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CORK Bibliography: Tuberculosis

64 citations. January 2003 to present

Prepared: September 2011

Brunet L; Pai M; Davids V; Ling D; Paradis G; Lenders L et al. High prevalence of smoking among patients with suspected tuberculosis in South Africa. European Respiratory Journal 38(1): 139-146, 2011. (34 refs.)

There is growing evidence that tobacco smoking is an important risk factor for tuberculosis (TB). There are no data validating the accuracy of self-reported smoking in TB patients and limited data about the prevalence of smoking in TB patients from high-burden settings. We performed a cross-sectional analysis of 500 patients with suspected TB in Cape Town, South Africa. All underwent comprehensive diagnostic testing. The accuracy of their self-reported smoking status was determined against serum cotinine levels. Of the 424 patients included in the study, 56 and 60% of those with active and latent TB infection (LTBI), respectively, were current smokers. Using plasma cotinine as a reference standard, the sensitivity of self-reported smoking was 89%. No statistically significant association could be found between smoking and active TB or LTBI. In Cape Town, the prevalence of smoking among patients with suspected and confirmed TB was much higher than in the general South African population. Self-reporting is an accurate measure of smoking status. These results suggest the need to actively incorporate tobacco cessation programmes into TB services in South Africa.

Buff AM; Moonan PK; Desai MA; McKenna TL; Harris DA; Rogers BJ et al. South Carolina tuberculosis genotype duster investigation: A tale of substance abuse and recurrent disease. International Journal of Tuberculosis and Lung Disease 14(10): 1347-1349, 2010. (10 refs.)

The South Carolina Tuberculosis (TB) Control Division ranked all the TB genotype clusters (two or more cases with matching genotypes) in the state based on the number of cases. The largest cluster, PCR00002, was investigated to determine if the cluster represented recent Mycobacterium tuberculosis transmission, and if so, to identify associated risk factors. The PCR0002 cluster, which included pediatric cases, clearly represented recent M. tuberculosis transmission. The two primary factors contributing to cluster growth were substance abuse and recurrent TB disease. Elimination of ongoing M. tuberculosis transmission in this population will require concurrent treatment for TB disease and substance abuse.

Chawarski MC; Mazlan M; Schottenfeld RS. Heroin dependence and HIV infection in Malaysia. Drug and Alcohol Dependence 82(Supplement 1): s39-s42, 2006. (18 refs.)

Background: Malaysia is experiencing severe problems with heroin dependence and HIV infection. This study evaluated drug use and other HIV risk behaviors and their association with HIV and other infectious diseases in heroin-dependent subjects enrolled in a clinical trial of drug abuse treatment in Muar, Malaysia. Methods: Baseline assessments of treatment-seeking subjects (n = 177) included the Addiction Severity Index; AIDS Risk Inventory; serological tests for HIV, hepatitis B, and hepatitis C; and chest X-ray. Results: All of the subjects were male; 67.8% were Malays, 28.8% Chinese, and 2.3% Indian. Subjects had a mean (SD) age of 37.2 (9.1) years and 14.4 (8.5) years of using heroin; 76.3% reported lifetime injection drug use (IDU), and 41.5% reported current IDIJ; 30 of 156 (19.2%) tested HIV positive, 143 of 159 (89.9%) tested hepatitis C positive, and 25 of 159 (15.7%) had radiological evidence of pulmonary tuberculosis. Malay subjects had a significantly higher prevalence of current IDU, needle sharing (p < 0.01), and HIV infection (p < 0.05) compared with Chinese subjects. Lifetime IDIJ, needle sharing, lack of consistent condom use, and Malay ethnicity were significantly associated with HIV infection. Conclusions: The high prevalence of HIV infection among heroin-dependent individuals in Malaysia supports the importance of interventions to reduce the major risk factors for HIV, including IDIJ, needle sharing, and unprotected sex.

Chemtob D; Levy A. Rationale and staff evaluation of using a therapeutic milieu for substance users within a tuberculosis ward. Substance Use & Misuse 44(5): 672-683, 2009. (20 refs.)

Approximately 30% of tuberculosis (TB) patients in Israel were treated, in part, in two dedicated hospital wards during the years 2003-2005. A portion of them manifested severe psychosocial conditions. An intervention based on the Therapeutic Milieu (TM) model was implemented in the larger ward and included a staff evaluation of this intervention. The concept of TM, based on psychosocial paradigms and behavioral medicine, is aimed at providing a supportive environment for patients. Weekly group patients' meetings and monthly group staff supervisions were performed during 15 months (2003-2005). Forty of the 196 (20%) TB patients, mainly complex, and 13 of 20 staff members (65%) attended regularly and discussed how to deal with substance abuse, personality disorders, and immigration-related crises. Out of 40 TB cases, 30 (75%) were also substance users. Ten staff members self-analyzed the impact of this intervention in terms of (1) having given adequate tools for the staff, (2) reducing physical violence, (3) increasing adherence to TB treatment, and (4) more efficient treatment for their substance use. No direct evaluation was done among the TB patients. According to staff members, this intervention had a positive overall impact. However, using Therapeutic Milieu in TB ward hospitalization, as a window of opportunity, remains the first step in a longer journey for rehabilitation. The study's limitations are noted.

Chiang CY; Slama K; Enarson DA. Associations between tobacco and tuberculosis. International Journal of Tuberculosis and Lung Disease 11(3): 258-262, 2007. (41 refs.)

The association between smoking and tuberculosis (TB) has been investigated since 1918. Both passive and active exposure to tobacco smoke have been shown to be associated with tuberculous infection and with the transition from being infected to developing TB disease. The association between smoking and developing TB disease (without separating the risk of transition from being exposed to being infected and that from being infected to developing TB disease) has been reported substantially. Smoking affects the clinical manifestations of TB. It has been shown that ever smokers are more likely to have cough, dyspnoea, chest radiograph appearances of upper zone involvement, cavity and miliary appearance, and positive sputum culture, but are less likely to have isolated extra-pulmonary involvement than non-smokers. Smoking has been found to be associated with both relapse of TB and TB mortality. There appears to be enough evidence to conclude that smoking is causally associated with TB disease. Patients with TB need and should receive counselling and assistance in stopping smoking.

Coker R; McKee M; Atun R; Dimitrova B; Dodonova E; Kuznetsov S et al. Risk factors for pulmonary tuberculosis in Russia: Case-control study. British Medical Journal 332(7533): 85-87, 2006. (6 refs.)

Objectives: To determine risk factors for pulmonary tuberculosis in Russia. Design Case-control study of exposure to a variety of risk factors before and during the development of pulmonary tuberculosis. Setting Large city in Russia. Participants: Cases were 334 consecutive adults diagnosed as having culture confirmed pulmonary tuberculosis between I January 2003 and 31 December 2003. Controls were 334 individuals sampled from a validated population registry, matched for age and sex to the patients with tuberculosis. A questionnaire collected information on potential risk factors. Main outcome measures Risk factors associated with the development of tuberculosis. Results The main risk factors for tuberculosis were low accumulated wealth (univariate odds ratio 16.70), financial insecurity (5.67), consumption of unpasteurised milk (3.58), diabetes (2.66), living with a relative with tuberculosis (2.94), being unemployed (6.10), living in overcrowded conditions (2.99), illicit drug use (8.74), and a history of incarceration in both pretrial detention centres (5.70) and prison (12.50). Conclusions: When prevalence of exposure is taken into account the most important factors in the development of pulmonary tuberculosis in Russia are exposure to raw milk and unemployment.

Davies PDO; Yew WW; Ganguly D; Davidow AL; Reichman LB; Dheda K et al. Smoking and tuberculosis: The epidemiological association and immunopathogenesis. Transactions of the Royal Society of Tropical Medicine and Hygiene 100(4): 291-298, 2006. (46 refs.)

There is increasing evidence of a link between tuberculosis and smoking. This paper reviews the epidemiological evidence from the UK, China, India and the USA, summarizing some of the main papers which indicate an association. Where an association has been found there seems to be an increase in tuberculosis case rates of between two- and four-fold for those smoking in excess of 20 cigarettes a day, but it may be difficult to control for other factors, particularly alcohol consumption. The final part of the paper reviews possible mechanisms. A likely possibility is that nicotine turns off the production of TNF-alpha by the macrophages in the lungs, rendering the patient more susceptible to the development of progressive disease from latent Mycobacterium tuberculosis infection.

de Albuquerque MDPM; Ximenes RAD; Lucena-Silva N; de Souza WV; Dantas AT; Dantas OMS et al. Factors associated with treatment failure, dropout, and death in a cohort of tuberculosis patients in Recife, Pernambuco State, Brazil. Cadernos de Saude Publica 23(7): 1573-1582, 2007. (33 refs.)

A cohort of cases initiating tuberculosis treatment from May 2001 to July 2003 was followed in Recife, Pernambuco State, Brazil, to investigate biological, clinical, social, lifestyle, and healthcare access factors associated with three negative tuberculosis treatment outcomes (treatment failure, dropout, and death) separately and as a group. Treatment failure was associated with treatment delay, illiteracy, and alcohol consumption. Factors associated with dropout were age, prior TB treatment, and illiteracy. Death was associated with age, treatment delay, HIV co-infection, and head of family's income. Main factors associated with negative treatment outcomes as a whole were age, HIV co-infection, illiteracy, alcoholism, and prior TB treatment. We suggest the following strategies to increase cure rates: further training of the Family Health Program personnel in TB control, awareness-raising on the need to tailor their activities to special care for cases (e.g., literacy training); targeting use of directly observed therapy for higher risk groups; establishment of a flexible referral scheme to handle technical and psychosocial problems, including alcoholism; and increased collaboration with the HIV/AIDS program.

Deiss RG; Rodwell TC; Garfein RS. Tuberculosis and illicit drug use: Review and update. (review). Clinical Infectious Diseases 48(1): 72-82, 2009. (180 refs.)

Illicit drug users continue to be a group at high risk for tuberculosis ( TB). Here, we present an updated review of the relationship between TB and illicit drug use, and we summarize more than a decade of new research. Drug users, and injection drug users in particular, have driven TB epidemics in a number of countries. The successful identification and treatment of TB among illicit drug users remain important components of a comprehensive TB strategy, but illicit drug users present a unique set of challenges for TB diagnosis and control. New diagnostic modalities, including interferon-gamma-release assays, offer potential for improved diagnosis and surveillance among this group, along with proven treatment strategies that incorporate the use of directly observed therapy with treatment for drug abuse. Special considerations, including coinfection with viral hepatitis and the rifampin-methadone drug interaction, warrant clinical attention and are also updated here.

dos Santos MAPS; Albuquerque MFPM; Ximenes RAA; Lucena-Silva NLCL; Braga C; Campelo ARL et al. Risk factors for treatment delay in pulmonary tuberculosis in Recife, Brazil. BMC Public Health 5: article no. 25, 2005. (22 refs.)

Background: Tuberculosis is still a great challenge to public health in Brazil and worldwide. Early detection followed by effective therapy is extremely important in controlling the disease. Recent studies have investigated reasons for delays in treatment, but there is no agreed definition of what constitutes an "acceptable" delay. This study investigates factors associated with total delay in treatment of tuberculosis. Methods: A cohort of adult cases of pulmonary tuberculosis diagnosed over a two-year period was studied. Patients were interviewed on entry, reporting the duration of symptoms before the start of treatment, and sputum and blood samples were collected. It was decided that sixty days was an acceptable total delay. Associations were investigated using univariable and multivariable analysis and the population attributable fraction was estimated. Results: Of 1105 patients, 62% had a delay of longer than 60 days. Age, sex, alcoholism and difficulty of access were not associated with delays, but associations were found in the case of unemployment, having given up smoking, having lost weight and being treated in two of the six health districts. The proportion attributable to: not being an ex-smoker was 31%; unemployment, 18%; weight loss, 12%, and going to the two worst health districts, 25%. Conclusion: In this urban area, delays seem to be related to unemployment and general attitudes towards health. Although they reflect the way health services are organized, delays are not associated with access to care.

