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Li H, Chee CBE, Geng T, Pan A, Koh WP. Joint Associations of Multiple Lifestyle Factors With Risk of Active Tuberculosis in the Population: The Singapore Chinese Health Study. Clin Infect Dis 2021; 75:213-220. [PMID: 34958367 PMCID: PMC9410721 DOI: 10.1093/cid/ciab935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Little is known about the joint associations of multiple lifestyle risk factors including smoking, low body mass index, physical inactivity, alcohol consumption, and low diet quality with risk of active tuberculosis. METHODS We analyzed data from the Singapore Chinese Health Study, a prospective cohort study of 63 257 Chinese adults aged 45-74 years enrolled between 1993 and 1998. Incident cases of active tuberculosis were identified via linkage with the National TB Registry through 31 December 2016. Cox proportional hazards regression models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) of tuberculosis risk in relation to the combined scores of lifestyle risk factors. RESULTS Compared with participants with none of the risk factors, the adjusted HRs (95% CI) of active tuberculosis for participants with 1, 2, 3, 4, and 5 risk factors were 1.24 (1.02-1.51), 1.84 (1.51-2.23), 2.52 (2.03-3.14), 4.07 (3.07-5.41), and 9.04 (5.44-15.02), respectively (Ptrend < .0001). The HR for those with 5 factors was ~1.5 times the product of individual risk estimates from the 5 factors on a multiplicative scale. The stepwise increase in risk of active tuberculosis with increasing number of lifestyle risk factors was significantly stronger in participants with diabetes than their counterparts without diabetes at recruitment (Pinteraction = .01). CONCLUSIONS Multiple lifestyle risk factors were associated with risk of active tuberculosis in a synergistic manner. Our findings highlight the importance of public health programs and interventions targeting these factors simultaneously to reduce the tuberculosis burden among the general population.
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Affiliation(s)
- Huiqi Li
- Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Cynthia B E Chee
- Singapore Tuberculosis Control Unit, Tan Tock Seng Hospital, Singapore
| | - Tingting Geng
- Department of Epidemiology and Biostatistics, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | | | - Woon Puay Koh
- Correspondence: W.-P. Koh, Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, 5 Science Drive 2, Singapore ()
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Subbaraman R, Jhaveri T, Nathavitharana RR. Closing gaps in the tuberculosis care cascade: an action-oriented research agenda. J Clin Tuberc Other Mycobact Dis 2020; 19:100144. [PMID: 32072022 PMCID: PMC7015982 DOI: 10.1016/j.jctube.2020.100144] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The care cascade-which evaluates outcomes across stages of patient engagement in a health system-is an important framework for assessing quality of tuberculosis (TB) care. In recent years, there has been progress in measuring care cascades in high TB burden countries; however, there are still shortcomings in our knowledge of how to reduce poor patient outcomes. In this paper, we outline a research agenda for understanding why patients fall through the cracks in the care cascade. The pathway for evidence generation will require new systematic reviews, observational cohort studies, intervention development and testing, and continuous quality improvement initiatives embedded within national TB programs. Certain gaps, such as pretreatment loss to follow-up and post-treatment disease recurrence, should be a priority given a relative paucity of high-quality research to understand and address poor outcomes. Research on interventions to reduce death and loss to follow-up during treatment should move beyond a focus on monitoring (or observation) strategies, to address patient needs including psychosocial and nutritional support. While key research questions vary for each gap, some patient populations may experience disparities across multiple stages of care and should be a priority for research, including men, individuals with a prior treatment history, and individuals with drug-resistant TB. Closing gaps in the care cascade will require investments in a bold and innovative action-oriented research agenda.
