Mortality during treatment for tuberculosis; a review of surveillance data in a rural county in Kenya

Background

Globally in 2016, 1.7 million people died of Tuberculosis (TB). This study aimed to estimate all-cause mortality rate, identify features associated with mortality and describe trend in mortality rate from treatment initiation.

Method

A 5-year (2012–2016) retrospective analysis of electronic TB surveillance data from Kilifi County, Kenya. The outcome was all-cause mortality within 180 days after starting TB treatment. The risk factors examined were demographic and clinical features at the time of starting anti-TB treatment. We performed survival analysis with time at risk defined from day of starting TB treatment to time of death, lost-to-follow-up or completing treatment. To account for ‘lost-to-follow-up’ we used competing risk analysis method to examine risk factors for all-cause mortality.

Results

10,717 patients receiving TB treatment, median (IQR) age 33 (24–45) years were analyzed; 3,163 (30%) were HIV infected. Overall, 585 (5.5%) patients died; mortality rate of 12.2 (95% CI 11.3–13.3) deaths per 100 person-years (PY). Mortality rate increased from 7.8 (95% CI 6.4–9.5) in 2012 to 17.7 (95% CI 14.9–21.1) in 2016 per 100PY (P_trend<0.0001). 449/585 (77%) of the deaths occurred within the first three months after starting TB treatment. The median time to death (IQR) declined from 87 (40–100) days in 2012 to 46 (18–83) days in 2016 (P_trend = 0·04). Mortality rate per 100PY was 7.3 (95% CI 6.5–7.8) and 23.1 (95% CI 20.8–25.7) among HIV-uninfected and HIV-infected patients respectively. Age, being a female, extrapulmonary TB, being undernourished, HIV infected and year of diagnosis were significantly associated with mortality.

Conclusions

We found most deaths occurred within three months and an increasing mortality rate during the time under review among patients on TB treatment. Our results therefore warrant further investigation to explore host, disease or health system factors that may explain this trend.

Clinical, microbiologic, and immunologic determinants of mortality in hospitalized patients with HIV-associated tuberculosis: A prospective cohort study

BACKGROUND

In high-burden settings, case fatality rates are reported to be between 11% and 32% in hospitalized patients with HIV-associated tuberculosis, yet the underlying causes of mortality remain poorly characterized. Understanding causes of mortality could inform the development of novel management strategies to improve survival. We aimed to assess clinical and microbiologic determinants of mortality and to characterize the pathophysiological processes underlying death by evaluating host soluble inflammatory mediators and determined the relationship between these mediators and death as well as biomarkers of disseminated tuberculosis.

METHODS AND FINDINGS

Adult patients with HIV hospitalized with a new diagnosis of HIV-associated tuberculosis were enrolled in Cape Town between 2014 and 2016. Detailed tuberculosis diagnostic testing was performed. Biomarkers of tuberculosis dissemination and host soluble inflammatory mediators at baseline were assessed. Of 682 enrolled participants, 576 with tuberculosis (487/576, 84.5% microbiologically confirmed) were included in analyses. The median age was 37 years (IQR = 31-43), 51.2% were female, and the patients had advanced HIV with a median cluster of differentiation 4 (CD4) count of 58 cells/L (IQR = 21-120) and a median HIV viral load of 5.1 log10 copies/mL (IQR = 3.3-5.7). Antituberculosis therapy was initiated in 566/576 (98.3%) and 487/576 (84.5%) started therapy within 48 hours of enrolment. Twelve-week mortality was 124/576 (21.5%), with 46/124 (37.1%) deaths occurring within 7 days of enrolment. Clinical and microbiologic determinants of mortality included disseminated tuberculosis (positive urine lipoarabinomannan [LAM], urine Xpert MTB/RIF, or tuberculosis blood culture in 79.6% of deaths versus 60.7% of survivors, p = 0.001), sepsis syndrome (high lactate in 50.8% of deaths versus 28.9% of survivors, p < 0.001), and rifampicin-resistant tuberculosis (16.9% of deaths versus 7.2% of survivors, p = 0.002). Using non-supervised two-way hierarchical cluster and principal components analyses, we describe an immune profile dominated by mediators of the innate immune system and chemotactic signaling (interleukin-1 receptor antagonist [IL-1Ra], IL-6, IL-8, macrophage inflammatory protein-1 beta [MIP-1β]/C-C motif chemokine ligand 4 [CCL4], interferon gamma-induced protein-10 [IP-10]/C-X-C motif chemokine ligand 10 [CXCL10], MIP-1 alpha [MIP-1α]/CCL3), which segregated participants who died from those who survived. This immune profile was associated with mortality in a Cox proportional hazards model (adjusted hazard ratio [aHR] = 2.2, 95%CI = 1.9-2.7, p < 0.001) and with detection of biomarkers of disseminated tuberculosis. Clinicians attributing causes of death identified tuberculosis as a cause or one of the major causes of death in 89.5% of cases. We did not perform longitudinal sampling and did not have autopsy-confirmed causes of death.

CONCLUSIONS

In this study, we did not identify a major contribution from coinfections to these deaths. Disseminated tuberculosis, sepsis syndrome, and rifampicin resistance were associated with mortality. An immune profile dominated by mediators of the innate immune system and chemotactic signaling was associated with both tuberculosis dissemination and mortality. These findings provide pathophysiologic insights into underlying causes of mortality and could be used to inform the development of novel treatment strategies and to develop methods to risk stratify patients to appropriately target novel interventions. Causal relationships cannot be established from this study.