Driver CR; Kreiswirth B; MaCaraig M; Clark C; Munsiff SS; Driscoll J et al. Molecular epidemiology of tuberculosis after declining incidence, New York City, 2001-2003. Epidemiology and Infection 135(4): 634-643, 2007. (36 refs.)

Tuberculosis incidence in New York City (NYC) declined between 1992 and 2000 from 51 center dot 1 to 16 center dot 6 cases per 100000 population. In January 2001, universal real-time genotyping of TB cases was implemented in NYC. Isolates from culture-confirmed tuberculosis cases from 2001 to 2003 were genotyped using IS6110 and spoligotype to describe the extent and factors associated with genotype clustering after declining TB incidence. Of 2408 (91 center dot 8 %,,) genotyped case Isolates, 873 (36 center dot 2 %) had a pattern indistinguishable from that of another study period case, forming 212 clusters; 248 (28 center dot 4 %) of the clustered cases had strains believed to have been widely transmitted during the epidemic years in the early 1990s in NYC. An estimated 27 center dot 4 % (873 minus 212) of the 2408 cases were due to recent infection that progressed to active disease during the study period. Younger age, birth in the United States, homelessness, substance abuse and presence of TB symptoms were independently associated with greater odds of clustering.

Drobniewski FA; Atun R; Fedorin I; Bikov A; Coker R. The 'bear trap': The colliding epidemics of tuberculosis and HIV in Russia. International Journal of STD & AIDS 15(10): 641 -646, 2004. (35 refs.)

In April, 2003 the World Bank approved a long-awaited $150 million loan to the Russian Federation to support tuberculosis (TB) and AIDS control. Although the Russian Federation accounts for a relatively small fraction of the global TB case-load the proportion of cases which are drug-resistant and particularly multidrug-resistant is very high in some regions. HIV incidence, principally associated with intravenous drug abuse, has increased dramatically and this will impact upon TB control efforts. Federation-wide data are limited but a focus on one region shows something of the confluence of the epidemics of HIV and TB. Approaching 200 cases of HIV-associated TB have occurred in the past two years, and the age structure of the HIV-infected population and that with high rates of TB shows sizeable overlap. The region has high rates of multidrug-resistant TB which are likely to impact considerably on efforts to meet this emerging and complex public health challenge. Insights gained through the examination of this one region can tell us something of the magnitude of the challenge now faced by both the international community and Russia.

Drobniewski FA; Balabanova YM; Ruddy MC; Graham C; Kuznetzov SI; Gusarova GI et al. Tuberculosis, HIV seroprevalence and intravenous drug abuse in prisoners. European Respiratory Journal 26(2): 298-304, 2005. (34 refs.)

High rates of tuberculosis (TB) and HIV are believed to exist in Russian prisons. Prisoners with TB were studied in order to identify the following: 1) prevalence of HIV, and risk factors for HIV and other blood-borne virus infections; and 2) clinical and social factors that might compromise TB treatment effectiveness and/or patient adherence and, hence, encourage treatment failure. A 1-yr cross-sectional prevalence study of 1,345 prisoners with TB was conducted at an in-patient TB facility in Samara, Russian Federation. HIV and hepatitis B and/or C co-infection occurred in 12.2% and 24.1% of prisoners, respectively, and rates were significantly higher than in civilians. Overall, 48.6% of prisoners used drugs, of which 88.3% were intravenous users. Prisoners were more likely to be intravenous drug users and HIV positive compared with civilians with TB, and 40.2% of prisoners shared needles. Two-thirds of prisoners (68.6%) had received previous TB drug therapy (frequently multiple, interrupted courses) and were significantly more likely than civilians to have had previous therapy consistent with the high drug-resistance rates seen. Prisons are major drivers of the tuberculosis and HIV epidemics. Novel strategies are needed to reduce the spread of blood borne diseases, particularly in intravenous drug users

Duarte EC; Bierrenbach AL; da Silva JB; Tauil PL; Duarte ED. Factors associated with deaths among pulmonary tuberculosis patients: A case-control study with secondary data. Journal of Epidemiology and Community Health 63(3): 233-238, 2009. (29 refs.)

Background: Tuberculosis remains an important public health problem in Brazil where over 100 000 new cases and 6000 deaths are reported every year. Current drug efficacy and wide availability should have curbed this toll. The goal was to study the factors associated with death in incident cases of pulmonary tuberculosis (PT) during treatment. Methods: This is a case-control study including all new cases of PT reported between 2000 and 2004; cases were patients who died of any cause and controls were those cured after initial PT treatment. Data analyses included unconditional multiple hierarchical logistic regression. Results: A total of 313 502 new cases of tuberculosis were reported between 2000 and 2004; 224 355 (71.6%) were cured after initial treatment and 20 721 (6.6%) died during the surveillance follow-up. Over 82% of all cases were diagnosed with PT. After controlling for significant variables, the factors associated with a higher risk of death included gender (males: odds ratio (OR) 1.4; 95% confidence interval (CI) 1.33 to 1.47), age (, 5 years of age: OR 1.90; 95% CI 1.51 to 2.38; 30-59 years: OR 2.78; 95% CI 2.61 to 2.97; over 60 years: OR 10.92; 95% CI 10.09 to 11.81), positive HIV serology (OR 10.59; 95% CI 9.76 to 11.48), alcoholism (OR 1.49; 95% CI 1.36 to 1.65), mental disorder (OR 1.80; 95% CI 1.43 to 2.27) and presence of additional lung pathology on chest x ray (OR 2.22; 95% CI 1.83 to 2.70). Protective variables included education (highest level: OR 0.67; 95% CI 0.63 to 0.70). Conclusions: Preventive interventions should target the most vulnerable patients, in particular the very young and the elderly, those infected with HIV and those presenting with a mental disorder or additional lung pathology.

El Sony A; Slama K; Salieh M; Elhaj H; Adam K; Hassan A et al. Feasibility of brief tobacco cessation advice for tuberculosis patients: a study from Sudan. International Journal of Tuberculosis and Lung Disease 11(2): 150-155, 2007. (13 refs.)

SETTING: Twenty-four health care centres in Sudan. OBJECTIVE: To examine the feasibility of introducing a tobacco cessation intervention into tuberculosis (TB) treatment programmes. DESIGN: A feasibility study of a tobacco cessation intervention for new cases of pulmonary tuberculosis (PTB) in men compared survey centres (controls) and tobacco cessation intervention centres. Feasibility was evaluated by examining 1) acceptance by health staff and 2) the impact of additional tasks on TB treatment outcomes. A secondary assessment looked at rate of stopping tobacco use among those enrolled in the intervention condition. RESULTS: Staff members did not differ in personal use of tobacco, in enforcing rules banning the use of tobacco at health centres or in rates of recruitment into the study. A total of 513 patients (44% of those eligible) were enrolled. Differences in TB treatment success were found between patients who were enrolled and those who were not: respectively 83% and 59% were cured or completed treatment. Of identified tobacco users undergoing the cessation intervention, 66% reported abstinence at the end of their TB treatment. CONCLUSION: Although differences existed between patients enrolled or not enrolled, the intervention was demonstrated to be feasible to implement and effective for those enrolled within routine TB services.

Fiske CT; Hamilton CD; Stout JE. Alcohol use and clinical manifestations of tuberculosis. Journal of Infection 57(5): 385-391, 2008. (32 refs.)

Objectives: Excess alcohol use represents a significant challenge in tuberculosis control. Whether alcohol use enhances transmission of Mycobacterium tuberculosis is not known. Methods: We analyzed North Carolina, USA surveillance data for all adult (> 14 years) tuberculosis cases reported 1994-2006 (N = 5556). Results: The prevalence of excess alcohol use among tuberculosis cases declined from 27.3% in 1994 to 17.9% in 2006. Cases with excess alcohol use were more likely to have pulmonary tuberculosis compared with cases without excess alcohol use (92.5% vs. 77.2%, p < 0.0001). Among pulmonary cases, excess alcohol use was associated with cavities on chest radiograph (36.8% vs. 28.2%, p < 0.0001) and positive acid-fast sputum smears (65.9% vs. 45.8%, p < 0.0001). Conclusions: Although excess alcohol use is becoming less prevalent among tuberculosis cases in North Carolina, cases who use excess alcohol had clinical features associated with greater infectiousness, and represent a significant public health problem.

Fleming MF; Krupitsky E; Tsoy M; Zvartau E; Brazhenko N; Jakubowiak W et al. Alcohol and drug use disorders, HIV status and drug resistance in a sample of Russian TB patients. International Journal of Tuberculosis and Lung Disease 10(5): 565-570, 2006. (15 refs.)

SETTING: Alcohol use, tuberculosis (TB) drug resistance and human immunodeficiency virus (HIV) risk behavior are of increasing concern in Russian TB patients. DESIGN: A prevalence study of alcohol use and HIV risk behavior was conducted in a sample of 200 adult men and women admitted to TB hospitals in St Petersburg and Ivanovo, Russia. RESULTS: Of the subjects, 72% were men. The mean age was 41. Active TB was diagnosed using a combination of chest X-ray, sputum smears and sputum cultures. Sixty-two per cent met DSM-IV criteria for current alcohol abuse or dependence. Drug use was uncommon, with only two patients reporting recent intravenous heroin use. There was one case of HIV infection. The mean total risk assessment battery score was 3.4. Depression was present in 60% of the sample, with 17% severely depressed. Alcohol abuse/dependence was associated with an eight-fold increase in drug resistance (OR 8.58; 95% CI 2.09-35.32). Patients with relapsing or chronic TB were more likely to meet the criteria for alcohol abuse/dependence (OR 2.56; 95% CI 1.0-6.54). CONCLUSION: Alcohol use disorders are common in patients being treated for active TB, and are associated with significant morbidity. Additional surveys are needed to examine the relationship between alcohol use disorders and anti-tuberculosis drug resistance.

Fry RS; Khoshnood K; Vdovichenko E; Granskaya J; Sazhin V; Shpakovskaya L et al. Barriers to completion of tuberculosis treatment among prisoners and former prisoners in St Petersburg, Russia. International Journal of Tuberculosis and Lung Disease 9(9): 1027-1033, 2005. (19 refs.)

SETTING: St Petersburg, Russian Federation. OBJECTIVES: To identify barriers to the completion of tuberculosis (TB) treatment among prisoners and former prisoners in St Petersburg, Russia. DESIGN: Questionnaires were administered to 60 prisoners and 40 former prisoners. Interviews were performed with prison and TB dispensary staff. Treatment follow-up rates were estimated by matching prison release records against attendance records from all 17 St Petersburg-based TB dispensaries over an 18-month period. RESULTS: Of 80 released prisoners with active TB in 2002, 21 (26.3%) appeared in dispensary attendance records. Barriers to the completion of TB treatment overall were homelessness, unemployment, alcoholism, drug addiction and difficulty tolerating TB medications with co-morbid illnesses such as human immunodeficiency virus and hepatitis. Prisoners and former prisoners ranked help with obtaining an internal passport and money first, followed closely by food and a job, as the most desirable incentives to completing TB treatment. CONCLUSIONS: A future program for soon-to-be released and released prisoners in St Petersburg that offers an array of desirable flexible social welfare services and incentives has the potential to attract and retain patients within TB treatment, but continued efforts must also be made to include drug treatment, job training and keeping former prisoners out of prison.

Gelmanova IY; Keshavjee S; Golubchikova VT; Berezina VI; Strelis AK; Yanova GV et al. Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: Non-adherence, default and the acquisition of multidrug resistance. Bulletin of the World Health Organization 85(9): 703-711, 2007. (31 refs.)

