[Show abstract][Hide abstract] ABSTRACT: Background
Recently, the World Health Organisation and the International Union Against Tuberculosis and Lung Disease published a Collaborative Framework for the Care and Control of Tuberculosis (TB) and Diabetes (DM) (CFTB/DM) proposing bidirectional screening and joint management.
To evaluate the feasibility and effectiveness of the CFTB/DM in Mexico. Design. Prospective observational cohort. Setting. 15 primary care units in 5 states in Mexico. Participants: Patients aged ≥20 years diagnosed with DM or pulmonary TB who sought care at participating clinics. Intervention: The WHO/Union CFTB/DM was adapted and implemented according to official Mexican guidelines. We recruited participants from July 2012 to April 2013 and followed up until March 2014. Bidirectional screening was performed. Patients diagnosed with TB and DM were invited to receive TB treatment under joint management. Main outcome measures. Diagnoses of TB among DM, of DM among TB, and treatment outcomes among patients with DM and TB.
Of 783 DM patients, 11 (1.4%) were unaware of their TB. Of 361 TB patients, 16 (4.4%) were unaware of their DM. 95 TB/DM patients accepted to be treated under joint management, of whom 85 (89.5%) successfully completed treatment. Multiple linear regression analysis with change in HbA1c and random capillary glucose as dependent variables revealed significant decrease with time (regression coefficients (β) = −0.660, (95% confidence interval (CI), −0.96 to −0.35); and β = −1.889 (95% CI, −2.77 to −1.01, respectively)) adjusting by sex, age and having been treated for a previous TB episode. Patients treated under joint management were more likely to experience treatment success than patients treated under routine DM and TB programs as compared to historical (adjusted OR (aOR), 2.8, 95%CI 1.28–6.13) and same period (aOR 2.37, 95% CI 1.13–4.96) comparison groups.
Joint management of TB and DM is feasible and appears to improve clinical outcomes.
PLoS ONE 09/2014; 9(9):e106961. DOI:10.1371/journal.pone.0106961 · 3.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Human tuberculosis caused by M. bovis is a zoonosis presently considered sporadic in developed countries, but remains a poorly studied problem in low and middle resource countries. The disease in humans is mainly attributed to unpasteurized dairy products consumption. However, transmission due to exposure of humans to infected animals has been also recognized. The prevalence of tuberculosis infection and associated risk factors have been insufficiently characterized among dairy farm workers (DFW) exposed in settings with poor control of bovine tuberculosis.
Tuberculin skin test (TST) and Interferon-gamma release assay (IGRA) were administered to 311 dairy farm and abattoir workers and their household contacts linked to a dairy production and livestock facility in Mexico. Sputa of individuals with respiratory symptoms and samples from routine cattle necropsies were cultured for M. bovis and resulting spoligotypes were compared. The overall prevalence of latent tuberculosis infection (LTBI) was 76.2% (95% CI, 71.4–80.9%) by TST and 58.5% (95% CI, 53.0–64.0%) by IGRA. Occupational exposure was associated to TST (OR 2.72; 95% CI, 1.31–5.64) and IGRA (OR 2.38; 95% CI, 1.31–4.30) adjusting for relevant variables. Two subjects were diagnosed with pulmonary tuberculosis, both caused by M. bovis. In one case, the spoligotype was identical to a strain isolated from bovines.
We documented a high prevalence of latent and pulmonary TB among workers exposed to cattle infected with M. bovis, and increased risk among those occupationally exposed in non-ventilated spaces. Interspecies transmission is frequent and represents an occupational hazard in this setting.
[Show abstract][Hide abstract] ABSTRACT: Objective
To determine the clinical consequences of pulmonary tuberculosis (TB) among patients with diabetes mellitus (DM).
We conducted a prospective study of patients with TB in Southern Mexico. From 1995 to 2010, patients with acid-fast bacilli or Mycobacterium tuberculosis in sputum samples underwent epidemiological, clinical and microbiological evaluation. Annual follow-ups were performed to ascertain treatment outcome, recurrence, relapse and reinfection.
