Tuberculosis associated mortality in a prospective cohort in Sub Saharan Africa: Association with HIV and antiretroviral therapy

Mortality among persons with tuberculosis in Zambian hospitals: A retrospective cohort study

Tuberculosis (TB) mortality in Zambia remains high at 86 per 100,000 populations, translating to approximately 15,000 TB-related deaths annually. We conducted a nationwide retrospective cohort study to understand predictors, time to death, and probable causes of mortality among persons on TB treatment in Zambia. We reviewed medical records for persons with TB registered in 54 purposively selected hospitals in Zambia between January and December 2019. We fitted a Cox proportional hazards model to identify predictors of mortality. Of the 13,220 records abstracted, 10,987 were analyzed after excluding records of persons who transferred in from other hospitals, those with inconsistent dates and those whose treatment outcome was not evaluated. The majority of persons with TB were men, (61.5%, n = 6,761) with a median age of 36 years (IQR: 27-46 years). Overall, 1,063 (9.7%) died before completing TB treatment (incidence rate = 16.9 deaths per 1,000 person-months). Median age at death was 40 years (IQR: 31-52). The majority of deaths (75.7%, n = 799) occurred in the first two months of TB treatment, with a median time to death of 21 days (IQR: 6-57). Independent risk factors for TB mortality included age >54 years, being treated in Eastern, Southern, Western, Muchinga and Central provinces, receiving treatment from a third-level or mission hospital, methods of diagnosis other than Xpert MTB/RIF, extrapulmonary TB (EPTB), and positive HIV status. Probable causes of death were septic shock (18.8%), TB Immune Reconstitution Inflammatory Syndrome (TB IRIS) (17.8%), end-organ damage (13.4%), pulmonary TB (11.4%), anemia (9.6%) and TB meningitis (7.8%). These results show high mortality among people undergoing TB treatment in Zambia. Interventions targeted at persons most at risk such as the elderly, those with EPTB, and those living with HIV, can help reduce TB-related mortalities in Zambia.

Incidence rate of mortality and its predictors among tuberculosis and human immunodeficiency virus coinfected patients on antiretroviral therapy in Ethiopia: systematic review and meta-analysis

Background

Tuberculosis (TB) is the leading cause of death among HIV-infected adults and children globally. Therefore, this study was aimed at determining the pooled mortality rate and its predictors among TB/HIV-coinfected patients in Ethiopia.

Methods

Extensive database searching was done via PubMed, EMBASE, SCOPUS, ScienceDirect, Google Scholar, and Google from the time of idea conception on March 1, 2023, to the last search via Google on March 31, 2023. A meta-analysis was performed using the random-effects model to determine the pooled mortality rate and its predictors among TB/HIV-coinfected patients. Heterogeneity was handled using subgroup analysis, meta-regression, and sensitivity analysis.

Results

Out of 2,100 records, 18 articles were included, with 26,291 total patients. The pooled incidence rate of mortality among TB/HIV patients was 12.49 (95% CI: 9.24-15.74) per 100 person-years observation (PYO); I2 = 96.9%. The mortality rate among children and adults was 5.10 per 100 PYO (95% CI: 2.15-8.01; I2 = 84.6%) and 15.78 per 100 PYO (95% CI: 10.84-20.73; I2 = 97.7%), respectively. Age ≥ 45 (pooled hazard ratios (PHR) 2.58, 95% CI: 2.00- 3.31), unemployed (PHR 2.17, 95% CI: 1.37-3.46), not HIV-disclosed (PHR = 2.79, 95% CI: 1.65-4.70), bedridden (PHR 5.89, 95% CI: 3.43-10.12), OI (PHR 3.5, 95% CI: 2.16-5.66), WHO stage IV (PHR 3.16, 95% CI: 2.18-4.58), BMI < 18.5 (PHR 4.11, 95% CI: 2.28-7.40), anemia (PHR 4.43, 95% CI: 2.73-7.18), EPTB 5.78, 95% CI: 2.61-12.78 significantly affected the mortality. The effect of TB on mortality was 1.95 times higher (PHR 1.95, 95% CI: 1.19-3.20; I2 = 0) than in TB-free individuals.

Conclusions

The mortality rate among TB/HIV-coinfected patients in Ethiopia was higher compared with many African countries. Many clinical factors were identified as significant risk factors for mortality. Therefore, TB/HIV program managers and clinicians need to design an intervention early.

