Tuberculosis control and elimination 2010-50: cure, care, and social development

Development of tuberculosis treatment decision algorithms in children below 5 years hospitalised with severe acute malnutrition in Zambia and Uganda: a prospective diagnostic cohort study

Background

In children with severe acute malnutrition (SAM) tuberculosis is common, challenging to diagnose, and often fatal. We developed tuberculosis treatment decision algorithms (TDAs) for children under the age of 5 years with SAM.

Methods

In this prospective diagnostic study, we enrolled and followed up children aged <60 months hospitalised with SAM at three tertiary hospitals in Zambia and Uganda from 4 November 2019 to 20 June 2022. We included children aged 2-59 months with SAM as defined by WHO and hospitalised following the WHO clinical criteria. We excluded children with current or history of antituberculosis treatment within the preceding 3 months. They underwent tuberculosis symptom screening, clinical assessment, chest X-ray, abdominal ultrasound, Xpert MTB/RIF Ultra (Ultra) and culture on respiratory and stool samples with 6 months follow-up. Tuberculosis was retrospectively defined using the 2015 standard case definition for childhood tuberculosis. We used logistic regression to develop diagnostic prediction models for a one-step diagnosis and a two-step screening and diagnostic approaches. We derived scores from models using WHO-recommended thresholds for sensitivity and proposed TDAs. This study is registered with ClinicalTrials.gov, NCT04240990.

Findings

Of 1906 children hospitalised with SAM during the study period, 1230 were screened, 1152 were eligible and 603 were enrolled. Of the 603 children enrolled-median age 15 (inter-quartile range (IQR): 11-20) months and 65 (11.0%) living with HIV-114 (18.9%) were diagnosed with tuberculosis, including 51 (8.5%) with microbiological confirmation and 104 (17.2%) initiated treatment at a median of 6(IQR: 2-10) days after inclusion. 108 children were retrospectively classified as having tuberculosis resulting in a prevalence of 17.9% (95% confidence intervals (CI): 15.1; 21.2). 75 (69.4%) children with tuberculosis reported cough of any duration, 32 (29.6%) cough ≥2 weeks and 11 (10.2%) tuberculosis contact history. 535 children had complete data and were included in the diagnostic prediction model. The one-step diagnostic model had 15 predictors, including Ultra, clinical, radiographic, and abdominal features, an area under the receiving operating curve (AUROC) of 0.910, and derived TDA sensitivity of 86.14% (95% CI: 78.07-91.56) and specificity of 80.88% (95% CI: 76.91-84.30). The two-step model had AUROCs of 0.750 and 0.912 for screening and diagnosis, respectively, and derived combined TDA sensitivity of 79.21% (95% CI: 70.30-85.98) and a specificity of 83.64% (95% CI: 79.87-86.82).

Interpretation

Tuberculosis prevalence was high among hospitalised children with SAM, with atypical clinical features. TDAs achieved satisfactory diagnostic accuracy and could be used to improve diagnosis in this vulnerable group.

Funding

Unitaid.

Immune profiles of MCP-1 with M tb antigens and recombinant cytokines stimulation in tuberculosis

Tuberculosis is caused by Mycobacterium tuberculosis (M tb), which is recognized by macrophages and produces inflammatory cytokines, and chemokines at the site of infection. The present study was proposed to understand the interaction of M tb antigens, cytokines, and chemokines. We have evaluated the chemokine MCP-1 levels and its expression in PBMCs stimulated with M tb antigens Ag85A, ESAT6 and recombinant cytokines rhTNF-α, rhIFN-γ, rhTGF-β, and rhIL-10 in active pulmonary TB (APTB) patients, household contacts (HHC) at 0 months, 6 months and healthy controls (HC). We have observed low levels of MCP-1 with Ag85A, ESAT6, and rhTNF-α stimulations in APTB 0M compared to HHC and HC (p < 0.0067, p < 0.0001, p < 0.01, p < 0.005, p < 0.0065, p < 0.0001) and significantly increased after treatment with rhTNF-α. The MCP-1 levels with rhIFN-γ were high in APTB, HHC at 0 M and significant between APTB 0 M vs. 6 M, HHC vs. HC, and HHC 0M vs. 6M (p < 0.0352, p < 0.0252, p < 0.00062). The rhTGF-β, rhIL-10 induced high MCP-1 levels in APTB, HHC compared to HC (p < 0.0414, p < 0.0312, p < 0.004, p < 0.0001) and significantly decreased after treatment with rhIL-10 (p < 0.0001). The MCP-1 expression was low with all the stimulations in APTB 0M when compared to HC and after treatment. Whereas, HHC shown low MCP-1 expression with rhTNF-α, rhIFN-γ and Ag85A and high with rhTGF-β, rhIL-10 and ESAT6. In conclusion, the study determined the differential expression and production of MCP-1 with M tb antigens and recombinant cytokines. Further, cohort studies are required to study these interaction to identify the high risk individuals, which might help for TB control.

The impact of ethical implications intertwined with tuberculosis household contact investigation: a qualitative study

Background

Household contact investigation (HCI) is an effective and widely used approach to identify persons with tuberculosis (TB) disease and infection, globally. Despite widespread recommendations for the use of HCI, there remains poor understanding of the impact on and value of contact investigation for participants. Further, how HCI as a practice impacts psychosocial factors, including stigma and possible unintended disclosure of illness among persons with TB, their families, and communities, is largely unknown.

Methods

This exploratory qualitative study nested within a randomized trial (ClinicalTrials.gov: NCT04520113, 17 August 2020) was conducted in South Africa to understand the impacts of HCI on index patients living with TB and their household contact persons in two rural districts in the Limpopo province (Vhembe and Capricorn) and Soshanguve, a peri-urban township in Gauteng province. People with TB and household members of people with TB were recruited to participate in in-depth interviews and focus group discussions using semi-structured guides. We explored individual, interpersonal, and community-level perceptions of potential impacts of household contact investigation to elucidate their perceptions of HCI. Thematic analysis identified key themes.

Results

Twenty-four individual interviews and six focus group discussions (n=39 participants) were conducted. Participants viewed HCI as an effective approach to finding TB cases, helpful in educating households about TB symptoms and reducing barriers to health-related services. At the interpersonal level, HCI aided people with TB in safely disclosing their TB status to family members and facilitated family and social support for accountability. The introduction of HIV testing during HCI was reported by some participants as making household members slightly uncomfortable, decreasing interest in household members being tested for TB. HCI negatively impacted community-level TB and HIV-related stigma due to healthcare worker visibility at home.

Conclusion

Our data suggests varying impacts of HCI on people with TB, their families and interpersonal relationships, and communities, highlighting the importance of considering approaches that address concerns about community stigma and HIV testing to enhance acceptance of HCI.

Undernutrition as a risk factor for tuberculosis disease

BACKGROUND

Tuberculosis (TB) is a leading cause of mortality due to an infectious disease, with an estimated 1.6 million deaths due to TB in 2022. Approximately 25% of the global population has TB infection, giving rise to 10.6 million episodes of TB disease in 2022. Undernutrition is a key risk factor for TB and was linked to an estimated 2.2 million TB episodes in 2022, as outlined in the World Health Organization (WHO) Global Tuberculosis Report.

OBJECTIVES

To determine the prognostic value of undernutrition in the general population of adults, adolescents, and children for predicting tuberculosis disease over any time period.

SEARCH METHODS

We searched the literature databases MEDLINE (via PubMed) and WHO Global Index Medicus, as well as the WHO International Clinical Trials Registry Platform (ICTRP) on 3 May 2023 (date of last search for all databases). We placed no restrictions on the language of publication.

SELECTION CRITERIA

We included retrospective and prospective cohort studies, irrespective of publication status or language. The target population comprised adults, adolescents, and children from diverse settings, encompassing outpatient and inpatient cohorts, with varying comorbidities and risk of exposure to tuberculosis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and the Quality In Prognosis Studies (QUIPS) tool to assess the risk of bias of the studies. Prognostic factors included undernutrition, defined as wasting, stunting, and underweight, with specific measures such as body mass index (BMI) less than two standard deviations below the median for children and adolescents and low BMI scores (< 18.5) for adults and adolescents. Prognostication occurred at enrolment/baseline. The primary outcome was the incidence of TB disease. The secondary outcome was recurrent TB disease. We performed a random-effects meta-analysis for the adjusted hazard ratios (HR), risk ratios (RR), or odds ratios (OR), employing the restricted maximum likelihood estimation. We rated the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 51 cohort studies with over 27 million participants from the six WHO regions. Sixteen large population-based studies were conducted in China, Singapore, South Korea, and the USA, and 25 studies focused on people living with HIV, which were mainly conducted in the African region. Most studies were in adults, four in children, and three in children and adults. Undernutrition as an exposure was usually defined according to standard criteria; however, the diagnosis of TB did not include a confirmatory culture or molecular diagnosis using a WHO-approved rapid diagnostic test in eight studies. The median follow-up time was 3.5 years, and the studies primarily reported an adjusted hazard ratio from a multivariable Cox-proportional hazard model. Hazard ratios (HR) The HR estimates represent the highest certainty of the evidence, explored through sensitivity analyses and excluding studies at high risk of bias. We present 95% confidence intervals (CI) and prediction intervals, which present between-study heterogeneity represented in a measurement of the variability of effect sizes (i.e. the interval within which the effect size of a new study would fall considering the same population of studies included in the meta-analysis). Undernutrition may increase the risk of TB disease (HR 2.23, 95% CI 1.83 to 2.72; prediction interval 0.98 to 5.05; 23 studies; 2,883,266 participants). The certainty of the evidence is low due to a moderate risk of bias across studies and inconsistency. When stratified by follow-up time, the results are more consistent across < 10 years follow-up (HR 2.02, 95% CI 1.74 to 2.34; prediction interval 1.20 to 3.39; 22 studies; 2,869,077 participants). This results in a moderate certainty of evidence due to a moderate risk of bias across studies. However, at 10 or more years of follow-up, we found only one study with a wider CI and higher HR (HR 12.43, 95% CI 5.74 to 26.91; 14,189 participants). The certainty of the evidence is low due to the moderate risk of bias and indirectness. Odds ratio (OR) Undernutrition may increase the odds of TB disease, but the results are uncertain (OR 1.56, 95% CI 1.13 to 2.17; prediction interval 0.61 to 3.99; 8 studies; 173,497 participants). Stratification by follow-up was not possible as all studies had a follow-up of < 10 years. The certainty of the evidence is very low due to the high risk of bias and inconsistency. Contour-enhanced funnel plots were not reported due to the few studies included. Risk ratio (RR) Undernutrition may increase the risk of TB disease (RR 1.95, 95% CI 1.72 to 2.20; prediction interval 1.49 to 2.55; 4 studies; 1,475,867 participants). Stratification by follow-up was not possible as all studies had a follow-up of < 10 years. The certainty of the evidence is low due to the high risk of bias. Contour-enhanced funnel plots were not reported due to the few studies included.

