Raquel Duarte - Academia.edu (original) (raw)
Papers by Raquel Duarte
Archivos de Bronconeumología, 2017
Infection, Genetics and Evolution, 2013
Human tuberculosis is an infectious disease caused by bacteria from the Mycobacterium tuberculosi... more Human tuberculosis is an infectious disease caused by bacteria from the Mycobacterium tuberculosis complex (MTBC). Although Spoligotyping and MIRU-VNTR are standard methodology in MTBC genetic epidemiology, recent studies suggest that Single Nucleotide Polymorphisms (SNP) are advantageous in phylogenetics and strain identification. In this work we use a set of 79 SNPs to characterize 1915 MTBC isolates from Portugal and 141 from Northeast Brazil. All Brazilian samples and a subset of 111 Portuguese isolates were further characterized using Spolygotyping. Phylogenetic analysis against a reference set revealed that about 95% of the isolates in both populations were singly attributed to bacterial lineage 4. Within this lineage, the most frequent strain groups in both Portugal and Brazil were LAM, followed by Haarlem and then X. Contrarily to these groups, strain group T showed a very different prevalence between Portugal and Brazil, with a frequency of 7% and less than 1.5%, respectively. Taking the classification by SNPs as the most accurate, we analyze the performance of Spoligotyping in strain identification. The former marker shows about 12% of miss-matches and less than 1% of unidentifiable strains. The miss-matches are observed in the most represented groups of our sample set (i.e., LAM, Haarlem and T) in almost the same proportion. Besides being more accurate in strain identification, SNPs typing can also provide phylogenetic relationships between the strain groups. Indeed, using this molecular markers we were able to observe possible signs of rare recombination events in Mtb. Overall, the use of SNP typing revealed striking similarities between MTBC populations from Portugal and Brazil. In addition this marker suggest that, albeit rare, recombination events in MTBC are likely to occur.
BMC Infectious Diseases, 2014
Background: Tuberculosis remains a high burden for Human society despite considerable investments... more Background: Tuberculosis remains a high burden for Human society despite considerable investments in its control. Unique features in the history of infection and transmission dynamics of tuberculosis pose serious limitations on the direct interpretation of surveillance data and call for models that incorporate latent processes and simulate specific interventions. Methods: A transmission model was adjusted to the dataset of active tuberculosis cases reported in Portugal between 2002 and 2009. We estimated key transmission parameters from the data (i.e. time to diagnosis, treatment length, default proportion, proportion of pulmonary TB cases). Using the adjusted model to the Portuguese case, we estimated the total burden of tuberculosis in Portugal. We further performed sensitivity analysis to heterogeneities in susceptibility to infection and exposure intensity. Results: We calculated a mean time to diagnose of 2.81 months and treatment length of 8.80 months in Portugal. The proportion defaulting treatment was calculated as 0.04 and the proportion of pulmonary cases as 0.75. Using these values, we estimated a TB burden of 1.6 million infected persons, corresponding to more than 15% of the Portuguese population. We further described the sensitivity of these estimates to heterogeneity. Conclusions: We showed that the model reproduces well the observed dynamics of the Portuguese data, thus demonstrating its adequacy for devising control strategies for TB and predicting the effects of interventions.
Archivos de Bronconeumología, 2017
The European respiratory journal, 2017
Acta reumatologica portuguesa, 2016
Delegates from the Tuberculosis Committee of the Portuguese Pulmonology Society, the Portuguese R... more Delegates from the Tuberculosis Committee of the Portuguese Pulmonology Society, the Portuguese Rheumatology Society, the Portuguese Dermatology and Venereology Society and the Portuguese Gastroenterology Society, have revised and updated, in 2012, their guidelines for the diagnosis and treatment of latent tuberculosis infection and active tuberculosis in patients that are candidates for therapy with biologic drugs. In order to identify perceived barriers to tuberculosis screening among patients candidate to anti-TNF treatment, we performed a cross-sectional survey including rheumatologists, gastroenterologists and dermatologists who prescribed anti-TNF agents, identified by the respective Scientific Societies, throughout Portugal. Ninety-five physicians (85 specialist and 10 trainees with more than 3 years of practice) participated in the survey, including 42 rheumatologists (response rate 28%), 32 dermatologists (12% response) and 21 gastroenterologists (4% response). No informati...
Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia, 2018
Multidrug-resistant and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB, respectively)... more Multidrug-resistant and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB, respectively) continue to represent a challenge for clinicians and public health authorities. Unfortunately, although there have been encouraging reports of higher success rates, the overall rate of favorable outcomes of M/XDR-TB treatment is only 54%, or much lower when the spectrum of drug resistance is beyond that of XDR-TB. Treating M/XDR-TB continues to be a difficult task, because of the high incidence of adverse events, the long duration of treatment, the high cost of the regimens used, and the drain on health care resources. Various trials and studies have recently been undertaken (some already published and others ongoing), all aimed at improving outcomes of M/XDR-TB treatment by changing the overall approach, shortening treatment duration, and developing a universal regimen. The objective of this review was to summarize what has been achieved to date, as far as new and repurposed drugs are ...
Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia, 2018
Case Reports in Pediatrics, 2017
The authors present a case report of antituberculosis drug-induced liver injury that offered diag... more The authors present a case report of antituberculosis drug-induced liver injury that offered diagnostic challenges (namely, the possibility of drug-induced autoimmune hepatitis) and treatment difficulties.
European Respiratory Journal, 2016
On July 4-5, 2016, representatives of the Asociación Latinoamericana de Tórax (ALAT), the Europea... more On July 4-5, 2016, representatives of the Asociación Latinoamericana de Tórax (ALAT), the European Respiratory Society (ERS) and of the Panamerican Health Organization (PAHO) met in Santiago de Chile to attend the VIII Regional Meeting of American Low Tuberculosis Incidence Countries. This meeting took place in connection with the 2016 ALAT Congress. Among the meeting attendees there were managers of national tuberculosis (TB) programmes and pulmonologists belonging to the ALAT Tuberculosis Dept. The Latin American countries with low TB incidence (defined as <10 cases per 100 000 population [1, 2]) and some of those approaching this threshold (Chile, Uruguay and Colombia were also invited as non-low TB incidence countries) had the possibility to report TB control and elimination policies in Latin America, and to discuss the results achieved with experts from PAHO, the World Health Organization (WHO) Global TB Programme and the ERS. Participants agreed that a clear epidemiological and programmatic heterogeneity exists in Latin America, with lack of published local scientific data. Local adaptation of global recommendations is needed in order to reach TB elimination (defined as fewer than one TB case per million population) [1, 2], and local evidence is mandatory to identify priorities and how to deal with them.
PLOS ONE, 2016
Tuberculosis imposes high human and economic tolls, including in Europe. This study was conducted... more Tuberculosis imposes high human and economic tolls, including in Europe. This study was conducted to develop a severity assessment tool for stratifying mortality risk in pulmonary tuberculosis (PTB) patients. A derivation cohort of 681 PTB cases was retrospectively reviewed to generate a model based on multiple logistic regression analysis of prognostic variables with 6-month mortality as the outcome measure. A clinical scoring system was developed and tested against a validation cohort of 103 patients. Five risk features were selected for the prediction model: hypoxemic respiratory failure (OR 4.7, 95% CI 2.8-7.9), age 50 years (OR 2.9, 95% CI 1.7-4.8), bilateral lung involvement (OR 2.5, 95% CI 1.4-4.4), 1 significant comorbidity-HIV infection, diabetes mellitus, liver failure or cirrhosis, congestive heart failure and chronic respiratory disease-(OR 2.3, 95% CI 1.3-3.8), and hemoglobin <12 g/dL (OR 1.8, 95% CI 1.1-3.1). A tuberculosis risk assessment tool (TReAT) was developed, stratifying patients with low (score 2), moderate (score 3-5) and high (score 6) mortality risk. The mortality associated with each group was 2.9%, 22.9% and 53.9%, respectively. The model performed equally well in the validation cohort. We provide a new, easy-to-use clinical scoring system to identify PTB patients with high-mortality risk in settings with good healthcare access, helping clinicians to decide which patients are in need of closer medical care during treatment.
The European respiratory journal, Sep 4, 2016
No evidence exists on tuberculosis (TB) and latent TB infection (LTBI) management policies among ... more No evidence exists on tuberculosis (TB) and latent TB infection (LTBI) management policies among refugees in European countries.A questionnaire investigating screening and management practices among refugees was sent to 38 national TB programme representatives of low and intermediate TB incidence European countries/territories of the WHO European Region.Out of 36 responding countries, 31 (86.1%) reported screening for active TB, 19 for LTBI, and eight (22.2%) reporting outcomes of LTBI treatment. Screening for TB is based on algorithms including different combinations of symptom-based questionnaires, bacteriology and chest radiography and LTBI screening on different combinations of tuberculin skin test and interferon-γ release assays. In 22 (61.1%) countries, TB and LTBI screening are performed in refugee centres. In 22 (61.1%) countries, TB services are organised in collaboration with the private sector. 27 (75%) countries answered that screening for TB is performed as per national...
