Arshad Javaid

Smoking habits in the Middle East and North Africa: Results of the BREATHE study

Few recent comparative data exist on smoking habits in the Middle East and North Africa (MENA) region. The objective of this analysis was to evaluate smoking patterns in a large general population sample of individuals aged ≥ 40 years in ten countries in the region (Algeria, Egypt, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, Turkey and United Arab Emirates), together with Pakistan, using a standardised methodology. A random sample of 457,258 telephone numbers was generated and called. This identified 65,154 eligible subjects, of whom 62,086 agreed to participate. A screening questionnaire was administered to each participant, which included six questions relating to cigarette consumption and waterpipe use. The age- and gender-adjusted proportion of respondents reporting current or past smoking of cigarettes or waterpipes was 31.2% [95% CI: 30.9-31.6%]. This proportion was significantly higher (p < 0.001) in men (48.0%) than in women (13.8%), but no relevant differences were observed between age groups. Smoking rates were in general lowest in the Maghreb countries and Pakistan and highest in the Eastern Mediterranean countries, ranging from 15.3% in Morocco to 53.9% in Lebanon. Consumption rates were 28.8% [28.4-29.2%] for cigarette smoking and 3.5% [3.4-3.6%] for waterpipe use. Use of waterpipes was most frequent in Saudi Arabia (8.5% of respondents) but remained low in the Maghreb countries (< 1.5%). Cumulative cigarette exposure was high, with a mean number of pack · years smoked of 18.5 ± 20.5 for women and 29.1 ± 26.2 for men. In conclusion, smoking is a major health issue in the MENA region.

Applicability of the World Health Organization recommended new shorter regimen in a multidrug-resistant tuberculosis high burden country.

In order to improve the adherence and treatment outcomes of multidrug-resistant (MDR) tuberculosis (TB) patients, the World Health Organization (WHO) has recently recommended a new, shorter and cheaper treatment regimen. The new regimen, comprised of 4–6 months of kanamycin, moxifloxacin, prothionamide, clofazimine, pyrazinamide, ethambutol and high dose isoniazid followed by 5 months of moxifloxacin, clofazimine, pyrazinamide and ethambutol [1], has produced excellent outcomes under operational research conditions is various settings [2–4]. However, the recommendation that it should be used only for MDR-TB patients who are neither previously treated with second-line anti-TB drugs, nor resistant to fluoroquinolones or injectable second-line anti-TB drugs [1], generates concerns about its applicability in MDR-TB high burden countries [5]. In the current cross-sectional study, culture-confirmed MDR-TB patients treated at two units for programmatic management of drug-resistant TB in Pakistan were evaluated for drug resistance pattern and eligibility to be treated with the new shorter regimen. High prevalence of ofloxacin resistance should not limit the applicability of the new shorter regimen in Pakistan http://ow.ly/HCAs306dUjU

Management and treatment outcomes of MDR-TB: results from a setting with high rates of drug resistance.

SETTINGS Although Pakistan has a high burden of multidrug-resistant tuberculosis (MDR-TB), little is known about the management and treatment outcomes of MDR-TB patients in Pakistan. OBJECTIVE To evaluate management and predictors of unsuccessful treatment outcomes among MDR-TB patients. METHODS In this observational cohort study, 196 MDR-TB patients enrolled at the Programmatic Management Unit for drug-resistant TB of Lady Reading Hospital, Peshawar, Pakistan, between 1 January 2012 and 28 February 2013 were included. Patients were followed until an outcome was recorded or 31 January 2015. RESULTS Extensive concurrent resistance to ofloxacin (OFX) and pyrazinamide (54.6%) was observed. Among 181 patients for whom treatment outcome was available, 135 (74.6%) were cured, 1 (0.6%) completed treatment, 35 (19.3%) died, 8 (4.4%) failed treatment and 2 (1.1%) defaulted. In multivariate analysis, predictors of unsuccessful treatment outcome (death, failure and default) were age >40 years (OR 3.412, P = 0.009), baseline body weight <40 kg (OR 2.966, P = 0.020), concurrent comorbidity (OR 3.785, P = 0.023), resistance to OFX (OR 2.777, P = 0.023), lung cavitations at baseline chest X-ray (OR 5.253, P < 0.001) and regimen modification due to adverse events (OR 3.492, P = 0.037). CONCLUSION The treatment outcome results were encouraging. Patients with identifiable predictors of poor treatment outcome should receive enhanced clinical management. Early detection and management of mild adverse effects can help prevent regimen modification and may improve treatment outcomes.

Predictors of two months culture conversion in multidrug-resistant tuberculosis: findings from a retrospective cohort study.

Background Various studies have reported culture conversion at two months as a predictor of successful treatment outcome in multidrug-resistant tuberculosis (MDR-TB). Objectives The present study was conducted with the aim to evaluate the rate and predictors of culture conversion at two months in MDR-TB patients. Methods All confirmed pulmonary MDR-TB patients enrolled for treatment at Lady Reading Hospital Peshawar, Pakistan from 1 January to 31 December 2012 and met the inclusion criteria were reviewed retrospectively. Rate and predictors of culture conversion at two months were evaluated. Results Eighty seven (53.4%) out of 163 patients achieved culture conversion at two months. In a multivariate analysis lung cavitation at baseline chest X-ray (P = 0.006, OR = 0.349), resistance to ofloxacin (P = 0.041, OR = 0.193) and streptomycin (P = 0.017, OR = 0.295) had statistically significant (P<0.05) negative association with culture conversion at two months. Conclusion A reasonable proportion of patients achieved culture conversion at two months. Factors negatively associated with culture conversion at two months can be easily identified either before diagnosis or early in the course of MDR-TB treatment. This may help in better care of individual patients by identifying them early and treating them vigorously.