Liberia adherence and loss-to-follow-up in HIV and AIDS care and treatment: A retrospective cohort of adolescents and adults from 2016-2019

Antiretroviral therapy (ART) is a lifesaving intervention for people living with HIV infection, reducing morbidity and mortality; it is likewise essential to reducing transmission. The "Treat all" strategy recommended by the World Health Organization has dramatically increased ART eligibility and improved access. However, retaining patients on ART has been a major challenge for many national programs in low- and middle-income settings, despite actionable local policies and ambitious targets. To estimate retention of patients along the HIV care cascade in Liberia, and identify factors associated with loss-to-follow-up (LTFU), death, and suboptimal treatment adherence, we conducted a nationwide retrospective cohort study utilizing facility and patient-level records. Patients aged ≥15 years, from 28 facilities who were first registered in HIV care from January 2016 -December 2017 were included. We used Cox proportional hazard models to explore associations between demographic and clinical factors and the outcomes of LTFU and death, and a multinomial logistic regression model to investigate factors associated with suboptimal treatment adherence. Among the 4185 records assessed, 27.4% (n = 1145) were males and the median age of the cohort was 37 (IQR: 30-45) years. At 24 months of follow-up, 41.8% (n = 1751) of patients were LTFU, 6.6% (n = 278) died, 0.5% (n = 21) stopped treatment, 3% (n = 127) transferred to another facility and 47.9% (n = 2008) were retained in care and treatment. The incidence of LTFU was 46.0 (95% CI: 40.8-51.6) per 100 person-years. Relative to patients at WHO clinical stage I at first treatment visit, patients at WHO clinical stage III [adjusted hazard ratio (aHR) 1.59, 95%CI: 1.21-2.09; p <0.001] or IV (aHR 2.41, 95%CI: 1.51-3.84; p <0.001) had increased risk of LTFU; whereas at registration, age category 35-44 (aHR 0.65, 95%CI: 0.44-0.98, p = 0.038) and 45 years and older (aHR 0.60, 95%CI: 0.39-0.93, p = 0.021) had a decreased risk. For death, patients assessed with WHO clinical stage II (aHR 2.35, 95%CI: 1.53-3.61, p<0.001), III (aHR 2.55, 95%CI: 1.75-3.71, p<0.001), and IV (aHR 4.21, 95%CI: 2.57-6.89, p<0.001) had an increased risk, while non-pregnant females (aHR 0.68, 95%CI: 0.51-0.92, p = 0.011) and pregnant females (aHR 0.42, 95%CI: 0.20-0.90, p = 0.026) had a decreased risk when compared to males. Suboptimal adherence was strongly associated with the experience of drug side effects-average adherence [adjusted odds ratio (aOR) 1.45, 95% CI: 1.06-1.99, p = 0.02) and poor adherence (aOR 1.75, 95%CI: 1.11-2.76, p = 0.016), and attending rural facility decreased the odds of average adherence (aOR 0.01, 95%CI: 0.01-0.03, p<0.001) and poor adherence (aOR 0.001, 95%CI: 0.0004-0.003, p<0.001). Loss-to-follow-up and poor adherence remain major challenges to achieving viral suppression targets in Liberia. Over two-fifths of patients engaged with the national HIV program are being lost to follow-up within 2 years of beginning care and treatment. WHO clinical stage III and IV were associated with LTFU while WHO clinical stage II, III and IV were associated with death. Suboptimal adherence was further associated with experience of drug side effects. Active support and close monitoring of patients who have signs of clinical progression and/or drug side effects could improve patient outcomes.

Retention in Care among Patients Attending a Large HIV Clinic in Nigeria Who Were Treated for Tuberculosis

A retrospective study of 2764 patients was conducted at an HIV clinic in Nigeria to evaluate retention in care in patients treated for TB. At 6 and 12 months after commencement of TB treatment, 1842(66.6%) and 1624(58.8%) participants remained in care. Of the 922 and 1140 not in care at 6 and 12 months, 814(88.3%) and 1006(88.2%) respectively were lost to follow-up (LTFU). VL < 1000copies/ml was associated with higher odds of retention in care at 6 and 12 months (OR  =  2.351 and 2.393) than VL > 1000 copies/ml. HAART use was associated with high likelihood of being in care at 12 months (OR  =  3.980). CD4 counts of 200–350 and >350 cells/mm³ were associated with increased odds of remaining in care at 12 months compared with CD4 < 200 cells/mm³ (p  =  0.005 and p  =  0.001). Targeted interventions such as early HAART and close follow-up for high risk groups are likely to improve retention in care.

