Risk factors for tuberculosis

Assessment of risk factors associated with drug-resistant tuberculosis in pulmonary tuberculosis patients

INTRODUCTION

Tuberculosis remains a global health problem worldwide and the risk progression of Tuberculosis to Drug Resistant Tuberculosis is influenced by various factors. These include immunocompromised status, past history of tuberculosis, life style and nutritional level. Hence, identifying the population at risk of multidrug-resistant tuberculosis is essential and may help in developing appropriate case-finding strategies. Therefore, the present study was designed to study the contributing risk-factors associated with Drug resistant Tuberculosis.

MATERIALS AND METHODS

In this prospective observational study, we assessed 189 Pulmonary tuberculosis diagnosed patients during the period of 2 years at government recognized tertiary care centers. Data was collected from all these patients checked to investigate risk factors associated with Drug resistant tuberculosis development by multivariant analysis.

RESULTS

Of the 189 participants, 36 were diagnosed with drug resistant tuberculosis and 153 with drug sensitive tuberculosis. Factors associated with drug resistant tuberculosis include low-weight (OR 8.50; p = 0.0008430991), low-BMI (p = 0.0000527166), lower economic status (OR-2.1351; p = 0.048608696) and tobacco (OR-4.5192; p = 0.0023003189) were found clinically and statistically significant in development of drug resistant tuberculosis. Binary logistic regression was performed to ascertain the effects of various statistically significant factors. Drug resistant tuberculosis patients were 7.77 times more likely to be tobacco users than drug sensitive tuberculosis.

CONCLUSIONS

Our study suggests that, there is a compelling and urgent need for increasing public awareness, initiating better nutrition and food programs, regular screening, and better management & control of MDR-TB.

Risk of mortality and clinical outcomes associated with healthcare delay among patients with tuberculosis

BACKGROUND

To eliminate tuberculosis (TB), World Health Organization (WHO) initiated "The End TB Strategy" with the goal of a 95% reduction in deaths. While many resources are contributed to eradicating TB, a substantial number of TB patients are still unlikely to receive timely treatment. Thus, we aimed to measure healthcare delay and its association with clinical outcomes from 2013 to 2018.

METHODS

We conducted a retrospective cohort study using linked data of the National Tuberculosis Surveillance Registry and the health insurance claims data of South Korea. We included incident TB patients, and healthcare delay was defined as the period between the first medical visit with TB-related symptoms and the initiation of an anti-TB regimen. We described the distribution of healthcare delay, and the study population was classified into two groups with mean as a cutoff. The association between healthcare delay and clinical outcomes (all-cause mortality, pneumonia, progression to multi/extensively drug-resistant, intensive care unit admission, and mechanical ventilation use) was evaluated using the Cox proportional hazard model. Several stratified and sensitivity analyses were also conducted.

RESULTS

Among 39,747 patients with pulmonary TB, mean healthcare delay was 42.3 days and delayed and non-delayed groups, classified by mean (or average), were 10,680 (26.9%) and 29,067 (73.1%), respectively. Healthcare delay was associated with an increased risk of all-cause mortality (HR 1.10, 95% CI 1.03-1.17), pneumonia (HR 1.13, 95% CI 1.09-1.18), and mechanical ventilation use (HR 1.15, 95% CI 1.01-1.32). We also observed the duration-response of healthcare delay. Stratified analyses showed patients with respiratory diseases were at higher risk, and consistent results were observed in sensitivity analyses.

CONCLUSIONS

We observed a substantial number of patients experiencing healthcare delays, and it was associated with the deterioration of clinical outcomes. Our findings suggest that attention from authorities and healthcare professionals is needed to attenuate the preventable burden caused by TB through timely treatment.

Latent Tuberculosis in Psoriasis Patients on Biologic Therapies: Real-World Data from a Care Center in Romania

Background and Objectives: Psoriasis is a chronic and inflammatory condition that has a huge impact on the patient's quality of life. Biological treatment improved psoriasis therapy, with impressive results seen in the evolution of the disease and the patient's quality of life. However, the risk of mycobacterium tuberculosis (MTB) infection reactivation is well-known to biological therapy, which raises problems especially in an endemic country. Materials and Methods: In this study, we followed moderate to severe psoriasis patients who had latent tuberculosis infection (LTBI) following treatment with a biological therapy approved in Romania. Results: The patients were evaluated at baseline and then followed-up with Mantoux tests and chest X-rays every year, resulting in 54 patients being diagnosed with LTBI. At the initial evaluation, 30 patients with LTBI were identified, and 24 more were identified during biological therapy. These patients were given prophylactic treatment. Out of the 97 participants in this retrospective study, 25 required association of methotrexate (MTX) alongside biological therapy. We compared the prevalence of positive Mantoux tests in patients with combined therapy with that of patients only on biological treatment, and the results were higher in the combined therapy group. Conclusion: All the patients in the study were vaccinated against tuberculosis (TB) after birth, and none were diagnosed with active tuberculosis (aTB) before or after the start of therapy according to the pulmonologist.

Reduced microbial diversity of the nasopharyngeal microbiome in household contacts with latent tuberculosis infection

The upper respiratory tract is an obliged pathway for respiratory pathogens and a healthy microbiota may support the host's mucosal immunity preventing infection. We analyzed the nasopharyngeal microbiome in tuberculosis household contacts (HHCs) and its association with latent tuberculosis infection (TBI). A prospective cohort of HHCs was established and latent TBI status was assessed by serial interferon-γ release assay (IGRA). Nasopharyngeal swabs collected at baseline were processed for 16S rRNA gene sequencing. The 82 participants included in the analysis were classified as: (a) non-TBI [IGRA negative at baseline and follow-up, no active TB (n = 31)], (b) pre-TBI [IGRA negative at baseline but converted to IGRA positive or developed active TB at follow-up (n = 16)], and (c) TBI [IGRA positive at enrollment (n = 35)]. Predominant phyla were Actinobacteriota, Proteobacteria, Firmicutes and Bacteroidota. TBI group had a lower alpha diversity compared to non-TBI (p_adj = 0.04) and pre-TBI (p_adj = 0.04). Only TBI and non-TBI had beta diversity differences (p_adj = 0.035). Core microbiomes' had unique genera, and genus showed differential abundance among groups. HHCs with established latent TBI showed reduced nasopharyngeal microbial diversity with distinctive taxonomical composition. Whether a pre-existing microbiome feature favors, are a consequence, or protects against Mycobacterium tuberculosis needs further investigation.

Influence of Sex and Sex-Based Disparities on Prevalent Tuberculosis, Vietnam, 2017-2018

To assess sex disparities in tuberculosis in Vietnam, we conducted a nested, case-control study based on a 2017 tuberculosis prevalence survey. We defined the case group as all survey participants with laboratory-confirmed tuberculosis and the control group as a randomly selected group of participants with no tuberculosis. We used structural equation modeling to describe pathways from sex to tuberculosis according to an a priori conceptual framework. Our analysis included 1,319 participants, of whom 250 were case-patients. We found that sex was directly associated with tuberculosis prevalence (adjusted odds ratio for men compared with women 3.0 [95% CI 1.7-5.0]) and indirectly associated through other domains. The strong sex difference in tuberculosis prevalence is explained by a complex interplay of factors relating to behavioral and environmental risks, access to healthcare, and clinical manifestations. However, after controlling for all those factors, a direct sex effect remains that might be caused by biological factors.

QcrB inhibition as a potential approach for the treatment of tuberculosis: A review of recent developments, patents, and future directions

The unmet medical need for drug-resistant tuberculosis (DRTB) is a significant concern. Accordingly, identifying new drug targets for tuberculosis (TB) treatment and developing new therapies based on these drug targets is one of the strategies to tackle DRTB. QcrB is an innovative drug target to create treatments for DRTB. This article highlights QcrB inhibitors and their therapeutic compositions for treating TB. The literature for this article was gathered from PubMed and free patent databases utilizing different keywords related to QcrB inhibitor-based inventions. The data was collected from the conceptualization of telacebec (2010) QcrB to December 2022. A little interesting and encouraging research has been performed on QcrB inhibitors. Telacebec and TB47 are established QcrB inhibitors in the clinical trial. The inventive QcrB inhibitor-based drug combinations can potentially handle DRTB and reduce the TB therapy duration. The authors anticipate great opportunities in fostering QcrB inhibitor-based patentable pharmaceutical inventions against TB. Drug repurposing can be a promising strategy to get safe and effective QcrB inhibitors. However, developing drug resistance, drug tolerance, and selectivity of QcrB inhibitors for Mtb will be the main challenges in developing effective QcrB inhibitors. In conclusion, QcrB is a promising drug target for developing effective treatments for active, latent, and drug-resistant TB. Many inventive and patentable combinations and compositions of QcrB inhibitors with other anti-TB drugs are anticipated as future treatments for TB.