Mid-upper arm circumference predicts death in adult patients admitted to a TB ward in the Philippines: A prospective cohort study

Background

The Philippines is ranked 3^rd globally for tuberculosis incidence (554/100,000 population). The tuberculosis ward at San Lazaro Hospital, Manila receives 1,800–2,000 admissions of acutely unwell patients per year with high mortality. Objectives of this prospective cohort study were to quantify the association of under-nutrition (primary) and diabetes (secondary) with inpatient mortality occurring between 3–28 days of hospital admission in patients with suspected or previously diagnosed TB.

Methods and results

We enrolled 360 adults (≥18 years); 348 were eligible for the primary analysis (alive on day 3). Clinical, laboratory, anthropometric and enhanced tuberculosis diagnostic data were collected at admission with telephone tracing for mortality up to 6 months post-discharge. In the primary analysis population (mean age 45 years, SD = 15.0 years, 70% male), 58 (16.7%) deaths occurred between day 3–28 of admission; 70 (20.1%) between day 3 and discharge and documented total post-day 3 mortality including follow-up was 96 (27.6%). In those in whom it could be assessed, body mass index (BMI) ranged from 11.2–30.6 kg/m² and 141/303 (46.5%) had moderate/severe undernutrition (BMI<17 kg/m²). A sex-specific cut-off for mid-upper arm circumference predictive of BMI<17 kg/m² was associated with inpatient Day 3–28 mortality in males (AOR = 5.04, 95% CI: 1.50–16.86; p = 0.009; p = 0.032 for interaction by sex). The inability to stand for weight/height for BMI assessment was also associated with mortality (AOR = 5.59; 95% CI 2.25–13.89; p<0.001) as was severe compared to normal/mild anaemia (AOR = 9.67; 95% CI 2.48–37.76; p<0.001). No TB specific variables were associated with Day 3–28 mortality, nor was diabetes (HbA1c ≥6.5% or diabetes treatment). Similar effects were observed when the same multivariable model was applied to confirmed TB patients only and to the outcome of all post-day 3 in-patient mortality.

Conclusion

This research supports the use of mid-upper arm circumference for triaging acutely unwell patients and the design and testing of nutrition-based interventions to improve patient outcomes.

High mortality during tuberculosis retreatment at a Ghanaian tertiary center: a retrospective cohort study

INTRODUCTION

High mortality among individuals receiving retreatment for tuberculosis (RT-TB) persists, although reasons for these poor outcomes remain unclear.

METHODS

We retrospectively reviewed 394 RT-TB patients diagnosed between January 2010 and June 2016 in Accra, Ghana.

RESULTS

Of RT-TB patients, 161 (40.9%) were treated empirically (negative/absent smear, culture or Xpert), of whom 30.4% (49/161) had only extrapulmonary TB signs or symptoms. Mortality during treatment was 19.4%; 15-day mortality was 10.8%. In multivariable proportional hazards regression, living with HIV (aHR=2.69 [95 CI: 1.51, 4.80], p<0.01) and previous loss-to-follow up (aHR=8.27 (95 CI: 1.10, 62.25), p=0.04) were associated with mortality, while drug susceptibility testing (DST, aHR=0.36 (95 CI: 0.13, 1.01), p=0.052) was protective. Isoniazid resistance was observed in 40% (23/58 tested) and rifampin resistance in 19.1% (12/63 tested).

CONCLUSION

High rates of extrapulmonary TB and smear/culture negative disease highlight the barriers to achieving DST-driven RT-TB regimens and the need for improved diagnostics. Our finding of poly-drug resistance in rifampin-susceptible cases supports access to comprehensive first line DST. Additionally, interventions to reduce mortality, especially in HIV co-infected RT-TB patients, are urgently needed.

Screening for Tuberculosis With Xpert MTB/RIF Assay Versus Fluorescent Microscopy Among Adults Newly Diagnosed With Human Immunodeficiency Virus in Rural Malawi: A Cluster Randomized Trial (Chepetsa)

BACKGROUND

Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV)-infected individuals globally. Screening for TB at the point of HIV diagnosis with a high-sensitivity assay presents an opportunity to reduce mortality.

METHODS

We performed a cluster randomized trial of TB screening among adults newly diagnosed with HIV in 12 primary health clinics in rural Thyolo, Malawi. Clinics were allocated in a 1:1 ratio to perform either point-of-care Xpert MTB/RIF assay (Xpert) or point-of-care light-emitting diode fluorescence microscopy (LED-FM) for individuals screening positive for TB symptoms. Asymptomatic participants were offered isoniazid preventive therapy in both arms. Investigators, but not clinic staff or participants, were masked to allocation. Our primary outcome was the incidence rate ratio (RR) of all-cause mortality within 12 months of HIV diagnosis.

RESULTS

Prevalent TB was diagnosed in 24 of 1001 (2.4%) individuals enrolled in clinics randomized to Xpert, compared with 10 of 841 (1.2%) in clinics randomized to LED-FM. All-cause mortality was 22% lower in the Xpert arm than in the LED-FM arm (6.7 vs 8.6 per 100 person-years; RR, 0.78 [95% confidence interval {CI}, .58-1.06]). A planned subgroup analysis suggested that participants with more advanced HIV (World Health Organization clinical stage 3 or 4) disease had lower mortality in clinics randomized to Xpert than to LED-FM (RR, 0.43 [95% CI, .22-.87]).

