Koomi KANAI, Takeshi KURATA1*, Somsak AKKSILP2, Wattana AUWANIT, Vipada CHAOWAGUL3 and Pimjai NAIGOWIT

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1 Jpn. J. Med. Sci. Biol., 45, , Short Communication A PRELIMINARY SURVEY FOR HUMAN IMMUNODEFICIENT VIRUS (HIV) INFECTIONS IN TUBERCULOSIS AND MELIOIDOSIS PATIENTS IN UBON RATCHATHANI, THAILAND Koomi KANAI, Takeshi KURATA1*, Somsak AKKSILP2, Wattana AUWANIT, Vipada CHAOWAGUL3 and Pimjai NAIGOWIT Department o f Medical Sciences, National Institute of Health, the Ministry of Public Health, Nonthaburi 11000, Thailand, 1Department of Pathology, National Institute of Health, Kamiosaki, Shinagawa-ku, Tokyo 141, Japan, 27th Zonal TB Center, Ubon Ratchathani, Thailand, and 3Sappasitthiprasong Ubon Hospital, Ub on Ratchathani, Thailand (Received October 12, Accepted February 1, 1993) SUMMARY : A preliminary survey was conducted for the prevalence of HIV infections in pulmonary tuberculosis and melioidosis patients in Ubon Ratchathani province, in Thailand, the second largest province in population which supplies labors to Bangkok metropolis. In this province, tuberculosis is prevalent in a higher rate than in most other provinces and melioidosis is endemic. Four HIV-seropositives were found in a total of 551 suspected and culture-positive cases of pulmonary tuberculosis, while no HIV-seropositive was found in 121 melioidosis patients. In view of the rapidly expanding HIVinfections in Thailand, a strict watch will be needed on the future epidemiological status of HIV-infection in tuberculous patient. *Present address : Takeshi Kurata, Department of Pathology, National Institute of Health, 23-1 Toyama 1-chome, Shinjuku-ku, Tokyo 162, Japan.

2 HIV causes an immune deficiency by attacking the CD4 + lymphocyte population and consequently bringing about the impairment of other defence mechanisms comprising B cell, cytotoxic T cell, natural killer cell, and macrophages. Therefore, HIV-infection develops not only to AIDS, but also it is a leading risk factor to cause many other infectious diseases due to depletion of T lymphocytes. The interrelated prevalence of tuberculosis (TB) and AIDS is one of such problems. Surveillance conducted in in the United States (1,2) and other recent studies (3-5) revealed a serious epidemiological situation of the relation. This aspect is of vital importance especially in the developing countries where mycobacterial and mycotic infections still have a high morbidity. In Thailand, Chuchottavorn et al. (6) reported in 1989 that they found nine HN-seropositive persons among 456 bacteriologically confirmed tuberculous patients (a 1.97% prevalence rate). Eight of them were intravenous heroin abusers at the time of study, and the remaining one had a history of chronic venereal disease. This report is primarily concerned with the relation between HIV-infection and intravenous drug abusers rather than with the general problem of HIV-infection and tuberculosis. In 1990, a more remarkable information (7) came from Bamrasnaradura Infectious Disease Hospital, the Government assigned central hospital for AIDS patients, that extrapulmonary and disseminated tuberculosis were the most frequent opportunistic infections among the cumulative 50 full-blown AIDS patients admitted there up to the end of October, This report indicates the high rate of tuberculosis manifestation in HIV-infections when it develops into AIDS. A personal communication from 10th Zonal TB Control in Chiang Mai informed that the incidence rate of HIN-seropositive in tuberculous patients there was 2.3% in a survey of November, 1989, to January, 1990, but it increased up to 6.67% in June, Thailand has an endemic disease, melioidosis, caused by P. pseudomallei living in environmental soil and water. The disease takes various clinical types; localized, systemic, acute, subacute, chronic, and inapparent; thus presenting the symptoms undistinguishable from many other infectious diseases. Pulmonary melioidosis shows a clinical feature similar to lung tuberculosis. Melioidosis occurs more easily in the individuals of impaired immunity, such as diabetes patients. According to available literatures, one case of recurrent melioidosis has been reported in Thailand as a complication of AIDS. The patient was a German 248

