Battling tuberculosis in an island context with a high burden of communicable and non-communicable diseases: epidemiology, progress, and lessons learned in Kiribati, 2000 to 2012

Objectives: To examine the epidemiology of tuberculosis (TB) in Kiribati from 2000 to 2012, document lessons learned, and recommend ways to mitigate the burden of TB in Kiribati. Methods: A descriptive study was performed using data on TB case notifications, prevalence, incidence, mortality, and treatment outcomes from global reports and data files. Progress towards meeting the Millennium Development Goal TB target (to reduce TB incidence by 2015) and the Regional Strategy to Stop Tuberculosis in the Western Pacific 2011–2015 targets (to reduce TB prevalence and mortality by half by 2015 relative to the level in 2000) was examined. Results: TB case notifications and the estimated incidence and prevalence have increased in Kiribati since 2000. From 2000 to 2012, Kiribati reported a total of 3863 TB notifications; in 2012, the case notification rate was 343/100 000 population. The majority (89%) of TB patients complete treatment and/or are cured, and the estimated TB mortality rate has remained relatively stable at around 16/100 000 population. HIV testing of TB patients has increased over recent years from 8% of notifications tested in 2003 to 43% tested in 2012. Of all 818 tests, only four (0.5%) patients were confirmed HIV-positive. Drug-resistant TB has been detected in a small number of cases. Conclusions: TB rates continue to increase in Kiribati and the 2015 goals for TB control are unlikely to be met. This is probably due to the complex mix of risk factors present in Kiribati, including smoking, diabetes, alcohol use, crowded living, and poverty. A comprehensive approach to address these risk factors is needed to mitigate the burden of TB in Kiribati

Re-emergence of thiamine deficiency disease in the Pacific islands (2014-15): A case-control study.

BACKGROUND:From late 2014 multiple atolls in Kiribati reported an unusual and sometimes fatal illness. We conducted an investigation to identify the etiology of the outbreak on the most severely affected atoll, Kuria, and identified thiamine deficiency disease as the cause. Thiamine deficiency disease has not been reported in the Pacific islands for >5 decades. We present the epidemiological, clinical, and laboratory findings of the investigation. METHODOLOGY/PRINCIPAL FINDINGS:We initially conducted detailed interviews and examinations on previously identified cases to characterize the unknown illness and develop a case definition. Active and passive surveillance was then conducted to identify additional cases. A questionnaire to identify potential risk factors and blood samples to assay biochemical indices were collected from cases and asymptomatic controls. Thiamine hydrochloride treatment was implemented and the response to treatment was systematically monitored using a five-point visual analogue scale and by assessing resolution of previously abnormal neurological examination findings. Risk factors and biochemical results were assessed by univariate and multivariate analyses. 69 cases were identified on Kuria (7% attack rate) including 34 confirmed and 35 unconfirmed. Most were adults (median age 28 years [range 0-62]) and 83% were male. Seven adult males and two infants died (13% case fatality rate). Resolution of objective clinical signs (78%) or symptoms (94%) were identified within one week of starting treatment. Risk factors included having a friend with thiamine deficiency disease and drinking kava; drinking yeast alcohol reduced the risk of disease. Higher chromium (p<0·001) but not thiamine deficiency (p = 0·66) or other biochemical indices were associated with disease by univariate analyses. Chromium (p<0·001) and thiamine deficiency (p = 0·02) were associated with disease by multivariate analysis. CONCLUSIONS/SIGNIFICANCE:An outbreak of thiamine deficiency disease (beriberi) in Kiribati signals the re-emergence of a classic nutritional disease in the Pacific islands after five decades. Although treatment is safe and effective, the underlying reason for the re-emergence remains unknown. Chromium was highly and positively correlated with disease in this study raising questions about the potential role of factors other than thiamine in the biochemistry and pathophysiology of clinical disease

Thiamine diphosphate and chromium in cases, controls and Tarawa participants, 2015.

<p>Thiamine diphosphate and chromium in cases, controls and Tarawa participants, 2015.</p

Demographics and mean thiamine diphosphate and chromium values in Kuria cases and controls and Tarawa participants.

<p>Demographics and mean thiamine diphosphate and chromium values in Kuria cases and controls and Tarawa participants.</p

Monthly cases of confirmed and unconfirmed thiamine deficiency disease by month and year of symptom onset on Kuria, Kiribati, during the period from 1 October 2012 to 13 February 2015.

<p>Monthly cases of confirmed and unconfirmed thiamine deficiency disease by month and year of symptom onset on Kuria, Kiribati, during the period from 1 October 2012 to 13 February 2015.</p

Crude and adjusted odds ratios and 95% CIs for risk factors for thiamine deficiency disease.

<p>Crude and adjusted odds ratios and 95% CIs for risk factors for thiamine deficiency disease.</p

Clinical features of cases and controls, Kuria, 2015.

<p>Clinical features of cases and controls, Kuria, 2015.</p

Biochemical results for cases and controls on Kuria, 2015.

<p>Biochemical results for cases and controls on Kuria, 2015.</p