Association between tuberculosis and pregnancy outcomes: a retrospective cohort study of women in Cape Town, South Africa

BACKGROUND

Tuberculosis (TB) remains a leading cause of mortality among women of childbearing age and a significant contributor to maternal mortality. Pregnant women with TB are at high risk of adverse pregnancy outcomes. This study aimed to determine risk factors for an adverse pregnancy outcome among pregnant women diagnosed with TB.

METHODS

Using TB programmatic data, this retrospective cohort analysis included all women who were routinely diagnosed with TB in the public sector between October 2018 and March 2020 in two health subdistricts of Cape Town, and who were documented to be pregnant during their TB episode. Adverse pregnancy outcome was defined as either a live birth of an infant weighing <2500 g and/or with a gestation period <37 weeks or as stillbirth, miscarriage, termination of pregnancy, maternal or early neonatal death. Demographics, TB and pregnancy characteristics were described by HIV status. Logistic regression was used to determine risk factors for adverse pregnancy outcome.

RESULTS

Of 248 pregnant women, half (52%) were living with HIV; all were on antiretroviral therapy at the time of their TB diagnosis. Pregnancy outcomes were documented in 215 (87%) women, of whom 74 (34%) had an adverse pregnancy outcome. Being older (35-44 years vs 25-34 years (adjusted OR (aOR): 3.99; 95% CI: 1.37 to 11.57), living with HIV (aOR: 2.72; 95% CI: 0.99 to 4.63), having an unfavourable TB outcome (aOR: 2.29; 95% CI: 1.03 to 5.08) and having presented to antenatal services ≤1 month prior to delivery (aOR: 10.57; 95% CI: 4.01 to 27.89) were associated with higher odds of an adverse pregnancy outcome.

CONCLUSIONS

Pregnancy outcomes among women with TB were poor, irrespective of HIV status. Pregnant women with TB are a complex population who need additional support prior to, during and after TB treatment to improve TB treatment and pregnancy outcomes. Pregnancy status should be considered for inclusion in TB registries.

Tuberculin test versus interferon gamma release assay in pregnant women with household contacts of tuberculosis patients

Background

Pregnant women who live in tuberculosis (TB)-affected households are more likely to develop latent TB infection (LTBI), which often escapes treatment. This study aims to determine if Interferon-gamma release (IGRA) is reliable in screening for LTBI in pregnant women, compare to the tuberculin skin test (TST).

Methods

It was a cross-sectional study that involved 60 pregnant women with TB contact history as a proxy for LTBI and 30 pregnant women without contact history. Latent TB was detected using the TST 5 tuberculin units and IGRA using the QuantiFERON Gold Plus TB Test kit (QFT-Plus). The sensitivity and specificity of the two diagnostic methods and the agreement between them were estimated using SPSS version 20.0.

Results

The sensitivity 95% (95% confidence interval [CI]: 86.08%-98.96%) and specificity 26.7% (95% CI: 12.28%-45.89%) of TST were compared to that of the IGRA with 60% (95% CI: 46.54%-72.44%) and 73.3% (95% CI: 54.11%-87.72%) sensitivity and specificity, respectively in detecting LTBI in pregnancy. Although there was a significant difference (P < 0.05) between TST and IGRA, the agreement was fair (kappa 0.39; 95% CI: 0.24-0.45).

Conclusion

TST assay is more sensitive than IGRA; however, the specificity of IGRA was superior to the TST method. In this study, a fair agreement of TST and IGRA was observed for detecting latent TB infection in pregnant women with household contact with TB patients.

What are the essential components of antenatal care? A systematic review of the literature and development of signal functions to guide monitoring and evaluation

BACKGROUND

Antenatal care (ANC) is one of the key care packages required to reduce global maternal and perinatal mortality and morbidity.

OBJECTIVES

To identify the essential components of ANC and develop signal functions.

SEARCH STRATEGY

MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed and Web of Science.

SELECTION CRITERIA

Papers and reports on content of ANC published from 2000 to 2020.

DATA COLLECTION AND ANALYSIS

Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

MAIN RESULTS

A total of 221 papers and reports are included from which 28 essential components of ANC were extracted and used to develop 15 signal functions with the equipment, medication and consumables required for implementation of each. Signal functions for the prevention and management of infectious diseases (malaria, HIV, tuberculosis, syphilis and tetanus) can be applied depending on population disease burden. Screening and management of pre-eclampsia, gestational diabetes, anaemia, mental and social health (including intimate partner violence) are recommended universally. Three signal functions address monitoring of fetal growth and wellbeing, and identification and management of obstetric complications. Promotion of health and wellbeing via education and support for nutrition, cessation of substance abuse, uptake of family planning, recognition of danger signs and birth preparedness are included as essential components of ANC.

