JOHOR HEALTH JOURNAL

Johor Health Journal Official Journal of Johor State Health Department EDITORIAL COMMITTEE PRINCIPAL ADVISER DR. HJH. ROOSHAIMI MERICAN BINTI A. RAHIM MERICAN DIRECTOR OF HEALTH JOHOR,

JOHOR STATE HEALTH DEPARTMENT TEL: 07-2245188 FAX: 07-2232603 EMAIL: [email protected]

ADVISER MRS. ROSIDAH MD DIN

STATE DEPUTY OF HEALTH (PHARMACY) JOHOR, JOHOR STATE HEALTH DEPARTMENT TEL: 07-2355120 FAX: 07-2355130 EMAIL: [email protected]

CHIEF EDITOR DR. BADRUL HISHAM BIN ABDUL SAMAD DISTRICT HEALTH OFFICER

DISTRICT HEALTH OFFICE JOHOR BAHRU TEL: 07-2224711 FAX: 07-2236549 EMAIL: [email protected]

EDITORS DR. SURIATI BT HASIM

MRS. MASLIZA BT ARIP

FAMILY MEDICINE SPECIALIST

SENIOR PRINCIPAL ASSISTANT DIRECTOR

MERSING DISTRICT HEALTH OFFICE

(ENFORCEMENT PHARMACY)

TEL: 07-7991836

FAX: 07-7994145

JOHOR STATE HEALTH DEPARTMENT

EMAIL: [email protected]

TEL: 07-2355120 FAX: 07-2355130

MRS. LEE CHING YAN

MR. ALI BIN ISMAIL

EMAIL: [email protected]

PRINCIPAL ASSISTANT DIRECTOR

SENIOR PRINCIPAL ASSISTANT DIRECTOR (PHARMACY)

(TRADITIONAL & COMPLEMENTARY MEDICINE) TEL: 07-2381787

JOHOR STATE HEALTH DEPARTMENT

FAX: 07-2384787

TEL: 07-2355120 FAX: 07-2355130

EMAIL: [email protected]

EMAIL: [email protected]

MEMBERS MRS. SURAYA HANI BT SHARON

MRS. SIAW JIA YI

PRINCIPAL ASSISTANT DIRECTOR (PHARMACY)

ASSISTANT DIRECTOR (PHARMACY)

JOHOR STATE HEALTH DEPARTMENT

JOHOR STATE HEALTH DEPARTMENT

TEL: 07-2355120 FAX: 07-2355130

TEL: 07-2355120 FAX: 07-2355130

EMAIL: [email protected]

EMAIL: [email protected]

i

Johor Health Journal Official Journal of Johor State Health Department REVIEWER BOARD DR. MASLIZA BINTI ZAID

DR. NOOR ALIZA BINTI MD TAREKH

PAKAR PERUBATAN PENYAKIT BERJANGKIT

PAKAR PERUBATAN RESPIRATORI (JUSA C)

HOSPITAL SULTANAH AMINAH

HOSPITAL SULTANAH AMINAH

DR. AKASHAH BIN ABDULLAH

MRS. PREMAA A/P SUPRAMANIAM

JABATAN PERUBATAN

JABATAN PERUBATAN

KETUA PENOLONG PENGARAH KANAN

PEGAWAI PENYELIDIK Q44

(UNIT TIBI & KUSTA)

CLINICAL RESEARCH CENTRE

BAHAGIAN KESIHATAN AWAM

HOSPITAL SULTANAH AMINAH

DR. KAN FOONG KEE

DR. HAIDAR RIZAL BIN TOHA

JABATAN KESIHATAN NEGERI JOHOR

PAKAR PERUBATAN PENYAKIT BERJANGKIT

KETUA PENOLONG PENGARAH KANAN

JABATAN PERUBATAN

(UNIT KESIHATAN PEKERJA & ALAM SEKITAR)

HOSPITAL SULTANAH AMINAH

BAHAGIAN KESIHATAN AWAM

JABATAN KESIHATAN NEGERI JOHOR

MRS. NOORAZLINDA YACOB

DR. NORHASHIM AHMAD

KETUA PENOLONG PENGARAH (A&P) UF52

PAKAR PERUNDING NEUROPSIKIATRI

JABATAN KESIHATAN NEGERI MELAKA

HOSPITAL SULTANAH AMINAH

BAHAGIAN PERKHIDMATAN FARMASI

(JABATAN PSIKIATRI))

