Mind the gap: TB trends in the USA and the UK, 2000-2011

A Systematic Review on Pulmonary TB Burden and Associated Factors Among Immigrants in the UK

Background

The rapid growth of international human migration has positioned the UK in the top five countries in the world with 9.4 million immigrants in 2022. These immigrants originate from low- and middle-income countries and remain particularly at risk of developing TB. In the UK, the number of TB cases has been increasing, and the influx of immigrants could be a contributing factor.

Objective

This review aims to map the burden of pulmonary TB among immigrants in the UK and investigate associated factors. It also reviews the TB management approaches among immigrants in the UK.

Design

The study utilized PRISMA guidelines to search electronic databases (PubMed and EMBASE) for articles published from 2000 to 2022 on TB prevalence and factors in immigrants and explored government websites for TB management strategies.

Results

Nineteen out of 530 initially identified articles were included. The included studies reported a prevalence rate of TB among immigrants ranging from 0.04 to 52.1%, showing a decrease in the burden over time. Additionally, a higher number of TB cases were observed among immigrants from the Asian region, particularly immigrants from South Asia, followed by those from sub-Saharan Africa. Stigma, misconception about the disease, language barrier, lack of confidentiality, and unfriendly healthcare system for immigrants were the main drivers of the TB burden among immigrants. The TB management approaches in the UK include pre-entry screening for active TB, LTBI testing for a specific population group, and antibacterial therapy for 3-6 months for TB patients.

Conclusion

The UK's control and prevention efforts in reducing tuberculosis prevalence among immigrants show optimism, but challenges persist. Key improvements include healthcare delivery, TB improvement programs, and policies addressing stigma and patient confidentiality.

Vitamin D and estrogen steroid hormones and their immunogenetic roles in Infectious respiratory (TB and COVID-19) diseases

The role of steroid hormones against infectious diseases has been extensively studied. From immunomodulatory action to direct inhibition of microorganism growth, hormones D3 (VD3) and 17β-estradiol (E2), and the genetic pathways modulated by them, are key targets for a better understanding pathogenesis of infectious respiratory diseases (IRD) such as tuberculosis (TB) and the coronavirus disease-19 (COVID-19). Currently, the world faces two major public health problems, the outbreak of COVID-19, accounting for more than 6 million so far, and TB, more than 1 million deaths per year. Both, although resulting from different pathogens, the Mtb and the SARS-CoV-2, respectively, are considered serious and epidemic. TB and COVID-19 present similar infection rates between men and women, however the number of complications and deaths resulting from the two infections is higher in men when compared to women in childbearing age, which may indicate a role of the sex hormone E2 in the context of these diseases. E2 and VD3 act upon key gene pathways as important immunomodulatory players and supporting molecules in IRDs. This review summarizes the main roles of these hormones (VD3 and E2) in modulating immune and inflammatory responses and their relationship with TB and COVID-19.

Incidence of and risk factors for tuberculosis among people with HIV on antiretroviral therapy in the United Kingdom

Objective:

The United Kingdom has a low tuberculosis incidence and earlier combination antiretroviral therapy (cART) is expected to have reduced incidence among people with HIV. Epidemiological patterns and risk factors for active tuberculosis were analysed over a 20-year period among people accessing HIV care at sites participating in the UK CHIC observational study.

Design:

Cohort analysis.

Methods:

Data were included for individuals over 15 years old attending for HIV care between 1996 and 2017 inclusive, with at least 3 months follow-up recorded. Incidence rates of new tuberculosis events were calculated and stratified by ethnicity (white/Black/other) as a proxy for tuberculosis exposure. Poisson regression models were used to determine the associations of calendar year, ethnicity and other potential risk factors after cART initiation.

Results:

Fifty-eight thousand seven hundred and seventy-six participants (26.3% women; 54.5% white, 32.0% Black, 13.5% other/unknown ethnicity; median (interquartile range) age 34 (29–42) years) were followed for 546 617 person-years. Seven hundred and four were treated for active tuberculosis [rate 1.3; 95% confidence interval (CI) 1.2–1.4/1000 person-years). Tuberculosis incidence decreased from 1.3 (1.2–1.5) to 0.6 (0.4–0.9)/1000 person-years from pre-2004 to 2011–2017. The decline among people of Black ethnicity was less steep than among those of white/other ethnicities, with incidence remaining high among Black participants in the latest period [2.1 (1.4–3.1)/1000 person-years]. Two hundred and eighty-three participants [191 (67%) Black African] had tuberculosis with viral load less than 50 copies/ml.

Conclusion:

Despite the known protective effect of cART against tuberculosis, a continuing disproportionately high incidence is seen among Black African people. Results support further interventions to prevent tuberculosis in this group.

