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Risk factors and algorithms to identify hepatitis C, hepatitis B, and HIV among Georgian tuberculosis patients

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Mark H Kuniholm
Mark H Kuniholm
Mark H Kuniholm
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Jennifer Mark at University of Washington Seattle
Jennifer Mark
Malvina Aladashvili
Malvina Aladashvili
Malvina Aladashvili
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Natalia Shubladze at National Center for Tuberculosis And Lung Diseases
Natalia Shubladze
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Abstract and Figures

To determine prevalence, risk factors, and simple identification algorithms for HIV, hepatitis B, and hepatitis C co-infection; factors that may predispose for anti-tuberculosis therapy-induced hepatotoxicity. We recruited 300 individuals at in-patient tuberculosis hospitals in three cities in Georgia, administered a behavioral questionnaire, and tested for antibody to HIV, hepatitis C (HCV), hepatitis B core antigen (anti-HBc), and the hepatitis B surface antigen (HBsAg). Of the individuals tested, 0.7% were HIV positive, 4.3% were HBsAg positive, 8.7% were anti-HBc positive, and 12.0% were HCV positive. In multivariable analysis, a history of blood transfusion, injection drug use, and prison were significant independent risk factors for HCV, while a history of blood transfusion, injection drug use, younger age at sexual debut, and a high number of sex partners were significant risk factors for HBV. Three-questionnaire item algorithms predicted HCV serostatus 74.1% of the time and HBV serostatus 85.2% of the time. Treatment of tuberculosis patients in resource-limited countries with concurrent epidemics of HCV, HBV, and HIV may be associated with significant hepatotoxicity. Serologic screening of tuberculosis patients for HBV, HCV, and HIV or using behavioral algorithms to identify patients in need of intensive monitoring during anti-tuberculosis therapy may reduce this risk.
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Risk factors and algorithms to identify hepatitis C, hepatitis B, and
HIV among Georgian tuberculosis patients
Mark H. Kuniholm
a,*
, Jennifer Mark
a
, Malvina Aladashvili
b
, N. Shubladze
c
, G.
Khechinashvili
c
, Tengiz Tsertsvadze
b
, Carlos del Rio
d
, and Kenrad E. Nelson
a,e
aDepartment of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205,
USA
bGeorgian AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
cNational Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
dDepartment of Medicine, Emory University School of Medicine, Atlanta, GA, 30322, USA
eDepartment of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
Summary
Objectives—To determine prevalence, risk factors, and simple identification algorithms for HIV,
hepatitis B, and hepatitis C co-infection; factors that may predispose for anti-tuberculosis therapy-
induced hepatoxicity.
Methods—We recruited 300 individuals at in-patient tuberculosis hospitals in three cities in
Georgia, administered a behavioral questionnaire, and tested for antibody to HIV, hepatitis C (HCV),
hepatitis B core antigen (anti-HBc), and the hepatitis B surface antigen (HBsAg).
Results—0.7% of the individuals were HIV positive, 4.3% were HBsAg positive, 8.7% were anti-
HBc positive, and 12.0% were HCV positive. In multivariable analysis, a history of blood transfusion,
injection drug use, and prison were significant independent risk factors for HCV, while a history of
blood transfusion, injection drug use, younger age at sexual debut, and a high number of sex partners
were significant risk factors for HBV. Three-questionnaire item algorithms predicted HCV serostatus
74.1% of the time and HBV serostatus 85.2% of the time.
Conclusions—Treatment of tuberculosis patients in resource-limited countries with concurrent
epidemics of HCV, HBV, and HIV may be associated with significant hepatoxicity. Serologic
screening of tuberculosis patients for HBV, HCV and HIV or using behavioral algorithms to identify
patients in need of intensive monitoring during anti-tuberculosis therapy may reduce this risk.
Keywords
hepatitis C; HIV; hepatitis B; tuberculosis; hepatoxicity; Georgia; epidemiology
Introduction
Although roughly one third of the human population is chronically infected with
Mycobacterium tuberculosis,
1
the distribution of infections is far from uniform. Sub-Saharan
Africa, Asia, and Eastern Europe have the highest prevalence and incidence rates worldwide,
*Corresponding author: Mark H. Kuniholm, Dept. of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Suite E7133,
615 N. Wolfe St., Baltimore, MD 21205, USA; Phone: +1-410-366-1807; Fax: +1-410-955-1836 ; E-mail: mkunihol@jhsph.edu.
NIH Public Access
Author Manuscript
Int J Infect Dis. Author manuscript; available in PMC 2009 March 2.
Published in final edited form as:
Int J Infect Dis. 2008 January ; 12(1): 51–56. doi:10.1016/j.ijid.2007.04.015.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
2
and are the areas where the World Health Organization (WHO) Directly Observed Therapy
Short-Course (DOTS) program for tuberculosis control has been most vigorously
implemented. Although highly effective,
3
several shortcomings have recently been identified
in the DOTS program.
4
One of these identified shortcomings is the failure of first-line DOTS
treatment regimens in difficult-to-treat populations, e.g. HIV co-infected patients, patients
infected with multi-drug resistant M. tuberculosis strains, and other patients with special needs.
Patients with increased susceptibility to the hepatotoxic effects of first-line treatment regimens
represent special populations and need to be identified prior to therapy initiation and monitored
more carefully than the general population of M. tuberculosis infected patients. Unfortunately,
although three of the first-line drugs, rifampin, pyrazinamide, and isoniazid are known to be
hepatotoxic,
5–9
the patient characteristics that confer greater risk of treatment-associated liver
injury are poorly understood. Older age,
10,11
concurrent or chronic alcohol use,
12–15
hepatitis C,
16
hepatitis B,
17
and HIV
16
virus infection have been found to increase the risk
of hepatoxicity in some studies, but non-significant associations for all of these putative risk
factors have also been reported.
5,14,15,18–23
Until definitive studies are conducted, caution
suggests that patient populations should be screened for the above-mentioned characteristics
and monitored carefully following initiation of therapy.
Many countries of the former Soviet Union have experienced major increases in tuberculosis
incidence over the past fifteen years,
2,24
and are attempting to control epidemics of HIV,
hepatitis B, and hepatitis C viruses with limited healthcare resources. Georgia is situated south
of the Russian Federation in the Caucasus region between the Black and Caspian Seas (see
Figure 1), and currently faces major concurrent epidemics of tuberculosis,
25–27
hepatitis B,
28,29
and hepatitis C.
28–31
World Health Organization estimates suggest that tuberculosis
incidence is 83 cases per 100,000 person-years, and 16% of new tuberculosis cases are
multidrug-resistant in Georgia.
32
Research studies have also found multidrug-resistant M.
tuberculosis strains to be common in Georgia,
27, 33
and an evaluation of the Georgian DOTS
program in the mid-1990s suggested that 25% of individuals who begin anti-tuberculosis
therapy regimens will not complete them.
