Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.

METHODS

22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.

FINDINGS

Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.

INTERPRETATION

Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.

FUNDING

Bill & Melinda Gates Foundation.

Bioaccumulation of lead in different organs of Ctenopharyngodon Idella (grass fish) and Tor putitora (Mahseer) fish

Abstract Bioaccumulation of toxic heavy metals in the human body can give rise to adverse health effects, the severity of which depends upon their dosage and duration of exposure. In this study, yearlings of two different species of edible fish, i.e., Tor putitora (Mahseer) and Ctenopharyngodon Idella (grass carp), were exposed to different concentrations of lead nitrate in a controlled environment of aquarium for three different lengths of duration (14, 28, and 60 days). The bioaccumulation of lead in different organs, including gills, skin, muscles, liver, intestine, and swim bladder of the fish, was assessed using atomic absorption spectrometry. Generally, the highest lead concentration was observed in the gills and lowest in the muscles for both species at each experimental dosage and duration. In 14-days exposure, the relative pattern of bioaccumulation in different organs was observed as gill > liver > skin > intestine > swim bladder > muscle for both fish species. Similarly, the pattern of bioaccumulation observed in 28-days exposure was as: gill > liver > intestine > skin > swim bladder > muscle in both species. Whereas, pattern in 60-days exposure was observed as gill > liver > intestine > swim bladder > muscle > skin. The data shows that grass carp had stored higher concentrations of lead than Mahseer, which may be attributed to the fact that they are omnivorous. Furthermore, the lowest bioaccumulation was recorded in the muscles until the 56th day of the exposure, after which the concentration steadily increased in the muscles. The observed pattern highlights the importance of exposure’s duration to lead; chronic exposure could result in its bioaccumulation at toxic concentrations in the muscles, which is particularly of concern because the fish muscles are heavily consumed as food worldwide.

The level and distribution of selected organochlorine pesticides in water of River Satluj Pakistan

The study was aimed to identify different environmental factors (selected organochlorine pesticides) affecting the river water of Satluj. River Sutlej is about 1400 kilometers long and its water is extensively used for irrigation in Punjab, located both in India and Pakistan, which was also a reason of dispute between both countries for its water share. The study area was divided into four zones, Sulemanki Zone, Islam Zone, Mailsi Syphone Zone and Panjnad Zone. Liquid Liquid Extraction (LLE) technique was used for the collected water samples followed by high performance liquid chromatography (HPLC) UV-Visible detector The current finding revealed that aldrin was not detected during summer period in water samples of SZ-1 (Sulemanki Barrage), SZ-2 and SZ-3 (Maisli Siphon) of the study area. Lindane and DDE were found more in the samples of sediments from the study area at SZ-4 ranging from 2.238-8.226 ppb and 4.234-6.876 ppb, respectively. Heaptachlor (in sediments) was found to be0.032-234 ppb only at SZ-4.Endosulfan concentrations in water (winter) at SZ-3 was 0.06 ppb and at SZ-4,it was 0.05 ppb; dieldrin in water (winter) at SZ-4 was 0.0314 ppb and heptachlor was detected at SZ-1 (0.0315 ppb) and SZ-2 (0.0310 ppb) in water during winter season, were reaching to the Maximum Concentrations Limits (MCL), while all other residues investigated were found below the MCLin all the compartments of the study area set by various agencies like WHO/FAO- Codex Alimenterious. Present findings revealed that although the organochlorine pesticides are banned for agricultural use in many countries, including Pakistan, their presence in various samples might be due to illegal use of these pesticides in the study area and its neighboring regions. The overall study area comprises of mainly urban, suburban and agricultural land being the largest cotton growing area of the country. There is a need to take serious steps to minimize water pollution caused by pesticides to achieve a healthy lifestyle.

