The incidence of tuberculosis among adolescents and young adults: a global estimate

Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

METHODS

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990-2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

FINDINGS

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5-14 years, 6·29% (5·05 to 7·70) in those aged 15-49 years, 5·72% (4·02 to 7·39) in those aged 50-69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5-14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15-49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50-69 years, and a 3·29% (-5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (-713 to 2180) fewer deaths.

INTERPRETATION

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.

FUNDING

Bill & Melinda Gates Foundation.

Patterns and Outcomes in Pediatric Abdominal Tuberculosis: A Single Centre Cohort Study

INTRODUCTION

Abdominal tuberculosis presents in a variety of ways. Different testing modalities must be applied in addition to having a high clinical suspicion to diagnose and initiate therapy. Medications have a good response; however, morbidity has been seen following surgical management of complicated presentations like intestinal obstruction and perforation. There is a paucity of studies in the pediatric age group which evaluate response to the different treatment regimen and identify factors associated with poorer outcomes in children with abdominal tuberculosis.

METHODS

Patient records of 75 children with abdominal tuberculosis at a single center were evaluated using a questionnaire, covering a 14-year period from 2007 to 2021. Demographic features, presenting signs and symptoms, investigations and treatment details were studied. In- person or telephonic follow-up was conducted to identify treatment outcomes.

RESULTS

Incidence of abdominal TB was 7%, of all TB children with a mean age of 10.1 years. Mesenteric lymph nodes were involved in 67% and small intestine in 33% cases. Surgery was required in 22 children. 85% children completed treatment. Small intestine involvement had higher probability of undergoing surgery. Of the 70 children with complete follow up, 64 were well and 6 children succumbed to the disease. Older age, small intestine involvement and surgery were independently associated with higher mortality.

CONCLUSION

Intestinal involvement is associated with greater need for surgical intervention and greater mortality. Adolescents have poorer outcomes. Further studies are required focusing on these individual subgroups to understand the patterns of presentation, causes for mortality and prevention.

LEVEL OF EVIDENCE

Level 5.

Global Burden of Tuberculosis in Adolescents and Young Adults: 1990-2019

OBJECTIVE

Tuberculosis (TB) is a major health threat in adolescents and young adults. However, its burden in this population remains unclear. This study aimed to assess TB burden and changing trends in individuals aged 10 to 24 years from 1990 to 2019.

METHODS

All data were obtained from the Global Burden of Disease Study 2019. We calculated the percentage of relative changes in incident cases, deaths, and disability-adjusted life years (DALYs). The temporal trends of the incidence, mortality, and DALYs were assessed using estimated annual percentage changes (EAPCs).

RESULTS

At global level, TB incidence (per 100 000 population) decreased from 144.12 in 1990 to 97.56 in 2019, with average 1.28% (95% confidence interval [CI]: 1.36%-1.19%) of decline per year. Similar decreasing trends occurred across sex, age, sociodemographic index regions, and in most Global Burden of Disease study regions and countries. TB incidence in female adolescents decreased faster than that in male. However, there was an increasing trend in the incidence of extensively drug-resistant TB (EAPC = 11.23, 95% CI: 8.22-14.33) and multidrug-resistant TB without extensive drug resistance (EAPC = 3.28, 95% CI: 1.73-4.86). South Africa had the highest increase in TB incidence (EAPC = 3.51, 95% CI: 3.11-3.92).

CONCLUSIONS

Global TB incidence, mortality, and DALYs in adolescents and young adults decreased from 1990 to 2019. However, the incidence of drug-resistant TB increased. TB remains a threat in adolescents and young adults worldwide, especially in low- and middle-income countries.

Vitamin D Status, VDR, and TLR Polymorphisms and Pulmonary Tuberculosis Epidemiology in Kazakhstan

BACKGROUND

Tuberculosis (TB) and vitamin D deficiency remain major public health problems in Kazakhstan. Due to the high incidence of pulmonary tuberculosis in the country and based on the importance of vitamin D in the modulation of the immune response and the association of its deficiency with many health conditions, the aim of our research was to study the vitamin D status, VDR and TLR gene polymorphisms, and pulmonary tuberculosis epidemiology in Kazakhstan.

METHODS

A case-control study included 411 individuals diagnosed with pulmonary TB and 686 controls with no family history of pulmonary tuberculosis. Concentrations of serum vitamin D (25-(OH)D) levels were measured by electrochemiluminescence immunoassay. The gene polymorphisms were determined by real-time polymerase chain reaction (PCR) allelic discrimination assay using TaqMan probes. The association between the risk of pulmonary TB and polymorphisms was evaluated using multimodal logistic regression and assessed with the ORs, corresponding to 95% Cis, and the significance level was determined as p < 0.05.

RESULTS

1097 individuals were recruited from 3 different regions of Kazakhstan. Biochemical data showed vitamin D deficiency (25-(OH)D < 20 ng/mL) was present in both groups, with the case group accounting for almost 95% and 43.7% in controls. Epidemiological data revealed that socioeconomic factors such as BMI < 25 kg/m2 (p < 0.001), employment (p < 0.001), diabetes (p < 0.001), and vitamin D deficiency (p < 0.001) were statistically different between case and control groups. Logistic regression analysis, adjusted by sex, age, BMI, residence, employment, smoking, alcohol consumption, and diabetes, showed that T/T polymorphism of the VDR gene (rs1544410, OR = 1.97, 95% CI: 1.04-3.72, p = 0.03) and A/A polymorphism of the TLR8 gene (rs3764880, OR = 2.44, 95% CI: 1.20-4.98, p = 0.01) were associated with a high risk of developing pulmonary tuberculosis.

CONCLUSIONS

Vitamin D deficiency remains prevalent in our study cohort and is associated with TB progression. Socioeconomic determinants such as unemployment, BMI under 25 kg/m2, and diabetes are the main risk factors for the development of pulmonary TB in our study. A/A polymorphism of TLR8 (rs3764880) and T/T polymorphism (BsmI, rs1544410) of VDR genes may act as biomarkers for pulmonary tuberculosis in the Kazakh population.

IL-27 alters inflammatory cytokine expression and limits protective immunity against Mycobacterium tuberculosis in a neonatal BCG vaccination model

Background

Efforts to control tuberculosis (TB), caused by the pathogen Mycobacterium tuberculosis (Mtb), have been hampered by the immense variability in protection from BCG vaccination. While BCG protects young children from some forms of TB disease, long-term protection against pulmonary disease is more limited, suggesting a poor memory response. New vaccines or vaccination strategies are required to have a realistic chance of eliminating TB disease. In TB endemic areas, routine immunization occurs during the neonatal period and as such, we hypothesized that inadequate protective immunity elicited by BCG vaccination could be the result of the unique early-life immune landscape. Interleukin (IL)-27 is a heterodimeric cytokine with immune suppressive activity that is elevated in the neonatal period.

Objective

We investigated the impact of IL-27 on regulation of immune responses during neonatal BCG vaccination and protection against Mtb.

Methods

Here, we used a novel model of neonatal vaccination and adult aerosol challenge that models the human timeline of vaccine delivery and disease transmission.

Results

Overall, we observed improved control of Mtb in mice unresponsive to IL-27 (IL-27Rα-/-) that was consistent with altered expression patterns of IFN-γ and IL-17 in the lungs. The balance of these cytokines with TNF-α expression may be key to effective bacterial clearance.

Conclusions

Our findings suggest the importance of evaluating new vaccines and approaches to combat TB in the neonatal population most likely to receive them as part of global vaccination campaigns. They further indicate that temporal strategies to antagonize IL-27 during early life vaccination may improve protection.

