Iranian Journal of

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Background & Objectives: Children are highly vulnerable to TB and childhood tuberculosis is a sign of TB transmission in community. This study aimed to determine the epidemiologic trend of this disease in Iranian children.
Method: A Trend Study was conducted to evaluate all Iranian patients aged below 14 who had been diagnosed with pulmonary or extrapulmonary TB from 1992 to 2005. Statistical relationships were tested using chi square tests (c²) and the software package SPSS (version 11.5).
Results: Out of the 6168 cases studied, 2528 (40.1%) were boys. Patients were assigned to three groups based on disease type: there were 1812 (29.4%) sputum- positive, 1920 (31.1%) sputum-negative, and 2449(39.7%) extrapulmonary cases.The incidence of sputum-positive TB declined from 0.8 per 100000 in 1992 to 0.2 per 100000 in 2005. A similar declining trend was observed for the overall TB incidence and in the incidence of sputum-negative and extrapulmonary cases. There was significant difference in TB incidence between girls and boys in the 10-14 year age group (P<0.001), but no sex difference was observed in 0-4y and 5-9y age groups.
Discussion: The incidence of sputum-positive TB decreased by 75 percent over the study period. This could be partly due to improvements in health status, better disease knowledge and the effects of Iran's National TB Control Program.
Conclusions: In children aged below 10 years, there was no significant difference in the incidence of tuberculosis between girls and boys. At puberty, the incidence of all types of TB was higher in girls. Based on these findings, further studies are needed to elucidate the gender distribution of childhood tuberculosis in Iran.

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Background & Objective: Because of uncertainty in interpretation of some tests for diagnosing TB, decision making for the tuberculosis treatment is based on multiple diagnostic tests. This study was conducted to assess the accuracy of Quanti FERON-TB Gold test in tuberculosis diagnosis.
Methods: The study was carried out on 30 cases and 46 controls. Statistical indices of sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, odds ratio and Receiver Operating Characteristics (ROC) curve were estimated.
Results: Sensitivity of QFT-G was 90.0% (95% CI=73.0-97.6), specificity 95.7% (95% CI=83.8-99.3), positive predictive value 93.1% (95% CI=76.3-98.9), negative predictive value 93.6% (95% CI=81.3-98.4). The area under ROC curve was 0.942 (95% CI=0.88-1.00), that significantly differed from chance diagonal area (P<0.0001). The optimum cut point for the Quanti FERON-TB Gold test was 0.35 IU/ml, with sensitivity of 0.90 and specificity of 0.957.
Conclusions: The Quanti FERON-TB Gold test displayed good validity indices in this study. Since the utility of this test has a high cost therefore this test would not be offered for routine tuberculosis detection. It suggested that this test are applicable for smear and culture negative tuberculosis, child tuberculosis, and assessment of TB contact tracing.

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Background and objective: The nested case-control study has become popular as an efficient alternative to the full-cohort design. This study compares the results of a nested case-control analysis approach with the full cohort analysis.
Methods: A cohort of 276 subjects (new cases from a TB registry) was used for this study. Cox Regression model was used for the full cohort analysis. In order to do the nested case-control analysis, for each death, three random controls were selected from those who did not suffer from the outcome at the time of the outcome took place. Case control data was analyzed by the conditional logistic regression model.
Results: Results from both cohort and nested case-control analyses show that treatment group is the only variable that affects on the outcome. Gender, place of residence, and age has no effect on the outcome. For binary exposure variables with trivial effects (e.g. Gender and place of residence), the relative efficiency of nested case-control study design is approximately 75%.
Conclusion: Results of this study show that nested case-control study is not only an easy and cost-effective method for data analysis but also is as robust as cohort analysis in rate ratio and its variance estimation.

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Background and objective: Participation of community-based services in the National Tuberculosis Control Programme is (NTCP) necessary to identify and treat all patients with tuberculosis (TB). We developed a novel model to encourage family members and relative to participate in the RNTCP in Darahshar city.
Methods: This community-based intervention was included of two groups of community (relatives of patients and schools). They were trained to identify and refer of patients to allocated health centers. Case finding indices were compared initially and one year intervention. The exponential distribution and logarithmic of incidence were used to compare the incidence of tuberculosis after the intervention with other cities of the province.
Results: The incidence of smear positive cases increased from 5.1/100,000 to 35.2/100,000 (p <001). There was a statistically significant difference between incidence of smear positive cases in Darehshar city and other cities in Ilam province (p <001). During the intervention, 408 suspected patients was identified, it showed about 297 percent increased in case finding (cases in the previous year of the intervention were 137 cases) (p <001).
Conclusion: It seems that community-based intervention could be an effective method to enhance of identify and control of patients with tuberculosis.

