Epidemiological, clinical and mechanistic perspectives of tuberculosis in older people

Clinical characteristics and prognostic factors of pulmonary tuberculosis with interstitial changes

BACKGROUND

Pulmonary tuberculosis (PTB) remains a significant global public health challenge, particularly in its manifestation as interstitial lung disease. This form complicates clinical presentation, increasing the difficulty of diagnosis and treatment. However, studies on PTB with interstitial changes are relatively scarce, and their clinical significance and prognostic value have not been fully explored. The objective of the present study was to identify the key factors affecting clinical characteristics and prognosis in these patients.

METHODS

This retrospective study analyzed data from patients diagnosed with PTB with Interstitial Changes at Zigong First People's Hospital in Sichuan Province between January 2014 and January 2024. Sixteen patients meeting strict inclusion and exclusion criteria were enrolled. Clinical characteristics and key prognostic factors were identified using descriptive statistics and random forest analysis, with partial dependence plots generated to illustrate the independent contributions of each variable to adverse outcomes.

RESULTS

Among the 16 patients studied, 75.0% were male and 25.0% were female. The average number of pathogen species detected was 1.56 ± 0.73, and 31.3% of patients presented with fever symptoms at admission. Hospital stay durations ranged from 8 to 67 days, with a mean of 22.00 ± 16.02 days. Regarding drug resistance, 25.0% of patients exhibited rifampicin resistance, and approximately 31.2% had underlying diseases. Ultimately, 11 patients (68.8%) recovered, while 5 (31.2%) died. The random forest model identified age, rifampicin resistance, and the number of pathogen species as the main determinants of prognosis. Advanced age and drug resistance were significantly associated with a higher risk of death, and patients infected with multiple pathogens experienced worse outcomes.

CONCLUSIONS

This study enhances our understanding of the clinical characteristics and prognosis of tuberculosis patients presenting with interstitial lung disease, particularly identifying advanced age, rifampicin resistance, and a higher number of pathogen species as key prognostic factors. These findings provide valuable insights for the development of personalized treatment strategies and precision medicine approaches for this patient group.

Systemic vasculitis with latent tuberculosis infection and associated factors: a cross-sectional multicenter study

OBJECTIVES

Systemic vasculitis patients are at a higher risk of developing latent tuberculosis infection (LTBI). However, there is currently no literature elucidating the positivity rate and risk factors for LTBI in systemic vasculitis patients.

METHODS

Our study is a multi-center, cross-sectional study that enrolled systemic vasculitis patients from 13 comprehensive hospitals in China. T-SPOT.TB as the screening method for LTBI, the study investigated the positivity rate of LTBI in systemic vasculitis patients and the factors associated with T-SPOT.TB results.

RESULTS

A total of 191 systemic vasculitis patients were included and the positive rate of T-SPOT.TB was 31.4%. The highest T-SPOT.TB positivity rate was observed in Behçet's syndrome (BD) (72/191, 37.7%). There were statistically significant differences between the LTBI group and non-LTBI group in terms of systemic vasculitis type (P = 0.010), albumin levels (P = 0.034), erythrocyte sedimentation rate (P = 0.016), and corticosteroid dosage (P = 0.047). Multivariate regression analysis revealed that smoking history (aOR = 3.809, 95%CI: 1.341-10.817) and BD (aOR = 2.106, 95%CI: 1.042-4.254) were independent risk factors of T-SPOT.TB postive results, besides decreased lymphocyte count (aOR = 0.114, 95%CI: 0.013-0.973), and high-dose glucocorticoids use (aOR = 0.386, 95%CI: 0.149-1.003) were independent risk factors of T-SPOT.TB negative results.

CONCLUSIONS

The prevalence of LTBI is high in systemic vasculitis patients, especially those with BD or smoking history. Patients with decreased lymphocyte counts and high-dose glucocorticoid use are more likely to have a negative T-SPOT.TB results. Therefore, LTBI screening should be performed based on the characteristics of the patient during the diagnosis and treatment of systemic vasculitis. Key Points • We explored the positivity rate and risk factors of LTBI in systemic vasculitis patients from 13 hospitals in China. • There were 191 systemic vasculitis patients in our study. The positive rate of T-SPOT.TB was 31.4%. The predominant type of systemic vasculitis was BD, with a T-SPOT.TB positive rate of 44.4%. The second type was TA, with a T-SPOT.TB positive rate of 25.0%. • The prevalence of LTBI is high in systemic vasculitis patients, especially those with Behçet's syndrome or smoking history. Decreased lymphocyte counts and high-dose glucocorticoid use are more likely to have a negative T-SPOT.TB results. • LTBI screening using T-SPOT.TB should be conducted during the diagnosis and treatment of systemic vasculitis.

Factors associated with pulmonary tuberculosis in elderly individuals: A protocol for a scoping review

BACKGROUND

Tuberculosis (TB) is an infectious disease with a significant impact on public health, with the pulmonary form being the most critical. The disease poses numerous risks to the elderly population, as it often manifests concomitantly with other age-related illnesses, thereby complicating its diagnosis and management. Several causal and associated factors contribute to the disease.

OBJECTIVE

The objective of this manuscript is to present a scoping review protocol aimed at mapping the available literature on factors associated with and contributing to the incidence of Pulmonary Tuberculosis (PTB) in the elderly.

METHODS AND ANALYSIS

The scoping review protocol was developed following the guidelines of the Joanna Briggs Institute (JBI) and the PRISMA-ScR checklist, and it has been registered on the Open Science Framework (DOI: 10.17605/OSF.IO/DHQVP). The databases to be searched include Medline via PubMed, Lilacs, Web of Science, Scopus, Embase, as well as gray literature through Google Scholar and the Brazilian Coordination for the Improvement of Higher Education Personnel (CAPES) Thesis and Dissertation Catalog. The search strategy is grounded on a research question formulated using the PCC acronym (P-Population; C-Concept; C-Context). Peer-reviewed journal articles, scientific books, editorials, conference proceedings, and theses/dissertations published in Portuguese, English, or Spanish between 2014 and 2024 will be included.

DISCUSSION

Elderly individuals are more susceptible to diseases due to the natural decline in immune response to Mycobacterium tuberculosis, the causative agent of tuberculosis. In this age group, symptoms are often difficult to detect. Understanding the causal and associated factors of the disease contributes to favorable outcomes and helps reduce the transmission chain to the rest of the population.

Control of Mycobacterium tuberculosis infection in the elderly: Is there a role for epigenetic reprogramming reversal?

With the increase in the elderly population worldwide, the number of subjects suffering from tuberculosis (TB) has shown an increased prevalence in this group. Immunosenescence is essential in this phenomenon because it may reactivate the lesions and render their adaptive immunity dysfunctional. In addition, inflammation in the lungs of the elderly subjects is also dysfunctional. Although effective drugs are available, they are often tolerated inadequately, reducing adherence to the therapy and leading to therapeutic failure. Comorbidities, poor general health status, and other medications may lead to increased drug adverse reactions and reduced adherence to treatment in the elderly. Hence, older adults require an individualized approach for better outcomes. Trained immunity, which involves epigenetic reprogramming, may contribute to balancing the dysfunction of innate and adaptive immunity in older people. This review analyzes the relationship between inflammation, age, and Mycobacterium tuberculosis. Moreover, we hypothesize that immunomodulation using trained immunity activators will help reduce inflammation while enhancing antimicrobial responses in the elderly. Understanding immunomodulation's molecular and physiological effects will lead to informed decisions about TB prevention and treatment strategies uniquely designed for the elderly.

Genomic and Spatial Analysis on the Recent Transmission of Mycobacterium tuberculosis in Eastern China: A 10-Year Retrospective Population-Based Study

Purpose

Understanding the mode of Mycobacterium tuberculosis (M. tuberculosis) transmission is crucial for disease prevention and control. Compared to traditional genotyping methods, whole genome sequencing (WGS) provides higher resolution and comprehensive genetic information, enabling the tracing of infection sources and determining of transmission routes to resolve extensive tuberculosis (TB) outbreaks. We conducted a ten-year study on the transmission of M. tuberculosis in a population in eastern China.