The Tuberculosis Sentinel Research Network (TB-SRN) of the International epidemiology Databases to Evaluate AIDS (IeDEA): protocol for a prospective cohort study in Africa, Southeast Asia and Latin America

INTRODUCTION

Tuberculosis (TB) is a leading infectious cause of death globally. It is the most common opportunistic infection in people living with HIV, and the most common cause of their morbidity and mortality. Following TB treatment, surviving individuals may be at risk for post-TB lung disease. The TB Sentinel Research Network (TB-SRN) provides a platform for coordinated observational TB research within the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium.

METHODS AND ANALYSIS

This prospective, observational cohort study will assess treatment and post-treatment outcomes of pulmonary TB (microbiologically confirmed or clinically diagnosed) among 2600 people aged ≥15 years, with and without HIV coinfection, consecutively enrolled at 16 sites in 11 countries, across 6 of IeDEA's global regions. Data regarding clinical and sociodemographic factors, mental health, health-related quality of life, pulmonary function, and laboratory and radiographic findings will be collected using standardised questionnaires and data collection tools, beginning from the initiation of TB treatment and through 12 months after the end of treatment. Data will be aggregated for proposed analyses.

ETHICS AND DISSEMINATION

Ethics approval was obtained at all implementing study sites, including the Vanderbilt University Medical Center Human Research Protections Programme. Participants will provide informed consent; for minors, this includes both adolescent assent and the consent of their parent or primary caregiver. Protections for vulnerable groups are included, in alignment with local standards and considerations at sites. Procedures for requesting use and analysis of TB-SRN data are publicly available. Findings from TB-SRN analyses will be shared with national TB programmes to inform TB programming and policy, and disseminated at regional and global conferences and other venues.

Hepatobiliary tuberculosis in the developing world

BACKGROUND

Hepatobiliary tuberculosis is a challenging disease that poses diagnostic difficulties due to its resemblance to other etiologies. Delayed diagnosis may lead to inadequate treatment, thus necessitating an urgent need for accurate diagnosis and appropriate management.

AIM

To systematically review case reports on hepatobiliary tuberculosis, focusing on symptomatology, diagnostic procedures, management, and outcomes to provide patient safety and ensure an uneventful recovery.

METHODS

A systematic search was conducted on PubMed from 1992 to 2022, using keywords such as hepatobiliary, liver, tuberculosis cholangitis, cholangiopathy, and mycobacterium. Only case reports or case series in English were included in the study, and research papers published as abstracts were excluded. The search yielded a total of 132 cases, which were further narrowed down to 17 case studies, consisting of 24 cases of hepatobiliary tuberculosis.

RESULTS

The 10 most common symptoms observed in these cases were fever, abdominal pain, weight loss, jaundice, anorexia, generalized weakness, pruritus, chills, fatigue, and chest pains. Objective findings in these cases included hepatomegaly, hepatic nodules, elevated liver enzymes, and elevated bilirubin. Computed tomography scan and ultrasound of the abdomen were the most useful diagnostic tools reported. Histologic demonstration of Mycobacterium tuberculosis confirmed the cases of hepatobiliary tuberculosis. Treatment regimens commonly used included Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol. Out of the 24 cases, 18 presented improvements while 4 had completely recovered.

CONCLUSION

Hepatobiliary tuberculosis is a disease that requires accurate diagnosis and appropriate management to avoid complications.

Childhood TB sequel: evaluating respiratory function after treatment for pulmonary tuberculosis in a prospective cohort of Gambian children - a study protocol

BACKGROUND

1.2 million children under 15 years are estimated to have developed tuberculosis (TB) in 2021. 85% of paediatric patients achieve successful treatment outcomes if treated for the first episode of TB. However, despite so-called successful treatment, TB leaves many survivors with permanently destroyed or damaged lungs. Data from prospective paediatric cohorts to establish the burden and evolution of post-TB lung disease (PTLD) are still absent. The Childhood TB Sequel study aims to describe respiratory consequences associated with pulmonary TB in Gambian children, describe the evolution of these sequelae, and determine associated epidemiological risk factors.

METHODS

We aim to recruit up to 80 subjects aged 19 years and below who have recently completed treatment for pulmonary TB. Recruitment started in April 2022 and is expected to continue until June 2024. Clinical assessment, chest X-ray, and comprehensive lung function assessment are carried out at treatment completion and again six and 12 months later.

DISCUSSION

The Childhood TB Sequel study will address existing research gaps to enhance our knowledge and understanding of the burden of PTLD in Gambian children. The study will also contribute to formulating a plan for post-TB evaluation and long-term follow-up strategies.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05325125, April 13, 2022.

Prevalence and risk factors of M tuberculosis infection in young people across 14 communities in Zambia and South Africa

BACKGROUND

From 2018-2021 the TB Reduction through Expanded Antiretroviral Treatment and TB Screening (TREATS) project took place in 21 Zambian and South African communities. The TREATS Incidence of TB Infection Cohort Study was conducted in adolescents and young people (AYP), aged 15-24 years in 14 communities. We describe the baseline prevalence and risk factors of Mycobacterium tuberculosis (M. tuberculosis) infection among this cohort and explore the quantitative QFT-Plus interferon gamma (IFN-γ) responses.

METHODS AND FINDINGS

A random sample of approximately 300 AYP per community were recruited and information on TB/HIV risk factors, TB symptoms and social mixing patterns collected. QuantiFERON TB Gold Plus assay (QFT-Plus) was used to detect M. tuberculosis infection, following manufacturer's instructions. Logistic regression was used to determine factors associated with infection. 5577 eligible AYP were invited to participate across both countries, with 4648 enrolled. QFT-Plus results were available for 4529: 2552(Zambia) and 1977(South Africa). Overall, 47.6% (2156/4529) AYP had positive QFT-Plus results, the prevalence of infection in South Africa being twice that in Zambia (64.7% (1280/1977) vs 34.3% (867/2552) p<0.001). Infection was associated with age, household contact with TB and alcohol in Zambia but showed no associations in South Africa. The antigen tube differential (TB2-TB1>0.6 IU/ml) of the assay at baseline showed no evidence of association with recent TB exposure.

CONCLUSION

The high prevalence of infection in AYP warrants urgent action to address TB control, especially in South Africa. Further research is required to delineate antigen tube responses of the QFT-Plus assay more precisely to fully realise the benefit of the additional TB2 tube in high TB/HIV burden settings.

Gonadotropin Levels and Underlying Diseases in Adolescent With Secondary Amenorrhea

Purpose

To provide characteristics and hormonal profiles of secondary amenorrhea cases in adolescent patients treated at Hasan Sadikin General Hospital in Bandung.

Patients and Methods

The study was retrospective in nature and involved the analysis of medical records from 2017 to 2022 for 44 adolescent patients aged 10-18 who had secondary amenorrhea.

Results

There were 44 adolescents included in this study after excluded 69 adults from 113 secondary amenorrhea cases. The majority of patients were 14-17 years old (38.63%), in senior high school (45.45%), had started menarche at 11 years old (45.45%), had normal nutritional status (65.91%), and had normal stature (65.91%). The underlying diseases found in most patients were systemic lupus erythematosus (SLE) and tuberculosis. Among the patients, 29 had FSH, LH, and estradiol levels measured. The results of hormonal assays showed a wide range of abnormal serum levels, with normal to low concentrations of FSH and low levels of LH and estradiol. The median (interquartile range) results for FSH, LH, and estradiol were 4.57 (0.64, 90.65), 1.635 (0.06, 55.76), and 24.3 (0.2, 154.71), respectively. Positive significant correlation between FSH and LH (p < 0.01) was found in children with secondary amenorrhea.