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Normal 0 false false false EN-US X-NONE AR-SA Background & Objectives: Tuberculosis (TB) is an important issue which its control is still unsatisfactory at global level. Traditional diagnostic techniques for active TB diagnosis are inadequate: the diagnostic gold standard is the cultural exam which suffers from lengthy processing and requires highly specialized laboratories. Nowadays more specific tests have been recommended. The aim of this study is to evaluate the performance of Quanti FERON-TB (QFT)Gold In Tube-Test as a substitute for specific test tuberculin skin test for diagnosis of latent tuberculosis infection in high risk groups.
Methods: One hundred thirty four (134) individuals who worked in Bo-Ali hospital (Zahedan) enrolled in this study. They had no active tuberculosis. TST and QFT tests were performed. The cut-off point of TST was considered based on 15 (mm) or more indurations as positive. The result of QFT was evaluated by manufactured guidelines. Multivariate logistic regression was used to identify the putative risk factors of positive tests.
Results: Proportion of employees with latent TB were 111(82.8%) were positive by either TST or QFT, and 76(56.7%) were positive by both tests. Agreement between the tests was high (73.8%, k=0.39 95%CI:
0.21-0.44). Positive family history of Tuberculosis was significant risk factor for both positive tests. 
Conclusion: This study showed high latent tuberculosis infection prevalence in hospital workers and high agreement between TST and QFT. Decision to select one of the tests will be depended on the population, purpose of study and availability of resources. The results revealed that the QFT can be appropriate alternative test for high risk group.  

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Background & Objectives: Tuberculosis (TB) is the largest single cause of death from infectious diseases and has a ten rating of global burden of disease. Despite the availability of effective treatment for pulmonary TB, sputum conversion of patients affected by various factors. This study aimed to determine the time course of sputum conversion in patients and possible affected factors in this process. Methods: In this Retrospective cohort study, 440 patients with smear-positive pulmonary TB in Hamadan province from 21 March 2006 to 20 March 2012 referred to health centers were included. Demographic, clinical data and treatment status of patients, including the time of sputum smear negative were extracted using TB Register software from patient registry. Time to sputum conversion was considered monthly during the patient’s treatmentand shown by Kaplan-Meier survival curve. The effects of some determinants including gender, location, age group and number of bacilli in the sputum of patients at the beginning of treatment were determined using Cox proportional hazard regression model.
Results: From 440 patients with smear-positive pulmonary TB, 51% (221 patients) were male and 49% (219 patients) were female. Fifty seven percent (57%) were living in urban and others in rural. The median of sputum conversion was 3 months. Totally, sputum conversion rate at the end of month 2 and 3 were 69% and 88%, respectively.
Conclusion: Our findings revealed that there has been a considerable difference between the expected sputum conversion rate and the observed rate in Hamadan province, Iran.

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Background & Objectives: Tuberculosis (TB) is one of the major infectious diseases in Iran and has pulmonary and extra-pulmonary manifestations. Considering the differences in the distribution of the cases across different regions, we decided to study the geographical distribution, epidemiologic characteristics, and disease pattern in Lorestan.

 Methods: This ecologic (descriptive analytical) survey was done in Lorestan between 2002 and 2008. The data was collected from the Health Department of Lorestan University of Medical Sciences and included the history of 1481 patients suffering from TB. The study variables were sex, disease type, residential location, age, and year. The data were analyzed using statistical package SAS 9.2 and descriptive and inferential statistics were applied.

Results: From 1481 registered patients 58.4% were male and 41.6% were female among which 68.74% and 29.98% lived in urban and rural areas and 1.28% were nomads. The mean age of the patients was 41.87. The highest and lowest incidence rates were observed in Khoram Abad (19.38 per 100000) and Azna (7.04 per 100000), respectively. Using Poisson regression, it was observed that the effects of age structure and residency on the incidence rate were significant.

Conclusion: The percentage of nomads was identified as the most important demographic factor in the incidence rate of TB in Lorestan. Allocation of better resources and appropriate training can be effective in controlling and preventing the disease.

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Background & Objectives: Bovine Tuberculosis (BTB) is one of the most important zoonoses. Mycobacterium bovis is the responsible agent of BTB in the cattle. The current study was conducted to investigate the determination factors of BTB in dairy farms covered by the tuberculin screening test.

