World Tuberculosis Day 2021 Theme - 'The Clock is Ticking' - and the world is running out of time to deliver the United Nations General Assembly commitments to End TB due to the COVID-19 pandemic

Inequities underlie the alarming resurgence of Tuberculosis as the world's top cause of death from an Infectious Disease - Breaking the silence and addressing the underlying root causes

•The WHO End TB strategy is stalling as shown in the Global Tuberculosis Report 2023.•The main reason is unequal access to tuberculosis diagnosis and treatment.•Tuberculosis diagnosis and treatment must be expanded outside urban centers down to the smallest and most remote unit.•Screening risk populations for latent tuberculosis will help identify infected persons before they develop active tuberculosis.

Effect of COVID-19 restriction measures on multidrug resistant tuberculosis case notifications and treatment outcomes at treatment centres in Uganda

BACKGROUND

Multidrug resistant tuberculosis (MDR-TB) is a global public health threat. In 2021, an incidence of 3.6% was reported among new TB patients, and 18% was reported among previously treated patients. The emergence of the COVID-19 pandemic impacted the health sector, although little is known about the effect of restrictive COVID-19 measures on MDR-TB case notifications and treatment outcomes in Uganda. This study aimed to assess the effect of COVID-19 restriction measures on MDR-TB case notifications and treatment outcomes at treatment centres in Uganda.

METHODS

This was a retrospective cohort study in which a total of 483 participants were enrolled-238 before (March 2018-February 2020) and 245 during (March 2020-February 2022) COVID-19 restrictions. The data were extracted from the Drug-Resistant Tuberculosis (DR-TB) Health Management Information System (HMIS), and patient charts, and census sampling was employed. Interrupted time series (ITSA) was used to compare MDR-TB case notifications and treatment outcomes.

RESULTS

Before the COVID-19 restrictions, the majority 58.0% were aged less than or equal to 38 years whereas during the restrictions, the majority 51.8% were aged greater than 38 years. A total of 238 cases of MDRTB were reported before, and 245 cases were reported during the restrictions. There was no immediate (β2; 0.134) or sustained (β3; 0.494) impact of COVID-19 restriction measures on monthly MDR-TB case notifications. The mean number of monthly MDR-TB notifications was similar for the 3-month period before (11.0 cases per month) and during (10.0 cases per month) the COVID-19 restrictions (p-value 0.661). The proportions of patients who achieved successful MDR-TB treatment before (81.5%) and during (81.7%) COVID-19 restriction was not significantly different (p- value < 0.001). During the COVID-19 restrictions, not being married (aPR 0.85, 95% CI: 0.74-0.97) and treatment delay greater than 7 days (aPR 0.87, 95% CI 0.78-0.96) were negatively associated with successful treatment outcomes.

CONCLUSION

Restrictive COVID-19 measures did not affect MDR-TB case notifications or treatment outcomes. Not being married and having a treatment delay greater than 7 days reduced the chances of a successful treatment outcome during COVID-19. The WHO and MoH should continue strengthening active case finding, contact screening and community engagement to consolidate MDR-TB control and management in preparation for similar future pandemics.

Evaluation of the Effectiveness of Global Tuberculosis Control Strategies at Different Stages and Analysis of Risk Factors: Findings From the Global Burden of Disease 2021

BACKGROUND

The purpose of this study was to analyze the prevention and control effects of the three-phase global tuberculosis control strategy, and analyze the influencing factors.

METHODS

We collected age-standardized incidence, prevalence, and mortality (ASIR, ASPR, and ASDR) data from the Global Burden of Disease Study (GBD 2021) database. Annual percentage change (AAPC) of ASIR, ASPR and ASDR were analyzed by Joinpoint regression. Correlation and decomposition analyses explored related epidemiological factors.

RESULTS

At the global level, in the first phase Directly-Observed Treatment Strategy (DOTS), the annual reduction in incidence was 1.18%, and prevalence was 0.71%. In the second phase Stop TB, the cumulative mortality decrease was 56.44% which met the desired goal. However, the cumulative decrease of prevalence was only 20.45%. In the third phase End TB, annual rate of reduction in mortality was 3.33%, while the annual rate of reduction in incidence was 1.14%. ASPR showed a large decrease in both low socio-demographic index (SDI) and high SDI regions, the decrease in medium SDI region was small, which might be dominated by demographic factors at the DOTS stage, changed to epidemiologic in the Stop TB stage and to aging factors in the End TB stage.

CONCLUSION

The control of TB morbidity and mortality had a great achievement in all the 3 different phases of the TB control strategy, and a concerted global effort is still needed in phase 3 to reach the END TB goal. TB prevalence control needs to be emphasized, especially in the middle and high SDI areas.

