Management Of Latent Tuberculosis Infection Research Articles

Tuberculosis preventive treatment uptake among people living with HIV during COVID-19 period in Addis Ababa, Ethiopia: a retrospective data review

BackgroundScreening for tuberculosis (TB) and providing TB preventive treatment (TPT) along with antiretroviral therapy is key components of human immune deficiency virus (HIV) care. The uptake of TPT during the coronavirus disease 2019 (COVID-19) period has not been adequately assessed in Addis Ababa City Administration. This study aimed at assessing TPT uptake status among People living with HIV (PLHIV) newly initiated on antiretroviral therapy during the COVID-19 period at all public hospitals of Addis Ababa City Administration, Ethiopia.MethodsA retrospective data review was conducted from April-July 2022. Routine District Health Information System 2 database was reviewed for the period from April 2020-March 2022. Proportion and mean with standard deviation were computed. Logistic regression analysis was conducted to assess factors associated with TPT completion. A p-value of < 0.05 was considered statistically significant.ResultsA total of 1,069 PLHIV, aged 18 years and above were newly initiated on antiretroviral therapy, and of these 1,059 (99.1%) underwent screening for TB symptoms. Nine hundred twelve (86.1%) were negative for TB symptoms. Overall, 78.8% (719) of cases who were negative for TB symptoms were initiated on TPT, and of these 70.5% and 22.8% were completed and discontinued TPT, respectively. Of 719 cases who were initiated on TPT, 334 (46.5%) and 385 (53.5%) were initiated on isoniazid plus rifapentine weekly for three months and Isoniazid preventive therapy daily for six months, respectively. PLHIV who were initiated on isoniazid plus rifapentine weekly for three months were more likely to complete TPT (adjusted odds ratio [AOR],1.68; 95% confidence interval [CI], 1.01, 2.79) compared to those who were initiated on Isoniazid preventive therapy daily for six months.ConclusionWhile the proportion of PLHIV screened for TB was high, TPT uptake was low and far below the national target of achieving 90% TPT coverage. Overall a considerable proportion of cases discontinued TPT in this study. Further strengthening of the programmatic management of latent TB infection among PLHIV is needed. Therefore, efforts should be made by the Addis Ababa City Administration Health Bureau authorities and program managers to strengthen the initiation and completion of TPT among PLHIV in public hospitals.

Diagnosis and Management of Latent Tuberculosis Infection: Updates.

India has the largest problem of tuberculosis (TB) infection globally (estimated at about 35-40 crores cases), and around 18-36 lakh develop active tuberculosis annually. Latent TB is defined as a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens with no evidence of clinically manifested active TB. The progression of a latent infection to active tuberculosis increases several-fold in children < 5 years of age and in people with some or the other form of an immunocompromising condition. Therefore, to cater to this gigantic problem of tuberculosis, it is necessary to have awareness about latent tuberculosis infection (LTBI) amongst clinicians and to prioritise its diagnosis and treatment in high-risk groups. India plans to end TB well before the deadline set by the World Health organisation (WHO). However, this can only be achieved with effective strategies targeting LTBI. Multiple treatment regimens have been approved for LTBI treatment, and all have comparable efficacy. The selection of one regimen over the other depends on various factors, such as availability, risk of adverse events, age, and drug interactions. Recently, the WHO, as well as the Revised National TB Control Programme (RNTCP), have updated their guidelines on TB preventive treatment in 2020 and 2021, respectively. This review has been especially prepared to acknowledge the differences in approach to LTBI in developed and developing countries.

Randomized Controlled Trial of Clinical Guidelines Versus Interactive Decision-Support for Improving Medical Trainees' Confidence with Latent Tuberculosis Care.