CONCLUSIONS

New signal functions have been developed which can be used for monitoring and evaluation of content and quality of ANC. Country adaptation and validation is recommended.

Prevalence, acceptability, and cost of routine screening for pulmonary tuberculosis among pregnant women in Cotonou, Benin

OBJECTIVES

We sought to evaluate the yield, cost, feasibility, and acceptability of routine tuberculosis (TB) screening of pregnant women in Cotonou, Benin.

DESIGN

Mixed-methods, cross-sectional study with a cost assessment.

SETTING

Eight participating health facilities in Cotonou, Benin.

PARTICIPANTS

Consecutive pregnant women presenting for antenatal care at any participating site who were not in labor or currently being treated for TB from April 2017 to April 2018.

INTERVENTIONS

Screening for the presence of TB symptoms by midwives and Xpert MTB/RIF for those with cough for at least two weeks. Semi-structured interviews with 14 midwives and 16 pregnant women about experiences with TB screening.

PRIMARY AND SECONDARY OUTCOME MEASURES

Proportion of pregnant women with cough of at least two weeks and/or microbiologically confirmed TB. The cost per pregnant woman screened and per TB case diagnosed in 2019 USD from the health system perspective.

RESULTS

Out of 4,070 pregnant women enrolled in the study, 94 (2.3%) had a cough for at least two weeks at the time of screening. The average (standard deviation) age of symptomatic women was 26 ± 5 years and 5 (5.3%) had HIV. Among the 94 symptomatic women, 2 (2.3%) had microbiologically confirmed TB for a TB prevalence of 49 per 100,000 (95% CI: 6 to 177 per 100,000) among pregnant women enrolled in the study. The average cost to screen one pregnant woman for TB was $1.12 USD and the cost per TB case diagnosed was $2271 USD. Thematic analysis suggested knowledge of TB complications in pregnancy was low, but that routine TB screening was acceptable to both midwives and pregnant women.

CONCLUSION

Enhanced screening for TB among pregnant women is feasible, acceptable, and inexpensive per woman screened, however in this setting has suboptimal yield even if it can contribute to enhance TB case finding.

HIV, placental pathology and birth outcomes - a brief overview

The spectrum of placental pathology in human immunodeficiency virus (HIV) is vast. Features observed are not only limited to the effects of the virus itself but may include that of coinfections such as tuberculosis and syphilis. The presence of other comorbidities and changes as a result of antiretroviral therapy may further confound the histologic findings. There is a paucity of unbiased information of the effects of maternal HIV on the placenta and how these changes relate to birth outcomes. Antiretroviral therapy, now in widespread use, has altered the course of maternal HIV disease and it is unknown whether this has altered the pathophysiology of HIV on the placenta. HIV-associated placental findings that have been most well described include acute chorioamnionitis, low placental weight and maternal vascular malperfusion, with a tendency towards lower rates of chronic villitis.

Maternal and Infant Outcomes Among Pregnant Women Treated for Multidrug/Rifampicin-Resistant Tuberculosis in South Africa

Background

Data on safety and efficacy of second-line tuberculosis drugs in pregnant women and their infants are severely limited due to exclusion from clinical trials and expanded access programs.

Methods

Pregnant women starting treatment for multidrug/rifampicin-resistant (MDR/RR)-tuberculosis at King Dinuzulu Hospital in KwaZulu-Natal, South Africa, from 1 January 2013 to 31 December 2017, were included. We conducted a record review to describe maternal treatment and pregnancy outcomes, and a clinical assessment to describe infant outcomes.

Results

Of 108 pregnant women treated for MDR/RR-tuberculosis, 88 (81%) were living with human immunodeficiency virus.. Favorable MDR/RR-tuberculosis treatment outcomes were reported in 72 (67%) women. Ninety-nine (91%) of the 109 babies were born alive, but overall, 52 (48%) women had unfavorable pregnancy outcomes. Fifty-eight (54%) women received bedaquiline, and 49 (45%) babies were exposed to bedaquiline in utero. Low birth weight was reported in more babies exposed to bedaquiline compared to babies not exposed (45% vs 26%; P = .034). In multivariate analyses, bedaquiline and levofloxacin, drugs often used in combination, were both independently associated with increased risk of low birth weight. Of the 86 children evaluated at 12 months, 72 (84%) had favorable outcomes; 88% of babies exposed to bedaquiline were thriving and developing normally compared to 82% of the babies not exposed.

Conclusions

MDR/RR-tuberculosis treatment outcomes among pregnant women were comparable to nonpregnant women. Although more babies exposed to bedaquiline were of low birth weight, over 80% had gained weight and were developing normally at 1 year.

