Tuberculosis-related deaths within a well-functioning DOTS control program. (Research).
To describe the molecular epidemiology molecular epidemiology Molecular medicine An evolving field that combines the tools of standard epidemiology–case studies, questionnaires and monitoring of exposure to external factors with the tools of molecular biology–eg, restriction endonucleases, of tuberculosis (TB)-related deaths in a well-managed program in a low-HIV area, we analyzed data from a cohort of 454 pulmonary TB pulmonary TB Pulmonary tuberculosis, see there patients recruited between March 1995 and October 2000 in southern Mexico. Patients who were sputum sputum /spu·tum/ (spu´tum) [L.] expectoration; matter ejected from the trachea, bronchi, and lungs through the mouth.
sputum cruen´tum bloody sputum. acid-fast bacillus bacillus (bəsĭl`əs), any rod-shaped bacterium or, more particularly, a rod-shaped bacterium of the genus Bacillus. Some bacterium in the genus cause disease, for example B. smear positive underwent clinical and mycobacteriologic evaluation (isolation, identification, drug-susceptibility testing, and IS6110-based genotyping Genotyping refers to the process of determining the genotype of an individual with a biological assay. Current methods of doing this include PCR, DNA sequencing, and hybridization to DNA microarrays or beads. and spoligotyping) and received treatment from the local directly observed treatment Directly Observed Treatment (DOT) or Directly Observed Therapy is watching the patient take his/her medication to ensure medications are taken in the right combination and for the correct duration. strategy (DOTS) program. After an average of 2.3 years of follow-up, death was higher for clustered cases (28.6 vs. 7%, p=0.01). Cox analysis revealed that TB-related mortality hazard ratios included treatment, default (8.9), multidrug resistance multidrug resistance,
n the adaptation of tumor cells or infectious agents to resist chemotherapeutic agents. (5.7), recently transmitted TB (4.1), weight loss (3.9), and having less than 6 years of formal education (2). In this community, TB is associated with high mortality rates.
In both humanistic and economic terms, the cost of deaths due to tuberculosis (TB) is staggering. In 1990 alone, approximately 2.5 million people died of TB, accounting for >25% of avoidable adult deaths in the developing world (1,2). Directly observed treatment strategy (DOTS), a comprehensive approach to TB control, is one of the most cost-effective health interventions available (3,4). In the context of a well functioning DOTS program, cure rates in excess of 80% can be expected. While these outcomes are assumed to decrease mortality rates, the detailed epidemiology of deaths in a well-functioning DOTS program by using modern molecular techniques has not been described.
Since 1995, we have conducted a population-based molecular epidemiologic study epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect of TB in a health district in southern Mexico. Previous reports have documented the TB control program approaches World Health Organization benchmarks (5) and drug resistance is considerable and has an important negative impact on treatment outcomes (6). We now report the short- and long- term mortality rates due to TB in this cohort of TB patients. These data suggest that, as has been described with other diseases, excess mortality may persist for months or years after treatment completion, default, or failure (7,8).
The study site, described previously (5,6,9), is located in a predominantly urban region in the Orizaba Health Jurisdiction in the state of Veracruz, which encompasses 134 square km and has a population of 284,728 (10). The incidence rate of TB during the year 2000 for the state was higher than that for the nation (28.0 vs. 15.9 per 100,000 inhabitants
The game is based loosely on the concepts from SameGame. ) (11).
Community-based screening of chronic coughers (>2 weeks) was performed from March 1995 to October 2000. Patients with positive AFB AFB
AFB Acid-fast bacillus, also 1. Aflatoxin B 2. Aorto-femoral bypass sputum smears underwent epidemiologic, clinical (standardized questionnaire, physical exam, chest x-ray chest x-ray,
n an examination of the chest using x-rays. Routinely performed in patients complaining of chest pain to rule out respiratory or heart disease.
chest X-ray Chest film, see there , and HIV test HIV test Various tests have been used to detect HIV and production of antibodies thereto; some HTs shown below are no longer actively used, but are listed for completeness and context. See HIV, Immunoblot. ), and mycobacteriologic evaluation. Treatment was provided in accordance with official norms (12,13). Treatment outcomes were classified as previously described (6). Annual follow-up was performed for treatment outcome and vital status. Deaths were confirmed with death certificates. A close caregiver was interviewed to elicit signs and symptoms of the terminal illness and "probable cause Apparent facts discovered through logical inquiry that would lead a reasonably intelligent and prudent person to believe that an accused person has committed a crime, thereby warranting his or her prosecution, or that a Cause of Action has accrued, justifying a civil lawsuit. of death" was assigned by two of the authors (JF, LF). Informed consent was obtained from participants. The study was approved by the appropriate institutional review boards.