The prevalence of DM among 1262 patients with pulmonary TB was 29.63% (n=374). Patients with DM and pulmonary TB had more severe clinical manifestations (cavities of any size on the chest x-ray, adjusted OR (aOR) 1.80, 95% CI 1.35 to 2.41), delayed sputum conversion (aOR 1.51, 95% CI 1.09 to 2.10), a higher probability of treatment failure (aOR 2.93, 95% CI 1.18 to 7.23), recurrence (adjusted HR (aHR) 1.76, 95% CI 1.11 to 2.79) and relapse (aHR 1.83, 95% CI 1.04 to 3.23). Most of the second episodes among patients with DM were caused by bacteria with the same genotype but, in 5/26 instances (19.23%), reinfection with a different strain occurred.
Given the growing epidemic of DM worldwide, it is necessary to add DM prevention and control strategies to TB control programmes and vice versa and to evaluate their effectiveness. The concurrence of both diseases potentially carries a risk of global spreading, with serious implications for TB control and the achievement of the United Nations Millennium Development Goals.
[Show abstract][Hide abstract] ABSTRACT: Objectives:
To examine the relationship between cigarette smoking and incidence and mortality rates of pulmonary tuberculosis (TB) and treatment outcomes.
From 1995 to 2010, we analyzed data from 1062 patients with TB and from 2001 to 2004, 2951 contacts in Southern Mexico. Patients with acid-fast bacilli or Mycobacterium tuberculosis in sputum samples underwent epidemiological, clinical and mycobacteriological evaluation and received treatment by the local DOTS program.
Consumers of 1-10 (LS) or 11 or more (HS) cigarettes per day incidence (1.75 and 11.79) and mortality (HS, 17.74) smoker-non-smoker rate ratios were significantly higher for smokers. Smoker population was more likely to experience unfavorable treatment outcomes (HS, adjusted OR 2.36) and retreatment (LS and HS, adjusted hazard ratio (HR) 2.14 and 2.37). Contacts that smoked had a higher probability of developing active TB (HR 2.38) during follow up.
Results indicate the need of incorporating smoking prevention and cessation, especially among men, into international TB control strategies.
The Journal of infection 09/2012; 66(4). DOI:10.1016/j.jinf.2012.09.005 · 4.44 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: worldwide, the frequency of tuberculosis among older people almost triples that observed among young adults.
to describe clinical and epidemiological consequences of pulmonary tuberculosis among older people.
we screened persons with a cough lasting more than 2 weeks in Southern Mexico from March 1995 to February 2007. We collected clinical and mycobacteriological information (isolation, identification, drug-susceptibility testing and IS6110-based genotyping and spoligotyping) from individuals with bacteriologically confirmed pulmonary tuberculosis. Patients were treated in accordance with official norms and followed to ascertain treatment outcomes, retreatment, and vital status.
eight hundred ninety-three tuberculosis patients were older than 15 years of age; of these, 147 (16.5%) were 65 years of age or older. Individuals ≥ 65 years had significantly higher rates of recently transmitted and reactivated tuberculosis. Older age was associated with treatment failure (OR=5.37; 95% CI: 1.06-27.23; P=0.042), and death due to tuberculosis (HR=3.52; 95% CI: 1.78-6.96; P<0.001) adjusting for sociodemographic and clinical variables.
community-dwelling older individuals participate in chains of transmission indicating that tuberculosis is not solely due to the reactivation of latent disease. Untimely and difficult diagnosis and a higher risk of poor outcomes even after treatment completion emphasise the need for specific strategies for this vulnerable group.
Age and Ageing 03/2012; 41(4):488-95. DOI:10.1093/ageing/afs028 · 3.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To compare the epidemiology, clinical variables, outcome and molecular characteristics between methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) bloodstream infections (BSI) of patients from a tertiary-care center.
We conducted a five-year retrospective cohort analysis of all patients with at least one peripherally-drawn blood culture positive for S. aureus. Patient characteristics, clinical data and outcome were analyzed, as well as microbiologic data.
