Reducing tuberculosis transmission: a consensus document from the World Health Organization Regional Office for Europe

Impact of isoniazid monoresistance on overall and vulnerable patient populations in Taiwan

Isoniazid is an early bactericidal anti-tuberculosis (TB) agent and isoniazid mono-resistance TB is the most prevalent drug-resistant TB worldwide. Concerns exist regarding whether resistance to isoniazid would lead to delayed culture conversion and worst outcomes. From January 2008 to November 2017, adult culture-positive pulmonary TB patients receiving isoniazid, rifampicin, pyrazinamide, and ethambutol were identified through Taiwan Center for Disease Control database and were followed until the end of 2017. Primary outcomes included time to sputum culture conversion (SCC) within two months. Secondary outcomes included death and unfavourable outcomes at the end of 2nd month. A total of 37,193 drug-susceptible and 2,832 isoniazid monoresistant pulmonary TB patients were identified. Compared with no resistance, isoniazid monoresistance was not associated with a delayed SCC (HR: 0.99, 95% CI: 0.94─1.05, p = 0.8145), a higher risk of 2-month mortality (HR: 1.19, 95% CI: 0.92─1.53, p = 0.1884), and unfavourable outcomes at 2nd month (OR: 1.05, 95% CI: 0.97─1.14, p = 0.2427). Isoniazid monoresistance was associated with delayed SCC (HR: 0.90, 95% CI: 0.83─0.98, p = 0.0099) and a higher risk of unfavourable outcomes (OR:1.18, 95% CI: 1.05─1.32, p = 0.0053) in patients aged between 20 and 65, and delayed SCC in patients without underlying comorbidities (HR: 0.90, 95% CI: 0.81─0.98, p = 0.0237). Isoniazid mono-resistant TB had a comparable outcome with drug-susceptible TB at the end of the intensive phase. Healthy, and non-elderly patients were more likely to had culture persistence, raising concerns about disease transmission in these subgroups and warranting early molecular testing for isoniazid resistance.

Pulmonary tuberculosis in non-HIV adults: an evergreen old-fashioned disease in high-income countries. A narrative review

INTRODUCTION

Tuberculosis (TB), an infective air-borne disease with worldwide non-homogeneous distribution, remains a top cause of morbidity and mortality. TB control is linked to early diagnosis and proper treatment of contagious TB cases and infected subjects at high risk of developing TB.

AREAS COVERED

A narrative review of pulmonary TB in non-HIV adults with reference to high-income countries. Modern medicine offers several advancements in diagnostics and therapeutics of TB, but they often remain to be extensively implemented in real life. In high-income countries TB is now relatively uncommon, but it remains a health and socio-economic burden that should not be underestimated.

EXPERT OPINION

Pulmonologists should maintain expertise toward TB for several reasons. First, the lung is the most common and the infectious moiety of TB. Second, TB remains a global issue due to common travels of western people and migrations from areas with high incidence of TB. Third, as TB has heterogenous clinics, its prompt diagnosis may be difficult. Fourth, TB is a curable disease, but its management is complex and predisposes to poor adherence with failures/relapses and selection of drug-resistant strains.

Prevalence of COVID-19 in prison population: a meta-analysis of 35 studies

PURPOSE

COVID-19 is an infectious disease caused by the SARS-CoV-2 virus. Considering the restricted and enclosed nature of prisons and closed environments and the prolonged and close contact between individuals, COVID-19 is more likely to have a higher incidence in these settings. This study aims to assess the prevalence of COVID-19 among prisoners.

DESIGN/METHODOLOGY/APPROACH

Papers published in English from 2019 to July 7, 2023, were identified using relevant keywords such as prevalence, COVID-19 and prisoner in the following databases: PubMed/MEDLINE, Scopus and Google Scholar. For the meta-analysis of the prevalence, Cochrane's Q statistics were calculated. A random effect model was used due to the heterogeneity in COVID-19 prevalence across included studies in the meta-analysis. All analyses were performed in STATA-13.

FINDINGS

The pooled data presented a COVID-19 prevalence of 20% [95%CI: 0.13, 0.26] and 24% [95%CI: 0.07, 0.41], respectively, in studies that used PCR and antibody tests. Furthermore, two study designs, cross-sectional and cohort, were used. The results of the meta-analysis showed studies with cross-sectional and cohort designs reported 20% [95%CI: 0.11, 0.29] and 25% [95%CI: 0.13, 0.38], respectively.

ORIGINALITY/VALUE

Through more meticulous planning, it is feasible to reduce the number of individuals in prison cells, thereby preventing the further spread of COVID-19.

Barriers and facilitators to tuberculosis diagnosis in Lima, Peru: a mixed methods study

BACKGROUND

Tuberculosis (TB) infectiousness decreases significantly with only a few days of treatment, but delayed diagnosis often leads to late treatment initiation. We conducted a sequential explanatory mixed methods study to understand the barriers and facilitators to prompt diagnosis among people with TB.

METHODS

We enrolled 100 adults who started TB treatment in the Carabayllo district of Lima, Peru, between November 2020 and February 2022 and administered a survey about their symptoms and healthcare encounters. We calculated total diagnostic delay as time from symptom onset to diagnosis. We conducted semi-structured interviews of 26 participants who had a range of delays investigating their experience navigating the health system. Interview transcripts were inductively coded for concepts related to diagnostic barriers and facilitators.

RESULTS

Overall, 38% of participants sought care first from public facilities and 42% from the private sector. Only 14% reported being diagnosed with TB on their first visit, and participants visited a median of 3 (interquartile range [IQR] health facilities before diagnosis. The median total diagnostic delay was 9 weeks (interquartile range [IQR] 4-22), with a median of 4 weeks (IQR 0-9) before contact with the health system and of 3 weeks (IQR 0-9) after. Barriers to prompt diagnosis included participants attributing their symptoms to an alternative cause or having misconceptions about TB, and leading them to postpone seeking care. Once connected to care, variations in clinical management, health facility resource limitations, and lack of formal referral processes contributed to the need for multiple healthcare visits before obtaining a diagnosis. Facilitators to prompt diagnosis included knowing someone with TB, supportive friends and family, referral documents, and seeing a pulmonologist.

CONCLUSIONS

Misinformation about TB among people with TB and providers, poor accessibility of health services, and the need for multiple encounters to obtain diagnostic tests were major factors leading to delays. Extending the hours of operation of public health facilities, improving community awareness and provider training, and creating a formal referral process between the public and private sectors should be priorities in the efforts to combat TB.

QMAC-DST for Rapid Detection of Drug Resistance in Pulmonary Tuberculosis Patients: A Multicenter Pre-Post Comparative Study

Background/Objectives: This study explores the impact of QMAC-DST, a rapid, fully automated phenotypic drug susceptibility test (pDST), on the treatment of tuberculosis (TB) patients. Methods: This pre-post comparative study, respectively, included pulmonary TB patients who began TB treatment between 1 December 2020 and 31 October 2021 (pre-period; pDST using the Löwenstein-Jensen (LJ) DST (M-kit DST)) and between 1 November 2021 and 30 September 2022 (post-period; pDST using the QMAC-DST) in five university-affiliated tertiary care hospitals in South Korea. We compared the turnaround times (TATs) of pDSTs and the time to appropriate treatment for patients whose anti-TB drugs were changed based on these tests between the groups. All patients were permitted to use molecular DSTs (mDSTs). Results: A total of 182 patients (135 in the M-kit DST group and 47 in the QMAC-DST group) were included. The median TAT was 36 days for M-kit DST (interquartile range (IQR), 30-39) and 12 days for QMAC-DST (IQR, 9-15), with the latter being significantly shorter (p < 0.001). Of the total patients, 10 (5.5%) changed their anti-TB drugs based on the mDST or pDST results after initiating TB treatment (8 in the M-kit DST group and 2 in the QMAC-DST group). In the M-kit DST group, three (37.5%) patients changed anti-TB drugs based on the pDST results. In the QMAC-DST group, all changes were due to mDST results; therefore, calculating the time to appropriate treatment for patients whose anti-TB drugs were changed based on pDST results was not feasible. In the QMAC-DST group, 46.8% of patients underwent the first-line line probe assay compared to 100.0% in the M-kit DST group (p < 0.001), indicating that rapid QMAC-DST results provide quicker assurance of the ongoing treatment by confirming susceptibility to the current anti-TB drugs. Conclusions: QMAC-DST delivers pDST results more rapidly than LJ-DST, ensuring faster confirmation for the current treatment regimen.

