ESTIMATION OF THE FUTURE EPIDEMIOLOGICAL SITUATION OF TUBERCULOSIS IN JAPAN

The management of active tuberculosis (TB) in solid organ transplantation (SOT) recipients is challenging given the pharmacological interaction and the potential delays in diagnosis due to atypical presentation. The incidence rates (IRs) of post-SOT TB from the whole recipients' cohort in a high-endemic country have not been evaluated. We established a SOT cohort (n = 15 598) and confirmed cases of TB between 2011 and 2015 from the Korean National Health Insurance Database using ICD-10 codes. After excluding 1302 and 180 SOT-recipients due to age (<18 years) and presence of pre-SOT TB and/or treatment for latent TB during wash-out period between 2006 and cohort entry, we analyzed 14 116 SOT recipients and 70 580 individuals with no history of SOT matched by age and sex. The hazard ratios (HRs) of IRs were adjusted for age, sex, low-income status, diabetes mellitus, chronic co-morbidities, and anti-TNF-α therapy. The IR of TB was significantly higher (adjusted HR [aHR]: 6.1, 95% confidence interval [CI]: 4.5-7.6) in SOT recipients (4.9/1000 person-years) than in non-SOT individuals (0.8/1000 person-years). Of the transplanted organs, the pancreas (pancreas alone and simultaneous pancreas-kidney) and lung had the highest IR (aHR: 16.3 [6.1-42.2] and 16.1 [5.9-43.8], respectively). The use of anti-thymocyte globulin and azathioprine was associated with a higher IR (aHR: 1.53 [1.01-2.43] and 3.92 [1.21-12.47], respectively), but basiliximab was associated with a lower IR (aHR: 0.67 [0.48-0.98]). The IR of TB in SOT recipients, especially in the pancreas and lung, was significantly higher than that in the non-SOT population.

Tuberculosis (TB) incidence and mortality rates are still high in Sub-Saharan Africa, and the knowledge about the current patterns is valuable for policymaking to decrease the TB burden. Based on the Global Burden of Disease (GBD) study 2019, we used a Joinpoint regression analysis to examine the variations in the trends of TB incidence and mortality, and the age-period-cohort statistical model to evaluate their risks associated with age, period, and cohort in males and females from Cameroon (CAM), Central African Republic (CAR), Chad, and the Democratic Republic of the Congo (DRC). In the four countries, TB incidence and mortality rates displayed decreasing trends in men and women; except for the males from DRC that recorded an almost steady pattern in the trend of TB incidence between 1990 and 2019. TB incidence and mortality rates decreased according to the overall annual percentage changes over the adjusted age category in men and women of the four countries, and CAM registered the highest decrease. Although TB incidence and mortality rates increased with age between 1990 and 2019, the male gender was mainly associated with the upward behaviors of TB incidence rates, and the female gender association was with the upward behaviors of TB mortality rates. Males and females aged between 15–54 and 15–49 years old were evaluated as the population at high risks of TB incidence and mortality respectively in CAM, CAR, Chad, and DRC. The period and cohort relative risks (RRs) both declined in men and women of the four countries although there were some upward behaviors in their trends. Relatively to the period and cohort RRs, females and males from CAM recorded the most significant decrease compared to the rest of the countries. New public health approaches and policies towards young adults and adults, and a particular focus on elderlies’ health and life conditions should be adopted in CAM, CAR, DRC, and Chad to rapidly decrease TB incidence and mortality in both genders of the four countries.

BackgroundUndiagnosed asymptomatic subclinical tuberculosis (TB) remains a significant threat to global TB control, accounting for a substantial proportion of cases among people living with human immunodeficiency virus (HIV)/AIDS (PLWHA). We determined incidence, progression, and outcomes of subclinical TB in antiretroviral therapy (ART)–accessing PLWHA with known previous TB in South Africa.MethodsA total of 402 adult PLWHA previously treated for TB were enrolled in the prospective Centre for the AIDS Programme of Research in South Africa TRuTH (TB Recurrence Upon TB and HIV treatment) Study. Participants were screened for TB with quarterly clinical and bacteriologic evaluation and biannual chest radiographs over 36 months. Those with suspected or confirmed TB were referred to the National TB Programme. Participants received HIV services, including ART. Incidence rate of TB was estimated using Poisson regression and descriptive statistical analyses summarized data.ResultsA total of 48 of 402 (11.9%) bacteriologically confirmed incident recurrent TB cases were identified, comprising 17 of 48 (35.4%) subclinical TB cases and 31 of 48 (64.5%) clinical TB cases. Age, sex, and body mass index were similar among subclinical, clinical, and no TB groups. Incidence rates (95% Confidence Interval [CI]) of recurrent TB overall, in clinical and subclinical TB groups were 2.3 (1.7-3.0), 1.5 (1.1-2.2), and 0.9 (0.5-1.4) per 100 person-years, respectively. In the subclinical TB group, 14 of 17 (82.4%) were diagnosed by TB culture only, 11 of 17 (64.7%) received TB treatment, and 6 of 17 (35.3%) resolved TB spontaneously.ConclusionsHigh incidence rates of recurrent subclinical TB in PLWHA highlight inadequacies of symptom-based TB screening in high TB–HIV burden settings.