The global impact of COVID-19 on tuberculosis: A thematic scoping review, 2020-2023

BACKGROUND

This thematic scoping review of publications sought to understand the global impact of COVID-19 on tuberculosis (TB), interpret the scope of resonating themes, and offer policy recommendations to stimulate TB recovery and future pandemic preparedness.

DATA SOURCES

Publications were captured from three search engines, PubMed, EBSCO, and Google Scholar, and applicable websites written in English from January 1, 2020, to April 30, 2023.

STUDY SELECTION

Our scoping review was limited to publications detailing the impact of COVID-19 on TB. Original research, reviews, letters, and editorials describing the deleterious and harmful--yet sometimes positive--impact of COVID-19 (sole exposure) on TB (sole outcome) were included. The objective was to methodically categorize the impacts into themes through a comprehensive review of selected studies to provide significant health policy guidance.

DATA EXTRACTION

Two authors independently screened citations and full texts, while the third arbitrated when consensus was not met. All three performed data extraction.

DATA SYNTHESIS/RESULTS

Of 1,755 screened publications, 176 (10%) covering 39 countries over 41 months met the inclusion criteria. By independently using a data extraction instrument, the three authors identified ten principal themes from each publication. These themes were later finalized through a consensus decision. The themes encompassed TB's care cascade, patient-centered care, psychosocial issues, and health services: 1) case-finding and notification (n = 45; 26%); 2) diagnosis and laboratory systems (n = 19; 10.7%) 3) prevention, treatment, and care (n = 22; 12.2%); 4) telemedicine/telehealth (n = 12; 6.8%); 5) social determinants of health (n = 14; 8%); 6) airborne infection prevention and control (n = 8; 4.6%); 7) health system strengthening (n = 22; 13%); 8) mental health (n = 13; 7.4%); 9) stigma (n = 11; 6.3%); and 10) health education (n = 10; 5.7%).

LIMITATIONS

Heterogeneity of publications within themes.

CONCLUSIONS

We identified ten globally generalizable themes of COVID-19's impact on TB. The impact and lessons learned from the themed analysis propelled us to draft public health policy recommendations to direct evidence-informed guidance that strengthens comprehensive global responses, recovery for TB, and future airborne pandemic preparedness.

Early Microbiologic Markers of Pulmonary Tuberculosis Treatment Outcomes

Rationale: Earlier biomarkers of pulmonary tuberculosis (PTB) treatment outcomes are critical to monitor shortened anti-TB treatment (ATT). Objectives: To identify early microbiologic markers of unfavorable TB treatment outcomes. Methods: We performed a subanalysis of 2 prospective TB cohort studies conducted from 2013 to 2019 in India. We included participants aged ⩾18 years who initiated 6-month ATT for clinically or microbiologically diagnosed drug-sensitive PTB and completed at least one follow-up visit. Sputum specimens were subjected to a baseline Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) assay, acid-fast bacilli (AFB) microscopy and liquid and solid cultures, and serial AFB microscopy and liquid and solid cultures at weeks 2, 4, and 8. Poisson regression was used to assess the impact of available microbiologic markers (test positivity, smear grade, time to detection, and time to conversion) on a composite outcome of failure, recurrence, or death by 18 months after the end of treatment. Models were adjusted for age, sex, nutritional status, diabetes, smoking, alcohol consumption, and regimen type. Results: Among 1,098 eligible cases, there were 251 (22%) adverse TB treatment outcomes: 127 (51%) treatment failures, 73 (29%) recurrences, and 51 (20%) deaths. The primary outcome was independently associated with the Xpert MTB/RIF assay (medium-positive adjusted incidence rate ratio [aIRR], 1.91; 95% confidence interval [CI], 1.07-3.40; high-positive aIRR, 2.51; 95% CI, 1.41-4.46), positive AFB smear (aIRR, 1.48; 95% CI, 1.06-2.06), and positive liquid culture (aIRR, 1.98; 95% CI, 1.21-3.23) at baseline; Week 2 positive liquid culture (aIRR, 1.47; 95% CI, 1.04-2.09); and Week 8 positive AFB smear (aIRR, 1.63; 95% CI, 1.06-2.50) and positive liquid culture (aIRR, 1.54; 95% CI, 1.07-2.22). There was no evidence of Mycobacterium tuberculosis growth in the Mycobacterium Growth Indicator Tube at Week 4 conferring a higher risk of adverse outcomes (aIRR, 1.25; 95% CI, 0.89-1.75). Conclusions: Our analysis identifies Week 2 respiratory mycobacterial culture as the earliest microbiologic marker of unfavorable PTB treatment outcomes.