Objective: To identify barriers to successful tuberculosis (TB) treatment in Tomsk, Siberia, by analysing individual and programmatic risk factors for non-adherence, default and the acquisition of multidrug resistance in a TB treatment cohort in the Russian Federation. Methods: We conducted a retrospective cohort study of consecutively enrolled, newly detected, smear and/or culture-positive adult TB patients initiating therapy in a DOTS programme in Tomsk between 1 January and 31 December 2001. Findings: Substance abuse was strongly associated with non-adherence [adjusted odds ratio (OR): 7.3; 95% confidence interval (0): 2.89-18.46] and with default (adjusted OR: 11.2; 95% CI: 2.55-49.17). Although non-adherence was associated with poor treatment outcomes (OR: 2.4; 95% CI: 1.1-5.5), it was not associated with the acquisition of multi-drug resistance during the course of therapy. Patients who began treatment in the hospital setting or who were hospitalized later during their treatment course had a substantially higher risk of developing multidrug-resistant TB than those who were treated as outpatients (adjusted HRs: 6.34; 95% Cl: 1.35-29.72 and 6.26; 95% CI: 1.02-38.35 respectively). Conclusion: In this cohort of Russian TB patients, substance abuse was a strong predictor of non-adherence and default. DOTS programmes may benefit from incorporating measures to diagnose and treat alcohol misuse within the medical management of patients undergoing TB therapy. Multidrug-resistant TB occurred among adherent patients who had been hospitalized in-the course of their therapy. This raises the possibility that treatment for drug-sensitive disease unmasked a pre-existing population of drug-resistant organisms, or that these patients were reinfected with a drug-resistant strain of TB.

Godoy P; Dominguez A; Alcaide J; Camps N; Jansa JM; Minguell S et al. Characteristics of tuberculosis patients with positive sputum smear in Catalonia, Spain. European Journal of Public Health 14(1): 71-75, 2004. (27 refs.)

Background: Patients with positive sputum smears are those with the capacity to spread infection. The objective of this study was to describe the incidence of tuberculosis in Catalonia (an autonomous community in the northeast of Spain which includes Barcelona) and to determine risk factors associated to patients with positive sputum smear test. Methods: New cases of tuberculosis detected by active surveillance between May 1996 and April 1997 were studied. The study was analysed as a coincident cases and controls study. The rate of incidence was calculated per 100,000 persons-year. The association of the dependent variable - case of tuberculosis with positive sputum smear - with the remainder of independent variables was determined by odds ratio (OR) with a 95% confidence interval (CI). Results: A total of 2508 cases of tuberculosis were detected. The rate of incidence was 41.4 per 100,000 persons-year. Of these 19.4% (487/2508) were coinfected with HIV and 35.6% (893/2508) presented a positive sputum smear, which implies a rate of 14.7 per 100,000 persons-year. In an adjusted multivariate analysis, cases with positive smears were positively associated with the 15-24 (OR=1.9; 95% CI: 1.4-2.4), 25-34 (OR=2.1; 95% CI: 1.7-2.7) and 35-44 years (OR=1.7; 95% CI: 1.3-2.2) age compared with persons 45 years old and above; with males (OR=1.8; 95% CI: 1.5-2.2) and consumers of alcohol (OR=2.1; 95% CI: 1.7-2.7) and negatively with those under 15 years of age (OR=0.1; 95% CI: 0.1-0.2) and coinfection with HIV (OR=0.5; 95% CI: 0.3-0.7). Conclusions: Measures to control tuberculosis transmission (prompt diagnosis, study of contacts and directly observed treatments) should be reinforced for male adults with excessive consumption of alcohol.

Greenfield SF; Shields A; Connery HS; Livchits V; Yanov SA; Lastimoso CS et al. Integrated management of physician-delivered alcohol care for tuberculosis patients: Design and implementation. (review). Alcoholism: Clinical and Experimental Research 34(2): 317-330, 2010. (127 refs.)

Background: While the integration of alcohol screening, treatment, and referral in primary care and other medical settings in the U.S. and worldwide has been recognized as a key health care priority, it is not routinely done. In spite of the high co-occurrence and excess mortality associated with alcohol use disorders (AUDs) among individuals with tuberculosis (TB), there are no studies evaluating effectiveness of integrating alcohol care into routine treatment for this disorder. Methods: We designed and implemented a randomized controlled trial (RCT) to determine the effectiveness of integrating pharmacotherapy and behavioral treatments for AUDs into routine medical care for TB in the Tomsk Oblast Tuberculosis Service (TOTBS) in Tomsk, Russia. Eligible patients are diagnosed with alcohol abuse or dependence, are newly diagnosed with TB, and initiating treatment in the TOTBS with Directly Observed Therapy-Short Course (DOTS) for TB. Utilizing a factorial design, the Integrated Management of Physician-delivered Alcohol Care for Tuberculosis Patients (IMPACT) study randomizes eligible patients who sign informed consent into 1 of 4 study arms: (1) Oral Naltrexone + Brief Behavioral Compliance Enhancement Therapy (BBCET) + treatment as usual (TAU), (2) Brief Counseling Intervention (BCI) + TAU, (3) Naltrexone + BBCET + BCI + TAU, or (4) TAU alone. Results: Utilizing an iterative, collaborative approach, a multi-disciplinary U.S. and Russian team has implemented a model of alcohol management that is culturally appropriate to the patient and TB physician community in Russia. Implementation to date has achieved the integration of routine alcohol screening into TB care in Tomsk; an ethnographic assessment of knowledge, attitudes, and practices of AUD management among TB physicians in Tomsk; translation and cultural adaptation of the BCI to Russia and the TB setting; and training and certification of TB physicians to deliver oral naltrexone and brief counseling interventions for alcohol abuse and dependence as part of routine TB care. The study is successfully enrolling eligible subjects in the RCT to evaluate the relationship of integrating effective pharmacotherapy and brief behavioral intervention on TB and alcohol outcomes, as well as reduction in HIV risk behaviors. Conclusions: The IMPACT study utilizes an innovative approach to adapt 2 effective therapies for treatment of alcohol use disorders to the TB clinical services setting in the Tomsk Oblast, Siberia, Russia, and to train TB physicians to deliver state of the art alcohol pharmacotherapy and behavioral treatments as an integrated part of routine TB care. The proposed treatment strategy could be applied elsewhere in Russia and in other settings where TB control is jeopardized by AUDs. If demonstrated to be effective, this model of integrating alcohol interventions into routine TB care has the potential for expanded applicability to other chronic co-occurring infectious and other medical conditions seen in medical care settings.

Greenfield SF; Shields A; Connery HS; Livchits V; Yanov SA; Lastimoso CS et al. Integrated management of physician-delivered alcohol care for tuberculosis patients: Design and implementation. (review). Alcoholism: Clinical and Experimental Research 34(2): 317-330, 2010. (127 refs.)

Grimes CZ; Hwang LY; Williams ML; Austin CM; Graviss EA. Tuberculosis infection in drug users: Interferon-gamma release assay performance. International Journal of Tuberculosis and Lung Disease 11(11): 1183-1189, 2007. (25 refs.)

SETTING: An inner city neighborhood in Houston, Texas, known for a high rate of drug use. OBJECTIVE: To determine the prevalence of latent tuberculosis infection (LTBI) using the QuantiFERON(R)-TB Gold (QFT-G) test, the TSPOT.TB(R) test and the tuberculin skin test (TST) in drug users and to evaluate the performance of the QFT-G and TSPOT.TB tests vs. the TST. DESIGN: Cross-sectional study. Bivariate and multivariate logistic regression analyses were used to determine risks associated with each test outcome. RESULTS: The prevalence of LTBI in 119 drug users studied was 28% by TST and 34% by QFT-G and TSPOT.TB. Kappa statistics indicated fair to moderate concordance between QFT-G and TSPOT.TB vs. TST. About one-fifth of the population that tested negative with TST was positive with either QFT-G or T-SPOT.TB. On multivariate analysis, the likelihood of testing QFT-positive or T-SPOT.TB-positive increased by 8% and 6%, respectively, for every year of age; TST positivity was associated with smoking crack at home; being Caucasian or having a history of alcohol use was positively associated with a positive T-SPOT.TB test. CONCLUSION: Interferon-gamma release assays (IGRAs) are superior to the TST in drug users with a higher prevalence of LTBI. Future studies need to assess the predictive value of IGRAs on the progression from LTBI to active TB in high-risk populations.

Harling G; Ehrlich R; Myer L. The social epidemiology of tuberculosis in South Africa: A multilevel analysis. Social Science & Medicine 66(2): 492-505, 2008. (50 refs.)

Increased risk of tuberculosis is widely recognized to be associated with increased poverty, yet there have been few analyses of the social determinants of tuberculosis, particularly in high-burden settings. We conducted a multilevel analysis of self-reported tuberculosis disease in a nationally representative sample of South Africans based on the 1998 Demographic and Health Survey (DHS). Individual and household-level demographic, behavioral and socioeconomic risk factors were taken from the DHS; data on community-level socioeconomic status (including measures of absolute wealth and income inequality) were derived from the 1996 national census. Of the 13,043 DHS respondents, 0.5% reported having been diagnosed with tuberculosis disease in the past 12 months and 2.8% reported having been diagnosed with tuberculosis disease in their lifetime. In a multivariate model adjusting for demographic and behavioral risk factors, tuberculosis diagnosis was associated with cigarette smoking, alcohol consumption and low body mass index, as well as a lower level of personal education, unemployment and lower household wealth. In a model including individual- and household-level risk factors, high levels of community income inequality were independently associated with increased prevalence of tuberculosis (adjusted odds ratio for lifetime tuberculosis comparing the most unequal quintile to the middle quintile of inequality: 2.37, 95% confidence interval: 1.59-3.53). These results provide novel insights into the socioeconomic determinants of tuberculosis in developing country settings, although the mechanisms through which income inequality may affect tuberculosis disease require further investigation.

Holtz TH; Lancaster J; Laserson KF; Wells CD; Thorpe L; Weyer K. Risk factors associated with default from multidrug-resistant tuberculosis treatment, South Africa, 1999-2001. International Journal of Tuberculosis and Lung Disease 10(6): 649-655, 2006. (17 refs.)

SETTING: Multidrug-resistant tuberculosis (MDR-TB) treatment centers in five provinces, South Africa. OBJECTIVES: To estimate the mortality and evaluate risk factors associated with default from MDR-TB treatment. DESIGN: Using registries and a standardized questionnaire, we conducted a case-control study among patients diagnosed and treated for MDR-TB. Cases were defined as patients who began MDR-TB treatment between 1 October 1999 and 30 September 2001 and defaulted from treatment for more than 2 months; controls were defined as patients who began MDR-TB treatment during the same time and were cured, completed or failed. RESULTS: After initial identification and reclassification, 269 cases and 401 controls were confirmed eligible for interview. Further investigation revealed that 74 (27%) cases and 44 (10%) controls had died. Among 96 cases located who consented and were interviewed, 70% had defaulted after receiving at least 6 months of treatment. In a multivariate model, the strongest individual risk factors for default included reporting smoking marijuana or mandrax during treatment, and having an unsatisfactory opinion about the attitude of health care workers. CONCLUSION: Mortality among MDR-TB defaulters was high. Interventions to reduce default from MDR-TB treatment should center on substance abuse treatment, patient education and support and improving provider-patient relationships.

Hser YI; Gelberg L; Hoffman V; Grella CE; McCarthy W; Anglini MD. Health conditions among aging narcotics addicts: Medical examination results. Journal of Behavioral Medicine 27(6): 607-622, 2004. (68 refs.)

The study examined health conditions among an aging cohort of male narcotics addicts. This prospective cohort study (1964-1998) included interviews and medical testing for 108 surviving subjects who had been admitted to the California Civil Addiction Program during the years 1962 through 1964. Medical testing results were: 51.9% had high blood pressure, 22.4% showed hyperlipidemia, 13.3% had elevated levels of blood glucose, 33.6% had abnormal pulmonary function, half of the sample had abnormal liver function, and 94.2% tested positive for hepatitis C, 85.6% for hepatitis B, 3.8% for syphilis, and 27.3% for TB. The study empirically demonstrated poor health conditions and high morbidity among surviving narcotics addicts.