We included 444 isolates derived from 172 patients. The highest rate of MRSA BSI was observed in 2005 (4.9 cases per 1,000 patients). MRSA BSIs were more likely to be originated from a skin and soft tissue infection (OR 2.44, CI 95% 1.05-5.67, p = 0.03). The only significant risk factor for MRSA BSI was the mean length of hospital stay (OR 1.01; CI 95% 1.00-1.02, p = 0.002). A difference in inadequate initial treatment was noticed in MRSA BSI (OR 8.35 CI 95% 1.55-8.39, p = 0.002); but it had no impact on mortality. All MRSA isolates were SCCmec type II, and we did not find any resistance to vancomycin or linezolid.
MRSA BSIs were associated with a prolonged hospital stay. We did not observe any difference in mortality between MRSA and MSSA BSIs. During the study period, we only identified SCCmec type II in MRSA isolates, which suggests that this infection was hospital- acquired.
Revista de investigacion clinica; organo del Hospital de Enfermedades de la Nutricion 11/2010; 62(6):553-9. · 0.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study describes the clinical and molecular characteristics of methicillin-resistant Staphylococcus aureus (MRSA) isolates that emerged after an index case in a tertiary-care oncology hospital in Mexico City and identifies whether these isolates were related with the index case. All MRSA strains isolated from January 2006 until December 2007 were included. The clinical and demographic characteristics of patients were analyzed; molecular typing by pulsed-field gel electrophoresis was used to characterize the isolates. We included 44 MRSA isolates from 55 patients. Thirty-eight patients (86.4%) were classified with nosocomial infection and the remainder with healthcare-related infection. A single pulsed-field gel electrophoresis pattern (C) was identified with minor variations (two subtypes). The isolates analyzed were staphylococcal chromosome cassette mec type II (related with the New York-Japan strain). This case underscores the need to intensify strategies that identify and limit the spread of multiresistant pathogens imported by infected patients referred from other healthcare centers.
[Show abstract][Hide abstract] ABSTRACT: Indoor air pollution produced by biomass cooking fuels in developing countries has been associated with acute and chronic lower respiratory diseases, but has not been identified as an occupational exposure among women.
To examine the relationship between the use of biomass cooking fuels (mainly wood) and tuberculosis (TB) among women living in rural areas in Southern Mexico.
We conducted a population based case-control study in the health jurisdiction of Orizaba, Mexico. Cases were all incident female pulmonary TB patients, with Mycobacterium tuberculosis in sputum, living in communities with fewer than 15,000 inhabitants, diagnosed between March 1995 and April 2003. Woodsmoke exposure was assessed by applying a standardized questionnaire (ATS-DLD-78 questionnaire). Controls were randomly selected from sex-matched neighbors. Appropriate IRB approval was obtained.
42 TB cases and 84 community controls were recruited. Multivariate assessment showed that more than 20 years of exposure to smoke from biomass fuels was three times more frequent among cases than among controls [Odds ratio (OR): 3.3, 95% confidence interval (CI):1.06-10.30, p = 0.03], after controlling for age, body mass, household crowding, years of formal education and tobacco use.
We found a strong association between the use of biomass cooking fuels and tuberculosis among women in a community-based, case-control study. Results of this study are intended to provide evidence to policy makers, community leaders and the general public on the importance of implementing gender oriented interventions that decrease the use of biomass fuels in poor communities in developing countries.
Revista de investigacion clinica; organo del Hospital de Enfermedades de la Nutricion 09/2009; 61(5):392-8. · 0.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mycobacterium tuberculosis (MTB) is one of the leading causes of morbidity and mortality worldwide and infects approximately 1/3 of the human population, but only 10% of all infected individuals will ever develop the disease and half of these may result in a rapid progression to disease during the first 2 years after being infected. On the other hand, some phenotypic differences among mycobacterial strains contribute to variations in the outcome of the infection, e.g., the hypervirulent phenotype described in the Beijing family has been associated with the production of a phenolic glycolipid, which reduces the production of Th1 cytokines in the experimental model and requires the activity of a polyketide synthase enzyme encoded by the pks15/1 gene.
We analyzed clinical isolates characterized by recent transmission and rapid progression to disease to identify factors that may influence such behavior from a rural and semi-urban community in eastern Mexico.