34
While this study did not evaluate the reasons for
therapy interruption among the Georgian patients, a recent study from Russia has suggested
that difficulty tolerating anti-tuberculosis therapy because of co-morbid illnesses such as HIV
and viral hepatitis is common.
35
Despite its potential effect on improving tuberculosis treatment completion rates (through
careful monitoring and treatment adjustment when indicated), serologic screening for hepatitis
B, hepatitis C, and HIV viruses is not routine practice among Georgian tuberculosis clinics
because of limited resources and the scarcity of diagnostic capabilities within tuberculosis
hospitals. In this study, we used behavioral and biomarker data collected between October,
1997 and June, 1998 in three Georgian in-patient tuberculosis hospitals to describe the
prevalence and risk factors for three putative viral risk factors for anti-tuberculosis therapy-
induced hepatotoxicity. We additionally assessed the ability of simple questionnaire algorithms
to accurately predict infection with HCV and HBV to determine whether this screening
mechanism could identify subsets of patients who are in need of intensive monitoring during
anti-tuberculosis therapy.
Materials and Methods
Study Population
Between October, 1997 and June, 1998, we recruited individuals at in-patient tuberculosis
hospitals as part of a HIV/AIDS surveillance project conducted by the Georgian AIDS and
Clinical Immunology Research Center.
28
Recruited individuals were between the ages of 18
and 65 and were patients in hospitals in the Georgian cities of Tbilisi, Batumi, and Poti. Subjects
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were enrolled into the study if they gave their informed consent to answer a confidential
questionnaire, be tested for HIV, HCV, and HBV and receive the results of these tests along
with appropriate counseling. The research protocol was reviewed and approved by Institutional
Review Boards at the AIDS and Clinical Immunology Research Center in Tbilisi, Georgia and
the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
Behavioral Questionnaire
Recruited individuals who agreed to participate in the study were interviewed confidentially
by trained interviewers regarding their clinical and demographic characteristics, history of drug
use, and sexual behaviors. After the interview data were collected they were transferred to a
Microsoft Access database for archival and analysis.
Laboratory Methods
Blood samples drawn from participating individuals were assayed for antibody to HIV-1 with
the Abbott Recombinant HIV-1 assay (Abbott Laboratories, Abbott Park, IL, USA). Blood
samples reactive for HIV-1 were confirmed using a licensed western blot assay (DuPont Co,
Willmington, DE, USA). Antibody to HCV was assessed using the Ortho HCV Version 3.0
ELISA (Ortho Diagnostics Systems, Raritan, NJ, USA). Hepatitis B surface antigen (HBsAg)
and core antibody (anti-HBcore) were assessed using Auszyme Monoclonal and Corzyme
assays (Abbott Laboratories, Abbott Park, IL, USA). All laboratory testing was conducted at
the AIDS and Clinical Immunology Research Center in Tbilisi, Georgia.
Statistical Methods
We calculated descriptive statistics for laboratory results and questionnaire variables. We used
bivariate and multivariable logistic regression models to evaluate the association of
demographic, drug use history, and sexual history variables with HCV and HBV seropositivity.
We defined individuals testing positive for either anti-HBcore or HBsAg to be HBV positive.
We used bivariate analysis to evaluate city of residence and age-group associations, and
multivariable analysis, with all evaluated variables in a single model, to evaluate all other
associations. Too few individuals were infected with HIV to conduct a statistical assessment
of HIV risk factors.
For our assessment of the ability of questionnaire combination algorithms to accurately predict
viral infection status, we constructed two- and three-questionnaire item combinations and
divided the number of individuals reporting yes to any of the questionnaire items in the
combination by the number of individuals serologically diagnosed with HCV or HBV
infection. This quotient then reflected the sensitivity of the questionnaire item combination
compared to the gold-standard of serology. All analyses were conducted using SAS 9.1 (SAS
Institute, Cary, NC, USA).
Results
Demographic, drug use history, and sexual history variables are listed in Table 1. Most patients
were male and were recruited from hospitals in Tbilisi. Patients were most often in their thirties
and most had completed secondary school. Histories of blood transfusion, prison, and injection
drug use were relatively rare, although sexual activity in the past two years was not.
Two (0.7%) of the 300 surveyed individuals were HIV positive, 13 (4.3%) were HBsAg
positive, 26 (8.7%) were anti-HBcore positive and 27 (9.0%) were positive for either HBsAg
or anti-HBcore. Thirty-six (12.0%) were HCV positive. One of the two HIV positive
individuals was HCV co-infected, and six individuals were positive for both HCV and HBV.
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The two HIV positive individuals were both male, one had received a blood transfusion and
the other had injected illicit drugs.
Risk factors for HCV and HBV seropositivity are listed in Table 2. In bivariate analysis, neither
HCV nor HBV seroprevalence differed significantly by city of recruitment or gender. In
multivariable adjusted analysis, having a university-level education was protective against the
presence of HCV, but not against the presence of HBV. Both a history of blood transfusion
and a history of injection drug use were highly significant risk factors for both HCV and HBV.
Having been in prison was a significant risk factor for HCV, but not for HBV. Older age at
first sexual contact was significantly protective against the presence of HBV, while having
four or more sexual partners in the past two years was a significant risk factor for HBV.
Table 3 shows the sensitivity of two-questionnaire item combinations to predict HCV and HBV
status as diagnosed by serology. As seen in the part a) of the table, three two-questionnaire
item combinations predicted HCV status 61.1% of the time. Inclusion of a third questionnaire
item to form the algorithm “Did you ever inject drugs?; Did you have your first sexual contact
at ≤ 18 years of age?; Did you ever have a blood transfusion?” increased the ability to predict
HCV serostatus to 72.2%.
As seen in section b) of Table 3, one two-questionnaire item combination predicted HBV status
74.1% of the time. Inclusion of a third questionnaire item to form the algorithm “Did you ever
inject drugs?; Did you have your first sexual contact at ≤ 18 years of age?; Have you had ≥ 4
sex partners in the past two years?” increased the ability to predict HBV status to 85.2%.
Discussion
Hepatotoxicity is a common side effect associated with the use of many therapeutic agents.
8,
35
Drug-related hepatotoxicity of antiretroviral therapy for HIV infection is more frequent
among patients who are co-infected with hepatitis viruses.
36
Although some studies examining
the role of viral hepatitis co-infection on adverse events following anti-tuberculosis therapy
have produced conflicting results, countries of the former Soviet Union, which are facing
serious epidemics of both tuberculosis and viral hepatitis, should exercise caution and carefully
monitor their patients for drug-associated hepatotoxicity.
Our study found that HIV infection was rare but HBV and HCV infections were common
among Georgian tuberculosis patients. High and increasing prevalence of HCV has been
reported among both tuberculosis patients and blood donors in Georgia between 1998 and
2001,
25,29,30
but this study is the first to indicate that HBV is a significant problem among
patients with tuberculosis in Georgia.
