Abstract

Tuberculosis (TB) surveillance commonly focuses on pulmonary (PTB) where the main organ affected is the lung. This might lead to underestimate extrapulmonary TB (EPTB) forms, where in addition to the lung other sites are affected by TB. In Germany, TB notification data provide the main site and the secondary site of disease. To gain an overview of all the different EPTB forms, we analysed German TB notification data between 2002 and 2009 using information on both main and secondary disease site to describe all individual EPTB forms. Further, we assessed factors associated with meningitis using multivariable logistic regression. Solely analysing the main site of disease, lead to one third of EPTB manifestations being overlooked. Case characteristics varied substantially across individual extrapulmonary forms. Of 46,349 TB patients, 422 (0.9%) had meningitis as main or secondary site. Of those, 105 (25%) of the 415 with available information had died. Multivariable analysis showed that meningitis was more likely in children younger than five years and between five and nine years-old (odds ratio (OR): 4.90; 95% confidence interval (CI): 3.40–7.07 and OR: 2.65; 95% CI: 1.40–5.00), in females (OR: 1.42; 95% CI: 1.17–1.73), and in those born in the World Health Organization (WHO) regions of south-east Asia (OR: 2.38; 95% CI: 1.66–3.43) and eastern Mediterranean (OR: 1.51; 95% CI: 1.02–2.23). Overall, EPTB manifestations, including meningitis, which is often fatal, were underestimated by routine analysis. We thus recommend using all information on disease manifestation generated by surveillance to monitor severe forms and to transfer the gained knowledge to TB case management where awareness of EPTB is most important.

Highlights

  • Global tuberculosis (TB) control focuses on pulmonary tuberculosis (PTB) to prevent transmission and reduce the number of new cases

  • extrapulmonary TB (EPTB) is more common in immunocompromised individuals, especially people living with human immunodeficiency virus (HIV) [3,4,5,6,7], and females and different ethnic groups [3,5,6,7,8,9,10]; for example, in the United Kingdom (UK) all non-white ethnic groups were associated with EPTB [8]

  • From 2002 to 2009, a total of 46,730 TB patients were reported in Germany

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Summary

Introduction

Global tuberculosis (TB) control focuses on pulmonary tuberculosis (PTB) to prevent transmission and reduce the number of new cases. In surveillance, TB cases are classified as pulmonary TB whenever lungs are involved, irrespective of any additional involvement of other organs [1]. Extrapulmonary TB (EPTB), a collective term for diverse manifestations affecting any other anatomic site than the lung parenchyma and the tracheobronchial tree, substantially contributes to the TB burden. EPTB is more common in immunocompromised individuals, especially people living with human immunodeficiency virus (HIV) [3,4,5,6,7], and females and different ethnic groups [3,5,6,7,8,9,10]; for example, in the United Kingdom (UK) all non-white ethnic groups were associated with EPTB [8]. Socio-behavioural factors including smoking and alcohol abuse, in contrast, were associated with pulmonary manifestation [6,7,11,12,13]

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