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Persons using assistive technology might not be able to fully access information in this file. For assistance, please send e-mail to: mmwrq cdc. Type Accommodation and the title of the report in the subject line of e-mail. Compared with drug-susceptible TB disease, MDR TB is resistant to at least isoniazid and rifampin, the two most effective TB medications, making treatment more difficult and outcomes more likely fatal 1.

This report describes the investigation by the World Health Organization WHO and CDC, which initially identified five confirmed cases in two distinct clusters, characterized by two distinct geographic locations, genotypes, and drug-susceptibility patterns. Multiple U. These simultaneous and continuing outbreaks demonstrate how a lack of basic TB control activities can allow the emergence and spread of drug-resistant TB. FSM comprises four states and more than islands spread across 1 million square miles in the western Pacific Ocean.

Half of the population of , lives in Chuuk, the largest state 2.

Neglected tropical diseases in the Western Pacific Region

TB is endemic in Chuuk, where 70 cases of TB were recorded in The incidence rate TB cases per , is 29 times higher than the U. Limited transportation hinders access to the only hospital in Chuuk, which provides chest radiography and smear microscopy services to help diagnose TB.

Culture confirmation, drug-susceptibility testing, and genotyping were not available routinely for TB cases in FSM until January , when referral laboratories in Hawaii and California began to offer these services. Before , the state's geography, combined with limited TB program staffing, precluded active case-finding via routine contact investigations or the administration of DOT, a cornerstone of TB treatment that improves completion of therapy and prevents the emergence of drug resistance.

Before July , TB patients were identified as they showed signs or symptoms of TB disease at the local clinic or hospital; all received self-administered therapy. In June , pulmonary TB was diagnosed in a Chuuk resident aged 37 years. Sputum-smear microscopy detected acid-fast bacilli, and a chest radiograph showed lung cavitation, both indicators of contagiousness.

In November , drug-susceptibility test results confirmed multidrug resistance.


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The patient did not have access to second-line drugs and died. None of the four patients were treated with second-line drugs; three died, including a child aged 2 years. A suspected case of MDR TB disease was defined as exposure based on intensity and duration of contact to a patient with confirmed TB and clinical findings of TB disease i. Patients or proxies for deceased patients were interviewed and laboratory and medical records reviewed. All patients were born in Chuuk; their median age was 16 years range: years , and four were female.

None of the patients had a history of TB disease or treatment with TB drugs. All five patients had pulmonary TB, two with cavitation on chest radiograph and hemoptysis.


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  4. None of the four patients who died before the investigation had been tested for human immunodeficiency virus HIV infection; the surviving patient had a negative HIV test result in July Two distinct clusters, associated with two different villages, were identified based on genotypes and drug-susceptibility patterns Figure.

    The Chi-square test or Fisher's exact test was applied to test significant differences between categorical data. Results: Among the 36 Filipino TB patients referred, Among these, 28 patients confirmed that they had started TB treatment in the Philippines.

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    The treatment success rate among the 23 TB patients excluding five patients who were still receiving treatment as of writing was However, only three out of five multidrug-resistant TB patients successfully started treatment. Conclusions: The current cross-border TB patient referral mechanism between Japan and the Philippines indicated successful results. However, it needs to be enhanced by strengthening the mechanism to track referral outcomes systemically.

    Advanced Search. Tuberculosis Surveillance Center. Tuberculosis in Japan — Annual Report Pulmonary tuberculosis treatment outcome among foreign nationals residing in Osaka city. Kekkaku ; Analysis of those transferred-out among pulmonary tuberculosis patients in Japan. BMC Public Health ; Espinal E, Frieden T. What are the causes of drug-resistant tuberculosis? In this context, meaning is understood as a determinate relation of the subject affected by language with history Thus, with this approach, one can understand how symbolic objects signifiers, discursive sequences, cutouts produce meanings and intervene in the real of meaning.

    Fifteen health professional subjects were intentionally interviewed by the main researcher, 4 physicians, 6 technicians and 5 nursing professionals, ranging in age from 25 to 55 years, who occupied the positions of managers at different levels central, provincial and district. Inclusion criteria were: to be working for more than a year in its role in the National Tuberculosis Control Program NTCP ; and be in the exercise of their activities at the time of data collection.

    For data collection, an interview script was used with the following questions guiding the interview: What are the difficulties faced in the process of detecting and reporting cases? How is the reporting of cases made? How is the flow of information? The questions were previously tested, and the interviews were conducted at locations defined by participants. They were audio-recorded by means of a voice recorder and had an average duration of 30 minutes. The interviews were transcribed and the step of returning the transcripts to the participants was waived.