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Affiliation(s)
- Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, USA
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
| | - Tulip Jhaveri
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, USA
| | - Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
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Thomas BE, Thiruvengadam K, S. R, Kadam D, Ovung S, Sivakumar S, Bala Yogendra Shivakumar SV, Paradkar M, Gupte N, Suryavanshi N, Dolla CK, Gupte AN, Kohli R, Pradhan N, Sivaramakrishnan GN, Gaikwad S, Kagal A, Dhanasekaran K, Deluca A, Golub JE, Mave V, Chandrasekaran P, Gupta A. Smoking, alcohol use disorder and tuberculosis treatment outcomes: A dual co-morbidity burden that cannot be ignored. PLoS One 2019; 14:e0220507. [PMID: 31365583 PMCID: PMC6668833 DOI: 10.1371/journal.pone.0220507] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 07/17/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND More than 20% of tuberculosis (TB) disease worldwide may be attributable to smoking and alcohol abuse. India is the second largest consumer of tobacco products, a major consumer of alcohol particularly among males, and has the highest burden of TB globally. The impact of increasing tobacco dose, relevance of alcohol misuse and past versus current or never smoking status on TB treatment outcomes remain inadequately defined. METHODS We conducted a multi-centric prospective cohort study of newly diagnosed adult pulmonary TB patients initiated on TB treatment and followed for a minimum of 6 months to assess the impact of smoking status with or without alcohol abuse on treatment outcomes. Smokers were defined as never smokers, past smokers or current smokers. Alcohol Use Disorder Identification Test (AUDIT) scores were used to assess alcohol misuse. The association between smoking status and treatment outcomes was assessed in univariate and multivariate random effects poisson regression models. RESULTS Of 455 enrolled, 129 (28%) had a history of smoking with 94 (20%) current smokers and 35 (8%) past smokers. Unfavourable treatment outcomes were significantly higher among past and current smokers as compared to never smokers. Specifically, the risk of treatment failure was significantly higher among past smokers (aIRR = 2.66, 95% CI: 1.41-4.90, p = 0.002), recurrent TB among current smokers (aIRR = 2.94, 95% CI: 1.30-6.67, p = 0.010) and death among both past (2.63, 95% CI: 1.11-6.24, p = 0.028) and current (aIRR = 2.59, 95% CI: 1.29-5.18, p = 0.007) smokers. Furthermore, the combined effect of alcohol misuse and smoking on unfavorable treatment outcomes was significantly higher among past smokers (aIRR: 4.67, 95% CI: 2.17-10.02, p<0.001) and current smokers (aIRR: 3.58, 95% CI: 1.89-6.76, p<0.001). CONCLUSION Past and current smoking along with alcohol misuse have combined effects on increasing the risk of unfavourable TB treatment outcomes. Innovative interventions that can readily address both co-morbidities are urgently needed.
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Affiliation(s)
| | - Kannan Thiruvengadam
- National Institute for Research in Tuberculosis, ICMR, Chennai, Tamil Nadu, India
| | - Rani S.
- National Institute for Research in Tuberculosis, ICMR, Chennai, Tamil Nadu, India
| | - Dileep Kadam
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Senthanro Ovung
- National Institute for Research in Tuberculosis, ICMR, Chennai, Tamil Nadu, India
| | - Shrutha Sivakumar
- National Institute for Research in Tuberculosis, ICMR, Chennai, Tamil Nadu, India
| | | | - Mandar Paradkar
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Nishi Suryavanshi
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - C. K. Dolla
- National Institute for Research in Tuberculosis, ICMR, Chennai, Tamil Nadu, India
| | - Akshay N. Gupte
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Rewa Kohli
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | - Neeta Pradhan
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
| | | | - Sanjay Gaikwad
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Anju Kagal
- Byramjee Jeejeebhoy Government Medical College, Pune, Maharashtra, India
| | - Kavitha Dhanasekaran
- National Institute for Research in Tuberculosis, ICMR, Chennai, Tamil Nadu, India
| | - Andrea Deluca
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Jonathan E. Golub
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College–Johns Hopkins University Clinical Research Site, Pune, Maharashtra, India
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | | | - Amita Gupta
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Seifert M, Georghiou SB, Garfein RS, Catanzaro D, Rodwell TC. Impact of Fluoroquinolone Use on Mortality Among a Cohort of Patients With Suspected Drug-Resistant Tuberculosis. Clin Infect Dis 2018; 65:772-778. [PMID: 28475735 DOI: 10.1093/cid/cix422] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 04/28/2017] [Indexed: 11/13/2022] Open
Abstract
Background Previous retrospective and in vitro studies suggest that use of later-generation fluoroquinolones may reduce mortality risk and improve treatment outcomes for drug-resistant tuberculosis (TB) patients, including individuals resistant to a fluoroquinolone. Meta-analysis results are mixed and few studies have examined this relationship prospectively. Methods As part of a comparative diagnostic study, we conducted a prospective cohort study with 834 Mycobacterium tuberculosis-infected patients from selected hospitals and clinics with high prevalence of drug-resistant TB in India, Moldova, and South Africa. We used Cox proportional hazards regression models to assess the association between later-generation fluoroquinolone (moxifloxacin or levofloxacin) use and patient mortality, adjusting for risk factors typically associated with poor treatment outcomes. Results After adjusting for phenotypic resistance profile, low body mass index (<18.5 kg/m2), human immunodeficiency virus status, and study site, participants treated with a later-generation fluoroquinolone had half the risk of mortality compared with participants either not treated with any fluoroquinolone or treated only with an earlier-generation fluoroquinolone (adjusted hazard ratio, 0.46 [95% confidence interval, .26-.80]) during follow-up. Conclusions Use of later-generation fluoroquinolones significantly reduced patient mortality risk in our cohort, suggesting that removal of a later-generation fluoroquinolone from a treatment regimen because of demonstrated resistance to an earlier-generation fluoroquinolone might increase mortality risk. Further studies should evaluate the effectiveness of later-generation fluoroquinolones among patients with and without resistance to early-generation fluoroquinolones. Clinical Trials Registration NCT02170441.
