TB Infection Control

Dear Ed,
This is a good news for policy makers who are trying to argue against
in-hospital transmission of DR TB and advocate for community or PHC based
models in TB care.
I believe there are two principal sources of acquired DR
TB: improper treatment and nosocomial transmission. The last one has a high
potency in East Europe because of huge number of TB hospitals,
prolonged hospitalization time and expensive/ineffective Infection Control
measures. In my opinion hospitalization of TB patients is the main driver
of DR TB in FSU. Avoiding unnecessary hospitalization can act as the
greatest tool for prevention of DR TB.
Indeed - great work. We are looking forward for publication.

A.Pasechnikov,
Senior TB Advisor, Az SHIP Project,
Abt Associates Inc.
133 B.Safaroglu, 14th floor, Baku, Azerbaijan, 1009
Tel +994 12 596 58 07 / 596 58 09
Fax +994 12 596 57 90
Mob +99450 235 75 23



2012/6/14 GHDonline (Edward Nardell, MD) <>

> Edward Nardell, MD added a new discussion to the TB Infection Control
> community.
>
> Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?
>
> Discussion contents:
> "I received this question from a doctor in Pakistan and thought it could ...

Dear Ed,
This is a good news for policy makers who are trying to argue against
in-hospital transmission of DR TB and advocate for community or PHC based
models in TB care.
I believe there are two principal sources of acquired DR
TB: improper treatment and nosocomial transmission. The last one has a high
potency in East Europe because of huge number of TB hospitals,
prolonged hospitalization time and expensive/ineffective Infection Control
measures. In my opinion hospitalization of TB patients is the main driver
of DR TB in FSU. Avoiding unnecessary hospitalization can act as the
greatest tool for prevention of DR TB.
Indeed - great work. We are looking forward for publication.

A.Pasechnikov,
Senior TB Advisor, Az SHIP Project,
Abt Associates Inc.
133 B.Safaroglu, 14th floor, Baku, Azerbaijan, 1009
Tel +994 12 596 58 07 / 596 58 09
Fax +994 12 596 57 90
Mob +99450 235 75 23



2012/6/14 GHDonline (Edward Nardell, MD) <>

> Edward Nardell, MD added a new discussion to the TB Infection Control
> community.
>
> Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?
>
> Discussion contents:
> "I received this question from a doctor in Pakistan and thought it could
> be the basis for a good general discussion on the impact of treatment on TB
> transmission.
>
> The question:
> From: adeel tahir
> Sent: Wednesday, June 13, 2012 6:07 AM
> To: Edward Nardell
> Subject: infectiousness of MDR-TB patients
>
> Dear Nardell,
>
> Hope you are doing well. I am Dr. Adeel Tahir. I am a medical doctor from
> Pakistan and currently working as a public health specialist in a NGO in
> Pakistan. Now a days i am working on a randomized controlled trial about
> the duration of hospital stay of MDR-TB patients. For that i need some
> information about the infectiousness of MDR-TB patients after the start of
> treatment. I searched literature and internet but am unable to find
> authentic reference. So, i am emailing you to get help as you have vast
> experience in this are. It would be a great help if you send me some
> references that explains how long it will take for MDR-TB patient to be
> non-infectious after the start of treatment.
>
> Thanking you in anticipation.
>
> Regards,
>
> --
> Dr. Adeel Tahir
> BSc, MBBS, MScPH (Aus)
> Public Health Specialist
> Association for Social Development
>
> My response:
>
> Hi Adeel,
>
> You are correct, there is not much in the literature yet. I have
> researched this carefully because our own studies in South Africa suggest
> that, exactly like drug susceptible patients, patients on EFFECTIVE
> treatment for MDR-TB become almost immediately non-infectious, regardless
> of smear status. I emphasize EFFECTIVE, because treating XDR TB patients
> with an MDR regimen will not have the same immediate (or any) effect on
> transmission. I suspect that susceptibility to fluoroquinalones is
> essential for the almost immediate effect of treatment on transmission.
> Our data comes from our guinea pig studies in South Africa and I do plan
> to publish this, but have not gotten to it yet. The data on drug
> susceptible TB is very clear - with effective treatment drug susceptible
> patients cannot infect sentinel guinea pigs from the very day that
> treatment is started even though they remain smear and culture positive.
> There is no sound basis for the 2-week rule that is commonly used -
> although it does acknowledge that most drug-susceptible TB patients are
> non-infectious before sputum smear and culture converts to negative.
>
> For MDR-TB it is only our data that shows a similar rapid response. For
> XDR our data suggests that MDR treatment is not similarly effective. So,
> we have RE-DISCOVERED what has been know from Richard Riley's work in the
> 50's - that the impact of treatment on transmission (aerosol) is much
> faster than the impact on sputum smear and culture, which in turn is much
> faster than the effect on cure. The most likely explanation for this
> immediate effect is that as respiratory droplets evaporate into droplet
> nuclei, as required for airborne transport, the drug concentration in these
> minute droplets soars since only water vapor comes off. We have a large
> study that is likely to be funded in South Africa to nail this down
> further, to demonstrate that for MDR TB, susceptibility to fluoroquinalones
> is essential for treatment to be effective in immediately stopping
> transmission.
>
> The problem has been that until the advent of rapid molecular testing,
> diagnosing MDR TB and XDR TB took many weeks or months, so that EFFECTIVE
> treatment of drug resistant patients could not be assured. Now that rapid
> molecular testing is possible it should be increasingly possible to rely on
> rapid diagnosis and EFFECTIVE treatment as the most important kind of
> transmission control. In a USAID-funded project, we have translated these
> concepts into a new campaign to re-focus TB IC as F-A-S-T, standing for
> Find cases Actively by cough surveillance , Separate safely*, and Treat
> effectively based on rapid DSTs. Separation is only until effective
> treatment starts.
>
> In summary, my answer to your question re. how much treatment is required
> for MDR treatment before transmission stops is: same day if treatment is
> EFFECTIVE, i.e., based on DSTs. If DSTs are not available, one must assume
> that some patients may remain infectious because they are not on EFFECTIVE
> treatment. In that case, the treatment duration is not based on treatment
> time, per se, but on diagnosis and DST turn-around time. There is no basis
> for 2 weeks, 4 weeks, or until smear or culture negative. We hope to
> publish this soon.
>
> May I use your inquiry on GHDonline with my response?
>
> Sincerely,
>
> Ed Nardell, MD
>
> Edward A. Nardell, MD
> Associate Professor
> Harvard Medical School
> Harvard School of Public Health
> Brigham & Women's Hospital
> Partners In Health
> 641 Huntington Avenue
> 3A-03
> Boston, MA 02115
> 617 432-2080"
>
> --
> View this post online:
> <
> http://www.ghdonline.org/ic/discussion/how-long-are-mdr-tb-patients-infectiou...
> >
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/alexander-pasechnikov/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it
> will be shared with all community members and posted as is. Files cannot be
> added via email attachment and must be uploaded directly to GHDonline.
>
>