DR. SITI NORLINA BINTI MD SAID

DR. HANS PRAKASH SATHASIVAM

KETUA PEGAWAI FARMASI UF54

PAKAR PATOLOGI MULUT & PERUBATAN MULUT

HOSPITAL SULTANAH AMINAH

HOSPITAL SULTAN ISMAIL

DR. SAADON BIN IBRAHIM

DR. ROZITA BINTI ZAKARIA

KETUA JABATAN ORTOPEDIK

PAKAR PERUBATAN KELUARGA

HOSPITAL SULTAN ISMAIL

KLINIK KESIHATAN SULTAN ISMAIL

PEJABAT KESIHATAN DAERAH JOHOR BAHRU

DR. NOORHAIDA BINTI UJANG

DR. LINAYATI BINTI ROSLI

PEGAWAI KESIHATAN KANAN

KETUA PENOLONG PENGARAH KANAN

PEJABAT KESIHATAN DAERAH MUAR

(UNIT SURVEILAN)

BAHAGIAN KESIHATAN AWAM JABATAN KESIHATAN NEGERI JOHOR

DR. YUZAIDI BIN MOHAMAD PAKAR PEMBEDAHAN

JABATAN PEMEDAHAN HOSPITAL SULTANAH AMINAH

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Johor Health Journal Official Journal of Johor State Health Department

Volume 12 2016

Contents 1

Impact of Diabetes Mellitus on the Sputum Conversion among New Smear Positive Pulmonary Tuberculosis Patients in Johor Bahru, Malaysia Tok P., Salvaraji L., Rosli N., Badrul H.A.S.

10

Post-traumatic Bronchial Stenosis Stenting. A Case Report Anith N.R., Rahmat O., Sarojah A.

12

Video-assisted Thorascoscopic Surgery (VATS) for Ectopic Intrathymic Parathyroid Adenoma. A Case Report Anith N.R., Rahmat O., Sarojah A.

14

Association between Patients’ Belief about Medicines and Adherence to Calcium Lactate among Orthopaedic Patients in Hospital Pakar Sultanah Fatimah Wong S.R., Tho L.Y.,Tan L.H., Zaitun M.S., Teo C.X., Loo P.L., Chua H.A.

29

Drug Attitude of People with Schizophrenia towards Their Medicines in Outpatient Clinic of Hospital Permai, Johor Bahru Chua Y.M., Abdul Hakim N., Ng C.Y., Zuraidah M.Z., Gan W.S.

41

An Evaluation on Pharmacist-managed Diabetes Medication Therapy Adherence Clinic (DMTAC) in Primary Health Clinic of Johor Bahru District, Malaysia Tai C.W.

54

Measles Outbreak among Inmates of Prison (A) in Kluang Johor, December 2015 Subahir M.N., Abd Razak M.F., Mohd Noor M.N.A., Sukimen N.

63

Percentage of Patients with Bimaxillary Proclination Referred to Orthodontic Specialist Clinic Jalan Abdul Samad, Johor Bahru Nivethiny N., Ummu A.Y.

68

Serotyping and Phylogenetic Analysis of Dengue Virus – Johor, 2012 - 2014 Nurulfateha M., Dr. Shaharom N.A.C.M.D., Nur Nadiah Y., Shamshulbahrin S., Sitinah O., NurHidayah A.N., Rosma M., Nordin Y., Haida Z.A.

79

Prevalence of Side Effects Profile of Clozapine and Its Contributing Factors Among Patients In Hospital Permai, Johor Bahru, Malaysia Chua W.W., Liong P.Z., Tan L.H., Wong A.L.