Active Case Finding among Adults using an Individual's Vulnerability Score for Pulmonary Tuberculosis in a Rural Village of Goa: A Cross-sectional Study

Background

"Detect-Treat-Prevent-Build" to achieve tuberculosis (TB)-free India is envisaged in the National Tuberculosis Elimination Program (NTEP). To be able to achieve this, it is important to address the fact that the most vulnerable and hard-to-reach groups need to undertake screening. The present review aimed to examine the vulnerability in connection with TB disparities faced by distinct sub-populations generally viewed as vulnerable and follow these for testing.

Materials and Methods

The community-based cross-sectional study was conducted in the field practice area of sub-center Carambolim in a rural area of Goa for 3 months. The households were visited, and data collected via personal interviews were recorded on the questionnaire study tool. Based on the data, the participants' vulnerability mapping was done per the parameters identified.

Results

Among 223 households, 528 persons were screened for vulnerability. The 47 highly vulnerable participants were advised sputum CBNAAT, of which 9 (19%) tested positive for pulmonary TB, while of the 86 moderately vulnerable participants, 4 (5%) tested positive for pulmonary TB. Among the 34 with symptoms suggestive of TB, 3 (9%) tested positive for pulmonary TB.

Conclusions

The study detected 16 new TB patients from the population and found a higher incidence of pulmonary TB among the vulnerable group with no symptoms of Pulmonary TB. A further state-wide survey is recommended to diagnose such cases.

PASS to End TB in Europe: Accelerated efforts on prevention and systematic screening to end tuberculosis in the WHO European Region by 2030

OBJECTIVES

Outline the objectives, methods, and initial stages of the Prevention and Systematic Screening (PASS) initiative, a complimentary element of the innovative new approach of technical assistance mechanisms of WHO and its partners to countries aligned to the Regional TB Action Plan to End TB in the European Region by 2030.

DESIGN

To provide an objective and critical overview of the existing landscape on TB epidemic in the WHO European Region (the European Region) and ii) identify the strategic significance of proactive measures aimed at approaching TB pre-elimination in the Region.

RESULTS

Interventions primarily include systematic screening for TB disease and treatment for TB infection (TBI).

CONCLUSIONS

PASS to End TB is an exemplary initiative of how technical and funding partners are joining hands to support national health programmes to work towards global commitments to curb major public health challenges like TB.

Risk of tuberculosis among pulmonary tuberculosis contacts: the importance of time of exposure to index cases

INTRODUCTION

The intensity of exposure to index cases of tuberculosis [TB] may increase the risk of TB in their contacts. The aim was to determine TB risk factors among contacts of TB index cases.

METHODS

A cohort study was carried out in the contacts of pulmonary TB cases registered by the epidemiological surveillance network from 01/01/2019 to 06/30/2021. The factors associated with the risk of TB in contacts were determined using the adjusted odds ratio [aOR] and its 95% confidence interval [CI].

RESULTS

From 847 TB cases, 7087 contacts were identified. The prevalence of TB was 2.0% [145/7087] and was higher in < 5 years compared to those ≥ 65 years [4.4% versus 1.2%; p < 0.001], in those exposed ≥ 6 h daily [4%], and < 6 h daily [1.6%] with respect to weekly exposure of < 6 h [0.7%; p < 0.001]. Those contacts exposed ≥ 6 h daily [aOR= 6.9; 95%CI:2.1-22.1], < 5 years [aOR= 8.3; 95%CI:1.8-37.8] and immigrants [aOR= 1.7; 95%CI:1.1-2.7] had a higher risk of TB.

CONCLUSIONS

The risk of TB increases with the time of exposure to the index case and this risk is also higher in < 5 years and immigrants. Contact tracing has a high yield for detecting new cases of TB.

Quantifying gaps in the tuberculosis care cascade in Brazil: A mathematical model study using national program data

BACKGROUND

In Brazil, many individuals with tuberculosis (TB) do not receive appropriate care due to delayed or missed diagnosis, ineffective treatment regimens, or loss-to-follow-up. This study aimed to estimate the health losses and TB program costs attributable to each gap in the care cascade for TB disease in Brazil.

METHODS AND FINDINGS

We constructed a Markov model simulating the TB care cascade and lifetime health outcomes (e.g., death, cure, postinfectious sequelae) for individuals developing TB disease in Brazil. We stratified the model by age, human immunodeficiency virus (HIV) status, drug resistance, state of residence, and disease severity, and developed a parallel model for individuals without TB that receive a false-positive TB diagnosis. Models were fit to data (adult and pediatric) from Brazil's Notifiable Diseases Information System (SINAN) and Mortality Information System (SIM) for 2018. Using these models, we assessed current program performance and simulated hypothetical scenarios that eliminated specific gaps in the care cascade, in order to quantify incremental health losses and TB diagnosis and treatment costs along the care cascade. TB-attributable disability-adjusted life years (DALYs) were calculated by comparing changes in survival and nonfatal disability to a no-TB counterfactual scenario. We estimated that 90.0% (95% uncertainty interval [UI]: 85.2 to 93.4) of individuals with TB disease initiated treatment and 10.0% (95% UI: 7.6 to 12.5) died with TB. The average number of TB-attributable DALYs per incident TB case varied across Brazil, ranging from 2.9 (95% UI: 2.3 to 3.6) DALYs in Acre to 4.0 (95% UI: 3.3 to 4.7) DALYs in Rio Grande do Sul (national average 3.5 [95% UI: 2.8 to 4.1]). Delayed diagnosis contributed the largest health losses along the care cascade, followed by post-TB sequelae and loss to follow up from TB treatment, with TB DALYs reduced by 71% (95% UI: 65 to 76), 41% (95% UI: 36 to 49), and 10% (95% UI: 7 to 16), respectively, when these factors were eliminated. Total health system costs were largely unaffected by improvements in the care cascade, with elimination of treatment failure reducing attributable costs by 3.1% (95% UI: 1.5 to 5.4). TB diagnosis and treatment of false-positive individuals accounted for 10.2% (95% UI: 3.9 to 21.7) of total programmatic costs but contributed minimally to health losses. Several assumptions were required to interpret programmatic data for the analysis, and we were unable to estimate the contribution of social factors to care cascade outcomes.

CONCLUSIONS

In this study, we observed that delays to diagnosis, post-disease sequelae and treatment loss to follow-up were primary contributors to the TB burden of disease in Brazil. Reducing delays to diagnosis, improving healthcare after TB cure, and reducing treatment loss to follow-up should be prioritized to improve the burden of TB disease in Brazil.

Magnitude and factors associated with delay in treatment-seeking among new pulmonary tuberculosis patients in public health facilities in Habro district, eastern Ethiopia

Background

In developing nations, almost two-thirds of people with active tuberculosis (TB) remain undetected and untreated. Delays in seeking treatment increase the severity of the illness, the likelihood of mortality, and the risk of the infection spreading to others in the community. Thus, this study aimed to assess the magnitude of delay in treatment-seeking and its associated factors among new adult pulmonary tuberculosis patients attending public health facilities in Habro District, West Harerge Zone, Oromia Region, Eastern Ethiopia.

Methods

A health facility-based cross-sectional study design was conducted among 420 randomly selected patients with pulmonary tuberculosis who visited public health facilities in Habro District from September 5 to October 5, 2022. Binary logistic regression analysis was used to determine the relationship between the dependent and independent variables, and a 95% confidence interval was used to select significant variables.