This study indicates that injection drug use and blood transfusions were major risk factors for
both HCV and HBV, and that spread of HCV was additionally common among prisoners, even
after adjusting for injection drug use. These results are consistent with those of Richards et al.
25
with regard to the spread of HCV in prisons but differ in finding that a history of blood
transfusion and injection drug use were both associated with HCV infection. Routine screening
of the Georgian blood supply for HCV was initiated in 1997,
28,29
so current blood transfusions
may be less likely to transmit HCV than those conducted prior to this time. Our results also
suggest that younger age of sexual initiation and multiple sex partners are significant risk
factors for the acquisition of HBV.
Our evaluations of simple two- and three-question behavioral algorithms suggest that HBV
can be predicted in many patients who respond in the affirmative to any one of three simple
questions. These data should be of interest to tuberculosis clinicians, since they represent a
simple and inexpensive screening tool to identify patients who may be at increased risk of
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hepatotoxic side effects to anti-tuberculosis drugs. The three-questionnaire item algorithm to
predict HCV status was less sensitive than that of the HBV algorithm, and additionally was
dependent on receipt of blood transfusion; a risk factor that may currently be of less significance
in Georgia. It is important to note however that the proposed algorithms, while valid for Georgia
and countries with similarly propagated HCV and HBV epidemics, may not be valid for
countries with epidemiologically distinct epidemics.
Georgia is just one of many countries in the former Soviet Union struggling to control its
burgeoning tuberculosis problem. Successful treatment of tuberculosis patients with viral
hepatitis and HIV co-infection will be a challenging task. However, it may be useful to utilize
behavioral algorithms to identify which patients are at highest risk of drug toxicity in
conjunction with serologic screening of high risk tuberculosis patients for HCV, HBV, and
HIV infection. Careful clinical and laboratory monitoring, and treatment adjustment as needed,
will also be necessary to avert serious hepatotoxicity in these patients.
Acknowledgements
Supported in part by the NIH/AIDS International Training and Research Program of Emory University (D43
TW01042) and the Civilian Research and Development Foundation (CRDF Grant #7213 and GB1-2013). The authors
have no conflicts of interest concerning the work reported in this paper.
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Figure 1.
Republic of Georgia
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Kuniholm et al. Page 9
Table 1
Characteristics of the Study Population (N=300)
Characteristic Number Percent (%)
Residence City
Tbilisi 245 81.7
Poti 32 10.7
Batumi 23 7.7
Gender
Male 242 80.7
Female 58 19.3
Age
18–27 years 95 31.7
28–37 years 126 42.0
≥ 38 years 79 26.3
Education
Primary 38 12.7
Secondary 173 57.7
University 89 29.7
Blood Transfusion
No 287 95.7
Yes 13 4.3
Ever injection drug use
No 277 92.3
Yes 23 7.7
Ever prison
No 278 92.7
Yes 22 7.3
Ever male homosexual contact
No 281 93.7
Yes 19 6.3
Age at first sexual contact
≤ 18 years 85 28.3
19 – 21 years 120 40.0
≥ 22 years 95 31.7
Number of sex partners in last 2 years
0 – 1 partners 113 37.7
2 – 3 partners 150 50.0
≥ 4 partners 37 12.3
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Kuniholm et al. Page 10
Table 2
Risk Factors for HCV and HBV Seropositivity (N=300)
HCV HBV
Variable OR 95% CI OR 95% CI
Residence City
Tbilisi 1.0 1.0
Poti 0.71 0.21, 2.49 1.61 0.51, 5.04
Batumi 0.66 0.15, 2.94 1.69 0.46, 6.17
Gender
Male 1.0 1.0
Female 0.82 0.35, 1.90 0.82 0.32, 2.14
Age
18–27 years 1.0 1.0
28–37 years 1.11 0.49, 2.52 1.04 0.40, 2.70
≥ 38 years 0.98 0.39, 2.50 1.23 0.44, 3.43
OR
*
95% CI
OR
*
95% CI
Education
Primary 1.0 1.0
Secondary 0.46 0.13, 1.66 1.09 0.13, 9.20
University 0.04 0.00, 0.55 0.84 0.20, 3.66
Blood Transfusion
No 1.0 1.0
Yes 12.37 2.52, 60.56 14.02 2.51, 78.29
Ever injection drug use
No 1.0 1.0
Yes 18.26 5.37, 62.12 12.72 3.57, 45.29
Ever prison
No 1.0 1.0
Yes 4.83 1.23, 18.97 1.28 0.29, 5.79
Ever male homosexual contact
No 1.0 1.0
Yes 0.62 0.11, 3.43 4.16 0.91, 18.96
Age at first sexual contact
≤18 years 1.0 1.0
19 – 21 years 1.39 0.49, 3.94 0.54 0.17, 1.72
≥ 22 years 0.54 0.13, 2.20 0.11 0.02, 0.65
Number of sex partners in last 2 years
0 – 1 partners 1.0 1.0
2 – 3 partners 0.45 0.14, 1.49 0.55 0.14, 2.12
≥ 4 partners 1.61 0.43, 6.00 4.45 1.19, 16.70
Int J Infect Dis. Author manuscript; available in PMC 2009 March 2.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Kuniholm et al. Page 11
*
ORs are adjusted for: city, gender, age group, education, blood transfusion, injection drug use, prison, male homosexual contact, age at first sexual
contact, and number of sex partner variables
Int J Infect Dis. Author manuscript; available in PMC 2009 March 2.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Kuniholm et al. Page 12
Table 3
Sensitivity (%) of Two Item Questionnaire Combinations to Detect Serologically Confirmed HCV (a) and HBV (b) Infection
a) Primary Education Blood Transfusion Injection drug use Prison ≤ 18 years at
first sex
Blood Transfusion 52.8
Injection drug use 55.6 58.3
Prison 44.4 41.7 52.8
≤ 18 years at first sex 52.8 55.7 61.1 61.1
≥ 4 sex partners 44.4 38.9 61.1 41.7 58.3
b) Primary Education Blood Transfusion Injection drug use Prison ≤ 18 years at
first sex
Blood Transfusion 33.3
Injection drug use 55.6 48.2
Prison 44.4 33.3 44.4
≤ 18 years at first sex 63.0 63.0 74.1 63.0
≥ 4 sex partners 55.6 55.6 63.0 59.3 70.4
Int J Infect Dis. Author manuscript; available in PMC 2009 March 2.
... HCV prevalence was reported by Reis et al. [11] to be 7.5% while in Thailand, a study revealed a very high prevalence of HCV [31%] [12] . Another study carried out in Georgia, Richards et al. [13] found that 22% were HCV seropositive, and Kuniholm et al. [14] revealed 12% HCVpositives, while Wang et al. [7] showed HCV 6.7%, Khalil et al. [15] documented HCV co-infections in TB were 28 [27.45%]. We studied five Hundred patients with tuberculosis either pulmonary or extra pulmonary, and found that 10.6% of them were positive for HCV, most of HCV-positive and negative patients were presented by pulmonary tuberculosis [77.7% and 84.7% respectively]. ...
