Tuberculosis, social determinants and co-morbidities (including HIV)

Community-Wide Universal HIV Test and Treat Intervention Reduces Tuberculosis Transmission in Rural Uganda: A Cluster-Randomized Trial

BACKGROUND

Human immunodeficiency virus (HIV) treatment reduces tuberculosis (TB) disease and mortality; however, the population-level impact of universal HIV-test-and-treat interventions on TB infection and transmission remain unclear.

METHODS

In a sub-study nested in the SEARCH trial, a community cluster-randomized trial (NCT01864603), we assessed whether a universal HIV-test-and-treat intervention reduced population-level incident TB infection in rural Uganda. Intervention communities received annual, population-level HIV testing and patient-centered linkage. Control communities received population-level HIV testing at baseline and endline. We compared estimated incident TB infection by arms, defined by tuberculin skin test conversion in a cohort of persons aged 5 and older, adjusting for participation and predictors of infection, and accounting for clustering.

RESULTS

Of the 32 trial communities, 9 were included, comprising 90 801 participants (43 127 intervention and 47 674 control). One-year cumulative incidence of TB infection was 16% in the intervention and 22% in the control; SEARCH reduced the population-level risk of incident TB infection by 27% (adjusted risk ratio = 0.73; 95% confidence interval [CI]: .57-.92, P = .005). In pre-specified analyses, the effect was largest among children aged 5-11 years and males.

CONCLUSIONS

A universal HIV-test-and-treat intervention reduced incident TB infection, a marker of population-level TB transmission. Investments in community-level HIV interventions have broader population-level benefits, including TB reductions.

Factors associated with unfavorable treatment outcomes among multidrug-resistant tuberculosis patients, Sierra Leone: a cross-sectional secondary data analysis

BACKGROUND

Globally, multidrug-resistant tuberculosis (MDR-TB) is a major public health problem. The tuberculosis rate in Sierra Leone is 298 per 100,000 people, and Sierra Leone is considered a country with a high burden of tuberculosis. In Sierra Leone, there are few studies on the outcomes of MDR-TB treatment, especially those exacerbated by COVID-19. We identified factors associated with unfavorable treatment outcomes among people with MDR-TB in Sierra Leone.

METHODS

We conducted a cross-sectional study to analyze hospital-based MDR-TB data from 2017 to 2021. Demographic, clinical, and treatment outcome data were extracted from the main MDR-TB referral hospital database. We defined unfavorable outcomes as patients who died, were lost to follow-up, or defaulted. We calculated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) to identify predictors of the outcomes of MDR-TB treatment.

RESULTS

Between 2017 and 2021, 628 people with MDR-TB were reported at Lakka Hospital; 441 (71%) were male, with a median age of 25 years (interquartile ranges: 17-34). Clinically, 21% of the 628 MDR-TB patients were HIV positive, and 413 were underweight (66%). 70% (440) of MDR-TB patients received tuberculosis treatment. The majority of patients, 457 (73%), were treated with a short treatment regimen, and 126 (20%) experienced unfavorable outcomes. Age 45 years or younger (aOR = 5.08; CI:1.87-13.82), 21-45 years (aOR = 2.22; CI:140-3.54), tuberculosis retreatment (aOR = 3.23; CI:1.82-5.73), age group, HIV status (aOR = 2.16; CI:1.33-3.53), and malnourishment status (aOR = 1.79; CI:1.12-2.86) were significantly associated with unfavorable treatment outcomes for DR-TB patients.

CONCLUSION

This analysis revealed a high proportion of unfavorable treatment outcomes among MDR-TB patients in Sierra Leone. Malnourishment, TB retreatment, HIV coinfection, and age 45 years or younger were associated with unfavorable outcomes of MDR-TB treatment. Increasing patients' awareness, mainly among young people, heightens treatment adherence and HIV monitoring by measuring the amount of HIV in patient blood, which can reduce adverse treatment outcomes in Sierra Leone and other sub-Saharan African countries.

Cost-effectiveness of TB diagnostic technologies in Ethiopia: a modelling study

BACKGROUND

Tuberculosis (TB) is a major threat to public health, particularly in countries where the disease is highly prevalent, such as Ethiopia. Early diagnosis and treatment are the main components of TB prevention and control. Although the national TB guideline recommends the primary use of rapid TB diagnostics whenever feasible, there is limited evidence available that assess the efficiency of deploying various diagnostic tools in the country. Hence, this study aims to evaluate the cost-effectiveness of rapid TB/MDR-TB diagnostic tools in Ethiopia.

METHODS

A hybrid Markov model for a hypothetical adult cohort of presumptive TB cases was constructed. The following TB diagnostic tools were evaluated: X-pert MTB/RIF, Truenat, chest X-ray screening followed by an X-pert MTB/RIF, TB-LAMP, and smear microscopy. Cost-effectiveness was determined based on incremental costs ($) per Disability-adjusted Life Years (DALY) averted, using a threshold of one times Gross Domestic Product (GDP) per capita ($856). Data on starting and transition probabilities, costs, and health state utilities were derived from secondary sources. The analysis is conducted from the health system perspective, and a probabilistic sensitivity analysis is performed.

RESULT

The incremental cost-effectiveness ratio for X-pert MTB/RIF, compared to the next best alternative, is $276 per DALY averted, making it a highly cost-effective diagnostic tool. Additionally, chest X-ray screening followed an X-pert MTB/RIF test is less cost-effective, with an ICER of $1666 per DALY averted. Introducing X-pert MTB/RIF testing would enhance TB detection and prevent 9600 DALYs in a cohort of 10,000 TB patients, with a total cost of $3,816,000.

CONCLUSION

The X-pert MTB/RIF test is the most cost-effective diagnostic tool compared to other alternatives. The use of this diagnostic tool improves the early detection and treatment of TB cases. Increased funding for this diagnostic tool will enhance access, reduce the TB detection gaps, and improve treatment outcomes.

Identification of DprE1 inhibitors for tuberculosis through integrated in-silico approaches

Decaprenylphosphoryl-β-D-ribose-2'-epimerase (DprE1), a crucial enzyme in the process of arabinogalactan and lipoarabinomannan biosynthesis, has become the target of choice for anti-TB drug discovery in the recent past. The current study aims to find the potential DprE1 inhibitors through in-silico approaches. Here, we built the pharmacophore and 3D-QSAR model using the reported 40 azaindole derivatives of DprE1 inhibitors. The best pharmacophore hypothesis (ADRRR_1) was employed for the virtual screening of the chEMBL database. To identify prospective hits, molecules with good phase scores (> 2.000) were further evaluated by molecular docking studies for their ability to bind to the DprE1 enzyme (PDB: 4KW5). Based on their binding affinities (< - 9.0 kcal/mole), the best hits were subjected to the calculation of free-binding energies (Prime/MM-GBSA), pharmacokinetic, and druglikeness evaluations. The top 10 hits retrieved from these results were selected to predict their inhibitory activities via the developed 3D-QSAR model with a regression coefficient (R2) value of 0.9608 and predictive coefficient (Q2) value of 0.7313. The induced fit docking (IFD) studies and in-silico prediction of anti-TB sensitivity for these top 10 hits were also implemented. Molecular dynamics simulations (MDS) were performed for the top 5 hit molecules for 200 ns to check the stability of the hits with DprE1. Based on their conformational stability throughout the 200 ns simulation, hit 2 (chEMBL_SDF:357100) was identified as the best hit against DprE1 with an accepted safety profile. The MD results were also in accordance with the docking score, MM-GBSA value, and 3D-QSAR predicted activity. The hit 2 molecule, (N-(3-((2-(((1r,4r)-4-(dimethylamino)cyclohexyl)amino)-9-isopropyl-9H-purin-6-yl)amino)phenyl)acrylamide) could serve as a lead for the discovery of a novel DprE1 inhibiting anti-TB drug.

The potential association between metabolic disorders and pulmonary tuberculosis: a Mendelian randomization study

BACKGROUND

Metabolic disorders (MetDs) have been demonstrated to be closely linked to numerous diseases. However, the precise association between MetDs and pulmonary tuberculosis (PTB) remains poorly understood.

METHOD

Summary statistics for exposure and outcomes from genome-wide association studies (GWASs) for exposures and outcomes were obtained from the BioBank Japan Project (BBJ) Gene-exposure dataset. The 14 clinical factors were categorized into three groups: metabolic laboratory markers, blood pressure, and the MetS diagnostic factors. The causal relationship between metabolic factors and PTB were analyzed using two-sample Mendelian Randomization (MR). Additionally, the direct effects on the risk of PTB were investigated through multivariable MR. The primary method employed was the inverse variance-weighted (IVW) model. The sensitivity of this MR analysis was evaluated using MR-Egger regression and the MR-PRESSO global test.

RESULTS

According to the two-sample MR, HDL-C, HbA1c, TP, and DM were positively correlated with the incidence of active TB. According to the multivariable MR, HDL-C (IVW: OR 2.798, 95% CI 1.484-5.274, P = 0.001), LDL (IVW: OR 4.027, 95% CI 1.140-14.219, P = 0.03) and TG (IVW: OR 2.548, 95% CI 1.269-5.115, P = 0.009) were positively correlated with the occurrence of PTB. TC (OR 0.131, 95% CI 0.028-0.607, P = 0.009) was negatively correlated with the occurrence of PTB. We selected BMI, DM, HDL-C, SBP, and TG as the diagnostic factors for metabolic syndrome. DM (IVW, OR 1.219, 95% CI 1.040-1.429 P = 0.014) and HDL-C (IVW, OR 1.380, 95% CI 1.035-1.841, P = 0.028) were directly correlated with the occurrence of PTB.

