Contacts Screening of Multidrug-Resistant Tuberculosis Patients

Every single person on the planet wishes to be well. Various diseases have afflicted humanity since the dawn of time, and millions of people have died due to these diseases. Among these diseases, infectious diseases are a disease which transmits from one person to another. Screening of household contacts for these infectious diseases is of much importance. Of all infectious disease household contacts screening of Tuberculosis (TB) and Multidrug-Resistant Tuberculosis (MDR-TB) Patients is very important. It is because that this disease poses a real danger to all efforts of health authorities of the world.

Tuberculosis

There are different types of infectious disease. Among these, Tuberculosis (TB) is one of the most terrible diseases which killed millions of people throughout the world. TB is present since ancient times, and some researchers concluded that TB is also present in Egyptian Mummies. This disease is related to the weak immune system of an individual. From ancient times different organizations and different government bodies start efforts for its control. Due to all these efforts, TB disease became controlled in many parts of the world. But unfortunately, TB resurgence in many parts in the form of drug-resistant TB (DR-TB).

Multidrug-resistant tuberculosis (MDR-TB)

Among DR-TB, Multidrug-resistant tuberculosis (MDR-TB) is one of the most severe cases that affect all these TB control program efforts. The responsible strains for MDR-TB are such strains of Mycobacterium tuberculosis (MTB) that is resistant to at least two 1st line anti-TB drugs, i.e., isoniazid (INH) and rifampicin (RMP). The occurrence of this resistance strain of MTB poses a severe threat to ongoing national TB control programs. 

MDR-TB is mainly man-made, and it most often occurs due to an ineffective treatment regimen, a lack of patient compliance, and a lack of patient awareness about therapy. Besides these factors, some other factors are also remaining challenging and help this resistant MTB spread in the community. Close contact with the patient is one of the most critical risk factors for MDR-TB. 

Contacts Screening of Multidrug-Resistant Tuberculosis Patients

Close contact includes household contacts and other near friends and colleagues of the patients who share different things for a long time. These close contacts in the community promote the transmission of these resistant strains from an already infected person to normal healthy individuals. MDR-TB patients’ close relatives are more likely to contract DR-TB. However, various studies on the risk of TB in close contacts of drug-susceptible and MDR-TB patients have shown contradictory results. 

Pakistan is one of the top listed countries, ranking 4th among the top 22 MDR-TB countries. Due to such a high rate, there is no data on the incidence of TB/MDR-TB among household contacts of MDR-TB patients is available from Pakistan to date. For this reason, this study was conducted to determine the occurrence of TB either in the form of susceptible TB or MDR-TB in household contacts of MDR-TB patients enrolled for treatment under Programmatic Management of Drug-Resistant TB treatment design. 

This study was a cross-sectional study conducted over a period of 3 years from May 2012 and May 2015. The study population included household contacts of all MDR-TB patients registered under the Programmatic Management of Drug-Resistant TB Unit, Lady Reading Hospital Peshawar (PMDT-LRH), Pakistan, who were initiated on MDR-TB treatment from January 2012 to December 2012. During this period, all index cases received supervised ambulatory treatment with second-line drugs and monthly food baskets, and travel incentives.

Household contacts were defined as individuals who had shared the same kitchen and sleeping area as the index case for at least three months before diagnosing the index case and included spouses, children, parents, siblings, and other relatives (uncles, grandfathers, cousins). A Treatment Coordinator Hospital DOTS Linkages (Treatment Coordinator HDL) conducted home visits to create a liaison between these patients with their district TB control officer, nearest DOTS center, and their treatment PMDT site. Another aim for this visit is to take care of infection control measurement at the patient’s house and to trace and motivate all household contacts to visit their nearest DOTS center to undergo the study investigations. During this visit, all household contacts were screened for disease, i.e., TB/MDR-TB.

Findings of Household Contacts Screening of Multidrug-Resistant Tuberculosis Patients

Results of this study showed that contacts of a total of 154 MDR-TB patients were screened. A total of six hundred and ten household contacts were screened during this study. Among study cases, 52% of contacts were female gender, whereas the remaining 48.0% were male MDR-TB patients. Of them, 67.6% of study cases were from rural areas, and 66.8% were married. Among contacts, 58.4% were female, and 42.6% were male, of which 61.9% were from rural areas, whereas 33.0% were married at the time of this study.

Four hundred and fifty-nine (75.2%) of the contacts have an age range from 15 to 44 years which are the most vulnerable age group of the community, whereas the majority of the index case 119 (77.3%) also belonged from the same age group, i.e., 15–44 years. In both cases, the leading productive group of a community (15–44 years) was affected.

