 samples was 63.4%. Registrars perceived simplicity in coding diagnosis as moderate. Notification process was moderately acceptable. Median duration of interval 1 was 5.7 months. CONCLUSIONS: The performances of registry's attributes are fairly positive in terms of simplicity, case reporting sensitivity, and predictive value positive. It is moderately acceptable, data completeness and inflexible. The usefulness of registry is the area of concern to achieve registry objectives. Timeliness of reporting is within international standard, whereas timeliness to data dissemination was longer up to 4 years. Integration between existing HIS and national registration department will improve data quality.

Predictors of death among drug-resistant tuberculosis patients in Kuala Lumpur, Malaysia: A retrospective cohort study from 2009 to 2013.

The emergence of drug-resistant tuberculosis (TB) is a major public health threat. However, little is known about the predictors of death in drug-resistant TB in Malaysia. This study aimed to determine the predictors of death in drug-resistant TB patients, including multidrug-resistant TB (MDR-TB), in Kuala Lumpur, Malaysia. This study adopted a retrospective cohort study design and involved laboratory-confirmed drug-resistant TB patients (n=426) from January 2009 to June 2013. A Cox regression model and Kaplan-Meier curves were used to model the outcome measure. Data were analysed by using SPSS v.20.0 for Windows. In this study, 15.3% (n=65) of the patients died. Among the study patients, 70.9% were monoresistant TB cases, 9.4% were poly-resistant TB and 19.7% were MDR-TB. MDR-TB [adjusted hazard ratio (aHR)=2.23, 95% confidence interval (CI) 1.26-3.95], ethnicity [Malay (aHR=5.95, 95% CI 2.30-15.41), Chinese (aHR=4.01, 95% CI 1.38-11.66) and Indian (aHR=3.76, 95% CI 1.19-11.85)], coronary heart disease (aHR=6.82, 95% CI 2.16-21.50), drug abuse (aHR=3.79, 95% CI 2.07-6.93) and treatment non-compliance (aHR=1.81, 95% CI 1.01-3.27) were independent predictors of poorer survival in the multivariate Cox regression analysis. This study suggests that MDR-TB, local ethnicity, coronary heart disease, history of drug abuse and treatment non-compliance are factors predicting poor survival in drug-resistant TB patients. More emphasis should be given to the management of drug-resistant TB patients with these characteristics to achieve better treatment outcomes.

Previous treatment, sputum-smear nonconversion, and suburban living: The risk factors of multidrug-resistant tuberculosis among Malaysians.

The number of multidrug-resistant tuberculosis patients is increasing each year in many countries all around the globe. Malaysia has no exception in facing this burdensome health problem. We aimed to investigate the factors that contribute to the occurrence of multidrug-resistant tuberculosis among Malaysian tuberculosis patients. An unmatched case-control study was conducted among tuberculosis patients who received antituberculosis treatments from April 2013 until April 2014. Cases are those diagnosed as pulmonary tuberculosis patients clinically, radiologically, and/or bacteriologically, and who were confirmed to be resistant to both isoniazid and rifampicin through drug-sensitivity testing. On the other hand, pulmonary tuberculosis patients who were sensitive to all first-line antituberculosis drugs and were treated during the same time period served as controls. A total of 150 tuberculosis patients were studied, of which the susceptible cases were 120. Factors found to be significantly associated with the occurrence of multidrug-resistant tuberculosis are being Indian or Chinese (odds ratio 3.17, 95% confidence interval 1.04-9.68; and odds ratio 6.23, 95% confidence interval 2.24-17.35, respectively), unmarried (odds ratio 2.58, 95% confidence interval 1.09-6.09), living in suburban areas (odds ratio 2.58, 95% confidence interval 1.08-6.19), are noncompliant (odds ratio 4.50, 95% confidence interval 1.71-11.82), were treated previously (odds ratio 8.91, 95% confidence interval 3.66-21.67), and showed positive sputum smears at the 2nd (odds ratio 7.00, 95% confidence interval 2.46-19.89) and 6th months of treatment (odds ratio 17.96, 95% confidence interval 3.51-91.99). Living in suburban areas, positive sputum smears in the 2nd month of treatment, and was treated previously are factors that independently contribute to the occurrence of multidrug-resistant tuberculosis. Those with positive smears in the second month of treatment, have a history of previous treatment, and live in suburban areas are found to have a higher probability of becoming multidrug resistant. The results presented here may facilitate improvements in the screening and detection process of drug-resistant patients in Malaysia in the future.