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CORK Bibliography: Tuberculosis

35 citations. January 2009 to present

Prepared: September 2012

Awaisu A; Mohamed MHN; Noordin NM; Abd Aziz N; Sulaiman SAS; Muttalif AR et al. The SCIDOTS Project: Evidence of benefits of an integrated tobacco cessation intervention in tuberculosis care on treatment outcomes. Substance Abuse Treatment, Prevention and Policy 6: e-article 26, 2011. (50 refs.)

Background: There is substantial evidence to support the association between tuberculosis (TB) and tobacco smoking and that the smoking-related immunological abnormalities in TB are reversible within six weeks of cessation. Therefore, connecting TB and tobacco cessation interventions may produce significant benefits and positively impact TB treatment outcomes. However, no study has extensively documented the evidence of benefits of such integration. SCIDOTS Project is a study from the context of a developing nation aimed to determine this. Methods: An integrated TB-tobacco intervention was provided by trained TB directly observed therapy short-course (DOTS) providers at five chest clinics in Malaysia. The study was a prospective non-randomized controlled intervention using quasi-experimental design. Using Transtheoretical Model approach, 120 eligible participants who were current smokers at the time of TB diagnosis were assigned to either of two treatment groups: conventional TB DOTS plus smoking cessation intervention (integrated intervention or SCIDOTS group) or conventional TB DOTS alone (comparison or DOTS group). At baseline, newly diagnosed TB patients considering quitting smoking within the next 30 days were placed in the integrated intervention group, while those who were contemplating quitting were assigned to the comparison group. Eleven sessions of individualized cognitive behavioral therapy with or without nicotine replacement therapy were provided to each participant in the integrated intervention group. The impacts of the novel approach on biochemically validated smoking cessation and TB treatment outcomes were measured periodically as appropriate. Results: A linear effect on both 7-day point prevalence abstinence and continuous abstinence was observed over time in the intervention group. At the end of 6 months, patients who received the integrated intervention had significantly higher rate of success in quitting smoking when compared with those who received the conventional TB treatment alone (77.5% vs. 8.7%; p < 0.001). Furthermore, at the end of TB treatment (6 months or later), there were significantly higher rates of treatment default (15.2% vs. 2.5%; p = 0.019) and treatment failure (6.5% vs. 0%; p = 0.019) in the DOTS group than in the SCIDOTS group. Conclusion: This study provides evidence that connecting TB-tobacco treatment strategy is significant among TB patients who are smokers. The findings suggest that the integrated approach may be beneficial and confer advantages on short-term outcomes and possibly on future lung health of TB patients who quit smoking. This study may have important implications on health policy and clinical practice related to TB management among tobacco users.

Copyright 2011, BioMed Central

Balabanova Y; Tchernyshev V; Tsigankov I; Maximova S; Mikheeva N; Fedyukovitch L et al. Analysis of undiagnosed tuberculosis-related deaths identified at post-mortem among HIV-infected patients in Russia: A descriptive study. BMC Infectious Diseases 11: 276, 2011. (22 refs.)

Background: Tuberculosis remains a serious public health threat and economic burden in Russia with escalating rates of drug resistance against a background of growing HIV-epidemic. Samara Oblast is one of the regions of the Russian Federation where more than 1% of the population is affected by the HIV-epidemic; almost half of the cases are concentrated in the largely-industrial city of Togliatti with a population of 800 000. Methods: We conducted a retrospective analysis of errors leading to death of HIV-positive patients in general health care hospitals in Togliatti, Russia, in 2008. All (n = 29) cases when tuberculosis was established at autopsy as a cause of death were included. Results: Median length of hospital stay was 20 days; in 11 cases the death occurred within the first 24 hours of admission. All cases were known to be HIV-positive prior to admission, however HAART was not initiated for any case, and no relevant tests to assess severity of immunosupression were performed despite their availability. No appropriate diagnostic algorithms were applied to confirm tuberculosis. Major gaps were identified in the work of hospital and consulting physicians including insufficient records keeping. In almost all patients earlier regular HIV-relevant tests were not performed due to poor compliance of patients, many of whom abused alcohol and drugs. Conclusions: We conclude that introduction of prompt and accurate diagnostics tests, adequate treatment protocols and intensive training of physicians in management of AIDS and TB is vital. This should include reviewing standards of care for HIV-positive individuals with accompanying social problems.

