Epidemiology and Prevention of Tuberculosis and Chronic Hepatitis B Virus Infection in the United States

A comparative study of clinical outcomes and risk factors of tuberculosis in kidney transplant recipients from deceased donors

OBJECTIVE

To investigate the clinical characteristics, diagnosis and treatment of tuberculosis infection after deceased donor kidney transplantation and to analyze the risk factors and prognosis of tuberculosis infection through a paired case-control study.

METHODS

This study investigated 31 kidney transplant recipients who developed tuberculosis among 2185 total recipients during 2012-2021. We employed a 1:1 paired case-control design, utilizing 31 patients who received kidneys from the same donor as the controls. The study analyzed clinical presentation, diagnosis, treatment, risk factors, and prognosis.

RESULTS

This study identified a 1.4% incidence of tuberculosis (TB) infection (31/2185) in kidney transplant recipients. The median onset was 10.8 months post-transplant (range: 5-24 months), with 51.6% occurring within the first year. Anti-TB therapy achieved cure in 30 patients, but one died and three experienced kidney transplant dysfunctions. While overall patient survival was not statistically different between groups, kidney graft survival was significantly lower in the TB group (p = 0.042). While kidney function was initially similar, the TB group experienced significant declines in creatinine and GFR at 3, 6, and 12 months post-treatment (p < 0.05). Multivariate analysis identified diabetes mellitus (p = 0.005) and hepatitis (p = 0.027) as independent risk factors for post-transplant TB infection.

CONCLUSION

Over half of the tuberculosis cases (51.6%) occurred within the first year post-transplant, highlighting the need for heightened vigilance during this early period. While standard anti-TB therapy achieved good overall patient survival, it takes a toll on kidney function which underscores the importance of close kidney function monitoring and delicate immunosuppressant management during TB treatment. Diabetes mellitus and hepatitis were identified as independent risk factors for post-transplant TB infection. Prophylaxis measures should be considered for these high-risk patients during early time post-transplant.

Epidemiology of Chronic Hepatitis B Virus Infection, Alameda County, California, 2017-2021

CONTEXT

In the United States, chronic hepatitis B (CHB) virus infection predominantly affects ethnic minorities and vulnerable populations.

OBJECTIVE

We analyzed surveillance data to describe CHB epidemiology to guide hepatitis B virus (HBV) elimination efforts in Alameda County.

DESIGN

Persons with CHB during 2017-2021 were identified by ≥2 positive HBV tests (ie, HBsAg, HbeAg, and HBV DNA) ≥180 days apart using data from California Reportable Disease Information Exchange. Persons with CHB were stratified by age, race/ethnicity, zip code-based Healthy Places Index (HPI), and federally designated Medically Underserved Areas (MUA). Comparisons of reported CHB prevalence between groups utilized z test; comparisons between MUA regions utilized chi-square testing.

RESULTS

A total of 8122 persons with CHB were identified; reported 5-year CHB prevalence was 0.53% (95% confidence interval: 0.52%-0.54%). Reported CHB 5-year prevalence was significantly higher among persons aged 50 to 69 years old than persons aged 30 to 49 years old (0.99%, 0.78%; P < .001) and Asians, Native Hawaiian/Pacific Islanders, African Americans compared to Whites (1.22%, 0.56%, 0.18%, 0.06%; P < .001). Reported CHB 5-year prevalence in the 2 lowest and most disadvantaged HPI quartiles was significantly higher than the 2 highest quartiles (0.55%, 0.68%, 0.37%, 0.42%; P < .001). The 1918 persons with CHB in MUA, compared to 5859 non-MUA persons, were significantly more likely to be African American (7%, 3%; P < .001) and from the lowest HPI quartile (79%, 19%; P < .001).

CONCLUSIONS

Reported CHB 5-year prevalence in Alameda County was 1.5 times the national prevalence estimates, and reported prevalence was highest among Asians and persons in more disadvantaged areas. Analysis of local CHB surveillance data can guide public health efforts toward HBV elimination.

