HIV testing among tuberculosis patients in the era of antiretroviral therapy: a population-based study in Brazil.

SETTING: Rio de Janeiro, Brazil, a city with 29862 cases of tuberculosis (TB) reported between January 1995 and June 1998. OBJECTIVES: To evaluate the counseling and testing practices for human immunodeficiency virus (HIV) infection among TB patients, and to identify the patient characteristics associated with HIV screening as antiretroviral therapy was introduced. DESIGN: Cross-sectional study of patients with TB who were reported to the health department and who initiated anti-TB treatment. The main outcome measure was screened versus not screened for HIV. RESULTS: The proportion of TB patients who received HIV screening increased from January 1995 through June 1998 (P < 0.001). Among young adults aged 20-49 years with TB, the independent predictors of HIV screening were a diagnosis of both pulmonary and extrapulmonary TB (odds ratio [OR] = 2.4, 95% confidence interval [CI] 2.1-2.8); TB meningitis (OR = 13.5, 95%CI 6.5-31.5); disseminated TB (OR = 8.2, 95%CI 5.3-12.9); lymphatic TB (OR = 5.6, 95%CI 4.7-6.6); and male sex (OR = 1.4, 95%CI 1.3-1.6). Patients with newly diagnosed TB who were women, lived in a low income neighborhood (OR = 0.7, 95%CI, 0.6-0.7), and sought TB treatment in their own residential neighborhood (OR = 0.3, 95%CI 0.3-0.4) were less likely to receive HIV counseling and testing. CONCLUSION: Health care providers in Rio de Janeiro selectively offered HIV counseling and testing to persons they perceived to be at risk for HIV and those with advanced stages of TB. HIV counseling and testing should be expanded and offered to all TB patients.     

The epidemiology of HIV-associated tuberculosis in rural Cambodia.

SETTING: Banteay Meanchey Province, Cambodia. OBJECTIVE: The World Health Organization recommends human immunodeficiency virus (HIV) testing for all tuberculosis (TB) patients and TB screening for all HIV-infected persons in countries with a TB-HIV syndemic. We sought to determine whether evidence supports implementing these recommendations in South-East Asia. DESIGN: We conducted a cross-sectional survey and retrospective cohort study of patients newly diagnosed with HIV or TB from October 2003 to February 2005 to identify risk factors for HIV infection and TB, and for death during TB treatment. RESULTS: HIV infection was diagnosed in 216/574 (38%) TB patients. TB disease was found in 124/450 (24%) HIV-infected persons. No sub-groups of patients had a low risk of HIV infection or TB. Of 180 TB patients with HIV infection and a recorded treatment outcome, 49 (27%) died compared to 17/357 (5%) without HIV infection (relative risk [RR] 5.2, 95% confidence interval [CI] 3.1-8.7). HIV-infected TB patients with smear-negative pulmonary disease died less frequently than those with smear-positive pulmonary disease (RR 0.39, 95%CI 0.16-0.93). CONCLUSIONS: No sub-groups of patients had low risk for HIV infection or TB, and mortality among HIV-infected TB patients was high. These data justify using the WHO global TB-HIV recommendations in South-East Asia. Urgent interventions are needed to reduce the high mortality rate in HIV-infected TB patients.     

HIV-associated tuberculosis in the era of highly active antiretroviral therapy. The Adult/Adolescent Spectrum of HIV Disease Group.

