Tuberculosis at extremes of age

Elderly patients with tuberculosis in a low-incidence country - Clinical characteristics, inflammation and outcome

BACKGROUND

Susceptibility to respiratory infections increases with age. Diagnosing and treating tuberculosis in the elderly comes with the challenges of fewer specific symptoms and possibly more side effects of treatment. Much is unknown when it comes to tuberculosis in the elderly, especially in relation to inflammation, which may impact mortality. We, therefore, investigated a clinical cohort of elderly tuberculosis patients.

METHODS

Patients aged ≥65 years, admitted to our tuberculosis reference center between 2005 and 2021, were retrospectively included in our cohort. Sociodemographic data, clinical characteristics, laboratory results, including inflammatory markers at baseline (monocyte, neutrophil, lymphocyte count, and CRP levels), and treatment outcomes were collected. They were compared to the National Dutch TB Registry and analyzed using descriptive statistics. Survival analysis was performed using univariate Cox regression analysis and a log-rank test. Results were visualized in Kaplan-Meier curves.

RESULTS

104 elderly tuberculosis patients, mostly European, with a mean age of 75 years, were included. None were HIV-infected. Miliary tuberculosis cases were overrepresented (14 %) compared to the National Dutch TB Registry (5 % in elderly, 2 % adults). Fever occurred in 77 % (57/74), and the duration of fever decreased with age. Innate immune markers, including monocyte/lymphocyte-ratio, moderately correlated with CRP. Overall mortality was 15 %, and highest (33 %) in patients with CRP levels >100 mg/mL.

CONCLUSION

In elderly tuberculosis patients in a low-incidence setting, mortality rates are higher in comparison to younger patients. The overrepresentation of miliary tuberculosis may suggest waning immunity, with a subset of patients exhibiting strong inflammation associated with increased mortality.

A retrospective study of tuberculosis prevalence and associated factors among HIV-positive key populations in Nigeria

HIV is a major risk factor for active Tuberculosis (TB.) This raises patients' risk of original infection, reinfection, and TB reactivation. Providing healthcare to KPLHIV in developing countries requires TB prevalence research. This study aims to determine the prevalence of TB and HIV co-infection and associated factors among KPLHIV. This is a retrospective cross-sectional study among KP's living with HIV enrolled on care in One Stop Shop (OSS) of Heartland Alliance Ltd/GTE across six states in Nigeria. Data were analysed using IBM SPSS version 25.0. Secondary data analysis of client's records from the RADET files of the KPCARE 1 project from 6 states was conducted. Means with standard deviations were computed for continuous variables like age, and frequency tables were generated for categorical variables. Chi-square tests and t-tests were used for the bivariate analysis of variables. All tests were done at a 5% level of statistical significance (p = 0.05).TB prevalence was 19.1% among KP's living with HIV, with variations observed in age groups, geographic locations, target populations, marital status, educational backgrounds, clinical characteristics, and antiretroviral therapy (ART) history. KPs aged 51 and above exhibited the highest TB prevalence (21.0%), while those aged below 20 years had the lowest (18.2%). Jigawa KPs recorded the highest TB prevalence (38.4%), and Niger had the least (13.3%). TB was more prevalent among People who inject drugs (20.3%), divorced (32.3%), and those who attained Qur'anic education (29.7%). KPs who had to restart ART exhibited the highest TB prevalence (22.0%), whereas those who experienced Interruption in treatment (IIT) reported the lowest at 10.0%. Immune-suppressed KPs (CD4 counts < 200 cells/m3) had a higher TB prevalence of 26.6%. TB prevalence among KPs living with HIV varies greatly, underlining the need for targeted treatments, especially for high-risk categories, to improve HIV treatment outcomes and reduce TB prevalence.

Factors associated with unfavorable treatment outcomes among multidrug-resistant tuberculosis patients, Sierra Leone: a cross-sectional secondary data analysis

BACKGROUND

Globally, multidrug-resistant tuberculosis (MDR-TB) is a major public health problem. The tuberculosis rate in Sierra Leone is 298 per 100,000 people, and Sierra Leone is considered a country with a high burden of tuberculosis. In Sierra Leone, there are few studies on the outcomes of MDR-TB treatment, especially those exacerbated by COVID-19. We identified factors associated with unfavorable treatment outcomes among people with MDR-TB in Sierra Leone.

METHODS

We conducted a cross-sectional study to analyze hospital-based MDR-TB data from 2017 to 2021. Demographic, clinical, and treatment outcome data were extracted from the main MDR-TB referral hospital database. We defined unfavorable outcomes as patients who died, were lost to follow-up, or defaulted. We calculated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to identify predictors of the outcomes of MDR-TB treatment.

RESULTS

Between 2017 and 2021, 628 people with MDR-TB were reported at Lakka Hospital; 441 (71%) were male, with a median age of 25 years (interquartile ranges: 17-34). Clinically, 21% of the 628 MDR-TB patients were HIV positive, and 413 were underweight (66%). 70% (440) of MDR-TB patients received tuberculosis treatment. The majority of patients, 457 (73%), were treated with a short treatment regimen, and 126 (20%) experienced unfavorable outcomes. Age 45 years or younger (aOR = 5.08; CI:1.87-13.82), 21-45 years (aOR = 2.22; CI:140-3.54), tuberculosis retreatment (aOR = 3.23; CI:1.82-5.73), age group, HIV status (aOR = 2.16; CI:1.33-3.53), and malnourishment status (aOR = 1.79; CI:1.12-2.86) were significantly associated with unfavorable treatment outcomes for DR-TB patients.

CONCLUSION

This analysis revealed a high proportion of unfavorable treatment outcomes among MDR-TB patients in Sierra Leone. Malnourishment, TB retreatment, HIV coinfection, and age 45 years or younger were associated with unfavorable outcomes of MDR-TB treatment. Increasing patients' awareness, mainly among young people, heightens treatment adherence and HIV monitoring by measuring the amount of HIV in patient blood, which can reduce adverse treatment outcomes in Sierra Leone and other sub-Saharan African countries.

Monocytes predict prognosis and successful treatment in older patients with miliary tuberculosis

Background

The increasing number of patients with miliary tuberculosis (MTB) is a concern in an aging society because of its high mortality rate. Several prognostic biomarkers for MTB have been identified; however, the predictive ability of monocytes as biomarkers remains unknown. This study demonstrates the usefulness of monocytes as prognostic biomarkers for MTB.

Materials and methods

We retrospectively compared the clinical findings of 52 patients with MTB hospitalized between April 2013 and October 2021. The predictive ability of biomarkers for 3-month prognosis and their cutoff values were calculated. Survival times and longitudinal changes in monocytes after initiating treatment were compared.

Results

A smaller number of monocytes (#M), higher lymphocyte-monocyte ratio (LMR), higher neutrophil-monocyte ratio, and poorer performance status were associated with death within 3 months. #M was an independent prognostic factor. #M and LMR exhibited the highest predictive performance compared to others using receiver operating characteristic curve analysis (area under the curve = 0.86 and 0.85, respectively). Survival time was shorter in patients with #M ≤ 200 cells/μL and LMR > 2.5. Rapidly increasing #M after treatment was related to better prognosis in patients with #M ≤ 200 cells/μL at diagnosis.

Conclusions

#M at diagnosis and longitudinal changes in monocytes are related to MTB prognosis.

Human alveolar lining fluid from the elderly promotes Mycobacterium tuberculosis intracellular growth and translocation into the cytosol of alveolar epithelial cells

The elderly population is highly susceptible to developing respiratory diseases, including tuberculosis, a devastating disease caused by the airborne pathogen Mycobacterium tuberculosis (M.tb) that kills one person every 18 seconds. Once M.tb reaches the alveolar space, it contacts alveolar lining fluid (ALF), which dictates host-cell interactions. We previously determined that age-associated dysfunction of soluble innate components in human ALF leads to accelerated M.tb growth within human alveolar macrophages. Here we determined the impact of human ALF on M.tb infection of alveolar epithelial type cells (ATs), another critical lung cellular determinant of infection. We observed that elderly ALF (E-ALF)-exposed M.tb had significantly increased intracellular growth with rapid replication in ATs compared to adult ALF (A-ALF)-exposed bacteria, as well as a dampened inflammatory response. A potential mechanism underlying this accelerated growth in ATs was our observation of increased bacterial translocation into the cytosol, a compartment that favors bacterial replication. These findings in the context of our previous studies highlight how the oxidative and dysfunctional status of the elderly lung mucosa determines susceptibility to M.tb infection, including dampening immune responses and favoring bacterial replication within alveolar resident cell populations, including ATs, the most abundant resident cell type within the alveoli.

