Clinical presentation, demographics and outcome of tuberculosis (TB) in a low incidence area: a 4-year study in Geneva, Switzerland

Is Tobacco Use Associated With Risk of Recurrence and Mortality Among People With TB?: A Systematic Review and Meta-Analysis

BACKGROUND

Associations between tobacco use and poor TB treatment outcomes are well documented. However, for important outcomes such as TB recurrence or relapse and mortality during treatment, as well as for associations with smokeless tobacco (ST), the evidence is not summarized systematically.

RESEARCH QUESTION

Is tobacco use associated with risk of poor treatment outcomes among people with TB?

STUDY DESIGN AND METHODS

The MEDLINE, Embase, and Cumulative Index of Nursing and Allied Health Literature databases were searched on November 22, 2021. Epidemiologic studies reporting associations between tobacco use and at least one TB treatment outcome were eligible. Independent double-screening, extractions, and quality assessments were undertaken. Random effects meta-analyses were conducted for the two primary review outcomes (TB recurrence or relapse and mortality during treatment), and heterogeneity was explored using subgroups. Other outcomes were synthesized narratively.

RESULTS

Our searches identified 1,249 records, of which 28 were included in the meta-analyses. Based on 15 studies, higher risk of TB recurrence or relapse was found with ever using tobacco vs never using tobacco (risk ratio [RR], 1.78; 95% CI, 1.31-2.43; I2 = 85%), current tobacco use vs no tobacco use (RR, 1.95; 95% CI, 1.59-2.40; I2 = 72%), and former tobacco use vs never using tobacco (RR, 1.84; 95% CI, 1.21-2.80; I2 = 4%); heterogeneity arose from differences in study quality, design, and participant characteristics. Thirty-eight studies were identified for mortality, of which 13 reported mortality during treatment. Ever tobacco use (RR, 1.55; 95% CI, 1.32-1.81; I2 = 0%) and current tobacco use (RR, 1.51; 95% CI, 1.09-2.10; I2 = 87%) significantly increased the likelihood of mortality during treatment among people with TB compared with never using tobacco and not currently using tobacco, respectively; heterogeneity was explained largely by differences in study design. Almost all studies in the meta-analyses scored high or moderate on quality assessments. Narrative synthesis showed that tobacco use was a risk factor for other unfavorable TB treatment outcomes, as previously documented. Evidence on ST was limited, but identified studies suggested an increased risk for poor outcomes with its use compared with not using it.

INTERPRETATION

Tobacco use significantly increases the risk of TB recurrence or relapse and mortality during treatment among people with TB, highlighting the need to address tobacco use to improve TB outcomes.

TRIAL REGISTRY

PROSPERO; No.: CRD42017060821; URL: https://www.crd.york.ac.uk/prospero/.

Approach for tuberculosis-associated immune reconstitution inflammatory syndrome in an HIV-negative patient

A male refugee from the Middle East was diagnosed with pulmonary tuberculosis and Pott’s disease with paravertebral abscess. After starting the standard regimen, the sputum culture converted to negative and the patient’s general condition improved. Six weeks later, the patient presented with clinical worsening of known symptoms, new appearance of focal neurological deficits and progress of radiological features showing progression of the paravertebral abscess. Immune reconstitution inflammatory syndrome with Mycobacterium tuberculosis (TB-IRIS) was presumed, and treatment with high-dose steroids was started. Due to recurrent relapses while tapering, corticosteroids had to be given over a prolonged period. After treatment completion, the patient was in a good general condition, abscesses had decreased and neurological deficits were in complete remission. This case presents the rare manifestation of TB-IRIS in HIV-negative patients and its management in a high-income country.

Treatment outcomes of extrapulmonary tuberculosis in Bahawalpur, Pakistan; a record review

Background

There is limited published data form Pakistan on treatment success rate among extrapulmonary tuberculosis (EPTB) patients. The aim of this study was to assess clinical form, treatment outcomes, and identify the factors associated with unfavorable treatment outcome among EPTB patients.

Methods

A retrospective study was conducted at the Chest Disease Unit of the Bahawal Victoria Hospital, Pakistan. Medical records of EPTB patients, registered at the study site from January 1, 2015 to September 30, 2017, were reviewed to obtain the data. Final treatment outcomes among EPTB patients were evaluated in accordance with the standard Word Health Organization (WHO) criteria. Multivariate binary logistic regression analysis was used to identify the factors associated with unfavorable treatment outcome.

