Table of Content

10 October 2012, Volume 34 Issue 10

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Analysis of referral and tracing of pulmonary tuberculosis cases reported by non -TB institutes from internet-based infectious disease reporting system from 2009 to 2011 in Miyun county

TANG Xiao-li，CHEN Xi

Chinese Journal of Antituberculosis. 2012, 34(10):  629-632. 

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Objective  To understand the situation of referral and tracing of pulmonary tuberculosis (PTB) cases reported by non-TB institutes from internet-based infectious disease reporting system from 2009 to 2011 in Miyun county in order to explore the measures to improve case detection.   Methods  TB control monthly reports, quarterly report and annual reports of Miyun county from 2009 to 2011 were collected and analysed, 523 PTB cases and suspects were reported by non-TB institutes during that period.   Results  68.6% (359/523) of the cases reported in internet-based infectious disease reporting system did not take sputum exam. The referral rate was 100.0%, the referral arrival rate was 65.2% (341/523) and tracing arrival rate was 66.7% (64/96). The tracking arrival rate were 82.1% (23/28), 73.0% (27/37) and 45.2% (14/31), respectively in 2009, 2010 and 2011, which were declined year by year (χ²_trend=10.1, P<0.05). The overall arrival rate was 93.9% (491/523). Among patients arrived in TB dispensary, 58.0% (285/491) were confirmed as pulmonary tuberculosis.   Conclusion  Non-TB institutes play an important role in TB case detection. Standardized working mechanism of TB recording, reporting and referral should be established, and sputum examination rate should be increased to improve PTB case detection.

The study on the filter efficiency and wearing time of medical protective mask

DU Jian, YUE Shu-min, XIE Zhong-yao, MA Yan, JIANG Xiao-ying, MI Feng-ling, GAO Jing-tao, GAO Wei-wei, LI Qi, LI Liang

Chinese Journal of Antituberculosis. 2012, 34(10):  633-636. 

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Objective  To test the filter efficiency and respiratory resistance of N95 medical mask, surgical masks and gauze masks（12 layer and 24 layer）before wear, test the filter efficiency and respiratory resistance change of N95 masks with different wearing time，and to provide a guidance for respiratory protection of respiratory infectious diseases.  Methods  Filtration efficiencies and respiratory resistances of 52 D32-N95 medical masks, 50 general surgical masks，42 12-layer gauze masks and 51 24-layer gauze masks, which were all produced by a science and technology development company were tested before wear by TSI-8130 produced by TSI Company of United States, the test method was the same as that used by NIOSH-N95 and National standard GB 19083-2010. N95 masks were worn half day, 1 day, 2 days  until 7 days  and 14 days（Taking four hours of woking time as 0.5 day） respectively, the filtration efficiency and respiratory resistance were tested within one hour after wear.  Results  The filter efficiency of N95 masks was 97.4%， 32.3% for 12-layer gauze masks, 43.9% for 24-layer masks and 18.4% for surgical masks, the differences were statistically significant (F=4511.5, P<0.05). N95 masks’ filtration efficiency were still more than 95% after wearing two days, more than 90% on the sixth day and more than 80% on the fourteenth day. According to the mathematical model, the filter efficiency of N95 masks was still higher than that of 24-layer of gauze masks (43.9%) after wearing 45 days. The respiratory resistances of different masks changed little and were less than 14 mmH₂O (1 mmH₂O=0.0098 kPa) on the fourteen day, which were lower than the national standard of 35 mmH₂O.  Conclusion  The filter efficiency of N95 mask is much higher than those of gauze masks and surgical masks, it can be used for longer time, and can be used in the field of respiratory disease control.

Preliminary study on school tuberculosis group infection control strategy

LU Xi-wei, SONG Qi-sheng, LIU Zuo-guang, WANG Cui, SHEN Jie

Chinese Journal of Antituberculosis. 2012, 34(10):  637-641. 

