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Cao W, Fu X, Li H, Bei J, Li L, Wang L. Tuberculosis in pregnancy and assisted reproductive technology. Drug Discov Ther 2024; 18:80-88. [PMID: 38631867 DOI: 10.5582/ddt.2024.01007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Tuberculosis is a chronic infectious disease caused by mycobacterium tuberculosis infection. In the world, tuberculosis is an important factor affecting women's reproductive health, which can cause reproductive tract anatomy abnormalities, embryo implantation obstacles, ovarian reserve and ovulation dysfunction, leading to female infertility. This group of women usually need to seek assisted reproductive technology to conceive. Latent tuberculosis infection during pregnancy has no clinical manifestation, but may develop into active tuberculosis, leading to adverse pregnancy outcomes. Most pregnant women do not need to be treated for latent tuberculosis infection, unless they are combined with high-risk factors for tuberculosis progress, but they need close follow-up. Early diagnosis and treatment of active tuberculosis in pregnancy can reduce the incidence rate and mortality of pregnant women and newborns, and treatment needs multidisciplinary cooperation.
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Affiliation(s)
- Wenli Cao
- Reproductive Medicine Center, Zhoushan Maternal and Child Health Care Hospital, Zhoushan, Zhejiang, China
| | - Xiayan Fu
- Reproductive Medicine Center, Zhoushan Maternal and Child Health Care Hospital, Zhoushan, Zhejiang, China
| | - Haiyang Li
- Reproductive Medicine Center, Zhoushan Maternal and Child Health Care Hospital, Zhoushan, Zhejiang, China
| | - Jialu Bei
- Reproductive Medicine Center, Zhoushan Maternal and Child Health Care Hospital, Zhoushan, Zhejiang, China
| | - Lisha Li
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
| | - Ling Wang
- Laboratory for Reproductive Immunology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
- The Academy of Integrative Medicine, Fudan University, Shanghai, China
- Shanghai Key Laboratory of Female Reproductive Endocrine-related Diseases, Shanghai, China
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Gupta A, Hughes MD, Cruz JL, Avihingsanon A, Mwelase N, Severe P, Omoz-Oarhe A, Masheto G, Moran L, Benson CA, Chaisson RE, Swindells S. Adverse Pregnancy Outcomes Among Women with Human Immunodeficiency Virus Taking Isoniazid Preventive Therapy During the First Trimester. Clin Infect Dis 2024; 78:667-673. [PMID: 37768207 PMCID: PMC10954322 DOI: 10.1093/cid/ciad583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/05/2023] [Accepted: 09/25/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Isoniazid preventive therapy (IPT) is recommended for tuberculosis prevention yet data on the safety of first-trimester pregnancy exposure are limited. METHODS Planned secondary analysis in a TB prevention trial of adverse pregnancy outcomes among participants assigned to 9-month IPT who became pregnant during (IPT-exposed) or after (unexposed) IPT. Regression models compared binary outcomes of a composite adverse outcome (any non-live birth, excluding induced abortion); preterm delivery <37 weeks; and low birth weight <2500 g) among exposure groups. Models were adjusted for latent TB infection, maternal age, CD4 count, and antiretroviral therapy (ART). RESULTS In total, 128 participants had a known pregnancy outcome; 39 IPT-exposed and 89 unexposed. At pregnancy outcome, ART use was lower in IPT-exposed (79%) than unexposed women (98%). Overall, 29 pregnancies ended in a composite adverse outcome (25 spontaneous abortions, 2 stillbirths and 2 ectopic pregnancies), 15 preterm deliveries, and 10 infants with low birth weight. IPT was associated with the composite adverse outcome adjusting for covariates at enrollment (adjusted relative risk [aRR] 1.98; 95% confidence interval [CI] 1.15, 3.41), but the effect was attenuated when adjusted for covariates at pregnancy outcome (aRR 1.47; 95% CI .84, 2.55); IPT was not associated with preterm delivery (relative risk [RR] 0.87; 95% CI .32-2.42) or low birth weight (RR 1.01; 95% CI .29, 3.56). CONCLUSIONS First-trimester IPT exposure was associated with nearly two-fold increased risk of fetal demise, mostly spontaneous abortion, though the association was attenuated when adjusted for covariates proximal to pregnancy outcome including ART use. Further study is needed to inform TB prevention guidelines.