Result

Twenty-one days after the start of their illness, 62.38% (95% CI: 57.4%, 66.6%) of the patients sought an initial consultation. Being female (AOR = 2.14, 95% CI: 1.26, 3.65), having poor knowledge about TB (AOR = 3.10, 95% CI: 1.77, 5.43), having no contact history with TB patients (AOR = 3.52, 95% CI: 1.29, 9.58), having clinically diagnosed pulmonary tuberculosis (AOR = 2.16, 95% CI: 1.26, 3.67), and living a long distance from the nearest health facility (AOR = 2.87, 95% CI: 1.31, 6.23) were important predictors contributing to TB patient treatment delay.

Conclusion

In the current study, more than three-fifths of TB patients delayed seeking treatment. Thus, awareness of tuberculosis should be created, especially targeting females and communities found at a distance from the health facility. Additionally, health professionals should emphasise the importance of getting medical attention early and knowing how to suspect and identify tuberculosis symptoms.

Racial and Ethnic Disparities in Tuberculosis Incidence, Arkansas, USA, 2010-2021

We conducted an epidemiologic assessment of disease distribution by race/ethnicity to identify subpopulation-specific drivers of tuberculosis (TB). We used detailed racial/ethnic categorizations for the 932 TB cases diagnosed in Arkansas, USA, during 2010-2021. After adjusting for age and sex, racial/ethnic disparities persisted; the Native Hawaiian/Pacific Islander (NHPI) group had the highest risk for TB (risk ratio 173.6, 95% CI 140.6-214.2) compared with the non-Hispanic White group, followed by Asian, Hispanic, and non-Hispanic Black. Notable racial/ethnic disparities existed across all age groups; NHPI persons 0-14 years of age were at a particularly increased risk for TB (risk ratio 888, 95% CI 403-1,962). The risks for sputum smear-positive pulmonary TB and extrapulmonary TB were both significantly higher for racial/ethnic minority groups. Our findings suggest that TB control in Arkansas can benefit from a targeted focus on subpopulations at increased risk for TB.

Accuracy of digital chest x-ray analysis with artificial intelligence software as a triage and screening tool in hospitalized patients being evaluated for tuberculosis in Lima, Peru

Introduction

Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy.

Methods

We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors.

Results

In the triage cohort (n=387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n=191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort.

Conclusions

qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs.

Determinants of Unsuccessful TB Treatment Outcomes Among Patients on Directly Observed Treatment Short Course in Jimma Town Health Facilities, Southwest Ethiopia: A Case-Control Study

Background

Even though Ethiopia's Federal Ministry of Health has been implementing several programs aimed at reducing the burden of tuberculosis (TB), It does not demonstrate adequate progress. As a result, identifying the determinants of unsuccessful outcomes of directly observed treatment, short-course (DOTS) is critical.

Purpose

This study aimed to assess the determinants of unsuccessful TB treatment outcomes among patients with DOTS in Jimma town, southwest Ethiopia.

Patients and Methods

An unmatched case-control study using secondary data was conducted among 118 cases and 472 controls from April 1 to June 1, 2021. Cases were TB cases with unsuccessful treatment courses whereas controls were those of successful treatment. Data were collected using a standardized tool. Statistical analysis was done using SPSS version 23 software. A binary logistic regression model was used to identify the determinants.

Results

We found that the determinants including age > 35 years (AOR=1.9, 95% CI: 1.14-3.2), lack of contact person (AOR= 27, 95% CI: 15.8-46.3), being HIV positive (AOR=7.3, 95% CI: 3.7-14.2)), and being malnourished (AOR=4.5, 95% CI: 1.5-12.9) were significantly associated with unsuccessful tuberculosis treatment outcome.

Conclusion

In this study, advanced age, being HIV positive, lack of contact person, and being malnourished were determinant factors for unsuccessful TB treatment outcomes. Hence, careful monitoring, screening, and management of risk factors are recommended.

Research tests for the diagnosis of tuberculosis infection

INTRODUCTION

Despite huge efforts, tuberculosis (TB) is still a major public health threat worldwide, it is estimated that a quarter of the global population is infected by Mycobacterium tuberculosis (Mtb). For controlling TB and reducing Mtb transmission it is fundamental to diagnose TB infection (TBI) as well as the progressors from TBI to disease to identify those requiring preventive therapy. At present, there is no gold standard test for TBI diagnosis although several new methodologies have been attempted.

AREAS COVERED

This review provides an update on the most recent approaches to develop reliable tests to diagnose TBI and progressors from infection to disease. Experimental tests are based on either the direct identification of Mtb (i.e., Mtb DNA upon host cells isolation; Mtb proteins or peptides) or host response (i.e., levels and quality of specific anti-Mtb antibodies; host blood transcriptome signatures).

EXPERT OPINION

The experimental tests described are very interesting. However, further investigation and randomized clinical trials are needed to improve the sensitivity and specificity of these new research-based tests. More reliable proofs-of-concept and simplification of technical procedures are necessary to develop new diagnostic tools for identifying TBI patients and those that will progress from infection to TB disease.

Attenuated Mycobacterium tuberculosis vaccine protection in a low-dose murine challenge model

Bacillus Calmette-Guérin (BCG) remains the only approved tuberculosis (TB) vaccine despite limited efficacy. Preclinical studies of next-generation TB vaccines typically use a murine aerosol model with a supraphysiologic challenge dose. Here, we show that the protective efficacy of a live attenuated Mycobacterium tuberculosis (Mtb) vaccine ΔLprG markedly exceeds that of BCG in a low-dose murine aerosol challenge model. BCG reduced bacterial loads but did not prevent establishment or dissemination of infection in this model. In contrast, ΔLprG prevented detectable infection in 61% of mice and resulted in anatomic containment of 100% breakthrough infections to a single lung. Protection was partially abrogated in a repeated low-dose challenge model, which showed serum IL-17A, IL-6, CXCL2, CCL2, IFN-γ, and CXCL1 as correlates of protection. These data demonstrate that ΔLprG provides increased protection compared to BCG, including reduced detectable infection and anatomic containment, in a low-dose murine challenge model.

Development and clinical validation of Swaasa AI platform for screening and prioritization of pulmonary TB

Acoustic signal analysis has been employed in various medical devices. However, studies involving cough sound analysis to screen the potential pulmonary tuberculosis (PTB) suspects are very few. The main objective of this cross-sectional validation study was to develop and validate the Swaasa AI platform to screen and prioritize at risk patients for PTB based on the signature cough sound as well as symptomatic information provided by the subjects. The voluntary cough sound data was collected at Andhra Medical College-India. An Algorithm based on multimodal convolutional neural network architecture and feedforward artificial neural network (tabular features) was built and validated on a total of 567 subjects, comprising 278 positive and 289 negative PTB cases. The output from these two models was combined to detect the likely presence (positive cases) of PTB. In the clinical validation phase, the AI-model was found to be 86.82% accurate in detecting the likely presence of PTB with 90.36% sensitivity and 84.67% specificity. The pilot testing of model was conducted at a peripheral health care centre, RHC Simhachalam-India on 65 presumptive PTB cases. Out of which, 15 subjects truly turned out to be PTB positive with a positive predictive value of 75%. The validation results obtained from the model are quite encouraging. This platform has the potential to fulfil the unmet need of a cost-effective PTB screening method. It works remotely, presents instantaneous results, and does not require a highly trained operator. Therefore, it could be implemented in various inaccessible, resource-poor parts of the world.

Caring for Adolescents and Young Adults With Tuberculosis or at Risk of Tuberculosis: Consensus Statement From an International Expert Panel

Background:

Despite being a preventable and treatable disease, tuberculosis (TB) is a leading cause of death among young people globally. Each year, an estimated 1.8 million adolescents and young adults (AYAs; 10–24 years old) develop TB. In 2019, an estimated 161,000 AYAs died of the disease. AYAs have unique developmental, psychosocial, and healthcare needs, but these needs have been neglected in both TB care and research agendas. In order to improve outcomes in this age group, the specific needs of AYAs must be considered and addressed.

Methods:

Through a consensus process, an international panel of 34 clinicians, researchers, TB survivors, and advocates with expertise in child/adolescent TB and/or adolescent health proposed interventions for optimizing AYA engagement in TB care. The process consisted of reviewing the literature on TB in AYAs; identifying and discussing priority areas; and drafting and revising proposed interventions until consensus, defined a priori , was reached.