Using various typing tools, we were able to identify intrafamilial clusters which belonged to the East Asian lineage of MTB isolates (Beijing family) and another that belonged to the Indo-Oceanic lineage (Manila family). All isolates within these two clusters showed an intact pks15/1 gene sequence. Additionally, we identified three more family clusters that belonged to the Euro-American lineage and showed the typical 7-bp deletion of the pks15/1 gene. This 7-bp deletion was also found in the remaining 23 cases from non-family clusters.
This is the first report of cases caused by strains with an intact pks15/1 gene in Mexico. Interestingly, we identified the three main mycobacterial lineages described so far: East-Asian, Indo-Oceanic, and Euro-American in a human population with almost no present-day migration.
Archives of medical research 12/2008; 39(8):809-14. DOI:10.1016/j.arcmed.2008.08.006 · 2.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Vaccination with Mycobacterium bovis bacille Calmette-Guérin (BCG) has variable efficacy in preventing tuberculosis. We hypothesized that some of this variation
might be due to differences among BCG strains. To test this, neonates in Orizaba, Mexico, were vaccinated with one of three
different BCG strains (BCG-Brazil [BBCG], BCG-Denmark [DBCG], or BCG-Japan [JBCG]). One year after vaccination, peripheral
blood mononuclear cells (PBMC) were obtained and recall immune responses to culture filtrate proteins (CFP) of Mycobacterium tuberculosis were evaluated using quantitative real-time PCR. CFP-activated PBMC from BBCG- and DBCG-immunized children expressed high
levels of cytokines characteristic of an adaptive immune response (gamma interferon, interleukin-2β [IL-12β], and IL-27),
while those from children immunized with JBCG did not. In contrast, vaccination with JBCG resulted in significantly greater
expression of cytokines characteristic of a proinflammatory immune response (IL-1α, IL-1β, IL-6, and IL-24) in PBMC activated
with CFP compared to PBMC from children vaccinated with BBCG or DBCG. Thus, different strains of BCG can activate different
immune pathways, which may affect long-term vaccine efficacy.
Infection and Immunity 08/2007; 75(7):3658-64. DOI:10.1128/IAI.00244-07 · 3.73 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In most low income countries there are twice as many cases of tuberculosis (TB) reported among men than among women, a difference commonly attributed to biological and epidemiological characteristics as well as socioeconomic and cultural barriers in access to health care. The World Health Organization has encouraged gender specific comparisons in TB rates to determine whether women with TB are less likely than men with TB to be diagnosed, reported, and treated. A study was undertaken to identify gender based differences in patients with pulmonary TB and to use this information to improve TB control efforts.
Individuals with a cough for more than 2 weeks in southern Mexico were screened from March 1995 to April 2003. Clinical and mycobacteriological information (isolation, identification, drug susceptibility testing and IS6110 based genotyping, and spoligotyping) was collected from those with bacteriologically confirmed pulmonary TB. Patients were treated in accordance with official norms and followed to ascertain treatment outcome, retreatment, and vital status.
623 patients with pulmonary TB were enrolled. The male:female incidence rate ratio for overall, reactivated, and recently transmitted disease was 1.58 (95% CI 1.34 to 1.86), 1.64 (95% CI 1.36 to 1.98), and 1.41 (95% CI 1.01 to 1.96), respectively. Men were more likely than women to default from treatment (adjusted OR 3.30, 95% CI 1.46 to 7.43), to be retreated (hazard ratio (HR) 3.15, 95% CI 1.38 to 7.22), and to die from TB (HR 2.23, 95% CI 1.25 to 3.99).
Higher rates of transmitted and reactivated disease and poorer treatment outcomes among men are indicators of gender differentials in the diagnosis and treatment of pulmonary TB, and suggest specific strategies in endemic settings.
[Show abstract][Hide abstract] ABSTRACT: Directly observed therapy (DOTS) is the main strategy for prevention and control of tuberculosis worldwide. However, its effect on tuberculosis transmission in populations with moderate rates of drug-resistant disease is not known.