Impact and Effectiveness of State-Level Tuberculosis Interventions in California, Florida, New York, and Texas: A Model-Based Analysis

The incidence of tuberculosis (TB) in the United States has stabilized, and additional interventions are needed to make progress toward TB elimination. However, the impact of such interventions depends on local demography and the heterogeneity of populations at risk. Using state-level individual-based TB transmission models calibrated to California, Florida, New York, and Texas, we modeled 2 TB interventions: 1) increased targeted testing and treatment (TTT) of high-risk populations, including people who are non-US-born, diabetic, human immunodeficiency virus (HIV)-positive, homeless, or incarcerated; and 2) enhanced contact investigation (ECI) for contacts of TB patients, including higher completion of preventive therapy. For each intervention, we projected reductions in active TB incidence over 10 years (2016-2026) and numbers needed to screen and treat in order to avert 1 case. We estimated that TTT delivered to half of the non-US-born adult population could lower TB incidence by 19.8%-26.7% over a 10-year period. TTT delivered to smaller populations with higher TB risk (e.g., HIV-positive persons, homeless persons) and ECI were generally more efficient but had less overall impact on incidence. TTT targeted to smaller, highest-risk populations and ECI can be highly efficient; however, major reductions in incidence will only be achieved by also targeting larger, moderate-risk populations. Ultimately, to eliminate TB in the United States, a combination of these approaches will be necessary.

Epidemiology and disease burden of tuberculosis in south of Tunisia over a 22-year period: Current trends and future projections

BACKGROUND

Tuberculosis (TB) is a public health problem worldwide. Characterizing its trends over time is a useful tool for decision-makers to assess the efficiency of TB control programs. We aimed to give an update on the current chronological trends of TB in Southern Tunisia from 1995 to 2016 and to estimate future trajectories of TB epidemic by 2030.

METHODS

We retrospectively collected data of all notified TB new cases by the Center of Tuberculosis Control between 1995 and 2016 in South of Tunisia. Joinpoint Regression Analysis was performed to analyze chronological trends and annual percentage changes (APC) were estimated.

RESULTS

In the past 22 years, a total of 2771 cases of TB were notified in Southern Tunisia. The annual incidence rate of TB was 13.91/100,000 population/year. There was a rise in all forms of TB incidence (APC = 1.63) and in extrapulmonary tuberculosis (EPTB) (APC = 2.04). The incidence of TB increased in children and adult females between 1995 and 2016 (APC = 4.48 and 2.37, respectively). The annual number of TB declined in urban districts between 2004 and 2016 (APC = -2.85). Lymph node TB cases increased (APC = 4.58), while annual number of urogenital TB decreased between 1995 and 2016 (APC = -3.38). Projected incidence rates would increase to 18.13 and 11.8/100,000 population in 2030 for global TB and EPTB, respectively.

CONCLUSIONS

Our study highlighted a rise in all forms of TB and among high-risk groups, notably children, females and lymph node TB patients in the last two decades and up to the next one.

Tuberculosis preventive treatment: the next chapter of tuberculosis elimination in India

The End TB Strategy envisions a world free of tuberculosis—zero deaths, disease and suffering due to tuberculosis by 2035. This requires reducing the global tuberculosis incidence from >1250 cases per million people to <100 cases per million people within the next two decades. Expanding testing and treatment of tuberculosis infection is critical to achieving this goal. In high-burden countries, like India, the implementation of tuberculosis preventive treatment (TPT) remains a low priority. In this analysis article, we explore potential challenges and solutions of implementing TPT in India. The next chapter in tuberculosis elimination in India will require cost-effective and sustainable interventions aimed at tuberculosis infection. This will require constant innovation, locally driven solutions to address the diverse and dynamic tuberculosis epidemiology and persistent programme monitoring and evaluation. As new tools, regimens and approaches emerge, midcourse adjustments to policy and practice must be adopted. The development and implementation of new tools and strategies will call for close collaboration between local, national and international partners—both public and private—national health authorities, non-governmental organisations, research community and the diagnostic and pharmaceutical industry. Leading by example, India can contribute to global knowledge through operational research and programmatic implementation for combating tuberculosis infection.

Combined transbronchoscopic needle aspiration (TBNA) and rapid on-site cytological evaluation (ROSE) for diagnosis of tuberculous mediastinal lymphadenitis: A case report

INTRODUCTION

The diagnosis of tuberculous mediastinal lymphadenitis remains a challenge, and the use of transbronchoscopic needle aspiration (TBNA) combined with rapid on-site cytological evaluation (ROSE) is still unclear. A case of tuberculous mediastinal lymphadenitis was illustrated to show the diagnostic value of TBNA and ROSE.