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Objective  To evaluate the effect of TST and IGRA in the assessment of tuberculosis (TB) group infection, and to explore the optimal strategy on TB group infection.  Methods  513 contacts in an outbreak of TB were divided into 6 groups according to the degree of exposure, the number of contacts in each group with decreasing degree of exposure (from 1 to 6) were 47, 81, 110, 90, 122 and 63 respectively. All contacts were tested by TST and IGRA jointly. Multiple logistic regression statistics was applied to analyse the correlation between Mtb infection criteria (PPD≥10 mm、PPD≥15 mm、PPD conversion and IGRA-positive) and degree of exposure. After exclusion of 40 contacts who were taking preventive treatment, binary logistic regression was used to determine high risk factors for secondary cases (a total of 19 secondary cases). Incidence rates  of different exposure degrees and infection criteria were compared, as well as the evaluation of the pros and cons of various infection control plan.  Results  PPD≥10 mm, PPD≥15 mm, PPD conversion and IGRA-positive  are closely related to the exposure level (6 levels), P<0.05,  OR values were 1.78 (95% CI: 1.14 to 2.78), 1.01 (95% CI: 0.69 to 1.47) and 2.84 (95% CI: 2.01 to 4.01). IGRA-positive (P=0.03,  OR=3.63) and the degree of exposure (P=0.00,  OR=2.77) are high risk factors for secondary cases. Secondary attack rates of high exposure (L1-L2), medium exposure (L3-L4) and low exposure (L5-L6) were 13.3% (13/98), 3.2% (6/190) and 0.0% (0/185) respectively. The secondary attack rate of a high close contact level was higher than the low exposure levels, there was  statistical significance, χ²=29.85,  P<0.05. The incidence rate of IGRA positive group (8.3%,15/180) was significantly higher than that of the IGRA negative group (1.4%,4/293), which was statistically significant, χ²=14.04，P＜0.05. For high exposure level (1st level), chemoprevention were provided for all contacts regardless of TST and IGRA results, for other groups contacts with positive IGRA were the objects of preventive treatment, the sensitivity of the prediction of TB was 94.7% (18/19) and specificity was 46.1% （124/269）, positive likelihood ratio was 1.8 and negative  likelihood ratio was 0.1, which was in line with the principle of the best benefits.  Conclusion  IGRA in the diagnosis of tuberculosis infection and incidence prediction is better than TST. Degree of exposure and IGRA positive are important references for the development of TB group infection control strategy.

Exploration and effect evaluation of the intervention of providing transportation subsidies to pulmonary tuberculosis patients in two counties in China

CHEN Qiu-lan，ZHOU Lin，WANG Ni，HU Dai-yu，LI Fang，CHEN Ming-ting

Chinese Journal of Antituberculosis. 2012, 34(10):  642-646. 

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Objective  To confirm the necessity and to explore the standard and proper way of providing transportation subsidies to pulmonary tuberculosis patients, in order to provide evidence for relative policy development.  Methods  Field test method was used: all of the 425 new smear positive tuberculosis patients(NSP) detected from April 1st to December 28th in 2008 both in Wuxi County and Shen County were selected as the intervention group, and 410 NSP registered in the corresponding period in 2007 as the control group. The transportation subsidies were given to the intervention group throughout the treatment period but in different ways in the two counties. Sputum examination rate at the end of 2nd, 5th and 6th month of treatment and on time drug taken rate were used to evaluate the effect. EpiData 3.0 and SPSS 11.5 were used to input and analyze the data. Descriptive statistics was used to analyze the socio-demographic characteristics of the subject investigated and chi-square test was applied to compare the treatment compliance between the two groups.  Results  The NSP in Wuxi County and Shen County needed (30.6±20.0) RMB and (22.2±10.1) RMB for one round trip respectively. 55.5% (231/416) of all the NSP reported that they couldn’t afford the traffic fees for 3-4 times follow-up during the treatment period. The average amount of the traffic subsidies provided to the NSP in Wuxi County and Shen County were (86.8±46.6) RMB and (59.2±23.3) RMB respectively. The sputum examination rate at the end of the 2nd month of treatment ［（Wuxi County χ²=67.523，P<0.05）,（Shen County  χ²=5.776，P<0.05）］ and the rate of on time drug taken ［（Wuxi County χ²=413.172,  P<0.05）,（Shen County  χ²=88.615，P<0.05）］during treatment period of the intervention group were higher than the control group. In Shen County the sputum examination rate at the end of the 5th （χ²=5.136,  P<0.05）and 6th treatment month (χ²=14.479,  P<0.05）of the intervention group were also higher than the control group. The vast majority of field staff considered that the implementation of transportation allowance was successful, as it helped the patients solve the practical difficulties and motivated patients to improve their treatment adherence.  Conclusion  The transportation subsidies could improve the patients’ adherence to treatment. The standard of the subsidy should be set according to the distance between patients’ home and the local TB dispensary, and it should be distributed at the beginning and after the complement of treatment.