CONCLUSIONS

In rural Malawi, using point-of-care Xpert MTB/RIF to test symptomatic patients for TB at the time of HIV diagnosis reduced all-cause 12-month mortality among individuals with advanced HIV.

CLINICAL TRIALS REGISTRATION

NCT01450085.

Cotrimoxazole prophylaxis decreases tuberculosis risk among Asian patients with HIV

INTRODUCTION

Cotrimoxazole (CTX) is recommended as prophylaxis against Pneumocystis jiroveci pneumonia, malaria and other serious bacterial infections in HIV-infected patients. Despite its in vitro activity against Mycobacterium tuberculosis, the effects of CTX preventive therapy on tuberculosis (TB) remain unclear.

METHODS

Adults living with HIV enrolled in a regional observational cohort in Asia who had initiated combination antiretroviral therapy (cART) were included in the analysis. Factors associated with new TB diagnoses after cohort entry and survival after cART initiation were analysed using Cox regression, stratified by site.

RESULTS

A total of 7355 patients from 12 countries enrolled into the cohort between 2003 and 2016 were included in the study. There were 368 reported cases of TB after cohort entry with an incidence rate of 0.99 per 100 person-years (/100 pys). Multivariate analyses adjusted for viral load (VL), CD4 count, body mass index (BMI) and cART duration showed that CTX reduced the hazard for new TB infection by 28% (HR 0.72, 95% CI l 0.56, 0.93). Mortality after cART initiation was 0.85/100 pys, with a median follow-up time of 4.63 years. Predictors of survival included age, female sex, hepatitis C co-infection, TB diagnosis, HIV VL, CD4 count and BMI.

CONCLUSIONS

CTX was associated with a reduction in the hazard for new TB infection but did not impact survival in our Asian cohort. The potential preventive effect of CTX against TB during periods of severe immunosuppression should be further explored.

Mortality risk in the population of HIV-positive individuals in Southern China: A cohort study

To evaluate the mortality risk in the HIV-positive population, we conducted an observational cohort study involving routine data collection of HIV-positive patients who presented at HIV clinics and multiple treatment centers throughout Guangxi province, Southern China in 2011. The patients were screened for tuberculosis (TB) and tested for hepatitis B (HBV) and C (HCV) virus infections yearly. Following the registration, the cohort was followed up for a 60-month period till the end-point (December 31, 2015). Univariable and multivariable Cox proportional hazards regression models were used to analyze the hazard ratio (HR) and 95% confidence interval (95% CI) for mortality after adjusting for confounding factors stratified by patients’ sociodemographic and behavioral characteristics. HRs were compared within risk-factor levels. With the median follow-up of 3.7-person years for each individual, 5,398 (37.8%) (of 14,293 patients with HIV/AIDS) died; among whom, 78.4% were antiretroviral therapy (ART)-naïve; 43.6% presented late; and 12.2% and 3.3% of patients had Mycobacterium tuberculosis (MTB) and HBV and HCV co-infection, respectively. Of individuals with CD4 counts, those with CD4 count >350 cells/μL formed 14.0% of those who died. Furthermore, gender [multivariable HR (95% CI):1.94 (1.68–2.25)], Han ethnicity [2.15 (1.07–4.32)], illiteracy [3.28 (1.96–5.5)], elementary education [2.91 (1.8–4.72)], late presentation [2.89 (2.46–3.39)], and MTB co-infection [1.28 (1.10–1.49)] strongly increased the all-cause mortality risk of HIV-positive individuals. The HR for ART-based stratification was 0.08 (0.07–0.09); and for HBV and HCV co-infection, HR was 1.02 (0.86–1.21). The findings emphasized that accessibility to HIV testing among high-risk populations and screening for viral hepatitis and TB co-infection are important for the survival of HIV-positive individuals. Initiating early ART, even for individuals with higher CD4 counts, is advisable to help increase the prolongation of lives within the community.

Treatment of HIV among tuberculosis patients: A replication study of timing of antiretroviral therapy for HIV-1-associated tuberculosis

Co-diagnosis of HIV and tuberculosis presents a treatment dilemma. Starting both treatments at the same time can cause a flood of immune response called immune reconstitution inflammatory syndrome (IRIS) which can be lethal. But, how long to delay HIV treatment is less understood. In 2011, based on the conclusions of three separate studies, WHO recommended starting HIV treatment earlier for those with later HIV disease progression. This paper conducts a replication study of one of the three studies, by Havlir and colleagues. Using their publicly available data, we were able to replicate most of the results presented in the original paper. In our measurement and estimation analyses we use different estimation techniques to assess the robustness of the results. We find that adjusting for loss to follow-up does not affect the main results of the paper. However, an ANCOVA estimation and an instrumental variable model weaken the main result of the paper of better outcomes with early HIV treatment only for those who are sicker, reducing significance from the 5% to the 10% level. A change-point analysis also detects no changes in effect by timing of HIV treatment initiation or different thresholds of CD4 count for the primary outcome. This result suggests that the choice of start time for HIV treatment initiation should be based on other factors including potential drug interactions, overlapping side effects, a high pill burden and severity of illness rather than CD4 threshold and preset timeframes. While we caution against overgeneralizing, the result of this replication is aligned with more recent studies that show no evidence that early initiation of HIV treatment reduces mortality for any patients.

