Sriprapa Nateniyom

Causes of death in HIV-infected persons who have tuberculosis, Thailand.

Many of these patients die of a cause other than tuberculosis; expanded use of antiretroviral therapy and modern diagnostic technologies may reduce case-fatality rates.

HIV care and treatment factors associated with improved survival during TB treatment in Thailand: an observational study

BackgroundIn 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.MethodsWe 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.ResultsOf 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.ConclusionAmong 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.A case study from the Katine parish in Uganda where the challenge of accessing antiretroviral drugs is exacerbated by abject poverty in the region. The article highlights the needs of the community members with HIV / AIDS in the region and the response of AMREF (the NGO working in the region) to addressing these issues.

Antiretroviral therapy for HIV-infected tuberculosis patients saves lives but needs to be used more frequently in Thailand.

Descemet stripping automated endothelial keratoplasty (DSAEK), as coined by myself, is rapidly becoming the most popular method of corneal transplantation for endothelial disease. It is an evolutionary step based on the pioneering work of Melles, with further development by Terry and Price. The advantages of the keratome system to cut donor tissue have not only improved clinical outcomes but also increased the number of corneal surgeons performing endothelial transplantation by eliminating highly skilled and laborious manual dissections. The current decision for a corneal surgeon is no longer DSAEK versus PKP but purchasing a keratome system for approximately

HIV-associated extrapulmonary tuberculosis in Thailand: epidemiology and risk factors for death.

30,000 versus letting the eye bank supply precut donor tissue (this scenario may change with the availability of less expensive keratome systems or Melles’ newest procedure called Descemet membrane endothelial keratoplasty). Like most expensive purchases, each surgeon must weigh many factors that include patient outcomes, convenience, and cost. This month’s edition of Cornea contains a pertinent article from the Iowa Lions eye bank on the results and surgeon satisfaction of precut donor tissue they supplied to 53 surgeons for 197 DSAEK cases. The favorable conclusions of their surgeon survey deserve further scrutiny. I would like to break down the discussion into 2 categories: clinical outcomes and financial considerations. Clinical outcomes should be the main driving force behind the evaluation of any medical procedure. Safety is the number one priority, but safety is predicated on many factors. Any increase in the number of subsequent intraocular procedures, even with ultimately good outcomes, decreases patient safety. In this survey, donor dislocations ranged from 33% to 20% depending on surgeon’s experience. The authors concluded that these numbers were in line with the previous studies and that there was no increased dislocation rate with precut tissue. I disagree with that conclusion. Although it is true that the original DSAEK papers, mine included, reported high dislocation rates consistent with the numbers in this survey, those were from seminal articles of the authors’ very first cases. Now, several years later, procedural evolution and increased numbers have reduced the present dislocation rate to single digits for experienced surgeons. One could conclude from this survey that precut tissue more than doubles the dislocation rate, which in turn decreases patient safety. To be fair, Chen and Price have reported no increased dislocation rate with precut tissue. Obviously, surgeon’s ability and technique are important factors in all aspects of DSAEK. Surgeon satisfaction should correlate with patient outcomes, especially in a retrospective survey such as the one under discussion. Ninety-eight percent of surgeons were happy with the precut tissue. Closer examination of the reported problems, however, indicates that either this group of surgeons was very easy to please or all the problems were only seen by a single surgeon. Twenty-one donor corneas (11%) required additional manual lamellar dissection by the surgeon to increase the bed size for adequate trephination size. That would make me unhappy. Fourteen cases (8%) failed, with one-third attributable to tissue-related factors. That also would not make me smile. Five donors were reported to be either totally unacceptable or too thick or too thin. I would be unhappy if I received any of those 5 donor tissues. Other annoying problems such as lack of centration mark in corneas or a free-floating anterior cap were reported. Those would be minor irritants. In totaling up all these problems, 98% of surgeons should not have been satisfied. I have never used precut tissue, but based on my discussions with both Drs Terry and Price, I believe that successful outcomes can be equally obtained with precut tissue and surgeon cut tissue. There is a level of security with precut tissue in terms of a post cut cell count and cost accountability in the rare event of an unusable donor from a poor surgeon cut. This leads us into the second half of the discussion, cost.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.