CASE PRESENTATION

In this case report, we presented a typical case of a 44-year-old male who underwent obvious odynophagia and mild symptom of dyspnea. One isolated mass positioned on posterior mediastinum was examined as positive discovery. Finally, he was diagnosed with tuberculous mediastinal lymphadenitis by using TBNA combined with ROSE and treated with anti-TB.

CONCLUSIONS

TBNA is an efficacious and safe approach, which is worth popularizing for the clinical diagnosis of mediastinal masses. Meanwhile, ROSE is useful to reduce the numbers of needle passes during TBNA. We aimed to emphasize 2 key points in this case report. Firstly, a rare symptom of Tuberculosis in adults was supported by the patient. Secondly, TBNA combined with ROSE is useful for the diagnosis of tuberculous mediastinal lymphadenitis.

Sexual dimorphism in bacterial infections

Background

Sex differences are important epidemiological factors that impact in the frequency and severity of infectious diseases. A clear sexual dimorphism in bacterial infections has been reported in both humans and animal models. Nevertheless, the molecular mechanisms involved in this gender bias are just starting to be elucidated. In the present article, we aim to review the available data in the literature that report bacterial infections presenting a clear sexual dimorphism, without considering behavioral and social factors.

Main body

The sexual dimorphism in bacterial infections has been mainly attributed to the differential levels of sex hormones between males and females, as well as to genetic factors. In general, males are more susceptible to gastrointestinal and respiratory bacterial diseases and sepsis, while females are more susceptible to genitourinary tract bacterial infections. However, these incidences depend on the population evaluated, animal model and the bacterial species. Female protection against bacterial infections and the associated complications is assumed to be due to the pro-inflammatory effect of estradiol, while male susceptibility to those infections is associated with the testosterone-mediated immune suppression, probably via their specific receptors. Recent studies indicate that the protective effect of estradiol depends on the estrogen receptor subtype and the specific tissue compartment involved in the bacterial insult, suggesting that tissue-specific expression of particular sex steroid receptors contributes to the susceptibility to bacterial infections. Furthermore, this gender bias also depends on the effects of sex hormones on specific bacterial species. Finally, since a large number of genes related to immune functions are located on the X chromosome, X-linked mosaicism confers a highly polymorphic gene expression program that allows women to respond with a more expanded immune repertoire as compared with men.

Conclusion

Notwithstanding there is increasing evidence that confirms the sexual dimorphism in certain bacterial infections and the molecular mechanisms associated, further studies are required to clarify conflicting data and to determine the role of specific hormone receptors involved in the gender bias of bacterial infections, as well as their potential as therapeutic targets.

Hospital length of stay and cost burden of HIV, tuberculosis, and HIV-tuberculosis coinfection among pregnant women in the United States

BACKGROUND

We sought to determine hospital length of stay (LOS) and cost burden associated with hospital admissions among pregnant women with HIV monoinfection, tuberculosis (TB) monoinfection, or HIV-TB coinfection in the United States.

METHODS

Analysis covered the period from 2002-2014 using data from the Nationwide Inpatient Sample. Relevant ICD-9-CM codes were used to determine HIV and TB status. Costs associated with hospitalization were calculated and adjusted to 2010 dollars using the medical care component of the Consumer Price Index.

RESULTS

We found modest annual average reduction in HIV, TB, and HIV-TB coinfection rates over the study period. The mean LOS was lowest among mothers free of HIV or TB disease and highest among those with HIV-TB coinfection. The average LOS among mothers diagnosed with TB monoinfection was 60% higher than for those with HIV monoinfection. The cost associated with pregnancy-related hospital admissions among mothers with HIV was approximately 30% higher than disease-free mothers, and the cost more than doubled among patients with TB monoinfection or HIV-TB coinfection.

CONCLUSIONS

TB significantly increased hospital care cost among HIV-positive and HIV-negative pregnant women.

Tuberculosis during pregnancy in the United States: Racial/ethnic disparities in pregnancy complications and in-hospital death

Background

Despite decades of efforts to eliminate tuberculosis (TB) in the United States (US), TB still contributes to adverse ill health, especially among racial/ethnic minorities. According to the Centers for Disease Control and Prevention, in 2016, about 87% of the TB cases reported in the US were among racial and ethnic minorities. The objective of this study is to explore the risks for pregnancy complications and in-hospital death among mothers diagnosed with TB across racial/ethnic groups in the US.

Methods

This retrospective cohort study utilized National Inpatient Sample data for all inpatient hospital discharges in the US. We analyzed pregnancy-related hospitalizations and births in the US from January 1, 2002 through December 31, 2014 (n = 57,393,459). Multivariable logistic regression was applied to generate odds ratios for the association between TB status and the primary study outcomes (i.e., pregnancy complications and in-hospital death) across racial/ethnic categories.