Based on these very important findings the fact of how adequate is TB treatment regimen should be one of most important factors in TB infection control program development.

I absolutely agree with Alexander on role of nosocomial transmission and "overhospitalism" in DR TB epidemic in the former Soviet Union region.

Dr. Grigory V. Volchenkov

Chief Doctor
Vladimir Oblast TB Dispensary

Sudogodskoe ave. 63
Vladimir, 600023, Russia

Phone/fax: +7 4922 323265
Mobile: +7 9206253227; +7 9190189226


Sent from iPad

14.06.2012, в 9:33, "GHDonline (Alexander Pasechnikov)" <> написал(а):

> Alexander Pasechnikov replied to the discussion "How long are MDR-TB patients infectious on EFFECTIVE therapy?" in the TB Infection Control community.
>
> Reply contents:
> "Dear Ed,
> This is a good news for policy makers who are trying to argue against
> in-hospital transmission of DR TB and advocate for community or PHC based
> models in TB care.
> I believe there are two principal sources of acquired DR
> TB: improper treatment and nosocomial transmission. The last one has a high
> potency in East Europe because of huge number of TB hospitals,
> prolonged hospitalization time and expensive/ineffective Infection Control
> measures. In my opinion hospitalization of TB patients ...

Based on these very important findings the fact of how adequate is TB treatment regimen should be one of most important factors in TB infection control program development.

I absolutely agree with Alexander on role of nosocomial transmission and "overhospitalism" in DR TB epidemic in the former Soviet Union region.

Dr. Grigory V. Volchenkov

Chief Doctor
Vladimir Oblast TB Dispensary

Sudogodskoe ave. 63
Vladimir, 600023, Russia

Phone/fax: +7 4922 323265
Mobile: +7 9206253227; +7 9190189226


Sent from iPad

14.06.2012, в 9:33, "GHDonline (Alexander Pasechnikov)" <> написал(а):