Incidence trend analysis of tuberculosis in Khuzestan Province, southwest of Iran: 2010-2019

Objectives

Identifying the trend of diseases and its changes over time can be highly important in evaluating the extent and method of achieving strategies for controlling them, developing health indicators, and health planning. This study aimed to investigate the incidence of tuberculosis.

Methods

As a repeated cross-sectional study in which the population under study was a census, this study involved all tuberculosis cases registered in 21 cities of Southwest of Iran, from 2010 to 2019. Data were obtained from the National System of Notification of Tuberculosis and included variables related to age, sex and Disease consequence. Segmented regression models were used to analyze the trend of tuberculosis changes. Also, data analysis software- Join Point Regression version 5.0.2 was used for data analysis.

Results

The results of evaluating the trend of tuberculosis from 2010 to 2019 showed no change in the general trend of tuberculosis and an annual 0.84% (95% CI: -5.17 to 6.82) increase in incidence rate is observed in the trend. Also, the findings of join point regression analysis show that between 2010 and 2013, an annual 18.10% (95% CI: 8.78 to 34.89) increase in the incidence of tuberculosis, and between 2013 and 2019, annual -5.42% (95% CI: -10.04 to -2.22) decrease in the incidence of tuberculosis was observed. From 2010 to 2012, a 33.10% (95% CI: 15.77 to 48.06) annual increase in the incidence of tuberculosis in males and - 9.47% (95%CI: -14.02 to -6.33) annual decrease in the incidence of tuberculosis in females was observed.

Conclusions

The results of this study showed that the incidence of tuberculosis had an upward trend from 2010 to 2013 and a downward trend from 2013 onwards.

Perinatal tuberculosis-An approach to an under-recognized diagnosis

Tuberculosis (TB) in young infants (<3 months of age), often referred to as perinatal TB, is underdiagnosed, leading to severe morbidity and high mortality. Perinatal TB includes both congenital and postnatal transmission of Mycobacterium tuberculosis. We aimed to increase an awareness of TB in neonates and young infants and to provide guidance on the assessment and management when in contact with mothers with TB during or soon after pregnancy. Approximately 217,000 pregnant women develop TB annually; if they are not diagnosed and treated during pregnancy, their infants are at high risk of adverse birth outcomes and TB disease. Although safe and effective antituberculosis treatment regimens are available during pregnancy, the diagnosis of TB is challenging. Infants born to mothers newly diagnosed with TB, not receiving any effective treatment or with cultures not yet negative, should be assessed for TB disease or M. tuberculosis infection. TB preventive therapy should be instituted if the infant is clinically well but exposed to TB, while prompt initiation of TB treatment is essential if TB disease is presumed. HIV status of mother and infant should be considered as this will affect the management. Further research is needed for the diagnosis and prevention of TB during pregnancy, an early diagnosis of TB in infants, and antituberculosis drug pharmacokinetics in young infants.

Drivers determining tuberculosis disease screening yield in four European screening programmes: a comparative analysis

BACKGROUND

The World Health Organization End TB Strategy emphasises screening for early diagnosis of tuberculosis (TB) in high-risk groups, including migrants. We analysed key drivers of TB yield differences in four large migrant TB screening programmes to inform TB control planning and feasibility of a European approach.

METHODS

We pooled individual TB screening episode data from Italy, the Netherlands, Sweden and the UK, and analysed predictors and interactions for TB case yield using multivariable logistic regression models.

RESULTS

Between 2005 and 2018 in 2 302 260 screening episodes among 2 107 016 migrants to four countries, the programmes identified 1658 TB cases (yield 72.0 (95% CI 68.6-75.6) per 100 000). In logistic regression analysis, we found associations between TB screening yield and age (≥55 years: OR 2.91 (95% CI 2.24-3.78)), being an asylum seeker (OR 3.19 (95% CI 1.03-9.83)) or on a settlement visa (OR 1.78 (95% CI 1.57-2.01)), close TB contact (OR 12.25 (95% CI 11.73-12.79)) and higher TB incidence in the country of origin. We demonstrated interactions between migrant typology and age, as well as country of origin. For asylum seekers, the elevated TB risk remained similar above country of origin incidence thresholds of 100 per 100 000.

CONCLUSIONS

Key determinants of TB yield included close contact, increasing age, incidence in country of origin and specific migrant groups, including asylum seekers and refugees. For most migrants such as UK students and workers, TB yield significantly increased with levels of incidence in the country of origin. The high, country of origin-independent TB risk in asylum seekers above a 100 per 100 000 threshold could reflect higher transmission and re-activation risk of migration routes, with implications for selecting populations for TB screening.

Case report: Miliary tuberculosis complicated by pediatric acute respiratory distress syndrome in a 12-year-old girl

Acute respiratory distress syndrome (ARDS) is a rare complication of miliary tuberculosis, particularly in pediatric patients. Comorbidities and delayed diagnosis can worsen the prognosis of patients with miliary tuberculosis. A 12-year-old girl presented with fever for 20 days, and cough and tachypnea for 4 days. She was diagnosed with miliary tuberculosis complicated by pediatric ARDS. She had atypical clinical manifestations and imaging findings, a negative contact history, and negative results of a tuberculin skin test (TST) and T-SPOT.TB. Diagnostic bronchoscopy and bronchoalveolar lavage helped make the diagnosis of tuberculosis. Effective treatment was promptly initiated after confirmation of the diagnosis, and the patient's condition improved. This case illustrates that a negative contact history and laboratory results cannot rule out tuberculosis. False-negative TST and T-SPOT.TB results should be evaluated carefully. Bronchoscopy may be useful for identifying pathogens in patients with pneumonia of unknown etiology, and corticosteroids should be administered with caution.

Imaging recommendations and algorithms for pediatric tuberculosis: part 1-thoracic tuberculosis

Tuberculosis (TB) remains a global health problem and is the second leading cause of death from a single infectious agent, behind the novel coronavirus disease of 2019. Children are amongst the most vulnerable groups affected by TB, and imaging manifestations are different in children when compared to adults. TB primarily involves the lungs and mediastinal lymph nodes. Clinical history, physical examination, laboratory examinations and various medical imaging tools are combined to establish the diagnosis. Even though chest radiography is the accepted initial radiological imaging modality for the evaluation of children with TB, this paper, the first of two parts, aims to discuss the advantages and limitations of the various medical imaging modalities and to provide recommendations on which is most appropriate for the initial diagnosis and assessment of possible complications of pulmonary TB in children. Practical, evidence-based imaging algorithms are also presented.

Tuberculosis in older adults: challenges and best practices in the Western Pacific Region

The Western Pacific has one of the fastest-growing older adult populations globally, and tuberculosis (TB) remains one of the foremost infectious causes of disease and death in the region. Older adults are at higher risk of TB due to immunosenescence, comorbidities, and increased institutionalisation. Atypical symptoms and reduced access to health services may delay care-seeking and TB diagnosis, while co-morbidity and increased risk of adverse drug reactions complicate TB treatment. Post-TB sequelae and socioeconomic challenges may decrease the quality of life after TB treatment completion. Despite their high disease burden and special challenges, there is a lack of regionally coordinated policies and guidelines to manage TB among older adults. Routine TB screening at aged-care facilities, age-friendly infrastructure and services, awareness of atypical TB features, integration of TB and non-communicable diseases services, and person-centred approaches to treatment support could improve TB management among older adults. Addressing these challenges and adopting the best practices identified should inform policy formulation and implementation.

Funding

This project was funded by 1) the World Health Organization Regional Office for the Western Pacific, with financial contributions from the Government of the Republic of Korea through the Korean Disease Control and Prevention Agency and the Government of Japan through the Ministry of Health, Labour and Welfare, and 2) NUS Start-up Grant. The funders had no role in the paper design, collection, analysis, and interpretation of data and in writing of the paper.