Survival and predictors of death in tuberculosis/HIV coinfection cases in Porto Alegre, Brazil: A historical cohort from 2009 to 2013

BACKGROUND

Tuberculosis is a curable disease, which remains the leading cause of death among infectious diseases worldwide, and it is the leading cause of death in people living with HIV. The purpose is to examine survival and predictors of death in Tuberculosis/HIV coinfection cases from 2009 to 2013.

METHODS

We estimated the survival of 2,417 TB/HIV coinfection cases in Porto Alegre, from diagnosis up to 85 months of follow-up. We estimated hazard ratios and survival curves.

RESULTS

The adjusted risk ratio (aRR) for death, by age, hospitalization, and Directly Observed Treatment was 4.58 for new cases (95% CI: 1.14-18.4), 4.51 for recurrence (95% CI: 1.11-18.4) and 4.53 for return after abandonment (95% CI: 1.12-18.4). The average survival time was 72.56 ± 1.57 months for those who underwent Directly Observed Treatment and 62.61 ± 0.77 for those who did not.

CONCLUSIONS

Case classification, age, and hospitalization are predictors of death. The occurrence of Directly Observed Treatment was a protective factor that increased the probability of survival. Policies aimed at reducing the mortality of patients with TB/HIV coinfection are needed.

Adoption of evidence-informed guidelines in prescribing protease inhibitors for HIV-Tuberculosis co-infected patients on rifampicin and effects on HIV treatment outcomes in Uganda

BACKGROUND

We aimed to determine how emerging evidence over the past decade informed how Ugandan HIV clinicians prescribed protease inhibitors (PIs) in HIV patients on rifampicin-based tuberculosis (TB) treatment and how this affected HIV treatment outcomes.

METHODS

We reviewed clinical records of HIV patients aged 13 years and above, treated with rifampicin-based TB treatment while on PIs between1st-January -2013 and 30th-September-2018 from twelve public HIV clinics in Uganda. Appropriate PI prescription during rifampicin-based TB treatment was defined as; prescribing doubled dose lopinavir/ritonavir- (LPV/r 800/200 mg twice daily) and inappropriate PI prescription as prescribing standard dose LPV/r or atazanavir/ritonavir (ATV/r).

RESULTS

Of the 602 patients who were on both PIs and rifampicin, 103 patients (17.1% (95% CI: 14.3-20.34)) received an appropriate PI prescription. There were no significant differences in the two-year mortality (4.8 vs. 5.7%, P = 0.318), loss to follow up (23.8 vs. 18.9%, P = 0.318) and one-year post TB treatment virologic failure rates (31.6 vs. 30.7%, P = 0.471) between patients that had an appropriate PI prescription and those that did not. However, more patients on double dose LPV/r had missed anti-retroviral therapy (ART) days (35.9 vs 21%, P = 0.001).

CONCLUSION

We conclude that despite availability of clinical evidence, double dosing LPV/r in patients receiving rifampicin-based TB treatment is low in Uganda's public HIV clinics but this does not seem to affect patient survival and viral suppression.

Mortality and associated factors among adult patients on tuberculosis treatment in Tanzania: A retrospective cohort study

INTRODUCTION

Tuberculosis (TB) is the global leading cause of death from an infectious agent. Tanzania is among the 30 high TB burden countries with a mortality rate of 47 per 100,000 population and a case fatality of 4%. This study assessed mortality rate, survival probabilities, and factors associated with death among adult TB patients on TB treatment in Tanzania.

METHODS

A retrospective cohort study was conducted utilizing case-based national TB program data of adult (≥15 years) TB cases enrolled on TB treatment from January 2017 to December 2017. We determined survival probabilities using the Kaplan-Meier estimator and a Cox proportional hazard model was used to identify independent risk factors of TB mortality. Hazard ratios and their respective 95% confidence intervals were reported.