Prevalence of pulmonary tuberculosis in homeless individuals in the Addis Ababa City, Ethiopia

Background

Homeless individuals are at a high risk of infection with Mycobacterium tuberculosis (M. tuberculosis) as compared to the general population. The number of homeless individuals has been increasing in Addis Ababa City during the last three decades due to the migration of rural inhabitants to the City for better living conditions. The objective of this study was to estimate the prevalence of pulmonary tuberculosis (PTB) and evaluate associated risk factors in homeless individuals in Addis Ababa City.

Methods

A total of 5,600 homeless individuals were screened for PTB symptoms using WHO guideline between February 2019 and December 2020. Sputum samples were cultured from individuals with symptoms of PTB for mycobacterial isolation. Logistic regression analysis was used to identify factors associated with PTB.

Results

The prevalence of bacteriologically confirmed cases was 1.1% (59/5,600) or 10.54 per 1000 population. Multinomial logistic regression analysis showed that being homeless for more than 5 years, body mass index (BMI) < 18.5, smoking cigarette, living in a group of more than five individuals, close contact with chronic coughers, imprisonment and HIV infection were significantly associated with the prevalence of PTB in homeless individuals (P < 0.05).

Conclusion

In conclusion, the result of this study indicated that the prevalence of PTB in homeless individuals was higher than the prevalence of PTB in the general population of Addis Ababa City requiring for the inclusion of the homeless individuals in the TB control program.

Factors associated with prevalent Mycobacterium tuberculosis infection and disease among adolescents and adults exposed to rifampin-resistant tuberculosis in the household

BACKGROUND

Understanding factors associated with prevalent Mycobacterium tuberculosis infection and prevalent TB disease in household contacts of patients with drug-resistant tuberculosis (TB) may be useful for TB program staff conducting contact investigations.

METHODS

Using data from a cross-sectional study that enrolled index participants with rifampin-resistant pulmonary TB and their household contacts (HHCs), we evaluated HHCs age ≥15 years for factors associated with two outcomes: Mycobacterium tuberculosis infection and TB disease. Among HHCs who were not already diagnosed with current active TB disease by the TB program, Mycobacterium tuberculosis infection was determined by interferon-gamma release assay (IGRA). TB disease was adjudicated centrally. We fitted logistic regression models using generalized estimating equations.

RESULTS

Seven hundred twelve HHCs age ≥15 years enrolled from 279 households in eight high-TB burden countries were a median age of 34 years, 63% female, 22% current smokers and 8% previous smokers, 8% HIV-positive, and 11% previously treated for TB. Of 686 with determinate IGRA results, 471 tested IGRA positive (prevalence 68.8% (95% Confidence Interval: 64.6%, 72.8%)). Multivariable modeling showed IGRA positivity was more common in HHCs aged 25-49 years; reporting prior TB treatment; reporting incarceration, substance use, and/or a period of daily alcohol use in the past 12 months; sharing a sleeping room or more evenings spent with the index participant; living with smokers; or living in a home of materials typical of low socioeconomic status. Forty-six (6.5% (95% Confidence Interval: 4.6%, 9.0%)) HHCs age ≥15 years had prevalent TB disease. Multivariable modeling showed higher prevalence of TB disease among HHCs aged ≥50 years; reporting current or previous smoking; reporting a period of daily alcohol use in the past 12 months; and reporting prior TB treatment.

CONCLUSION

We identified overlapping and distinct characteristics associated with Mycobacterium tuberculosis infection and TB disease that may be useful for those conducting household TB investigations.

Neutrophils in Mycobacterium tuberculosis

Mycobacterium tuberculosis (M. tb) continues to be a leading cause of mortality within developing countries. The BCG vaccine to promote immunity against M. tb is widely used in developing countries and only in specific circumstances within the United States. However, current the literature reports equivocal data on the efficacy of the BCG vaccine. Critical within their role in the innate immune response, neutrophils serve as one of the first responders to infectious pathogens such as M. tb. Neutrophils promote effective clearance of M. tb through processes such as phagocytosis and the secretion of destructive granules. During the adaptative immune response, neutrophils modulate communication with lymphocytes to promote a strong pro-inflammatory response and to mediate the containment M. tb through the production of granulomas. In this review, we aim to highlight and summarize the role of neutrophils during an M. tb infection. Furthermore, the authors emphasize the need for more studies to be conducted on effective vaccination against M. tb.

Innovative Therapeutic Approaches Based on Nanotechnology for the Treatment and Management of Tuberculosis

Tuberculosis (TB), derived from bacterium named Mycobacterium tuberculosis, has become one of the worst infectious and contagious illnesses in the world after HIV/AIDS. Long-term therapy, a high pill burden, lack of compliance, and strict management regimens are disadvantages which resulted in the extensively drug-resistant (XDR) along with multidrug-resistant (MDR) in the treatment of TB. One of the main thrust areas for the current scenario is the development of innovative intervention tools for early diagnosis and therapeutics towards Mycobacterium tuberculosis (MTB). This review discusses various nanotherapeutic agents that have been developed for MTB diagnostics, anti-TB drugs and vaccine. Undoubtedly, the concept of employing nanoparticles (NPs) has strong potential in this therapy and offers impressive outcomes to conquer the disease. Nanocarriers with different types were designed for drug delivery applications via various administration methods. Controlling and maintaining the drug release might be an example of the benefits of utilizing a drug-loaded NP in TB therapy over conventional drug therapy. Furthermore, the drug-encapsulated NP is able to lessen dosage regimen and can resolve the problems of insufficient compliance. Over the past decade, NPs were developed in both diagnostic and therapeutic methods, while on the other hand, the therapeutic system has increased. These "theranostic" NPs were designed for nuclear imaging, optical imaging, ultrasound, imaging with magnetic resonance and the computed tomography, which includes both single-photon computed tomography and positron emission tomography. More specifically, the current manuscript focuses on the status of therapeutic and diagnostic approaches in the treatment of TB.

Tuberculosis of the Spine in a Patient With Kidney Cancer

Tuberculosis is a widespread, airborne infectious disease caused by Mycobacterium tuberculosis bacteria. This infection is often misdiagnosed, particularly in the case of spinal tuberculosis which can present atypically. Although rare, tuberculosis can mimic bone tumors or metastatic lesions in the spine. In patients with immunosuppression who have cancer and show signs of lymph node involvement and bone lesions, it is important to explore other potential causes as part of the diagnosis process. Here, we present a case of renal cell carcinoma in which a lytic lesion in the spinal cord was initially misdiagnosed as a metastatic lesion due to the presence of cancer. Skeletal tuberculosis is a rare condition, and it is crucial to maintain a high level of suspicion for a proper diagnosis.

Causes of Moderate and Severe Anaemia in a High-HIV and TB-Prevalent Adult Population in the Eastern Cape Province, South Africa

BACKGROUND

Anaemia affects one in four adults in South Africa, with a higher prevalence in persons with HIV and tuberculosis. The aim of this study is to characterise the causes of anaemia in primary care and a district hospital setting.

METHODS

A cross-sectional study design investigated a purposive sample of adult males and non-pregnant females at two community health centres and a hospital casualty and outpatients. Fingerpick blood haemoglobin was measured with HemoCueHb201+. Those with moderate and severe anaemia underwent clinical examination and laboratory tests.

RESULTS

Of 1327 patients screened, median age was 48 years, and 63.5% were female. Of 471 (35.5%) with moderate and severe anaemia on HemoCue, 55.2% had HIV, 16.6% tuberculosis, 5.9% chronic kidney disease, 2.6% cancer, and 1.3% heart failure. Laboratory testing confirmed 227 (48.2%) with moderate and 111 (23.6%) with severe anaemia, of whom 72.3% had anaemia of inflammation, 26.5% iron-deficiency anaemia, 6.1% folate deficiency, and 2.5% vitamin B12 deficiency. Overall, 57.5% had two or more causes of anaemia. Multivariate modelling showed that patients with severe anaemia were three times more likely to have tuberculosis (OR = 3.1, 95% CI = 1.5-6.5; p-value = 0.002). Microcytosis was present in 40.5% with iron deficiency, macrocytosis in 22.2% with folate deficiency, and 33.3% with vitamin B12 deficiency. The sensitivities of the reticulocyte haemoglobin content and % hypochromic red blood cells in diagnosing iron deficiency were 34.7% and 29.7%, respectively.