... In the same line, Behzadifar et al. [17] showed that men had a higher risk of HCV than women. In disagreement with the current study, Kuniholm et al. [14] showed that HCV seropositivity in patients with TB did not differ significantly by gender. ...
Impact of Hepatitis C Virus Co-Infection on Tuberculous Patients
Article
Full-text available
  • Oct 2021
Background: Tuberculosis [TB] and hepatitis C virus [HCV] infections are both common infectious diseases. Although HCV infection is frequent in patients with TB, few studies have been conducted worldwide and there is still little evidence concerning this topic.Aim of the work: To assess the prevalence of HCV infection among tuberculous patients and to investigate its impact on tuberculosis and its treatment outcome.Patients and Methods: A cross-sectional study was done on 500 tuberculous patients. Socio-demographic data, clinical history and examination, clinical severity, response to drugs, laboratory and radiological investigation, Tuberculin skin test, and HCV screening were done.Results: HCV infection was detected among 54 tuberculosis patients [10.8%]. HCV- positive patients suffered more from almost all clinical presentation than HCV- negative patients but without statistical significant difference. Tuberculin skin test induration and reactions were more in HCV- negative patients with 17.9 ± 4.9 mm compared to 12.9 ± 2 mm in HCV- positive patients. Lung cavitation and lung infiltration were the most predominant radiological finding among HCV- positive patients. CAT [category] IV and modified CAT I were the most treatment regimen used in HCV- positive patients. Failure of treatment was significantly higher among HCV- positive patients [59.3%] compared to 9.9% of their counterparts. Moreover, multidrug resistance [MDR] and rifampicin resistance were significantly higher in HCV- positive group than their comparable group [31.5% and 29.6%, and 9% and 4.3% respectively].Conclusion: Co-infection of HCV in Patients with TB is frequent. It increases the frequency of almost all clinical presentation and had its predominant findings on laboratory and radiological investigations. Co-infection also alters the response to TB treatment and should be screened among tuberculous patients before treatment and closely monitored during treatment to detect early any drug resistance or treatment failure.
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... The estimated prevalence of hepatitis B surface antigen (HBsAg), a marker of chronic/active HBV infection, in Georgia was 5.5% among women of child-bearing age in 2000 [2]. The HBsAg prevalence in surveys focused on high-risk groups was 4.1-4.3% between 1997 and 1998 and 2.8% in 2012 [3][4][5]. In 2015, a nationwide serosurvey among adults ≥ 18 years showed an HBsAg prevalence of 2.9%, while the prevalence of antibodies against HBV core antigen (anti-HBc), indicating exposure to HBV, was 25.9% [6]. ...
Toward reaching hepatitis B goals: hepatitis B epidemiology and the impact of two decades of vaccination, Georgia, 2021
Article
Full-text available
  • Jul 2023
  • Euro Surveill
Background Georgia has adopted the World Health Organization European Region's and global goals to eliminate viral hepatitis. A nationwide serosurvey among adults in 2015 showed 2.9% prevalence for hepatitis B virus (HBV) surface antigen (HBsAg) and 25.9% for antibodies against HBV core antigen (anti-HBc). HBV infection prevalence among children had previously not been assessed.AimWe aimed to assess HBV infection prevalence among children and update estimates for adults in Georgia.Methods This nationwide cross-sectional serosurvey conducted in 2021 among persons aged ≥ 5 years used multi-stage stratified cluster design. Participants aged 5-20 years were eligible for hepatitis B vaccination as infants. Blood samples were tested for anti-HBc and, if positive, for HBsAg. Weighted proportions and 95% confidence intervals (CI) were calculated for both markers.ResultsAmong 5-17 year-olds (n = 1,473), 0.03% (95% CI: 0-0.19) were HBsAg-positive and 0.7% (95% CI: 0.3-1.6) were anti-HBc-positive. Among adults (n = 7,237), 2.7% (95% CI: 2.3-3.4) were HBsAg-positive and 21.7% (95% CI: 20.4-23.2) anti-HBc-positive; HBsAg prevalence was lowest (0.2%; 95% CI: 0.0-1.5) among 18-23-year-olds and highest (8.6%; 95% CI: 6.1-12.1) among 35-39-year-olds.Conclusions Hepatitis B vaccination in Georgia had remarkable impact. In 2021, HBsAg prevalence among children was well below the 0.5% hepatitis B control target of the European Region and met the ≤ 0.1% HBsAg seroprevalence target for elimination of mother-to-child transmission of HBV. Chronic HBV infection remains a problem among adults born before vaccine introduction. Screening, treatment and preventive interventions among adults, and sustained high immunisation coverage among children, can help eliminate hepatitis B in Georgia by 2030.
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... 36 and Georgia (13%; 95% CI: 9.5-17.5). 37 Overall, the prevalence of OBI in different world regions varies from 1 to 87%. It is affected by several factors, such as HBV prevalence, study population, HBV immunization programs, and the sensitivity of diagnostic assays. ...
Rate of occult hepatitis B virus infection among individuals with tuberculosis in northeastern Iran: A molecular epidemiological study
Article
Full-text available
  • Jun 2023
One third of the world population has a history of exposure to the hepatitis B virus (HBV), and two billion people are infected with latent tuberculosis (TB). Occult hepatitis B infection (OBI) is defined as the presence of replicative-competent HBV DNA in the liver with detectable or undetectable HBV DNA in the serum of individuals testing negative for the HBV surface antigen (HBsAg). Screening with HBV DNA could identify OBI and significantly reduce carriers and complications of chronic hepatitis B (CHB). This study aims to assess HBV serological markers and OBI molecular diagnosis among people with TB in Mashhad, northeastern Iran. We have performed HBV serological markers (HBsAg, HBc antibodies (Ab) and HBs Ab) in 175 participants. Fourteen HBsAg+ sera were excluded for further analysis. The presence of HBV DNA (C, S, and X gene regions) was assessed by the qualitative real-time PCR (qPCR) method. Frequencies of HBsAg, HBc, and HBs Ab were 8% (14/175), 36.6% (64/175), and 49.1% (86/175), respectively. Among these 42.9% (69/161) were negative for all HBV serological markers. The S, C, and X gene regions were positive in 10.3% (16/156), 15.4% (24/156), and 22.4% (35/156) of participants, respectively. The total OBI frequency was estimated at 33.3% (52/156) when based on detecting one HBV genomic region. Twenty-two and 30 participants had a seronegative and seropositive OBI, respectively. Thorough screening of high-risk groups with reliable and sensitive molecular methods could lead to OBI identification and decrease CHB long-term complications. Mass immunization remains critical in preventing, reducing, and potentially eliminating HBV complications.