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Affiliation(s)
- Amita Gupta
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Michael D Hughes
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Jorge Leon Cruz
- Center for Biostatistics in AIDS Research, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Anchalee Avihingsanon
- HIV-NAT, Thai Red Cross AIDS Research Centre and Center of Excellence in Tuberculosis, Faculty of Medicine Chulalongkorn University, Bangkok, Thailand
| | - Noluthando Mwelase
- Department of Medicine, University of Witwatersrand, Johannesburg, South Africa
| | - Patrice Severe
- Clinical Trials Unit, Les Centres GHESKIO, Port-au-Prince, Haiti
| | - Ayotunde Omoz-Oarhe
- Botswana Harvard AIDS Institute Partnership, Clinical Trials Unit, Gaborone, Botswana
| | - Gaerolwe Masheto
- Botswana Harvard AIDS Institute Partnership, Clinical Trials Unit, Gaborone, Botswana
| | - Laura Moran
- Public Health and Scientific Research Unit, Social & Scientific Systems, a DLH Company, Silver Spring, Maryland, USA
| | - Constance A Benson
- Division of Infectious Diseases, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Richard E Chaisson
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Susan Swindells
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Zang Z, Hu M, Yan Y, Su Y, Yan J, Chen ZJ, Li Y. Pregnancy and neonatal outcomes in infertile patients with positive tuberculin skin test results. Reprod Biomed Online 2023; 47:103307. [PMID: 37666021 DOI: 10.1016/j.rbmo.2023.103307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/12/2023] [Accepted: 07/21/2023] [Indexed: 09/06/2023]
Abstract
RESEARCH QUESTION Do infertile women with positive tuberculin skin test (TST) results have a higher risk of adverse pregnancy outcomes after IVF or intracytoplasmic sperm injection and embryo transfer (ICSI-ET) and does preventive anti-tuberculosis treatment applied to infertile women with positive TST results before IVF/ICSI-ET affect pregnancy and neonatal outcomes? DESIGN This was a retrospective cohort analysis of 6283 infertile women who underwent IVF/ICSI-ET treatment for the first time at the Reproductive Hospital affiliated to Shandong University from November 2016 to September 2022. None of the participants had prior tuberculosis or active tuberculosis. According to their TST results, 5947 patients who had never received preventive anti-tuberculosis treatment were divided into a TST-positive group (1704 cases) and a TST-negative group (4243 cases). A total of 504 patients with TST (+++) results (using the 20 mm sclerosis threshold) were divided into a treated TST (+++) group (336 cases) and an untreated TST (+++) group (168 cases) according to whether they received preventive anti-tuberculosis treatment before IVF/ICSI-ET. The outcome measures were pregnancy outcomes and neonatal outcomes. RESULTS There were no significant differences in pregnancy or neonatal outcomes between the TST-positive group and the TST-negative group (P > 0.05). In the TST (+++) group, there were no significant differences in pregnancy or neonatal outcomes between the treated TST (+++) group and the untreated TST (+++) group (P > 0.05). CONCLUSIONS For infertile women undergoing IVF/ICSI-ET without prior tuberculosis or active tuberculosis, positive TST results and preventive anti-tuberculosis treatments prior to IVF/ICSI-ET do not affect pregnancy or neonatal outcomes.
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Affiliation(s)
- Zhaowen Zang
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, China
| | - Min Hu
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, China
| | - Yueyue Yan
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, China
| | - Yaxin Su
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, China
| | - Junhao Yan
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, China
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, China
| | - Yan Li
- Center for Reproductive Medicine, Shandong University, Jinan, Shandong, China.; Medical Integration and Practice Center, Shandong University, Jinan, Shandong, China..