Tuberculosis (TB) in pregnancy - A review

Tuberculosis (TB) is a common infectious pathology especially in low-income countries, which may complicate pregnancy. Although pulmonary TB is more common in pregnancy than extra pulmonary TB (EPTB), EPTB is becoming more common especially in those living with human deficiency virus (HIV) co infection or have other comorbidities. The diagnosis of TB may be delayed in pregnancy due to the masking of its symptoms by those of pregnancy. If diagnosed and treated on time both pulmonary TB and EPTB are associated with excellent maternal and perinatal outcome. If, however, there is delay in diagnosis and treatment then there could be adverse maternal and fetal consequences like preterm labour, fetal growth restriction and even stillbirths. Similarly severe forms of TB like disseminated disease (miliary TB) or multi drug resistant TB (MDR TB) are associated with poor outcome. Diagnosis and management is same as in non-pregnant patients. Both drug sensitive pulmonary TB and EPTB are treated with four drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) orally daily for 2 months followed by three drugs (isoniazid, rifampicin and ethambutol) orally daily for 4 months. Drug resistant TB is treated with second line drugs with caution, as some of these drugs are teratogenic. Optimum antenatal care and nutrition therapy along with anti-tuberculosis drugs provide for optimum maternal and perinatal outcome. This review discusses maternal and perinatal outcomes, diagnosis and management of pulmonary TB and extrapulmonary TB as well as perinatal tuberculosis.

Clinical Pharmacokinetics and Pharmacodynamics of Anti-Tubercular Drugs in Pregnancy

The objectives of this qualitative review were to critically evaluate and summarize the currently available data on the use of anti-tuberculosis (TB) drugs during pregnancy, with a focus on treatment outcomes, safety, and pharmacokinetics. This qualitative, narrative review was based on literature searches in Medline, Pubmed, Embase, and Google Scholar (from their inception to 13 August 2020). Our search identified 22 papers related to treatment outcomes and 14 papers related to pharmacokinetic exposures and fetal distributions. While it is challenging to study this patient population, current evidence supports treatment of drug-susceptible TB, multidrug-resistant TB and latent TB infections. However, decisions regarding initiating, continuing, or discontinuing anti-tubercular medications while pregnant should be individualized and discussed with a specialist. Similarly, the pharmacokinetic data of anti-TB agents were mainly derived from small scale, observational studies many of which lacked high quality controls. Based on these data, it does not appear that pregnancy has an extensive impact on the pharmacokinetics of the majority of first-line and second-line agents, although caution (discussed in the review) should be exercised in data interpretation. Fetal drug exposure can also be significant and should be considered when selecting an anti-TB agent for longer term treatment. Overall, it is generally difficult to predict pregnancy-associated pharmacokinetic changes based only on drug's physiochemical characteristics.

Tuberculosis in pregnant women and neonates: A meta-review of current evidence

Pregnant women and their infants are a vulnerable but neglected population in tuberculosis (TB) control efforts. Recent advances in TB prevention, diagnosis and treatment have implications for their care, despite their frequent exclusion from research. We have conducted a meta-review of current evidence and clinical guidelines for TB prevention, diagnosis and management in pregnant women and neonates, focusing on review articles published since 2010. The actual burden of TB in pregnancy is unmeasured, but has been estimated at 216,500 cases per year. Although the effect of pregnancy on TB risk is uncertain and controversial, two large whole-of-population studies found that pregnancy was associated with a two- to three-fold increase in risk of TB. Congenital TB is rare but extremely serious. Neonates exposed to TB after delivery will be at high risk of disease, and preventive therapy is recommended once disease has been ruled out. At present, there is limited evidence regarding the performance of different screening strategies for pregnant women, appropriate drug dosing for either pregnant women or neonates, and the safety of most second-line drugs in pregnancy. High quality evidence on these topics is needed, as are detailed guidelines to inform efforts by TB control programs and clinicians working with pregnant women and their infants.

Contribution of Xpert® MTB/RIF to tuberculosis case finding among pregnant women in Botswana

Setting

Seven health facilities with antenatal care (ANC) clinics in two districts near Gaborone, Botswana.

Objectives

To determine 1) the prevalence of tuberculosis (TB) and HIV-TB co-infection in pregnancy, and 2) the sensitivities of symptomatic TB screening and Xpert testing against gold standard culture.

Design

This was a cross-sectional study. Pregnant women were randomly enrolled and screened using TB symptoms. HIV status was determined from ANC clinics' client records. Two sputum specimens were collected from all clients and each was tested using Xpert^® and culture for Mycobacterium tuberculosis.

Results

Of 407 cases, eight had one or more TB symptoms, and all tested negative with Xpert^® and culture. Another two (0.5%, 95%CI 0.08-1.96) asymptomatic clients tested positive with both tests. The adjusted TB prevalence was higher than that of the general population (0.6% vs. 0.24%; P < 0.001). The prevalence of TB among HIV-positive and HIV-negative clients was 1/69 (1.45%, 95%CI 0.29-2.61) and 1/336 (0.3%, 95%CI 0.23-0.83), respectively (Fisher's exact test P = 0.312). Xpert^® demonstrated a 100% sensitivity and 100% specificity, while symptom screening had 0.0% sensitivity and 98% specificity.