Factors associated with adverse drug reactions or death in very elderly hospitalized patients with pulmonary tuberculosis

The aging of patients with tuberculosis and better therapeutic management for them are recent concerns. This study aimed to identify risk factors for adverse drug reactions (ADRs) or death in very elderly patients with pulmonary tuberculosis and to assess the association between the dosage of antituberculosis drugs and outcomes. We conducted a multicenter retrospective study at two hospitals. Hospitalized patients (≥ 80 years old) with pulmonary tuberculosis who were treated with antituberculosis drugs were enrolled. Multivariate analysis was performed to assess factors associated with ADRs or death within 60 days after treatment initiation. In total, 632 patients were included. The primary endpoint occurred in 268 patients (190 ADRs and 78 deaths). A serum albumin level < 2.5 g/dL, respiratory failure, and dependent activities of daily living were independent risk factors for ADRs or death. However, a low dosage (< 8 mg/kg/day) of rifampicin was associated with a lower risk of the primary outcomes. Delayed time to negative sputum culture conversion was not observed in the lower dosage of rifampicin group. Very elderly hospitalized tuberculosis patients with the aforementioned risk factors should be carefully monitored to receive safer treatment. Rifampicin dosage reduction may be considered for very elderly tuberculosis patients to prevent ADRs/death.

Congenital pulmonary tuberculosis

Congenital tuberculosis is a fatal disease in the absence of treatment. The diagnosis is difficult due to polymorphic and nonspecific symptoms in neonates, as well as the lack of alertness of neonatologists and pediatricians. Less than 500 confirmed cases of congenital tuberculosis have been described in the available literature. Mortality ranges from 15 to 33%. Early diagnosis and adequate therapy are essential to improve the prognosis of the disease. Two cases of pulmonary congenital tuberculosis in premature neonates with a positive maternal and familial history of tuberculosis is presented. The clinical symptoms and radiological features started on the days 24 and 48 of life, respectively. Shortness of breath, low blood oxygen level requiring oxygen therapy, fever, and impaired general well-being revealed. The chest X-ray revealed bilateral polysegmental infiltrative lesions with the formation of a cavity of destruction in one case. The diagnosis was established after the detection of M. tuberculosis DNA in gastric aspirates. Patients received therapy according to a regimen designed for multidrug-resistant tuberculosis, including conventional anti-TB drugs in combination with linezolid, fluoroquinolones, meropenem, and aminoglycosides. The infectious syndrome in a premature newborn associated with pneumonia resistant to standard antibiotic therapy, the presence of tuberculosis in the mother, relatives, or siblings require a work-up for the detection of M. tuberculosis and instrumental diagnostics. Early diagnosis and treatment are critical for improving the prognosis of the disease.

Congenital Tuberculosis After In Vitro Fertilization: A Case for Tuberculosis Screening of Women Evaluated for Infertility

We report a case of multidrug-resistant congenital tuberculosis (TB) in an infant conceived by in vitro fertilization and review 22 additional infant-mother pairs in the literature. Females evaluated for infertility should be screened for TB risk, and those at risk require a TB-specific diagnostic evaluation before receiving assisted reproductive treatment.

Factors Associated with Medication Adherence in Elderly Individuals with Tuberculosis: A Qualitative Study

Methods

This qualitative study was conducted in two phases, using an integrative literature review and individual interviews. Studies were gathered without time restriction from MEDLINE databases, Institute for Scientific Information (ISI), Google Scholar, Scopus, and EMBASE, as well as national databases, including Scientific Information Database and Magiran. The findings of 38 studies that met the inclusion criteria were analyzed through the conventional content analysis method based on the ecological approach. After reviewing and forming the data matrix, purposive sampling was performed among healthcare professionals, elderly tuberculosis patients aged 60 and over, and family caregivers of elderly patients to conduct individual interviews. Data obtained from 20 interviews were analyzed using the directed content analysis method. After coding, the data from individual interviews were entered based on similarity and difference in the categories of data matrix obtained from the literature review.

Results

In general, the aforementioned codes were placed in four main categories, including individual factors (i.e., biological factors, affective-emotional factors, behavioral factors, cognitive factors, tuberculosis-related factors, and economic factors), interpersonal factors (i.e., patient's relationship with treatment team and family-related factors), factors related to healthcare service provider centers (i.e., medical centers' facilities and capacity building in healthcare service provider), and extraorganizational factors (i.e., social factors and health policymaking).

Conclusion

The results of this study showed that medication adherence in elderly patients with tuberculosis was a complex and multidimensional phenomenon. Therefore, society, policymakers, and healthcare providers should scrutinize the factors affecting medication adherence in this group of patients to plan and implement more effective interventions.

Mouse Models for Mycobacterium tuberculosis Pathogenesis: Show and Do Not Tell

Science has been taking profit from animal models since the first translational experiments back in ancient Greece. From there, and across all history, several remarkable findings have been obtained using animal models. One of the most popular models, especially for research in infectious diseases, is the mouse. Regarding research in tuberculosis, the mouse has provided useful information about host and bacterial traits related to susceptibility to the infection. The effect of aging, sexual dimorphisms, the route of infection, genetic differences between mice lineages and unbalanced immunity scenarios upon Mycobacterium tuberculosis infection and tuberculosis development has helped, helps and will help biomedical researchers in the design of new tools for diagnosis, treatment and prevention of tuberculosis, despite various discrepancies and the lack of deep study in some areas of these traits.

Challenges in treating tuberculosis in the elderly population in tertiary institute

Tuberculosis (TB) epidemic is most prevalent in the India with increase in mortality and morbidity. Ongoing elderly population as a result of increase in health care facilities are at high risk of TB. Elderly people are four-fold more prone to TB. Most cases of TB in the elderly result from reactivation of latent TB due to immunosenescence. Major challenge in dealing with therapeutic aspects of elderly patients is recognising frailty to prevent loss of independence. Challenges facing with elderly TB are difficult to reach out to hospital because of poor health seeking behaviour especially elderly female either due to ignorance or neglected by the family members, atypical presentation mimicking other disorders leading to diagnostic delay, if at all diagnosed impoverished tolerance and adherence to treatment due to various factors like associated comorbidities leading to pill load, impaired renal and hepatic functions with aging and stigma. Emerging resistance with usage of non-standard treatment regimens lead to unpropitious outcomes and increases mortality. The mortality rate is six times higher in elderly compared to younger individuals. Hence elderly people need tertiary level health care facilities for enhancing the diagnosis and appropriate management of tuberculosis and its complications. New set of guidelines to be made for elderly to increase adherence and tolerance thereby decreasing drug interactions and adverse drug reactions. With the increased prevalence of TB in the elderly, it is the need of the hour for India, to focus on this vulnerable population as they are a potential source of infection in the community. Awareness to be created among the elderly community regarding this deadly disease and its outcomes to increase their health consciousness and medical attention. Priming the special focus on females coterie as they are the most neglected population in our society.

Detection of multidrug and extensively drug-resistance and mutation pattern in geriatric patients from North Indian referral institute

INTRODUCTION

Geriatric population are predisposed to reactivation to tuberculosis (TB) and multi-drug resistance (MDR) due to deteriorated immune system. Limited data is available in this population hence present study is undertaken to study drug resistance and associated mutations among geriatric presumptive DR-TB patients by genotypic methods METHODS: From October 2011 to December 2018, demographic characteristics of enrolled patients was collected. Smear-positive processed sputum samples were subjected directly while cultures positive for Mycobacterium Tuberculosis (MTB) from smear-negative pulmonary and all extra-pulmonary samples were subjected to LPA. The LPA used were Genotype MTBDR plus (1st line LPA) for detection of susceptibility to rifampicin (RIF) and isoniazid (INH) and Genotype MTBDR sl (2nd line LPA), for susceptibility to fluoroquinolones (FQ) and aminoglycosides (AG).

RESULTS

Total of 2041 samples were received from presumptive MDR-TB patients above 60 years of age during study period, of which 1406; 68.9% were within 60-70 year followed by 495; 24.3% within 71-80 year and 140; 6.9% more than 80 years. Total of 1055 MTB were detected, of which those diagnosed as RIF resistant were 117/1055; 11.2% including 89/1055; 8.5% MDR-TB and resistance to INH was in 84/1055; 8%. Total 67, 2nd line LPA gave valid results, of which 19/67 (28.4%) isolates were resistant to only FQ, and one isolate was resistant to AG.