Conclusion

Hormonal assay for FSH, LH, and Estradiol showed a wide range of abnormal serum level. Normal to low concentration levels of FSH and low LH and estradiol. The majority of secondary amenorrhea patients are associated with autoimmune disease and infection.

Challenges of Diagnosing Mendelian Susceptibility to Mycobacterial Diseases in South Africa

Inborn errors of immunity (IEI) are genetic disorders with extensive clinical presentations. They can range from increased susceptibility to infections to significant immune dysregulation that results in immune impairment. While IEI cases are individually rare, they collectively represent a significant burden of disease, especially in developing countries such as South Africa, where infectious diseases like tuberculosis (TB) are endemic. This is particularly alarming considering that certain high penetrance mutations that cause IEI, such as Mendelian Susceptibility to Mycobacterial Disease (MSMD), put individuals at higher risk for developing TB and other mycobacterial diseases. MSMD patients in South Africa often present with different clinical phenotypes than those from the developed world, therefore complicating the identification of disease-associated variants in this setting with a high burden of infectious diseases. The lack of available data, limited resources, as well as variability in clinical phenotype are the reasons many MSMD cases remain undetected or misdiagnosed. This article highlights the challenges in diagnosing MSMD in South Africa and proposes the use of transcriptomic analysis as a means of potentially identifying dysregulated pathways in affected African populations.

SARS-CoV-2 infection and pulmonary tuberculosis in children and adolescents: a case-control study

BACKGROUND

The Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) pandemic has had an impact on the global tuberculosis (TB) epidemic but evidence on the possible interaction between SARS-CoV-2 and TB, especially in children and adolescents, remains limited. We aimed to evaluate the relationship between previous infection with SARS-CoV-2 and the risk of TB in children and adolescents.

METHODS

An unmatched case-control study was conducted using SARS-CoV-2 unvaccinated children and adolescents recruited into two observational TB studies (Teen TB and Umoya), between November 2020 and November 2021, in Cape Town, South Africa. Sixty-four individuals with pulmonary TB (aged < 20 years) and 99 individuals without pulmonary TB (aged < 20 years) were included. Demographics and clinical data were obtained. Serum samples collected at enrolment underwent quantitative SARS-CoV-2 anti-spike immunoglobulin G (IgG) testing using the Abbott SARS-CoV-2 IgG II Quant assay. Odds ratios (ORs) for TB were estimated using unconditional logistic regression.

RESULTS

There was no statistically significant difference in the odds of having pulmonary TB between those who were SARS-CoV-2 IgG seropositive and those who were seronegative (adjusted OR 0.51; 95% CI: 0.23-1.11; n = 163; p = 0.09). Of those with positive SARS-CoV-2 serology indicating prior infection, baseline IgG titres were higher in individuals with TB compared to those without TB (p = 0.04) and individuals with IgG titres in the highest tertile were more likely to have pulmonary TB compared to those with IgG levels in the lowest tertile (OR: 4.00; 95%CI: 1.13- 14.21; p = 0.03).

CONCLUSIONS

Our study did not find convincing evidence that SARS-CoV-2 seropositivity was associated with subsequent pulmonary TB disease; however, the association between magnitude of SARS-CoV-2 IgG response and pulmonary TB warrants further investigation. Future prospective studies, evaluating the effects of sex, age and puberty on host immune responses to M. tuberculosis and SARS-CoV-2, will also provide more clarity on the interplay between these two infections.

Adolescent tuberculosis in the ICU

TB is a major concern in the paediatric age group, especially in India. More than 3.33 lakh children between 0 and 14 years of age are affected by TB. Adolescent tuberculosis has been a neglected area and this age group accounts for about 800,000 cases of tuberculosis (TB) cases every year. Information regarding adolescent tuberculosis patient requiring ICU admission/care is very scanty (unlike adult tuberculosis), and the authors believe that the mode of ICU presentation and challenges in adolescents would almost be the same as in adults, although the outcome is generally expected to be better in the adolescent population in view of lesser comorbidities when compared to adults. ARDS, multiorgan dysfunction and meningitis are the most common reasons for admission to ICU. Critically ill patients with TB carry a high mortality and the increased mortality is likely due to multiorgan dysfunction, nosocomial infections and sepsis. Advanced disease with chronic undernourishment influences not just morbidity but mortality as well. Further, the heavy financial burden incurred for ICU care in TB patients with poor expected outcome is a major concern since TB occurs predominantly in low socio-economic populations.

Nutrition literacy mediates the relationship between self-efficacy and eating behavior in young tuberculosis patients: A cross-sectional study

Objective

To assess the associations between self-efficacy, nutrition literacy and eating behavior, and to examine if nutrition literacy mediates the relationship between self-efficacy and eating behavior in young tuberculosis patients.

Methods

This cross-sectional study used a convenience sampling strategy to select 230 young tuberculosis patients at the Second Hospital of Nanjing (Public Health Medical Center of Nanjing), China, from June 2022 to August 2022. The data were collected using a demographic data form, the Eating Behavior Scale, the Food and Nutrition Literacy Questionnaire and the Tuberculosis Self-Efficacy Scale. Descriptive statistics, Pearson bivariate correlation analysis, Pearson partial correlation analysis, hierarchical multiple regression, and mediation analysis were conducted in the study.

Results

The mean self-efficacy score for young tuberculosis patients was 92.56 (SD = 9.89, range = 21 ∼ 105). The average nutrition literacy score for young tuberculosis patients was 68.24（SD = 6.75, range = 0 ∼ 100). The bivariate correlation analysis and partial correlation analysis found that self-efficacy was positively correlated with nutrition literacy (P < 0.01). The regression analysis showed that self-efficacy (F = 5.186, β = 0.233, P < 0.001)and nutrition literacy (F = 7.749, β = 0.545, P < 0.001) significantly predicted eating behavior. The three dimensions of nutrition literacy including nutritional knowledge (mediation effect ratio = 13.1%, 95% CI =  - 0.089; -0.005), preparing food (mediation effect ratio = 17.4%, 95 %CI = 0.011; 0.077) and eating (mediation effect ratio = 54.7%, 95 %CI = 0.070; 0.192) mediated the relationship between self-efficacy and eating behavior in young tuberculosis patients.

Conclusion

Nutrition literacy mediated the relationship between self-efficacy and eating behavior. To promote healthy eating behavior among young tuberculosis patients, interventions aimed at improving self-efficacy and nutrition literacy should be conducted.

Epidemiological characteristics of pulmonary tuberculosis among students in Guizhou, China: a retrospective study from 2010 to 2020

OBJECTIVE

We described epidemiological characteristics of pulmonary tuberculosis (PTB) among students and evaluated susceptible populations and areas in Guizhou province and also to provide scientific suggestions for prevention and control.

SETTING

Guizhou, China.

DESIGN

This is a retrospective epidemiological study on PTB in students.

METHODS

Data are from the China Information System for Disease Control and Prevention. We collected all PTB cases among the student population from 2010 to 2020 in Guizhou. Incidence, composition ratio and hotspot analysis were used to describe epidemiological and some clinical characteristics.

RESULTS

A total of 37 147 new student PTB cases were registered among the population aged 5-30 years during 2010-2020. The proportions of men and women were 53.71% and 46.29%, respectively. Cases aged 15-19 years dominated (63.91%), and the proportion of ethnic groups was increasing during the period. Generally, the raw annual incidence of PTB among the population was increasing from 32.585 per 100 000 persons in 2010 to 48.872 per 100 000 persons in 2020 (c 2 trend=1283.230, p<0.001). March and April were the peak months of a year, and cases were clearly grouped in Bijie city. New cases were mainly identified via physical examination, and cases from active screening were still low (0.76%). Additionally, secondary PTB accounted for 93.68%, positive rate of pathogen was only 23.06%, and the recovery rate was 94.60%.