CONCLUSIONS

HIV, iron deficiency, and tuberculosis were the most prevalent causes of moderate and severe anaemia. The majority had multiple causes. Iron, folate, and vitamin B12 deficiencies should be identified by biochemical testing rather than by red cell volume.

Pathogenicity of Type I Interferons in Mycobacterium tuberculosis

Tuberculosis (TB) is a leading cause of mortality due to infectious disease and rates have increased during the emergence of COVID-19, but many of the factors determining disease severity and progression remain unclear. Type I Interferons (IFNs) have diverse effector functions that regulate innate and adaptive immunity during infection with microorganisms. There is well-documented literature on type I IFNs providing host defense against viruses; however, in this review, we explore the growing body of work that indicates high levels of type I IFNs can have detrimental effects to a host fighting TB infection. We report findings that increased type I IFNs can affect alveolar macrophage and myeloid function, promote pathological neutrophil extracellular trap responses, inhibit production of protective prostaglandin 2, and promote cytosolic cyclic GMP synthase inflammation pathways, and discuss many other relevant findings.

A cost-effectiveness evaluation of latent tuberculosis infection screening of a migrant population in Malaysia

To estimate the costs and benefits of screening for latent tuberculosis infection (LTBI) in a migrant population in Malaysia. An economic model was developed from a Malaysian healthcare perspective to compare QuantiFERON-TB Gold Plus (QuantiFERON) with the tuberculin skin test (TST). A decision tree was used to capture outcomes relating to LTBI screening followed by a Markov model that simulated the lifetime costs and benefits of the patient cohort. The Markov model did not capture the impact of secondary infections. The model included an R shiny interactive interface to allow adaptation to other scenarios and settings. QuantiFERON is both more effective and less costly than TST (dominant). Compared with QuantiFERON, the lifetime risk of developing active TB increases by approximately 40% for TST due to missed LTBI cases during screening (i.e. a higher number of false negative cases for TST). For a migrant population in Malaysia, QuantiFERON is cost-effective when compared with TST. Further research should consider targeted LTBI screening for migrants in Malaysia based on common risk factors.

Mandatory, voluntary, repetitive, or one-off post-migration follow-up for tuberculosis prevention and control: A systematic review

BACKGROUND

Post-migration follow-up of migrants identified to be at-risk of developing tuberculosis during the initial screening is effective, but programmes vary across countries. We aimed to review main strategies applied to design follow-up programmes and analyse the effect of key programme characteristics on reported coverage (i.e., proportion of migrants screened among those eligible for screening) or yields (i.e., proportion of active tuberculosis among those identified as eligible for follow-up screening).

METHODS AND FINDINGS

We performed a systematic review and meta-analysis of studies reporting yields of follow-up screening programmes. Studies were included if they reported the rate of tuberculosis disease detected in international migrants through active case finding strategies and applied a post-migration follow-up (defined as one or more additional rounds of screening after finalising the initial round). For this, we retrieved all studies identified by Chan and colleagues for their systematic review (in their search until January 12, 2017) and included those reporting from active follow-up programmes. We then updated the search (from January 12, 2017 to September 30, 2022) using Medline and Embase via Ovid. Data were extracted on reported coverage, yields, and key programme characteristics, including eligible population, mode of screening, time intervals for screening, programme providers, and legal frameworks. Differences in follow-up programmes were tabulated and synthesised narratively. Meta-analyses in random effect models and exploratory analysis of subgroups showed high heterogeneity (I2 statistic > 95.0%). We hence refrained from pooling, and estimated yields and coverage with corresponding 95% confidence intervals (CIs), stratified by country, legal character (mandatory versus voluntary screening), and follow-up scheme (one-off versus repetitive screening) using forest plots for comparison and synthesis. Of 1,170 articles, 24 reports on screening programmes from 7 countries were included, with considerable variation in eligible populations, time intervals of screening, and diagnostic protocols. Coverage varied, but was higher than 60% in 15 studies, and tended to be lower in voluntary compared to compulsory programmes, and higher in studies from the United States of America, Israel, and Australia. Yield varied within and between countries and ranged between 53.05 (31.94 to 82.84) in a Dutch study and 5,927.05 (4,248.29 to 8,013.71) in a study from the United States. Of 15 estimates with narrow 95% CIs for yields, 12 were below 1,500 cases per 100,000 eligible migrants. Estimates of yields in one-off follow-up programmes tended to be higher and were surrounded by less uncertainty, compared to those in repetitive follow-up programmes. Yields in voluntary and mandatory programmes were comparable in magnitude and uncertainty. The study is limited by the heterogeneity in the design of the identified screening programmes as effectiveness, coverage and yields also depend on factors often underreported or not known, such as baseline incidence in the respective population, reactivation rate, educative and administrative processes, and consequences of not complying with obligatory measures.

CONCLUSION

Programme characteristics of post-migration follow-up screening for prevention and control of tuberculosis as well as coverage and yield vary considerably. Voluntary programmes appear to have similar yields compared with mandatory programmes and repetitive screening apparently did not lead to higher yields compared with one-off screening. Screening strategies should consider marginal costs for each additional round of screening.

Intestinal tuberculosis in a patient with Cushing's syndrome

A 39-year-old woman presented with cushingoid features was worked up and diagnosed to have ACTH-independent Cushing's syndrome. Computed tomography of the whole abdomen revealed a left adrenal mass. She was scheduled for elective laparoscopic left adrenalectomy, however, a few days prior to the surgery, the patient had hematochezia. Colonoscopy revealed multiple ulcers on the terminal ileum, to which biopsy revealed Mycobacterium tuberculosis infection. The patient underwent laparoscopic left adrenalectomy on the same admission, which revealed adrenal adenoma on histopathology.

Tuberculosis Infection in Children and Adolescents

The burden of tuberculosis (TB) in children and adolescents remains very significant. Several million children and adolescents are infected with TB each year worldwide following exposure to an infectious TB case and the risk of progression from TB infection to tuberculosis disease is higher in this group compared to adults. This review describes the risk factors for TB infection in children and adolescents. Following TB exposure, the risk of TB infection is determined by a combination of index case characteristics, contact features, and environmental determinants. We also present the recently recommended approaches to diagnose and treat TB infection as well as novel tests for infection. The tests for TB infection have limitations and diagnosis still relies on an indirect immunological assessment of cellular immune response to Mycobacterium tuberculosis antigens using immunodiagnostic testing. It is recommended that TB exposed children and adolescents and those living with HIV receive TB preventive treatment (TPT) to reduce the risk of progression to TB disease. Several TPT regimens of similar effectiveness and safety are now available and recommended by the World Health Organisation.

Progress towards the 2020 milestones of the end TB strategy in Cambodia: estimates of age and sex specific TB incidence and mortality from the Global Burden of Disease Study 2019

BACKGROUND

Cambodia was recently removed from the World Health Organization's (WHO's) top 30 high tuberculosis (TB) burden countries. However, Cambodia's TB burden remains substantial, and the country is on the WHO's new global TB watchlist. We aimed to examine the levels and trends in the fatal and non-fatal TB burden in Cambodia from 1990 to 2019, assessing progress towards the WHO End TB interim milestones, which aim to reduce TB incidence rate by 20% and TB deaths by 35% from 2015 to 2020.

METHODS

We leveraged the Global Burden of Disease 2019 (GBD 2019) analytical framework to compute age- and sex-specific TB mortality and incidence by HIV status in Cambodia. We enumerated TB mortality utilizing a Bayesian hierarchical Cause of Death Ensemble modeling platform. We analyzed all available data sources, including prevalence surveys, population-based tuberculin surveys, and TB cause-specific mortality, to produce internally consistent estimates of incidence and mortality using a compartmental meta-regression tool (DisMod-MR 2.1). We further estimated the fraction of tuberculosis mortality among individuals without HIV coinfection attributable to the independent effects of alcohol use, smoking, and diabetes.