CONCLUSION

Study finding highlights need for dedicated efforts for diagnosis, and treatment of geriatric tuberculosis. Suitable intervention at programmatic country level at country will help in strengthening tuberculosis control strategies in this population.

Clinical spectrum of TB in elderly in a TB & respiratory institution

Tuberculosis has maximum burden among young population in developing countries like India. However, children and elderly form a special group where TB may have atypical presentation. This presents with epidemiological, diagnostic and treatment challenges in these groups which may need special attention in the national programmes for TB. Due to atypical presentation, elderly population is vulnerable to frequent misdiagnosis and disease may already be in advanced stage when correct diagnosis is made. Not only this, adjustment of drug dosages and high chances of adverse drug reaction make the management of TB more complicated in elderly. Mortality due to TB is also higher in this group as compared to young patients of TB. This view point briefly highlights the epidemiological, clinical and disease outcome aspects of TB disease in elderly patients.

Tuberculosis in an Aging World

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

Clinico-epidemiologic Considerations in the Diagnosis of Tuberculous Lymphadenitis: Evidence from a high burden country

Tuberculosis is the biggest global health issue, tuberculous lymphadenopathy (TBL) being its commonest extra-pulmonary manifestation. Clinical diagnoses of TBL often pose challenges,thus this study aimed to analyze the clinical, epidemiologic and laboratory aspects of TBL in Debre Markos Specialized Comprehensive Hospital (DMSCH), North-west Ethiopia.

METHODS

The study was conducted at DMSCH, from October 2019 to March 2021. Patients with lymphadenopathy displaying cytomorphologic features of TB were enrolled. Checklist was used to collect clinico-demographic data.

RESULTS

Among a total of 294 TBL patients, majority 237 (80.61%) were adults aged 15-45 years. A fluctuant consistency 177 (60.20%; n=294) with predominant involvement of cervical lymph nodes 229 (77.8%) was the most frequent presentation. Most patients did not have either HIV infection 235 (94.37%; n=261) or known chronic medical illnesses 250(95.8%). Constitutional symptoms 113 (41.85%; n=270) and chronic cough 56 (20.74%; n=270) were infrequent. Erythrocyte Sedimentation Rate (ESR) raised in majority 133 (80%; n=165), of whom, extreme elevation (≥ 100mm/hr) seen in 63 (38.18 %).

CONCLUSION

TBL typically present as a fluctuant neck mass, predominantly in adults. Majority patients have no constitutional symptoms or cough. HIV infection or chronic medical illnesses are uncommon. Raised ESR is a fairly consistent finding.

Association between averaged meteorological factors and tuberculosis risk: A systematic review and meta-analysis

Inconsistencies were discovered in the findings regarding the effects of meteorological factors on tuberculosis (TB). This study conducted a systematic review of published studies on the relationship between TB and meteorological factors and used a meta-analysis to investigate the pooled effects in order to provide evidence for future research and policymakers. The literature search was completed by August 3rd, 2021, using three databases: PubMed, Web of Science and Embase. Relative risks (RRs) in included studies were extracted and all effect estimates were combined together using meta-analysis. Subgroup analyses were carried out based on the resolution of exposure time, regional climate, and national income level. A total of eight studies were included after screening for inclusion and exclusion criteria. Our results show that TB risk was positively correlated with precipitation (RR = 1.32, 95% CI: 1.14, 1.51), while temperature (RR = 1.15, 95% CI: 1.00, 1.32), humidity (RR = 1.05, 95% CI: 0.99, 1.10), air pressure (RR = 0.89, 95% CI: 0.69, 1.14) and sunshine duration (RR = 0.95, 95% CI: 0.80, 1.13) all had no statistically significant correlation. Subgroup analysis shows that quarterly measure resolution, low and middle Human Development Index (HDI) level and subtropical climate increase TB risk not only in precipitation, but also in temperature and humidity. Moreover, less heterogeneity was observed in "high and extremely high" HDI areas and subtropical areas than that in other subgroups (I² = 0%). Precipitation, a subtropical climate, and a low HDI level are all positive influence factors to tuberculosis. Therefore, residents and public health managers should take precautionary measures ahead of time, especially in extreme weather conditions.

Epidemiological features of tuberculosis infection in a rural prefecture of Japan from 2007 to 2018

This study aimed to investigate the epidemiological features of reported tuberculosis (TB) infections in a western prefecture (Nagasaki Prefecture) from 2007 to 2018, and to identify the high-risk group for TB infection. The characteristics of 12 years of reported TB infections from the Nagasaki Prefectural Informational Center of Infectious Diseases were summarized by median (interquartile range [IQR]) and proportion; the annual TB infections’ notification rate regarding sex/age was calculated accordingly. The diagnosis of TB infection was made according to clinic symptoms and laboratory examination. In total, 4364 TB infections were reported in 2007 and 2018, with a median age (IQR) of 74 (55–84) years. The majority of TB infections were male (52.6%, 2297/4364), > 65 years (65.8%, 2869/4364), and indigenous (98.1%, 4276/4364). Among active TB, 66.9% (1833/2740) had pulmonary TB, and 25.3% (694/2740) were diagnosed as extrapulmonary TB. The highest notification rate of TB infection was observed in the elderly male population (> 85 years). The annual notification rate of TB infections ranged between 19.4/and 34.0/100,000 for 12 years. The notification rates of TB infections were high in older people of both sexes, especially in men aged > 85. Therefore, appropriate interventions and health management are essential for TB control in (and with a focus on) the elderly population.

Hidden loss to follow-up among tuberculosis patients managed by public-private mix institutions in South Korea

In South Korea, public-private mix (PPM) was launched in 2011. This retrospective cohort study sought to determine the rate of loss to follow-up (LTFU) among drug-susceptible tuberculosis (DS-TB) patients in all nationwide PPM institutions, and the risk factors for LTFU. National notification data for DS-TB patients diagnosed between August 2011 and July 2014 in PPM institutions were analysed. Determination of LTFU included detection of instances where patients were transferred out, but when they did not attend at other TB centres in the following two months. Univariable and multivariable competing risk models were used to determine risk factors for LTFU. 73,046 patients with 78,485 records were enrolled. Nominally, 3426 (4.4%) of records were LTFU. However, after linking the multiple records in each patient, the percentage of LTFU was 12.3% (9004/73,046). Risk factors for LTFU were: being foreign-born (3.13 (95% CI 2.77-3.53)), prior LTFU (2.31 (2.06-2.59)) and greater distance between the patient's home and the TB centre (4.27 (4.03-4.53)). 'Transfer-out' was a risk factor in patients managed by treatment centres close to home (1.65 (1.49-1.83)), but protective for those attending centres further (0.77 (0.66-0.89)) or far-away (0.52 (0.46-0.59)) from home. By considering the complete picture of a patient's interactions with healthcare, we identified a much higher level of LTFU than previously documented. This has implications for how outcomes of treatment are reported and argues for a joined-up national approach for the management and surveillance of TB patients, in nations with similar healthcare systems.

Multidrug-Resistant Tuberculosis Treatment Outcome and Associated Factors at the University of Gondar Comprehensive Specialized Hospital: A Ten-Year Retrospective Study

Background

Multidrug-resistant tuberculosis (MDR-TB) remains a public health crisis and a health security threat worldwide. Poor public health infrastructure, inefficient infection control and mismanagement of TB treatment are among the reasons for the continuous emergence and spread of drug-resistant TB (DR-TB). The final treatment outcome is the most direct measurement of TB control programs. Therefore, this study sought to determine the proportions and predictors of TB treatment outcomes among MDR/RR-TB treated patients.

Methods

A 10-year, 2011 to 2021, hospital-based retrospective cohort study was conducted at the University of Gondar Comprehensive Specialized Hospital. The records of 408 MDR-TB patients, 389 with treatment outcome and 19 on treatment, were collected using a structured checklist.

Results

A total of 389 patients with a recorded MDR/RR-TB treatment outcome were included. The treatment success rate was 77.12%, with 58.35% cured and 18.76% treatment completed. The proportion of death rate, treatment default loss to follow-up, treatment failure, and unknown treatment outcome was 9.25%, 6.94%, 3.1%, and 3.6%, respectively. Regarding the patient category, the most successful treatment outcome (83.5%) came from patients diagnosed with relapse cases, followed by new cases (81.8%). An unsuccessful treatment outcome was significantly associated with patients aged >44 years (AOR, 3.3, 95% CI = 1.55–6.99).