The operational research of referral arrival rate of pulmonary tuberculosis patients in general hospitals of Yuexiu District, Guangdong

LIANG Zhi-qiang, SONG Tao,LIU Guo-biao,LI Xiao-yan,BAO Wan-ling

Chinese Journal of Antituberculosis. 2012, 34(10):  647-650. 

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Objective  To analyze the reporting, referral, and tracking in place situation of TB patients and suspected TB patients in Guangzhou Yuexiu District general hospitals, and explore the measures of improving TB patients referral in place rate.   Methods  We collected the reporting and referral records and case information of pulmonary TB patients reported by 31 general hospitals and 22 community health service centers between January 2008—2010 December 31 to analyze the changes of rates of referral, in place and total arrival, and the reasons.   Results  From 2008 to 2010, a total of 2988 cases of pulmonary TB and suspected TB were reported. Through referral and tracking, the overall in place rate was 87.75%, 66.51%(433/651)，92.21%(1054/1143) and 95.06%(1135/1194) respectively in each year from 2008 to 2010. The trend test showed a statistically significant difference(χ²_trend=364.42，P<0.05). Among the patients reported, 1467 were referred in place with the referral in place rate of 49.10%. The remaining 1521 were tracked by TB institutions, and the tracking in place rate was 75.94%. This rate rose gradually from 38.07%(134/352) in 2008 to 84.49%(485/574) in 2009, and reached 90.08%(536/595) in 2010. The trend test also showed a significant difference (χ²_trend=353.68，P<0.05). The main reasons for tracking not in place including 242 cases of wrong names or addresses, accounting for 66.12%（242/366）, 9.84%（36/366）of returning to hometown, 3.55%(13/366) of declining the treatment, 11.75%（43/366） of death, and 8.20%（30/366）of other reasons.   Conclusion  We should strengthen the cooperation between TB control institution and the general hospital, and referral management in general hospital, hence to improve the referral in place rate of TB patients.

The application of mobile phone text messages on the management of compliance of TB patients

LU Feng, XU Hong, FU Jian

Chinese Journal of Antituberculosis. 2012, 34(10):  651-654. 

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Objective  To evaluate the effect of mobile phone model of case management subproject of China MOH-Gates project, and provide reference for promotion of mobile phone text messages on the management of TB cases.   Methods  During the project implementation period, a total of 533 new pulmonary TB patients were diagnosed in Chongchuan and Tongzhou district of Nantong city, among which 270 were enrolled in Gates project. According to the digit table method, 100 cases were randomly selected in Gates-group and non-Gates group respectively as case and control group to investigate their treatment compliance at the end of intensive period and treatment completion.   Results  At the end of 2-month intensive period,94.0%（94/100） and 79.0%（79/100） of patients took medicine regularly in the case and control group respectively, and the difference is statistically significant(χ²=144 508.67，P＜0.05); 92.0%（92/100）and 75.0%（75/100）of patients returned the clinic for follow-up examination timely, the difference is statistically significant (χ²=10.49，P＜0.05). While at the end of 6-month treatment, the rates of regularly taking medicine were 84.0%（84/100） and 48.0%（48/100）respectively, and the difference is statistically significant(χ²=28.87，P＜0.05); so is the rates of follow-up examination on time, 81.0%（81/100） and 40.0%（40/100） respectively(χ²=35.17，P＜0.05).    Conclusion  The patients managed by mobile phone text messages has better compliance than the control group, therefore this mode should be promoted.

The analysis of TB aggregation epidemic of a tuberculosis outbreak in a middle school through combination methods of molecular epidemiology and traditional survey

LI Jian-cui, WANG Yan-ju, SHI Yan-xi, WANG Xiu-zhen, LI Xue-zheng, WANG Hai-ying

Chinese Journal of Antituberculosis. 2012, 34(10):  655-658. 