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... Of the 354 papers we identified, 264 were excluded because they were not cross-sectional (See Table S1 and Figure S1 in the Supplementary Material). Among the 90 articles that reported cross-sectional studies, we found that only eleven adjusted by cluster (12.2%), five reported the prevalence ratio as the measure of association [5,[17][18][19][20], and six reported the odds ratio [21][22][23][24][25][26]. The information about the search strategy and reviewed papers are reported in Table S1. ...
Tuberculosis in Prisons: Importance of Considering the Clustering in the Analysis of Cross-Sectional Studies
Article
Full-text available
The level of clustering and the adjustment by cluster-robust standard errors have yet to be widely considered and reported in cross-sectional studies of tuberculosis (TB) in prisons. In two cross-sectional studies of people deprived of liberty (PDL) in Medellin, we evaluated the impact of adjustment versus failure to adjust by clustering on prevalence ratio (PR) and 95% confidence interval (CI). We used log-binomial regression, Poisson regression, generalized estimating equations (GEE), and mixed-effects regression models. We used cluster-robust standard errors and bias-corrected standard errors. The odds ratio (OR) was 20% higher than the PR when the TB prevalence was >10% in at least one of the exposure factors. When there are three levels of clusters (city, prison, and courtyard), the cluster that had the strongest effect was the courtyard, and the 95% CI estimated with GEE and mixed-effect models were narrower than those estimated with Poisson and binomial models. Exposure factors lost their significance when we used bias-corrected standard errors due to the smaller number of clusters. Tuberculosis transmission dynamics in prisons dictate a strong cluster effect that needs to be considered and adjusted for. The omission of cluster structure and bias-corrected by the small number of clusters can lead to wrong inferences.
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... These potential biases may be one explanation for the 16% of female and 38% of male participants who did not report risk factors. Third, the study population did not include people experiencing incarceration or homelessness during the study period, groups both known to be at higher risk of HCV infection [39]. Therefore, our findings may not represent risk factors or genotype distribution in these subpopulations. ...
Risk factors and genotype distribution of hepatitis C virus in Georgia: A nationwide population-based survey
Article
Full-text available
In preparation for the National Hepatitis C Elimination Program in the country of Georgia, a nationwide household-based hepatitis C virus (HCV) seroprevalence survey was conducted in 2015. Data were used to estimate HCV genotype distribution and better understand potential sex-specific risk factors that contribute to HCV transmission. HCV genotype distribution by sex and reported risk factors were calculated. We used explanatory logistic regression models stratified by sex to identify behavioral and healthcare-related risk factors for HCV seropositivity, and predictive logistic regression models to identify additional variables that could help predict the presence of infection. Factors associated with HCV seropositivity in explanatory models included, among males, history of injection drug use (IDU) (aOR = 22.4, 95% CI = 12.7, 39.8) and receiving a blood transfusion (aOR = 3.6, 95% CI = 1.4, 8.8), and among females, history of receiving a blood transfusion (aOR = 4.0, 95% CI 2.1, 7.7), kidney dialysis (aOR = 7.3 95% CI 1.5, 35.3) and surgery (aOR = 1.9, 95% CI 1.1, 3.2). The male-specific predictive model additionally identified age, urban residence, and history of incarceration as factors predictive of seropositivity and were used to create a male-specific exposure index (Area under the curve [AUC] = 0.84). The female-specific predictive model had insufficient discriminatory performance to support creating an exposure index (AUC = 0.61). The most prevalent HCV genotype (GT) nationally was GT1b (40.5%), followed by GT3 (34.7%) and GT2 (23.6%). Risk factors for HCV seropositivity and distribution of HCV genotypes in Georgia vary substantially by sex. The HCV exposure index developed for males could be used to inform targeted testing programs.
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... These are also very different percentages from ours, but it is essential to underline that the study was conducted in a general urban population. Our data, however, confirm previous observations that the prevalence of HBV infection in people with TB is higher than in the normal population (29)(30)(31)(32). This observation supports the view that TST-positive individuals deserve a special attention with regard to hepatitis B screening, not only to avoid an unknown reservoir of untreated hepatitis B, but also because standard therapy drugs for TB infection are associated with significant side effects, the most serious being drug induced liver injury (DILI), which carries a fatality rate of up to 5% (33)(34)(35). ...
Screening for hepatitis B virus infection among refugees diagnosed with latent tuberculosis in an Italian community
Article
  • Jul 2021
Background: Refugees are a growing population in the EU-27 area with specific health needs that are to be addressed in the most rapid and effective way at their arrival in the host country. Screening for Hepatitis B Virus infection is offered to specific categories and it could be useful and effective to extend its indications. The aim of this study was to define the epidemiological profile regarding Hepatitis B Virus infection in refugees hosted in the Asylum Seekers Centers of Verona (Italy), diagnosed with latent tuberculosis infection and eligible for chemoprophylaxis. Methods: We conducted a retrospective study in 715 refugees diagnosed with latent tuberculosis infection from January 1st, 2015 to December 31st, 2017. Screening for Hepatitis B Virus infection was offered to latent tuberculosis infection patients who were due to commence treatment. Subjects were tested for Hepatitis B surface Antigen and Hepatitis B core antigen total antibodies. None of the screened patients reported previous vaccination for hepatitis B. Conclusions: Screening for Hepatitis B Virus is of paramount importance not only for the control and prevention of infection, but also in terms of long-term healthcare issues. Making screening more systematic can have an important impact on public health, while always considering cost-effectiveness and promotion of awareness among ethnic groups in order to gain their compliance to treatment/vaccination. Results: Among the 715 refugees diagnosed with latent tuberculosis infection, 593 were eligible for treatment for latent tuberculosis infection. Of these, 211 (35.6%) accepted to be screened for Hepatitis B Virus infection. One hundred and ninety-five of the 211 (92.4%) came from African countries, and 16 (7.6%) from Asia; the majority (80.9%) were males. Median age was 23 years (95% CI 22-24). Of the 211, 58 individuals (27.5%) were Hepatitis B surface Antigen and Hepatitis B core antigen total antibodies positive; 74 (35.1%) were Hepatitis B surface Antigen negative and Hepatitis B core antigen total antibodies positive; and 79 (37.4%) were Hepatitis B surface Antigen and Hepatitis B core antigen total antibodies negative. Male gender and African origin were associated with a lower probability of being Hepatitis B surface Antigen- and Hepatitis B core antigen total antibodies-negative.
