Gender differentials in tuberculosis: the role of socio-economic and cultural factors

Tuberculosis case fatality is higher in male than female patients in Europe: a systematic review and meta-analysis

PURPOSE

Epidemiological TB data indicate differences in infection prevalence, progression rates, and clinical disease incidence between sexes. In contrast, evidence on sex-specific differential (post) TB case fatality in Europe has not been synthesized systematically.

METHODS

We searched electronic databases and grey literature up to December 2020 for studies reporting sex-stratified TB death data for Europe. The JBI critical appraisal tools served for bias risk assessment and subgroup analyses for studying heterogeneity. Random-effects models meta-analyses enabled estimating pooled relative risks of sex-associated TB fatality. Considering associations of comorbidities and risk factors on fatality differences, we applied relative risk meta-regression.

RESULTS

Based on 17,400 records screened, 117 studies entered quantitative analyses. Seventy-five studies providing absolute participant data with moderate quality and limited sex stratification reported 33 to 235,000 TB cases and 7 to 27,108 deaths. The pooled male-to-female TB fatality risk ratio was 1.4 [1.3-1.5]. Heterogeneity was high between studies and subgroups. Study time, concurrent comorbidities (e.g., HIV, diabetes, cancers), and mean participant ages showed no effect modification. We identified higher male TB fatality in studies with higher homelessness (coefficient 3.18, 95% CI [-0.59 to 6.94], p-value 0.10) and lower migrants proportion (coefficient - 0.24, 95% CI [- 0.5 to 0.04], p-value 0.09).

CONCLUSION

We found 30-50% higher TB case fatality for males in Europe. Except for homelessness, migration, and a trend for some comorbidities, assessing effect modification could not reduce our meta-analysis' high heterogeneity. Public health authorities should take heed of this higher risk of dying in male patients' treatment services.

Using intersectional gender analysis to identify challenges in tuberculosis care at four health care facilities in Uganda

BACKGROUND

Tuberculosis (TB) care could be considered as a continuum from symptom recognition, decision to seek care, diagnosis, treatment initiation and treatment completion, with care along the continuum influenced by several factors. Gender dimensions could influence TB care, and indeed, more men than women are diagnosed with TB each year. The study was done to identify social stratifiers that intersect with gender to influence TB care.

METHODS

A cross-sectional qualitative study was done at four health facilities in 3 districts in central Uganda between October 2020 and December 2020. Data was collected from patients seeking a diagnosis or on TB treatment through focus group discussions and key informant interviews. Key themes around gender guided by a gender and intersectionality lens were developed and thereafter thematic content analysis was done.

RESULTS

Women have increased vulnerability to TB due to bio mass exposure through roles like cooking. Women have increased access to health care services as they interface with the health care system frequently given their role as child bearers and child care givers. Men have a duty to provide for their families and this most often is prioritised over healthcare seeking, and together with belief that they are powerful beings leads to poor healthcare seeking habits and delays in healthcare seeking. Decisions on when and where to seek care were not straightforward for women, who most often rely on their husbands/partners to make decisions.

CONCLUSIONS

Men and women experience challenges to TB care, and that these challenges are deeply rooted in roles assigned to them and further compounded by masculinity. These challenges need to be addressed through intersectional gender responsive interventions if TB control is to be improved.

Tuberculosis Notification in Jordan, 2016-2020

The burden of tuberculosis (TB) in Jordan is largely unknown due to the paucity of high-quality data, under-reporting, and a lack of good quality vital registration system. This study aimed to assess the characteristics of TB patients in Jordan, determine the TB notification rate and assess the trend of TB notification in Jordan between 2016 and 2020. Methods: This study analyzed the TB Surveillance data in Jordan for the period 2016-2020. The obtained data included information on age, gender, nationality, marital status, date of symptoms onset and date of diagnosis, and site of TB. Results: During the period 2016-2020, a total of 1711 patients (989 women and 722 men) were diagnosed with and treated for tuberculosis. The mean (SD) age of patients was 30.1 (17.2) years. Almost half of them (48.4%) were Jordanians. The majority of non-Jordanian patients were from Syria, Philippines, and Bangladesh. Two thirds of patients (66.0%) had pulmonary TB and 34.0% had extra-pulmonary TB. Almost half (50.7%) of the patients were diagnosed within one month of the symptoms' onset. The average annual TB notification rate during 2016-2020 was 3.32 per 100,000 pop (4.08 per 100,000 women and 2.64 per 100,000 men). The average annual standardized notification rate was 4.13 per 100,000 pop (4.52 per 100,000 women and 3.52 per 100,000 men). The overall age-standardized notification rate increased from 3.88 per 100,000 pop in 2016 to 4.58 per 100,000 pop in 2019 and declined to 2.46 per 100,000 pop in 2020. The trend in TB notification differed significantly according to gender. While the notification increased in the last three years among women, it decreased significantly among men. Conclusions: While TB notification increased in the last three years among women, it decreased significantly among men. There is a need to ensure that the national TB plans set clear targets for reducing the burden of TB.

Interrelationships between tuberculosis and chronic obstructive pulmonary disease

PURPOSE OF REVIEW

Our objective was to review the current literature regarding socioeconomic, environmental, clinical, and immunologic factors common to chronic obstructive pulmonary disease (COPD) and tuberculosis (TB).

RECENT FINDINGS

Recent studies suggest that TB patients might be at increased risk for developing COPD. Conversely, additional prospective cohort studies have determined that COPD patients are at increased risk for active TB: a risk that appears to be partially mediated through inhaled corticosteroid use. Tobacco smoking, poverty, air pollution, and malnutrition are associated with COPD and TB. Vitamin D has been shown to prevent COPD exacerbations, but its use for preventing TB infection remains unclear. Surfactant deficiency, elevated matrix metalloproteinases, and toll-like receptor 4 polymorphisms play key roles in the pathogenesis of both diseases.

SUMMARY

Recent studies have elucidated interrelationships between COPD and TB. Future research is needed to optimize clinical and public health approaches that could mitigate risk factors contributing to both diseases.

Gender and Drug-Resistant Tuberculosis in Nigeria

We conducted a retrospective study of 2555 DR-TB patients admitted to treatment between 2010 and 2016 in six geopolitical zones in Nigeria. We characterized the gender distribution of DR-TB cases and the association between demographics and clinical data, such as age, treatment category, number of previous TB treatment cycles, and geopolitical zone, with gender. The independent effects of being a male or female DR-TB patient were determined using bivariate and multivariate analyzes with statistical significance of p < 0.05 and a 95% confidence interval. Records from a total of 2555 DR-TB patients were examined for the study. A majority were male (66.9%), largest age-group was 30-39 years old (35.8%), most had MDR-TB (61.4%), were HIV-negative (76.6%), and previously treated for TB (77.1%). The southwest treatment zone had the highest proportion of DR-TB patients (36.9%), and most DR-TB diagnoses occurred in 2016 (36.9%). On bivariate analysis, age, HIV status, treatment zone, and clinical patient group in DR-TB were significantly associated with male gender. On multivariate analysis, males aged 20-29 years (AOR: 0.19, 95% CI: 0.33-0.59, p = 0.001) and HIV-positive males (AOR: 0.44, 95% CI: 0.33-0.59, p = 0.001) had lower likelihood of MDR-TB as males in the south-south treatment zone (AOR: 1.88, 95% CI: 1.23-2.85, p = 0.03), and being male and aged ≥60 years (AOR: 2.19, 95% CI: 1.05-4.54, p = 0.036) increased the probability of DR-TB. The older male population from south-southern Nigeria and women of childbearing age had lower incidence of DR-TB than men of the same age. Tailored interventions to reduce HIV and DR-TB prevalence in the general population, particularly among women of childbearing potential, and treatment support for young and older men are relevant strategies to reduce DR-TB in Nigeria.

What Makes People With Chronic Illnesses Discontinue Treatment? A Practice Theory Informed Analysis of Adherence to Treatment among Patients With Drug-Resistant Tuberculosis in Pakistan

BACKGROUND

Non-adherence to treatment is a frequently observed phenomenon amongst those on long-term treatment for chronic illnesses. This qualitative study draws upon the tenets of 'practice theory' to reveal what shapes patients' ability to adhere to the demanding treatment for drug-resistant tuberculosis (DR-TB) at three treatment sites in Khyber-Pakhtunkhwa (KP) province of Pakistan.

METHODS

This qualitative study involved observation of service provision over a period of nine months of stay at, and embedment within the three treatment sites and in-depth interviews with 13 service providers and 22 patients who became non-adherent to their treatment.

RESULTS

Consistent with the extensive research based on the barriers and facilitator approach, both patients, and providers in our study also talked of patients' doubts about diagnosis and treatment efficacy, side-effects of drugs, economic constraints, unreliable disbursements of monetary incentive, attitude of providers and co-morbidities as reasons for non-adherence to treatment. Applying a practice theory perspective yielded more contextualised insights; inadequate help with patients' physical complaints, unempathetic responses to their queries, and failure to provide essential information, created conditions which hindered the establishment and maintenance of the 'practice' of adhering to treatment. These supply-side gaps created confusion, bred resentment, and exacerbated pre-existing distrust of public health services among patients, and ultimately drove them to disengage with the TB services and stop their treatment.