Patients and Methods

We selected Lianyungang, an eastern city in China, as the study site. Patients diagnosed with active pulmonary TB from 2011 to 2020 were enrolled as the study subjects. We isolated and sequenced 2252 M. tuberculosis. Strains with pairwise genetic distances of less than 12 single nucleotide polymorphisms were defined as genomic clusters and which were considered recent transmissions. Kernel density estimation and K-function analysis were applied to explore the spatial distribution of recently transmitted strains.

Results

After excluding non-tuberculous mycobacteria and duplicated samples, 2114 strains were included in the final analysis. These strains comprised lineage 2 (1593, 75.35%) and 4 (521, 24.65%). There were 672 clustered strains, with a recent transmission rate of 31.79%. The logistic regression model showed that the risk of recent transmission was high in students [adjusted odds ratio (aOR): 2.68, 95% confidence interval (CI): 1.63-4.49, P<0.001] and people infected with L2.2.1 strains (aOR: 1.59, 95% CI: 1.20-2.12). Higher spatial aggregation of TB transmission has been concentrated in Haizhou, Donghai, and Guanyun for the past 10 years. Three outbreaks affecting 46 patients were spatially spaced, with 11 to 23 persons each. Different groups exhibited varying geographic distances between the initial and later cases.

Conclusion

There are areas with a high risk of transmission for M. tuberculosis in the research site, and the risk varies among different populations. Accurate prevention strategies targeted at specific regions and key populations can help curb the prevalence of TB.

Assessing the quality of life in patients with drug-resistant tuberculosis: a cross-sectional study

BACKGROUND

This study investigated the current status of the quality of life (QOL) of drug-resistant tuberculosis (DR-TB) patients in Nanjing, China, and analyzed the influencing factors.

METHODS

The survey was conducted among patients with DR-TB who were hospitalized in the tuberculosis department of the Second Hospital of Nanjing (Nanjing Public Health Medical Center) from July 2022 to May 2023. The Chinese version of the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire was used to investigate the QOL levels of patients with DR-TB, and a multiple linear regression model was used to analyze the QOL influencing factors.

RESULTS

A total of 135 patients participated in the study; 69.6% were male, the average age was 46.30 ± 17.98 years, 13.33% had an education level of elementary school or below, and 75.56% were married. The QOL scores were 51.35 ± 17.24, 47.04 ± 20.28, 43.89 ± 17.96, and 35.00 ± 11.57 in the physiological, psychological, social, and environmental domains, respectively. The differences between the four domain scores and the Chinese normative results were statistically significant (P < 0.05). The results of multiple linear regression analysis showed that the factors related to the physiological domain included residence, family per-capita monthly income, payment method, adverse drug reactions (ADRs), and comorbidities; psychological domain correlates included educational level, family per-capita monthly income, course of the disease, and caregivers; social domain correlates included age and comorbidities; and factors related to the environmental domain included age, education level, and comorbidities.

CONCLUSIONS

In Nanjing, China, patients with younger age, higher education level, living in urban areas, high family per-capita monthly income, no adverse drug reactions, no comorbidities, and having caregivers have better quality of life. Future interventions to improve the quality of life of patients with drug-resistant tuberculosis could be tailored to a specific factor.

Changing epidemic of tuberculosis amidst the COVID-19 pandemic in the Western Pacific Region: analysis of tuberculosis case notifications and treatment outcomes from 2015 to 2022

Background

Coronavirus disease-2019 (COVID-19) pandemic has deeply impacted tuberculosis (TB) services globally. This study aims to assess the COVID-19 pandemic's impact on TB diagnosis and care and explore associated factors in the Western Pacific Region.

Methods

We analysed TB case notifications and treatment outcomes for the Region and 14 selected countries and areas from 2015 to 2022. We further explored differences in reported cases from predicted cases by the UHC service coverage index and Human Development Index (HDI), and the relationship between the Stringency Index and TB case notifications during the pandemic.

Findings

TB case notifications declined in 2020 (21%) and 2021 (23%) compared to predicted cases and partly recovered in 2022 (18%). The shortfalls in 2020 and 2021 were more prominent in priority countries with high TB burden, where the decrease in clinically diagnosed pulmonary cases and paediatric cases was particularly pronounced. In priority countries, TB case notifications have a positive relationship with UHC service coverage index and HDI in 2021 and an inverse relationship with Stringency Index during the pandemic. In contrast, treatment outcomes have not changed significantly due to the pandemic across countries in the Region.

Interpretation

The COVID-19 pandemic has adversely impacted TB diagnosis and care in the Western Pacific Region, especially TB case detection. Stringent government policies against the pandemic, coupled with weak health systems and suboptimal socio-economic development, may have brought a more profound and prolonged impact in priority countries.

Funding

The Korea Disease Control and Prevention Agency and the Japan Ministry of Health, Labour and Welfare.

Trends of type 2 diabetes with pulmonary tuberculosis patients,2013-2022, and changes after the coronavirus disease 2019 (COVID-19) pandemic

BACKGROUND

To describe the trends of Type 2 Diabetes with Pulmonary Tuberculosis (T2DM-TB) patients from 2013 to 2022 and to investigate the impact of COVID-19 lockdown on glycemic control and associated factors in T2DM-TB.

METHODS

In this population-based study of the First Affiliated Yijishan Hospital of Wannan Medical College in China, we described the 10-year trends of patients diagnosed with T2DM-TB. We included patients diagnosed with TB, T2DM-TB and T2DM-TB patients for comparative analysis, aged 15 years or older. Data were missing, and both multidrug-resistant (MDR) TB patients and non-T2DM patients were excluded from our study.

RESULTS

We pooled Type 2 Diabetes (T2DM) and Tuberculosis (TB) data from The First Affiliated Yijishan Hospital of Wannan Medical College in China, gathered between January 1, 2013, and December 31, 2022. The data included 14,227 T2DM patients, 6130 TB patients, and 982 T2DM-TB patients. During the past 10 years, the number of inpatients with TB decreased, while the number of patients with T2DM and T2DM-TB increased year by year. To rule out any influence factors, we analyzed the ratio of the three groups. The ratio of TB/T2DM decreased year by year (p < 0.05), while the ratio of TB-T2DM/TB increasing year by year (p = 0.008). During the COVID-19 epidemic period, there was no significant change in the ratio of TB-T2DM/T2DM (p = 0.156). There was no significant change in the proportion of male patients with TB and TB-T2DM (p = 0.325; p = 0.190), but the proportion of male patients with T2DM showed an increasing trend (p < 0.001). The average age of TB patients over the past 10 years was 54.5 ± 18.4 years and showed an increasing trend year by year (p < 0.001). However, there was no significant change in the age of T2DM or TB-T2DM patients (p = 0.064; p = 0.241). Patients data for the first (2013-2017) and the last (2018-2022) five years were compared. We found that the number of T2DM and TB-T2DM in the last five years was significantly higher than in the first five years, but the number of TB was significantly lower than in the first five years. There is a significant statistical difference in the proportion of TB/T2DM and TB-T2DM/TB, which is similar to the previous results. The average age (56.0 ± 17.6 years) of TB patients in the last five years is significantly higher than in the first five years (53.1 ± 18.9) (p < 0.001). The number of male patients with T2DM in the last five years is higher than that in the first five years, with significant difference (p < 0.001).

CONCLUSION

The trends of T2DM-TB among hospitalized TB patients have increased significantly over the past 10 years, which may be related to the increase in the number of T2DM cases. The COVID-19 pandemic has been effective in controlling the transmission of TB, but it has been detrimental to the control of T2DM. Male patients with T2DM and elderly TB patients are the key populations for future prevention and control efforts.

Prospective cohort study on tuberculosis incidence and risk factors in the elderly population of eastern China

Background

Tuberculosis continues to be a significant public health concern in China, particularly among the elderly population. This study aimed to assess the risk factors of tuberculosis among elderly individuals in China through a cohort study, focusing on this high-risk population.

Methods

The population-based census was strategically designed to cover diverse regions and demographics across the city. The survey captured demographic and lifestyle information, as well as a clinical examination. Participants were prospectively followed up over a specified duration to monitor the incidence of tuberculosis cases.

