Original articleThe diagnosis and management of tuberculosis in common hostel dwellers
Abstract
Edinburgh hostel dwellers have been regularly screened for pulmonary tuberculosis since 1957. Sixty-eight cases were notified during the 7 years 1976–1982: 42 (65 %) were detected by 4687 hostel survey X-rays, and a further 26 presented with symptoms. Disease was more advanced in the symptomatic hostellers both by radiological and bacteriological criteria with twice as many being sputum smear positive (58 % vs. 26 %).
Full clinical details were available for 65 of the 68. Four were diagnosed at post mortem examination and two had chemotherapy stopped because the disease was considered inactive. Of the remaining 59 eligible for treatment, 47 (80 %) received a complete course of adequate chemotherapy; 16 as hospital in-patients, 26 first in hospital and then under out-patient supervision and five simply as supervised outpatients; none relapsed. Twelve (20 %) of the 59 defaulted from supervision after a mean follow-up period of 2.4 months.
Résumé
Depuis 1957 on a régulièrement rechereché la tuberculose pulmonaire chez les personnes vivant dans des pensions à Edimbourg. Au cours des 7 années de 1976 à 1982, 68 cas ont été declares: 42 (65 %) ont été déceles a la suite de 4.687 clichés radiologiques à l'occasion d'enquêtes clans ces pensions, et 26 autres cas se sont présentés, porteurs de symptomes. La maladie était plus avancée, tant du point de vue radiologique que bactériologique, chez les habitants des pensions qui présentaient des symptomes et deux fois plus nombreux parmi ces sujets symptomatiques étaient ceux qui se sont montrés frottis positifs (58 % contre 26%).
Des details cliniques sont disponibles pour 65 sujets parmi les 68. Quatre d'entre eux ont été diagnostiqués a l'autopsie et deux ont vu leur chimiotherapie arrêtée parce que la maladie a été considérée comme inactive. Parmi les 59 sujets susceptibles de bénéficier d'un traitement, 47 (80 %) ont reçu un traitement complet d'une chimiotherapie appropriée; 16 en tant que malades hospitalises, 26 d'abord a l'hôpital puis comme malades externes sous supervision, et 5 simplement comme malades externes sous supervision; aucun de ces malades n'a rechuté. Douze malades (20 %) parmi les 59 ont échappé a la supervision après une période moyenne de suivi de 2,4 mois.
Resumen
Desde 1957 se ha investigado la tuberculosis pulmonar en las personas albergadas en las hospederias de Edimburgo. Durante 7 años, entre 1976 y 1982, fueron notificados 68 casos: 42 (65 %) fueron detectados entre los 4687 exámenes radiológicos practicados en las hospederias y otros 26 casos se presentaron con síntomas. La enfermedad estaba mas avanzada tanto desde el punto de vista radiológico como bacteriológico en huéspedes que presentaban sintomas y entre estos últimos la proporción de sujetos con frotis positivos era 2 veces mas elevada (57 % contra 26 %).
Se dispone de detalles clinicos para 65 de los 68 sujetos. Cuatro de ellos fueron diagnosticados por la autopsia y dos suspendieron la quimioterapia por haberse considerado que la enfermedad estaba inactiva. De los 59 enfermos con posibilidades de tratamiento, 47 (80 %) recibieron una quimioterapia completa y adecuada 16 en el hospital, 26 primero en el hospital y leugo en ambulatorio supervisado y 5 simplemente en ambulatorio supervisado; ninguno de estos enfermos presentó recaídas. Doce (20 %) de los 59 escaparon de la supervision después de un periodo promedio de seguimiento de 2,4 meses.
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Cited by (22)
Does tuberculosis screening improve individual outcomes? A systematic review
2021, eClinicalMedicineCitation Excerpt :One Indian study found no difference in smear grade among screened and PCF groups (Table 3 showing proportions and prevalence ratios) [29]. Three European and one Brazilian study reported on smear positivity among culture-confirmed TB patients [31-33,35]. The proportion with positive smears was lower in those screened in three [31-33].
To determine if tuberculosis (TB) screening improves patient outcomes, we conducted two systematic reviews to investigate the effect of TB screening on diagnosis, treatment outcomes, deaths (clinical review assessing 23 outcome indicators); and patient costs (economic review).