Sputum smear microscopy was performed from 235 (38.5%) contacts, whereas the remaining 375 (61.5%) were unable to provide sputum. Chest X-ray was performed in 225 contacts. Sputum for AFB yielded a negative result for 184 (78.3%) cases, while it was positive in 51 (21.7%). All sputum-positive and other suspected cases were referred to the PMD-LRH unit for Xpert testing and Drug susceptibility testing (DST). Xpert and DST results of 41 (17.4%) contacts declared MDR-TB, whereas 10 (4.2%) were declared drug-susceptible TB.

Among 610 screened contacts, 218 (35.73%) were symptomatic. The most common symptoms found during this study were;

• Cough in 220 (91.7%) cases,
• Fever in 80 (36.7%) cases,
• Loss of appetite in 78 (35.7%) study cases,
• Hemoptysis in 28 (12.8%) cases,
• History of loss of weight was present in fifty-three (n = 53) contacts.

MDR-TB patients included in the study resided in houses with an average of 2 rooms. Their monthly income is less than 10 000 Pakistani rupees. Cough was reported by all MDR-TB index cases. The cavitary disease was present on the initial chest X-ray in 92% of the MDR-TB index cases.

MDR-TB interactions in the home pose a higher risk of contracting active TB and MDR-TB. However, there has been some inconsistency in data on TB/MDR-TB infection rates among MDR-TB contacts. There are few studies on disease and infection among MDR-TB patients’ contacts in Pakistan.

Impact of Early Detection of Ill Cases

The early detection of MDR-TB and prevention of transmission to close contacts are two primary programmatic goals of PMDT in managing MDR-TB. The present research uncovered a high prevalence of MDR-TB among MDR-TB cases’ household contacts. As the rate of MDR-TB is much higher among ill people, this needs special attention.

Tuberculosis (TB) still exists in low and middle-income countries, and the situation worsens in a few parts of the world. Therefore, a unique investigation process is needed for a higher detection rate and disease control. Disease prevalence is exceptionally high in these areas, reaching up to 22%. This condition worsens in areas where the HIV prevalence is high. In such areas rate of the disease is up to nine times higher than in areas where passive case finding is used.

A genetic study told us about the genetic transmission of any disease, and the limitation of this study was that it is not a genetic study, so we were unable to determine whether an indication caused the infection or not. There is, however, sufficient evidence that MDR-TB can be transmitted from one person to another. Primary transmission is thought to be responsible for half of all MDR-TB cases worldwide. Furthermore, since most index cases were reversal cases, transfers could have taken place sooner, when the patients were at risk of a drug overdose.

The contact and control techniques used in this study revealed a range of operational issues. About one-third of contacts having coughs for more than two weeks were unable to produce sputum samples for processing. This study showed that some contacts were unable to generate sputum on time. Similarly, several others contacts were not at home when the Treatment Coordinator HDL visited. This study reports careful consideration of timed monitoring and diagnosis of all cases required.

While in high-risk areas, family members with MDR-TB are more likely to become infected individually. There is no evidence present for the probability that two family members with MDR-TB will pose the same types of infected particles. Particular guidelines are present for dealing with contacts of MDR-TB patients, which is very helpful in making public health policy. This international guideline recommends conventional second-line drug treatment based on a treatment of index case of the contacts. 

Importance of Study

This study is being conducted for the first time in Pakistan. And this study is also among a few from developing countries regarding MDR-TB transmission among household contacts. This study provides valuable information that could serve as a base for planning on a larger scale.

This study also focused on the importance of early detection of TB in household contacts of MDR-TB, who represent the most vulnerable group. It is hoped that early detection and treatment of possible cases will eventually reduce disease, mortality, and the spread of infection in the community. 

This study also suggests that effective follow-up of home contacts of MDR-TB cases may impact the diagnosis and treatment of MDR-TB. Surely this could be a very effective way to save more lives. This also may help in cut down the chain of transmission in the community. 

Origin of Household Contacts Screening of Multidrug-Resistant Tuberculosis Patients Research Study

This study about Household Contacts Screening of Multidrug-Resistant Tuberculosis Patients originally conducted at Programmatic Management of Drug-Resistant TB unit, Lady Reading Hospital Peshawar, Pakistan, and published in Asian Pacific Journal of Tropical Medicine. Authors for this study are; Arshad Javaid, Mazhar Ali Khan, Mir Azam Khan, Sumaira Mehreen, Anila Basit, Raza Ali Khan, Muhammad Ihtesham, Irfan Ullah, Afsar Khan, Ubaid Ullah. This study may be cited as; Javaid A, Khan MA, Khan MA, Mehreen S, Basit A, Khan RA, Ihtesham M, Ullah I, Khan A, Ullah U. Screening outcomes of household contacts of multidrug-resistant tuberculosis patients in Peshawar, Pakistan. Asian Pacific journal of tropical medicine. 2016 Sep 1;9(9):909-12. Click here for the complete study.