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Coinfections with Hepatitis B virus and Hepatitis C virus among tuberculosis patients in Jos, Nigeria
Article
  • Sep 2023
Objectives This study investigated the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) among tuberculosis (TB) patients in Jos, Nigeria. Materials and Methods Seventy-one (71) TB-positive individuals visiting anti-retroviral clinics (male and female between the ages of 15–55 years) were enrolled in the study. Questionnaires and consent forms were issued to these patients after obtaining ethical clearance for the study. Two milliliters of blood samples were obtained from each TB-positive individual by venipuncture and were analyzed using a hepatitis B and C rapid kit (Solid rapid test kit manufactured by Hangzhou Deangel Biological Engineering Co., Ltd. China). Analysis of data was performed with version 26 of SPSS software. Results Out of the seventy-one (71) TB patients recruited in the research, 4 (5.6%) and 2 (2.8%) patients had hepatitis B and C virus, respectively. In this study, HBV seroprevalence, 3 (13.1%) and 1 (11.1%) were recorded among two age groups: 26–30 and 36–40 years, respectively. HCV seroprevalence, 2 (9.1%) was reported within the age group 26–30 years only. The age group and the prevalence of HBV and HCV among the study subjects had no statistically significant relationship ( P > 0.05). Of the 37 females examined, 2 (5.4%) were positive for HBV or HCV, respectively, while of the 34 males, 2 (5.9%) had only HBV. The variables which showed no significant relationship with hepatitis B and C virus were age ( P = 0.423; P = 0.436), sex ( P = 0.660; P = 0.268), newly diagnosed TB patients and those on treatment ( P = 0.416; P = 0.111), blood transfusion ( P = 0.433; P = 0.330), illegitimate sex ( P = 0.668; P = 0.239), tattoo ( P = 0.298; P = 0.298), human immunodeficiency virus status ( P = 0.542; P = 0.654), use of sharp objects ( P = 0.409; P = 0.686), and knowledge of the virus ( P = 0.702; P = 0.614) as P > 0.05. In addition, variables that showed a significant relationship with HCV infection are those that have not been vaccinated with hepatitis B ( P = 0.015) as P < 0.05. Conclusion TB patients attending the Faith Alive Foundation Hospital and Plateau Specialist State Hospital, Jos have a low seroprevalence of HBV and HCV and it is recommended that more sensitive and reliable diagnostic options such as enzyme-linked immunosorbent assay and polymerase chain reaction are employed in further studies. TB patients seropositive for HBV or HCV were referred to physicians for appropriate management to prevent complications and the likelihood of damage to the liver as a result of treatment with drugs against TB.
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Bidirectional Screening for Tuberculosis, Diabetes Mellitus and other Comorbid Conditions in a Resource Constrained Setting: A Pilot Study in Lagos, Nigeria
Article
  • Dec 2022
  • W Afr J Med
Background: The epidemiological transition in developing countries is increasing the burden of non-communicable diseases such as diabetes. We aimed to determine the outcomes of bidirectional screening for TB and diabetes (DM) in resource constrained communities, Lagos, Nigeria. Methods: A quasi-experimental study without control was conducted from March 1-31st, 2017 as part of the series of activities to mark the World TB Day. Community screening took place at multiple locations in multiple days. Participants were registered and screened for Tuberculosis (TB), Diabetes Mellitus (DM) and other comorbid conditions (viral hepatitis and HIV) during open medical outreaches carried out across six resource constrained communities in Lagos, Nigeria. Relevant data were collected and analyzed. Yield of TB among DM patients and vice-versa was analyzed. Associations between MTB detection among those with DM (versus those with no DM) and among those who were HIV positive (compared with those HIV negative) were determined at p ≤0.05. Results: Some (24.7%) of the participants were between the ages 25-34 years. Majority were males (65.8%), Christians (55.7%), Married (73.7%), and 37.8% had secondary education. Many (41.0%) of the participants had 3-4 persons per household, and 1-2 persons per room (44.5%). 109(26%) of individuals screened were presumptive and 18(16.5%) of the 109 presumptive were MTB detected. Also, hyperglycemia (Fasting Blood Sugar, FBS >126 mg/dl or random blood sugar, RBS level >200mg/dl) was diagnosed in 31(5%) of the 620 patients screened. Overall, 1(3.2%) of the 32 patients with DM were diagnosed with TB while 1(5.5%) of the 18 patients with MTB detected were diagnosed with DM and no significant difference in TB or DM detection in either of the groups (p=1.000). The overall yield (in all participants) of HIV in this intervention was 1.27%, DM was 5.0% and HBsAg was 2.1%. Conclusion: This intervention showed that approximately one out of every twenty newly diagnosed TB patients in resource constrained communities had DM as a comorbid condition. This finding underlines the need to strengthen bidirectional screening for TB-DM in order to achieve additional gains in tuberculosis case findings in resource constrained and high TB burden countries.
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Frequency of Hepatitis C Virus in Diagnosed Tuberculosis Cases
Article
  • May 2021
Background: The frequency of hepatitis C virus infection along with tuberculosis has not been widely investigated and very low statistics on rates of hepatitis C virus co-infection in tuberculosis patients. Hepatotoxicity is the major side effect of anti-tuberculosis therapy hepatitis HCVliver disease elevates the chances of hepatotoxicity up-to five folds. Aim: To see the frequency of Hepatitis Cvirus infection amongst people with diagnosed Tuberculosis using gene X-pert technique. To evaluate the factors associated with HCVinfection in patients with MTBtuberculosis and to determine sensitivity and specificity of the tests. Study design: Comparative analytical study. Place and duration of study: Pathology Department, Civil Hospital Mirpur Khas Sindh from 1stJanuary 2017 to 31st December 2018. Methodology: Three hundred and thirteen patients of tuberculosis diagnosed by Genexpert included while testing hepatitis C virus using immunochromotography rapid test technique, enzyme linked immunosorbent assay method and polymerase chain reaction test for confirmation. Results:Higher frequency of tuberculosis infection in males 57.8%, 42.5% between 20-39 years and 22% of hepatitis C virus infection in tuberculosis patients.Sensitivity of rapid test and enzyme-linked immunosorbent assay was 79% and 96% respectively while the specificity of rapid test and enzyme-linked immunosorbent assay was 91% and 99% respectively. Conclusion: The high frequency of hepatitis C virus co-infection was found among tuberculosis cases in Mirpur Khas Division Sindh. Enzyme-linked immunosorbent assay method is more accurate, reliable as compared to rapid immunochromatographytest for hepatitis C virus and polymerase chain reaction is still gold standard. Keywords: TB, Hepatitis C virus, Mycobacterium tuberculosis,, PCR, Genexpert, Rapid test
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Estimating Prevalence of Hepatitis B Virus Coinfection Among Adults With Tuberculosis: A Systematic Review With Meta-analysis
Article
  • Apr 2021
Background: While patients with hepatitis B virus (HBV) infection and tuberculosis (TB) have similar risk factors, little is known regarding the prevalence of HBV and TB coinfection. We aim to evaluate the prevalence of HBV among patients with TB across world regions. Methods: We systematically reviewed the literature using PubMed from inception through September 1, 2019, to identify studies that provided data to calculate HBV coinfection prevalence among adults with TB infection. Prevalence estimates of HBV coinfection among TB patients were stratified by world regions and calculated using meta-analyses with random-effects models. Results: A total of 36 studies met inclusion criteria (4 from the Africa region, 6 from the Americas region, 5 from the Eastern Mediterranean region, 2 from European region, 6 from Southeast Asia region, and 13 from the Western Pacific region). On meta-analysis, overall pooled HBV coinfection prevalence among TB patients was 7.1%, but varied by world region. Region-specific pooled HBV prevalence among TB patients was highest in Africa region [11.4%, 95% confidence interval (CI): 3.45-19.31] and Western Pacific region (10.8%, 95% CI: 8.68-12.84), and was lowest in the Americas (2.2%, 95% CI: 0.78-3.53). Sensitivity analyses yielded similar HBV prevalence estimates across world regions. Conclusions: In this meta-analysis, we observed HBV coinfection prevalence among TB patients to be 38% to 450% higher than published estimates from the Polaris group of region-specific overall HBV prevalence. Timely identification of HBV infection among TB patients will improve patient outcomes by allowing for closer clinical monitoring and management, which may reduce the risk of liver dysfunction and liver failure related to TB treatment.