Accelerating the elimination of viral hepatitis: a Lancet Gastroenterology & Hepatology Commission

Viral hepatitis is a major public health threat and a leading cause of death worldwide. Annual mortality from viral hepatitis is similar to that of other major infectious diseases such as HIV and tuberculosis. Highly effective prevention measures and treatments have made the global elimination of viral hepatitis a realistic goal, endorsed by all WHO member states. Ambitious targets call for a global reduction in hepatitis-related mortality of 65% and a 90% reduction in new infections by 2030. This Commission draws together a wide range of expertise to appraise the current global situation and to identify priorities globally, regionally, and nationally needed to accelerate progress. We identify 20 heavily burdened countries that account for over 75% of the global burden of viral hepatitis. Key recommendations include a greater focus on national progress towards elimination with support given, if necessary, through innovative financing measures to ensure elimination programmes are fully funded by 2020. In addition to further measures to improve access to vaccination and treatment, greater attention needs to be paid to access to affordable, high-quality diagnostics if testing is to reach the levels needed to achieve elimination goals. Simplified, decentralised models of care removing requirements for specialised prescribing will be required to reach those in need, together with sustained efforts to tackle stigma and discrimination. We identify key examples of the progress that has already been made in many countries throughout the world, demonstrating that sustained and coordinated efforts can be successful in achieving the WHO elimination goals.

National scale-up of tuberculosis-human immunodeficiency virus collaborative activities in Myanmar from 2005 to 2016 and tuberculosis treatment outcomes for patients with human immunodeficiency virus-positive tuberculosis in the Mandalay Region in 2015

Background

HIV-associated TB is a serious public health problem in Myanmar. Study objectives were to describe national scale-up of collaborative activities to reduce the double burden of TB and HIV from 2005 to 2016 and to describe TB treatment outcomes of individuals registered with HIV-associated TB in 2015 in the Mandalay Region.

Methods

Secondary analysis of national aggregate data and, for treatment outcomes, a cohort study of patients with HIV-associated TB in the Mandalay Region.

Results

The number of townships implementing collaborative activities increased from 7 to 330 by 2016. The number of registered TB patients increased from 1577 to 139 625 in 2016, with the number of individuals tested for HIV increasing from 432 to 114 180 (82%) in 2016: 10 971 (10%) were diagnosed as HIV positive. Uptake of co-trimoxazole preventive therapy (CPT) and antiretroviral therapy (ART) nationally in 2016 was 77% and 52%, respectively. In the Mandalay Region, treatment success was 77% and mortality was 18% in 815 HIV-associated TB patients. Risk factors for unfavourable outcomes and death were older age (≥45 years) and not taking CPT and/or ART.

Conclusion

Myanmar is making good progress with reducing the HIV burden in TB patients, but better implementation is needed to reach 100% HIV testing and 100% CPT and ART uptake in TB-HIV co-infected patients.

Spatial patterns and effects of air pollution and meteorological factors on hospitalization for chronic lung diseases in Beijing, China

Chronic obstructive pulmonary disease (COPD), lung cancer (LC) and tuberculosis (TB) are common chronic lung diseases that generate a large disease burden and significant health care resource use in China. The aim of this study was to quantify spatial patterns and effects of air pollution and meteorological factors on hospitalization of COPD, LC and TB in Beijing. Daily counts of hospitalization for 2010 were obtained from the Beijing Urban Employees Basic Medical Insurance (UEBMI) system. Bayesian hierarchical Poisson regression models were applied to identify spatial patterns of hospitalization for COPD, LC and TB at the district level and explore associations with inhalable particulate matter (aerodynamic diameter <10 μm, PM₁₀), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), mean temperature and relative humidity. There were 18,882, 14,295 and 2,940 counts of hospitalizations for COPD, LC and TB respectively, in Beijing in 2010. Clusters of high relative risk were in different locations for the three diseases. The effect of relative humidity on COPD hospitalization was most significant with a relative risk (RR) of 1.070 (95%CI: 1.054, 1.086) per one percent increase. For lung cancer hospitalization, exposure to ambient SO₂ was associated with a RR of 1.034 (95%CI: 1.011, 1.058) per μg m^-3 increase. For tuberculosis, the effect of mean temperature was significant with a RR of 1.107 (95%CI: 1.038, 1.180) per °C increase. Risk factors and spatial patterns were different for hospitalization of non-infectious and infectious chronic lung disease in Beijing. Even over a short time period (one year), associations were apparent with air pollution and meteorological factors.

A decade of antiretroviral therapy in Uganda: what are the emerging causes of death?

BACKGROUND

The roll out of antiretroviral therapy (ART) in Sub-Saharan Africa led to a decrease in mortality. Few studies have documented the causes of deaths among patients on long term antiretroviral therapy in Sub-Saharan Africa. Our objective was to describe the causes of death among patients on long term ART in Sub-Saharan Africa.

METHODS

We used data from a prospective cohort of ART naïve patients receiving care and treatment at the Infectious Diseases Institute in Kampala, Uganda. Patients were followed up for 10 years. All deaths were recorded and possible causes established using verbal autopsy. Deaths were grouped as HIV-related (ART toxicities, any opportunistic infections (OIs) and HIV-related malignancies) and non-HIV related deaths while some remained unknown. We used Kaplan Meier survival methods to estimate cumulative incidence and rates of mortality for all causes of death.