Results

A total of 651 EPTB patients were included in the study. Highest proportion of patients had pleural TB (n = 217, 33.3%). Out of the total 651 patients, 463 (71.1%) successfully completed the treatment. Among 177 (27.2%) patients with unfavorable treatment outcome, 10 (1.5%) died, while 165 (25.4%) lost to follow-up the treatment. Lymph node TB (AOR 0.65, 95% CI 0.422, 0.989) and meningeal TB (AOR 2.1, 95% CI 1.065, 4.144) were significantly associated with unfavorable treatment outcome.

Conclusion

The treatment success (favorable outcome) rate among EPTB patients was less than the target (i.e., ≥ 90%) set by the WHO. Highest proportion of patients lost to follow-up during the treatment.

A 5-year experience characterizing the demographic and clinical profile and directly observed treatment short-course treatment outcome in National Tuberculosis Center of Duhok province, Iraqi Kurdistan

BACKGROUND

The objectives were to describe the demographic and clinical profile and treatment outcomes in the National Tuberculosis Program Center of Duhok governorate.

METHODS

This was a descriptive retrospective study of all forms of drug-susceptible tuberculosis cases in the National Tuberculosis Program Center of Duhok. The Electronic Nominal Recording Reporting System data of tuberculosis cases were reviewed during 2014-2018. Information on the demographic, clinical, and laboratory characteristics of the patients were analyzed. Tuberculosis trends and treatment outcomes were determined.

RESULTS

A total of 1063 tuberculosis patients visited the National Tuberculosis Program Center, of whom 905 were from Duhok. The estimated tuberculosis notification rate per 100,000 people in Duhok governorate was 14.06, 16.16, 10.43, 11.05, and 10.34 for the years 2014, 2015, 2016, 2017, and 2018, respectively. The most affected age group was 15-24 years. The male cases were predominant. Most patients (97.3%) were native Iraqi. There were 718 (67.5%) pulmonary tuberculosis cases and 345 (32.5%) extra-pulmonary tuberculosis cases; tuberculosis lymphadenitis was the most common presentation. The majority of extra-pulmonary tuberculosis patients were females aged 15-24 years (p = 0.019), and patients aged ⩾65 years were associated with pulmonary tuberculosis and extra-pulmonary tuberculosis in males (p ⩽ 0.001). The highest tuberculosis incidence occurred in winter (288 patients). The patient treatment outcomes were as follows: 90.7% successful treatment, 1.6% lost to follow-up, 6.7% death, 0.3 transferred out, and 0.8 treatment failure.

CONCLUSION

There was a high frequency of extra-pulmonary tuberculosis, which may reflect overestimation in its diagnosis. Therefore, meticulous evaluations should be provided. The treatment outcome was satisfactory in the center. Hence, we should maintain the favorable work to attain tuberculosis control objectives. Performing GeneXpert for all tuberculosis cases and introducing culture and drug susceptibility testing should be an urgent plan to strengthen the diagnosis of susceptible and drug-resistant tuberculosis cases.

Pulmonary Versus Extrapulmonary Tuberculosis Associated Factors: A Case-Case Study

BACKGROUND

Tuberculosis (TB) incidence remains low in health departments of Castellon and La Plana-Vila-real, but TB elimination is challenging. The objective of this study was to estimate associated factors of pulmonary tuberculosis (PTB) compared with extrapulmonary tuberculosis (ETB) and investigate epidemiological characteristics of these pathologies to orient control and prevention actions.

MATERIALS AND METHODS

A prospective case-case study was implemented by comparing PTB and ETB incidences during 2013-2016 from notification reports, epidemiological surveillance, and microbiological results of hospitals' laboratories Hospital General Castellon and La Plana-Vila-Real in the province of Castellon of Valencia region in Spain. In this design, cases were patients with PTB and controls were patients with ETB. Directed acyclic graph approach was used for selection of potential risk and confounding factors. Adjusted odds ratios (AORs) were estimated by logistic regression models.