CONCLUSION

We argue that the lack of supply-side 'responsiveness' to patient needs beyond the provision of a few material inputs is what is lacking in the existing DR-TB program in Pakistan. We conclude that unless Pakistan's TB program explicitly engages with these supply side, system level gaps, patients will continue to struggle to adhere to their treatments and the TB program will continue to lose patients. Conceptually, we make a case for reimagining the act of adherence (or not) to long-term treatment as a 'Practice.'

Prevalence and predictive factors of tuberculosis treatment interruption in the Asia region: a systematic review and meta-analysis

INTRODUCTION

Tuberculosis (TB) treatment interruption remains a critical challenge leading to poor treatment outcomes. Two-thirds of global new TB cases are mostly contributed by Asian countries, prompting systematic analysis of predictors for treatment interruption due to the variable findings.

METHODS

Articles published from 2012 to 2021 were searched through seven databases. Studies that established the relationship for risk factors of TB treatment interruption among adult Asian were included. Relevant articles were screened, extracted and appraised using Joanna Briggs Institute's checklists for cohort, case-control and cross-sectional study designs by three reviewers. Meta-analysis was performed using the random effect model in Review Manager software. The pooled prevalence and predictors of treatment interruption were expressed in ORs with 95% CIs; heterogeneity was assessed using the I₂ statistic. The publication bias was visually inspected using the funnel plot.

RESULTS

Fifty eligible studies (658 304 participants) from 17 Asian countries were included. The overall pooled prevalence of treatment interruption was 17% (95% CI 16% to 18%), the highest in Southern Asia (22% (95% CI 16% to 29%)), followed by Eastern Asia (18% (95% CI 16% to 20%)) and South East Asia (16% (95% CI 4% to 28%)). Seven predictors were identified to increase the risk of treatment interruption, namely, male gender (OR 1.38 (95% CI 1.26 to 1.51)), employment (OR 1.43 (95% CI 1.11 to 1.84)), alcohol intake (OR 2.24 (95% CI 1.58 to 3.18)), smoking (OR 2.74 (95% CI 1.98 to 3.78)), HIV-positive (OR 1.50 (95% CI 1.15 to 1.96)), adverse drug reactions (OR 2.01 (95% CI 1.20 to 3.34)) and previously treated cases (OR 1.77 (95% CI 1.39 to 2.26)). All predictors demonstrated substantial heterogeneity except employment and HIV status with no publication bias.

CONCLUSION

The identification of predictors for TB treatment interruption enables strategised planning and collective intervention to be targeted at the high-risk groups to strengthen TB care and control in the Asia region.

Qualitative Identification of Intervention Preferences to Support Men's Engagement and Retention in TB Care in South Africa

Globally and in South African specifically, men account for 56% and 62% of all tuberculosis (TB) cases, respectively. Men are at increased risk of not accessing TB testing or treatment, and having poor treatment outcomes. Unfortunately, no interventions exist to address these issues. Toward the development of targeted, patient-centered TB care and support interventions, we used semistructured interviews to explored men's social network composition, TB testing behaviors, disclosure and treatment support, clinical experiences, and TB's influence on daily living. Data were analyzed using a thematic approach guided by the Network Individual Resource Model to identify mental and tangible resources influential and preferred during engagement in TB treatment. Men emphasized the desire for peer-to-peer support to navigate TB-related stigma and unhealthy masculinity norms. Men advocated for awareness events to educate communities about their challenges with TB. Men strongly suggested that interventions be delivered in familiar locations where men congregate. Since 2022, no TB treatment support interventions have included the preferred components or delivery modes described by men in our study. To improve men's TB-related health outcomes, the global TB community must identify and address men's unique challenges when designing interventions.

Evaluation of Xpert MTB/RIF Assay, MTB Culture and Line Probe Assay for the Detection of MDR Tuberculosis in AFB Smear Negative Specimens

The global burden of tuberculosis (TB), particularly with multidrug resistance (MDR), is escalating and has become a major health challenge. It is well known that acid-fast bacilli (AFB) smear-negative TB patients are the major source of spreading TB to healthy individuals when left untreated. Early diagnosis of TB and rapid detection of drug resistance are important for the proper management of drug-resistant TB (DR-TB). Therefore, a laboratory based cross-sectional study was conducted from July to December 2019 at the National Tuberculosis Centre, Thimi, Nepal, with the objective of evaluating the diagnostic performance of Xpert MTB/RIF assay, Mycobacterium tuberculosis (MTB) culture and line probe assay (LPA) for the detection of MDR-TB in AFB smear-negative sputum samples. We evaluated a total of 222 AFB smear-negative sputum specimens, of which 21.6% (n = 48) showed MTB positive with Xpert MTB/RIF assay and, while culturing on Lowenstein-Jensen (LJ) media, 21.2% (n = 47) were MTB culture positive. The sensitivity, specificity, PPV and NPV at 95% confidence interval of Xpert MTB/RIF assay on diagnosing M. tuberculosis from smear-negative specimens were 73% (57-84), 92% (87-96), 71% (59-81) and 93% (89-95), respectively. In addition, the sensitivity of Xpert MTB/RIF assay and LPA in detecting rifampicin resistance was 75% (42-94, 95% CI) and 91.67% (62-99, 95% CI), respectively. The current study also assessed a significant association between the occurrence of pulmonary tuberculosis with different age group, TB history and alcohol consumption. These findings indicate that Xpert MTB/RIF assay and LPA are appropriate methods for early detection and accurate diagnosis of TB and RIF mono-resistant cases.

Population benefits of addressing programmatic and social determinants of gender disparities in tuberculosis in Viet Nam: A modelling study

High prevalence of infectious tuberculosis among men suggests potential population-wide benefits from addressing programmatic and social determinants of gender disparities. Utilising a sex-stratified compartmental transmission model calibrated to tuberculosis burden estimates for Viet Nam, we modelled interventions to increase active case finding, to reduce tobacco smoking, and to reduce alcohol consumption by 2025 in line with national and global targets. For each intervention, we examined scenarios differentially targeting men and women and evaluated impact on tuberculosis morbidity and mortality in men, women, and children in 2035. Active case finding interventions targeting men projected greater reductions in tuberculosis incidence in men, women, and children (16.2%, uncertainty interval, UI, 11.4-23.0%, 11.8%, UI 8.0-18.6%, and 21.5%, UI 16.9-28.5%, respectively) than those targeting women (5.2%, UI 3.8-7.1%, 5.4%, UI 3.9-7.3%, and 8.6%, UI 6.9-10.7%, respectively). Projected reductions in tuberculosis incidence for interventions to reduce male tobacco smoking and alcohol consumption were greatest for men (17.4%, UI 11.8-24.7%, and 11.0%, UI 5.4-19.4%, respectively), but still substantial for women (6.9%, UI 3.8-12.5%, and 4.4%, UI 1.9-10.6%, respectively) and children (12.7%, UI 8.4-19.0%, and 8.0%, UI 3.9-15.0%, respectively). Comparable interventions targeting women projected limited impact, with declines of 0.3% (UI 0.2%-0.3%) and 0.1% (UI 0.0%-0.1%), respectively. Addressing programmatic and social determinants of men's tuberculosis burden has population-wide benefits. Future interventions to increase active case finding, to reduce tobacco smoking, and to reduce harmful alcohol consumption, whilst not ignoring women, should focus on men to most effectively reduce tuberculosis morbidity and mortality in men, women, and children.

Prevalence and associated risk factors for tuberculosis among people living with HIV in Nepal

Background

Worldwide tuberculosis (TB) takes more lives than any other infectious diseases. WHO estimates around 68,000 incident TB cases in Nepal. However, in 2018 only around 27,232 new TB cases were reported in the national system, resulting around 40,768 incident TB cases missing every year in Nepal. National Tuberculosis Control Center carried out this study in anti-retroviral therapy (ART) sites to estimate the prevalence of TB and identify the associated risk factors for TB among the people living with Human Immunodeficiency Virus (PLHIVs) in Nepal.

Methods

It was a cross-sectional institution-based study conducted between March and August 2018. Six ART sites with high caseloads of PLHIVs were selected. PLHIVs who were equal or above 18 years of age and were in ART program at the selected study sites were considered eligible for the study. Diagnosis of tuberculosis among PLHIVs who agreed to participate in the study was carried out as per the National Tuberculosis Management Guideline of National Tuberculosis Program of Nepal.

Results

Among 403 PLHIVs, tuberculosis was diagnosed in 40 (9.9%) individuals. Median age of the participants was 36 (30–43) years. Prevalence of TB was significantly higher among male PLHIVs than female PLHIVs (13.6% Vs 5.8%; P = 0.02) and Dalit ethnic group compared to Brahmin/Chettri (22.0%Vs5.9%, P = 0.01). The risk of developing TB was found significant among those with HIV stage progressed to WHO stage 3 and 4 (OR = 4.85, P<0.001) and with the family history of TB (OR = 4.50, P = 0.002).

Conclusions

Prevalence of TB among PLHIVs in Nepal was found 9.9%. Risk of developing TB was higher among PLHIVs who were male, Dalit, with HIV stage progressed to WHO stage 3 and 4 and with family history of TB. Hence, targeted interventions are needed to prevent the risk of developing TB among PLHIVs. Similarly, integrated, and comprehensive TB and HIV diagnosis and treatment services are needed for the management of TB/HIV co-infection in Nepal.