COVID-19-related excess mortality - an overview of the current evidence

Analysis of excess deaths, defined as the difference in the total number of deaths in an emergency compared to the number of deaths expected under normal conditions, allows a more reliable assessment of the impact on health systems caused by the global threat of SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus-2). So far, data for the two years of the pandemic (2020-2021) indicates the occurrence of 14.9 million excess deaths according to WHO (World Health Organization) estimates. The purpose of the analysis conducted was to define the concept and identify the causes of excess mortality during the COVID-19 pandemic. Inconsistent and unreliable death registration systems; overburdened health systems in low- and middle-income countries; reduced access to medical services for patients with health problems other than COVID-19; the introduction of social distancing and lockdown rules, which translated into increased deaths from psychiatric illnesses and addictions; political considerations and media messages that interfered with vaccination acceptance and adherence; and the additional impact of other natural disasters (hurricanes, floods, drought) were identified as the most important reasons for excess deaths occurrence. The correct identification of country-specific factors and the correct response and countermeasures taken appear crucial in terms of limiting the negative impact of the current pandemic, but also of future threats of a similar nature, in order to reduce excess deaths.

The WHO Global Tuberculosis 2021 Report - not so good news and turning the tide back to End TB

OBJECTIVE

To review the data presented in the 2021 WHO global TB report and discuss the current constraints in the global response.

INTRODUCTION AND METHODS

The WHO global TB reports, consolidate TB data from countries and provide up to date assessment of the global TB epidemic. We reviewed the data presented in the 2021 report.

RESULTS

We noted that the 2021 WHO global TB report presents a rather grim picture on the trajectory of the global epidemic of TB including a stagnation in the annual decline in TB incidence, a decline in TB notifications and an increase in estimated TB deaths. All the targets set at the 2018 United Nations High Level Meeting on TB were off track.

INTERPRETATION AND CONCLUSION

The sub-optimal global performance on achieving TB control targets in 2020 is attributed to the on-going COVID-19 pandemic, however, TB programs were already off track well before the onset of the pandemic, suggesting that the pandemic amplified an already fragile global TB response. We emphasize that ending the global TB epidemic will require bold leadership, optimization of existing interventions, widespread coverage, addressing social determinants of TB and importantly mobilization of adequate funding required for TB care and prevention.

High Mycobacterium tuberculosis Bacillary Loads Detected by Tuberculosis Molecular Bacterial Load Assay in Patient Stool: a Potential Alternative for Nonsputum Diagnosis and Treatment Response Monitoring of Tuberculosis

Not all patients produce sputum, yet most available TB tests use sputum. We investigated the utility of a novel RNA-based quantitative test, the tuberculosis molecular bacterial load assay (TB-MBLA), for the detection and quantification of Mycobacterium tuberculosis in stool. Stools from 100 adult individuals were treated with OMNIgene-sputum reagent and tested using Xpert MTB/RIF ultra (Xpert ultra), auramine O smear microscopy (smear), mycobacterial growth indicator tube (MGIT), and Lowenstein-Jensen (LJ) cultures. The remaining portions were frozen at −20°C and later tested by TB-MBLA. MGIT sputum culture was used as a TB confirmatory test and reference for stool tests. Sixty-one of 100 participants were already confirmed TB positive by MGIT sputum culture, 20 (33%) of whom were HIV coinfected. TB-MBLA detected M. tuberculosis in 57/100 stool samples, including 49 already confirmed for TB. The mean bacterial load measured by stool TB-MBLA was 5.67 ± 1.7 log₁₀ estimated CFU (eCFU) per mL in HIV-coinfected participants, which was higher than the 4.83 ± 1.59 log₁₀ eCFU per mL among the HIV-negative participants (P = 0.04). The sensitivities (95% confidence intervals [CI]) of stool assays were 80% (68 to 89) and 90% (79 to 98) for TB-MBLA and Xpert ultra, which were both higher than the 44% (32 to 58), 64% (51 to 76), and 62% (45 to 77) for smear, MGIT, and Lowenstein-Jensen (LJ) stool cultures, respectively. The specificity (95% CI) of stool assays was highest for smear, at 97% (87 to 100), followed by Xpert ultra at 91% (76 to 98), TB-MBLA at 79% (63 to 90), LJ at 80% (64 to 91), and MGIT at 62% (45 to 77). Twenty-six percent of MGIT and 21% of LJ stool cultures were indeterminate due to contamination. Detection and quantification of viable M. tuberculosis bacilli in stool raises its utility as an alternative to sputum as a sample type for TB diagnosis.

