Multidrug-resistant Mycobacterium tuberculosis (MDR-TB) is a leading cause of morbidity and mortality in the Philippines. The purpose of this study was to gain knowledge about the relationship between potential risk factors and MDR-TB. Risk factors (the independent variables) for MDR-TB (the dependent variable) include previous TB treatment, infection with HIV, exposure to patients with drug-susceptible TB/MDR-TB, delays in diagnosis and treatment, employment status, smoking, imprisonment, alcohol abuse, and poor compliance with TB treatment regimens. The study was based on the epidemiological approach to causal inference work. A case-control study design was used wherein a quantitative method was applied in data analysis to assess the strength of the pre-identified possible risk factor(s) association to MDR-TB infection. Data were collected using survey questionnaires that were administered to patients (N = 172) from health centers in Leyte, San Mateo Rizal, and San Lazaro. Hypotheses were tested using chi-square analysis, Fisher's exact test, and an odd ratio. Drug-susceptible TB respondents who smoked on a daily basis were three times more likely (95% CI 1.021-13.341, OR 3.69) to develop an MDR-TB infection than were other respondents. Respondents who did not comply with the anti-TB treatment regimen were nine times more likely (95% CI 2.104-43.059, OR 9.519) to develop an MDR-TB infection than other respondents. Health care providers may be able to use study findings to develop programs to help drug-susceptible TB patients stop smoking and better comply with treatment regimens designed to prevent MDR-TB infection, resulting, potentially, in improved public health outcomes for patients.

Philosophiae Doctor - PhD / Polyamic acid (PAA) nanostructured materials were successfully produced by electrochemical deposition and electrospinning using polyvinlypyrrolidone (PVP) as supporting polymer. Polyamic acid thin film and nanofibers were deposited directly at the surface of a screen-printed carbon electrode (SPCE) as electro-catalysts for reliable analytical reporting of sulphonamide as contaminants of emerging concern by electrochemical techniques. Fourier transform infrared (FTIR) spectroscopy was used to confirm the structural integrity of the PAA electrospun nanofibers compared to the chemical synthesized PAA. Brunauer-Emmett-Teller (BET) was used to determine the surface area of the nanofibers. The surface morphology and surface thickness of the polyamic acid (PAA) nanofibers on the screen-printed electrodes was studied using scanning electron microscopy (SEM) and atomic force microscopy (AFM). Cyclic voltammetry (CV) was used to study redox behavior of the nanostructured PAA modified screen-printed carbon electrodes. Electrochemical parameters surface concentration, diffusion coefficient, formal potential and peak separation were determined. Three sulphonamides were selected based on the United States of protection agency (US EPA) and World Health Organization (WHO) list of emerging contaminants and detected sulphonamides in environmental waters in South Africa and other African regions. The selected sulfonamides were evaluated at the unmodified and modified screen-printed carbon electrodes. The sulphonamides were evaluated in three different supporting electrolytes at pH < 7 and >7 to enhance electrochemical signal reporting. Sulfadiazine (SDZ), sulfamethoxazole (SMX) and sulfamethazine (SMZ) displayed peaks at 0.80 V vs Ag/AgCl in 0.1 M tris-HCl using square wave voltammetry at the unmodified transducer. At the PAA thin film transducer, SDZ, SMX and SMZ displayed well-defined analytical oxidative peaks at 0.77 V 0.82 V and 0.83 V vs Ag/AgCl respectively. The LOD (n=3) for SDZ was found to be 12.14 ųM with a correlation coefficient of 0.9950. The LOD (n=3) for SMX and SMZ was found to 14.59 ųM (R2 =0.9928) and 10.41 ųM (R2 =0.9963). These sulphonamides were also electro-analytical evaluated at the screen-printed carbon PAA nanofiber modified transducer. SDZ, SMX and SMZ produced well-defined analytical signals at 0.79 V, 0.81 V and 0.78 V vs Ag/AgCl respectively. The determined LOD (n=3) for the individual sulphonamides was 8.26 ųM, 16.59 ųM and 8.81 ųM SDZ, SMX and SMZ respectively. The linearity correlation coefficient (R2) was determined to be 0.9977, 0.9956 and 0.9974 respectively. The efficacy of the proposed nanostructured PAA thin film modified screen-printed carbon sensor was evaluated by performing recovery studies for the selected sulphonamides using square wave voltammetry. Tap water was used to simulate environmental matrix. The recoveries of SDZ with respect to each concentration were 98.84% (RSD 4.98%) to 40.58% (RSD 6.74%). For SMX the recoveries were 154.17% (RSD 11.00%) to 111.03% (RSD 16.80%). The recoveries for SMZ with respect to each concentration were 184% (RSD 8.19%) to 90.26 (RSD 18.26%) indicating the reliability of the analytical results. / 2021-09-01

No description available.