CONCLUSIONS

The population aged 15-19 years is the vulnerable population, and Bijie city is the susceptible area. BCG vaccination and promotion for active screening should be the priority of futural PTB prevention and control. Tuberculosis laboratory capacity should be improved.

Global estimates and determinants of antituberculosis drug pharmacokinetics in children and adolescents: a systematic review and individual patient data meta-analysis

BACKGROUND

Suboptimal exposure to antituberculosis (anti-TB) drugs has been associated with unfavourable treatment outcomes. We aimed to investigate estimates and determinants of first-line anti-TB drug pharmacokinetics in children and adolescents at a global level.

METHODS

We systematically searched MEDLINE, Embase and Web of Science (1990-2021) for pharmacokinetic studies of first-line anti-TB drugs in children and adolescents. Individual patient data were obtained from authors of eligible studies. Summary estimates of total/extrapolated area under the plasma concentration-time curve from 0 to 24 h post-dose (AUC0-24) and peak plasma concentration (C max) were assessed with random-effects models, normalised with current World Health Organization-recommended paediatric doses. Determinants of AUC0-24 and C max were assessed with linear mixed-effects models.

RESULTS

Of 55 eligible studies, individual patient data were available for 39 (71%), including 1628 participants from 12 countries. Geometric means of steady-state AUC0-24 were summarised for isoniazid (18.7 (95% CI 15.5-22.6) h·mg·L-1), rifampicin (34.4 (95% CI 29.4-40.3) h·mg·L-1), pyrazinamide (375.0 (95% CI 339.9-413.7) h·mg·L-1) and ethambutol (8.0 (95% CI 6.4-10.0) h·mg·L-1). Our multivariate models indicated that younger age (especially <2 years) and HIV-positive status were associated with lower AUC0-24 for all first-line anti-TB drugs, while severe malnutrition was associated with lower AUC0-24 for isoniazid and pyrazinamide. N-acetyltransferase 2 rapid acetylators had lower isoniazid AUC0-24 and slow acetylators had higher isoniazid AUC0-24 than intermediate acetylators. Determinants of C max were generally similar to those for AUC0-24.

CONCLUSIONS

This study provides the most comprehensive estimates of plasma exposures to first-line anti-TB drugs in children and adolescents. Key determinants of drug exposures were identified. These may be relevant for population-specific dose adjustment or individualised therapeutic drug monitoring.

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.

Understanding the biology, morbidity and social contexts of adolescent tuberculosis: a prospective observational cohort study protocol (Teen TB)

INTRODUCTION

A considerable burden of the tuberculosis (TB) epidemic is found in adolescents. The reasons for increased susceptibility to TB infection and higher incidence of TB disease in adolescence, compared with the 5-10 years old age group, are incompletely understood. Despite the pressing clinical and public health need to better understand and address adolescent TB, research in this field remains limited.

METHODS AND ANALYSIS

Teen TB is an ongoing prospective observational cohort study that aims to better understand the biology, morbidity and social context of adolescent TB. The study plans to recruit 50 adolescents (10-19 years old) with newly diagnosed microbiologically confirmed pulmonary TB disease and 50 TB-exposed controls without evidence of TB disease in Cape Town, South Africa, which is highly endemic for TB. At baseline, cases and controls will undergo a detailed clinical evaluation, chest imaging, respiratory function assessments and blood collection for viral coinfections, inflammatory cytokines and pubertal hormone testing. At 2 weeks, 2 months and 12 months, TB disease cases will undergo further chest imaging and additional lung function testing to explore the patterns of respiratory abnormalities. At week 2, cases will complete a multicomponent quantitative questionnaire about psychological and social impacts on their experiences and longitudinal, in-depth qualitative data will be collected from a nested subsample of 20 cases and their families.

ETHICS AND DISSEMINATION

The study protocol has received ethical approval from the Stellenbosch University Health Research Ethics Committee (N19/10/148). The study findings will be disseminated through peer-reviewed publications, academic conferences and formal presentations to health professionals. Results will also be made available to participants and caregivers.

Regional distribution of Mycobacterium tuberculosis infection and resistance to rifampicin and isoniazid as determined by high-resolution melt analysis

Background

Identifying the transmission mode and resistance mechanism of Mycobacterium tuberculosis (MTB) is key to prevent disease transmission. However, there is a lack of regional data. Therefore, the aim of this study was to identify risk factors associated with the transmission of MTB and regional patterns of resistance to isoniazid (INH) and rifampicin (RFP), as well as the prevalence of multidrug-resistant tuberculosis (MDR-TB).

Methods

High-resolution melt (HRM) analysis was conducted using sputum, alveolar lavage fluid, and pleural fluid samples collected from 17,515 patients with suspected or confirmed MTB infection in the downtown area and nine counties of Luoyang City from 2019 to 2021.

Results

Of the 17,515 patients, 82.6% resided in rural areas, and 96.0% appeared for an initial screening. The HRM positivity rate was 16.8%, with a higher rate in males than females (18.0% vs. 14.1%, p < 0.001). As expected, a positive sputum smear was correlated with a positive result for HRM analysis. By age, the highest rates of MTB infection occurred in males (22.9%) aged 26–30 years and females (28.1%) aged 21–25. The rates of resistance to RFP and INH and the incidence of MDR were higher in males than females (20.5% vs. 16.1%, p < 0.001, 15.9% vs. 12.0%, p < 0.001 and 12.9% vs. 10.2%, p < 0.001, respectively). The HRM positivity rate was much higher in previously treated patients than those newly diagnosed for MTB infection. Notably, males at the initial screening had significantly higher rates of HRM positive, INH resistance, RFP resistance, and MDR-TB than females (all, p < 0.05), but not those previously treated for MTB infection. The HRM positivity and drug resistance rates were much higher in the urban vs. rural population. By multivariate analyses, previous treatment, age < 51 years, residing in an urban area, and male sex were significantly and positively associated with drug resistance after adjusting for smear results and year of testing.

Conclusion

Males were at higher risks for MTB infection and drug resistance, while a younger age was associated with MTB infection, resistance to INH and RFP, and MDR-TB. Further comprehensive monitoring of resistance patterns is needed to control the spread of MTB infection and manage drug resistance locally.

Resistance patterns among drug-resistant tuberculosis patients and trends-over-time analysis of national surveillance data in Gabon, Central Africa

Objective

Routinely generated surveillance data are important for monitoring the effectiveness of MDR-TB control strategies. Incidence of rifampicin-resistant tuberculosis (RR-TB) is a key indicator for monitoring MDR-TB.

Methods

In a longitudinal nationwide retrospective study, 8 years (2014–2021) of sputum samples from presumptively drug-resistant tuberculosis patients from all regions of Gabon were referred to the national tuberculosis reference laboratory. Samples were analysed using GeneXpert MTB/RIF and Genotype MTBDRsl version 2/Line Probe Assay.

Results

Of 3057 sputum samples from presumptive tuberculosis patients, both from local hospital and from referral patients, 334 were RR-TB. The median patient age was 33 years (interquartile range 26–43); one third was newly diagnosed drug-resistant tuberculosis patients; one-third was HIV-positive. The proportion of men with RR-TB was significantly higher than that of women (55% vs 45%; p < 0.0001). Patients aged 25–35 years were most affected (32%; 108/334). The cumulative incidence of RR-TB was 17 (95% CI 15–19)/100,000 population over 8 years. The highest incidences were observed in 2020 and 2021. A total of 281 samples were analysed for second-line drug resistance. The proportions of study participants with MDR-TB, pre-XDR-TB and XDR-TB were 90.7% (255/281), 9% (25/281) and 0.3% (1/281), respectively. The most-common mutations in fluoroquinolones resistance isolates was gyrA double mutation gyrA MUT3B and MUT3C (23%; 4/17). Most (64%; 6/8) second-line injectable drugs resistance isolates were characterised by missing both rrs WT2 and MUT2 banding.