Presence of selected organochlorine pesticides (OCPs) in sediments and biota of River Satluj, Pakistan: first report

Abstract In the developed countries, the use of OCPs (organochlorine pesticides) has been banned. However, in South Asia several of them are still in use. In Pakistan and India a constant addition of OCPs into the atmosphere has been indicated by various researchers. In this study levels of selected organochlorine pesticide residues were assessed in sediment and biota collected from four (4) water reservoirs (3 Barrages & 1 Siphon) on the River Satluj Pakistan, along 231 miles (372 km) of River stretch which was further divided into 12 sampling sites. It was aimed to find out the levels of organochlorine pesticide (OCPs) residues in sediments and from selected fish species (Labeo rohita, Wallagu attu, Cyprinus carpio) of the River Satluj Pakistan. The Organochlorine residues (seven pesticides) present in samples of sediments and biota were investigated through multi residue method, using Gas Chromatograph (GC-ECD).In the current study, the concentration of DDT, was investigated in Wallago attu (0.786-3.987 ppb), Labeo rohita (0.779-4.355 ppb) and Cyprinus carpio (1.234-5.654 ppb). DDE was also found in Cyprinus carpio (1.244-6.322 ppb), Wallag attu (0.877-4.221 ppb) and Labeo rohita (2.112-5.897 ppb). Aldrin was not observed in Labeo rohita and Wallago attu. Currently, lindane and DDE was found predominately high in the sediments of study area at SZ-4 (Panjnad Barrage) ranging (2.238-8.226 ppb) and (4.234-6.876 ppb), respectively. Heaptachlor was found only at SZ-4 (Panjnad Barrage) from the sediments with concentration ranging (0.032-234 ppb). In short all other residues investigated were found below the MCL (maximum concentration level) in all the compartments of the study area set by various agencies like WHO/FAO- Codex Alimenterious.

Downregulation of nc886 contributes to prostate cancer cell invasion and TGFβ1-induced EMT

Epithelial-to-mesenchymal transition (EMT) activation is important in cancer progression and metastasis. Evidence indicates that nc886 is a representative Pol III gene that processes microRNA products via Dicer and further downregulates its target gene transforming growth factor- β1 (TGF-β1), which is the most prominent inducer of EMT in prostate cancer (PC). Consistent with the previous literature, we found that nc886 downregulation was strongly associated with metastatic behavior and showed worse outcomes in PC patients. However, little is known about the association between nc886 and the EMT signaling pathway. We developed a PC cell model with stable overexpression of nc886 and found that nc886 changed cellular morphology and drove MET. The underlying mechanism may be related to its promotion of SNAIL protein degradation via ubiquitination, but not to its neighboring genes, TGFβ-induced protein (TGFBI) and SMAD5, which are Pol II-transcribed. TGF-β1 also override nc886 promotion of MET via transient suppression the transcription of nc886, promotion of TGFBI or increase in SMAD5 phosphorylation. Both nc886 inhibition and TGFBI activation occur regardless of their methylation status. The literature suggests that MYC inhibition by TGF-β1 is attributed to nc886 downregulation. We incidentally identified MYC-associated zinc finger protein (MAZ) as a suppressive transcription factor of TGFBI, which is controlled by TGF-β1. We elucidate a new mechanism of TGF-β1 differential control of Pol II and the transcription of its neighboring Pol III gene and identify a new EMT unit consisting of nc886 and its neighboring genes.

Sahel rainfall strength and onset improvements due to more realistic Atlantic cold tongue development in a climate model

The simulation of Sahel rainfall and its onset during the West African Monsoon (WAM) remains a challenge for current state-of-the-art climate models due to their persistent biases, especially in the tropical Atlantic region. Here we show that improved representation of Atlantic Cold Tongue (ACT) development is essential for a more realistic seasonal evolution of the WAM, which is due to a further inland migration of the precipitation maximum. The observed marked relationship between ACT development and Sahel rainfall onset only can be reproduced by a climate model, the Kiel Climate Model (KCM), when sufficiently high resolution in its atmospheric component is employed, enabling enhanced equatorial Atlantic interannual sea surface temperature variability in the ACT region relative to versions with coarser atmospheric resolution. The ACT/Sahel rainfall relationship in the model critically depends on the correct seasonal phase-locking of the interannual variability rather than on its magnitude. We compare the KCM results with those obtained from climate models participating in the Coupled Model Intercomparison Project phase 5 (CMIP5).