> Alexander Pasechnikov replied to the discussion "How long are MDR-TB patients infectious on EFFECTIVE therapy?" in the TB Infection Control community.
>
> Reply contents:
> "Dear Ed,
> This is a good news for policy makers who are trying to argue against
> in-hospital transmission of DR TB and advocate for community or PHC based
> models in TB care.
> I believe there are two principal sources of acquired DR
> TB: improper treatment and nosocomial transmission. The last one has a high
> potency in East Europe because of huge number of TB hospitals,
> prolonged hospitalization time and expensive/ineffective Infection Control
> measures. In my opinion hospitalization of TB patients is the main driver
> of DR TB in FSU. Avoiding unnecessary hospitalization can act as the
> greatest tool for prevention of DR TB.
> Indeed - great work. We are looking forward for publication.
>
> A.Pasechnikov,
> Senior TB Advisor, Az SHIP Project,
> Abt Associates Inc.
> 133 B.Safaroglu, 14th floor, Baku, Azerbaijan, 1009
> Tel +994 12 596 58 07 / 596 58 09
> Fax +994 12 596 57 90
> Mob +99450 235 75 23
>
>
>
> 2012/6/14 GHDonline (Edward Nardell, MD) <>
>
>> Edward Nardell, MD added a new discussion to the TB Infection Control
>> community.
>>
>> Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?
>>
>> Discussion contents:
>> "I received this question from a doctor in Pakistan and thought it could
>> be the basis for a good general discussion on the impact of treatment on TB
>> transmission.
>>
>> The question:
>> From: adeel tahir
>> Sent: Wednesday, June 13, 2012 6:07 AM
>> To: Edward Nardell
>> Subject: infectiousness of MDR-TB patients
>>
>> Dear Nardell,
>>
>> Hope you are doing well. I am Dr. Adeel Tahir. I am a medical doctor from
>> Pakistan and currently working as a public health specialist in a NGO in
>> Pakistan. Now a days i am working on a randomized controlled trial about
>> the duration of hospital stay of MDR-TB patients. For that i need some
>> information about the infectiousness of MDR-TB patients after the start of
>> treatment. I searched literature and internet but am unable to find
>> authentic reference. So, i am emailing you to get help as you have vast
>> experience in this are. It would be a great help if you send me some
>> references that explains how long it will take for MDR-TB patient to be
>> non-infectious after the start of treatment.
>>
>> Thanking you in anticipation.
>>
>> Regards,
>>
>> --
>> Dr. Adeel Tahir
>> BSc, MBBS, MScPH (Aus)
>> Public Health Specialist
>> Association for Social Development
>>
>> My response:
>>
>> Hi Adeel,
>>
>> You are correct, there is not much in the literature yet. I have
>> researched this carefully because our own studies in South Africa suggest
>> that, exactly like drug susceptible patients, patients on EFFECTIVE
>> treatment for MDR-TB become almost immediately non-infectious, regardless
>> of smear status. I emphasize EFFECTIVE, because treating XDR TB patients
>> with an MDR regimen will not have the same immediate (or any) effect on
>> transmission. I suspect that susceptibility to fluoroquinalones is
>> essential for the almost immediate effect of treatment on transmission.
>> Our data comes from our guinea pig studies in South Africa and I do plan
>> to publish this, but have not gotten to it yet. The data on drug
>> susceptible TB is very clear - with effective treatment drug susceptible
>> patients cannot infect sentinel guinea pigs from the very day that
>> treatment is started even though they remain smear and culture positive.
>> There is no sound basis for the 2-week rule that is commonly used -
>> although it does acknowledge that most drug-susceptible TB patients are
>> non-infectious before sputum smear and culture converts to negative.
>>
>> For MDR-TB it is only our data that shows a similar rapid response. For
>> XDR our data suggests that MDR treatment is not similarly effective. So,
>> we have RE-DISCOVERED what has been know from Richard Riley's work in the
>> 50's - that the impact of treatment on transmission (aerosol) is much
>> faster than the impact on sputum smear and culture, which in turn is much
>> faster than the effect on cure. The most likely explanation for this
>> immediate effect is that as respiratory droplets evaporate into droplet
>> nuclei, as required for airborne transport, the drug concentration in these
>> minute droplets soars since only water vapor comes off. We have a large
>> study that is likely to be funded in South Africa to nail this down
>> further, to demonstrate that for MDR TB, susceptibility to fluoroquinalones
>> is essential for treatment to be effective in immediately stopping
>> transmission.
>>
>> The problem has been that until the advent of rapid molecular testing,
>> diagnosing MDR TB and XDR TB took many weeks or months, so that EFFECTIVE
>> treatment of drug resistant patients could not be assured. Now that rapid
>> molecular testing is possible it should be increasingly possible to rely on
>> rapid diagnosis and EFFECTIVE treatment as the most important kind of
>> transmission control. In a USAID-funded project, we have translated these
>> concepts into a new campaign to re-focus TB IC as F-A-S-T, standing for
>> Find cases Actively by cough surveillance , Separate safely*, and Treat
>> effectively based on rapid DSTs. Separation is only until effective
>> treatment starts.
>>
>> In summary, my answer to your question re. how much treatment is required
>> for MDR treatment before transmission stops is: same day if treatment is
>> EFFECTIVE, i.e., based on DSTs. If DSTs are not available, one must assume
>> that some patients may remain infectious because they are not on EFFECTIVE
>> treatment. In that case, the treatment duration is not based on treatment
>> time, per se, but on diagnosis and DST turn-around time. There is no basis
>> for 2 weeks, 4 weeks, or until smear or culture negative. We hope to
>> publish this soon.
>>
>> May I use your inquiry on GHDonline with my response?
>>
>> Sincerely,
>>
>> Ed Nardell, MD
>>
>> Edward A. Nardell, MD
>> Associate Professor
>> Harvard Medical School
>> Harvard School of Public Health
>> Brigham & Women's Hospital
>> Partners In Health
>> 641 Huntington Avenue
>> 3A-03
>> Boston, MA 02115
>> 617 432-2080"
>>
>> --
>> View this post online:
>> <
>> http://www.ghdonline.org/ic/discussion/how-long-are-mdr-tb-patients-infectiou...
>>>
>>
>> Unsubscribe or change your email notification settings:
>> <http://www.ghdonline.org/users/alexander-pasechnikov/edit/>
>>
>> Contact the GHDonline team:
>> <http://www.ghdonline.org/contact/>
>>
>> You can reply to this discussion by responding directly to this e-mail; it
>> will be shared with all community members and posted as is. Files cannot be
>> added via email attachment and must be uploaded directly to GHDonline.
>>
>> "
>
> --
> View this post online:
> <http://www.ghdonline.org/ic/discussion/how-long-are-mdr-tb-patients-infectiou...>
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/grigory-volchenkov/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline.

We say until the sputum culture is negative (times three) regards
Shaheen Mehtar
Sent via my BlackBerry from Vodacom - let your email find you!

-----Original Message-----
From: "GHDonline (Edward Nardell, MD)" <>
Date: Wed, 13 Jun 2012 21:59:02
To: Mehtar, S, Prof <>
Reply-To: TB Infection Control <>
Subject: [TB Infection Control] How long are MDR-TB patients infectious on
EFFECTIVE therapy?