RESULTS

Of the 559, (386, 69%) were female, median age 36 years (IQR: 21-44), 89% had WHO clinical stages 3 and 4, and median CD4 count at ART initiation was 98 cells/μL (IQR: 21-163). A total of 127 (22.7%) deaths occurred in 10 years. The HIV related causes of death (n = 70) included the following; Tuberculosis 17 (24.3%), Cryptococcal meningitis 10 (15.7%), Kaposi's Sarcoma 7(10%), HIV related toxicity 6 (8.6%), HIV related anemia 5(7.1%), Pneumocystis carinii Pneumonia (PCP) 5 (7.1%), HIV related chronic diarrhea 4 (5.7%), Non-Hodgkin Lymphoma 3 (4.3%), Herpes Zoster 2 (2.8%), other 10 (14.3%). The non-HIV related causes of death (n = 20) included non-communicable diseases (diabetes, hypertension, stroke) 6 (30%), malaria 3 (15%), pregnancy-related death 2 (10%), cervical cancer 2 (10%), trauma 1(5%) and others 6 (30%).

CONCLUSION

Despite the higher rates of deaths from OIs in the early years of ART initiation, we observed an emergence of non-HIV related causes of morbidity and mortality. It is recommended that HIV programs in resource-limited settings start planning for screening and treatment of non-communicable diseases.

Development and validation of a risk score to predict mortality during TB treatment in patients with TB-diabetes comorbidity

BACKGROUND

Making an accurate prognosis for mortality during tuberculosis (TB) treatment in TB-diabetes (TB-DM) comorbid patients remains a challenge for health professionals, especially in low TB prevalent populations, due to the lack of a standardized prognostic model.

METHODS

Using de-identified data from TB-DM patients from Texas, who received TB treatment had a treatment outcome of completed treatment or died before completion, reported to the National TB Surveillance System from January 2010-December 2016, we developed and internally validated a mortality scoring system, based on the regression coefficients.

RESULTS

Of 1227 included TB-DM patients, 112 (9.1%) died during treatment. The score used nine characteristics routinely collected by most TB programs. Patients were divided into three groups based on their score: low-risk (< 12 points), medium-risk (12-21 points) and high-risk (≥22 points). The model had good performance (with an area under the receiver operating characteristic (ROC) curve of 0.83 in development and 0.82 in validation), and good calibration. A practical mobile calculator app was also created ( https://oaa.app.link/Isqia5rN6K ).

CONCLUSION

Using demographic and clinical characteristics which are available from most TB programs at the patient's initial visits, our simple scoring system had good performance and may be a practical clinical tool for TB health professionals in identifying TB-DM comorbid patients with a high mortality risk.

Tuberculosis in Poland in 2017

AIM OF THE STUDY

To evaluate the main features of TB epidemiology in 2017 in Poland and to compare with the situation in the EU/EEA countries.

METHODS

Analysis of case- based data on TB patients from National TB Register, data on anti-TB drug susceptibility testing results in cases notified in 2017, data from National Institute of Public Health- National Institute of Hygiene on cases of tuberculosis as AIDS-defining disease, data from Central Statistical Office on deaths from tuberculosis based on death certificates, data from ECDC report „European Centre for Disease Prevention and Control/WHO Regional Office for Europe. Tuberculosis surveillance and monitoring in Europe 2019-2017 data. Stockholm: European Centre for Disease Prevention and Control, 2019”.

RESULTS

In 2017, 5 787 TB cases were reported in Poland. The incidence rate was 15.1 cases per 100 000, with large variability between voivodeships from 8.9 to 21.9 per 100 000. The mean annual decrease of TB incidence in 2013-2017 was 4.2%. In 2017, 5127 cases were newly diagnosed with no history of previous treatment i.e. 13.3 per 100 000. 660 cases i.e. 1.7 per 100 000 – 11.4% of all registered subjects were previously treated for tuberculosis. In 2017, the number of all pulmonary tuberculosis cases was 5 531 i.e. 14.4 per 100 000. Pulmonary cases represented 95.6% of all TB cases. In 2017, 256 extrapulmonary TB cases were found. In the whole country there were 68 pediatric cases of tuberculosis. TB in children represented 1.2% of all cases notified in Poland in 2017. The incidence rates of tuberculosis were growing along with the age group from 1.2 per 100 000 among children to 25.6 per 100 000 among subjects in the age group 45-64 years (the highest incidence rate). In 2017, the incidence rate in the age group ≥65 years was 22.6 per 100 000. The TB incidence among men i.e. 22.2 per 100.000 was 2.4 times higher than among women i.e. 8,4 per 100 000. The biggest difference in the TB incidence between the two sex groups occurred in persons aged 45 to 49 years – 36.1 vs. 8.1 and in age group 55- 59 years – 45.2 vs. 10.7. The TB incidence in rural population was lower than in urban, respectively 14.2 per 100.000 and 15.6 per 100 000. The number of all registered culture positive TB cases was 4 179. Pulmonary tuberculosis was bacteriologically confirmed in 4 057 subjects. Culture-confirmed cases represented 72.2% of all TB cases and 73.4% of all pulmonary TB cases. The number of smear-positive pulmonary TB cases reported in 2017 was 2 472 i.e. 6.4 per 100 000 accounting for 44.7% of all pulmonary TB cases and 60.9% of culture confirmed pulmonary TB cases.. TB was AIDS indicative disease in 16 subjects. In all patients with tuberculosis in Poland in 2017 there were 44 cases with MDR-TB (among them 12 foreigners) and 85 patients with resistance to isoniazid only, representing respectively 1.2% and 2.2% of cases with known DST results (DSTs were available in 90.5% of all cultureconfirmed TB cases). In 2017, there were 108 patients of foreign origin among all cases of tuberculosis in Poland.