Results:

The panel acknowledged the dearth of evidence on best practices for identifying and managing AYAs with TB. The final consensus statement, based on expert opinion, proposes nine interventions to reform current practices that may harm AYA health and well-being, and nine interventions to establish high-quality AYA-centered TB services.

Conclusion:

AYA-specific interventions for TB care and research are critical for improving outcomes in this age group. In the absence of evidence on best practices, this consensus statement from an international group of experts can help address the needs of AYA with TB or at risk for TB.

Tuberculosis control at a South African correctional centre: Diagnosis, treatment and strain characterisation

Background

Correctional centres provide ideal conditions for tuberculosis (TB) transmission and disease progression. Despite the high TB incidence and incarceration rate in South Africa, data from South African correctional centres are scarce. Thus, the study evaluated TB diagnosis, treatment initiation and completion, and identified prevalent Mycobacterium tuberculosis strains among detainees entering a South African correctional centre.

Methods

This study was a prospective observational study that enrolled participants between February and September 2017 from a correctional centre located in the Western Cape, South Africa. All adult male detainees who tested positive for TB during admission screening were eligible to participate in the study. Sputum samples from enrolled participants underwent smear microscopy and culture. Strain typing was performed on culture-positive samples. The time between specimen collection and diagnosis, the time between diagnosis and treatment initiation, and the proportion of detainees completing TB treatment at the correctional centre were calculated.

Results

During the study period, 130 TB cases were detected through routine admission screening (126 male, 2 female, 2 juvenile). Out of the 126 eligible male detainees, 102 were enrolled in the study (81%, 102/126). All TB cases were detected within 30 hrs of admission screening. The majority (78%, 80/102) of participants started treatment within 48 hrs of TB diagnosis. However, only 8% (9/102) of participants completed treatment at the correction centre. Sputa from 90 of the 102 participants were available for smear and culture. There was a high smear positivity, with 49% (44/90) of isolates being smear positive. The Beijing family was the most frequent lineage (55.2%) in the study.

Conclusion

The strengths of the current TB control efforts at the correctional centre include rapid detection of cases through admission screening and prompt treatment initiation. However, a high number of detainees exiting before treatment completion highlights the need to strengthen links between correctional TB services and community TB services to ensure detainees complete TB treatment after release and prevent TB transmission.

Connecting the dots: understanding how human mobility shapes TB epidemics

Tuberculosis (TB) remains a leading infectious cause of death worldwide. Reducing TB infections and TB-related deaths rests ultimately on stopping forward transmission from infectious to susceptible individuals. Critical to this effort is understanding how human host mobility shapes the transmission and dispersal of new or existing strains of Mycobacterium tuberculosis (Mtb). Important questions remain unanswered. What kinds of mobility, over what temporal and spatial scales, facilitate TB transmission? How do human mobility patterns influence the dispersal of novel Mtb strains, including emergent drug-resistant strains? This review summarizes the current state of knowledge on mobility and TB epidemic dynamics, using examples from three topic areas, including inference of genetic and spatial clustering of infections, delineating source-sink dynamics, and mapping the dispersal of novel TB strains, to examine scientific questions and methodological issues within this topic. We also review new data sources for measuring human mobility, including mobile phone-associated movement data, and discuss important limitations on their use in TB epidemiology.

The role of IGRA in the diagnosis of tuberculosis infection, differentiating from active tuberculosis, and decision making for initiating treatment or preventive therapy of tuberculosis infection

OBJECTIVES

The World Health Organization estimated that a quarter of the global population is infected by Mycobacterium tuberculosis (Mtb). A better control of tuberculosis (TB) is based on the ability to detect Mtb infection, identifying the progressors to TB disease, undergoing to preventive therapy and implementing strategies to register the infections and treatment completion.

DESIGN

we reviewed the literature regarding the tests available for TB infection diagnosis, the preventive therapies options and the cascade of care for controlling TB at a public health level.

RESULTS

current tests for TB infection diagnosis as IFN-γ release assays or tuberculin skin tests are based on the detection of an immune response to Mtb in the absence of clinical disease. The main limit is their low accuracy to detect progressors to disease. New preventive treatments are available with short duration that are associated with better adherence. Options to register TB infections are presented.

CONCLUSIONS

Tests to diagnose TB infection are available but they lack accuracy to identify the progressors from infection to TB disease. Shorter preventive TB therapy are available but need to be implemented worldwide. A TB infection registry is crucial for improving the cascade of care leading to a better TB control.

Drug resistant TB - latest developments in epidemiology, diagnostics and management

AIM

The aim of this review is to inform the reader on the latest developments in epidemiology, diagnostics and management.

EPIDEMIOLOGY

Drug-resistant Tuberculosis (DR-TB) continues to be a current global health threat, and is defined by higher morbidity and mortality, sequelae, higher cost and complexity. The WHO classifies drug-resistant TB into 5 categories: isoniazid-resistant TB, rifampicin resistant (RR)-TB and MDR-TB, (TB resistant to isoniazid and rifampicin), pre-extensively drug-resistant TB (pre-XDR-TB) which is MDR-TB with resistance to a fluoroquinolone and finally XDR-TB that is TB resistant to rifampicin, plus any fluoroquinolone, plus at least one further priority A drug (bedaquiline or linezolid). Of 500,000 estimated new cases of RR-TB in 2020, only 157 903 cases are notified. Only about a third of cases are detected and treated annually.

DIAGNOSTICS

Recently newer rapid diagnostic methods like the GeneXpert, whole genome sequencing and Myc-TB offer solutions for rapid detection of resistance.

TREATMENT

The availability of new TB drugs and shorter treatment regimens have been recommended for the management of DR-TB.

CONCLUSION

Despite advances in diagnostics and treatments we still have to find and treat two thirds of the drug resistant cases that go undetected and therefore go untreated each year. Control of TB and elimination will only occur if cases are detected, diagnosed and treated promptly.

Impact of prolonged isolation on adolescents with drug-susceptible tuberculosis in Lima, Peru: a qualitative study

OBJECTIVES

Patients with tuberculosis (TB) generally are instructed to isolate at the beginning of treatment in order to prevent disease transmission. The duration of isolation varies and may be prolonged (ie, lasting 1 month or more). Few studies have examined the impact of isolation during TB treatment on adolescents, who may be more vulnerable to its negative effects.

METHODS

This study took place from 2018 through 2019 in Lima, Peru, where the Ministry of Health mandates the exclusion of patients with TB from educational institutions for at least 2 months. Using semi-structured guides, we conducted individual in-depth interviews with adolescents who received treatment for drug-susceptible TB, their primary caregivers and health providers. We performed thematic analysis of the transcribed interviews.

RESULTS

We interviewed 85 participants: 34 adolescents, 36 caregivers and 15 healthcare workers. At the time of their TB diagnoses, 28 adolescents were in secondary, postsecondary, vocational or military school. Adolescents with drug-susceptible TB were prescribed home isolation usually for 2 (and occasionally for 1) months. Consequently, they could neither attend school nor socialise with family members or friends. Two primary themes emerged from the interviews. First, as a result of their exclusion from school, most adolescents fell behind academically and had to repeat a semester or academic year. Second, absence from school, separation from friends and loved ones, and reinforcement of TB-related stigma (arising from fear of TB transmission) harmed adolescents' mental health.

CONCLUSION

Prolonged isolation led to educational setbacks and emotional trauma among adolescents with TB. Prolonged isolation is not supported by current evidence on TB transmission and is problematic from a human rights perspective, as it violates adolescents' rights to education and freedom of movement. Isolation recommendations should be re-evaluated to align with data on TB transmission and the principles of patient-centred care.

Assessment of knowledge, attitude, and practices of tuberculosis patients towards DOTs regimen in Jimma health center, Jimma zone, southwest Ethiopia

Objectives

The purpose of conducting this study was to assess the knowledge, attitude, and practices of tuberculosis patients towards dots regimen in Jimma health Center. In addition, assessing the attitude of tuberculosis towards factors, modern, and traditional medicine was another aim of this study.

