Background
Although the price increase of pyrimethamine in 2015 received heavy media coverage, there is little data regarding specific implications to hospitals and the total costs of treating inpatients with toxoplasmosis encephalitis (TE).
Methods
Utilizing average drug wholesale costs, we estimated the inpatient drug costs of TE drugs three years pre- and post- pyrimethamine price increase in August 2015. The drug regimens and total doses were determined through retrospective chart review of patients living with HIV who received treatment for toxoplasmosis encephalitis while inpatient during this period.
Results
The three-year pre-increase TE drug costs for 66 admissions were estimated at $50,310 compared to a total drug cost of $1,026,006 for 61 admissions post-increase. Pyrimethamine made up 98% of the drug costs post-increase, compared to 57% pre-increase. Pyrimethamine-based regimens were the most frequently used throughout the study period.
Conclusions
The price increase of pyrimethamine in 2015 led to a substantial and unnecessary financial burden to hospitals. This required healthcare systems to shift valuable resources in order to continue to provide medications to a vulnerable patient population. There has been more focus on providing high value care in recent years. Our study highlights the need for further examination of pharmaceutical companies’ arbitrary determination of medication costs and how they contribute to patient care.
Objective: We explored barriers to proper foot care in this population using a qualitative approach with focus group discussions (FGD). Methods: Participants were recruited from clinics at a safety-net hospital in Atlanta, Georgia and stratified into two groups: diabetic foot ulcer (DFU) and minor amputation (below ankle). The FGDs addressed patient experience in receiving care with a goal of understanding: foot care knowledge, barriers to care, and preferred educational methods. Surveys were performed to supplement FGDs. Results: Forty participants (90% Black) were enrolled. Dominant themes emerging from FGDs were: 1-Patients reported adequate understanding of recommended foot care practices; 2-Personal barriers to self-care included lack of motivation, high cost, poor insurance coverage of supplies, and difficulty limiting activity for proper offloading; 3-Hospital system barriers included difficulty making timely appointments and reaching a provider to arrange care; 4-Access to footcare-related information and services improved with greater disease severity. Participants stressed that improved access often came too late to alter their course. They expressed interest in developing peer support groups to facilitate learning and sharing information relating to DFU. Conclusion: We found that patients with DFU or minor amputations have adequate footcare-related knowledge, but personal and systemic barriers limited appropriate foot care.
Background. It is uncertain whether diabetes affects the risk of developing latent tuberculosis infection (LTBI) following exposure to Mycobacterium tuberculosis (Mtb). We assessed the relationship of diabetes or prediabetes and LTBI among close and household contacts (HHCs) of patients with active pulmonary tuberculosis (TB) disease in Addis Ababa, Ethiopia. Methods. In this cross-sectional study, we performed interferon-γ release assays, TB symptom screening, and point-of-care glycolated hemoglobin (HbA1c) testing among HHCs of active TB cases. Diabetes status was classified into diabetes (HbA1c ≥6.5% or self-reported diagnosis), prediabetes (5.7%-6.4%), and euglycemia (≤5.6%). Multivariable logistic regression was used to determine the association of diabetes with LTBI. Results. Among 597 study participants, 123 (21%) had dysglycemia including diabetes (n = 31) or prediabetes (n = 92); 423 (71%) participants were diagnosed with LTBI. Twelve of 31 (39%) HHCs with diabetes were previously undiagnosed with diabetes. The prevalence of LTBI among HHCs with diabetes, prediabetes, and euglycemia was 87% (27/31), 73% (67/92), and 69% (329/474), respectively. In multivariable analysis adjusted for age, sex, and HIV status, the odds of LTBI among HHCs with diabetes were 2.33 (95% confidence interval [CI], .76-7.08) times the odds of LTBI without diabetes. When assessing interaction with age, the association of diabetes and LTBI was robust among participants aged ≥40 years (adjusted odds ratio [aOR], 3.68 [95% CI, .77-17.6]) but not those <40 years (aOR, 1.15 [95% CI, .22-6.1]). Conclusions. HHCs with diabetes may be more likely to have LTBI than those with euglycemia. Further investigations are needed to assess mechanisms by which diabetes may increase risk of LTBI after Mtb exposure.