Lic.-avh. Stockholm : Karolinska institutet, 2006.

Magister Scientiae (Occupational Therapy) - MSc(OT) / TB is a multi- faceted public health problem spurred on by the biological progression of the disease as well as the social issues associated with it. The treatment of TB is however primarily driven by the medical model where the focus is on the disease and not on a holistic view of the patient. Occupational therapy is a profession concerned with the use of occupation in the promotion of health and well being through the facilitation of the process of occupational adaptation. There is however a paucity of literature pertaining to the role that occupational therapy could play within the TB context. The aim of this study was to explore how adults with MDR- TB who undergo long-term hospitalisation at a hospital in the Western Cape experience occupational adaptation. The objectives of the study were to explore how the participants perceive their occupational identity, to explore the meaning and purpose the participants assign to their occupational engagement and to explore the how the participants perceive their occupational competence. The interpretive research paradigm employing a phenomenological qualitative research approach was utilized in this study. Purposive sampling was used to select four participants based on specific selection criteria. The data gathering methods utilized included diaries, semistructured interviews, participant observation and a focus group. Photographs taken by the researcher for the purpose of participant observation were used to elicit a rich, in depth response from the participants during the focus group discussion. All data was analysed through thematic content analysis. The study findings highlighted that the participants viewed themselves as occupational beings and that they valued the role that occupational engagement played in facilitating their occupational competence and ultimately their ability to adapt to long- term hospitalisation. The environmental demands and constraints that they experienced however infringed their engagement in meaningful occupation and hampered their ability to achieve occupational competence. It was recommended that the hospital adopt an integrative intervention approach to the management of MDR- TB patients that include principles of psychosocial rehabilitation and occupational enrichment to address occupational risk factors and institutionalisation.

Background: There is a dearth of information regarding prevalence of extensively drugresistant tuberculosis (XDR-TB) in Africa. Although countries in Africa conduct national tuberculosis surveys on a regular basis, this information has not been systematically reviewed to ascertain the overall prevalence of XDR-TB in Africa. Methods: The study aimed to perform a systematic review and meta-analysis of the prevalence and factors associated with prevalence of pulmonary XDR-TB among adults in Africa. Eligible studies, published between 2006 and 2018, were sourced from various electronic databases including PubMed, Scopus, and Web of Science. Meta-analysis was performed using STATA (version 14.2) statistical software. The protocol of this review was registered with PROSPERO, reg No CRD42018117037. Result: A total of 6242 records were retrieved. Forty-eight studies were screened for eligibility and seven, which varied in terms of country setting and study design, were included. The prevalence of XDR-TB is 4% (95%CI 2-7) among participants tested for second-line anti-TB drug resistance, and 3% (95%1-6) among participants with drug resistant TB. The prevalence of XDR-TB was 7% (95%CI 1-18) among participants with MDR-TB. A few studies reported on the factors associated with the prevalence of XDR-TB. Discussion: The reported prevalence of XDR-TB among participants tested for second-line anti-TB drug resistance is low compared to WHO estimates. The systematic review underscores a dearth of studies depicting the reality regarding the prevalence of XDR-TB in Africa. Policymakers and stakeholders interested in drug-resistant TB should apply prudence when considering XDR-TB prevalence reported for Africa.