Synovium as a widespread pathway to the adjacent joint in undifferentiated high-grade pleomorphic sarcoma of the tibia: A case report

RATIONALE

Undifferentiated high-grade pleomorphic sarcoma (UPS), originated from bone, is a rare tumor, accounting for 2% to 5% of all primary maligment bone neoplasms. Skip lesion can be found in undifferentiated high-grade pleomorphic sarcoma of bone (UPS-B). However, the direct invasion across the articular synovium to bone has not been reported previously.

PATIENT CONCERNS

We report an unusual case of a 65-year-old man complained of a year history of pain, swelling, and limitation of activity in the left knee joint. At the proximal tibia, there was extensive invasion of articular synovium, which provides a direct anatomic pathway for the tumor invasion to the adjacent bone, including patella and femoral condyle.

DIAGNOSES

Magnetic resonance imaging was important in defining the marrow involvement and joint invasion, including the thickening articular synovium. Subsequent pathological examination confirmed the diagnosis of UPS.

INTERVENTIONS

The patient underwent an extensive resection of the knee joint, except for the patellar.

OUTCOMES

After operation, routine chemotherapy was performed. Unfortunately, half a year later, soft tissue swelling of whole thigh was found. Then this patient came our hospital again. Positron emission tomography imaging showed there was recurrence of UPS with lung metastasis. A week later, this patient died.

LESSONS

In contrast to frequent infiltration pathway, the articular synovium as a media for this tumor spread is rare. This study adds a better understanding of this direct invasion way to the medical literature.

Cementoma of the calcaneus: a case report

Background

The cementoma is a common disease of the dental root apex, which generally occurs in the maxilla and the mandible, but the cementoma occurring in the long bone is rare. Moreover, the incidence of cementoma in the calcaneus is extremely infrequent.

Case presentation

The present study reports an unusual case of a 19-year-old girl, who complained of pain in the left heel. Subsequent radiographs and computed tomography (CT) were used in the diagnosis. The imaging features of the lesion included a radiopaque matrix and radiolucent tissue, particularly an arc-shaped fat band. An excisional biopsy was performed. Histopathological examination confirmed the diagnosis of cementoma in the calcaneus. After the operation, the patient was followed up without recurrence.

Conclusions

Imaging examination plays an important role in the differential diagnosis of cementoma of the calcaneus.

Sclerotic multiple myeloma with an unusual sunburst periosteal reaction occurring in the sternum

Multiple myeloma is a disseminated neoplastic monoclonal gammopathy that usually affects the skull, clavicle, rib, pelvis, spinal column, and proximal portions of the humerus and femur. The initial manifestation of multiple myeloma in the sternum is rare. The classic radiological presentations of multiple myeloma are multiple "punched-out" areas of bone destruction, expansile lytic lesions, and generalized osteoporosis. Primary sclerotic presentation is rare and occurs in only 3 % of cases. A sclerotic multiple myeloma with a sunburst periosteal reaction occurring in the sternum has not been reported in the English literature. We report a case of sclerotic multiple myeloma of a 49-year-old woman. In the sternum, the lesion displayed extensive sclerosis mixed with mottled lytic areas with a sunburst periosteal reaction occurring in the periphery, which radiologically mimicked an osteosarcoma. Multiple focal areas of sclerosis were also found in the right clavicle, pelvis, multiple ribs, and vertebrae.

Imaging appearance of giant cell tumour of the spine above the sacrum

Giant cell tumour (GCT) of the spine is rarely encountered in daily clinical practice. Most of the tumours occur at the sacrum instead of at the spine above the sacrum, which has been reported to account for 1.3-9.3% of all spine GCTs. This article is a review of our radiological experience of the diagnosis of spine GCT above the sacrum based on 34 patients at a single institution. The purpose of this pictorial review is to highlight the imaging findings of GCT and to provide clues that may distinguish it from other, more common neoplasms.

Axial view of acetabular anterior column: a new X-ray projection of percutaneous screw placement

INTRODUCTION

To search for a new radiographic view/projection of the acetabular anterior column to provide a safe guide for percutaneous screw placement for acetabular fractures.