Pubmed, EMBASE, Scopus and the Cochrane Library were searched between 1/1/1980-13/4/2020 (clinical review) and 1/1/2010-14/8/2020 (economic review). As studies were heterogeneous, data synthesis was narrative.
Clinical review: of 27,270 articles, 18 (n=3 trials) were eligible. Nine involved general populations. Compared to passive case finding (PCF), studies showed lower smear grade (n=2/3) and time to diagnosis (n=2/3); higher pre-treatment losses to follow-up (screened 23% and 29% vs PCF 15% and 14%; n=2/2); and similar treatment success (range 68-81%; n=4) and case fatality (range 3-11%; n=5) in the screened group. Nine reported on risk groups. Compared to PCF, studies showed lower smear positivity among those culture-confirmed (n=3/4) and time to diagnosis (n=2/2); and similar (range 80-90%; n=2/2) treatment success in the screened group. Case fatality was lower in n=2/3 observational studies; both reported on established screening programmes. A neonatal trial and post-hoc analysis of a household contacts trial found screening was associated with lower all-cause mortality. Economic review: From 2841 articles, six observational studies were eligible. Total costs (n=6) and catastrophic cost prevalence (n=4; range screened 9-45% vs PCF 12-61%) was lower among those screened.
We found very limited patient outcome data. Collecting and reporting this data must be prioritised to inform policy and practice.
WHO and EDCTP.
Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: A systematic review and meta-analysis
2012, The Lancet Infectious DiseasesCitation Excerpt :After removal of duplicates and initial screening, we reviewed 210 papers in full. After exclusion of ineligible reports, our final sample was 43 studies (n=63 812) published between December, 1984, and Jan 12, 2012, including 17 studies (43 605) of tuberculosis9,20,35–49 (table 1), 12 (5391) of hepatitis C21,22,50–59 (table 2), and 22 (14 816) of HIV10,14,21–27,50,52–55,59–66 (table 3). After taking into account duplication of patients because of overlapping samples, the overall population consisted of 59 736 homeless individuals.
100 million people worldwide are homeless; rates of mortality and morbidity are high in this population. The contribution of infectious diseases to these adverse outcomes is uncertain. Accurate estimates of prevalence data are important for public policy and planning and development of clinical services tailored to homeless people. We aimed to establish the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people.
We searched PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature for studies of the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless populations. We also searched bibliographic indices, scanned reference lists, and corresponded with authors. We explored potential sources of heterogeneity in the estimates by metaregression analysis and calculated prevalence ratios to compare prevalence estimates for homeless people with those for the general population.
We identified 43 eligible surveys with a total population of 63 812 (59 736 homeless individuals when duplication due to overlapping samples was accounted for). Prevalences ranged from 0·2% to 7·7% for tuberculosis, 3·9% to 36·2% for hepatitis C virus infection, and 0·3% to 21·1% for HIV infection. We noted substantial heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus infection, and HIV infection (all Cochran's χ2 significant at p<0·0001; I2=83%, 95% CI 76–89; 95%, 94–96; and 94%, 93–95; respectively). Prevalence ratios ranged from 34 to 452 for tuberculosis, 4 to 70 for hepatitis C virus infection, and 1 to 77 for HIV infection. Tuberculosis prevalence was higher in studies in which diagnosis was by chest radiography than in those which used other diagnostic methods and in countries with a higher general population prevalence than in those with a lower general prevalence. Prevalence of HIV infection was lower in newer studies than in older ones and was higher in the USA than in the rest of the world.
Heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus, and HIV suggests the need for local surveys to inform development of health services for homeless people. The role of targeted and population-based measures in the reduction of risks of infectious diseases, premature mortality, and other adverse outcomes needs further examination. Guidelines for screening and treatment of infectious diseases in homeless people might need to be reviewed.
The Wellcome Trust.
Tuberculosis in the Republic of Cuba: its possible elimination
1994, Tubercle and Lung DiseaseSetting: Tuberculosis elimination is a priority in most developed countries, although the AIDS epidemic and drug resistance are a handicap in some of them. Tuberculosis is an even greater problem in developing countries.
Objective: To evaluate the epidemiological situation in Cuba, the trend of new cases reported for 1979–1991 by clinical category and age group is described.
Design: A simple regression model was fitted to the time series data on ‘new case’ rates taken from the national surveillance system. The annual variation percentage was estimated.