In order to eliminate tuberculosis (TB) in the USA, primary care providers must take on an expanded role in the diagnosis and management of latent tuberculosis infection (LTBI). Clinical practice guidelines and recommendations exist for LTBI management, but there is a need for innovative tools to improve medical students' and residents' knowledge of evidence-based practices for LTBI testing and treatment. To assess the impact of LTBI-ASSIST, a free online decision support aid, as a novel educational tool and mechanism of delivering clinical practice guidelines for medical trainees. A single site, randomized controlled trial of trainees delivered by electronic survey. Medical students and Internal Medicine residents at the Johns Hopkins University School of Medicine. Participants were randomized in 1:1 ratio to receive the US clinical practice guidelines and recommendations for Latent TB management (control arm) or the guidelines plus an introduction to LTBI-ASSIST (LTBI-ASSIST arm) as they completed a case-based knowledge assessment and reported confidence with domains of LTBI care. (1) Proportion of questions answered correctly on a case-based knowledge assessment; (2) change in reported confidence with domains of LTBI care. One hundred and thirty participants completed the knowledge assessment. Those randomized to receive the LTBI-ASSIST Tool performed better on the case-based knowledge assessment with a mean score of 75.9% (95% CI: 70.6-81.1), compared to 57.4% (52.8-62.0) in the group that received the guidelines only (p <0.001). Similarly, the LTBI-ASSIST group reported a higher change in confidence (measured as post-assessment confidence minus pre-assessment confidence), compared to the control group, in six of the seven domains of LTBI care. LTBI-ASSIST can be an effective supplement to existing guidelines in educating medical trainees and helping providers find evidence-based, guideline-supported answers for questions encountered in clinical practice. NIH Clinical Trial Registry No. NCT05772065.

1869. Knowledge about and Perceptions of Latent Tuberculosis Infection (LTBI) among Physicians and Advanced Practice Providers at Tufts Medical Center

Abstract Background Mycobacterium Tuberculosis (TB) is a leading cause of infectious disease mortality worldwide. Most active TB cases result from reactivation of latent tuberculosis infection (LTBI). A large reservoir of latent TB is a major public health problem worldwide and in the United States. A better understanding of provider perspectives on LTBI could improve a sub-optimal LTBI care cascade. Methods A 13-question survey was fielded to attending physicians, fellows, and advanced practice providers working in the infectious disease, pulmonary/critical care, and general medicine departments at Tufts Medical Center (TMC), an academic tertiary care center in Boston, Massachusetts. Results The response rate of the survey was 33% (62/186). Only 17 (30.9%) providers were able to correctly identify all indications for screening. When asked how they decide who to treat, 26.8% (15/56) of providers selected that they would refer their patient to another specialist. Overall, provider confidence in LTBI management decreased along the care cascade (Figure 1). Infectious disease providers expressed more confidence in management than general medicine and pulmonary/critical care providers. The two most observed issues/barriers to care for patients were language, reported by 39 (76.5%) providers, and lack of knowledge or understanding about TB, reported by 39 (76.5%) providers. The two most selected interventions to improve LTBI care at TMC were use of in-person language interpreters, chosen by 37 (71.2%) providers, and information pamphlets available in patients’ preferred languages, chosen by 36 (69.2%) providers. Providers were asked “On a scale of 1-5, (“1” = not at all, and “5” = perfectly) “How confident are you in your ability to do the following” for the listed management tasks. Conclusion Results suggest that providers believe the largest barriers to patient LTBI treatment completion are due to a lack of patient comprehension about their infection. Improving patient understanding could be accomplished through in-person interpreters, information pamphlets about LTBI in patients’ preferred languages, and forming community partnerships to improve awareness and understanding of the risks of LTBI. Additionally, ensuring that providers feel confident in their ability to manage LTBI, are updated on screening guidelines, and have referral resources when needed, could help close the gaps in the LTBI care cascade. Disclosures All Authors: No reported disclosures

Effect of a Latent Tuberculosis Infection Programme for Healthcare Workers in a Country with an Intermediate Tuberculosis Burden

Management of latent tuberculosis infection (LTBI) among healthcare workers (HCWs) is crucial for the prevention of nosocomial tuberculosis (TB) transmission. We aimed to determine the effect of an LTBI programme for HCWs in a tertiary care hospital in a country with an intermediate TB burden. In 2013, baseline LTBI screening was implemented for newly hired doctors and nurses, along with annual screening of HCWs in high-risk departments. HCWs with LTBI were also provided with treatment. Since 2017, all HCWs without an LTBI test result have been tested for LTBI. We assessed the annual incidence of active TB among HCWs between 2013 and 2020. Additionally, we evaluated the incidence of active TB among HCWs employed at the hospital in 2020, with a specific focus on those who had undergone LTBI tests between 2013 and 2018, considering their LTBI test results and treatment status. The incidence of active TB among HCWs significantly decreased between 2013 and 2020. The average risk reduction for pulmonary TB was 10.2% per year (95% CI, 1.0-19.0; p = 0.034). Among HCWs employed at the hospital in 2020, 4,354 individuals underwent LTBI tests between 2013 and 2018. Out of them, 927 (21.3%) tested positive. Nine (1.5%) out of 588 without LTBI treatment developed active TB. Among the 1,285 HCWs who underwent follow-up testing, 62 (4.8%) converted, and one (4.3%) out of the 23 without treatment developed active TB. None of those who received treatment were diagnosed with active TB. The LTBI programme significantly reduced the incidence of active TB in HCWs. LTBI screening and treatment should be implemented, particularly in countries with a high or intermediate TB burden.