MATERIALS AND METHODS

Eight pelvic specimens taken from normal adult cadavers were positioned in a supine position on the operating table. First, the ipsilateral ilium-oblique view of the observed side was obtained on C-arm fluoroscopy by tilting the C-arm approximately 35° toward the contralateral hip joint. Then, the tilting angle of the C-arm was changed gradually until an oval track image (acetabular anterior column axial view) appeared. The oval shadow was clear only in one position as the angle of the C-arm was changed toward the caudal side of the operating table. A guide pin was put on the skin of the cadaver, and the location and tilting direction of the guide pin were adjusted under C-arm fluoroscopy until the pin's shadow became a point in the center of the oval track. Then, the guide pin was inserted into the bone using a battery-powered drill. The degree of inclination of the guide pin in the cadaver in the frontal and sagittal planes was measured using computed tomography (CT).

RESULTS

Axial views of the anterior column were found successfully in all of the pelvic specimens, and the guide pins were inserted accurately into the acetabular anterior column under C-arm fluoroscopic guidance. On the CT-reconstructed image, the average degree of angle between the guide pin and the sagittal plane was 33.6° (range 29.6°-36.5°). The average angle between the guide pin and the transverse plane was 59.1° (range 56.4°-63.2°).

CONCLUSION

This axial view of the acetabular anterior column is a novel X-ray projection which provides an optimal method for guiding percutaneous insertion of anterior column screws for acetabular fractures.

[Diagnosis of bovine viral respiratory diseases]

Enzootic bronchopneumonia (EBP) is an infectious, multifactorial respiratory disease of cattle. Different viruses may be involved in its pathogenesis. In this study an adapted method of endoscopic bronchoalveolar lavage (BAL) of caudal parts of the right cranial lung lobe was established and evaluated. The obtained bronchoalveolar lavage fluid (BALF) served as template for the detection of BRSV, BPIV-3 and BCoV specific nucleic acids by RT-PCR. BALF samples of 44 cattle affected with respiratory disease were compared to nasal swabs in their reliability to detect the causative agent(s). In 6/7 animals tested positive for BRSV, RNA of this virus was detected in the BALF, in 4 animals it could be found in the nasal swabs. In two of the three BPIV-3 positive animals, the BALF was the only material that tested positive. The most reliable samples for detection of 15 BCoV positive animals were the nasal swabs. BAL was easy to perform, it led to severe coughing in one case and moderate worsening of dyspnoe in three cases. In conclusion this study shows that BAL of the right cranial lung lobe is in many cases the only tool to detect BRSV and BPIV-3, major viral triggers of EBP.

Nasal polyps do not contain olfactory structures

BACKGROUND

Nasal polyposis can lead to olfactory dysfunction, either due to physical obstruction of the olfactory cleft or physiological disruption of the olfactory neuroepithelium. Where medical therapy has failed to relieve symptoms of nasal polyposis, surgical excision can be considered. However, removal of polyps medial to the middle turbinate is controversial: some believe this will relieve physical obstruction to odourants, others state that removal here risks excising olfactory neuroepithelium.

METHODS

We stained 25 nasal polypectomy samples from the area medial to the middle turbinate with olfactory marker protein.

RESULTS

We confirmed that our staining method worked on normal olfactory tissue. However, no positive staining of nasal polyps was demonstrated.

CONCLUSION

We conclude that nasal polyps medial to the middle turbinate do not contain olfactory neurons, and surgical excision is not contraindicated.

