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Tuberculosis (TB), caused by the bacterium Mycobacterium tuberculosis, is a global public health issue; 8.6 million incident cases and 1.3 million deaths were attributed to TB in 2012 (1). A [...]

Up to 50% of persons with HIV and a diagnosis of tuberculosis (TB) in Thailand die during TB treatment. In a prospective observational study, a team of physicians ascribed the [...]

Objective WHO&apos;s new Global Plan to Stop T8 2006-2015 advises countries with a high burden of tuberculosis (TB) to expand case-finding in the private sector as well as services for patients with HIV and multidrug-resistant TB (MDR-TB). The objective of this study was to evaluate these strategies in Thailand using data from the Thailand TB Active Surveillance Network, a demonstration project begun in 2004. Methods In October 2004, we began contacting public and private health-care facilities monthly to record data about people diagnosed with TB, assist with patient care, provide HIV counselling and testing, and obtain sputum samples for culture and susceptibility testing. The catchment area included 3.6 million people in four provinces. We compared results from October 2004-September 2005 (referred to as 2005) to baseline data from October 2002-September 2003 (referred to as 2003). Findings In 2005, we ascertained 5841 TB cases (164/100 000), including 2320 new smear-positive cases (65/100 000). Compared with routine passive surveillance in 2003, active surveillance increased reporting of all TB cases by 19% and of new smear-positive cases by 13%. Private facilities diagnosed 634 (11%) of all TB cases. In 2005, 1392 (24%) cases were known to be HIV positive. The proportion of cases with an unknown HIV status decreased from 66% (3226/4904)in 2003 to 23% (1329/5841) in 2005 (P< 0.01). Of 4656 pulmonary cases, mycobacterial culture was performed in 3024 (65%) and MDR-TB diagnosed in 60 (1%). Conclusion In Thailand, piloting the new WHO strategy increased case-finding and collaboration with the private sector, and improved HIV services for TB patients and the diagnosis of MDR-TB. Further analysis of treatment outcomes and costs is needed to assess this programme&apos;s impact and cost effectiveness. Objectif Le nouveau Plan mondial << Halte a la tuberculose >> 2006-2015 de l&apos;OMS conseille aux pays supportant une forte charge de tuberculose (TB) de renforcer la participation du secteur prive dans le depistage de cette maladie et de developper davantage les services destines aux personnes porteuses du VlH et atteintes d&apos;une tuberculose a bacille multiresistant (TB-MR). La presente etude a pour objectif d&apos;evaluer la mise en oeuvre de ces strategies en Thailande a partir des donnees fournies par le Thailand TB Active Surveillance Network (reseau de surveillance active de la tuberculose en Thailande), projet experimental lance en 2004. Methodes En octobre 2004, nous avons etabii des contacts avec des etablissements de soins de sante publics et prives pour recueillir des donnees sur les personnes diagnostiquees comme tuberculeuses, aider a la delivrance de soins de sante, fournir des prestations de conseil et de depistage concernant le VIH et obtenir des echantillons d&apos;expectorations en vue de pratiquer des cultures et des tests de pharmacosensibilite. La zone de desserte comptait 3,6 millions d&apos;habitants repartis dans quatre provinces. Nous avons compare les resultats pour la periode octobre 2004-septembre 2005 (designee par 2005) avec des donnees de reference pour la periode octobre 2002-septembre 2003 (designee par 2003). Resultats En 2005, nous avons enregistre 5841 cas de TB (164/100 000), dont 2320 nouveaux cas de TB a frottis positif (65/100 000). Par rapport aux resultats fournies par la surveillance passive systematique en 2003, la surveillance active apermis une augmentation de la notification de 19 % pour le nombre total de cas de TB et de 13 % pour le nombre de nouveaux cas de TB a frottis positif. Les etablissements prives ont diagnostique 634 (11%) des nouveaux cas de TB. En 2005, 1392 (24%) cas de TB etaient connus comme seropositifs pour le VIH. La proportion de cas de TB avec un statut VIH inconnu est passee de 66 % (3226/4904) en 2003 a 23 % (1329/5841) en 2005 (p < 0,01). Parmi les 4656 cas de TB pulmonaire, 3024 (65%) ont fait l&apos;objet d&apos;une culture mycobacterienne et 60 (1%) ont ete diagnostiques comme atteints d&apos;une TB-MR. Conclusion En Thailande, l&apos;experimentation de la nouvelle strategie OMS a permis d&apos;accroitre le nombre de cas de TB depistes, de renforcer la collaboration avec le secteur prive et d&apos;ameliorer les services lies au VlH a l&apos;intention des personnes tuberculeuses, ainsi que le diagnostic des TB-MR. Une analyse plus poussee des resultats et des couts therapeutiques s&apos;impose pour evaluer l&apos;impact du programme et son rapport cout-efficacite. Objetivo El nuevo Plan Mundial de la OMS para Detener la Tuberculosis 2006-2015 aconseja a los paises que presentan una alta carga de la enfermedad que amplien la busqueda de casos en el sector privado, asi como los servicios destinados a los pacientes con infeccion por VIH y tuberculosis multirresistente (TB-MR). El objetivo del estudio fue evaluar esas estrategias en Tailandia utilizando los datos de la Red de Vigilancia Activa de la Tuberculosis del pais, un proyecto de demostracion iniciado en 2004. Metodos En octubre de 2004 empezamos aponernos en contacto cada mes con servicios de atencion sanitaria publicos y privados a fin de registrar los datos pertinentes sobre las personas con diagnostico de tuberculosis, contribuir a la asistencia a los enfermos, ofrecer asesoramiento y pruebas del VIH y obtener muestras de esputo para la realizacion de cultivos y pruebas de sensibilidad. La zona de captacion abarcaba a 3,6 millones de personas en cuatro provincias. Comparamos los resultados de octubre de 2004 a septiembre de 2005 (en adelante 2005) con los datos de partida correspondientes ai periodo de octubre de 2002 a septiembre de 2003 (en adelante 2003). Resultados En 2005 evaluamos 5841 casos de tuberculosis (164/100 000), incluidos 2320 casos baciliferos nuevos (65/ 100 000). En comparacion con la vigilancia pasiva sistematica de 2003, la vigilancia activa aumento la notificacion de todos los casos de tuberculosis en un 19%, y de los casos baciliferos nuevos en un 13%. Los servicios privados diagnosticaron el 11% (634) de todos los casos de tuberculosis. En 2005 se detectaron 1392 (24%) casos VIH-positivos. La proporcion de casos con serologia VIH desconocida disminuyo del 66% (3226/4904) en 2003 al 23% (1329/5841) en 2005 (p < 0,01). De 4656 casos pulmonares, se realizo un cultivo micobacteriano en 3024 (65%), y se diagnostico TB-MR en 60 (1%). Conclusion En Tailandia, la aplicacion piloto de la nueva estrategia de la OMS aumento la busqueda de casos y la colaboracion con el sector privado, y ademas mejoro los servicios de VIH para los enfermos tuberculosos y el diagnostico de TB-MR. Es necesario seguir analizando los resultados terapeuticos y los costos a fin de evaluar el impacto y la costoeficacia de este programa., Background Tuberculosis (TB) remains one of the world's leading causes of severe illness and death, particularly in developing countries. Since 1993, efforts to control TB have focused on a strategy [...]