CONCLUSIONS

This MR study demonstrated that metabolic disorders, mainly hyperglycemia, and dyslipidemia, are associated with the incidence of active pulmonary tuberculosis.

Sex-based tuberculosis mortality in Newfoundland, 1900-1949: Implications for populations in transition

OBJECTIVE

During the second epidemiological transition, tuberculosis (TB) is one disease that declined substantially enough to reduce all-cause mortality. Sex-based differences in TB mortality may reveal an important dimension of population health transitions between the urbanizing and rural regions of Newfoundland.

MATERIALS AND METHODS

For the island of Newfoundland, yearly age-standardized sex-based TB mortality rates were calculated using individual death records from 1900 to 1949 (n = 30 393). Multiple linear regression models predict the relative rates (RR) of sex-based mortality and the absolute difference between males and females while controlling for time and region (the urbanizing Avalon Peninsula or rural Newfoundland). Multiple linear regression models also predict the median age at death from TB while controlling for time, region, and sex to assess if TB was shifting to an older adult disease compared to those typically afflicted in ages 20-44.

RESULTS

Female TB mortality was relatively and absolutely higher than males; additionally, RR and absolute differences between male and female mortality were significantly lower in rural Newfoundland than the Avalon Peninsula. Median age at death for males was significantly higher than females, and differences in median age at death increased over time.

DISCUSSION

The historically high prevalence of TB throughout Newfoundland, including domestic, social, and public health responsibilities of women, likely contributed to increased exposure and transmission, leading to higher observed mortality. Sex-based TB outcomes should be considered in the discussion of the progression of the epidemiological transition as dynamic inequalities that do not necessarily fit contemporary generalizations of sex-based TB epidemiology.

"Harm reduction approach for tuberculosis and substance use disorders: A review of approaches and implications in the Indian context"

There are limitations to traditional treatment approaches in addressing the needs of individuals with dual comorbidity of TB and SUD. The concept of harm reduction as a distinct approach to addressing substance use, focusing on minimising the negative consequences associated with it rather than advocating for complete abstinence. Different harm reduction strategies, such as opioid substitution therapy, needle and syringe programmes, testing for viral infections etc. have been effectively employed for SUDs in past. Similarly, TB risk minimization approaches like improving housing and nutrition and focused testing strategies are considered as harm reduction strategies for TB management. The relationship between tuberculosis (TB) and substance use disorders (SUDs) involves a complex interplay of biopsychosocial factors. It is crucial to prioritise integrated and closely monitored care in order to address the treatment challenges and potential drug interactions that may arise. In light of the acknowledged challenges like limited awareness, infrastructure, drug resistance, and stigma, it is imperative to explore potential avenues for the implementation of harm reduction strategies targeting individuals with comorbid TB and SUD in India. Potential strategies for addressing the issue includes a range of measures, such as augmenting investments in healthcare, integrating policies, tackling social determinants, and establishing shared platforms for psychosocial rehabilitation.

Global burden of MDR-TB and XDR-TB attributable to high fasting plasma glucose from 1990 to 2019: a retrospective analysis based on the global burden of disease study 2019

PURPOSE

High fasting plasma glucose (HFPG) has been identified as a risk factor for drug-resistant tuberculosis incidence and mortality. However, the epidemic characteristics of HFPG-attributable multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) remain unclear. We aimed to analyze the global spatial patterns and temporal trends of HFPG-attributable MDR-TB and XDR-TB from 1990 to 2019.

METHODS

Utilizing data from the Global Burden of Disease 2019 project, annual deaths and disability-adjusted life years (DALYs) of HFPG-attributable MDR-TB and XDR-TB were conducted from 1990 to 2019. Joinpoint regression was employed to quantify trends over time.

RESULTS

From 1990 to 2019, the deaths and DALYs due to HFPG-attributable MDR-TB and XDR-TB globally showed an overall increasing trend, with a significant increase until 2003 to 2004, followed by a gradual decline or stability thereafter. The low sociodemographic index (SDI) region experienced the most significant increase over the past 30 years. Regionally, Sub-Saharan Africa, Central Asia and Oceania remained the highest burden. Furthermore, there was a sex and age disparity in the burden of HFPG-attributable MDR-TB and XDR-TB, with young males in the 25-34 age group experiencing higher mortality, DALYs burden and a faster increasing trend than females. Interestingly, an increasing trend followed by a stable or decreasing pattern was observed in the ASMR and ASDR of HFPG-attributable MDR-TB and XDR-TB with SDI increasing.

CONCLUSION

The burden of HFPG-attributable MDR-TB and XDR-TB rose worldwide from 1990 to 2019. These findings emphasize the importance of routine bi-directional screening and integrated management for drug-resistant TB and diabetes.

Design, synthesis and characterization of ethyl 3-benzoyl-7-morpholinoindolizine-1-carboxylate as anti-tubercular agents: In silico screening for possible target identification

A thorough search for the development of innovative drugs to treat tuberculosis, especially considering the urgent need to address developing drug resistance, we report here a synthetic series of ethyl 3-benzoyl-7-morpholinoindolizine-1-carboxylate analogues (5a-o) as potent anti-tubercular agents. These morpholino-indolizines were synthesized by reacting 4-morpholino pyridinium salts, with various electron-deficient acetylenes to afford the ethyl 3-benzoyl-7-morpholinoindolizine-1-carboxylate analogues (5a-o). All synthesized intermediate and final compounds are characterized by spectroscopic methods such as 1H NMR, 13C NMR and HRMS and further examined for their anti-tubercular activity against the M. tuberculosis H37Rv strain (ATCC 27294-American type cell culture). All the compounds screened for anti-tubercular activity in the range of 6.25-50 μM against the H37Rv strain of Mycobacterium tuberculosis. Compound 5g showed prominent activity with MIC99 2.55 μg/mL whereas compounds 5d and 5j showed activity with MIC99 18.91 μg/mL and 25.07 μg/mL, respectively. In silico analysis of these compounds revealed drug-likeness. Additionally, the molecular target identification for Malate synthase (PDB 5CBB) is attained by computational approach. The compound 5g with a MIC99 value of 2.55 μg/mL against M. tuberculosis H37Rv emerged as the most promising anti-TB drug and in silico investigations suggest Malate synthase (5CBB) might be the compound's possible target.

Spatial distribution and determinants of tuberculosis incidence in Mozambique: A nationwide Bayesian disease mapping study

INTRODUCTION

Mozambique is a high-burden country for tuberculosis (TB). International studies show that TB is a disease that tends to cluster in specific regions, and different risk factors (HIV prevalence, migration, overcrowding, poverty, house condition, temperature, altitude, undernutrition, urbanization, and inadequate access to TB diagnosis and treatment) are reported in the literature to be associated with TB incidence. Although Mozambique has a higher burden of TB, the spatial distribution, and determinants of TB incidence at the sub-national level have not been studied yet for the whole country. Therefore, we aimed to analyze the spatial distribution and determinants of tuberculosis incidence across all 154 districts of Mozambique and identify the hotspot areas.

METHOD

We conducted an ecological study with the district as our unit of analysis, where we included all cases of tuberculosis diagnosed in Mozambique between 2016 and 2020. We obtained the data from the Mozambique Ministry of Health and other publicly available open sources. The predictor variables were selected based on the literature review and data availability at the district level in Mozambique. The parameters were estimated through Bayesian hierarchical Poisson regression models using Markov Chain Monte Carlo simulation.

RESULTS

A total of 512 877 people were diagnosed with tuberculosis in Mozambique during our five-year study period. We found high variability in the spatial distribution of tuberculosis incidence across the country. Sixty-two districts out of 154 were identified as hotspot areas. The districts with the highest incidence rate were concentrated in the south and the country's central regions. In contrast, those with lower incidence rates were mainly in the north. In the multivariate analysis, we found that TB incidence was positively associated with the prevalence of HIV (RR: 1.23; 95 % CrI 1.13 to 1.34) and negatively associated with the annual average temperature (RR: 0.83; 95 % CrI 0.74 to 0.94).

CONCLUSION

The incidence of tuberculosis is unevenly distributed across the country. Lower average temperature and high HIV prevalence seem to increase TB incidence. Targeting interventions in higher-risk areas and strengthening collaboration between HIV and TB programs is paramount to ending tuberculosis in Mozambique, as established by the WHO's End TB strategy and the Sustainable Development Goals.

Multi-ancestry meta-analysis of host genetic susceptibility to tuberculosis identifies shared genetic architecture

The heritability of susceptibility to tuberculosis (TB) disease has been well recognized. Over 100 genes have been studied as candidates for TB susceptibility, and several variants were identified by genome-wide association studies (GWAS), but few replicate. We established the International Tuberculosis Host Genetics Consortium to perform a multi-ancestry meta-analysis of GWAS, including 14,153 cases and 19,536 controls of African, Asian, and European ancestry. Our analyses demonstrate a substantial degree of heritability (pooled polygenic h2 = 26.3%, 95% CI 23.7-29.0%) for susceptibility to TB that is shared across ancestries, highlighting an important host genetic influence on disease. We identified one global host genetic correlate for TB at genome-wide significance (p<5 × 10-8) in the human leukocyte antigen (HLA)-II region (rs28383206, p-value=5.2 × 10-9) but failed to replicate variants previously associated with TB susceptibility. These data demonstrate the complex shared genetic architecture of susceptibility to TB and the importance of large-scale GWAS analysis across multiple ancestries experiencing different levels of infection pressure.