Latent Tuberculosis: Challenges in Diagnosis and Treatment, Perspectives, and the Crucial Role of Biomarkers.

Tuberculosis (TB) is the major cause of morbidity and mortality globally, which is caused by a single infectious agent Mycobacterium tuberculosis. For years, many TB control programmes are established for effective diagnosis and treatment of active TB cases, but these approaches alone are insufficient for TB eradication. This review aims to discourse on the crucial management of latent tuberculosis infection. This review will first summarize the current status, and methods for diagnosing latent tuberculosis then describes the challenges involved in the diagnosis and treatment of latent tuberculosis, and finally encounters the purpose of biomarkers as predicting tool in latent tuberculosis.

Facilitators and barriers to latent tuberculosis infection treatment among primary healthcare workers in Malaysia: a qualitative study

BackgroundHealthcare workers (HCWs) have an increased risk of active and latent tuberculosis infection (LTBI) compared to the general population. Despite existing guidelines on the prevention and management of LTBI, little is known about why HCWs who tested positive for LTBI refuse treatment. This qualitative study sought to explore the facilitators and barriers to LBTI treatment uptake among primary HCWs in Malaysia.MethodsThis qualitative study used a phenomenological research design and was conducted from July 2019 to January 2021. A semi-structured topic guide was developed based on literature and the Common-Sense Model of Self-Regulation. We conducted one focus group discussion and 15 in-depth interviews with primary care HCWs. Interviewees were 7 physicians and 11 allied HCWs who tested positive for LTBI by Tuberculin Skin Test or Interferon Gamma Release Assay. Audio recordings were transcribed verbatim and thematic analysis was used to analyse the data.ResultsWe found four factors that serve as barriers to HCWs’ LTBI treatment uptake. Uncertainties about the need for LTBI treatment, alongside several other factors including the attitude of the treating physician towards treatment, time constraints during clinical consultations, and concerns about the treatment itself. On the other hand, facilitators for LTBI treatment uptake can be grouped into two themes: diagnostic modalities and improving knowledge of LTBI treatment.ConclusionsImproving HCWs’ knowledge and informative clinical consultation on LTBI and its treatment benefit, aided with a definitive diagnostic test can facilitate treatment uptake. Additionally, there is a need to improve infection control measures at the workplace to protect HCWs. Utilizing behavioural insights can help modify risk perception among HCWs and promote treatment uptake.

Latent tuberculosis infection in liver transplant patients: a review.

Latent tuberculosis infection in liver transplant patients: a review.

Impact of COVID-19 Pandemic on Tuberculosis Preventive Services and Their Post-Pandemic Recovery Strategies: A Rapid Review of Literature.

Coronavirus disease 2019 (COVID-19) pandemic has disrupted tuberculosis (TB) care and prevention around the world. The aim of this study is to review literature on the impact of COVID-19 on TB preventive services and discuss their policy options during and after the pandemic. We conducted a rapid review of scientific literature on the impact of COVID-19 on TB preventive services and their recovery strategies. After conducting a line-by-line open coding, their codes were applied in the descriptive theme building process, which was guided by the End TB strategy. TB preventive measures were selected and classified into five analytical categories: 1) vaccination against TB, 2) detection and treatment of latent TB infection (LTBI), 3) screening and diagnostics, 4) active case finding and contact tracing, and 5) surveillance. We identified 93 articles, of which 65 were research articles. During the pandemic, we observed decrease in Bacillus Calmette-Guérin (BCG) coverage, TB diagnostic services, case finding activities, and LTBI management. TB case detection was declined, which was not resumed to the pre-pandemic level after loosening the lock-down. Several recommendations were highlighted: 1) secure BCG stocks and its supply chains, 2) consider catch-up activities of routine immunization and LTBI screening, 3) maintain minimal TB health services, infection prevention and control, and surveillance, 4) leverage laboratory capacity and contact tracing mechanisms, 5) consider simultaneous testing for TB and COVID-19, and 6) Incorporate digital health technologies. Our findings and lessons learnt from the pandemic can aid in the development of future national TB control program.