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Hui SYA, Lao TT. Tuberculosis in pregnancy. Best Pract Res Clin Obstet Gynaecol 2022; 85:34-44. [PMID: 36002371 PMCID: PMC9339097 DOI: 10.1016/j.bpobgyn.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/07/2022] [Accepted: 07/14/2022] [Indexed: 12/14/2022]
Abstract
Due to COVID-19 pandemic, the latest progress of the End Tuberculosis (TB) Strategy was far from optimal and services for TB needs to be quickly restored. Pregnancy is a unique opportunity to screen and manage TB, and it is an essential step in TB eradication. Early diagnosis and treatment for active disease can reduce maternal and neonatal morbidities and mortality. The more widespread utilization of newer rapid molecular assays with drug-susceptibility testing has significantly shortened the diagnostic process for active TB disease. First-line anti-TB drugs are proven to be safe in pregnancy. Management of latent TB infection (LTBI) during pregnancy is controversial, but puerperium is a period of increased susceptibility to progress to active disease. Extrapulmonary TB (EPTB), multidrug-resistant TB (MDR-TB) and HIV co-infection remain significant issues surrounding TB management during pregnancy and often require input from a multidisciplinary team including TB experts.
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Affiliation(s)
- Shuk Yi Annie Hui
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Terence T Lao
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Hong Kong SAR, China
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Pastick KA, Kagimu E, Dobbin J, Ssebambulidde K, Gakuru J, Milln J, Nakabuye B, Meya DB, Boulware DR, Cresswell FV, Bahr NC. Pregnancy-Related Tuberculous Meningitis and Immune Reconstitution Inflammatory Syndrome: A Case Series and Systematic Review. Open Forum Infect Dis 2022; 9:ofac513. [PMID: 36267255 PMCID: PMC9578166 DOI: 10.1093/ofid/ofac513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 10/03/2022] [Indexed: 11/27/2022] Open
Abstract
Background Tuberculosis is a leading cause of death among women of reproductive age. However, tuberculous meningitis, the most severe form of extrapulmonary tuberculosis, is rarely discussed in pregnancy despite this being a unique period of immune modulation that may predispose women to active disease. Methods We identified and described cases of tuberculous meningitis among pregnant or postpartum women screened during meningitis clinical trials in Uganda from 2018 to 2022. We conducted a systematic literature review via PubMed/Medline and Embase for all English-language publications from 1970 to 10 July 2022, to identify additional cases. Results We identified 8 cases of pregnancy-related tuberculous meningitis in Ugandan women living with human immunodeficiency virus (HIV) and 40 additional cases via systematic literature review (none HIV-positive). Of all combined cases, 50% (24/48) were diagnosed postpartum; 50% (24/48) had initial onset during pregnancy, of which 38% (9/24) had worsening of symptoms or disease relapse following pregnancy cessation. Diagnosis was missed or delayed in 33% (16/48) of cases. For those with known outcomes, maternal mortality was 23% (11/48) and fetal/neonatal mortality was 30% (13/44). Of maternal survivors, 30% (11/37) had residual neurologic deficits. Conclusions The true incidence of tuberculous meningitis in pregnancy or the postpartum period is unclear but likely underappreciated. To date, nearly all published cases have occurred in HIV-negative or otherwise immunocompetent women. Given the well-described physiological immunosuppression during pregnancy and subsequent reconstitution postpartum, physicians must be aware of tuberculous meningitis and pregnancy-related immune reconstitution inflammatory syndrome, especially in countries with a high burden of tuberculosis and in women living with HIV.
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Affiliation(s)
- Katelyn A Pastick
- Correspondence: Katelyn A. Pastick, MD, Massachusetts General Hospital, Department of Medicine, 55 Fruit St, Boston, MA 02114 ()
| | - Enock Kagimu
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Joanna Dobbin
- Primary Care and Population Health, University College London, London, United Kingdom
| | | | - Jane Gakuru
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Jack Milln
- Department of Obstetric Medicine, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Betty Nakabuye
- Department of Obstetrics and Gynecology, Uganda Martyrs Hospital Lubaga, Kampala, Uganda
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - David R Boulware
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Fiona V Cresswell
- Medical Research Council/Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
- Global Health and Infection, Brighton and Sussex Medical School, Brighton, United Kingdom
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Abstract
Mycobacterium tuberculosis, the causative agent of tuberculosis (TB), continues to pose a major public health problem and is the leading cause of mortality in people infected with human immunodeficiency virus (HIV). HIV infection greatly increases the risk of developing TB even before CD4+ T-cell counts decrease. Co-infection provides reciprocal advantages to both pathogens and leads to acceleration of both diseases. In HIV-coinfected persons, the diagnosis and treatment of tuberculosis are particularly challenging. Intensifying integration of HIV and tuberculosis control programmes has an impact on reducing diagnostic delays, increasing early case detection, providing prompt treatment onset, and ultimately reducing transmission. In this Review, we describe our current understanding of how these two pathogens interact with each other, new sensitive rapid assays for TB, several new prevention methods, new drugs and regimens.