Compliance and illiteracy when treating tuberculosis

According to Centers for Disease Control and Prevention, one-fourth of the worlds' population was infected with tuberculosis (TB) in 2017. It is estimated that globally, more than 1 billion woken are infected with TB. The treatment of TB is limited to follow the treatment schedule. A small pause in taking the meds, forgetting the meds for a day or two etc will result in relapse of the disease. Unfortunately, illiteracy is associated with poor compliance and understanding of the importance of following the treatment protocol. In 2015, it was estimated that about 11% of the world's population over 15 y were illiterate. Where two-thirds were women. This is even worse in sub-Saharan Africa, where 34.7% of all adults above 15 y were illiterate in 2019.

Host-Pathogen Interaction: Biology and Public Health

Interactions between host and pathogenic microorganisms are common in nature and have a significant impact on host health, often leading to several types of infections. These interactions have evolved as a result of the ongoing battle between the host's defense mechanisms and the pathogens' invasion strategies. In this chapter, we will explore the evolution of host-pathogen interactions, explore their molecular mechanisms, examine the different stages of interaction, and discuss the development of pharmacological treatments. Understanding these interactions is crucial for improving public health, as it enables us to develop effective strategies to prevent and control infectious diseases. By gaining insights into the intricate dynamics between pathogens and their hosts, we can work towards reducing the burden of such diseases on society.

Factors contributing to pre-treatment loss to follow-up in adults with pulmonary tuberculosis: a qualitative evidence synthesis of patient and healthcare worker perspectives

BACKGROUND

Since 2018, over 14 million people have been treated for tuberculosis (TB) globally. However, pre-treatment loss to follow-up (PTLFU) has been shown to contribute substantially to patient losses in the TB care cascade with subsequent high community transmission and mortality rates.

OBJECTIVE

To identify, appraise, and synthesise evidence on the perspectives of patients and healthcare workers on factors contributing to PTLFU in adults with pulmonary TB.

METHODS

We registered the title with PROSPERO (CRD42021253212). We searched nine relevant databases up to 24 May 2021 for qualitative studies. Two review authors independently reviewed records for eligibility and extracted data. We assessed methodological quality with the Evidence for Policy and Practice Information Centre tool and synthesised data using the Supporting the Use of Research Evidence framework. We assessed confidence in our findings using Confidence in the Evidence from Reviews of Qualitative Research (GRADE-CERQual).

RESULTS

We reviewed a total of 1239 records and included five studies, all from low- and middle-income countries. Key themes reported by patients and healthcare workers were communication challenges among healthcare workers and between healthcare workers and patients; knowledge, attitudes, and behaviours about TB and its management; accessibility and availability of facilities for TB care; and human resource and financial constraints, weakness in management and leadership in TB programmes. Patients' change of residence, long waiting times, and poor referral systems were additional factors that contributed to patients disengaging from care. We had moderate confidence in most of our findings.

CONCLUSION

Findings from our qualitative evidence synthesis highlight multiple factors that contribute to PTLFU. Central to addressing these factors will be the need to strengthen health systems and offer people-centred care.

Factors associated with TB screening among agricultural workers in Limpopo Province, South Africa

BACKGROUND

Tuberculosis (TB) continues to be a public health issue of concern in South Africa. Workers in the agricultural sector are generally at increased risk of TB due to multiple interacting factors such as exposure to silica dust, co-worker infection, and occupations falling within the lower socio-economic sectors.

OBJECTIVE

This study investigates factors associated with TB screening uptake for agricultural workers in Limpopo Province, South Africa.

METHOD

This cross-sectional study targeted a study population of 16,787 agricultural workers across 96 agricultural worksites in South Africa. A two-stage cluster random sampling design identified 24 agricultural worksites and a potential 2500 participants. The outcome variable was self-reported TB screening. Descriptive statistics and unadjusted and adjusted logistic regression analyses were performed to determine factors associated with TB screening. A literature review informed the selection of covariates as possible confounders.

RESULTS

The final study sample comprised 2144 workers across 24 sites, with 55% being women. TB screening uptake was 1155 (56.3%). Factors such as living with human immunodeficiency virus (HIV) (AOR 3.16, 95% CI: 2.44-4.09), accessing health services in the workplace (AOR 1.94, 95% CI: 1.09-3.46), and having prior TB knowledge (AOR 18.45, 95% CI: 9.8-34.74) were positively associated with TB screening. Participants in the age group 36-49 years had significantly higher odds of self-reporting TB screening, compared with those aged 18-25 years (AOR 1.37, 95% CI 1.07-1.77). Migrant workers from Mozambique (OR 0.52, 95% CI: 0.34-0.79) and Zimbabwe (OR 0.71, 95% CI 0.57-0.89) were significantly less likely to self-report TB screening compared to their South African counterparts.

CONCLUSION

The findings underscore the importance of workplace health services in achieving end-TB targets. We recommend programs and interventions for preventing TB in South Africa that target the agricultural sector in general, and in particular migrant workers.

The community as an active part in the implementation of interventions for the prevention and care of tuberculosis: A scoping review

Interventions involving direct community stakeholders include a variety of approaches in which members take an active role in improving their health. We evaluated studies in which the community has actively participated to strengthen tuberculosis prevention and care programs. A literature search was performed in Pubmed, Scopus, ERIC, Global Index Medicus, Scielo, Cochrane Library, LILACS, Google Scholar, speciality journals, and other bibliographic references. The primary question for this review was: ¿what is known about tuberculosis control interventions and programs in which the community has been an active part?. Two reviewers performed the search, screening, and selection of studies independently. In cases of discrepancies over the eligibility of an article, it was resolved by consensus. 130 studies were selected, of which 68.47% (n = 89/130) were published after 2010. The studies were conducted in Africa (44.62%), the Americas (22.31%) and Southeast Asia (19.23%). It was found that 20% (n = 26/130) of the studies evaluated the participation of the community in the detection/active search of cases, 20.77% (n = 27/130) in the promotion/prevention of tuberculosis; 23.07% (n = 30/130) in identifying barriers to treatment, 46.15% (n = 60/130) in supervision during treatment and 3.08% (n = 4/130) in social support for patient. Community participation not only strengthens the capacities of health systems for the prevention and care of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient and the affected community by identifying barriers and difficulties through of the tuberculosis care cascade. Engaging key community stakeholders in co-creating solutions offers a critical pathway for local governments to eradicate TB.

Long-term outcomes after tuberculosis for people with HIV in eastern Europe

BACKGROUND

Eastern Europe has a high burden of tuberculosis (TB)/HIV coinfection with high mortality shortly after TB diagnosis. This study assesses TB recurrence, mortality rates and causes of death among TB/HIV patients from Eastern Europe up to 11 years after TB diagnosis.

METHODS

A longitudinal cohort study of TB/HIV patients enrolled between 2011 and 2013 (at TB diagnosis) and followed-up until end of 2021. A competing risk regression was employed to assess rates of TB recurrence, with death as competing event. Kaplan-Meier estimates and a multivariable Cox-regression were used to assess long-term mortality and corresponding risk factors. The Coding Causes of Death in HIV (CoDe) methodology was used for adjudication of causes of death.

RESULTS

Three hundred and seventy-five TB/HIV patients were included. Fifty-three (14.1%) were later diagnosed with recurrent TB [incidence rate 3.1/100 person-years of follow-up (PYFU), 95% confidence interval (CI) 2.4-4.0] during a total follow-up time of 1713 PYFU. Twenty-three of 33 patients with data on drug-resistance (69.7%) had multidrug-resistant (MDR)-TB. More than half with recurrent TB ( n  = 30/53, 56.6%) died. Overall, 215 (57.3%) died during the follow-up period, corresponding to a mortality rate of 11.4/100 PYFU (95% CI 10.0-13.1). Almost half of those (48.8%) died of TB. The proportion of all TB-related deaths was highest in the first 6 ( n  = 49/71; 69%; P  < 0.0001) and 6-24 ( n  = 33/58; 56.9%; P  < 0.0001) months of follow-up, compared deaths beyond 24 months ( n  = 23/85; 26.7%).

CONCLUSION

TB recurrence and TB-related mortality rates in PWH in Eastern Europe are still concerningly high and continue to be a clinical and public health challenge.

Epidemiological features and temporal trends of HIV-negative tuberculosis burden from 1990 to 2019: a retrospective analysis based on the Global Burden of Disease Study 2019

OBJECTIVE

This study aimed to analyse the burden and temporal trends of tuberculosis (TB) incidence and mortality globally, as well as the association between mortality-to-incidence ratio (MIR) and Socio-Demographic Index (SDI).

DESIGN

A retrospective analysis of TB data from 1990 to 2019 was conducted using the Global Burden of Disease Study database.

RESULTS

Between 1990 and 2019, there was a declining trend in the global incidence and mortality of TB. High SDI regions experienced a higher declining rate than in low SDI regions during the same period. Nearly half of the new patients occurred in South Asia. In addition, there is a sex-age imbalance in the overall burden of TB, with young males having higher incidence and mortality than females. In terms of the three subtypes of TB, drug-sensitive (DS)-TB accounted for more than 90% of the incidents and deaths and experienced a decline over the past 30 years. However, drug-resistant TB (multidrug-resistant (MDR)-TB and extensively drug-resistant (XDR)-TB) showed an overall increasing trend in age-standardised incidence rates and age-standardised mortality rates, with an inflection point after the year 2000. At the regional level, South Asia and Eastern Europe remained a high burden of drug-resistant TB incidence and mortality. Interestingly, a negative correlation was found between the MIR and SDI for TB, including DS-TB, MDR-TB and XDR-TB. Notably, central sub-Saharan Africa had the highest MIR, which indicated a higher-than-expected burden given its level of sociodemographic development.