Conclusion

The increasing incidence of MDR-TB infection in Gabon is alarming. It is highest in the 25–35 years age category. The incidence of MDR-TB infection in treatment-naïve patients calls for case finding and contact tracing strategy improvement.

Carborane clusters increase the potency of bis-substituted cyclam derivatives against Mycobacterium tuberculosis

Bis-substituted cyclam derivatives have recently emerged as a promising new class of antibacterial agents, displaying excellent activity against drug-resistant Mycobacterium tuberculosis (Mtb) and in vivo efficacy in a zebrafish assay. Herein we report the synthesis and biological activity of new carborane derivatives within this class of antitubercular compounds. The resulting carborane-cyclam conjugates incorporating either hydrophobic closo-1,2-carborane or anionic, hydrophilic nido-7,8-carborane clusters display promising activity in an antibacterial assay employing the virulent Mtb strain H37Rv. The most active of these carborane derivatives exhibit MIC50 values of <1 μM, making them the most active compounds in this unique class of antibacterial cyclams reported to date.

Profile and treatment outcomes among young patients with tuberculosis aged 15-24 years in Faridabad district of Haryana, India

OBJECTIVE

This study examined profile and treatment outcomes of young patients with tuberculosis (TB) registered at a district TB centre under the National TB Elimination Programme in Faridabad district of Haryana state in India.

METHODS

In this secondary data analysis, we studied the records of young TB patients aged 15-24 years registered under a TB programme during October 2013-December 2017 in Faridabad district of Haryana state.

RESULTS

We analysed records of 5257 young patients with TB. Majority (58.7%) were patients with pulmonary TB and most of them (83.6%) were registered as new patients. Majority of the young patients with TB (93.2%) had a successful treatment outcome, and patients having sputum result 2+ or less and patients who did not have a previous history of TB were found to be significantly associated with a successful treatment outcome on multivariable analysis.

CONCLUSION

There was a high treatment success rate noted in young patients with TB. More focus is needed to patients having a history of TB and sputum result >2+. Targeted interventions can be designed for these groups in future programmatic strategies to reduce disease burden in this section of young population.

Whole-Genome Sequencing and Epidemiological Investigation of Tuberculosis Outbreaks in High Schools in Hunan, China

Background

Tuberculosis (TB) seriously threatens individual and public health. Recently, TB outbreaks in schools have been reported more frequently in China and have attracted widespread attention. We reported three TB outbreaks in high schools in Hunan Province, China.

Methods

When a tuberculosis patient was reported in a school, we carried out field epidemiological investigations, including tuberculin skin testing (TST), chest X-ray (CXR) and laboratory test for all close contacts, and whole-genome sequencing (WGS) analyses to understand the transmission patterns, the causes and the risk factors for the outbreaks, thereby providing a foundation for the control of TB epidemics in schools.

Results

A total of 49 students with TB patients were identified in the three schools where TB outbreaks occurred, including nine patients in School A, 14 patients in School B, and 26 patients in School C. In Schools A, B and C, the putative attack rates in the classes of the index case were 13.8% (8/58), 7.6% (5/66), and 40.4% (21/52), while the putative attack rates of expanding screening in the school were 0.3% (1/361), 0.2% (9/3955), and 0.2% (5/2080), respectively. Thirteen patients had patient delay, with a median delay interval of 69 days (IQR 30.5–113 days). Twelve patients had a healthcare diagnostic delay with a median delay interval of 32 days (IQR 24–82 days). Phylogenetic analysis of culture-positive patients revealed that most of them shared a small genetic distance (≤12 SNPs), with three separate genetic clusters (including one MDR-TB genomic cluster), indicating the recent transmission of Mycobacterium tuberculosis strains.

Conclusion

This combination of field investigation and WGS analysis revealed the transmission of three TB outbreaks in schools. Reinforced implementation is needed to improve timely case finding and reduce diagnosis delay in routine TB control in the school population.

Heterogeneous impact of Covid-19 response on tuberculosis burden by age group

Apart from the incidence and mortality caused by it, Coronavirus disease (COVID-19) has had a significant impact on other diseases. This study aimed to estimate the influences of COVID-19 pandemic on the incidence of tuberculosis (TB) and the number of TB-associated deaths in Republic of Korea. A dynamic compartment model incorporating age-structure was developed for studying TB transmission and progression using the Korean population data. After calibration with notification of incidence data from South Korea, the TB burden over 6 years (2020-2025) was predicted under the nine different scenarios. Under the scenario of strong social distancing and low-level health service disruption, new TB cases were reduced by 761 after 1 year in comparison to the baseline. However, in the elderly population, social distancing had little impact on TB incidence. On the other hand, the number of TB-related deaths mainly depends on the level of health service disruption for TB care. It was predicted that with a high degree of health service disruption, the number of TB-related deaths would increase up to 155 in 1 year and 80 percent of the TB-related deaths would be in the elderly population. The decrease of tuberculosis incidence is significantly affected by social distancing, which is owing to reduction of contacts. The impact of health service disruption is dominant on TB-related deaths, which occurs mainly in the elderly. It suggests that it is important to monitor TB-related deaths by COVID-19 because the TB burden of the elderly is high in the Republic of Korea.

Drug resistant Mycobacterium tuberculosis in Oman: resistance-conferring mutations and lineage diversity

Background

The Sultanate of Oman is country a low TB-incidence, with less than seven cases per 10⁵ population detected in 2020. Recent years have witnessed a persistence in TB cases, with sustained incidence rate among expatriates and limited reduction among Omanis. This pattern suggests transmission from the migrant population. The present study examined the genetic profile and drug resistance-conferring mutations in Mycobacterium tuberculosis collected from Omanis and expatriates to recognise possible causes of disease transmission.

Methods

We examined M. tuberculosis cultured positive samples, collected from Omanis (n = 1,344) and expatriates (n = 1,203) between 2009 and 2018. These isolates had a known in vitro susceptibility profile to first line anti-TB, Streptomycin (SM), Isoniazid (INH), Rifampicin (RIF), Ethambutol (EMB) and Pyrazinamide (PZA). The diversity of the isolates was assessed by spacer oligo-typing (spoligotyping). Drug resistance-conferring mutations resulted from full-length sequence of nine genes (katG, inhA, ahpc, rpoB, rpsL, rrs, embB, embC, pncA) and their phenotypic relationship were analysed.

Results

In total, 341/2192 (13.4%), M. tuberculosis strains showed resistance to any drug, comprising mono-resistance (MR) (242, 71%), poly-resistance (PR) (40, 11.7%) and multi-drug resistance (MDR) (59, 17.3%). The overall rate of resistance among Omanis and expatriates was similar; however, MDR and PZA^R were significantly higher among Omanis, while INH^R was greater among expatriates. Mutations rpsL K43R and rpoB S450L were linked to Streptomycin (SM^R) and Rifampicin resistance (RIF^R) respectively. Whereas, katG S315T and inhA -C15T/G-17T were associated with Isoniazid resistance (INH^R). The resistance patterns (mono-resistant, poly-resistant and MDR) and drug resistance-conferring mutations were found in different spoligo-lineages. rpsL K43R, katG S315T and rpoB S450L mutations were significantly higher in Beijing strains.