RESULTS

The study included 136 patients with PTB and 57 patients with ETB, with microbiological confirmation of 93.4% and 52.6%, and the annual median of incidence rates were 7.5 and 3.1 per 100 000 inhabitants, respectively. In general, patients with PTB were younger with higher male proportion than patients with ETB. Risk factors of PTB were smoking tobacco (AOR = 3.98; 95% confidence interval [CI] = 1.66-9.56), social problems (social marginalization, homeless, residence in shelters for the poor, or stay in prison) (AOR = 3.39; 95% CI = 1.05-10.94), and contact with patients with TB (AOR = 2.51; 95% CI = 1.06-5.95). No-smoking tobacco and no-drug abuse interaction decrease PTB risk (AOR = 0.27; 95% CI = 0.12-0.64). From these results, specific measures of health promotion and prevention can be addressed.

CONCLUSIONS

The estimated associated factors of PTB may be prevented, and it was demonstrated that the case-case design is useful in the study of TB.

Evaluating the Contribution of Nocardia spp. and Mycobacterium tuberculosis to Pulmonary Infections among HIV and Non-HIV Patients at the Komfo Anokye Teaching Hospital, Ghana

Tuberculosis (TB) is a major cause of human mortality particularly in association with the human immunodeficiency virus (HIV). Nocardia spp. has emerged as an opportunistic infection especially in HIV patients. The high prevalence of TB and HIV coupled with the lack of a definitive laboratory diagnosis for Nocardia spp. could lead to misdiagnosed pulmonary TB. This study determined the prevalence of pulmonary infections due to Nocardia spp. and Mycobacterium tuberculosis in sputum of HIV and non-HIV patients with suspected pulmonary tuberculosis at KATH. A total of sixty sputum samples were obtained from HIV and non-HIV patients with suspected pulmonary tuberculosis. Samples were examined by fluorescence based Ziehl–Neelsen staining, culture, and PCR methods. The prevalence of Nocardia spp. and Mycobacterium tuberculosis was 18.3% and 20%, respectively, with the latter having the highest rate among patients aged 21–40 years (P=0.075). The prevalence of Nocardia spp. among HIV patients was 90.9% whilst 16.7% of the patients had HIV/Nocardia spp. coinfection. Detection of Mycobacterium tuberculosis by fluorescence-based Ziehl–Neelsen staining, culture, and PCR yielded 9 (15%), 11 (18.3%), and 12 (20%), respectively. There is a high prevalence of nocardiosis especially in HIV patients. PCR is a better diagnostic method that detects both Nocardia spp. and Mycobacterium tuberculosis and should be incorporated into routine diagnosis for pulmonary infections.

Multidrug-resistant tuberculosis treatment adherence in migrants: a systematic review and meta-analysis

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is a growing concern in meeting global targets for TB control. In high-income low-TB-incidence countries, a disproportionate number of MDR-TB cases occur in migrant (foreign-born) populations, with concerns about low adherence rates in these patients compared to the host non-migrant population. Tackling MDR-TB in this context may, therefore, require unique approaches. We conducted a systematic review and meta-analysis to identify and synthesise data on MDR-TB treatment adherence in migrant patients to inform evidence-based strategies to improve care pathways and health outcomes in this group.

METHODS

This systematic review and meta-analysis was conducted in line with PRISMA guidelines (PROSPERO 42017070756). The databases Embase, MEDLINE, Global Health and PubMed were searched to 24 May 2017 for primary research reporting MDR-TB treatment adherence and outcomes in migrant populations, with no restrictions on dates or language. A meta-analysis was conducted using random-effects models.

RESULTS

From 413 papers identified in the database search, 15 studies reporting on MDR-TB treatment outcomes for 258 migrants and 174 non-migrants were included in the systematic review and meta-analysis. The estimated rate of adherence to MDR-TB treatment across migrant patients was 71% [95% confidence interval (CI) = 58-84%], with non-adherence reported among 20% (95% CI = 4-37%) of migrant patients. A key finding was that there were no differences in estimated rates of adherence [risk ratio (RR) = 1.05; 95% CI = 0.82-1.34] or non-adherence (RR = 0.97; 95% CI = 0.79-1.36) between migrants and non-migrants.

CONCLUSIONS

MDR-TB treatment adherence rates among migrants in high-income low-TB-incidence countries are approaching global targets for treatment success (75%), and are comparable to rates in non-migrants. The findings highlight that only just over 70% of migrant and non-migrant patients adhere to MDR-TB treatment. The results point to the importance of increasing adherence in all patient groups, including migrants, with an emphasis on tailoring care based on social risk factors for poor adherence. We believe that MDR-TB treatment targets are not ambitious enough.