OBJECTIVE: To determine the effect of highly active antiretroviral therapy (HAART) on the risk of tuberculosis (TB) among persons infected with the human immunodeficiency virus (HIV), and to examine trends in TB. METHODS: For the risk factor analysis, we examined data from the Adult/Adolescent Spectrum of HIV Disease (ASD) project from January 1996 through June 1998. ASD is an observational cohort study conducted in over 100 clinics and hospitals in 11 US cities. Poisson regression was used to model the incidence of TB while controlling for HIV-exposure mode, race, country of birth, CD4 count, TB preventive therapy, and half-year of diagnosis. We also examined trends in TB incidence January 1992 to June 1998. RESULTS: During the risk factor analysis period, 80 cases of TB occurred in 16,032 person-years (5.0 cases/1000 person-years). In multivariate analysis, the risk of TB was much lower among persons prescribed HAART (RR = 0.2, 95%CI 0.1-0.5, P < 0.001), and also lower among persons prescribed other antiretroviral therapy (RR = 0.6, 95% CI 0.4-1.0, P = 0.05), than the risk in persons not prescribed antiretroviral therapy. In addition, TB rates declined from January 1992 to June 1998 (P < 0.001). CONCLUSION: Widespread use of HAART reduced the risk for TB and may help bring about further declines in TB among persons infected with HIV.     

Determinants of drug-resistant tuberculosis: analysis of 11 countries.

SETTING: Eleven countries/territories. OBJECTIVES: Global information on the determinants of drug-resistant tuberculosis (TB) based on representative data is not available. We therefore studied the relationship between demographic characteristics, prior TB treatment, and human immunodeficiency virus (HIV) infection with anti-tuberculosis drug resistance. METHODS: Population-based representative data on new and previously treated patients with TB collected within an international drug resistance surveillance network. RESULTS: Of 9,615 patients, 8,222 (85.5%) were new cases of TB and 1,393 (14.5%) were previously treated cases. Compared with new cases, previously treated cases were significantly more likely to have resistance to one (OR = 2.5,95% CI 2.1-3.0; P < 0.001), two (OR = 4.6, 95%CI 3.7-5.6; P < 0.001), three (OR = 11.5, 95%CI 8.6-15.3; P < 0.001), and four (OR = 18.5, 95% CI 12.0-28.5; P < 0.001) drugs. An approximately linear increase in the likelihood of having multidrug-resistant tuberculosis (MDR-TB) was observed as the total time (measured in months) of prior anti-tuberculosis treatment increased (P < 0.001, chi2 for trend). In multivariate analysis, prior TB treatment for 6-11 months (OR = 7.6, 95% CI 2.6, 22.4; P < 0.001) and > or = 12 months (OR 13.7, 95% CI 4.5-41.6; P < 0.001), but not HIV positivity, was associated with MDR-TB. CONCLUSION: This study shows that prior but ineffective treatment is a strong predictor of drug resistance, and that HIV is not an independent risk factor for MDR-TB. The association between length of treatment and drug resistance may reflect longer treatment as a result of treatment failure in patients with drug resistance; it may also reflect irregular prior treatment for TB, leading to drug resistance.     

Factors associated with an increased case-fatality rate in HIV-infected and non-infected South African gold miners with pulmonary tuberculosis.

SETTING: A gold mining company in the Free State Province, South Africa. AIM AND DESIGN: A retrospective cohort study to investigate factors associated with an increased case-fatality rate (CFR) at 6 months in human immunodeficiency virus (HIV) positive and negative tuberculosis (TB) patients. RESULTS: Between April 1993 and March 1997, there were 2236 men with culture-confirmed pulmonary TB in whom HIV status and treatment outcome were known. The overall CFR within the first 6 months of therapy was low (3.6%). After adjusting for confounding factors, HIV infection (OR 15.0, 95%CI 7.4-30.6), self-presentation compared to detection by the active radiological screening programme (OR 5.6, 95%CI 2.6-12.2) and presence of silicosis (OR 3.0, 95%CI 1.4-6.3) were significantly associated with an increased CFR. Opportunistic infections accounted for 56.2% (36/64) of deaths in HIV-positive men. Cryptococcal disease accounted for 75% (27/36) of deaths from opportunistic infections. CONCLUSION: HIV infection and silicosis are both powerful risk factors for TB and are associated with an increased risk of death. Strategies aimed at reducing these two risk factors within the workforce could reduce TB incidence and mortality. In settings with functional DOTS programmes and sufficient resources, expanding the DOTS programme to include active case detection should be explored as a means of reducing TB prevalence and mortality.     

Current status of treatment completion and fatality among tuberculosis patients in Spain.

