Distribution of MTB among newly diagnosed HIV patients at Malindi District Hospital during July 2012 to June Sheldon kalu 1 1 Malindi District Hospital ABSTRACT Objective: To establish the distribution of MTB Rifampicin resistance in newly diagnosed HIV patients at Malindi District Hospital. Background: TB is a major cause of death among people living with HIV with Sub-Saharan Africa bearing the brunt of the HIV fuelled TB epidemic. Method: Xpert MTB/RIF Assay was used to analyse sputum samples from each patient for detection of MTB and Rifampicin resistance. Results: 88 males were positive for MTB (35% of total males) with 5(5.68% of total positive males) Rifampicin resistant. October had highest males tested with 56, March, with 5 patients, was the lowest. 21 males were averagely tested each month with mean positives of 7. Males had negative Chitest of with positive Chitest of A total of 42 females (22% of total females) were positive with 1Rifampicin resistant (1.14% of total positive females). October had highest females-58 tested while March lowest, had 2. On average, 16 females were tested each month with mean positive of 4. Female negative chitest was while positive chitest was Conclusion: Infection with MTB and Rifampicin resistant MTB strains were found in the newly diagnosed HIV patients. Key words:MTB- Mycobacterium tuberculosis bacilli,PCR- Polymerase Chain Reaction, Resistance,HIV.

ACKNOWLEDGEMENT Entire Laboratory Team – Malindi District Hospital Malindi District Hospital Management DEDICATION All HIV/TB infected individuals

INTRODUCTION BACKGROUND OF THE STUDY Justification: Kenya is one of the 22 high TB burden countries and is ranked 13 th according to the WHO Global Tuberculosis Report And the management cost of TB is increasingly becoming expensive with the increase in TB co-infection with HIV.WHO Global Tuberculosis Report 2010 Malindi District Hospital has 250 beds. It enjoys a maternity shelter for pregnant women, Maternal Child Health Care department with pediatrics ward, CCC (HIV and Aids wing which also constitutes counseling and testing area). Given the distance from other centers for health facilities such as Garrisa and Kilifi, the hospital receives a lot of patients both for inpatient and outpatient. The District Laboratory is net worked for CD4 & Gene Xpert with Lamu District, Tana Delta District, Tana River District & Kilifi District. Objective: To establish the distribution of MTB and Rifampicin resistance strains of MTB in newly diagnosed HIV patients at Malindi District Hospital.

Literature Review Globally, around 2 billion people are infected with M. tuberculosis 1. Every year almost 9 million people develop active disease and 2 million people lose their lives to the illness. Active tuberculosis is predominantly pulmonary in nature. The route of transmission of pulmonary TB is through the air, which makes this a highly transmissible disease. Given the infectious nature of pulmonary TB, fast and accurate diagnosis is an important element of TB treatment and control. Treatment involves prolonged administration of multiple drugs and is usually highly effective. However, M. tuberculosis strains may become resistant to one or more of the drugs, making cure much more difficult to achieve. Four common first-line drugs used in antituberculosis therapy are Isoniazid (INH), Rifampicin (also known as Rifampin, RIF), Ethambutol (EMB), and Pyrazinimide (PZA). As documented by WHO, RIF resistance is rarely encountered by itself, and usually indicates resistance to a number of other anti-TB drugs 2. It is most commonly seen in multi-drug resistant (MDR-TB) strains and has a reported frequency of greater than 95% in such isolates 3, 4, 5. MDR-TB is defined as a tuberculous disease caused by a bacterial strain that is resistant to at least INH and RIF. Resistance to RIF or other first-line drugs usually indicates the need for full susceptibility testing, including testing against second-line agents. Molecular detection of TB and rpoB gene mutations associated with RIF resistance greatly speeds the diagnosis of both drug-susceptible and MDR tuberculosis. With the Xpert MTB/RIF test, this can be accomplished in fresh sputum samples and in prepared sediments in less than 2 hours. The rapid detection of MTB and RIF resistance allows the physician to make critical patient management decisions regarding therapy during the same medical encounter.