Objective. To better understand hospital infection control practices in Ethiopia.
Design. A cross-sectional evaluation of healthcare worker (HCW)knowledge, attitudes, and practices about hand hygiene and tuberculosis (TB) infection control measures.
Methods. An anonymous 76-item questionnaire was administered to HCWs at 2 university hospitals in Addis Ababa, Ethiopia. Knowledge items were scored as correct/incorrect. Attitude and practice items were assessed using a Likert scale.
Results. In total, 261 surveys were completed by physicians (51%) and nurses (49%). Fifty-one percent of respondents were male; mean age was 30 years. While hand hygiene knowledge was fair, self-reported practice was suboptimal. Physicians reported performing hand hygiene 7% and 48% before and after patient contact, respectively. Barriers for performing hand hygiene included lack of hand hygiene agents (77%), sinks (30%), and proper training (50%) as well as irritation and dryness (67%) caused by hand sanitizer made in accordance with the World Health Organization formulation. TB infection control knowledge was excellent (more than 90% correct). Most HCWs felt that they were at high risk for occupational acquisition of TB (71%) and that proper TB infection control can prevent nosocomial transmission (92%). Only 12% of HCWs regularly wore a mask when caring for TB patients. Only 8% of HCWs reported that masks were regularly available, and 76% cited a lack of infrastructure to isolate suspected/known TB patients.
Conclusions. Training HCWs about the importance and proper practice of hand hygiene along with improving hand sanitizer options may improve patient safety. Additionally, enhanced infrastructure is needed to improve TB infection control practices and allay HCW concerns about acquiring TB in the hospital.
Following large declines in tuberculosis transmission the United States, large-scale screening programs targeting low-risk healthcare workers are increasingly a source of false-positive results. We report a large cluster of presumed false-positive tuberculin skin test results in healthcare workers following a change to 50-dose vials of Tubersol tuberculin.
Background: Post-treatment morbidity among subjects with drug-resistant tuberculosis (DR-TB) is unclear. Methods: This was a cross-sectional study of patients from Tbilisi, Georgia with cavitary DR-TB and an outcome of cure. Participants had a chest X-ray (CXR), St. George Respiratory Quality (SGRQ) survey, and pulmonary function tests (PFTs) performed. Correlations between SGRQ and PFT results and factors associated with pulmonary impairment were examined. Results: Among 58 subjects (median age 31 years), 40% used tobacco, 59% had prior TB, and 47% underwent adjunctive surgical resection. The median follow-up time was 41 months. Follow-up CXR revealed fibrosis in 30 subjects (52%) and bronchiectasis in seven (12%). The median forced expiratory volume (FEV 1 )/forced vital capacity (FVC) ratio was 0.72, with 24 subjects (41%) having a ratio of ≤0.70. Significant correlations existed between PFT measures and overall and component SGRQ scores. In linear regression, age, prior TB, and CXR fibrosis or bronchiectasis were significantly associated with decreased pulmonary function. Adjunctive surgery was significantly associated with a higher percent predicted FEV 1 and FVC. Conclusions: A high proportion of DR-TB subjects had residual pulmonary impairment, particularly with recurrent TB and severe radiological disease. The association of surgical resection with improved lung function deserves further study. PFTs and SGRQ may both be useful to evaluate lung health.
Concordant with the emergence of methicillin-resistant Staphylococcus aureus (MRSA) in the community setting, colonization and infections with this pathogen have become a prevalent problem among the human immunodeficiency virus (HIV)-positive population. A variety of different host- and, possibly, pathogen-related factors may play a role in explaining the increased prevalence and incidence observed. In this article, we review pathophysiology, epidemiology, clinical manifestations, and treatment of MRSA in the HIV-infected population.