Conclusion and Recommendations

This study indicated that nearly 23% of MDR/RR-TB patients had unsuccessful treatment outcomes and being older was significantly correlated with these outcomes. For better outcomes, it is recommended to strengthen combined treatment adherence interventions and evaluate treatment regimens and administration options. A prospective cohort study may be required to investigate the full range of potential causes of unfavorable outcomes.

Investigating the appropriate adenosine deaminase cutoff value for the diagnosis of tuberculous pleural effusion in a country with decreasing TB burden

As the burden of tuberculosis (TB) in South Korea decreases while that of malignancy increases with an aging society, the composition of etiology for pleural effusion is changing. The aim of this study was to investigate the diagnostic value of adenosine deaminase (ADA) for diagnosis of tuberculous pleural effusion (TPE) in this circumstance. Medical records of patients who underwent medical thoracoscopy from May 2015 to September 2020 in Incheon St. Mary Hospital, Korea were retrospectively reviewed. TPE was diagnosed if one of the following criteria was met: (1) granuloma in pleura, (2) positive TB polymerase chain reaction or culture in pleural fluid or tissue with non-specific pathologic findings in pleura, or (3) bacteriologically confirmed pulmonary TB with non-specific pathologic findings in pleura. A total of 292 patients, including 156 with malignant pleural effusion (MPE), 52 with TPE, and 84 with other benign effusion, were analyzed. Among 206 patients with lymphocyte dominant pleural effusion, the area under receiver characteristic curve of ADA for diagnosis of TPE was 0.971. The sensitivity and specificity of a current cutoff value of 40 IU/L were 1.00 and 0.61, respectively, whereas those of a raised cutoff value of 70 IU/L were 0.93 and 0.93, respectively. Among 54 patients with ADA levels of 40–70 IU/L, 30 (55.6%) patients were diagnosed as MPE, 21 (38.9%) as other benign effusion, and only 3 (5.6%) as TPE. Caution is needed in clinical diagnosis of TPE with current ADA cutoff value in countries with decreasing TB incidence, due to many false positive cases.

Diagnosis and Surveillance of Neonatal Infections by Metagenomic Next-Generation Sequencing

Microbial infections cause significant morbidity and mortality in neonates. Metagenomic next-generation sequencing is a hypothesis-free and culture-free test that enables broad identification of pathogens and antimicrobial resistance genes directly from clinical samples within 24 h. In this study, we used mNGS for etiological diagnosis and monitoring the efficacy of antibiotic treatment in a cohort of neonatal patients with severe infections. The median age was 19.5 (3–52) days, median gestational age was 37.96 (31–40⁺³) weeks, and the median birth weight was 3,261 (1,300–4,300) g. The types of infectious diseases included pneumonia, sepsis, and meningitis. mNGS reported microbial findings in all cases, which led to changes in antibiotic treatment. These included cases of Mycobacterium tuberculosis, Legionella pneumophila, and Bacillus cereus. Eight of ten infants recovered after antibiotic adjustment and showed normal development during follow-up. On the other hand, neurological retardation was seen in two infants with meningitis. mNGS enabled etiological diagnosis and guided antibiotic therapy when all conventional methods failed to discover the culprit. It has the potential to cut down the overall cost and burden of disease management in neonatal infections.

The Relationship Between Socio-Demographic Factors and Tuberculosis Mortality in the Republic of Korea During 2008-2017

The Republic of Korea has a high incidence of tuberculosis (TB) and TB-specific mortality rate. In 2019, it had the second highest TB-specific mortality among Organization for Economic Co-operation and Development countries. Understanding the factors associated with TB-specific deaths may help eradicate the disease. Therefore, we aimed to identify the general characteristics associated with TB-specific mortality among Koreans. Using Causes of Death Statistics data from Statistics Korea, we assessed the year of death, sex, age, occupation, area of residence, marital status, and education level reported between 2008 and 2017. Patient characteristics associated with TB-specific deaths were analyzed using the Chi-squared test, while influencing factors of TB-specific mortality were analyzed using logistic regression analysis to calculate adjusted odds ratios (AOR). Female (AOR: 0.509, 95% CI: 0.493–0.526), those with a graduate degree or higher (AOR: 0.559, 95% CI: 0.474–0.660) had lower TB-specific mortality rates than those of their counterparts. Conversely, those aged ≥70 years (AOR: 1.239, 95% CI: 1.199–1.280), single (AOR: 1.355, 95% CI: 1.315–1.396), and skilled agricultural, forestry, and fishery workers (AOR: 1.441, 95% CI: 1.359–1.529) had higher TB-specific mortality rates than those of their counterparts. In conclusion, TB-specific mortality rates differed according to the characteristics of the deceased patients. In order to establish effective TB control, multisectoral action on broader determinants should be strengthened.

Selective functional antibody transfer into the breastmilk after SARS-CoV-2 infection

Antibody transfer via breastmilk represents an evolutionary strategy to boost immunity in early life. Although severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific antibodies have been observed in the breastmilk, the functional quality of these antibodies remains unclear. Here, we apply systems serology to characterize SARS-CoV-2-specific antibodies in maternal serum and breastmilk to compare the functional characteristics of antibodies in these fluids. Distinct SARS-CoV-2-specific antibody responses are observed in the serum and breastmilk of lactating individuals previously infected with SARS-CoV-2, with a more dominant transfer of immunoglobulin A (IgA) and IgM into breastmilk. Although IgGs are present in breastmilk, they are functionally attenuated. We observe preferential transfer of antibodies capable of eliciting neutrophil phagocytosis and neutralization compared to other functions, pointing to selective transfer of certain functional antibodies to breastmilk. These data highlight the preferential transfer of SARS-CoV-2-specific IgA and IgM to breastmilk, accompanied by select IgG subpopulations, positioned to create a non-pathologic but protective barrier against coronavirus disease 2019 (COVID-19).

Combined assessment of tuberculosis case notification rate and infection control at health facilities of Dale districts, Sidama Zone, Southern Ethiopia

Background

Mycobacterium tuberculosis (TB) is the deadliest disease that claims millions of deaths globally. Ethiopia is among the countries heavily hit by the disaster. Despite the effective directly observed treatment and TB infection control (TBIC) measures provided by the world health organization (WHO), the rate of new cases increased daily throughout the country. Healthcare workers (HCWs) are at highest risk serving without having the necessary facility in place while overcrowding of patients exacerbated TB transmission. The study aimed to assess TBIC implementation and analyze case notification rate (CNR) of smear-positive pulmonary TB in the selected health facilities at Dale district, Sidama Zone, Southern Ethiopia.

Methods

Seven health care facilities have been visited in the study area and smear-positive pulmonary TB notification rate was determined retrospectively during the years 2012 to 2014. Data on smear positive test results and demographic characteristics were collected from the TB unit registries. A structured questionnaire, facility survey, and observation checklists were used to assess the presence of TBIC plans at the health care facilities.

Results

The overall case notification rate of smear-positive pulmonary tuberculosis was 5.3% among all 7696 TB suspected patients. The odds of being diagnosed with smear-positive TB were 24% more in males than in females (adj OR = 1.24, 95% CI: (1.22, 1.55). Moreover, in the study area, only 28% of the facilities have been practiced TB infection control and 71% of the facilities assigned a focal person for the TBIC plan. The implementation of environmental control measures in the facilities was ranged between 16–83%. N95 particulate respirators were found only in 14% of the facilities.

Conclusion

TB CNR in Dale district was low. Moreover, implementations of TBIC in Dale district health facilities were poor when the survey was done. Hence, urgent measures should be taken to reverse the burden of TB.

A scoping review on climate change and tuberculosis

Climate change is a global public health challenge. The changes in climatic factors affect the pattern and burden of tuberculosis, which is a worldwide public health problem affecting low and middle-income countries. However, the evidence related to the impact of climate change on tuberculosis is few and far between. This study is a scoping review following a five-stage version of Arksey and O'Malley's method. We searched the literature using the keywords and their combination in Google scholar, and PubMed. Climate change affects tuberculosis through diverse pathways: changes in climatic factors like temperature, humidity, and precipitation influence host response through alterations in vitamin D distribution, ultraviolet radiation, malnutrition, and other risk factors. The rise in extreme climatic events induces population displacement resulting in a greater number of vulnerable and risk populations of tuberculosis. It creates a conducive environment of tuberculosis transmission and development of active tuberculosis and disrupts tuberculosis diagnosis and treatment services. Therefore, it stands to reasons that climate change affects tuberculosis, particularly in highly vulnerable countries and areas. However, further studies and novel methodologies are required to address such a complex relationship and better understand the occurrence of tuberculosis attributable to climate change.