MATERIALS AND METHOD Permission to carry out the retrospective study was sought from the Malindi District Hospital Laboratory Manager and the Hospital Administration and approval given by the Hospital Ethical Committee and DTLC. The Kenya’s Ministry of Health National Leprosy and Tuberculosis Programme Lab Register for AFB together with the genexpert register were used to tally the total number of Newly diagnosed HIV TB suspects and the positive sputum smears counted against total smears for the respective newly diagnosed HIV patients during the study period. Quality Control Each test includes a Sample Processing Control (SPC) and probe check (PCC). Sample Processing Control (SPC)—Ensures the sample was correctly processed. The SPC contains non-infectious spores in the form of a dry spore cake that is included in each cartridge to verify adequate processing of MTB. The SPC verifies that lysis of MTB has occurred if the organisms are present and verifies that specimen processing is adequate. Additionally, this control detects specimen associated inhibition of the real-time PCR assay. The SPC should be positive in a negative sample and can be negative or positive in a positive sample. The SPC passes if it meets the validated acceptance criteria. The test result will be “Invalid” if the SPC is not detected in a negative test. Probe Check Control (PCC)—Before the start of the PCR reaction, the GeneXpert Dx System measures the fluorescence signal from the probes to monitor bead rehydration, reaction-tube filling, probe integrity and dye stability. Probe Check passes if it meets the assigned acceptance criteria.

DATA MANAGEMENT AND ANALYSIS: The data collected was recorded in a form then later transferred to Microsoft Excel statistical package for analysis guided by gender. The results was then presented in charts, tables and graphs. RESULTS 35% and 22% males and females respectively had MTB detected

monthmalefemale Jul247 Aug3014 Sep910 Oct5658 Nov4943 Dec93 Jan82 Feb1815 Mar57 Apr2318 May119 Jun115 COMMENTS: MONTH WITH HIGHEST MALE/FEMALE TURN OUT – OCTOBER MONTH WITH LOWEST MALE TURN OUT – MARCH

monthly distribution of MTB/RIF Resistance occurrencegenderJulAugSepOctNovDecJanFebMarAprMayJun total male female grand total MTB detected male female RIF Resistance male female

Monthly gender distribution of MTB detection occurrencemtb gendermalefemale Jul81 Aug80 Sep34 Oct2215 Nov1512 Dec30 Jan41 Feb54 Mar21 Apr80 May81 Jun23 Total8842 minimum20 maximum2215 mean74

CONCLUSION Newly diagnosed HIV patients have MTB the infectious agent responsible for TB disease with males at high risk than their female counterparts. Rifampicin resistance strain of MTB was confirmed among positive MTB patients with HIV infection

References 1. WHO report Anti-tuberculosis resistance in the world: fourth global report. WHO/HTM/TB/ Morris SL, Bai Gh, Suffys P, Portillo-Gomez L, Fairchok M, Rouse D. Molecular mechanisms of multidrug resistance in clinical isolates of Mycobacterium tuberculosis. J Infect Dis 1995; 171: Ashok Rattan, Awdhesh Kalia, and Nishat Ahmad, Multidrug-Resistant Mycobacterium tuberculosis: Molecular Perspectives, Emerging Infectious Diseases, Vol.4 No.2, 5. Francis J. Curry National Tuberculosis Center and California Department of Public Health, 2008: Drug-Resistant Tuberculosis, A Survival Guide for Clinicians, Second Edition. McKinney RW (eds) (1993). HHS Publication number (CDC) Clinical and Laboratory Standards Institute (formerly National Committee for Clinical Laboratory Standards). Protection of laboratory workers from occupationally acquired infections; Approved Guideline. Document M29 (refer to latest edition). 8. Kent PT, Kubica GP Public Health Mycobacteriology—A Guide for Level III Laboratory, Centers of Disease Control, Atlanta, Publication no. PB Laboratory Services in Tuberculosis Control: Part II, Microscopy WHO/TB/98.258; p 1-61.