OBJECTIVES: To determine treatment completion among patients with tuberculosis (TB), and to analyse factors associated with treatment default and fatality. METHODS: A prospective cohort study of patients who began treatment between 1 June 1999 and 31 May 2000 in areas where members of the SEPAR Tuberculosis and Respiratory Infections Group work. Factors associated with treatment default and fatality were studied using logistic regression, calculating odds ratios (OR) and their 95% confidence intervals (95%CI). RESULTS: The study involved 142 physicians from 76 different hospitals who provided information on 1515 cases. Eighty-two per cent of the patients completed treatment correctly, 14% defaulted, 5% died, 0.5% failed, and 8.7% interrupted treatment due to transfer or other reasons. The variables associated with default were intravenous drug use (IVDU) (OR 6.00, 95%CI 2.59-13.89) and immigration (OR 8.57, 95%CI 3.78-19.45); sex, age, homelessness, incarceration, directly observed treatment (DOT) or hospitalisation were not associated with default. Variables found to be predictive of fatality were alcoholism (OR 6.38, 95%CI 2.09-19.48), human immunodeficiency virus (HIV) infection (OR 7.08, 95%CI 2.08-29.15) and age >64 years (OR 10, 95%CI 2.9-34.07), whereas sex, IVDU, homelessness, DOT and hospitalisation were not. CONCLUSIONS: In industrialised countries, IVDU patients and immigrants should be targeted for DOT, while to reduce fatality rates stricter monitoring is required for patients who are alcoholic, HIV-infected, or aged >64 years.     

Successful use of rifampicin for Hispanic foreign-born patients with latent tuberculosis infection.

SETTING: Four months of rifampicin (4R) is recommended for the treatment of latent tuberculosis infection (LTBI), although data regarding its use are limited. The majority of tuberculosis (TB) cases in the USA occur among foreign-born persons. OBJECTIVE: To determine tolerability, hepatotoxicity and completion rates associated with 4R among foreign-born persons. DESIGN: We retrospectively evaluated 4R treatment among a cohort of predominantly Hispanic foreign-born LTBI patients in four Middle-Tennessee public health clinics from February 2000 to February 2004. Patients' charts were reviewed to abstract demographic, social and clinical data. 4R completion rates, new symptoms and hepatotoxicity (serum aminoalanine transferase >or=120U/l with gastrointestinal symptoms or >or=200 regardless of symptoms) were evaluated. RESULTS: Of 749 patients treated, 571 (76%) completed 4R. Among all subjects, Hispanics had a lower risk of non-completion (OR 0.6, 95%CI 0.4-0.7) than non-Hispanics. Among non-Hispanic subjects, the risk of non-completion was higher for Blacks than non-Blacks (adjusted OR 2.6, 95%CI 1.5-4.7), but was lower for foreign-born than non-foreign-born subjects (adjusted OR 0.5, 95%CI 0.2-0.9). During treatment, 85 subjects (11%) developed new symptoms, and hepatotoxicity occurred in three patients. CONCLUSION: With high completion rates and minimal side effects, 4R is a favorable LTBI treatment regimen for Hispanic and other foreign-born patients.     

Incidence of tuberculosis and the importance of treatment of latent tuberculosis infection in a Spanish prison population.

OBJECTIVE: To establish the incidence of tuberculosis (TB) in a prison population and its link with latent tuberculosis infection treatment (LTIT). METHODS: From 1991 to 1999 a TB programme was run in a Spanish prison. A cohort study was conducted to know TB incidence and the associated variables. RESULTS: Of 1,050 people studied, 10% were co-infected by the human immunodeficiency virus (HIV) and Mycobacterium tuberculosis. Twenty-three cases of TB were detected, an incidence rate of 6.39 per 1,000 person-years of follow-up. Multivariate analysis showed HIV-infected patients (RR 4.07, 95%CI 2.61-6.35), and those infected by M. tuberculosis who did not undergo LTIT (RR 10.15, 95%CI 0.90-50.59) to be at greater risk of developing TB. In TST reactors, those co-infected with HIV (RR 10.15, 95%CI 3.80-27.07) and those who had not undergone LTIT (RR 8.53, 95%CI 1.12-64.86) were shown to be at the greatest risk of developing TB. CONCLUSIONS: The observed incidence of TB is much higher in prisons than in the community at large. HIV-M. tuberculosis co-infection appears as the main risk factor for developing TB, while LTIT significantly reduces incidence.     