Estimating the burden of nosocomial exposure to tuberculosis in South Korea, a nationwide population based cross-sectional study

BACKGROUND/AIMS

The aim of the study was to investigate the current nationwide burden of nosocomial exposure to tuberculosis (TB) using national health insurance claims data.

METHODS

All patients who had claims for drug susceptibility testing for TB from 2012 to 2016, which indicated culture-proven TB, were included. The first day of the infectious period was defined as 3 months before a doctor's suspicion of TB in patients with respiratory symptoms and 1 month before in patients without symptoms. The last day of the infectious period was defined as one day before the prescription of anti-TB medications. Patients hospitalized during infectious periods were investigated and their hospitalization days were calculated. Records of medical procedures which increased the risk of nosocomial transmission by generating aerosols were also investigated.

RESULTS

A total of 7,186 cases with 94,636 person-days of hospitalization with unrecognized active TB were found. Patients above 60 years of age accounted for 63.99% of the total number and 69.70% of the total duration of hospitalization. TB patients in the older age group showed a trend toward higher risks for hospitalization with unrecognized active TB. Patients in their 80s showed the highest risk (12.65%). Bronchoscopy (28.86%), nebulizer therapy (28.48%), and endotracheal intubation (13.02%) were common procedures performed in these patients during hospitalization.

CONCLUSION

The burden of nosocomial exposure to TB in South Korea is still substantial. Hospitalization with unrecognized active TB, especially among the elderly TB patients could be a serious public health issue in South Korea.

Comparison of profile and treatment outcomes between elderly and non-elderly tuberculosis patients in Puducherry and Tamil Nadu, South India

The rising geriatric population and the increased susceptibility of this age group to tuberculosis (TB), the deadliest single infectious agent, is bothersome for India. This study tried to explore the demographic and treatment outcome differences between the elderly (aged 60 years and above) and non-elderly TB (<60 years) patients from South India. This study was part of a large ongoing cohort study under the RePORT India consortium. Newly diagnosed TB patients recruited into the cohort between 2014 and 2018 were included in this study. Pretested and standardized questionnaire and tools were used to collect data and were stored securely for the entire cohort. Required demographic, anthropometric and treatment related variables were extracted from this database and analyzed using Stata version 14.0. Prevalence of elderly TB was summarized as percentage with 95% confidence interval (CI). Generalized linear modelling was attempted to find the factors associated with elderly TB. A total of 1,259 eligible TB patients were included into this present study. Mean (SD) of the participants in the elderly and non-elderly group was 65.8 (6.2) and 40.2 (12.0) respectively. Prevalence of elderly TB was 15.6% (95%CI: 13.6%-17.6%) with nearly 71% belonging to 60–69 age category. Male sex, OBC caste, poor education, unemployment, marriage, alcohol consumption and unable to work as per Karnofsky score were found to be significantly associated with an increased prevalence of elderly TB. Unfavorable outcomes (12% vs 6.5%, p value: 0.018), including death (9.3% vs 3.4%, p value: 0.001) were significantly higher among the elderly group when compared to their non-elderly counterparts. The current TB programme should have strategies to maintain follow up with due attention to adverse effects, social support and outcomes. Additional research should focus on predictors for unfavorable outcomes among the elderly TB group and explore ways to handle the same. Rendering adequate social support from the health system side and family side would be a good start.

Tuberculosis in a 2.5-month-old infant: congenital or acquired dilemma?

Infants may develop congenital tuberculosis from an infectious mother or acquire the disease postnatally by contact with an infectious adult. Delayed diagnosis is common, especially in infants under 1 year of age, and, if unrecognised, there is an increased risk of death. A 2.5-month-old boy presented with respiratory distress, small inhomogeneous opacities in both lungs and hepatosplenomegaly mimicking sepsis. He had received BCG vaccination and there was no history of contact with tuberculosis (TB). He had had fever since 1 month of age for which there had been several outpatient visits. Gastric aspirate cartridge-based nucleic acid amplification test (CBNAAT) confirmed TB and sonological evaluation demonstrated multiple granulomata in the liver and spleen, and a liver biopsy supported TB. He responded well to 12 months of anti-tuberculous treatment. The mother's tuberculin test, chest radiograph and endometrial biopsy showed no evidence of TB. There was no history of tuberculous contact with close family members. Despite the lack of proof of current tuberculous TB infection in the mother, it is likely that the infant had congenital TB.

Pulmonary Tuberculosis in Older Adults: Increased Mortality Related to Tuberculosis Within Two Months of Treatment Initiation

BACKGROUND

The proportion of tuberculosis (TB) patients who are older adults is increasing worldwide. Nearly 60% of TB patients in Japan are 70 years or older, and the TB incidence rate in Japan is one of the highest among high-income countries. The previous TB treatment guidelines prior to 2018 in Japan recommended excluding pyrazinamide (PZA) from the initial regimen for patients aged over 80 years.

OBJECTIVES

We aimed to examine differences in TB treatment outcomes among different age groups, and between those who received PZA and those who did not.

METHODS

We performed a retrospective cohort study of patients with pulmonary TB who were managed at a single medical center in Japan. We compared treatment outcomes and adverse events that resulted in treatment interruption across the age groups.

RESULTS

Of 246 patients, 117 (48%) were aged 75 years or older. Compared with patients aged < 74 years, those ≥ 75 years were less likely to have PZA in the initial regimen (53.0% vs 89.9%; p < 0.0001), more likely to die during treatment (38.5% vs 6.2%; p < 0.0001), and more likely to experience adverse events (30.8% vs 19.4%; p < 0.05). The mortality rate related to TB at 2 months after TB treatment initiation was 28% in those aged ≥ 84 years. Furthermore, among patients aged ≥ 84 years, those who did not receive PZA were significantly more likely to die than those who did (65.8% vs 36.8%; p < 0.05).

CONCLUSIONS

Patients aged ≥ 75 years with pulmonary TB experienced increased mortality related to TB during treatment and more frequent adverse events than younger patients, even though PZA was often avoided among older patients.

Impact of Diabetes and Low Body Mass Index on Tuberculosis Treatment Outcomes

BACKGROUND

Diabetes was identified as a tuberculosis (TB) risk factor mostly in retrospective studies with limited assessments of metabolic variables. The prospective Effects of Diabetes on Tuberculosis Severity study compared adults with pulmonary TB in Chennai, India, who were classified as having either diabetes or a normal glucose tolerance at enrollment.

METHODS

Baseline TB severity, sputum conversion, and treatment outcomes (cure, failure, death, or loss to follow-up) were compared between groups with respect to glycemic status and body mass index (BMI).

RESULTS

The cohort of 389 participants included 256 with diabetes and 133 with a normal glucose tolerance. Low BMIs (<18.5 kg/m2) were present in 99 (74.4%) of nondiabetic participants and 85 (33.2%) of those with diabetes. Among participants with normal or high BMIs, rates of cure, treatment failure, or death did not vary by glycemic status. Participants with low BMIs had the highest radiographic severity of disease, the longest time to sputum culture conversion, and the highest rates of treatment failure and death. Among participants with low BMIs, poorly controlled diabetes (glycohemoglobin [HbA1c] ≥8.0%) was unexpectedly associated with better TB treatment outcomes. A high visceral adiposity index was associated with adverse outcomes and, despite an overall correlation with HbA1c, was elevated in some low-BMI individuals with normal glucose tolerance.

CONCLUSIONS

In this South Indian cohort, a low BMI was significantly associated with an increased risk for adverse TB treatment outcomes, while comorbid, poorly controlled diabetes lessened that risk. A high visceral adiposity index, either with or without dysglycemia, might reflect a novel TB susceptibility mechanism linked to adipose tissue dysfunction.