Gender differences in tuberculosis incidence rates-A pooled analysis of data from seven high-income countries by age group and time period

Introduction

Gender differences in the incidence rates for tuberculosis are occasionally reported. However, the magnitude and consistency of the differences by age group, among different populations, and over extended periods of time are not clear.

Materials and methods

We obtained national data from seven countries from open-access internet sites or personal communications with official representatives. We computed the male-to-female incidence rate ratios (IRRs) by country and year for every age group and pooled these ratios using meta-analytic methods. Meta-regression analysis was performed to estimate the contribution of age, country, and calendar years to the variation in the IRRs.

Results

In the age groups of < 1, 1-4, 5-9, and 10-14, the pooled male-to-female IRRs (with 95% CI) were as follows: 1.21 (1.05, 1.40), 0.99 (0.95, 1.04), 1.01 (0.96, 1.06), and 0.83 (0.77, 0.89), respectively. In the age groups 15-44, 45-64, and 65+ years, incidence rates were significantly higher in men, with IRRs of 1.25 (1.16, 1.35), 1.79 (1.56, 2.06), and 1.81 (1.66, 1.96), respectively. Meta-regression analysis revealed that age significantly contributed to the variation in the IRRs.

Conclusions

There were gender differences in the incidence rates for tuberculosis, with higher rates in boys aged less than one, no significant differences in boys of ages 1-9, and higher rates in boys/men older than 15. The only excess in female gender was in the age group 10-14 years. The age-related gender differences in tuberculosis incidence rates observed over several countries indicate the importance of including sex as a biological variable when assessing the risk factors for tuberculosis.

Body Mass Index, Diabetes, and Risk of Tuberculosis: A Retrospective Cohort Study

Although both diabetes mellitus (DM) and underweight are associated with increased risk of tuberculosis (TB), there are limited data evaluating TB risk while considering two factors simultaneously—body mass index (BMI) and DM. A retrospective cohort study was performed with 10,087,903 participants of the Korean National Health Screening Program in 2009. The cohort was followed up to the date of TB incidence, death, or until December 31, 2018. We compared the incidence and risk of TB according to BMI category and DM. During the 7.3-year follow-up duration, the incidence of TB was 0.92 per 1,000 person-years in the normal weight without DM, 2.26 in the normal weight with DM, 1.80 in the underweight without DM, and 5.35 in the underweight with DM. Compared to the normal weight without DM, the normal weight with DM, the underweight without DM, and the underweight with DM showed a 1.51-fold (95% CI, 1.46–1.57), a 2.21-fold (95% CI, 2.14–2.28), and a 3.24-fold (95% CI, 2.95–3.56) increased risk of TB, respectively. However, compared to the normal weight without DM, the severely obese without DM and those with DM showed a 0.37 (95% CI, 0.36–0.38) and a 0.42 (95% CI, 0.36–0.48)-fold decreased risk of TB, respectively. There was no significant joint effect of BMI and DM on the risk of incident TB in the overall population; a synergistic effect of underweight and DM was evident in participants <65 years of age, current smokers, and heavy drinkers. In conclusion, being underweight or DM individually increases the risk of incident TB. Based on our study results, a focused screening of incident TB in patients with DM may be beneficial.

Persistent high prevalence of pulmonary tuberculosis in a resource-limited setting: threat to India's TB Free campaign

BACKGROUND

Tuberculosis (TB) is a major public health problem among Saharia, a particularly vulnerable tribal group residing in remote rural areas in central India. This article presents the findings from the baseline survey among Saharias and provides comprehensive prevalence data of pulmonary TB (PTB) in this marginalised community.

METHODS

A community-based cross-sectional PTB prevalence survey was carried out during January-May 2019 in selected villages using multistage stratified cluster sampling. All eligible adults (≥15 years of age) were screened for the symptoms of PTB. Sputum samples were collected and processed for microscopy and culture for Mycobacterium tuberculosis.

RESULTS

A total of 20 114 eligible individuals were screened for symptoms of PTB. Among these, 3001 (14.9%) individuals reported at least one PTB symptom and sputum was collected from 2890 (96.3%) individuals. Among these, 273 (9.4%) were bacteriologically positive for PTB. The overall prevalence was 1357 per 100 000 population.

CONCLUSIONS

The findings indicate that TB continues to be a major health problem in this marginalised community despite large investments by the government for TB control. This emphasizes the need to look into the causes and barriers in implementation of the TB elimination programme in the community, especially in view of India's TB elimination goal by 2025.

Systematic Review and Meta-Analysis of Sex Differences in Social Contact Patterns and Implications for Tuberculosis Transmission and Control

Social contact patterns might contribute to excess burden of tuberculosis in men. We conducted a study of social contact surveys to evaluate contact patterns relevant to tuberculosis transmission. Available data describe 21 surveys in 17 countries and show profound differences in sex-based and age-based patterns of contact. Adults reported more adult contacts than children. Children preferentially mixed with women in all surveys (median sex assortativity 58%, interquartile range [IQR] 57%–59% for boys, 61% [IQR 60%–63%] for girls). Men and women reported sex-assortative mixing in 80% and 95% of surveys (median sex assortativity 56% [IQR 54%–58%] for men, 59% [IQR 57%–63%] for women). Sex-specific patterns of contact with adults were similar at home and outside the home for children; adults reported greater sex assortativity outside the home in most surveys. Sex assortativity in adult contacts likely contributes to sex disparities in adult tuberculosis burden by amplifying incidence among men.

Functional Polymorphism in the NFE2L2 Gene Associated With Tuberculosis Susceptibility

Background

Nuclear transcription factor erythroid 2 p45-related factor 2 (Nrf2), encoded by NFE2L2, functions as a key transcription factor and regulates expression of antioxidant genes. Our study aimed to investigate the association of single nucleotide polymorphisms of NFE2L2 with tuberculosis (TB) and latent tuberculosis infection (LTBI) and the underlying causal mechanisms.

Methods

1950 unrelated Chinese Han participants were included in our two independent study groups. Five tag polymorphisms were selected and genotyped. The functional effects of the rs13005431 polymorphism were confirmed by dual-luciferase reporter assays and mRNA level comparisons.

Results

Rs13005431_C and rs2364723_G were associated with increased TB susceptibility (P = 0.010 and P = 0.041) after adjustment for confounding factors. rs6726395_A was associated with increased risk of active TB (P=0.035) in a comparison with the LTBI group. The frequency of haplotype rs1049751- rs13005431 AC was higher in the TB group (P =0.013), while frequency of haplotype AT was higher in the healthy control group (P =0.025). The luciferase activity of a plasmid with the rs13005431C-promoter was significantly lower than that of the rs13005431T-promoter. In addition, neutrophils with the CC/TC genotypes which were activated by GM-CSF showed a decreased level of NFE2L2 mRNA when compared with the rs13005431 TT genotype.

Conclusions

Our study suggests that allele C of rs13005431 might increase the susceptibility to TB by down-regulating the transcriptional activity of NFE2L2.

Assortative social mixing and sex disparities in tuberculosis burden

Globally, men have higher tuberculosis (TB) burden but the mechanisms underlying this sex disparity are not fully understood. Recent surveys of social mixing patterns have established moderate preferential within-sex mixing in many settings. This assortative mixing could amplify differences from other causes. We explored the impact of assortative mixing and factors differentially affecting disease progression and detection using a sex-stratified deterministic TB transmission model. We explored the influence of assortativity at disease-free and endemic equilibria, finding stronger effects during invasion and on increasing male:female prevalence (M:F) ratios than overall prevalence. Variance-based sensitivity analysis of endemic equilibria identified differential progression as the most important driver of M:F ratio uncertainty. We fitted our model to prevalence and notification data in exemplar settings within a fully Bayesian framework. For our high M:F setting, random mixing reduced equilibrium M:F ratios by 12% (95% CrI 0-30%). Equalizing male case detection there led to a 20% (95% CrI 11-31%) reduction in M:F ratio over 10 years-insufficient to eliminate sex disparities. However, this potentially achievable improvement was associated with a meaningful 8% (95% CrI 4-14%) reduction in total TB prevalence over this time frame.

Modelling the effects of environmental heterogeneity within the lung on the tuberculosis life-cycle

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In silico model of TB in the lung incorporating environmental heterogeneity.

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Preferential conditions at the apex of lung localise post-primary disease there.

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Analysis of the key influences driving disease at different regions of the lung.

Progress in shortening the duration of tuberculosis (TB) treatment is hampered by the lack of a predictive model that accurately reflects the diverse environment within the lung. This is important as TB has been shown to produce distinct localisations to different areas of the lung during different disease stages, with the environmental heterogeneity within the lung of factors such as air ventilation, blood perfusion and oxygen tension believed to contribute to the apical localisation witnessed during the post-primary form of the disease.

Building upon our previous model of environmental lung heterogeneity, we present a networked metapopulation model that simulates TB across the whole lung, incorporating these notions of environmental heterogeneity across the whole TB life-cycle to show how different stages of the disease are influenced by different environmental and immunological factors. The alveolar tissue in the lung is divided into distinct patches, with each patch representing a portion of the total tissue and containing environmental attributes that reflect the internal conditions at that location. We include populations of bacteria and immune cells in various states, and events are included which determine how the members of the model interact with each other and the environment. By allowing some of these events to be dependent on environmental attributes, we create a set of heterogeneous dynamics, whereby the location of the tissue within the lung determines the disease pathological events that occur there.