Conclusions

TB prevalence among pregnant women was high and TB symptom screening had limited ability to detect TB. An alternative TB screening algorithm for pregnant women is urgently needed irrespective of TB symptoms.

Pregnancy and the global disease burden

Pregnant women experience unique physiological changes pertinent to the effective prevention and treatment of common diseases that affect their health and the health of their developing fetuses. In this paper, the impact of major communicable (HIV/AIDS, tuberculosis, malaria, helminth infections, emerging epidemic viral infections) as well as non-communicable conditions (mental illness, substance abuse, gestational diabetes, eclampsia) on pregnancy is discussed. The current state of research involving pregnant women in these areas is also described, highlighting important knowledge gaps for the management of key illnesses that impact pregnancy globally.

Characteristics of infants exposed to maternal tuberculosis and chemoprophylaxis using 3 months of isoniazid and rifampicin

BACKGROUND

Although the clinical features of infants with congenital tuberculosis (TB) are well established, the features of infants exposed to TB in utero including those who are non-infected, are not well reported. TB-exposed infants are at risk of developing TB post-delivery, and chemoprophylaxis, usually isoniazid, is therefore recommended. Isoniazid/rifampicin combined is an alternative, but little is known about its effectiveness.

OBJECTIVE

To determine the clinical features of infants exposed to TB in utero and the proportion who develop TB infection and disease despite chemoprophylaxis with a 3-month course of isoniazid/rifampicin.

METHODS

This was a retrospective review of TB-infected women and their infants between 2007 and 2010. Features of mothers and infants at delivery, and follow-up of infants after completion of isoniazid/rifampicin are described.

RESULTS

Eighty-eight infants born to 86 TB-infected women were studied. TB diagnosis was made peri-partum in 24.4% of women, and only 46.2% of those diagnosed ante-partum were on anti-TB treatment for >2 months. Human immunodeficiency virus (HIV) was positive in 97.7% of the TB-infected women and in 74.6% the CD4 count was <200 cells/mm³. Fifty-six (63.6%) infants had a low birthweight (LBW) and 45 (51.2%) were preterm. Mycobacterial culture was positive in four (4.5%) infants (three were also smear-positive) and none was diagnosed with TB on clinical or radiological findings only. At 3-month follow-up, 17 (20.2%) defaulted, and, of 67 who returned, seven (10%) did not return for tuberculin test reading, but one of 60 (1.7%) tested positive. Five infants (7.2%) were HIV PCR-positive at 6 weeks and four of their mothers were on HAART.

CONCLUSION

The majority of TB-exposed infants were born to mothers with TB/HIV co-infection, and a high proportion were pre-term and of low birthweight. Although the high attrition rate made it difficult to assess the effectiveness of chemoprophylaxis with isoniazid/rifampicin, only one of the 60 infants who completed follow-up to 3 months was found to have tuberculous infection.

Maternal and perinatal mortality and morbidity associated with tuberculosis during pregnancy and the postpartum period: a systematic review and meta-analysis

BACKGROUND

There is a dearth of data on the clinical features and outcomes of active tuberculosis (TB) in pregnancy. Studies have shown varied results and the relationship between TB and adverse pregnancy outcomes remains unclear.

OBJECTIVES

We conducted a systematic review and meta-analysis to evaluate pregnancy outcomes associated with TB.

SEARCH STRATEGY

Major databases were searched from inception until December 2015 without restrictions using the terms: 'TB', 'pregnancy', 'maternal morbidity', 'mortality' and 'perinatal morbidity', 'mortality'.

SELECTION CRITERIA

We included studies that compared the outcomes of pregnant women with and without active TB.

DATA COLLECTION AND ANALYSIS

We computed odds ratios for maternal and perinatal complications, and pooled them using a random effects model. We assessed for heterogeneity using chi-squared tests and evaluated its magnitude using the I2 statistic. We used the Newcastle-Ottawa scale for quality assessment.

MAIN RESULTS

Thirteen studies, including 3384 pregnancies with active TB and 119 448 without TB were included. Compared with pregnant women without TB, pregnant women with active TB was associated with increased odds of maternal morbidity [odds ratio (OR) 2.8, 95% CI 1.7-4.6; I2  = 60.3%], anaemia (OR 3.9, 95% CI 2.2-6.7; I2  = 29.8%), caesarean delivery (OR 2.1, 95% CI 1.2-3.8; I2  = 61.1%), preterm birth (OR 1.7, 95% CI 1.2-2.4; I2  = 66.5%), low birth weight (OR 1.7, 95% CI 1.2-2.4; I2  = 53.7%), birth asphyxia (OR 4.6, 95% CI 2.4-8.6; I2  = 46.3), and perinatal death (OR 4.2, 95% CI 1.5-11.8; I2  = 57.2%).