emanating from or pertaining to mycobacterium.
may be caused by Mycobacterium tuberculosis (see cutaneous tuberculosis), M. culture, identification, and susceptibility testing were performed on sputa from each enrolled patient. In brief, unconcentrated sputum was spread onto Lowenstein-Jensen media (DIFCO, Detroit, MI) at the local laboratory, and the remaining sputum was frozen at -70[degrees]C. The tubes were examined on a weekly basis until growth was detected. Cultures were reported as negative if no growth occurred after 8 weeks. Cultures with visible growth were forwarded to the department of Mycobacteriology at the Instituto de Diagnostico y Referencia Epidemiologicos (March 1995 to December 1997) or to the Clinical Microbiology Clinical microbiology
The adaptation of microbiological techniques to the study of the etiological agents of infectious disease. Clinical microbiologists determine the nature of infectious disease and test the ability of various antibiotics to inhibit or kill Laboratory of the Instituto Nacional de Ciencias Medicas y Nutricion (INCMNSZ) (January 1998 to October 2000) for definitive biochemical identification at the species level (14,15). The frozen sputum sample was processed if the first sample was contaminated contaminated,
v 1. made radioactive by the addition of small quantities of radioactive material.
2. made contaminated by adding infective or radiographic materials.
3. an infective surface or object. or had no growth. Identification and drug susceptibility tests were carried out using conventional methods and the BACTEC system (Becton Dickinson BD (NYSE: BDX), is a medical technology company that manufactures and sells medical devices, instrument systems and reagents. Founded in 1897 and headquartered in Franklin Lakes, New Jersey, BD employs 27,000 people in nearly 50 countries. , Cockeysville, MD).
Mycobacterium tuberculosis Mycobacterium tuberculosis
Mycobacterium tuberculosis Fingerprinting
members of the genus Mycobacterium.
see opportunist (atypical) mycobacteria (below).
see opportunist (atypical) mycobacteria (below). isolated from study patients were genotyped at Stanford University Stanford University, at Stanford, Calif.; coeducational; chartered 1885, opened 1891 as Leland Stanford Junior Univ. (still the legal name). The original campus was designed by Frederick Law Olmsted. David Starr Jordan was its first president. from March 1995 to February 1997 and at INCMNSZ from March 1997 to October 2000 with the internationally standardized IS6110-based restriction fragment length polymorphism restriction fragment length polymorphism
n. Abbr. RFLP
Intraspecies variations in the length of DNA fragments generated by the action of restriction enzymes and caused by mutations that alter the sites at which these enzymes act, changing (RFLP RFLP
restriction fragment length polymorphism
restriction fragment length polymorphism.
RFLP ) technique and compared by using a computer-assisted visual approach (Bioimage AQ-1 analyzer and Molecular Fingerprinting Analyzer, version 2.0) (16,17). Isolates with identical IS6110 fingerprints that contained five or fewer hybridizing bands underwent spoligotyping at INCMNSZ as described (18,19). To assess transmission of M tuberculosis that rapidly progressed to disease, we established a 1-year period for defining clustering as described (20). Cases were considered "clustered" if two or more isolates from different patients were identified within a year that had 1) six or more IS6110 bands in an identical pattern, or 2) five or fewer bands with identical IS6110 fingerprints and matching spoligotypes. The first patient diagnosed in each cluster and those with unique fingerprints were classified as having reactivated disease.
Deaths were attributed to TB based on the death certificate (TB listed as the cause of death), interview of close caregiver (TB identified as probable cause of death), and active TB at the time of death (positive AFB smear after last treatment or during treatment if the patient did not complete treatment performed [less than or equal to]6 months before death). A patient's death was attributed to TB if two or more of these conditions were met. Bivariate bi·var·i·ate
Mathematics Having two variables: bivariate binomial distribution.
Adj. 1. and ,multivariate analyses were performed to describe association between sociodemographic (age, sex, household characteristics, occupation, ethnicity, years of formal education, place of residence, and social security), behavioral (usage of drugs and alcohol, and previous incarceration Confinement in a jail or prison; imprisonment.