RESULTS

In 2019, there were 6500 (95% uncertainty interval 4830-8680) deaths due to all-form TB and 50.0 (43.8-57.8) thousand all-form TB incident cases in Cambodia. The corresponding age-standardized rates were 53.3 (39.9-69.4) per 100,000 population for mortality and 330.5 (289.0-378.6) per 100,000 population for incidence. From 2015 to 2019, the number of all-form TB deaths decreased by 11.8% (2.3-21.1), while the age-standardized all-form TB incidence rate decreased by 11.1% (6.3-15.6). Among individuals without HIV coinfection in 2019, alcohol use accounted for 28.1% (18.2-37.9) of TB deaths, smoking accounted for 27.0% (20.2-33.3), and diabetes accounted for 12.5% (7.1-19.0). Removing the combined effects of these risk factors would reduce all-form TB deaths by 54.2% (44.2-62.2).

DISCUSSION

Despite significant progress in reducing TB morbidity and mortality since 1990, Cambodia is not on track to achieve the 2020 WHO End TB interim milestones. Existing programs in Cambodia can benefit from liaising with risk factor control initiatives to accelerate progress toward eliminating TB in Cambodia.

Effect of Oral Antidiabetic Drugs on Tuberculosis Risk and Treatment Outcomes: Systematic Review and Meta-Analysis

Tuberculosis and diabetes mellitus are two global pandemics and rising public health problems. Recent studies suggest that oral antidiabetic drugs (OADs) could reduce the risk of tuberculosis and improve clinical outcomes. However, the evidence is controversial. Therefore, we aimed to assess the effect of OADs on the risk of tuberculosis and treatment outcomes. We systematically searched for six databases from inception to 31 August 2022. We followed a predefined PICO/PECO strategy and included two randomized controlled trials and sixteen observational studies. This study collects 1,109,660 participants, 908,211 diabetic patients, and at least 13,841 tuberculosis cases. Our results show that metformin decreases the risk of active tuberculosis by 40% (RR 0.60; 95% CI 0.47-0.77) in diabetic patients. In addition, metformin exhibits a dose-response gradient (medium doses reduce the risk of active tuberculosis by 45%, while high doses reduce this risk by 52%). On the other hand, DPP IV inhibitors increase the risk of active tuberculosis by 43% (RR 1.43; 95% CI 1.02-2.02). Subgroup analysis showed that study design and metformin dose accounted for the heterogeneity. We conclude that metformin significantly protects against active tuberculosis among diabetic patients. On the contrary, DPP IV inhibitors could increase the risk of developing active tuberculosis.

Evaluation of Xpert MTB/RIF Assay, MTB Culture and Line Probe Assay for the Detection of MDR Tuberculosis in AFB Smear Negative Specimens

The global burden of tuberculosis (TB), particularly with multidrug resistance (MDR), is escalating and has become a major health challenge. It is well known that acid-fast bacilli (AFB) smear-negative TB patients are the major source of spreading TB to healthy individuals when left untreated. Early diagnosis of TB and rapid detection of drug resistance are important for the proper management of drug-resistant TB (DR-TB). Therefore, a laboratory based cross-sectional study was conducted from July to December 2019 at the National Tuberculosis Centre, Thimi, Nepal, with the objective of evaluating the diagnostic performance of Xpert MTB/RIF assay, Mycobacterium tuberculosis (MTB) culture and line probe assay (LPA) for the detection of MDR-TB in AFB smear-negative sputum samples. We evaluated a total of 222 AFB smear-negative sputum specimens, of which 21.6% (n = 48) showed MTB positive with Xpert MTB/RIF assay and, while culturing on Lowenstein-Jensen (LJ) media, 21.2% (n = 47) were MTB culture positive. The sensitivity, specificity, PPV and NPV at 95% confidence interval of Xpert MTB/RIF assay on diagnosing M. tuberculosis from smear-negative specimens were 73% (57-84), 92% (87-96), 71% (59-81) and 93% (89-95), respectively. In addition, the sensitivity of Xpert MTB/RIF assay and LPA in detecting rifampicin resistance was 75% (42-94, 95% CI) and 91.67% (62-99, 95% CI), respectively. The current study also assessed a significant association between the occurrence of pulmonary tuberculosis with different age group, TB history and alcohol consumption. These findings indicate that Xpert MTB/RIF assay and LPA are appropriate methods for early detection and accurate diagnosis of TB and RIF mono-resistant cases.

Cerebral Tuberculoma with Mild Posterior Cervical Pain as the Main Symptom Despite Extensive Brain Lesions

A 59-year-old woman with a diabetes history experienced mild neck pain. A neurological examination revealed only mild neck stiffness. Magnetic resonance imaging showed extensive T2-weighted high-intensity lesions with patchy gadolinium enhancement mainly involving the white matter in the right parietal lobe. A cerebrospinal fluid analysis revealed increased protein levels and pleocytosis. While QuantiFERON-TB Gold was positive, computed tomography (CT) and fluorodeoxyglucose on positron emission tomography-CT of the whole body showed no abnormal accumulation, suggesting tuberculosis. A brain biopsy revealed cerebral tuberculoma. As cerebral tuberculoma can show minimal neurological symptoms despite extensive lesions, a cautious examination and early treatment are required to prevent a devastating prognosis.

Tuberculosis in an Aging World

Tuberculosis (TB) is one of the leading causes of death due to its being an infectious disease, caused by the airborne pathogen Mycobacterium tuberculosis (M.tb). Approximately one-fourth of the world’s population is infected with latent M.tb, and TB is considered a global threat killing over 4000 people every day. The risk of TB susceptibility and mortality is significantly increased in individuals aged 65 and older, confirming that the elderly represent one of the largest reservoirs for M.tb infection. The elderly population faces many challenges that increase their risk of developing respiratory diseases, including TB. The challenges the elderly face in this regard include the following: decreased lung function, immuno-senescence, inflammaging, adverse drug effects, low tolerance to anti-TB drugs, lack of suitable diagnoses/interventions, and age-associated comorbidities. In order to find new therapeutic strategies to maintain lung homeostasis and resistance to respiratory infections as we age, it is necessary to understand the molecular and cellular mechanisms behind natural lung aging. This review focuses primarily on why the elderly are more susceptible to TB disease and death, with a focus on pulmonary function and comorbidities.

Utilisation of village health workers’ services for tuberculosis screening in Lesotho

Background

Village health workers (VHWs) play an essential role because they extend the capacity of primary healthcare, particularly for developing countries. In Lesotho, VHWs are part of the primary healthcare connecting the community with clinics in their respective villages. They contribute to the prevention of the spread of tuberculosis (TB) within their catchment areas by encouraging communities to partake in TB screening. This study aimed at identifying factors associated with the utilisation of VHWs’ service to undertake TB screenings in Lesotho.

Methods

This study emanates from the main study that used a cross-sectional descriptive design. A total of 19 health service areas (HSAs) comprised 17 catchment areas and two clinics, each randomly selected from the District Health Management Team (DHMT) and the Lesotho Flying Doctors Service (LFDS), respectively. A total of 2928 individual household members aged 15 and above were included in the study. Data analysis included descriptive and inferential statistics.

Results

There were more female than male respondents, with a majority (77%) below 65 years of age. Tuberculosis knowledge of respondents was mostly on the TB symptoms and curability of TB, but they were less knowledgeable about the causes of TB. The use of VHWs’ services for TB screening was very low (23.3%).

Conclusion

The study revealed that while respondents were to some extent knowledgeable about TB, their utilisation of VHWs’ services for TB screening varied with education level, having worked in South Africa and the household size at α = 0.01.

Impact of Macrophage Migration Inhibitory Factor Gene Polymorphisms and Serum Macrophage Migration Inhibitory Factor Levels on Pulmonary and Spinal Tuberculosis Susceptibility: A Pooled Analysis

Objective: This study was designed to evaluate the association between macrophage migration inhibitory factor (MIF) gene polymorphisms, serum MIF levels and tuberculosis (TB) susceptibility. Methods: All satisfactory studies were included; the MIF genotype number and serum MIF levels were reviewed. The Stata and Review Manager software were used for the pooled analyses. Results: The pooled analyses showed that the MIF-173G/C gene polymorphism was associated with TB (allele C vs allele G: odds ratio (OR) = 1.44, 95% confidence interval (CI): 1.28-1.62, p < 0.01; genotype CC vs genotype GG: OR = 1.69, 95% CI: 1.05-2.73, p = 0.03; genotype CC+GC vs genotype GG: OR = 1.56, 95% CI: 1.34-1.81, p < 0.01; genotype GC vs genotype GG: OR = 1.50, 95% CI: 1.28-1.75, p < 0.01). The subgroup analysis showed that the MIF-173G/C gene polymorphism was significantly associated with the risk of both pulmonary tuberculosis (PTB) and spinal tuberculosis (STB).The MIF CATT-794 gene polymorphism was associated with the PTB susceptibility in Asian subjects (genotypes 5/X+6/X vs genotypes 7/X+8/X: OR = 0.39, 95% CI: 0.24-0.64, p < 0.01; genotypes 5 + 6 vs genotypes 7 + 8: OR = 0.57, 95% CI: 0.48-0.69, p < 0.01). Both PTB and STB patients had significantly elevated serum MIF levels compared to healthy controls. Conclusion: The MIF-173G/C gene polymorphism is related to both PTB and STB susceptibility in both Asian and Caucasian populations. The C allele and CC genotype of the MIF-173G/C SNP appear to be TB risk factors. The MIF CATT-794 gene polymorphism is associated with the PTB susceptibility in Asian subjects; serum MIF levels were significantly increased in PTB and STB patients.