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Affiliation(s)
- Marva Seifert
- Department of Medicine, University of California, San Diego, La Jolla
| | | | - Richard S Garfein
- Department of Medicine, University of California, San Diego, La Jolla
| | | | - Timothy C Rodwell
- Department of Medicine, University of California, San Diego, La Jolla
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Padmapriyadarsini C, Shobana M, Lakshmi M, Beena T, Swaminathan S. Undernutrition & tuberculosis in India: Situation analysis & the way forward. Indian J Med Res 2017; 144:11-20. [PMID: 27834321 PMCID: PMC5116882 DOI: 10.4103/0971-5916.193278] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Undernutrition and tuberculosis (TB) are linked and have a bidirectional relationship. Undernutrition increases the risk of TB which in turn, can lead to malnutrition. Undernutrition not only is a risk factor for progression of latent TB infection to active disease, but also increases the risk of drug toxicity, relapse and death once TB develops. The dietary intake of TB patients in the country is inadequate. Nutritional supplementation in patients with TB is associated with faster sputum conversion, higher cure and treatment completion rates, significant gain in body weight and body composition as well as better performance status. The Government of India has various social support schemes (including nutrition supplementation schemes) and policies, at the Centre as well as State levels. Here we discuss some successful examples and suggest a few solutions to address this gap; like considering TB patients as a vulnerable group for “Targeted Public Distribution System” and providing extra rations for the duration of treatment. Recommendations for the research community, civil societies, government organizations, non-governmental and corporate sector on the actions needed to achieve the goals of the End TB Strategy are also provided. Ultimately, reduction of TB burden in India and its elimination will require improving the nutritional status of the community as a whole.
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Affiliation(s)
- C Padmapriyadarsini
- Department of Clinical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - M Shobana
- Department of Home Science, Bharathidasan Government College for Women, Puducherry, India
| | - M Lakshmi
- Medical & Rural Health Services (TB), Tamil Nadu, India
| | - T Beena
- Department of Socio-Behavioral Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Soumya Swaminathan
- National Institute for Research in Tuberculosis, Chennai, Tamil Nadu; Director-General, Indian Council of Medical Research & Secretary, Department of Health Research, Government of India, New Delhi, India
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Naik AL, Rajan MG, Manjrekar PA, Shenoy MT, Shreelata S, Srikantiah RM, Hegde A. Effect of DOTS Treatment on Vitamin D Levels in Pulmonary Tuberculosis. J Clin Diagn Res 2017; 11:BC18-BC22. [PMID: 28571130 PMCID: PMC5449776 DOI: 10.7860/jcdr/2017/24501.9759] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/05/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Vitamin D (Vit D) modulates a variety of processes and regulatory systems including host defense, inflammation, immunity, and repair. Vit D Deficiency (VDD) is been implicated as a cause in diabetes, immune dysfunction and Tuberculosis (TB). Impaired metabolism of Vit D and an adverse outcome is associated with Pulmonary Tuberculosis (PTB). Directly Observed Treatment Short Course (DOTS) consist of drugs like rifampicin and isoniazid, which respectively cause accelerated loss of Vit D due to increased clearance and impairment of 25-hydroxylation causing diminished Vit D action. AIM The aim of the present study was to estimate and compare serum Vit D status in newly diagnosed PTB patients before and after DOTS to validate the supplementation of Vit D in PTB patients. MATERIALS AND METHODS Forty four newly diagnosed PTB patients of both the sexes in the age group of 18 to 60 years before starting DOTS were recruited to participate in this non- randomized controlled trial with their voluntary consent. Vit D status in these patients and the effect of DOTS on Vit D were evaluated. RESULTS Mean Vit D levels of the study population aged 43±13 years was 20.74 ng/ml (normal >30 ng/ml) at the time of diagnosis. After completion of six months of therapy mean Vit D reduced to 17.49 ng/ml (p-value=0.041). On individual observations, 70% of the participants showed a decrease in Vit D levels from their baseline, whereas 30% showed an increase. Comparison between the two groups indicated the possible role of younger age in the improved status. CONCLUSION VDD was seen in PTB patients, which worsened in majority of the study population after treatment; hence it would be advisable to recommend Vit D supplementation in PTB patients for a better outcome.