Isralowitz RE; Straussner SL; Rosenblum A. Drug abuse, risks of infectious diseases and service utilization among former Soviet Union immigrants: A view from New York City. Journal of Ethnicity in Substance Abuse 5(1): 91-96, 2006

Based on the high rates of injection drug use and infectious disease such as HIV, HCV and tuberculosis in their home country, immigrants from the Former Soviet Union (FSU) comprise a high-risk population in the United States. Yet, little is known about their drug abuse and health problems relative to other immigrant populations like Hispanics. The objectives of this exploratory study were to identify disease risk behavior, and utilization of and barriers to treatment services among drug using immigrants from the FSU. Focused interviews were conducted with 27 public officials and administrators in New York City. This study found that FSU immigrants tend to have culturally unique drug abuse patterns and behavior, such as rapid transition to injection drug use, and suspicion and avoidance of traditional drug treatment approaches. The findings of this exploratory study point to the need for further research and the need to take immediate steps to promote culturally appropriate treatment and prevention services that can address the spread of harmful behavior that threatens the public health of FSU immigrants and others.

Jakubowiak WM; Bogorodskaya EM; Borisov SE; Danilova ID; Lomakina OB; Kourbatova EV. Social support and incentives programme for patients with tuberculosis: experience from the Russian Federation. International Journal of Tuberculosis and Lung Disease 11(11): 1210-1215, 2007. (27 refs.)

SETTING: Tuberculosis (TB) services including social support and incentive programmes in four Russian regions (Orel, Vladimir, Belgorod Oblasts and Republic of Mari-El). OBJECTIVES: To determine reasons for TB treatment default among non-adherent patients and to describe patient views of social support programmes and the organisation of treatment. METHODS: Standard anonymous questionnaires were administered to new pulmonary TB patients registered for treatment. RESULTS: A total of 87 non-adherent patients and 1302 adherent patients were interviewed. The leading reasons for treatment default given by non-adherent patients were the need to earn money (30%), alcohol use (30%) and not perceiving themselves as being sick (25%). Monetary incentives were preferred by the majority of patients (67%), followed by food/hot meals (41%) and transportation reimbursement (32%). Overall, among the proposed social support programmes, those that offered small daily incentives (23%) or a big final bonus (21%) were the most popular. The majority of patients (67%) preferred out-patient treatment. CONCLUSION: Collaboration between TB services and social organisations and substance abuse services as well as availability of psychological testing/counselling for patients are social support modalities for improving adherence suggested by study findings. Social support should be combined with a patient-centred approach to TB treatment.

Kolappan C; Gopi PG; Subramani R; Narayanan PR. Selected biological and behavioural risk factors associated with pulmonary tuberculosis. International Journal of Tuberculosis and Lung Disease 11(9): 999-1003, 2007. (19 refs.)

OBJECTIVES: To measure the independent association of risk factors age, sex, smoking and alcoholism with pulmonary tuberculosis (TB) in terms of prevalence odds ratio (POR). METHOD: A community-based cross-sectional survey was conducted from June 2001 to December 2003. A total of 93 945 individuals aged >= 15 years selected from a random sample of villages in a district from South India were screened for pulmonary TB by chest symptoms and chest X-ray (MMR). Two sputum samples were collected (one spot and one early morning) from patients with chest symptoms and those with abnormal X-rays for examination by microscopy for acid-fast bacilli and by culture for Mycobacterium tuberculosis. Bacillary cases are bacteriologically positive cases diagnosed by either spu turn smear or culture examination. In addition, data on exposure to tobacco smoking and alcohol consumption were collected from the male population only. All females were considered non-smokers and non-alcoholics. RESULTS: A total of 429 bacteriologically positive cases were detected during the survey. The adjusted PORs (with 95%CI) for age, sex, smoking and alcoholism were 3.3 (2.7-4.1), 2.5 (1.9-3.3), 2.1 (1.7-2.7) and 1.5 (1.22.0), respectively. CONCLUSION: Risk factors such as age, sex, smoking and alcoholism are independently associated with pulmonary TB. Risk factors age and sex show a stronger association than smoking and alcoholism.

Krupitsky EM; Zvartau EE; Lioznov DA; Tsoy MV; Egorova VY; Belyaeva TV; E. Co-morbidity of infectious and addictive diseases in St. Petersburg and the Leningrad region, Russia. European Addiction Research 12(1): 12-19, 2006. (18 refs.)

The Russian health care system is organized around specific diseases, with relatively little focus on integration across specialties to address co-morbidities. This organizational structure presents new challenges in the context of the recent epidemics of injection drug use (IDU) and HIV. This paper uses existing and new data to examine the prevalence of reported new cases of drug dependence (heroin) and HIV over time as well as associations between drug dependence and alcoholism, hepatitis B and C, and tuberculosis in the City of St. Petersburg and the Leningrad region. We found a sharp rise in reported cases of IDU beginning in 1991 and continuing until 2002/2003, followed by a sharp rise in newly reported cases of HIV. These rises were followed by a drop in new cases of HIV and drug addiction in 2002/2003 and a drop in the proportion of HIV-positive individuals with IDU as a risk factor. Infection with hepatitis B and C were common, especially among injection drug users (38 and 85%, respectively), but also in alcoholics (7 and 14%). Tuberculosis was more common in alcoholics (53%) than in persons with alcoholism and drug dependence (10%), or with drug dependence alone (4%). Though these data have many limitations, they clearly demonstrate that drug dependence and/or alcoholism, HIV, hepatitis, and tuberculosis frequently co-occur in St. Petersburg and the Leningrad Region. Prevention and treatment services across medical specialties should be integrated to address the wide range of issues that are associated with these co-morbidities.

Kunins HV; Howard AA; Klein RS; Arnsten JH; Litwin AH; Schoenbaum EE. Validity of a self-reported history of a positive tuberculin skin test: A prospective study of drug users. Journal of General Internal Medicine 19(10): 1039 -1044, 2004. (25 refs.)

OBJECTIVE: To define the prevalence of and factors associated with having a negative purified protein derivative (PPD) among persons who self-report a prior positive PPD and to define the safety of repeat testing in such persons. DESIGN: Observational cohort study. SETTING: Methadone maintenance program with onsite primary care. PATIENTS/PARTICIPANTS: Current or former drug users enrolled in methadone maintenance treatment. INTERVENTIONS: Structured interview, tuberculin skin testing regardless of self-reported PPD status, and anergy testing. MEASUREMENTS AND MAIN RESULTS: Nearly one third (31%) of participants who self-reported a prior positive PPD had a negative measured PPD, despite receipt of a "booster" PPD. A single participant (0.5%) blistered in response to the PPD without lasting ill effect. Participants with PPD results discordant from their history were more likely to be HIV-seropositive and nonreactive to the anergy panel. The discordance rate among HIV-infected participants was 43%, and was largely attributable to immune dysfunction. Among HIV-seronegative participants, the discordance rate was 27%. Recent crack-cocaine use was independently associated with discordance in the absence of HIV infection. CONCLUSIONS: We confirmed that planting a PPD in patients who self-report a positive PPD history confers minimal risk. Substantial rates of discordance exist between self-reported history of a positive PPD and measured PPD status. Further research is needed to define the optimal management of PPD-negative patients who self-report a prior positive PPD and who have not received prior treatment for latent tuberculosis.

Lavigne M; Rocher I; Steensma C; Brassard P. The impact of smoking on adherence to treatment for latent tuberculosis infection. BMC Public Health 6: article 66, 2006. (18 refs.)

Background: Studies have shown an association between smoking and tuberculosis (TB) infection, disease and TB-related mortality. We hypothesized that smokers with latent tuberculosis infection (LTBI) are less likely to comply with their LTBI treatment regimen, thus increasing their risk of developing active disease. We thus documented the impact of smoking on adherence to LTBI treatment. Method: Between 1998 and 2000, a convenience sample of patients undergoing treatment for LTBI completed a questionnaire on smoking status. Level of adherence to LTBI treatment was tested for associations with socio-demographic profile, and smoking status Results: 320 patients were recruited, and 302 (94%) completed the questionnaire. Smoking prevalence was 21%. 72% of patients were adherent to LTBI treatment. Women (OR = 2.0; 95% CI: 1.2-3.3) and non-smokers (OR = 1.8; 95% CI: 1.0-3.3) were associated with adherence to LTBI treatment. Only gender was found as an independent predictor of adherence after adjusting for age and smoking status (OR = 1.9; 95% CI: 1.06-3.3). Conclusion: Males and smokers need to have extra supervision to ensure compliance with LTBI treatment.

Leung CC; Lam TH; Ho KS; Yew WW; Tam CM; Chan WM et al. Passive smoking and tuberculosis. Archives of Internal Medicine 170(3): 287-292, 2010. (31 refs.)

Background: Increasing evidence has incriminated active smoking as a causal factor for tuberculosis (TB). However, the effect of secondhand tobacco smoke exposure on TB has not been similarly elucidated. Methods: A cohort of 15486 female never-smokers aged 65 to 74 years and living with their surviving husband were enrolled at 18 Elderly Health Centers in Hong Kong from 2000 to 2003 and followed up prospectively through linkage with the territory-wide TB notification registry and death registry for TB and death until December 31, 2008, using an identity card number as a unique identifier. The relationship between passive smoking and the development of TB was assessed with adjustment for other baseline characteristics. Results: Passive exposure to secondhand tobacco smoke in the household was independently associated with obstructive lung disease (odds [OR], 1.43; 95% confidence interval [CI], 1.16-1.77) and diabetes mellitus (OR, 1.13; 95% CI, 1.02-1.26) at baseline and with the development of both active TB (hazard ratio [HR], 1.49; 95% CI, 1.01-2.19) and culture-confirmed TB (HR, 1.70; 95% CI, 1.04-2.80) on prospective follow-up after potentially confounding background variables were controlled for. Passive smoking accounted for 13.7% of active TB and for 18.5% of culture-positive TB in this cohort. Conclusions: Similar to active smoking, passive exposure to secondhand tobacco smoke in the household also predisposes to the development of TB. Increased emphasis should therefore be put on tobacco control in national TB programs.

Leung CC; Lam TH; Ho KS; Yew WW; Tam CM; Chan WM et al. Passive smoking and tuberculosis. Archives of Internal Medicine 170(3): 287-292, 2010. (31 refs.)

Leung CC; Li T; Lam TH; Yew WW; Law WS; Tam CM et al. Smoking and tuberculosis among the elderly in Hong Kong. American Journal of Respiratory and Critical Care Medicine 170(9): 1027-1033, 2004. (36 refs.)

A cohort of 42,655 clients that were first registered with the Elderly Health Service in 2000 were followed prospectively through the tuberculosis (TB) notification registry until the end of 2002. A total of 286 active TB cases (186 culture confirmed) were identified. The annual TB notification rates were 735, 427, and 174 per 100,000 among current smokers, ex-smokers, and never-smokers, respectively (p < 0.001). The trend in TB risk persisted after the control of background characteristics using Cox proportional hazards analysis (adjusted hazard ratios [HRs]: 2.63,1.41, and 1, p < 0.001). In comparison with never-smokers, current smokers had an excess risk of pulmonary TB (adjusted FIR, 2.87; 95% confidence interval [CI], 2.00-4.11; p < 0.001), but not extrapulmonary TB (adjusted HR, 1.04; 95% CI, 0.33-3.30; p = 0.95). Among the current smokers, those who developed TB smoked more cigarettes per day than those who did not (13.43, SD 8.76 vs. 10.96, SD 7.87, p = 0.01). A statistically significant dose-response relationship was observed with respect to active TB and culture-confirmed TB (both p < 0.05). Smoking accounted for 32.8% (95% CI, 14.9-48.0%),8.6% (95% CI, 3.3-15.1%), and 18.7% (95% Cl, 7.7-30.4%) of the TB risk among males, females, and the entire cohort, respectively. Approximately 44.9% (95% CI, 20.764.6%) of the sex difference was attributable to smoking.

Leung CC; Yew WW; Chan CK; Tam CM; Lam CW; Chang KC et al. Smoking and tuberculosis in Hong Kong. International Journal of Tuberculosis and Lung Disease 7(10): 980-986, 2003. (23 refs.)