Police officers and other law enforcement officers are authorized by federal, state, and local lawmakers to arrest and confine persons suspected of crimes. The judicial system is authorized to confine persons convicted of crimes. ), clinical (previous diagnosis of TB; other associated diseases, previous hospitalizations; HIV HIV (Human Immunodeficiency Virus), either of two closely related retroviruses that invade T-helper lymphocytes and are responsible for AIDS. There are two types of HIV: HIV-1 and HIV-2. HIV-1 is responsible for the vast majority of AIDS in the United States. infection, duration of symptoms previous to diagnosis; time elapsed e·lapse
intr.v. e·lapsed, e·laps·ing, e·laps·es
To slip by; pass: Weeks elapsed before we could start renovating.
n. between diagnosis and initiation of treatment and between initiation of treatment and smear conversion; and symptoms such as cough, hemoptysis Hemoptysis Definition
Hemoptysis is the coughing up of blood or bloody sputum from the lungs or airway. It may be either self-limiting or recurrent. Massive hemoptysis is defined as 200-600 mL of blood coughed up within a period of 24 hours or less. , fever, night sweats, weight loss, and general malaise), bacteriologic bac·te·ri·ol·o·gy
The study of bacteria, especially in relation to medicine and agriculture.
bac·te (number of bacilli bacilli /ba·cil·li/ (bah-sil´i) plural of bacillus.
see bacillus. per microscopic field Noun 1. microscopic field - the areas that is visible through a microscope
field of view, field - the area that is visible (as through an optical instrument) , drug resistance, RFLP, or spoligotype pattern), therapeutic (compliance, treatment outcome, and retreatment) variables, and death due to TB and other causes. Survival analyses included Kaplan-Meier curves and Cox proportional hazards model for TB and non-TB-related deaths using as reference time the period elapsed from diagnosis. Variables were entered into the models according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. their statistical significance in univariate analysis and their biological relevance. The percentage of population attributable risk attributable risk Epidemiology Any factor which ↑ the risk of suffering a particular condition. See Relative risk, Risk factor. Cf Nonattributable risk Statistics The rate of a disorder in exposed subjects that is attributable to the exposure derived from was calculated for variables that were included in the final model (21). DBASE IV and STATA 5.0 programs were used for data analysis (22).
During the study period, 454 patients were diagnosed with pulmonary TB. Most patients were men (270 [59.5%] of 454) and the median age was 42 years (range 12-97 years). Most came from lower socioeconomic status socioeconomic status,
n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. as indicated by household characteristics, formal years of education, and occupation. Of 438 patients, 74 (17%) lived in households with earthen floor An earthen floor, also called an adobe floor, is a floor made of dirt, raw earth, or other unworked ground materials. It is usually constructed, in modern times, with a mixture of sand, finely chopped straw and clay, mixed to a thickened consistency and spread with a trowel on a , 214 (49.3%) of 434 had no access to potable potable /pot·a·ble/ (po´tah-b'l) fit to drink.
Fit to drink; drinkable.
fit to drink. water within the household, 293 (65.4%) of 448 had <6 years of formal education, and 104 (23.4%) of 445 were manual workers. The prevalence of HIV was 2.1% (9 of 429), combined resistance to isoniazid isoniazid (ī'sōnī`əzĭd), drug used to treat tuberculosis. Also known as isonicotinic acid hydrazide, isoniazid is the most effective antituberculosis drug currently available. and rifampin rifampin (rĭfăm`pĭn), antibiotic used in the treatment of tuberculosis. It is also used to eliminate the meningococcus microorganism from carriers and to treat leprosy, or Hansen's disease. was seen in 26 (6.7%) of 388 patients, and other resistance patterns in an additional 61 (15.7%) of 388. One hundred fifty-one (37%) of 413 patients had chest radiographs with evidence of pulmonary cavitation cavitation
Formation of vapour bubbles within a liquid at low-pressure regions that occur in places where the liquid has been accelerated to high velocities, as in the operation of centrifugal pumps, water turbines, and marine propellers. , and 72 (17.4%) of 413 patients had interstitial In a separate window. See interstitial ad.
(World-Wide Web) interstitial - A World-Wide Web page that appears before the expected content page. Interstitials can be used for advertising (intermercial, transition ad) or to confirm that the user is old enough to view the pulmonary infiltrates Infiltrates
Cells or body fluids that have passed into a tissue or body cavity.
Mentioned in: Eosinophilic Pneumonia . Median time from initiation of symptoms to treatment was 101 days (range 3-2,307 days), median time from diagnosis to initiation of treatment was 5 days (range 0-594 days), and median time for sputum conversion was 42 days (range 15-1,228 days).