Evaluating the potential impact of the new Global Plan to Stop TB: Thailand, 2004-2005

BACKGROUND We conducted a prospective, multicenter observational cohort study in Thailand to characterize the epidemiology of extrapulmonary tuberculosis (TB) in HIV-infected persons and to identify risk factors for death. METHODS From May 2005 to September 2006, we enrolled, interviewed, examined, and performed laboratory tests on HIV-infected adult TB patients and followed them from TB treatment initiation until the end of TB treatment. We conducted multivariate proportional hazards analysis to identify factors associated with death. RESULTS Of the 769 patients, pulmonary TB only was diagnosed in 461 (60%), both pulmonary and extrapulmonary TB in 78 (10%), extrapulmonary TB at one site in 223 (29%), and extrapulmonary TB at more than one site in seven (1%) patients. Death during TB treatment occurred in 59 of 308 patients (19%) with any extrapulmonary involvement. In a proportional hazards model, patients with extrapulmonary TB had an increased risk of death if they had meningitis, and a CD4+ T-lymphocyte count <200 cells/microl. Patients who received co-trimoxazole, fluconazole, and antiretroviral therapy during TB treatment had a lower risk of death. CONCLUSIONS Among HIV-infected patients with TB, extrapulmonary disease occurred in 40% of the patients, particularly in those with advanced immune suppression. Death during TB treatment was common, but the risk of death was reduced in patients who took co-trimoxazole, fluconazole, and antiretroviral therapy.

Childhood TB epidemiology and treatment outcomes in Thailand: a TB active surveillance network, 2004 to 2006

OBJECTIVE WHOs new Global Plan to Stop TB 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 programmes impact and cost effectiveness.

Directly Observed Therapy and Improved Tuberculosis Treatment Outcomes in Thailand

BackgroundOf 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.MethodsIn 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.ResultsOnly 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).ConclusionChildhood 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.

Viral hepatitis and HIV-associated tuberculosis: Risk factors and TB treatment outcomes in Thailand

Background The World Health Organization (WHO) recommends that tuberculosis (TB) patients receive directly observed therapy (DOT). Randomized controlled trials have not consistently shown that this practice improves TB treatment success rates. In Thailand, one of 22 WHO-designated high burden TB countries, patients may have TB treatment observed by a health care worker (HCW), family member, or no one. We studied whether DOT improved TB treatment outcomes in a prospective, observational cohort. Methods and Findings We prospectively collected epidemiologic data about TB patients treated at public and private facilities in four provinces in Thailand and the national infectious diseases hospital from 2004–2006. Public health staff recorded the type of observed therapy that patients received during the first two months of TB treatment. We limited our analysis to pulmonary TB patients never previously treated for TB and not known to have multidrug-resistant TB. We analyzed the proportion of patients still on treatment at the end of two months and with treatment success at the end of treatment according to DOT type. We used propensity score analysis to control for factors associated with DOT and treatment outcome. Of 8,031 patients eligible for analysis, 24% received HCW DOT, 59% family DOT, and 18% self-administered therapy (SAT). Smear-positive TB was diagnosed in 63%, and 21% were HIV-infected. Of patients either on treatment or that defaulted at two months, 1601/1636 (98%) patients that received HCW DOT remained on treatment at two months compared with 1096/1268 (86%) patients that received SAT (adjusted OR [aOR] 3.8; 95% confidence interval [CI] 2.4–6.0) and 3782/3987 (95%) patients that received family DOT (aOR 2.1; CI, 1.4–3.1). Of patients that had treatment success or that defaulted at the end of treatment, 1369/1477 (93%) patients that received HCW DOT completed treatment compared with 744/1074 (69%) patients that received SAT (aOR 3.3; CI, 2.4–4.5) and 3130/3529 (89%) patients that received family DOT (aOR 1.5; 1.2–1.9). The benefit of HCW DOT compared with SAT was similar, but smaller, when comparing patients with treatment success to those with death, default, or failure. Conclusions In Thailand, two months of DOT was associated with lower odds of default during treatment. The magnitude of benefit was greater for DOT provided by a HCW compared with a family member. Thailand should consider increasing its use of HCW DOT during TB treatment.

Factors associated with death among HIV-uninfected TB patients in Thailand, 2004–2006

BackgroundThe 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.MethodsPatients 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.ResultsOf 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.ConclusionAmong 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.

Mycobacterium bovis (Bacille Calmette-Guérin) bacteremia in immunocompetent neonates following vaccination

Objectives  In countries with both TB and human immunodeficiency virus (HIV) epidemics, HIV is known to be the most powerful risk factor for death during tuberculosis (TB) treatment. Few recent studies have evaluated risk factors for death among HIV‐uninfected TB patients in these countries. We analysed data from a multi‐province demonstration project in Thailand to answer this question.