Results

After a follow-up period of more than 7 years, 246 individuals developed tuberculosis, resulting in an incidence rate of 92.21 per 100,000 person-years (95 % CI 81.2-104.3). In multivariate analysis, the following factors were found to have significant associations with active tuberculosis. Increasing age correlated with a higher risk of active tuberculosis (AHR = 1.03 per 1-year increase in age, 95%CI: 1.01, 1.04, P < 0.001). Males continued to have a higher risk compared to females (HR = 2.73, 95%CI: 2.08, 3.58, P < 0.001). Individuals with a normal Body Mass Index (BMI) faced nearly three times higher risk compared to their obese counterparts (HR = 2.87, 95 % CI: 1.51, 5.46, P = 0.001). Conversely, those with an underweight BMI had a ten-fold higher risk compared to the obese group (HR = 9.89, 95 % CI: 4.92, 19.85, P < 0.001). Elderly individuals who quit smoking had a 1.35-fold increased risk compared to non-smokers (HR = 1.35, 95%CI: 1.12, 1.64, P < 0.001).

Conclusions

Tuberculosis incidence among the elderly population in China remained alarmingly high. This finding emphasizes the urgent need for implementing proactive case detection measures specifically tailored to address the specific needs of this vulnerable demographic, particularly in individuals who are male, have a history of former or current smoking, and have a low BMI. Moreover, we must not underestimate the influence of former smoking on tuberculosis risk.

Spatial spillover effect of environmental factors on the tuberculosis occurrence among the elderly: a surveillance analysis for nearly a dozen years in eastern China

BACKGROUND

In many areas of China, over 30% of tuberculosis cases occur among the elderly. We aimed to investigate the spatial distribution and environmental factors that predicted the occurence of tuberculosis in this group.

METHODS

Data were collected on notified pulmonary tuberculosis (PTB) cases aged ≥ 65 years in Zhejiang Province from 2010 to 2021. We performed spatial autocorrelation and spatial-temporal scan statistics to determine the clusters of epidemics. Spatial Durbin Model (SDM) analysis was used to identify significant environmental factors and their spatial spillover effects.

RESULTS

77,405 cases of PTB among the elderly were notified, showing a decreasing trend in the notification rate. Spatial-temporal analysis showed clustering of epidemics in the western area of Zhejiang Province. The results of the SDM indicated that a one-unit increase in PM2.5 led to a 0.396% increase in the local notification rate. The annual mean temperature and precipitation had direct effects and spatial spillover effects on the rate, while complexity of the shape of the greenspace (SHAPE_AM) and SO2 had negative spatial spillover effects.

CONCLUSION

Targeted interventions among the elderly in Western Zhejiang may be more efficient than broad, province-wide interventions. Low annual mean temperature and high annual mean precipitation in local and neighboring areas tend to have higher PTB onset among the elderly.

Active tuberculosis of spine: Current updates

Background

Spinal tuberculosis (TB) is the most common extrapulmonary form of tuberculosis. In both developing and developed countries, TB has been on the rising trend due to factors such as increasing HIV coinfection, multidrug resistance of the organism, and global migration. Spinal TB, which most often affects the lower thoracic and thoracolumbar area, accounts for 50% of all musculoskeletal tuberculosis.

Methods

Using the Cochrane Database of Systematic Reviews, EMBASE, and PubMed, a systematic computerized literature search was performed. Analyses of studies published within the past 10 years were conducted. The searches were performed using Medical Subject Headings terms, with "spinal tuberculosis," "diagnosis," "epidemiology," and "etiology","management," "surgery," and "therapy" as subheadings.

Results

Progressive collapse, kyphosis, and neurological deficiency are hallmarks of the disease because of its destructive effect on the intervertebral disc and adjacent vertebral bodies. The condition may be identified using laboratory testing and distinctive imaging features, but the gold standard for diagnosis is tissue diagnosis using cultures, histology, and polymerase chain reaction. Uncomplicated spinal TB is today a medical condition that can be adequately treated by multidrug ambulatory chemotherapy. Surgery is reserved for individuals who have instability, neurological impairment, and deformity correction. Debridement, deformity correction, and stable fusion are the cornerstones of surgical treatment.

Conclusions

Clinical results for the treatment of spinal TB are generally satisfactory when the disease is identified and treated early. However, the major health issue and the biggest obstacle in achieving the goals of the "End TB strategy" is the recent rise in the emergence of drug resistance. Hence strict vigilance and patient perseverance in the completion of the treatment is the main need of the hour.

Tuberculosis presentation and outcomes in older Hispanic adults from Tamaulipas, Mexico

Older people are at high risk of developing and dying from pulmonary infections like tuberculosis (TB), but there are few studies among them, particularly in Hispanics. To address these gaps, we sought to identify host factors associated with TB and adverse treatment outcomes in older Hispanics by conducting a cross-sectional study of TB surveillance data from Tamaulipas, Mexico (2006-2013; n = 8381). Multivariable logistic regressions were assessed for older adults (OA ≥65 years) when compared to young (YA, 18-39 years) and middle-aged adults (40-64 years). We found that the OA had features associated with a less complicated TB (e.g., lower prevalence of extra-pulmonary TB and less likely to abandon treatment or have drug resistant TB), and yet, were more likely to die during TB treatment (adj-OR 3.9, 95% 2.5, 5.25). Among the OA, excess alcohol use and low body mass index increased their odds of death during TB treatment, while a higher number of reported contacts (social support) was protective. Diabetes was not associated with adverse outcomes in OA. Although older age is a predictor of death during TB disease, OA are not prioritized by the World Health Organization for latent TB infection screening and treatment during contact investigations. With safer, short-course latent TB infection treatment available, we propose the inclusion of OA as a high-risk group in latent TB management guidelines.

Disease burden of tuberculosis and post-tuberculosis in Inner Mongolia, China, 2016-2018 - based on the disease burden of post-TB caused by COPD

BACKGROUND

Tuberculosis (TB) remains one of the most serious infectious diseases worldwide. China has the second highest TB burden globally, but existing studies have mostly neglected the post-tuberculosis (post-TB) disease burden. This study estimated the disease burden of TB and post-TB in Inner Mongolia, China, from 2016 to 2018.

METHODS

Population data were collected from TB Information Management System. Post-TB disease burden was defined as the burden caused by Chronic Obstructive Pulmonary Disease (COPD) occurring after patients with TB were cured. To estimate the incidence rate of TB, standardized mortality rate, life expectancy, and cause eliminated life expectancy, using descriptive epidemiological, abridged life table and cause eliminated life table. On this basis, the Disability-Adjusted Life Years (DALY), Years Lived with Disability (YLD) and Years of Life Lost (YLL) due to TB were further be estimated. The data were analyzed using Excel 2016 and SPSS 26.0. Joinpoint regression models were used to estimate the time and age trends of the disease burden of TB and post-TB.

RESULTS

The TB incidence in 2016, 2017, and 2018 was 41.65, 44.30, and 55.63/100,000, respectively. The standardized mortality in the same period was 0.58, 0.65, and 1.08/100,000, respectively. From 2016 to 2018, the total DALYs of TB and post-TB were 5923.33, 6258.03, and 8194.38 person-years, and the DALYs of post-TB from 2016 to 2018 were 1555.89, 1663.33, and 2042.43 person-years. Joinpoint regression showed that the DALYs rate increased yearly from 2016 to 2018, and the rate of males was higher than that of females. TB and post-TB DALYs rates showed a rising tendency with increasing age (AAPC values were 149.6% and 157.0%, respectively, P < 0.05), which was higher in the working-age population and elderly.

CONCLUSION

The disease burden of TB and post-TB was heavy and increased year by year in Inner Mongolia from 2016 to 2018. Compared with the youngster and females, working-age population and the elderly and males had a higher disease burden. Policymakers should be paid more attention to the patients' sustained lung injury after TB cured. There is a pressing need to identify more effective measures for reducing the burden of TB and post-TB of people, to improve their health and well-being.

Association between long-term exposure to ambient air pollutants and the risk of tuberculosis: A time-series study in Nantong, China

Background

Increasing evidence has shown that the risk of tuberculosis (TB) might be related to the exposure to air pollutants; however, the findings are inconsistent and studies on long-term air pollutant exposure and TB risk are scarce. This study aime to assess the relationship between monthly exposure to air pollution and TB risk in Nantong, China.

Methods

We collected the time series data on the number of TB cases, as well as environmental and socioeconomic covariates from January 2005 to December 2020. The impact of air pollutant exposure on TB risk was evaluated using the distributed lag nonlinear model (DLNM). Stratified analyses were conducted to examine the effect modifications of sex and age on the association between air pollutants and TB risk. Sensitivity analyses were applied to test the stability of the model.

