RESUMEN
In a remote region of western Alaska where tuberculosis (TB) incidence remains relatively high, a rapid molecular detection assay (Xpert MTB/RIF) was introduced four years ago with goal of improving the ability to diagnose active pulmonary tuberculosis (TB). Our aggressive testing programme was intended for all patients acutely evaluated for pulmonary TB at our regional hospital and multiple clinics over a large area. All 223 consecutive patients evaluated for active pulmonary TB were tested with Xpert MTB/RIF (Xpert) per our protocol of which 192 (86.1%) had at least one additional (paired) sputum sample collected for standard acid-fast bacilli (smear) microscopy and culture. Fourteen patients eventually became culture-positive for Mycobacterium tuberculosis (MTB), all but one having initially tested positive (MTB detected) by Xpert (sensitivity 92.9%). All remaining culture-negative individuals had tested negative (not detected) by Xpert (specificity 100%). By contrast, smear microscopy sensitivity and specificity was 64.3% and 98.9% respectively. This represents the addition of four active TB patients detected by Xpert over smear. In remote regions, the ability of Xpert to quickly and reliably detect TB while determine which patients are not contagious represents a huge healthcare savings as in most cases these patients will not require hospitalized isolation.
Asunto(s)
Esputo/microbiología , Tuberculosis Pulmonar/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Alaska , Regiones Árticas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Mycobacterium tuberculosis , Sensibilidad y Especificidad , Factores de Tiempo , Adulto JovenRESUMEN
BACKGROUND: The process by which active pulmonary tuberculosis (TB) is detected can be tediously slow in rural and often roadless Alaska, where several hundred air or boat miles can separate a patient from a chest x-ray and/or sputum collection. Additionally, the only TB reference lab in the state is many hundreds of air miles away, albeit centrally located in Anchorage. Under such conditions, it may take up to a week to process serial sputum AFB smears. This can result in either delayed onset of treatment or unnecessary empiric treatment, all while safety for the community is being considered. This dilemma often results in precautionary hospital isolation of a patient who might otherwise have been able to travel home by air. This article proposes a roadmap for remote health care settings that might bridge our current TB diagnostic ability to a better way in the future. METHODS: Current TB diagnostic guidelines in our area (Yukon-Kuskokwim Delta) were reviewed for integration of the Xpert MTB/ RIF assay with the purpose of improving TB health care while emphasizing patient benefits and cost savings. RESULTS: A clinical guideline that integrates the rapid TB assay into the current TB diagnostic algorithms for adults and adolescents is proposed. Crude cost savings at our hospital resulting from this guideline are estimated to be $316,000 per year. CONCLUSION: The proven utility of a new rapid TB diagnostic, the Xpert MTB/RIF assay, offers the promise of more efficient TB medical care, improved patient human rights and improved hospital and community environmental safety, all with likely huge reduced health care costs in remote Alaska.
Asunto(s)
Mycobacterium tuberculosis/aislamiento & purificación , Reacción en Cadena de la Polimerasa , Población Rural/estadística & datos numéricos , Tuberculosis Pulmonar/diagnóstico , Tuberculosis Pulmonar/epidemiología , Adolescente , Adulto , Alaska/epidemiología , Diagnóstico Precoz , Guías como Asunto , Costos de la Atención en Salud , Humanos , Mycobacterium tuberculosis/genética , Reacción en Cadena de la Polimerasa/métodos , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Sensibilidad y Especificidad , Esputo/microbiología , Tuberculosis Pulmonar/economía , Tuberculosis Pulmonar/microbiologíaRESUMEN
BACKGROUND: A brief but comprehensive TB elimination program began in a remote region of Taiwan in 1997 involving five contiguous villages (n=2308). METHODS: An aggressive intervention included tuberculin skin testing and treatment of latent TB infection. Normal program data was collected and later analyzed forming the basis of an operational research study. RESULTS: An initial 31% reduction in active TB cases (81 to 56 over 4 years) (p=0.033) was observed and persisted until the end of the 10-year follow-up period despite no further intervention. In the control population, no sustained reduction of TB was noted for the same period. CONCLUSIONS: Although encouraging, a more robust study is needed to reasonably attribute the persistence of this significantly lower TB rate to this brief intensive intervention.