The epidemiologic impact and cost-effectiveness of new tuberculosis vaccines on multidrug-resistant tuberculosis in India and China

BACKGROUND

Despite recent advances through the development pipeline, how novel tuberculosis (TB) vaccines might affect rifampicin-resistant and multidrug-resistant tuberculosis (RR/MDR-TB) is unknown. We investigated the epidemiologic impact, cost-effectiveness, and budget impact of hypothetical novel prophylactic prevention of disease TB vaccines on RR/MDR-TB in China and India.

METHODS

We constructed a deterministic, compartmental, age-, drug-resistance- and treatment history-stratified dynamic transmission model of tuberculosis. We introduced novel vaccines from 2027, with post- (PSI) or both pre- and post-infection (P&PI) efficacy, conferring 10 years of protection, with 50% efficacy. We measured vaccine cost-effectiveness over 2027-2050 as USD/DALY averted-against 1-times GDP/capita, and two healthcare opportunity cost-based (HCOC), thresholds. We carried out scenario analyses.

RESULTS

By 2050, the P&PI vaccine reduced RR/MDR-TB incidence rate by 71% (UI: 69-72) and 72% (UI: 70-74), and the PSI vaccine by 31% (UI: 30-32) and 44% (UI: 42-47) in China and India, respectively. In India, we found both USD 10 P&PI and PSI vaccines cost-effective at the 1-times GDP and upper HCOC thresholds and P&PI vaccines cost-effective at the lower HCOC threshold. In China, both vaccines were cost-effective at the 1-times GDP threshold. P&PI vaccine remained cost-effective at the lower HCOC threshold with 49% probability and PSI vaccines at the upper HCOC threshold with 21% probability. The P&PI vaccine was predicted to avert 0.9 million (UI: 0.8-1.1) and 1.1 million (UI: 0.9-1.4) second-line therapy regimens in China and India between 2027 and 2050, respectively.

CONCLUSIONS

Novel TB vaccination is likely to substantially reduce the future burden of RR/MDR-TB, while averting the need for second-line therapy. Vaccination may be cost-effective depending on vaccine characteristics and setting.

Active Pulmonary Tuberculosis in Elderly Patients: A 2016-2019 Retrospective Analysis from an Italian Referral Hospital

Tuberculosis (TB) in the elderly (>65 years old) has increasingly become a global health problem. It has long been recognized that older people are vulnerable to developing tuberculosis. We retrospectively evaluated data from patients older than 65 years diagnosed with pulmonary TB admitted to the National Institute for Infectious Diseases L. Spallanzani, Rome, Italy, from 1 January 2016 to 31 December 2019. One hundred and six consecutive patients were diagnosed with pulmonary TB and 68% reported at least one comorbidity and 44% at least one of the TB risk-factors. Out of the 26 elderly patients who reported an adverse event, having risk factors for TB (O.R. (Odds Ratios) = 1.45; 95% CI 1.12-3.65) and the presence of cavities on Chest X-rays (O.R. = 1.42; 95% CI 1.08-2.73) resulted in being more likely to be associated with adverse events in elderly patients. Having weight loss (O.R. = 1.31; 95% CI 1.08-1.55) and dyspnea (O.R. = 1.23; 95% CI 1.13-1.41) resulted in being significant predictors of unsuccessful treatment outcome in elderly patients. Older people with TB represent a vulnerable group, with high mortality rate, with a challenging diagnosis. Hospitalizations in tertiary referral hospital with clinical expertise in TB management can be useful to improve the outcome of these fragile patients.

Clinical characteristics of elderly pulmonary tuberculosis in an acute-care general hospital in Tokyo, Japan: A 12-year retrospective study

OBJECTIVE

A significant feature of tuberculosis (TB) in Japan is the fact that a high proportion of cases belong to the elderly population. Furthermore, previous reports have pointed out the delayed diagnosis of pulmonary TB in acute-care settings. We aimed to examine the clinical characteristics of pulmonary TB patients in an acute-care general hospital, particularly focusing on the elderly population.

METHODS

We retrospectively reviewed the medical records of patients with pulmonary TB who presented at our institution between May 2005 and December 2016. We described the overall clinical characteristics of these patients and compared them according to age.

RESULTS

Overall, 289 patients were eligible for the analysis, with a median age of 58 [42-73] years, and 29.4% being older than 70 years. Among the elderly patients, 42.4% were characterized by atypical presentation.

CONCLUSION

Our findings suggest that the elderly population tends to present as atypical cases lacking respiratory complaints, thereby being at a risk of misdiagnosis.

Reactive arthritis induced by active extra-articular tuberculosis: A case report

RATIONALE

Rare cases of reactive arthritis induced by active extra-articular tuberculosis (Poncet disease) have been reported. Complete response to antitubercular treatment and evidence of active extra-articular tuberculosis are the most important clinical features of Poncet disease. We report the case of successfully treated a patient with reactive arthritis induced by active extra-articular tuberculosis with a TNF inhibitor after sufficient antitubercular treatment.

PATIENT CONCERNS

A 56-year-old Japanese man was admitted to our department with polyarthralgia, low back pain, and high fever. The results of rheumatoid factor, anti-citrullinated protein antibody, human leukocyte antigen B27, and the assays for the detection of infections (with an exception of T-SPOT.TB) were all negative. Fluoro-deoxy-D-glucose-positron emission tomography with CT (PET/CT) showed moderate uptake in the right cervical, right supraclavicular, mediastinal, and abdominal lymph nodes. As magnetic resonance imaging and power Doppler ultrasonography showed peripheral inflammation (tendinitis, tenosynovitis, ligamentitis, and enthesitis in the limbs).

DIAGNOSIS

A diagnosis of tuberculous lymphadenitis was eventually established on the basis of lymph node biopsy results. There was no evidence of a bacterial infection including acid-fast bacteria in his joints, and the symptoms of polyarthralgia and low back pain were improved but not completely resolved with NSAID therapy; in addition, a diagnosis of reactive arthritis induced by active extraarticular tuberculosis was made.

INTERVENTIONS

The patient experienced persistent peripheral inflammation despite antitubercular treatment for more than nine months and was then successfully treated with a tumor necrosis factor inhibitor (adalimumab 40 mg every 2 weeks).

OUTCOMES

Finally, the patient responded to the treatment and has been in remission for over 4 months as of this writing.

LESSONS

In patients who present with symptoms associated with spondyloarthritis, it is important to distinguish between classic reactive arthritis and reactive arthritis induced by extra-articular tuberculosis infection. Introduction of biological agents should be carefully considered in settings where reactive arthritis induced by active extra-articular tuberculosis shows progression to chronicity despite sufficient antitubercular treatment.

Time to diagnosis of tuberculosis is greater in older patients: a retrospective cohort review

Introduction

Age-related immunosenescence influences the presentation of tuberculosis (TB) in older patients. Here, we explore the clinical and radiological presentation of TB in the elderly and the factors associated with time to treatment for TB.

Methods

This is a retrospective cohort study comparing the clinical, radiological and demographic characteristics of TB patients aged ≥65 years with TB patients aged 18–64 years in a large cohort of TB patients in the UK. Factors associated with the time to presentation and time to treatment were identified using a multivariable analysis model.

Results

1023 patients were included in the analyses: 679 patients aged 18–64 years and 344 patients aged ≥65 years. “Classical” symptoms of TB (cough, haemoptysis, fever, nights sweats and weight loss) were less common among older patients with pulmonary TB (PTB) (p<0.05), but dyspnoea was more common among older patients (p=0.001). Time from presenting in secondary care to starting treatment was shorter in younger compared with older patients: 3 versus 15 days (p=0.001). When adjusted for age, factors associated with shorter time to treatment from symptom onset include sex (male versus female) (hazard ratio (HR) 1.23 (95% CI 1.05–1.46)), UK born (HR 1.23 (95% CI 1.05–1.46)) and HIV (HR 2.07 (95% CI 1.30–3.29)). Only age remained an independent predictor of time to treatment in a multivariable model (HR 0.98 (95% CI 0.98–0.99)). For those with PTB, chest radiography findings showed that cavitation and lymphadenopathy were more common among younger patients (p=0.001).

Conclusions

Older patients aged ≥65 years with TB had fewer “classical” clinical and radiological presentations of TB, which may explain longer times to starting treatment from symptom onset compared with younger patients aged <65 years.