Results

There were a total of 54,096 cases of TB in Nantong during the study period. In the single-pollutant model, for each 10 μg/m³ increase in concentration, the pooled relative risks (RRs) of TB reached the maximum to 1.10 (95% confidence interval (CI): 1.04-1.16, lag 10 months) for particulate matter with aerodynamic diameter less than 2.5 μm (PM_2.5), 1.05 (95% CI: 1.01-1.10, lag 9 months) for particulate matter with aerodynamic diameter less than 10 μm (PM₁₀), and 1.11 (95%CI: 1.04-1.19, lag 10 months) for nitrogen dioxide (NO₂). Ozone (O₃) did not show significant effect on TB risk. Effect modifications of sex and age on the association between air pollutants and TB risk were not observed. The multi-pollutant model results showed no significant variation compared with the single-pollutant model.

Conclusions

Our study suggests that air pollutants pose a substantial threat to the TB risk. Reducing air pollution might be crucial for TB prevention and control.

Clinical manifestations and immune response to tuberculosis

Tuberculosis is a far-reaching, high-impact disease. It is among the top ten causes of death worldwide caused by a single infectious agent; 1.6 million tuberculosis-related deaths were reported in 2021 and it has been estimated that a third of the world's population are carriers of the tuberculosis bacillus but do not develop active disease. Several authors have attributed this to hosts' differential immune response in which cellular and humoral components are involved, along with cytokines and chemokines. Ascertaining the relationship between TB development's clinical manifestations and an immune response should increase understanding of tuberculosis pathophysiological and immunological mechanisms and correlating such material with protection against Mycobacterium tuberculosis. Tuberculosis continues to be a major public health problem globally. Mortality rates have not decreased significantly; rather, they are increasing. This review has thus been aimed at deepening knowledge regarding tuberculosis by examining published material related to an immune response against Mycobacterium tuberculosis, mycobacterial evasion mechanisms regarding such response and the relationship between pulmonary and extrapulmonary clinical manifestations induced by this bacterium which are related to inflammation associated with tuberculosis dissemination through different routes.

Tuberculosis of the spine

Pott's spine, commonly known as spinal tuberculosis (TB), is an extrapulmonary form of TB caused by Mycobacterium TB. Pott's paraplegia occurs when the spine is involved. Spinal TB is usually caused by the hematogenous spread of infection from a central focus, which can be in the lungs or another location. Spinal TB is distinguished by intervertebral disc involvement caused by the same segmental arterial supply, which can result in severe morbidity even after years of approved therapy. Neurological impairments and spine deformities are caused by progressive damage to the anterior vertebral body. The clinical, radiographic, microbiological, and histological data are used to make the diagnosis of spinal TB. In Pott's spine, combination multidrug antitubercular therapy is the basis of treatment. The recent appearance of multidrug-resistant/extremely drug-resistant TB and the growth of human immunodeficiency virus infection have presented significant challenges in the battle against TB infection. Patients who come with significant kyphosis or neurological impairments are the only ones who require surgical care. Debridement, fusion stabilization, and correction of spinal deformity are the cornerstones of surgical treatment. Clinical results for the treatment of spinal TB are generally quite good with adequate and prompt care.

Factors associated with adverse drug reactions or death in very elderly hospitalized patients with pulmonary tuberculosis

The aging of patients with tuberculosis and better therapeutic management for them are recent concerns. This study aimed to identify risk factors for adverse drug reactions (ADRs) or death in very elderly patients with pulmonary tuberculosis and to assess the association between the dosage of antituberculosis drugs and outcomes. We conducted a multicenter retrospective study at two hospitals. Hospitalized patients (≥ 80 years old) with pulmonary tuberculosis who were treated with antituberculosis drugs were enrolled. Multivariate analysis was performed to assess factors associated with ADRs or death within 60 days after treatment initiation. In total, 632 patients were included. The primary endpoint occurred in 268 patients (190 ADRs and 78 deaths). A serum albumin level < 2.5 g/dL, respiratory failure, and dependent activities of daily living were independent risk factors for ADRs or death. However, a low dosage (< 8 mg/kg/day) of rifampicin was associated with a lower risk of the primary outcomes. Delayed time to negative sputum culture conversion was not observed in the lower dosage of rifampicin group. Very elderly hospitalized tuberculosis patients with the aforementioned risk factors should be carefully monitored to receive safer treatment. Rifampicin dosage reduction may be considered for very elderly tuberculosis patients to prevent ADRs/death.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Sleep quality and its associated factors among patients with tuberculosis: A cross-sectional study

Background

Tuberculosis (TB) patients commonly suffer from sleep issues owing to various adverse drug reactions (ADRs), disease symptoms, and the contagious nature of their disease. These sleep issues negatively affect the treatment outcome and quality of life. However, the prevalence of sleep disturbance and its associated factors among TB patients have rarely been reported.

Methods

A total of 497 inpatients with TB from three hospitals in China were enrolled in this cross-sectional study to investigate their sleep quality using the Pittsburgh sleep quality index (PSQI). Clinical data, including demographic information, TB-related stigma, perceived stress, and nutrition- and immunity-related indicators, were also collected to explore the factors associated with sleep disturbance among the recruited patients.

Results

Approximately 70% of the recruited patients reported a sleep disturbance to varying degrees, presenting poorer global and subjective sleep qualities, longer sleep latency, shorter sleep duration, lower sleep efficiency, more frequent sleep disturbances, greater use of sleeping medication, and more severe daytime dysfunction. Furthermore, the body mass index (BMI), hemoglobin levels, albumin levels, and T lymphocyte count of the patients in the poor sleep quality group were significantly lower than those in the good sleep quality group (p < 0.05). Increasing age, higher income, drug resistance, higher stigma or stress perception, lower albumin levels, and lower CD4 levels were significantly associated with sleep disturbance among TB patients (p < 0.05).

Conclusion

Three-quarters of the participants were found to suffer from a probable sleep disturbance. And sleep problems are linked to biological traits that interact with psychological, cultural, and social factors in complex ways. It is therefore important to pay attention to the sleep quality of TB patients, especially those with the identified risk factors. Besides, taking care of these risk factors may prove to be an effective sleep management strategy.

Tuberculosis in elderly population: A cross-sectional comparative study

BACKGROUND

Tuberculosis (TB) is a common but neglected infectious disease of global significance. It has a varied presentation in the elderly compared to adults. The present study was conceived to study the resemblances and differences shared in terms of clinical profile, comorbidities, and laboratory investigations by TB in adults and the elderly population.

METHODS

In this cross-sectional study, 68 adults and 72 elderly patients of both genders were enrolled. We collected information on demographics, comorbidities, clinical presentations, and laboratory investigations. The comparison of data between groups was done using the unpaired t-test for continuous variables and the Chi-square test for frequency distribution analysis.

RESULTS

The mean age of the adults and elderly population was 42.13 ± 10.7 years and 68.78 ± 7.62 years, respectively. The elderly TB group demonstrated loss of weight, appetite, the prevalence of comorbid conditions (coronary artery disease, hypertension, and malnutrition), bilateral, predominantly lower lobe, and diffuse involvement of lungs.

CONCLUSION

As the elderly population increases, nonspecific clinical manifestations or laboratory results in this population mandate awareness of these atypical features for effective management of TB in this group.

Correlates of quality of life among persons living with tuberculosis: A cross-sectional study

Introduction

The correlates of quality of life originating from the demographic characteristics, comorbidities and sources of social support among persons living with tuberculosis remain underreported. The aim of this study was to examine the correlates of quality of life among persons living with tuberculosis within Greater Accra, Ghana.

Methods

A cross-sectional survey design was used to assess the correlates of quality of life among 250 randomly sampled persons living with tuberculosis. Quality of life was assessed with the Quality of Life Brief Version (WHOQOL-BREF) questionnaire and correlates were derived using Spearman rho correlations. Chi-square analyses assessed associations among respondent characteristics.