Despite efforts towards the management and prevention of Tuberculosis (TB) having shown some success, Multidrug-Resistant Tuberculosis (MDR-TB) may potentially compromise these endeavours. MDR-TB has the potential to become the most dominant form of TB in low- and middle-income countries (LMICs). The impact of environmental health factors on the optimization of health of MDR-TB infected individuals, as well as on the prevention of transmission to household contacts, is not well documented. Current Sustainable Development Goals (SDGs) aim to achieve inclusivity, sustainability and resilience, not only through economic and social changes, but also through environmental targets in order to achieve optimal health and well-being for all. However, without appropriate acknowledgment of the environment's influence on outcomes during TB treatment, these targets are potentially unattainable. Establishing the recommendations of environmental health risk factors for individuals living at home with MDR-TB will have important policy implications as well as assist in decision making for those affected with MDR-TB in LMICs, such as South Africa. This systematic review, therefore, sought to identify the environmental health factors in LMICs that affect treatment outcomes for individuals living at home with MDR-TB, to optimize their health during completion of their treatment regimen and prevent transmission to household contacts. Part A outlines the current literature available for such a topic as well as methodology used within the systematic search and analysis of included articles. Prominent environmental health exposure variables of interest that have previously been identified as having a significant role in TB transmission or influencing the well-being of infected individuals, were identified within the literature. These included air pollution, nutrition, migration, urbanization, smoking, alcohol, other substance use and housing. Outcomes of interest included optimization of health and prevention of MDR-TB transmission to household contacts. The article (part B) represents the results from the systematic search as well as the application to current policy recommendations. After screening and reviewing the full text of potential articles for inclusion (N = 87), only thirteen articles were eligible for inclusion into the final sample. All included studies were primary observational studies, examining the relationship between MDRTB and the pre-defined exposures and outcomes in populations ≥13 years of age. Environmental risk factors for household transmission of MDR-TB potentially included malnutrition but showed no significant relationship with overcrowding. There was disagreement as to whether smoking was as a significant predictor of mortality but findings did indicate that smoking did have a negative impact on sputum culture conversion among patients receiving treatment. Other substance use was found to have a significant role in the default of treatment. The use of alcohol was associated with poor treatment outcomes, default of treatment and lack of sputum culture conversion. In terms of household conditions, an association was found between substandard housing conditions and treatment default. Formal housing was associated with a decline in treatment default but a residential address change was associated with defaulting treatment. The results of the review presented contradictory results regarding the risk of mortality and underweight/overweight BMI estimates. The review potentially highlighted vulnerable population groups including gender groups, children and HIV positive individuals. Therefore, this systematic review highlighted the potential relationship between environmental risk factors and optimising the health of individuals on treatment for MDR-TB, as well as the role that promoting environmental health may play in preventing the transmission to household contacts. In conclusion, environmental risk factors should be incorporated into local health system strategies and global policy. This includes WHO targets in TB prevention efforts, as well as in action areas for the attainment of relevant SDGs (e.g. SDG 3 and SDG 5), to address the burden of MDR-TB and decrease MDR-TB transmission in LMICs, effectively and sustainably.