RESULTS

Of 53,753 adult TB patients, 1927 (3.6%) died during TB treatment and the crude mortality rate was 6.31 per 1000 person-months. Male accounted for 33,297 (61.9%) of the study population and the median (interquartile range [IQR]) age was 40 (30-53) years. More than half 1027 (56.7%) of deaths occurred in first two months of treatment. Overall survival probabilities were 96%, and 92% at 6th and 12th month respectively. The independent risk factors for TB mortality among TB patients included: advanced age ≥ 45 years (adjusted hazard ratio (aHR) = 1.74, 95% confidence interval (CI) = 1.45-2.08); receiving service at the hospital level (aHR = 1.22, 95% CI = 1.09-1.36); TB/HIV co-infection (aHR = 2.51, 95% CI = 2.26-2.79); facility-based direct observed therapy (DOT) option (aHR = 2.23, 95% CI = 1.95-2.72); having bacteriological unconfirmed TB results (aHR = 1.58, 95% CI = 1.42-1.76); and other referral type (aHR = 1.44, 95% CI = 1.16-1.78).

CONCLUSION

Advanced age, TB/HIV co-infection, bacteriological unconfirmed TB results, other referral types, receiving service at facility-based DOT option and obtaining service at the hospital level were significant contributors to TB death in Tanzania. Appropriate targeted intervention to improve TB referral systems, improve diagnostic capacity in the primary health facilities, minimize delay and misdiagnosis of TB patients might reduce TB mortality.

Tuberculosis Treatment Outcome in Patients with TB-HIV Coinfection in Kuala Lumpur, Malaysia

Background

Tuberculosis (TB) is a serious health threat to people living with human immunodeficiency virus (HIV). This study aimed to identify the characteristics, unsuccessful TB treatment rate, and determinants of unsuccessful TB treatment outcome among patients with TB-HIV coinfection in Kuala Lumpur.

Methods

This was a cross-sectional study. The data of all patients with TB-HIV in the federal territory of Kuala Lumpur from 2013 to 2017 were collected and reviewed. The data were retrieved from the national database (TB Information System) at the Kuala Lumpur Health Department from 1 March 2018 to 31 May 2018.

Results

Out of 235 randomly selected patients with TB-HIV, TB treatment outcome was successful in 57.9% (cured and completed treatment) and unsuccessful in 42.1% (died, failed, or lost to follow-up). Patients who did not receive DOTS (directly observed treatment, short course) (adjusted odds ratio: 21.71; 95% confidence interval: 5.36–87.94) and those who received shorter treatment duration of <6 months (aOR: 34.54; 95% CI: 5.97–199.93) had higher odds for unsuccessful TB treatment outcome.

Conclusions

Nearly half of the patients with TB-HIV had unsuccessful TB treatment outcome. Therefore, it is important to ensure that such patients receive DOTS and continuous TB treatment of >6 months. It is crucial to strengthen and widen the coverage of DOTS, especially among high-risk groups, in healthcare settings. Strict follow-up by healthcare providers is needed for patients with TB-HIV to gain treatment adherence and for better rates of successful TB treatment.

Comparison of first-line tuberculosis treatment outcomes between previously treated and new patients: a retrospective study in Machakos subcounty, Kenya

BACKGROUND

Since 2016, patients with rifampicin-susceptible tuberculosis (TB) have been treated with the 6-month first-line regimen, regardless of treatment history. We assessed treatment outcomes of previously treated and new patients in Machakos subcounty, Kenya.

METHODS

We performed a retrospective cohort study in patients started on first-line treatment between 2016 and 2017. Firth's logistic regression was used to estimate the effect of previous treatment on having a programmatic adverse outcome (either lost to follow-up, death, failure) and treatment failure vs treatment success (either cure or completion).

RESULTS

Of 1024 new and 79 previously treated patients, 88.1% and 74.7% were treated successfully, 6.5% and 7.6% died, 4.2% and 10.1% were lost to follow-up and 1.2% and 7.6% had treatment failure, respectively. Previous treatment predicted having a programmatic adverse outcome (adjusted odds ratio [aOR] 2.4 [95% confidence interval {CI} 1.4 to 4.2]) and treatment failure (aOR 7.3 [95% CI 2.6 to 20.4]) but not mortality. Similar correlations were found in 334 new and previously treated patients with confirmed baseline rifampicin susceptibility.

CONCLUSION

Previously treated patients were more at risk of experiencing a poor treatment outcome, mainly lost to follow-up and treatment failure. Adherence support may reduce lost to follow-up. Rifampicin drug susceptibility testing coverage should increase. More robust retreatment regimens may reduce treatment failure.