Impact of tuberculosis on the course of HIV-infected patients with a high initial CD4 lymphocyte count.

OBJECTIVE: To assess the influence of tuberculosis (TB) on the progression of human immunodeficiency virus (HIV) infection in patients without immunological impairment. MATERIAL AND METHODS: In an observational study of retrospective cohorts, the evolution of 28 HIV-infected patients with TB and a CD4 lymphocyte count >500 x 10(6) cells/l was compared with 56 HIV-infected patients without TB. Each case was paired with two controls by CD4 lymphocyte count (+/-50 x 10(6)/l) and date of starting follow-up (+/-6 months). The progression of HIV infection was evaluated as: 1) immunological progression: time to CD4 lymphocyte count <200 x 10(6)/l; 2) clinical progression: time to development of acquired immune-deficiency syndrome (AIDS), excluding TB; 3) survival; and 4) global disease progression: time to the first defined event in 1, 2 and/or 3. The times to these events were estimated using Kaplan Meier curves. RESULTS: There were no significant differences between the cohorts for age, sex and risk group. Faster immunological impairment (RR 2.94; 95%CI 1.46-8.6; P < 0.01), greater progression to AIDS (RR 4.01; 95%CI 1.66-9.69; P < 0.01), lower survival (RR 3.89; 95%CI 1.53-9.87; P < 0.05) and higher global disease progression (RR 2.82; 95%CI 1.57-5.09; P < 0.01) were found in the cohort of TB patients. These associations were still significant after adjustment for CD4 lymphocyte counts. CONCLUSION: The diagnosis of TB in HIV-infected patients with a high initial CD4 lymphocyte count (>500 x 10(6)/l) was related to greater progression to AIDS and shorter survival.     

Meta-analysis on the association of TIRAP S180L variant and tuberculosis susceptibility

The missense variant S180L in TIRAP (Toll-interleukin-1 receptor domain-containing adaptor protein) gene is implicated in attenuating TLRs signal transaction and may affect individual response to Mycobacterium tuberculosis infection. Several studies investigated the association between TIRAP S180L and risk of tuberculosis (TB), but the results were controversial. In this study, we quantitatively synthesized nine studies relevant to the association between TIRAP S180L polymorphism and TB risk with total 6584 TB cases and 7294 controls using meta-analysis. We found that the variant allele Leu180 and heterozygous genotype Ser/Leu were not significantly associated with risk of TB (allelic OR = 0.99, 95%CI: 0.88-1.11; Ser/Leu vs Ser/Ser: OR = 0.99, 95%CI: 0.87-1.13) with heterogeneity P values > 0.05. In subgroup analysis, none of the significant associations were observed for S180L and TB risk in Africans (allelic OR = 0.58, 95%CI: 0.29-1.61; heterozygous OR = 0.65, 95%CI: 0.32-1.32) or Asians (allelic OR = 1.30, 95%CI: 0.97-1.74; heterozygous OR = 1.17, 95%CI: 0.84-1.65) or risk of pulmonary tuberculosis (PTB) (allelic OR = 0.92, 95%CI: 0.69-1.22; heterozygous OR = 0.98, 95%CI: 0.86-1.12). This meta-analysis indicates that TIRAP S180L polymorphism is unlikely to substantially contribute to TB susceptibility.     

HTLV-1 infection is frequent among out-patients with pulmonary tuberculosis in northern Lima, Peru.

