Saturday, 18 June 2016

6 drug resistant TB cases in AMK

TB cases in Ang Mo Kio: Risk of an epidemic low, no cause for panic, say experts

A "highly unusual" outbreak of six tuberculosis cases within a period of four years at Block 203 in Ang Mo Kio has brought a forgotten disease back into the spotlight.

Even as the block's residents queued up for TB screenings yesterday, the Government and healthcare experts have assured the public that the risk of an epidemic is low.

TB, especially its multi-drug resistant strain, is not that common. According to statistics released by the Ministry of Health (MOH), the incidence of TB among Singaporeans and permanent residents last year was 38.4 per 100,000 - the second lowest in Asia after Japan.

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6 cases of multi-drug resistant TB in Ang Mo Kio block, MOH offers free screening to residents

The detection of an unusual cluster of 6 multi-drug resistant tuberculosis (MDRTB) infections at a block of flats in Ang Mo Kio has prompted health authorities to offer free TB screenings to the block's residents starting Thursday (Jun 16) until Sunday (Jun 19).

In a statement, the Health Ministry assured the public that the 6 pose no ongoing public health risk, as they have either completed or are receiving treatment.

The 6 individuals with MDRTB come from four separate units at Block 203 Ang Mo Kio Avenue 3. The first 3 cases come from the same household, with the first individual in that unit diagnosed in February 2012. The rest of the household was subsequently monitored for the infection. 2 were later diagnosed with active MDRTB in May 2012 and October last year.

related:
'High alert’ after 3rd case in same HDB block: Doctor who flagged TB cases
MOH to review list of notifiable diseases
5 child patients found with latent TB after screening: NUH
178 children to be tested after NUH nurse found to have TB
About 70 residents from affected Ang Mo Kio block screened for TB so far
'High alert’ after 3rd case in same HDB block: Doctor who flagged TB cases
Residents of affected Ang Mo Kio block undergo tuberculosis screening


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Screening for residents of Ang Mo Kio block after 6 TB cases found

The residents of a block of flats in Ang Mo Kio Avenue 3 are being urged to undergo screening for tuberculosis (TB), after 6 of their neighbours were diagnosed with the same drug-resistant strain of the disease over a four-year period.

Last night, grassroots volunteers, officers from the Ministry of Health (MOH) and Ang Mo Kio GRC MP Koh Poh Koon knocked on the doors of the 160 units of Block 203 to inform residents of the situation, which MOH described as "highly unusual".

3 of the six TB patients lived in the same unit but the other 3 were from different households. All 4 households said they did not know and had not interacted with one another.

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Drug-resistant TB ‘takes longer to cure, poses more risk’

Compared with patients diagnosed with tuberculosis (TB), those infected with the multi-drug-resistant strain of the disease will have to take more medicines a day, and the types of medication they consume also put them at risk of side effects such as kidney, liver or psychiatric problems.

Doctors TODAY spoke to also noted that patients diagnosed with such multi-drug-resistant strains will take more time to be completely cured. The doctors were commenting after the Ministry of Health (MOH) said on Wednesday that there was an unusual cluster of 6 multi-drug resistant TB cases at a public housing block on Ang Mo Kio Avenue 3.

The inappropriate treatment of TB and patients’ poor adherence to the treatment increases the likelihood that drug-resistant strains will develop. The use of antibiotics has also led to the rise of such strains 
of the disease.

related:
Doctor who helped connect dots praised for her ‘astute observation’
Lack of symptoms, patients’ reticence hinder TB detection
6 TB cases found at Ang Mo Kio block
AMK TB cluster: Man who caught disease from friend ‘angry’ at his ‘negligence’
S’poreans at higher risk of heart failure
Ang Mo Kio TB cases: Residents surprised, but not overly alarmed

TB cases in AMK could stem from 2012 Parklane cluster

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Mystery over how 6 patients ended up with same TB strain

How 6 people from 4 different households managed to pick up the same strain of multi-drug resistant tuberculosis (TB) is a mystery.

The 6 patients told Health Ministry officials that apart from the 3 from the same household, they did not know or interact with one another and had not congregated at common areas. They ranged in age from early 20s to 70.

The index case was a man who was first diagnosed with drug-resistant TB in February 2012. Another member of his household was diagnosed with the same strain 3 months later. That year, a woman living in the same unit was also diagnosed with a latent form of TB. This meant she would have shown no symptoms of the disease. However, in October last year, she too developed an active infection.

related: TB cases in Ang Mo Kio: What you need to know about TB

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Cluster of multi-drug resistant TB cases discovered in a single block in Ang Mo Kio

The Ministry of Health (MOH) is investigating a cluster of drug resistant tuberculosis (TB) cases residing at Blk 203 Ang Mo Kio Ave 3.

TB can be spread through fine respiratory droplets containing the TB bacteria when a person with infectious TB coughs or sneezes. Persons with close or prolonged contact with persons with TB may be at risk of becoming infected. Drug resistant TB takes longer to treat.