Evaluating treatment outcomes and durations among cases of smear-positive pulmonary tuberculosis in Yemen: a prospective follow-up study

BACKGROUND

Evaluating outcomes after tuberculosis (TB) treatment can help identify the primary reasons for treatment success or failure. However, Yemen has a treatment success rate that remains below the World Health Organization's target. This study aimed to identify factors that were associated with unsuccessful treatment and prolonged treatment (>1 year).

METHOD

Newly diagnosed cases of smear-positive pulmonary TB were prospectively followed at two centers (Taiz and Alhodidah, Yemen) between April 2014 and March 2015. Standardized forms were used to obtain information from the patients regarding their socio-demographic and clinical characteristics, treatment duration, and TB-related information. Multivariate logistic regression analyses were performed to identify factors that were associated with unsuccessful treatment and prolonged treatment (>1 year).

RESULTS

The study included data from 273 cases of newly diagnosed TB, with treatment being successful in 227 cases (83.1%) and unsuccessful in 46 cases (16.9%). Among the 46 patients with unsuccessful treatment, 29 patients (10.6%) stopped treatment, 6 patients (2.2%) transferred to another facility, 6 patients (2.2%) experienced treatment failure, and 5 patients (1.8%) died. The multivariate logistic regression analyses revealed that unsuccessful treatment was associated with female sex, illiterate status, and the presence of comorbidities. Prolonged treatment durations were associated with living in a rural area, smoking, chewing khat, a cough that lasted for >3 weeks at the beginning of treatment, and bilateral cavities during radiography.

CONCLUSION

These results confirm that the treatment success rate in Yemen is lower than the World Health Organization's target for smear-positive pulmonary tuberculosis. Targeting the risk factors that we identified may help improve treatment outcomes. Furthermore, it may not be prudent to re-treat patients using first-line TB drugs after an initial treatment failure.

Assessment of the influence of direct tobacco smoke on infection and active TB management

BACKGROUND

Smoking is a risk factor for tuberculosis (TB) infection and disease progression. Tobacco smoking increases susceptibility to TB in a variety of ways, one of which is due to a reduction of the IFN-γ response. Consequently, an impaired immune response could affect performance of IFN-γ Release Assays (IGRAs).

OBJECTIVE

In the present study, we assess the impact of direct tobacco smoking on radiological manifestations, sputum conversion and immune response to Mycobacterium tuberculosis, analyzing IFN-γ secretion by IGRAs.

METHODS

A total of 525 participants were studied: (i) 175 active pulmonary TB patients and (ii) 350 individuals coming from contact tracing studies, 41 of whom were secondary TB cases. Clinical, radiological and microbiological data were collected. T-SPOT.TB and QFN-G-IT were processed according manufacturer's instructions.

RESULTS

In smoking patients with active TB, QFN-G-IT (34.4%) and T-SPOT.TB (19.5%) had high frequencies of negative results. In addition, by means of an unconditional logistic regression, smoking was a main factor associated with IGRAs' false-negative results (aOR: 3.35; 95%CI:1.47-7.61; p<0.05). Smoking patients with active TB presented a high probability of having cavitary lesions (aOR: 1.88; 95%CI:1.02-3.46;p<0.05). Mean culture negativization (months) ± standard deviation (SD) was higher in smokers than in non-smokers (2.47±1.3 versus 1.69±1.4). Latent TB infection (LTBI) was favored in smoking contacts, being a risk factor associated with infection (aOR: 11.57; 95%CI:5.97-22.41; p<0.00005). The IFN-γ response was significantly higher in non-smokers than in smokers. Smoking quantity and IFN-γ response analyzed by IGRAs were dose-dependent related.

CONCLUSIONS

Smoking had a negative effect on radiological manifestations, delaying time of sputum conversion. Our data establish a link between tobacco smoking and TB due to a weakened IFN-γ response caused by direct tobacco smoke.