TUBERCULOSIS MORTALITY

There were 543 deaths due to tuberculosis reported in 2016 – 1.4 per 100 000; 526 people died from pulmonary and 17 from extrapulmonary tuberculosis. Mortality among males – 2.2 per 100 000 – was 3.7 X higher than among females – 0.6. 37.9% of all TB deaths were cases 65 years old and older – 3.3 per 100 000. In 2016, there was one death from tuberculosis in children and no deaths in adolescents. In 2016, tuberculosis represented 0.14% of total mortality in Poland and 28.1% of mortality from infectious diseases.

CONCLUSIONS

In 2017, the incidence of tuberculosis in Poland was lower than in 2016. Despite a continuous decline it is still higher than the average in the EU/EEA countries. The highest incidence rates were observed in older age groups. The incidence in males was more than 2 times higher than in females. The impact of migration on the characteristics of tuberculosis in Poland is not substantial. In Poland, tuberculosis in children, tuberculosis in persons infected with HIV and MDR-TB is less common than the average in the EU/EEA countries.

Is the decline in neonatal mortality in northern Ghana, 1996-2012, associated with the decline in the age of BCG vaccination? An ecological study

OBJECTIVE

To examine the association between early Bacille Calmette-Guerin (BCG) vaccination and neonatal mortality in northern Ghana.

METHODS

This ecological study used vaccination and mortality data from the Navrongo Health and Demographic Surveillance System. First, we assessed and compared changes in neonatal mortality rates (NMRs) and median BCG vaccination age from 1996 to 2012. Second, we compared the changes in NMR and median BCG vaccination age from 2002 to 2012 by delivery place when data on delivery place were available.

RESULTS

Neonatal mortality rates declined from 46 to 12 per 1000 live births between 1996 and 2012 (trend test: p<0.001). Within the same period, median BCG vaccination age declined from 46 to 4 days (trend test: p<0.001). Among home deliveries, BCG vaccination age declined from 39 days in 2002 to 7 days in 2012 (trend test: p<0.001) and neonatal mortality declined by 24/1000 (trend test: p<0.001). Among health facility deliveries, BCG vaccination age was stable around 3 days from 2002 to 2012 (trend test: p=0.49) and neonatal mortality declined by 9/1000 (trend test: p=0.04). In a small study of children whose vaccination cards were inspected within the first 28 days of life, the HR for BCG-vaccinated compared with BCG-unvaccinated children was 0.55 (95% CI 0.12 to 2.40).

CONCLUSION

The data support the hypothesis that early BCG vaccination may be associated with a decrease in neonatal mortality. However, as suggested by WHO, randomised control trials are required to address the question of whether there is indeed a causal association between early BCG vaccination and neonatal mortality.

Tuberculosis Mortality by Occupation in South Africa, 2011⁻2015

Work-related tuberculosis (TB) remains a public health concern in low- and middle-income countries. The use of vital registration data for monitoring TB deaths by occupation has been unexplored in South Africa. Using underlying cause of death and occupation data for 2011 to 2015 from Statistics South Africa, age-standardised mortality rates (ASMRs) were calculated for all persons of working age (15 to 64 years) by the direct method using the World Health Organization (WHO) standard population. Multivariate logistic regression analysis was performed to calculate mortality odds ratios (MORs) for occupation groups, adjusting for age, sex, year of death, province of death, and smoking status. Of the 221,058 deaths recorded with occupation data, 13% were due to TB. ASMR for TB mortality decreased from 165.9 to 88.8 per 100,000 population from 2011 to 2015. An increased risk of death by TB was observed among elementary occupations: agricultural labourers (MOR_adj = 3.58, 95% Confidence Interval (CI) 2.96⁻4.32), cleaners (MOR_adj = 3.44, 95% CI 2.91⁻4.09), and refuse workers (MOR_adj = 3.41, 95% CI 2.88⁻4.03); among workers exposed to silica dust (MOR_adj = 3.37, 95% CI 2.83⁻4.02); and among skilled agricultural workers (MOR_adj = 3.31, 95% CI 2.65⁻4.19). High-risk TB occupations can be identified from mortality data. Therefore, TB prevention and treatment policies should be prioritised in these occupations.

Global, regional, and national burden of tuberculosis, 1990-2016: results from the Global Burden of Diseases, Injuries, and Risk Factors 2016 Study

BACKGROUND

Although a preventable and treatable disease, tuberculosis causes more than a million deaths each year. As countries work towards achieving the Sustainable Development Goal (SDG) target to end the tuberculosis epidemic by 2030, robust assessments of the levels and trends of the burden of tuberculosis are crucial to inform policy and programme decision making. We assessed the levels and trends in the fatal and non-fatal burden of tuberculosis by drug resistance and HIV status for 195 countries and territories from 1990 to 2016.