Results

The prevalence of TB was 7.1 per 100,000 pregnancy-related hospitalizations. The overall prevalence of pregnancy complications was 80% greater among TB-infected mothers than their uninfected counterparts. Severe pre-eclampsia, eclampsia, placenta previa, post-partum hemorrhage, sepsis and anemia occurred with greater frequency among mothers with a TB diagnosis than those without TB, irrespective of race/ethnicity. The rate of in-hospital death among TB patients was 37 times greater among TB-infected than in non-TB infected mothers (468.8 per 100,000 versus 12.6 per 100,000). A 3-fold increased risk of in-hospital death was observed among black TB-negative mothers compared to their white counterparts. No racial/ethnic disparities in maternal morbidity or in-hospital death were found among mothers with TB disease.

Conclusion

TB continues to be an important cause of morbidity and mortality among pregnant women in the US. Resources to address TB disease should also target pregnant women, especially racial/ethnic minorities who bear the greatest burden of the disease.

Epidemiology of Mycobacterium bovis Disease in Humans in England, Wales, and Northern Ireland, 2002-2014

Despite slightly increased cases in these areas, human infection with this cattle pathogen remains rare.

Despite control efforts, Mycobacterium bovis incidence among cattle remains high in parts of England, Wales, and Northern Ireland, attracting political and public health interest in potential spread from animals to humans. To determine incidence among humans and to identify associated factors, we conducted a retrospective cohort analysis of human M. bovis cases in England, Wales, and Northern Ireland during 2002–2014. We identified 357 cases and observed increased annual case numbers (from 17 to 35) and rates. Most patients were >65 years of age and born in the United Kingdom. The median age of UK-born patients decreased over time. For 74% of patients, exposure to risk factors accounting for M. bovis acquisition, most frequently consumption of unpasteurized milk, was known. Despite the small increase in case numbers and reduction in patient age, M. bovis infection of humans in England, Wales, and Northern Ireland remains rare.

Resistance to First-Line Antituberculosis Drugs in Washington State by Region of Birth and Implications for Latent Tuberculosis Treatment Among Foreign-Born Individuals

The United States has a low burden of drug resistance among tuberculosis (TB) cases compared with other world regions. TB is increasingly concentrated among foreign-born individuals who have higher rates of drug resistance than U.S.-born individuals. While universal drug susceptibility testing is the standard for detecting active tuberculosis, there are limited guidelines for latent tuberculosis infection (LTBI) treatment based on risk factors for drug resistance. To quantify the variable risk of drug resistance among foreign-born individuals, all TB cases in Washington State between 1994 and 2014 with drug resistance data for isoniazid, rifampin, pyrazinamide, and ethambutol were divided into eight regions of birth. Logistic regression was used to characterize regional differences in resistance patterns. Genotypic cluster and lineage data were compared against drug resistance in a subanalysis. Among 4,298 cases, isoniazid resistance was more common in foreign-born individuals (12.6% versus 4.8%; P < 0.001), with the highest burden among individuals from the Asia-Pacific (14.8%) region. Rifampin resistance was slightly higher among foreign-born individuals (1.9% versus 1.1%; P = 0.063). Multivariate logistic regression demonstrated that older age was associated with a lower risk of resistance to isoniazid and rifampin (odds ratio [OR] = 0.86, P = 0.006 and OR = 0.64, P = 0.003 for each 20-year interval, respectively). These data suggest drug resistance in LTBI will remain a challenge and that rifampin-based regimens for treatment of LTBI in non-human immunodeficiency virus-infected adults may be preferable for individuals born in regions with high levels of isoniazid resistance. However, further research is needed to demonstrate whether LTBI treatment based on region of birth further decreases TB reactivation.

Tuberculous suprasternal notch abscess in a child

Tuberculosis has been declared a 'Global Emergency' by the WHO. Owing to the magnitude of the problem, knowledge of unusual presentations at rare sites can help identify the disease early and achieve good to fair results. We present one such rare case of a child with an anterior midline swelling. An anterior midline swelling in a child raises multiple diagnostic possibilities. Although cervical lymphadenitis is a common cause of neck swelling, tuberculous suprasternal notch abscess, secondary to lymphadenitis, has rarely been described. Radiological investigations revealed necrotic tissue in the base of the suprasternal notch. The diagnosis was made using needle aspiration and cytology, which was suggestive of tuberculous lymphadenitis for the neck swelling. Antituberculous therapy gave good results, with complete healing of the ulcer and resolution of the abscess.