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Affiliation(s)
- Qiaoli Yang
- Department of Infectious Diseases, Changzhi Medical College, Changzhi, Shanxi Province, China
| | - Jinjin Han
- Department of Infectious Diseases, Changzhi Medical College, Changzhi, Shanxi Province, China
| | - Jingjing Shen
- Department of Infectious Diseases, Changzhi people’s Hospital, Changzhi, Shanxi Province, China
| | - Xinsen Peng
- Department of Cardiology, Changzhi Medical College, Changzhi, Shanxi Province, China
| | - Lurong Zhou
- Department of Infectious Diseases, Changzhi Medical College, Changzhi, Shanxi Province, China
- *Correspondence: Lurong Zhou, Vice President, Chief Physician, Professor, Department of Infectious Diseases, Changzhi People’s Hospital, No.502 Changzhi Middle Road, Changzhi 046000, Shanxi Province, China. (e-mail: )
| | - Xuejing Yin
- Department of Neurology, Changzhi Medical College, Changzhi, Shanxi Province, China
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Zhou X, Fang G, Xie Y, Wei A, Huang F. Safety Evaluation of Antituberculosis Drugs During Pregnancy: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:871321. [PMID: 35449551 PMCID: PMC9018108 DOI: 10.3389/fsurg.2022.871321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 02/28/2022] [Indexed: 11/25/2022] Open
Abstract
Background Pregnant women are a common group of people with tuberculosis,especially in patients infected with HIV at the same time. Antituberculosis drug prophylaxis is effective in reducing tuberculosis infection in pregnant women and fetuses after pregnancy, but its safety is still worthy of in-depth discussion. In this study, we conducted a systematic review and meta-analysis of reports on the use of antituberculosis drugs during pregnancy in recent years to provide evidence for clinical diagnosis and treatment. Methods The PubMed, Embase, Web of Science databases, Ovid, and clinicaltrials.gov were searched. Search for clinical randomized controlled studies and cohort studies on the use of antituberculosis drugs during pregnancy published in the databases from January 2000 to September 2021 was performed using the Stata 16.0 software after screening qualified bodies of literature. Results On the basis of the initial search of 408 articles, this study included a total of 8 articles and 2,563 patients after screening; meta-analysis results showed that preventive treatment with antituberculosis drugs did not increase the incidence of serious maternal adverse events [RR = 0.99, 95% CI (.88, 1.12), Z = −0.108, P = 0.914], did not increase drug hepatotoxicity [RR = 1.13, 95% CI (.9, 1.43), Z = 1.071, P = 0.284], did not increase the incidence of peripheral nerve disease [RR = 1.52, 95% CI (.85, 2.71), Z = 1.412, P = 0.158], did not increase maternal mortality [RR = 0.67, 95% CI (.27, 1.7), Z = −0.84, P = 0.401], and could significantly reduce adverse pregnancy outcomes [RR = 0.78, 95% CI (0.68, 0.89), Z = −3.581, P < 0.0001]. Discussion The use of antituberculosis drugs for preventive treatment during pregnancy is safe and can obtain better pregnancy outcomes.