CONCLUSION

This study provides comprehensive insights into the global burden and temporal trends of TB incidence and mortality, as well as the relationship between MIR and SDI. These findings contribute to our understanding of TB epidemiology and can inform public health strategies for prevention and management.

Silicosis as a predictor of tuberculosis mortality and treatment failure and need for incorporation in differentiated TB care models in India

BACKGROUND

Differentiated tuberculosis (TB) care is an approach to improve treatment outcomes by tailoring TB management to the particular needs of patient groups based on their risk profile and comorbidities. In silicosis-prone areas, the coexistence of TB and silicosis may exacerbate treatment outcomes. The objective of the study was to determine predictors of TB-related mortality, treatment failure, and loss to follow-up in a silicosis-prone region of western India.

METHODS

A retrospective cohort was conducted among 2748 people with TB registered between January 2006 and February 2022 in Khambhat, a silicosis-prone block in western India. Death, treatment failure, and loss to follow up were the outcome variables. The significant predictors of each outcome variable were determined using multivariable logistic regression and reported as adjusted odds ratios (aOR) with 95% confidence intervals (CIs).

RESULTS

In the cohort of 2,748 people with TB, 5% presented with silicosis, 11% succumbed to the disease, 5% were lost to follow-up during treatment, and 2% encountered treatment failure upon completion of therapy. On multivariable logistic regression, concomitant silicosis [aOR 2.3 (95% CI 1.5-3.5)], advancing age [aOR 1.03 (95% CI 1.02-1.04)], male gender [aOR 1.4 (95% 1.1-1.9)], human immunodeficiency virus (HIV) positive [aOR 2.2 (95% 1.02-4.6)], and previous TB treatment [aOR 1.5 (95% CI 1.1-1.9)] significantly predicted mortality among people with TB. Concomitant silicosis [aOR 3 (95% CI 1.4-6.5)], previous TB treatment [aOR 3 (95% CI 2-6)], and multi-drug resistant TB [aOR 18 (95% CI 8-41)] were the significant predictors of treatment failure on adjusted analysis. Advancing age [aOR 1.012 (1.001-1.023)], diabetes [aOR 0.6 (0.4-0.8)], and multi-drug resistance [aOR 6 (95% CI 3-12)] significantly predicted loss to follow-up after adjusting for confounders.

CONCLUSIONS

Controlling silicosis might decrease TB mortality and treatment failure in silicosis-prone regions. The coexistence of HIV and silicosis may point to an increase in TB deaths in silicosis-prone areas. Silicosis should now be acknowledged as a major comorbidity of TB and should be included as one of the key risk factors in the differentiated TB care approach. Primary care physicians should have a high clinical suspicion for silicosis among individuals diagnosed with TB in silicosis-prone blocks.

Patient and provider perceptions of the relationship between alcohol use and TB and readiness for treatment: a qualitative study in South Africa

Background

Unhealthy alcohol use is widespread in South Africa and has been linked to tuberculosis (TB) disease and poor treatment outcomes. This study used qualitative methods to explore the relationship between TB and alcohol use during TB treatment.

Methods

Focus groups (FGs) were conducted with 34 participants who had previous or current drugsusceptible TB and self-reported current alcohol use. Eight interviews were conducted with healthcare workers who provide TB services in Worcester, South Africa.

Results

In this rural setting, heavy episodic drinking is normalized and perceived to be related to TB transmission and decreased adherence to TB medication. Both healthcare workers and FG participants recommended the introduction of universal screening, brief interventions, and referral to specialized care for unhealthy alcohol use. However, participants also discussed barriers to the provision of these services, such as limited awareness of the link between alcohol and TB. Healthcare workers also specified resource constraints while FG participants or patients mentioned widespread stigma towards people with alcohol concerns. Both FG participants and health providers would benefit from education on the relationship between TB and unhealthy alcohol use as well and had specific recommendations about interventions for alcohol use reduction. Healthcare workers also suggested that community health worker-delivered interventions could support access to and engagement in both TB and alcohol-related services.

Conclusion

Findings support strengthening accessible, specialized services for the identification and provision of interventions and psychosocial services for unhealthy alcohol use among those with TB.

The impact of comorbidities on tuberculosis treatment outcomes in Poland: a national cohort study

Background

Tuberculosis (TB) is a complex disease associated with other medical conditions, that may affect disease severity. This study aimed to investigate the impact of comorbidities on treatment outcomes and mortality rates in patients with TB in Poland.

Methods

We analyzed a national cohort of 19,217 adult TB patients diagnosed between 2011 and 2016 in Poland. We compared treatment success rates and mortality rates in patients with comorbidities and those without to assess the impact of various comorbidities on these outcomes. Odds ratios (OR) were calculated to quantify the association between comorbidities and TB treatment outcomes.

Results

Patients with comorbidities had lower treatment success rates and higher mortality rates. Diabetes was identified as a significant risk factor for increased TB mortality (OR = 1.9) and mortality from all other causes (OR = 4.5). Similar associations were found for alcoholism (OR = 8.3 and OR = 7.1), immunosuppressive therapy (OR = 5.7 and OR = 5.9), and cancer (OR = 3.4 and OR = 15.4). HIV and tobacco use were associated with an increased risk of mortality from causes other than TB, with odds ratios of 28.6 and 2.2, respectively. The overall treatment success rate in the study population was 88.0%, with 9.2% of patients failing to achieve treatment success and 2.8% dying. Comorbidities such as diabetes, alcoholism, substance addiction, immunosuppressive therapy, cancer, and tobacco use increased the risk of tuberculosis treatment failure.

Conclusion

Patients with comorbidities face a higher risk of unsuccessful treatment outcomes and increased mortality. It is essential to implement integrated management strategies that address both TB and comorbid conditions to improve treatment success rates and reduce mortality.

Hospitalizations for tuberculosis in Sicily over the years 2009-2021: Clinical features, comorbidities, and predictors of mortality

BACKGROUND

Very few data are available in the literature regarding tuberculosis (TB) hospitalization, and few studies have reported the clinical characteristics and comorbidities of admitted patients and burden and cost of hospitalization. In our study, we described the occurrence of TB hospital admissions in the southern Italian region of Sicily over 13 years (2009-2021), explored the characteristics of patients with TB, and determined the comorbidities associated with mortality.

METHOD

Data on the hospital discharge of all patients with TB hospitalized in all Sicilian hospitals were retrospectively collected from hospital standard discharge forms. Age, sex, nationality, length of hospital stay, comorbidities, and TB localization were evaluated using univariate analysis according to in-hospital mortality. The factors associated with mortality were included in the logistic regression model.

RESULTS

In Sicily, 3745 people were hospitalized for TB, with 5239 admissions and 166 deaths from 2009 to 2021. Most hospitalizations involved Italian-born people (46.3%), followed by African-born people (32.8%) and Eastern European-born people (14.1%). The average hospitalization cost was EUR 5259 ± 2592, with a median length of stay of 16 days (interquartile range, 8-30) days. Multivariate analysis showed that the development of acute kidney failure (adjusted odds ratio [aOR]=7.2, p < 0.001), alcohol consumption (aOR=8.9, p = 0.001), malignant tumors (aOR=2.1, p = 0.022), human immunodeficiency virus infection (aOR=3.4, p < 0.001), sepsis (aOR=15.2, p < 0.001), central nervous system involvement (aOR=9.9, p < 0.001), and miliary TB (aOR=2.5, p = 0.004) were independent predictors of mortality.

CONCLUSION

TB in Sicily remains an important cause of hospitalization. HIV infection and comorbidities may complicate patient management and worsen patient outcomes.

Building bridges: multidisciplinary teams in tuberculosis prevention and care

People with or affected by tuberculosis (TB) experience complex social and cultural constraints that may affect treatment outcomes by impeding access to proper care or by hindering treatment adherence. Low levels of health literacy which leads to inadequate disease information; stigma, discrimination and other forms of prejudice that may result in marginalisation and ostracisation; and socioeconomic vulnerabilities that hamper one's capacity to access essential goods or increase the risk of exposure to the disease are some of the barriers highlighted. These complex hurdles are also disproportionately felt by people with or affected by TB due to gender-related inequalities that need to be properly addressed. Additionally, TB prevention and care should encompass interventions aimed at improving and promoting mental health, given that mental unhealth may further thwart treatment adherence and success. A multifaceted and multidisciplinary approach to TB is required to answer these complex barriers.

Nontuberculous Mycobacterial Infection in Wisconsin Adults and Its Relationship to Race and Social Disadvantage

Rationale: Population-based data on the epidemiology of nontuberculosis mycobacterial (NTM) infections are limited, particularly with respect to variation in NTM infection among racial groups and socioeconomic strata. Wisconsin is one of a handful of states where mycobacterial disease is notifiable, allowing large, population-based analyses of the epidemiology of NTM infection in this state. Objectives: To estimate the incidence of NTM infection in Wisconsin adults, describe the geographic distribution of NTM infection across the state, identify the frequency and type of infection caused by different NTM species, and investigate associations between NTM infection and demographics and socioeconomic status. Methods: We conducted a retrospective cohort study using laboratory reports of all NTM isolates from Wisconsin residents submitted to the Wisconsin Electronic Disease Surveillance System from 2011 to 2018. For the analyses of NTM frequency, multiple reports from the same individual were enumerated as separate isolates when nonidentical, collected from different sites or collected more than one year apart. Results: A total of 8,135 NTM isolates from 6,811 adults were analyzed. Mycobacterium avium complex accounted for 76.4% of respiratory isolates. The M. chelonae-abscessus group was the most common species isolated from skin and soft tissue. The annual incidence of NTM infection was stable over the study period (from 22.1 per 100,000 to 22.4 per 100,000). The cumulative incidence of NTM infection among Black (224 per 100,000) and Asian (244 per 100,000) individuals was significantly higher compared with that among their White counterparts (97 per 100,000). Total NTM infections were significantly more frequent (P < 0.001) in individuals from disadvantaged neighborhoods, and racial disparities in the incidence of NTM infection generally remained consistent when stratified by measures of neighborhood disadvantage. Conclusions: More than 90% of NTM infections were from respiratory sites, with the vast majority caused by M. avium complex. Rapidly growing mycobacteria predominated as skin and soft tissue pathogens and were important minor respiratory pathogens. We found a stable annual incidence of NTM infection in Wisconsin between 2011 and 2018. NTM infection occurred more frequently in non-White racial groups and in individuals experiencing social disadvantage, suggesting that NTM disease may be more frequent in these groups as well.