Role of Antimicrobial Peptides in Treatment and Prevention of Mycobacterium Tuberculosis: A Review

Tuberculosis (TB) is one of the leading cause of death worldwide, and the world is fighting with this global health emergency from the past 25 year. The current clinical interventions for the management of TB face a number of inherent challenges which includes low patient compliance due to the long therapy regimen, and emerging antimicrobial resistance. Therefore, there is an unmet need of new anti-TB therapeutic agent with enhanced safety profile, which can reduce the duration of therapy, enhanced bioavailability and efficacy against drug resistant forms of TB. Bacteriocins or anti microbial peptides (AMPs) occurring in microbes, human beings and other life forms have been investigated as host defense peptides. Structurally AMPs are short and ionized and play crucial role in innate immunity of host. Some AMPs can kill microbial infections directly while others function indirectly by altering the host defense mechanisms. Amidst rising issue of antibiotic resistance, AMPs are being tested in clinical research as potential antibiotics and novel therapeutics to fight against infections and non-infectious diseases. Studies have also highlighted the ability of AMPs to act against the bacteria spreading tuberculosis. The present review provides information on antimicrobial peptides, highlights their biological role, classification and mode of action in treatment and prevention of tuberculosis. It further mentions the prospects and challenges of developing peptides for their therapeutic applications against mycobacterium tuberculosis.

Unusual patterns of tuberculosis on cross-sectional imaging: a pictorial review

Background

Tuberculosis is routinely encountered on imaging throughout the world. Radiologists are usually familiar with the common patterns of tuberculosis on cross-sectional imaging. However, tuberculosis frequently presents with unfamiliar imaging patterns and/or uncommon anatomic sites which still pose a diagnostic challenge.

Discussion

Rapid improvements in the management of acquired immunodeficiency syndrome patients leading to increased survival as well as advances in chemotherapy and immunosuppressive medication have complicated the presentation of tuberculosis by increasing the probability of unconventional sites and patterns of involvement in tuberculosis leading to unfamiliar imaging appearances. In this review, we describe these unfamiliar imaging patterns of tuberculosis and provide a diagnostic protocol for arriving at the right diagnosis and differentiating these from other pathologies with similar imaging appearances. These are described through case-based illustrations of unusual patterns and anatomic locations of tuberculosis.

Conclusions

It is important for radiologists to be aware of such unusual imaging patterns of tuberculosis in order to facilitate early and accurate diagnosis for appropriate patient management in the face of changing patient demographics and pathological profile of tuberculosis in the current era of scientific advancements.

Tuberculosis at a university hospital, Thailand: A surprising incidence of TB among a new generation of highly exposed health care workers who may be asymptomatic

Objectives

There are a few reports of TB disease among healthcare workers (HCWs) in Thailand. The authors assessed the demographic data and incidence of overall TB disease including specific profession among HCWs in order to reduce the incidence rate.

Methods

This was a descriptive, cross-sectional study of 195 HCWs at King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand, who had TB disease from 2003–2020.

Results

The average incidence of TB disease in HCWs at KCMH was 164 per 100,000 HCWs with 95% confidential interval [CI], 107 to 220; (94.4% had pulmonary TB). Most of the HCWs were from a young age group (43.08% were 20–29 years old) and the duration of work was short (58.82% had worked at KCMH for less than 5 years). Radiological technicians had the highest incidence of TB, followed by supportive teams, scientists, and physicians (429, 241, 205, and 193 per 100,000 HCWs according to their profession, respectively). Seventy five percent of TB disease was found in physicians who worked at KCMH within 2 years. TB incidence was highest among residents (688 per 100,000 residents) in a subgroup of physicians.

Conclusions

The incidence of TB disease in HCWs was close to the general population of Thailand (153 per 100,000 population with 95% CI, 116 to 195). A higher incidence was observed in the profession that had contact with TB patients and their specimens. A high proportion of asymptomatic HCWs also had TB disease and TB incidence was found in a new generation of HCWs who have worked for less than 5 years. More rigorous epidemiology investigations are needed to establish a definitive relation to subsequently developing TB after working in a hospital. The authors suggest active surveillance in all new incoming HCWs and TB preventive therapy should also be provided to recent converters.

Tuberculosis and Cardiovascular Complications: An Overview

Tuberculosis (TB) is a dominant cause of mortality from a single infectious disease agent. It is a global health issue that has been tagged as a public health emergency for decades. The disease process, which is caused by Mycobacterium tuberculosis (MTB), affects the respiratory system as well as many other organ systems in the body, such as the lymphatic system, central nervous system (CNS), gastrointestinal system, and cardiovascular system (CVS). Generally, cardiovascular diseases are the leading cause of death worldwide, with most of the mortality in low and middle-income countries. Also, the high mortality rate of TB is skewed to these regions, making the mortality of TB with CVS involvement exceptionally high.

The multisystemic involvement of TB impacts the cardiovascular system in various forms. While pericarditis caused by TB is quite common, other complications like myocarditis, coronary artery disease, and aortitis are rarer, necessitating a high index of suspicion and holistic management.

This article reviews the pathophysiology of cardiovascular complications in TB, highlighting mechanisms of occurrence, common complications, management protocols, and prognostic factors. Our review highlights some of the gaps in understanding cardiovascular complications in TB, necessitating further research to investigate causal mechanisms and treatment.

An Investigation of Risk Factors Associated with Tuberculosis Transmission in South Africa Using Logistic Regression Model

Background: South Africa has a high burden of tuberculosis (TB) disease and is currently not meeting the national and international reduction outcome targets. The TB prevalence rate of South Africa in 2015 was estimated at approximately 690 per 100,000 population per year, with an incidence rate of about 834 per 100,000 population. This study examines risk factors associated with development of TB in South Africa. Materials and Methods: This study utilised readily available open access secondary data of 2019 South African Health and Demographic Survey from Statistics South Africa (StatsSA) website, which was collected from self-reported information relating to TB in the household questionnaire. The factors analysed were of demographic, socio-economic and health nature. Bivariate and binary logistics analyses were carried out from which appropriate inferences were drawn on the association of TB with demographic, socio-economic and health factors. Results: In multivariate analysis the study revealed that age, personal weight, smoke, alcohol, asthma, province of residence, race and usually coughing were significantly associated with an increased risk of having TB. Conclusions and Recommendations: The results strongly suggest that young and older people coming from black and coloured ethic groups, who are asthmatic and cough frequently, and/or smoking and consuming alcohol are at high risk of developing TB. In addition, those who are overweight appear to have an increased risk of TB transmission, with the Western Cape, Eastern Cape, Northern Cape, Free State, North West and Gauteng being the hardest hit provinces. Hence, the study recommends that these factors must be taken into account in the planning and development of TB policies in order to work successfully towards the achievement of sustainable development goal of reducing TB by 80% before 2030.

Tuberculosis-Associated Anemia: A Narrative Review

Tuberculosis (TB) is an airborne illness that induces systemic inflammation. It often affects the lungs causing cough, fever, and chest pain. A commonly associated comorbid condition in TB is anemia. This review article has summarized various studies with an aim to gain a better understanding of pathogenesis and the role of cytokines that contribute to the development of anemia in TB. The study has gathered risk factors that enhance the likelihood of TB patients acquiring anemia. It has reviewed therapeutic modalities such as antitubercular therapy and iron therapy in an attempt to find which of them are effective in reducing the severity of anemia. This review article has also emphasized the importance of measuring hepcidin and ferritin and has touched upon the investigations that can be easily implemented.