Treatment and Follow-Up
Of 11 patients who refused treatment, 4 died. Of 443 initiating treatment, 75.4% initiated treatment <10 days after diagnosis; 96.5% received supervised treatment. Outcomes for patients were as follows: 357 (80.6%) were cured of whom 314 (70.9%) were bacteriologically confirmed, 41 (9.3%) defaulted, and 20 (4.5%) failed treatment; 16 (3.6%) died during treatment, and 9 (2%) transferred out of study area. Patients were tracked for a median of 839 days (range 32,402). Sixty-one additional patients died during follow-up after treatment. Death was due to TB in 34 (41.9%) of 81 instances; 2 deaths were in patients who did not receive treatment, 11 in patients receiving treatment, and 21 after treatment. Tuberculosis mortality rates were higher during treatment versus after treatment (1.3/10,000 days vs. 0.7/ 10,000 days, p<0.01). Crude comparison of sociodemographic, bacteriologic, and clinical characteristics of patients who died from TB or from other causes and surviving patients are shown in Table 1. Patients who died from TB had a higher probability of having been treated for a previous TB episode, showed more severe clinical symptoms, and had drug-resistant isolates. Less frequently they had other coexisting chronic conditions, such as HIV infection or hepatic cirrhosis cirrhosis (sərō`səs), degeneration of tissue in an organ resulting in fibrosis, with nodule and scar formation. The term is most often used in relation to the liver, because that organ is most often involved in cirrhosis. . The patients who died from TB also had longer delays before diagnosis, treatment, and sputum conversion. These patients had higher probabilities of default, failure, and having subsequent TB episodes. The most common non-TB causes of death included diabetes (12), cirrhosis and other liver diseases (9), AIDS (6), cancer (2), and cardiovascular diseases (3). Kaplan Meier survival probabilities from TB deaths were 97.3% after the first 6 months, 95.8% after 1 year, 93.7% after 2 years, and 91% after 3 years.
RFLP and Spoligotyping Results
M. tuberculosis M. tuberculosis,
n the bacterium responsible for tuberculosis, generally a respiratory infection in man; nonrespiratory tuberculosis is considered an indicator disease for AIDS. See also tuberculosis. culture, drug test, and IS6110 RFLP and spoligotyping were available for 326 (72%) isolates. Comparison of patients whose isolates were available for genotyping to those whose isolates were unavailable indicated that patients for whom fingerprint analysis was not performed had a higher probability of being of native origin in Mexico (30 [24.2%] of 124 vs. 39 [12%] of 324, p= 0.001) and of living in households with earthen floor (31 [25.8%] of 120 vs. 43 [13.5%] of 318, p=0.002). Forty (12.3%) of the 326 evaluated cases were in clusters. The frequency of being members of clusters of recently transmitted disease was higher among .patients dying from TB than among those dying from other causes or surviving (8 [28.5%] of 28 patients who died from TB vs. 32 [10.7%] of 298 patients who died from other causes and survivors, p=0.01).
Factors Associated with Mortality Rates
Predictors of death due to TB by Cox regression analysis In statistics, a mathematical method of modeling the relationships among three or more variables. It is used to predict the value of one variable given the values of the others. For example, a model might estimate sales based on age and gender. included treatment default, resistance to isoniazid and rifampin, and recently transmitted TB controlling for time of occurrence of death, weight loss >15%, and years of formal education (Table 2). The effect was not modified when gender, age, HIV infection, crowding in the household, household characteristics, occupation, ethnicity, previous treatment, delay in seeking treatment, specific symptoms, type of radiologic lesions, and other kinds of diseases were introduced into the model.
After controlling for age, predictors of non-TB death included HIV-infection, hepatic cirrhosis, and weight loss. Recently transmitted TB was not associated with other causes of death (Table 2).
The proportion of death due to TB and to other causes attributable to the different categories of risk factors is shown in Table 2. In the study population, 60% of deaths due to TB were attributable to drug resistance and treatment default.
Patients with recently transmitted disease had a lower probability of survival compared with patients with reactivated disease (p=0.007) (Figure). When causes of death were analyzed according to genotype genotype (jēn`ətīp'): see genetics.
Genetic makeup of an organism. The genotype determines the hereditary potentials and limitations of an individual. , we found that TB was the cause of death in 8 (20%) of 40 patients with recently transmitted disease and in 20 (7%) of 286 patients with reactivated disease (p=0.01).
