Tuberculosis screening in a novel substance abuse treatment center in Malaysia: Implications for a comprehensive approach for integrated care

People who use drugs (PWUD) represent a key high risk group for tuberculosis (TB). The prevalence of both latent TB infection (LTBI) and active disease in drug treatment centers in Malaysia is unknown. A cross-sectional convenience survey was conducted to assess the prevalence and correlates of LTBI among attendees at a recently created voluntary drug treatment center using a standardized questionnaire and tuberculin skin testing (TST). Participants (N = 196) were mostly men (95%), under 40 (median age = 36 years) and reported heroin use immediately before treatment entry (75%). Positive TST prevalence was 86.7%. Nine (4.6%) participants were HIV-infected. Previous arrest/incarcerations (AOR = 1.1 for every entry, p < 0.05) and not being HIV-infected (AOR = 6.04, p = 0.03) were significantly associated with TST positivity. There is an urgent need to establish TB screening and treatment programs in substance abuse treatment centers and to tailor service delivery to the complex treatment needs of patients with multiple medical and psychiatric co-morbidities.     

Chronic hepatitis C treatment outcomes in low- and middle-income countries: a systematic review and meta-analysis

Objective

To assess the effectiveness of treatment for hepatitis C virus (HCV) infection in low- and middle-income countries and identify factors associated with successful outcomes.

Methods

We performed a systematic review and meta-analysis of studies of HCV treatment programmes in low- and middle-income countries. The primary outcome was a sustained virological response (SVR). Factors associated with treatment outcomes were identified by random-effects meta-regression analysis.

Findings

The analysis involved data on 12 213 patients included in 93 studies from 17 countries. The overall SVR rate was 52% (95% confidence interval, CI: 48–56). For studies in which patients were predominantly infected with genotype 1 or 4 HCV, the pooled SVR rate was 49% (95% CI: 43–55). This was significantly lower than the rate of 59% (95% CI: 54–64) found in studies in which patients were predominantly infected with other genotypes (P = 0.012). Factors associated with successful outcomes included treatment with pegylated interferon and ribavirin, infection with an HCV genotype other than genotype 1 or 4 and the absence of liver damage or human immunodeficiency virus infection at baseline. No significant difference in the SVR rate was observed between weight-adjusted and fixed-dose ribavirin treatment. Overall, 17% (95% CI: 13–23) of adverse events resulted in treatment interruption or dose modification, but only 4% (95% CI: 3–5) resulted in treatment discontinuation.

Conclusion

The outcomes of treatment for HCV infection in low- and middle-income countries were similar to those reported in high-income countries.     

Lack of Reduction in Buprenorphine Injection After Introduction of Co-Formulated Buprenorphine/Naloxone to the Malaysian Market

Background: Diversion of buprenorphine (BPN) has been described in settings where it is legally prescribed and has resulted in increasing concern. To address this concern, co-formulation of buprenorphine/naloxone (BPN/NLX) replaced buprenorphine alone in Malaysia in December 2006. Methods: To assess the significance of BPN/NLX introduction, 41 BPN/NLX injectors in Kuala Lumpur, Malaysia were recruited using a modified snowball recruitment technique. Results: In January 2007, all subjects had previously injected BPN alone. During the transition from injecting BPN alone to co-formulated BPN/NLX, the mean daily BPN injection dose increased from 1.88 mg (range 1.0–4.0 mg) to 2.49 mg/day (p < .001). Overall, 18 (44%) subjects increased their daily amount of injection while 22 (54%) had no change in dose; only one subject reduced the amount of injection. Development of opioid withdrawal symptoms was the primary outcome, however the only symptom that was significantly associated with BPN/NLX dosage was the report of “stomach pains” (p = .01). In logistic regression analysis, the development of opioid withdrawal symptoms was associated with increased benzodiazepine injection and increased syringe sharing. Conclusion and Scientific Significance: These data suggests that the introduction of BPN/NLX did not reduce injection related risk behaviors such as syringe sharing and was associated with increased benzodiazepine use. Evidence-based approaches to treat BPN injection are urgently needed.     

Prevalence of nosocomial infection and antibiotic use at a university medical center in Malaysia.

BACKGROUND AND OBJECTIVE: Most reports of nosocomial infection (NI) prevalence have come from developed countries with established infection control programs. In developing countries, infection control is often not as well established due to lack of staff and resources. We examined the rate of NI in our institution. METHODS: A point-prevalence study of NI and antibiotic prescribing was conducted. On July 16 and 17, 2001, all inpatients were surveyed for NI, risk factors, pathogens isolated, and antibiotics prescribed and their indication. NIs were diagnosed according to CDC criteria. Cost of antibiotic acquisition was calculated by treatment indication. SETTING: Tertiary-care referral center in Malaysia. PATIENTS: All inpatients during the time of the study. RESULTS: Five hundred thirty-eight patients were surveyed. Seventy-five had 103 NIs for a prevalence of 13.9%. The most common NIs were urinary tract infections (12.2%), pneumonia (21.4%), laboratory-confirmed bloodstream infections (12.2%), deep surgical wound infections (11.2%), and clinical sepsis (22.4%). Pseudomonas aeruginosa, MRSA, and MSSA were the most common pathogens. Two hundred thirty-seven patients were taking 347 courses of antibiotics, for an overall prevalence of antibiotic use of 44%. NI treatment accounted for 36% of antibiotic courses prescribed but 47% of antibiotic cost. Cost of antibiotic acquisition for NI treatment was estimated to be approximately 2 million per year (Malaysian dollars). CONCLUSION: Whereas the rate of NI is relatively high at our center compared with rates from previous reports, antibiotic use is among the highest reported in any study of this kind. Further research into this high rate of antibiotic use is urgently required.