Difference and Factor Associated with Interferon Gamma Level in Pulmonary Tuberculosis Patients and Healthy Control

BACKGROUND : Interferon-gamma (INF-γ) is an important cytokine in the immune response against Mycobacterium tuberculosis. Interferon-gamma activates macrophage to kill intracellular mycobacterium. AIM: The aim of this study is to determine the difference of plasma INF-γ level in pulmonary tuberculosis (PTB) patients compared to a healthy control and factors associated with interferon-gamma level. METHODS: This is a case–control study. Fifty subjects were selected, including 25 new PTB patients with positive sputum smear, and 25 healthy control (non TB patients) with no symptoms of tuberculosis, normal chest X-Ray and no history of previous tuberculosis. Interferon-gamma concentration was determined by an ELISA technique. Data were analyzed with independent t-test and the results were statistically significant at p < 0.05. RESULTS: Interferon-gamma level was significantly higher in PTB patients compared to healthy control (p = 0.024). Mean ± SD interferon gamma level was 317.2 ± 201.97 pg/ml in PTB patients and 213.5 ± 86.43 pg/ml in healthy control. Acid fast bacilli (AFB) positivity was significantly associated with interferon gamma level (p < 0.001). Interferon gamma level in TB patients with AFB 1+ was 503.22 ± 146.15 pg/ml, AFB 2+ was 337 ± 81.61 pg/ml, and AFB 3+ was 88.27 ± 51.32 pg/ml. Sex, body mass index (BMI), and age were not associated with INF-γ level. CONCLUSIONS: Interferon gamma level was significantly higher in PTB patients than healthy control. Sex, BMI, and age were not associated with INF-γ level. Interferon-gamma level was significantly associated with AFB positivity in pulmonary tuberculosis patients.

Bone and Joint Tuberculosis in Greece: A Retrospective Study From 2011 to 2019

Purpose: Bone and joint tuberculosis (BJTB) represents approximately 2-5% of all tuberculosis (TB) cases and its characteristics are infrequently discussed. The aim of this study was to examine the epidemiology, characteristics, and management of BJTB in Greece.

Methods: We conducted retrospective analyses of demographic clinical and treatment data accessed from medical records of patients with BJTB and with pulmonary involvement between 2011 and 2019 from the national TB reference hospital in Greece. Factors associated with treatment outcomes among patients were evaluated.

Results: Out of the total 3064 confirmed TB cases during the study period, 54 patients had either BJTB or skeletal TB with pulmonary involvement. The majority of patients were males (81.5%) and the mean age of the patients was 37.81±18.92 years. Out of the total patients, 11 were Greek and 43 were immigrants. Women had a higher probability of experiencing a stable or negative treatment outcome. Also, the patients that received therapy for less than nine months had 16.3 times higher probability of experiencing a stable or negative treatment outcome, compared to those that received therapy for more than 12 months.

Conclusions: The study indicated that the sex and the duration of treatment correlated with the treatment outcomes. It is essential to monitor and accurately report treatment outcomes so as to achieve disease control.

Ethanol Consumption Induces Nonspecific Inflammation and Functional Defects in Alveolar Macrophages

Chronic alcohol drinking is associated with increased susceptibility to viral and bacterial respiratory pathogens. In this study, we use a rhesus macaque model of voluntary ethanol self-administration to study the effects of long-term alcohol drinking on the immunological landscape of the lung. We report a heightened inflammatory state in alveolar macrophages (AMs) obtained from ethanol (EtOH)-drinking animals that is accompanied by increased chromatin accessibility in intergenic regions that regulate inflammatory genes and contain binding motifs for transcription factors AP-1, IRF8, and NFKB p-65. In line with these transcriptional and epigenetic changes at the basal state, AMs from EtOH-drinking animals generate elevated inflammatory mediator responses to lipopolysaccharides and respiratory syncytial virus. However, the transcriptional analysis revealed an inefficient induction of interferon-stimulated genes with EtOH in response to the respiratory syncytial virus, suggesting disruption of antimicrobial defenses. Correspondingly, AMs from EtOH-drinking animals exhibited transcriptional shifts indicative of increased oxidative stress and oxidative phosphorylation, which was coupled with higher cytosolic reactive oxygen species and mitochondrial potential. This heightened oxidative stress state was accompanied by decreased ability to phagocytose bacteria. Bulk RNA and assay for transposase-accessible chromatin sequencing data further revealed reduced expression and chromatin accessibility of loci associated with tissue repair and maintenance with chronic EtOH drinking. Similarly, analysis of single-cell RNA sequencing data revealed shifts in cell states from tissue maintenance to inflammatory responses with EtOH. Collectively, these data provide novel insight into mechanisms by which chronic EtOH drinking increases susceptibility to infection in patients with alcohol use disorders.

Barriers faced by patients in the diagnosis of multidrug-resistant tuberculosis in Brazil

OBJECTIVE

To understand patients' narratives about the barriers they faced in the diagnosis and treatment of multidrug-resistant tuberculosis, and their consequences in Rio de Janeiro State, Brazil.

METHODS

This is a qualitative cross-sectional study with non-probabilistic sampling. A theoretical saturation criterion was considered for composing the number of interviewees. Semi-structured interviews were conducted from August to December 2019 with 31 patients undergoing treatment for multidrug-resistant tuberculosis at an outpatient referral center in Rio de Janeiro. Data were transcribed and processed with the aid of the NVIVO software. Interviews were evaluated by content analysis, and their themes, cross-referenced with participants' characterization data.

RESULTS

Our main findings were: a) participants show a high proportion of primary drug resistance, b) patients experience delays in the diagnosis and effective treatment of multidrug-resistant tuberculosis ; c) healthcare providers fail to value or seek the diagnosis of drug-resistant tuberculosis, thus beginning the inadequate treatment for drug-susceptible tuberculosis, d) primary health units show low report rates of active case-finding and contact monitoring, and e) patients show poor knowledge about the disease.

CONCLUSIONS

We need to improve referral systems, and access to the diagnosis and effective treatment of multidrug-resistant tuberculosis; conduct an active investigation of contacts; intensify the training of healthcare providers, in collaboration with medical and nursing schools, in both public and private systems; and promote campaigns to educate the population on tuberculosis signs and symptoms.

Development and Validation of the Tuberculosis Risk Score for Smokers (TBRSS)

Tuberculosis (TB) remains a significant public health issue worldwide. However, the effectiveness of TB screening programmes among smokers is still questionable. There is a need for a simple, reliable, and validated screening system for this risk population. This study aimed to develop and validate the tuberculosis risk score for smokers (TBRSS) in Kelantan, Malaysia. A case–control study was conducted on 159 patients (smokers with and without TB) between January and July 2020. Simple and multiple logistic regressions were applied to determine the variables to be included in the risk score. The cut-off points to determine a score indicating low or high risk for TB disease were obtained based on the receiver operating characteristics curve. Content validation was carried out through interviews with eight experts to measure each variable′s relevancy. The face validation was conducted among 20 health clinic staff. Seven variables were selected for inclusion in the risk score. The chosen cut-off point was 16 (out of 43), with 91% and 78% sensitivity and specificity, respectively. The scale-level content validity index was 0.83, while the face validity index scores for each element ranged between 0.85 and 1.00. The TBRSS can be considered a validated screening tool for use in screening TB disease risk among smokers, which potentially may lead to an increased detection of TB disease in the community.

Some Manifestations of Tuberculosis in Otorhinolaryngology - Case Series and a Short Review of Related Data from South-Eastern Europe

Tuberculosis is a disease of global outreach that may affect the entire human body but is most commonly located in the lungs. Otorhinolaryngological manifestations of tuberculosis are rare, mostly occurring secondary to pulmonary disease but nevertheless represent significant diagnostic challenges. Nasopharyngeal tuberculosis is rare, representing around 1% of all upper air-way localizations and the most common presentation is in the form of adenoids. Tuberculous glossitis (oral tuberculosis) is even scarcer and may present in various clinical forms, usually mimicking a malignant neoplasm, or, less often, trauma or other infectious lesions. Oropharynx tuberculosis is usually misdiagnosed as hypertrophic chronic tonsillitis. We present four rare cases of ENT tuberculosis, primary adenoiditis and tonsillitis in a 13-year-old girl, a curious case of tuberculous glossitis in a 65-year-old woman, clinically diagnosed as a lingual neoplasm and two cases of tuberculous lymphadenopathy uncommonly located in the submandibular and supraclavicular regions. A comprehensive review of literature follows the case presentations. Tuberculous manifestation in the ear, nose and throat area remains a difficult diagnosis to establish, particularly because of its rarity and non-specific clinical appearance, and should be included in the differential diagnosis of pharynx lesions. An early diagnosis is essential to avoid occurrence of complications.