Analysis of the distribution of the time between diagnosis dates of successive matching fingerprints indicated that 49.4% (95% confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI] 44% to 54%) of all isolates with matching fingerprints patterns were identified within 1 year. When the interval was modified to 6, 18, 24, 30, and 36 months, we found that the proportion of clustered cases increased (8.3%, 13.8%, 13.8%, 14.4%, and 14.7%, respectively), ([chi square chi square (kī),
n a nonparametric statistic used with discrete data in the form of frequency count (nominal data) or percentages or proportions that can be reduced to frequencies. ] trend, p=0.02). The association between clustered cases and death due to TB continued to be positive for each of the other definitions of interval for clustering: 3.6 (1.1 to 10.5), p=0.01; 2.8 (1.0 to 7.3), p=0.03; 2.8 (1.0 to 7.3), p=0.03; 2.7 (0.9 to 6.8), p=0.04; and 2.6 (0.9 to 6.6) p=0.04.
This study describes high mortality rates from TB in a cohort of pulmonary TB patients who resided in an area with a low rate of HIV infection and were treated in the context of a well-functioning DOTS program. Patients were followed for an average of 2.3 years after diagnosis. Tuberculosis was associated with high rates of deaths both during treatment and after treatment completion, default, or failure. The main independent risk factors for death due to TB were treatment default and being infected with multidrug-resistant M. tuberculosis. Additionally, data indicate that cases due to ongoing transmission of TB may have higher mortality rates than cases due to reactivation reactivation
to become active after a period of quiescence or, as in bacterial and viral infections, latency.
cross reactivation of latent disease. These results suggest that current techniques underestimate death associated with TB and provide further impetus not only to treat but also to prevent TB.
Case completion rates are the standard by which the effectiveness of DOTS-based treatment programs are judged. A large body of evidence collected under diverse settings demonstrates completion rates of 81% and cure rates of 73% (23). The epidemiology of death in these programs is less well studied. Studies performed in HIV-endemic settings constitute an exception as the high rate of deaths occurring while patients are still on antituberculous therapy are cited as an impediment to achieving desired cure rates (24).
Our study reports TB mortality rates both during and after treatment completion, default, or failure. Of the 443 patients who were started on therapy, 16 died before completing therapy. This frequency (3.6%) compares favorably to that reported in other studies (4% in the Gambia , 15% in Bolivia , 25% in Malawi , and 28% in India ). However, in contrast to previous reports, we had a median of 833 days of follow-up after the completion of therapy, during which 21 additional patients (4.6%) died of TB, comparable with reports from the 1960s and 1970s (29). This mortality rate exceeds that expected according to age-adjusted state mortality statistics (30).
Although not novel, the risk factors for death due to TB identified in this cohort are noteworthy; these findings suggest that, even in a high-quality TB control program, additional efforts could yield important benefits. Treatment default has been previously described as associated with higher mortality rates in Mexico (31) and elsewhere (32,33). Concerted efforts to further reduce default may disproportionately decrease deaths. We also found that drug resistance, and particularly multidrug resistance, are associated with death (6,14,34). Although the most appropriate strategy for managing drug-resistant TB is debated, these data provide additional impetus for evaluating novel approaches, such as those recently introduced in Mexico, for managing drug-resistant TB (13,35). We estimate that 60% of deaths due to TB in this setting were attributable to treatment default and multidrug-resistance. Additional studies are needed to quantitate quan·ti·tate
tr.v. quan·ti·tat·ed, quan·ti·tat·ing, quan·ti·tates
To determine or measure the quantity of.
[Back-formation from quantitative (analysis). the presumably pre·sum·a·ble
That can be presumed or taken for granted; reasonable as a supposition: presumable causes of the disaster. greater mortality rates that result from default and drug resistance in other settings.
Although relatively uncommon in this setting, HIV was associated with a high overall mortality rate. Most of these deaths were due to non-TB-related death. HIV/AIDS HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome was the main predictor for non-TB deaths in this cohort. In our study, eight of the nine HIV-seropositive persons died, three of them a year or more after completing antituberculous therapy. Several studies have demonstrated excess mortality rates after successful TB treatment in HIV-infected patients (24,36,37); the high rates have been attributed to HIV-related disease (38). These data emphasize the need to improve integration of quality treatment for both TB- and HIV-infected persons in populations that suffer from both diseases.