Objective — to study trends and characteristics of the patterns of tuberculosis (TB) incidence among medical workers of Vinnytsya region during 2007—2023. Materials and methods. The primary medical records (cards of inpatients and outpatients, report forms) of 207 medical workers of the Vinnytsya region who were diagnosed with TB from 2007 to 2023 was analyzed. The study included only employees of healthcare institutions of Vinnytsya who provided medical services to patients (doctors, middle and junior medical staff), excluding the staff of the technical sector of medical institutions. Based on the data of the official documentation, the peculiarities of the incidence and clinical course of TB among medical workers of the general treatment network and anti-tuberculosis institutions were studied. Results and discussion. According to the results of the analysis, from 2007 to 2023, 207 cases of TB were observed among medical workers in the Vinnytsya region, which accounted for 1.6 % of all TB cases in the region. In general, during the 17-year study period, the incidence of TB among medical workers in the Vinnytsya region was lower than the incidence of the population (48.7 per 100 000 medical workers versus 58.9 per 100,000 population of the region, p &lt; 0.01). The incidence among medical workers in anti-tuberculosis facilities in general amounted to 535.5 per 100,000 medical workers in anti-tuberculosis facilities. In general healthcare facilities, the incidence of middle medical personnel was 42.3 per 100,000 people, junior medical staff — 46.9 per 100.000 people, and doctors — 42.4 per 100,000 doctors, and among healthcare workers of anti-tuberculosis facilities — 766, 525 and 113 per 100,000 people, respecti­vely. Pulmonary forms of the disease were diagnosed in 173 people (83.6 %), and extrapulmonary forms were diagnosed in 34 medical workers (16.4 %). Among all cases of pulmonary TB, focal forms were found in 39 medical workers (22.5 %), infiltrative forms in 57 medical workers (32.9 %), and disseminated forms in 67 medical workers (38.7 %), and in 8 people (5.9 %) were diagnosed with pulmonary tuberculomas. The number of TB relapses was 36 (17.4 %), and the incidence rate was 8.1 per 100,000 medical workers. Conclusions. From 2007 to 2023, the incidence of TB among medical workers in the Vinnytsya region was lower than in the general population (46.8 per 100,000 medical workers versus 56.8 per 100,000 population of the region), while among healthcare workers in TB facilities, it was 11 times higher than among those in general healthcare facilities (535.5 and 46.8 per 100,000 medical workers, respectively). The highest number of TB cases among medical workers in general healthcare facilities was registered in junior medical staff, whereas in TB facilities, it was most common among middle medical staff. The incidence of extrapulmonary TB among medical workers was higher than in the general population — 7.6 and 5.1 per 100,000 people, respectively. Among pulmonary forms of TB in medical workers, limited forms predominated (61.3 %), and disease relapses were less frequent compared to the general population (the incidence rate was 8.1 and 10.5 per 100,000 people, respectively).

An alternative estimation of tuberculosis incidence from 1980 to 2010: methods from the Global Burden of Disease 2010

BackgroundAccelerating declines in tuberculosis (TB) incidence is paramount for achieving global goals set for 2030 by the Sustainable Development Goals and the End TB Strategy. The aim of this study was to identify key country-level social determinants of national TB incidence trends.MethodsThis longitudinal ecological study used country-level data extracted from online databases from the period 2005–2015. We used multivariable Poisson regression models allowing for distinct within- and between-country effects to estimate associations between national TB incidence rates and 13 social determinants of health. The analysis was stratified by country income status.ResultsThe study sample included 48 low- and lower-middle-income countries (LLMICs) and 68 high- and upper-middle income countries (HUMICs), with a total of 528 and 748 observations between 2005–2015, respectively. National TB incidence rates declined in 108/116 countries between 2005–2015, with an average drop of 12.95% in LLMICs and 14.09% in HUMICs. Between LLMICs, higher Human Development Index (HDI), social protection spending, TB case detection, and TB treatment success were associated with lower TB incidence. Higher prevalence of HIV/AIDS was associated with higher TB incidence. Within LLMICs, increases in HDI over time were associated with lower TB incidence rates. Between HUMICs, higher HDI, health spending, and diabetes prevalence were associated with lower TB incidence, whereas higher prevalence of HIV/AIDS and alcohol-use were associated with higher TB incidence. Within HUMICs, increases in HIV/AIDS and diabetes prevalence over time were associated with higher TB incidence.ConclusionsIn LLMICs, TB incidence rates remain highest in countries with low human development, social protection spending and TB programme performance, and high rates of HIV/AIDS. Strengthening human development is likely to accelerate declines in TB incidence. In HUMICs, TB incidence rates remain highest in countries with low human development, health spending and diabetes prevalence, and high rates of HIV/AIDS and alcohol use. Here, slowing rising rates of HIV/AIDS and diabetes is likely to accelerate declines in TB incidence.

