Pre-migration tuberculosis screening - do be aware that the first step is always the hardest.

As the proportion of foreign-born persons among TB notifications continues to rise, Japan is preparing to introduce pre-migration TB screening for those coming from selected countries, who are intending to stay for more than 90 days. It has announced that the programme will commence in 2020. In this review, the authors examine the experiences from two countries which already have years of experience in operating pre-migration TB screening, namely the United Kingdom and Australia. The authors point out that both countries have developed strong health information system not only to collect and analyse screening results, but also to use the data to effectively monitor and evaluate the screening programme itself. The critical role which health information system plays within pre-migration screening is often overlooked. Here we argue that Japan, as with any other countries planning to introduce pre-migration screening for TB, must also plan for data management

The published research paper: is it an important indicator of successful operational research at programme level?

Is a published research paper an important indicator of successful operational research at programme level in low-income countries? In academia, publishing in peer-reviewed scientific journals is highly encouraged and strongly pursued for academic recognition and career progression. In contrast, for those who engage in operational research at programme level, there is often no necessity or reward for publishing the results of research studies; it may even be criticized as being an unnecessary detraction from programme-related work. We present arguments to support publishing operational research from low-income countries; we highlight some of the main reasons for failure of publication at programme level and suggest ways forward

Prevalence and associated factors of depressive state among pulmonary tuberculosis patients in Manila, The Philippines

SETTING: Both depression and tuberculosis (TB) are global public health problems that have a substantial impact on human health. However, depressive state among TB patients has not been well investigated in the Philippines. OBJECTIVE: To assess depressive state among pulmonary tuberculosis (PTB) patients and to identify factors associated with depressive state in Manila, the Philippines. DESIGN: A cross-sectional survey of PTB patients was conducted at 10 public health centres and two nongovernment organisation clinics providing directly observed treatment in District I, Tondo, Manila. Face-toface interviews with 561 PTB patients using a structured questionnaire were conducted. RESULTS: Depressive state was observed in 16.8% of the participants. Logistic regression analysis indicated that body mass index < 18.5 kg/m2, marital status of cohabitation compared with married, four or more symptoms, four or more adverse drug reactions, grade 3 or higher on the Medical Research Council dyspnoea scale and low perceived confidant social support were significantly associated with depressive state. CONCLUSION: Depressive state among PTB patients in economically depressed areas is common, and screening for depression in the primary care setting can identify patients who need support and treatment, especially for malnourished patie nts and those with poor social support

Operational research in Malawi: making a difference with cotrimoxazole preventive therapy in patients with tuberculosis and HIV.

BACKGROUND: In Malawi, high case fatality rates in patients with tuberculosis, who were also co-infected with HIV, and high early death rates in people living with HIV during the initiation of antiretroviral treatment (ART) adversely impacted on treatment outcomes for the national tuberculosis and ART programmes respectively. This article i) discusses the operational research that was conducted in the country on cotrimoxazole preventive therapy, ii) outlines the steps that were taken to translate these findings into national policy and practice, iii) shows how the implementation of cotrimoxazole preventive therapy for both TB patients and HIV-infected patients starting ART was associated with reduced death rates, and iv) highlights lessons that can be learnt for other settings and interventions. DISCUSSION: District and facility-based operational research was undertaken between 1999 and 2005 to assess the effectiveness of cotrimoxazole preventive therapy in reducing death rates in TB patients and subsequently in patients starting ART under routine programme conditions. Studies demonstrated significant reductions in case fatality in HIV-infected TB patients receiving cotrimoxazole and in HIV-infected patients about to start ART. Following the completion of research, the findings were rapidly disseminated nationally at stakeholder meetings convened by the Ministry of Health and internationally through conferences and peer-reviewed scientific publications. The Ministry of Health made policy changes based on the available evidence, following which there was countrywide distribution of the updated policy and guidelines. Policy was rapidly moved to practice with the development of monitoring tools, drug procurement and training packages. National programme performance improved which showed a significant decrease in case fatality rates in TB patients as well as a reduction in early death in people with HIV starting ART. SUMMARY: Key lessons for moving this research endeavour through to policy and practice were the importance of placing operational research within the programme, defining relevant questions, obtaining "buy-in" from national programme staff at the beginning of projects and having key actors or "policy entrepreneurs" to push forward the policy-making process. Ultimately, any change in policy and practice has to benefit patients, and the ultimate judge of success is whether treatment outcomes improve or not

Transmission of Specific Genotype Streptomycin Resistant Strains of Mycobacterium tuberculosis in the Tokyo Metropolitan Area in Japan