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Objective  To analyze the TB aggregation epidemic situation of a school TB outbreak in Ji’ning city of Shandong.    Methods  We performed tuberculin skin test and symptom screening to 3254 students for detecting latent and active TB in the school. The M. tuberculosis isolates were genotyped by 24-locus MIRU-VNTR. Using the logistic regression analysis, we analyzed the relationship between exposure levels to the culture positive cases and the possibility of being diagnosed as latent or active TB.   Results  The rate of latent tuberculosis infection was 28.8% in the middle school students, a total of 10 active cases were diagnosed, among which 3 of them were culture positive. The results of 24 points MIRU-VNTR genotyping showed that two isolates were clustered. One isolate had three different hypervariable loci: Mutub4, Mtub21 and QUB-26. The logistic regression analysis indicated that being the same class or the same grade with the three culture positive cases are risk factors for both latent and active TB.   Conclusion  The three culture positive cases may caused certain level of transmissions, which may lead to the outbreak of the other seven active TB cases. Therefore, the timely diagnosis and effective treatment of student cases and timely TB screening are important to control the TB outbreaks in schools.

CT manifestations and diagnosis of bronchial tuberculosis with mucus impaction

YU Hui-shan, LI Bao-xue, QIN Li-xin, JING Qiu-sheng, LI Jing, ZHOU Chun-hua, TIAN Kui, SHA Jin-lu

Chinese Journal of Antituberculosis. 2012, 34(10):  659-663. 

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Objective  The CT manifestations and features of endobrochial tuberculosis (EBTB) complicated by mucous plug impact (MPI) were analyzed in order to improve the levels of imaging diagnosis.   Methods  CT features and morphological characteristics of 25 cases of EBTB complicated by MPI who were confirmed the diagnosis by fiberoptic bronchoscopy was analyzed.   Results  There were typical CT features in EBTB complicated by MPI: (1)Direct signs: 10 cases (40.0%) of crotch-like shadow, 8 cases (32.0%) of squeezing toothpaste-like shadow, 7 cases (28.0%) of glove-like shadow. (2) Distribution and morphology of lesions:  irregular lumpy shadows distributed in interior 2/3 lung fields in each lobe, lesions are expansive, with sharp edges, and concentrically distributed. (3)Characteristic of accompanied signs: around the main lesions, 23 (92.0%) cases surrounded by multiple punctate and small pieces of satellite lesions, 13 (52.0%) patients had chronic formation process, like concentrated lung-markings in focals, reduced lung volume, and emphysema. 6 cases (24.0%) with CT examination showed the left or right main bronchus stenosis. (4)Characteristic of enhanced CT: CT valuation of mass focals of 12 patients was less than 20HU for enhanced CT. After the regular anti-TB treatment, all 25 patients had good therapeutic effect.   Conclusion  EBTB complicated by MPI could display crotch, squeezingtoothpaste or glovelike signs. Mastering the CT manifestations and features is conducive to improve the imaging diagnosis levels of EBTB complicated by MPI.

Analysis on direct medical expenses and its financial burden of pulmonary tuberculosis patients in Shanghai

WU Lai-wa, YAN Fei, WANG Wei, JIA Huan, SHEN Xin, MEI Jian

Chinese Journal of Antituberculosis. 2012, 34(10):  664-669. 

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Objective  To understand the direct medical expense for diagnosis and treatment of pulmonary tuberculosis (PTB) patients and its financial burden on family in Shanghai, and to provide evidence for improving TB derating policy.   Methods  Seven districts in Shanghai were selected, and 491 pulmonary TB patients who had completed treatment were investigated by questionnaire. Information about the social economic conditions and direct medical expenses was collected. Ranksum test was used for analysis of patients’ social economic conditions and medical expenses.   Results  The medians (inter-quartile range) of TB patients’ total direct medical expenses and the derating proportion were 4000 (2500, 10 500) yuan/person and 54.9% (32.3%,70.0%) respectively. 34.4% of patients (169/491) had been hospitalized. There was significant difference between total direct medical expenses of outpatients and oncehospitalized patients (Z=-16.059,  P=0.000), the medians (inter-quartile range) of which were 3000(2000, 4000) yuan/person and 14 955(9200, 21 705) yuan/person respectively. The derating proportion of the total direct medical expenses in smear-positive patients was higher than that in smear-negative patients (Z=-2.092, P =0.036), the medians (inter-quartile range) of which were 57.1% (40.0%,71.5%) and 52.1%(25.0%,69.2%) respectively. There was significant difference between the ratio of out of pocket medical fee to family net per-capita income in outpatients and once-hospitalized patients（Z=-7.463, P=0.000）, the medians (inter-quartile range) of which were 9.4%(3.8%,18.0%) and 29.5%(14.8%,89.2%) respectively.   Conclusion  The diagnosis and treatment expenses of TB patients in Shanghai were relatively high, which resulted in a heavier financial burden to the patient’s family.

