Tuberculosis and its future in the COVID-19 era: The Pulmonology series 2021

Drug-Resistant Tuberculosis and COVID-19: A Scoping Review on a New Threat to Antimicrobial Resistance

OBJECTIVE

To assess the impact of COVID-19 on the morbidity and mortality associated with drug-resistant tuberculosis (DR-TB).

METHODS

A comprehensive review of articles published in international databases since December 2019 was conducted. The findings are presented in a narrative format, supplemented with tables, diagrams, and a map created using ArcGIS software.

RESULTS

Thirty-five studies were selected, highlighting the significant consequences of COVID-19 on TB and DR-TB treatment progress. Four main thematic areas were identified: Clinical and epidemiological aspects of the interaction between COVID-19 and DR-TB; Management of physical resources and the team; Challenges and circumstances; Perspectives and possibilities.

CONCLUSIONS

This study revealed that the COVID-19 pandemic significantly negatively impacted the control of long-standing diseases like TB, particularly in the context of morbidity and mortality related to DR-TB.

Decline of tuberculosis notification rate in different populations and regions in Portugal, 2010-2017

BACKGROUND

Tuberculosis (TB) incidence declined in Portugal in recent decades, but trends differ between regions and population subgroups. We investigated these differences to inform prevention and control programmes.

METHODS

We extracted TB notifications from the Portuguese National TB Surveillance System (SVIG-TB) in 2010-2017, disaggregated by region, age group, nationality and HIV status. We calculated notification rates using denominators from the Portuguese National Institute of Statistics and the Joint United Nations Programme on HIV/AIDS and performed stratified time series analysis. We estimated interannual decline percentages and 95% confidence intervals (CI) using Poisson and binomial negative regression models.

RESULTS

The overall TB notification rate decreased from 25.7 to 17.5/100,000 population from 2010 to 2017 (5.2%/year) in Portugal. Interannual decline did not differ significantly between regions, but it was smaller amongst non-Portuguese nationals (-1.57% [CI: -4.79%, 1.75%] vs -5.85% [CI: -6.98%, -4.70%] in Portuguese nationals); children under five years of age (+1.77% [CI: -4.61%, 8.58%] vs -5.38% [CI: -6.33%, -4.42%] in other age groups); and HIV-negative people (-6.47% [CI: -9.10%, -3.77%] vs -11.29% [CI; -17.51%, -4.60%] in HIV-positive).

CONCLUSIONS

The decline in TB notification rates in Portugal during the study period has been steady. However, the decline amongst non-Portuguese nationals, children under five years of age and non-infected-HIV patients was lower. No significant differences were observed between regions. Changes in TB epidemiology in specific risk groups and geographical areas should be closely monitored to achieve the objectives of the End TB Strategy. We recommend intensifying screening of TB in the subpopulations identified.

Effect of COVID-19 pandemic on incidence of mycobacterial diseases among suspected tuberculosis pulmonary patients in Tehran, Iran

Background

Recent pandemic of coronavirus SARS-CoV-2 (COVID-19) caused limitations in the country's strategies to fight against mycobacterial infections. The aim of this study was to compare the suspected tuberculosis (TB) pulmonary patients before and during the COVID-19 pandemic (January 2018-December 2021) who were referred to the National Reference TB Laboratory (NRL TB), Tehran, Iran. The mycobacterial isolated strains were identified and compared with previous data.

Methods

A total of 16,899 clinical samples collected from 7041 suspected pulmonary TB patients were received from 2018 to 2021. Primary isolation of Mycobacterium isolates was done on Löwenstein-Jensen medium. Then, the DNA was extracted from acid-fast bacillus culture-positive samples and identification was performed by IS6110, Hsp65, and 16S-23S rRNA genes using polymerase chain reaction (PCR), PCR-restriction fragment length polymorphism, and nested PCR methods.

Results

A total of 11679 specimens (69.1%) from 4866 suspected TB patients were collected in 2018-2019 and 5220 specimens (30.8%; from 2175 patients) in 2020-2021. Out of 11679 specimens, 2046 samples that belong to 852 patients were infected with Mycobacterium tuberculosis, and the remaining were non-TB Mycobacterium (NTM) species (n = 244) isolated from 102 patients. The cultures for 12894 specimens were either negative (76.3%) or contaminated (845/16899; 5%). A comparison of the total number of patients who were referred for diagnosis and treatment (954/666 patients, P > 0.05) showed a 30.1% reduction during the COVID-19 pandemic. Although, with these low number of patients, the significant increases of NTM species (P < 0.05) among suspected TB pulmonary patients were observed. Besides, new species of NTM, for example, Mycobacterium peregrinum and Mycobacterium montefiorense, were detected. For the past 20 years, these two species were not reported from pulmonary patients in Iran.

Conclusions

During the pandemic of COVID-19, the TB diagnosis network became irregular, as a consequence, many patients could not reach the treatment center, and this could increase the circulation of mycobacterial diseases (TB and NTM). The study shows the emergence of new opportunistic NTM species also.

Improving Assignments for Therapeutic and Prophylactic Treatment Within TB Households. A Potential for Immuno-Diagnosis?