Edward Nardell, MD added a new discussion to the TB Infection Control community.

Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?

Discussion contents:
"I received this question from a doctor in Pakistan and thought it could be the basis for a good general discussion on the impact of treatment on TB transmission.

The question:
From: adeel tahir
Sent: Wednesday, June 13, 2012 6:07 AM
To: Edward Nardell
Subject: infectiousness of MDR-TB patients

Dear Nardell,

Hope you are doing well. I am Dr. Adeel Tahir. I am a medical doctor from Pakistan and currently working as a public health specialist in a NGO in Pakistan. Now a days i am working on a randomized controlled trial about the duration of ...

We say until the sputum culture is negative (times three) regards
Shaheen Mehtar
Sent via my BlackBerry from Vodacom - let your email find you!

-----Original Message-----
From: "GHDonline (Edward Nardell, MD)" <>
Date: Wed, 13 Jun 2012 21:59:02
To: Mehtar, S, Prof <>
Reply-To: TB Infection Control <>
Subject: [TB Infection Control] How long are MDR-TB patients infectious on
EFFECTIVE therapy?

Edward Nardell, MD added a new discussion to the TB Infection Control community.

Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?

Discussion contents:
"I received this question from a doctor in Pakistan and thought it could be the basis for a good general discussion on the impact of treatment on TB transmission.

The question:
From: adeel tahir
Sent: Wednesday, June 13, 2012 6:07 AM
To: Edward Nardell
Subject: infectiousness of MDR-TB patients

Dear Nardell,

Hope you are doing well. I am Dr. Adeel Tahir. I am a medical doctor from Pakistan and currently working as a public health specialist in a NGO in Pakistan. Now a days i am working on a randomized controlled trial about the duration of hospital stay of MDR-TB patients. For that i need some information about the infectiousness of MDR-TB patients after the start of treatment. I searched literature and internet but am unable to find authentic reference. So, i am emailing you to get help as you have vast experience in this are. It would be a great help if you send me some references that explains how long it will take for MDR-TB patient to be non-infectious after the start of treatment.

Thanking you in anticipation.

Regards,

--
Dr. Adeel Tahir
BSc, MBBS, MScPH (Aus)
Public Health Specialist
Association for Social Development

My response:

Hi Adeel,

You are correct, there is not much in the literature yet. I have researched this carefully because our own studies in South Africa suggest that, exactly like drug susceptible patients, patients on EFFECTIVE treatment for MDR-TB become almost immediately non-infectious, regardless of smear status. I emphasize EFFECTIVE, because treating XDR TB patients with an MDR regimen will not have the same immediate (or any) effect on transmission. I suspect that susceptibility to fluoroquinalones is essential for the almost immediate effect of treatment on transmission. Our data comes from our guinea pig studies in South Africa and I do plan to publish this, but have not gotten to it yet. The data on drug susceptible TB is very clear - with effective treatment drug susceptible patients cannot infect sentinel guinea pigs from the very day that treatment is started even though they remain smear and culture positive. There is no sound basis for the 2-week rule that is commonly used - although it does acknowledge that most drug-susceptible TB patients are non-infectious before sputum smear and culture converts to negative.

For MDR-TB it is only our data that shows a similar rapid response. For XDR our data suggests that MDR treatment is not similarly effective. So, we have RE-DISCOVERED what has been know from Richard Riley's work in the 50's - that the impact of treatment on transmission (aerosol) is much faster than the impact on sputum smear and culture, which in turn is much faster than the effect on cure. The most likely explanation for this immediate effect is that as respiratory droplets evaporate into droplet nuclei, as required for airborne transport, the drug concentration in these minute droplets soars since only water vapor comes off. We have a large study that is likely to be funded in South Africa to nail this down further, to demonstrate that for MDR TB, susceptibility to fluoroquinalones is essential for treatment to be effective in immediately stopping transmission.

The problem has been that until the advent of rapid molecular testing, diagnosing MDR TB and XDR TB took many weeks or months, so that EFFECTIVE treatment of drug resistant patients could not be assured. Now that rapid molecular testing is possible it should be increasingly possible to rely on rapid diagnosis and EFFECTIVE treatment as the most important kind of transmission control. In a USAID-funded project, we have translated these concepts into a new campaign to re-focus TB IC as F-A-S-T, standing for Find cases Actively by cough surveillance , Separate safely*, and Treat effectively based on rapid DSTs. Separation is only until effective treatment starts.

In summary, my answer to your question re. how much treatment is required for MDR treatment before transmission stops is: same day if treatment is EFFECTIVE, i.e., based on DSTs. If DSTs are not available, one must assume that some patients may remain infectious because they are not on EFFECTIVE treatment. In that case, the treatment duration is not based on treatment time, per se, but on diagnosis and DST turn-around time. There is no basis for 2 weeks, 4 weeks, or until smear or culture negative. We hope to publish this soon.

May I use your inquiry on GHDonline with my response?

Sincerely,

Ed Nardell, MD

Edward A. Nardell, MD
Associate Professor
Harvard Medical School
Harvard School of Public Health
Brigham & Women's Hospital
Partners In Health
641 Huntington Avenue
3A-03
Boston, MA 02115
617 432-2080"

--
View this post online:
<http://www.ghdonline.org/ic/discussion/how-long-are-mdr-tb-patients-infectiou...>

Unsubscribe or change your email notification settings:
<http://www.ghdonline.org/users/s-mehtar/edit/>

Contact the GHDonline team:
<http://www.ghdonline.org/contact/>

You can reply to this discussion by responding directly to this e-mail; it will be shared with all community members and posted as is. Files cannot be added via email attachment and must be uploaded directly to GHDonline.