Results: From 1979–1991 tuberculosis decreased by 59.5% (from 11.6-4.7 per 105 persons per year). This decline occurred in all age groups; 60% of new cases in 1991 were aged 45 years and over, of which 30% were aged 65 and over. Drug resistance of Mycobacterium tuberculosis strains (2.49% in 1989) remains uncommon and HIV infection (0.009% in 1991) is rare in the general population.
Conclusions: The continuing steady decline of the number of new cases reported, in addition to the favorable trend of drug resistance and the low rate of HIV infection in the general population so far seem to indicate the real possibility of maintaining the effectiveness of the National Programme for Tuberculosis Control in the future, making it reasonable to formulate new strategies for the elimination of the disease.
Cadre: L'élimination de la tuberculose est l'un des objectifs principaux de la plupart des pays industrialisés, même si l'endémie du SIDA et la résistance aux drogues sont des problèmes graves chez certains. La tuberculose est encore plus répandue dans les pays en développement.
Objet: Afin d'évaluer la situation épidémiologique en Cuba, est décrite ici l'évolution des cas nouveaux notifiés 1979–1991 selon la catégorie clinique et le groupe d'âge.
Schéma: Un modèle de régression simple a été appliqué aux données en série temporelle des taux de ‘cas nouveaux’ obtenues du Système National de Contrôle. A été estimé le pourcentage annuel de variation.
Résultats: Dans la période de 1979 à 91 la tuberculose a diminué de 59,5% (de 11,6 à 4,7 par an pour 105 habitants). Cette baisse s'est produite dans tous les groupes d'âge; en 1991 60% des cas nouveaux se trouvaient dans le groupe âgé de 45 ans et davantage, dont 30% étaient âgés de 65 ans et davantage. La résistance aux drogues des souches de Mycobacterium tuberculosis (2,49% en 1989) demeure une condition hors du commun et l'infection par le VIH est rare (0,009% en 1991) dans la population générale.
Conclusion: La baisse progressive du nombre de cas nouveaux notifiés, ainsi que la tendance favorable des taux de résistance aux drogues et le taux faible d'infection VIH dans la population générale jusqu'ici semblent indiquer la possibilité concrète de maintenir l'efficacité du Programme National du Contrôle de la Tuberculose dans l'avenir et de justifier la recherche de nouvelles stratégies pour l'élimination de la maladie.
Marco de referencia: La eliminación de la tuberculosis es uno de los objetivos de la mayoría de los países desarrollados, aunque el SIDA y el problema de la resistencia a las drogas es un inconveniente en algunos de ellos. La tuberculosis es un serio problema de salud aún mayor en los países en desarrollo.
Objetivo: Para evaluar la situación epidemiologica en Cuba, se describe la evolución de casos nuevos de tuberculosis notificados durante el período 1979–1991 según la categoria clínica y el grupo de edad.
Método: Se aplicó un modelo de regresión lineal simple a los datos en serie temporal de las tasas de ‘casos nuevos’ tomadas del Programa Nacional de Control de la Tuberculosis. Se estimó el porcentaje anual de variación.
Resultados: Desde 1979 hasta 1991 la tuberculosis disminuyó de 59,5% (de 11,6 a 4,7 por 105 habitantes). Esta disminución se produjo en todos los grupos de edad; el 60% de casos nuevos en 1991 tenía 45 años y más, de los cuales el 30% tenía 65 años y más. La resistencia a las drogas de las cepas de Mycobacterium tuberculosis (2,49% en 1989) sigue siendo una situación poco común y la infección con VIH es rara (0,009% en 1991) en la población general.
Conclusiones: La disminución progresiva y sostenida de los casos nuevos, asi como la evolución favorable de la resistancia a las drogas y la tasa baja de infección VIH en la población general hasta ahora, revelan la posibilidad de mantener la efectividad del Programa Nacional de Control de la Tuberculosis en el futuro y lo ponen condiciones de plantearse nuevas estrategias para la eliminación de esta enfermedad.