Impact of Deprivation on the Incidence and Severity of Tuberculosis in Children: A Retrospective Study from 2007 to 2020 in a Tertiary Care Center in Paris, France

OBJECTIVE

To assess the association between deprivation and the incidence and clinical severity of tuberculosis (TB) in children.

STUDY DESIGN

Children ≤18 years old who were admitted for TB between 2007 and 2020 at a tertiary hospital were included in this retrospective study. Deprivation was assessed using the French Deprivation Index. TB severity was assessed using the Wiseman classification. Multivariate analyses were carried out.

RESULTS

In total, 222 patients were included. The median age was 10.8 years (IQR 4.5-14.4). TB was considered severe in 126 patients (56.8%), with 50% of the patients included in the 2 most deprived groups. The most-deprived children had a TB incidence that was 58 times greater than that of the least-deprived children (95% CI 28.49-119.40). There was no significant association between deprivation and severity in the multivariable analysis after adjusting for age and circumstances of diagnosis. Deprivation was associated with an increased length of stay in the most-deprived groups (OR 3.79, 95% CI 1.55-10.23). There was a trend toward a greater proportion of symptomatic children in the most-deprived group.

CONCLUSIONS

TB incidence and hospital length of stay increased with deprivation levels but not with the severity of TB.

Models of integration of TB and HIV services and factors associated with perceived quality of TB-HIV integrated service delivery in O. R Tambo District, South Africa

BACKGROUND

Tuberculosis is the leading infectious cause of death among people living with HIV. Reducing morbidity and mortality from HIV-associated TB requires strong collaboration between TB and HIV services at all levels with fully integrated, people-centered models of care.

METHODS

This is a qualitative study design using principles of ethnography and the application of aggregate complexity theory. A total of 54 individual interviews with healthcare workers and patients took place in five primary healthcare facilities in the O.R. Tambo district. The participants were purposively selected until the data reached saturation point, and all interviews were tape-recorded. Quantitative analysis of qualitative data was used after coding ethnographic data, looking for emerging patterns, and counting the number of times a qualitative code occurred. A Likert scale was used to assess the perceived quality of TB/HIV integration. Regression models and canonical discriminant analyses were used to explore the associations between the perceived quality of TB and HIV integrated service delivery and independent predictors of interest using SPSS® version 23.0 (Chicago, IL) considering a type I error of 0.05.

RESULTS

Of the 54 participants, 39 (72.2%) reported that TB and HIV services were partially integrated while 15 (27.8%) participants reported that TB/HIV services were fully integrated. Using the Likert scale gradient, 23 (42.6%) participants perceived the quality of integrated TB/HIV services as poor while 13 (24.1%) and 18 (33.3%) perceived the quality of TB/HIV integrated services as moderate and excellent, respectively. Multiple linear regression analysis showed that access to healthcare services was significantly and independently associated with the perceived quality of integrated TB/HIV services following the equation: Y = 3.72-0.06X (adjusted R2 = 23%, p-value = 0.001). Canonical discriminant analysis (CDA) showed that in all 5 municipal facilities, long distances to healthcare facilities leading to reduced access to services were significantly more likely to be the most impeding factor, which is negatively influencing the perceived quality of integrated TB/HIV services, with functions' coefficients ranging from 9.175 in Mhlontlo to 16.514 in KSD (Wilk's Lambda = 0.750, p = 0.043).

CONCLUSION

HIV and TB integration is inadequate with limited access to healthcare services. Full integration (one-stop-shop services) is recommended.

Clinical Features, Biochemical Parameters, and Treatment Adherence of Individuals Who Started the Treatment for Active Pulmonary Tuberculosis during the Pandemic Period

This descriptive prospective study investigated the clinical features and treatment adherence of individuals who started the treatment for Pulmonary tuberculosis (TB) during the COVID-19 pandemic in São Luís. Thirty-six TB patients and thirty-five age/sex-matched individuals were recruited between January 2021 and January 2022. The clinical features, sociodemographic information, and serum were obtained at the diagnosis time. Adherence to treatment and adverse reactions were investigated monthly. The most common symptoms in TB patients were cough (91.6%) and fever (83.3%). All TB patients had elevated pre-therapy levels of CRP and reduced HDL: 88.9% presented hypocalcemia and 47.2% showed elevated ALP and GGT. TB patients showed higher levels of ALT, AST, ALP, GGT, CRP, amylase, and triglycerides than the comparison group (p < 0.05), while the calcium levels were reduced (p < 0.0001). TB patients with anti-SARS-CoV-2-IgG antibodies (seroprevalence of 66.7%) presented higher values of amylase and lower CRP levels (p < 0.05). Most patients (~70%) reported at least one adverse drug reaction, mainly pruritus and nausea. The treatment abandonment rate was 19.2%. In conclusion, TB patients showed elevated pre-therapy levels of CRP, low levels of HDL, and hypocalcemia. Liver and pancreatic functions were also compromised in several patients before the therapy. The treatment non-adherence rate observed was similar to other studies performed before the pandemic period.

A distributional regression approach to modeling the impact of structural and intermediary social determinants on communities burdened by tuberculosis in Eastern Amazonia - Brazil

BACKGROUND

Tuberculosis (TB) is a disease that is influenced by social determinants of health. However, the specific structural and intermediary determinants of TB in Eastern Amazonia remain unclear. Despite being rich in natural resources, the region faces significant challenges related to poverty, inequality, and neglected diseases. The objective of this study was to use mathematical modeling to evaluate the influence of structural and intermediary determinants of health on TB in Eastern Amazonia, Brazil.

METHODS

This cross-sectional included all TB cases diagnosed and registered in the Notifiable Diseases Information System (SINAN) from 2001 to 2017. Data on social determinants were collected at the census tract level. The generalized additive model for location, scale, and shape (GAMLSS) framework was employed to identify the effect of social determinants on communities with a high TB prevalence. The Double Poisson distribution (DPO) was chosen, and inclusion of quadratic effects was tested.

RESULTS

A total of 1730 individuals were diagnosed with TB and reported in SINAN during the analyzed period. The majority were female (59.3%), aged 31 to 59 years (47.6%), identified as blacks (67.9%), and had incomplete elementary education (46.6%). The prevalence of alcoholism was 8.6% and mental illness was 0.7%. GAMLSS analyses demonstrated that the risk of community incidence of TB is associated with the proportion of the population lacking basic sanitation, as well as with the age groups of 16-31 years and > 61 years.

CONCLUSIONS

The study highlights the strategic utility of GAMLSS in identifying high-risk areas for TB. Models should encompass a broader range of social determinants to inform policies aimed at reducing inequality and achieving the goals of the End TB strategy.

A mixed methods evaluation of a differentiated care model piloted for TB care in south India

Background

India's National TB Elimination Program emphasizes patient-centered care to improve TB treatment outcomes. We describe the lessons learned from the implementation of a differentiated care model for TB care among individuals diagnosed with active TB.

Design and methods

Used mixed methods to pilot the Differentiated Care Model. Community health workers (CHWs) conducted a risk and needs assessment among individuals who were recently began TB treatment. Individuals identified with specific factors that are associated with poor treatment adherence were provided education, counseling, and linked to treatment and support services. Examined changes in TB treatment outcomes between the two cohorts of individuals on TB treatment before and after the intervention. We used qualitative research methods to explore the experiences of patients, family members, and front-line TB workers with the implementation of the DCM pilot.

Results

The CHWs were adept at the identification of individuals with risks to non-adherence. However, only a few provided differentiated care, as envisioned. There was no significant change in the TB treatment outcomes between the two cohorts of patients examined. CHWs' ability to provide differentiated care on a scale was limited by the short duration of implementation, their inadequate skills to manage co-morbidities, and the suboptimal support at the field level.

Conclusions

It is feasible for a cadre of well-trained front-line workers, mentored and supported by counselors and doctors, to provide differentiated care to those at risk for unfavorable TB treatment outcomes. However, differentiated care must be implemented on a scale for a duration that allows a change from the conventional practice of front-line workers, in order to influence the outcomes of population-level TB treatment.