OBJECTIVE: To study the relationship between smoking and tuberculosis in Hong Kong. METHOD: Indirect sex and age adjustment was used to compare the prevalence of ever smokers between a sample of 851 patients from the 1996 tuberculosis notification registry and the general population. The clinical characteristics of smokers and non-smokers were compared by stratified univariate analysis and multiple logistic regression. RESULTS: Tuberculosis patients were more likely to have smoked than population controls. The respective odds ratios for ever smoking between tuberculosis patients and population controls were 2.44 and 2.08 for males and females aged 16-64 (Mantel-Haenszel weighted OR = 2.40, P < 0.001), and 2.09 and 2.83 for males and females aged greater than or equal to65 (Mantel-Haenszel weighted odds ratio = 2.19, P < 0.001). Male sex, age greater than or equal to65, working at onset of illness, regular alcohol use, drug abuse and absence of contact history were associated with ever smokers (all P < 0.05). Ever smokers were more likely to have cough (OR 1.69), dyspnoea (OR 1.84), upper zone involvement (OR 1.67), cavity (OR 1.76), miliary lung involvement (OR 2.77), positive sputum culture (OR 1.43), but less isolated extrathoracic involvement (OR 0.31), even after controlling for the confounding background variables (all P < 0.05).CONCLUSION: There was a consistent association between smoking and tuberculosis. More aggressive lung involvement was also found among ever smokers.

Leung CC; Yew WW; Law WS; Tam CM; Leung M; Chung YW et al. Smoking and tuberculosis among silicotic patients. European Respiratory Journal 29(4): 745-750, 2007. (29 refs.)

The aim of the present study was to investigate the relationship between smoking and tuberculosis (TB) among high-risk silicotic patients in Hong Kong. A cohort of 435 silicotic patients tuberculin tested from 1995-2002 was prospectively followed-up until the end of 2005. Baseline characteristics were analysed with respect to positive tuberculin reaction (>= 10 mm) at baseline and subsequent development of TB. Smoking, alcohol use and body mass index were independent predictors of positive tuberculin reaction at baseline in multiple logistic regression analysis. Total cigarette pack-yrs did not demonstrate any significant effect. The annual incidences of TB were 1,841, 2,294 and 4,181 per 100,000 for never-, ex- and current smokers, respectively. On Cox proportional hazard analysis, current smokers have a significantly higher risk of TB than other silicotic patients (adjusted hazard ratio (95% confidence interval (Cl)): 1.96 (1.14-3.35)) after controlling for age, alcohol use, tuberculin status, treatment for latent TB infection and other relevant background/disease factors. A significant dose-response relationship was also observed with the daily number of cigarettes currently smoked. Smoking cessation may reduce 32.4% (95% Cl: 6.5-54.0) of the risk. Smoking increases the risk of both tuberculosis infection and subsequent development of the disease among silicotic patients.

Lin HH; Ezzati M; Chang HY; Murray M. Association between tobacco smoking and active tuberculosis in Taiwan prospective cohort study. American Journal of Respiratory and Critical Care Medicine 180(5): 475-480, 2009. (56 refs.)

Rationale: Previous case-control studies and a small number of cohort studies in high-risk populations have found an association between tobacco and active tuberculosis, but no cohort studies have been conducted in the general population on this association to date. Objectives: To investigate the association between tobacco smoking and active tuberculosis in a cohort of a general population. Methods: 17,699 participants (>= 12 y of age) in Taiwan National Health Interview Survey were followed up from 2001 to 2004. Smoking status and other covariates were measured by an in-person interview at baseline. Incident cases of active tuberculosis were identified from the National Health Insurance database. Multivariate logistic regression was used to estimate the association between smoking status and active tuberculosis, with adjustment for age, sex, alcohol consumption, socioeconomic status, and other covariates. Measurements and Main Results: Fifty-seven new cases of active tuberculosis occurred during the 3.3 years of follow-up. Current smoking was associated with an increased risk of active tuberculosis (adjusted odds ratio [OR], 1.94; 95% confidence interval, 1.01-3.73). The association was stronger among those less than 65 years of age (adjusted OR, 3.04) than those greater than 65 years of age (adjusted OR, 0.78; P-interaction = 0.036). We found significant dose-response relations for cigarettes per day (P-trend = 0.0036), years of smoking (P-trend = 0.023), and pack-years (P-trend = 0.0023). Conclusions: Tobacco smoking was associated with a twofold increased risk of active tuberculosis in a representative cohort of Taiwan's population.

Lin HH; Ezzati M; Chang HY; Murray M. Association between tobacco smoking and active tuberculosis in Taiwan prospective cohort study. American Journal of Respiratory and Critical Care Medicine 180(5): 475-480, 2009. (56 refs.)

Lin HH; Ezzati M; Murray M. Tobacco smoke, indoor air pollution and tuberculosis: A systematic review and meta-analysis. (review). PLoS Medicine 4(1): 173-189 (article e-20), 2007. (76 refs.)

Background: Tobacco smoking, passive smoking, and indoor air pollution from biomass fuels have been implicated as risk factors for tuberculosis (TB) infection, disease, and death. Tobacco smoking and indoor air pollution are persistent or growing exposures in regions where TB poses a major health risk. We undertook a systematic review and meta-analysis to quantitatively assess the association between these exposures and the risk of infection, disease, and death from TB. Methods and Findings: We conducted a systematic review and meta-analysis of observational studies reporting effect estimates and 95% confidence intervals on how tobacco smoking, passive smoke exposure, and indoor air pollution are associated with TB. We identified 33 papers on tobacco smoking and TB, five papers on passive smoking and TB, and five on indoor air pollution and TB. We found substantial evidence that tobacco smoking is positively associated with TB, regardless of the specific TB outcomes. Compared with people who do not smoke, smokers have an increased risk of having a positive tuberculin skin test, of having active TB, and of dying from TB. Although we also found evidence that passive smoking and indoor air pollution increased the risk of TB disease, these associations are less strongly supported by the available evidence. Conclusions: There is consistent evidence that tobacco smoking is associated with an increased risk of TB. The finding that passive smoking and biomass fuel combustion also increase TB risk should be substantiated with larger studies in future. TB control programs might benefit from a focus on interventions aimed at reducing tobacco and indoor air pollution exposures, especially among those at high risk for exposure to TB.

Lin HH; Murray M; Cohen T; Colijn C; Ezzati M. Effects of smoking and solid-fuel use on COPD, lung cancer, and tuberculosis in China: A time-based, multiple risk factor, modelling study. Lancet 372(9648): 1473-1483, 2008. (79 refs.)

Background: Chronic obstructive pulmonary disease (COPD), lung cancer, and tuberculosis are three leading causes of death in China, where prevalences of smoking and solid-fuel use are also high. We aimed to predict the effects of risk-factor trends on COPD, lung cancer, and tuberculosis. Methods: We used representative data sources to estimate past trends in smoking and household solid-fuel use and to construct a range of future scenarios. We obtained the aetiological effects of risk factors on diseases from meta-analyses of epidemiological studies and from large studies in China. We modelled future COPD and lung cancer mortality and tuberculosis incidence, taking into account the accumulation of hazardous effects of risk factors on COPD and lung cancer over time, and dependency of the risk of tuberculosis infection on the prevalence of disease. We quantified the sensitivity of our results to methods and data choices. Findings: If smoking and solid-fuel use remain at current levels between 2003 and 2033, 65 million deaths from COPD and 18 million deaths from lung cancer are predicted in China; 82% of COPD deaths and 75% of lung cancer deaths will be attributable to the combined effects of smoking and solid-fuel use. Complete gradual cessation of smoking and solid-fuel use by 2033 could avoid 26 million deaths from COPD and 6.3 million deaths from lung cancer; interventions of intermediate magnitude would reduce deaths by 6-31% (COPD) and 8-26% (lung cancer). Complete cessation of smoking and solid-fuel use by 2033 would reduce the projected annual tuberculosis incidence in 2033 by 1.4-52% if 80% DOTS coverage is sustained, 27-62% if 50% coverage is sustained, or 33-71% if 20% coverage is sustained. Interpretation: Reducing smoking and solid-fuel use can substantially lower predictions of COPD and lung cancer burden and would contribute to effective tuberculosis control in China.

Lonnroth K; Jaramillo E; Williams BG; Dye C; Raviglione M. Drivers of tuberculosis epidemics: The role of risk factors and social determinants. Social Science & Medicine 68(12): 2240-2246, 2009. (97 refs.)

The main thrust of the World Health Organization's global tuberculosis (TB) control strategy is to ensure effective and equitable delivery of quality assured diagnosis and treatment of TB. Options for including preventive efforts have not yet been fully considered. This paper presents a narrative review of the historical and recent progress in TB control and the role of TB risk factors and social determinants. The review was conducted with a view to assess the prospects of effectively controlling TB under the current strategy, and the potential to increase epidemiological impact through additional preventive interventions. The review suggests that, while the current strategy is effective in curing patients and saving lives, the epidemiological impact has so far been less than predicted. In order to reach long-term epidemiological targets for global TB control, additional interventions to reduce peoples' vulnerability for TB may therefore be required. Risk factors that seem to be of importance at the population level include poor living and working conditions associated with high risk of TB transmission, and factors that impair the host's defence against TB infection and disease, such as HIV infection, malnutrition, smoking, diabetes, alcohol abuse, and indoor air pollution. Preventive interventions may target these factors directly or via their underlying social determinants. The identification of risk groups also helps to target strategies for early detection of people in need of TB treatment. More research is needed on the suitability, feasibility and cost-effectiveness of these intervention options.

Mathew T; Shields A; Yanov S; Golubchikova V; Strelis A; Yanova G. Performance of the Alcohol Use Disorders Identification Test among tuberculosis patients in Russia. Substance Use & Misuse 45(4): 598-612, 2010. (28 refs.)

The alcohol use disorders identification test (AUDIT), a screening instrument to identify individuals at risk of alcohol use-related problems, has not been validated in a Russian primary care population. We assessed the reliability, factor structure, sensitivity, and specificity of AUDIT scores among 254 subjects initiating tuberculosis treatment from 2005 to 2007 in Tomsk City. Our findings support the use of the AUDIT as a screening instrument among Russian individuals seeking primary care. We discuss implications, limitations, and future research.

Mathew T; Shields A; Yanov S; Golubchikova V; Strelis A; Yanova G. Performance of the Alcohol Use Disorders Identification Test among tuberculosis patients in Russia. Substance Use & Misuse 45(4): 598-612, 2010. (28 refs.)

Mathew TA; Ovsyanikova TN; Shin SS; Gelmanova I; Balbuena DA; Atwood S et al. Causes of death during tuberculosis treatment in Tomsk Oblast, Russia. International Journal of Tuberculosis and Lung Disease 10(8): 857-863, 2006. (34 refs.)

SETTING: Tuberculosis (TB) incidence and mortality in Russia have risen dramatically over the past 15 years. OBJECTIVE: To identify risk factors and causes of death among TB patients in Russia. DESIGN: A retrospective study conducted to determine the risk factors and causes of death in patients receiving TB therapy in Tomsk, Siberia. RESULTS: Of 1916 patients who initiated treatment between 1 January 2002 and 31 December 2003, 183 (9.6%) died during treatment, 38 (21%) in the first week of therapy. Twenty-five per cent of deaths were not directly attributable to TB. Risk factors for death included older age, previous treatment for TB, multidrug resistance and alcoholism. CONCLUSIONS: The high death rate during TB treatment observed in this cohort likely reflects an increased risk of dying not only from TB, but also from comorbid conditions, such as alcoholism and cardiovascular disease. Overall, alcoholism and late presentation both contributed substantially to the mortality in this cohort.

Mertens JR; Flisher AJ; Ward CL; Bresick GF; Sterling SA; Weisner CM. Medical conditions of hazardous drinkers and drug users in primary care clinics in Cape Town, South Africa. Journal of Drug Issues 39(4): 989-1014, 2009. (42 refs.)

Research has identified a wide range of health conditions related to alcohol and drug use in studies conducted primarily in developed countries and in populations with severe alcohol and drug problems. Little is known about medical conditions in those with less severe alcohol and drug use in developing countries. We used WHO AUDIT and ASSIST screeners to identify hazardous drinking or drug use in public health clinics in Cape Town, South Africa, and included questions about doctor-diagnosed medical conditions. Using logistic regression we examined the relationship of medical conditions to hazardous alcohol, drug and tobacco use. Those with hazardous substance use had higher prevalence of many health conditions including tuberculosis, Hepatitis B, migraine, chronic bronchitis, and liver cirrhosis. Optimal treatment for some medical conditions may include treatment of underlying hazardous substance use, particularly use of drugs other than alcohol. In these populations, access to substance use treatment is limited and even brief interventions or advice may be useful.