The most striking finding of the molecular epidemiologic component of this study is the association between clustering, which we interpret as indicative of recently transmitted disease, and TB-related death. Death due to TB was significantly more common among those who had recently transmitted disease than those with reactivated disease (28.6% vs. 7%, p=0.01). This association was independent of treatment default, multidrug resistance, time of occurrence of death, weight loss, and years of formal education. Furthermore, the effect was not modified when other variables indicative of sociodemographic level (such as occupation, characteristics of the household, or ethnicity) or clinical variables indicating other diseases, including HIV infection were introduced in the model. Inferring causality causality, in philosophy, the relationship between cause and effect. A distinction is often made between a cause that produces something new (e.g., a moth from a caterpillar) and one that produces a change in an existing substance (e.g. from such associations is difficult, it seems biologically implausible im·plau·si·ble
Difficult to believe; not plausible.
im·plausi·bil that being more likely to die made people more likely to acquire recently transmitted TB. A more plausible explanation is that rapidly progressing to disease contributes to deterioration of the health of these patients and thus increases their likelihood of death. The phenomenon is well described for other diseases such as measles. However, why this would be more pronounced for recently transmitted disease is unclear.
The association between clustering and death could be spurious because of limitations in molecular or conventional epidemiology. The validity of clustering as a proxy for recent transmission might be challenged by the fact that we did not perform fingerprint analysis on all isolates (39). Comparison between patients whose isolates were genotyped and those whose isolates were not genotyped showed that results of this study may not be generalizable gen·er·al·ize
v. gen·er·al·ized, gen·er·al·iz·ing, gen·er·al·iz·es
a. To reduce to a general form, class, or law.
b. To render indefinite or unspecific.
2. to indigenous or lower socioeconomic groups. Our selection of the time interval allowed us to consider TB that was transmitted very recently and progressed to disease. The validity of using a 1-year interval was confirmed with the sensitivity analysis using different time periods (6, 18, 24, 30, and 36 months) as association between clustered cases and death persisted, despite modification of the time interval and by the fact that almost 50% of isolates with matching DNA fingerprint DNA fingerprint
An individual's unique sequence of DNA base pairs. Also called genetic fingerprint. patterns occurred within 1 year of identification of the previous case. Conventional epidemiologic approaches to studying the cause of death are difficult. Death certificate data are notoriously unreliable, and whether patients died of TB or other causes is not certain (40). Therefore, we added other criteria that included the interview of a close caregiver and activity of TB at the time of death to validate our definition of death due to TB. The cause-of-death profile derived from interview of a close caregiver has been demonstrated to be useful for planning purposes (41). We consider that this definition adequately identified TB-related death as characteristics of patients dying from TB differed from patients dying from other causes in several important aspects (drug resistance, coexisting chronic conditions, and clinical severity) and allowed the identification of different risk factors for TB-related death and for death due to other causes. If confirmed in other settings, the conclusions of this study have important implications for control programs. Most importantly Adv. 1. most importantly - above and beyond all other consideration; "above all, you must be independent"
above all, most especially , given that current surveillance data are collected at the conclusion of therapy, this method probably underestimates the true impact of TB on a population's death. Given the increasing role of cost-efficacy modeling in setting health-care priorities, this oversight has important consequences. In addition, if recently acquired TB exhorts a greater mortality rate than that due to reactivated infection, the importance of interrupting TB transmission is further elevated.