3 homosexual male who had been living in this country for more than 10 years (8) and showed a fatal course with interstitial pneumonitis. Ubon Ratchathani province is an endemic area of both tuberculosis and melioidosis. The province is a major supplier of labors to Bangkok. These facts led us to a preliminary survey on interrelated epidemiology of HIV-infections, tuberculosis, and melioidosis in Ubon Ratchathani province. Blood specimens were obtained from culture-positive TB patients and X-ray diagnosed or clinically suspected TB cases who visited 7th Zonal TB Center in Ubon Ratchathani. The specimens were assayed for HIV antibodies after completion of the other clinical tests. Patient-identifying information was removed from the specimens before HIV testing so that the results could not be linked to individual patients. The specimens were then sent to NIH for confirmation of HIV antibodies. In Sappasitthiprasong Ubon Hospital, various clinical specimens were obtained from bacteriologically confirmed patients of melioidosis including sera, sputum, throat swab, urine, pus, and bacterial isolates. They were sent to NIH for the bacteriological and serological confirmation of melioidosis and for serology of HIV-infections. In case of pulmonary melioidosis, the sputum specimens were subjected also to the staining for acid-fast bacilli. In NIH as Central Reference Laboratory, serotesting for HIV-infection routinely performed in three steps, first by ELISA, then, if necessary, by IFA and western blot. The serum specimens sent from Ubon Ratchathani were processed according to this confirmation system. ELISA was conducted with a commercial kit, Wellcozyme HIV 1+2 (Wellcone Diagnostics, Darfors, England DA 15 All). IFA was carried out with slide kits prepared in NIH. For western blot tests, a commercial kit, Vironostika anti-htlv-iii, was employed. In TB Center Zonal 7th, serotesting for HIV-infection was performed by ELISA with a commercial kit of Organon. The results are summarized in Table I. In the serosurvey for HIV-infection with the sera of melioidosis patients sent from Sappasitthiprasong Ubon Hospital, all of the 121 specimens in 1990 and 1991 were found negative by the tests in NIH. One of the total 87 serum specimens of X-ray diagnosed or clinically suspected tuberculous patients was confirmed to be HIV-positive by the tests performed independently in TB Center and NIH. He was a farmer, and showed typical tuberculous lesions in chest X-ray. In another group of culture-positive tuberculous patients, one out of 25 was confirmed to be HIV-seropositive. a drug abuser. is He was 249

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5 Table II. Serosurveillance in 1992 for HIV infections and P, pseudomallei infections in 439 culture-positive tuberculous patients in Ubon Ratchathani, Thailand The second survey was then conducted on 439 culture-positive tuberculous patients who visited TB Center Zonal 7th in On this occasion, the serum specimens underwent not only the tests for HIV-infection but also the tests for P. pseudomallei infection by indirect hemagglutination assay (IHA) and by immunofluorescent assay (IFA) for IgM and IgG. The positive criteria were 1:160 in IHA,1:8 in IFA-IgM and 1:32 in IFA-IgG according to our previous experiences (9). The results are shown in Table II. Two HIV-positive cases (0.46%) were found out of 439 culture-positive tuberculous patients, and 22 seropositive cases (5.0%) of P. pseudomallei infection were diagnosed on the basis of criteria shown in the table. Through the surveys I and II, the seropositive rate of HIV-infection was 0.73%. On the other hand, the 251