iii

NOTICE TO CONTRIBUTORS The Jurnal Kesihatan Johor welcomes original papers and research notes on all aspects of health. Articles for publication must be contributed solely to the Jurnal Kesihatan Johor and the authors are solely responsible for the views and statements expressed in their contributions. Neither the Editorial Committee nor the Publishers will accept responsibility. All contributors shall comply to the guidelines issued by the National Institutes of Health, on conduct of medical research in the Ministry of Health (MOH) Malaysia as follows: 1. All research must obtain the approval of the MOH in accordance with prescribed procedures 2. All research conducted in the MOH must be registered online in the National Medical Research Register (www.nmrr.gov.my) 3. Research that involves human subjects have to obtain prior approval from the Medical Research and Ethics Committee (MREC), MOH. 4. All publications resulting from the MOH research must obtain prior approval from the Director-General of Health (Lampiran P1) 5. Any dissemination or communication of research findings via written, advertised, presented or to the media must obtain prior approval from the Director-General of Health Details of the above guidelines can be downloaded or viewed at https://www.nmrr.gov.my/doc/01_NIH_Guidelines_for_Conducting_Research_in_MOH_v2_2 _03March2008.pdf To avoid delays in publication, authors are advised to adhere closely to the instructions given below: 1. Type and Font Size Authors must use default font Arial 11 points typed single-spaced on one side of A4 paper with wide margins throughout (including in the abstract, tables, legends and references). 2. Acronyms For the first mention, write in full followed by the abbreviations in a bracket eg. World Health Organisation (WHO). For subsequent mention, use only the abbreviations in the text. 3. Notation of Dates Write notation of dates in full sentence as follows: 2 July 2003 or 23 July 2003 but not 2/7/2003 or 23.7.2003 or 02 July 2003 or 23 Jul 2003 4. Footnotes and Superscripts Words or specific terminologies should be defined or explained using the superscript notation. The definition or explanation should be given as footnote at the bottom of the same page. The superscript must be in Arabic numerals which are 1, 2, 3. iv

5. Tables, Figures, Graphs, Maps and Pictures Tables, figures, graphs, maps and pictures should be inserted in accordance to the text (not in separate files from the text). Pictures must be sent in JPEG format. In the preparation of tables, only horizontal lines (Academic Form) are allowed. Omit the vertical and internal horizontal lines. Example of Academic Form of table (according to SPSS) Table 1: The Distribution of Cases and Control Pairs According to Age, Gender, and Race Cases Characteristics

Controls

Total

%

Total

%

Age 15-29 30-44 45-59 ≥60

4 17 39 102

2.5 10.5 24.1 63.0

4 17 39 102

2.5 10.5 24.1 63.0

Gender Male Female

119 43

73.5 26.5

119 43

73.5 26.5

Race Malay Chinese Indians

82 75 5

50.6 46.3 3.1

82 75 5

50.6 46.3 3.1

Use Arabic numerals (1, 2, 3 etc.) followed by a colon (:) when numbering the tables and figures. Use Title Case for all headings except for prepositions (by, of, for etc). Do not use the full stop at the end of the headings. Title of the table should be placed above the table whereas title of the figure should be placed below the figure. Examples: Table 2: Amount of Rainfall (mm) Recorded at Johor Meteorological Stations Station

Senai Batu Pahat Kluang Mersing Average

16th

Rainfall reading (mm) by dates December 2006 17th 18th 19th 20th 11th

January 2007 12th 13th

14th

46.4 0.8 0.0 0.8 12.0

94.6 10.8 53.2 1.8 40.1

213.0 94.0 222.0 134.0 165.8

19.0 0.4 16.0 167.0 50.6

128.0 93.4 126.8 7.4 88.9

236.0 71.6 266.0 133.6 176.8

40.0 2.0 18.0 6.0 16.5

264.0 121.0 171.0 64.0 155.0

9.0 9.0 42.0 237.0 74.3

Source: The Research Division, Meteorological Department, the Ministry of Science, Technology and Innovation, Malaysia

v

Figure 1: Notified Influenza-like Illness (ILI) and Influenza A(H1N1) Cases for Epidemiological Week 18 – 52 Year 2009, Johor, Malaysia 6. Format of Manuscripts Each manuscript must be divided into the various sections using IMRaD format (http://sokogskriv.no/en/writing/structure/the-imrad-format/) with the following headings:         

Title Abstract Introduction Materials and Methods Results Discussion Conclusion Acknowledgement References

7. Title of Manuscripts The title should be simple, concise but complete. Use Title Case (not bold) for all headings except for prepositions (by, of, for etc) at the centre of the first line in the first page. Below the title, provide the initials and name(s)of the author(s)without any designation. Initials of the author(s) should follow the surname or preferred name eg. Abdul Khalid M.S., Ravindran S. or Tan B.L. The address (es) of the author(s) should be indicated using superscripts. Example: A Study of Medication Errors in Johor Bahru, Malaysia Tan A.B.1 & Lim T.T. 1 1

