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SETTING In many high tuberculosis (TB) burden countries, there is substantial geographical heterogeneity in TB burden. In addition, decisions on TB funding and policy are highly decentralised. Subnational estimates of burden, however, are usually unavailable for planning and target setting.OBJECTIVE and DESIGN We developed a statistical model termed SUBsET to estimate the distribution of the national TB incidence through a weighted score using selected variables, and applied the model to the 514 districts in Indonesia, which have substantial policy and budgetary autonomy in TB. Estimated incidence was compared to reported facility and domicile-based notifications to estimate the case detection rate (CDR). Local stakeholders led model development and dissemination.RESULTS The final SUBsET model included district population size, level of urbanisation, socio-economic indicators (living floor space and high school completion), human immunodeficiency virus prevalence and air pollution. We estimated district-level TB incidence to be between 201 and 2,485/100 000/year. The facility-based CDR varied between 0 and 190%, with high variation between neighbouring districts, suggesting strong cross-district health utilisation, which was confirmed by domicile-based CDR estimation. SUBsET results informed district-level TB action plans across Indonesia.CONCLUSION The SUBsET model could be used to estimate the subnational burden in high-burden countries and inform TB policymaking at the relevant decentralised administrative level.SETTING Nine high-burden public tuberculosis (TB) clinics in Gaborone, Botswana.OBJECTIVE To evaluate the challenges encountered, healthcare worker (HCW) approaches, and supported interventions in TB and TB-HIV (human immunodeficiency virus) care for adolescents and young adults (AYA, aged 10-24 years).DESIGN Semi-structured interviews with HCW in TB clinics, analyzed using thematic analysis.RESULTS Sixteen HCWs were interviewed. AYA developmental needs included reliance on family support for care, increasing autonomy, attending school or work, building trust in HCWs, and intensive TB education and adherence support. Stigma strongly influenced care engagement, including clinic attendance and HIV testing. Health system barriers to optimal AYA TB care included limited staffing and resources to follow-up or support. HCWs utilized intensive education and counseling, and transitioned AYA to community-based directly observed therapy whenever feasible. HCWs supported implementation of youth-friendly services, such as AYA-friendly spaces or clinic days, training in AYA care, use of mobile applications, and peer support interventions, in addition to health system strengthening.CONCLUSION HCWs utilize dedicated approaches for AYA with TB, but have limited time and resources for optimal care. They identified several strategies likely to improve care and better retain AYAs in TB treatment. Further work is needed to study interventions to improve AYA TB care and outcomes.BACKGROUND Pyrazinamide (PZA) is an important anti-tuberculosis drug for multidrug-resistant tuberculosis (MDR-TB). However, PZA has recently been demoted within the hierarchy of TB drugs used for MDR-TB.METHODS We conducted a retrospective cohort study to investigate treatment outcomes for simple MDR-TB (susceptible to both second-line injectable drugs and fluoroquinolones) according to PZA susceptibility.RESULTS Among 216 pulmonary MDR-TB patients included in the study, 68 (31.5%) were PZA-resistant (PZA-R). The mean age was 41.8 years, and 63.4% were male. Baseline characteristics such as comorbidity, previous TB history, acid-fast bacilli (AFB) smear positivity and cavitation were similar in PZA-susceptible (PZA-S) and PZA-R patients. The number of potentially effective drugs was slightly higher among PZA-S patients than among the PZA-R (5.1 vs. 4.8, respectively; P = 0.003). PZA was more frequently used in PZA-S patients (73.0%) than in the PZA-R (14.7%), while para-aminosalicylic acid was more frequently used in PZA-R than in PZA-S patients (76.5% vs. 50.7%). The treatment success rate was similar in PZA-S (77.7%) and PZA-R (75.0%) patients. PZA resistance was not associated with treatment success in multivariate analysis.CONCLUSIONS PZA-resistant simple MDR-TB patients had the same treatment success rate as the PZA-susceptible group even without using novel anti-TB drugs.SETTING A referral hospital in South Africa.OBJECTIVE To describe the clinical presentation, serial brain imaging findings during treatment and outcome of patients with intracranial tuberculoma in a high human immunodeficiency virus (HIV) prevalence setting.DESIGN This was a retrospective observational study conducted over a 12.5-year period. Records of adults (age ≥18 years) who presented with neurological TB were screened. We included patients with tuberculoma in whom sequential brain imaging was performed.RESULTS Of 66 patients enrolled, HIV status was known in 61; 47 (71%) were HIV-infected and 14 (21%) were non-HIV-infected. Clinical and imaging findings and outcomes were similar between these groups. Persistent tuberculoma was present at 18 months follow-up in 20/41 (49%) patients who underwent repeat imaging at that timepoint; those with persistent tuberculoma were more likely to have persisting neurological abnormalities (85% vs. 52%; P = 0.043). Larger tuberculoma size at presentation (≥3 cm) was the only factor significantly associated with tuberculoma persistence (multivariable logistic regression, OR 19.9, 95%CI 1.27-309.68; P = 0.033).CONCLUSION Tuberculoma is a severely disabling TB