Abstract Background In Southeast Asia, HIV-infected patients frequently die during TB treatment. Many physicians are reluctant to treat HIV-infected TB patients with anti-retroviral therapy (ART) and have questions about the added value of opportunistic infection prophylaxis to ART, the optimum ART regimen, and the benefit of initiating ART early during TB treatment. Methods We conducted a multi-center observational study of HIV-infected patients newly diagnosed with TB in Thailand. Clinical data was collected from the beginning to the end of TB treatment. We conducted multivariable proportional hazards analysis to identify factors associated with death. Results Of 667 HIV-infected TB patients enrolled, 450 (68%) were smear and/or culture positive. Death during TB treatment occurred in 112 (17%). In proportional hazards analysis, factors strongly associated with reduced risk of death were ART use (Hazard Ratio [HR] 0.16; 95% confidence interval [CI] 0.07–0.36), fluconazole use (HR 0.34; CI 0.18–0.64), and co-trimoxazole use (HR 0.41; CI 0.20–0.83). Among 126 patients that initiated ART after TB diagnosis, the risk of death increased the longer that ART was delayed during TB treatment. Efavirenz- and nevirapine-containing ART regimens were associated with similar rates of adverse events and death. Conclusion Among HIV-infected patients living in Thailand, the single most important determinant of survival during TB treatment was use of ART. Controlled clinical trials are needed to confirm our findings that early ART initiation improves survival and that the choice of non-nucleoside reverse transcriptase inhibitor does not.

Abstract Background Of the 9.2 million new TB cases occurring each year, about 10% are in children. Because childhood TB is usually non-infectious and non-fatal, national programs do not prioritize childhood TB diagnosis and treatment. We reviewed data from a demonstration project to learn more about the epidemiology of childhood TB in Thailand. Methods In four Thai provinces and one national hospital, we contacted healthcare facilities monthly to record data about persons diagnosed with TB, assist with patient care, provide HIV counseling and testing, and obtain sputum for culture and susceptibility testing. We analyzed clinical and treatment outcome data for patients age < 15 years old registered in 2005 and 2006. Results Only 279 (2%) of 14,487 total cases occurred in children. The median age of children was 8 years (range: 4 months, 14 years). Of 197 children with pulmonary TB, 63 (32%) were bacteriologically-confirmed: 56 (28%) were smear-positive and 7 (4%) were smear-negative, but culture-positive. One was diagnosed with multi-drug resistant TB. HIV infection was documented in 75 (27%). Thirteen (17%) of 75 HIV-infected children died during TB treatment compared with 4 (2%) of 204 not known to be HIV-infected (p < 0.01). Conclusion Childhood TB is infrequently diagnosed in Thailand. Understanding whether this is due to absence of disease or diagnostic effort requires further research. HIV contributes substantially to the childhood TB burden in Thailand and is associated with high mortality.