Pharmacy Division, Johor State Health Department

___________________________ Corresponding author: Tan Ai Bee, Pharmacy Division, vi

Johor State Health Department, Suite 10-02, 10th Floor, Menara MSC Cyberport 5, Jalan Bukit Meldrum 80300 Johor Bahru Phone:+607-2272800 ext. 124 Fax: +607-2236146 Email: [email protected] Authorship should comply to the recommendation by International Committee for Medical Journal Editors (http://www.icmje.org/ethical_1author.html) which is defined in the following statement: “Authorship credit should be based on: 1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3.” 8. Abstract An abstract of not more than 300 words should be provided immediately after the title. Below the abstract, provide and identify 3 to 10 keywords or short phrases that will assist indexers in cross-indexing your article. Use terms from all the medical subject headings (MESH) listed in MEDLINE. The abstract should be written using IMRAD format subheadings in bold: Introduction, Methods, Results & Conclusion, which describe the background and objective of the study and procedures used including the selection of subjects, data collection and analysis as well as important findings and conclusions. It should be in one (1) paragraph and should not be enclosed in a box. The abstract should be placed below the main title. Write the heading "Abstract" without bold or italic. Example: Abstract Introduction: There has been pressing need to increase elective operating time/ list to contain complaints of long waiting time for surgery, possibly due to increased patient load not met by proportionate increase in manpower and infrastructure expansion. This study aimed to determine actual waiting time for elective surgeries (WTES) in Hospital Sultanah Aminah Johor Bahru (HSAJB), in comparison to Ministry Of Health (MOH) hospitals, and the effect of manpower, OT time and workload factors which are commonly believed to be the cause of long wait. Methods: A retrospective national audit was conducted to determine the actual WTES (i.e. booking date to operation date) for surgeries done in 2007. One surgical procedure was identified as the indicator surgery to represent elective surgeries of each surgical discipline. The data from HSAJB was compared to this national data as well as the standard. The correlation of WTES and the factors were examined. Results: 701 cases from 10 disciplines were sampled, of which 457 (65.2%) analyzed. Overall median and 90th centile WTES of HSAJB was 18.6 and 34.7 weeks (wks) respectively. This is significantly vii

longer than the national WTES (8.9 and 30.6wks respectively), p=0.001. 2.9% of HSAJB cases waited more than a year before surgery. In HSAJB, Paediatric had the longest WTES (90th centile, 60.6wks) and Plastic Surgery had the least (16.0wks). 86% of herniotomies were done after 6 months, and 3.9% within 3 months. The odds of waiting more than 3 months among Paediatric Surgical patients is 19.4 times(CI 9.1-41.5) of non-paediatric, and that of 6 months is 36.6 (CI 23.5-56.9) times. Weak correlation found between WTES and OT time availability, manpower or workload. Conclusion: WTES in HSAJB was longer than the national WTES. Correlation of OT time availability, manpower and workload on WTES was weak. Manipulation of these factors may not be adequate to solve the problem of long waiting time. Keywords: waiting time, elective surgery, public hospital 9. Introduction The introduction must provide the background of the research and summarise the rationale and importance of the study. It should state the general and specific objectives of the research or the research hypothesis. Avoid reviewing the subject extensively and do not provide any data or conclusion of the study. 10. Materials and Methods This section should start with a statement like this: “This research is registered on the National Medical Research Register, Ministry Of Health Malaysia (ID NMRR-10-1323-7843 S4 R2) and approved by the Medical Research and Ethics Committee (MREC), Ministry Of Health Malaysia”. This section should contain only information that is already available when the research plan or protocol is formulated. All information obtained when the research is being carried out should be reported in the Results section. Describe the selection criteria of your subjects or samples clearly and describe the population from which the sample is derived from. Methods used, equipment (manufacturer's name and addresses in parenthesis) and procedures must be given in detail to enable other researchers to reproduce the results. Give references to established methods used including statistical methods or provide a brief description of methods that have been published but are not well known. Describe new or substantially modified methods and give reasons for using them and evaluate their limitations. Identify precisely all drugs and chemicals used, including generic names, dosages and the route of administration. Do not use patients' names, initials or registration numbers. Include the number of observation and statistical significance of the findings where appropriate. 11. Results Present your results in a logical sequence. Research findings should be given in texts, tables and illustrations with priority given to the main or the most important finding. Avoid repeating in the text of all the data presented in the tables or illustrations. Instead, emphasise or summarise only important findings. Tables and Illustrations Limit the use of tables and illustrations (eg. figures) to those required to explain and support viii