Table 1. Sociodemographic, clinical, bacteriologic, and therapeutic characteristics of smear-positive pulmonary tuberculosis (TB) patients according to cause of death, Orizaba, Veracruz, 1995-2000 Died from TB Variables (n=34) (%) Sociodemographic Median age (range) 30 (24-73) Men 52.9 Indigenous origin 20.6 <6 years formal education 73.5 Rural and industrial workers 11.8 Previous imprisonment 14.7 Previous TB treatment 47.1 Previous hospitalization 58.8 Residence in shelters 5.9 Alcohol use 38.2 Household crowding 47.1 Household with earthen floor 20.6 Clinical HIV infection 8.8 Hepatic cirrhosis 0 Body mass index ([less than or equal to] 18) 47.1 Hemoptysis 26.5 Fever 44.1 Night sweats 58.8 Weight loss (>15 %) 47.1 Radiologic nodes 5.9 Cavities 44.1 Median time interval between initiation of 17 (1-212) symptoms and treatment (range in days) Median time interval between diagnosis and 141.5 (78-991) treatment (range in days) Bacteriologic Resistance to isoniazid and rifampin 29.4 Other resistance 11.8 <10 bacilli per 100 fields 79.4 Median time interval between treatment and 95 (35-530) sputum conversion (range in days) Treatment outcome Cure 5.9 Failure 20.6 Default 32.4 Retreatment 17.6 Died from other causes Variables (n=47) (%) Sociodemographic Median age (range) 47 (22-70) Men 76.6 Indigenous origin 4.3 <6 years formal education 76.6 Rural and industrial workers 25.5 Previous imprisonment 34.0 Previous TB treatment 34.0 Previous hospitalization 51.1 Residence in shelters 10.6 Alcohol use 66.0 Household crowding 27.7 Household with earthen floor 10.6 Clinical HIV infection 10.6 Hepatic cirrhosis 6.4 Body mass index ([less than or equal to] 18) 27.7 Hemoptysis 38.3 Fever 61.7 Night sweats 59.6 Weight loss (>15 %) 46.8 Radiologic nodes 6.4 Cavities 25.5 Median time interval between initiation of 8 (0-158) symptoms and treatment (range in days) Median time interval between diagnosis and 126 (4-439) treatment (range in days) Bacteriologic Resistance to isoniazid and rifampin 17.0 Other resistance 19.1 <10 bacilli per 100 fields 87.2 Median time interval between treatment and 44 (19-182) sputum conversion (range in days) Treatment outcome Cure 61.7 Failure 10.6 Default 10.6 Retreatment 23.4 Survived Variables (n=373) (%) Sociodemographic Median age (range) 40.5 (12-82) Men 57.9 Indigenous origin 16.1 <6 years formal education 62.2 Rural and industrial workers 23.6 Previous imprisonment 27.9 Previous TB treatment 14.2 Previous hospitalization 45.6 Residence in shelters 5.1 Alcohol use 43.7 Household crowding 37.5 Household with earthen floor 16.6 Clinical HIV infection .3 Hepatic cirrhosis 1.3 Body mass index ([less than or equal to] 18) 20.4 Hemoptysis 37.8 Fever 44.0 Night sweats 57.6 Weight loss (>15 %) 29.2 Radiologic nodes 7.0 Cavities 33.2 Median time interval between initiation of 5 (0-322) symptoms and treatment (range in days) Median time interval between diagnosis and 99.5 (4-1,723) treatment (range in days) Bacteriologic Resistance to isoniazid and rifampin 2.1 Other resistance 12.9 <10 bacilli per 100 fields 86.1 Median time interval between treatment and 42.5 (15-348) sputum conversion (range in days) Treatment outcome Cure 87.4 Failure 2.1 Default 6.7 Retreatment 5.4 Variables p value (a) Sociodemographic Median age (range) 0.05 Men 0.04 Indigenous origin 0.07 <6 years formal education 0.02 Rural and industrial workers 0.2 Previous imprisonment 0.2 Previous TB treatment <0.0001 Previous hospitalization 0.2 Residence in shelters 0.3 Alcohol use 0.005 Household crowding 0.2 Household with earthen floor 0.4 Clinical HIV infection <0.0001 Hepatic cirrhosis 0.06 Body mass index ([less than or equal to] 18) <0.0001 Hemoptysis 0.5 Fever 0.04 Night sweats 0.2 Weight loss (>15 %) 0.002 Radiologic nodes 0.9 Cavities 0.2 Median time interval between initiation of 0.004 symptoms and treatment (range in days) Median time interval between diagnosis and 0.01 treatment (range in days) Bacteriologic Resistance to isoniazid and rifampin <0.0001 Other resistance 0.2 <10 bacilli per 100 fields 0.5 Median time interval between treatment and 0.03 sputum conversion (range in days) Treatment outcome Cure <0.0001 Failure <0.0001 Default <0.0001 Retreatment <0.0001 (a) Chi square test, analysis of variance test. Table 2. Population attributable-risk percent and hazard ratios for death among smear-positive tuberculosis (TB) patients, Orizaba, Veracruz, 1995-2000 (a) Variables Population attributable risk (%) Death due to TB (c) Treatment default 28.7 Resistance to isoniazid and rifampin 25.9 Clustered 18.8 Weight loss (>15%) - Formal education <6 yr - Death due to other causes HIV/AIDS 11.1 Hepatic cirrhosis 6.6 Weight loss (>15%) - Age (yrs) - Variables Adjusted hazard ratio Death due to TB (c) Treatment default 8.9 Resistance to isoniazid and rifampin 5.7 Clustered 4.1 Weight loss (>15%) 3.9 Formal education <6 yr 1.8 Death due to other causes HIV/AIDS 33.1 Hepatic cirrhosis 5.7 Weight loss (>15%) 3.3 Age (yrs) 1.02 Variables 95% CI p value (b) Death due to TB (c) Treatment default 3.3 to 24.4 <0.0001 Resistance to isoniazid and rifampin 2.0 to 16.3 <0.001 Clustered 1.6 to 10.0 0.002 Weight loss (>15%) 1.5 to 10.9 0.007 Formal education <6 yr 0.6 to 5.2 0.3 Death due to other causes HIV/AIDS 11.4 to 95.4 <0.0001 Hepatic cirrhosis 1.6 to 19.7 0.006 Weight loss (>15%) 1.6 to 6.7 0.001 Age (yrs) 0.99 to 1.04 0.07 (a) CI, confidence interval; -, not applicable. (b) Cox proportional hazards model. (c) Controlling for death before or after treatment completion, default, or failure.