Methods: A herd level case- control study was carried out in 124 (62 cases & 62 controls) dairy farms in the provinces of Tehran, Alborz, Hamedan, Isfahan, Qazvin, Qom, Mazandaran and Semnan. The control farms were individually matched with case farms by farm capacity and distance. Statistical analyses were done by Stata 11.2 using conditional logistic regression.

Results: Proper management of manure (OR=0.12 95% CI: 0.03-0.49), regular flaming of stalls (OR= 0.21 95% CI: 0.04-0.92) and complete fencing around the farm (OR= 0.17 95% CI: 0.03-0.81) decreased while the presence of rodents (rat) (OR= 4.90 95% CI: 1.04-23.01) increased the risk of infection. The interaction among these variables was not statistically significant

Conclusion: According to the results, there is an essential need to pay more attention to rodent control in farms.

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Background and Objectives: One of the applications of population attributable risk percent (PAR%) is to estimate the disease burden in a population exposed to several risk factors. Therefore, this study was conducted to estimates the PAR% of the space-time clusters of pulmonary tuberculosis.

Methods: In this study, the data of pulmonary TB cases were obtained from the health department of Hamadan University of Medical Sciences. After detecting significant clusters using the spatiotemporal scan statistic, PAR% was used to analyze the clusters and to detect the location of clusters more accurately.

Results: Four primary space-time clusters and three secondary spatiotemporal clusters were detected for patients with pulmonary tuberculosis and 92% of the patients who did not have a clear state in term of HIV infection. Despite differences in the location of clusters and PAR%  attributed to them, the second primary cluster of pulmonary tuberculosis cases (consisting of the cities of Razan, Famenain and Kabudrahang) had the highest amount of PAR% that needs more attention.

Conclusion: The presence of significance spatiotemporal clusters in Hamadan highlights the necessity of the use of PAR% to distinguish cluster areas and to implement prevention and control policy. However, more analytical studies are needed to detect the on the determinants of the occurrence of pulmonary TB.

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Background and Objectives: Using the anthropometric indicators of children is one of the ways of monitoring their growth. Because of the racial divisions and levels of health and welfare, comparing these indicators with the global reference is not reasonable; therefore, designing a local reference seems necessary. This study aimed to evaluate the growth indices for boys and girls aged 5 to 18 years old living in Isfahan and to compare the indices with standard values.
Methods: In this cross-sectional study, 53,839 subjects were included. Percentiles of body mass index, height, and weight were calculated using the LMS method in the LMS Light software. After normalization of the growth indices, their mean and standard deviation were calculated for each age group and anthropometric indices curves were plotted versus the 5th, 50th and 95th percentiles of the NCHS reference.
Results: In all age categories, the mean SDS scores of BMI in boys and girls was -0.004 ± 0.029 and 0.014 ± 0.062, respectively, indicating no difference with reference values. However, the 95th percentile of the body mass index for the reference population was consistent with the 90th percentile for the population studied. Also, weight in boys below 13 years of age was higher than the reference line while in girls, weight was always higher than the reference value.
Conclusion: Due to differences in the pattern of growth and also lower anthropometric values, particularly among boys, it seems that a national growth curve can be a better guide for future decisions.

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Background and Objectives: Tuberculosis is the most common cause of death among single-factor infectious diseases and is the tenth cause of death among all diseases in the world. The disease is spread mainly from an infected person through close contact with other people living in one place. The aim of this study was to investigate the relationship between the spatial correlation structure and the recovery time of patients with pulmonary tuberculosis in Iran.
Methods: In this applied study, the data of 20554 patients with sputum smear-positive pulmonary tuberculosis in Iran from 1389 to 1393 were used. A parametric accelerated failure time model with spatial frailty and batesian approach was used to analyze the data. The OpenBUGS 1.4 was used for programming and the ArcGIS 9.2 was used for mapping the environmental impact on tuberculosis.
Results: The mean age of the patients was 50.35 years with a standard deviation of 21.6 years. The results showed that the geographical environment, gender, prison condition, degree of smear positivity at diagnosis and location (urban-rural) had a significant impact on the recovery time of pulmonary tuberculosis patients. The recovery time of patients with smear grade 1-9 bacilli, 1+ and 2+ who were treated was significantly shorter than the others.
Conclusion: According to the study, geographical environment and the location have a significant impact on smear positive patients’ recovery time. This impact depends on the degree of smear positivity in some provinces and is independent of it in some other provinces.