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Affiliation(s)
- Xiaomei Zhou
- Department of Pharmacy, Hangzhou Women's Hospital, Hangzhou, China
| | - Guoying Fang
- Department of Pharmacy, Hangzhou Women's Hospital, Hangzhou, China
| | - Yaqing Xie
- Department of Pharmacy, Hangzhou Women's Hospital, Hangzhou, China
| | - Anqi Wei
- Department of Pharmacy, Hangzhou Women's Hospital, Hangzhou, China
| | - Feixiang Huang
- Department of Traditional Chinese Medicine (TCM) Gynecology, Hangzhou Women's Hospital, Hangzhou, China
- *Correspondence: Feixiang Huang
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Kaplan SR, Escudero JN, Mecha J, Richardson BA, Maleche-Obimbo E, Matemo D, Kinuthia J, John-Stewart GC, LaCourse SM. Interferon Gamma Release Assay and Tuberculin Skin Test Performance in Pregnant Women Living With and Without HIV. J Acquir Immune Defic Syndr 2022; 89:98-107. [PMID: 34629414 PMCID: PMC8665065 DOI: 10.1097/qai.0000000000002827] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND HIV and pregnancy may affect latent TB infection (LTBI) diagnostics. Tuberculin skin test (TST) and newer generation QuantiFERON-TB Gold Plus (QFT-Plus) evaluations in pregnant women living with HIV (WLHIV) and without HIV are lacking. METHODS In this cross-sectional study, pregnant women underwent TST and QFT-Plus testing during antenatal care in Kenya. We estimated LTBI prevalence and TST and QFT-Plus performances. Diagnostic agreement was assessed with kappa statistic, participant characteristics associated with LTBI and HIV were assessed with generalized linear models, and QFT-Plus quantitative responses were assessed with Mann-Whitney U test. RESULTS We enrolled 400 pregnant women (200 WLHIV/200 HIV-negative women) at median 28 weeks gestation (interquartile range 24-30). Among WLHIV (all on antiretroviral therapy), the median CD4 count was 464 cells/mm3 (interquartile range 325-654); 62.5% (125) had received isoniazid preventive therapy. LTBI prevalence was 35.8% and similar among WLHIV and HIV-negative women. QFT-Plus testing identified 3-fold more women with LTBI when compared with TST (32% vs. 12%, P < 0.0001). QFT-Plus positivity prevalence was similar regardless of HIV status, although TB-specific antigen responses were lower in WLHIV than in HIV-negative women with LTBI (median QFT-TB1 1.05 vs. 2.65 IU/mL, P = 0.035; QFT-TB2 1.26 vs. 2.56 IU/mL, P = 0.027). TST positivity was more frequent among WLHIV than among HIV-negative women (18.5% vs 4.6%; P < 0.0001). CONCLUSIONS QFT-Plus assay had higher diagnostic yield than TST for LTBI in WLHIV and HIV-negative women despite lower TB-specific antigen responses in WLHIV. Higher TST positivity was observed in WLHIV. LTBI diagnostic performance in the context of pregnancy and HIV has implications for clinical use and prevention studies, which rely on these diagnostics for TB infection entry criteria or outcomes.
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Affiliation(s)
| | | | - Jerphason Mecha
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Elizabeth Maleche-Obimbo
- Department of Global Health, University of Washington, Seattle, WA
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, WA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
- Department of Epidemiology, University of Washington, Seattle, WA; and
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Sylvia M LaCourse
- Department of Global Health, University of Washington, Seattle, WA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
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Bhosale R, Alexander M, Deshpande P, Kulkarni V, Gupte N, Gupta A, Mathad J. Stages of pregnancy and HIV affect diagnosis of tuberculosis infection and Mycobacterium tuberculosis (MTB)-induced immune response: Findings from PRACHITi, a cohort study in Pune, India. Int J Infect Dis 2021; 112:205-211. [PMID: 34517050 PMCID: PMC8715310 DOI: 10.1016/j.ijid.2021.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/21/2021] [Accepted: 09/06/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Accurate tuberculosis infection (TBI) tests are critical for pregnant women, especially those with HIV, who have a high risk of TB disease. METHODS We enrolled interferon gamma release assay (IGRA)+ pregnant women with and without HIV in a longitudinal study, followed up at delivery and 6 months postpartum. Tuberculin skin test (TST) and IGRA were compared by HIV status at each timepoint. RESULTS Of 165 enrolled IGRA+ pregnant women: 35 (21%) had HIV and were on antiretroviral therapy with median CD4 of 476 (IQR 399-586). Compared to antepartum, significantly fewer women remained IGRA+ at delivery [HIV+ n=21/35 (62%, p=0.009); HIV- n=100/130 (77%, p=0.002)] and postpartum [HIV+ n=30/35 (87%, p=0.03); HIV- n=116/130 (89%, p=0.01)]. IGRA/TST discordance was high in pregnant women (HIV+: 51%; HIV-: 25%). Median IFN-γ was lowest for all women at delivery; significantly lower in women with HIV at all timepoints compared to women without HIV. TB incidence was 50/ 1000 person-years and 18/1000 person-years among women with and without HIV respectively. CONCLUSIONS Pregnancy affects TBI test results and reduces IFN-γ response to M. tuberculosis stimulation. Despite adequate CD4 counts, women with HIV express less IFN-γ than women without HIV, which may explain the high TB incidence in postpartum women with HIV.