Elevated tuberculosis (TB) incidence rates have recently been reported for racial/ethnic minority populations in the United States. Tracking such disparities is important for assessing progress toward national health equity goals and implementing change. To quantify trends in racial/ethnic disparities in TB incidence among U.S.-born persons. Time-series analysis of national TB registry data for 2011 to 2021. United States. U.S.-born persons stratified by race/ethnicity. TB incidence rates, incidence rate differences, and incidence rate ratios compared with non-Hispanic White persons; excess TB cases (calculated from incidence rate differences); and the index of disparity. Analyses were stratified by sex and by attribution of TB disease to recent transmission and were adjusted for age, year, and state of residence. In analyses of TB incidence rates for each racial/ethnic population compared with non-Hispanic White persons, incidence rate ratios were as high as 14.2 (95% CI, 13.0 to 15.5) among American Indian or Alaska Native (AI/AN) females. Relative disparities were greater for females, younger persons, and TB attributed to recent transmission. Absolute disparities were greater for males. Excess TB cases in 2011 to 2021 represented 69% (CI, 66% to 71%) and 62% (CI, 60% to 64%) of total cases for females and males, respectively. No evidence was found to indicate that incidence rate ratios decreased over time, and most relative disparity measures showed small, statistically nonsignificant increases. Analyses assumed complete TB case diagnosis and self-report of race/ethnicity and were not adjusted for medical comorbidities or social determinants of health. There are persistent disparities in TB incidence by race/ethnicity. Relative disparities were greater for AI/AN persons, females, and younger persons, and absolute disparities were greater for males. Eliminating these disparities could reduce overall TB incidence by more than 60% among the U.S.-born population. Centers for Disease Control and Prevention.

Safety of resuming biologic DMARDs in patients who develop tuberculosis after anti-TNF treatment

The aim of this study was to assess the risk of active tuberculosis (TB) in patients with immune-mediated inflammatory diseases treated with biologics and tofacitinib in randomized controlled trials (RCTs) and long-term extension (LTE) studies. A systematic review of the English-language literature by was performed by searching the Medline, Embase, Cochrane and Web of Knowledge databases. The search strategy focused on synonyms of diseases, biologics and tofacitinib. Data from RCTs were combined to assess the rate of TB using a random effects model. The incidence rate (IR) of TB and its association with disease, location and treatment were assessed in LTE studies. The search captured 11 130 articles and abstracts. One-hundred RCTs (75 000 patients) and 63 LTE studies (80 774.45 patient-years) met the inclusion criteria. There were 31 TB cases with TNF inhibitors, 1 with abatacept and none with rituximab, tocilizumab, ustekinumab or tofacitinib. The odds ratio for TNF inhibitors was 1.92 (95% CI 0.91, 4.03, P = 0.085). In LTE studies, the IR of TB was >40/100 000 with tofacitinib and all biologics except rituximab. IR was higher in RA patients with anti-TNF monoclonal antibodies [307.71 (95% CI 184.79, 454.93)] than in those with rituximab [20.0 (95% CI 0.10, 60)] and etanercept [67.58 (95% CI 12.1, 163.94)] or AS, PsA and psoriasis with etanercept [60.01 (95% CI 3.6, 184.79)]. The IR of TB was higher in high-background TB areas. RCTs are not sensitive enough to assess the risk of reactivation of latent TB infection (LTBI). Disease, treatment and background TB rate are associated with different frequencies of active TB. The benefit/risk balance of preventing reactivation of LTBI in different backgrounds should be considered in clinical practice.

Tuberculosis incidence and mortality in aboriginal areas of Taiwan, 1997-2001.