AUTHORS' CONCLUSIONS

Undernutrition probably increases the risk of TB two-fold in the short term (< 10 years) and may also increase the risk in the long term (> 10 years). Policies targeted towards the reduction of the burden of undernutrition are not only needed to alleviate human suffering due to undernutrition and its many adverse consequences, but are also an important part of the critical measures for ending the TB epidemic by 2030. Large population-based cohorts, including those derived from high-quality national registries of exposures (undernutrition) and outcomes (TB disease), are needed to provide high-certainty estimates of this risk across different settings and populations, including low and middle-income countries from different WHO regions. Moreover, studies including children and adolescents and state-of-the-art methods for diagnosing TB would provide more up-to-date information relevant to practice and policy.

FUNDING

World Health Organization (203256442).

REGISTRATION

PROSPERO registration: CRD42023408807 Protocol: https://doi.org/10.1002/14651858.CD015890.

Combating antimicrobial resistance in malaria, HIV and tuberculosis

Antimicrobial resistance poses a significant threat to the sustainability of effective treatments against the three most prevalent infectious diseases: malaria, human immunodeficiency virus (HIV) infection and tuberculosis. Therefore, there is an urgent need to develop novel drugs and treatment protocols capable of reducing the emergence of resistance and combating it when it does occur. In this Review, we present an overview of the status and underlying molecular mechanisms of drug resistance in these three diseases. We also discuss current strategies to address resistance during the research and development of next-generation therapies. These strategies vary depending on the infectious agent and the array of resistance mechanisms involved. Furthermore, we explore the potential for cross-fertilization of knowledge and technology among these diseases to create innovative approaches for minimizing drug resistance and advancing the discovery and development of new anti-infective treatments. In conclusion, we advocate for the implementation of well-defined strategies to effectively mitigate and manage resistance in all interventions against infectious diseases.

Evaluating Treatment Outcomes and Tuberculosis Infection Risks: A Comparative Study of Centralized Hospitalization vs. Home-Based Treatment

Background: Guizhou Province in Southwest China has experimented with a centralized hospitalization (CH) treatment for active and severe cases of pulmonary tuberculosis (PTB). The objective of this study was to compare treatment outcomes of patients with tuberculosis (TB) receiving care in a CH setting with those receiving home-based (HB) care. In addition, this study aimed to assess the probability of their household contacts contracting tuberculosis infection. Method: A retrospective review of medical records was undertaken for patients with TB who completed their treatment in four counties in Guizhou, China, spanning from January 2022 to August 2023. In addition, a cross-sectional survey was conducted on the tuberculin skin test (TST) among household contacts of new patients with TB who had completed their treatment. Results: In the retrospective study, 94.8% had successful CH treatment, and 93.1% had successful HB treatment (p value = 0.70). In the prospective study, 559 and 448 household contacts of patients receiving CH treatment had 16 positive and 89 negative TST results, whereas those with HB treatment showed 26 positive and 74 negative TST results. Regarding a logistic regression analysis, the CH group was nearly two times more likely to test negative on the TST, 1.95 (95% CI: 0.98, 3.92). After adjusting for confounding variables, the odds ratio increased significantly to 4.42 (95% CI: 1.22, 16.04). Conclusions: CH for treatment of TB did not show superior success rates, but it may reduce the risk of transmitting tuberculosis infection to household contacts compared to home treatment.

Food Insecurity and Undernutrition Are Associated With Distinct Immunologic Profiles in People With Tuberculosis and Advanced HIV Starting Antiretroviral Therapy

BACKGROUND

Food insecurity and undernutrition are related but distinct concepts contributing to poor HIV and tuberculosis outcomes. Pathways linking them with immunologic profile, which may relate to clinical outcomes, remain understudied.

METHODS

We analyzed data from a cohort study of 165 antiretroviral therapy (ART)-naïve adults with advanced HIV and newly diagnosed tuberculosis in Botswana from 2009 to 2013. Twenty-nine plasma biomarkers were measured pre-ART and 4 weeks post-ART initiation. We used principal components analysis (PCA) and multivariable linear regression models to assess relationships between immunological profiles and food insecurity (based on the Household Food Insecurity Access Scale), undernutrition (body mass index <18.5 kg/m 2 ), and clinical outcomes.

RESULTS

PCA identified 5 principal components with eigenvalues >1. After adjustment, food insecurity was associated with PC3 pre-ART (0.19 per increased category of severity, 95% CI: 0.02 to 0.36) and post-ART (0.24, 95% CI: 0.07 to 0.41). PC3 was driven by higher levels of IFN-α, IFN-γ, interleukin (IL)-12p40, vascular endothelial growth factor, IL-1α, and IL-8 and decreased concentrations of IL-3. Undernutrition was associated with PC5 post-ART (0.49, 95% CI: 0.16 to 0.82). PC5 was driven by higher levels of IL-8, MIP-1α, IL-6, and IL-10 and decreased concentrations in IP-10 and IFN-α. Post-ART PC3 (4.3 percentage point increased risk per increased score of 1, 95% CI: 0.3 to 8.9) and post-ART PC5 (4.8, 95% CI: 0.6 to 8.9) were associated with death in adjusted models.

DISCUSSION

We identified 2 distinct immunologic profiles associated with food insecurity, undernutrition, and clinical outcomes in patients with advanced HIV and tuberculosis. Different pathophysiologic processes may link food insecurity and undernutrition with poor outcomes in this vulnerable patient population. Future studies should assess the impact of improving food access and intake on immune function and clinical outcomes.

Study of Culture Conversion in Drug-Resistant Pulmonary Tuberculosis on All-Oral Longer Regimen at IGIMS, Patna

Background

Multidrug-resistant tuberculosis (MDR-TB) refers to tuberculosis that resists at least two primary drugs, namely isoniazid and rifampicin. To assess the management of MDR-TB, sputum culture conversion is performed. This study aimed to determine the culture conversion status of MDR-TB patients undergoing an all-oral longer regimen.

Methods

This research constitutes an observational and prospective study conducted within a hospital setting. The study was done at the Department of Microbiology, IGIMS, Patna, from October 2020 to March 2022. Culture conversion in multidrug resistance pulmonary tuberculosis on all-oral longer regimens took one spot and one morning sample of sputum as per standard protocol after completing two months of all-oral longer regimens and culturing it in liquid broth using Mycobacterium Growth Indicator Tube (MGIT) 960 System at two, four then six months till we got a negative result.

Results

Maximum number of the cases, 77 (74.8%), belonged to 19-35 years of age group. Males were 68 (66.1%) and females were 35 (33.9%), respectively, with male to female ratio of 1.9:1. After 2 months of oral longer regimen treatment, out of 103 cases, we found 98 (95.1%) patients had sputum for culture positive and only five (4.2%) patients had sputum for culture negative. After 6 months of oral longer regimen treatment, out of 101 cases, we found 16 (15.8%) patients had sputum for culture positive and 85 (85.2%) patients had sputum for culture negative.

Conclusion

In patients with multidrug-resistant pulmonary tuberculosis (MDR-TB) who received an all-oral longer regimen, the introduction of bedaquiline led to positive outcomes as evidenced by a greater number of negative sputum cultures, a decrease in culture reversions, and a reduced risk of developing a more resistant form of MDR-TB.

Analysis of Dietary and Nutritional Status of Tuberculosis Patients in Hulunbuir Region

Objective

Tuberculosis (TB) is a major public health problem that affects millions of people worldwide. Malnutrition is a common complication of TB and can worsen the disease outcome. The purpose of this study was to investigate the dietary and nutritional status, as well as the dietary structure, of TB patients in Hulunbuir City, Inner Mongolia, China. Additionally, the study aimed to analyze the factors that influence the nutritional status in order to provide a theoretical foundation for the prevention and treatment of TB and related issues.

Methods

A cross-sectional study was conducted on 334 randomly selected TB patients from Hulunbuir City Second Hospital. A questionnaire survey was administered to collect information on demographic characteristics, dietary habits, and food intake. Nutritional status was assessed by body mass index (BMI). Dietary diversity score (DDS) was calculated based on the number of food groups consumed in the previous 24 hours. Statistical analysis was performed using SPSS 20.0 software. Descriptive statistics employed rates and composition ratios, and categorical data was represented using frequencies and percentages. The chi-square test was used to analyze the association between nutritional status and other variables, with a significance level set at α=0.05. Multivariable ordinal logistic regression analysis was performed to identify the independent factors affecting the nutritional status of TB patients.

Results

The univariate analysis revealed statistically significant differences (P < 0.05) in the nutritional status (as measured by BMI) among tuberculosis patients, considering ethnicity, educational level, smoking, meat-based diet, vegetable consumption, and DDS grading. No statistically significant differences were found regarding gender, age, marital status, occupation, sleep duration, alcohol consumption, and consumption of rice and flour dishes. Statistically significant variables from the univariate analysis were included in a multivariable ordinal logistic regression analysis model. The findings highlighted that educational level (high school or below), smoking, meat-based diet, DDS scores of 1-3, and a primarily vegetable-based diet had independent effects on the nutritional status of tuberculosis patients (all P < 0.05). No significant difference was found in nutritional status between the Han ethnic group and other ethnicities.

Conclusion

The study revealed that the dietary and nutritional status of TB patients in Hulunbuir City was suboptimal and influenced by several factors. Smoking, meat-based diet, and low dietary diversity score were the primary risk factors for malnutrition among TB patients. The study suggests that nutritional education and intervention programs should be implemented for TB patients to improve their dietary quality and nutritional status.

Toward tuberculosis elimination by understanding epidemiologic characteristics and risk factors in Hainan Province, China

BACKGROUND

The disease burden of tuberculosis (TB) was heavy in Hainan Province, China, and the information on transmission patterns was limited with few studies. This atudy aims to further explore the epidemiological characteristics and influencing factors of TB in Hainan Province, and thereby contribute valuable scientific evidences for TB elimination in Hainan Province.

METHODS

The TB notification data in Hainan Province from 2013 to 2022 were collected from the Chinese National Disease Control Information System Tuberculosis Surveillance System, along with socio-economic data. The spatial-temporal and population distributions were analyzed, and spatial autocorrelation analysis was conducted to explore TB notification rate clustering. In addition, the epidemiological characteristics of the cases among in-country migrants were described, and the delay pattern in seeking medical care was investigated. Finally, a geographically and temporally weighted regression (GTWR) model was adopted to analyze the relationship between TB notification rate and socio-economic indicators. The tailored control suggestions in different regions for TB elimination was provided by understanding epidemiological characteristics and risk factors obtained by GTWR.