Mertens JR; Flisher AJ; Ward CL; Bresick GF; Sterling SA; Weisner CM. Medical conditions of hazardous drinkers and drug users in primary care clinics in Cape Town, South Africa. Journal of Drug Issues 39(4): 989-1014, 2009. (42 refs.)

Molina PE; Happel KI; Zhang P; Kolls JK; Nelson S. Focus on: Alcohol and the immune system. Alcohol Research & Health 33(1-2): 97-108, 2010. (79 refs.)

Alcohol abuse suppresses multiple arms of the immune response, leading to an increased risk of infections. The course and resolution of both bacterial and viral infections is severely impaired in alcohol-abusing patients, resulting in greater patient morbidity and mortality. Multiple mechanisms have been identified underlying the immunosuppressive effects of alcohol. These mechanisms involve structural host defense mechanisms in the gastrointestinal and respiratory tract as well as all of the principal components of the innate and adaptive immune systems, which are compromised both through alcohol's direct effects and through alcohol-related dysregulation of other components. Analyses of alcohol's diverse effects on various components of the immune system provide insight into the factors that lead to a greater risk of infection in the alcohol-abusing population. Some of these mechanisms are directly related to the pathology found in people with infections such as HIV/AIDS, tuberculosis, hepatitis, and pneumonia who continue to use and abuse alcohol.

Moller V; Erstad I; Zani D. Drinking, amoking, and morality: Do 'drinkers and smokers' constitute a stigmatised stereotype or a real TB risk factor in the time of HIV/AIDS? Social Indicators Research 98(2): 217-238, 2010. (59 refs.)

This paper follows up an unexpected finding from a community survey that identified drinking and smoking as the most important tuberculosis (TB) risk factor, far ahead of ones commonly associated with TB such as poverty, overcrowded living conditions, and HIV-positive status. It reports perceptions of drinking and smoking from a three-phased study of the stigma associated with TB, consisting of a qualitative pilot study using focus-group discussions (2006), a larger-scale community survey (2007), and follow-up group discussions (2009). The community attitude survey was conducted with a sample of 1,020 adults living in a low-income township in the Eastern Cape Province, South Africa. The study found that the moral and the biomedical understanding of TB risk are intertwined. In the community survey, perceptions of drinking and smoking as TB risk were predicted by fear of contracting TB and being a self-reported born-again Christian. In the follow-up study, heavy drinking and smoking in shebeens (unlicensed township liquor outlets) was associated with a risky lifestyle that can spread both TB and HIV. The paper discusses the similarities and differences in the roles of church and shebeen in providing social support to township dwellers to cope with problems of daily life. It is tentatively concluded that the stereotypical shebeen 'drinkers and smokers', alternatively pitied and maligned by moral society, might serve as the scapegoat that deflects pollution from the 'new' TB linked to the AIDS epidemic.

Molina PE; Happel KI; Zhang P; Kolls JK; Nelson S. Focus on: Alcohol and the immune system. Alcohol Research & Health 33(1-2): 97-108, 2010. (79 refs.)

Moran A; Harbour DV; Teeter LD; Musser JM; Graviss EA. Is alcohol use associated with cavitary disease in tuberculosis? Alcoholism: Clinical and Experimental Research 31(1): 33-38, 2007. (30 refs.)

Background: Alcohol mediates detrimental alterations in the immune response to Mycobacterium tuberculosis. The association between quantity and frequency of alcohol use and the prevalence of cavitary disease in tuberculosis (TB) has not been analyzed. To investigate the relationship of alcohol use and the prevalence of cavitary disease in a 6-year population-based data set of individuals with TB. Methods: We assessed quantity and frequency of alcohol use (daily alcohol use, years of alcohol use, and lifetime alcohol use) with a standardized questionnaire. The study group consisted of 1,250 patients analyzed for cavitary disease (HIV sero-negative subjects that were 18 years or older). Significant covariates for cavitary disease were entered into multiple logistic regression models. Results: Although daily alcohol use, years of alcohol use, and alcohol use 30 days or 6 months before symptom onset were significant predictors of cavitary disease in univariate analysis, no independent associations were found between alcohol use and cavitary disease in the multivariate analysis. Only diabetes mellitus was independently associated with cavitary disease at any level or frequency of alcohol use. Conclusion: Alcohol use is not independently associated with increased prevalence of cavitary disease in adult patients with TB.

Munch Z; Van Lill SWP; Booysen CN; Zietsman HL; Enarson DA; Beyers N. Tuberculosis transmission patterns in a high-incidence area: A spatial analysis. International Journal of Tuberculosis and Lung Disease 7(3): 271-277, 2003. (40 refs.)

SETTING: In the Cape Town suburbs of Ravensmead and Uitsig, tuberculosis has reached epidemic levels, with notifications of 1340/100000 in 1996. These suburbs are characterised by overcrowding, high unemployment and poverty. It is traditionally believed that tuberculosis transmission takes place mainly in households after close contact with an infectious person. Studies have recently linked tuberculosis transmission to locations outside the household, and have associated these places with a particular high-risk lifestyle. Anthropological studies in some suburbs of Cape Town, in which a very high number of local drinking places (shebeens) were identified (17 per km(2)), have suggested that social drinking is part of such a lifestyle. OBJECTIVE: To investigate various risk factors and places of transmission of tuberculosis using a geographical information system (GIS). RESULTS AND CONCLUSION: The 1128 bacteriologically-proven cases of tuberculosis studied over the period 1993-1998 were investigated using spatial epidemiological techniques of exploratory disease mapping. Point pattern analysis and spatial statistics indicated clustering of cases in the areas of high incidence. Significant associations of tuberculosis notifications were found with unemployment, overcrowding and number of shebeens per enumerator sub-district. High tuberculosis notifications with unemployment and its associated poverty emerged as the strongest association.

Munckhof WJ; Konstantinos A; Wamsley M; Mortlock M; Gilpin C. A cluster of tuberculosis associated with use of a marijuana water pipe. International Journal of Tuberculosis and Lung Disease 7(9): 860-865, 2003. (20 refs.)

SETTING: New cases of pulmonary tuberculosis (TB) were noted in a cluster of young Caucasian males, an unusual ethnic group for this disease in Queensland, Australia. It was noted that marijuana water pipe ('bong') smoking was common amongst cases and contacts. OBJECTIVE: To report this cluster of TB and to investigate whether shared use of a marijuana water pipe was associated with transmission of TB.DESIGN: All contacts were identified and screened according to standard protocols. Cases were asked to list contacts with whom they had shared a marijuana water pipe. RESULTS: Five cases of open pulmonary TB were identified clinically and on sputum culture, and all isolates of Mycobacterium tuberculosis were identical on typing. Of 149 contacts identified, 114 (77%) completed screening, and 57 (50%) had significant tuberculin skin test (TST) reactions on follow-up. Of 45 contacts who had shared a marijuana water pipe with a case, 29 (64%) had a significant TST reaction. CONCLUSION: Sharing a marijuana water pipe with a case of pulmonary TB was associated with transmission of TB (OR 2.22, 95% CI 0.96-5.17), although the most important risk factor for acquiring TB infection in this cluster was close household contact with a case (OR 4.91, 95% CI 1.13-20.70).

Nyamathi A; Sands H; Pattatucci-Aragon A; Berg J; Leake B. Tuberculosis knowledge, perceived risk and risk behaviors among homeless adults: Effect of ethnicity and injection drug use. Journal of Community Health 29(6): 483-497, 2004. (50 refs.)

The objectives of this study were to investigate Tuberculosis (TB) knowledge, perceived risk, and risk behaviors in a sample of homeless persons with latent TB in the Skid Row district. of Los Angeles. Particular emphasis was given to comparing these variables among homeless persons of varying ethnic backgrounds and among those who did and did not report a history of injection drug use (IDU). Baseline data were collected from 415 homeless individuals recruited to participate in a Tuberculosis chemoprophylaxis intervention. Areas of interest, relative to TB knowledge and perceived risk for infection were behavioral factors surrounding substance use and abuse; personal factors measured in terms of current depression; and sociodemographic and situational factors, such as age, ethnicity, history of incarceration, and duration of homelessness. Findings revealed differences in substance abuse. IDUs were more likely to have histories of daily drug use and alcohol dependency, but were less apt to report recent Use of crack cocaine. TB knowledge deficits centered on ignorance with respect to modes of transmission and risk factors for TB infection. IDU was also associated with depression. Latinos and IDUs were most likely to lack TB knowledge. There is a pressing need for accessible, available, culturally acceptable and sustained TB screening and intervention programs designed to address multiple risk factors and knowledge deficits with respect to TB infection in homeless populations.

Oeltmann JE; Kammerer JS; Pevzner ES; Moonan PK. Tuberculosis and substance abuse in the United States, 1997-2006. Archives of Internal Medicine 169(2): 189-197, 2009. (61 refs.)

Background: Tuberculosis ( TB) control efforts are often ineffective in controlling TB among patients who use illicit drugs or abuse alcohol (substance abuse). This study examined the prevalence of substance abuse among TB cases reported in the United States and assessed the relation between substance abuse and indicators of TB transmission. Methods: A cross-sectional analysis was performed of data on US TB cases in patients 15 years or older reported from 1997 through 2006. Analyses included number and proportion of patients with TB characterized by substance abuse and associations between substance abuse, sputum smear status, treatment failure, and inclusion in a county-level genotype cluster. Results: Of 153 268 patients with TB, 28 650 (18.7%) reported substance abuse, including 22 293 of 76 816 US-born patients (29.0%). Multivariate analysis showed that, among patients negative for human immunodeficiency virus, odds of sputum smear-positive disease were 1.8 (99% confidence interval [CI], 1.7-1.9) times greater among those who reported substance abuse; this association was weaker among patients with human immunodeficiency virus infection (odds ratio [OR], 1.2; 99% CI, 1.1-1.4). Among female patients, odds of treatment failure were 2.4 ( 99% CI, 1.9-3.0) times greater among those who reported substance abuse. The association was weaker among male patients (OR, 1.5; 99% CI, 1.3-1.7). Patients who abused substances were more likely to be involved in a county-level genotype cluster (US-born: OR, 2.3; 99% CI, 2.0-2.7; foreign-born: 1.5; 1.2-2.0). Conclusions: Substance abuse is the most commonly reported behavioral risk factor among patients with TB in the United States. Patients who abuse substances are more contagious (eg, smear positive) and remain contagious longer because treatment failure presumably extends periods of infectiousness. Increased transmission is consistent with our finding that patients who abuse substances were more likely to be involved in a localized genotype cluster, which can represent recent transmission.

Selassie AW; Pozsik C; Wilson D; Ferguson PL. Why pulmonary tuberculosis recurs: A population-based epidemiological study. Annals of Epidemiology 15(7): 519-525, 2005. (48 refs.)

PURPOSE: To evaluate the factors associated with recurrent pulmonary tuberculosis using a well-defined, population-based tuberculosis registry system. METHODS: A case-control study of persons with recurrent pulmonary tuberculosis cases (n = 437) and systematically sampled nonrecurrent controls (n = 442) matched by year of initial diagnosis in South Carolina. Data were acquired from the tuberculosis registry and medical chart reviews. Conditional logistic regression was used to model the relationship between recurrent disease and clinical and demographic characteristics in a multivariable analysis. RESULTS: From 1970 through 2002, there were 15,464 pulmonary tuberculosis patients, of which 2.9% were recurrent disease. After adjusting for the covariates, odds ratios (OR) and 95% confidence intervals (95% CI) for suboptimal therapy was 6.4 (3.9-10.5), alcoholism 3.9 (2.5-6.1), interaction between treatment duration exceeding 24 months and poor compliance 3.8 (2-4-4.3), and age older than 65 years 1.9 (1.2-2.9). Our study noted an interaction between poor patient compliance and duration of treatment. CONCLUSION: Treatment regimen, duration of treatment, compliance, alcoholism, and older age are strong predictors of recurrent disease. Reinforcing the tuberculosis treatment guideline and applications of directly observed therapy have to remain integral components of tuberculosis control and elimination program.