Screening for tuberculosis in an urban shelter for homeless in Switzerland: a prospective study

Background

Whereas high risk groups such as asylum seekers are systematically screened for active tuberculosis (TB) upon entry in Switzerland, this strategy does not apply to homeless persons despite a reported high risk. Geneva health and social authorities implemented an intersectoral project to screen for active TB in homeless persons. We aimed to assess acceptability of this program and prevalence of active TB in this group.

Methods

This prospective study targeted all homeless adults registering for shelter accommodation in Geneva during winter 2015. Applicants were proposed a questionnaire-based screening (www.tb-screen.ch) exploring epidemiological and clinical risk factors for active TB. Participants with a positive score underwent diagnostic procedures at Geneva University Hospital. Enhanced TB surveillance targeting homeless persons in the community was continued 3 months after the study termination.

Results

Overall, 726/832 (87.3%) homeless persons accepted the screening procedure. Most were young male migrants without access to care in Switzerland. Male gender (adjusted OR: 2.14; 95% confidence interval: 1.27–3.62), age below 25 years (aOR: 4.16; 95% CI: 1.27–13.64) and short duration of homelessness (aOR: 1.75; 95% CI: 1.06–2.87) were predictors of acceptance. Thirty (4.1%) had positive screening scores but none of the 24 who underwent further testing had active TB. Post-study surveillance did not identify any incident case in Geneva.

Conclusions

Active TB screening targeting highly mobile homeless persons in shelters was well accepted and feasible. The participants’ sociodemographic profile highlighted the heterogeneity of homeless groups in Europe and the null TB prevalence the variability of their active TB risks. These findings underline the feasibility of health programs targeting this hard to reach group and the need for close monitoring of this social group considering the rapid changes in international mobility patterns to tailor preventive and screening strategies to the local context.

Impact of HIV infection on treatment outcome of tuberculosis in Europe

BACKGROUND

The effect of HIV on tuberculosis (TB) treatment outcomes has not been well established. We aimed to assess the impact of HIV infection on TB treatment outcomes by using data from notifiable disease surveillance in Europe.

METHODS

We analyzed the treatment outcomes of TB cases reported from nine European countries during 2010-2012. We investigate the effect of HIV on TB treatment outcomes using a multilevel and a multinomial logistic model, and considering the interaction between HIV and multidrug-resistant (MDR) TB.

RESULTS

A total of 61,138 TB cases including 5.5% HIV-positive were eligible for our analysis. In the multilevel model adjusted for age and an interaction with MDR TB, HIV was significantly associated with lower treatment success in all MDR strata [non-MDR TB: odds ratio (OR) 0.24 CI (confidence interval) 0.20-0.29; unknown MDR TB status: OR 0.26 CI 0.23-0.30; MDR TB: OR 0.57 CI 0.35-0.91]. In the multinomial regression model, HIV-positive cases had significantly higher relative risk ratio (RRR) for death (non-MDR TB: RRR 4.30 CI 2.31-7.99; unknown MDR TB status: 5.55 CI 3.10-9.92; MDR TB: 3.59 CI 1.56-8.28) and being 'still on treatment' (non-MDR TB: RRR 7.27 CI 3.00-17.6; unknown MDR TB status: 5.36 CI 2.44-11.8; MDR TB: 3.76 CI 2.48-5.71). We did not find any significant association between HIV and TB treatment failure (non-MDR TB: RRR 0.50 CI 0.15-1.67; unknown MDR TB status: 1.51 CI 0.86-2.64; MDR TB: 0.51 CI 0.13-1.87).

CONCLUSION

This large study confirms that HIV is a strong risk factor for an adverse TB treatment outcome, which is mainly manifested by an increased risk of death and still being on TB treatment.

Epidemiology, Diagnosis and Management of Extra-Pulmonary Tuberculosis in a Low-Prevalence Country: A Four Year Retrospective Study in an Australian Tertiary Infectious Diseases Unit

OBJECTIVES

Extra-pulmonary tuberculosis (EPTB) is relatively neglected and increasing in incidence, in comparison to pulmonary tuberculosis (PTB) in low-burden settings. It poses particular diagnostic and management challenges. We aimed to determine the characteristics of EPTB in Western Sydney, Australia, and to conduct a quality assurance investigation of adherence to guidelines among Infectious Diseases (ID) practitioners managing EPTB cases.