The cluster of infections in Ang Mo Kio was detected by a vigilant doctor from the Tuberculosis Control Unit at Tan Tock Seng Hospital.  The doctor reported his findings to MOH in May 2016, leading to an investigation that established in June 2016 that the six individuals were infected with the same MDRTB strain, with the last case confirmed on 10 June.

related: TB Experts: FT influx from 3rd world increases reported cases in Singapore

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6 drug resistant TB cases in AMK
6 residents of Block 203, Ang Mo Kio Avenue 3 have contracted multidrug-resistant tuberculosis (MDR TB).

While 3 of them, including Patient Zero, live in the same flat, the other 3 are from different units.

Announcing this at a press conference last evening, Associate Professor Benjamin Ong, director of medical services at the Ministry of Health (MOH), said this makes it "highly unusual to find cases of the same strain of the MDR TB who do not share common activities with one another".

related:
What is TB, how it spreads, how it is treated
I'll make kids wear masks, says mum at TB affected block
DIFFERENT TYPES OF TB
AMK resident recounts tough battle with TB

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TB cases in Ang Mo Kio: Astute of Tan Tock Seng Hospital doctor to identify cluster, says MP Koh Poh Koon

'Astute' ? where are the prevention measures?

Why is Singapore seeing an increase in cases of tuberculosis (TB)? Is Singapore regressing into a 'developing country'?

Is there screening for foreigners coming to Singapore to work screened? especially from the countries that have high incidence of TB?

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MDR-TB Cluster in AMK, Singapore

There are many criticisms made of our local press, but it is clear that we have good journalists. Ms Kelly Ng from Today has figured out what MOH appeared to have left out from its press release, which is that the Ang Mo Kio MDR-TB cluster ultimately has its roots in the 2012 Parklane cybercafe outbreak. The index case of the Ang Mo Kio cluster was also one of the Parklane cybercafe patrons who developed MDR-TB 4 years ago. It appears that he had been living with his friend and his friend’s mother then, and had  – according to this friend – infected both of them due to “negligence in taking medicine”. While he appeared to have been diagnosed with active MDR-TB during the original contact investigations in 2012, his mother had latent MDR-TB that only progressed onto active MDR-TB 3 years later.

Should this person’s mother (and others diagnosed with latent MDR-TB during the original contact investigations in 2012) receive treatment for latent MDR-TB? Experts are split on this issue currently, because there is not enough high-quality evidence to favour one approach over the other. So some would advocate preventive treatment – usually using a fluoroquinolone-based regimen – while others would recommend close follow-up for at least 2 years.

With regards to the Parklane MDR-TB cybercafe outbreak, the TB Control Unit and MOH had written up a report a year ago, and it is apparent from the write-up (I was involved in the molecular epidemiology aspect of the MDR-TB isolates) that the officials had experienced considerable difficulty with contact investigations perhaps due to the unusual social circumstances. Ultimately, one of several important long-term approaches to TB control is to educate the public and remove all stigma from this infectious disease. If TB patients are willing to name all their close contacts, and even go the extra step of actively telling these contacts to come for TB screening, we will certainly be able to reduce the transmission of TB gradually in the long run. One part of destigmatization has to do with ensuring job security – from the Today report, we can only sympathise with the young man who had to quit his job because of the side effects of MDR-TB treatment. Hence TB control is not just dependent on the government, but should also involve active participation from the community, healthcare services and businesses.

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Multi-drug-resistant tuberculosis

Multi-drug-resistant tuberculosis (MDR-TB, also known as Vank's disease) is defined as a form of TB infection caused by bacteria that are resistant to treatment with at least two of the most powerful first-line anti-TB drugs, isoniazid (INH) and rifampicin (RMP).

Five percent (5%) of all TB cases across the globe in 2013 were estimated to be MDR-TB cases, including 3.5% of newly diagnosed TB cases, and 20.5% of previously treated TB cases. While rates of MDR-TB infections are relatively low in North America and Western Europe, they are an increasingly serious problem worldwide, in particular in areas of the Russian Federation, the former Soviet Union and other parts of Asia.

MDR-TB infection may be classified as either primary or acquired.[5] Primary MDR-TB occurs in patients who have not previously been infected with TB but who become infected with a strain that is resistant to treatment. Acquired MDR-TB occurs in patients during treatment with a drug regimen that is not effective at killing the particular strain of TB with which they have been infected. Rates of primary MDR-TB are low in North America and Western Europe: in the US in 2000, the rate of primary MDR-TB was 1% of all cases of TB nationally. Most cases of acquired MDR-TB are due to inappropriate treatment with a single anti-TB drug, usually INH. This can occur due to a medical provider, such as a doctor or nurse, improperly prescribing ineffective treatment, but may also be due to the patient not taking the medication correctly, which can be due to a variety of reasons, including expense or scarcity of medicines, patient forgetfulness, or patient stopping treatment early because they feel better.