RESULTS

From 2013 to 2022, 64,042 cases of TB were notified in Hainan Province. The estimated annual percentage change of TB notification rate in Hainan Province from 2013 to 2020 was - 6.88% [95% confidence interval (CI): - 5.30%, - 3.69%], with higher rates in central and southern regions. The majority of patients were males (76.33%) and farmers (67.80%). Cases among in-country migrants primarily originated from Sichuan (369 cases), Heilongjiang (267 cases), Hunan (236 cases), Guangdong (174 cases), and Guangxi (139 cases), accounting for 53%. The majority (98.83%) of TB cases were notified through passive case finding approaches, with delay in seeking care. The GTWR analysis showed that gross domestic product per capita, the number of medical institutions and health personnel per 10,000 people were main factors affecting the high TB notification rates in some regions in Hainan Province. Different regional tailored measures such as more TB specialized hospitals were proposed based on the characteristics of each region.

CONCLUSIONS

The notification rate of TB in Hainan Province has been declining overall but still remained high in central and southern regions. Particular attention should be paid to the prevalence of TB among males, farmers, and out-of-province migrant populations. The notification rate was also influenced by economic development and medical conditions, indicating the need of more TB specialized hospitals, active surveillance and other tailored prevention and control measures to promote the progress of TB elimination in Hainan Province.

The environmental and socioeconomic effects of tuberculosis patients in the southwest of China: a population-based study

OBJECTIVE

The objective of this study was to assess the incidence of tuberculosis (TB) and find the risk factors of TB patients with a high burden of TB in socioeconomic level, the high level of TB incidence and the great changes of economic and social factors, explore the possible factors, construct scientific and robust prediction model, and analyse whether the task of stopping TB can be accomplished by the expected global deadline.

STUDY DESIGN

This was an ecological study.

METHODS

Descriptive analysis, spatial and space-time scan, correlation analysis, and regression analysis were carried out, based on cases of TB in Sichuan Province and ecological data from 2006 to 2017, to explore the characters of TB and ecological factors, using the transfer function-noise model to forecast the trend of TB until 2035.

RESULTS

Factors affecting the incidence of TB, increasing per capita green area, reporting status of TB among Tibetans and Yi minorities, comprehensive treatment management, total cost of TB per capita for urban residents, proportion of males with high school education, 20 to 20 h of 24-h accumulated precipitation, reducing HIV at the same time as AIDS deaths, the increase in the proportion of males in junior high school education, and the increase in the number of registered TB cases can reduce the incidence of TB.

CONCLUSIONS

There was concentration mainly on enhanced control of the environment and society measures, helpful in guiding government planning to control TB. Reinforcement is required to reduce the TB of population aged 15-24 and aged 25-64 in socioeconomic level by 2035.

Spatial distribution and determinants of tuberculosis incidence in Mozambique: A nationwide Bayesian disease mapping study

INTRODUCTION

Mozambique is a high-burden country for tuberculosis (TB). International studies show that TB is a disease that tends to cluster in specific regions, and different risk factors (HIV prevalence, migration, overcrowding, poverty, house condition, temperature, altitude, undernutrition, urbanization, and inadequate access to TB diagnosis and treatment) are reported in the literature to be associated with TB incidence. Although Mozambique has a higher burden of TB, the spatial distribution, and determinants of TB incidence at the sub-national level have not been studied yet for the whole country. Therefore, we aimed to analyze the spatial distribution and determinants of tuberculosis incidence across all 154 districts of Mozambique and identify the hotspot areas.

METHOD

We conducted an ecological study with the district as our unit of analysis, where we included all cases of tuberculosis diagnosed in Mozambique between 2016 and 2020. We obtained the data from the Mozambique Ministry of Health and other publicly available open sources. The predictor variables were selected based on the literature review and data availability at the district level in Mozambique. The parameters were estimated through Bayesian hierarchical Poisson regression models using Markov Chain Monte Carlo simulation.

RESULTS

A total of 512 877 people were diagnosed with tuberculosis in Mozambique during our five-year study period. We found high variability in the spatial distribution of tuberculosis incidence across the country. Sixty-two districts out of 154 were identified as hotspot areas. The districts with the highest incidence rate were concentrated in the south and the country's central regions. In contrast, those with lower incidence rates were mainly in the north. In the multivariate analysis, we found that TB incidence was positively associated with the prevalence of HIV (RR: 1.23; 95 % CrI 1.13 to 1.34) and negatively associated with the annual average temperature (RR: 0.83; 95 % CrI 0.74 to 0.94).

CONCLUSION

The incidence of tuberculosis is unevenly distributed across the country. Lower average temperature and high HIV prevalence seem to increase TB incidence. Targeting interventions in higher-risk areas and strengthening collaboration between HIV and TB programs is paramount to ending tuberculosis in Mozambique, as established by the WHO's End TB strategy and the Sustainable Development Goals.

Mycobacterium marinum mediates regulation of prostaglandin E2 expression on host immune response through cyclooxygenase pathway

PURPOSE

Investigate the role of COX signaling in activating the PGE2-EP2 pathway.

METHODS

Utilized a marine Mycobacterium infection model in zebrafish. Marine mycobacteria were stained with fluorescein isothiocyanate. The COX inhibitor indomethacin, EP2 receptor inhibitor AH6809, EP4 receptor inhibitor AH23848 and clodronate Liposomes were used to investigate the role of COX, EP2, EP4 and macrophage whether participating in combat marine mycobacterial infection. The expression level of the target gene was detected using real-time fluorescence quantitative PCR instrument.

RESULTS

The findings revealed that larvae exposed to the COX inhibitor indomethacin or the EP2 receptor inhibitor AH6809 demonstrated a significantly higher mortality rate due to marine mycobacterium infection than those in the control group. Administration of exogenous prostaglandin E2 (PGE2) rescued the survival of zebrafish infected with marine mycobacteria and treated with indomethacin. Additionally, a significant reduction in survival rate was noted in macrophage-depleted zebrafish infected with marine mycobacteria.

CONCLUSION

The host may combat marine mycobacterium infection via COX signaling, which activates the PGE2-EP2 pathway and mediates macrophage resistance.

"I Would Rather Die Drinking than take the Medicine": Role of Alcohol Use Disorder in Loss-to-follow-up of Tuberculosis Treatment in a Rural Area of Ballabgarh, Haryana

Introduction

Alcohol use disorder (AUD) is a significant risk factor for tuberculosis (TB) treatment loss-to-follow-up (LTFU). This field-based study was undertaken to understand the role of AUD and TB treatment LTFU and the reasons behind this association in a rural area of Ballabgarh, Haryana.

Material and Methods

TB patients who had completed their treatment and who had been LTFU were included in the study, along with the National TB Elimination Program (NTEP) staff, healthcare providers, family, and community members from Ballabgarh block of the north Indian state of Haryana. In-depth interviews (IDIs) and focused group discussions (FGDs) were conducted to gauge the perceptions of stakeholders regarding reasons for LTFU, especially in the context of alcohol use. Inductive analysis of the transcripts was done in keeping with the grounded theory, and themes with their sub-themes were identified. A conceptual framework of TB-AUD was constructed, and potential areas for intervention were determined.

Results

Fifty-eight IDIs and four FGDs were conducted in mid-2018. Almost all key informants and many patient participants believed that alcohol use makes TB patients highly susceptible to treatment LTFU. Key themes identified were shared personality traits and attitudes, combined side effects of anti-tubercular drugs and alcohol use, lack of family support, and an adverse financial situation.

Conclusion

These findings call for a change in NTEP's approach to AUD-TB. Interventions may include collecting alcohol use information at patient enrolment and closure, integrating brief interventions for alcohol cessation in NTEP, and linking patients to deaddiction centers with the provision of appropriate dietary and financial support.

'They didn't look at me with good eyes' - experiences of the socioeconomic impact of tuberculosis and support needs among adults in a semi-rural area in Mozambique: A Qualitative Study

Tuberculosis is recognised as a disease of the economically disadvantaged people due to its association with financial vulnerability. Mozambique still faces the challenge of the high burden of TB and associated costs. We aimed to understand the social and economic impacts of TB and the need for social support among people with TB in Mozambique. We conducted a qualitative study using a phenomenological approach focusing on the lived experiences and perceptions of people with TB. A total of 52 semi-structured one-to-one in-depth interviews were conducted and data were analysed using a reflexive thematic analysis. Three themes were drawn from the analysis: (i) TB has a social and economic impact that requires adaptation and resourcefulness amongst those affected; (ii) People with TB have different preferences and needs for social support, and (iii) People with TB have different knowledge of, and experiences with, formal social support. TB affects family and community relationships mainly due to impacts on the household's finances. People with TB in Mozambique are not entitled to any form of social support, and they need to rely on help from family and the community which is often insufficient. Further investigation is needed on how social support schemes can be developed in Mozambique.

Development and validation of a risk prediction model for pulmonary tuberculosis among presumptive tuberculosis cases in Ethiopia

BACKGROUND

Early diagnosis and treatment of tuberculosis (TB) is one of the key strategies to achieve the WHO End TB targets. This study aimed to develop and validate a simple, convenient risk score to diagnose pulmonary TB among presumptive TB cases.

METHODS

This prediction model used Ethiopian national TB prevalence survey data and included 5459 presumptive TB cases from all regions of Ethiopia. Logistic regression was used to determine which variables are predictive of pulmonary TB. A risk prediction model was developed, incorporating significant variables (p<0.05). The Youden Index method was used to choose the optimal cut-off point to separate the risk score of the patients as high and low. Model performance was assessed using discrimination power and calibration. Internal validation of the model was assessed using Efron's enhanced bootstrap method, and the clinical utility of the risk score was assessed using decision curve analysis.

RESULTS

Of total participants, 94 (1.7%) were confirmed to have TB. The final prediction model included three factors with different scores: (1) TB contact history, (2) chest X-ray (CXR) abnormality and (3) two or more symptoms of TB. The optimal cut-off point for the risk score was 6 and was found to have a good discrimination accuracy (c-statistic=0.70, 95% CI: 0.65 to 0.75). The risk score has sensitivity of 51.1%, specificity of 79.9%, positive predictive value of 4.3% and negative predictive value of 98.9%. After internal validation, the optimism coefficient was 0.003, which indicates the model is internally valid.