Results

All four quality of life domains (physical, psychological, social relationship and environmental) of persons living with tuberculosis were positively correlated. Furthermore, receiving social support from family or friends correlated positively with respondents’ quality of life. Human Immunodeficiency Virus (HIV) infection and receiving social support mainly from work colleagues or religious institutions correlated negatively with respondents’ quality of life domains. Other correlates of quality of life included age, pleuritis with pleural effusion, number of dependants and distance to tuberculosis treatment centres. Social support from family and friends corresponded with better quality of life among persons living with tuberculosis.

Conclusion

The quality of life domains of persons living with tuberculosis are interrelated and can be enhanced by social support. Healthcare providers should involve the significant others of persons living with tuberculosis, human immunodeficiency virus and pleuritis with pleural effusion in their care to promote patients’ quality of life.

Associations of hyponatremia and SIADH with increased mortality, young age and infection parameters in patients with tuberculosis

BACKGROUND AND OBJECTIVE

Hyponatremia and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) are associated with and can be caused by tuberculosis (TB) through meningitis by locally invading the hypothalamus, adrenal, or pituitary glands or possibly through ectopic ADH production. This study assessed the association of TB mortality with hyponatremia and SIADH in a large cohort of a university hospital in Austria.

METHODS

This retrospective study enrolled patients with hyponatremia and patients diagnosed with TB from 01/2001-11/2019 to assess the prevalence of TB in hyponatremia and TB morbidity and mortality in patients with and without hyponatremia. Sex, age, microbiological results, laboratory tests and comorbidities were analysed and used to calculate survival rates.

RESULTS

Of 107.532 patients with hyponatremia (0.07%) and 186 patients with TB (43%), 80 patients were diagnosed with both-hyponatremia and TB. Only three TB patients had SIADH, precluding further SIADH analysis. In hyponatremia, young age and high CRP levels showed significant associations with TB diagnosis (p<0.0001). Survival rates of patients diagnosed with TB with moderate to profound hyponatremia were significantly lower than those without hyponatremia (p = 0.002).

CONCLUSION

In this study of a large cohort from a tertiary care hospital in a non-endemic area of TB, 0.07% of patients presenting with hyponatremia, but especially younger patients and patients with high CRP values, were diagnosed with TB. Crucially, patients with moderate to profound hyponatremia had a significantly higher mortality rate and thus required increased medical care.

Health-Related Quality of Life of Tuberculosis Patients during the COVID-19 Pandemic in Conakry, Guinea: A Mixed Methods Study

The COVID-19 pandemic has had a significant impact on all facets of life and has exacerbated many challenges faced by people living with tuberculosis (TB). This study aimed to assess the health-related quality of life (HRQoL) of TB patients in Guinea during the first wave of the COVID-19 pandemic. A mixed methods study was conducted using two validated tools to assess HRQoL and qualitative interviews among TB patients enrolled in treatment at 11 health centers in Conakry, Guinea. Logistic regression was used to identify factors associated with the deterioration of HRQoL. We included 439 participants in the study, among whom 44% and 31% experienced pain and anxiety, respectively. We found that an increase in the number of household size and the distance from participants' residence to the health centers were significantly associated with lower HRQoL. Qualitative interviews highlighted nutritional and financial issues, which were exacerbated during the COVID-19 pandemic and beliefs that the Guinean Government's assistance plan was insufficient. This study supports the implementation of specific relief plans for TB patients, which includes nutritional and psychological support, especially those whose movements are limited by travel restrictions, preventing access to TB care, reducing work opportunities and exacerbating financial needs and stress.

Impact of the synergistic effect of pneumonia and air pollutants on newly diagnosed pulmonary tuberculosis in southern Taiwan

BACKGROUND

An increased incidence of pulmonary tuberculosis (PTB) among patients with pulmonary diseases exposed to air pollution has been reported.

OBJECTIVE

To comprehensively investigate the association between pneumonia (PN) and air pollution with PTB through a large-scale follow-up study.

METHODS

We conducted a retrospective study using data from the Kaohsiung Medical University Hospital Research Database and the Taiwan Air Quality Monitoring Database. We included adult patients with PN, PTB and other comorbidities according to ICD-9 codes. Control subjects without PN were matched by age, sex and ten comorbidities to each PN patient at a ratio of 4:1.

RESULTS

A total of 82,590 subjects were included. The PTB incidence rate was significantly higher in the PN group (2,391/100,000) than in the control group (1,388/100,000). The crude hazard ratio (HR) of PN-associated PTB incidence decreased with time, and the overall 7 years the HR (95% confidence interval; CI) was 1.74 (1.55-1.96). The overall adjusted HR and 95% CI of PN-related PTB in the multivariate Cox regression analysis was 3.38 (2.98-3.84). In addition, there was a cumulative lag effect of all air pollutants within 30 days of exposure. The peak adjusted HRs for PTB were noted on the 3rd, 8th, 12th and 12th days of PM_2.5, O₃, SO₂ and NO exposure, respectively. The overall peak HRs (95% CI) of PM_2.5, O₃, SO₂ and NO were 1.145 (1.139-1.152), 1.153 (1.145-1.161), 1.909 (1.839-1.982) and 1.312 (1.259-1.367), respectively, and there was a synergistic effect with pneumonia on the risk of PTB.

CONCLUSIONS

A strong association was found between past episodes of PN and the future risk of PTB. In addition, air pollutants including PM_2.5, SO₂, O₃ and NO, together with previous episodes of PN, had both long-term and short-term impact on the incidence of PTB.

Association between diagnostic delay and prognosis of pulmonary tuberculosis in Shandong, China: a retrospective study

BACKGROUND

Tuberculosis (TB) is one of the main infectious diseases that seriously threatens global health, while diagnostic delay (DD) and treatment dramatically threaten TB control.

METHODS

Between 2005 and 2017 in Shandong, China, we enrolled pulmonary tuberculosis (PTB) patients with DD. DD trends were evaluated by Joinpoint regression, and associations between PTB patient characteristics and DD were estimated by univariate and multivariate logistic regression. The influence of DD duration on prognosis and sputum smear results were assessed by Spearman correlation coefficients.

RESULTS

We identified 208,822 PTB cases with a median DD of 33 days (interquartile range (IQR) 18-63). The trend of PTB with DD declined significantly between 2009 and 2017 (annual percent change (APC): - 4.0%, P = 0.047, 2009-2013; APC: - 6.6%, P = 0.001, 2013-2017). Patients aged > 45 years old (adjusted odds ratio (aOR): 1.223, 95% confidence interval (CI) 1.189-1.257, 46-65 years; aOR: 1.306, 95% CI 1.267-1.346, > 65 years), farmers (aOR: 1.520, 95% CI 1.447-1.596), and those with a previous treatment history (aOR: 1.759, 95% CI 1.699-1.821) were prone to developing long DD (> 30 days, P < 0.05). An unfavorable outcome was negatively associated with a short DD (OR: 0.876, 95% CI 0.843-0.910, P < 0.001). Sputum smear positive rate and unfavorable outcomes were positively correlated with DD duration (Spearman correlation coefficients (rs) = 1, P < 0.001).

CONCLUSIONS

The DD situation remains serious; more efficient and comprehensive strategies are urgently required to minimize DD, especially for high-risk patients.

Bridging the Gap in End Tuberculosis Targets in the Elderly Population in Eastern China: Observational Study From 2015 to 2020

BACKGROUND

With a progressive increase in the aging process, the challenges posed by pulmonary tuberculosis (PTB) are also increasing for the elderly population.

OBJECTIVE

This study aimed to identify the epidemiological distribution of PTB among the elderly, forecast the achievement of the World Health Organization's 2025 goal in this specific group, and predict further advancement of PTB in the eastern area of China.

METHODS

All notified active PTB cases aged ≥65 years from Zhejiang Province were screened and analyzed. The general epidemiological characteristics were depicted and presented using the ArcGIS software. Further prediction of PTB was performed using R and SPSS software programs.

RESULTS

Altogether 41,431 cases aged ≥65 years were identified by the surveillance system from 2015 to 2020. After excluding extrapulmonary TB cases, we identified 39,832 PTB cases, including laboratory-confirmed (23,664, 59.41%) and clinically diagnosed (16,168, 40.59%) PTB. The notified PTB incidence indicated an evident downward trend with a reduction of 30%; however, the incidence of bacteriologically positive cases was steady at approximately 60/100,000. Based on the geographical distribution, Quzhou and Jinhua Cities had a higher PTB incidence among the elderly. The delay in PTB diagnosis was identified, and a significantly prolonged treatment course was observed in the elderly. Moreover, a 50% reduction of PTB incidence by the middle of 2024 was predicted using a linear regression model. It was found that using the exponential smoothing model would be better to predict the PTB trend in the elderly than a seasonal autoregressive integrated moving average model.