AUTHOR'S CONCLUSION

Active TB in pregnancy is associated with adverse maternal and fetal outcomes. Early diagnosis of TB is important to prevent significant maternal and perinatal complications.

TWEETABLE ABSTRACT

Active tuberculosis in pregnancy is associated with adverse maternal and perinatal outcomes.

TB-HIV co-infection among pregnant women in Karnataka, South India: A case series

Tuberculosis (TB) is a significant contributor to mortality in HIV-infected patients. Concurrent TB infection is also a significant contributing factor to maternal mortality in human immunodeficiency virus (HIV)-infected pregnant women. Studies addressing the outcomes of TB and HIV co-infection among pregnant women are generally infrequent. Although limited, the records maintained by the Revised National Tuberculosis Control Programme (RNTCP) and the National AIDS Control Programme (NACP) in Karnataka State, Southern India provide information about the numbers of pregnant women who are co-infected with TB and HIV and their pregnancy outcomes. We reviewed the data and conducted this study to understand how TB-HIV co-infection influences the outcomes of pregnancy in this setting. We sought to determine the incidence and treatment and delivery outcomes of TB-HIV co-infected pregnant women in programmatic settings in Karnataka State in southern India. The study participants were all the HIV-infected pregnant women who were screened for tuberculosis under the NACP from 2008 to 2012. For the purposes of this study, the program staff in the field gathered the data regarding on treatment and delivery outcomes of pregnant women. A total of seventeen pregnant women with TB-HIV co-infection were identified among 3,165,729 pregnant women (for an incidence of 5.4 per million pregnancies). The median age of these pregnant women was 24 years, and majority were primiparous women with WHO HIV stage III disease and were on a stavudine-based ART regimen. The maternal mortality rates were 18% before delivery and 24% after delivery. The abortion rate was 24%, and the neonatal mortality rate was 10%. The anti-tuberculosis treatment and anti-retroviral treatment outcome mortality rates were 30% and 53%, respectively. Although the incidence of TB among the HIV-infected pregnant women was marginally less than that among the non-HIV-infected women, the delivery outcomes were relatively poorer. The current strategy for the management of TB among the HIV-positive pregnant women needs urgent review.

Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya

OBJECTIVES

1) To explore the utility of tuberculosis (TB) symptom screening for symptoms of ≥2 weeks' duration in a routine setting, and 2) to compare differences in TB diagnosis between human immunodeficiency virus (HIV) infected and non-HIV-infected pregnant women in western Kenya.

DESIGN

Comparative cross-sectional study among pregnant women with known HIV status screened for TB from 2010 to 2012, in Eldoret, western Kenya.

RESULTS

Of 2983 participants, respectively 34 (1%), 1488 (50.5%) and 1461 (49.5%) had unknown, positive and negative HIV status. The median age was respectively 30 years (interquartile range [IQR] 26-35) and 26 years (IQR 24-31) in HIV-infected and non-infected participants. A positive symptom screen was found in respectively 8% (119/1488) and 5% (67/1461) of the HIV-infected and non-infected women. The median CD4 count at enrolment was 377 cells/μl (IQR 244-530) for HIV-infected women. One non-HIV-infected patient was sputum-positive. For HIV-infected women, TB was presumptively treated in 1% (16/1488) based on clinical symptoms and chest X-ray. Cumulatively, anti-tuberculosis treatment was offered to 0.6% (17/2949) of the participants.

CONCLUSION

This study does not seem to demonstrate the utility of TB symptom screening questionnaires in a routine setting among pregnant women, either HIV-infected or non-infected, in western Kenya.

Global Tuberculosis Control: Toward the 2015 Targets and Beyond

Since 1990, progress has been made toward global tuberculosis (TB) control, as measured by targets set for 2015. However, TB remains a major threat to health around the world. In 2013, there were an estimated 11 million prevalent cases, and an estimated 9.0 million incident cases occurred globally. Approximately 1.5 million deaths were caused by TB, including 360,000 among people living with HIV. Substantial challenges threaten future control efforts. These include multidrug-resistant forms and co-infection with HIV, as well as other factors, such as the increased prominence of noncommunicable diseases and adverse socioeconomic conditions. Beyond 2015, TB control must be seen as both a public health imperative unto itself and a vital component of economic development plans. To that end, control strategies should exploit technical and operational innovations to improve TB control and care and should promote universal health coverage and social protection mechanisms to expand access to essential prevention, diagnostics, and treatment services while avoiding catastrophic costs incurred by patients.