Analysis and Simulation of Fractional Order Smoking Epidemic Model

In recent years, there are many new definitions that were proposed related to fractional derivatives, and with the help of these definitions, mathematical models were established to overcome the various real-life problems. The true purpose of the current work is to develop and analyze Atangana-Baleanu (AB) with Mittag-Leffler kernel and Atangana-Toufik method (ATM) of fractional derivative model for the Smoking epidemic. Qualitative analysis has been made to `verify the steady state. Stability analysis has been made using self-mapping and Banach space as well as fractional system is analyzed locally and globally by using first derivative of Lyapunov. Also derive a unique solution for fractional-order model which is a new approach for such type of biological models. A few numerical simulations are done by using the given method of fractional order to explain and support the theoretical results.

Reverse vaccinology approach to design a multi-epitope vaccine construct based on the Mycobacterium tuberculosis biomarker PE_PGRS17

Mycobacterium tuberculosis (Mtb) is responsible for high mortality rates in many low- and middle-income countries. This infectious disease remains accountable for around 1.4 million deaths yearly. Finding effective control measures against Mtb has become imperative. Vaccination has been regarded as the safe and lasting control measure to curtail the impact of Mtb. This study used the Mtb protein biomarker PE_PGRS17 to design a multi-epitope vaccine. A previous study predicted a strong antigenic property of PE_PGRS17. Immunogenic properties such as antigenicity, toxicity, and allergenicity were predicted for the PE_PGRS17 biomarker, specific B- and T-cell epitope sequences, and the final multiple epitope vaccine (MEV) construct. Algorithmic tools predicted the T- and B-cell epitopes and those that met the immunogenic properties were selected to construct the MEV candidate for predicted vaccine development. The epitopes were joined via linkers and an adjuvant was attached to the terminals of the entire vaccine construct. Immunogenic properties, and physicochemical and structural predictions gave insight into the MEV construct. The assembled vaccine candidate was docked with a receptor and validated using web-based tools. An immune simulation was performed to imitate the immune response after exposure to a dosed administrated predicted MEV subunit. An in silico cloning and codon optimisation gave insight into optimal expression conditions regarding the MEV candidate. In conclusion, the generated MEV construct may potentially emit both cellular and humoral responses which are vital in the development of a peptide-based vaccine against Mtb; nonetheless, further experimental validation is still required.

Association of the rs4646994 in ACE gene with susceptibility to tuberculosis in a region of the Brazilian Amazon

Background

Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis and represents an important global public health issue. Single-nucleotide polymorphisms and INDELs are common genetic variations that can be located in genes associated with immune response and, therefore, they may have direct implications over the phenotype of susceptibility to infections like tuberculosis. This study aimed to investigate the association between the 17 genetic polymorphisms and susceptibility to tuberculosis in a Brazilian population.

Methods

This case-control study enrolled 283 individuals with active tuberculosis and 145 health care workers. Four INDELs and 13 single nucleotide polymorphisms and were genotyped using Multiplex PCR method and TaqMan SNP Genotyping Assays. Group comparisons for categorical variables were performed using the chi-squared test, whilst the t-Student test was used to analyze the continuous variables. Multiple logistic regression analyses were performed to estimate the odds ratio (OR) with 95% confidence intervals (CI). Deviation from Hardy-Weinberg equilibrium was assessed using chi-squared tests with Bonferroni correction. The results were analyzed comparing the genotypic distributions adopting the dominant model and the estimated values ​​of p corrected for multiple tests through FDR (False Discovery Rate) test.

Results

The HWE test confirmed that the genotypic frequencies for polymorphisms were balanced. The frequency of Del allele was 73 and 75%, in cases and controls respectively. Frequency of Del allele was significantly higher in the control group than TB group. The homozygous Del/Del genotype was present in 51.6% of cases and 58.6% of controls. The rare Ins/Ins genotype was present in only 7.6% of controls and 6% of cases. The ACE Del/Del genotype was significantly higher in the cases than in controls revealing significant protection for TB in the domain model (OR = 0.465; p < 0.005).

Conclusions

The Del/Del genotype of the rs4646994 in ACE gene was associated with susceptibility to tuberculosis. The identification of genetic variants responsible for susceptibility to tuberculosis will allow the development of new diagnostic tools for tuberculosis infection. These studies will help improve control and the future eradication of this disease.

Isolation, Characterization, and Drug Sensitivity of Mycobacterium tuberculosis in Captive Sloth Bears (Melursus ursinus): Unnatural Habitat With Human Environment May Predispose Sloth Bears to Tuberculosis

We describe the isolation, molecular characterization, and drug sensitivity of Mycobacterium tuberculosis recovered from lung tissues of four rescued captive sloth bears (Melursus ursinus) at Bannerghatta Biological Park (BBP), Bangalore, India. These bears had lived most of their life with humans in circus companies. They were rescued and housed in the Bear Rescue Center (BRC) of BBP. Upon rescue, they showed signs of unthriftiness, chronic debility, and failed to respond to symptomatic treatments. Over the period of the next 12–14 months, the four sloth bears died and the post-mortem examination revealed nodular lesions in the lungs that showed the presence of acid-fast bacilli. Polymerase chain reaction (PCR), culture, and nucleotide sequencing confirmed the bacilli as Mycobacterium tuberculosis. Histopathology of the lungs revealed characteristic granulomatous reaction with caseation. We determined the sensitivity of these isolates to rifampicin and isoniazid drugs by a WHO approved test, Line Probe Assay (LPA) using Genotype MTBDRplus VER 2.0. We discuss the role of unnatural habitat with the human environment in predisposing captive sloth bears for tuberculosis (TB). In the absence of any other reliable ante-mortem diagnostic test, this study recommends the use of LPA for early detection of TB in captive wild animals, which will help in taking necessary steps to prevent its further spread to animal caretakers and other susceptible animals in captivity.

Diagnostic Potential of the Serological Response to Synthetic Peptides from Mycobacterium tuberculosis Antigens for Discrimination Between Active and Latent Tuberculosis Infections

Diagnosis and treatment of active tuberculosis (ATB) as well as latent tuberculosis infection (LTBI) are required for effective tuberculosis (TB) control, especially in TB endemic area. The usefulness of conventional tests to distinguish between ATB and LTBI has remained challenging. The present study was aimed to demonstrate the usefulness of the serological response to synthetic peptides from Mycobacterium tuberculosis (Mtb) antigens for discrimination between ATB and LTBI in Warao Amerindians. Serum IgG antibody levels were measured by the indirect ELISA assay using 22 designed and synthesized peptides derived from immunogenic Mtb ESAT-6 and Ag85A proteins. A total of 211 adult Warao Amerindians were included; cases with active TB (ATB, n = 75), latent TB infection (LTBI, n = 85) and non-infected (NI, n = 51). The approach’s diagnostic information was compared using receiver operating characteristic (ROC) curves. For ATB diagnostic performance between ATB and NI; ESAT-6; P-12037 had 100% of sensitivity (AUC = 0.812; 0.733 to 0.891 95% CI); and Ag85A; P-10997 had 100% of specificity (AUC = 0.691; 0.597 to 0.785 95% CI); and ATB and LTBI; Ag85A; P-29878 had 100% of sensitivity (AUC = 0.741; 0.666–0.817 95% CI), and P-29879 had 99% of specificity (AUC = 0.679; 0.593–0.765 95% CI). While that ESAT-6 P-12037 also allowed differentiation between LTBI and NI or healthy ones. It had 98.8% of sensitivity and 98.0% of specificity (AUC = 0.640; 0.545–0.735 95% CI). The potential of combination-antigen immunoassays with peptides could discriminate between Warao Amerindians with ATB, LTBI and NI. Further validation of this approach could lead to developing a complementary tool for rapid diagnosis of TB infections.

Comparing the Treatment Outcomes of Tuberculosis Patients in a Private Clinic with a Governmental Health Center in Jimma City, Ethiopia: Retrospective Study

Background

Tuberculosis (TB) is a common and often deadly infectious disease caused by various strains of mycobacterium, usually mycobacterium tuberculosis in humans. The disease has major causes of morbidity and mortality, particularly where the diagnostic and control program is not far extended.

Objective

To compare the treatment outcomes of tuberculosis patients in a private clinic with a governmental health center in Jimma city, Ethiopia.