Is it not true for all types of TB? (three sputum culture negative in a series)


Dr. Altaf Ahmed
Director Laboratory Services & Consultant Microbiologist
The Indus Hospital
Korangi Crossing
Korangi
Karachi
Pakistan

Cell: 03008291947
Off: +92-21-35112709-17
Fax: +92-21-35112718
E-mail:
Website: www.indushospital.org.pk
Website: www.idspak.org


________________________________
From: GHDonline (S. Mehtar) <>
To: "Altaf Ahmed, MD" <>
Sent: Thursday, 14 June 2012, 14:06
Subject: Re: [TB Infection Control] How long are MDR-TB patients infectious on EFFECTIVE therapy?

S. Mehtar replied to the discussion "How long are MDR-TB patients infectious on EFFECTIVE therapy?" in the TB Infection Control community.

Reply contents:
"We say until the sputum culture is negative (times three) regards
Shaheen Mehtar
Sent via my BlackBerry from Vodacom - let your email find you!

-----Original Message-----
From: "GHDonline (Edward Nardell, MD)" <>
Date: Wed, 13 Jun 2012 21:59:02
To: Mehtar, S, Prof <>
Reply-To: TB Infection Control <>
Subject: [TB Infection Control] How long are MDR-TB patients infectious on
EFFECTIVE therapy?

Edward Nardell, MD added a new discussion to the TB Infection Control community.

Title: How ...

Is it not true for all types of TB? (three sputum culture negative in a series)


Dr. Altaf Ahmed
Director Laboratory Services & Consultant Microbiologist
The Indus Hospital
Korangi Crossing
Korangi
Karachi
Pakistan

Cell: 03008291947
Off: +92-21-35112709-17
Fax: +92-21-35112718
E-mail:
Website: www.indushospital.org.pk
Website: www.idspak.org


________________________________
From: GHDonline (S. Mehtar) <>
To: "Altaf Ahmed, MD" <>
Sent: Thursday, 14 June 2012, 14:06
Subject: Re: [TB Infection Control] How long are MDR-TB patients infectious on EFFECTIVE therapy?

S. Mehtar replied to the discussion "How long are MDR-TB patients infectious on EFFECTIVE therapy?" in the TB Infection Control community.

Reply contents:
"We say until the sputum culture is negative (times three) regards
Shaheen Mehtar
Sent via my BlackBerry from Vodacom - let your email find you!

-----Original Message-----
From: "GHDonline (Edward Nardell, MD)" <>
Date: Wed, 13 Jun 2012 21:59:02
To: Mehtar, S, Prof <>
Reply-To: TB Infection Control <>
Subject: [TB Infection Control] How long are MDR-TB patients infectious on
EFFECTIVE therapy?

Edward Nardell, MD added a new discussion to the TB Infection Control community.

Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?

Discussion contents:
"I received this question from a doctor in Pakistan and thought it could be the basis for a good general discussion on the impact of treatment on TB transmission.

The question:
From: adeel tahir
Sent: Wednesday, June 13, 2012 6:07 AM
To: Edward Nardell
Subject: infectiousness of MDR-TB patients

Dear Nardell,

Hope you are doing well. I am Dr. Adeel Tahir. I am a medical doctor from Pakistan and currently working as a public health specialist in a NGO in Pakistan. Now a days i am working on a randomized controlled trial about the duration of hospital stay of MDR-TB patients. For that i need some information about the infectiousness of MDR-TB patients after the start of treatment. I searched literature and internet but am unable to find authentic reference. So, i am emailing you to get help as you have vast experience in this are. It would be a great help if you send me some references that explains how long it will take for MDR-TB patient to be non-infectious after the start of treatment.

Thanking you in anticipation.

Regards,

--
Dr. Adeel Tahir
BSc, MBBS, MScPH (Aus)
Public Health Specialist
Association for Social Development

My response:

Hi Adeel,

You are correct, there is not much in the literature yet.  I have researched this carefully because our own studies in South Africa suggest that, exactly like drug susceptible patients, patients on EFFECTIVE treatment for MDR-TB become almost immediately non-infectious, regardless of smear status. I emphasize EFFECTIVE, because treating XDR TB patients with an MDR regimen will not have the same immediate (or any) effect on transmission.  I suspect that susceptibility to fluoroquinalones is essential for the almost immediate effect of treatment on transmission.  Our data comes from our guinea pig studies in South Africa and I do plan to publish this, but have not gotten to it yet.  The data on drug susceptible TB is very clear - with effective treatment drug susceptible patients cannot infect sentinel guinea pigs from the very day that treatment is started even though they remain smear and culture positive. There is no sound basis for the 2-week rule
that is commonly used - although it does acknowledge that most drug-susceptible TB  patients are non-infectious before sputum smear and culture converts to negative. 