CONCLUSION

We developed a risk score that combines TB contact, number of TB symptoms and CXR abnormality to estimate individual risk of pulmonary TB among presumptive TB cases. Though the score is easy to calculate and internally validated, it needs external validation before widespread implementation in a new setting.

Distribution incidence, mortality of tuberculosis and human development index in Iran: estimates from the global burden of disease study 2019

BACKGROUND

Tuberculosis is one of the most serious challenges facing the global healthcare system. This study aims to investigate the incidence and mortality of tuberculosis in Iran from 2010 to 2019 as well as its relationship with the human development index (HDI).

METHODS

The present study is an ecological study aiming at investigating the incidence and mortality of tuberculosis in Iran during the years 2010 to 2019. The related data were extracted from the Global Burden of Disease (GBD) website. The spatial pattern attributed to tuberculosis in the provinces of Iran was analyzed using ArcGIS software. In this study, the two-variable correlation method was used to analyze the data extracted to study the correlation between Tuberculosis and HDI.

RESULT

Based on the results recorded in GBD, the incidence of tuberculosis in 2010, that is, 14.61 (12.72, 16.74), declined compared to 2019, namely 12.29 (10.71, 14.09). The age-standardized mortality rate which was 1.63 (1.52, 1.73) in 2010, has decreased compared to 2019: 1.17 (1.07, 1.32). The incidence and mortality rates of tuberculosis in Iran in all age groups have decreased in 2019 compared to 2010. The highest incidence and mortality among tuberculosis patients were recorded in Sistan and Baluchistan and Golestan provinces. The results indicated that there was a negative and significant correlation between the mortality rate of tuberculosis and the human development index in 2010 (r = -0.509, P-value = 0.003) and 2019 (r = -0.36, P-value = 0.001); however, this correlation between incidence and human development index was not significant (p > 0.05).

CONCLUSION

Since mortality is mostly observed in areas with low HDI, health system policymakers must pay more attention to these areas in order to improve care and perform screenings to diagnose and treat patients thus reducing the mortality rate of tuberculosis and preventing an increase in its incidence in Iran.

Burden and associated phenotypic characteristics of tuberculosis infection in adult Africans with diabetes: a systematic review

Diabetes mellitus (DM) increases the risk of developing tuberculosis infection (TBI). However, the evidence on the burden and phenotypic characteristics of TBI in African patients with DM is limited. This study aimed to determine the prevalence and characterisation of TBI in native African patients living with DM. We searched PubMed, EMBASE, and African Journals Online for original studies reporting information on the prevalence and characteristics of TBI in adult Africans with DM. A forest plot was used to describe the pooled prevalence estimate of TBI and the corresponding 95% confidence intervals (CI). Six studies conducted in four African countries involving 721 participants with DM were included in this systematic review. The pooled prevalence estimate of TBI was 40% (95% CI 20-60%, I2 = 98.52%, p < 0.001). Age ≥ 40 years and glycated haemoglobin levels independently predicted TBI positivity in patients with DM in three studies. Africans with DM have a high prevalence of TBI, especially those who are older or with poorly controlled diabetes. This justifies the need for studies to explore how to screen and manage TBI to avert the progression to active TB disease.

Short-term effects of high-resolution (1-km) ambient PM2.5 and PM10 on hospital admission for pulmonary tuberculosis: a case-crossover study in Hainan, China

Introduction

There is limited evidence regarding particulate matter (PM)'s short-term effects on pulmonary tuberculosis (PTB) hospital admission. Our study aimed to determine the short-term associations of the exposure to ambient PM with aerodynamic diameters <2.5 μm (PM2.5) and < 10 μm (PM10) with hospital admission for PTB in Hainan, a tropical province in China.

Methods

We collected individual data on patients hospitalized with PTB, PM2.5, PM10, and meteorological data from 2016 to 2019 in Hainan Province, China. Conditional logistic regression models with a time-stratified case-crossover design were used to assess the short-term effects of PM2.5 and PM10 on hospital admission for PTB at a spatial resolution of 1 km  ×  1 km. Stratified analyses were performed according to age at admission, sex, marital status, administrative division, and season of admission.

Results

Each interquartile range (IQR) increases in the concentrations of PM2.5 and PM10 were associated with 1.155 (95% confidence interval [CI]: 1.041-1.282) and 1.142 (95% CI: 1.033-1.263) hospital admission risks for PTB at lag 0-8 days, respectively. The stratified analyses showed that the effects of PM2.5 and PM10 were statistically significant for patients aged ≥65 years, males, married, and those residing in prefecture-level cities. Regarding seasonal differences, the associations between PM and hospital admission for PTB were statistically significant in the warm season but not in the cold season. The effect of PM2.5 was consistently stronger than that of PM10 in most subgroups.

Conclusion

Short-term exposure to PM increases the risk of hospital admission for PTB. The potential impact of PM with smaller aerodynamic diameter is more detrimental. Our findings highlight the importance of reducing ambient PM level to alleviate the burden of PTB.

Spatial-temporal patterns and influencing factors for pulmonary tuberculosis transmission in China: an analysis based on 15 years of surveillance data

Profiting from a series of anti-tuberculosis programs in China, the number of tuberculosis (TB) cases has diminished dramatically in the past decades. However, long-term spatial-temporal variations, regional trends of prevalence, and mechanisms of determinant factors remain unclear. Age-period-cohort analysis and Bayesian space-time hierarchy statistics were conducted to identify high-risk populations and areas in mainland China, and the geographical detector model was used to evaluate the important drivers of the disease. The prevalence of pulmonary TB has declined from 73.3/100,000 in 2004 to 55.45/100,000 in 2018. A bimodal distribution was found in age groups, and the birth cohorts before 1978 had relative higher risk. The high-risk areas were mainly distributed in western China and south-central China, and several provinces in eastern China showed a potential increasing trend, including Beijing, Shanghai, Liaoning, and Guangdong province. The index of night light (Q = 0.46), the population density (Q = 0.41), PM10 (Q = 0.38), urbanization rate (Q = 0.32), and PM 2.5 (Q = 0.31) contributed substantially to the spatial distribution of pulmonary tuberculosis. The identifications of epidemic patterns, high-risk areas and influence factors would help design targeted intervention measures to achieve milestones of the end TB strategy.

Impact of Deprivation on the Incidence and Severity of Tuberculosis in Children: A Retrospective Study from 2007 to 2020 in a Tertiary Care Center in Paris, France

OBJECTIVE

To assess the association between deprivation and the incidence and clinical severity of tuberculosis (TB) in children.

STUDY DESIGN

Children ≤18 years old who were admitted for TB between 2007 and 2020 at a tertiary hospital were included in this retrospective study. Deprivation was assessed using the French Deprivation Index. TB severity was assessed using the Wiseman classification. Multivariate analyses were carried out.

RESULTS

In total, 222 patients were included. The median age was 10.8 years (IQR 4.5-14.4). TB was considered severe in 126 patients (56.8%), with 50% of the patients included in the 2 most deprived groups. The most-deprived children had a TB incidence that was 58 times greater than that of the least-deprived children (95% CI 28.49-119.40). There was no significant association between deprivation and severity in the multivariable analysis after adjusting for age and circumstances of diagnosis. Deprivation was associated with an increased length of stay in the most-deprived groups (OR 3.79, 95% CI 1.55-10.23). There was a trend toward a greater proportion of symptomatic children in the most-deprived group.

CONCLUSIONS

TB incidence and hospital length of stay increased with deprivation levels but not with the severity of TB.

A Comparative Analysis of Microscopy, Culture, and the Xpert Mycobacterium tuberculosis/Rifampicin Assay in Diagnosing Pulmonary Tuberculosis in Human Immunodeficiency-Positive Individuals

INTRODUCTION

Individuals with human immunodeficiency virus (HIV) infection have an increased likelihood of developing tuberculosis (TB). The primary objective of this study was to compare the diagnostic accuracy of microscopy, culture, and the Xpert Mycobacterium tuberculosis/Rifampicin (MTB/RIF) assay in the diagnosis of pulmonary TB in sputum samples of HIV-infected patients. The secondary objectives were to evaluate the sensitivity and specificity of these three methods along with a comparison of diagnostic approaches for detecting drug-resistant strains.

MATERIAL AND METHODS

This prospective, laboratory-based study was done in the Microbiology Department of IGIMS, Patna. The study included sputum samples of 102 individuals who were HIV-positive and exhibited symptoms indicative of tuberculosis.

RESULTS

Out of 102 individuals suspected of having tuberculosis, 18 tested positive for M. tuberculosis. Male individuals between the ages of 31 and 40 were more affected by both HIV and tuberculosis, and in most of these cases, their CD4 cell count was below 200 cells/µl. Among the 102 sputum samples collected, 18% (18 samples) were found to be positive using the Mycobacterium Growth Indicator Tube (MGIT) 960 liquid culture method. Two samples were contaminated, and 14.7% (15 cases) tested positive using the cartridge-based nucleic acid amplification test (CBNAAT) method. Additionally, 3.92% (four samples) were positive using the ZN staining method.

CONCLUSION

The study found that Xpert MTB/RIF outperformed other methods in identifying resistance to RIF, showed better agreement with gene sequencing results for RIF resistance, and had higher accuracy in detecting tuberculosis cases, including both smear-positive and smear-negative cases.

Estimating the prevalence of poor-quality anti-TB medicines: a neglected risk for global TB control and resistance

OBJECTIVES

Tuberculosis (TB) remains a major global public health problem, especially with the recent emergence of multidrug-resistant TB and extensively drug-resistant TB. There has been little consideration of the extent of substandard and falsified (SF) TB medicines as drivers of resistance. We assessed the evidence on the prevalence of SF anti-TB medicines and discussed their public health impact.

MATERIALS/METHODS

We searched Web of Science, Medline, Pubmed, Google Scholar, WHO, US Pharmacopeia and Medicines Regulatory Agencies websites for publications on anti-TB medicines quality up to 31 October 2021. Publications reporting on the prevalence of SF anti-TB drugs were evaluated for quantitative analysis.

RESULTS

Of the 530 screened publications, 162 (30.6%) were relevant to anti-TB medicines quality; of those, 65 (40.1%) described one or more TB quality surveys in a specific location or region with enough information to yield an estimate of the local prevalence of poor-quality TB medicines. 7682 samples were collected in 22 countries and of those, 1170 (15.2%) failed at least one quality test. 14.1% (879/6255) of samples failed in quality surveys, 12.5% (136/1086) in bioequivalence studies and 36.9% (87/236) in accelerated biostability studies. The most frequently assessed were rifampicin monotherapy (45 studies, 19.5%) and isoniazid monotherapy (33, 14.3%), rifampicin-isoniazid-pyrazinamide-ethambutol fixed dose combinations (28, 12.1%) and rifampicin-isoniazid (20, 8.6%). The median (IQR) number of samples collected per study was 12 (1-478).