Study on the rifampicin-dependent characteristics of Mycobacterium tuberculosis clinical isolate

JIN Hai-xia, FU Lei, WANG Bin, ZHENG Mei-qin, LU Yu

Chinese Journal of Antituberculosis. 2012, 34(10):  670-675. 

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Objective  To validate the rifampicin (RFP)dependent characteristics of M. tuberculosis clinical isolate in mice, and identify the characteristics of RFPdependent strains.   Methods  RFP-dependent strains were selected from RFP-resistant clinical isolates on 7H11 medium (the final concentrations of rifampicin were 1 μg/ml and 10 μg/ml). The dependence was further studied in mouse TB model, in which the mice were treated with 0.5% carboxymethyl cellulose sodium (control group), 10 mg/kg rifabutin (Rfb₁₀ group), 10 mg/kg RFP (RFP₁₀ group) and 20 mg/kg RFP (RFP₂₀ group), respectively. The differences of rpoB gene mutations between RFP-dependent and non-dependent strains were analyzed.   Results  18 of 46 RFP-resistant isolates were RFP-dependent. After treatment with RFP or Rfb for 8 weeks in mouse model challenged by aerosol with RFP-dependent clinical isolate，the lung CFU counts showed a concentration-dependent increase (RFP₂₀ group lgCFU were 6.60±0.82, RFP₁₀ group 6.44±0.36、Rfb₁₀ group 6.32±0.55、control group 6.20±0.28)，but there were not significant difference in comparasion with control group (F value were 0.68, 2.21, 2.45, P>0.05). Five of 8 RFP-dependent strains and 10 of 11 non-dependent strains had mutations of  rpoB codon 526 and 531, respectively.   Conclusion  RFP-dependent strains did exist and showed a high prevalence, and the dependence was further validated in mouse TB model. The RFPdependent and non-dependent strains had common rpoB mutations, whether the dependence is a result of phenotype variation needs more evidence.

Skin test with Mycobacterium tuberculosis recombinant ESAT6-CFP10 protein in Guinea pigs sensitized with mycobacteria

PU Jiang, TAO Li-feng, DENG Hai-qing, WANG De-hai

Chinese Journal of Antituberculosis. 2012, 34(10):  676-680. 

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Objective  To study skin test with Mycobacterium tuberculosis recombinant ESAT6-CFP10 protein in Guinea pigs sensitized with several clinical common pathogenic mycobacteria and environmental mycobacteria.   Methods  Guinea pigs were infected by subcutaneous inguinal injection with 16 kinds of live mycobacterial liquids, respectively. There were 5 Guinea pigs each group. After 3 to 4 weeks, the Guinea pigs were injected intradermally with 0.1 ml of TB-PPD, PPD-B and the recombinant protein ESAT6-CFP10, respectively. The longitudinal and transverse diameters of local indurations were observed at 24 h and 48 h after the injection. The skin test were determined as positive result when average diameter was ≥5 mm at 48 h after the injection.  Results  In PPD-B group, the skin tests of Guinea pigs sensitized with 16 kinds of mycobacteria were all positive. In TB-PPD group, the skin tests of Guinea pigs sensitized with M. tuberculosis, M. bovis, M. africanum, M. bovis BCG were also positive. In ESAT6-CFP10 group, the skin tests of Guinea pigs sensitized with M. tuberculosis, M. bovis and M. africanum were positive, other Guinea pigs sensitized were negative.  Conclusion  Mycobacterium tuberculosis recombinant ESAT6-CFP10 protein can improve the specificity of Mycobacterium tuberculosis infection diagnosis.

Research progress of clarithromycin resistance mechanism of rapidly growing mycobacteria

WU Bi-tong，TAN Shou-yong，CAI Xing-shan，KUANG Xiao-jia

Chinese Journal of Antituberculosis. 2012, 34(10):  681-683. 

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