BMC Infectious Diseases, 2015
Background: Multidrug resistant-tuberculosis (MDR-TB) is a threat to global tuberculosis control ... more Background: Multidrug resistant-tuberculosis (MDR-TB) is a threat to global tuberculosis control which is worsened by human immune-deficiency virus (HIV) co-infection. There is however paucity of data on the effects of antiretroviral treatment (ART) before or after starting MDR-TB treatment. This study determined predictors of mortality and treatment failure among HIV co-infected MDR-TB patients on ART. Methods: A retrospective medical record review of 1200 HIV co-infected MDR-TB patients admitted at Sizwe Tropical Disease Hospital, Johannesburg from 2007 to 2010 was performed. Chi-square test was used to determine treatment outcomes in HIV co-infected MDR-TB patients on ART. Multivariable logistic regression and Poisson models were used to determine predictors of mortality and treatment failure respectively. Results: Mortality was higher (21.8 % vs. 15.4 %) among patients who started ART before initiating MDR-TB treatment compared with patients initiated on ART after commencing MDR-TB treatment (p = 0.013). Factors significantly associated with mortality included: the use of ART before starting MDR-TB treatment (OR 1.65, 95 % CI 1.02-2.73), severely-underweight (OR 3.71, 95 % CI 1.89-7.29) and underweight (OR 2.35, 95 % CI 1.30-4.26), cavities on chest x-rays at baseline (OR 1.76, 95 % CI 1.08-2.94), presence of other opportunistic infections (OR 1.80, 95 % CI 1.10-2.94) and presence of other co-morbidities (OR 2.26, 95 % CI 1.20-4.21). Factors predicting failure were severe anaemia (IRR (OR 4.72, 95 % CI 1.47-15), other co-morbidities (OR 2.39, 95 % CI 1.05-5.43) and modified individualised regimen at baseline (OR 2.15, 95 % CI 0.98-4.71). Conclusions: High mortality among patients already on ART before initiating MDR-TB treatment is a worrisome development. Management of adverse-events, opportunistic infections and co-morbidities in these patients is important if the protective benefits of being on ART are to be maximized. There is the need to intensify intervention programmes targeted at early identification of MDR-TB, treatment initiation, drug monitoring and increasing adherence among HIV co-infected MDR-TB patients.
Revista portuguesa de pneumologia
Tumor necrosis factor-alpha (TNF-␣) is a pleomorphic cytokine involved in the pathogenesis of man... more Tumor necrosis factor-alpha (TNF-␣) is a pleomorphic cytokine involved in the pathogenesis of many rheumatic diseases. Following anti-TNF therapy, the relative risk for tuberculosis is increased by up to 25 times, often as a rapidly progressive disease, extra-pulmonary or disseminated. 1-4 Aiming to evaluate compliance with guidelines for tuberculosis screening, the authors conducted an enquiry among northern Portuguese hospitals which prescribe anti-TNF therapy. From all hospitals in northern Portugal the authors identified those that prescribed anti-TNF therapy, and from them randomly selected from among the Internal Medicine medical doctors (the specialty which most commonly prescribed biological therapy in these hospitals) those who had at least, one weekly consultation of autoimmune disease and were familiar with the hospital prescription procedures. One hospital which had only one doctor prescribing was excluded. The enquiry was carried out in September 2012. The interview consisted of ten multiple-choice questions relating to each recommendation: TB screening, diagnostic exams, preventive treatment, when to start anti-TNF␣ therapy and TB monitoring through the course of anti-TNF␣ treatment. Compliance rates were determined for each clinical recommendation and each guideline [national, international or European consensus] (Table 1). 5,1,6,7 Eleven hospitals were identified and ten were eligible. They performed TB screening in all patients treated with anti-TNF therapy. The screening method used by all hospitals was patient history and tuberculin skin test (TST), seven (70%) used interferon-gamma-release-assay (IGRA) and six (60%) used chest radiography (CRX). Compliance rate: 60% for UK guidelines and 50% for European consensus, USA and national guidelines (Table 2). All hospitals performed TB screening prior to anti-TNF treatment (compliance rate of 100% with all guidelines); seven (70%) re-screened during anti-TNF treatment, due to