Conclusions

Diverse drug resistant M. tuberculosis strains exist in Oman, with drug resistance-conferring mutations widespread in multiple spoligo-lineages, indicative of a large resistance reservoir. Beijing's M. tuberculosis lineage was associated with MDR, and multiple drug resistance-conferring mutations, favouring the hypothesis of migration as a possible source of resistant lineages in Oman.

Tuberculosis in Adolescents in Bulgaria for a Three-Year Period: 2018-2020

Background: Each year, approximately two million adolescents and young adults in the world become infected with tuberculosis (TB). The problem is that the classification of the disease includes children in the age group 0−14 years and young adults aged 15 and over. The present study aims to analyze and compare the epidemiology and clinical presentation of TB in Bulgaria in the different age subgroups of childhood. Methods: A retrospective study was undertaken of the newly diagnosed children (n = 80) with TB treated onsite from January 2018 to December 2020 at the Multiprofile Hospital for Active Treatment of Pulmonary Diseases (“St. Sofia”). They were distributed into three age groups: aged 8−11 (prepuberty), aged 12−14 (younger adolescents), and aged above 15 (older adolescents). Results: A clear finding of the research indicated that adolescent children develop TB both as primary and secondary infections. In a large number of cases with the children under our care, we found enlarged intrathoracic lymph nodes as well as infiltrative changes in the lungs, i.e., we observed transitional forms. There were statistically significant differences between the age group >15 years old and each of the other two younger groups for diagnosis, the severity of intoxication, and BK spreading status. Conclusion: The course of tuberculosis in adolescence has its own specifics and differences between the three age groups in the current study.

Addressing the Data Gaps on Child and Adolescent Tuberculosis

The burden of tuberculosis (TB) among children and young adolescents (<15 years old) is estimated at 1.1 million; however, only 400,000 are treated for TB, indicating a large gap between the number who are cared for and the number estimated to have TB. Accurate data on the burden of pediatric TB is essential to guide action. Despite several improvements in estimating the burden of pediatric TB in the last decade, as well as enhanced data collection efforts, several data gaps remain, both at the global level, but also at the national level where surveillance systems and collaborative research are critical. In this article, we describe recent advances in data collection and burden estimates for TB among children and adolescents, and the remaining gaps. While data collection continues to improve, burden estimates must evolve in parallel, both in terms of their frequency and the methods used. Currently, at the global level, there is a focus on age-disaggregation of TB notifications, the collection of data on TB-HIV, multi-drug resistant (MDR)-TB and treatment outcomes, as well as estimates of the disease burden. Additional data from national surveillance systems or research projects on TB meningitis, as well as other forms of extra-pulmonary TB, would be useful. We must capitalize on the current momentum in child and adolescent TB to close the remaining data gaps for these age groups to better understand the epidemic and further reduce morbidity and mortality due to TB.

Priority Activities in Child and Adolescent Tuberculosis to Close the Policy-Practice Gap in Low- and Middle-Income Countries

Over the past 15 years, and despite many difficulties, significant progress has been made to advance child and adolescent tuberculosis (TB) care. Despite increasing availability of safe and effective treatment and prevention options, TB remains a global health priority as a major cause of child and adolescent morbidity and mortality—over one and a half million children and adolescents develop TB each year. A history of the global public health perspective on child and adolescent TB is followed by 12 narratives detailing challenges and progress in 19 TB endemic low and middle-income countries. Overarching challenges include: under-detection and under-reporting of child and adolescent TB; poor implementation and reporting of contact investigation and TB preventive treatment services; the need for health systems strengthening to deliver effective, decentralized services; and lack of integration between TB programs and child health services. The COVID-19 pandemic has had a significant negative impact on case detection and treatment outcomes. Child and adolescent TB working groups can address country-specific challenges to close the policy–practice gaps by developing and supporting decentral ized models of care, strengthening clinical and laboratory diagnosis, including of multidrug-resistant TB, providing recommended options for treatment of disease and infection, and forging strong collaborations across relevant health sectors.

Drug resistance characteristics of Mycobacterium tuberculosis isolates obtained between 2018 and 2020 in Sichuan, China

We investigated the drug resistance of Mycobacterium tuberculosis isolates from patients with tuberculosis (TB) and HIV, and those diagnosed with only TB in Sichuan, China. TB isolates were obtained from January 2018 to December 2020 and subjected to drug susceptibility testing (DST) to 11 anti-TB drugs and to GeneXpert MTB/RIF testing. The overall proportion of drug-resistant TB (DR-TB) isolates was 32.1% (n = 10 946). HIV testing was not universally available for outpatient TB cases, only 29.5% (3227/10 946) cases had HIV testing results. The observed proportion of multidrug-resistant TB (MDR-TB) isolates was almost double than that of the national level, with approximately 1.5% and 0.1% of the isolates being extensively drug resistant and universally drug resistant, respectively. The proportions of resistant isolates were generally higher in 2018 and 2019 than in 2020. Furthermore, the sensitivities of GeneXpert during 2018–2020 demonstrated a downward trend (80.9, 95% confidence intervals (CI) 76.8–85.0; 80.2, 95% CI 76.4–84.1 and 75.4, 95% CI 70.7–80.2, respectively). Approximately 69.0% (7557/10 946) of the TB cases with DST results were subjected to GeneXpert detection. Overall, the DR-TB status and the use of GeneXpert in Sichuan have improved, but DR-TB challenges remain. HIV testing for all TB cases is recommended.

Estimating Tuberculosis Transmission Risks in a Primary Care Clinic in South Africa: Modeling of Environmental and Clinical Data

BACKGROUND

Congregate settings, such as healthcare clinics, may play an essential role in Mycobacterium tuberculosis (Mtb) transmission. Using patient and environmental data, we studied transmission at a primary care clinic in South Africa.

METHODS

We collected patient movements, cough frequency, and clinical data, and measured indoor carbon dioxide (CO2) levels, relative humidity, and Mtb genomes in the air. We used negative binomial regression model to investigate associations.

RESULTS

We analyzed 978 unique patients who contributed 14 795 data points. The median patient age was 33 (interquartile range [IQR], 26-41) years, and 757 (77.4%) were female. Overall, median CO2 levels were 564 (IQR 495-646) parts per million and were highest in the morning. Median number of coughs per day was 466 (IQR, 368-503), and overall median Mtb DNA copies/μL/day was 4.2 (IQR, 1.2-9.5). We found an increased presence of Mtb DNA in the air of 32% (95% credible interval, 7%-63%) per 100 additional young adults (aged 15-29 years) and 1% (0-2%) more Mtb DNA per 10% increase of relative humidity. Estimated cumulative transmission risks for patients attending the clinic monthly for at least 1 hour range between 9% and 29%.

CONCLUSIONS

We identified young adults and relative humidity as potentially important factors for transmission risks in healthcare clinics. Our approach should be used to detect transmission and evaluate infection control interventions.

Epidemiological profile of tuberculosis in Iraq during 2011-2018

BACKGROUND

Tuberculosis (TB) is one of the most progressive infectious diseases caused by Mycobacterium tuberculosis. The pathogen is the first cause of mortality linked to a single pathogen worldwide, especially in poor and developing countries.

METHODS

A cross-sectional descriptive study was conducted to estimate incidence rate (IR) of TB in Iraq during a period of eight years (2011-2018). TB data were extracted from the computer system of the National Specialized Center for Chest and Respiratory Diseases in Baghdad.