Copyright 2011, BioMed Central

Bam TS; Enarson DA; Hinderaker SG; Bam DS. Longer delay in accessing treatment among current smokers with new sputum smear-positive tuberculosis in Nepal. International Journal of Tuberculosis and Lung Disease 16(6): 822-827, 2012. (19 refs.)

SETTING: Kathmandu, Nepal, which has 7% of the national population and 18% of the tuberculosis (TB) burden. OBJECTIVES: To determine the association of smoking with total delay among new sputum smear-positive TB patients. METHODS: Direct interviews were conducted among 605 TB patients registered in 37 randomly selected clinics within 30 days of initiating anti-tuberculosis treatment using a semi-structured questionnaire. Total delay was calculated from the date of the first reported symptom to the commencement of treatment. Logistic regression analyses were performed to determine the factors associated with total delay. RESULTS: Of the 605 TB patients interviewed, 271 (44.8%) were current smokers, 33 (5.5%) were ex-smokers and 301 (49.8%) were never smokers. The median total delay was 103 days (current smokers 133 days, ex-smoker 103 days and never smokers 80 days). Longer delay was more common among current smokers (aOR 2.03, 95%CI 1.24-3.31). Covariates with significantly more delay were female sex, lower levels of education and higher degrees of sputum smear positivity. CONCLUSION: Total delay was unacceptably longer in current smokers. Anti-smoking interventions are needed as an integral part of the TB programme to address this problem.

Copyright 2012, International Union Against Tuberculosis Lung Disease

Basu S; Stuckler D; Bitton A; Glantz SA. Projected effects of tobacco smoking on worldwide tuberculosis control: mathematical modelling analysis. British Medical Journal 343: d5506, 2011. (49 refs.)

Objectives: Almost 20% of people smoke tobacco worldwide-a percentage projected to rise in many poor countries. Smoking has been linked to increased individual risk of tuberculosis infection and mortality, but it remains unclear how these risks affect population-wide tuberculosis rates. Design We constructed a state transition, compartmental, mathematical model of tuberculosis epidemics to estimate the impact of alternative future smoking trends on tuberculosis control. We projected tuberculosis incidence, prevalence, and mortality in each World Health Organization region from 2010 to 2050, and incorporated changing trends in smoking, case detection, treatment success, and HIV prevalence. Results The model predicted that smoking would produce an excess of 18 million tuberculosis cases (standard error 16-20) and 40 million deaths from tuberculosis (39-41) between 2010 and 2050, if smoking trends continued along current trajectories. The effect of smoking was anticipated to increase the number of tuberculosis cases by 7% (274 million v 256 million) and deaths by 66% (101 million v 61 million), compared with model predictions that did not account for smoking. Smoking was also expected to delay the millennium development goal target to reduce tuberculosis mortality by half from 1990 to 2015. The model estimated that aggressive tobacco control (achieving a 1% decrease in smoking prevalence per year down to eradication) would avert 27 million smoking attributable deaths from tuberculosis by 2050. However, if the prevalence of smoking increased to 50% of adults (as observed in countries with high tobacco use), the model estimated that 34 million additional deaths from tuberculosis would occur by 2050. Conclusions: Tobacco smoking could substantially increase tuberculosis cases and deaths worldwide in coming years, undermining progress towards tuberculosis mortality targets. Aggressive tobacco control could avert millions of deaths from tuberculosis.

Copyright 2011, BMJ Publishing

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.

Copyright 2011, European Respiratory Society

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.

Copyright 2010, International Union Against Tuberculosis and Lung Disease

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.

Copyright 2009, Taylor & Francis

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.

Copyright 2009, University of Chicago Press

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.

Copyright 2009, BMJ Publishing Group

Ferrara G; Murray M; Winthrop K; Centis R; Sotgiu G; Migliori GB et al. Risk factors associated with pulmonary tuberculosis: Smoking, diabetes and anti-TNF alpha drugs. (review). Current Opinion in Pulmonary Medicine 18(3): 233-240, 2012. (69 refs.)