Thesis (MScMedSc)--Stellenbosch University, 2008. / ENGLISH ABSTRACT: Application of molecular fingerprinting highlights transmission as the driving force behind the drug resistant epidemic in South Africa. Different strains dominate within different geographical regions, which is a reflection of micro-epidemics of drug resistance in the different regions. Cluster analysis shows that strains within the same strain family are different. The Beijing drug resistant strain family is the most dominant strain family (31%) in the Western Cape and of particular concern is the highly transmissible Beijing cluster 220 strain in the Western Cape communities. This cluster is widespread in the region and was previously identified in a MDR outbreak in a high school in Cape Town. Results suggest that the spread of Beijing drug resistant cluster 220 in the community was due to a combination of acquisition of drug resistant markers and transmission. This study also indicate that atypical Beijing can acquire drug resistance and become fit amongst HIV infected individuals. This is contrary to believe that atypical Beijing strains are not frequently associated with drug resistance and are attenuated. This implies that HIV levels the playing field for all drug resistant strains. Mechanisms leading to the evolution of MDR-TB and XDR-TB in a mine setting with a wellfunctioning TB control program which exceeds the target for cure rates set by the WHO were investigated. Despite the excellent control program, an alarming increase in the number of drug resistant cases was observed in 2003 and subsequent years. Phylogenetic analysis shows sequential acquisition of resistance to first and second-line anti-TB drugs leading to the development of MDR and XDR-TB. Contact tracing indicate extensive transmission of drug resistant TB in the shafts, hospital and place of residence. This study shows that despite exceeding the WHO cure rate target, it was not possible to control the spread and amplification of drug resistance. In summary, as a top priority, future TB control plans need to address diagnostic delay more vigorously. / AFRIKAANSE OPSOMMING: Molukulêre tegnieke toon transmissie as die hoofrede vir die toename in die anti-tuberkulose middelweerstandigheid epidemie in Suid-Afrika. Die verskillende Mikobakterium tuberkulose rasse wat domineer in verskillende areas is ‘n refleksie van middelweerstandige mikro-epidemies in verskillende gebiede. Analise van identiese rasgroepe demonstreer dat ras families bestaan uit verskillende rasse. Die Beijing middelweerstandige rasfamilie is die mees dominante familie in die Wes-Kaap (31% van monsters van middelweerstandige families) en van spesifieke belang is die hoogs oordraagbare Beijing 220 groep. Hierdie groep is die mees wydverspreide groep in die studie area en was voorheen geïdentifiseer tydens ‘n meervoudige middelweerstandige uitbreking in ‘n hoërskool in Kaapstad. Die resultate dui aan dat die Beijing middelweerstandige groep 220 in die gemeenskap versprei as gevolg van ‘n kombinasie van middelweerstand verwerwing en transmissie. Hierdie studie dui verder aan dat die atipiese Beijing ook middelweerstandigheid kan verwerf en hoogs geskik is vir infeksie veral in MIV geïnfekteerde individue. Hierdie data is in teenstelling met die algemene denke dat atipiese Beijing nie gereeld geassosieer word met middelweerstandigheid nie en dat dit dikwels geattenueer is. Dit beteken dat MIV die hoof faktor is wat alle middelweerstandige rasse kans gee om te versprei. Hierdie studie het die meganisme wat lei tot die evolusie van middelweerstandigheid en “XDRTB” in die myne ondersoek. Die myn besit ‘n goeie funksioneerde tuberkulose kontrole program wat alreeds die Wêreld Gesondheids Organisasie se mikpunt vir tuberkulose genesing oortref. Ten spyte van ‘n uitstekende tuberkulose kontrole program, is daar ‘n bekommerenswaardige toename in die aantal middelweerstandige tuberkulose gevalle waargeneem in 2003 en in die daaropvolgende jare. Filogenetiese analise wys dat opeenvolgende verwerwing van middelweerstandigheid teen eerste en tweede vlak anti-tuberkulose middels gelei het tot die ontwikkeling van meervoudige middelweerstandigheid en “XDR-TB”. Die opsporing van kontakpersone om transmissie te bewys dui aan dat transmissie van middelweerstandige tuberkulose in die werk plek, hospitaal en woon plek plaasvind. Hierdie studie wys dat ongeag die feit dat die Wêreld Gesondheids Organisasie se genesings verwagtinge oortref is, dit steeds onmoontlik was om die verspreiding en amplifisering van middelweerstandigheid te beheer. ‘n Top prioriteit vir tuberkulose kontrole planne in die toekoms behoort die vertraging van diagnose sterk aan te spreek.