Mortality and risk of tuberculosis among people living with HIV in whom TB was initially ruled out

Tuberculosis (TB) misdiagnosis remains a public health concern, especially among people living with HIV (PLHIV), given the high mortality associated with missed TB diagnoses. The main objective of this study was to describe the all-cause mortality, TB incidence rates and their associated risk factors in a cohort of PLHIV with presumptive TB in whom TB was initially ruled out. We retrospectively followed a cohort of PLHIV with presumptive TB over a 2 year-period in a rural district in Southern Mozambique. During the study period 382 PLHIV were followed-up. Mortality rate was 6.8/100 person-years (PYs) (95% CI 5.2-9.2) and TB incidence rate was 5.4/100 PYs (95% CI 3.9-7.5). Thirty-six percent of deaths and 43% of TB incident cases occurred in the first 12 months of the follow up. Mortality and TB incidence rates in the 2-year period after TB was initially ruled out was very high. The TB diagnostic work-up and linkage to HIV care should be strengthened to decrease TB burden and all-cause mortality among PLHIV with presumptive TB.

Improving survival with tuberculosis & HIV treatment integration: A mini-review

Tuberculosis (TB) is a leading cause of morbidity and mortality among HIV-infected patients while HIV remains a key risk factor for the development of active TB infection. Treatment integration is a key in reducing mortality in patients with HIV-TB co-infection. However, this opportunity to improve outcomes of both infections is often missed or poorly implemented. Challenges in TB-HIV treatment integration range from complexities involving clinical management of co-infected patients to obstacles in health service-organization and prioritization. This is evident in high prevalence settings such as in sub-Saharan Africa where TB-HIV co-infection rates reach up to 80 per cent. This review discusses published literature on clinical trials and cohort studies of strategies for TB-HIV treatment integration aimed at reducing co-infection mortality. Studies published since 2009, when several treatment guidelines recommended treatment integration, were included. A total of 43 articles were identified, of which a total of 23 observational studies and nine clinical trials were informative on TB-HIV treatment integration. The data show that the survival benefit of AIDS therapy in patients infected with TB can be maximized among patients with advanced immunosuppression by starting antiretroviral therapy (ART) soon after TB treatment initiation, i.e. in patients with CD4+ cell counts <50 cells/μl. However, patients with greater CD4+ cell counts should defer initiation of ART to no less than eight weeks after initiation of TB treatment to reduce the occurrence and extent of immune reconstitution disease and subsequent hospitalization. Addressing operational challenges in integrating TB-HIV care can significantly improve patient outcomes, generate substantial public health impact by decreasing morbidity and death in settings with a high burden of HIV and TB.

What Are the Barriers for Uptake of Antiretroviral Therapy in HIV-Infected Tuberculosis Patients? A Mixed-Methods Study from Ayeyawady Region, Myanmar

Antiretroviral therapy (ART) coverage among HIV-infected tuberculosis (HIV-TB) patients has been suboptimal in Myanmar and the reasons are unknown. We aimed to assess the ART uptake among HIV-TB patients in public health facilities of Ayeyawady Region from July 2017-June 2018 and explore the barriers for non-initiation of ART. We conducted an explanatory mixed-methods study with a quantitative component (cohort analysis of secondary programme data) followed by a descriptive qualitative component (thematic analysis of in-depth interviews of 22 providers and five patients). Among 12,447 TB patients, 11,057 (89%) were HIV-tested and 627 (5.7%) were HIV-positive. Of 627 HIV-TB patients, 446 (71%) received ART during TB treatment (86 started on ART prior to TB treatment and rest started after TB treatment). Among the 181 patients not started on ART, 60 (33%) died and 41 (23%) were lost-to-follow-up. Patient-related barriers included geographic and economic constraints, poor awareness, denial of HIV status, and fear of adverse drug effects. The health system barriers included limited human resource, provision of ART on 'fixed' days only, weaknesses in counselling, referral and feedback mechanism, and clinicians' reluctance to start ART early due to concerns about immune reconstitution inflammatory syndrome. We urge the national TB and HIV programs to take immediate actions to improve the ART uptake.