CONCLUSIONS

More comprehensive and effective interventions such as active PTB screening combined with physical checkup and succinct health education should be implemented and strengthened in the elderly. A more systematic assessment of the PTB epidemic trend in the elderly population should be considered to incorporate more predictive factors.

Correlation between tuberculosis-specific interferon-γ release assay and intrathoracic calcification: A cross-sectional study

Background

Although persistent tuberculosis (TB) infection is known to cause calcification in the lungs, the relationship between intrathoracic calcification and the results of the interferon-γ release assay (IGRA) has not been fully elucidated. This study aimed to assess the association between intrathoracic calcification and IGRA results.

Methods

We retrospectively included consecutive patients who concurrently underwent chest X-ray, chest computed tomography (CT), and an IGRA. Patients with a current diagnosis of active TB or treatment history of active TB or latent tuberculosis infection (LTBI) were excluded. The association between calcification according to the chest X-ray or CT and IGRA results were analyzed using binomial logistic regression.

Results

This study included 574 patients, and 38 (7%) patients had a positive IGRA result. Patients with a positive result were significantly older and had a higher proportion of comorbidities, and history of tuberculosis exposure compared to those with a negative result. Calcification of the lung field and mediastinal lymph nodes according to chest CT was more frequently observed in patients with a positive IGRA result, whereas no significant difference was observed concerning the proportion of lung field calcification on chest X-ray between patients with positive and negative IGRA results. In multivariate analysis, calcification of mediastinal lymph nodes alone (adjusted odds ratio [OR] = 3.82, 95% confidence interval [CI] = 1.76–8.26) and the combination of lung field and mediastinal lymph node calcification (adjusted OR = 4.12, 95% CI = 1.51–11.76) on chest CT was independently associated with positive IGRA results.

Conclusions

The finding of mediastinal lymph node calcification, with or without lung field calcification, on chest CT was associated with positive IGRA results independent of TB exposure history. Previous TB infection including eliminated TB infection and LTBI can be suspected when calcified lymph nodes in are observed the mediastinum on chest CT.

Association between depression or anxiety symptoms and immune-inflammatory characteristics in in-patients with tuberculosis: A cross-sectional study

BACKGROUND

Depression and anxiety are major psychological issues among patients with tuberculosis (TB) owing to chronic and complex treatments, have been reported to be closely correlated with immune and inflammation. However, the association of peripheral immune-inflammatory characteristics with depression/anxiety symptoms in in-patients with TB has rarely been reported.

METHODS

A cross-sectional study of 338 in-patients with TB from 3 hospitals in China were enrolled to investigate their depression and anxiety status by using the nine-item Patient Health Questionnaire (PHQ-9) and seven-item Generalized Anxiety Disorder Scale (GAD-7). Participants were divided into groups based on their PHQ-9 and GAD-7 scores, and differences in demography and immune-inflammatory characteristics were studied. Logistic analysis was performed to explore factors related to depression and anxiety symptoms.

RESULTS

Depression and anxiety prevalence among patients with TB was 47.9 and 42.6%, respectively. Furthermore, 38.5% of patients reported a comorbidity of depression and anxiety symptoms. The counts of CD3, CD4, CD8, and lymphocytes decreased, whereas those of neutrophils, platelets, and peripheral blood cells and their derived indices increased among TB patients with depression or anxiety in comparison with those without symptoms (p < 0.05). In addition, increasing age, lower income (monthly income ≤ 3,000 yuan), divorced or widowed, drug resistance, and higher systemic immune inflammation index (SII) were significantly associated with depression or anxiety symptoms (p < 0.05).

CONCLUSION

Approximately half of the patients with TB suffered from depression or/and anxiety symptoms. Patients with depression or anxiety present worse cell immune status and stronger inflammatory responses compared to those without symptoms. We emphasized the importance of paying attention to the dysfunction of immune-inflammation process of TB patients with depression or anxiety symptoms. Especially, SII has a potential application value in guiding the evaluation of TB-related depression or anxiety owing to its easily accessibility and being economical.

Tuberculosis in the Elderly

The tuberculosis (TB) epidemic is most prevalent in the elderly, and there is a progressive increase in the notification rate with age. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. The mortality rate from tuberculosis remains higher in elderly patients. Symptoms of active TB are nonspecific and less pronounced in the elderly. Diagnostic difficulties in the elderly are common in many diseases but it is important to use all possible techniques to make a microbiological diagnosis. Recognising frailty to prevent loss of independence is a major challenge in dealing with the therapeutic aspects of elderly patients. Several studies report contrasting data about poorer tolerance of TB drugs in this population. Adherence to antituberculosis treatment is a fundamental issue for the outcome of treatment. Decreased completeness of treatment was shown in older people as well as a higher risk of treatment failure.

Factors associated with unfavorable outcome of tuberculosis treatment in people deprived of liberty: a systematic review

OBJECTIVE

to analyze factors associated with unfavorable outcome of tuberculosis treatment in people deprived of liberty.

METHOD

systematic review, carried out in March 2021 in seven databases, with no delimitation of period of publication. The selection process of publications and data extraction was carried out by two independent reviewers.

RESULTS

a total of 1,448 publications was identified and nine were included in the study. Unfavorable outcome was higher among those who were men; had low level of education; were living in a rural area before detention; had longer prison time; received occasional visits; had been transferred between prisons; with no sputum smear microscopy or with a positive result at the diagnosis; with no follow-up sputum smear microscopy, previous history of tuberculosis; having both clinical forms of the disease, HIV/AIDS; alcoholics; smokers; low body weight; and self-administered treatment. Treatment default was associated with young people and death with older people.

CONCLUSION

prison health managers and professionals are expected to establish mechanisms of surveillance and health actions innovation aimed at the population deprived of liberty, making efforts to reduce the unfavorable outcomes of tuberculosis treatment.

Comparison of profile and treatment outcomes between elderly and non-elderly tuberculosis patients in Puducherry and Tamil Nadu, South India

The rising geriatric population and the increased susceptibility of this age group to tuberculosis (TB), the deadliest single infectious agent, is bothersome for India. This study tried to explore the demographic and treatment outcome differences between the elderly (aged 60 years and above) and non-elderly TB (<60 years) patients from South India. This study was part of a large ongoing cohort study under the RePORT India consortium. Newly diagnosed TB patients recruited into the cohort between 2014 and 2018 were included in this study. Pretested and standardized questionnaire and tools were used to collect data and were stored securely for the entire cohort. Required demographic, anthropometric and treatment related variables were extracted from this database and analyzed using Stata version 14.0. Prevalence of elderly TB was summarized as percentage with 95% confidence interval (CI). Generalized linear modelling was attempted to find the factors associated with elderly TB. A total of 1,259 eligible TB patients were included into this present study. Mean (SD) of the participants in the elderly and non-elderly group was 65.8 (6.2) and 40.2 (12.0) respectively. Prevalence of elderly TB was 15.6% (95%CI: 13.6%-17.6%) with nearly 71% belonging to 60-69 age category. Male sex, OBC caste, poor education, unemployment, marriage, alcohol consumption and unable to work as per Karnofsky score were found to be significantly associated with an increased prevalence of elderly TB. Unfavorable outcomes (12% vs 6.5%, p value: 0.018), including death (9.3% vs 3.4%, p value: 0.001) were significantly higher among the elderly group when compared to their non-elderly counterparts. The current TB programme should have strategies to maintain follow up with due attention to adverse effects, social support and outcomes. Additional research should focus on predictors for unfavorable outcomes among the elderly TB group and explore ways to handle the same. Rendering adequate social support from the health system side and family side would be a good start.

Clinical evaluation of QuantiFERON®-TB Gold Plus directly compared with QuantiFERON®-TB Gold In-Tube and T-Spot®.TB for active pulmonary tuberculosis in the elderly

BACKGROUND

Reduced sensitivity of tuberculosis (TB) interferon-γ release assays (IGRAs) among the elderly has been reported, which is presumably due to diminished immune function. We evaluated the clinical performance of QuantiFERON®-TB Gold plus (QFT-Plus) compared with QuantiFERON®-TB Gold In-Tube (QFT-GIT) and T-Spot®.TB (T-SPOT) in the elderly.