Our results show that the environmental heterogeneity within the lung is a plausible driving force behind the apical localisation during post-primary disease. After initial infection, bacterial levels will grow in the initial infection location at the base of the lung until an adaptive immune response is initiated. During this period, bacteria are able to disseminate and create new lesions throughout the lung. During the latent stage, the lesions that are situated towards the apex are the largest in size, and once a post-primary immune-suppressing event occurs, it is the uppermost lesions that reach the highest levels of bacterial proliferation. Our sensitivity analysis also shows that it is the differential in blood perfusion, causing reduced immune activity towards the apex, which has the biggest influence of disease outputs.

Risk factors for TB among household contacts of patients with smear-positive TB in eight provinces of Vietnam: a nested case-control study

BACKGROUND

Tuberculosis (TB) continues to account for significant morbidity and mortality annually. Household contacts (HHCs) of persons with TB are a key population for targeting prevention and control interventions. We aimed to identify risk factors associated with developing TB among HHCs.

METHODS

We conducted a nested case-control study among HHCs in eight provinces in Vietnam who were enrolled in a randomized control trial of active case finding for TB. Cases were any HHCs diagnosed and registered with TB within the Vietnam National TB programme during two years of follow-up. Controls were selected by simple random sampling from the remaining HHCs. Risk factor data were collected at enrolment and during follow-up. A logistic regression model was developed to determine predictors of TB among HHCs.

RESULTS

We selected 1,254 HHCs for the analysis; 214 cases and 1,040 controls. Underlying characteristics varied between both groups; cases were older, more likely to be male, higher proportion of reported previous TB and diabetes. Risk factors associated with a TB diagnosis included being male (aOR 1.4; 95% CI: 1.03-2.0), residing in an urban setting (aOR 1.8; 1.3-2.5), prior TB (aOR 4.6; 95% CI: 2.5-8.7), history of diabetes (aOR 3.1; 95% CI: 1.7-5.8), current smoking (aOR 3.1; 95% CI: 2.2-4.4) and prolonged history of coughing in the source case at enrolment (OR 1.6; 95% CI: 1.1-2.3).

CONCLUSIONS

Household contacts remain and important key population for TB prevention and control. TB programmes should ensure effective contact investigations are implemented for household contacts, particularly those with additional risk factors for developing tuberculosis.

Prophylaxis for Tuberculosis in Pregnant Women

As more women at increased risk for tuberculosis (TB) reactivation immigrate to the United States, perinatal screening and chemoprophylaxis are increasingly important. Interferon-gamma release assays and the tuberculin skin test are acceptable screening tests with the latter supported by more data in pregnancy. Women screening positive should have active TB excluded, and if negative, latent TB is likely. Prophylaxis should be deferred until 3 months postpartum except in those severely immunosuppressed, human immunodeficiency virus positive, or recently exposed. Isoniazid with pyridoxine for 9 months is preferred with reasonable safety in pregnancy and breastfeeding. Monitoring for maternal hepatotoxicity is recommended.

Stigma matters in ending tuberculosis: Nationwide survey of stigma in Ethiopia

BACKGROUND

Tuberculosis (TB) affects, and claims the lives of, millions every year. Despite efforts to find and treat TB, about four million cases were missed globally in 2017. Barriers to accessing health care, inadequate health-seeking behavior of the community, poor socioeconomic conditions, and stigma are major determinants of this gap. Unfortunately, TB-related stigma remains unexplored in Ethiopia.

METHODS

This mixed methods survey was conducted using multistage cluster sampling to identify 32 districts and 8 sub-cities, from which 40 health centers were randomly selected. Twenty-one TB patients and 21 family members were enrolled from each health center, and 11 household members from each community in the catchment population.

RESULTS

A total of 3463 participants (844 TB patients, 836 from their families, and 1783 from the general population) were enrolled for the study. The mean age and standard deviation were 34.3 ± 12.9 years for both sexes (34.9 ± 13.2 for men and 33.8 ± 12.5 for women). Fifty percent of the study participants were women; 32.1% were illiterate; and 19.8% came from the lowest wealth quintile. The mean stigma score was 18.6 for the general population, 20.5 for families, and 21.3 for TB patients. The general population of Addis Ababa (AOR: 0.1 [95% CI: 0.06-0.17]), those educated above secondary school (AOR: 0.58 [95% CI: 0.39-0.87]), and those with a high score for knowledge about TB (AOR: 0.62 [95% CI: 0.49-0.78]) had low stigma scores. Families of TB patients who attended above secondary school (AOR: 0.37 [95% CI: 0.23-0.61]) had low stigma scores. TB patients educated above secondary school (AOR: 0.61 [95% CI: 0.38-0.97]) had lower stigma scores, while those in the first (AOR: 1.93: 95% CI 1.05-3.57) and third quintiles (AOR: 1.81: 95% CI: 1.08-3.05) had stigma scores twice as high as those in the highest quintile. Fear of job loss (32.5%), isolation (15.3%), and feeling avoided (9.3%) affected disclosure about TB.

CONCLUSIONS

More than a third of Ethiopians have high scores for TB-related stigma, which were associated with educational status, poverty, and lack of awareness about TB. Stigma matters in TB prevention, care, and treatment and warrants stigma reduction interventions.

Trends in tuberculosis notification and mortality and factors associated with treatment outcomes in Serbia, 2005 to 2015

Background

Previously a country with medium tuberculosis (TB) burden, Serbia almost reached a low TB burden during the period 2005 to 2015.

Aim

The aim of this study was to analyse the trends in notification rates and treatment success rates as well as to identify predictors of treatment outcomes.

Methods

We performed a trend analysis and logistic regression analysis of 17,441 TB cases registered from 2005 to 2015 in all health facilities in Serbia, to identify predictors of treatment success, loss to follow-up and mortality.

Results

From 2005 to 2015, TB notification rate and mortality in Serbia decreased but treatment success remained below the global target. Loss to follow-up was associated with retreatment (odds ratio (OR) = 2.38; 95% confidence interval (CI): 2.08–2.77), male sex (OR = 1.57; 95% CI: 1.39–1.79), age younger than 65 years (OR = 1.37; 95% CI: 1.20–1.51), lower education level (OR = 2.57; 95% CI: 1.74–3.80) and pulmonary TB (OR = 1.28; 95% CI: 1.06–1.56). Deaths were more frequent in retreatment cases (OR = 1.39; 95% CI: 1.12–1.61), male patients (OR = 1.34; 95% CI: 1.19–1.52), those 65 years and older (OR = 4.34; 95% CI: 4.00–5.00), those with lower education level (OR = 1.63; 95% CI: 1.14–2.33) and pulmonary TB (OR = 2.24; 95% CI: 1.78–2.83).

Conclusions

Special interventions should be implemented to address groups at risk of poor treatment outcome.

Molecular epidemiological study of multidrug-resistant tuberculosis isolated from sputum samples in Eastern Cape, South Africa

Drug-resistant tuberculosis prevalence is still a global challenge. Making it imperative to examine the molecular epidemiology of drug resistant tuberculosis. Molecular epidemiology methods can evaluate transmission patterns and risk factors, ascertain transmission cases of multidrug-resistant tuberculosis (MDR-TB) and furthermore determine transmission patterns in a human populace. This work focuses on MDR-TB isolates in distinguishing them into several species and genotyping the MDR-TB isolates, mainly for epidemiological studies using the genomic regions of difference and the spoligotyping techniques. A total of 184 deoxyribonucleic acid isolated from sputum samples that showed resistance against the two major first-line anti-tuberculosis drugs (Rifampicin and Isoniazid) were examined. The deoxyribonucleic acid samples were amplified with primers specific for each flanking region of the genomic regions of difference for the identification of different MTBC species. Isolates were further characterized into different lineages using the spoligotyping commercial kit. The M. tuberculosis species was detected in 83.7% (154/184) of the deoxyribonucleic acid isolates, followed by the M. caprae in 8.7% (16/184) and the least detected species was the M. africanum in 2.2% (4/184). Nineteen spoligotype international types (SITs) were identified in this study. The pre-existing shared types were from 94.6% (174/184) isolates with 1.1% (2/184) isolates recognized as orphans and 4.3% (8/184) isolates were not found in the SITVIT database. The predominant family (spoligotype) was the Beijing with 67.4% (124/184) strains. This study gives a general overview of drug resistant strains and the circulating strains in the Eastern Cape, South Africa and it shows that the common Mycobacteria in the province is the Beijing strain.

Exposure to Latent Tuberculosis Treatment during Pregnancy. The PREVENT TB and the iAdhere Trials

RATIONALE

Data are limited regarding the safety of 12-dose once-weekly isoniazid (H, 900 mg) plus rifapentine (P, 900 mg) (3HP) for latent infection treatment during pregnancy.

OBJECTIVES

To assess safety and pregnancy outcomes among pregnant women who were inadvertently exposed to study medications in two latent tuberculosis infection trials (PREVENT TB or iAdhere) evaluating 3HP and 9 months of daily isoniazid (H, 300 mg) (9H).

METHODS

Data from reproductive-age (15-51 yr) women who received one or more study dose of 3HP or 9H in either trial were analyzed. Drug exposure during pregnancy occurred if the estimated date of conception was on or before the last dose date.