Purpose of review: Tuberculosis (TB) remains a global emergency and continues to kill 1.4 million people every year. The interaction between noncommunicable and infectious diseases like TB has important implications with regard to the attainment of the Millennium Development Goals (MDGs). Smoking, diabetes mellitus, anti-TNF alpha drugs and other immunosuppressive therapies are well known major risk factors associated with TB. The purpose of this review is to summarize the recent literature on these risk factors and interventions that reduce the risk. Recent findings: Mathematical models and aggregate data from the field show that smoking, diabetes and anti-TNF alpha drugs independently increase the risk of developing active TB. There is consensus on the great need for screening for active TB disease in patients with these conditions and targeted preventive interventions through a combined multidisciplinary approach. Summary: Smoking, diabetes mellitus, anti-TNF alpha drugs and new immunosuppressive treatments represent important common risk factors for TB. A high degree of clinical awareness of the possibility of TB should be considered in patients with these risk factors, and active screening and prevention should be undertaken. Further operational research is needed to optimize screening for latent Mycobacterium tuberculosis infection, instituting preventive intervention measures.

Copyright 2012, Lippincott, Williams & Wilkins

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.

Copyright 2010, Research Society on Alcoholism

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.

Copyright 2010, American Medical Association

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.

Copyright 2009, American Thoracic Society

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.

Copyright 2009, Elsevier Science

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.

Copyright 2010, Taylor & Francis

McCance-Katz EF; Moody DE; Prathikanti S; Friedland G; Rainey PM. Rifampin, but not rifabutin, may produce opiate withdrawal in buprenorphine-maintained patients. Drug and Alcohol Dependence 118(2-3): 326-334, 2011. (43 refs.)

Background: This series of studies examines the pharmacokinetic/pharmacodynamic interactions between buprenorphine, an opioid partial agonist increasingly used in treatment of opioid dependence, and rifampin, a medication used as a first line treatment for tuberculosis; or rifabutin, an alternative antituberculosis medication. Methods: Opioid-dependent individuals on stable doses of buprenorphine/naloxone underwent two, 24-h blood sampling studies: (1) for buprenorphine pharmacokinetics and (2) following 15 days of rifampin 600 mg daily or rifabutin 300 mg daily for buprenorphine and rifampin or rifabutin pharmacokinetics. Results: Rifampin administration produced significant reduction in plasma buprenorphine concentrations (70% reduction in mean area under the curve (AUC); p = <0.001) and onset of opiate withdrawal symptoms in 50% of participants (p = 0.02). While rifabutin administration to buprenorphine-maintained subjects resulted in a significant decrease in buprenorphine plasma concentrations (35% decrease in AUC; p <0.001) no opiate withdrawal was seen. Compared with historical control data, buprenorphine had no significant effect on rifampin pharmacokinetics, but was associated with 22% lower rifabutin mean AUC (p = 0.009), although rifabutin and its active metabolite concentrations remained in the therapeutic range. Conclusions: Rifampin is a more potent inducer of buprenorphine metabolism than rifabutin with pharmacokinetic and pharmacodynamic adverse consequences. Those patients requiring rifampin treatment for tuberculosis and receiving buprenorphine therapy are likely to require an increase in buprenorphine dose to prevent withdrawal symptoms. Rifabutin administration was associated with decreases in buprenorphine plasma concentrations, but no clinically significant adverse events were observed.

Copyright 2011, Elsevier Science

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.

Copyright 2009, Journal of Drug Issues, Inc.

Millet JP; Orcau A; Rius C; Casals M; de Olalla PG; Moreno A et al. Predictors of death among patients who completed tuberculosis treatment: A population-based cohort study. PLoS ONE 6(9): e25315, 2011. (44 refs.)