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Affiliation(s)
- Ramesh Bhosale
- Byramjee Jeejeebhoy Government Medical College, Jai Prakash Narayan Rd. Pune, 411001, Maharashtra, India
| | - Mallika Alexander
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Trials Unit, 1st Floor, ENT department, Jai Prakash Narayan Rd. Pune, 411001, Maharashtra, India.
| | - Prasad Deshpande
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Trials Unit, 1st Floor, ENT department, Jai Prakash Narayan Rd. Pune, 411001, Maharashtra, India
| | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Trials Unit, 1st Floor, ENT department, Jai Prakash Narayan Rd. Pune, 411001, Maharashtra, India
| | - Nikhil Gupte
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Trials Unit, 1st Floor, ENT department, Jai Prakash Narayan Rd. Pune, 411001, Maharashtra, India; Johns Hopkins School of Medicine, 600 N. Wolfe Street, Phipps 540, Baltimore, MD 1287, USA
| | - Amita Gupta
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Trials Unit, 1st Floor, ENT department, Jai Prakash Narayan Rd. Pune, 411001, Maharashtra, India; Johns Hopkins School of Medicine, 600 N. Wolfe Street, Phipps 540, Baltimore, MD 1287, USA
| | - Jyoti Mathad
- Byramjee Jeejeebhoy Government Medical College- Johns Hopkins University Clinical Trials Unit, 1st Floor, ENT department, Jai Prakash Narayan Rd. Pune, 411001, Maharashtra, India; Weill Cornell Medical College, 402 E. 67th Street, 2nd floor, New York, NY 10065, USA
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Montepiedra G, Kim S, Weinberg A, Theron G, Sterling TR, LaCourse SM, Bradford S, Chakhtoura N, Jean-Philippe P, Evans S, Gupta A. Using a Composite Maternal-Infant Outcome Measure in Tuberculosis-Prevention Studies Among Pregnant Women. Clin Infect Dis 2021; 73:e587-e593. [PMID: 33146706 DOI: 10.1093/cid/ciaa1674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 10/28/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tuberculosis (TB-)-preventive therapy (TPT) among pregnant women reduces risk of TB in mothers and infants, but timing of initiation should consider potential adverse effects. We propose an analytical approach to evaluate the risk-benefit of interventions. METHODS A novel outcome measure that prioritizes maternal and infant events was developed with a 2-stage Delphi survey, where a panel of stakeholders assigned scores from 0 (best) to 100 (worst) based on perceived desirability. Using data from TB APPRISE, a trial among pregnant women living with human immunodeficiency virus (WLWH) that randomized the timing of initiation of isoniazid, antepartum versus postpartum, was evaluated. RESULTS The composite outcome scoring/ranking system categorized mother-infant paired outcomes into 8 groups assigned identical median scores by stakeholders. Maternal/infant TB and nonsevere adverse pregnancy outcomes were assigned similar scores. Mean (SD) composite outcome scores were 43.7 (33.0) and 41.2 (33.7) in the antepartum and postpartum TPT initiation arms, respectively. However, a modifying effect of baseline antiretroviral regimen was detected (P = .049). When women received nevirapine, composite scores were higher (worse outcomes) in the antepartum versus postpartum arms (adjusted difference, 14.3; 95% confidence interval [CI], 2.4-26.2; P = .02), whereas when women received efavirenz there was no difference by timing of TPT (adjusted difference, .62; 95% CI, -3.2-6.2; P = .53). CONCLUSIONS For TPT, when used by otherwise healthy persons, preventing adverse events is paramount from the perspective of stakeholders. Among pregnant WLWH in high-TB-burden regions, it is important to consider the antepartum antiretroviral regimen taken when deciding when to initiate TPT. Clinical Trials Registration. NCT01494038 (IMPAACT P1078).
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Affiliation(s)
- Grace Montepiedra
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Soyeon Kim
- Frontier Science Foundation, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | - Scott Evans
- The George Washington University, Washington, DC, USA
| | - Amita Gupta
- Johns Hopkins University, Baltimore, Maryland, USA
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