Pattern of Drug Resistance and Risk Factors Associated with Development of Drug Resistant Mycobacterium tuberculosis in Pakistan.

Background Drug resistant tuberculosis (DR-TB) is a major public health problem in developing countries such as Pakistan. Objective The current study was conducted to assess the frequency of drug resistant tuberculosis including multi drug resistance (MDR- TB) as well as risk factors for development of DR-TB, in Punjab, Pakistan. Methodology Drug susceptibility testing (DST) was performed, using proportion method, for 2367 culture positive Mycobacterium tuberculosis (MTB) cases that were enrolled from January 2012 to December 2013 in the province of Punjab, Pakistan, against first-line anti-tuberculosis drugs. The data was analyzed using statistical software; SPSS version 18. Results Out of 2367 isolates, 273 (11.5%) were resistant to at least one anti-TB drug, while 221 (9.3%) showed MDR- TB. Risk factors for development of MDR-TB were early age (ranges between 10–25 years) and previously treated TB patients. Conclusion DR-TB is a considerable problem in Pakistan. Major risk factors are previous history of TB treatment and younger age group. It emphasizes the need for effective TB control Program in the country.

Rapid detection of Mycobacterium tuberculosis and rifampicin resistance in extrapulmonary tuberculosis and sputum smear-negative pulmonary suspects using Xpert MTB/RIF.

Background. Tuberculosis (TB) is a serious public health problem in developing countries such as Pakistan. Rapid diagnosis of TB and detection of drug resistance are very important for timely and appropriate management of multidrug‐resistant TB (MDR‐TB). Objective. The purpose of this study was to determine the diagnostic efficacy of the Xpert MTB/RIF assay for rapid diagnosis of TB and detection of rifampicin (RIF) resistance in extrapulmonary and smear‐negative pulmonary TB suspects. Methods. A total of 98 bronchoalveolar lavage fluid (BALF) and 168 extrapulmonary specimens were processed by Xpert MTB/RIF. Culture results are considered as the gold standard for diagnosis of TB, and drug susceptibility testing for detection of RIF resistance. Diagnostic efficacy was measured in terms of sensitivity, specificity and positive and negative predictive values. Results. The Xpert MTB/RIF assay detected 40 (40.8%) of 98 BALF of presumptive pulmonary TB and 60 (35.7%) of 168 extrapulmonary specimens. Sensitivity and specificity of the Xpert MTB/RIF assay for detection of TB was 86 and 88.4%, respectively. The positive predictive value was 71.5% while negative predictive value was 95.1%. Conclusion. The Xpert MTB/RIF assay is a rapid and simple technique with high sensitivity and specificity for diagnosing TB and detecting drug resistance in extrapulmonary and smear‐negative TB cases.

Characteristics and treatment outcomes of patients with multi-drug resistant tuberculosis at a tertiary care hospital in Peshawar, Pakistan

Objectives: To determine characteristics and treatment outcomes of multidrugs resistant tuberculosis (MDR-TB) patients and risk factors for poor outcomes in MDR-TB patients in a tertiary care hospital in Peshawar, Pakistan. Methods: This retrospective study was conducted at the Programmatic Management of Drug Resistant TB Unit, Lady Reading Hospital Peshawar, Pakistan and included all MDR-TB patients registered between January 2012 and December 2012. A special proforma was used for data collection. Analysis was performed using SPSS version 16, after exporting data from the proforma. Differences in proportions were assessed using Pearson’s Chi square test whereas for predictors of poor outcomes, multivariate logistic regression analysis with Wald Statistical criteria using backward elimination method was performed. Results: The treatment success rate was 74.3%. In univariate analysis, poor outcomes were associated in patients with age ≥44 years (odds ratio [OR]=0.250; 95% confidence interval [CI]: 0.114-0.519, p=0.001), rural residence (OR=0.417; 95% CI: 0.18-0.937, p=0.03), lung cavitation (OR=0.22; 95% CI, 0.007-0.067, p=0.001), resistance to second line drugs (SLD) (OR=3.441; 95% CI: 1.579-7.497, p=0.001), and resistance to ofloxacin (OR=2.944; 95% CI: 1.361-6.365, p=0.005); whereas multivariate logistic regression analysis, poor outcomes were associated in patients with age ≥44 years (OR=0.249, 95% CI: 0.075-0.828, p=0.023), rural residence (OR=0.143, 95% CI: 0.052-0.774, p=0.032), and cavitatory lungs (OR=0.022, 95% CI: 0.007-0.072, p=0.000). Conclusion: The MDR-TB patient needs special attention for better treatment outcomes. The presence of older age, rural area residence, resistance to ofloxacin, SLD resistance, and cavitary disease are independent prognostic factors for poor outcome in patients with MDR-TB.

Screening outcomes of household contacts of multidrug-resistant tuberculosis patients in Peshawar, Pakistan

OBJECTIVE To assess the profile of TB/multidrug-resistant TB (MDR-TB) among household contacts of MDR-TB patients. METHODS Close contacts of MDR-TB patients were traced in the cross-sectional study. Different clinical, radiological and bacteriological were performed to rule out the evidence of TB/MDR-TB. RESULTS Between January 2012 and December 2012, a total of 200 index MDR-TB patients were initiated on MDR-TB treatment, out of which home visit and contacts screening were conducted for 154 index cases. Of 610 contacts who could be studied, 41 (17.4%) were diagnosed with MDR-TB and 10 (4.2%) had TB. The most common symptoms observed were cough, chest pain and fever. CONCLUSIONS The high incidence of MDR-TB among close contacts emphasize the need for effective contact screening programme of index MDR-TB cases in order to cut the chain of transmission of this disease.