<p>Abstract</p> <p>Background</p> <p>From 2003 through to 2004, an outbreak of tuberculosis was identified at a university campus in Yokohama City, located in the southern part of the Tokyo Metropolitan Area (TMA). All <it>Mycobacterium tuberculosis </it>(<it>M. tuberculosis</it>) strains detected with regards to this outbreak turned out to be Streptomycin resistant with matched patterns of 14 IS<it>6110 </it>bands of Restriction Fragment Length Polymorphism (RFLP). The <it>M. tuberculosis </it>bacilli, which had the matched IS<it>6110 </it>band patterns with resistance to Streptomycin to those of bacilli isolated in the outbreak, were also concurrently detected through either the population-based or the hospital-based DNA fingerprinting surveillance of <it>M. tuberculosis </it>either in Shinjuku City or in Kawasaki City respectively.</p> <p>The aim of the present study is to describe the spread of the specific genotype strains of <it>M. tuberculosis </it>in the TMA as observed in the above incident, and to identify the possible transmission routes of the strains among people living in urban settings in Japan.</p> <p>Methods</p> <p>We applied Variable Numbers of Tandem Repeats (VNTR) analysis to all <it>M. tuberculosis </it>isolates which were resistant to Streptomycin with a matched IS<it>6110</it>-RFLP band pattern (M-strains). They were isolated either from cases related to the tuberculosis outbreak that happened at a university, or through DNA fingerprinting surveillance of <it>M. tuberculosis </it>both in Shinjuku City and in Kawasaki City. For VNTR analysis, 12MIRU loci, 4ETR loci, seven loci by Supply, four loci by Murase (QUB15, Mtub24, VNTR2372, VNTR3336) were selected.</p> <p>Results</p> <p>Out of a total of 664 isolates collected during the study period, 46 isolates (6.9%) were identified as M-strains. There was a tendency that there was a higher proportion of those patients whose isolates belonged to M4-substrains, with four copies of tandem repeat at the ETR-C locus, to have visited some of the internet-cafés in the TMA than those whose isolates belonged to M5-substrains, with five copies at the ETR-C locus, although statistically not significant (38.1% vs. 10.0%, Exact p = 0.150).</p> <p>Conclusion</p> <p>Although firm conclusions could not be reached through the present study, it suggested that we have to take into consideration that tuberculosis can be transmitted in congregated facilities like internet cafés where tuberculosis high-risk people and general people share common spaces.</p

Follow-Up of Patients with Multidrug Resistant Tuberculosis Four Years after Standardized First-Line Drug Treatment

Background: In 2004, an anti-tuberculosis (TB) drug resistance survey in Heilongjiang province, China, enrolled 1574 (79%) new and 421 (21%) retreatment patients. Multi-drug resistant (MDR) TB was detected in 7.2% of new and 30.4% of retreatment patients. All received treatment with standardized first-line drug (FLD) regimens. Methodology/Principal Findings: We report treatment outcomes of the 2004 cohort, and long-term outcomes as assessed in the second half of 2008. The reported cure rate for MDR-TB patients was 83% (94/113) among new and 66% (85/128) among retreatment patients (P<0.001). Ten of the 241 MDR-TB patients died during treatment. Of the remaining 231, 129 (56%) could be traced in 2008. The overall recurrence rates among new and retreatment cases were 46% and 66%, respectively (P=0.03). The overall death rates among new and retreatment cases were 25% and 46%, respectively (P=0.02). Forty percent of the traced new cases and 24% of the retreatment cases were alive and without recurrent TB (P=0.01). Of the 16 patients who failed or defaulted from treatment in 2004, only two patients were not re-diagnosed with TB by 2008. Of the 111 (86%) patients with an initial successful treatment outcome 63 (57%) had developed recurrent TB, 40 (36%) had died, 27 (24%) of them died of TB. The follow-up period of four years precluded follow-up of all patients. In a highly conservative sensitivity analysis in which we assumed that all non-included patients were alive and did not have recurrent TB, the recurrence and death rate were 33% and 21%. Conclusions/Significance: Documentation of cure based on conventional smear microscopy was a poor predictor of long term outcomes. MDR-TB patients in Heilongjiang province in China had high recurrence and death rates four years after treatment with standardized FLD regimens, reinforcing the need for early diagnosis and treatment of MDR-TB, including assessment of treatment outcomes with more sensitive laboratory method

Clonal Expansion of Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis, Japan

Strain clustering suggests community transmission plays a critical role in incidence

Detection of Tuberculosis Infection Hotspots Using Activity Spaces Based Spatial Approach in an Urban Tokyo, from 2003 to 2011

Background: Identifying ongoing tuberculosis infection sites is crucial for breaking chains of transmission in tuberculosis-prevalent urban areas. Previous studies have pointed out that detection of local accumulation of tuberculosis patients based on their residential addresses may be limited by a lack of matching between residences and tuberculosis infection sites. This study aimed to identify possible tuberculosis hotspots using TB genotype clustering statuses and a concept of "activity space", a place where patients spend most of their waking hours. We further compared the spatial distribution by different residential statuses and describe urban environmental features of the detected hotspots. Methods: Culture-positive tuberculosis patients notified to Shinjuku city from 2003 to 2011 were enrolled in this case-based cross-sectional study, and their demographic and clinical information, TB genotype clustering statuses, and activity space were collected. Spatial statistics (Global Moran\u27s I and Getis-Ord Gi? statistics) identified significant hotspots in 152 census tracts, and urban environmental features and tuberculosis patients\u27 characteristics in these hotspots were assessed. Results: Of the enrolled 643 culture-positive tuberculosis patients, 416 (64.2%) were general inhabitants, 42 (6.5%) were foreign-born people, and 184 were homeless people (28.6%). The percentage of overall genotype clustering was 43.7%. Genotype-clustered general inhabitants and homeless people formed significant hotspots around a major railway station, whereas the non-clustered general inhabitants formed no hotspots. This suggested the detected hotspots of activity spaces may reflect ongoing tuberculosis transmission sites and were characterized by smaller residential floor size and a higher proportion of nonworking households. Conclusions: Activity space-based spatial analysis suggested possible TB transmission sites around the major railway station and it can assist in further comprehension of TB transmission dynamics in an urban setting in Japan