El Nino/Southern Oscillation response to global warming

The El Niño/Southern Oscillation (ENSO) phenomenon, originating in the Tropical Pacific, is the strongest natural interannual climate signal and has widespread effects on the global climate system and the ecology of the Tropical Pacific. Any strong change in ENSO statistics will therefore have serious climatic and ecological consequences. Most global climate models do simulate ENSO, although large biases exist with respect to its characteristics. The ENSO response to global warming differs strongly from model to model and is thus highly uncertain. Some models simulate an increase in ENSO amplitude, others a decrease, and others virtually no change. Extremely strong changes constituting tipping point behavior are not simulated by any of the models. Nevertheless, some interesting changes in ENSO dynamics can be inferred from observations and model integrations. Although no tipping point behavior is envisaged in the physical climate system, smooth transitions in it may give rise to tipping point behavior in the biological, chemical, and even socioeconomic systems. For example, the simulated weakening of the Pacific zonal sea surface temperature gradient in the Hadley Centre model (with dynamic vegetation included) caused rapid Amazon forest die-back in the mid-twenty-first century, which in turn drove a nonlinear increase in atmospheric CO(2), accelerating global warming.

El Nino/Southern Oscillation response to global warming

The El Niño/Southern Oscillation (ENSO) phenomenon, originating in the Tropical Pacific, is the strongest natural interannual climate signal and has widespread effects on the global climate system and the ecology of the Tropical Pacific. Any strong change in ENSO statistics will therefore have serious climatic and ecological consequences. Most global climate models do simulate ENSO, although large biases exist with respect to its characteristics. The ENSO response to global warming differs strongly from model to model and is thus highly uncertain. Some models simulate an increase in ENSO amplitude, others a decrease, and others virtually no change. Extremely strong changes constituting tipping point behavior are not simulated by any of the models. Nevertheless, some interesting changes in ENSO dynamics can be inferred from observations and model integrations. Although no tipping point behavior is envisaged in the physical climate system, smooth transitions in it may give rise to tipping point behavior in the biological, chemical, and even socioeconomic systems. For example, the simulated weakening of the Pacific zonal sea surface temperature gradient in the Hadley Centre model (with dynamic vegetation included) caused rapid Amazon forest die-back in the mid-twenty-first century, which in turn drove a nonlinear increase in atmospheric CO(2), accelerating global warming.

Advancing decadal-scale climate prediction in the North Atlantic sector

The climate of the North Atlantic region exhibits fluctuations on decadal timescales that have large societal consequences. Prominent examples include hurricane activity in the Atlantic, and surface-temperature and rainfall variations over North America, Europe and northern Africa. Although these multidecadal variations are potentially predictable if the current state of the ocean is known, the lack of subsurface ocean observations that constrain this state has been a limiting factor for realizing the full skill potential of such predictions. Here we apply a simple approach-that uses only sea surface temperature (SST) observations-to partly overcome this difficulty and perform retrospective decadal predictions with a climate model. Skill is improved significantly relative to predictions made with incomplete knowledge of the ocean state, particularly in the North Atlantic and tropical Pacific oceans. Thus these results point towards the possibility of routine decadal climate predictions. Using this method, and by considering both internal natural climate variations and projected future anthropogenic forcing, we make the following forecast: over the next decade, the current Atlantic meridional overturning circulation will weaken to its long-term mean; moreover, North Atlantic SST and European and North American surface temperatures will cool slightly, whereas tropical Pacific SST will remain almost unchanged. Our results suggest that global surface temperature may not increase over the next decade, as natural climate variations in the North Atlantic and tropical Pacific temporarily offset the projected anthropogenic warming.

Localization of brain abnormal signal sources using blind source separation

An effective and simple algorithm for localization of abnormal sources of the EEG signals within the brain has been developed here. In this method the signals are separated first, then the estimated independent components are lowpass filtered and normalized. In the next stage the correlation values between the estimated sources and the electrode signals are measured. On the other hand the sources with known locations are separated offline using narrowband bandpass filters. Finally, as the main contribution of the paper the mixing matrix is estimated using the information about the known sources and the estimated sources. The locations of the unknown sources are then measured with respect to the columns of the mixing matrix and the geometrical properties of the head and electrode locations.

The Challenge of Long-Term Climate Change

Climate policy needs to address the multidecadal to centennial time scale of climate change. Although the realization of short-term targets is an important first step, to be effective climate policies need to be conceived as long-term programs that will achieve a gradual transition to an essentially emission-free economy on the time scale of a century. This requires a considerably broader spectrum of policy measures than the primarily market-based instruments invoked for shorter term mitigation policies. A successful climate policy must consist of a dual approach focusing on both short-term targets and long-term goals.