RESULTS

During 2011-2018, 65,102 confirmed TB cases were reported in Iraq; 39,640 pulmonary TB (PTB) and 25,462 extra-pulmonary TB (EPTB). The average IR (case/100,000 inhabitants) of TB was 23.4 (14.2 for PTB and 9.1 for EPTB). Annual rate of TB cases showed a gradual decline over years (from 29.2 in 2011 to 18.6 in 2018). The decline in IR was more pronounced in PTB than EPTB. However PTB/EPTB ratio showed a gradual decreasing over years (from 2.04 in 2011 to 1.56 in 2018). GIS-mapping revealed that PTB and EPTB IRs show variations between the 18 governorates of Iraq. Most of the recorded PTB cases were new (average: 90.5%), followed by relapse cases (average: 7.9%). Among the reported PTB cases, percentage of males was greater than females (average: 52.1 vs. 47.9%), whereas an opposite trend was observed in EPTB (42.9 vs. 57.1%). The frequency distribution of PTB and EPTB varied between age groups, and lowest average frequency was recorded in age groups 1-4 and 5-14 year.

CONCLUSIONS

TB is still a public health threat, and although a declining trend in incidence was depicted over the years 2011-2018, the disease is still out of control in Iraq, and more investments of resource are necessitated to eliminate the disease. In this context, EPTB and PTB relapse need a recognized attention.

Tuberculosis infection among youths in overcrowded university hostels in Kenya: a cross-sectional study

Background

Tuberculosis (TB) remains a top global health problem and its transmission rate among contacts is higher when they are cohabiting with a person who is sputum smear-positive. Our study aimed to describe the prevalence of TB among student contacts in the university and determine factors associated with TB transmission.

Methods

We performed a cross-sectional study with an active contact case finding approach among students receiving treatment at Kilifi County Hospital from January 2016 to December 2017. The study was conducted in a public university in Kilifi County, a rural area within the resource-limited context of Kenya. The study population included students attending the university and identified as sharing accommodation or off-campus hostels, or a close social contact to an index case. The index case was defined as a fellow university student diagnosed with TB at the Kilifi County Hospital during the study period. Contacts were traced and tested for TB using GeneXpert.

Results

Among the 57 eligible index students identified, 51 (89%) agreed to participate. A total of 156 student contacts were recruited, screened and provided a sputum sample. The prevalence of TB (GeneXpert test positive/clinical diagnosis) among all contacts was 8.3% (95% CI 4.5–14%). Among the 8.3% testing positive 3.2% (95% CI 1.0–7.3%) were positive for GeneXpert only. Sharing a bed with an index case was the only factor significantly associated with TB infection. No other demographic or clinical factor was associated with TB infection.

Conclusion

Our study identified a high level of TB transmission among university students who had contact with the index cases. The study justifies further research to explore the genetic sequence and magnitude of TB transmission among students in overcrowded university in resource limited contexts.

The impact of a change in infant BCG vaccination policy on adolescent TB incidence rates: A South African population-level cohort study

OBJECTIVE

South Africa's infant Bacille Calmette Guerin (BCG) vaccine policy changed from percutaneous (PC) BCG Japan to intradermal (ID) BCG Denmark in 2000. This study investigated whether this change in infant BCG vaccination had any durable impact on TB incidence rates (IR) into adolescence.

METHODS

The Cape Town electronic TB register provided data (from 2008 to 2018) on HIV-negative TB patients born in 1991-1999 (BCG Japan cohort) and 2001-2008 (BCG Denmark cohort). Statistics South Africa provided population estimates. Annual TB IR per 100,000 population were calculated stratified by age, gender and birth year. Interrupted time series analysis with a segmented Poisson regression and birth cohort analyses were used to compare incidence between the BCG cohorts and trends over time.

FINDINGS

TB IR increased throughout adolescence, with 17-year-olds having 7.34 [95% confidence interval (CI), 6.48-8.32] times higher TB IR than 10-year-olds. Females had 1.22 [95% CI 1.17-1.27] higher IR than males. Overall, adolescents who received ID BCG Denmark had a lower TB IR compared to PC BCG Japan (rate ratio 0.86, [95% CI 0.80-0.94]). No interaction between BCG and age, nor BCG and gender were identified. Birth cohort analyses showed the increase in TB IR started around one year earlier in females than in males.

CONCLUSION

The change in infant BCG policy was associated with a modest decrease in TB incidence in 10- to 17-year-old HIV-negative adolescents. However, TB incidence rapidly increased with age in both adolescent cohorts and remained high despite BCG vaccination at birth.

Provision of Decentralized TB Care Services: A Detect-Treat-Prevent Strategy for Children and Adolescents Affected by TB

In this review, we discuss considerations and successful models for providing decentralized diagnosis, treatment, and prevention services for children and adolescents. Key approaches to building decentralized capacity for childhood TB diagnosis in primary care facilities include provider training and increased access to child-focused diagnostic tools and techniques. Treatment of TB disease should be managed close to where patients live; pediatric formulations of both first- and second-line drugs should be widely available; and any hospitalization should be for as brief a period as medically indicated. TB preventive treatment for child and adolescent contacts must be greatly expanded, which will require home visits to identify contacts, building capacity to rule out TB, and adoption of shorter preventive regimens. Decentralization of TB services should involve the private sector, with collaborations outside the TB program in order to reach children and adolescents where they first enter the health care system. The impact of decentralization will be maximized if programs are family-centered and designed around responding to the needs of children and adolescents affected by TB, as well as their families.

Paediatric tuberculosis diagnosis using Mycobacterium tuberculosis real-time polymerase chain reaction assay: a systematic review and meta-analysis

BACKGROUND

Rapid and accurate diagnosis of paediatric tuberculosis (TB) is key to manage the disease and to control and prevent its transmission. Collection of quality sputum samples without invasion methods from paediatrics (age < 16 years) with presumptive pulmonary tuberculosis (PTB) remains a challenge. Thus, the aim of this meta-analysis was to assess the overall accuracy of a real-time polymerase chain reaction (RT-PCR)-based assay, for routine diagnosis of MTB in different samples from paediatrics with active pulmonary and extra-pulmonary tuberculosis using mycobacterial culture as the gold standard in clinical microbiology laboratories.

METHODS

We conducted a systematic review and meta-analysis to examine the diagnostic test accuracy of RT-PCR based assay for the detection of MTB in paediatric clinical samples. A systematic literature search was performed for publications in any language. MEDLINE via PubMed, EMBASE, and Web of Science were among 9 bibliographic databases searched from August 2019 until November 2020. Bivariate random-effects model of meta-analysis were performed to generate pooled summary estimates (95% CIs) for overall accuracy of RT-PCR based assay compared to mycobacterial culture as the reference standard.

RESULTS

Of the 1592 candidate studies, twenty-one eligible studies met our inclusion criteria. In total, the review and meta-analysis included 5536 (3209 PTB and 2327 EPTB). Summary estimates for pulmonary TB (11 studies) were as follows: sensitivity 56 (95% CI 51-62), specificity 97 (95% CI 96-98) and summary estimates for extra-pulmonary TB (10 studies) were as follows: sensitivity 87 (95% CI 82-91)) specificity 100 (95% CI 99-100). There was significant heterogeneity in sensitivity and specificity among the enrolled studies (p < 0.001).

CONCLUSIONS

Our results suggested that the RT-PCR based assay could be a useful test for the diagnosis of paediatrics TB with high sensitivity and specificity in low-income/high-burden and upper medium income/low-burden settings. From the study, RT-PCR assay demonstrated a high degree of sensitivity for extra-pulmonary TB and good sensitivity for pulmonary TB which is an important factor in achieving effective global control and for patient management in terms of initiating early and appropriate anti-tubercular therapy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018104052.