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Background and Objectives: Tuberculosis is a chronic bacterial disease and a major cause of morbidity and mortality. It is caused by a Mycobacterium tuberculosis. Awareness of the incidence and number of new cases of the disease is valuable information for revising the implemented programs and development indicators. time series and regression are commonly used models for prediction but these methods require some assumptions. The purpose of this study was to predict new TB cases using the hidden Markov model which does not require many assumption.
 
Methods: The data used in this study was the monthly number of new TB cases during 2006-2016 identified and recorded in Hamedan Province. Rorecasting the number of new TB cases was done using hidden Markov models using the hidden Markov package in the R software.
Results: According to the AIC and BIC criterion, two states had the best fit to the data, i.e. the data of this study were a mixture of two Poisson distributions with average number of event 5.96 and 10.2 respectively. The results also predicted the number of new cases over the next 24 months based on the hidden Markov model would be between 8 and 9 new cases in each month.
Conclusion: The hidden Markov model is the best model for prediction using the Markov chain. This model, in addition to detection of an appropriate model for the available data, can determine the transition probability matrix, which can help physicians predict the future state of the disease and take preventive measures befor reaching advanced stages.

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Background and Objectives: Social marketing is a method that acts through identifying the needs and demands of the audience and specifying the components of the behavioral market using the results of developmental research. So far, social marketing has not been used to involve the private sector in the tuberculosis (TB) control program. The aim of this study was to design a Public-Private Mix (PPM) program using social marketing.
 
Methods: This qualitative study was conducted using focused group discussions (FGD) with six different groups, including tuberculosis coordinator physicians, specialists from different fields in the private section, and managers of selected private laboratories and hospitals in Karaj in 2013 and the components of the PPM program were determined according to the results of the qualitative study.
 
Results: Most of the participants believed that participation of the private sector in the TB program was associated with significant challenges, including the lack of a well-defined process for communicating with the private sector, lack of a suitable platform, lack of appropriate monitoring tools, private sector’s lack of compliance, private sector’s lack of familiarity with national TB program protocols, lack of appropriate incentive and punitive measures, lack of appropriate feedback to the private sector, and monopoly in laboratories.
 
Conclusion: To run PPM in the TB program, it is necessary to involve laboratories in the program voluntarily. It is also essential to provide an informational and incentive package containing effective and low-volume tutorials; the package should facilitate feedback and promote respect for the private sector.

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Background and Objectives: Over the past decades, the Iran’s anti-tuberculosis campaign has become highly structured and many achievements have been made. The purpose of this study was to describe the characteristics of the TB surveillance system and its components in the Islamic Republic of Iran.
 
Methods: The data of this study were obtained from the surveillance system of the Center for Communicable Disease Control, a review of the records, documents, books and published articles, and also interviews with process owners and experts of TB surveillance during 2017-2019.
 
Results: Case finding and treatment and follow-up of TB patients and their household contacts are done In the TB surveillance system. The implementation of the DOTS, (DIRECTLY OBSERVED TREATMENT SHORT-Course) is a major component of the TB surveillance system. Patient registration is done in an online application, which allows extracting and reporting the important indicators of the program. In this surveillance system, there is a special sensitivity to the treatment of patients, so the incidence of multi drug-resistant TB in the country is lower than that of the neighbors. The presence of regional laboratories that cover the entire region of the country is one of the strengths of the TB surveillance program in Iran.
 
Conclusion: Despite budget problems, the anti-TB program in Iran has many achievements. However, new strategies need to be considered to reduce the incidence of TB.

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Background and Objectives: In addition to effective treatment, tuberculosis recurrence is a very important challenge regarding the treatment of this infection. This study was conducted to evaluate the risk factors associated with tuberculosis recurrence.
 
Methods: In this nested case-control study, 202 tuberculosis patients with recurrence and 202 matched controls in terms of age, sex and place of residence were studied. The cases and controls were selected from a cohort of tuberculosis patients in Sistan and Baluchestan province between 2011 and 2018. The data were collected using interviews and patients’ records. The independent t-test, chi-square and multiple conditional logistic regression were used to analyze the data.
 
Results: The drug abuse history (OR=6.1), 3+ smear positive (OR=3.03), chest X-ray suggestive of tuberculosis (OR=4.9), drug resistance (OR=7.3), low socioeconomic status (OR=3.9), weight loss (OR=3.1), chest pain (OR=3.2), history of digestive disease (OR=22.1), smoking (OR=6.1), and imprisonment (OR=3.7) significantly increased the chance of recurrence among tuberculosis patients (p<0.05). On the other hand, the chance of recurrence was significantly lower in patients with coughs (OR=0.29) and a small family size (OR=0.28).
 