Magister Public Health - MPH / Background: Multidrug resistant tuberculosis (MDR TB) is a growing threat globally. The large increase in the incidence and prevalence of MDR TB in South Africa in recent years has impacted on the way in which MDR TB is managed within the health services. It became logistically difficult to manage MDR TB by treating all patients as in-patients in a specialized tuberculosis (TB) hospital. The clinics, which are run by nurses and/or general medical officers, are then required to manage this more complex form of TB, with limited resources, less experience and assumingly with less MDR TB knowledge. Of particular concern is that shifting of the patient management from specialized TB hospitals to Primary Health Care clinics which might worsen the already poor MDR TB treatment outcomes. There has been minimal assessment of the management of MDR TB at clinic level and hence the comparison of treatment outcomes for those patients initiated on treatment in clinics compared to in-patients in specialized TB hospitals is urgently needed. Aim: To compare the treatment outcomes and the effectiveness of medication regimens provided to MDR TB patients initiated on treatment in specialized TB hospitals as inpatients, to that of MDR TB patients initiated on treatment as outpatients at community clinics within the Western Cape Province, South Africa. Methodology Study Design: A retrospective cohort study was undertaken, as the length of treatment for a MDR TB patient can be for 24 months or longer and this study was based on treatment outcome data. Study Population and sample: The study population was uncomplicated MDR TB patients initiated on treatment in hospitals and clinics from January 2010 to December 2012. The sample comprised of 568 participants that were laboratory confirmed to have MDR TB and had the outcomes of their treatment recorded in an electronic database or a paper register. Data Collection: The researcher collected MDR TB information from standardized MDR TB registers as well as an electronic MDR TB database. Analysis: Data was analyzed comparing the exposed (clinic initiated) and unexposed (hospital initiated) cohorts incidence of 4 key treatment outcomes, namely: successfully treated, failed treatment, died and defaulted treatment. Bivariate analysis (relative and absolute) was done to determine the cumulative incidence ratio and cumulative incidence difference and multivariate logistic regression analysis for the adjusted odds ratio to control for confounders and effect modifiers. Ethics: Permission to conduct this research was obtained from the relevant authorities. The confidentiality of the participants as per the Department of Health policy and in adherence to general ethical guidelines was strictly maintained. The study proposal received ethical clearance and approval from the University of the Western Cape Research Committee. Results: All participants within this study received the appropriate treatment as per the MDR TB guidelines. The incidence rate for the main outcomes of this study indicated that successfully treated for the clinic initiated participants was 41% and 31% for the hospital initiated participants. ‘Defaulted’ treatment was 39% and 41%, ‘failed’ treatment 7% and 13% and ‘died’ was 14% and 16%, respectively. The clinic initiated participants appeared to have better treatment outcomes on bivariate analysis, however on multivariate analysis, there was no difference in the treatment outcomes of the clinic initiated participants compared to the hospital initiated participants, and therefore the clinic initiated treatment is seen as effective. The time to treatment initiation for clinic and hospital initiated participants is excessively long for both cohorts, with a median of 29 days, and 37 days respectively. The key findings of note in the multivariate analysis is that the Human Immunodeficiency Virus positive (HIV+) participants provided with antiretrovirals therapy (ART) were, based on adjusted cumulative incidence ratios, 6.6 times more likely to have a successfully treated outcome (95% CI 1.48-29.84), and were 0.2 times less likely to die (95% CI 0.08-0.53). Having a previous cured history of TB and no previous history of TB were 2.9 times more likely to have a successfully treated outcome (95% CI 1.48-5.56) and were 0.1 times (0.04-0.38) less likely to fail treatment. An interesting finding was that participants living in the rural districts were 2.6 times more likely to die. Conclusion: Clinic initiated treatment for uncomplicated MDR TB is as effective as hospital initiated treatment. Also, those provided with ART and those without previous TB or who had a previous bout of TB cured, had better outcomes. Main Recommendations: The Western Cape health department should continue with the decentralization of MDR TB services to the clinics and could safely consider expanding the decentralization to include uncomplicated Preextensively drug-resistant TB and Extensively drug-resistant TB patients. Offering ART to HIV+ patients should be mandatory. The delays in the time to treatment initiation of MDR TB need to be further investigated.