Methods

A 10-year cross-sectional retrospective systemic record review was conducted to compare the treatment outcomes, and to describe the socio-demographic factors associated with the outcome in a private clinic with a governmental health center in Jimma city, Jimma, Ethiopia from September 12, 2007, to September 10, 2017. Finally, SPSS/EPI INFO analyzed data.

Results

The present study revealed that within a 10 year duration the private clinic gives anti-TB treatment coverage for 582 patients whereas the governmental health center treats 510 patients. The treatment success rate of the private clinic is 98.1% which is 1.03-fold that of the governmental health center (95.3%); while the treatment failure of the private clinic was 0.2%, but there was no treatment failure in the governmental health center.

Conclusion

Both sectors achieved the expected WHO targets by newly recommended strategy for TB treatment, DOTS (Directly Observed Treatment Short Course) and treatment success is much better to standard. This shows good progress of DOTS strategy and a decrease of noncompliance in this area. Age, educational level, and the types of TB diagnosis and treatment outcome of the patients were statistically associated in both sectors. Better counseling and awareness about the disease should have to be given for every anti-TB treatment receiving patients, despite their educational level and occupational status in both sectors.

Tuberculosis and Migrant Pathways in an Urban Setting: A Mixed-Method Case Study on a Treatment Centre in the Lisbon Metropolitan Area, Portugal

Tuberculosis (TB) is an infectious disease associated with poverty. In the European Union TB tends to concentrate in urban settings. In Lisbon, previous studies revealed, the presence of migrant populations from a high endemic country, is one of the risk factors contributing to TB. To better understand TB in foreign-born individuals in the Lisbon Metropolitan Area, a mixed-method case study was undertaken on a TB treatment centre in a high-risk part of urban Portugal. Quantitatively, annual TB cases were analysed from 2008 to 2018, dividing foreign-origin cases into recent migrants and long-term migrants. Qualitatively, we explored recent migrants’ reasons, experiences and perceptions associated with the disease. Our results showed that foreign-born individuals accounted for 45.7% of cases, mainly originated from Angola, Guinea-Bissau, and Cabo Verde. TB in recent migrants increased over the years for Angola and Guinea-Bissau, while for Cabo Verde TB cases were due to migrants residing in Portugal for more than 2 years. Recent migrants’ reasons to travel to Portugal were to study, to live and work, tourism, and seeking better healthcare. Visiting family and friends, historical links and common language were key drivers for the choice of country. Recent migrants and long-term migrants may present distinct background profiles associated with diagnosed TB.

Tuberculosis Screening via Chest X-Ray is Financially Burdensome in Previously Independently Living Elective Total Knee Arthroplasty Patients

BACKGROUND

In 1995, to reduce the transmission of Tuberculosis (TB) the Centers for Disease Control and Prevention recommended that all patients discharged from hospitals be required to have chest x-rays (i.e., radiography) performed before admission to long term care facilities (LTCFs). Previously independently living patients (PILPs) who undergo elective total knee replacement (TKA) surgery are a population at higher risk to end up in LTCFs for rehabilitation. By 2017, the incidence of TB was 9,105 cases compared to 22,762 in 1995. However, the recommendations that hospitals be required to perform a chest x-ray in all patients (including PILPs) being transferred to LTCF's have remained in place. The purposes of this study were to: a) determine the incidence of TB-positive chest x-rays in PILPS discharged to LTCFs after undergoing elective TKA surgery, and b) assess the cost (i.e., both financial and possible exposure to unnecessary radiation) of mandated chest x-rays before hospital discharge to LTCF for PILPs.

METHODS

Retrospective 2012-2017 patient chart data were collected from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) to identify all elective TKAs for PILPs performed at two Ascension participating centers. Study data included sex, age, body mass index (BMI), length of stay, comorbidities, and chest x-ray results before discharge. Patients who underwent surgery for fracture, infection, trauma, or malignancy were excluded from the study. Categorical data were analyzed using Fisher's exact test and Student's t-test were used for continuous data.

RESULTS

The authors identified 4,041 total elective TKA's, from which 500 PILPs were discharged to a LTCF due to functional, medical and/or social concerns. Chest x-rays were associated with 500 (100%) negative findings for TB. Overall hospital costs for chest x-rays for patient's being discharged to an extended care facility totaled $90,848.

CONCLUSIONS

The mandated use of chest x-rays for TB screening of PILPs undergoing elective surgery TKA prior to discharge to LTCFs appear to place an unnecessary financial burden on the healthcare system. The mandatory use of x-rays for assessment of possible TB infection before transfer to LTCFs appears to also expose PILPs unnecessarily to radiation. Although further studies are needed to verify these results, the authors recommend that perhaps instead chest x-rays should be reserved for patients with specific comorbidities (e.g., patients on immunosuppressive therapy, with HIV, etc.) or for those patients residing in LTCFs prior to surgery.

Global, regional, and national sex differences in the global burden of tuberculosis by HIV status, 1990-2019: results from the Global Burden of Disease Study 2019

BACKGROUND

Tuberculosis is a major contributor to the global burden of disease, causing more than a million deaths annually. Given an emphasis on equity in access to diagnosis and treatment of tuberculosis in global health targets, evaluations of differences in tuberculosis burden by sex are crucial. We aimed to assess the levels and trends of the global burden of tuberculosis, with an emphasis on investigating differences in sex by HIV status for 204 countries and territories from 1990 to 2019.

METHODS

We used a Bayesian hierarchical Cause of Death Ensemble model (CODEm) platform to analyse 21 505 site-years of vital registration data, 705 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, and 680 site-years of mortality surveillance data to estimate mortality due to tuberculosis among HIV-negative individuals. We used a population attributable fraction approach to estimate mortality related to HIV and tuberculosis coinfection. A compartmental meta-regression tool (DisMod-MR 2.1) was then used to synthesise all available data sources, including prevalence surveys, annual case notifications, population-based tuberculin surveys, and tuberculosis cause-specific mortality, to produce estimates of incidence, prevalence, and mortality that were internally consistent. We further estimated the fraction of tuberculosis mortality that is attributable to independent effects of risk factors, including smoking, alcohol use, and diabetes, for HIV-negative individuals. For individuals with HIV and tuberculosis coinfection, we assessed mortality attributable to HIV risk factors including unsafe sex, intimate partner violence (only estimated among females), and injection drug use. We present 95% uncertainty intervals for all estimates.

FINDINGS

Globally, in 2019, among HIV-negative individuals, there were 1·18 million (95% uncertainty interval 1·08-1·29) deaths due to tuberculosis and 8·50 million (7·45-9·73) incident cases of tuberculosis. Among HIV-positive individuals, there were 217 000 (153 000-279 000) deaths due to tuberculosis and 1·15 million (1·01-1·32) incident cases in 2019. More deaths and incident cases occurred in males than in females among HIV-negative individuals globally in 2019, with 342 000 (234 000-425 000) more deaths and 1·01 million (0·82-1·23) more incident cases in males than in females. Among HIV-positive individuals, 6250 (1820-11 400) more deaths and 81 100 (63 300-100 000) more incident cases occurred among females than among males in 2019. Age-standardised mortality rates among HIV-negative males were more than two times greater in 105 countries and age-standardised incidence rates were more than 1·5 times greater in 74 countries than among HIV-negative females in 2019. The fraction of global tuberculosis deaths among HIV-negative individuals attributable to alcohol use, smoking, and diabetes was 4·27 (3·69-5·02), 6·17 (5·48-7·02), and 1·17 (1·07-1·28) times higher, respectively, among males than among females in 2019. Among individuals with HIV and tuberculosis coinfection, the fraction of mortality attributable to injection drug use was 2·23 (2·03-2·44) times greater among males than females, whereas the fraction due to unsafe sex was 1·06 (1·05-1·08) times greater among females than males.

INTERPRETATION

As countries refine national tuberculosis programmes and strategies to end the tuberculosis epidemic, the excess burden experienced by males is important. Interventions are needed to actively communicate, especially to men, the importance of early diagnosis and treatment. These interventions should occur in parallel with efforts to minimise excess HIV burden among women in the highest HIV burden countries that are contributing to excess HIV and tuberculosis coinfection burden for females. Placing a focus on tuberculosis burden among HIV-negative males and HIV and tuberculosis coinfection among females might help to diminish the overall burden of tuberculosis. This strategy will be crucial in reaching both equity and burden targets outlined by global health milestones.

FUNDING

Bill & Melinda Gates Foundation.