METHODS

All adult EPTB cases managed by a large ID service during 01/01/2008-31/12/2011 were eligible for inclusion in the retrospective review. Data were extracted from patient medical records on demographic, diagnostic, clinical and management details, and on clinician adherence to local and international TB guidelines.

RESULTS

129 cases managed by the ID service were identified, with files available for 117. 98 cases were managed by the Respiratory service and were excluded. 98.2%(112/114) had been born in a country other than Australia. HIV status was tested or previously known in 97 people, and positive in 4 (4%). Microbiological confirmation was obtained in 68/117 (58.1%), an additional 24 had histopathological findings considered confirmatory (92/117, 78.6%), with the remainder diagnosed on clinical and/or radiological grounds. Median time to diagnosis post-migration from a high TB-burden country was 5 years (range 0-41). 95 cases were successfully treated, 11 cases defaulted, refused therapy or transferred, 2 cases relapsed and outcomes unknown or pending in 9 cases. No deaths occurred in the sample analysed. Clinician adherence to guidelines was high, but with scope for improvement in offering testing for co-infections, performing eye checks, monitoring blood glucose in patients receiving adjunctive corticosteroids, and considering drug interactions.

CONCLUSIONS

Despite excellent TB outcomes in this setting, the low proportion of cases with susceptibility data is worrying in this era of increasing drug resistance, and illustrates the diagnostic difficulties faced even in a well-resourced setting. Vigilance for EPTB needs to remain high in those moving from high prevalence countries to Australia, even decades after immigration.

Treatment outcome of new smear positive pulmonary tuberculosis patients in Penang, Malaysia

BACKGROUND

According to the World Health Organization's recent report, in Malaysia, tuberculosis (TB) treatment success rate for new smear positive pulmonary tuberculosis (PTB) patients is still below the global success target of 85%. In this study, we evaluated TB treatment outcome among new smear positive PTB patients, and identified the predictors of unsuccessful treatment outcome and longer duration of treatment (i.e., > 6 months).

METHODS

The population in this study consisted of all new smear positive PTB patients who were diagnosed at the chest clinic of Penang General Hospital between March 2010 and February 2011. During the study period, a standardized data collection form was used to obtain socio-demographic, clinical and treatment related data of the patients from their medical charts and TB notification forms (Tuberculosis Information System; TBIS). These data sources were reviewed at the time of the diagnosis of the patients and then at the subsequent follow-up visits until their final treatment outcomes were available. The treatment outcomes of the patients were reported in line with six outcome categories recommended by World Health Organization. Multiple logistic regression analysis was used to find the independent risk factors for unsuccessful treatment outcome and longer treatment duration. Data were analyzed using the PASW (Predictive Analysis SoftWare, version 19.0. Armonk, NY: IBM Corp).

RESULTS

Among the 336 PTB patients (236 male and 100 female) notified during the study period, the treatment success rate was 67.26% (n = 226). Out of 110 patients in unsuccessful outcome category, 30 defaulted from the treatment, 59 died and 21 were transferred to other health care facilities. The mean duration of TB treatment was 8.19 (SD 1.65) months. In multiple logistic regression analysis, risk factors for unsuccessful treatment outcome were foreign nationality, male gender and being illiterate. Similarly, risk factors for mortality due to TB included high-grade sputum and presence of lung cavities at the start of treatment, being alcoholic and elderly. Likewise, concurrent diabetes, presence of lung cavities at the start of the treatment and being a smoker were the significant predictors of longer treatment duration.

CONCLUSION

Our findings indicated that the treatment success rate among the new smear positive PTB patients was less than the success target set by World Health Organization. The proportion of patients in the successful outcome category may be increased by closely monitoring the treatment progress of the patients with aforementioned high risk characteristics. Similarly, more aggressive follow-up of the treatment defaulters and transferred out patients could also improve the TB treatment success rate.

Tuberculosis among HIV-infected patients in Stockholm, Sweden, 1987-2010: treatment outcomes and adverse reactions

BACKGROUND

The treatment of patients co-infected with human immunodeficiency virus (HIV) and tuberculosis (TB) is challenging. The aim of this study was to compare socio-demographic and clinical characteristics among HIV-infected patients before and after the introduction of combined antiretroviral therapy (cART) in a Swedish cohort, and to identify factors associated with anti-TB treatment success as well as adverse reactions.