Methods

A cross-sectional study was conducted based on patient card and registration book at TB follow-up clinic at Jimma health center, southwest Ethiopia. The study population comprises 150 participants, who were selected from the patient registration book by interviewing and questionnaires. Additionally, cross-tabulation and OR with 95% confidence interval were computed.

Results

In this study, only 103 (68.7%) and 47 (31.3%) patients scored higher and lower knowledge status respectively. Of the total enrolled governmental employee, 25 (16.7 %) patients had an overall high knowledge status. On the other hand, 101 (67.3%) and 49 (32.7 %) patients scored high and low overall attitude respectively.

Conclusions

In this study, the knowledge and attitude of patients about TB and its treatment were found within a low level of perception. Therefore, implementation of health education and awareness creation through different mobilization mechanisms are required to avoid the problem for patients.

CT and 18F-FDG PET abnormalities in contacts with recent tuberculosis infections but negative chest X-ray

Close contacts of individuals with pulmonary tuberculosis are at risk for tuberculosis infection and the development of active tuberculosis. In current contact investigations, immunologic tests (the tuberculin skin test and interferon-gamma release assay) and chest X-ray examinations are used to dichotomize contacts with Mycobacterium tuberculosis infections into those with active (X-ray abnormalities) versus latent tuberculosis (normal radiographs). This article is a critical review of computed tomographic (CT) and 18-fluorodeoxyglucose positron emission tomographic (PET) findings of incipient tuberculosis without X-ray abnormalities based on a systematic literature review of twenty-five publications. The CT and 18-fluorodeoxyglucose PET studies revealed minimal pauci-nodular infiltrations in the lung parenchyma and mediastinal lymph nodes abnormalities with metabolic uptake in approximately one-third of asymptomatic close contacts with negative chest radiographic and bacteriological/molecular results for active tuberculosis. Tuberculosis with minimal changes challenge the validity of simply dichotomizing cases of recent M. tuberculosis infections in contacts depending on the presence of X-ray abnormalities as the recent infections may spontaneously regress, remain stagnant, or progress to active tuberculosis in human and nonhuman primate studies. Whether contacts with tuberculosis with minimal changes are interpreted as having active tuberculosis or latent tuberculosis has clinical implications in terms of specific benefits and harms under the current contact management. Advanced imaging tools may help further stratify contacts intensely exposed to M. tuberculosis on a continuous spectrum from latent tuberculosis to incipient, subclinical and active tuberculosis. Identifying incipient tuberculosis would provide an opportunity for earlier and tailored treatment before active tuberculosis is established.

Effects of 25-hydroxy vitamin D on T lymphocyte subsets and sputum smear conversion during anti-tuberculosis treatment

Objectives This study was aimed to explore the effects of 25-hydroxy vitamin D [25(OH)D] on T lymphocyte subsets and sputum smear conversion during anti-tuberculosis (TB) treatment. Methods 120 newly diagnosed active pulmonary TB patients were collected and classified into vitamin D sufficiency group, vitamin D insufficiency group, and vitamin D deficiency group according to serum 25(OH)D levels. The clinical data and sputum smear conversion were collected, serum 25(OH)D and T lymphocyte subsets were also measured and compared. Results Our data showed that 25(OH)D levels reached the lowest point at 2 months of anti-TB treatment. Significant differences existed in the increase of CD4+ and CD8+ T cells based on vitamin D levels. Vitamin D sufficiency group had a significantly higher increase of CD4+ T cells during 6 months of anti-TB treatment and CD8+ T cells after 4 months of anti-TB treatment than the other groups. Vitamin D had no effect on the time to sputum smear conversion [vitamin D sufficiency group: adjusted hazard ratio (HR): 1.27 (95% CI: 0.78 - 2.06); vitamin D insufficiency group: adjusted HR: 1.05 (95% CI: 0.63 - 1.75)]. Conclusions Through null effects on sputum smear conversion, vitamin D may have a beneficial effect on the increase of CD4+ and CD8+ T cells during anti-TB treatment.

Scaling up investigation and treatment of household contacts of tuberculosis patients in Brazil: a cost-effectiveness and budget impact analysis

Background

In Brazil, investigation and treatment of tuberculosis infection (TBI) in households contacts (HHC) of TB patients is not a priority. We estimated the cost-effectiveness and budget-impact of scaling-up an enhanced HHC management in Brazil.

Methods

We conceptualized a cascade-of-care that captures how HHC of tuberculosis patients are investigated in Brazil (status quo) and two enhanced strategies for management of HHC focusing on: (1) only tuberculosis disease (TBD) detection and, (2) TBD and TBI detection and treatment. Effectiveness was the number of HHC diagnosed with TBD and completing TBI treatment. Proportions in the cascades-of-care were derived from a meta-analysis. Health-system costs (2019 US$) were based on literature and official data from Brazil. The impact of enhanced strategies was extrapolated using reported data from 2019.

Findings

With the status quo, 0 (95% uncertainty interval: 0-1) HHC are diagnosed with TBD and 2 (0-16) complete TBI treatment. With strategy(1), an additional 15 (3-45) HHC would be diagnosed with TBD at a cost of US$346 each. With strategy(2), 81 (19-226) additional HHC would complete TBI treatment at a cost of US$84 each. A combined strategy, implemented nationally to enhance TBD detection and TBI treatment would result in an additional 9,711 (845-28,693) TBD being detected, and 51,277 (12,028-143,495) more HHC completing TBI treatment each year, utilizing 10.9% and 11.6% of the annual national tuberculosis program budget, respectively.

Interpretation

Enhanced detection and treatment of TBD and TBI among HHC in Brazil can be achieved at a national level using current tools at reasonable cost.

Funding

None.

Clinical standards for the diagnosis, treatment and prevention of TB infection

BACKGROUND: Tuberculosis (TB) preventive therapy (TPT) decreases the risk of developing TB disease and its associated morbidity and mortality. The aim of these clinical standards is to guide the assessment, management of TB infection (TBI) and implementation of TPT.METHODS: A panel of global experts in the field of TB care was identified; 41 participated in a Delphi process. A 5-point Likert scale was used to score the initial standards. After rounds of revision, the document was approved with 100% agreement.RESULTS: Eight clinical standards were defined: Standard 1, all individuals belonging to at-risk groups for TB should undergo testing for TBI; Standard 2, all individual candidates for TPT (including caregivers of children) should undergo a counselling/health education session; Standard 3, testing for TBI: timing and test of choice should be optimised; Standard 4, TB disease should be excluded prior to initiation of TPT; Standard 5, all candidates for TPT should undergo a set of baseline examinations; Standard 6, all individuals initiating TPT should receive one of the recommended regimens; Standard 7, all individuals who have started TPT should be monitored; Standard 8, a TBI screening and testing register should be kept to inform the cascade of care.CONCLUSION: This is the first consensus-based set of Clinical Standards for TBI. This document guides clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage TBI.

Wearing time and respiratory volume affect the filtration efficiency of masks against aerosols at different sizes

Face masks are critical in preventing the spread of respiratory infections including coronavirus disease 2019 (COVID-19). Different types of masks have distinct filtration efficiencies (FEs) with differential costs and supplies. Here we reported the impact of breathing volume and wearing time on the inward and outward FEs of four different mask types (N95, surgical, single-use, and cloth masks) against various sizes of aerosols. Specifically, 1) Mask type was an important factor affecting the FEs. The FEs of N95 and surgical mask were better than those of single-use mask and cloth mask; 2) As particle size decreased, the FEs tended to reduce. The trend was significantly observed in FEs of aerosols with particle size < 1 μ m ; 3) After wearing N95 and surgical masks for 0, 2, 4, and 8 h, their FEs (%) maintained from 95.75 ± 0.09 to 100 ± 0 range. While a significant decrease in FEs were noticed for single-use masks worn for 8 h and cloth masks worn >2 h under deep breathing (30 L/min); 4) Both inward and outward FEs of N95 and surgical masks were similar, while the outward FEs of single-use and cloth masks were higher than their inward FEs; 5) The FEs under deep breathing was significantly lower than normal breathing with aerosol particle size <1 μ m. In conclusion, our results revealed that masks have a critical role in preventing the spread of aerosol particles by filtering inhalation, and FEs significantly decreased with the increasing of respiratory volume and wearing time. Deep breathing may cause increasing humidity and hence decrease FEs by increasing the airflow pressure. With the increase of wearing time, the adsorption capacity of the filter material tends to be saturated, which may reduce FEs. Findings may be used to provide information for policies regarding the proper use of masks for general public in current and future pandemics.