Tuberculosis among the homeless people of Nagoya, Japan
1994, Respiratory MedicineA survey was conducted in order to clarify the tuberculosis (TB) situation in the homeless during the period from 1982 to 1991 in an urban district of Nagoya, using the registration cards of pulmonary TB patients and the data of chest roentgenograms of the Nagoya City Nakamura Health Centre. The incidence and prevalence of pulmonary TB per 100 000 among the homeless were estimated at 950–2150 and 1900–3250, respectively, which were around 30 and 20 times higher than those for the non-homeless. An increase in the incidence rate among homeless pulmonary TB patients was found in 1989, after a gradual decrease to the year 1988. The detected prevalence rate by chest examinations of the homeless was also around 30 times higher than that for the non-homeless. The percentage of patients with cavities indicated by chest roentgenograms when they were first registered was 76·9% among the homeless, but only 42·9% among the non-homeless.
Health status and the housing system
1990, Social Science and MedicineMost research on housing and health seeks causal links between dwelling conditions and the incidence of physical and mental disease. Less attention has been paid to the more sociological question of how health status affects housing opportunities. This paper shows how, and considers why, medical factors influence access to housing, whether in the public sector (where accommodation is traditionally allocated according to ‘need’) or in the housing market (where dwelling availability depends on ability to pay). In Britain, whose experience is taken as an example, a shrinking council housing stock can no longer accommodate general medical needs. Consequently, notwithstanding the importance of ‘special’ housing initiatives, many sick people are forced to seek accommodation in the private sector. Whether they succeed or fail (and so become homeless), this raises questions concerning the health selective role of the housing system which analysts have scarcely begun to address.
Twenty-three new cases of pulmonary tuberculosis were notified among 21 951 National Health Service staff working in the Lothian area during the 6 years 1978–1983. Eight of the 23 cases were detected by pre-employment screening. Five further cases were detected during employment by voluntary chest X-ray screening. During the same period a further 10 cases presented with symptoms, suggesting that voluntary screening during employment was relatively unproductive in the detection of new cases.
There was no evidence of an increased risk of pulmonary tuberculosis in most occupational groups of Health Service staff; the average annual incidence during employment was 11/105 overall with 9/105 in nurses and 23/105 in doctors, rates very similar to the local population of working age. However two cases occurred in 300 medical laboratory technicians giving a much higher incidence of 111/105 (p<0.005).
Vingt-trois (23) nouveaux cas de tuberculose pulmonaire ont été notifiés parmi les 21 951 employés du Service national de Santé de la Région du Loth en 6 ans (1978–1983). Huit (8) de ces 23 cas ont ete depistes lors de I'examen d'embauche; cinq (5) autres cas ont été dépistés pendant la période d'emploi par des examens radiographiques volontaires.
Pendant la même période, 10 autres personnes ont présenté des symptômes, ce qui suggère que le rendement de I'examen volontaire pendant la période d'emploi s'est montré relativement bas en vue de la détection de nouveaux cas.
Il nest pas apparu qu'il existait un risque accru de tuberculose pulmonaire pour la plupart des groupes professionnels du Service national de Santé. Le taux moyen d'incidence annuel pendant la periode d'emploi a été de 11/100 000 pour l'ensemble du personnel, de 9 pour 100 000 pour les infirmières et de 23 pour 100 000 pour les médecins.
Ces taux sont très similaires à celui de la population locale en âge de travailler.
Néanmoins, deux cas ont été détectés parmi les 300 technicians de laboratoires médicaux, ce qui donne une incidence beaucoup plus élevée de 111/100000 (p<0,005).
En 6 años (1978–1985) se notificaron 23 casos nuevos de tuberculosis pulmonar entre los 21 951 empleados del Servicio National de Salud de la regiòn de Loth. De estos 23 casos, 8 fueron detectados en el examen previo al empleo; otros 5 durante el período de empleo por exámenes radiográficos voluntarios.
Durante este mismo período otras 10 personas presentaron síntomas, to que sugiere que el rendimiento del examen voluntario durante el período de empleo fue relativamente bajo para la detección de casos nuevos.
No hubo evidencias de que existiera un aumento del riesgo de tuberculosis pulmonar en la mayoría de los grupos profesionales del Servicio Nacional de Salud. La tasa promedio de incidencia anual durante el periodo de empleo fue de 11/100 000 para el conjunto del personal, de 9/100 000 para las enfermeras y de 23/100 000 para los médicos. Estas tasas son similares a la de la población local en edad de trabajo.
Sin embargo, se detectaron 2 casos entre 300 técnicos de laboratorios médicos, lo que da una incidencia mucho más elevada de 111/100000 (p<0,005).