RESULTS

Of 126 pregnancies (125 participants) that occurred during treatment or follow-up, 87 were exposed to study drugs. Among these, fetal loss was reported for 4/31 (13%) and 8/56 (14%), 3HP and 9H, respectively (difference, 13% - 14% = -1%; 95% confidence interval = -17% to +18%) and congenital anomalies in 0/20 and 2/41 (5%) live births, 3HP and 9H, respectively (difference, 0% - 5% = -5%; 95% confidence interval = -18% to +16%). All fetal losses occurred in pregnancies of less than 20 weeks. Of the total 126 pregnancies, fetal loss was reported in 8/54 (15%) and 9/72 (13%), 3HP and 9H, respectively; and congenital anomalies in 1/37 (3%) and 2/56 (4%) live births, 3HP and 9H, respectively. The overall proportion of fetal loss (17/126 [13%]) and anomalies (3/93 [3%]) were similar to those estimated for the United States, 17% and 3%, respectively.

CONCLUSIONS

Among reported pregnancies in these two latent tuberculosis infection trials, there was no unexpected fetal loss or congenital anomalies. These data offer some preliminary reassurance to clinicians and patients in circumstances when these drugs and regimens are the best option in pregnancy or in women of child-bearing potential. This work used the identifying trial registration numbers NCT00023452 and NCT01582711, corresponding to the primary clinical trials PREVENT TB and iAdhere (Tuberculosis Trials Consortium Study 26 and 33).

Quality of life with tuberculosis

Tuberculosis diagnosis and treatment currently revolves around clinical features and microbiology. The disease however adversely affects patients’ psychological, economic, and social well-being as well, and therefore our focus also additionally needs to shift towards quality of life (QOL). The disease influences all QOL domains and substantially adds to patient morbidity, and these complex and multidimensional interactions pose challenges in accurately quantifying impairment in QOL. For this review, PubMed database was queried using keywords like quality of life, health status and tuberculosis, and additional publications identified by a bibliographic review of shortlisted articles. Both generic and specific QOL scales show a wide variety of derangements in scores, and results vary across countries and patient groups. In particular, diminished capacity to work, social stigmatization, and psychological issues worsen QOL in patients with tuberculosis. Although QOL has been consistently shown to improve during standard anti-tubercular therapy, many patients continue to show residual impairment. It is also not clear if specific situations like presence of comorbid illnesses, drug resistance, or co-infection with human immunodeficiency virus additionally worsen QOL in these patients. There is a definite need to incorporate QOL assessment as adjunct outcome measures in tuberculosis control programs. Governments and program managers need to step up socio-cultural reforms and health education, and provide additional incentives to patients, to counter impairment in QOL.

Gender equity in mass drug administration for neglected tropical diseases: data from 16 countries

BACKGROUND

Gender equity in global health is a target of the Sustainable Development Goals and a requirement of just societies. Substantial progress has been made towards control and elimination of neglected tropical diseases (NTDs) via mass drug administration (MDA). However, little is known about whether MDA coverage is equitable. This study assesses the availability of gender-disaggregated data and whether systematic gender differences in MDA coverage exist.

METHODS

Coverage data were analyzed for 4784 district-years in 16 countries from 2012 through 2016. The percentage of districts reporting gender-disaggregated data was calculated and male-female coverage compared.

RESULTS

Reporting of gender-disaggregated coverage data improved from 32% of districts in 2012 to 90% in 2016. In 2016, median female coverage was 85.5% compared with 79.3% for males. Female coverage was higher than male coverage for all diseases. However, within-country differences exist, with 64 (3.3%) districts reporting male coverage >10 percentage points higher than female coverage.

CONCLUSIONS

Reporting of gender-disaggregated data is feasible. And NTD programs consistently achieve at least equal levels of coverage for women. Understanding gendered barriers to MDA for men and women remains a priority.

Effects of Adherence to Traditional Female Sex Roles on Compliance with Diabetic Regimens: A Case History

This article investigates the possible association between adherence to traditional feminine sex roles, poor compliance with treatment for diabetes, and the onset of diabetic retinopathy. The authors present a case study and suggestions for health care professionals and future research in this area.

Spatiotemporal epidemiology of, and factors associated with, the tuberculosis prevalence in northern China, 2010-2014

Background

Tuberculosis (TB) is an important public health issue worldwide. However, evidence concerning the impact of environmental factors on TB is sparse. We performed a retrospective analysis to determine the spatiotemporal trends and geographic variations of, and the factors associated with, the TB prevalence in Inner Mongolia.

Methods

We performed a retrospective analysis of the epidemiology of TB. A Bayesian spatiotemporal model was used to investigate the spatiotemporal distribution and trends of the TB prevalence. A spatial panel data model was used to identify factors associated with the TB prevalence in the 101 counties of Inner Mongolia, using county-level aggregated data collected by the Inner Mongolia Center for Disease Control and Prevention.

Results

From January 2010 to December 2014, 79,466 (6.36‱) incident TB cases were recorded. The TB prevalence ranged from 4.97‱ (12,515/25,167,547) in 2014 to 7.49‱ (18,406/ 24,578,678) in 2010; the majority of TB cases were in males, and in those aged 46–60 years; by occupation, farmers and herdsmen were the most frequently affected. The Bayesian spatiotemporal model showed that the overall TB prevalence decreased linearly from 2010 to 2014 and occupation-stratified analyses yielded similar results, corroborating the reliability of the findings. The decrease of TB prevalence in the central-western and eastern regions was more rapid than that in the overall TB prevalence. A spatial correlation analysis showed spatial clustering of the TB prevalence from 2011 to 2014 (Moran’s index > 0, P < 0.05); in the spatial panel data model, rural residence, birth rate, number of beds, population density, precipitation, air pressure, and sunshine duration were associated with the TB prevalence.

Conclusions

The overall TB prevalence in Inner Mongolia decreased from 2010 to 2014; however, the incidence of TB was high throughout this period. The TB prevalence was influenced by a spatiotemporal interaction effect and was associated with epidemiological, healthcare, and environmental factors.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3910-x) contains supplementary material, which is available to authorized users.

Smoking and pulmonary tuberculosis treatment failure: a case-control study

Objective:

To determine the association between smoking and pulmonary tuberculosis treatment failure.

Methods:

This was a case-control study conducted at the Brazilian Institute for Tuberculosis Research in the city of Salvador, Brazil, between 2007 and 2015. We evaluated 284 patients treated for pulmonary tuberculosis, comparing 50 cases of treatment failure with 234 control cases in which the final outcome was cure.

Results:

Treatment failure was attributed to smoking and age rather than to gender, income, level of education, alcohol consumption, or marital status. Therefore, even after adjustment for age, the risk of treatment failure was 2.1 times (95% CI: 1.1-4.1) higher among the patients with a history of smoking. In addition, being over 50 years of age was found to increase the likelihood of treatment failure by 2.8 times (95% CI: 1.4-6.0).

Conclusions:

Smoking and aging are both associated with pulmonary tuberculosis treatment failure. Therefore, as part of a tuberculosis control program, health personnel should be prepared to offer strategies to promote smoking cessation and should be more careful with older patients.

[Magnitude of social determinants in the risk of death from tuberculosis in Central-west Brazil]

OBJECTIVE

To evaluate the magnitude of social determinants in areas of risk of mortality due to tuberculosis in a high incidence city.

METHOD

Ecological study, which recruited the cases of tuberculosis deaths registered between 2006 and 2016 in the capital of Mato Grosso-Brazil. The social determinants were obtained from the Human Development Units. Sweep statistics were used to identify areas of risk of mortality due to tuberculosis. Principal component analysis was carried out to identify dimensions of social determinants. Multiple logistic regression was applied to verify associations between the dimensions of social determinants and the risk of mortality from tuberculosis. A 5% error was fixed. The standard error was established at 5% for all statistical tests.

RESULTS

A total of 225 deaths due to tuberculosis were registered in the period, distributed heterogeneously in the space. A cluster of risk for tuberculosis mortality was identified, with RR=2.09 (95%CI: 1.48-2.94; p=0.04). Social determinants, low educational level and poverty were associated with the risk of mortality due to tuberculosis (OR: 2.92; 95%CI: 1.17-7.28). Income had a negative association with the risk of mortality due to tuberculosis (OR: 0.05; 95%CI: 0.00-0.70). The value of the ROC curve of the model was 92.1%.

CONCLUSIONS

The results confirmed that the risk of mortality due to tuberculosis is a problem associated with social determinants. Health policies and social protection programmes can collaborate to address this problem.

Tuberculosis incidence inequalities and its social determinants in Manaus from 2007 to 2016

Background

Brazil is among the 30 countries with high-burden of tuberculosis worldwide, and Manaus is the capital with the highest tuberculosis incidence. The accelerated economic and population growth in Manaus in the last 30 years has strengthened the process of social stratification that may result in population groups that are less favored in terms of healthcare and are vulnerable to infection and illness due to tuberculosis. This study aimed to characterize inequalities associated with tuberculosis incidence in relation to the socioeconomic and demographic characteristics of the resident population of Manaus and to identify their determinants from 2007 to 2016.