METHODS

We analysed 15 943 site-years of vital registration data, 1710 site-years of verbal autopsy data, 764 site-years of sample-based vital registration data, and 361 site-years of mortality surveillance data to estimate mortality due to tuberculosis using the Cause of Death Ensemble model. We analysed all available data sources, including annual case notifications, prevalence surveys, population-based tuberculin surveys, and estimated tuberculosis cause-specific mortality to generate internally consistent estimates of incidence, prevalence, and mortality using DisMod-MR 2.1, a Bayesian meta-regression tool. We assessed how the burden of tuberculosis differed from the burden predicted by the Socio-demographic Index (SDI), a composite indicator of income per capita, average years of schooling, and total fertility rate.

FINDINGS

Globally in 2016, among HIV-negative individuals, the number of incident cases of tuberculosis was 9·02 million (95% uncertainty interval [UI] 8·05-10·16) and the number of tuberculosis deaths was 1·21 million (1·16-1·27). Among HIV-positive individuals, the number of incident cases was 1·40 million (1·01-1·89) and the number of tuberculosis deaths was 0·24 million (0·16-0·31). Globally, among HIV-negative individuals the age-standardised incidence of tuberculosis decreased annually at a slower rate (-1·3% [-1·5 to -1·2]) than mortality did (-4·5% [-5·0 to -4·1]) from 2006 to 2016. Among HIV-positive individuals during the same period, the rate of change in annualised age-standardised incidence was -4·0% (-4·5 to -3·7) and mortality was -8·9% (-9·5 to -8·4). Several regions had higher rates of age-standardised incidence and mortality than expected on the basis of their SDI levels in 2016. For drug-susceptible tuberculosis, the highest observed-to-expected ratios were in southern sub-Saharan Africa (13·7 for incidence and 14·9 for mortality), and the lowest ratios were in high-income North America (0·4 for incidence) and Oceania (0·3 for mortality). For multidrug-resistant tuberculosis, eastern Europe had the highest observed-to-expected ratios (67·3 for incidence and 73·0 for mortality), and high-income North America had the lowest ratios (0·4 for incidence and 0·5 for mortality).

INTERPRETATION

If current trends in tuberculosis incidence continue, few countries are likely to meet the SDG target to end the tuberculosis epidemic by 2030. Progress needs to be accelerated by improving the quality of and access to tuberculosis diagnosis and care, by developing new tools, scaling up interventions to prevent risk factors for tuberculosis, and integrating control programmes for tuberculosis and HIV.

FUNDING

Bill & Melinda Gates Foundation.

Effect of the Number of Pregnancies on Mortality Risk in HIV-Infected Women: a Prospective Cohort Study in Rural KwaZulu-Natal, South Africa

We investigated whether mortality risk increases with the number of full-term pregnancies in HIV-infected women. Our study is based on data from the ACDIS cohort, collected in rural KwaZulu-Natal, South Africa. Mortality risk for different number of pregnancies in HIV-infected women was analyzed using Cox proportional hazards model. The risk of TB or AIDS mortality in HIV-uninfected women did not change with the number of full-term pregnancies, while the corresponding risk increased markedly in HIV-infected women. The risk of TB or AIDS mortality increased 1.48-fold (95% CI 1.25-1.75), 1.76-fold (95% CI 1.45-2.13), and 1.59-fold (95% CI 1.31-1.94) for one, two, and three or more full-term pregnancies compared to none, respectively. Finally, women who are young (age < 26) have greater risk of TB or AIDS mortality compared to women who are old (age ≥ 26), and women residing in rural areas have greater risk compared to women who reside in non-rural areas.

Time to death predictors of HIV/AIDS infected patients on antiretroviral therapy in Ethiopia

OBJECTIVE

The purpose of this study was to identify the major risk factors, which contributed to shortened survival time to death of HIV patients on antiretroviral therapy. Six-hundred HIV patients were included from two hospitals and six health centers record from January 2003 to December 2017. Kaplan-Meier and Cox proportional hazard model were implemented.

RESULTS

From the Kaplan-Meier, log-rank test result indicated that there was a significant difference between tuberculosis comorbidity (P = .000), occupation (P = .027), and WHO clinical stage (P = .012) on the survival experience of patients at 5% statistical significance level. From the Cox regression result, the risk of death for patients who lived with tuberculosis was about 2.872-fold times higher than those patients who were negative. Most of the HIV/AIDS patients on antiretroviral therapy were died in a short period due to tuberculosis comorbidity, began with lower amount of CD4, being underweight, merchant, and being on WHO clinical stage IV.

The global tuberculosis epidemic and progress in care, prevention, and research: an overview in year 3 of the End TB era