Jornal Brasileiro de Pneumologia, 2015
The European respiratory journal, 2015
This paper describes an action framework for countries with low tuberculosis (TB) incidence (<... more This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards…
International Journal of Infectious Diseases, 2015
The emergence and spread of multidrug-resistant tuberculosis (MDR-TB), defined as TB caused by My... more The emergence and spread of multidrug-resistant tuberculosis (MDR-TB), defined as TB caused by Mycobacterium tuberculosis strains resistant to isoniazid and rifampicin (the two most important anti-TB drugs currently in use), and extensively drug resistant tuberculosis (XDR-TB), defined as MDR-TB caused by strains resistant to at least one fluoroquinolone and one injectable second-line anti-TB drug in addition to isoniazid and rifampicin, has attracted interest at different levels 1-5. In recent years, the alarming rates of M/XDR-TB in Eastern Europe and other settings of the world resulted in strong expressions of concern by national and international health authorities, partners and scientific societies. At media level, the key words MDR-TB and XDR-TB have caught spikes of citations and consistent interest since the time the term XDR-TB appeared for the first time, as a simple Google search can testify (Figure 1). From the public health point of view, M/XDR-TB is considered a serious threat for TB control and elimination. Therefore, the
European Respiratory Journal, 2014
Although the incidence of tuberculosis (TB) has increased in healthcare workers (HCWs) [1-3], sev... more Although the incidence of tuberculosis (TB) has increased in healthcare workers (HCWs) [1-3], several studies have shown that HCWs are not compliant with screening and/or preventive measures [4-7]. For example, a Portuguese study found that the estimated TB incidence was three-to seven-fold higher in HCWs than in the general population [8]. Latent TB infection (LTBI) diagnosis and treatment constitute the core of TB elimination, integrating the post-2015 strategies of the World Health Organization [9, 10]. To evaluate TB screening practices among HCWs and their reasons for nonadherence in Portugal, we developed a survey and distributed it to nurses and physicians from December 25, 2012 to January 31, 2013, closing when we received fewer than one response per day. The survey was anonymous, voluntary and digitally distributed through our network of contacts using a "snowball" distribution method where volunteers subsequently distribute the questionnaire to their contacts and so forth. Continuous data are presented as mean±SD and compared using t-tests. Categorical data are presented as n (%) and compared using the Chi-squared or Fisher's test, as appropriate. Multiple logistic regression analysis was used to identify statistically significant determinants of TB infection, exposure and screening. Crude and adjusted odds ratios and 95% confidence intervals were determined. Goodness-of-fit of the models was evaluated; comparisons with the null model used the difference of deviances, as determined by Chi-squared tests, while comparisons with the saturated model used the difference of deviances, determined using the Chi-squared or Hosmer-Lemeshow test, as appropriate. The area under the receiver operating characteristic (ROC) curve was calculated for each model. All statistical analyses were performed using the R language and software, version 2.12.1 [11]. The level of significance was fixed at 0.05. In Portugal, in 2008, there were 38 932 physicians and 56 859 nurses registered by their respective boards [12]. We obtained 2414 responses, of which 399 did not meet the inclusion criteria. Thus, responses from 2015 subjects were analysed; table 1 summarises the results. Of these subjects, 1540 (76.4%) were females and 1133 (56.2%) nurses. Subjects were aged 18-73 years (mean±SD 39.02±10.60 years). 44 (2.2%) subjects had a history of TB (20 before beginning professional activity).