CONCLUSIONS

SF, especially substandard, anti-TB medicines are present worldwide. However, TB medicine quality data are few and are therefore not generalisable that 15.2% of global anti-TB medicine supply is SF. The evidence available suggests that the surveillance of the quality of TB medicines needs to be an integral part of treatment programmes. More research is needed on the development and evaluation of rapid, affordable and accurate portable devices to empower pharmacy inspectors to screen for anti-TB medicines.

Nearly one out of every five adult TB patients suffered from food insecurity in Grawa District, Eastern Ethiopia: a multicenter facility-based cross-sectional study

Background

Despite a dramatic decline in tuberculosis mortality over the past 10 years, tuberculosis is still the leading cause of death globally. In the last 2 years, tuberculosis has affected an estimated 10 million individuals, and 1.4 million people have died worldwide. In Ethiopia, the weight of the problem is less known in the study area. As a result, the purpose of this study was to assess food insecurity and associated factors among adult patients with tuberculosis attending public health facilities in Grawa district, Eastern Ethiopia.

Methods

A multicenter facility-based cross-sectional study was conducted from 01 March to 31 March 2022, among 488 randomly selected adult tuberculosis patients on treatment follow-up at public health facilities in Grawa district, Eastern Ethiopia. Data were collected using a pretested structured questionnaire through a face-to-face interview and document review, entered into EpiData version 3.1, and analyzed using SPSS version 25. The prevalence was reported using a 95% confidence interval (CI) and summary measures. Predictors were assessed using a multivariable logistic regression analysis model and reported using an adjusted odds ratio (AOR) with 95% CI. Statistical significance was declared at a p-value of <0.05.

Results

Overall, the prevalence of food insecurity among the study participants was 19.5%, with a 95% CI (15.8%, 23.2%). Factors such as being male [AOR = 0.58, 95% CI: (0.34, 0.97)], being married [AOR = 2.93, 95% CI: (1.33, 6.47)], being merchant [AOR = 0.22, 95% CI: (0.04, 0.67)], having low wealth quintiles [AOR = 2.10,95%CI:(1.04-4.23)], receiving anti-TB treatment for two or fewer months [AOR = 0.48, 95% CI: (0.26-0.91)], using khat [AOR = 2.18, 95% CI: (1.29, 3.70)], and owning livestock (AOR = 0.56, 95% CI: 0.29-0.94) were significantly associated with food insecurity.

Conclusions

According to this study, nearly one out of every five adults TB patients is food insecure. Factors such as being male, being married, being merchant, having low wealth quintiles, receiving anti-TB treatment for two or less months, those who chew mKhat and having a livestock were significantly associated with food insecurity. As a result, all stakeholders and concerned entities should prioritize improving the livelihood of TB patients through social security system programs, which are critical to the success of TB control and prevention efforts.

Trends in pulmonary tuberculosis mortality between 1985 and 2018: an observational analysis

BACKGROUND

Pulmonary tuberculosis (TB) is a major source of global morbidity and mortality. Latent infection has enabled it to spread to a quarter of the world's population. The late 1980s and early 1990s saw an increase in the number of TB cases related to the HIV epidemic, and the spread of multidrug-resistant TB. Few studies have reported pulmonary TB mortality trends. Our study reports and compares trends in pulmonary TB mortality.

METHODS

We utilized the World Health Organization (WHO) mortality database from 1985 through 2018 to analyze TB mortality using the International Classification of Diseases-10 codes. Based on the availability and quality of data, we investigated 33 countries including two countries from the Americas; 28 countries from Europe; and 3 countries from the Western Pacific region. Mortality rates were dichotomized by sex. We computed age-standardized death rates per 100,000 population using the world standard population. Time trends were investigated using joinpoint regression analysis.

RESULTS

We observed a uniform decrease in mortality in all countries across the study period except the Republic of Moldova, which showed an increase in female mortality (+ 0.12 per 100,000 population). Among all countries, Lithuania had the greatest reduction in male mortality (-12) between 1993-2018, and Hungary had the greatest reduction in female mortality (-1.57) between 1985-2017. For males, Slovenia had the most rapid recent declining trend with an estimated annual percentage change (EAPC) of -47% (2003-2016), whereas Croatia showed the fastest increase (EAPC, + 25.0% [2015-2017]). For females, New Zealand had the most rapid declining trend (EAPC, -47.2% [1985-2015]), whereas Croatia showed a rapid increase (EAPC, + 24.9% [2014-2017]).

CONCLUSIONS

Pulmonary TB mortality is disproportionately higher among Central and Eastern European countries. This communicable disease cannot be eliminated from any one region without a global approach. Priority action areas include ensuring early diagnosis and successful treatment to the most vulnerable groups such as people of foreign origin from countries with a high burden of TB and incarcerated population. Incomplete reporting of TB-related epidemiological data to WHO excluded high-burden countries and limited our study to 33 countries only. Improvement in reporting is crucial to accurately identify changes in epidemiology, the effect of new treatments, and management approaches.

Evaluating the impact of cash transfers on tuberculosis (ExaCT TB): a stepped wedge cluster randomised controlled trial

Background

Mitigating financial barriers to tuberculosis (TB) diagnosis and treatment is a core priority of the global TB agenda. We evaluated the impact of a cash transfer intervention on completion of TB testing and treatment initiation in Uganda.

Methods

We conducted a pragmatic complete stepped wedge randomised trial of a one-time unconditional cash transfer at 10 health centres between September 2019 and March 2020. People referred for sputum-based TB testing were enrolled to receive UGX 20 000 (∼USD 5.39) upon sputum submission. The primary outcome was the number initiating treatment for micro-bacteriologically confirmed TB within 2 weeks of initial evaluation. The primary analysis included cluster-level intent-to-treat and per-protocol analyses using negative binomial regression.

Results

4288 people were eligible. The number diagnosed with TB initiating treatment was higher in the intervention period versus the pre-intervention period (adjusted rate ratio (aRR)=1.34) with a 95% CI of 0.62-2.91 (p=0.46), indicating a wide range of plausible true intervention effects. More were referred for TB testing (aRR=2.60, 95% CI 1.86-3.62; p<0.001) and completed TB testing (aRR=3.22, 95% CI 1.37-7.60; p=0.007) per National Guidelines. Results were similar but attenuated in per-protocol analyses. Surveys revealed that while the cash transfer supported testing completion, it was insufficient to address long-term underlying social/economic barriers.

Interpretation

While it is uncertain whether a single unconditional cash transfer increased the number of people diagnosed and treated for TB, it did support higher completion of diagnostic evaluation in a programmatic setting. A one-time cash transfer may offset some but not all of the social/economic barriers to improving TB diagnosis outcomes.

Geographical evolutionary pathway of global tuberculosis incidence trends

BACKGROUNDS

Tuberculosis (TB) remains a serious public health and human development problem, especially in developing countries. Despite the effectiveness of directly observed therapy, short course programs in reducing transmission and progression of TB, poverty reduction and socioeconomic development remain crucial factors in decreasing TB incidence. However, the geographical pathway on the planet is not yet clear.

OBJECTIVES

This study was to reconstruct the geographical evolutionary process of TB in 173 countries and territories from 2010 to 2019 to analyze the socioeconomic determinants that impact the global TB epidemic. In addition, the TB incidence in 2030 was predicted.

METHODS

This study analyses TB incidence data from 173 countries and territories between 2010 and 2019. The Geotree model would be used to reconstruct the geographical evolutionary process of TB, which provides a simplified schema for geo-visualizing the trajectories of TB incidence and their socioeconomic drivers. Additionally, to estimate the future TB incidence in 2030, a multilevel model was utilized in conjunction with the hierarchical nature of the Geotree based on a stratified heterogeneity analysis.

RESULTS

Global TB incidence was found to be associated with the country type and development stages. Between 2010 and 2019, the average TB incidence rate in 173 countries and territories was -27.48%, with marked spatially stratified heterogeneity by country type and development stage. Low-income and lower-middle-income countries were most vulnerable to TB. Upper-middle-income countries experienced a faster decline in TB incidence than high-income countries, and TB incidence generally decreased as the development stage increased, except for the lower-middle development stage in 2019.The highest average rate of decline in TB incidence was observed in the upper-middle development stage of high-income countries, with a reduction of 45.24%. Meanwhile, 37 high-income countries in the high development stage demonstrated an average rate of change of -13.93%. Socioeconomic determinants, including gross domestic product per capita, urbanization rate, and sociodemographic index, were found to inhibit TB incidence. Based on current trends, the predicted average global TB incidence in 2030 is 91.581 per 100,000 population.

CONCLUSIONS

The trajectories of the global TB incidence have been reconstructed to formulate targeted public health responses. To eliminate TB, countries at similar development stage can draw on the experiences of countries at higher development stages that are tailored to their unique characteristics. By learning from successful TB control strategies, countries can take strategic steps toward eradicating TB and improving public health outcomes.

The differences in drug resistance between drug-resistant tuberculosis patients with and without diabetes mellitus in northeast China: a retrospective study

BACKGROUND

Diabetes mellitus (DM) and drug-resistant tuberculosis (DR-TB) are serious global public health problems. This study aimed to explore the differences in drug resistance between DR-TB patients with and without DM. Risk factors for developing multidrug-resistant tuberculosis (MDR-TB) were also investigated among DR-TB patients.

METHODS

The patient's basic demographic,　clinical characteristics, and drug susceptibility testing (DST) data were collected from the Chinese Disease Control Information System. Descriptive statistics were used to estimate the frequency and proportion of included variables. Categorical variables were compared using the Chi-square test or Fisher's exact test. Chi-square tests for trends were used to determine changes and trends in MDR-TB and pre-extensively drug-resistantTB (pre-XDR-TB) patterns over time. Univariate and multivariate logistic regression analysis was used to explore the risk factors of MDR-TB.

RESULTS

Compared with DR-TB patients with DM, DR-TB patients without DM had significantly higher rates of mono-resistant streptomycin (SM) and any resistance to kanamycin (KM), but significantly lower rates of any resistance to protionamide (PTO) and mono-resistance to levofloxacin (LFX), and pre-XDR-TB (P<0.05). The proportion of resistance to other anti-TB drugs was not statistically different between the DR-TB with and without DM. Among DR-TB patients without and with DM, the proportion of patients with MDR-TB and pre-XDR-TB patterns showed a significant downward trend from 2016 to 2021 (P<0.05). Among DR-TB patients without DM, male, previously treated DR-TB cases, and immigration were risk factors for MDR-TB (P<0.05). In DR-TB patients with DM, a negative sputum smear is a risk factor for MDR-TB (P<0.05).