Methods

An ecological study was conducted using the data from the Diseases Notification Information System. Tuberculosis incidence rates by population characteristics (gender, ethnicity, and socioeconomic level) were calculated for each year, studied, and represented in equiplot charts. To measure the disparity of tuberculosis incidence in the resident population in Manaus, the Gini index of tuberculosis in each neighborhood was calculated based on the incidence rates of the census sectors. A thematic map was constructed to represent the spatial distribution of tuberculosis incidence inequality. Linear regression models were used to identify the relationship between the tuberculosis incidence inequality and its social determinants.

Results

From 2007 to 2016, there was an increase in the tuberculosis incidence in Manaus, together with an increase in incident inequality among genders, ethnic groups, and socioeconomic level. The incidence of tuberculosis inequality was associated with the inequalities of its possible determinants (Gini of the proportion of male population, Gini of the proportion of indigenous population, Gini of the proportion of illiteracy, Gini of income, Gini of the proportion of households connected to the water network, and Gini of the mean number of bathrooms per inhabitant), the per capita income, and the proportion of cases with laboratory confirmation.

Conclusions

Disparities in tuberculosis incidence in the resident population in neighborhoods can be explained by the sociodemographic and economic heterogeneity. Our findings recommend that public policies and tuberculosis control strategies consider differences in the determinants of tuberculosis inequality for the development of specific actions for each population group.

Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India

Background:

Stigma associated with tuberculosis (TB) is still common in many societies, contributing to delays in treatment seeking and treatment non-compliance. India has the highest burden of TB in the world with female TB patients bearing a considerable burden of TB-related stigma.

Objectives:

This study aimed to explore the manifestations and consequences of stigma experienced by female TB patients in an urban setting in India and their strategies to cope with the social stigma of TB.

Methods:

Twenty qualitative interviews were conducted with female TB patients who were either currently on treatment or had undergone treatment at a TB clinic in Kolkata, India. Data were coded and analyzed with the NVivo qualitative software using a thematic approach.

Results:

Our results indicated that TB stigma mainly manifested through social isolation and avoidance due to fear of contagion, gossip and verbal abuse, failed marriage prospects, and neglect from family. Consequences of stigma described by the women included non-disclosure, feelings of guilt, and mental health issues including suicidal ideation. Positive coping strategies used by women to cope with the experiences of stigma included positive reframing, prayer, talking to other patients, focusing on school work, and relaxation activities. Negative coping activities included self-imposed social isolation and anger. In some cases, non-disclosure due to stigma had an impact on TB transmission and control behaviors.

Conclusions:

Stigma-reduction strategies, such as community awareness programs and formation of social support groups to dispel the myths and misconceptions associated with TB, may improve TB treatment seeking and adherence.

Acknowledgement:

Our deepest thanks to the Reverend, St. James’ Church, Dr. Ali Akbar Chowdhury (Medical Officer), staff and participants at the Calcutta Diocesan Tuberculosis Relief Trust, without whom this study would not be possible. We also thank Sushmita Mukherjee for help with translations. Lastly, we thank the Sparkman Center for Global Health at the University of Alabama at Birmingham for providing travel funds for this study.

Exploring Manifestations of TB-Related Stigma Experienced by Women in Kolkata, India

BACKGROUND

Stigma associated with tuberculosis (TB) is still common in many societies, contributing to delays in treatment seeking and treatment non-compliance. India has the highest burden of TB in the world with female TB patients bearing a considerable burden of TB-related stigma. Objectives: This study aimed to explore the manifestations and consequences of stigma experienced by female TB patients in an urban setting in India and their strategies to cope with the social stigma of TB.

METHODS

Twenty qualitative interviews were conducted with female TB patients who were either currently on treatment or had undergone treatment at a TB clinic in Kolkata, India. Data were coded and analyzed with the NVivo qualitative software using a thematic approach.

RESULTS

Our results indicated that TB stigma mainly manifested through social isolation and avoidance due to fear of contagion, gossip and verbal abuse, failed marriage prospects, and neglect from family. Consequences of stigma described by the women included non-disclosure, feelings of guilt, and mental health issues including suicidal ideation. Positive coping strategies used by women to cope with the experiences of stigma included positive reframing, prayer, talking to other patients, focusing on school work, and relaxation activities. Negative coping activities included self-imposed social isolation and anger. In some cases, non-disclosure due to stigma had an impact on TB transmission and control behaviors. Conclusions: Stigma-reduction strategies, such as community awareness programs and formation of social support groups to dispel the myths and misconceptions associated with TB, may improve TB treatment seeking and adherence.Acknowledgement: Our deepest thanks to the Reverend, St. James' Church, Dr. Ali Akbar Chowdhury (Medical Officer), staff and participants at the Calcutta Diocesan Tuberculosis Relief Trust, without whom this study would not be possible. We also thank Sushmita Mukherjee for help with translations. Lastly, we thank the Sparkman Center for Global Health at the University of Alabama at Birmingham for providing travel funds for this study.

A Bayesian Approach to Understanding Sex Differences in Tuberculosis Disease Burden

Globally, men have a higher epidemiologic burden of tuberculosis (incidence, prevalence, mortality) than women do, possibly due to differences in disease incidence, treatment initiation, self-cure, and/or untreated-tuberculosis mortality rates. Using a simple, sex-stratified compartmental model, we employed a Bayesian approach to explore which factors most likely explain men's higher burden. We applied the model to smear-positive pulmonary tuberculosis in Vietnam (2006-2007) and Malawi (2013-2014). Posterior estimates were consistent with sex-specific prevalence and notifications in both countries. Results supported higher incidence in men and showed that both sexes faced longer durations of untreated disease than estimated by self-reports. Prior untreated disease durations were revised upward 8- to 24-fold, to 2.2 (95% credible interval: 1.7, 2.9) years for men in Vietnam and 2.8 (1.8, 4.1) years for men in Malawi, approximately a year longer than for women in each country. Results imply that substantial sex differences in tuberculosis burden are almost solely attributable to men's disadvantages in disease incidence and untreated disease duration. The latter, for which self-reports provide a poor proxy, implies inadequate coverage of case-finding strategies. These results highlight an urgent need for better understanding of gender-related barriers faced by men and support the systematic targeting of men for screening.

Utility of GeneXpert in the diagnosis, reliance on urine microscopy and clinical characteristics of genitourinary tuberculosis at a tertiary care hospital

Background

One-third of the world's population is infected with tuberculosis (TB) with new infection occurring every second. In humans, TB is primarily caused by Mycobacterium tuberculosis(MTB). Genitourinary TB (GUTB) is still a major health problem in many developing countries including India and had been declared by the World Health Organisation as 'public health emergency' in 1993.

Materials and Methods

This is a prospective study conducted at a tertiary care hospital involving 46 patients who presented with clinical feature suggestive of GUTB - urine specimens of these 46 patients were analysed for acid-fast bacilli (AFB), AFB culture, GeneXpert, and other relevant investigations were done to reach the diagnosis. Majority of patients were female (65.25%). This is especially relevant to rural and low socioeconomic areas in developing countries where women's health is worse than men's (in terms of nutrition); women's risk of disease may be increased. Most of our patients were above 30 years of age and exhibited nonspecific symptoms such as dysuria, haematuria and frequency. All patients were put on antitubercular drugs and followed as per the guidelines.

Conclusion

The sample size in the present study is small to arrive at a brisk inference, but it may safely be postulated that yield of detection for GeneXpert may be improved using multiple sampling, especially the early morning ones. It is also pertinent to mention here that GeneXpert may not be able to pick up mutant genomes.

Investigation of household contacts of pulmonary tuberculosis patients increases case detection in Mwanza City, Tanzania

Background

Tuberculosis (TB) contact tracing is a key strategy for containing TB and provides addition to the passive case finding approach. However, this practice has not been implemented in Tanzania, where there is unacceptably high treatment gap of 62.1% between cases estimated and cases detected. Therefore calls for more aggressive case finding for TB to close this gap. We aimed to determine the magnitude and predictors of bacteriologically-confirmed pulmonary TB among household contacts of bacteriologically-confirmed pulmonary TB index cases in the city of Mwanza, Tanzania.

Methods

This study was carried out from August to December 2016 in Mwanza city at the TB outpatient clinics of Tertiary Hospital of the Bugando Medical Centre, Sekou-Toure Regional Hospital, and Nyamagana District Hospital. Bacteriologically-confirmed TB index cases diagnosed between May and July 2016 were identified from the laboratory registers book. Contacts were traced by home visits by study TB nurses, and data were collected using a standardized TB screening questionnaire. To detect the bacterioriologically-confirmed pulmonary TB, two sputum samples per household contact were collected under supervision for all household contacts following standard operating procedures. Samples were transported to the Bugando Medical Centre TB laboratory for investigation for TB using fluorescent smear microscopy, GeneXpert MTB/RIF and Löwenstein–Jensen (LJ) culture. Logistic regression was used to determine predictors of bacteriologically-confirmed pulmonary TB among household contacts.

Results

During the study period, 456 household contacts from 93 TB index cases were identified. Among these 456 household contacts, 13 (2.9%) were GeneXpert MTB/RIF positive, 18 (3.9%) were MTB-culture positive and four (0.9%) were AFB-smear positive. Overall, 29 (6.4%) of contacts had bacteriologically-confirmed pulmonary TB. Predictors of bacteriologically-confirmed pulmonary TB among household contacts were7being married (Odds ratio [OR], 3.3; 95% confidence interval [CI], 1.4–8.0; p = 0.012) and consuming less than three meals a day (OR, 3.7; 95% CI, 1.6–8.7; p = 0.009).