Developing a Model for Integrating of Tuberculosis, Human Immunodeficiency Virus and Primary Healthcare Services in Oliver Reginald (O.R) Tambo District, Eastern Cape, South Africa

Despite the policy, frameworks for integration exist; integration of TB and HIV services is far from ideal in many resource-limited countries, including South Africa. Few studies have examined the advantages and disadvantages of integrated TB and HIV care in public health facilities, and even fewer have proposed conceptual models for proven integration. This study aims to fill this vacuum by describing the development of a paradigm for integrating TB, HIV, and patient services in a single facility and highlights the importance of TB-HIV services for greater accessibility under one roof. Development of the proposed model occurred in several phases that included assessment of the existing integration model for TB-HIV and synthesis of quantitative and qualitative data from the study sites, which were selected public health facilities in rural and peri-urban areas in the Oliver Reginald (O.R.) Tambo District Municipality in the Eastern Cape, South Africa. Secondary data on clinical outcomes from 2009-2013 TB-HIV were obtained from various sources for the quantitative analysis of Part 1. Qualitative data included focus group discussions with patients and healthcare workers, which were analyzed thematically in Parts 2 and 3. The development of a potentially better model and the validation of this model shows that the district health system was strengthened by the guiding principles of the model, which placed a strong emphasis on inputs, processes, outcomes, and integration effects. The model is adaptable to different healthcare delivery systems but requires the support of patients, providers (professionals and institutions), payers, and policymakers to be successful.

Impact of aging on immunity in the context of COVID-19, HIV, and tuberculosis

Knowledge of aging biology needs to be expanded due to the continuously growing number of elderly people worldwide. Aging induces changes that affect all systems of the body. The risk of cardiovascular disease and cancer increases with age. In particular, the age-induced adaptation of the immune system causes a greater susceptibility to infections and contributes to the inability to control pathogen growth and immune-mediated tissue damage. Since the impact of aging on immune function, is still to be fully elucidated, this review addresses some of the recent understanding of age-related changes affecting key components of immunity. The emphasis is on immunosenescence and inflammaging that are impacted by common infectious diseases that are characterized by a high mortality, and includes COVID-19, HIV and tuberculosis.

Nationwide Treatment Outcomes of Patients With Multidrug/Rifampin-Resistant Tuberculosis in Korea, 2011-2017: A Retrospective Cohort Study (Korean TB-POST)

BACKGROUND

The treatment outcomes of patients with multidrug/rifampin-resistant (MDR/RR) tuberculosis (TB) are important indicators that reflect the current status of TB management and identify the key challenges encountered by TB control programs in a country.

METHODS

We retrospectively evaluated the treatment outcomes as well as predictors of unfavorable outcomes in patients with MDR/RR-TB notified from 2011 to 2017, using an integrated TB database.

RESULTS

A total of 7,226 patients with MDR/RR-TB were included. The treatment success rate had significantly increased from 63.9% in 2011 to 75.1% in 2017 (P < 0.001). Among unfavorable outcomes, the proportion of patients who failed, were lost to follow up, and were not evaluated had gradually decreased (P < 0.001). In contrast, TB-related death rate was not significantly changed (P = 0.513), while the non-TB related death rate had increased from 3.2% in 2011 to 11.1% in 2017 (P < 0.001). Older age, male sex, immigrants, low household income, previous history of TB treatment, and comorbidities were independent predictors of unfavorable outcomes. Of the 5,308 patients who were successfully treated, recurrence occurred in 241 patients (4.5%) at a median 18.4 months (interquartile range, 9.2-32.4) after completion treatment.

CONCLUSION

The treatment outcomes of patients with MDR/RR-TB has gradually improved but increasing deaths during treatment is an emerging challenge for MDR-TB control in Korea. Targeted and comprehensive care is needed for vulnerable patients such as the elderly, patients with comorbidities, and those with low household incomes.

Tuberculin skin test versus QuantiFERON-TB gold in-tube for latent tuberculosis screening in people living with HIV in a resource-limited setting

OBJECTIVE

To compare QuantiFERON-TB Gold-in-Tube (QFT) and tuberculin skin test (TST) in the diagnosis of latent tuberculosis infection (LTBI) among people living with HIV (PLWHIV).

METHODS

A cross-sectional study was carried out between 2017-2018. Tuberculin skin test and QFT were performed and their concordance was measured. The gold standard for LTBI was defined as positivity to any of the tests. A logistic regression model was carried out to predict the QFT result in patients with a negative TST.

RESULTS

A total of 510 PLWHIV were included, with 409 (80.2%) being male. The mean age of the patients was 41.3 ± 11.8 years. The median time since HIV diagnosis was 5 years (IQR 2-10), with a median CD4⁺ count of 541 (IQR 340-757) cells/mm³. Overall, 20 patients had an isolated TST+, 22 an isolated QFT+ and 15 had both positive. Concordance between tests showed a kappa coefficient of .37. Overcrowding was the only predictor for a positive QFT after a negative TST (p = .003).

CONCLUSION

There was fair agreement between tests in PLWHIV. In conditions of limited access to QTF, a TST-based strategy could be considered, with sequential use of QTF in high-risk patients with a negative result, especially those who live in overcrowded conditions.

A spatial analysis of TB cases and abnormal X-rays detected through active case-finding in Karachi, Pakistan

Tuberculosis (TB) is the leading cause of avoidable deaths from an infectious disease globally and a large of number of people who develop TB each year remain undiagnosed. Active case-finding has been recommended by the World Health Organization to bridge the case-detection gap for TB in high burden countries. However, concerns remain regarding their yield and cost-effectiveness. Data from mobile chest X-ray (CXR) supported active case-finding community camps conducted in Karachi, Pakistan from July 2018 to March 2020 was retrospectively analyzed. Frequency analysis was carried out at the camp-level and outcomes of interest for the spatial analyses were mycobacterium TB positivity (MTB+) and X-ray abnormality rates. The Global Moran's I statistic was used to test for spatial autocorrelation for MTB+ and abnormal X-rays within Union Councils (UCs) in Karachi. A total of 1161 (78.1%) camps yielded no MTB+ cases, 246 (16.5%) camps yielded 1 MTB+, 52 (3.5%) camps yielded 2 MTB+ and 27 (1.8%) yielded 3 or more MTB+. A total of 79 (5.3%) camps accounted for 193 (44.0%) of MTB+ cases detected. Statistically significant clustering for MTB positivity (Global Moran's I: 0.09) and abnormal chest X-rays (Global Moran's I: 0.36) rates was identified within UCs in Karachi. Clustering of UCs with high MTB positivity were identified in Karachi West district. Statistically significant spatial variation was identified in yield of bacteriologically positive TB cases and in abnormal CXR through active case-finding in Karachi. Cost-effectiveness of active case-finding programs can be improved by identifying and focusing interventions in hotspots and avoiding locations with no known TB cases reported through routine surveillance.

Gender differences in tuberculosis patients with comorbidity: A cross-sectional study using national surveillance data and national health insurance claims data in South Korea

The coexistence of tuberculosis and other chronic diseases complicates disease management. Particularly, the lack of information on the difference in the prevalence of chronic diseases in tuberculosis based on age and gender can hinder the establishment of appropriate public health strategies. This study aimed to identify age- and gender-based differences in the prevalence of chronic diseases as comorbidities in patients with tuberculosis. An anonymized data source was established by linking the national health insurance claims data to the Korean national tuberculosis surveillance data from 2014 to 2018. The prevalence of chronic diseases was stratified by gender and age (age groups: ≤64, 65-74, and ≥75 years), and the differences in the prevalence of chronic diseases were analyzed by multinomial logistic regression and classified using the Charlson Comorbidity Index. A total of 148,055 patients with tuberculosis (61,199 women and 86,856 men) were included in this study. Among the patients aged ≥65 years, 48.2% were female and 38.1% were male. In this age group, the probability of chronic disease comorbidity was higher in female patients than in male patients. The prevalence of congestive heart failure and dementia as comorbidities in patients with tuberculosis increased more drastically with age in women than in men. Thus, the present study confirmed gender and age differences in the distribution of comorbidities among patients with tuberculosis. A more comprehensive gender-responsive approach for patients with tuberculosis and chronic diseases is required to alleviate the double burden of infectious diseases and non-communicable diseases in an aging society.

The community as an active part in the implementation of interventions for the prevention and control of tuberculosis: a scoping review

Interventions involving direct community stakeholders include a variety of approaches in which members take an active role in improving their health. We evaluated studies in which the community has actively participated to strengthen tuberculosis prevention and control programs. A literature search was performed in Pubmed, Scopus, ERIC, Global Index Medicus, Scielo, Cochrane Library, LILACS, Google Scholar, speciality journals, and other bibliographic references. The primary question for this review was: what is known about tuberculosis control interventions and programs in which the community has been an active part?. Two reviewers performed the search, screening and selection of studies independently. In cases of discrepancies over the eligibility of an article, it was resolved by consensus. 130 studies were selected, of which 68.47% (n=89/130) were published after 2010. The studies were conducted in Africa (44.62%), the Americas (22.31%) and Southeast Asia (19.23%). It was found that 20% (n=26/130) of the studies evaluated the participation of the community in the detection/active search of cases, 20.77% (n=27/130) in the promotion/prevention of tuberculosis; 23.07% (n=30/130) in identifying barriers to treatment, 46.15% (n=60/130) in supervision during treatment and 3.08% (n=4/130) in social support for patient. Community participation not only strengthens the capacities of health systems for the prevention and control of tuberculosis, but also allows a better understanding of the disease from the perspective of the patient and the affected community by identifying barriers and difficulties through of the tuberculosis care cascade. Engaging key community stakeholders in co-creating solutions offers a critical pathway for local governments to eradicate TB.

High risk of unsuccessful treatment outcome in migrant population with tuberculosis: Data from three Italian hospitals

Introduction

Tuberculosis (TB) remains an unresolved global health problem and vulnerable groups such as migrants remain the most affected with a higher risk of worse outcomes. The aim of this study was to evaluate clinical features, outcomes, and adverse events in migrant and native Italian patients admitted to three Italian hospitals in Southern Italy in order to assess differences and targeted strategies.