Shamaei M; Marjani M; Baghaei P; Chitsaz E; Tabar ER; Abrishami Z et al. Drug abuse profile -- patient delay, diagnosis delay and drug resistance pattern -- among addict patients with tuberculosis. International Journal of STD and AIDS 20(5): 320-323, 2009. (19 refs.)

Socioeconomic problems limit the access of drug users to health-care services. This descriptive cross-sectional study was carried out by making use of the medical records of new case tuberculosis (TB) patients hospitalized at Masih Daneshvari Hospital, the national referral centre in Iran, from 2003 to 2006. Demographic and personal characteristics of the patients and type of disease were collected and categorized. Of the 944 patients with confirmed TB, 143 (15.1%) were drug users, among whom 140 (97.9%) were men with just three women drug users. The mean age of the drug users group was 43.04 +/- 13.81 years. The type of drug used was opium in 100 cases (69.9%), heroin in 29 (20.3%), opium and heroin together in four (2.8%) and all three, opium, heroin and crack, in two (11.4%). For 238 high-risk patients, an HIV test was performed and HIV infection was confirmed in 33 cases. Patient delay was longer in drug users (P = 0.000) against other patients, whereas diagnosis delay was shorter (P = 0.007). Drug susceptibility tests were performed for 515 patients with positive cultures. One hundred and thirty-three (14.1%) were found to have 'any resistance' to anti-TB drugs, and 10 (1.1%) individuals had multidrug-resistant TB. Twenty-six (19.5%) of the individuals who showed resistance to first-line agents were drug users. There was no significant relation between drug resistance and drug use (P = 0.4). In conclusion, it seems that active case finding for TB and HIV in addict cases must be contained in harm reduction packages. Moreover, the manifestations of the disease should be considered seriously regardless of attributing them to drug use.

Sitas F; Urban M; Bradshaw D; Kielkowski D; Bah S; Peto R. Tobacco attributable deaths in South Africa. Tobacco Control 13(4): 396-399, 2004. (19 refs.)

Background: In mid 1998, a question "Was the deceased a smoker five years ago?'' was introduced on the newly revised South African death notification form. Design: A total of 16 230 new death notification forms from 1998 have been coded, and comparison of the prevalence of smoking among those who died of different causes was used to estimate, by case - control comparisons, tobacco attributed mortality in South Africa. Cases comprised deaths from causes known (from other studies) to be causally associated with smoking, and controls comprised deaths from medical conditions expected to be unrelated to smoking. Those who died from external causes, and from diseases strongly related to alcohol consumption, were excluded. Subjects: Reports were available from 5340 deceased adults (age 25+), whose smoking status was given by a family member. Results: Significantly increased risks were found for deaths from tuberculosis (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.23 to 2.11), chronic obstructive pulmonary disease (COPD) (OR 2.5, 95% CI 1.9 to 3.4), lung cancer (OR 4.8, 95% CI 2.9 to 8.0), other upper aerodigestive cancer (OR 3.0, 95% CI 1.9 to 4.9) and ischaemic heart disease (OR 1.7, 95% CI 1.2 to 2.3). Conclusion: If smokers had the same death rate as non-smokers, 58% of lung cancer deaths, 37% of COPD deaths, 20% of tuberculosis deaths, and 23% of vascular deaths would have been avoided. About 8% of all adult deaths in South Africa (more than 20 000 deaths a year) were caused by smoking.

Sivapalasingam S; Klein RS; Howard A; Qin A; Tseng CH; Gourevitch MN. Housing insecurity and lack of public assistance are risk factors for tuberculin skin test conversion among persons who use illicit drugs in New York City. Journal of Addiction Medicine 3(3): 172-177, 2009. (24 refs.)

Background: Persons who use illicit drugs are at increased risk of new tuberculosis infection. We conducted a prospective cohort study to assess rates and risk factors for tuberculin skin test (TST) conversion among persons with a history of illicit drug use, who were enrolled in a methadone program and had a negative baseline 2-step TST (eligible participants). Methods: TST and standardized interviews were administered to 401 eligible participants from 1995 to 1999, every 6 months or a 2-year follow-up time. Analyses were conducted in 2006. Results: A total of 1447 repeat TSTs were performed during 843 person-years of follow-up (median: 2.0 years). The TST conversion rate was 3.68 per 100 person-years. In multivariate analysis, participants who converted were more likely to report ever having been homeless or ever having lived in a homeless shelter at the baseline interview (hazard ratio [HR] 2.95; 95% confidence interval [CI] 1.29 to 6.72), and less likely to have reported receiving public assistance since the last study visit (H R 0.11; 95% CI 0.05 to 0.26). Conclusions: This is the first study using 2-step TST at baseline to measure the incidence of TST conversion among persons who use illicit drugs. Controlling for homelessness, persons with a lack of current public assistance were identified as a risk factor for TST conversion. These individuals may mostly benefit from annual TST.

Sivapalasingam S; Klein RS; Howard A; Qin A; Tseng CH; Gourevitch MN. Housing insecurity and lack of public assistance are risk factors for tuberculin skin test conversion among persons who use illicit drugs in New York City. Journal of Addiction Medicine 3(3): 172-177, 2009. (24 refs.)

Smit RNV; Pai M; Yew WW; Leung CC; Zumla A; Bateman ED et al. Global lung health: The colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD. European Respiratory Journal 35(1): 27-33, 2010. (96 refs.)

Tuberculosis (TB), smoking, HIV and chronic obstructive pulmonary disease (COPD) are burgeoning epidemics in developing countries. The link between TB and HIV is well established. Less well recognised is the strong relationship between tobacco smoking and the development and natural history of TB. These associations are of considerable relevance to public health and disease outcomes in individuals with TB. Moreover, tobacco smoking, a modifiable risk factor, is associated with poorer outcomes in HIV-associated opportunistic infections, of which TB is the commonest in developing countries. It is now also becoming clear that TB, like tobacco smoke, besides its known consequences of bronchiectasis and other pulmonary morbidity, is also a significant risk factor for the development of COPD. Thus, there is a deleterious and synergistic interaction between TB, HIV, tobacco smoking and COPD in a large proportion of the world's population. Further work, specifically mechanistic and epidemiological studies, is required to clarify the role of tobacco smoke on the progression of TB and HIV infection, and to assess the impact of smoking cessation interventions. These interactions deserve urgent attention and have major implications for coordinated public health planning and policy recommendations in the developing world.

Smit RNV; Pai M; Yew WW; Leung CC; Zumla A; Bateman ED et al. Global lung health: The colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD. European Respiratory Journal 35(1): 27-33, 2010. (96 refs.)

Suhadev M; Thomas BE; Sakthivel MR; Murugesan P; Chandrasekaran V; Charles N et al. Alcohol use disorders among tuberculosis patients: A study from Chennai, South India. PLoS ONE 6(5): e19485, 2011. (35 refs.)

Background: Alcohol Use Disorders (AUDs) among tuberculosis (TB) patients are associated with nonadherence and poor treatment outcomes. Studies from Tuberculosis Research Centre (TRC), Chennai have reported that alcoholism has been one of the major reasons for default and mortality in under the DOTS programme in South India. Hence, it is planned to conduct a study to estimate prevalence of alcohol use and AUDs among TB patients attending the corporation health centres in Chennai, India. Methodology: This is a cross-sectional cohort study covering 10 corporation zones at Chennai and it included situational assessment followed by screening of TB patients by a WHO developed Alcohol Use Disorders Identification Test AUDIT scale. Four zones were randomly selected and all TB patients treated during July to September 2009 were screened with AUDIT scale for alcohol consumption. Results: Out of 490 patients, 66% were males, 66% were 35 years and above, 57% were married, 58% were from the low monthly income group of 8. Age (>35 years), education (less educated), income (Copyright 2011, Public Library Science

Swaminathan S; Schoenbaum EE; Klein RS; Howard AA; Lo YT; Gourevitch MN. Two-step tuberculin skin testing in drug users. Journal of Addictive Diseases 26(2): 71-79, 2007. (37 refs.)

To assess the utility of booster testing and to identify factors associated with a positive booster test, two-step tuberculin testing was performed in drug users recruited from methadone treatment. Participants also received a standardized interview on demographics and testing for HIV and CD4+ lymphocyte count. Of 619 enrollees completing the protocol, 174 (28%) had a positive PPD and 24 of the remaining 445 (5%) had a positive booster test. On multivariate analysis, boosting was associated with older age (adjusted odds ratio [ORadj] 2.38/decade, 95% confidence interval [CI] 1.34-4.22), history of using crack cocaine (ORadj 2.61, 95% CI 1.10-6.18) and a history of working as a home health aide (ORadj 4.23, 95% CI 1.39-12.86). Two-step tuberculin skin testing increased the proportion of participants with latent tuberculosis infection from 22% to 25%. Given the effectiveness of chemoprophylaxis, booster testing should be considered when drug users are screened for tuberculosis infection.

Sylla L; Bruce RD; Kamarulzaman A; Altice FL. Integration and co-location of HIV/AIDS, tuberculosis and drug treatment services. International Journal of Drug Policy 18(4): 306-312, 2007. (54 refs.)

Injection drug use (IDU) plays a critical role in the HIV epidemic in several countries throughout the world. In these countries, injection drug users are at significant risk for both HIV and tuberculosis, and active IDU negatively impacts treatment access, adherence and retention. Comprehensive strategies are therefore needed to effectively deliver preventive, diagnostic and curative services to these complex patient populations. We propose that developing co-located integrated care delivery systems should become the focus of national programmes as they continue to scale-up access to antiretroviral medications for drug users. Existing data suggest that such a programme will expand services for each of these diseases; increase detection of tuberculosis (TB) and HIV; improve medication adherence; increase entry into substance use treatment; decrease the likelihood of adverse drug events; and improve the effectiveness of prevention interventions. Key aspects of integration programmes include: co-location of services convenient to the patient; provision of effective substance use treatment, including pharmacotherapies; cross-training of generalist and specialist care providers; and provision of enhanced monitoring of drug-drug interactions and adverse side effects. Central to implementing this agenda will be fostering the political will to fund infrastructure and service delivery, expanding street-level outreach to IDUs, and training community health workers capable of cost effectively delivering these services.

Wang JM; Shen HB. Review of cigarette smoking and tuberculosis in China: Intervention is needed for smoking cessation among tuberculosis patients. BMC Public Health 9(article 292), 2009. (21 refs.)

Background: As a risk factor of tuberculosis ( TB), tobacco smoking has increased substantially over the past three decades, especially in developing countries. However, the association between smoking and TB, which has been shown to exist in different studies with different ethnic background, has not yet received sufficient attention in terms of TB care standards and research in China. Methods: An observational study was conducted in two rural areas of China. A total of 613 TB patients frequency matched with 1226 controls were interviewed by using a structured questionnaire. The associations between cigarette smoking and risk of TB were estimated by computing odds ratios (ORs) and 95% confidence intervals ( 95% CIs) from logistic regression model. Patients' smoking behavior and patterns of smoking cessation were followed after TB diagnosis. Multivariate Cox proportional hazards model was applied to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs) in analyzing the risk factors for smoking relapse. The Kaplan-Meier estimate was computed to plot the ability of smoking-free after cessation among different groups, with the Log-rank test being used to compare the difference. Results: The proportion of cigarette smoking was 54.6% in TB cases, which was significantly higher than that in controls (45.1%) with adjusted OR of 1.93( 95% CI: 1.51-2.48). Though 54.9% smokers stopped smoking after being diagnosed with TB, more than 18% relapsed during the follow-up period. The proportion of relapse was higher within 6-9 months (6%) and 12-15 months (11%) after cessation. In the Cox regression estimates adjusted for age and gender, compared with those highly educated and previously treated patients, the hazard ratios of smoking relapse were 3.48( 95% CI: 1.28-9.47) for less educated (< 6 years) and 4.30( 95% CI: 1.01-18.30) for newly treated patients, respectively. Conclusion: Cigarette smoking is associated with TB in the Chinese. Interventions of smoking cessation are recommended to be included in the current TB control practice.