CONCLUSION

There was no statistical difference in resistance patterns between DR-TB with and without DM, except in arbitrary resistance to PTO and KM, mono-resistant SM and LFX, and pre-XDR-TB. Great progress has been made in the prevention and control of MDR-TB and pre-XDR-TB. However, DR-TB patients with and without DM differ in their risk factors for developing MDR-TB.

Mortality, risk factors, and causes of death among people with tuberculosis in Denmark, 1990-2018

OBJECTIVES

This study aimed to analyze mortality, risk factors, and causes of death among people with tuberculosis (TB).

METHODS

This is a population-based cohort study with patients with TB ≥18 years notified from 1990 to 2018 in Denmark, compared with sex- and age-matched controls. Mortality was assessed in Kaplan-Meier models and risk factors for death were estimated in Cox proportional hazards models.

RESULTS

Overall mortality was twofold higher among people with TB compared with controls up to 15 years after TB diagnosis (hazard ratio [HR]: 2.18, 95% confidence interval [CI]: 2.06-2.29, P <0.0001). Danes with TB were three times more likely to die than migrants (adjusted HR: 3.13, 95% CI: 2.84-3.45, P <0.0001). Risk factors for death included living alone, being unemployed, having low income, and comorbidities such as mental illness with substance abuse, lung diseases, hepatitis, and HIV. TB was the most common cause of death (21%), followed by chronic obstructive pulmonary disease (7%), lung cancer (6%), alcoholic liver disease (5%), and mental illness with substance abuse (4%).

CONCLUSION

People with TB had substantially inferior survival up to 15 years after TB diagnosis, in particular, socially disadvantaged Danes with TB with specific comorbidities. This may reflect unmet needs for enhanced treatment of other medical/social conditions during TB treatment.

The social determinants of national tuberculosis incidence rates in 116 countries: a longitudinal ecological study between 2005-2015

BACKGROUND

Accelerating declines in tuberculosis (TB) incidence is paramount for achieving global goals set for 2030 by the Sustainable Development Goals and the End TB Strategy. The aim of this study was to identify key country-level social determinants of national TB incidence trends.

METHODS

This longitudinal ecological study used country-level data extracted from online databases from the period 2005-2015. We used multivariable Poisson regression models allowing for distinct within- and between-country effects to estimate associations between national TB incidence rates and 13 social determinants of health. The analysis was stratified by country income status.

RESULTS

The study sample included 48 low- and lower-middle-income countries (LLMICs) and 68 high- and upper-middle income countries (HUMICs), with a total of 528 and 748 observations between 2005-2015, respectively. National TB incidence rates declined in 108/116 countries between 2005-2015, with an average drop of 12.95% in LLMICs and 14.09% in HUMICs. Between LLMICs, higher Human Development Index (HDI), social protection spending, TB case detection, and TB treatment success were associated with lower TB incidence. Higher prevalence of HIV/AIDS was associated with higher TB incidence. Within LLMICs, increases in HDI over time were associated with lower TB incidence rates. Between HUMICs, higher HDI, health spending, and diabetes prevalence were associated with lower TB incidence, whereas higher prevalence of HIV/AIDS and alcohol-use were associated with higher TB incidence. Within HUMICs, increases in HIV/AIDS and diabetes prevalence over time were associated with higher TB incidence.

CONCLUSIONS

In LLMICs, TB incidence rates remain highest in countries with low human development, social protection spending and TB programme performance, and high rates of HIV/AIDS. Strengthening human development is likely to accelerate declines in TB incidence. In HUMICs, TB incidence rates remain highest in countries with low human development, health spending and diabetes prevalence, and high rates of HIV/AIDS and alcohol use. Here, slowing rising rates of HIV/AIDS and diabetes is likely to accelerate declines in TB incidence.

Prevalence of latent tuberculosis infection among participants of the national LTBI screening program in South Korea - A problem of low coverage rate with current LTBI strategy

Background

The Government of South Korea launched a national preemptive latent tuberculosis infection (LTBI) screening program in 2016, including more than 1. 6 million population in congregate settings. The objective of this study was to analyze LTBI prevalence and its risk factors in each setting. Additionally, the proportion of LTBI pool covered by the current national LTBI strategy was investigated.

Methods

Database for results of interferon gamma release assay (IGRA), X-ray, and baseline demographic information was linked with National Health Information Database, national tuberculosis (TB) surveillance database, and national contact investigation database. Participants were categorized into three groups: Group A, workers of postpartum care centers, social welfare facilities and educational institutions; Group B, first year students in high school and out-of-school youths; and Group C, inmates of correctional facilities. Relative risks of LTBI by sex, age, place of living, income level, and comorbidities were calculated.

Results

A total of 444,394 participants in Group A, 272,224 participants in Group B, and 11,511 participants in Group C who participated in the national LTBI screening program between 2017 and 2018 were included, with LTBI prevalence of 20.7, 2.0, and 33.2%, respectively. Age was the single most important risk factor in Group A and Group C. Low-income level was another risk factor commonly identified in all groups. Among participants with positive IGRA results, 2.7, 4.4, and 3.3% in Groups A, B and C, respectively, had past TB exposure history since 2013. Current LTBI guideline targeting high or moderate TB risk disease covered 6.5, 0.6, and 1.1% of participants with positive IGRA results in Groups A, B and C, respectively.

Conclusion

Only a small proportion of participants with positive IGRA results could be covered by the current LTBI strategy. Expansion of LTBI strategy by identifying further high-TB risk group in the general population is required.

Sex and Gender Differences in Tuberculosis Pathogenesis and Treatment Outcomes

Tuberculosis remains a daunting public health concern in many countries of the world. A consistent observation in the global epidemiology of tuberculosis is an excess of cases of active pulmonary tuberculosis among males compared with females. Data from both humans and animals also suggest that males are more susceptible than females to develop active pulmonary disease. Similarly, male sex has been associated with poor treatment outcomes. Despite this growing body of evidence, little is known about the mechanisms driving sex bias in tuberculosis disease. Two dominant hypotheses have been proposed to explain the predominance of active pulmonary tuberculosis among males. The first is based on the contribution of biological factors, such as sex hormones and genetic factors, on host immunity during tuberculosis. The second is focused on non-biological factors such as smoking, professional exposure, and health-seeking behaviors, known to be influenced by gender. In this chapter, we review the literature regarding these two prevailing hypotheses by presenting human but also experimental animal studies. In addition, we presented studies aiming at examining the impact of sex and gender on other clinical forms of tuberculosis such as latent tuberculosis infection and extrapulmonary tuberculosis, which both appear to have their own specificities in relation to sex. We also highlighted potential intersections between sex and gender in the context of tuberculosis and shared future directions that could guide in elucidating mechanisms of sex-based differences in tuberculosis pathogenesis and treatment outcomes.

Tuberculosis in elderly population: A cross-sectional comparative study

Background

Tuberculosis (TB) is a common but neglected infectious disease of global significance. It has a varied presentation in the elderly compared to adults. The present study was conceived to study the resemblances and differences shared in terms of clinical profile, comorbidities, and laboratory investigations by TB in adults and the elderly population.

Methods

In this cross-sectional study, 68 adults and 72 elderly patients of both genders were enrolled. We collected information on demographics, comorbidities, clinical presentations, and laboratory investigations. The comparison of data between groups was done using the unpaired t-test for continuous variables and the Chi-square test for frequency distribution analysis.

Results

The mean age of the adults and elderly population was 42.13 ± 10.7 years and 68.78 ± 7.62 years, respectively. The elderly TB group demonstrated loss of weight, appetite, the prevalence of comorbid conditions (coronary artery disease, hypertension, and malnutrition), bilateral, predominantly lower lobe, and diffuse involvement of lungs.

Conclusion

As the elderly population increases, nonspecific clinical manifestations or laboratory results in this population mandate awareness of these atypical features for effective management of TB in this group.

Understanding barriers to tuberculosis diagnosis and treatment completion in a low-resource setting: A mixed-methods study in the Kingdom of Lesotho

BACKGROUND

Lesotho is one of the 30 countries with the highest tuberculosis incidence rates in the world, estimated at 650 per 100,000 population. Tuberculosis case detection is extremely low, particularly with the rapid spread of COVID-19, dropping from an estimated 51% in 2020 to 33% in 2021. The aim of this study is to understand the barriers to tuberculosis diagnosis and treatment completion.

METHODS

We used a convergent mixed methods study design. We collected data on the number of clients reporting symptoms upon tuberculosis screening, their sputum test results, the number of clients diagnosed, and the number of clients who started treatment from one district hospital and one health center in Berea district, Lesotho. We conducted in-depth interviews and focus group discussions with 53 health workers and patients. We used a content analysis approach to analyze qualitative data and integrated quantitative and qualitative findings in a joint display.

FINDINGS

During March-August, 2019, 218 clients at the hospital and 292 clients at the health center reported tuberculosis symptoms. The full diagnostic testing process was completed for 66% of clients at the hospital and 68% at the health center. Among clients who initiated tuberculosis treatment, 68% (61/90) at the hospital and 74% (32/43) at the health center completed treatment. The main barriers to testing and treatment completion were challenges at sample collection, lack of decentralized diagnostic services, and socioeconomic factors such as food insecurity and high patient movement to search for jobs.

CONCLUSIONS

Tuberculosis diagnosis could be improved through the effective decentralization of laboratory services at the health facility level, and treatment completion could be improved by providing food and other forms of social support to patients.

Population-based active screening strategy contributes to the prevention and control of tuberculosis

Despite the achievements obtained worldwide in the control of tuberculosis in recent years, many countries and regions including China still face challenges such as low diagnosis rate, high missed diagnosis rate, and delayed diagnosis of the disease. The discovery strategy of tuberculosis in China has changed from "active discovery by X-ray examination" to "passive discovery by self-referral due to symptoms", and currently the approach is integrated involving self-referral due to symptoms, active screening, and physical examination. Active screening could help to identify early asymptomatic and untreated cases. With the development of molecular biology and artificial intelligence-assisted diagnosis technology, there are more options for active screening among the large-scale populations. Although the implementation cost of a population-based active screening strategy is high, it has great value in social benefits, and active screening in special populations can obtain better benefits. Active screening of tuberculosis is an important component of the disease control. It is suggested that active screening strategies should be optimized according to the specific conditions of the regions to ultimately ensure the benefit of the tuberculosis control.