We thank Luis Juarez and Bulmaro Cano for data processing data processing or information processing, operations (e.g., handling, merging, sorting, and computing) performed upon data in accordance with strictly defined procedures, such as recording and summarizing the financial transactions of a ; Ed Desmond, Travis Jobe, and Areli Martinez-Gamboa for training and technical support with spoligotyping; Carmen Carmen
throws over lover for another. [Fr. Lit.: Carmen; Fr. Opera: Bizet, Carmen, Westerman, 189–190]
See : Faithlessness
the cards repeatedly spell her death. [Fr. Soler for support for HIV tests; Manuel Tielve and Ruben Acevedo for support in interpreting chest x-rays; and the physicians, nurses, chemists, health promoters, recruiters, and interviewers in Orizaba who supported the diagnosis, treatment, and follow-up of patients.
This study was supported by the National Institutes of Health of the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. project no. A135969, by the Wellcome Trust The Wellcome Trust is a United Kingdom-based charity established in 1936 to administer the fortune of the American-born pharmaceutical magnate Sir Henry Wellcome. Its income was derived from what was originally called Burroughs Wellcome & Co, later renamed in the UK as the , by the Howard Hughes Medical Institute Howard Hughes Medical Institute, (HHMI), nonprofit medical research organization founded in 1953 by Howard Hughes and largly funded from proceeds of the 1984–85 sale of Hughes Aircraft. Headquartered in Chevy Chase, Md. (ID 55000632) and by the Mexican Council Of Science and Technology, project nos. G26264M and 30987-M.
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Maria de Lourdes Garcia-Garcia, * Alfredo Ponce-de-Leon, [dagger] Maria Cecilia Garcia-Sancho, [double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.
Noun 1. ] Leticia Ferreyra-Reyes, * Manuel Palacios-Martinez, * Javier Fuentes, [subsection] Midori Kato-Maeda, [dagger] Miriam Bobadilla, [dagger] Peter Small, [paragraph] and Jose Sifuentes-Osornio, [dagger]
* Instituto Nacional de Salud Publica, Cuernavaca, Mexico; [dagger] Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran," Mexico City Mexico City
Spanish Ciudad de México
City (pop., 2000: city, 8,605,239; 2003 metro. area est., 18,660,000), capital of Mexico. Located at an elevation of 7,350 ft (2,240 m), it is officially coterminous with the Federal District, which occupies 571 sq mi , Mexico; [double dagger] Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico; [subsection] Secretaria de Salud del Estado de Veracruz, Xalapa, Mexico; and [paragraph] Stanford University, Palo Alto, California “Palo Alto” redirects here. For other uses, see Palo Alto (disambiguation).
Palo Alto (IPA: /ˌpæloʊˈʔæltoʊ/, from Spanish: palo: "stick" and alto: "high", i.e. , USA
Dr. Garcia-Garcia is senior researcher and head of the Tuberculosis Unit at the National Institute of Public Health in Cuernavaca, Mexico, and International Research Scholar of the Howard Hughes Medical Institute. Her research interests lie in the epidemiology of TB.
Address for correspondence: Ma. de Lourdes Garcia Garcia, Unidad de tuberculosis, Instituto Nacional de Salud Publica Ave., Universidad No. 655, Col. Sta. Maria Ahuacatitlan, Cuernavaca, Mexico, 62508; fax: 52777 317 55 29; e-mail: email@example.com