Preventing tuberculosis transmission at a maternity hospital by targeted screening radiography of migrants

BACKGROUND

Israel has been the destination of large numbers of illegal migrants from East African countries in recent years. Despite efforts to detect and treat active tuberculosis (TB) at the border, 75% of all active TB cases diagnosed in our hospital were illegal migrants. In 2012, there was a large-scale TB exposure in our maternity ward, neonatal, and paediatric intensive care units following the admission of an infectious but apparently asymptomatic migrant who was in labour. A hospital-wide screening programme was subsequently implemented to prevent exposure of patients and staff to TB.

AIM

To report the results of the first year of this intervention in the maternity hospital.

METHODS

All illegal migrants from countries where TB is highly prevalent were screened by chest radiography (CR) upon admission to the maternity hospital. The results were immediately categorized by a radiologist as either 'suggestive of active pulmonary TB' or 'non-suggestive'. Patients with CR suggestive of TB were placed in airborne isolation and underwent further evaluation.

FINDINGS

Four hundred and thirty-one apparently asymptomatic migrant women underwent CR screening. Most (363, 84%) presented in labour. Eleven women (2.6%) had a CR suggestive of active pulmonary TB which was confirmed in three (0.7% of screened women). No TB cases were missed by the CRs. Neither patients nor hospital staff were exposed to TB.

CONCLUSION

Targeted CR screening for TB among high-risk women upon their admission to a maternity hospital had a high yield and was an effective strategy to prevent in-hospital transmission of TB.

Preventing tuberculosis among HIV-infected pregnant women in Lesotho: the case for rolling out active case finding and isoniazid preventive therapy

BACKGROUND

The Lesotho Ministry of Health issued guidelines on active case finding (ACF) for tuberculosis (TB) and isoniazid preventive therapy (IPT) in April 2011. ACF has been recommended in maternal and child health (MCH) settings globally, however, the feasibility of implementing IPT within MCH in countries with high concurrent HIV and TB epidemics is unknown.

DESIGN/METHODS

The study evaluated the implementation of ACF and IPT guidelines in MCH settings in 2 health facilities in Lesotho. This descriptive prospective study analyzed data collected during routine services. Categorical data and continuous variables were summarized using descriptive statistics. The χ test or Wilcoxon rank-sum test was used to ascertain significant associations between categorical and continuous variables, respectively.

RESULTS

Data from 160 HIV-positive and 640 HIV-negative women were reviewed. Within this study population, 99.8% of women were screened for TB, and 11.4% HIV-positive women compared with 2.3% HIV-negative women were reported to have symptoms of TB (P < 0.001). IPT was initiated in 124/158 (78.5%) HIV-positive pregnant women, 64.5% women completed a 6-month IPT regimen, 2 (1.6%) died of causes unrelated to IPT/TB, and 31.5% were lost to follow-up. Predictors of IPT initiation among HIV-positive women included gestational age at the first antenatal visit (unadjusted odds ratio, -0.93; 95% confidence interval: -0.88 to 0.98), and receipt of antiretroviral therapy for treatment rather than for prevention of mother-to-child transmission prophylaxis only (odds ratio, 4.59; 95% confidence interval: 1.32 to 15.93).

CONCLUSIONS

Implementation of ACF and IPT is feasible within the MCH setting. Uptake of IPT during pregnancy among HIV-positive women was high, but with a high rate of loss to follow-up.

Tuberculosis care for pregnant women: a systematic review

Background

Tuberculosis (TB) during pregnancy may lead to severe consequences affecting both mother and child. Prenatal care could be a very good opportunity for TB care, especially for women who have limited access to health services. The aim of this review was to gather and evaluate studies on TB care for pregnant women.

Methods

We used a combination of the terms “tuberculosis” and “pregnancy”, limited to human, to search for published articles. Studies reflecting original data and focusing on TB care for pregnant women were included. All references retrieved were collected using the Reference Manager software (Version 11).

Results

Thirty five studies were selected for review and their data showed that diagnosis was often delayed because TB symptoms during pregnancy were not typical. TB prophylaxis and anti-TB therapy appeared to be safe and effective for pregnant women and their babies when suitable follow up and early initiation were present, but the compliance rate to TB prophylaxis is still low due to lack of follow up and referral services. TB care practices in the reviewed studies were in line in principle with the WHO International Standards for Tuberculosis Care (ISTC).

Conclusions

Integration of TB care within prenatal care would improve TB diagnosis and treatment for pregnant women. To improve the quality of TB care, it is necessary to develop national level guidelines based on the ISTC with detailed guidelines for pregnant women.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0617-x) contains supplementary material, which is available to authorized users.