The definition of tuberculosis infection based on the spectrum of tuberculosis disease

Latent tuberculosis infection was the term traditionally used to indicate tuberculosis (TB) infection. This term was used to define “a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens through tests such as the tuberculin skin test (TST) or an interferon-γ release assay (IGRA) without clinically active TB”. Recent evidence indicates that the spectrum from TB infection to TB disease is much more complex, including a “continuum” of situations didactically reported as uninfected individual, TB infection, incipient TB, subclinical TB without signs/symptoms, subclinical TB with unrecognised signs/symptoms, and TB disease with signs/symptoms. Recent evidence suggests that subclinical TB is responsible for important M. tuberculosis transmission. This review describes the different stages described above and their relationships. It also summarises the new developments in prevention, diagnosis and treatment of TB infection as well as their public health and policy implications.

The evolution from TB infection to disease is now described as a “continuum process”. Understanding of this is important to appreciate what is new on prevention, diagnosis and treatment of TB infection.https://bit.ly/3jauRKA

How much do smear-negative patients really contribute to tuberculosis transmissions? Re-examining an old question with new tools

BACKGROUND

Sputum smear microscopy is a common surrogate for tuberculosis infectiousness. Previous estimates that smear-negative patients contribute 13-20% of transmissions and are, on average, 20 to 25% as infectious as smear-positive cases are understood to be high. Herein, we use an ideal real-world setting, a comprehensive dataset, and new high-resolution techniques to more accurately estimate the true transmission risk of smear-negative cases.

METHODS

We treated all adult culture-positive pulmonary TB patients diagnosed in the province of Alberta, Canada from 2003 to 2016 as potential transmitters. The primary data sources were the Alberta TB Registry and the Provincial Laboratory for Public Health. We measured, as primary outcomes, the proportion of transmissions attributable to smear-negative sources and the relative transmission rate. First, we replicated previous studies by using molecular (DNA) fingerprint clustering. Then, using a prospectively collected registry of TB contacts, we defined transmission events as active TB amongst identified contacts who either had a 100% DNA fingerprint match to the source case or a clinical diagnosis. We supplemented our analysis with genome sequencing on temporally and geographically linked DNA fingerprint clusters of cases not identified as contacts.

FINDINGS

There were 1176 cases, 563 smear-negative and 613 smear-positive, and 23,131 contacts. Replicating previous studies, the proportion of transmissions attributable to smear-negative source cases was 16% (95% CI, 12-19%) and the relative transmission rate was 0.19 (95% CI, 0.14-0.26). With our combined approach, the proportion of transmission was 8% (95% CI, 3-14%) and the relative transmission rate became 0.10 (95% CI, 0.05-0.19).

INTERPRETATION

When we examined the same outcomes as in previous studies but refined transmission ascertainment with the addition of conventional epidemiology and genomics, we found that smear-negative cases were ∼50% less infectious than previously thought.

FUNDING

Alberta Innovates Health Solutions.

The Impact of Tuberculosis on the Well-Being of Adolescents and Young Adults

The health needs of adolescents and young adults (AYAs) have been neglected in tuberculosis (TB) care, control, and research. AYAs, who are distinct from younger children and older adults, undergo dynamic physical, psychological, emotional, cognitive, and social development. Five domains of adolescent well-being are crucial to a successful transition between childhood and adulthood: (1) Good health; (2) connectedness and contribution to society; (3) safety and a supportive environment; (4) learning, competence, education, skills, and employability; and (5) agency and resilience. This review summarizes the evidence of the impact of TB disease and treatment on these five domains of AYA well-being.

Screening for Tuberculosis in Migrants: A Survey by the Global Tuberculosis Network

Tuberculosis (TB) does not respect borders, and migration confounds global TB control and elimination. Systematic screening of immigrants from TB high burden settings and-to a lesser degree TB infection (TBI)-is recommended in most countries with a low incidence of TB. The aim of the study was to evaluate the views of a diverse group of international health professionals on TB management among migrants. Participants expressed their level of agreement using a six-point Likert scale with different statements in an online survey available in English, French, Mandarin, Spanish, Portuguese and Russian. The survey consisted of eight sections, covering TB and TBI screening and treatment in migrants. A total of 1055 respondents from 80 countries and territories participated between November 2019 and April 2020. The largest professional groups were pulmonologists (16.8%), other clinicians (30.4%), and nurses (11.8%). Participants generally supported infection control and TB surveillance established practices (administrative interventions, personal protection, etc.), while they disagreed on how to diagnose and manage both TB and TBI, particularly on which TBI regimens to use and when patients should be hospitalised. The results of this first knowledge, attitude and practice study on TB screening and treatment in migrants will inform public health policy and educational resources.

Clinical standards for the assessment, management and rehabilitation of post-TB lung disease

BACKGROUND: Increasing evidence suggests that post-TB lung disease (PTLD) causes significant morbidity and mortality. The aim of these clinical standards is to provide guidance on the assessment and management of PTLD and the implementation of pulmonary rehabilitation (PR).METHODS: A panel of global experts in the field of TB care and PR was identified; 62 participated in a Delphi process. A 5-point Likert scale was used to score the initial ideas for standards and after several rounds of revision the document was approved (with 100% agreement).RESULTS: Five clinical standards were defined: Standard 1, to assess patients at the end of TB treatment for PTLD (with adaptation for children and specific settings/situations); Standard 2, to identify patients with PTLD for PR; Standard 3, tailoring the PR programme to patient needs and the local setting; Standard 4, to evaluate the effectiveness of PR; and Standard 5, to conduct education and counselling. Standard 6 addresses public health aspects of PTLD and outcomes due to PR.CONCLUSION: This is the first consensus-based set of Clinical Standards for PTLD. Our aim is to improve patient care and quality of life by guiding clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage PTLD.

A comprehensive review of various categories of face masks resistant to Covid-19

The science about the usage of face masks by the common public to avert COVID-19 transmission is proceeding swiftly. A primary route of transmission of COVID-19 is probably through small respiratory droplets, and it is transmissible from asymptomatic and pre-symptomatic individuals. According to the World Health Organization, wearing a mask in public can help reduce the transmission of the COVID-19 virus. Different categories and types of masks and their usage are reviewed in this work. In a nutshell, this review work elucidates the aspects of utilizing the various face masks along with all possibilities to fight against the ongoing pandemic of COVID-19.

Performance of QuantaMatrix Microfluidic Agarose Channel system integrated with mycobacteria growth indicator tube liquid culture

The QuantaMatrix Microfluidic Agarose Channel (QMAC) system was used for rapid drug susceptibility testing (DST). Here, we performed DST using QMAC integrated with the mycobacteria growth indicator tube (MGIT) liquid culture employing a specially designed cross agarose channel for the tuberculosis chip. MGIT-, QMAC-, and Löwenstein-Jensen (LJ)-DSTs were performed using 13 drugs. The protocol for QMAC-DST was optimized using the inoculum obtained after the disaggregation of Mycobacterium tuberculosis clumps in MGIT culture. The completion times of QMAC-DST and MGIT-DST were analyzed, and the results of all three DSTs were compared. Discrepant results were analyzed using line probe assays and DNA sequencing. Nontuberculous mycobacteria were distinguished using the ρ-nitrobenzoic acid inhibition test. The overall agreement rate of QMAT-DST and LJ-DST was 97.0% and that of QMAT-DST and MGIT-DST was 86.3%. An average turnaround time for DST was 5.4 days, which was considerably less than the time required for MGIT-DST. The overall time required to obtain DST results using QMAC-DST integrated with MGIT culture was an average of 18.6 days: 13.2 days for culture and identification and 5.4 days for DST. Hence, QMAC-DST integrated with liquid culture can be used to perform DSTs with short turnaround times and effective detection. KEY POINTS: • QMAC system can simultaneously perform phenotypic DST with 13 anti-TB drugs and PNB. • An optimized DST protocol led to a marked decrease in clumping in MGIT culture. • QMAC system integrated with MGIT liquid culture system reduced the turnaround time.