For MDR-TB  it is only our data that shows a similar rapid response.  For XDR our data suggests that MDR treatment is not similarly effective.  So, we have RE-DISCOVERED what has been know from Richard Riley's work in the 50's - that the impact of treatment on transmission (aerosol) is much faster than the impact on sputum smear and culture, which in turn is much faster than the effect on cure. The most likely explanation for this immediate effect is that as respiratory droplets evaporate into droplet nuclei, as required for airborne transport, the drug concentration in these minute droplets soars since only water vapor comes off.  We have a large study that is likely to be funded in South Africa to nail this down further, to demonstrate that for MDR TB, susceptibility to fluoroquinalones is essential for treatment to be effective in immediately stopping transmission.

The problem has been that until the advent of rapid molecular testing, diagnosing MDR TB and XDR TB took many weeks or months, so that EFFECTIVE treatment of drug resistant patients could not be assured. Now that rapid molecular testing is possible it should be increasingly possible to rely on rapid diagnosis and EFFECTIVE treatment as the most important kind of transmission control.  In a USAID-funded project, we have translated these concepts into a new campaign to re-focus TB IC as F-A-S-T, standing for Find cases Actively by cough surveillance , Separate safely*, and Treat effectively based on rapid DSTs. Separation is only until effective treatment starts.

In summary, my answer to your question re. how much treatment is required for MDR treatment before transmission stops is: same day if treatment is EFFECTIVE, i.e., based on DSTs.  If DSTs are not available, one must assume that some patients may remain infectious because they are not on EFFECTIVE treatment. In that case, the treatment duration is not based on treatment time, per se, but on diagnosis and DST turn-around time.  There is no basis for 2 weeks, 4 weeks, or until smear or culture negative.  We hope to publish this soon.

May I use your inquiry on GHDonline with my response?

Sincerely,

Ed Nardell, MD

Edward A. Nardell, MD
Associate Professor
Harvard Medical School
Harvard School of Public Health
Brigham & Women's Hospital
Partners In Health
641 Huntington Avenue
3A-03
Boston, MA 02115
617 432-2080"

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For pulmonary TB. The others are not really infectiousm s
Sent via my BlackBerry from Vodacom - let your email find you!

-----Original Message-----
From: "GHDonline (Altaf Ahmed, MD)" <>
Date: Thu, 14 Jun 2012 10:11:33
To: Mehtar, S, Prof <>
Reply-To: TB Infection Control <>
Subject: Re: [TB Infection Control] How long are MDR-TB patients infectious
on EFFECTIVE therapy?

Altaf Ahmed, MD replied to the discussion "How long are MDR-TB patients infectious on EFFECTIVE therapy?" in the TB Infection Control community.

Reply contents:
"Is it not true for all types of TB? (three sputum culture negative in a series)


Dr. Altaf Ahmed
Director Laboratory Services & Consultant Microbiologist
The Indus Hospital
Korangi Crossing
Korangi
Karachi
Pakistan

Cell: 03008291947
Off: +92-21-35112709-17
Fax: +92-21-35112718
E-mail:
Website: www.indushospital.org.pk
Website: www.idspak.org


________________________________
From: GHDonline (S. Mehtar) <>
To: "Altaf Ahmed, MD" <>
Sent: Thursday, 14 June 2012, 14:06
Subject: Re: [TB Infection Control] How long are MDR-TB patients infectious on EFFECTIVE therapy?

S. Mehtar replied to the discussion "How long are MDR-TB patients infectious on EFFECTIVE therapy?" in ...

For pulmonary TB. The others are not really infectiousm s
Sent via my BlackBerry from Vodacom - let your email find you!

-----Original Message-----
From: "GHDonline (Altaf Ahmed, MD)" <>
Date: Thu, 14 Jun 2012 10:11:33
To: Mehtar, S, Prof <>
Reply-To: TB Infection Control <>
Subject: Re: [TB Infection Control] How long are MDR-TB patients infectious
on EFFECTIVE therapy?

Altaf Ahmed, MD replied to the discussion "How long are MDR-TB patients infectious on EFFECTIVE therapy?" in the TB Infection Control community.

Reply contents:
"Is it not true for all types of TB? (three sputum culture negative in a series)


Dr. Altaf Ahmed
Director Laboratory Services & Consultant Microbiologist
The Indus Hospital
Korangi Crossing
Korangi
Karachi
Pakistan

Cell: 03008291947
Off: +92-21-35112709-17
Fax: +92-21-35112718
E-mail:
Website: www.indushospital.org.pk
Website: www.idspak.org


________________________________
From: GHDonline (S. Mehtar) <>
To: "Altaf Ahmed, MD" <>
Sent: Thursday, 14 June 2012, 14:06
Subject: Re: [TB Infection Control] How long are MDR-TB patients infectious on EFFECTIVE therapy?

S. Mehtar replied to the discussion "How long are MDR-TB patients infectious on EFFECTIVE therapy?" in the TB Infection Control community.

Reply contents:
"We say until the sputum culture is negative (times three) regards
Shaheen Mehtar
Sent via my BlackBerry from Vodacom - let your email find you!

-----Original Message-----
From: "GHDonline (Edward Nardell, MD)" <>
Date: Wed, 13 Jun 2012 21:59:02
To: Mehtar, S, Prof <>
Reply-To: TB Infection Control <>
Subject: [TB Infection Control] How long are MDR-TB patients infectious on
EFFECTIVE therapy?

Edward Nardell, MD added a new discussion to the TB Infection Control community.

Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?

Discussion contents:
"I received this question from a doctor in Pakistan and thought it could be the basis for a good general discussion on the impact of treatment on TB transmission.