Delays in diagnosis and treatment of pulmonary tuberculosis (TB) can lead to more severe disease and increased transmission. Contact investigation among household contacts (HHCs) of TB patients is crucial to ensure optimal outcomes. In the context of a prospective cohort study in Palamaner, Southern India, this study attempted to assess the potential of 27 different soluble immune markers to accurately assign HHCs for appropriate treatment. A multiplex bead assay was applied on QuantiFERON (QFT)-nil supernatants collected from 89 HHCs grouped by longitudinal QFT status; M. tuberculosis (Mtb) infected (QFT positive at baseline and follow-up, n = 30), recent QFT converters (QFT-negative at baseline, n = 27) and converted to QFT-positivity within 6 months of exposure (at follow-up, n = 24) and QFT consistent negatives (n = 32). The 29 TB index cases represented Active TB. Active TB cases and HHCs with Mtb infection produced significantly different levels of both pro-inflammatory (IFNγ, IL17, IL8, IP10, MIP-1α, MIP1β, and VEGF) and anti-inflammatory (IL9 and IL1RA) cytokines. We identified a 4-protein signature (bFGF, IFNγ, IL9, and IP10) that correctly classified HHCs with Mtb infection vs. Active TB with a specificity of 92.6%, suggesting that this 4-protein signature has the potential to assign HHCs for either full-length TB treatment or preventive TB treatment. We further identified a 4-protein signature (bFGF, GCSF, IFNγ, and IL1RA) that differentiated HHCs with Mtb infection from QFT consistent negatives with a specificity of 62.5%, but not satisfactory to safely assign HHCs to no preventive TB treatment. QFT conversion, reflecting new Mtb infection, induced an elevated median concentration in nearly two-thirds (19/27) of the analyzed soluble markers compared to the levels measured at baseline. Validation in other studies is warranted in order to establish the potential of the immune biosignatures for optimized TB case detection and assignment to therapeutic and preventive treatment of Mtb infected individuals.

The Magnitude of MTB and Rifampicin Resistance MTB Using Xpert-MTB/RIF Assay Among Tuberculosis Suspected Patients in Gedeo Zone, Southern Ethiopia

Background

Tuberculosis (TB) remains a major global health problem causing death among millions of people each year. The new barrier that challenges the control of tuberculosis is the emerging and the increasing number of drug-resistant TB that becomes a world concern. This study aimed to determine the magnitude of rifampicin-resistant Mycobacterium tuberculosis (RR-MTB) among presumptive TB patients attending Dilla University Referral Hospital, Gedeo Zone, Ethiopia.

Methods

A retrospective cross-sectional study was conducted at Dilla University Referral Hospital from January 2014 to December 2020. Sputum results were done using Xpert MTB/RIF assay and other necessary data were collected from the registration logbooks using a standardized data extraction format and analyzed using SPSS version 23 statistical software.

Results

A total of 17,745 presumptive TB patients were included, of which 62.2% were males. The overall prevalence of Mycobacterium tuberculosis (MTB) was 11.8%, of which 5.1% were confirmed to have RR-MTB. Extra-pulmonary TB was reported in 1.5% of the study participants. The highest prevalence of MTB and RR-MTB was recorded in 2017 with a prevalence of 20.1% and 8.5%, respectively. All age groups were significantly associated with a higher prevalence of MTB (p < 0.036). TB patients with a history of previous treatment and HIV positive were significantly associated with MTB (P < 0.021), while RR-MTB was only significantly associated with patients with a history of previous treatment (P < 0.018).

Conclusion

A high magnitude of MTB and RR-MTB was reported among TB patients with HIV and a history of previous treatment. Therefore, coordinated efforts should be applied to the improvement of treatment adherence of known TB cases, and appropriate control and prevention methods to reduce the emergence and increase of MTB and RR-MTB cases.

Gauging the impact of the COVID-19 pandemic on tuberculosis services: a global study

The effects of the coronavirus disease 2019 (COVID-19) pandemic on tuberculosis (TB) disease and TB services emerged in the beginning of 2020 [1, 2]. Epidemiological and clinical studies, including mortality rates of the first cohort of patients with COVID-19 and TB co-infection were described [3, 4]. Several reports from individual countries suggested that the COVID-19 pandemic significantly affected TB services [5–9], including validation by modelling studies [10]. The Global Tuberculosis Network (GTN) reported that the COVID-19 pandemic affected TB services in 33 TB centres from 16 countries in the first 4 months of 2020 [11]. An increased use of telehealth during the COVID-19 pandemic was observed in some TB centres [11]. The major limitations of that study were the short period of observation (January to April 2020 compared to the same period in 2019) and the limited number of variables analysed [11–14].

This global study of 43 TB centres from 19 countries demonstrates the impact of COVID-19 pandemic on TB services. Newly diagnosed TB disease, drug-resistant TB, TB deaths, outpatient clinic attendances and newly diagnosed TB infection were reduced.https://bit.ly/3sdHbfk

Peritoneal Tuberculosis Mimicking Ovarian Cancer: Gynecologic Ultrasound Evaluation with Histopathological Confirmation

Peritoneal tuberculosis (TBP) is a very rare condition, accounting for about 1–2% of all tuberculosis cases. The diagnosis of TBP can be easily mistaken for advanced ovarian cancer (AOC) or peritoneal carcinoma because of overlapping laboratory and clinical findings. We reported the ultrasound characteristics of a case of TBP in a 67-year-old woman who presented to our institute with a 1-month history of intermittent lower abdominal pain, fever, and asthenia. Overall, 20 biopsy-retrieved specimen histopathological features were suggestive of peritoneal tuberculosis. Gynecologic ultrasound revealed increased adnexa with multiple nodular formations spread across the surface, suggestive of caseous nodules. Although this is a rare occurrence, clinicians should consider TBP as a differential diagnosis of ovarian or peritoneal cancer.