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Global burden of tuberculosis
Article
Full-text available
  • Sep 1999
To estimate the risk and prevalence of Mycobacterium tuberculosis (MTB) infection and tuberculosis (TB) incidence, prevalence, and mortality, including disease attributable to human immunodeficiency virus (HIV), for 212 countries in 1997. A panel of 86 TB experts and epidemiologists from more than 40 countries was chosen by the World Health Organization (WHO), with final agreement being reached between country experts and WHO staff. Incidence of TB and mortality in each country was determined by (1) case notification to the WHO, (2) annual risk of infection data from tuberculin surveys, and (3) data on prevalence of smear-positive pulmonary disease from prevalence surveys. Estimates derived from relatively poor data were strongly influenced by panel member opinion. Objective estimates were derived from high-quality data collected recently by approved procedures. Agreement was reached by (1) participants reviewing methods and data and making provisional estimates in closed workshops held at WHO's 6 regional offices, (2) principal authors refining estimates using standard methods and all available data, and (3) country experts reviewing and adjusting these estimates and reaching final agreement with WHO staff. In 1997, new cases of TB totaled an estimated 7.96 million (range, 6.3 million-11.1 million), including 3.52 million (2.8 million-4.9 million) cases (44%) of infectious pulmonary disease (smear-positive), and there were 16.2 million (12.1 million-22.5 million) existing cases of disease. An estimated 1.87 million (1.4 million-2.8 million) people died of TB and the global case fatality rate was 23% but exceeded 50% in some African countries with high HIV rates. Global prevalence of MTB infection was 32% (1.86 billion people). Eighty percent of all incident TB cases were found in 22 countries, with more than half the cases occurring in 5 Southeast Asian countries. Nine of 10 countries with the highest incidence rates per capita were in Africa. Prevalence of MTB/HIV coinfection worldwide was 0.18% and 640000 incident TB cases (8%) had HIV infection. The global burden of tuberculosis remains enormous, mainly because of poor control in Southeast Asia, sub-Saharan Africa, and eastern Europe, and because of high rates of M tuberculosis and HIV coinfection in some African countries.
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Isoniazid Preventive Therapy, Hepatitis C Virus Infection, and Hepatotoxicity among Injection Drug Users Infected with Mycobacterium tuberculosis
Article
Full-text available
  • Nov 2001
Treatment of latent Mycobacterium tuberculosis infection with isoniazid can cause hepatotoxicity, but the risk of isoniazid-associated hepatotoxicity among persons coinfected with hepatitis C virus (HCV) is unknown. We conducted a prospective study among 146 injection drug users with M. tuberculosis infection and normal baseline hepatic transaminase values who were treated with isoniazid. Of 146 participants, 138 (95%) were HCV-seropositive. Thirty-seven participants (25%) were human immunodeficiency virus (HIV)-seropositive. Thirty-two (22%; 95% confidence interval [CI], 16%–30%) of 146 participants developed transaminase value elevations to >3 times the upper limit of normal. Transaminase value elevation was associated with concurrent alcohol use but not with race, age, presence of hepatitis B surface antigen, HIV-1 infection, or current injection drug use. Isoniazid was withdrawn from 11 participants (8%; 95% CI, 4%–13%). Of 8 deaths during follow-up, none were attributed to isoniazid-associated hepatotoxicity. The risk of transaminase value elevation and drug discontinuation for HCV-infected persons receiving isoniazid was within the range reported for populations with lower HCV prevalence.
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Evaluation of Clinical and Immunogenetic Risk Factors for the Development of Hepatotoxicity during Antituberculosis Treatment
Article
Full-text available
  • Oct 2002
Though several risk factors for the development of hepatotoxicity due to antituberculosis drugs have been suggested, involvement of genetic factors is not fully established. We have studied the major histocompatibility complex (MHC) class II alleles and clinical risk factors for the development of hepatotoxicity in 346 North Indian patients with tuberculosis undergoing antituberculosis treatment. Of these, 56 patients developed drug-induced hepatotoxicity (DIH group), whereas the remaining 290 patients did not (non-DIH group). The DIH group was comparatively older, had lower pretreatment serum albumin, and a higher frequency of moderately/far advanced disease radiographically than the latter. Further, patients with high alcohol intake had threefold higher odds of developing hepatotoxicity. In multivariate logistic regression analysis, older age (odds ratio [OR] 1.2), moderately/far advanced disease (OR 2.0), serum albumin < 3.5 g/dl (OR 2.3), absence of HLA-DQA1*0102 (OR 4.0), and presence of HLA-DQB1*0201 (OR 1.9) were independent risk factors for DIH. Our results suggest that the risk of hepatotoxicity from antituberculosis drugs is influenced by clinical and genetic factors.
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Risk factors for hepatotoxicity from antituberculosis drugs: A case-control study
Article
  • Mar 1996
Several risk factors for the development of hepatotoxicity during short course antituberculosis therapy have been suggested. A case-control study was undertaken to assess the role of age, sex, disease extent, nutritional status, past history of liver disease, infection with hepatitis viruses, acetylator status, and high alcohol intake as risk factors in the development of hepatotoxicity in patients with pulmonary tuberculosis receiving antituberculosis treatment. The cases comprised 86 consecutive patients who were diagnosed as having hepatitis induced by antituberculosis drugs and who were negative for any of the hepatitis markers (HAV-IgM, HBsAg, HBc-IgM, and anti-HCV). The control group comprised 406 consecutive patients attending the chest clinic who completed antituberculosis treatment without developing hepatitis. The variables analysed were age, sex, body mass index (BMI), history of high alcohol intake, radiological extent of the disease, acetylator status, and serum proteins. The cases were older and their serum albumin levels were lower than in the control group. High alcohol intake was more common among the cases, they had more extensive disease radiologically, and the proportion of slow acetylators was higher. No differences were observed between the two groups in the other risk factors analysed. Of the various risk factors analysed, only advanced age, hypoalbuminaemia, high alcohol intake, slow acetylator phenotype, and extensive disease were risk factors for the development of hepatotoxicity. The risk of hepatitis in the presence of one or more of these risk factors may be increased.