Treatment seeking delay and associated factors among tuberculosis patients attending health facility in Ethiopia from 2000 to 2020: A systematic review and meta analysis

Background

Treatment seeking delay is defined as the time interval between the onset of the major symptoms of tuberculosis (TB) and the first visit to the formal health care facility. The patient was said to be delayed if the patient visited the health-facility after 3 weeks onset of major symptoms. However, in low-income countries like Ethiopia, the delay in treatment-seeking among tuberculosis patients contributes to a widespread transmission and high prevalence of tuberculosis.

Methods

Studies were retrieved from PubMed, Cochrane Database, Cinahl, Scopus, Mednar, and Google Scholar by employing a combination of search terms with Boolean operators. Heterogeneity across studies was assessed using the Cochrane Q test. A funnel plot was used for visual assessment of publication bias. Subgroup analyses were performed to explore the possible causes of heterogeneity. Egger’s weighted regression test at a p-value < 0.05 was used to assess the presence of publication bias. Sensitivity analysis was performed to judge whether the pooled effect size was influenced by individual study. STATA software version 14 was used for all statistical analyses.

Result

A total of 12 studies with 5122 total sample size were included. The national pooled prevalence of treatment seeking delay was 44.29% (95% CI: 39.805, 48.771). The visual inspection of the funnel plot showed the asymmetrical distribution, and the Egger test showed insignificant (P = 0.348). Patients who did not seek formal health care providers on a first contact had about 7 times more likely to delay than patients who sought formal health care provider on a first contact (OR: 7.192 ((95% CI 5.587–9.257), P = 0.001, I²: 85%). The others independent predictors of delay were rural residence (OR: 3.459 ((95% CI 1.469–8.148), P ≤ 0.001), extra pulmonary TB (OR: 2.520 ((95% CI 1.761–3.605), 0.180), lower educational level (OR 11.720 ((95% CI 1.006–2.938), P <0.001), and distance more than 10km from health facility (OR: 1.631 ((95% CI (10.858–3.101), P = 0.001).

Conclusion

In this review, we identified a substantial treatment seeking delay among TB patients in Ethiopia. And, the independent predictors of delay were treatment sought before formal health care provider, residence of the patient, type of TB, educational level, and distance from a health facility. Thus, we recommend health extension workers, health professionals and other stakeholders to focus on patient education, and to continuously mobilize the whole communities on early treatment seeking with a special emphasis given to where treatment sought before formal health care provider, rural resident, extra pulmonary TB, and a patient living farther than 10km distance from health facility.

Effectiveness and outcomes of air travel-related TB incident follow-up: a systematic review

The World Health Organization (WHO) recommends following up passengers after possible exposure to a case of infectious tuberculosis (TB) during air travel. This is time-consuming and difficult, and increasingly so with higher numbers each year of flights and passengers to and from countries with high TB endemicity. This paper systematically reviews the literature on contact tracing investigations after a plane exposure to active pulmonary TB. Evidence for in-flight transmission was assessed by reviewing the positive results of contacts without prior risk factors for latent TB.A search of Medline, EMBASE, BIOSIS, Cochrane Library and Database of Systematic Reviews was carried out, with no restrictions on study design, index case characteristics, duration of flight or publication date.In total, 22 papers were included, with 469 index cases and 15 889 contacts. Only 26.4% of all contacts identified completed screening after exposure. The yield of either a single positive tuberculin skin test (TST) or a TST conversion attributable to in-flight transmission was between 0.19% (95% CI 0.13%-0.27%) and 0.74% (95% CI 0.61%-0.88%) of all contacts identified (0.00%, 95% CI 0.00%-0.00% and 0.13%, 95% CI 0.00%-0.61% in random effects meta-analysis). The main limitation of this study was heterogeneity of reporting.The evidence behind the criteria for initiating investigations is weak and it has been widely demonstrated that active screening of contacts is labour-intensive and unlikely to be effective. Based on our findings, formal comprehensive contact tracing may be of limited utility following a plane exposure.

Tuberculosis and COVID-19, the new cursed duet: what differs between Brazil and Europe?

On April 1st, 2020, COVID-19 surpassed tuberculosis regarding the number of deaths per day worldwide. The combination of tuberculosis and COVID-19 has great potential for morbidity and mortality. In addition, the COVID-19 pandemic has had a significant impact on the diagnosis and treatment of tuberculosis. In this review article, we address concurrent tuberculosis and COVID-19, with particular regard to the differences between Brazil and Europe. In addition, we discuss priorities in clinical care, public health, and research.

Outcome of treatment of MDR-TB or drug-resistant patients treated with bedaquiline and delamanid: Results from a large global cohort

The World Health Organization (WHO) recommends countries introduce new anti-TB drugs in the treatment of multidrug-resistant tuberculosis. The aim of the study is to prospectively evaluate the effectiveness of bedaquiline (and/or delamanid)- containing regimens in a large cohort of consecutive TB patients treated globally. This observational, prospective study is based on data collected and provided by Global Tuberculosis Network (GTN) centres and analysed twice a year. All consecutive patients (including children/adolescents) treated with bedaquiline and/or delamanid were enrolled, and managed according to WHO and national guidelines. Overall, 52 centres from 29 countries/regions in all continents reported 883 patients as of January 31st 2021, 24/29 countries/regions providing data on 100% of their consecutive patients (10-80% in the remaining 5 countries). The drug-resistance pattern of the patients was severe (>30% with extensively drug-resistant -TB; median number of resistant drugs 5 (3-7) in the overall cohort and 6 (4-8) among patients with a final outcome). For the patients with a final outcome (477/883, 54.0%) the median (IQR) number of months of anti-TB treatment was 18 (13-23) (in days 553 (385-678)). The proportion of patients achieving sputum smear and culture conversion ranged from 93.4% and 92.8% respectively (whole cohort) to 89.3% and 88.8% respectively (patients with a final outcome), a median (IQR) time to sputum smear and culture conversion of 58 (30-90) days for the whole cohort and 60 (30-100) for patients with a final outcome and, respectively, of 55 (30-90) and 60 (30-90) days for culture conversion. Of 383 patients treated with bedaquiline but not delamanid, 284 (74.2%) achieved treatment success, while 25 (6.5%) died, 11 (2.9%) failed and 63 (16.5%) were lost to follow-up.

Tuberculosis, COVID-19 and hospital admission: Consensus on pros and cons based on a review of the evidence

The scientific debate on the criteria guiding hospitalization of tuberculosis (TB) and COVID-19 patients is ongoing. The aim of this review is to present the available evidence on admission for TB and TB/COVID-19 patients and discuss the criteria guiding hospitalization. Furthermore, recommendations are made as derived from recently published World Health Organization documents, based on Global Tuberculosis Network (GTN) expert opinion. The core published documents and guidelines on the topic have been reviewed. The proportion of new TB cases admitted to hospital ranges between 50% and 100% while for multidrug-resistant (MDR) TB patients it ranges between 85 and 100% globally. For TB patients with COVID-19 the proportion of cases admitted is 58%, probably reflecting different scenarios related to the diagnosis of COVID-19 before, after or at the same time of the active TB episode. The hospital length of stay for drug-susceptible TB ranges from 20 to 60 days in most of countries, ranging from a mean of 10 days (USA) to around 90 days in the Russian Federation. Hospitalization is longer for MDR-TB (50-180 days). The most frequently stated reasons for recommending hospital admission include: severe TB, infection control concerns, co-morbidities and drug adverse events which cannot be managed at out-patient level. The review also provides suggestions on hospital requirements for safe admissions as well as patient discharge criteria, while underlining the relevance of patient-centred care through community/home-based care.