METHODS

Blood samples for all three IGRAs were drawn at the same time from all the participants. Both CD4 and CD8 T-cell counts in patients' peripheral blood were also measured.

RESULTS

A total of 142 active pulmonary TB patients (median age: 84, interquartile range; 76-89 years) were recruited. The sensitivities of the tested IGRAs (excluding invalid/indeterminate cases) were as follows: QFT-Plus, 93.6%; QFT-GIT, 91.4%; and T-SPOT 68.1%. QFT-Plus displayed significantly higher sensitivity than T-SPOT (p < 0.00001). All three IGRAs exhibited the same specificity (100%), as assessed using blood samples from healthy, low TB-risk individuals (n = 118; median age: 39, IQR; 32-47 years). Positivity in 43 active TB patients with CD4 T-cell counts <200/μL, 39 of whom were ≥80 years of age, was as follows: QFT-Plus, 83.7%; QFT-GIT, 74.4%; and T-SPOT, 58.1%. The difference between TB2-TB1 of the QFT-Plus assay was statistically correlated with CD8 but not CD4 T-cell counts in blood (r = 0.193, p = 0.0298).

CONCLUSIONS

QFT-Plus showed high performance in the detection of TB infection in patients irrespective of their advanced age (≥80 years) or lower CD4 counts. QFT-Plus can be useful for the diagnosis of TB infection in all patients, including those who are elderly and/or immunocompromised.

Population-Based Geospatial and Molecular Epidemiologic Study of Tuberculosis Transmission Dynamics, Botswana, 2012-2016

Tuberculosis (TB) elimination requires interrupting transmission of Mycobacterium tuberculosis. We used a multidisciplinary approach to describe TB transmission in 2 sociodemographically distinct districts in Botswana (Kopanyo Study). During August 2012-March 2016, all patients who had TB were enrolled, their sputum samples were cultured, and M. tuberculosis isolates were genotyped by using 24-locus mycobacterial interspersed repetitive units-variable number of tandem repeats. Of 5,515 TB patients, 4,331 (79%) were enrolled. Annualized TB incidence varied by geography (range 66-1,140 TB patients/100,000 persons). A total of 1,796 patient isolates had valid genotyping results and residential geocoordinates; 780 (41%) patients were involved in a localized TB transmission event. Residence in areas with a high burden of TB, age <24 years, being a current smoker, and unemployment were factors associated with localized transmission events. Patients with known HIV-positive status had lower odds of being involved in localized transmission.

The clinical presentation and treatment outcomes of ocular tuberculosis: a 5-year experience in an endemic area

PURPOSE

To report the clinical presentations of ocular tuberculosis infection (OTB) and the treatment regimen and outcome in an endemic area.

METHODS

This is a retrospective case series of patients with presumed OTB treated in a tertiary teaching hospital in Hong Kong in 2014-2019.

RESULTS

Among the nineteen patients recruited, the most common clinical presentation of OTB was retinal vasculitis (42.1%), followed by scleritis, intermediate uveitis, and choroidal tuberculoma (15.8% respectively). 94.7% and 94.4% of the subjects were treated with ATT and steroid, respectively, and 31.6% were put on systemic immunosuppressant prior to the initiation of ATT. Apart from those suffering from intermediate uveitis, most demonstrated good clinical response within 8 weeks of ATT initiation.

CONCLUSION

Ocular involvement of TB has been increasingly recognized, especially in endemic regions like Hong Kong. High index of suspicion is recommended for OTB in typical clinical phenotypes or recurrent/resistant ocular inflammation unresponsive to conventional therapy. TB retinal vasculitis was the most common presentation of OTB in this study and OTB generally requires treatment with either regional or systemic steroid together with ATT.

Oxidative Stress and Trace Elements in Pulmonary Tuberculosis Patients During 6 Months Anti-tuberculosis Treatment

Pulmonary tuberculosis (TB) is a well-known cause of imbalance in oxidative stress (OS) status and trace element levels. However, little information is available for targeting the correlation between OS and trace elements in pulmonary TB patients. The aim of our study was to analyze the OS status and its correlation with trace elements in patients initially and during 6 months anti-TB treatment. Eighty-six newly diagnosed pulmonary TB patients were consecutively recruited, and 112 age- and sex-matched healthy controls participated in the study. Serum markers of OS and trace elements levels were tested and analyzed in all subjects during 6 months anti-TB treatment. Compared with healthy controls, significantly increased level of malondialdehyde (MDA), decreased glutathione (GSH) level, superoxide dismutase (SOD), and catalase (CAT) activities were found in TB patients. The activities of SOD and CAT and GSH level recovered till normal range at treatment final. Zinc (Zn), selenium (Se), and copper (Cu) concentrations were significantly lower in TB patients in comparison with healthy controls, whereas Zn, Cu, and Se concentrations rise during 6 months anti-TB treatment. Zn was positively correlated with Cu, Se, and GSH, while MDA was negatively correlated with Zn, Se, SOD, and CAT, and SOD was positively correlated with Cu, Zn, and CAT. Our findings indicate that anti-TB treatment could reduce the status of OS and increase the levels of trace elements. The routine assessment of OS markers and element traces may guarantee improved monitoring the anti-TB treatment.

Population aging and trends of pulmonary tuberculosis incidence in the elderly

BACKGROUND

To explore population aging and the epidemic trend of pulmonary tuberculosis (PTB) in the elderly, and provide a basis for the prevention and control of pulmonary tuberculosis among the elderly.

METHODS

We collected clinical information of 239,707 newly active PTB patients in Shandong Province from 2005 to 2017. We analyzed and compared the clinical characteristics, reported incidence and temporal trend of PTB among the elderly group (≥60 years) and the non-elderly group (< 60 years) through logistic model and Join-point regression model.

RESULTS

Among the total PTB cases, 77,192(32.2%) were elderly. Compared with non-elderly patients, newly active elderly PTB patients account for a greater proportion of male cases (OR 1.688, 95% CI 1.656-1.722), rural population cases (OR 3.411, 95% CI 3.320-3.505) and bacteriologically confirmed PTB cases (OR 1.213, 95%CI 1.193-1.234). The annual reported incidence of total, elderly, pulmonary bacteriologically confirmed cases were 35.21, 68.84, 35.63 (per 100,000), respectively. The annual reported incidence of PTB in the whole population, the elderly group and the non-elderly group has shown a slow downward trend since 2008. The joinpoint regression model showed that the overall reported incidence of PTB in the elderly significantly decreased from 2007 to 2017 (APC = -5.3, P < 0.05). The reported incidence of bacteriologically confirmed PTB among elderly patients declined rapidly from 2005 to 2014(2005-2010 APC = -7.2%, P < 0.05; 2010-2014 APC = -22.6%, P < 0.05; 2014-2017 APC = -9.0%, P = 0.1). The reported incidence of clinically diagnosed PTB among elderly patients from 2005 to 2017 (11.48-38.42/100,000) increased by about 235%. It rose significantly from 2007 to 2014 (APC = 9.4, P<0.05).

CONCLUSIONS

Compared with the non-elderly population, the reported incidence of PTB in the elderly population is higher. The main burden of PTB will shift to the elderly, men, rural population, and clinically diagnosed patients. With the intensification of aging, more researches on elderly PTB prevention and treatment will facilitate the realization of the global tuberculosis (TB) control targets.

Tuberculosis Contact Investigations Conducted in New York City Adult Day Care and Senior Centers, 2011-2018

OBJECTIVES

Multiple tuberculosis (TB) exposures have been reported in New York City (NYC) adult day care and senior centers. Strategies to identify TB transmission at such locations are needed.

METHOD

Review of the NYC TB Registry identified 12 contact investigations (CIs) at adult day care or senior centers (2011-2018).

RESULTS

Median age of the 12 index patients was 81 years. Of 148 contacts identified who had no history of TB infection or disease, 141 (95%) were tested for TB, primarily with interferon gamma release assays; 46 (33%) tested positive. Transmission was probable (n = 3) or possible (n = 1) at 4 (33%) centers; at all of these, the index patient had an acid-fast bacilli-positive sputum smear. Transmission was not found from index patients with negative sputum smears.