main findings. Provide the absolute number from which derivative data such as percentages are obtained together with the statistical methods used in the analysis. Use graphs as an alternative to tables. Avoid repeating the same data in graphs and tables. All tables, illustrations and diagrams should be fully labeled so that each is comprehensible without reference to the text. All measurements should be reported in metric system. The contents of all tables should be carefully checked to ensure all totals and subtotals are tally. All illustrations and diagrams should be referred to as "Figure" and numbered consecutively. The size of the figure should not be more than half a page. Whenever possible, please include all data used for the construction of graphs in order to ensure clarity or reproduction. 12. Discussion This section should highlight the new and important aspects of the study and the conclusion(s) that can be derived from them. Avoid repeating in detail the data or areas that have been touched under the 'Introduction' or 'Results' sections. Include in the discussion, the implications of the findings and their limitations and relate the findings to other relevant studies. Authors may refer to CONSORT statement in reporting clinical trial as in the following website, http://www.consort-statement.org/consort-statement/20-22---discussion 13. Conclusion The conclusion made should be related to the objective(s) of the study. Avoid unqualified statements and conclusion that are not completely supported by your research findings especially statements on economic benefits and costs unless the manuscript contains economic data that have been analysed. Avoid claiming priority and alluding to work that has not been completed. State new hypotheses when warranted, clearly label them as such. Recommendation(s), where appropriate, may be included. 14. Acknowledgement This section should start with a statement like this: “The author(s) would like to thank the Director General of Health Malaysia for permission to publish this paper.” This requirement is stated in the MOH circular with reference number: (18)dlm KKM/NIHSEC/100-1/1/1which can be viewed at https://www.nmrr.gov.my/ doc/circulars/SuratPekelilingKPKBil_1_2013.pdf) 15. References The references should follow the Vancouver citation style as below: Personal Author(s) Osler AG. Complement: mechanism and functions. Englewood Cliffs: Prentice-Hall, 1976. Corporate Author American Medical Association Department of Drugs. AMA drugs evaluation (3rd ed.) Littleton: Publishing Sciences Group, 1977. Editor, Compiler, Chairman as author Rhodes, AJ, Van Rooyen CE (comps). Textbook of virology: For students and practitioners of medicine and other health sciences (5th ed). Baltimore Williams & Wilkins, 1968. ix

Chapter in Book Gilstrap LC 3rd, Cunningham FG, VanDorsten JP, editors. Operative obstetrics. 2nd ed. New York: McGraw-Hill; 2002. Weinstein L, Swartz MN. Pathogenic properties of invading micro-organisms, In: Sodeman WA Jr, Sodeman WA (eds). Pathogenic physiology: mechanisms of disease. Philadelphia: WB Saunders, 1974: 157-72. Agency Publication National Centre for Health Statistics. Acute conditions: incidence and associated disability, United States, July 1968 – June 1969. Rockville, Me: National Centre for Health Statistics, 1972. (Vital and health statistics). Series 10: data from the National Survey, No 69).(DHEW Publication No [HSM] 72-1036). Proceedings Christensen 5, Oppacher F. An analysis ofKoza's computational effort statistic for genetic programming. In: Foster JA, Lutton E, Miller J, Ryan C, Tettamanzi AG, editors. Genetic programming. EuroGP 2002: Proceedings of the 5th European Conference on Genetic Programming; 2002 Apr 3-5; Kinsdale, Ireland. Berlin; Springer; 2002. p 182-91. Websites Abood S. Quality improvement initiative in nursing homes; the ANA acts in an advisory role. Am J Nurs [serial on the Internet]. 2002 Jun [cited 2002 Aug 12]. 102(6);[about 3 p]. Available from: http://www. nursin gworl d. oal/AIN /2002/j une/Wa watch. htm Foley KM, Gelband H, editor. Improving palliative care for cancer [monograph on the internet]. Washington: National Academy Press; 2001 [cited 2002 Jul 9], Available from: http://www.nap.ednibooks./0309074029/htird/ Cancer-Pain.org [homepage on the Internet]. New York: Association of Cancer Online Resources, Inc.; c2000-01 [updated 2002 May 16; cited 2002 Jul 9]. Available from: http://www.cancer-vin.or2i. Other Articles Newspaper Article Shaffer RA. Advances in chemistry are starting to unlock the mysteries of the brain: discoveries could help cure alcoholism and insomnia, explain mental illness. Wall Street journal 1977; Aug 12: 1 (col 1), 10 (col 1). Magazine Article Roucehe B. Annals of Medicine: the Santa Claus culture. The New Yorkers 1971, Sep 4: 6681 16. Case Reports Papers on case reports (one to five cases) must follow these rules:  Maximum of 1,000 words  Maximum of three figures/tables x