Development, coinfection, and the syndemics of pregnancy in Sub-Saharan Africa

Notable among gaps in the achievement of the global health Millennium Development Goals (MDG) are shortcomings in addressing maternal health, an issue addressed in the fifth MDG. This shortfall is particularly acute in Sub-Saharan Africa (SSA), where over half of all maternal deaths occur each year. While there is not as yet a comprehensive understanding of the biological and social causes of maternal death in SSA, it is evident that poverty, gendered economic marginalization, social disruptions, hindered access to care, unevenness in the quality of care, illegal and clandestine abortions, and infections are all critical factors. Beyond these factors, this paper presents a review of the existing literature on maternal health in SSA to argue that syndemics constitute a significant additional source of maternal morbidity and mortality in the region. Increasing focus on the nature, prevention, and treatment of syndemics, as a result, should be part and parcel of improving maternal health in SSA.

Protective effect of pregnancy in rural South Africa: questioning the concept of "indirect cause" of maternal death

Background

Measurement of the level and composition of maternal mortality depends on the definition used, with inconsistencies leading to inflated rates and invalid comparisons across settings. This study investigates the differences in risk of death for women in their reproductive years during and outside the maternal risk period (pregnancy, delivery, puerperium), focusing on specific causes of infectious, non-communicable and external causes of death after separating out direct obstetrical causes.

Methods

Data on all deaths of women aged 15–49 years that occurred in the Agincourt sub-district between 1992 and 2010 were obtained from the Agincourt health and socio-demographic surveillance system (HDSS) located in rural South Africa. Causes of death were assessed using a validated verbal autopsy instrument. Analysis included 2170 deaths, of which 137 occurred during the maternal risk period.

Findings

Overall, women had significantly lower mortality during the maternal risk period than outside it (age-standardized RR = 0.75; 95% CI = 0.63–0.89). This was true in most age groups with the exception of adolescents aged 15–19 years where the risk of death was higher. Mortality from most causes, other than obstetric causes, was lower during the maternal risk period except for malaria, cardiovascular diseases and violence where there were no differences. Lower mortality was significant for HIV/AIDS (RR = 0.29, P<0.0001), cancers (RR = 0.10, P<0.023), and accidents (RR = 0, P<0.0001).

Interpretation

In this rural setting typical of much of Southern Africa, pregnancy was largely protective against the risk of death, most likely because of a strong selection effect amongst those women who conceived successfully. The concept of indirect cause of maternal death needs to be re-examined.

The anthropometric match between high school learners of the Cape Metropole area, Western Cape, South Africa and their computer workstation at school

STUDY DESIGN

Descriptive study.

OBJECTIVE

The objective of this study was to present anthropometric data from high school students in Cape Metropole area, Western Cape, South Africa that are relevant for chair design and whether the dimensions of computer laboratory chairs currently used in high schools match linear anthropometrics of high-school students. Summary of Background Data. Learner-chair mismatch is proposed as a cause of poor postural alignment and spinal pain in adolescents. A learner-chair mismatch is defined as the incompatibility between the dimensions of a chair and the anthropometric dimensions of the learner. Currently, there is no published research to ascertain whether the furniture dimensions in school computer laboratories match the anthropometrics of the students. This may contribute to the high prevalence of adolescent spinal pain.

METHODS

The sample consisted of 689 learners, 13-18 years old. The following body dimensions were measured: stature, popliteal height, buttock-to-popliteal length and hip width. These measurements were matched with the corresponding chair seat dimensions: height, depth and width. Popliteal and seat height mismatch was defined when the seat height is either >95% or <88% of the popliteal height. Buttock-popliteal length and seat depth mismatch was defined when the seat depth is either >95% or <80% of the buttock-popliteal length. Seat width mismatch is defined where the seat width should be at least 10% and at the most 30% larger than hip width.

RESULTS

An 89% of learners did not match the seat. Five percent of learners matched the chair depth, the majority was found to be too big. In contrast, 65% of the learners matched the chair width dimension.

CONCLUSIONS

A substantial mismatch was found. The school chairs failed standard ergonomics recommendations for the design of furniture to fit the user. This study supports the conclusion that there is no one-size-fits-all solution. There is an urgent need for chairs that are of different sizes or that are adjustable.

High prevalence of pulmonary tuberculosis but low sensitivity of symptom screening among HIV-infected pregnant women in South Africa