Background: Mortality among patients who complete tuberculosis (TB) treatment is still high among vulnerable populations. The objective of the study was to identify the probability of death and its predictive factors in a cohort of successfully treated TB patients. Methods: A population-based retrospective longitudinal study was performed in Barcelona, Spain. All patients who successfully completed TB treatment with culture-confirmation and available drug susceptibility testing between 1995-1997 were retrospectively followed-up until December 31, 2005 by the Barcelona TB Control Program. Socio-demographic, clinical, microbiological and treatment variables were examined. Mortality, TB Program and AIDS registries were reviewed. Kaplan-Meier and a Cox regression methods with time-dependent covariates were used for the survival analysis, calculating the hazard ratio (HR) with 95% confidence intervals (CI). Results: Among the 762 included patients, the median age was 36 years, 520 (68.2%) were male, 178 (23.4%) HIV-infected, and 208 (27.3%) were alcohol abusers. Of the 134 (17.6%) injecting drug users (IDU), 123 (91.8%) were HIV-infected. A total of 30 (3.9%) recurrences and 173 deaths (22.7%) occurred (mortality rate: 3.4/100 person-years of follow-up). The predictors of death were: age between 41-60 years old (HR: 3.5; CI: 2.1-5.7), age greater than 60 years (HR: 14.6; CI: 8.9-24), alcohol abuse (HR: 1.7; CI: 1.2-2.4) and HIV-infected IDU (HR: 7.9; CI: 4.7-13.3). Conclusions: The mortality rate among TB patients who completed treatment is associated with vulnerable populations such as the elderly, alcohol abusers, and HIV-infected IDU. We therefore need to fight against poverty, and promote and develop interventions and social policies directed towards these populations to improve their survival.

Copyright 2011, Public Library of Science

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.

Copyright 2010, National Institute on Alcohol Abuse and Alcoholism

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.

Copyright 2010, Springer

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.

Copyright 2009, American Medical Association

Pednekar MS; Sansone G; Gupta PC. Association of alcohol, alcohol and tobacco with mortality: Findings from a prospective cohort study in Mumbai (Bombay), India. Alcohol 46(2): 139-146, 2012. (32 refs.)

The aim of the present study was to examine the association between alcohol, alcohol and tobacco, and mortality in a large adult population in the city of Mumbai. A total of 35,102 men aged 45 years and older were surveyed about their alcohol drinking as part of a cohort study. These respondents were followed up over time, and all deaths were recorded. Compared with those who never drank alcohol, alcohol drinkers had 1.22 times higher risk of mortality, with the highest risk observed for liver disease (hazard ratio [HR] = 3.19). Among ever drinkers, risk of mortality varied according to types (country/desi), frequency (four or less times a week, HR = 1.39), and quantity of alcohol consumed (> 100 mL) per day. In addition, country/desi drinkers (HR = 1.34) had the highest mortality risk compared with all other types of alcohol (HR = 0.97). Alcohol drinkers had increased risk of mortality for tuberculosis (HR = 2.53), cerebrovascular disease (HR = 1.83), and liver disease (HR = 3.19). Synergistic joint effect of tobacco and alcohol on mortality was also observed, with lowest risk in never tobacco user drinkers (HR = 1.02) and highest in mixed tobacco user drinkers (HR = 1.79). The results of this study show a direct association between greater consumption of alcohol and increased risk of mortality from alcohol-specific causes. In addition to individual effect, this study demonstrates the synergistic interaction between alcohol and tobacco use in various forms on mortality.

Copyright 2012, Elsevier Science

Pevzner ES; Robison S; Donovan J; Allis D; Spitters C; Friedman R et al. Tuberculosis transmission and use of methamphetamines in Snohomish County, WA, 1991-2006. American Journal of Public Health 100(12): 2481-2486, 2010. (35 refs.)

Objectives: We investigated a cluster of tuberculosis (TB) cases among persons using methamphetamines in Snohomish County Washington to determine the extent of the outbreak examine whether methamphetamine use contributed to TB transmission and implement strategies to prevent further infections. Methods: We screened contacts to find and treat persons with TB disease or infection. We then formed a multidisciplinary team to engage substance abuse services partners and implement outreach strategies including novel methods for finding contacts and a system of incentives and enablers to promote finding screening and treating patients with TB and their infected contacts. Results: We diagnosed and completed treatment with 10 persons with TB disease. Eight of 9 adult patients and 67% of their adult contacts reported using methamphetamines. Of the 372 contacts: 319 (85.8%) were screened ;80 (25.1%) were infected; 71 (88 8%) started treatment for latent infection; and 57 (80.3%) completed treatment for latent infection Conclusions: Collaborative approaches integrating TB control outreach in centives and enablers resulted in high rates of treatment adherence and completion among patients and infected contacts. TB control programs should collaborate with substance abuse programs to address addiction overcome, substance abuse-related barriers to treatment, treat TB, and prevent ongoing transmission.