    For the analysis of the data, the steps proposed by Orlandi 11 were followed: the first one consisted in the passage from the linguistic surface to the discursive object, in which the transcription of the interviews and successive readings were made to identify the ideas of references that belonged to the identified discursive blocks. The second step was to move from the object of discourse to the discursive process, in which the discursive, significant or enunciated sequences that played an important role in the creation of meanings were discriminated against, taking into account the signification process.

    It is signaled that, at this stage, the discursive sequences were related to the different discursive formations. In the third step, the discursive process itself ideological formation returned to the discourse sequences highlighted for analysis, framing itself in a theoretical framework on the subject under study, in a continuous process of discretion and interpretation.

    Four discursive blocks emerged: Detection of TB cases in laboratories; Underreporting of TB cases; Obstacles for detecting TB cases: long distances and lack of transportation; and Reporting of cases for decision-making.

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    The existence of at least one laboratory in each district of the province is indicated, on the one hand, as important in the TB detection process, but on the other, as insufficient to cover the population demand as it is stated by the subject in the following discursive sequence:. However, the same signifiers indirectly leave traces of several cases that are not being detected and reported to the national health system in Mozambique.

    This situation leads to the need to increase laboratories at the district level. On the laboratories, a speech emerged that focused on the difficulty of acquiring a microscope, an indispensable instrument for the detection of TB in patients:. The main difficulty [ The maintenance is generally not local, when failure is necessary to take the microscope to the province and if necessary to request another one [ So we also have problem with the physical location itself, where it works the laboratory does not allow sample processing in some places all day long.

    In this context, it is indicated, in these words, the denunciation of infrastructures unfit for the detection and processing of biological material for TB analysis. The sequence also produces meanings that imply that the government is finding it difficult to comply with the guidelines of the NTCP and WHO recommendations on the sites for the collection of the sputum sample, which should be performed in an airy outdoors, in addition to violating Biosafety standards for the processing of biological samples.

    The low detection and reporting of TB cases, especially in children, emerge as the main guideline in the following discursive cuts, where the subjects are enrolled in discursive formations that focus on underreporting of cases as a barrier to both the reporting system and the treatment. The difficulty is research, first diagnosis, second follow-up, especially in the south zone of the district; we have three sanitary units with laboratory nearby.


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    The patients we treat there even come from other districts. The lack of inputs has also contributed to low screening because it is not possible to screen for TB without these issues [ Among them, the lack of adequate professionals and means for the detection of TB and the lack of evidence-based studies recommending health practices that compete for the control of TB. Under these production conditions, the sequence suggests that these difficulties have become cyclical, interfering negatively in TB control in the country.

    The major difficulties are many [ The main problem is transport as we get to the units when our access roads are damaged? Added to the problem of distances is the lack of laboratories, which requires the patient to look for the health unit with conditions to perform the TB test:. People go to the hospital, they do not have a laboratory, they are indicated to go to other health units, but the patients do not have money to transport them.

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    It is observed that the professional health subjects are inscribed in discursive formations of the lamenting speech that focuses the lack of transportation as one of the obstacles in the control of TB and the detection of the cases. This discursive sequence, considering the socio-historical, economic and ideological conditions of Mozambique, instigates to think that the lack of means of transport is not simply a matter of cars, buses, but other means known to the population as are the cases of bicycles and motorcycles, which are the main means of locomotion of the population.

    In this case, the sequence produces the sense that people living for more than 8 km present difficulties from the identification of the symptoms to the treatment of the disease. This requires a policy design that can help reduce the distances that prevent the detection and consequent reporting of cases.

    There are record books in the sanitary units and then each health unit compiles the information according to the model of the Ministry, so we have the meeting and compile the data in a summary form, both in manual and electronic compilation and we take the province for planning.

    It is pointed out in the above clipping that the actions of compiling the information in a manual or electronic file suggest both the double registration that can guarantee the data conservation and the incipient process of the use of electronic means that are being introduced in those districts belonging to the rural area of Mozambique.

    From the discursive sequence below, it is observed that the reporting system of case reports seems to have the purpose of controlling the performance of health professionals and not to give the real situation of TB in the districts and in the province as can be deduced:. But quarterly the peripheral health unit is [ This receives analyzes and gives feedback from what has to be agreed and then sends it to the central level in DOTS and other TB areas. After that, within 45 days the central level has to tell the provinces what the feedback is in terms of performance, what has happened well or not, and how it should improve.

    The action of sending information to the district and to the province produces meanings that mean upward communication, which starts from the basis for those responsible. It can be understood from the following statement that the flow of information regarding reporting has had some difficulties. However, this flow has had irregularities, unfortunately is not processed within these periods, because there is a high turnover of human resources in TB.

    It is a difficult program to manage and often people who are placed as district managers in less than 2 years have to change. So there has to be new HR training and adaptation. So the time the information takes from the district to the province and the province to rectify, above all there are new district managers, and to get here takes time.