Tuberculosis is the number one cause of death from infectious disease globally and drug-resistant forms of the disease are a major risk to global health security. On the occasion of World Tuberculosis Day (March 24, 2018), we provide an up-to-date review of the status of the tuberculosis epidemic, recommended diagnostics, drug treatments and vaccines, progress in delivery of care and prevention, progress in research and development, and actions needed to accelerate progress. This Review is presented in the context of the UN Sustainable Development Goals and WHO's End TB Strategy, which share the aim of ending the global tuberculosis epidemic. In 2016, globally there were an estimated 10·4 million new cases of tuberculosis, and 600 000 new cases with resistance to rifampicin (the most powerful first-line drug). All countries and age groups are affected by tuberculosis, but most cases (90%) in 2016 were in adults, and almost two-thirds were accounted for by seven countries: India, Indonesia, China, Philippines, Pakistan, South Africa, and Nigeria. The sex ratio (male to female) was 1·9 and 10% of patients with newly diagnosed tuberculosis were also HIV-positive. There were 1·7 million deaths from tuberculosis in 2016, including 0·4 million deaths among people co-infected with HIV (officially classified as deaths caused by HIV/AIDS). Progress in care and prevention means that the global mortality rate (deaths per 100 000 people per year) is decreasing by 3·4% per year and incidence (new cases per 100 000 people per year) is decreasing by 1·9% per year. From 2000 to 2016, the annual global number of tuberculosis deaths decreased by 24% and the mortality rate declined by 37%. Worldwide, an estimated 53 million deaths were averted through successful treatment. Nonetheless, major gaps in care and prevention remain. For example, the 6·3 million new cases of tuberculosis reported globally in 2016 represented only 61% of the estimated incidence; only one in five of the estimated number of people with drug-resistant tuberculosis was enrolled in treatment. Pipelines for new diagnostics, drugs, and vaccines are progressing, but slowly. Actions needed to accelerate progress towards global milestones and targets for reductions in the burden of tuberculosis disease set for 2020, 2025, 2030, and 2035 include closing coverage gaps in testing, reporting of cases, and overall access to health care, especially in countries that account for the largest share of the global gap; multisectoral efforts to reduce prevalence of major risk factors for infection and disease; and increased investment in research and development.

Opportunistic diseases diminish the clinical benefit of immediate antiretroviral therapy in HIV-tuberculosis co-infected adults with low CD4+ cell counts

INTRODUCTION

HIV-tuberculosis (TB) co-infection remains an important cause of mortality in sub-Saharan Africa. Clinical trials have reported early (within 2 weeks of TB therapy) antiretroviral therapy (ART) reduces mortality among HIV-TB co-infected research participants with low CD4 cell counts, but this has not been consistently observed. We aimed to evaluate the current WHO recommendations for ART in HIV-TB co-infected patients on mortality in routine clinical settings.

METHODS

We compared two cohorts before (2008-2010) and after (2012-2013) policy change on ART timing after TB and examined the effectiveness of early versus delayed ART on mortality in HIV-TB co-infected participants with CD4 cell count 100 cells/μl or less. We used inverse probability censoring-weighted Cox models on baseline characteristics to balance the study arms and generated hazard ratios for mortality.

RESULTS

Of 356 participants with CD4 cell counts 100 cells/μl or less, 180 were in the delayed ART cohorts whereas 176 were in the early ART cohorts. Their median age (32.5 versus 32 years) and baseline CD4 cell counts (26.5 versus 26 cells/μl) respectively were similar. There was no difference in mortality rates of both cohorts. The risk of death increased in participants with a positive Cryptococcal antigen (CrAg) test in both the early ART cohort (aHR = 2.6, 95% CI 1.0-6.8; P = 0.045) and the delayed ART cohort (aHR = 4.2, 95% CI 1.9-9.0; P < 0.001 CONCLUSION:: Early ART in patients with HIV-TB co-infection was not associated with reduced risk of mortality in routine care. Asymptomatic Cryptococcal antigenaemia increased the risk of mortality in both cohorts.

HIV and TB co-infection in the ART era: CD4 count distributions and TB case fatality in Cape Town

BACKGROUND

In Cape Town, the roll-out of antiretroviral therapy (ART) has increased over the last decade with an estimated coverage of 63% of HIV- positive patients in 2013. The influence of ART on the characteristics of the population of HIV-positive patients presenting to the primary care TB programme is unknown. In this study, we examined trends in CD4 count distribution, ART usage and treatment outcomes among HIV-positive TB patients in Cape Town from 2009 to 2013.

METHODS

Data from the electronic TB register on all newly registered drug-sensitive TB patients ≥18 years were analyzed retrospectively. Descriptive statistics were used to compare baseline characteristics, the CD4 count distribution and TB treatment outcomes both by year of treatment and ART status at the start of TB treatment. Survival analyses were used to assess the change in mortality risk during TB treatment over time, stratified by ART status at start of TB treatment.

RESULTS

118,989 patients were treated over 5 years. HIV prevalence among TB patients decreased from 50.9% in 2009 to 49.0% in 2013. The absolute number of HIV-positive TB cases declined by 13.2% between 2010 and 2013. More patients entered the TB programme on ART in 2013 compared to 2009 (30.0% vs 9.9%). Among these, the CD4 count distribution showed a year by year shift to higher CD4 counts. In 2013, over 75% of ART-naïve TB patients still had a CD4 count < 350 cells/mm3. ART initiation among ART-naive patients increased from 37.0 to 77.7% and TB case fatality declined from 7.4 to 5.2% (p < 0.001). In multivariate analysis a decrease in TB mortality was most strongly associated with CD4 count (Adjusted HR 0.82 per increase of 50 cells/mm3, 95% CI: 0.81-0.83, p < 001) and the initiation of ART during TB treatment (Adjusted HR 0.39, 95% CI: 0.35-0.42, p < 0.001).

CONCLUSION

Comprehensive changes in the ART and TB treatment programmes resulted in incremental increases in ART coverage for HIV-positive TB patients and a subsequent decrease in TB case fatality due to increased ART uptake in HIV-positive ART-naïve patients. However TB still remained a major presenting opportunistic infection with the majority of cases occurring at low CD4 counts.