Copyright 2010, American Public Health Association

Rao VG; Gopi PG; Bhat J; Yadav R; Selvakumar N; Wares DF. Selected risk factors associated with pulmonary tuberculosis among Saharia tribe of Madhya Pradesh, central India. European Journal of Public Health 22(2): 271-273, 2012. (10 refs.)

Tuberculosis (TB) is a major public health problem among the Saharia, a marginalized tribal group in Madhya Pradesh state, central India. However, there is no information on the risk factors associated with the development of TB disease in this community. A cross-sectional TB prevalence survey was conducted among the Saharia residing in Sheopur district of Madhya Pradesh. Information on tobacco smoking and alcohol consumption was collected from all the individuals. Persons aged epsilon 45 years, males, smokers and alcohol consumers had higher risks of developing TB disease. There is an urgent need to develop and implement culturally appropriate awareness raising activities to target smoking and alcohol consumption to support the efforts to control TB in this community.

Copyright 2012, Oxford University Press

Schwarz RK; Bruce RD; Ball SA; Herme M; Altice FL. Comparison of tuberculin skin testing reactivity in opioid-dependent patients seeking treatment with methadone versus buprenorphine: Policy implications for tuberculosis screening. American Journal of Drug and Alcohol Abuse 35(6): 439-444, 2009. (33 refs.)

Background: Buprenorphine's availability in primary care settings offers increased access to treatment and linkage to primary care for opioid-dependent patients. Currently, tuberculin skin testing (TST) is recommended for patients enrolling in methadone maintenance treatment (MMT), but not for those enrolling in buprenorphine maintenance treatment (BMT). Objectives: To compare TST screening results in enrollees in BMT and MMT programs and assess the correlates of TST positivity among these subjects. Methods: A cross-sectional analysis of a retrospective cohort study was conducted to compare concurrent TST results among contemporaneously matched groups of MMT and BMT patients in the same community. Results: TST positivity was similar to 9% in both MMT and BMT settings (p=.27). Increased TST positivity was associated with being Black (AOR = 3.53, CI = 1.28-9.77), Hispanic (AOR = 3.11, CI = 1.12-8.60), and having higher education (AOR = 3.01, CI = 1.20-7.53). Conclusions: These results confirm a similar high prevalence of TST positivity in opioid-dependent patients enrolling in MMT and BMT programs. Racial and ethnic health disparities remain associated with TST positivity, yet a relationship between higher education and tuberculosis requires further investigation. Scientific significance: These data suggest the importance of incorporating TST screening in emerging BMT programs as a mechanism to provide increased detection and treatment of tuberculosis infection in opioid-dependent patient populations.

Copyright 2009, Informa Healthcare

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.

Copyright 2009, Royal Society of Medicine Press

Shin SS; Xiao D; Cao M; Wang C; Li Q; Chai WX; Lindsay RP et al. Patient and doctor perspectives on incorporating smoking cessation into tuberculosis care in Beijing, China. International Journal of Tuberculosis and Lung Disease 16(1): 126-131, 2012. (24 refs.)

SETTING: Tuberculosis (TB) hospital in Beijing, China. OBJECTIVE: To describe perspectives of patients and physicians regarding the incorporation of smoking cessation interventions as part of TB treatment. DESIGN: Seven focus groups were conducted with 39 patients and 17 physicians. RESULTS: Patients were more receptive to physicians' advice to quit smoking due to increased concerns about their health after becoming ill with TB. However, patients indicated that they might start smoking again after they recovered from TB. Patients' attempts to quit smoking may have been inhibited by exposure to smoking at the TB facility. Physicians had low levels of knowledge regarding the effect of smoking on TB. Many doctors, particularly those who smoked, did not view smoking cessation as an integral part of TB treatment. CONCLUSION: Despite the presence of a 'teachable moment', TB patients experience significant barriers to quitting smoking. Patient education in TB treatment programs should address the specific effects of smoking on TB and the general health benefits of cessation. Smoke-free policies should be strictly enforced in TB facilities. Successful integration of smoking cessation interventions within TB treatment regimens may require that providers adopt smoking cessation as an essential part of TB treatment.