Survival model analysis of tuberculosis treatment among patients with human immunodeficiency virus coinfection

Background

Tuberculosis (TB) with human immunodeficiency virus (HIV) coinfection is the highest clinical epidemiology and public health issue. Despite many programs established to tackle the epidemic, TB target controls have not been reached. One of the many factors attributed to the failure in TB treatment is HIV coinfection. The aim of this study is to assess the survival rate of HIV infection among TB patients and the risk factors of death among the TB patients with HIV coinfection during the retro of directly observed treatment, short-course (DOTS) program.

Methods

This study is a retrospective cohort conducted to compare the survivorship between TB/HIV patients for 8 months DOTS. Death among TB patients was considered as failures and those defaulted or survived were censored. The Cox proportional-hazards regression and log-linear model were used to establish the hazard ratio (HR) of death for each variable at baseline and estimate the risk factors effect among TB patients.

Results

The findings revealed that 50% of death from TB/HIV patients were from HIV coinfection (advanced HR = 2.01, 95% confidence interval = 1.13-3.17). The risk of death was significantly higher in HIV-positive TB patients (P = 0.000) during the extension care phase. TB/HIV-positive patients on antiretroviral therapy have decreased survival rate (log-rank test = 14.88, df = 2, P = 0.0001). The probability of TB patients surviving is significantly decreased in HIV positive with some factors such as age, weight, smoking, and alcohol found significant.

Conclusion

The probability of survival in HIV-positive TB patients was significantly lower during the TB treatment. Weight loss, age, alcohol, smoking, and pregnancy were showed to affect the survival probability of TB/HIV patients' coinfection significantly.

Trend Analysis And Seasonality Of Tuberculosis Among Patients At The Hiwot Fana Specialized University Hospital, Eastern Ethiopia: A Retrospective Study

Purpose

Tuberculosis (TB) is one of the top 10 leading killer diseases in developing countries, particularly in Sub-Saharan Africa, including Ethiopia. Thus, this study aimed to assess the trend analysis and seasonality of TB at Hiwot Fana Specialized University Hospital, Eastern Ethiopia.

Methods and patients

A hospital-based retrospective study was conducted on 8,001 patients by reviewing all available patients’ data from January 1, 2015 to April 30, 2019, at the Hiwot Fana Specialized University Hospital, Eastern Ethiopia. Socio-demographic characteristics and results of the GeneXpert assay were taken from the registration book. The data were entered into EpiData 3.1 and analyzed by using the statistical Package for Social Sciences (SPSS) version 20.

Results

From a total of 8,001 samples tested using Genexpert, the overall prevalence of Mycobacterium tuberculosis and rifampicin resistance was found to be 1,254 (15.7%) and 53 (4.1%), respectively. A decreasing trend of TB prevalence was observed, and decreased from 19.3% in 2015, 18.6% in 2016, to 18.4% in 2017, 13.5% in 2018 and down to 13.0% in 2019 (P-value<0.001). The maximum number of TB cases were reported during autumn (454, 17.1%) and summer (310, 17.2%) compared to other seasons of all the study period. Being between the ages of 15–29 years (adjusted odds ratio (AOR)=1.7, 95% confidence interval (CI)=1.41–1.98), of male gender (AOR=0.84, 95% CI=0.75–0.96), experiencing a relapse of TB (AOR=0.51, 95% CI=0.35–0.78), and being HIV positive (AOR=0.51, 95% CI=0.3–0.86) were found to be factors associated with high proportion of tuberculosis.

Conclusion

Prevalence of TB has decreased year to year between January 2015 and April 2019. However, a high percentage of patients are still testing positive for TB with different seasonal variations. Thus, understanding and managing TB in seasonal variation, controlling relapse of TB, and screening of all HIV positive patients are recommended steps to reduce the transmission of tuberculosis in Ethiopia.

Mortality during treatment for tuberculosis; a review of surveillance data in a rural county in Kenya

Background

Globally in 2016, 1.7 million people died of Tuberculosis (TB). This study aimed to estimate all-cause mortality rate, identify features associated with mortality and describe trend in mortality rate from treatment initiation.

Method

A 5-year (2012–2016) retrospective analysis of electronic TB surveillance data from Kilifi County, Kenya. The outcome was all-cause mortality within 180 days after starting TB treatment. The risk factors examined were demographic and clinical features at the time of starting anti-TB treatment. We performed survival analysis with time at risk defined from day of starting TB treatment to time of death, lost-to-follow-up or completing treatment. To account for ‘lost-to-follow-up’ we used competing risk analysis method to examine risk factors for all-cause mortality.