The question:
From: adeel tahir
Sent: Wednesday, June 13, 2012 6:07 AM
To: Edward Nardell
Subject: infectiousness of MDR-TB patients

Dear Nardell,

Hope you are doing well. I am Dr. Adeel Tahir. I am a medical doctor from Pakistan and currently working as a public health specialist in a NGO in Pakistan. Now a days i am working on a randomized controlled trial about the duration of hospital stay of MDR-TB patients. For that i need some information about the infectiousness of MDR-TB patients after the start of treatment. I searched literature and internet but am unable to find authentic reference. So, i am emailing you to get help as you have vast experience in this are. It would be a great help if you send me some references that explains how long it will take for MDR-TB patient to be non-infectious after the start of treatment.

Thanking you in anticipation.

Regards,

--
Dr. Adeel Tahir
BSc, MBBS, MScPH (Aus)
Public Health Specialist
Association for Social Development

My response:

Hi Adeel,

You are correct, there is not much in the literature yet.  I have researched this carefully because our own studies in South Africa suggest that, exactly like drug susceptible patients, patients on EFFECTIVE treatment for MDR-TB become almost immediately non-infectious, regardless of smear status. I emphasize EFFECTIVE, because treating XDR TB patients with an MDR regimen will not have the same immediate (or any) effect on transmission.  I suspect that susceptibility to fluoroquinalones is essential for the almost immediate effect of treatment on transmission.  Our data comes from our guinea pig studies in South Africa and I do plan to publish this, but have not gotten to it yet.  The data on drug susceptible TB is very clear - with effective treatment drug susceptible patients cannot infect sentinel guinea pigs from the very day that treatment is started even though they remain smear and culture positive. There is no sound basis for the 2-week rule
that is commonly used - although it does acknowledge that most drug-susceptible TB  patients are non-infectious before sputum smear and culture converts to negative. 

For MDR-TB  it is only our data that shows a similar rapid response.  For XDR our data suggests that MDR treatment is not similarly effective.  So, we have RE-DISCOVERED what has been know from Richard Riley's work in the 50's - that the impact of treatment on transmission (aerosol) is much faster than the impact on sputum smear and culture, which in turn is much faster than the effect on cure. The most likely explanation for this immediate effect is that as respiratory droplets evaporate into droplet nuclei, as required for airborne transport, the drug concentration in these minute droplets soars since only water vapor comes off.  We have a large study that is likely to be funded in South Africa to nail this down further, to demonstrate that for MDR TB, susceptibility to fluoroquinalones is essential for treatment to be effective in immediately stopping transmission.

The problem has been that until the advent of rapid molecular testing, diagnosing MDR TB and XDR TB took many weeks or months, so that EFFECTIVE treatment of drug resistant patients could not be assured. Now that rapid molecular testing is possible it should be increasingly possible to rely on rapid diagnosis and EFFECTIVE treatment as the most important kind of transmission control.  In a USAID-funded project, we have translated these concepts into a new campaign to re-focus TB IC as F-A-S-T, standing for Find cases Actively by cough surveillance , Separate safely*, and Treat effectively based on rapid DSTs. Separation is only until effective treatment starts.

In summary, my answer to your question re. how much treatment is required for MDR treatment before transmission stops is: same day if treatment is EFFECTIVE, i.e., based on DSTs.  If DSTs are not available, one must assume that some patients may remain infectious because they are not on EFFECTIVE treatment. In that case, the treatment duration is not based on treatment time, per se, but on diagnosis and DST turn-around time.  There is no basis for 2 weeks, 4 weeks, or until smear or culture negative.  We hope to publish this soon.

May I use your inquiry on GHDonline with my response?

Sincerely,

Ed Nardell, MD

Edward A. Nardell, MD
Associate Professor
Harvard Medical School
Harvard School of Public Health
Brigham & Women's Hospital
Partners In Health
641 Huntington Avenue
3A-03
Boston, MA 02115
617 432-2080"

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Dear Sir

what would you like to mean by IMMEDIATE? Are you suggesting right after
the first dose/day/week ? Whatever literature has been there and
discussions have taken place - no chest specialist will be able to accept
this? In a way public health people are defensive with this subset of
specialists when it comes to a tuberculosis treatment regime.

Thank you

On Wed, Jun 13, 2012 at 4:00 PM, GHDonline (Edward Nardell, MD) <
> wrote:

> Edward Nardell, MD added a new discussion to the TB Infection Control
> community.
>
> Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?
>
> Discussion contents:
> "I received this question from a doctor in Pakistan and thought it could
> be the basis for a good general discussion on the impact of treatment on TB
> transmission.
>
> The question:
> From: adeel tahir
> Sent: Wednesday, June 13, 2012 6:07 AM
> To: Edward Nardell
> Subject: infectiousness of MDR-TB patients
>
> Dear Nardell,
>
> Hope you are doing well. I am Dr. Adeel Tahir. I am a medical doctor from
> Pakistan and currently working as a public health specialist in a NGO in
> Pakistan. Now a days i am working on a randomized controlled trial ...

Dear Sir

what would you like to mean by IMMEDIATE? Are you suggesting right after
the first dose/day/week ? Whatever literature has been there and
discussions have taken place - no chest specialist will be able to accept
this? In a way public health people are defensive with this subset of
specialists when it comes to a tuberculosis treatment regime.