Bakgrund Antibiotikaresistens är rangeras idag som ett av de största hoten mot folkhälsan. Bärare av multiresistenta bakterier är ofta dåligt införstådda i vad det innebär att vara bärare vilket leder till ett minskat välbefinnande. Sjuksköterskor har en central roll i att informera patienter om deras hälsotillstånd och ska säkerställa att informationen är förstådd. Syfte Att undersöka sjuksköterskors upplevelse av att informera patienter som bär på multiresistenta bakterier om deras bärarskap. Metod Kvalitativ intervjustudie med induktiv ansats. Semistrukturerade intervjuer genomfördes med sju sjuksköterskor på ett sjukhus i Mellansverige. Data analyserades med kvalitativ innehållsanalys. Resultat Analysen resulterade i fyra kategorier: arbetsmiljö, sjuksköterskans roll, patientens förutsättningar och okunskap. Informanterna upplevde att det var otydliga rutiner kring vilken information som skulle ges till patienterna. Informanterna antog att patienter redan var införstådda i sitt bärarskap när de ankom avdelningen. Patientens tillstånd och språk var faktorer som påverkade informationsgivandet. Det fanns en okunskap hos patienter och anhöriga som ofta ledde till en rädsla och onödig förstorning av bärarskapet. Kunskapsbrister existerade även hos vårdutbildade och kunde leda till att patienter blev felbehandlade. Slutsats Informanterna upplevde att det förekom otydliga rutiner kring vilken information som skulle ges till bärare av MRB om deras bärarskap. Förförståelse om att patienten redan var införstådd i sitt bärarskap samt patientens förutsättning att kunna motta information påverkade givandet av information. Att ge korrekt information till patienten och säkerställa sig om att informationen är förstådd är viktiga faktorer som leder till minskat lidande hos patienten samt minskad spridning av MRB i samhället. / Background Antimicrobial resistance is an increasingly serious threat to public health. Carriers of multidrug-resistant bacteria are often poorly understood in what it implies to be a carrier. This can lead to a reduced sense of wellbeing. Nurses have a central role in informing patients about their health condition and also in ensuring that the information is apprehended. Aim To investigate nurses’ experience of informing patients who carry multidrug-resistant bacteria about their colonisation. Method Qualitative interview study. Semi structured interviews were conducted with 7 nurses at a university hospital in central Sweden. The interviews were analyzed using content analysis. Result The analyze resulted in four categories: work environment, role of the nurse, patients’ conditions and lack of knowledge. The informants experienced uncertain routines concerning what information they should distribute to the patients about multidrug-resistant bacteria. The informants often assumed that the patients were well informed and understood  about colonisation of multidrug-resistant bacteria prior to the hospital stay. The patients’ condition and language could affect the distributed information. The informants recognized a lack of knowledge in patients and relatives that could lead to fear and exaggeration of the colonisation. Lack of knowledge was also seen among health care professionals and could lead to patients being mistreated at the hospital. Conclusion The informants experienced uncertain guidelines about what information to give carriers of multidrug-resistant bacteria. The patients’ condition and the preunderstanding that the patient already was well informed about being a carrier were two factors affecting the distribution of information. It is essential that nurses distribute adequate information and ensure that patients understand their condition in order to reduce the patient suffering and the spreading of multidrug-resistant bacteria in the society.