Association of Area-Based Socioeconomic Measures with Tuberculosis Incidence in California

We assessed the association of area-based socio-economic status (SES) measures with tuberculosis (TB) incidence in California. We used TB disease data for 2012-2016 (n = 9901), population estimates, and SES measures to calculate incidence rates, rate ratios, and 95% confidence intervals (95% CI) by SES and birth country. SES was measured by census tract and was categorized by quartiles for education, crowding, and the California Healthy Places Index (HPI)and by specific cutoffs for poverty. The lowest SES areas defined by education, crowding, poverty, and HPI had 39%, 40%, 41%, and 33% of TB cases respectively. SES level was inversely associated with TB incidence across all SES measures and birth countries. TB rates were 3.2 (95% CI 3.0-3.4), 2.1 (95% CI 1.9-2.2), 3.6 (95% CI 3.3-3.8), and 2.0 (95% CI 1.9-2.1) times higher in lowest SES areas vs. highest SES areas as defined by education, crowding, poverty and HPI respectively. Area-based SES measures are associated with TB incidence in California. This information could inform TB prevention efforts in terms of materials, partnerships, and prioritization.

Closing the Evidence Gap of Cash Transfer for Tuberculosis-Affected Households Comment on "Does Direct Benefit Transfer Improve Outcomes Among People With Tuberculosis? - A Mixed-Methods Study on the Need for a Review of the Cash Transfer Policy in India"

Achieving the targets of eliminating tuberculosis (TB) requires a combination of biomedical, epidemiological, and social approaches. Having hitted by the coronavirus disease 2019 (COVID-19) pandemic which diminishes the financial capacity of TB-affected households, the importance of delivering socioeconomic support to TB-affected household emerges. However, the evidence of TB-related socioeconomic support is still scarce, and some questions are left unanswered. A sequential explanatory mixed-methods study by Dave and Rupani shows that the direct benefit transfer (DBT), a form of cash transfer, to TB-affected households improves TB treatment outcomes in India despite the challenges. Some critical issues remain to be discussed: trading-off between the amount of cash and its sustainability, choosing the most appropriate support packages, detecting, and reaching the target population, and arranging the most effective delivery strategy. Knowledge gap remains to be answered, and a global research agenda and political commitment are critical to encourage more evidence in delivering socioeconomic support for TB control.

Incidence and Temporal Trend of Antituberculosis Drug-Induced Liver Injury: A Systematic Review and Meta-Analysis

Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards were followed, and the protocol was registered in PROSPERO (CRD42020200077). Five electronic databases were searched to identify eligible studies published between 1990 and 2022. Search terms included anti-TB treatment and drug-induced liver injury. Studies that reported the incidence of ATLI or provided sufficient data to calculate the incidence of ATLI were included, and duplicate studies were excluded. Meta-analysis was conducted on the basis of logit-transformed metrics for the incidence of ATLI with 95% confidence intervals (CIs), followed by a predefined subgroup meta-analysis. Temporal trend analyses were performed to describe the change in pooled incidence over time. A random effects metaregression was conducted to explore the source of heterogeneity. All statistical analyses were carried out using R 4.0.1.

Results

A total of 160 studies from 156 records with 116147 patients were included in the meta-analysis. Based on the random effects model, the pooled incidence of ATLI was 11.50% (95% CI: 10.10%–12.97%) and showed an upward trend over time (P < 0.001). Patients who received first-line anti-TB drugs, patients in South America, and patients with hepatitis B and C virus coinfection had a higher incidence of ATLI (13.66%, 18.16%, and 39.19%, respectively). Sensitivity analyses also confirmed this robust incidence after the exclusion of some studies. The metaregression showed that different anti-TB regimens and geographical regions were important explanatory factors of the heterogeneity between studies.

Conclusions

The present systematic review provided a basis for estimating the incidence of ATLI worldwide, which varied among patients with different anti-TB regimens in different geographical regions and with different coinfections and had an upward trend. Regular liver function monitoring is imperative for patient safety during the anti-TB treatment course.

High Glucose and Carbonyl Stress Impair HIF-1-Regulated Responses and the Control of Mycobacterium tuberculosis in Macrophages

Diabetes mellitus (DM) increases the risk of developing tuberculosis (TB), but the mechanisms behind diabetes-TB comorbidity are still undefined. Here, we studied the role of hypoxia-inducible factor-1 (HIF-1), a main regulator of metabolic and inflammatory responses, in the outcome of Mycobacterium tuberculosis infection of bone marrow-derived macrophages (BMM). We observed that M. tuberculosis infection of BMM increased the expression of HIF-1α and HIF-1-regulated genes. Treatment with the hypoxia mimetic deferoxamine (DFO) further increased levels of HIF-1-regulated immune and metabolic molecules and diminished the intracellular bacterial load in BMM and in the lungs of infected mice. The expression of HIF-1-regulated immunometabolic genes was reduced, and the intracellular M. tuberculosis levels were increased in BMM incubated with high-glucose levels or with methylglyoxal (MGO), a reactive carbonyl compound elevated in DM. In line with the in vitro findings, high M. tuberculosis levels and low HIF-1-regulated transcript levels were found in the lungs from hyperglycemic Lepr^db/db compared with wild-type mice. The increased intracellular M. tuberculosis growth and the reduced expression of HIF-1-regulated metabolic and inflammatory genes in BMM incubated with MGO or high glucose were reverted by additional treatment with DFO. Hif1a-deficient BMM showed ablated responses of immunometabolic transcripts after mycobacterial infection at normal or high-glucose levels. We propose that HIF-1 may be targeted for the control of M. tuberculosis during DM. IMPORTANCE People living with diabetes who are also infected with M. tuberculosis are more likely to develop tuberculosis disease (TB). Why diabetic patients have an increased risk for developing TB is not well understood. Macrophages, the cell niche for M. tuberculosis, can express microbicidal mechanisms or be permissive to mycobacterial persistence and growth. Here, we showed that high glucose and carbonyl stress, which mediate diabetes pathogenesis, impair the control of intracellular M. tuberculosis in macrophages. Infection with M. tuberculosis stimulated the expression of genes regulated by the transcription factor HIF-1, a major controller of the responses to hypoxia, resulting in macrophage activation. High glucose and carbonyl compounds inhibited HIF-1 responses by macrophages. Mycobacterial control in the presence of glucose or carbonyl stress was restored by DFO, a compound that stabilizes HIF-1. We propose that HIF-1 can be targeted to reduce the risk of developing TB in people with diabetes.

Tuberculosis Disability Adjusted Life Years, Colombia 2010-2018

Estimating the burden of tuberculosis disease is relevant for assessing and identifying population health status and progress in policies and programs aimed at epidemic control. The objective of this study was to estimate disability-adjusted life years attributable to Tuberculosis in Colombia 2010-2018. A longitudinal descriptive study was conducted. The variables, sex, age groups and origin were studied. This study included 110,475 cases of morbidity and 8514 cases of mortality. Indicators of years of life lost, years of life with disability and disability-adjusted life years at the subnational level were determined using the methodology of the World Health Organization. With the results of this last indicator, an epidemiological risk stratification was carried out. The DALY rate of the study period was 684 (95% CI 581.2-809.1) per 100,000 inhabitants. According to sex, 68.4% occurred in men; for every DALY in women, 2.21 occur in men. People of productive age (15 to 69 years) account for 56% of DALYs. Amazonas (1857.1 CI 95% 1177.1-2389.6) was the territorial entity with the highest rate. A total of 51.5% of the territorial entities of departmental order of the country are of high burden for Tuberculosis. For the first time in Colombia, a comprehensive assessment of the status of the disease burden at a subnational (departmental) territorial level attributable to Tuberculosis is being carried out using the updated World Health Organization methodology. The results obtained allow us to specify that there is a knowledge gap in terms of the realization and clear understanding of the burden of the disease in Colombia. There are territorial gaps that are necessary to know in order to plan, develop, implement and redirect policies to improve health and eliminate disparities according to the territorial context.

Effects of zinc and vitamin A supplementation on prognostic markers and treatment outcomes of adults with pulmonary tuberculosis: a systematic review and meta-analysis

INTRODUCTION

Undernutrition is a major risk factor for tuberculosis (TB), which is estimated to be responsible for 1.9 million TB cases per year globally. The effectiveness of micronutrient supplementation on TB treatment outcomes and its prognostic markers (sputum conversion, serum zinc, retinol and haemoglobin levels) has been poorly understood. This study aimed to determine the effect of zinc and vitamin A supplementation on prognostic markers and TB treatment outcomes among adults with sputum-positive pulmonary TB.

METHODS

A systematic literature search for randomised controlled trials (RCTs) was performed in PubMed, Embase and Scopus databases. Meta-analysis with a random effect model was performed to estimate risk ratio (RR) and mean difference (MD), with a 95% CI, for dichotomous and continuous outcomes, respectively.

RESULTS

Our search identified 2195 records. Of these, nine RCTs consisting of 1375 participants were included in the final analyses. Among adults with pulmonary TB, zinc (RR: 0.94, 95% CI: 0.86 to 1.03), vitamin A (RR: 0.90, 95% CI: 0.80 to 1.01) and combined zinc and vitamin A (RR: 0.98, 95% CI: 0.89 to 1.08) supplementation were not significantly associated with TB treatment success. Combined zinc and vitamin A supplementation was significantly associated with increased sputum smear conversion at 2 months (RR: 1.16, 95% CI: 1.03 to 1.32), serum zinc levels at 2 months (MD: 0.86 μmol/L, 95% CI: 0.14 to 1.57), serum retinol levels at 2 months (MD: 0.06 μmol/L, 95% CI: 0.04 to 0.08) and 6 months (MD: 0.12 μmol/L, 95% CI: 0.10 to 0.14) and serum haemoglobin level at 6 months (MD: 0.29 μg/dL, 95% CI: 0.08 to 0.51), among adults with pulmonary TB.

CONCLUSIONS

Providing zinc and vitamin A supplementation to adults with sputum-positive pulmonary TB during treatment may increase early sputum smear conversion, serum zinc, retinol and haemoglobin levels. However, the use of zinc, vitamin A or both was not associated with TB treatment success.

PROSPERO REGISTRATION NUMBER

CRD42021248548.