SETTING: Tuberculosis (TB) and human T-lymphotropic virus 1 (HTLV-1) are frequent in Peru. The prevalence of HTLV-1 among Peruvian TB patients is unknown. OBJECTIVE: To determine the prevalence of HTLV-1, HTLV-2 and the human immunodeficiency virus (HIV) in out-patients with TB and to compare HTLV-1-infected patients with seronegative patients. DESIGN: Cross-sectional study including subjects aged 18-65 years diagnosed with smear-positive pulmonary TB at health centres in northern Lima from November 2004 to August 2005. HTLV and HIV screening was performed using enzyme-linked immunosorbent assay; HTLV-1 and HTLV-2 were confirmed using line immunoassay. RESULTS: There were 311 participants with a median age of 29 years; 173 (56%) were men. HTLV-1 prevalence was 5.8% (18/311, 95%CI 3.2-8.4) and HIV prevalence was 1.3% (4/304, 95%CI 0.4-3.3). HTLV-2 was not diagnosed. In comparison with HIV- and HTLV-seronegative patients, HTLV-1-infected subjects were older (median age 44 vs. 28, P < 0.001) and were more likely to have been born in the southern Andes (OR 4.4, 95%CI 1.6-11.9). They were also more likely to report a history of TB deaths in the family (OR 5.4, 95%CI 1.7-16.8) and had more sputum smear results graded as 3+ (OR 4.1, 95%CI 1.5-11.2). CONCLUSION: HTLV-1 screening among Peruvian TB patients is important. Because 3+ sputum smears are frequent and mortality is high among relatives, families of HTLV-1/TB-positive cases merit special attention.     

Factors contributing to treatment success among tuberculosis patients: a prospective cohort study in Bangkok

SETTING: Chest Clinic, Ministry of Public Health and health care centres, Bangkok Metropolitan Administration. OBJECTIVE: To determine patient factors predicting successful tuberculosis (TB) treatment. DESIGN: A prospective cohort was conducted during May 2004 to November 2005. Newly diagnosed TB patients aged > or = 15 years were recruited after giving informed consent. Three sets of questionnaires were used to collect data from the patients three times. Data were also gathered from treatment cards. RESULTS: Of 1241 patients, 81.1% were successfully treated. Bivariate analysis indicated that patients' sex, education, occupation, level of knowledge about TB and adverse effects were associated with treatment success. Unconditional logistic regression analysis showed that females had a higher success rate than males (OR = 1.9, 95%CI 1.2-2.9). Patients with regular incomes had twice the likelihood of success of the unemployed (OR = 2.0, 95%CI 1.1-3.5). Patients with high knowledge levels were more likely to complete treatment (OR = 2.0, 95%CI 1.2-3.4), while those with adverse effects were less likely to adhere (OR = 0.6, 95%CI 0.4-0.9). CONCLUSION: The current low treatment success rate may be partly due to inadequate knowledge about TB among patients. Improvements in health education and early detection and management of adverse effects should be prioritised by the National Tuberculosis Programme.     

Factors associated with the development of tuberculosis in BCG immunized children

In this hospital-based case-control study, children attending Siriraj Hospital and Queen Sirikit National Institute of Child Health from 1 December 2002 to 30 June 2003 were studied to define factors associated with TB in BCG immunized children (n = 260). Subjects of the same age and sex were divided into case and control groups by tuberculosis status. Caregivers were interviewed with a structured questionnaire. Data were analyzed by univariate analysis and multivariate analysis for biological factors (birth weight, health status, nutritional status), socioeconomic factors (parental education, education of caregiver, parental occupation, household incomes, and stability of household incomes), and environmental factors (history of contact with a tuberculosis patient, housing ventilation, child's bedroom ventilation, biomass smoke, passive smoking, crowded family and crowded in child's bedroom). Our findings show that children who had contact with TB patients had a very high risk of tuberculosis, even though they were vaccinated at birth. The risks vary according to the closeness level: very close (OR 85.67, 95%CI = 11.33-647.79), close (OR 31.11, 95%CI = 3.93-246.22) and not close (OR 32.70, 95%CI = 4.18-255.94). In order to identify the effect of others variables, the data was reanalyzed only in the group with no history of TB patient contacts (n = 192). Living in a crowded family, which was reflected by an average of 5 or more persons per room, also increased the risk (OR 11.18, 95%CI = 2.35-53.20). The other factor that increased the risk for tuberculosis was passive smoking. Children who were exposed to passive smoking had a 9.31 times increased risk of getting tuberculosis (95%CI = 3.14-27.58). These findings suggest that the public health department must develop a TB surveillance system in high TB prevalence areas, and in high density communities, and encourage smokers in every family to avoid smoking near children. Latent tuberculosis treatment recommendations for TB control cluster, as set by the Bureau of AIDS/TB and STIs, must be implemented in all health centers and an effective TB control program must be reinforced.     