Methods

We performed a retrospective study on TB patients admitted between January 1, 2013, and December 31, 2021, in three Apulia hospitals. Two logistic regression models were used, with the dependent variables being (I) unsuccessful treatment (died, loss to follow-up, and failed treatment) and (II) adverse events.

Results

We enrolled 543 consecutive patients admitted at three Italian hospitals with a diagnosis of TB during the study period, of them 323 (59.5%) were migrants and 220 Italian patients. The treatment success rate in the migrant group was 44.9% (137/305), while in the non-migrant group was 97.1% (203/209). Independent factors of unsuccess treatment (death, failure or loss to follow up) were: migrant status (O.R. = 11.31; 95% CI 9.72-14.23), being male (O.R. = 4.63; 95% CI 2.16-6.10), homelessness (O.R. = 3.23; 95% CI 2.58-4.54), having a MDR (Multidrug-resistant) (O.R = 6.44; 95% CI 4.74-8.23), diagnostic delay (O.R. = 3.55; 95% CI 1.98-5.67), and length of hospitalization (O.R. = 3.43; 95% CI 1.88-5.87). While, age >65 ys (O.R. = 3.11; 95% CI 1.42-4.76), presence of extrapulmonary TB (O.R. = 1.51; 95% CI 1.31-2.18), monoresistance (O.R. = 1.45; 95% CI 1.25-3.14) and MDR pattern (O.R. = 2.44; 95% CI 1.74-5.03) resulted associated with adverse events.

Conclusion

Migrant population is at high risk of unsuccessful treatment (death, loss to follow-up, and treatment failure). Policies targeted specifically to this group are needed to really impact and improve their health status and also to contain the TB burden.

The socio-demographic, clinical characteristics and outcomes of tuberculosis among HIV infected adults in Lithuania: A thirteen-year analysis

BACKGROUND

Tuberculosis (TB) is a public health problem in Lithuania, among the 18 high-priority TB countries in the European region, and the most common AIDS-indicative disease with the highest proportion in the EU/EEA since 2015. The study aimed to identify socio-demographic, clinical characteristics and their relationship with TB outcomes in TB-HIV co-infected patients in Lithuania.

METHODS

A retrospective chart review analysed the characteristics of TB-HIV co-infected adults registered in State Information System of Tuberculosis over 2008-2020. The factors associated with drug-resistant TB and unsuccessful treatment outcome were identified by multivariable logistic regression.

RESULTS

The study included 345 cases in 311 patients (239 new, 106 previously treated cases), median age 40 years (IQR 35-45), 80.7% male. 67.8% patients knew their HIV-positive status before TB diagnosis, median time to TB diagnosis was 8 years (IQR 4-12). 83.6% were unemployed, 50.5%-anytime intravenous drug users (IDU), 34.9% abused alcohol. Drug-resistant TB rates in new and previously treated TB cases were 38.1% and 61.3%, respectively. In multivariable analysis, higher risk of drug-resistant TB was associated with imprisonment in new (aOR 3.35; 95%CI 1.17-9.57) and previously treated (aOR 6.63; 95%CI 1.09-40.35) cases. In 52.3% of new TB cases and in 42.5% previously treated TB cases the treatment outcomes were unsuccessful. In multivariable analysis of new TB cases, current imprisonment (aOR 2.77; 95%CI 1.29-5.91) and drug-resistant TB (aOR 2.18; 95%CI 1.11-4.28) were associated with unsuccessful treatment outcome. In multivariable analysis of previously treated TB cases, female gender (aOR 11.93; 95%CI 1.86-76.69), alcohol abuse (aOR 3.17; 95%CI 1.05-9.58), drug-resistant TB (aOR 4.83; 95%CI 1.53-15.28) were associated with unsuccessful treatment outcome.

CONCLUSIONS

In the TB-HIV-infected adult cohort in Lithuania, unemployment, imprisonment, IDU, alcohol abuse, known to be risk factors for TB, were very frequent. Drug resistance was an undeniable risk factor for unsuccessful treatment outcome and imprisonment was associated with drug resistant TB.

Association of duration of undernutrition with occurrence of tuberculosis

Undernutrition is a risk factor of tuberculosis (TB), but the association between duration of undernutrition and occurrence of TB is inconclusive. The objective of this study was to determine whether there is a difference in occurrence of TB according to the duration of undernutrition expressed as accumulated number of underweight in Republic of Korea, an intermediate TB burden country. The National Health Insurance database was used.Eligible subjects were individuals who received a national health examination between 1 and 2009 and 31 December 2010, and who also had received health examinations for four consecutive years prior to 2009.Finally included individuals in the analysis were followed until 31 December 2017. Accumulated number of underweight was defined as the number of times recorded as underweight over four consecutive years. The outcome of the study was newly diagnosed TB according to accumulated number of underweight. Among a study population of 2,396,434, TB was identified in 9,322 (3.89%) cases. The highest accumulated number of underweight was significantly associated with occurrence of TB (adjusted hazard ratio [aHR] 2.563, 95% CI 2.319-2.833). This association remained consistent after adjusting for demographic factors and underlying diseases (aHR 3.326, 95% CI 3.004-3.84). In stratified analysis based on age, sex, diabetes (DM), hypertension (HTN), and waist circumference (WC) in metabolic syndrome (MS), age and sex were identified as effect modifiers. Occurrence of TB was significantly higher in the group with the highest accumulated number of underweight under 65 years of age.

Tuberculosis epidemiological trend in Sousse, Tunisia during twenty years (2000-2019)

Describe the epidemiology of tuberculosis in the last two decades (2000-2019) in the East region of Tunisia (city of Sousse). This was a descriptive retrospective analysis of notified incident cases of tuberculosis from 2000 to 2019 in Sousse Governorate, Tunisia. The data collection was done via the regional registry of tuberculosis. Stata software was used to characterize the socio-demographic and clinical profile of tuberculosis, to calculate its incidence, mortality and fatality rates and to determine predictive factors of mortality. R software was used to analyze the chronological trend of tuberculosis incidence and mortality. A total of 2606 incident cases of tuberculosis were declared from 2000 to 2019 in Sousse. The mean age was 39 ± 19 years with a sex ratio (male/female) of 1.19. Only one case was HIV positive among the total 2606 incident cases. Extra-pulmonary tuberculosis was the most recorded (1,534 cases, 58.9%). The mean annual case notification and deaths were 130 and four respectively. After adjusting for confounders, individuals with pulmonary tuberculosis were 1.9 significantly more likely to die from tuberculosis compared to those suffering from extra-pulmonary tuberculosis. There was a trend of increasing mortality with increasing age. The association was statistically significant only for those above 60 years' old who had 12.5 times higher odds of dying compared to those below 60 years. After adjusting for age and gender, with every year there was an increase in the total incidence rate (+0.35 per 100,000) with p = 0.005 and in the extra-pulmonary incidence (+0.27 per 100,000), with p = 0.001. This study demonstrated the increasing trend of tuberculosis in Sousse, Tunisia from 2000 to 2019. The national program against tuberculosis should enhance community knowledge and centralize the national and regional epidemiological information for better epidemiological surveillance.

Biocultural perspectives of infectious diseases and demographic evolution: Tuberculosis and its comorbidities through history

Anthropologists recognize the importance of conceptualizing health in the context of the mutually evolving nature of biology and culture through the biocultural approach, but biocultural anthropological perspectives of infectious diseases and their impacts on humans (and vice versa) through time are relatively underrepresented. Tuberculosis (TB) has been a constant companion of humans for thousands of years and has heavily influenced population health in almost every phase of cultural and demographic evolution. TB in human populations has been dramatically influenced by behavior, demographic and epidemiological shifts, and other comorbidities through history. This paper critically discusses TB and some of its major comorbidities through history within a biocultural framework to show how transitions in human demography and culture affected the disease-scape of TB. In doing so, I address the potential synthesis of biocultural and epidemiological transition theory to better comprehend the mutual evolution of infectious diseases and humans.

Patient and health-care provider experience of a person-centred, multidisciplinary, psychosocial support and harm reduction programme for patients with harmful use of alcohol and drug-resistant tuberculosis in Minsk, Belarus

Background

Tuberculosis (TB) often concentrates in groups of people with complex health and social issues, including alcohol use disorders (AUD). Risk of TB, and poor TB treatment outcomes, are substantially elevated in people who have AUD. Médecins sans Frontières and the Belarus Ministry of Health have worked to improve treatment adherence in patients with multi-drug or rifampicin resistant (MDR/RR)-TB and harmful use of alcohol. In 2016, a person-centred, multidisciplinary, psychosocial support and harm reduction programme delivered by TB doctors, counsellors, psychiatrists, health-educators, and social workers was initiated. In 2020, we described patient and provider experiences within the programme as part of a wider evaluation.

Methods

We recruited 12 patients and 20 health-care workers, using purposive sampling, for in-depth individual interviews and focus group discussions. We used a participant-led, flexible, exploratory approach, enabling participants and the interviewer to shape topics of conversation. Qualitative data were coded manually and analysed thematically. As part of the analysis process, identified themes were shared with health-care worker participants to enable their reflections to be incorporated into the findings.

Results

Key themes related to the patients’ and practitioners experience of having and treating MDRTB with associated complex health and social issues were: fragility and despair and guidance, trust and health. Prejudice and marginalisation were global to both themes. Counsellors and other health workers built a trusting relationship with patients, enabling guidance through a multi-disciplinary approach, which supported patients to achieve their vision of health. This guidance was achieved by a team of social workers, counsellors, doctors and health-educators who provided professional and individualised help for patients’ illnesses, personal or interpersonal problems, administrative tasks, and job searches.