IMPORTANCE This paper highlights the value of stool as a sample type for diagnosis of tuberculosis. While other studies have used DNA-based assays like the Xpert MTB/RIF and culture to detect Mycobacterium tuberculosis in stool, this is the first study that has applied TB-MBLA, an RNA-based assay, to quantify TB bacteria in stool. The high microbial density and diversity in stool compromises the specificity and sensitivity of culture-based tests due to overgrowth of non-M. tuberculosis flora. Consequently, TB-MBLA becomes the most sensitive and specific test for the detection and quantification of viable TB bacteria in stool. Most crucially, this study raises the possibility of a nonsputum alternative sample type for diagnosis of TB among people who have difficulty in producing sputum.

Insight into microRNAs-Mediated Communication between Liver and Brain: A Possible Approach for Understanding Acute Liver Failure?

Acute liver failure (ALF) is a life-threatening consequence of hepatic function rapid loss without preexisting liver disease. ALF may result in a spectrum of neuropsychiatric symptoms that encompasses cognitive impairment, coma, and often death, collectively defined as acute hepatic encephalopathy. Micro RNAs are small non-coding RNAs that modulate gene expression and are extensively verified as biomarker candidates in various diseases. Our systematic literature review based on the last decade's reports involving a total of 852 ALF patients, determined 205 altered circulating miRNAs, of which 25 miRNAs were altered in the blood, regardless of study design and methodology. Selected 25 miRNAs, emerging predominantly from the analyses of samples obtained from acetaminophen overdosed patients, represent the most promising biomarker candidates for a diagnostic panel for symptomatic ALF. We discussed the role of selected miRNAs in the context of tissue-specific origin and its possible regulatory role for molecular pathways involved in blood-brain barrier function. The defined several common pathways for 15 differently altered miRNAs were relevant to cellular community processes, indicating loss of intercellular, structural, and functional components, which may result in blood-brain barrier impairment and brain dysfunction. However, a causational relationship between circulating miRNAs differential expression, and particular clinical features of ALF, has to be demonstrated in a further study.

Evidence of TB Services at Primary Healthcare Level during COVID-19: A Scoping Review

Tuberculosis (TB) is still a major public health concern, despite the availability of preventative and curative therapies. Significant progress has been made in the past decade towards its control. However, the emergence of the novel coronavirus disease 2019 (COVID-19) has disrupted numerous essential health services, including those for TB. This scoping review maps the available evidence on TB services at the primary healthcare (PHC) level during the COVID-19 period. A comprehensive literature search was conducted in PubMed, Web of Science, Medline OVID, Medline EBSCO, and Scopus. A total of 820 articles were retrieved from the databases and 21 met the eligibility criteria and were used for data extraction. The emerging themes were the effect of the COVID-19 pandemic on TB services, patient and provider experiences, recommendations for TB services during the COVID-19 period, and the implementation of the recommendations. The review found that the mitigation strategies, as well as fear and stigma experienced at the start of the COVID-19 pandemic may have led to TB cases potentially going undetected, which may threaten TB treatment outcomes. Therefore, efforts must be directed at finding these missing cases and ensuring that PHC facilities are equipped to adequately diagnose and treat them.

Lack of latent tuberculosis (TB) screening and delay in anti-retroviral therapy initiation in HIV-TB co-infection: an 11-year study in an intermediate TB-burden country

OBJECTIVES

To examine the prevalence and characteristics of HIV-tuberculosis (TB) co-infected patients in Singapore, an intermediate TB-burden country.

METHODS

Retrospective data across 11 years was obtained from the National University Hospital (NUH), a quaternary hospital and the National Centre for Infectious Diseases (NCID), the national HIV center.

RESULTS

From December 2005 to December 2016, 4015 HIV-infected patients were managed at NUH and NCID, of whom, respectively, 48 and 272 were diagnosed with active TB disease. Only 2 patients (0.6%) were screened for latent TB infection on HIV diagnosis. Mean CD4 count at TB diagnosis was 125.0 ± 153.9 cells/mm³. More patients with HIV diagnosed ≥6 weeks before TB (41%) were associated with CD4 counts >200 cells/mm³ than patients with TB diagnosed ≥6 weeks before HIV (2%). Of 124 (38.6%) HIV-TB patients with CD4 count ≤50 cells/mm³, only 18 (14.2%) started anti-retroviral therapy (ART) in <2 weeks. Of patients with pulmonary TB, 33.5% had normal chest x-ray.

CONCLUSIONS

Latent TB infection screening in HIV-infected patients is low, and ART initiation is delayed in HIV-TB patients with CD4 ≤50 cells/mm³. Pulmonary TB patients with HIV can be infectious despite normal chest x-ray. Clinical practices can be further improved to benefit HIV-TB patients.