5' dinucleotide repeat polymorphism of NRAMP1 and susceptibility to tuberculosis among Caucasian patients in Houston, Texas.

SETTING: Houston Tuberculosis Initiative (HTI) and Baylor College of Medicine, Houston, Texas. OBJECTIVE: To further explore the association between the polymorphisms of NRAMP1 and human susceptibility/resistance to tuberculosis (TB), specifically to determine whether the reported association shown for blacks and Asians holds true for Caucasian populations. DESIGN: In a case-control study, 135 adult Caucasian TB patients and 108 adult Caucasian HIV-seronegative non-TB controls were analyzed for the association between the polymorphisms in NRAMP1 gene and clinical TB. RESULTS: Heterozygote at 5'(GT)n, a dinucleotide repeat polymorphism in the promoter of NRAMP1, was observed at significantly higher frequencies among HIV-negative patients with pulmonary TB (41.6%; OR 2.02; 95%CI 1.11-3.64), extra-pulmonary TB (66.7%; OR 4.80; 95%CI 1.34-17.15), and HIV-seropositive TB patients (50%; OR 3.77; 95%CI 1.33-10.66) in comparison with the controls (27.8%). Homozygotes (GT)(10,10) were over-represented among HIV-positive TB patients (18.2%; OR 6.86; 95%CI 1.55-30.21) compared to the controls (5.5%). CONCLUSION: These findings suggest that the 5'(GT)n polymorphism of NRAMP1 modifies TB susceptibility in this Caucasian population, and could possibly be related to the site of infection among HIV-negative individuals and HIV-coinfected TB.     

结核病与艾滋病低流行地区MTB/HIV双重感染患者发现模式的效果评价

目的 回顾性分析上海市近10年在结核病患者与HIV/AIDS人群中对HIV抗体和活动性结核病双向筛查的数据,评价MTB/HIV双重感染患者发现模式的效果,为进一步完善相关政策提供依据。 方法 通过《中国结核病信息管理系统》收集2012—2020年结核病患者(68155例)HIV抗体检测结果及结核病诊断、治疗相关资料;通过《结核菌/艾滋病病毒双重感染防治管理工作年度报表》收集2012—2020年HIV/AIDS人群接受结核病相关检查情况。采用线性回归模型评价筛查阳性率随年度的变化趋势,并计算年度变化百分比(APC)和需筛查人数(NNS),评价筛查效果;采用单因素方差分析和多因素logistic回归分析评价2012—2019年上海市长宁区、浦东新区10769例肺结核患者中HIV阳性的影响因素。 结果 2012—2020年上海市累积发现MTB/HIV双重感染患者308例,其中新确诊HIV感染者64例,占全部MTB/HIV双重感染患者的20.78%。2012—2020年间,结核病患者中HIV抗体检测阳性率由2.42%(32/1322)下降到0.50%(20/3995),总体呈下降趋势(APC=-16.64,t=-7.007,P<0.001);HIV/AIDS人群中活动性结核病确诊率由1.02%(50/4912)下降到0.21%(25/11878),同样呈下降趋势(APC=-14.27,t=-4.038,P=0.005)。多因素logistic回归分析显示,男性[OR(95%CI)=5.386(2.306~12.581)],年龄36~75岁[36~45、46~55、56~65、66~75岁OR(95%CI)值分别为26.243(3.230~213.244)、32.736(3.993~268.358)、20.309(2.482~166.144)、13.461(1.692~107.059)],在结核病治疗过程中死亡[OR(95%CI)=14.875(3.192~69.312)],并发肺外结核[OR(95%CI)=3.451(1.607~7.409)]是MTB/HIV双重感染的危险因素。 结论 上海市目前采取的 MTB/HIV双重感染患者发现模式取得了较好的效果,结核病患者的HIV阳性率和HIV/AIDS人群的活动性结核病确诊率均迅速下降。男性、年龄36~75岁、在治疗过程中死亡、并发肺外结核是MTB/HIV双重感染的危险因素。     