Enhanced contact tracing and spatial tracking of Mycobacterium tuberculosis infection by enumeration of antigen-specific T cells

BACKGROUND

Identification of individuals latently infected with Mycobacterium tuberculosis is an important part of tuberculosis control. The current method, the tuberculin skin test (TST), has poor specificity because of the antigenic cross-reactivity of purified protein derivative (PPD) with M bovis BCG vaccine and environmental mycobacteria. ESAT-6 is a secreted antigen that is highly specific for M tuberculosis complex, but is absent from M bovis BCG. With an enzyme-linked immunospot (ELISPOT) assay for interferon gamma, we have identified ESAT-6-specific T cells as an accurate marker of M tuberculosis infection.

METHODS

We did a prospective, masked study of 50 healthy contacts, with varying but well defined degrees of exposure to M tuberculosis, who attended an urban contact-tracing clinic. We assessed and compared the efficacy of our assay and TST for detection of symptomless infected individuals by correlation of test results with the degree of exposure to an infectious index case.

FINDINGS

The ESAT-6 ELISPOT assay results had a strong positive relation with increasing intensity of exposure (odds ratio=9.0 per unit increase in level of exposure [95% CI 2.6--31.6], p=0.001), whereas TST results had a weaker relation with exposure (1.9 [1.0--3.5], p=0.05). By contrast, ELISPOT results were not correlated with BCG vaccination status (p=0.7), whereas TST results were significantly more likely to be positive in BCG-vaccinated contacts (12.1 [1.3--115.7], p=0.03).

INTERPRETATION

This new antigen-specific T cell-based assay could allow more accurate identification of symptom-free individuals recently exposed to M tuberculosis, and thereby help to improve tuberculosis control.

Rapid detection of Mycobacterium tuberculosis infection by enumeration of antigen-specific T cells

There is no reliable means of detecting latent M. tuberculosis infection, and even in patients with active tuberculosis, infection is often unconfirmed. We hypothesized that M. tuberculosis antigen-specific T cells might reliably indicate infection. We enumerated peripheral blood-derived interferon gamma (IFN-gamma)-secreting T cells responding to epitopes from ESAT-6, an antigen that is highly specific for M. tuberculosis complex but absent from BCG, in four groups of individuals. Forty-five of 47 patients with bacteriologically confirmed tuberculosis had ESAT-6-specific IFN-gamma-secreting T cells, compared with four of 47 patients with nontuberculous illnesses, indicating that these T cells are an accurate marker of M. tuberculosis infection. This assay thus has a sensitivity of 96% (95% confidence interval [CI] 92-100) for detecting M. tuberculosis infection in this patient population. By comparison, of the 26 patients with tuberculosis who had a diagnostic tuberculin skin test (TST), only 18 (69%) were positive (p = 0.003). In addition, 22 of 26 (85%) TST-positive exposed household contacts had ESAT-6-specific T cells, whereas zero of 26 unexposed BCG-vaccinated subjects responded. This approach enables rapid detection of M. tuberculosis infection in patients with active tuberculosis and in exposed asymptomatic individuals at high risk of latent infection; it also successfully distinguishes between M. tuberculosis infection and BCG vaccination. This capability may facilitate tuberculosis control in nonendemic regions.

High frequencies of circulating IFN-gamma-secreting CD8 cytotoxic T cells specific for a novel MHC class I-restricted Mycobacterium tuberculosis epitope in M. tuberculosis-infected subjects without disease