METHODS

This was a retrospective observational study of HIV/TB co-infected patients in Stockholm County from 1987 to 2010. The study population was stratified into an early and a late cohort (before and after the introduction of cART in 1996). Data were analyzed using descriptive statistics and multiple logistic regression analysis.

RESULTS

The study population comprised 127 patients; the majority were foreign-born (87%). The proportion of female patients more than doubled from the early to the late cohort, and anti-TB treatment success increased from 65% to 91%. The median duration of successful treatment was 8 months in both cohorts. Predictors of treatment success in the late cohort were cART (odds ratio (OR) 13.3, 95% confidence interval (CI) 1.5-114.8) and a CD4 cell count at TB diagnosis > 200 cells/μl (OR 17.2, 95% CI 1.2-236.6). Severe adverse reactions in the late cohort occurred in 23% and were associated with the initiation of cART after TB diagnosis (OR 13.3, 95% CI 1.6-112.4).

CONCLUSION

The introduction of cART was favourable for the treatment outcome of HIV-infected patients with concomitant TB. However, adverse reactions increased in patients who initiated cART during anti-TB treatment and these patients require careful attention.

Tuberculosis deaths: are we measuring accurately?

Death among tuberculosis patients is one of the major reasons for non-attainment of 85% treatment success target set by World Health Organization. In this short paper, we evaluated whether the overall mortality rate in pulmonary tuberculosis is being affected by other comorbid conditions. All new smear positive pulmonary tuberculosis patients (N =336), who started their treatment at the chest clinic of the Penang General Hospital, between March 2010 and February 2011, were followed-up until December 2011. Tuberculosis treatment outcomes were reported according to six treatment outcome categories recommended by World Health Organization. The outcome category 'died' was defined as 'a patient who died due to tuberculosis or other cause during tuberculosis treatment'. Our findings showed that out of 336 smear positive pulmonary tuberculosis patients, 59 (17.6%) died during treatment (mortality rate = 1.003 cases per 1000 person-days of follow-up). Among the deceased patients, the mean age was 55.8 years (SD =16.17) and 49 were male. According to the mortality review forms, 29 deaths were tuberculosis-related, while the remaining 30 patients died due to reasons other than tuberculosis. Cerebrovascular accident (n =7), septicaemia shock (n =4) and acute coronary syndrome (n =4) were the most common non-tuberculosis related reasons for mortality in the patients. If the 30 patients, for whom tuberculosis was incidental to death, are excluded from the final cohort, the proportion of patients in the 'died' outcome category could be reduced to 9.5%. The treatment outcome criterion (i.e., died) set by World Health Organization has limitations. Therefore, it requires improvement for more objective evaluation of the performance of the National Tuberculosis Program.

Meta-analysis: the association between HIV infection and extrapulmonary tuberculosis

BACKGROUND

Extrapulmonary tuberculosis has been an AIDS-defining condition. Individual studies that highlight the association between HIV and extrapulmonary TB are available. Our objectives were to synthesis evidence on the association between extrapulmonary tuberculosis and HIV and to explore the effective preventive measures of these two diseases.

METHODS

This is a meta-analysis of observational studies reporting effect estimates on how HIV is associated with extrapulmonary tuberculosis. We searched for the eligible studies in the electronic databases using search terms related to HIV and extrapulmonary tuberculosis. Where possible, we estimated the summary odds ratios using random effects meta-analysis. We stratified analysis by the type of study design. We assessed heterogeneity of effect estimates within each group of studies was assessed using I (2) test.

RESULTS

Nineteen studies (7 case control studies and 12 cohort studies) were identified for the present study. The pooled analysis shows a significant association between HIV and extrapulmonary tuberculosis (summary odds ratio: 1.3; 95 % confidence interval (CI) 1.05-1.6; I (2): 0 %). In a subgroup analysis with two studies, a significant association was found between CD4+ count less than 100 and the incidence of extrapulmonary tuberculosis (summary OR: 1.31; 95 % CI 1.02-1.68; I (2): 0 %).

CONCLUSIONS

Findings show evidence on the association between extrapulmonary tuberculosis and HIV, based on case control studies. Further studies to understand the mechanisms of interaction of the two pathogens are recommended.