Risk of development of tuberculosis in HIV-infected patients.

OBJECTIVE: To estimate the rate of development of active tuberculosis (TB) in a cohort of human immunodeficiency virus (HIV) positive patients, and to identify the characteristics of these patients. DESIGN: A total of 175 HIV-positive individuals were recruited from clinics for sexually transmitted diseases and followed up for 31 +/- 6.8 months. Clinical examination, chest X-ray, sputum smear for acid-fast bacilli and culture for mycobacteria and HIV serology were performed at the time of registration and repeated periodically. RESULTS: Seventeen patients had TB at intake and another 24 developed TB during follow-up, giving a breakdown rate of 6.9/100 person-years (p-y) (95% confidence interval [CI] 4.1-9.6). The attack rates were similar in tuberculin positive (7.1/100 p-y, 95%CI 3.4-10.8) and negative (6.7/100 p-y, 95%CI 2.6-10.8) patients. There was a trend towards higher mortality in patients who developed TB (10.5/100 p-y, 95%CI 4.8-15.2) compared to those who did not (6.1/100 p-y, 95%CI 3.2-8.8). CONCLUSIONS: The results of this study provide information regarding the high risk of development of active tuberculosis and its associated mortality in HIV-infected persons. The risk of developing TB appears to be equally high in tuberculin positive and negative individuals, suggesting that new infections could play a major role in this susceptible population.     

Diabetes mellitus is strongly associated with tuberculosis in Indonesia.

SETTING: Diabetes mellitus is a known risk factor for tuberculosis (TB), but no studies have been reported from South-East Asia, which has a high burden of TB and a rapidly growing prevalence of diabetes. OBJECTIVE: To examine if and to what extent diabetes is associated with an increased risk of TB in an urban setting in Indonesia. DESIGN: Case-control study comparing the prevalence of diabetes mellitus (fasting blood glucose level >126 mg/dl) among newly diagnosed pulmonary TB patients and matched neighbourhood controls. RESULTS: Patients and control subjects had a similar age (median 30 years) and sex distribution (52% male), but malnutrition was more common among TB patients (median body mass index 17.7 vs. 21.5 kg/m2). HIV infection was uncommon (1.5% of patients). Diabetes mellitus was present in 60 of 454 TB patients (13.2%) and 18 of 556 (3.2%) control subjects (OR 4.7; 95%CI 2.7-8.1). Adjustment for possible confounding factors did not reduce the risk estimates. Following anti-tuberculosis treatment, hyperglycaemia reverted in a minority (3.7%) of TB patients. CONCLUSION: Diabetes mellitus is strongly associated with TB in young and non-obese subjects in an urban setting in Indonesia. This may have implications for TB control and patient care in this region.     

Extra-pulmonary tuberculosis at a regional hospital in Thailand

The purpose of this study was to analyze the cases of extra-pulmonary tuberculosis (EPTB) at Maharat Nakhon Ratchasima Hospital, a tertiary care regional hospital in Northeast Thailand. There were 398 cases of EPTB (46.9%) and 450 cases of pulmonary tuberculosis (PTB) (53.1%). The mean age of EPTB patients (47.58 years) was lower than that of PTB patients (51.6 years) (p < 0.01). Human Immunodeficiency Virus (HIV) seropositivity was found in 50 cases of EPTB (12.6%) and 55 cases of PTB (12.2%) which was not significantly different. The common sites of extra-pulmonary involvement were the lymph nodes (29.7%), followed by the pleura (27.4%), the bones and spine (25.1%), the meninges and brain (4.5%), the pericardium (3.5%) and the gastrointestinal tract (3.0%). Disseminated TB occurred in only 8 cases (2.0%). HIV seropositivity rates were more common in disseminated TB (OR 41.51, 95% CI 4.98-34.5), TB of the meninges and brain (OR 4.47, 95% CI 1.57-12.6) and TB of the lymph nodes (OR 3.49, 95% CI 1.86-6.54) and were less common in TB of the bones and spine (OR 0.05, 95% CI 0.01-0.37) and TB of the pleura (OR 0.24, 95%CI 0.09-0.63).     