MHC class I-restricted CD8 cytotoxic T lymphocytes (CTL) are essential for protective immunity to Mycobacterium tuberculosis in animal models but their role in humans remains unclear. We therefore studied subjects who had successfully contained M. tuberculosis infection in vivo, i.e. exposed healthy household contacts and individuals with inactive self-healed pulmonary tuberculosis. Using the ELISPOT assay for IFN-gamma, we screened peptides from ESAT-6, a secreted antigen that is highly specific for M. tuberculosis. We identified a novel nonamer epitope: unstimulated peripheral blood-derived CD8 T cells displayed peptide-specific IFN-gamma release ex vivo while CD8 T cell lines and clones exhibited HLA-A68.02-restricted cytolytic activity and recognized endogenously processed antigen. The frequency of CD8 CTL specific for this single M. tuberculosis epitope, 1/2500 peripheral blood lymphocytes, was equivalent to the combined frequency of all IFN-gamma-secreting purified protein derivative-reactive T cells ex vivo. This highly focused CTL response was maintained in an asymptomatic contact over 2 years and is the most potent antigen-specific antimycobacterial CD8 CTL response hitherto described. Thus, human M. tuberculosis-specific CD8 CTL are not necessarily associated with active disease per se. Rather, our results are consistent with a protective role for these ESAT-6-specific CD8 T cells in the long-term control of M. tuberculosis in vivo in humans.

Influence of vitamin D deficiency and vitamin D receptor polymorphisms on tuberculosis among Gujarati Asians in west London: a case-control study

BACKGROUND

Susceptibility to disease after infection by Mycobacterium tuberculosis is influenced by environmental and host genetic factors. Vitamin D metabolism leads to activation of macrophages and restricts the intracellular growth of M. tuberculosis. This effect may be influenced by polymorphisms at three sites in the vitamin D receptor (VDR) gene. We investigated the interaction between serum vitamin D (25-hydroxycholecalciferol) concentrations and VDR genotype on susceptibility to tuberculosis.

METHODS

This study was a hospital-based case-control analysis of Asians of Gujarati origin, a mainly vegetarian immigrant population with a high rate of tuberculosis. We typed three VDR polymorphisms (defined by the presence of restriction endonuclease sites for Taq1, Bsm1, and Fok1) in 91 of 126 untreated patients with tuberculosis and 116 healthy contacts who had been sensitised to tuberculosis. Serum 25-hydroxycholecalciferol was recorded in 42 contacts and 103 patients.

FINDINGS

25-hydroxycholecalciferol deficiency was associated with active tuberculosis (odds ratio 2.9 [95% CI 1.3-6.5], p=0.008), and undetectable serum 25-hydroxycholecalciferol (<7 nmol/L) carried a higher risk of tuberculosis (9.9 [1.3-76.2], p=0.009). Although there was no significant independent association between VDR genotype and tuberculosis, the combination of genotype TT/Tt and 25-hydroxycholecalciferol deficiency was associated with disease (2.8 [1.2-6.5]) and the presence of genotype ff or undetectable serum 25-hydroxycholecalciferol was strongly associated with disease (5.1 [1.4-18.4]).

INTERPRETATION

25-hydroxycholecalciferol deficiency may contribute to the high occurrence of tuberculosis in this population. Polymorphisms in the VDR gene also contribute to susceptibility when considered in combination with 25-hydroxycholecalciferol deficiency.

Xenovulene A, a novel GABA-benzodiazepine receptor binding compound produced by Acremonium strictum

Xenovulene A, a novel inhibitor of benzodiazepine binding to the GABA-benzodiazepine receptor is produced by submerged fermentation of Acremonium strictum. It was isolated from the mycelium by solvent extraction and purified by chromatography on Sephadex LH-20 and octadecyl silica. The structure of xenovulene A was determined to be a novel oxygenated sesquiterpene containing a humulene moiety by interpretation of various spectroscopic data, especially from 2D NMR experiments. Xenovulene A inhibited binding of the benzodiazepine, flunitrazepam, with an IC50 of 40 nM in an in vitro assay using bovine synaptosome membrane preparations.

Causes of Decadal Climate Variability over the North Pacific and North America

The cause of decadal climate variability over the North Pacific Ocean and North America is investigated by the analysis of data from a multidecadal integration with a state-of-the-art coupled ocean-atmosphere model and observations. About one-third of the low-frequency climate variability in the region of interest can be attributed to a cycle involving unstable air-sea interactions between the subtropical gyre circulation in the North Pacific and the Aleutian low-pressure system. The existence of this cycle provides a basis for long-range climate forecasting over the western United States at decadal time scales.