S E T T I N G: Hawassa Prison, Southern Region of Ethiopia.
O B J E C T I V E: To determine the burden of pulmonary tuberculosis (TB) using active case finding among prisoners.
D E S I G N: In this cross-sectional study, prisoners were screened for TB using a symptom screen. Those with cough of 72 weeks had spot and morning sputum samples collected for acid-fast bacilli (AFB) smear microscopy and molecular diagnostic testing (Xpert w MTB/RIF).
R E S U LT S: Among 2068 prisoners, 372 (18%) had a positive cough screen. The median age of these 372 persons was 23 years, 97% were male and 63% were from urban areas. Among those with a positive symptom screen, 8 (2%) were AFB sputum smear-positive and 31 (8%) were Xpert-positive. The point prevalence of pulmonary TB at the prison was 1748 per 100 000 persons. In multivariate analysis, persons with cough .4 weeks were more likely to have TB (OR 3.34, 95%CI 1.54-7.23).
C O N C L U S I O N: A high prevalence of TB was detected among inmates at a large Ethiopian prison. Active case finding using a cough symptom screen in combination with Xpert had high utility, and has the potential to interrupt transmission of Mycobacterium tuberculosis in correctional facilities in low- and middle-income, high-burden countries.
SETTING: A well-trained and sufficient tuberculosis (TB) workforce is essential for disease control, especially in an era of newly implemented diagnostics and medications. However, there are few reports on the status of the TB workforce in many endemic countries. OBJECTIVE: To evaluate the demographics, salary, career satisfaction, and attitudes towards the field of TB among the physician TB workforce in the country of Georgia.
DESIGN: A cross-sectional study of physicians in the current Georgian National TB Programme (NTP) using an anonymous 31-item questionnaire.
RESULTS: Among 184 NTP physicians countrywide, 142 (77%) were contacted and 138 (75%) completed questionnaires. The median age was 56 years (inter-quartile range 50-64); most (81%) were female. The monthly salary from TB work was ≤USD205 for 50% of respondents. Nearly half (47%) received an additional salary from another source. Many physicians (65%) indicated that they were satisfied with their work, but over half (55%) were unsatisfied with reimbursement. While most physicians (78%) were concerned about the lack of interest in TB, only 36% would recommend a career in TB care. CONCLUSION: While the current TB workforce in Georgia finds their work fulfilling, an ageing workforce, low salaries and perceived lack of interest in the field are a matter of concern for future TB control.
Background. Given very limited data, we assessed the long-term outcomes among patients with extensively drug-resistant (XDR) tuberculosis (TB).
Methods. A retrospective population-based cohort study was performed in patients with XDR-TB diagnosed during 2011- 2013 in the country of Georgia. Data were abstracted from the National TB Program, medical charts, interviews, and the national Georgian death registry.
Results. Among 111 patients starting treatment for XDR-TB, 59 (53.2%) had newly diagnosed tuberculosis, and 3 (2.9%) had human immunodeficiency virus (HIV) coinfection. The median length of follow-up from diagnosis of XDR-TB to death or the end of study was 53.9 months (interquartile range, 27.2-66.3 months). End-of-treatment outcomes were available for 106 patients; 35 (33.0%) had a favorable outcome, and 71 (67.0%) had an unfavorable outcome, including death in 16 (15.1%). An additional 20 patients died after cessation of initial treatment, increasing the overall mortality rate to 34.0%. In multivariable analysis, an unfavorable initial end-of-treatment outcome was associated with posttreatment death (adjusted odds ratio, 14.41; 95% confidence interval, 1.78-117.13).
Conclusions. The overall mortality rate and specifically the posttreatment mortality rate were high among patients with XDR-TB. Patients with an unfavorable end-of-treatment outcome had an increased risk of death during follow-up. Our findings highlight the need for improved adherence, better-tolerated and shorter therapies, and enhanced posttreatment surveillance among patients treated for XDR-TB.