Expected vs Reported Chronic Hepatitis B Infection Cases in Persons with Active Tuberculosis - California, 2016-2020

Epidemiologic data regarding persons with active tuberculosis (TB) and chronic hepatitis B virus (cHBV) infection are limited because of lack of routine surveillance of cHBV in persons with TB. Potential underdiagnosis of cHBV in California among those with TB is concerning. We matched TB and cHBV registries to identify cHBV infections among persons diagnosed with TB during 2016-2020 and described their demographic characteristics. We calculated expected cHBV cases among persons with TB for each demographic characteristic using published cHBV prevalence estimates for the locations of birth for persons with TB. Estimates were from general or emigrant adult and teen populations. Reported cHBV infection among persons with TB were 23% lower than expected, particularly among Asian persons, persons living in the two healthiest Healthy Places Index quartiles, and residents of less populated jurisdictions in California. Results show the possibility exists for underdiagnosis of cHBV in persons with TB in California.

Epidemiology and Treatment Outcomes of Tuberculosis With Chronic Hepatitis B Infection-California, 2016-2020

BACKGROUND

Improved epidemiologic and treatment data for active tuberculosis (TB) with chronic hepatitis B virus (cHBV) infection might inform and encourage screening and vaccination programs focused on persons at risk of having both conditions.

METHODS

We matched the California Department of Public Health TB registry during 2016-2020 to the cHBV registry using probabilistic matching algorithms. We used chi-square analysis to compare the characteristics of persons with TB and cHBV with those with TB only. We compared TB treatment outcomes between these groups using modified Poisson regression models. We calculated the time between reporting of TB and cHBV diagnoses for those with both conditions.

RESULTS

We identified 8435 persons with TB, including 316 (3.7%) with cHBV. Among persons with TB and cHBV, 256 (81.0%) were non-US-born Asian versus 4186 (51.6%) with TB only (P < .0001). End-stage renal disease (26 [8.2%] vs 322 [4.0%]; P < .001) and HIV (21 [6.7%] vs 247 [3.0%]; P = .02) were more frequent among those with TB and cHBV compared with those with TB only. Among those with both conditions, 35 (11.1%) had TB diagnosed >60 days before cHBV (median, 363 days) and 220 (69.6%) had TB diagnosed >60 days after cHBV (median, 3411 days).

CONCLUSIONS

Persons with TB and cHBV were found more frequently in certain groups compared with TB only, and infrequently had their conditions diagnosed together. This highlights an opportunity to improve screening and treatment of TB and cHBV in those at high risk for coinfection.

Screening Practices and Risk Factors for Co-Infection with Latent Tuberculosis and Hepatitis B Virus in an Integrated Healthcare System - California, 2008-2019

BACKGROUND

Hepatitis B virus (HBV) and latent tuberculosis infection are associated with a significant global burden, but both are underdiagnosed and undertreated. We described the screening patterns and risk factors for co-infection with latent tuberculosis and HBV within a large healthcare system.

METHODS

Using data from Kaiser Permanente Southern California during 2008-2019, we described HBV infections, defined as a positive HBV surface antigen, e-antigen, or DNA test, and latent tuberculosis, defined as a positive Mantoux tuberculin skin test or interferon-gamma release assay test. We estimated adjusted odds ratios (aOR) for co-infection among screened adults with either infection.

RESULTS

Among 1997 HBV patients screened for latent tuberculosis, 23.1% were co-infected, and among 35,820 patients with latent tuberculosis screened for HBV, 1.3% were co-infected. Among HBV patients, co-infection risk was highest among Asians compared with White race/ethnicity (29.4% vs 5.7%, aOR 4.78; 95% confidence interval [CI], 2.75-8.31), and persons born in a high-incidence country compared with low-incidence countries (31.0% vs 6.6%; aOR 4.19; 95% CI, 2.61-6.73). For patients with latent tuberculosis, risk of co-infection was higher among Asian (aOR 9.99; 95% CI, 5.79-17.20), or Black race/ethnicity (aOR 3.33; 95% CI, 1.78-6.23) compared with White race/ethnicity. Persons born in high-incidence countries had elevated risk of co-infection compared with persons born in low-incidence countries (aOR 2.23; 95% CI, 1.42-3.50). However, Asians or persons born in high-incidence countries were screened at similar rates to other ethnicities or persons born in low-incidence countries.