Adolescents in a tuberculosis hospital: Qualitative study of how relationships with doctors, caregivers, and peers mediate their mental wellbeing

Lengthy hospitalization can impact adolescents’ mental wellbeing in a number of negative ways. Scholarship has indicated that a young patient’s relationships play an important role in reducing the amount of stress felt and in improving emotional state. In this article we turn to the experiences of adolescents with tuberculosis [TB] in Russia to explore how exactly hospitalization together with the TB diagnosis itself impact their mental wellbeing and how relationships with others mediate these impacts. We conducted a qualitative, interview-based study in Tomsk pediatric TB clinic. Interviews were conducted with three groups relevant for reaching the aim of this research: adolescent patients, their adult caregivers, and their treating physicians [17 informants in total]. Interview data were complemented with prolonged observations in the same clinic. The results of our study highlight that threats to mental wellbeing of adolescents with TB are multiple. Adolescents who are about to enter the in-patient treatment feel apprehensive and anxious about their future. They tend to have a hard time accepting their diagnosis, which they often feel is something shameful, and, consequently, may develop a negative attitude towards themselves. Most importantly, many undergo painful loss of personal relationships and expect or actually experience rejection by peers because of having tuberculosis. However, relationships with physicians, caregivers, and other patients in the clinic mediate negative impacts of TB diagnosis and hospitalization on adolescents’ mental wellbeing and can open ways for providing support. Supportive practices include physicians leaving it up to adolescents to decide what they want to discuss and when, caregivers remaining available for contact and keeping regular communication, and other adolescents with TB proactively seeking contact with the newcomers and behaving in a non-judgmental way. These results can inform design of adolescent-friendly TB services.

A scoping review on climate change and tuberculosis

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

Social and health factors associated with unfavourable treatment outcome in adolescents and young adults with tuberculosis in Brazil: a national retrospective cohort study

BACKGROUND

Tuberculosis elimination strategies in Brazil might neglect adolescents and young adults aged 10-24 years, hampering tuberculosis control. However, little is known about factors associated with tuberculosis treatment outcomes in this underserved group. In this study, we aimed to investigate social and health factors associated with unfavourable treatment outcomes in young people with tuberculosis in Brazil.

METHODS

A national retrospective cohort study was done using data from Sistema de Informação de Agravos de Notificação (SINAN), the national tuberculosis registry in Brazil. People aged 10-24 years (young people) with tuberculosis registered in SINAN between Jan 1, 2015, and Dec 31, 2018, were included. Unfavourable outcomes were defined as loss to follow-up, treatment failure, and death. Favourable outcome was defined as treatment success. Multiple logistic regression models estimated the association between social and health factors and tuberculosis treatment outcomes.

FINDINGS

67 360 young people with tuberculosis were notified to SINAN, and we included 41 870 young people in our study. 7024 (17%) of the 41 870 included individuals had unfavourable treatment outcomes. Young people who received government cash transfers were less likely to have an unfavourable outcome (adjusted odds ratio 0·83, 95% CI 0·70-0·99). Homelessness (3·03, 2·07-4·42), HIV (2·89, 2·45-3·40), and illicit drug use (2·22, 1·93-2·55) were the main factors associated with unfavourable treatment outcome.

INTERPRETATION

In this national cohort of young people with tuberculosis in Brazil, tuberculosis treatment success rates were lower than WHO End TB Strategy targets, with almost a fifth of participants experiencing unfavourable treatment outcomes. Homelessness, HIV, and illicit drug use were the main factors associated with unfavourable outcome. In Brazil, strategies are required to support this underserved group to ensure favourable tuberculosis treatment outcomes.

FUNDING

Wellcome Trust, UK Medical Research Council, and UK Foreign Commonwealth and Development Office.

The Impact of the Evolving Human Immunodeficiency Virus Response on the Epidemiology of Tuberculosis in South African Children and Adolescents

BACKGROUND

Few studies have evaluated tuberculosis control in children and adolescents. We used routine tuberculosis surveillance data to quantify age- and human immunodeficiency virus (HIV)-stratified trends over time and investigate the relationship between tuberculosis, HIV, age, and sex.

METHODS

All children and adolescents (0-19 years) routinely treated for drug-susceptible tuberculosis in South Africa and recorded in a de-duplicated national electronic tuberculosis treatment register (2004-2016) were included. Age- and HIV-stratified tuberculosis case notification rates (CNRs) were calculated in four age bands: 0-4, 5-9, 10-14, and 15-19 years. The association between HIV infection, age, and sex in children and adolescents with tuberculosis was evaluated using multivariable logistic regression.

RESULTS

Of 719 400 children and adolescents included, 339 112 (47%) were 0-4 year olds. The overall tuberculosis CNR for 0-19 year olds declined by 54% between 2009 and 2016 (incidence rate ratio [IRR] = 0.46; 95% confidence interval [CI], .45-.47). Trends varied by age and HIV, with the smallest reductions (2013-2016) in HIV-positive 0-4 year olds (IRR = 0.90; 95% CI, .85-.95) and both HIV-positive (IRR = .84; 95% CI, .80-.88) and HIV-negative (IRR = 0.89; 95% CI, .86-.92) 15-19 year olds. Compared with 0- to 4-year-old males, odds of HIV coinfection among 15-19 year olds were nearly twice as high in females (adjusted odds ratio [aOR] = 2.49; 95% CI, 2.38-2.60) than in males (aOR = 1.35; 95% CI, 1.29-1.42).

CONCLUSIONS

South Africa's national response to the HIV epidemic has made a substantial contribution to the observed declining trends in tuberculosis CNRs in children and adolescents. The slow decline of tuberculosis CNRs in adolescents and young HIV-positive children is concerning. Understanding how tuberculosis affects children and adolescents beyond conventional age bands and by sex can inform targeted tuberculosis control strategies.

Age and sex distribution of Mycobacterium tuberculosis infection and rifampicin resistance in Myanmar as detected by Xpert MTB/RIF

Background

Detection of tuberculosis disease (TB) and timely identification of Mycobacterium tuberculosis (Mtb) strains that are resistant to treatment are key to halting tuberculosis transmission, improving treatment outcomes, and reducing mortality.

Methods

We used 332,657 Xpert MTB/RIF assay results, captured as part of the Myanmar Data Utilization Project, to characterize Mtb test positivity and rifampicin resistance by both age and sex, and to evaluate risk factors associated with rifampicin resistance.

Results

Overall, 70% of individuals diagnosed with TB were males. Test positivity was higher among males (47%) compared to females (39%). The highest positivity by age occurred among individuals aged 16–20, with test positivity for females (65%) higher than for males (57%). Although a greater absolute number of males were rifampicin resistant, a greater proportion of females (11.4%) were rifampicin resistant as compared to males (9.3%). In the multivariate model, history of previous treatment, age less than 30, testing in the Yangon region, and female sex were significantly positively associated with rifampicin resistance after adjusting for HIV status and year test was performed.

Conclusions

Our results indicate that young adults were more likely to test positive for TB and be identified as rifampicin resistant compared to older adults.

Tuberculosis in Adolescents and Young Adults: Emerging Data on TB Transmission and Prevention among Vulnerable Young People

Adolescents and young adults (AYA, ages 10-24 years) comprise a uniquely important but understudied population in global efforts to end tuberculosis (TB), the leading infectious cause of death by a single agent worldwide prior to the COVID-19 pandemic. While TB prevention and care strategies often overlook AYA by grouping them with either children or adults, AYA have particular physiologic, developmental, and social characteristics that require dedicated approaches. This review describes current evidence on the prevention and control of TB among AYA, including approaches to TB screening, dynamics of TB transmission among AYA, and management challenges within the context of unique developmental needs. Challenges are considered for vulnerable groups of AYA such as migrants and refugees; AYA experiencing homelessness, incarceration, or substance use; and AYA living with HIV. We outline areas for needed research and implementation strategies to address TB among AYA globally.