Symptom screening is a recommended component of intensified case-finding (ICF) for pulmonary tuberculosis (TB) among HIV-infected individuals. Symptomatic individuals are further investigated to either exclude or diagnose pulmonary TB, thus reducing the number of individuals requiring costly laboratory investigation. Those with laboratory evaluations negative for pulmonary TB or who lack symptoms may be eligible for antiretroviral therapy (ART) and/or TB isoniazid preventive therapy (IPT). A four-part symptom screen has been recommended by the World Health Organization (WHO) for identifying TB suspects and those unlikely to have TB. A meta-analysis of studies among HIV-infected individuals calculated a sensitivity of 90.1% for the four-part symptoms screen - of any of cough, fever, night sweats, or weight loss - among patients in clinical care, making it an effective tool for identifying most patients with TB. An important population for intensified case-finding not included in that meta-analysis was HIV-infected pregnant women. We undertook a cross-sectional survey among HIV-infected pregnant women receiving prenatal care at community clinics in South Africa. We obtained a four-symptom review and sputum smear microscopy and mycobacterial culture on all participants. Among 1415 women, 226 (16%) had a positive symptom screen, and 35 (2.5%) were newly diagnosed with culture-positive TB. Twelve were on TB treatment at the time of screening, yielding 47 (3.3%) women with prevalent TB. Symptom screening among women without known TB had a sensitivity of 28% and specificity of 84%. The poor performance of symptom screening to identify women with TB suggests that other approaches may be needed for intensified case-finding to be effective for this population.

Trends in childhood tuberculosis in Zambia: a situation analysis

OBJECTIVES

To ascertain childhood tuberculosis (TB) trends, human immunodeficiency virus (HIV) co-infection rates and multi-drug resistant TB (MDR-TB) prevalence rates in Zambia.

METHODS

A retrospective review of Zambian annual TB notification data and National TB Programme reports for a 7 year period (2004-2011). TB trends were stratified by age and HIV status.

RESULTS

The total number of children notified during this period with all forms of TB was 40 976. A total of 2670 of 40 976 (6%) were smear-positive cases. Notification rates of all forms of childhood TB show a decline in trends from 135 per 100 000 population in 2004, to 69 per 100 000 population in 2011.

CONCLUSIONS

Childhood TB is an important but neglected problem in Zambia highlighted by the fact that no data exists on HIV co-infection and MDR-TB. Strengthening of the National TB Programme and diagnostics services/algorithms are required to accurately define the TB burden, HIV co-infection and MDR-TB rates in children in Zambia.

Estimating obstetric mortality from pregnancy-related deaths recorded in demographic censuses and surveys

Demographic surveys and censuses often record pregnancy-related deaths, defined as those occurring during the maternal risk period (pregnancy, delivery, and six weeks postpartum), but do not include cause of death. This study presents a method for estimating obstetric mortality from pregnancy-related deaths data. Calculations are based on multiple-decrement life tables, and data needed are simply age-specific fertility and mortality rates that are commonly available in Demographic and Health Survey (DHS) or census data, and an estimate of the relative risk of death from nonobstetric causes during the maternal risk period. The method is tested on 59 DHS surveys from Africa. Results show that, on average, less than half of the pregnancy-related deaths are attributable to obstetric causes. This proportion varies with the level of mortality and fertility, and in particular with the prevalence of HIV in the population.

Neonatal tuberculosis: neonatal intensive care unit considerations in the United States

According to the World Health Organization, more than 2 billion people, equal to one third of the world's population, are infected with Mycobacterium tuberculosis (TB) bacilli, the microbes that cause TB. In addition, over the past decade, the incidence of postnatal TB in infants has shown an escalating trend in response to the global increase in TB. In providing the best possible care for infants in newborn nurseries and NICU, providers must recognize the trends of TB and multidrug resistant TB in infants globally and consider the possible effects on health care in the United States. The potential risk factors, clinical manifestations, diagnostic strategies, and management plans, specific to the care of infants in the neonatal intensive care unit, is vastly important in maintaining a high index of suspicion for neonatal TB.

A model of tuberculosis screening for pregnant women in resource-limited settings using Xpert MTB/RIF

Timely diagnosis and treatment of maternal tuberculosis (TB) is important to reduce morbidity and mortality for both the mother and child, particularly in women who are coinfected with HIV. The World Health Organization (WHO) recommends the integration of TB/HIV screening into antenatal services but available diagnostic tools are slow and insensitive, resulting in delays in treatment initiation. Recently the WHO endorsed Xpert MTB/RIF, a highly sensitive, real-time PCR assay for Mycobacterium tuberculosis that simultaneously detects rifampicin resistance directly from sputum and provides results within 100 minutes. We propose a model for same-day TB screening and diagnosis of all pregnant women at antenatal care using Xpert MTB/RIF. Pilot studies are urgently required to evaluate strategies for the integration of TB screening into antenatal clinics using new diagnostic technologies.

Pelvic tuberculosis and shock in the puerperium

Pelvic tuberculosis (TB) in pregnancy and puerperium is rare. Its atypical presentation as puerperal shock is more rare. We describe a case of pelvic TB that manifested as shock in a teenager who was two weeks postpartum. She failed to respond to antibiotics. Ziehl-Neelsen staining of aspirated pus from the left fossa collection in the abdominal cavity was positive for mycobacterium TB. Prompt treatment with antitubercular therapy could save patients from this life-threatening condition.