Revista Portuguesa de Pneumologia (English Edition), 2010
Artigo Especial Special Article Resumo O diagnóstico e tratamento da infecção latente por Mycobac... more Artigo Especial Special Article Resumo O diagnóstico e tratamento da infecção latente por Mycobacterium tuberculosis reduz significativamente o risco de desenvolvimento de tuberculose activa e a transmissão da doença na comunidade. O rastreio da tuberculose infecção latente deve passar pela exclusão de doença activa (inquérito de sintomas e radiografia pulmonar) e avaliação da resposta imunológica ao M. tuberculosis através dos testes actualmente ao dispor, como o teste tuberculínico e os testes IGRA (interferon-gamma release assay). A escolha do esquema de tratamento deve ter em linha de conta a eficácia, a Tratamento da tuberculose de infecção latente. As recomendações actuais Latent tuberculosis infection treatment. Current recommendations Recebido para publicação/received for publication: 25.01.10 Aceite para publicação/accepted for publication: 11.05.10
Archivos de Bronconeumología, 2017
Infection, Genetics and Evolution, 2013
Human tuberculosis is an infectious disease caused by bacteria from the Mycobacterium tuberculosi... more Human tuberculosis is an infectious disease caused by bacteria from the Mycobacterium tuberculosis complex (MTBC). Although Spoligotyping and MIRU-VNTR are standard methodology in MTBC genetic epidemiology, recent studies suggest that Single Nucleotide Polymorphisms (SNP) are advantageous in phylogenetics and strain identification. In this work we use a set of 79 SNPs to characterize 1915 MTBC isolates from Portugal and 141 from Northeast Brazil. All Brazilian samples and a subset of 111 Portuguese isolates were further characterized using Spolygotyping. Phylogenetic analysis against a reference set revealed that about 95% of the isolates in both populations were singly attributed to bacterial lineage 4. Within this lineage, the most frequent strain groups in both Portugal and Brazil were LAM, followed by Haarlem and then X. Contrarily to these groups, strain group T showed a very different prevalence between Portugal and Brazil, with a frequency of 7% and less than 1.5%, respectively. Taking the classification by SNPs as the most accurate, we analyze the performance of Spoligotyping in strain identification. The former marker shows about 12% of miss-matches and less than 1% of unidentifiable strains. The miss-matches are observed in the most represented groups of our sample set (i.e., LAM, Haarlem and T) in almost the same proportion. Besides being more accurate in strain identification, SNPs typing can also provide phylogenetic relationships between the strain groups. Indeed, using this molecular markers we were able to observe possible signs of rare recombination events in Mtb. Overall, the use of SNP typing revealed striking similarities between MTBC populations from Portugal and Brazil. In addition this marker suggest that, albeit rare, recombination events in MTBC are likely to occur.
BMC Infectious Diseases, 2014
Background: Tuberculosis remains a high burden for Human society despite considerable investments... more Background: Tuberculosis remains a high burden for Human society despite considerable investments in its control. Unique features in the history of infection and transmission dynamics of tuberculosis pose serious limitations on the direct interpretation of surveillance data and call for models that incorporate latent processes and simulate specific interventions. Methods: A transmission model was adjusted to the dataset of active tuberculosis cases reported in Portugal between 2002 and 2009. We estimated key transmission parameters from the data (i.e. time to diagnosis, treatment length, default proportion, proportion of pulmonary TB cases). Using the adjusted model to the Portuguese case, we estimated the total burden of tuberculosis in Portugal. We further performed sensitivity analysis to heterogeneities in susceptibility to infection and exposure intensity. Results: We calculated a mean time to diagnose of 2.81 months and treatment length of 8.80 months in Portugal. The proportion defaulting treatment was calculated as 0.04 and the proportion of pulmonary cases as 0.75. Using these values, we estimated a TB burden of 1.6 million infected persons, corresponding to more than 15% of the Portuguese population. We further described the sensitivity of these estimates to heterogeneity. Conclusions: We showed that the model reproduces well the observed dynamics of the Portuguese data, thus demonstrating its adequacy for devising control strategies for TB and predicting the effects of interventions.
Archivos de Bronconeumología, 2017
The European respiratory journal, 2017
Acta reumatologica portuguesa, 2016
Delegates from the Tuberculosis Committee of the Portuguese Pulmonology Society, the Portuguese R... more Delegates from the Tuberculosis Committee of the Portuguese Pulmonology Society, the Portuguese Rheumatology Society, the Portuguese Dermatology and Venereology Society and the Portuguese Gastroenterology Society, have revised and updated, in 2012, their guidelines for the diagnosis and treatment of latent tuberculosis infection and active tuberculosis in patients that are candidates for therapy with biologic drugs. In order to identify perceived barriers to tuberculosis screening among patients candidate to anti-TNF treatment, we performed a cross-sectional survey including rheumatologists, gastroenterologists and dermatologists who prescribed anti-TNF agents, identified by the respective Scientific Societies, throughout Portugal. Ninety-five physicians (85 specialist and 10 trainees with more than 3 years of practice) participated in the survey, including 42 rheumatologists (response rate 28%), 32 dermatologists (12% response) and 21 gastroenterologists (4% response). No informati...
Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia, 2018
Multidrug-resistant and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB, respectively)... more Multidrug-resistant and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB, respectively) continue to represent a challenge for clinicians and public health authorities. Unfortunately, although there have been encouraging reports of higher success rates, the overall rate of favorable outcomes of M/XDR-TB treatment is only 54%, or much lower when the spectrum of drug resistance is beyond that of XDR-TB. Treating M/XDR-TB continues to be a difficult task, because of the high incidence of adverse events, the long duration of treatment, the high cost of the regimens used, and the drain on health care resources. Various trials and studies have recently been undertaken (some already published and others ongoing), all aimed at improving outcomes of M/XDR-TB treatment by changing the overall approach, shortening treatment duration, and developing a universal regimen. The objective of this review was to summarize what has been achieved to date, as far as new and repurposed drugs are ...
Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia, 2018
Case Reports in Pediatrics, 2017
The authors present a case report of antituberculosis drug-induced liver injury that offered diag... more The authors present a case report of antituberculosis drug-induced liver injury that offered diagnostic challenges (namely, the possibility of drug-induced autoimmune hepatitis) and treatment difficulties.
European Respiratory Journal, 2016
On July 4-5, 2016, representatives of the Asociación Latinoamericana de Tórax (ALAT), the Europea... more On July 4-5, 2016, representatives of the Asociación Latinoamericana de Tórax (ALAT), the European Respiratory Society (ERS) and of the Panamerican Health Organization (PAHO) met in Santiago de Chile to attend the VIII Regional Meeting of American Low Tuberculosis Incidence Countries. This meeting took place in connection with the 2016 ALAT Congress. Among the meeting attendees there were managers of national tuberculosis (TB) programmes and pulmonologists belonging to the ALAT Tuberculosis Dept. The Latin American countries with low TB incidence (defined as <10 cases per 100 000 population [1, 2]) and some of those approaching this threshold (Chile, Uruguay and Colombia were also invited as non-low TB incidence countries) had the possibility to report TB control and elimination policies in Latin America, and to discuss the results achieved with experts from PAHO, the World Health Organization (WHO) Global TB Programme and the ERS. Participants agreed that a clear epidemiological and programmatic heterogeneity exists in Latin America, with lack of published local scientific data. Local adaptation of global recommendations is needed in order to reach TB elimination (defined as fewer than one TB case per million population) [1, 2], and local evidence is mandatory to identify priorities and how to deal with them.
PLOS ONE, 2016
Tuberculosis imposes high human and economic tolls, including in Europe. This study was conducted... more Tuberculosis imposes high human and economic tolls, including in Europe. This study was conducted to develop a severity assessment tool for stratifying mortality risk in pulmonary tuberculosis (PTB) patients. A derivation cohort of 681 PTB cases was retrospectively reviewed to generate a model based on multiple logistic regression analysis of prognostic variables with 6-month mortality as the outcome measure. A clinical scoring system was developed and tested against a validation cohort of 103 patients. Five risk features were selected for the prediction model: hypoxemic respiratory failure (OR 4.7, 95% CI 2.8-7.9), age 50 years (OR 2.9, 95% CI 1.7-4.8), bilateral lung involvement (OR 2.5, 95% CI 1.4-4.4), 1 significant comorbidity-HIV infection, diabetes mellitus, liver failure or cirrhosis, congestive heart failure and chronic respiratory disease-(OR 2.3, 95% CI 1.3-3.8), and hemoglobin <12 g/dL (OR 1.8, 95% CI 1.1-3.1). A tuberculosis risk assessment tool (TReAT) was developed, stratifying patients with low (score 2), moderate (score 3-5) and high (score 6) mortality risk. The mortality associated with each group was 2.9%, 22.9% and 53.9%, respectively. The model performed equally well in the validation cohort. We provide a new, easy-to-use clinical scoring system to identify PTB patients with high-mortality risk in settings with good healthcare access, helping clinicians to decide which patients are in need of closer medical care during treatment.
The European respiratory journal, Sep 4, 2016
No evidence exists on tuberculosis (TB) and latent TB infection (LTBI) management policies among ... more No evidence exists on tuberculosis (TB) and latent TB infection (LTBI) management policies among refugees in European countries.A questionnaire investigating screening and management practices among refugees was sent to 38 national TB programme representatives of low and intermediate TB incidence European countries/territories of the WHO European Region.Out of 36 responding countries, 31 (86.1%) reported screening for active TB, 19 for LTBI, and eight (22.2%) reporting outcomes of LTBI treatment. Screening for TB is based on algorithms including different combinations of symptom-based questionnaires, bacteriology and chest radiography and LTBI screening on different combinations of tuberculin skin test and interferon-γ release assays. In 22 (61.1%) countries, TB and LTBI screening are performed in refugee centres. In 22 (61.1%) countries, TB services are organised in collaboration with the private sector. 27 (75%) countries answered that screening for TB is performed as per national...