Wang JM; Shen HB. Review of cigarette smoking and tuberculosis in China: Intervention is needed for smoking cessation among tuberculosis patients. BMC Public Health 9(article 292), 2009. (21 refs.)

Wang JY; Hsueh PR; Jan IS; Lee LN; Liaw YS; Yang PC et al. The effect of smoking on tuberculosis: different patterns and poorer outcomes. International Journal of Tuberculosis and Lung Disease 11(2): 143-149, 2007. (34 refs.)

SETTING: It has been well documented that smoking increases the risk of tuberculosis (TB). However, few studies have evaluated the impact of smoking on TB. We conducted this retrospective study to evaluate the influences of smoking on the manifestation and outcome of TB. DESIGN: All culture-confirmed TB patients from July 2002 to December 2003 were identified and their medical records reviewed. RESULTS: A total of 523 TB patients, including 207 (39.6%) who had ever smoked, were studied. The ever-smokers were significantly older, more likely to have underlying diseases and a duration of symptoms >60 days, and less likely to have extra-pulmonary involvement and have completed treatment (64.7% vs. 78.5%). Radiographically, more ever-smokers with pulmonary tuberculosis (PTB) presented with miliary lesions, multiple nodules or masses, upper lung predominance and cavitation than never-smokers. Although smoking was associated with poor prognosis on univariate survival analysis, multivariate analysis revealed that independent poor prognostic factors included age, underlying disease, symptom duration <= 60 days, extra-pulmonary involvement, serum albumin level < 3.5 g/dl and delayed treatment. CONCLUSIONS: Our results demonstrate that smoking is significantly associated with radiographic manifestations of PTB, but not with death among PTB patients.

Wang WH; Xiao H; Lu LY. Case-control retrospective study of pulmonary tuberculosis in heroin-abusing patients in China. Journal of Psychoactive Drugs 38(2): 203-205, 2006. (5 refs.)

The objective of this study was to observe the clinical significance of pulmonary tuberculosis in heroin abusers. A case-retrospective study was done to analyze clinical symptoms and severity based on chest X-rays, results of sputum bacterial test and effects of treatment. The clinical symptoms in patients with tuberculosis and heroin addiction were more severe than those in the nonheroin-addicted group. An examination of chest X-rays showed that tuberculosis lesions were involved in two or more lung fields in 80% of the heroin-addicted cases. In 73.3% of the cases, sputum bacterial tests were positive for tuberculosis. After anti-tuberculosis treatment, chest X-rays showed a recovery rate of 46.67%, caves became smaller by 41.7%, and the sputum negative conversion rate was 45.5%. There are significant differences compared with the control group (p < 0.05). The patients with pulmonary tuberculosis combined with heroin addiction had more severe clinical symptoms, more lesion zones found in their chest X-rays, higher sputum tuberculosis positive rates, and poorer treating effects.

Weiss MG; Somma D; Karim F; Abouihia A; Auer C; Kemp J et al. Cultural epidemiology of TB with reference to gender in Bangladesh, India and Malawi. International Journal of Tuberculosis and Lung Disease 12(7): 837-847, 2008. (32 refs.)

SETTING: TB control programmes in Bangladesh, India and Malawi. OBJECTIVE: To identify and compare socio-cultural features of tuberculosis (TB) and the distribution of TB-related experiences, meanings and behaviours with reference to gender across cultures in three high-endemic low-income countries. DESIGN: Approximately 100 patients at three sites were interviewed with in-depth semi-structured Explanatory Model Interview Catalogue (EMIC) interviews inquiring about patterns of distress, perceived causes and help-seeking behaviours in the context of illness narratives. RESULTS: Female patients reported more diverse symptoms and men more frequently focused on financial concerns. Most patients reported psychological and emotional distress. Men emphasised smoking and drinking alcohol as causes of TB, and women in Malawi reported sexual causes associated with HIV/AIDS. In Bangladesh, exaggerated concerns about the risk of spread despite treatment contributed to social isolation of women. Public health services were preferred in Malawi, and private doctors in India and Bangladesh. CONCLUSION: Cross-site analysis of these studies has identified features of TB that influence the burden of disease and are likely to affect timely help seeking and adherence to treatment. Health systems benefit from sex-disaggregated epidemiological data complemented by cultural epidemiological study, which together clarify the role of gender and contribute to the knowledge base for TB control at various levels.

Wen CP; Chan TC; Chan HT; Tsai MK; Cheng TY; Tsai SP. The reduction of tuberculosis risks by smoking cessation. BMC Infectious Diseases 10: article 156, 2010. (34 refs.)

Background: Smoking is known to aggravate tuberculosis (TB), but such information has been ignored in clinical practice, as it was not thought to be relevant. The aim of this study is to assess the benefits of smoking cessation on TB mortality reduction. Methods: The study attempts to quantify smokers' risks on subsequent TB mortality and the change in such risks after smokers quit smoking. In this prospective cohort study, the TB mortality risks of smokers, never smokers and former smokers were compared, by using the Cox proportional model to estimate the hazard ratio (HR) of TB. The cohort, consisting of 486,341 adults, participated in standard medical screening programs since 1994, including 5,036 with self-reported TB history. Of 15,268 deaths identified as of 2007, 77 were coded as TB. Results: Smokers with self-reported TB history (1.2%) had very high TB mortality (HR = 44.02). Among those without self-reported TB history, smoking increased TB mortality by nine-fold (HR = 8.56), but when they quit smoking, the risk was reduced by more than half (65%), to a level not different from those who had never smoked. The overwhelming majority of TB deaths (83%) occurred among those without self-reported TB history. Given the high smoking prevalence and the high HR, smoking accounted for more than one-third (37.7%) of TB mortality in Taiwan. Smokers reported less TB history but died more from TB than those who had never smoked. Conclusions: Smokers had very high TB mortality, as much as nine times those who had never smoked, but once they quit, the risk reduced substantially and was similar to those who never smoked. Smoking cessation has benefits to the smokers far beyond reducing TB risk, but successful tobacco control could favorably impact the TB mortality rate and reduce this public health burden, which has long haunted the Taiwanese population. Smoking cessation could reduce nearly one-third of tuberculosis deaths.

Wen CP; Chan TC; Chan HT; Tsai MK; Cheng TY; Tsai SP. The reduction of tuberculosis risks by smoking cessation. BMC Infectious Diseases 10: article 156, 2010. (34 refs.)

Wolfe D; Carneri MP; Shepard D. Treatment and care for injecting drug users with HIV infection: A review of barriers and ways forward. (review). Lancet 376(9738): 355-366, 2010. (145 refs.)

We review evidence for effectiveness, cost-effectiveness, and coverage of antiretroviral therapy (ART) for injecting drug users (IDUs) infected with HIV, with particular attention to low-income and middle-income countries. In these countries, nearly half (47%) of all IDUs infected with HIV are in five nations-China, Vietnam, Russia, Ukraine, and Malaysia. In all five countries, IDU access to ART is disproportionately low, and systemic and structural obstacles restrict treatment access. IDUs are 67% of cumulative HIV cases in these countries, but only 25% of those receiving ART Integration of ART with opioid substitution and tuberculosis treatment, increased peer engagement in treatment delivery, and reform of harmful policies -- including police use of drug-user registries, detention of drug users in centres offering no evidence-based treatment, and imprisonment for possession of drugs for personal usea -- are needed to improve ART coverage of IDUs.

CORK Bibliography: Tuberculosis

64 citations. January 2003 to present

Prepared: September 2011

Brunet L; Pai M; Davids V; Ling D; Paradis G; Lenders L et al. High prevalence of smoking among patients with suspected tuberculosis in South Africa. European Respiratory Journal 38(1): 139-146, 2011. (34 refs.)

Buff AM; Moonan PK; Desai MA; McKenna TL; Harris DA; Rogers BJ et al. South Carolina tuberculosis genotype duster investigation: A tale of substance abuse and recurrent disease. International Journal of Tuberculosis and Lung Disease 14(10): 1347-1349, 2010. (10 refs.)

Chawarski MC; Mazlan M; Schottenfeld RS. Heroin dependence and HIV infection in Malaysia. Drug and Alcohol Dependence 82(Supplement 1): s39-s42, 2006. (18 refs.)

Chemtob D; Levy A. Rationale and staff evaluation of using a therapeutic milieu for substance users within a tuberculosis ward. Substance Use & Misuse 44(5): 672-683, 2009. (20 refs.)

Chiang CY; Slama K; Enarson DA. Associations between tobacco and tuberculosis. International Journal of Tuberculosis and Lung Disease 11(3): 258-262, 2007. (41 refs.)

Coker R; McKee M; Atun R; Dimitrova B; Dodonova E; Kuznetsov S et al. Risk factors for pulmonary tuberculosis in Russia: Case-control study. British Medical Journal 332(7533): 85-87, 2006. (6 refs.)

Davies PDO; Yew WW; Ganguly D; Davidow AL; Reichman LB; Dheda K et al. Smoking and tuberculosis: The epidemiological association and immunopathogenesis. Transactions of the Royal Society of Tropical Medicine and Hygiene 100(4): 291-298, 2006. (46 refs.)

de Albuquerque MDPM; Ximenes RAD; Lucena-Silva N; de Souza WV; Dantas AT; Dantas OMS et al. Factors associated with treatment failure, dropout, and death in a cohort of tuberculosis patients in Recife, Pernambuco State, Brazil. Cadernos de Saude Publica 23(7): 1573-1582, 2007. (33 refs.)

Deiss RG; Rodwell TC; Garfein RS. Tuberculosis and illicit drug use: Review and update. (review). Clinical Infectious Diseases 48(1): 72-82, 2009. (180 refs.)

dos Santos MAPS; Albuquerque MFPM; Ximenes RAA; Lucena-Silva NLCL; Braga C; Campelo ARL et al. Risk factors for treatment delay in pulmonary tuberculosis in Recife, Brazil. BMC Public Health 5: article no. 25, 2005. (22 refs.)

Driver CR; Kreiswirth B; MaCaraig M; Clark C; Munsiff SS; Driscoll J et al. Molecular epidemiology of tuberculosis after declining incidence, New York City, 2001-2003. Epidemiology and Infection 135(4): 634-643, 2007. (36 refs.)

Drobniewski FA; Atun R; Fedorin I; Bikov A; Coker R. The 'bear trap': The colliding epidemics of tuberculosis and HIV in Russia. International Journal of STD & AIDS 15(10): 641 -646, 2004. (35 refs.)

Drobniewski FA; Balabanova YM; Ruddy MC; Graham C; Kuznetzov SI; Gusarova GI et al. Tuberculosis, HIV seroprevalence and intravenous drug abuse in prisoners. European Respiratory Journal 26(2): 298-304, 2005. (34 refs.)

Duarte EC; Bierrenbach AL; da Silva JB; Tauil PL; Duarte ED. Factors associated with deaths among pulmonary tuberculosis patients: A case-control study with secondary data. Journal of Epidemiology and Community Health 63(3): 233-238, 2009. (29 refs.)

El Sony A; Slama K; Salieh M; Elhaj H; Adam K; Hassan A et al. Feasibility of brief tobacco cessation advice for tuberculosis patients: a study from Sudan. International Journal of Tuberculosis and Lung Disease 11(2): 150-155, 2007. (13 refs.)

Fiske CT; Hamilton CD; Stout JE. Alcohol use and clinical manifestations of tuberculosis. Journal of Infection 57(5): 385-391, 2008. (32 refs.)

Fleming MF; Krupitsky E; Tsoy M; Zvartau E; Brazhenko N; Jakubowiak W et al. Alcohol and drug use disorders, HIV status and drug resistance in a sample of Russian TB patients. International Journal of Tuberculosis and Lung Disease 10(5): 565-570, 2006. (15 refs.)

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