Maximum of five references quoted



Having a unique lesson in the diagnosis, pathology or management of the case is more valuable than mere finding of a rare entity. Being able to report the outcome and length of survival of a rare problem is more valuable than merely describing what treatment was rendered at the time of diagnosis.

17. Submission Manuscript(s) may be submitted in English or Bahasa Malaysia. For the manuscript written in Bahasa Malaysia, it must have precise translation of scientific or medical terms used, accompanied by an abstract in English. All manuscripts to be submitted in softcopy using Microsoft Word Version 1997-2003 to: Chief Editor Jurnal Kesihatan johor Office of the Johor Deputy Director of Health (Pharmacy) d/a Hospital Permai Lama Jalan Persiaran Permai 81200 Johor Bahru Johor Darul Ta'zim Email: [email protected]

xi

Impact of Diabetes Mellitus on the Sputum Conversion among New Smear Positive Pulmonary Tuberculosis Patients in Johor Bahru, Malaysia Tok P.1, 2, Salvaraji L.3, 4, Rosli N.4, Badrul H.A.S.4 1

Clinical Research Centre, Hospital Sultanah Aminah, Ministry of Health, Malaysia 2 National Clinical Research Centre, Ministry of Health, Malaysia 3 Johor State Health Department, Ministry of Health, Malaysia 4 Johor Bahru District Health Office, Ministry of Health, Malaysia _____________________________________ Corresponding author: patients (70.8% conversion rate) had successful conversion from positive acidDr. Peter Tok, fast bacilli (AFB) sputum to negative AFB National Clinical Research Centre sputum during end of intensive phase. DM (NCRC), status of patients were not found to be Level 3, Dermatology Block, associated with sputum conversion (OR: Hospital Kuala Lumpur, Jalan Pahang, 1.21, 95% CI: 0.70, 2.10) but we found 50586 Kuala Lumpur, Malaysia. that patients who are older were at higher Phone: +60326980310 odds of sputum non-conversion (OR 1.03, 95% CI: 1.01, 1.04). Conclusion: The Fax: +60326911682 Email: [email protected] high prevalence of DM among TB patients in the study cohort indicates the emerging Abstract convergence of these two epidemics in our local population. Further studies to Introduction: Tuberculosis (TB) is a investigate the association between DM major public health concern while diabetes and TB in local population and regular mellitus (DM) is a growing worldwide audits and monitoring of the TB reporting epidemic. The association between DM system are recommended. and TB patients’ outcomes has important implications in guiding healthcare Keywords: tuberculosis, diabetes mellitus, decisions. Methods: A retrospective treatment outcome, Malaysia cohort study was conducted involving all Introduction the new smear positive pulmonary TB patients in the district of Johor Bahru for year 2014 to investigate the impact of DM Tuberculosis (TB) ranks among the on TB patients’ outcome, specifically the leading cause of death worldwide, with an sputum smear conversion at the end of estimated 1.5 million people succumbing intensive phase (two months treatment). to this disease in 2014 alone.1 An Secondary data were extracted from estimated 9.6 million people globally fell ill national TB registry for analysis. Results: with this disease in 2014, highlighting it as A total of 392 cases were recruited, with a major public health concern. The End 78 patients were recorded to have DM, TB strategy was initiated by the World translating into DM prevalence of 19.9% Health Organization (WHO) from year among the study cohort. Overall mean age 2016 onwards as a blueprint for a vision of was 41.9 years old (SD: 16.43 years) but world free of TB. This strategy aims to patients with DM were significantly older reduce TB deaths by 90% by 2030 than those without DM. None of the (compared to 2015 rates), cuts new cases foreigners (n=41) in study cohort were by 90% and aims to ensure that no TB diagnosed with DM. There were no affected families have to face catastrophic observable gender differences between costs due to TB.2 the two groups. Similarly, the TB patients’ The association between diabetes mellitus clinical disease profiles were comparable (DM) and TB was well known and studied between those with DM and without DM. in the past, with early documentation by Sputum smear examination results were Avicenna who lived from 980 through available for 367 patients, and 260 1027, but was largely neglected with Jurnal Kesihatan Johor, Vol. 12, 2016