CONCLUSIONS

Latent tuberculosis risk is elevated among HBV patients, and vice versa. Risk of co-infection was highest among persons born in high-incidence countries and Asians. These findings support recent guidelines to increase HBV and tuberculosis screening, particularly among persons with either infection.

Transplantation and immigration: Comparing infectious complications and outcomes between foreign-born and US-born kidney transplant recipients in Minnesota

BACKGROUND

Foreign-born kidney transplant recipients (FBKTRs) are at increased risk for reactivation of latent infections that may impact outcomes. We aimed to compare the etiology of infections and outcomes between FBKTR and United States KTRs (USKTR).

METHODS

We performed a retrospective study of patients who underwent kidney transplantation between January 1, 2014 and December 31, 2018 at two transplant centers in Minnesota. Frequency and etiology of infections as well as outcomes (graft function, rejection, and patient survival) at 1-year post-transplant between FBKTR and USKTR were compared.

RESULTS

Of the 573 transplant recipients, 124 (21.6%) were foreign-born and 449 (78.4%) US-born. At least one infection occurred in 411 (71.7%) patients (38.2% bacterial, 55% viral, 9.4% fungal). Viral infections were more frequent in FBKTR, particularly BK viremia (38.7% vs. 21.2%, p < .001). No statistical differences were found for bacterial or fungal infections; no parasitic infections were identified in either group. No geographically-restricted infections were noted aside from a single case of Madura foot in a FBKTR. Rejection episodes were more common in USKTR (p = .037), but stable/improving graft function (p = .976) and mortality (p = .451) at 1-year posttransplantation were similar in both groups. After adjusting for covariates, previous transplantation was associated with a higher number of infections (IRR 1.35, 95% confidence intervals 1.05-1.73, p = .020).

CONCLUSION

Although viral infections were more frequent in FBKTR, overall frequency and etiology of most infections and outcomes were similar between FBKTR and USKTR suggesting that comprehensive transplant care is providing timely prevention, diagnosis, and treatment of latent infections in FBKTR.

Risk of drug-induced liver injury in chronic hepatitis B and tuberculosis co-infection: A systematic review and meta-analysis

Patients with tuberculosis (TB) disease treated with multi-drug regimens are at risk of developing drug induced liver injury (DILI), and DILI risk might be even higher in patients with underlying liver disease. We aimed to evaluate whether underlying chronic hepatitis B virus (HBV) and TB co-infection are associated with a higher risk of TB therapy-related DILI. We conducted a systematic review and meta-analysis using MEDLINE/PubMed from inception to 31 December 2021. Primary outcome assessed was development of DILI following multi-drug TB treatment. Meta-analysis using random-effects models were utilized to evaluate whether underlying chronic HBV was associated with increased risk of DILI in patients undergoing active TB treatment. A total of 10 studies met inclusion criteria to be analysed, among which 520 patients had HBV-TB co-infection and 2988 patients had active TB disease without HBV. Prevalence of DILI was 21.9% in HBV-TB co-infected patients and 11.9% in TB patients without HBV. On meta-analysis, HBV-TB co-infected patients had significantly higher risk of DILI when treated with TB therapies compared with TB patients without HBV (pooled risk ratio 1.98, 95% CI 1.38-2.83, I²  = 68%). Sub-analysis of prospective cohort studies conducted after year 2000 detected a pooled risk ratio of 2.75 (95% CI 2.10-3.59, I²  = 0%). In conclusion, HBV-TB co-infected patients undergoing multi-drug TB therapy have 2-3 times higher risk of DILI compared with TB patients without HBV. Routine HBV screening prior to initiation of TB therapy is critical for early identification of HBV-TB co-infection, so that clinicians can modify TB and HBV treatment and management to reduce risks of DILI.