This population-based prospective study in southern Mexico between March, 1995, and February, 2000, was based on passive case finding and detection of acid-fast bacilli in sputum samples to diagnose pulmonary tuberculosis. We also used cultures, drug-susceptibility testing, bacterial genotyping, and monitoring of treatment outcomes.
We enrolled 436 patients; the HIV seroprevalence rate was 2%. We used three indicators to monitor continuing tuberculosis transmission: the incidence rate of pulmonary tuberculosis, which decreased by 54.4% between 1995 and 2000, from 42.1 to 19.2 per 10(5) population (p=0.00048); the percentage of clustered pulmonary tuberculosis cases, which decreased by 62.6% from 22% to 8% (p=0.02); and the rate of primary drug resistance, which decreased by 84.0% from 9.4 to 1.5 per 10(5) population (p=0.004). Rates of multidrug-resistant (MDR) tuberculosis also decreased (p<0.0001). The case-fatality ratio was 12% for MDR tuberculosis (five of 41), 7% for strains resistant to at least one drug after exclusion of MDR (four of 55), and 3% for pansusceptible strains (nine of 272). There were 13 treatment failures (11%) in 1995 and one (2%) in 2000 (p=0.012).
Even in settings with moderate rates of MDR tuberculosis, DOTS can rapidly reduce the transmission and incidence of both drug-susceptible and drug-resistant tuberculosis. However, further interventions, such as drug-susceptibility testing and standardised or individualised treatment regimens, are needed to reduce mortality rates for MDR tuberculosis.
The Lancet 04/2005; 365(9466):1239-45. DOI:10.1016/S0140-6736(05)74812-1 · 45.22 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We assessed the performance of a rapid, single-well, real-time PCR assay for the detection of rifampin-resistant Mycobacterium tuberculosis by using clinical isolates from north India and Mexico, regions with a high incidence of tuberculosis. The assay uses five differently colored molecular beacons to determine if a short region of the M. tuberculosis rpoB gene contains mutations that predict rifampin resistance in most isolates. Until now, the assay had not been sufficiently tested on samples from countries with a high incidence of tuberculosis. In the present study, the assay detected mutations in 16 out of 16 rifampin-resistant isolates from north India (100%) and in 55 of 64 rifampin-resistant isolates from Mexico (86%) compared to results with standard susceptibility testing. The assay did not detect mutations (a finding predictive of rifampin susceptibility) in 37 out of 37 rifampin-susceptible isolates from India (100%) and 125 out of 126 rifampin-susceptible isolates from Mexico (99%). DNA sequencing revealed that none of the nine rifampin-resistant isolates from Mexico, which were misidentified as rifampin susceptible by the molecular beacon assay, contained a mutation in the region targeted by the molecular beacons. The one rifampin-susceptible isolate from Mexico that appeared to be rifampin resistant by the molecular beacon assay contained an S531W mutation, which is usually associated with rifampin resistance. Of the rifampin-resistant isolates that were correctly identified in the molecular beacon assay, one contained a novel L530A mutation and another contained a novel deletion between codons 511 and 514. Overall, the molecular beacon assay appears to have sufficient sensitivity (89%) and specificity (99%) for use in countries with a high prevalence of tuberculosis.
[Show abstract][Hide abstract] ABSTRACT: We described the trends of drug-resistant organisms isolated in blood cultures from patients detected in a teaching hospital from 1995 to 2000. We found an increase in the number of clinical isolates of Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacter spp, Serratia spp, Staphylococcus aureus, S. epidermidis and Enterococcus spp, resistant to antibiotics commonly used to treat infections caused by these organisms. The frequency of gram-negative bacilli resistant to third-generation cephalosporins and quinolones increased during the period of study, and in 2000 more than 20% of the isolates were resistant. In contrast, the frequency of resistance to aminoglycosides and carbapenems was less than 20%. The frequency of resistant staphylococci increased exuberantly fifty fold to quinolones and five fold to oxacillin during the study period, therefore in 2000, 26.1% of S. aureus isolates and 61% of S. epidermidis were resistant to oxacillin. The frequency of resistant enterococci also increased, and in 2000, 50% were resistant to ampicillin, and 37.5% to gentamicin. The increase of drug resistant organisms isolated in blood had a direct impact in the empirical treatment of severely infected patients in our hospital. It is important to continuously supervise antibiotic use, and to adopt more strict control measures to decrease the frequency of infections caused by drug resistant organisms.