1

development of proper treatment for both diseases.3, 4 However, with the current global increase in DM, where its prevalence is projected to reach approximately 300 million by 2025, the association between TB and DM is reemerging.5, 6 Epidemiological studies have shown that DM increases the risk of active TB, regardless of their study design and population.7 The mechanisms between poorly controlled DM leading to increased susceptibility of infection, in this case, TB, include those direct effects of hyperglycemia and cellular insulinopenia as well as indirect effects on macrophage and lymphocyte function.8, 9 DM had also been shown to be impactful towards outcomes of TB management. A recent meta-analysis of 54 studies examining the impact of DM on TB treatment outcomes had also shown significant association, with increased likelihoods for death during treatment, TB relapse and sputum culture positivity after two to three months of treatment.10 Findings from the meta-analysis summarized that TB patients with DM have increased odds for the combined outcome of treatment failure and death of nearly two times compared to those without DM (OR: 1.96, 95%CI: 1.64, 2.33). Similarly, there was also an almost two times higher chance for TB relapse among patients with DM (OR: 1.97, 95% CI: 1.42, 2.74). However, in another systematic review by Baker et al, analysis of studies assessing impact of DM on sputum culture conversion after two to three months of TB therapy yielded heterogeneous outcomes, with relative risks ranging from 0.79 to 3.25.11 In Malaysia, although the prevalence rate of TB cases has considerably decreased from the rate of 227/100,000 in 1990 to the latest 103/100,000 in 2014, intensive efforts should remain in order to end this epidemic.1,12 At the same time, the prevalence of DM in Malaysia had progressively increased over the last decade. Results from the National Health and Morbidity Survey (NHMS) showed that in 2006, only 11.6% of people over 18 years of age were found to have DM but this figure increased to 17.5% in 2015.13

Jurnal Kesihatan Johor, Vol. 12, 2016

Despite the increasing DM prevalence, local evidence on the association between DM and TB in Malaysia remains scarce. A retrospective study in Kuala Lumpur from 2000 until 2007 looking at admitted TB cases recognized that majority of patients (82%) suffered from DM, hypertension, ischemic heart disease or all three conditions, but potential association was not investigated further.14 Another two separate cohort studies done in Pulau Pinang also failed to demonstrate significant differences between TB patients with and without DM with regard to treatment outcomes.12, 15 Similarly, analysis of TB cases from the national registry in 2012 also did not find DM to be predictive of TB treatment outcomes and mortality.16 To the best of the authors’ knowledge, there are no published studies in Johor that attempted to investigate the association between DM and TB. This study, therefore, aims to examine the possible relationship between DM and TB outcome, looking specifically at the sputum (smear) conversion at the end of intensive phase (end of two months treatment). Findings from this study will add to the existing literature on local population and highlight potential relationship between the two important epidemics. Materials and Methods This research is registered on the National Medical Research Register, Ministry Of Health Malaysia (ID NMRR-15-209028347) and conduct of the study had been approved by the Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia. Personal information and patient identifiers were not collected and analyzed as part of the study. A retrospective cohort analysis was conducted involving all the TB patients in the district of Johor Bahru, Malaysia for the year 2014. Data was gathered from the MyTB database (mytb.moh.gov.my), which is the national TB surveillance database/registry. As TB is among the communicable diseases notifiable under Malaysian law17, diagnosed cases will be notified to local district health office and 2

have their data captured into the MyTB database. Management of TB cases in respective healthcare facilities were guided by the local clinical practice guidelines (CPG).18 Follow-up of cases and directly observed treatment, short-course (DOTS) for antiTB regimen were carried out in respective healthcare facilities, and data on patients outcomes will be entered into the registry. Data collection and reporting for the registry for all the healthcare centers were standardized according to the national TB information system manual.19 For this study, only the new smear positive pulmonary TB patients were included for analysis as the primary endpoint of interest was the sputum conversion at the end of the intensive phase of anti-TB regimen (end of 2nd month treatment). New cases refer to patients who had never been treated for TB or had taken anti-TB drugs for