Clinical relevance of vitamin B12 level and vitamin B12 metabolic gene variation in pulmonary tuberculosis

The aim of this study was to assess the association of vitamin B12 level and single nucleotide polymorphisms (SNPs) in vitamin B12 metabolic genes with pulmonary tuberculosis (PTB) in Chinese Han population. The plasma vitamin B12 expression level was detected using ELISA. Ten SNPs in six key genes (TCN1, TCN2, CUBN, MMACHC, FUT6, and MUT) of vitamin B12 metabolic pathway were included for genotyping by the SNPscan technique among 454 PTB patients and 467 controls. Our results found that vitamin B12 level was significantly reduced in PTB patients when compared with controls. There was no significant association between TCN1 rs526934, TCN2 rs1801198, CUBN rs7906242, rs10904861, rs1801222, MMACHC rs10789465, FUT6 rs3760776, rs3760775, MUT rs9473555, rs9381784 variants, and PTB susceptibility. TCN2 rs1801198 CC genotype, C allele was significantly associated with hypoproteinemia in PTB patients. In CUBN, rs7906242 GG genotype, G allele, rs10904861 TT genotype, and T allele were significantly related to the decreased frequency of sputum smear-positive, and rs10904861 variant affected the occurrence of drug resistance in PTB patients. In addition, the increased frequency of CUBN rs1801222 AA genotype was significantly associated with leukopenia. The decreased frequency of MUT rs9473555 CC genotype was found in the PTB patients with hypoproteinemia. However, vitamin B12 expression was not associated with the genotype distribution of above SNPs. In conclusion, vitamin B12 level was significantly decreased in PTB patients and genetic variants in vitamin B12 metabolic genes were not contributed to PTB susceptibility. Several SNPs in TCN2, CUBN, and MUT gene might associate with multiple clinical manifestations in PTB.

Prevalence of Hepatitis B Virus and Latent Tuberculosis Coinfection in the United States

CONTEXT

Underlying chronic hepatitis B virus (HBV) infection increases the risk of drug-induced liver injury (DILI) when receiving tuberculosis therapies. Prevalence of HBV and latent tuberculosis infection (LTBI) coinfection is not well reported and no studies have evaluated testing patterns for and prevalence of HBV-LTBI coinfection in the United States.

OBJECTIVE

To evaluate patterns of HBV and LTBI testing and prevalence of HBV-LTBI coinfection in the United States.

DESIGN

Retrospective cohort study.

SETTING

Quest Diagnostics clinical laboratory data, 2014-2020.

PATIENTS

Chronic HBV infection was defined as any combination of 2 positive HBV surface antigen, HBV e antigen, or detectable HBV DNA tests at least 6 months apart. LTBI was defined as a positive QuantiFERON-TB or T-SPOT.TB test without evidence of active tuberculosis infection.

MAIN OUTCOME MEASUREMENTS

Testing patterns for chronic HBV infection and LTBI and prevalence of HBV-LTBI coinfection were evaluated from 2016 through 2020 and stratified by age, sex, and race and ethnicity.

RESULTS

Among 89 259 patients with chronic HBV infection, 9508 (10.7%) were tested for LTBI, among whom prevalence of HBV-LTBI coinfection was 19.6%, more than twice the observed prevalence of LTBI in patients with no chronic HBV infection in our cohort. Among 394 817 LTBI patients, 127 414 (32.3%) were tested for HBV, among whom prevalence of HBV-LTBI coinfection was 1.5%, approximately 3 times higher than prevalence of HBV infection in patients with no LTBI. The HBV-LTBI coinfection prevalence was highest among Asian Americans and older individuals.

LIMITATIONS

The HBV-LTBI coinfection prevalence was likely underestimated because of suboptimal awareness and testing among at-risk populations.

CONCLUSION

Among US individuals with chronic HBV infection or LTBI, prevalence of HBV-LTBI coinfection is substantial and highlights the need of testing for HBV-LTBI coinfection to mitigate risk of DILI associated with tuberculosis medications in patients with chronic HBV infection.