Conclusions

Patients with MDR/RR-TB and harmful use of alcohol faced complex issues during treatment. Our findings describe how person-centred, multi-disciplinary, psychosocial support helped patients in this setting to cope with these challenges and complete the treatment programme. We recommend that these findings are used to: i) inform programmatic changes to further boost the person-centred care nature of this program; and ii) advocate for this type of person-centred care approach to be rolled out across Belarus, and in contexts that face similar challenges.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08525-x.

Association of underweight status with the risk of tuberculosis: a nationwide population-based cohort study

In studies evaluating the association between body mass index (BMI) and risk of tuberculosis (TB), the data for the underweight population has been limited and results were conflicting. Our study aimed to evaluate whether being underweight increases the risk of TB using a nationwide representative sample from the Republic of Korea. A large population-based cohort study of over ten million subjects who participated in the health screening in 2010 was performed using the Korean National Health Insurance database 2010–2017. We evaluated the incidence and risk of TB by BMI category (kg/m²) for Asians using a multivariable Cox regression model, adjusting for age, sex, smoking, alcohol consumption, regular exercise, low-income state, and underlying hypertension, diabetes mellitus, and dyslipidemia. To evaluate the association between BMI and TB risk, the underweight population was further subdivided according to the degree of thinness. During 70,063,154.3 person-years of follow-up, 52,615 of 11,135,332 individuals developed active TB with an incidence of 0.75 per 1000 person-years. Overall, there was a log-linear inverse relationship between TB incidence and BMI, within the BMI range of 15–30 kg/m² (R² = 0.95). The estimated adjusted hazard ratio (HR) for incident TB in the underweight population (BMI < 18.5) was 2.08 (95% confidence intervals, CI 2.02–2.15), overweight (23 ≤ BMI < 25) was 0.56 (0.55–0.58) and obese (BMI ≥ 25) was 0.40 (0.39–0.41) relative to the normal weight population. Among the underweight population, TB risk increased as the degree of thinness increased (adjusted HR = 1.98, 1.91–2.05; 2.50, 2.33–2.68; and 2.83, 2.55–3.15, for mild, moderate and severe thinness, respectively) (p for trend < 0.001). We found a significant inverse relationship between BMI and TB incidence, which was especially profound in the underweight population. Public health strategies to screen TB more actively in the underweight population and improve their weight status may help reduce the burden of TB.

Tuberculosis in an Aging World

Tuberculosis (TB) is one of the leading causes of death due to its being an infectious disease, caused by the airborne pathogen Mycobacterium tuberculosis (M.tb). Approximately one-fourth of the world’s population is infected with latent M.tb, and TB is considered a global threat killing over 4000 people every day. The risk of TB susceptibility and mortality is significantly increased in individuals aged 65 and older, confirming that the elderly represent one of the largest reservoirs for M.tb infection. The elderly population faces many challenges that increase their risk of developing respiratory diseases, including TB. The challenges the elderly face in this regard include the following: decreased lung function, immuno-senescence, inflammaging, adverse drug effects, low tolerance to anti-TB drugs, lack of suitable diagnoses/interventions, and age-associated comorbidities. In order to find new therapeutic strategies to maintain lung homeostasis and resistance to respiratory infections as we age, it is necessary to understand the molecular and cellular mechanisms behind natural lung aging. This review focuses primarily on why the elderly are more susceptible to TB disease and death, with a focus on pulmonary function and comorbidities.

Utilisation of village health workers’ services for tuberculosis screening in Lesotho

Background

Village health workers (VHWs) play an essential role because they extend the capacity of primary healthcare, particularly for developing countries. In Lesotho, VHWs are part of the primary healthcare connecting the community with clinics in their respective villages. They contribute to the prevention of the spread of tuberculosis (TB) within their catchment areas by encouraging communities to partake in TB screening. This study aimed at identifying factors associated with the utilisation of VHWs’ service to undertake TB screenings in Lesotho.

Methods

This study emanates from the main study that used a cross-sectional descriptive design. A total of 19 health service areas (HSAs) comprised 17 catchment areas and two clinics, each randomly selected from the District Health Management Team (DHMT) and the Lesotho Flying Doctors Service (LFDS), respectively. A total of 2928 individual household members aged 15 and above were included in the study. Data analysis included descriptive and inferential statistics.

Results

There were more female than male respondents, with a majority (77%) below 65 years of age. Tuberculosis knowledge of respondents was mostly on the TB symptoms and curability of TB, but they were less knowledgeable about the causes of TB. The use of VHWs’ services for TB screening was very low (23.3%).

Conclusion

The study revealed that while respondents were to some extent knowledgeable about TB, their utilisation of VHWs’ services for TB screening varied with education level, having worked in South Africa and the household size at α = 0.01.

Tuberculosis Disability Adjusted Life Years, Colombia 2010-2018

Estimating the burden of tuberculosis disease is relevant for assessing and identifying population health status and progress in policies and programs aimed at epidemic control. The objective of this study was to estimate disability-adjusted life years attributable to Tuberculosis in Colombia 2010-2018. A longitudinal descriptive study was conducted. The variables, sex, age groups and origin were studied. This study included 110,475 cases of morbidity and 8514 cases of mortality. Indicators of years of life lost, years of life with disability and disability-adjusted life years at the subnational level were determined using the methodology of the World Health Organization. With the results of this last indicator, an epidemiological risk stratification was carried out. The DALY rate of the study period was 684 (95% CI 581.2-809.1) per 100,000 inhabitants. According to sex, 68.4% occurred in men; for every DALY in women, 2.21 occur in men. People of productive age (15 to 69 years) account for 56% of DALYs. Amazonas (1857.1 CI 95% 1177.1-2389.6) was the territorial entity with the highest rate. A total of 51.5% of the territorial entities of departmental order of the country are of high burden for Tuberculosis. For the first time in Colombia, a comprehensive assessment of the status of the disease burden at a subnational (departmental) territorial level attributable to Tuberculosis is being carried out using the updated World Health Organization methodology. The results obtained allow us to specify that there is a knowledge gap in terms of the realization and clear understanding of the burden of the disease in Colombia. There are territorial gaps that are necessary to know in order to plan, develop, implement and redirect policies to improve health and eliminate disparities according to the territorial context.

Investigating Spatial Patterns of Pulmonary Tuberculosis and Main Related Factors in Bandar Lampung, Indonesia Using Geographically Weighted Poisson Regression

Tuberculosis (TB) is a highly infectious disease, representing one of the major causes of death worldwide. Sustainable Development Goal 3.3 implies a serious decrease in the incidence of TB cases. Hence, this study applied a spatial analysis approach to investigate patterns of pulmonary TB cases and its drivers in Bandar Lampung (Indonesia). Our study examined seven variables: the growth rate of pulmonary TB, population, distance to the city center, industrial area, green open space, built area, and slum area using geographically weighted Poisson regression (GWPR). The GWPR model demonstrated excellent results with an R2 and adjusted R2 of 0.96 and 0.94, respectively. In this case, the growth rate of pulmonary TB and population were statistically significant variables. Spatial pattern analysis of sub-districts revealed that those of Panjang and Kedaton were driven by high pulmonary TB growth rate and population, whereas that of Sukabumi was driven by the accumulation of high levels of industrial area, built area, and slums. For these reasons, we suggest that local policymakers implement a variety of infectious disease prevention and control strategies based on the spatial variation of pulmonary TB rate and its influencing factors in each sub-district.

Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts

BACKGROUND

Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs).

METHODS

We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB.

DISCUSSION

This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings.

TRIAL REGISTRATION

NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.

Mapping local variation in household overcrowding across Africa from 2000 to 2018: a modelling study

BACKGROUND

Household overcrowding is a serious public health threat associated with high morbidity and mortality. Rapid population growth and urbanisation contribute to overcrowding and poor sanitation in low-income and middle- income countries, and are risk factors for the spread of infectious diseases, including COVID-19, and antimicrobial resistance. Many countries do not have adequate surveillance capacity to monitor household overcrowding. Geostatistical models are therefore useful tools for estimating household overcrowding. In this study, we aimed to estimate household overcrowding in Africa between 2000 and 2018 by combining available household survey data, population censuses, and other country-specific household surveys within a geostatistical framework.

METHODS

We used data from household surveys and population censuses to generate a Bayesian geostatistical model of household overcrowding in Africa for the 19-year period between 2000 and 2018. Additional sociodemographic and health-related covariates informed the model, which covered 54 African countries.

FINDINGS

We analysed 287 surveys and population censuses, covering 78 695 991 households. Spatial and temporal variability arose in household overcrowding estimates over time. In 2018, the highest overcrowding estimates were observed in the Horn of Africa region (median proportion 62% [IQR 57-63]); the lowest regional median proportion was estimated for the north of Africa region (16% [14-19]). Overall, 474·4 million (95% uncertainty interval [UI] 250·1 million-740·7 million) people were estimated to be living in overcrowded conditions in Africa in 2018, a 62·7% increase from the estimated 291·5 million (180·8 million-417·3 million) people who lived in overcrowded conditions in the year 2000. 48·5% (229·9 million) of people living in overcrowded conditions came from six African countries (Nigeria, Ethiopia, Democratic Republic of the Congo, Sudan, Uganda, and Kenya), with a combined population of 538·3 million people.

INTERPRETATION

This study incorporated survey and population censuses data and used geostatistical modelling to estimate continent-wide overcrowding over a 19-year period. Our analysis identified countries and areas with high numbers of people living in overcrowded conditions, thereby providing a benchmark for policy planning and the implementation of interventions such as in infectious disease control.

FUNDING

UK Department of Health and Social Care, Wellcome Trust, Bill & Melinda Gates Foundation.