Treatment of MDR-TB requires treatment with second-line drugs, usually four or more anti-TB drugs for a minimum of 6 months, and possibly extending for 18–24 months if rifampin resistance has been identified in the specific strain of TB with which the patient has been infected.[6] In general, second-line drugs are less effective, more toxic and much more expensive than first-line drugs. Under ideal program conditions, MDR-TB cure rates can approach 70%.

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WHO: What is multidrug-resistant tuberculosis (MDR-TB) and how do we control it?

The bacteria that cause TB can develop resistance to the antimicrobial drugs used to cure the disease. Multidrug-resistant TB (MDR-TB) is TB that does not respond to at least isoniazid and rifampicin, the two most powerful anti-TB drugs.

The reasons why multidrug resistance continues to emerge and spread are mismanagement of TB treatment and person-to-person transmission. Most people with TB are cured by a strictly followed, six-month drug regimen that is provided to patients with support and supervision. Inappropriate or incorrect use of antimicrobial drugs, or use of ineffective formulations of drugs (e.g. use of single drugs, poor quality medicines or bad storage conditions), and premature treatment interruption can cause drug resistance, which can then be transmitted, especially in crowded settings such as prisons and hospitals.

In some countries, it is becoming increasingly difficult to treat MDR-TB. Treatment options are limited and expensive, recommended medicines are not always available, and patients experience many adverse effects from the drugs. In some cases even more severe drug-resistant TB may develop. Extensively drug-resistant TB, XDR-TB, is a form of multidrug-resistant TB with additional resistance to more anti-TB drugs that therefore responds to even fewer available medicines. It has been reported in 105 countries worldwide.

Drug resistance can be detected using special laboratory tests which test the bacteria for sensitivity to the drugs or detect resistance patterns. These tests can be molecular in type (eg, Xpert MTB/RIF) or else culture-based. Molecular techniques can provide results within hours and have been successfully implemented even in low resource settings.

Solutions to control drug-resistant TB are to:
  • cure the TB patient the first time around;
  • provide access to diagnosis;
  • ensure adequate infection control in facilities where patients are treated;
  • ensure the appropriate use of recommended second-line drugs.
In 2014, an estimated 480 000 people worldwide developed MDR-TB. It is estimated that about 9.7% of these cases were XDR-TB.

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Full Coverage:
6 cases of multi-drug resistant TB in AMK block, MOH offers free screening
Cluster of multi-drug resistant TB cases discovered in a single block in AMK
Drug-resistant TB 'takes longer to cure, poses more risk'
6 drug resistant TB cases in AMK
Screening for residents of Ang Mo Kio block after 6 TB cases found
6 TB cases found at Ang Mo Kio block
About 70 residents from affected Ang Mo Kio block screened for TB so far
TB cases in AMK: Risk of an epidemic low, no cause for panic, say experts
TB cases in Ang Mo Kio: What you need to know about TB
'High alert' after 3rd case in same HDB block: Doctor who flagged TB cases
Doctor who helped connect dots praised for her 'astute observation'
Disease now rarely fatal, but cases on an uptick
TB cases in AMK could stem from 2012 Parklane cluster
Doctor 'astute' to spot TB pattern, says MP
Astute of Tan Tock Seng Hospital doctor to identify cluster, says MP KPK
Ang Mo Kio TB cases: Residents surprised, but not overly alarmed
AMK resident recounts tough battle with TB
Residents of affected Ang Mo Kio block undergo tuberculosis screening
Lack of symptoms, patients' reticence hinder TB detection
Residents worried about spread of TB to family members
The news in three mysteries



related:
NUH recalling 178 children cared for by nurse with TB
5 child patients found with latent TB after screening: NUH
TB cases in AMK could stem from 2012 Parklane cluster
5 children found to have latent TB
1 baby found to have latent TB after NUH recalled patients for screening

Three recent healthcare outbreaks in Singapore
Another Hospital Makes A Boo-Boo

14 babies at the KK Women’s and Children’s Hospital (KKH) Neonatal Intensive Care Unit (NICU) were diagnosed with conjunctivitis — or more commonly known as red eye or sore eye —  between mid Oct and 1 Dec.

According to the Health Promotion Board, Conjunctivitis (Red eye) is an inflammation or infection of the transparent membrane (conjunctiva) that lines the eyeball that causes the eye to be swollen and makes small blood vessels in the eye become more prominent resulting in red eye. Can the ICU still be called Intensive Care Unit if the care provided is not adequate?


This is the third recent healthcare saga in Singapore. In October, Singapore General Hospital revealed cases of hepatitis C. Just last week (4 Dec), National University Hospital (NUH) also came clean with their tuberculosis (TB) cases.


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related:
6 drug resistant TB cases in AMK
Hepatitis C: Chronic & Acute infections
Hepatitis C cluster @SGH: 22 infected, 4 have died
Three recent healthcare outbreaks in Singapore
Staff Disciplined after Hepatitis C Outbreak