Tuberculosis in HIV-negative and HIV-infected patients in a low-incidence country: clinical characteristics and treatment outcomes

Background

In Switzerland and other developed countries, the number of tuberculosis (TB) cases has been decreasing for decades, but HIV-infected patients and migrants remain risk groups. The aim of this study was to compare characteristics of TB in HIV-negative and HIV-infected patients diagnosed in Switzerland, and between coinfected patients enrolled and not enrolled in the national Swiss HIV Cohort Study (SHCS).

Methods and Findings

All patients diagnosed with culture-confirmed TB in the SHCS and a random sample of culture-confirmed cases reported to the national TB registry 2000–2008 were included. Outcomes were assessed in HIV-infected patients and considered successful in case of cure or treatment completion. Ninety-three SHCS patients and 288 patients selected randomly from 4221 registered patients were analyzed. The registry sample included 10 (3.5%) coinfected patients not enrolled in the SHCS: the estimated number of HIV-infected patients not enrolled in the SHCS but reported to the registry 2000–2008 was 146 (95% CI 122–173). Coinfected patients were more likely to be from sub-Saharan Africa (51.5% versus 15.8%, P<0.0001) and to present disseminated disease (23.9% vs. 3.4%, P<0.0001) than HIV-negative patients. Coinfected patients not enrolled in the SHCS were asylum seekers or migrant workers, with lower CD4 cell counts at TB diagnosis (median CD4 count 79 cells/µL compared to 149 cells/µL among SHCS patients, P = 0.07). There were 6 patients (60.0%) with successful outcomes compared to 82 (88.2%) patients in the SHCS (P = 0.023).

Conclusions

The clinical presentation of coinfected patients differed from HIV-negative TB patients. The number of HIV-infected patients diagnosed with TB outside the SHCS is similar to the number diagnosed within the cohort but outcomes are poorer in patients not followed up in the national cohort. Special efforts are required to address the needs of this vulnerable population.

[Extrapulmonary tuberculosis]

Extrapulmonary tuberculosis represents an increasing proportion of all cases of tuberculosis reaching 20 to 40% according to published reports. Extrapulmonary TB is found in a higher proportion of women, black people and immunosuppressed individuals. A significant proportion of cases have a normal chest X-Ray at the time of diagnosis. The most frequent clinical presentations are lymphadenitis, pleuritis and osteoarticular TB. Peritoneal, urogenital or meningeal tuberculosis are less frequent, and their diagnosis is often difficult due to the often wide differential diagnosis and the low sensitivity of diagnostic tests including cultures and genetic amplification tests. The key clinical elements are reported and for each form the diagnostic yield of available tests. International therapeutic recommendations and practical issues are reviewed according to clinical presentation.

Epidemiology of tuberculosis in a low-incidence Italian region with high immigration rates: differences between not Italy-born and Italy-born TB cases

BACKGROUND

Emilia Romagna, a northern Italian region, has a population of 4.27 million, of which 9.7% are immigrants. The objective of this study was to investigate the epidemiology of tuberculosis (TB) during the period 1996-2006 in not Italy-born compared to Italy-born cases.

METHODS

Data was obtained from the Regional TB surveillance system, from where personal data, clinical features and risk factors of all notified TB cases were extracted.

RESULTS

5377 TB cases were reported. The proportion of immigrants with TB, over the total number of TB cases had progressively increased over the years, from 19.1% to 53.3%. In the not Italy-born population, TB incidence was higher than in Italians (in 2006: 100.7 cases per 100,000 registered not Italy-born subjects and 83.9/100,000 adding 20% of estimated irregular presences to the denominators. TB incidence among Italians was 6.5/100,000 Italians). A progressive rise in the not Italy-born incident cases was observed but associated with a decline in TB incidence. Not Italy-born cases were younger compared to the Italy-born cases, and more frequently classified as "new cases" (OR 2.0 95%CI 1.61-2.49 for age group 20-39); 60.7% had pulmonary TB, 31.6% extra pulmonary and 7.6% disseminated TB. Risk factors for TB in this population group were connected to lower income status (homeless: OR 149.9 95%CI 20.7-1083.3 for age group 40-59).

CONCLUSIONS

In low-incidence regions, prevention and control of TB among sub-groups at risk such as the foreign-born population is a matter of public health concern. In addition, increasing immigration rates may affect TB epidemiology. TB among immigrants is characterized by particular clinical features and risk factors, which should be analyzed in order to plan effective action.