Results

10,717 patients receiving TB treatment, median (IQR) age 33 (24–45) years were analyzed; 3,163 (30%) were HIV infected. Overall, 585 (5.5%) patients died; mortality rate of 12.2 (95% CI 11.3–13.3) deaths per 100 person-years (PY). Mortality rate increased from 7.8 (95% CI 6.4–9.5) in 2012 to 17.7 (95% CI 14.9–21.1) in 2016 per 100PY (P_trend<0.0001). 449/585 (77%) of the deaths occurred within the first three months after starting TB treatment. The median time to death (IQR) declined from 87 (40–100) days in 2012 to 46 (18–83) days in 2016 (P_trend = 0·04). Mortality rate per 100PY was 7.3 (95% CI 6.5–7.8) and 23.1 (95% CI 20.8–25.7) among HIV-uninfected and HIV-infected patients respectively. Age, being a female, extrapulmonary TB, being undernourished, HIV infected and year of diagnosis were significantly associated with mortality.

Conclusions

We found most deaths occurred within three months and an increasing mortality rate during the time under review among patients on TB treatment. Our results therefore warrant further investigation to explore host, disease or health system factors that may explain this trend.

Time delay and associated mortality from negative smear to positive Xpert MTB/RIF test among TB/HIV patients: a retrospective study

Background

The GeneXpert MTB/RIF Assay (Xpert®) is known to be a feasible, effective and a hopeful tool for rapid tuberculosis (TB) diagnosis and treatment. However, little is known about the time delay caused by initial negative sputum smear microscopy (NSSM), but consecutive positive Xpert TB test (PXTBt) and its association with TB mortality in resource-constrained settings. We aimed to estimate the median time delay between initial NSSM but consecutive PXTBt and TB treatment initiation and its association with TB mortality among TB/HIV co-infected patients in Beira, Mozambique.

Methods

we used data from a retrospective cohort study of TB/HIV co-infected patients in six TB services in Beira city. The study included all patients that tested NSSM, followed by a PXTBt in the six health centers with TB services during the year 2015. Data were extracted from the laboratory and TB treatment registers. To assess the difference in median time delays between groups, Mann-Whitney and Kruskal-Wallis tests were computed. To analyze the associations between the time delays and TB mortality, logistic regression model was used.

Results

Among the 283 patients included in the study, median (IQR) age was 31 (17) years, 59.0% were males, 57.6% in the WHO clinical fourth stage of HIV. The median (IQR) values for diagnostic delay, treatment delay and total time delay was 10 (9) days, 13 (12) days and 28 (20) days, respectively. For TB/HIV co-infected patients who tested negative for smear microscopy initially, a total time delay of one month or longer was associated with high mortality (aOR = 12.40, 95% CI: 5.70–22.10).

Conclusion

Our study indicates that delays in TB diagnosis and treatment resulting from initial NSSM, but consecutive PXTBt are common in Beira city and are one of the main factors associated with TB mortality among TB/HIV co-infected patients. Applying GeneXpert assay as gold standard for HIV-positive patients with suspected pulmonary TB or replacing the sputum smear microscopy by Xpert assay and its availability within 24 h is urgently needed to ensure early diagnosis and treatment, and to maximize the impact of the few resources available in the country.

Structural Prediction and Mutational Analysis of Rv3906c Gene of Mycobacterium tuberculosis H37Rv to Determine Its Essentiality in Survival

The emergence of tuberculosis is at the peak; therefore to station it at its lower level we hereby try bioinformatics approach against Mycobacterium tuberculosis [M. tuberculosis] pathogenesis. Rv3906c is a conserved hypothetical gene of M. tuberculosis and contains many GTP binding protein motif DXXG which demonstrate that this gene might be processed in a GTP binding or in GTP hydrolyzing manner. This gene shows interaction with its adjacent genes as well as pcnA which is a polymerase and localized in the extracellular region and found to be a soluble protein. Rv3906c has binding pockets for calcium atom at various positions which prove that calcium might have some role during the process of this gene. GTP binding protein motif DXXG is present in various positions and calcium binds at this site with a C-score of 0.25. Mutational analysis on this motif shows the large decrease of stability after mutation of aspartate residue with glycine. Stress conditions like pH and temperature also change stability of the protein. A decrease in stability at this position might play a role in inhibition of survival of the pathogen. These computational studies of this gene might be a successful step towards drug development against tuberculosis.