To describe the incidence rates of inflammatory bowel disease (IBD) and tuberculosis (TB) in Korean patients with ankylosing spondylitis receiving biologics. Data from a Korean claims database between 2010 and 2021 was used to calculate crude incidence rates of TB and IBD using number of events and total patient-years (PYs). Overall, 43 643 and 43 396 patients were included in TB and IBD cohorts, respectively. Exposure-adjusted incidence rates (EAIRs) of TB for non-exposure, TNF inhibitors (TNFis), and IL-17 inhibitors (IL-17is) were 0.14, 0.25 and 0.12 and of IBD were 0.18, 0.19 and 0.44 per 100 PYs, respectively. Incidence rates during biologic DMARD (bDMARD) non-exposure, adalimumab, etanercept, golimumab, infliximab, secukinumab and ixekizumab exposures for TB were 13.96, 27.79, 14.28, 21.19, 33.62, 12.74 and 0.00 and for IBD were 18.29, 19.98, 22.41, 18.85, 15.73, 44.99 and 0.00 per 10 000 PYs, respectively. Compared with bDMARD non-exposure, adalimumab, golimumab and infliximab exposures were associated with a significantly higher risk of TB. Etanercept and secukinumab exposure showed no significant increase in risk of TB. Compared with bDMARD non-exposure, exposure to biologics did not show a significant difference in risk of IBD. EAIRs of TB and IBD with use of IL-17is in patients with AS were within anticipated low range. IL-17is had numerically lower incidence of TB, and numerically higher incidence of IBD compared with TNFis. Notably, secukinumab showed no increased risk of TB compared with bDMARD non-exposure. Neither TNFis nor IL-17is showed increased risk of IBD compared with bDMARD non-exposure.

BACKGROUND AND OBJECTIVES:There are few reports of cutaneous tuberculosis with immunosuppressed states such as HIV, use of immunosuppressants or malignancy. Diagnosis is thus difficult and despite scientific advances such as polymerase chain reaction, it is frequently missed. Although rare, given its worldwide prevalence and the rising incidence of HIV, it is important for clinicians to recognize the variants and promptly treat the patient.DESIGN AND SETTING:Retrospective study of all cases of cutaneous tuberculosis diagnosed from October 2007 to November 2009 at an outpatient clinic of a tertiary-care hospital in northern India.METHODS:We collected information on the clinical form of disease, histopathology and HIV concurrence rates and looked for differences in presentation between mmunocompetent and immunocompromised states. We also looked for differences and HIV concurrence between immunocompetent and immunocomprised patients. Diagnosis was based on clinical, histopathological and microbiological tests for tuberculosis and a test for HIV.RESULTS:The overall incidence of cutaneous tuberculosis was 0.7% (131 of 18720 outpatients). HIV concurrence was 9.1% (12 cases) of all cutaneous tuberculosis cases. Most common variants seen were scrofuloderma (36.5%), lupus vulgaris (31%), tuberculosis verruca cutis (12.9%), lichen scrofulosorum (11.4%), papulonecrotic tuberculids (3.8%), erythema nodosum (2.2%) and erythema induratum of Bazin (1.5%).CONCLUSIONS:Cutaneous tuberculosis rates were slightly higher in our study than in other studies from India. HIV co-infection rates were similar to those in other studies. Many atypical morphological forms and presentations were observed in HIV co-infected patients. Due to the varied clinical presentations, physician awareness and a high index of suspicion are necessary to diagnose cutaneous forms of tuberculosis.

Aim:Tuberculosis (TB) continues to be a considerable burden especially for millions of young adults and disadvantaged people worldwide. The TB incidence and notification rates are good indicators of TB situation in a country. Our aim was to compare TB incidence and notification rates in Kosovo and in seven other Balkan countries.Methods:Retrospective epidemiologic analysis of published data on TB incidence and notification rates in eight Balkan countries in 2012. Notification rates were expressed per 100,000 inhabitants and were calculated based on the number of TB cases reported divided by the population of each country under analysis.Results:The TB incidence in Kosovo (47/100,000) was considerably higher compared to its four neighboring countries: Albania (16/100,000), Macedonia, Montenegro (18/100,000) and Serbia (23/100,000). The TB notification rates in Kosovo and other countries closely mimicked the incidence rates in these countries.Conclusion:The exceptionally high TB incidence rate in Kosovo could be due to many factors including low health and medical-seeking behaviors of the local population, poverty and low education levels. Effective interventions should be adapted to the local context in order to increase the chances of success.

Epidemiology News

BackgroundBiological therapy, especially anti-tumor necrosis factor alpha, increases the risk of reactivation of latent tuberculosis (TB) infection in patients with rheumatoid arthritis (RA) (1). The influence of the underlying RA...