Abstract Background The occurrence of tuberculosis (TB), human immunodeficiency virus (HIV), and viral hepatitis infections in the same patient poses unique clinical and public health challenges, because medications to treat TB and HIV are hepatotoxic. We conducted an observational study to evaluate risk factors for HBsAg and/or anti-HCV reactivity and to assess differences in adverse events and TB treatment outcomes among HIV-infected TB patients. Methods Patients were evaluated at the beginning, during, and at the end of TB treatment. Blood samples were tested for aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (BR), complete blood count, and CD4+ T lymphocyte cell count. TB treatment outcomes were assessed at the end of TB treatment according to international guidelines. Results Of 769 enrolled patients, 752 (98%) had serologic testing performed for viral hepatitis: 70 (9%) were reactive for HBsAg, 237 (31%) for anti-HCV, and 472 (63%) non-reactive for both markers. At the beginning of TB treatment, 18 (26%) patients with HBsAg reactivity had elevated liver function tests compared with 69 (15%) patients non-reactive to any viral marker (p = 0.02). At the end of TB treatment, 493 (64%) were successfully treated. Factors independently associated with HBsAg reactivity included being a man who had sex with men (adjusted odds ratio [AOR], 2.1; 95% confidence interval [CI], 1.1–4.3) and having low TB knowledge (AOR, 1.8; CI, 1.0–3.0). Factors most strongly associated with anti-HCV reactivity were having injection drug use history (AOR, 12.8; CI, 7.0–23.2) and living in Bangkok (AOR, 15.8; CI, 9.4–26.5). The rate of clinical hepatitis and death during TB treatment was similar in patients HBsAg reactive, anti-HCV reactive, both HBsAg and anti-HCV reactive, and non-reactive to any viral marker. Conclusion Among HIV-infected TB patients living in Thailand, markers of viral hepatitis infection, particularly hepatitis C virus infection, were common and strongly associated with known behavioral risk factors. Viral hepatitis infection markers were not strongly associated with death or the development of clinical hepatitis during TB treatment.

Background: Tuberculosis (TB) screening affords clinicians the opportunity to diagnose or exclude TB disease and initiate isoniazid preventive therapy (IPT) for people living with HIV (PLHIV)., Methods: We implemented an algorithm to diagnose or rule out TB among PLHIV in 11 HIV clinics in Thailand and Vietnam. We assessed algorithm yield and uptake of IPT and factors associated with TB disease among PLHIV., Results: A total of 1448 PLHIV not yet on antiretroviral therapy (ART) were enrolled and screened for TB. Overall, 634 (44%) screened positive and 119 (8%) were diagnosed with TB; of these, 40% (48/119) were diagnosed by a positive culture following a negative sputum smear microscopy. In total, 55% of those eligible (263/477) started on IPT and of those, 75% (196/263) completed therapy. The prevalence of TB disease we observed in this study was 8.2% (8218 per 100,000 persons): 46 and 25 times the prevalence of TB in the general population in Thailand and Vietnam, respectively. Several factors were independently associated with TB disease including being underweight [aOR (95% CI): 2.3 (1.2 to 2.6)] and using injection drugs [aOR (95% CI): 2.9 (1.3 to 6.3)]., Conclusions: The high yield of TB disease diagnosed among PLHIV screened with the algorithm, and higher burden among PLHIV who inject drugs, underscores the need for innovative, tailored approaches to TB screening and prevention. As countries adopt test-and-start for antiretroviral therapy, TB screening, sensitive TB diagnostics, and IPT should be included in differentiated-care models for HIV to improve diagnosis and prevention of TB among PLHIV.

Introduction: The impact of antiretroviral therapy (ART) on HIV-infected tuberculosis (TB) patients in public health programs in resource-limited settings is not well documented due to problems with statistical bias in observational studies., Methods: We measured the impact of ART on survival of HIV-infected TB patients in Thailand using a propensity score analysis that adjusted for factors associated with receiving ART., Results: Of 626 HIV-infected TB patients started on ART during TB treatment, 68 (11%) died compared with 295/643 (46%) of patients not prescribed ART (relative risk 0.24, 95% confidence interval: 0.19 to 0.30); in patients with very low CD4 (<10), 12/56 (21%) patients receiving ART died compared with 35/43 (81%) patients not receiving ART (relative risk 0.26, 95% confidence interval: 0.16 to 0.44). Patients treated in the private sector and in rural areas were less commonly prescribed ART. After controlling for propensity to receive ART, the hazard ratio for death among patients treated with ART was 0.17 (95% confidence interval: 0.12 to 0.24)., Discussion: Patients who received ART had one sixth the risk of death of those not receiving ART. The survival benefit persisted even for those with a very low CD4 count. Expanding use of ART in HIV-infected TB patients will require increasing ART use in the private sector and rural areas.