Conclusion: According to the results, tobacco use, drug use, low socio-economic status, life conditions, and disease conditions are the most important determinants of tuberculosis recurrence. In general, epidemiologic factors related to tuberculosis recurrence are not similar in different regions; therefore, educational programs for patients and their families and prevention methods should be considered based on related factors in different regions.

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Background and Objectives: A great number of tuberculosis (TB) patients present to the private sector to receive care; therefore, integrating TB control programs into private sector activities can enhance the control of TB. The Public-Private Mix (PPM) program is suggested by the World Health Organization to engage the private sector in TB control programs. In this study, a plan designed for PPM was piloted Karaj, Alborz Province, Iran.
 
Methods: In this community trial, pre-intervention assessment covered 18 months prior to the study. The intervention was a PPM package that was integrated into the health system by Karaj County Health Center. Then, three-month post-intervention data were collected. Analysis was performed with the SPSS 16 software using chi-square test.
 
Results: After the intervention, there was an increase of 40.7% in suspected cases of TB per month and an increase of 101.7% in smear positive TB cases diagnosed by Karaj laboratories. The ratio of smear positive cases to all suspected TB patients was 4.57% before and 6.56% after the intervention. The percentage of three sputum sample positive patients was 75.5% and 89.9% before and after the intervention, respectively.
 
Conclusion: The developed PPM program markedly improved the case detection; therefore, it is suggested to fix the potential defects of the program and implement it in all parts of the country.

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Background and Objectives: Immune deficiency syndrome is an epidemic disease. During immunodeficiency caused by HIV, infections such as tuberculosis, hepatitis B and hepatitis C may occur. Given that the transmission of these infections is similar to that of HIV, the risk of HIV infection with these infections is high. The purpose of this study was to determine the prevalence of common HIV infections and the related risk factors in HIV positive individuals.
 
Method:This study was conducted as a retrospective cohort study performed on 3047 HIV patients at Imam Khomeini Counseling Center in Tehran who have been admitted in 2004 -2018.Required data were extracted from patient records and entered into Excel software. For data analysis, SPSS version 21 was used.
 
Results: The mean age of the patients was 44.24 ± 9.46 years and 77.3% of them were male. Of them, 98 (3.2%) were co-infected with hepatitis B, 961 (31.5%) were co-infected with hepatitis C, and 415 (13.6%) were co-infected with tuberculosis. According to the results, hepatitis B and hepatitis C had a significant  association with age, marital status, gender, education, prison history, history of injection, history of addiction, and needle sharing.
 
Conclusion: Due to the common route of HIV transmission and these infections, there is the possibility of co-infection. The demographic variables and behavioral factors are the most effective risk factors for developing co-infections.

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Background and Objectives: At present, investigation of extensive contact of tuberculosis (TB) patients’ families is not a routine part of TB control efforts in most countries. This study was conducted to evaluate the effective contacts of TB cases to assess the potential risk of transmission and its determinants in their families.
 
Methods: In this cross-sectional study, registered TB cases in Kerman, Iran provided information about their family size and type and frequency of unprotected effective contacts with their families from 2014 to 2015. The unprotected effective contact was defined using the Centre for Disease Control (CDC) classification (2005) based on the close, frequent, and long-term contact of TB cases. The demographic variables and the frequency of effective contact were analyzed using a logistic regression model with Stata version 12 with 95% confidence intervals.
 
Results: Overall, among 407 contacts of 74 TB cases, 73% had effective contacts. Having an effective contact was significantly higher among females (Adjusted Odds Ratio (AOR)=5.1; 95% CI:1.9-13.7); those with a lower education level (AOR=4.0; 95% CI: 1.4-15.1), lower income (AOR=7.7; 95% CI: 2.2-27.0), and a house size ≤80 m2 (AOR=16.6; 95% CI: 5.1-54.3); Afghan patients (AOR=30.2; 95% CI: 3.4-272.1); and those living in the rural areas (AOR=4.9; 95% CI: 1.8-21.9).
 
Conclusion: It seems that unprotected effective contact with the family members is high among TB patients, which can be a serious concern for the control of TB in this area. Reducing these unprotected effective contacts through educating patients and their families besides screening of the family members can help the health sector to decrease the burden of TB in Iran.

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