Conclusions

Our data suggest that in Mwanza, Tanzania, seven in 100 contacts living in the same house with a TB patient develop bacteriologically-confirmed pulmonary TB. These results therefore underscore the need to implement routine TB contact tracing to control tuberculosis in high TB burden countries such as Tanzania.

Sexual inequality in incident tuberculosis: a cohort study in Taiwan

OBJECTIVE

Animal studies showed that male subjects had lower activity of immune response to infections than female subjects, which may increase the risk of the development of tuberculosis in male population. This study intended to investigate the risk of incident tuberculosis in male and female adults in Taiwan.

DESIGN

This is a retrospective cohort study.

SETTING

The present analyses used data of Taiwan National Health Interview Survey 2001, 2005 and 2009, National Register of Deaths Dataset, and National Health Insurance Research Database from 2000 to 2013.

PARTICIPANTS

A total of 43 424 subjects with a mean age of 43.04 years were analysed.

PRIMARY OUTCOME MEASURES

Incidence of tuberculosis.

RESULTS

During 381 561 person-years of follow-up period, incident tuberculosis was recognised in 268 individuals. The incidence rates of tuberculosis were 97.56 and 43.24 per 100 000 person-years among male and female participants, respectively. Kaplan-Meier curves comparing male and female subjects showed statistical significance (log-rank test, P value<0.01). After adjusting for subjects' demographics and comorbidities, men showed increased risks of incident tuberculosis (adjusted HR, 1.68; 95% CI 1.21 to 2.34; P value<0.01) compared with women. On subgroup analysis, after stratifying by age, smoking and alcohol use, men had a higher risk of incident tuberculosis than women in all patient subgroups, except those who were current smokers.

CONCLUSIONS

This study suggests that men had a higher risk of incident tuberculosis than women. Future tuberculosis control programmes should particularly target the male population.

Epidemiological profile of multidrug-resistant tuberculosis patients in Gorakhpur Division, Uttar Pradesh, India

Introduction:

Multidrug-resistant tuberculosis (MDR-TB) poses a major threat to control of TB worldwide. Adequate information on socioepidemiological factors and their interaction is required for its control. The aim was to study the social and epidemiological profile of MDR-TB patient in Gorakhpur division.

Methodology:

A cross-sectional study of 157 MDR-TB patients from Gorakhpur division admitted at DR-TB Center of a tertiary care center were interviewed during initiation of MDR-TB treatment using structured questionnaire and collected data were described using descriptive statistics.

Results:

More than 2/3^rd of patients were male and the mean age was 32.15 ± 13.19 years. Overcrowding was present in 82.8% of households and ventilation of living room was inadequate in 72.7% of households. About 21.7% had history of contact with TB cases. Two-third of the patients practice unhygienic sputum disposal practices at home and at public places it was more than 90%. More than 60% of patients have the history of irregular treatment in intensive phase and 80% in continuation phase. Nearly 68.8% of patients were resistance to isoniazid (H) and rifampicin (R) and 18.5% were resistance to H, R, and S (streptomycin) followed by H, R and E (Ethambutol). Nearly 3.8% of patients were HIV positive and 7% had history of diabetes. 64.3% were under severe thinness category according to the WHO classification.

Conclusion:

Study point out need of nutritional counseling and support throughout the treatment. Use of incentives, enhancing contact tracing and increasing awareness regarding sputum disposal practices are recommended for effective control.

Status of tuberculosis-related stigma and associated factors: a cross-sectional study in central China

OBJECTIVES

Tuberculosis (TB) poses a significant challenge to public health worldwide. Stigma is a major obstacle to TB control by leading to delay in diagnosis and treatment non-adherence. This study aimed to evaluate the status of TB-related stigma and its associated factors among TB patients in China.

METHODS

Cross-sectional survey. Thus, 1342 TB patients were recruited from TB dispensaries in three counties in Hubei Province using a multistage sampling method and surveyed using a structured anonymous questionnaire including validated scales to measure TB-related stigma. A generalised linear regression model was used to identify the factors associated with TB-related stigma.

RESULTS

The average score on the TB-related Stigma Scale was 9.33 (SD = 4.25). Generalised linear regression analysis revealed that knowledge about TB (ß = -0.18, P = 0.0025), family function (ß = -0.29, P < 0.0001) and doctor-patient communication (ß = -0.32, P = 0.0005) were negatively associated with TB-related stigma.

CONCLUSIONS

TB-related stigma was high among TB patients in China. Interventions concentrating on reducing TB patients' stigma in China should focus on improving patients' family function and patients' knowledge about TB.

Survey on Tuberculosis Patients in Rural Areas in China: Tracing the Role of Stigma in Psychological Distress

Depressed patients had risks of non-adherence to medication, which brought a big challenge for the control of tuberculosis (TB). The stigma associated with TB may be the reason for distress. This study aimed to assess the psychological distress among TB patients living in rural areas in China and to further explore the relation of experienced stigma to distress. This study was a cross-sectional study with multi-stage randomized sampling for recruiting TB patients. Data was collected by the use of interviewer-led questionnaires. A total of 342 eligible and accessible TB patients being treated at home were included in the survey. Psychological distress was measured using the Kessler Psychological Distress Scale (K10). Experienced stigma was measured using a developed nine-item stigma questionnaire. Univariate analysis and multiple logistic regression were used to analyze the variables related to distress, respectively. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to present the strength of the associations. Finally, the prediction of logistic model was assessed in form of the Receiver Operating Characteristic (ROC) curve and the area under the ROC curve (AUC). According to the referred cut-off point from K10, this study revealed that 65.2% (223/342) of the participants were categorized as having psychological distress. Both the stigma questionnaire and the K10 were proven to be reliable and valid in measurement. Further analysis found that experienced stigma and illness severity were significant variables to psychological distress in the model of logistic regression. The model was assessed well in predicting distress by use of experienced stigma and illness severity in form of ROC and AUC. Rural TB patients had a high prevalence of psychological distress. Experience of stigma played a significant role in psychological distress. To move the barrier of stigma from the surroundings could be a good strategy in reducing distress for the patients and TB controlling for public health management.

Insights into secular trends of respiratory tuberculosis: The 20th century Maltese experience

Over half a century ago, McKeown and colleagues proposed that economics was a major contributor to the decline of infectious diseases, including respiratory tuberculosis, during the 19^th and 20^th centuries. Since then, there is no consensus among researchers as to the factors responsible for the mortality decline. Using the case study of the islands of Malta and Gozo, we examine the relationship of economics, in particular, the cost of living (Fisher index) and its relationship to the secular trends of tuberculosis mortality. Notwithstanding the criticism that has been directed at McKeown, we present results that improvement in economics is the most parsimonious explanation for the decline of tuberculosis mortality. We reaffirmed that the reproductively aged individuals were most at risk of dying of tuberculosis, seeing that 70 to 90% of all deaths due to tuberculosis occurred between the ages of 15 and 45. There was a clear sex differential in deaths in that, prior to 1930, rates in females were generally higher than males. During times of extreme hardship, the sex differential was exacerbated. Over the course of World War I, the sex gap in tuberculosis rates increased until peaking in 1918 when there was also the influenza pandemic. The heightened differential was most likely a result of gendered roles as opposed to biological differences since female tuberculosis rates again surpassed male rates in 1945 during World War II. Respiratory tuberculosis in both urban and rural settlements (in Malta proper) was significantly influenced by the Fisher index, which explains approximately 61% of the variation in TB death rates (R = 0.78; p<0.0001). In Gozo, there was no significant impact on respiratory tuberculosis (R = 0.23; p = 0.25), most likely a consequence of the island’s isolation, a self-sufficient economy and limited exposure to tuberculosis.

Identifying risk factors associated with smear positivity of pulmonary tuberculosis in Kazakhstan

Background

Sputum smear-positive tuberculosis (TB) patients have a high risk of transmission and are of great epidemiological and infection control significance. Little is known about the smear-positive populations in high TB burden regions, such as Kazakhstan. The objective of this study is to characterize the smear-positive population in Kazakhstan and identify associated modifiable risk factors.

Methods

Data on incident TB cases’ (identified between April 2012 and March 2014) socio-demographic, risk behavior, and comorbidity characteristics were collected in four regions of Kazakhstan through structured survey and medical record review. We used multivariable logistic regression to determine factors associated with smear positivity.

Results

Of the total sample, 193 (34.3%) of the 562 study participants tested smear-positive. In the final adjusted multivariable logistic regression model, sex (adjusted odds ratio (aOR) = 2.0, 95% CI:1.3–3.1, p < 0.01), incarceration (aOR = 3.6, 95% CI:1.2–11.1, p = 0.03), alcohol dependence (aOR = 2.6, 95% CI:1.2–5.7, p = 0.02), diabetes (aOR = 5.0, 95% CI:2.4–10.7, p < 0.01), and physician access (aOR = 2.7, 95% CI:1.3–5.5p < 0.01) were associated with smear-positivity.

Conclusions

Incarceration, alcohol dependence, diabetes, and physician access are associated with smear positivity among incident TB cases in Kazakhstan. To stem the TB epidemic, screening, treatment and prevention policies should address these factors.