Copyright 2012, International Union Against Tuberculosis and Lung Disease

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.

Copyright 2009, Lippincott, Williams & Wilkins

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.

Copyright 2010, European Respiratory Society

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

Tachfouti N; Nejjari C; Benjelloun MC; Berraho M; Elfakir S; El Rhazi K et al. Association between smoking status, other factors and tuberculosis treatment failure in Morocco. International Journal of Tuberculosis and Lung Disease 15(6): 838-843, 2011. (37 refs.)

BACKGROUND: The association between smoking and tuberculosis (TB) treatment failure has not yet been assessed in Morocco. OBJECTIVE: To evaluate the impact of smoking on the failure rate of patients with TB. METHODS: A cohort of 727 new TB cases was followed between 2004 and 2009. Socio-demographic measurements and smoking status were collected by questionnaire. Treatment failure was defined according to international guidelines. Univariate analyses were used to assess associations of treatment failure with smoking status and demographic characteristics. Multivariate logistic regression was used to adjust for potential confounding. RESULTS: The patients' mean age was 35.0 +/- 13.2 years. The monthly household income was <(sic)180 for 71.4% of the patients. The rate of treatment failure was 6.9%. Failure was significantly higher among smokers (9.1% vs. 4.5%; P < 0.01), alcohol drinkers (18.5% vs. 4.9%; P < 0.01), and those with a monthly income of <(sic)180 (8.4% vs. 3.3%; P < 0.01). After adjusting for confounding variables, smoking and low income remained significantly associated with treatment failure (adjusted OR 2.25, 95%CI 1.06-4.76, and 3.23, 95%CI 1.12-9.32). CONCLUSION: Smoking is associated with TB treatment failure in Morocco. Anti-smoking interventions should be incorporated into current TB case management.

Copyright 2011, International Union Against Tuberculosis and Lung Disease

Tran BX; Ohinmaa A; Duong AT; Do NT; Nguyen LT; Mills S et al. Cost-effectiveness of methadone maintenance treatment for HIV-positive drug users in Vietnam. AIDS Care 24(3): 283-290, 2012. (34 refs.)

Methadone maintenance treatment (MMT) is efficacious in reducing drug use that may improve HIV/AIDS care and treatment outcomes. This study evaluated the incremental cost-effectiveness of MMT for HIV-positive drug users from the perspective of health service providers. A sample of 370 HIV-positive drug users (age: mean+/-SD: 29.5+/-5.9 years; 95.7% male) taking MMT in multi-sites was assessed at baseline, three, six and nine months. Costs of MMT services were analyzed and converted to the year 2009. Quality-adjusted life years (QALYs) were modeled from changes in health-related quality of life of patients using the modified World Health Organization Quality of Life - Brief Version (WHOQOL-BREF). Inverse probability-of-treatment weights, constructed using propensity score of non-responses, were applied to adjust for potential confounding. Over nine months, MMT substantially improved QALYs of HIV/AIDS patients (0.076 QALY [0.066-0.084]). The increments in QALY were large and stabilized in those patients taking antiretroviral treatment and abstinent to drug use. For one QALY gained, the MMT program would cost US$3745.3, approximately 3.2 times Vietnam GDP per capita in 2009. The cost-effectiveness of MMT intervention was robust against HIV advanced status or co-morbidity, e. g., TB treatment, but it might not be cost-effective for those patients who continued to use drug. Findings of this study indicate that providing MMT for HIV-positive drug users is a cost-effective intervention in Vietnam. Integrating MMT to HIV/AIDS care and treatment services would be beneficial in injection-driven HIV epidemics.

Copyright 2012, Taylor & Francis

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.

Copyright 2009, BioMed Central

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.

Copyright 2010, Biomedical Central

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.

Copyright 2010, Elsevier Science