DISCUSSION

We found evidence of transmission of smear-positive respiratory TB disease to contacts in adult day care or senior centers, underscoring the importance of CI.

Which sample type is better for Xpert MTB/RIF to diagnose adult and pediatric pulmonary tuberculosis?

Objective: This review aimed to identify proper respiratory-related sample types for adult and pediatric pulmonary tuberculosis (PTB), respectively, by comparing performance of Xpert MTB/RIF when using bronchoalveolar lavage (BAL), induced sputum (IS), expectorated sputum (ES), nasopharyngeal aspirates (NPAs), and gastric aspiration (GA) as sample.

Methods: Articles were searched in Web of Science, PubMed, and Ovid from inception up to 29 June 2020. Pooled sensitivity and specificity were calculated, each with a 95% confidence interval (CI). Quality assessment and heterogeneity evaluation across included studies were performed.

Results: A total of 50 articles were included. The respective sensitivity and specificity were 87% (95% CI: 0.84–0.89), 91% (95% CI: 0.90–0.92) and 95% (95% CI: 0.93–0.97) in the adult BAL group; 90% (95% CI: 0.88–0.91), 98% (95% CI: 0.97–0.98) and 97% (95% CI: 0.95–0.99) in the adult ES group; 86% (95% CI: 0.84–0.89) and 97% (95% CI: 0.96–0.98) in the adult IS group. Xpert MTB/RIF showed the sensitivity and specificity of 14% (95% CI: 0.10–0.19) and 99% (95% CI: 0.97–1.00) in the pediatric ES group; 80% (95% CI: 0.72–0.87) and 94% (95% CI: 0.92–0.95) in the pediatric GA group; 67% (95% CI: 0.62–0.72) and 99% (95% CI: 0.98–0.99) in the pediatric IS group; and 54% (95% CI: 0.43–0.64) and 99% (95% CI: 0.97–0.99) in the pediatric NPA group. The heterogeneity across included studies was deemed acceptable.

Conclusion: Considering diagnostic accuracy, cost and sampling process, ES was a better choice than other sample types for diagnosing adult PTB, especially HIV-associated PTB. GA might be more suitable than other sample types for diagnosing pediatric PTB. The actual choice of sample types should also consider the needs of specific situations.

Risk-benefit analysis of tuberculosis infection testing for household contact management in high-burden countries: a mathematical modelling study

BACKGROUND

Preventive therapy for tuberculosis reduces the risk of disease in people who have been infected but who are not sick. Countries with a high burden of tuberculosis that are expanding preventive therapy use must decide how tuberculosis infection testing should be used for risk stratification among household contacts of patients with tuberculosis.

METHODS

We modelled the risks of tuberculosis disease and severe adverse events, comparing the following two preventive therapy strategies: preventive therapy for all household contacts, or preventive therapy for only household contacts with a positive tuberculin skin test (TST) result. We used data from clinical trials and literature on tuberculosis natural history to model outcomes, assuming different preventive therapy regimens, ages, and TST positivity prevalence.

FINDINGS

Assuming 25% prevalence of TST positivity among 1000 household contacts aged 0-17 years, a treat-all approach with isoniazid and rifapentine compared with a treat-TST-only approach led to 13 fewer incident tuberculosis cases (IQR -5 to -18) and four additional severe adverse events (2 to 6). With rifampicin, the difference was 11 fewer incident tuberculosis cases (-3 to -17) and two additional severe adverse events (1 to 3). For adults, a treat-all approach led to fewer incident tuberculosis cases, and additional adverse events increased with age. Assuming 25% prevalence of TST positivity among adult contacts, a treat-all approach would lead to around two fewer tuberculosis cases per 1000 contacts for all regimens; the number of additional severe adverse events ranged from seven (IQR 5 to 8) for 18 to 34-year-olds treated with rifampicin to 63 (50 to 74) for people older than 64 years treated with isoniazid and rifapentine. A rifampicin-only regimen was associated with the fewest additional severe adverse events (seven [IQR 5 to 8] per 1000 adults aged 18-34 years and 35-64 years, and 17 [9 to 23] per 1000 adults older than 64 years).

INTERPRETATION

Based on the available data, giving preventive therapy to all household contacts would probably reduce the incidence of tuberculosis cases in high-burden settings. Adverse events could be minimised by using non-isoniazid regimens and, in adults older than 18 years, focusing treatment on individuals with a positive infection test.

FUNDING

Bill & Melinda Gates Foundation, UK Medical Research Council, and UK Department for International Development.

[Low detection rate and therapeutic success of tuberculosis in a prison in EcuadorBaixo recrutamento de pacientes e sucesso no tratamento da tuberculose em uma prisão do Equador]

Objetivo.

Evaluar el control de la tuberculosis pulmonar en un centro de privación de la libertad e identificar los factores de riesgo asociados con tratamiento no exitoso en la cárcel más grande en Ecuador.

Métodos.

Se analizaron los datos de vigilancia de la prisión y de una cohorte de internos diagnosticados con tuberculosis (TB) entre los años 2015 y 2016. Se excluyeron los registros sin desenlace en el tratamiento. Se estimó el porcentaje de sintomáticos respiratorios (SR) identificados y la tasa de incidencia de TB. Los factores asociados con el tratamiento no exitoso se estimaron con regresión logística binomial.

Resultados.

De 59 846 consultas médicas, 3% se identificó como SR y, de estos, 326 reclusos tenían TB, 184 fueron analizados. La tasa de incidencia de TB en la prisión fue de 3 947/100 000 habitantes. El porcentaje de tratamiento exitoso fue de 70,4% (65,6% curado y 4,8% con tratamiento completo) y 29,4% de tratamiento no exitoso (12,5% de pérdidas durante el seguimiento, 5% fallecieron, 1,1% de fracasos de tratamiento y 10,8% no fueron evaluados). La seropositividad para el virus de la inmunodeficiencia humana (VIH) se asoció con un mayor riesgo de tratamiento no exitoso (riesgo relativo: 1,66, intervalo de confianza de 95%: 1,33-2,07).

Conclusión.

La incidencia de TB en la prisión es 123 veces más alta que en la población general de Ecuador. Los prisioneros coinfectados con TB-VIH tienen mayor riesgo de no tener un tratamiento exitoso y se requiere articulación entre los ministerios de salud y de justicia que permita la implementación adecuada de protocolos de salud y de la estrategia Fin a la TB.

Altered monocyte phenotypes but not impaired peripheral T cell immunity may explain susceptibility of the elderly to develop tuberculosis

Tuberculosis (TB) is the leading killer due to a single infectious disease worldwide. With the aging of the global population, the case rate and deaths due to TB are highest in the elderly population. While general immunosenescence associated with old age is thought to contribute to the susceptibility of the elderly to develop active TB disease, very few studies of immune function in elderly individuals with Mycobacterium tuberculosis (M.tb) infection or disease have been performed. In particular, impaired adaptive T cell immunity to M.tb is one proposed mechanism for the elderly's increased susceptibility primarily on the basis of the decreased delayed type hypersensitivity response to tuberculin-purified protein derivative in the skin of elderly individuals. To investigate immunological reasons why the elderly are susceptible to develop active TB disease, we performed a cross-sectional observational study over a five year period (2012-2016) enrolling participants from 2 age groups (adults: 25-44 years; elderly: 65 and older) and 3 M.tb infection statuses (active TB, latent TB infection, and healthy controls without history of M.tb infection). We hypothesized that impaired peripheral T cell immunity plays a role in the biological susceptibility of the elderly to TB. Contrary to our hypothesis, we observed no evidence of impaired M.tb specific T cell frequency or altered production of cytokines implicated in M.tb control (IFN-γ, IL-10) in peripheral blood in the elderly. Instead, we observed alterations in monocyte proportion and phenotype with age and M.tb infection that suggest their potential role in the susceptibility of the elderly to develop active TB. Our results suggest a potential link between the known widespread low-grade systemic inflammation of old age, termed "inflammaging," with the elderly's specific susceptibility to developing active TB. Moreover, our results highlight the need for further research into the biological reasons why the elderly are more susceptible to disease and death from TB, so that public health systems can be better equipped to face the present and future problem of TB in an aging global population.