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Antituberculosis Drug–induced Hepatotoxicity: The Role of Hepatitis C Virus and the Human Immunodeficiency Virus
Article
  • Jul 1998
Until recently it was thought that age greater than 35 yr was the main risk factor for the development of drug-induced hepatitis (DIH) in patients receiving antituberculosis therapy. We conducted a study to determine whether infection with either the hepatitis C virus or the human immunodeficiency virus (HIV) were significant risk factors for the development of DIH in patients receiving antituberculosis therapy. Our study consisted of two parts. In the first part, 134 consecutive patients admitted for the treatment of tuberculosis (TB) were followed for the development of DIH. All of these patients were also screened for the presence of hepatitis C and HIV. In the second part of the study, those patients who were hepatitis C positive and who developed DIH on repeated reintroduction of the anti-TB drugs were offered a liver biopsy. If active inflammation, which may be suggestive of hepatitis C infection, was present on the biopsy specimen, treatment with alpha-interferon was begun and the anti-TB drugs were subsequently reintroduced. During the 18 mo of the study, 22 patients developed DIH. The relative risk of developing DIH if the patient was hepatitis C or HIV positive was fivefold and fourfold, respectively (p < 0.05). If a patient was coinfected with both hepatitis C and HIV the relative risk of developing DIH was increased 14.4-fold (p < 0.002). In the treatment part, four patients were treated with alpha-interferon, and all were able to undergo the reintroduction of anti-TB therapy without reoccurrence of DIH. Infection with hepatitis C and HIV are independent and additive risk factors for the development of DIH during TB therapy. The treatment of hepatitis C with alpha-interferon may allow the reintroduction of anti-TB agents in those who previously developed DIH when exposed to these drugs.
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Tuberculosis control in the Caucasus: Successes and constraints in DOTS implementation
Article
  • Jun 1999
The pilot projects for tuberculosis (TB) control, supported by the World Health Organization (WHO) and based on the WHO recommended control strategy, directly-observed treatment, short-course (DOTS) in the Caucasian countries (Armenia, Azerbaijan, Georgia). To evaluate the results 2 years after the implementation of the pilot projects. Analysis of data on case detection, sputum conversion and treatment outcome reported quarterly to the WHO from the Ministries of Health in each country. Since the establishment of the project, 1330, 764 and 4866 new cases and relapses, respectively, of TB have been detected in the pilot areas of Armenia, Azerbaijan and Georgia. In Armenia and Azerbaijan, respectively 46% and 57% of all cases were smear positive, whilst in Georgia, the corresponding figure was only 12%. After 3 months' treatment, 93% of new smear-positive patients had become smear-negative. The sputum conversion rate for relapses and other retreatment cases (failure, treatment interrupted) was 85%. In Armenia, 78.1% of new smear-positive patients were treated successfully (cured or completed treatment). The corresponding percentages for Azerbaijan and Georgia were 87.9% and 59.6%. Treatment success rates among retreatment cases was generally low, at respectively 46%, 64%, and 35%, in Armenia, Azerbaijan, and Georgia. The results of the implementation of the WHO TB control pilot projects in Armenia, Azerbaijan and Georgia suggest that the DOTS strategy is feasible in emergency situations in general, and in the Caucasus in particular.
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Pulmonary tuberculosis in prisons of the ex-USSR state Georgia: Results of a nation-wide prevalence survey among sentenced inmates
Article
  • Jan 2001
The penitentiary system of the ex-USSR state of Georgia. To measure the prevalence of active pulmonary tuberculosis and drug-resistant disease among prisoners. To identify factors associated with active tuberculosis and multidrug resistance (MDR). A comprehensive multiphasic screening survey for tuberculosis. The prevalence of smear- or culture-positive tuberculosis was 5995 per 100,000 prisoners (n = 448 cases among 7473 inmates). Of all the strains, 215 (77.9%) were resistant to at least one drug and 37 (13.0%) were MDR. Independent risk markers associated smear- or culture-positive tuberculosis with included prison stay of 2 years or more, body mass index <20 kg/m2, accommodation in a large size prison, previous anti-tuberculosis treatment, cough of 2 weeks or more and loss of appetite. Risk markers associated with MDR were a prison stay of less than 2 years and being over 25 years of age. In Georgia, the excess risk for tuberculosis among prisoners is unprecedented, suggesting that prisons represent a significant reservoir of tuberculosis. Only a comprehensive strategy for tuberculosis control in prisons, including prison reform, control of anti-tuberculosis drugs, and prompt and efficient diagnosis and treatment of patients can have an impact on the tuberculosis burden in the prison system.
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Risk for tuberculosis infection among internally displaced persons in the Republic of Georgia
Article
  • Feb 2001
To determine the prevalence of tuberculosis (TB) infection and disease among internally displaced persons residing in Tbilisi, Republic of Georgia. Residents of eight refugee hostels were screened for TB infection using a tuberculin skin test (TST) and a symptom questionnaire. Participation was voluntary. TST-positive individuals were referred for chest radiography. Subjects with cough, fever, or night sweats of > 2 weeks duration provided sputum for acid-fast bacilli (AFB) microscopy and culture. Of approximately 4000 potential subjects (internally displaced persons), 988 (24.7%) participated in the screening program. Of these 988, 931 (94.2%) who had a TST placed returned at 48-72 hours to have the skin test examined; 447 (48.0%) were TST-positive (> or = 10 mm induration). In multivariate analysis, risk factors for a positive TST included male sex, ever having received BCG, history of close contact with a case of active tuberculosis, and living in one specific refugee hostel. Risk for a positive TST was greater among subjects > 20 years old, but there was no difference between age groups over the age of 20 years. Five patients with active TB were identified through the screening program, giving a case rate of 537 per 100,000 population. Tuberculosis infection and disease were common in this group of internally displaced persons. Screening was a useful mechanism of case finding among this high prevalence population.
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Prevalence of hepatitis B, hepatitis C, syphilis and HIV in Georgian blood donors
Article
  • Feb 2001
Prevalence of human immunodeficiency (HIV), hepatitis B (HBV), hepatitis C (HCV) virus and syphilis in the population of blood donors in Georgia has been investigated. Out of 4970 donors 7.3% had anti-HCV (6.9% confirmed), HbsAg was positive in 4.1% (3.4% confirmed), Seroprevalence of Syphilis was 2.3%. Three individuals had HIV. Prevalence of HCV and HBV in Georgia is higher than national prevalence estimates of viral hepatitis in neighboring countries.
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