A retrospective UK study in patients with TB shows only age remains an independent predictor of time to treatment in a multivariable model. Older patients have fewer of the “classical” clinical and radiological features of TB compared with younger patients.http://bit.ly/2yHc0OL

Ambulatory independence is associated with higher incidence of latent tuberculosis infection in long-term care facilities in Taiwan

BACKGROUND/PURPOSE

Tuberculosis (TB) in the elderly population remains a major challenge in areas with intermediate disease burden like Taiwan. Despite the increasing burden and high risks of TB in the elderly population, particularly those living in long-term care facilities (LTCFs), diagnostic testing for latent tuberculosis infection (LTBI) has not been carefully evaluated in this group. This study aimed to investigate the prevalence and predictors of LTBI in older adults living in LTCFs.

METHODS

Older adults living in seven LTCFs in Taiwan were prospectively enrolled between January and July 2017. Interferon-gamma release assay (IGRA) through QuantiFERON-TB Gold In-tube was used to determine presence of LTBI. Predictors for LTBI were analyzed.

RESULTS

A total of 258 participants were enrolled, including 240 older residents (mean age, 81.6 years; male, 51.2%) and 18 employees (mean age, 64.8 years; male, 22.2%). The proportion of independent status in ambulation assessments significantly declined with aging (p < 0.001). The IGRA-positivity rate in LTCFs was 31.4% (81/258), which consisted of 73 (30.4%) residents and 8 (44.4%) employees. The IGRA results were different with respect to the ambulation status (p = 0.052). In the multivariate logistic regression analysis, the only independent predictor of LTBI among older adults in LTCFs was independent ambulation (odds ratio, 2.16; 95% confidence interval, 1.09-4.28; p = 0.027).

CONCLUSIONS

There was a high prevalence of LTBI among older adults in LTCFs in Taiwan. Independent ambulation was the only independent predictor of LTBI.

Forecasting the impact of population ageing on tuberculosis incidence

Background

Tuberculosis (TB) disease reactivates from distant latent infection or recent (re)infection. Progression risks increase with age. Across the World Health Organisation Western Pacific region, many populations are ageing and have the highest per capita TB incidence rates in older age groups. However, methods for analysing age-specific TB incidence and forecasting epidemic trends while accounting for demographic change remain limited.

Methods

We applied the Lee-Carter models, which were originally developed for mortality modelling, to model the temporal trends in age-specific TB incidence data from 2005 to 2018 in Taiwan. Females and males were modelled separately. We combined our demographic forecasts, and age-specific TB incidence forecasts to project TB incidence until 2035. We compared TB incidence projections with demography fixed in 2018 to projections accounting for demographic change.

Results

Our models quantified increasing incidence rates with age and declining temporal trends. By 2035, the forecast suggests that the TB incidence rate in Taiwan will decrease by 54% (95% Prediction Interval (PI): 45%-59%) compared to 2015, while most age-specific incidence rates will reduce by more than 60%. In 2035, adults aged 65 and above will make up 78% of incident TB cases. Forecast TB incidence in 2035 accounting for demographic change will be 39% (95% PI: 36%-42%) higher than without population ageing.

Conclusions

Age-specific incidence forecasts coupled with demographic forecasts can inform the impact of population ageing on TB epidemics. The TB control programme in Taiwan should develop plans specific to older age groups and their care needs.

Completion rate of latent tuberculosis infection treatment in patients aged 65 years and older

INTRODUCTION

There are insufficient data on the treatment of latent tuberculosis infection (LTBI) in elderly patients. We investigated the completion rate of treatment in elderly LTBI patients.

METHODS

A retrospective multicentre study was conducted at five university hospitals in South Korea. We reviewed the electronic medical records of patients aged 65 years and older who were diagnosed with LTBI via positive interferon-gamma release assay results between January 2016 and December 2018. Treatment completion was defined as ingestion of more than 80% of all prescribed medications without loss to follow-up.

RESULTS

During the study period, 127 LTBI patients aged 65 years and older visited outpatient department. Among them, 77 patients aged 65-78 years (median age, 69 years [interquartile range, 66-71 years]) who received LTBI treatment were analysed. Common reasons for IGRA testing in elderly patients were health-care worker (n = 33, 42.9%) and household contact with infectious TB patients (n = 18, 23.4%). The overall completion rate of LTBI treatment was 83.1% (n = 64), and the completion rate of 3-month isoniazid plus rifampin regimen was 88.4%. Adverse effects were reported in 23 patients (29.9%), and an increase in aminotransferase level was the most common adverse effect (n = 11, 14.3%). Three patients (3.9%) with the adverse effect discontinued treatment and 10 (13.0%) patients were lost to follow-up.

CONCLUSIONS

LTBI treatment in patients aged 65-78 years was relatively well tolerated. In LTBI treatment in elderly patients, the majority of discontinuation of treatment was due to loss to follow-up rather than adverse effects of anti-TB medications.

Aspiration in the Fiberoptic Endoscopic Evaluation of Swallowing Associated with an Increased Risk of Mortality in a Cohort of Patients Suspected of Oropharyngeal Dysphagia

There is a general lack of published studies on the risk of mortality due to alterations in the safety of swallowing detected during the fiberoptic endoscopic evaluation of swallowing (FEES). We aimed at assessing the risk of mortality of the detection of aspiration, penetration, and pharyngeal residues by FEES. A cohort of consecutively evaluated patients suspected of experiencing oropharyngeal dysphagia undergoing FEES at a tertiary care university hospital were prospectively followed up on to assess mortality. The FEES findings, comorbidities, and potential confounders were studied as predictors of death using a Cox multivariate regression analysis. A total of 148 patients were included, 85 of whom were male (57.4%). The mean age (± standard deviation) was 52.7 years (± 22.1). The median of the follow-up time was 4.5 years. The most frequent conditions were stroke in 50 patients (33.8%), brain and spine traumas in 27 (18.2%), and neurodegenerative diseases in 19 (12.8%). Variables associated with mortality in bivariate analyses were age > 65 years (p < 0.001), pneumonia (p = 0.046), aspiration of any consistency (p < 0.001), and pharyngeal residues (p = 0.017). Variables independently associated with mortality in the Cox multivariate model were age (> 65 years) [adjusted hazard ratio (HR) 5.76; 95% CI 2.72 to 17.19; p = 0.001] and aspiration (adjusted HR: 3.96; 95% CI 1.82 to 14.64; p = 0.003). Aspiration detected by FEES and an age > 65 years are independent predictors of mortality in patients with oropharyngeal dysphagia.

Diagnosis and treatment of congenital tuberculosis: a systematic review of 92 cases

BACKGROUND

Congenital tuberculosis is rare and carries a high mortality rate. Our objective was to summarize the current experience of the diagnosis and treatment of patients with congenital tuberculosis.

METHODS

In total, 73 reported cases of congenital tuberculosis published in Chinese and 19 patients with congenital tuberculosis admitted to West China Second University Hospital, Sichuan University, were retrospectively reviewed.

RESULTS

Sixty-four male and 28 female patients were identified. The majority of the patients were less than 3 weeks old at the time of presentation (range, 0-67 days). With regard to the tuberculosis type, 89 patients had pulmonary tuberculosis, and 20 patients had hepatic tuberculosis. There was active tuberculosis in 71 mothers, no tuberculosis in 12 mothers, and an unknown history of tuberculosis in 9 mothers. Fever, cyanosis, jaundice, shortness of breath, cough, pulmonary moist rales, hepatomegaly, splenomegaly and abdominal distention were the main clinical symptoms at the time of presentation. The abnormal ratios of chest, abdomen and head radiographic images were 97.53, 75 and 81.25%, respectively. The positive rates of acid-fast staining of sputum smears and tuberculosis bacillus DNA were 62.50 and 66.67%, respectively. The misdiagnosis rate was 59.78%. The overall mortality due to congenital tuberculosis was 43.48%. Respiratory failure was the most common cause of death. Sixty-five patients received anti-tuberculosis therapy, and of those, only 16 (15.38%) died.

CONCLUSIONS

The clinical manifestations and radiographic findings of congenital tuberculosis are nonspecific. It is important to thoroughly evaluate the mothers of infants with suspected congenital tuberculosis. Good outcomes can be achieved in infants with the early identification of congenital tuberculosis and early administration of anti-tuberculosis treatment.