A network-based model to explore the role of testing in the epidemiological control of the COVID-19 pandemic

BACKGROUND

Testing is one of the most effective means to manage the COVID-19 pandemic. However, there is an upper bound on daily testing volume because of limited healthcare staff and working hours, as well as different testing methods, such as random testing and contact-tracking testing. In this study, a network-based epidemic transmission model combined with a testing mechanism was proposed to study the role of testing in epidemic control. The aim of this study was to determine how testing affects the spread of epidemics and the daily testing volume needed to control infectious diseases.

METHODS

We simulated the epidemic spread process on complex networks and introduced testing preferences to describe different testing strategies. Different networks were generated to represent social contact between individuals. An extended susceptible-exposed-infected-recovered (SEIR) epidemic model was adopted to simulate the spread of epidemics in these networks. The model establishes a testing preference of between 0 and 1; the larger the testing preference, the higher the testing priority for people in close contact with confirmed cases.

RESULTS

The numerical simulations revealed that the higher the priority for testing individuals in close contact with confirmed cases, the smaller the infection scale. In addition, the infection peak decreased with an increase in daily testing volume and increased as the testing start time was delayed. We also discovered that when testing and other measures were adopted, the daily testing volume required to keep the infection scale below 5% was reduced by more than 40% even if other measures only reduced individuals' infection probability by 10%. The proposed model was validated using COVID-19 testing data.

CONCLUSIONS

Although testing could effectively inhibit the spread of infectious diseases and epidemics, our results indicated that it requires a huge daily testing volume. Thus, it is highly recommended that testing be adopted in combination with measures such as wearing masks and social distancing to better manage infectious diseases. Our research contributes to understanding the role of testing in epidemic control and provides useful suggestions for the government and individuals in responding to epidemics.

RISK FACTORS OF LATENT TUBERCULOSIS INFECTION IN HEALTHCARE WORKERS AT HOSPITALS IN JEMBER CITY INDONESIA

Background:

Healthcare workers in Tuberculosis (TB) and non-TB units in hospitals have a high risk of experiencing Latent Tuberculosis Infection (LTBI), because of exposure to droplets containing Mycobacterium tuberculosis. This study aims to prove LTBI incidence and risk factors to healthcare workers at the hospital in Jember City.

Material and Methods:

a cross-sectional study, from January to March 2020 in two hospitals in Jember City. Healthcare workers in the TB care and non-TB care unit were examined using Tuberculin skin test (TST) with a cut off ≥ 10 mm for positive LTBI. Chest x-ray and clinical examination to rule out active TB and a standardized questionnaire were also used.

Results:

128 healthcare workers completed the questionnaires, clinical, tuberculin skin test (TST), and chest x-ray data. LTBI incidence of positive results 61.7% (n = 79). Contacts TB in the workplace (p value = 0.219; OR = 1.643; CI = 0.742-3.641) and a unit of work (p value = 0.102; OR = 0.760; CI = 0.559-1.031) has no relationship with LTBI. The profession (p value = 0.020; OR = 1.112; CI = 0.896-1.403), the duration of the work (p value = 0.039; OR = 2.984; CI = 1.067-8.342), and BCG immunization (p value =0.000; OR = 0.151; CI = 0.052-0.438) have important relationships with LTBI.

Conclusion:

TB infection with a high incidence, a risk of transmission to healthcare workers, and a relationship between occupational risk factors and LTBI among healthcare workers in Jember City, Indonesia have been established in this study.

Harnessing the energy of the corporate sector to end TB: BE health

The World Health Organization (WHO) estimates that 3 million people with TB are missing’ from the official information system. They remain often undiagnosed and untreated or are managed outside the national TB programme structure by various care providers (including the private for-profit sector) and are not notified. The care provided to these patients is often sub-standard, not aligned with national and international guidelines, and un-regulated. WHO has repeatedly underlined the importance of collaborating with the private sector to improve prevention, diagnosis and treatment of TB, Private organisations could join public healthcare institutions’ efforts and expand their breadth of interventions to preventive interventions and play a complementary role to the public healthcare systems. Having access to a large scope of employees, customers, suppliers and other stakeholders, corporations should indeed be able to undertake prevention activities utilising their capacity to generate the necessary resources.

BE Health is an example of such a private initiative. It was established to build bridges between the workplace and the local communities aiming to empower high-risk populations to address their own major killers such as TB, HIV/AIDS and malaria, within the framework and targets of the United Nations Sustainable Development Goals. In collaboration with healthcare experts, BE Health decided at first to build awareness and spread information on health at the workplace. The approach focused on training newly-formed peer health educators capable of transferring knowledge to their local community. BE Health managed to create a solid network of peer health educators (selected among skilled employees) and community health volunteers selected among slum dwellers) operating in the metropolitan areas of Bangkok and Djibouti and focused on TB and HIV prevention among local impoverished communities.

Between 2013 and 2019, 51 peer Health Educators were trained, over 213 health promotion activities were organised at the workplace and more than 4,000 employees were reached through prevention activities, 730 community visits were conducted, over 1900 households were screened for TB and/or HIV with more than 22,000 people reached directly by prevention activities.

Similar third party approaches need to be further assessed, harnessed and expanded to complement efforts of the public health sector.

Coronavirus Disease-19: An Interim Evidence Synthesis of the World Association for Infectious Diseases and Immunological Disorders (Waidid)

Coronavirus disease 2019 (COVID-19) is a rapidly evolving, highly transmissible, and potentially lethal pandemic caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of June 11 2020, more than 7,000,000 COVID-19 cases have been reported worldwide, and more than 400,000 patients have died, affecting at least 188 countries. While literature on the disease is rapidly accumulating, an integrated, multinational perspective on clinical manifestations, immunological effects, diagnosis, prevention, and treatment of COVID-19 can be of global benefit. We aimed to synthesize the most relevant literature and experiences in different parts of the world through our global consortium of experts to provide a consensus-based document at this early stage of the pandemic.

Epidemic and pandemic viral infections: impact on tuberculosis and the lung: A consensus by the World Association for Infectious Diseases and Immunological Disorders (WAidid), Global Tuberculosis Network (GTN), and members of the European Society of Clinical Microbiology and Infectious Diseases Study Group for Mycobacterial Infections (ESGMYC)

Major epidemics, including some that qualify as pandemics, such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), HIV, influenza A (H1N1)pdm/09 and most recently COVID-19, affect the lung. Tuberculosis (TB) remains the top infectious disease killer, but apart from syndemic TB/HIV little is known regarding the interaction of viral epidemics and pandemics with TB. The aim of this consensus-based document is to describe the effects of viral infections resulting in epidemics and pandemics that affect the lung (MERS, SARS, HIV, influenza A (H1N1)pdm/09 and COVID-19) and their interactions with TB. A search of the scientific literature was performed. A writing committee of international experts including the European Centre for Disease Prevention and Control Public Health Emergency (ECDC PHE) team, the World Association for Infectious Diseases and Immunological Disorders (WAidid), the Global Tuberculosis Network (GTN), and members of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) Study Group for Mycobacterial Infections (ESGMYC) was established. Consensus was achieved after multiple rounds of revisions between the writing committee and a larger expert group. A Delphi process involving the core group of authors (excluding the ECDC PHE team) identified the areas requiring review/consensus, followed by a second round to refine the definitive consensus elements. The epidemiology and immunology of these viral infections and their interactions with TB are discussed with implications for diagnosis, treatment and prevention of airborne infections (infection control, viral containment and workplace safety). This consensus document represents a rapid and comprehensive summary on what is known on the topic.

Tuberculosis in the time of COVID-19: quality of life and digital innovation

The year 2020 will be remembered as the year coronavirus disease 2019 (COVID-19) swept the world and overwhelmed healthcare systems, demonstrating several vulnerabilities and a lack of capacity.

COVID-19 affects healthy individuals, patients and healthcare professionals, as well as tuberculosis services. The importance of digital technologies and the impact on quality of life are discussed. https://bit.ly/2U8nA0h