Patterns of Presentation of Drug-Resistant Tuberculosis in Nigeria: A Retrospective File Review

Background: An understanding of the patterns of drug-resistant tuberculosis (DR-TB) is needed to develop the best diagnostic tools and decide on optimal treatment combination therapies for the management of DR-TB in Nigeria. Objective: We aimed to investigate patterns of DR-TB for the five first-line anti-TB drugs over a period of seven years (2010–2016) and the associated clinical and socio-demographic factors. Methods: A retrospective study recruited 2555 DR-TB patients between 2010 and 2016 across the six geopolitical treatment zones in Nigeria. We determined DR-TB patterns based on standard case definition and their association with demographic and clinical information. Data were analyzed using Statistical Package for Social Sciences (SPSS) software. Independent predictors of DR-TB patterns/types were determined using bivariate and multivariate analyses with a statistical significance of p < 0.05 and a 95% confidence interval. Results: The majority of the participants were males, 66.93% (1710), 31–40 years old, 35.19% (899), previously treated, 77.10% (1909), had received at least two treatments, 411 (49.94%) and were multi-drug resistant, 61.41% (1165). The Southwest zone had the highest number of DR-TB cases, 36.92%. We found an upward trend in the prevalence of DR-TB from 2010 to 2016. Participants who had received one previous treatment showed statistically significant higher rifampicin resistance (59.68%), those with two previous treatments reported a statistically significant higher polydrug resistance (78.57%), and those with three or more previous treatments had a statistically significant higher multidrug resistance (19.83%) (χ2 = 36.39; p = 0.001). Mono-drug resistance and rifampicin resistance were statistically significantly higher in the southwest zone (29.48% and 34.12% respectively), polydrug resistance in the northcentral (20.69%) and south-south zones (20.69%), and multidrug resistance in the southwest (30.03%) and northcentral zones (19.18%) (χ2 = 98.26; p = 0.001). Conclusions: We present patterns of DR-TB across the six geopolitical zones in Nigeria. Clinicians should weigh in on these patterns while deciding on the best first-line drug combinations to optimize treatment outcomes for DR-TB patients. A national scale-up plan for DST services should focus on patients with previous multiple exposures to anti-TB treatments and on those in the Northeastern zone of the country.

Identification of novel inhibitors for mycobacterial polyketide synthase 13 via in silico drug screening assisted by the parallel compound screening with genetic algorithm-based programs

Identifying small compounds capable of inhibiting Mycobacterium tuberculosis polyketide synthase 13 (Pks13), in charge of final step of mycolic acid biosynthesis, could lead to the development of a novel antituberculosis drug. This study screened for lead compounds capable of targeting M. tuberculosis Pks13 from a chemical library comprising 154,118 compounds through multiple in silico docking simulations. The parallel compound screening (PCS), conducted via two genetic algorithm-based programs was applied in the screening strategy. Out of seven experimentally validated compounds, four compounds showed inhibitory effects on the growth of the model mycobacteria (Mycobacterium smegmatis). Subsequent docking simulation of analogs of the promising leads with the assistance of PCS resulted in the identification of three additional compounds with potent antimycobacterial effects (compounds A1, A2, and A5). Further, molecular dynamics simulation predicted stable interaction between M. tuberculosis Pks13 active site and compound A2, which showed potent antimycobacterial activity comparable to that of isoniazid. The present study demonstrated the efficacy of in silico structure-based drug screening through PCS in antituberculosis drug discovery.

Prevalence and associated factors of tuberculosis among isoniazid users and non-users of HIV patients in Dessie, Ethiopia

Tuberculosis (TB) is major public health concern and Isoniazid Preventive Therapy (IPT) helps to prevent TB development among patients living with human immune deficiency virus (PLWHIV). However, the evidence is limited especially in the study area. Therefore, this study aimed to determine the prevalence and factors associated with TB among IPT users and non-IPT users of PLWHIV in Dessie, Ethiopia. A comparative cross-sectional study was employed for1 month in Dessie. A total of 326 respondents were selected using systematic random sampling. Bivariable and multivariable logistic regression analyses were computed to identify factors associated with Tuberculosis. In multivariable analysis, AOR with 95% CI was used to declare statistically significant variables with TB. The prevalence of TB among non-IPT users was 48.5%, (95% CI 40.8-56.2%), and among IPT users was 8%, (95% CI 5-13%). Cotrimoxazole prophylaxis therapy (CPT) (AOR = 5.835, 95% CI 2.565-13.274), IPT (AOR = 10.359, 95% CI 4.054-26.472), ART adherence (AOR = 30.542, 95% CI 12.871-72.475), and believing that IPT use prevents TB (AOR = 0.093, 95% CI 0.018-0.484) were statistically significant factors. The prevalence of TB was higher among non-IPT users than among IPT users. Therefore, efforts should be strengthened to implement widespread use of IPT among adult PLWHIV.

Modeling the impact of COVID-19 on future tuberculosis burden

Background

The ongoing COVID-19 pandemic has greatly disrupted our everyday life, forcing the adoption of non-pharmaceutical interventions in many countries and putting public health services and healthcare systems worldwide under stress. These circumstances are leading to unintended effects such as the increase in the burden of other diseases.

Methods

Here, using a data-driven epidemiological model for tuberculosis (TB) spreading, we describe the expected rise in TB incidence and mortality if COVID-associated changes in TB notification are sustained and attributable entirely to disrupted diagnosis and treatment adherence.

Results

Our calculations show that the reduction in diagnosis of new TB cases due to the COVID-19 pandemic could result in 228k (CI 187-276) excess deaths in India, 111k (CI 93-134) in Indonesia, 27k (CI 21-33) in Pakistan, and 12k (CI 9-18) in Kenya.

Conclusions

We show that it is possible to reverse these excess deaths by increasing the pre-covid diagnosis capabilities from 15 to 50% for 2 to 4 years. This would prevent almost all TB-related excess mortality that could be caused by the COVID-19 pandemic if no additional preventative measures are introduced. Our work therefore provides guidelines for mitigating the impact of COVID-19 on tuberculosis epidemic in the years to come.

Improved Conventional and New Approaches in the Diagnosis of Tuberculosis

Tuberculosis (TB) is a life-threatening infectious disease caused by Mycobacterium tuberculosis (M. tuberculosis). Timely diagnosis and effective treatment are essential in the control of TB. Conventional smear microscopy still has low sensitivity and is unable to reveal the drug resistance of this bacterium. The traditional culture-based diagnosis is time-consuming, since usually the results are available after 3–4 weeks. Molecular biology methods fail to differentiate live from dead M. tuberculosis, while diagnostic immunology methods fail to distinguish active from latent TB. In view of these limitations of the existing detection techniques, in addition to the continuous emergence of multidrug-resistant and extensively drug-resistant TB, in recent years there has been an increase in the demand for simple, rapid, accurate and economical point-of-care approaches. This review describes the development, evaluation, and implementation of conventional diagnostic methods for TB and the rapid new approaches for the detection of M. tuberculosis.

Perspectives d’élimination de la tuberculose : la stratégie OMS à l’épreuve de la pandémie de COVID-19

La tuberculose (TB) reste un problème majeur de santé publique au niveau mondial. En 2020, elle était la deuxième cause de décès due à un seul agent infectieux, après le COVID-19. La stratégie « Mettre fin à la TB » de l'Organisation Mondiale de la Santé vise à obtenir, d'ici à 2035, une réduction de 95 % de la mortalité et de 90 % de l'incidence de la tuberculose par rapport à 2015. Après 20 années de baisse régulière de l'incidence estimée dans le monde (2 %/an en moyenne), la situation mondiale de la tuberculose s'est heurtée aux effets de la pandémie de COVID-19. Pour la première fois depuis plus de dix ans, une augmentation nette des décès et une réaugmentation du nombre de nouveaux cas estimés a été constatée. La pandémie pourrait présenter une opportunité pour de nouvelles solutions technologiques et collaborations et le partage des ressources visant à renforcer l'ensemble des systèmes de santé.

Social determinants of tuberculosis: a nationwide case-control study, Denmark, 1990-2018

BACKGROUND

The global vision is a world free of tuberculosis (TB). Even in resource-rich TB low-incidence settings, we need more focus on the role of social risk factors to end the TB epidemic.

METHODS

Nationwide, retrospective register-based, case-control study from 1990 to 2018, including all TB patients in Denmark ≥18 years old (n = 9581) matched 1:3 on sex and age with population controls. TB risk factors were assessed in logistic regression models and estimated by odds ratio (OR).

RESULTS

All TB patients had considerably lower socio-economic status compared with controls (P < 0.0001). Among ethnic Danes, TB was mostly found among males, persons between 35 and 65 years, those living alone, those with low educational level, persons on social welfare benefits and those with low income. Conversely, for migrants, being younger, sex and living alone were less important, whereas having children was protective. In an adjusted multivariable regression model among Danes, key risk factors for TB were being on disability pension (OR = 2.7) and cash benefits (OR = 4.7). For migrants, fewer social risk factors increased TB risk, although low income and cash benefits did (OR = 3.1).

CONCLUSION

Even today in a resourceful setting, socio-economic status drives disparities in health. In our study, multifactorial social deprivation was highly associated with TB. Especially household structure, education, employment and income were important risk factors that should be addressed in the future to accelerate TB control and end the TB epidemic.

National tuberculosis spending efficiency and its associated factors in 121 low-income and middle-income countries, 2010–19: a data envelopment and stochastic frontier analysis

Background

Maximising the efficiency of national tuberculosis programmes is key to improving service coverage, outcomes, and progress towards End TB targets. We aimed to determine the overall efficiency of tuberculosis spending and investigate associated factors in 121 low-income and middle-income countries between 2010 and 2019.

Methods

In this data envelopment and stochastic frontier analysis, we used data from the WHO Global TB report series on tuberculosis spending as the input and treatment coverage as the output to estimate tuberculosis spending efficiency. We investigated associations between 25 independent variables and overall efficiency.

Findings

We estimated global tuberculosis spending efficiency to be between 73·8% (95% CI 71·2–76·3) and 87·7% (84·9–90·6) in 2019, depending on the analytical method used. This estimate suggests that existing global tuberculosis treatment coverage could be increased by between 12·3% (95% CI 9·4–15·1) and 26·2% (23·7–28·8) for the same amount of spending. Efficiency has improved over the study period, mainly since 2015, but a substantial difference of 70·7–72·1 percentage points between the most and least efficient countries still exists. We found a consistent significant association between efficiency and current health expenditure as a share of gross domestic product, out-of-pocket spending on health, and some Sustainable Development Goal (SDG) indicators such as universal health coverage.

Interpretation

To improve efficiency, treatment coverage will need to be increased, particularly in the least efficient contexts where this might require additional spending. However, progress towards global End TB targets is slow even in the most efficient countries. Variables associated with TB spending efficiency suggest efficiency is complimented by commitments to improving health-care access that is free at the point of use and wider progress towards the SDGs. These findings support calls for additional investment in tuberculosis care.

Funding

None.