manifestation regardless of HIV coinfection, with half of patients showing radiologically persistent lesions at 18 months follow-up. Large size of tuberculoma at presentation heralds lower chance of its resolution within 18 months.Non-tuberculous mycobacteria (NTM) have evolved as an emerging group of pathogens globally. Due to the pitfalls in identification, the majority of them are not familiar or remain 'rare' to clinicians and microbiologists. In available literatures, a consolidated global data analysis is non-existent on rarely encountered NTM. A systematic review and meta-analysis have been carried out on 100 rare NTM species, which are possibly identified only by DNA sequencing methods, to establish their global epidemiology, emergence and clinical relevance. TP-0903 supplier Articles published in English from 1956 to 2018 reporting rare NTM species were searched in MEDLINE, Scopus, Ovid and Embase. A total of 447 articles matched the selection criteria, and 1670 rare NTM cases were identified from 52 countries. The majority of the incidences were reported from North America (33.4%), followed by Europe (23.8%) and Asia (20.8%). link2 Of 100 species, 43 were defined as emerging species, with 1351 (80.9%) new incidence cases globally. In total, 87 species caused clinically relevant pulmonary and extrapulmonary diseases. Interestingly, some NTM species showed significant geographic predominance, such as M. conceptionense to South Korea, M. shinjukuense to Japan; M. arupense and M. nonchromogenicum to the United States and M. riyadhense to Saudi Arabia. Rare NTM species mainly caused pulmonary infection (67.1%), while extrapulmonary infections generally comprised mycobacteremia and skin/soft tissue infections. In conclusion, the majority of rarely encountered NTM species are now well-established pathogens with valid clinical implications. The emergence of these rare pathogens warrants immediate local and international follow-ups. Their increasing clinical and pathological significance should not be disregarded.BACKGROUND Peru has one of the highest burdens of multidrug-resistant tuberculosis (MDR-TB), but universal drug susceptibility testing (DST) has not yet been achieved.OBJECTIVE To estimate the proportion of drug resistance among smear-positive TB patients in Peru.DESIGN From September 2014 to March 2015, we performed a national drug resistance survey of patients aged ≥15 years; TB was diagnosed based on sputum smear positivity. We performed DST at the National Reference Laboratory of the Peruvian National Institute of Health, Lima, Peru, using the proportion method in Middlebrook 7H10 agar for four first-line drugs and six second-line drugs, and the Wayne method for pyrazinamide.RESULTS Of the 1908 new and 272 previously treated patients included in the analysis, 638 (29.3%) patients had resistance to at least one first-line drug. MDR-TB was diagnosed in 7.3% of new and 16.2% of previously treated patients (P less then 0.001). There were five (0.2%) patients with extensively drug-resistant TB.CONCLUSION MDR-TB has increased to 7.3% in new patients from 5.3% in the previous survey, indicating that resistance to anti-tuberculosis drugs is increasing in Peru. Ongoing community transmission of resistant strains highlights an urgent need for early diagnosis, optimised treatment and effective contact tracing of MDR-TB patients.BACKGROUND Chronic obstructive lung disease (COPD) is the third most common cause of death in the world. Factors other than smoking, such as socio-economic status, could be involved in the development of COPD.OBJECTIVE To investigate the association between chronic airflow obstruction and socio-economic status in Morocco.DESIGN Questionnaires were administered and spirometry tests performed as part of the BOLD (Burden of Obstructive Lung Disease) Study carried out in Fez, Morocco. Socio-economic status was evaluated using a wealth score (0-10) based on household assets. The ratio of forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) was used to measure airflow obstruction.RESULTS A total of 760 subjects were included in the analysis. The mean age was 55.3 years (standard deviation [SD] 10.2); the average wealth score was 7.54 (SD 1.63). After controlling for other factors and potential confounders, FEV1/FVC increased by 0.4% (95%CI 0.01-0.78; P less then 0.04) per unit increase in wealth score. Ageing, tobacco smoking, underweight, history of tuberculosis and asthma were also independently associated with a higher risk of airflow obstruction.CONCLUSION Our findings suggest that airflow obstruction is associated with poverty in Morocco. Further investigations are needed to better understand the mechanisms of this association.SETTING QuantiFERON TB assay (QFT) is used to screen tuberculosis (TB) infection, but it cannot distinguish active TB from latent TB infection (LTBI).OBJECTIVE To evaluate the quantitative expression of the high-affinity FCgamma receptor I (CD64) on neutrophils (NE) and monocytes (MO) in peripheral blood using flow cytometry, measured in antibody binding capacity (ABC) units as a predictive biomarker of TB.DESIGN Fifty-two patients were enrolled (45 QFT-positive and 7 QFT-indeterminate). Cultures and molecular analyses were performed.RESULTS Of the 45 QFT-positive patients, 29 were culture-positive (active TB) and 16 were negative (LTBI). link3 The median NE CD64 ABC and MO CD64 ABC expression was significantly higher (P 25 800; two culture-negative cases had lower values.CONCLUSION The CD64 quantitative expression on peripheral blood cells may be used as a predictive biomarker for active TB.
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