Genotyping and Prevalence of Pyrazinamide- and Moxifloxacin-Resistant Tuberculosis in China, 2000 to 2010

We investigated the prevalence, trends, and risk factors for pyrazinamide (PZA) and moxifloxacin (MOX) resistance among tuberculosis (TB) cases in China and also analyzed the population structure of Mycobacterium tuberculosis strains. All the M. tuberculosis strains enrolled in this study were collected from the national TB prevalence surveys. Each strain was genotyped by analyzing the regions of RD105 and IS6110 in the NTF region. The Bactec MGIT 960 system was used to detect the drug susceptibility of M. tuberculosis isolates to PZA and MOX. Based on the genotyping results, 241 (66.4%) strains were classified as Beijing genotype in 2000, which was significantly lower than in 2010 (76.2%, P < 0.01). The proportion of the modern Beijing genotype increased significantly from 49.6% in 2000 to 68.1% in 2010 (P < 0.01), while no significant difference was observed in the rate of ancient Beijing genotype between 2000 and 2010 (P = 0.676). In addition, we found that the proportion of PZA resistance in 2010 (15.0%) was significantly higher than that in 2000 (9.6%, P = 0.04). For MOX, there were more MOX-resistant isolates detected in 2010 (7.7%) than in 2000 (3.0%). In conclusion, our data demonstrate that the Beijing genotype was the predominant M. tuberculosis lineage during the past decade. The proportion of Beijing genotype isolates significantly increased from 2000 to 2010, largely due to an increase in the modern Beijing sublineage. In addition, resistance to PZA and MOX increased significantly in China between 2000 and 2010.

30 Years Retrospective Review of Tuberculosis Cases in a Tuberculosis Dispensary in Bursa/Nilufer, Turkey (1985-2014): Changes of Epidemics. Mediterr J Hematol Infect Dis 2016;8:e2016059. [PMID: 27872739 PMCID: PMC5111538 DOI: 10.4084/mjhid.2016.059]

OBJECTIVE

The aim of this study is to describe the epidemiological and clinical aspects of patients who applied to the Bursa Nilufer Tuberculosis Dispensary by investigating the trends in epidemics over three decades.

METHOD

In this retrospective observational study, the records of all tuberculosis cases (1630 patients) treated in the last 30 years (1985-2014) at the Bursa Nilufer Tuberculosis Dispensary were examined and statistically analyzed.

RESULTS

Males comprised 65.2% of the patients. The ages of the patients ranged from 1 to 87 years, and the mean age was 37.4 (95% CI: 36.6-38.2). Among the cases, 86.7% were new infections and 74.1% were pulmonary tuberculosis. In the last decade, the education level, the percentage of patients who had received a BCG vaccination, the proportion of women and active employees among them increased (p<0.05), while it decreased among men (p<0.05). Clinical symptoms accompanying TB such as weakness, anorexia, weight loss, and cough, decreased to a statistically significant degree (p<0.05). In the last decade, the mortality rate was 3.6% and increased compared with previous decades (p<0.05). Mortality was higher among patients who were elderly, male, did not have a BCG scar or had a chronic disease (p<0.05).

CONCLUSION

This study adds information about the change of TB epidemics in Turkey in the last 30 years. Further studies are needed to determine the risk factors associated with tuberculosis mortality and to evaluate the effectiveness control programs of this disease.

Patients infected by tuberculosis and human immunodeficiency virus facing their disease, their reactions to disease diagnosis and its implication about their families and communities, in Burkina Faso: a mixed focus group and cross sectional study

Background

Patients facing tuberculosis (TB) and human immunodeficiency virus (HIV) infection receive particular care. Despite efforts in the care, misconceptions about TB and HIV still heavily impact patients, their families and communities. This situation severely limits achievement of TB and HIV programs goals. This study reports current situation of TB patients and patients living with HIV/AIDS (PLWHA) facing their disease and its implications, by comparing results from both qualitative and quantitative study design.

Methods

Cross sectional study using mixed methods was used and excluded patients co-infected by TB and HIV. Focus group included 96 patients (6 patients per group) stratified by setting, disease profile and gender; from rural (Orodara Health District) and urban (Bobo Dioulasso) areas, all from Hauts-Bassins region in Burkina Faso. Quantitative study included 862 patients (309 TB patients and 553 PLWHA) attending TB and HIV care facilities in two main regions (Hauts-Bassins and Centre) of Burkina Faso.

Results

A content analysis of reports found TB patients and PLWHA felt discriminated and stigmatized because of misconceptions with its aftermaths (rejection, emotional and financial problems), mainly among PLWHA and women patients. PLWHA go to healers when facing limited solutions in health system. There are fewer associations for TB patients, and less education and sensitization sessions to give them opportunity for sharing disease status and learning from other TB patients. TB patients and PLWHA still need to better understand their disease and its implication. Access to care (diagnosis and treatment) remains one of the key issues in health system, especially for PLWHA. Individual counseling is centered among PLWHA but not for TB patients. With research progress and experiences sharing, TB patients and PLWHA have some hope to implement their life project, and to receive psychosocial and nutritional support.

Conclusion

Despite international aid, TB patients and PLWHA are facing misconceptions effects. There is a need to reinforce health education towards patients and healers, inside community, health centers and associations, and for specific settings. International aid must be adapted to specific targets and strategies implementing programs. Maintaining psychosocial and nutritional support is crucial for better outcomes of medication adherence. Individual counseling has to be centered among TB patients and PLWHA.

The Challenge of Infectious Disease: Time to Take Gender into Account

Efforts to address infectious diseases have long been hindered by the failure to take into account the social aspects of these diseases. Gender is a fundamental dimension of these social aspects. There is currently a focus in international health on the import ance of addressing diseases of poverty. Attention to gender is a crucial part of a poverty-focused response to the challenges posed by infectious disease. In this article we provide a framework for analysing gender inequities in infectious disease in developing countries, and briefly draw implications for policy and practice.

Gender identities, status, roles and responsibilities influence vulnerability to dis ease, access to health care, and the impact of disease for women, men, girls and boys. Women's and men's roles affect their risk of infection with specific diseases, whilst gender relations influence their ability to protect their own health. Gender differences in access to and control over resources, in decision-making power in the household and in roles and activities can limit women's ability to access health care for them selves and their children. Gendered norms and identities influence both women's and men's willingness and ability to seek care. The social consequences of infectious disease are often more severe for women than for men, and illness imposes a parti cularly heavy labour burden upon women.

Health services need to adjust their practices to improve the appropriateness of preventive and curative services for infectious disease control for both women and men amongst the poor and disadvantaged. However, measures to reduce gender inequities in health cannot be limited to the health sector alone.

Factors Influencing Delayed Health Care Seeking Among Pulmonary Tuberculosis Suspects in Rural Communities in Ntcheu District, Malawi

Delayed diagnosis and treatment of tuberculosis (TB) among individuals suspected of having TB may lead to continued transmission of Mycobacterium tuberculosis in communities, higher mortality rates, and increase in government health expenditure because of prolonged illness due to late diagnosis and treatment initiation. The study explored factors leading to delayed health care seeking among individuals living in Ntcheu District, Malawi. Two key informant interviews, 16 in-depth interviews, and three focus group discussions were conducted. Participants were aged 18 years and older and never had TB. Data were analyzed using content analysis and factors were identified: inadequate knowledge about cause and transmission of TB, low self-awareness of personal risk to TB, cultural and traditional beliefs about sources of TB, stigma, and strong belief in witchcraft as a cause of illness. The TB Control Program needs to invest in social mobilization and education of communities to mitigate early health care seeking.

Are current case-finding methods under-diagnosing tuberculosis among women in Myanmar? An analysis of operational data from Yangon and the nationwide prevalence survey

Background

Although there is a large increase in investment for tuberculosis control in Myanmar, there are few operational analyses to inform policies. Only 34 % of nationally reported cases are from women. In this study, we investigate sex differences in tuberculosis diagnoses in Myanmar in order to identify potential health systems barriers that may be driving lower tuberculosis case finding among women.

Methods

From October 2014 to March 2015, we systematically collected data on all new adult smear positive tuberculosis cases in ten township health centres across Yangon, the largest city in Myanmar, to produce an electronic tuberculosis database. We conducted a descriptive cross-sectional analysis of sex differences in tuberculosis diagnoses at the township health centres. We also analysed national prevalence survey data to calculate additional case finding in men and women by using sputum culture when smear microscopy was negative, and estimated the sex-specific impact of using a more sensitive diagnostic tool at township health centres.

Results

Overall, only 514 (30 %) out of 1371 new smear positive tuberculosis patients diagnosed at the township health centres were female. The proportion of female patients varied by township (from 21 % to 37 %, p = 0.0172), month of diagnosis (37 % in February 2015 and 23 % in March 2015 p = 0.0004) and age group (26 % in 25–64 years and 49 % in 18–25 years, p < 0.0001). Smear microscopy grading of sputum specimens was not substantially different between sexes. The prevalence survey analysis indicated that the use of a more sensitive diagnostic tool could result in the proportion of females diagnosed at township health centres increasing to 36 % from 30 %.

Conclusions

Our study, which is the first to systematically compile and analyse routine operational data from tuberculosis diagnostic centres in Myanmar, found that substantially fewer women than men were diagnosed in all study townships. The sex ratio of newly diagnosed cases varied by age group, month of diagnosis and township of diagnosis. Low sensitivity of tuberculosis diagnosis may lead to a potential under-diagnosis of tuberculosis among women.