Revista de investigacion clinica; organo del Hospital de Enfermedades de la Nutricion 11/2003; 55(6):600-5. · 0.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In a prospective study conducted in a diagnostic laboratory in Mexico City, luciferase reporter mycobacteriophages (LRPs) were evaluated for their utility and performance in identification and antibiotic-susceptibility testing of Mycobacterium tuberculosis complex (MTC) isolates from MGIT-960 cultures. Eighty-four consecutive MGIT cultures recovered from 54 patients were included in this study. The LRPs confirmed mycobacterial growth in 79 (94 %) of 84 MGIT cultures. Failure to confirm growth was due to low inoculum (n = 1) or growth with non-tuberculous mycobacteria (n = 4). The median time to confirmation of MGIT cultures was 1 day (range 1-55). Confirmed cultures were identified with p-nitro-alpha-acetylamino-beta-hydroxypropiophenone (NAP), a selective inhibitor of MTC species, and results obtained with LRPs were compared with those obtained by BACTEC-460. The sensitivity and specificity of the LRP NAP test were respectively 97 and 100 %, and the median turnaround time for identification was 3 days with both methods. The accuracy and speed of the LRPs for susceptibility testing with rifampicin, streptomycin, isoniazid and ethambutol were compared with BACTEC-460 and discrepant results were tested by the conventional agar proportion method. In total, 72 MTC cultures were tested. The overall agreement between the LRPs and BACTEC-460 was 98.6 %. Four isolates (5.6 %) were falsely identified as ethambutol-resistant. The median turnaround time for susceptibility testing was 3 days (range 3-57) with the LRPs and 9 days (range 7-29) with BACTEC-460. LRPs offer an accurate and rapid approach for identification and susceptibility testing of M. tuberculosis from MGIT-960 cultures.
Journal of Medical Microbiology 08/2003; 52(Pt 7):557-61. · 2.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Tuberculosis may be a lethal disease. Its ocular manifestations are commonly associated with severe difficulties in diagnosis and therapy; furthermore, it may cause blindness. DNA amplification methods may allow early detection of small amounts of Mycobacterium tuberculosis DNA to afford the possibility of prompt diagnosis. We evaluated a nested polymerase chain reaction (nPCR) assay for detection of Mycobacterium tuberculosis DNA in aqueous and vitreous.
In a case-control study, 22 cases of diagnosed TB uveitis (three HIV-infected patients) and 38 controls (18 HIV-infected patients) with other types of uveitis (syphilis, nine; cytomegalovirus, seven; toxoplasmosis, five; herpes simplex, one; autoimmune vasculitis, eight; Vogt-Koyanagi-Harada, four; pars planitis, one; serpinginous choroiditis, one; Wegener granulomatosis, one; and Fuchs iridocyclitis, one studied). Samples from aqueous or vitreous were cultured and analyzed by nPCR for presence of M. tuberculosis nucleic acids. We used two sets of primers corresponding to IS6110 region coding for 219 bp and 123 bp DNA sequences.
Results were confirmed by Southern blot. All samples were tested by PCR simultaneously for Herpes simplex I, Herpes zoster, cytomegalovirus (CMV) and Toxoplasma gondii. nPCR was positive in 17 cases (77.2%) and only in three controls (8.8%) p = 0.022. All cultures were negative. Southern blot confirmed all positive nPCR tests. According to our definition of cases, there were five false negative results: two in patients with pulmonary tuberculosis; two in patients with tuberculous lymphadenitis, and one with positive skin test and hematuria. There were three cases considered false positives for nPCR: one with autoimmune vasculitis, and two with toxoplasmic uveitis.
nPCR for TB in ocular fluids was positive in the majority of cases of ocular TB. This method is useful in early confirmation of ocular tuberculosis.
Archives of Medical Research 03/2003; 34(2):116-9. DOI:10.1016/S0188-4409(02)00467-8 · 2.65 Impact Factor