Exploring the determinants of treatment success for tuberculosis cases in Europe.

SETTING: Pooled tuberculosis (TB) notifications from 13 European countries. OBJECTIVE: To analyse the determinants of TB treatment success in different countries using individual data. DESIGN: We asked 18 European countries with both outcome data and individual TB records to code outcomes for cases notified in 2000 and/or 2001. Cases completing treatment regardless of bacteriological proof of cure were considered successful. RESULTS: Ten European Union countries and Iceland, Norway and Romania participated (72% response). Among 24 660 TB cases (Romania excluded), 'success' was reported in 69% (country range 60-88%), 9% (0-11%) died, 1% (0-5%) failed, 4% defaulted or transferred (2-15%) and 12% (0-23%) were 'unknown'. On logistic regression among cases with drug susceptibility results (n = 10 303), 'success' was associated with younger age (>74 years: reference; 55-74 years: OR = 2.0, 95%CI 1.8-2.4; 35-54 years: 3.0, 95%CI 2.6-3.5; 15-34 years: 3.7, 95%CI 3.2-4.4; <15 years: 4.4, 95%CI 2.9-6.7), female sex (1.4, 95%CI 1.3-1.6), and no polyresistance (9.2, 95%CI 6.8-12.4). The Netherlands (1.6, 95%CI 1.3-2.0) and Slovakia (1.8, 95%CI 1.4-2.2) had higher success than Estonia (reference: lowest percentage success), while Austria was lower (0.64, 95%CI 0.52-0.78). CONCLUSION: Preventing drug resistance, increasing adherence and improving care in the elderly should be priorities. Inter-country variations in treatment success suggest differences in the completeness of monitoring data and in the efficacy of national control programmes.     

Normal chest radiography in pulmonary tuberculosis: implications for obtaining respiratory specimen cultures.

SETTING: Urban tuberculosis (TB) clinic, Nashville, Tennessee, USA. OBJECTIVE: Chest radiographs (CXRs) help in the diagnosis of pulmonary TB, but may be normal. Mycobacterium tuberculosis in culture is diagnostic of TB, but cultures are not routinely obtained in resource-poor settings. We examined rates and risk factors for pulmonary TB associated with normal CXR. DESIGN: An observational cohort study was performed among all respiratory culture-positive TB cases referred to the Nashville Health Department from October 1992 to July 2003. Clinical factors, demographics and underlying medical conditions were assessed. RESULTS: Of 601 study patients, 53 (9%) had normal CXRs: 31/138 (22%) were human immunodeficiency virus (HIV) infected and 22/463 (5%) were non-HIV-infected/unknown (P<0.001). Among HIV-infected patients, normal CXR was more likely in persons with renal failure (13% vs. 3%, P=0.048). Among non-HIV-infected/unknown patients, normal CXR was more likely in those who were asymptomatic at presentation (32% vs. 13%, P=0.022). In multivariable logistic regression analysis, HIV infection was associated with an increased risk of normal CXR (odds ratio [OR] 6.61, P<0.0001); factors associated with reduced risk were dyspnea (OR 0.24, P=0.026), positive sputum smear (OR 0.45, P=0.028) and cough (OR 0.48, P=0.038). CONCLUSIONS: The rate of normal CXR among persons with culture-confirmed pulmonary TB was high. Respiratory specimen cultures should be obtained in TB suspects with a normal CXR, particularly HIV-infected persons.