Thank you

On Wed, Jun 13, 2012 at 4:00 PM, GHDonline (Edward Nardell, MD) <
> wrote:

> Edward Nardell, MD added a new discussion to the TB Infection Control
> community.
>
> Title: How long are MDR-TB patients infectious on EFFECTIVE therapy?
>
> Discussion contents:
> "I received this question from a doctor in Pakistan and thought it could
> be the basis for a good general discussion on the impact of treatment on TB
> transmission.
>
> The question:
> From: adeel tahir
> Sent: Wednesday, June 13, 2012 6:07 AM
> To: Edward Nardell
> Subject: infectiousness of MDR-TB patients
>
> Dear Nardell,
>
> Hope you are doing well. I am Dr. Adeel Tahir. I am a medical doctor from
> Pakistan and currently working as a public health specialist in a NGO in
> Pakistan. Now a days i am working on a randomized controlled trial about
> the duration of hospital stay of MDR-TB patients. For that i need some
> information about the infectiousness of MDR-TB patients after the start of
> treatment. I searched literature and internet but am unable to find
> authentic reference. So, i am emailing you to get help as you have vast
> experience in this are. It would be a great help if you send me some
> references that explains how long it will take for MDR-TB patient to be
> non-infectious after the start of treatment.
>
> Thanking you in anticipation.
>
> Regards,
>
> --
> Dr. Adeel Tahir
> BSc, MBBS, MScPH (Aus)
> Public Health Specialist
> Association for Social Development
>
> My response:
>
> Hi Adeel,
>
> You are correct, there is not much in the literature yet. I have
> researched this carefully because our own studies in South Africa suggest
> that, exactly like drug susceptible patients, patients on EFFECTIVE
> treatment for MDR-TB become almost immediately non-infectious, regardless
> of smear status. I emphasize EFFECTIVE, because treating XDR TB patients
> with an MDR regimen will not have the same immediate (or any) effect on
> transmission. I suspect that susceptibility to fluoroquinalones is
> essential for the almost immediate effect of treatment on transmission.
> Our data comes from our guinea pig studies in South Africa and I do plan
> to publish this, but have not gotten to it yet. The data on drug
> susceptible TB is very clear - with effective treatment drug susceptible
> patients cannot infect sentinel guinea pigs from the very day that
> treatment is started even though they remain smear and culture positive.
> There is no sound basis for the 2-week rule that is commonly used -
> although it does acknowledge that most drug-susceptible TB patients are
> non-infectious before sputum smear and culture converts to negative.
>
> For MDR-TB it is only our data that shows a similar rapid response. For
> XDR our data suggests that MDR treatment is not similarly effective. So,
> we have RE-DISCOVERED what has been know from Richard Riley's work in the
> 50's - that the impact of treatment on transmission (aerosol) is much
> faster than the impact on sputum smear and culture, which in turn is much
> faster than the effect on cure. The most likely explanation for this
> immediate effect is that as respiratory droplets evaporate into droplet
> nuclei, as required for airborne transport, the drug concentration in these
> minute droplets soars since only water vapor comes off. We have a large
> study that is likely to be funded in South Africa to nail this down
> further, to demonstrate that for MDR TB, susceptibility to fluoroquinalones
> is essential for treatment to be effective in immediately stopping
> transmission.
>
> The problem has been that until the advent of rapid molecular testing,
> diagnosing MDR TB and XDR TB took many weeks or months, so that EFFECTIVE
> treatment of drug resistant patients could not be assured. Now that rapid
> molecular testing is possible it should be increasingly possible to rely on
> rapid diagnosis and EFFECTIVE treatment as the most important kind of
> transmission control. In a USAID-funded project, we have translated these
> concepts into a new campaign to re-focus TB IC as F-A-S-T, standing for
> Find cases Actively by cough surveillance , Separate safely*, and Treat
> effectively based on rapid DSTs. Separation is only until effective
> treatment starts.
>
> In summary, my answer to your question re. how much treatment is required
> for MDR treatment before transmission stops is: same day if treatment is
> EFFECTIVE, i.e., based on DSTs. If DSTs are not available, one must assume
> that some patients may remain infectious because they are not on EFFECTIVE
> treatment. In that case, the treatment duration is not based on treatment
> time, per se, but on diagnosis and DST turn-around time. There is no basis
> for 2 weeks, 4 weeks, or until smear or culture negative. We hope to
> publish this soon.
>
> May I use your inquiry on GHDonline with my response?
>
> Sincerely,
>
> Ed Nardell, MD
>
> Edward A. Nardell, MD
> Associate Professor
> Harvard Medical School
> Harvard School of Public Health
> Brigham & Women's Hospital
> Partners In Health
> 641 Huntington Avenue
> 3A-03
> Boston, MA 02115
> 617 432-2080"
>
> --
> View this post online:
> <
> http://www.ghdonline.org/ic/discussion/how-long-are-mdr-tb-patients-infectiou...
> >
>
> Unsubscribe or change your email notification settings:
> <http://www.ghdonline.org/users/dr-shanta-ghatak/edit/>
>
> Contact the GHDonline team:
> <http://www.ghdonline.org/contact/>
>
> You can reply to this discussion by responding directly to this e-mail; it
> will be shared with all community members and posted as is. Files cannot be
> added via email attachment and must be uploaded directly to GHDonline.
>
>

Absolutely agree with colleagues (Alexander Pasechnikov, Grigory Volchenkov) from former Soviet Union countries.