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Affiliation(s)
- Akshatha Lalesh Naik
- Assistant Professor, Department of Biochemistry, Shridevi Institute of Medical Sciences and Research Hospital, Tumkur, Karnataka, India
| | - Madan Gopal Rajan
- Assistant Professor, Department of Biochemistry, AJ Institute of Medical Sciences, Mangalore, Karnataka, India
| | - Poornima A. Manjrekar
- Professor and Head, Department of Biochemistry, Kasturba Medical College, Mangalore, karnataka, India
| | - Mamatha T. Shenoy
- Assistant Professor, Department of Biochemistry, KVG Medical College and Hospital, Sullia, Karnataka, India
| | - Souparnika Shreelata
- Junior Research Fellow, Department of Biochemistry, Kasturba Medical College, Mangalore, Karnataka, India
| | - Rukmini Mysore Srikantiah
- Associate Professor, Department of Biochemistry, Kasturba Medical College, Mangalore, Karnataka, India
| | - Anupama Hegde
- Associate Professor, Department of Biochemistry, Kasturba Medical College, Mangalore, Karnataka, India
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Patra J, Jha P, Rehm J, Suraweera W. Tobacco smoking, alcohol drinking, diabetes, low body mass index and the risk of self-reported symptoms of active tuberculosis: individual participant data (IPD) meta-analyses of 72,684 individuals in 14 high tuberculosis burden countries. PLoS One 2014; 9:e96433. [PMID: 24789311 PMCID: PMC4008623 DOI: 10.1371/journal.pone.0096433] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 04/07/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The effects of multiple exposures on active tuberculosis (TB) are largely undetermined. We sought to establish a dose-response relationship for smoking, drinking, and body mass index (BMI) and to investigate the independent and joint effects of these and diabetes on the risk of self-reported symptoms of active TB disease. METHODS AND FINDINGS We analyzed 14 national studies in 14 high TB-burden countries using self-reports of blood in cough/phlegm and cough lasting > = 3 weeks in the last year as the measures of symptoms of active TB. The random effect estimates of the relative risks (RR) between active TB and smoking, drinking, diabetes, and BMI<18.5 kg/m2 were reported for each gender. Floating absolute risks were used to examine dyads of exposure. Adjusted for age and education, the risks of active TB were significantly associated with diabetes and BMI<18.5 kg/m2 in both sexes, with ever drinking in men and with ever smoking in women. Stronger dose-response relationships were seen in women than in men for smoking amount, smoking duration and drinking amount but BMI<18.5 kg/m2 showed a stronger dose-response relationship in men. In men, the risks from joint exposures were statistically significant for diabetics with BMI<18.5 kg/m2 (RR = 6.4), diabetics who smoked (RR = 3.8), and diabetics who drank alcohol (RR = 3.2). The risks from joint risk factors were generally larger in women than in men, with statistically significant risks for diabetics with BMI<18.5 kg/m2 (RR = 10.0), diabetics who smoked (RR = 5.4) and women with BMI<18.5 kg/m2 who smoked (RR = 5.0). These risk factors account for 61% of male and 34% of female estimated TB incidents in these 14 countries. CONCLUSIONS Tobacco, alcohol, diabetes, and low BMI are significant individual risk factors but in combination are associated with triple or quadruple the risk of development of recent active TB. These risk factors might help to explain the wide variation in TB across countries.
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Affiliation(s)
- Jayadeep Patra
- Centre for Global Health Research, St Michael's Hospital, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Prabhat Jha
- Centre for Global Health Research, St Michael's Hospital, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Jürgen Rehm
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Centre for Addiction and Mental Health, Toronto, Canada
| | - Wilson Suraweera
- Centre for Global Health Research, St Michael's Hospital, Toronto, Canada
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