BMC Infectious Diseases, 2015
Background: Multidrug resistant-tuberculosis (MDR-TB) is a threat to global tuberculosis control ... more Background: Multidrug resistant-tuberculosis (MDR-TB) is a threat to global tuberculosis control which is worsened by human immune-deficiency virus (HIV) co-infection. There is however paucity of data on the effects of antiretroviral treatment (ART) before or after starting MDR-TB treatment. This study determined predictors of mortality and treatment failure among HIV co-infected MDR-TB patients on ART. Methods: A retrospective medical record review of 1200 HIV co-infected MDR-TB patients admitted at Sizwe Tropical Disease Hospital, Johannesburg from 2007 to 2010 was performed. Chi-square test was used to determine treatment outcomes in HIV co-infected MDR-TB patients on ART. Multivariable logistic regression and Poisson models were used to determine predictors of mortality and treatment failure respectively. Results: Mortality was higher (21.8 % vs. 15.4 %) among patients who started ART before initiating MDR-TB treatment compared with patients initiated on ART after commencing MDR-TB treatment (p = 0.013). Factors significantly associated with mortality included: the use of ART before starting MDR-TB treatment (OR 1.65, 95 % CI 1.02-2.73), severely-underweight (OR 3.71, 95 % CI 1.89-7.29) and underweight (OR 2.35, 95 % CI 1.30-4.26), cavities on chest x-rays at baseline (OR 1.76, 95 % CI 1.08-2.94), presence of other opportunistic infections (OR 1.80, 95 % CI 1.10-2.94) and presence of other co-morbidities (OR 2.26, 95 % CI 1.20-4.21). Factors predicting failure were severe anaemia (IRR (OR 4.72, 95 % CI 1.47-15), other co-morbidities (OR 2.39, 95 % CI 1.05-5.43) and modified individualised regimen at baseline (OR 2.15, 95 % CI 0.98-4.71). Conclusions: High mortality among patients already on ART before initiating MDR-TB treatment is a worrisome development. Management of adverse-events, opportunistic infections and co-morbidities in these patients is important if the protective benefits of being on ART are to be maximized. There is the need to intensify intervention programmes targeted at early identification of MDR-TB, treatment initiation, drug monitoring and increasing adherence among HIV co-infected MDR-TB patients.
Revista portuguesa de pneumologia
Tumor necrosis factor-alpha (TNF-␣) is a pleomorphic cytokine involved in the pathogenesis of man... more Tumor necrosis factor-alpha (TNF-␣) is a pleomorphic cytokine involved in the pathogenesis of many rheumatic diseases. Following anti-TNF therapy, the relative risk for tuberculosis is increased by up to 25 times, often as a rapidly progressive disease, extra-pulmonary or disseminated. 1-4 Aiming to evaluate compliance with guidelines for tuberculosis screening, the authors conducted an enquiry among northern Portuguese hospitals which prescribe anti-TNF therapy. From all hospitals in northern Portugal the authors identified those that prescribed anti-TNF therapy, and from them randomly selected from among the Internal Medicine medical doctors (the specialty which most commonly prescribed biological therapy in these hospitals) those who had at least, one weekly consultation of autoimmune disease and were familiar with the hospital prescription procedures. One hospital which had only one doctor prescribing was excluded. The enquiry was carried out in September 2012. The interview consisted of ten multiple-choice questions relating to each recommendation: TB screening, diagnostic exams, preventive treatment, when to start anti-TNF␣ therapy and TB monitoring through the course of anti-TNF␣ treatment. Compliance rates were determined for each clinical recommendation and each guideline [national, international or European consensus] (Table 1). 5,1,6,7 Eleven hospitals were identified and ten were eligible. They performed TB screening in all patients treated with anti-TNF therapy. The screening method used by all hospitals was patient history and tuberculin skin test (TST), seven (70%) used interferon-gamma-release-assay (IGRA) and six (60%) used chest radiography (CRX). Compliance rate: 60% for UK guidelines and 50% for European consensus, USA and national guidelines (Table 2). All hospitals performed TB screening prior to anti-TNF treatment (compliance rate of 100% with all guidelines); seven (70%) re-screened during anti-TNF treatment, due to
Jornal Brasileiro de Pneumologia, 2015
The European respiratory journal, 2015
This paper describes an action framework for countries with low tuberculosis (TB) incidence (<... more This paper describes an action framework for countries with low tuberculosis (TB) incidence (<100 TB cases per million population) that are striving for TB elimination. The framework sets out priority interventions required for these countries to progress first towards…