6 seropositive rate of 5.0% for P, pseudomallei infection was lower than the general population of the province as represented by healthy blood donors (29%) (9) and confirmed our previous observations (10). Our present attempt is only the beginning of such survey in a selected area. The survey should be continued long enough to play a sentinel role for the whole country. Because of the still limited number of available subjects, it will be early to say something conclusive concerning the interrelated epidemics of tuberculosis and HIV. However, the fact that the dual infections were discovered in such small groups, if any, may encourage our further survey along this line. In the United States, a recent serosurveillance for HIV-infection in the patients of selected 20 tuberculosis clinics ( ) reported that the total 3,077 specimens were tested to reveal the median positive rate of 3.4% (range 0 to 46.3%), being higher in the North and Atlantic coastal areas (1). Another survey (2) informed that at least 4% of AIDS patients in the United States had been diagnosed as tuberculosis. From the epidemiological information, four HIVseropositives out of 551 clinically and culture-positive tuberculous cases in our survey would not be a small number, if not large. The national surveillance reports (11,12) of tuberculosis in Thailand show that, though tuberculosis morbidity rate per 100,000 in Thailand decreased down from in 1977 to in 1986, the mortality rate has still remained at the level of around 10 per 100,000 in the past several years. The actual number of tuberculous patients may be much larger if more detailed surveillance is performed. In Ubon Ratchathani province, tuberculosis morbidity rate has been three to four times as high as the rate of the whole country in the period from 1981 to ACKNOWLEDGEMENTS We thank Mrs. Samai Paratsakarn and Miss Anong Wongsriraksa for their technical assisstance, and Mrs. Suwanna Navacharoen for her secretarial cooperation in preparation of the manuscript. Appreciation is also expressed to Japanese Foundation for AIDS Prevention for their financial support of this study. 252

7 REFERENCES 1. Onorato, I. M., McCray, E. and the Field Services Branch (1992): Prevalence of human immunodeficiency virus infection among patients attending tuberculosis clinics in the United States. J. Infect. Dis., 165, Centers for Disease Control (1989): Tuberculosis and human immunodeficiency virus infection: recommendation of the Advisery Committee for the Elimination of Tuberculosis (ACET). MMWR, 38, Shaffer, R. W., Kim, D. S., Weiss, J. P. and Quale, J. M. (1991): Extrapulmonary tuberculosis in patients with human immunodeficiency virus infection. Medicine, 70, Centers for Disease Control (1991): Tuberculosis outbreak among HIVinfected persons. J. Amer. Med. Assoc., 266, Hill, A. R., Premkumar, S., Brustein, S., Vaidya, K., Powell, S., Li, P.-W. and Suster, B. (1991): Disseminated tuberculosis in the acquired immunodeficiency syndrome era. Amer. Rev. Resp. Dis., 144, Chuchottavorn, C., Buranajarn, B., Likanonsakui, S. and Panyatungsakul, P. (1990): Prevalence of human immunodeficiency virus infection in Thai tuberculous patients. Proc. Intern. Congr. AIDS, Bongkok, Thailand, Dec Wiriyakitjar, D., Ratanadilok, Na Bhuket, T., Rienthong, D, and Kowathana, K. (1992): Surveillance of HIV infection among tuberculous patients in Bangkok Central Chest Clinic. Thai AIDS J., 4, Tanphaichitra, D., Sahaphong, S. and Srimuang, S. (1989): A case comparison of acquired immune deficiency syndrome (AIDS) in homosexual males with spindle-endotherlial cell abnormalities and with recrudescent melioidosis. Asian Pacific J. Allerg. Immunol., 3, Naigowit, P., Maneeboonyoung, W., Wongroonsub, P., Chaowagul, V. and Kanai, K. (1992): Surveillance of Pseudomonas pseudomallei infection in Thailand. Jpn. J. Med. Sci. Biol., 45, Kanai, K., Akksilp, S., Naigowit, P., Chaowagul, V. and Kurata, T. (1992): Serosurveillance for double infection with Pseudomonas pseudomallei in tuberculous patients. Jpn. J. Med. Sci. Biol., 45, Ministry of Public Health, Thailand (1985): Tuberculosis, Public Health Statiotics, ISSN Ministry of Public Health, Thailand (1986): Tuberculosis. Annual Epidemiological Surveilance Report, ISSN