International Journal of Infectious Diseases, 2015
The emergence and spread of multidrug-resistant tuberculosis (MDR-TB), defined as TB caused by My... more The emergence and spread of multidrug-resistant tuberculosis (MDR-TB), defined as TB caused by Mycobacterium tuberculosis strains resistant to isoniazid and rifampicin (the two most important anti-TB drugs currently in use), and extensively drug resistant tuberculosis (XDR-TB), defined as MDR-TB caused by strains resistant to at least one fluoroquinolone and one injectable second-line anti-TB drug in addition to isoniazid and rifampicin, has attracted interest at different levels 1-5. In recent years, the alarming rates of M/XDR-TB in Eastern Europe and other settings of the world resulted in strong expressions of concern by national and international health authorities, partners and scientific societies. At media level, the key words MDR-TB and XDR-TB have caught spikes of citations and consistent interest since the time the term XDR-TB appeared for the first time, as a simple Google search can testify (Figure 1). From the public health point of view, M/XDR-TB is considered a serious threat for TB control and elimination. Therefore, the
European Respiratory Journal, 2014
Although the incidence of tuberculosis (TB) has increased in healthcare workers (HCWs) [1-3], sev... more Although the incidence of tuberculosis (TB) has increased in healthcare workers (HCWs) [1-3], several studies have shown that HCWs are not compliant with screening and/or preventive measures [4-7]. For example, a Portuguese study found that the estimated TB incidence was three-to seven-fold higher in HCWs than in the general population [8]. Latent TB infection (LTBI) diagnosis and treatment constitute the core of TB elimination, integrating the post-2015 strategies of the World Health Organization [9, 10]. To evaluate TB screening practices among HCWs and their reasons for nonadherence in Portugal, we developed a survey and distributed it to nurses and physicians from December 25, 2012 to January 31, 2013, closing when we received fewer than one response per day. The survey was anonymous, voluntary and digitally distributed through our network of contacts using a "snowball" distribution method where volunteers subsequently distribute the questionnaire to their contacts and so forth. Continuous data are presented as mean±SD and compared using t-tests. Categorical data are presented as n (%) and compared using the Chi-squared or Fisher's test, as appropriate. Multiple logistic regression analysis was used to identify statistically significant determinants of TB infection, exposure and screening. Crude and adjusted odds ratios and 95% confidence intervals were determined. Goodness-of-fit of the models was evaluated; comparisons with the null model used the difference of deviances, as determined by Chi-squared tests, while comparisons with the saturated model used the difference of deviances, determined using the Chi-squared or Hosmer-Lemeshow test, as appropriate. The area under the receiver operating characteristic (ROC) curve was calculated for each model. All statistical analyses were performed using the R language and software, version 2.12.1 [11]. The level of significance was fixed at 0.05. In Portugal, in 2008, there were 38 932 physicians and 56 859 nurses registered by their respective boards [12]. We obtained 2414 responses, of which 399 did not meet the inclusion criteria. Thus, responses from 2015 subjects were analysed; table 1 summarises the results. Of these subjects, 1540 (76.4%) were females and 1133 (56.2%) nurses. Subjects were aged 18-73 years (mean±SD 39.02±10.60 years). 44 (2.2%) subjects had a history of TB (20 before beginning professional activity).
Revista Portuguesa de Pneumologia (English Edition), 2010
Artigo Especial Special Article Resumo O diagnóstico e tratamento da infecção latente por Mycobac... more Artigo Especial Special Article Resumo O diagnóstico e tratamento da infecção latente por Mycobacterium tuberculosis reduz significativamente o risco de desenvolvimento de tuberculose activa e a transmissão da doença na comunidade. O rastreio da tuberculose infecção latente deve passar pela exclusão de doença activa (inquérito de sintomas e radiografia pulmonar) e avaliação da resposta imunológica ao M. tuberculosis através dos testes actualmente ao dispor, como o teste tuberculínico e os testes IGRA (interferon-gamma release assay). A escolha do esquema de tratamento deve ter em linha de conta a eficácia, a Tratamento da tuberculose de infecção latente. As recomendações actuais Latent tuberculosis infection treatment. Current recommendations Recebido para publicação/received for publication: 25.01.10 Aceite para publicação/accepted for publication: 11.05.10