“It’s too hard” – the management of latent TB in under-served populations in the UK: a qualitative study

BackgroundUK national guidance recommends systematic screening for latent tuberculosis infection (LTBI) in under-served populations, including people experiencing homelessness and people who use drugs. This is not routinely implemented in the UK, and the reasons for this policy-practice mismatch remain underexplored.MethodsSemi-structured qualitative interviews were conducted with 19 healthcare professionals from across the UK. Participants were recruited using purposive sampling and snowballing, identifying individuals with excellent knowledge of their regions practice and policy of LTBI management. The interviews were conducted online, and were audio recorded, with transcripts thematically analysed using a two-stage inductive coding process to explore perceived barriers and enablers to LTBI screening.ResultsMost participants had previous experience managing LTBI in under-served populations, but none were conducting systematic screening as per national guidance. We identified service provision challenges and low prioritisation of LTBI as the key explanatory themes driving this policy-practice mismatch. Lack of resource, and the complexity of clinical decision making were two key service level barriers. System and service inertia, and lack of cost effectiveness evidence led to LTBI being deprioritised. Service integration and promotion of WHO targets for TB elimination were highlighted as potential solutions.ConclusionIntegrating LTBI testing and treatment with existing health services for under-served populations could improve feasibility and efficacy. Promotion of UK TB elimination goals and generation of regional evidence to support commissioning for LTBI care is vital. Without such a multi-pronged approach inertia is likely to persist and the zeitgeist will remain: “it’s too hard”.

Optimizing tuberculosis screening for immigrants in southern New Brunswick: A pilot study protocol.

Immigrants from high tuberculosis-burdened countries have been shown to have an increased risk of latent tuberculosis infection (LTBI). To reduce the risk of increased tuberculosis cases in Canada, the country has a comprehensive immigration medical examination process that identifies individuals with active tuberculosis using chest X-ray; however, it fails to identify LTBI. The lack of LTBI identification is concerning because immigrants with LTBI are at an increased risk of developing active tuberculosis within their first few years of migration due to stressful experiences common to many immigrants. The goal of this pilot study is to improve the current LTBI screening protocols among immigrants from high tuberculosis incidence countries and to better prevent and manage tuberculosis cases, by introducing an LTBI screening pilot program. The objectives are threefold: 1) to screen LTBI in immigrants from high tuberculosis incidence countries, including immigrants identified as being at risk of LTBI by the NB health care system, using the QuantiFERON-TB Gold Plus interferon-gamma release assay (IGRA); 2) to offer LTBI treatment and supports to those identified as having LTBI; and 3) to assess immigrant and health care providers (HCPs) satisfaction of the LTBI screening pilot program. This cross-sectional study seeks to recruit 288 participants. Participants will be recruited via posters, social media platforms, invitations at immigrant wellness check-ups, presentations to local ethnocultural groups, and by snowball sampling. Consenting participants will be asked to submit a blood sample for LTBI screening; if positive, participants will be assessed and offered treatment for LTBI based on clinical assessment. Participants and HCPs' feedback will be gathered via short questionnaires. For the quantitative portion of the study, descriptive statistics will be used to summarize participant characteristics and feedback. Simultaneous logistic regression will be performed to identify variables associated with the IGRA test outcome and evidence of increased CD8 T-cell immune response among those found to be LTBI-positive. Qualitative results will be analyzed using inductive thematic analysis. The findings from this study will allow us to understand the role of the IGRA LTBI screening assay and its feasibility and acceptability by immigrants and HCPs in New Brunswick. The findings will additionally provide information on the enhancers and barriers of LTBI screening and management useful in determining how best to expand the LTBI screening program if deemed appropriate.

The burden and predictors of latent tuberculosis infection among elder adults in high epidemic rural area of tuberculosis in Zhejiang, China.

Diagnosis and treatment of latent tuberculosis infection (LTBI) is critical to tuberculosis (TB) control. Identifying the risk factors associated with LTBI can contribute to developing an optimized strategy for LTBI management. We conducted a survey of adults aged 65 years and older living in rural areas in Zhejiang Province during July 2021, followed by a one-year follow-up period to determine TB incidence. Participants underwent a physical examination and 5-6 mL of blood was drawn to test for Mycobacterium tuberculosis infection A total of 1856 individuals participated in the study, of whom 50.5% were men and 80.1% were married. Most participants (96.8%) often opened windows for ventilation at home. One-third (33.4%) of participants had abnormal chest radiographs and 34.9% had LTBI. Nine participants (0.5%) developed active TB patients during the one-year follow-up period. People who frequented closed entertainment places such as chess and card rooms had a relatively high percentage of LTBI (39.5%). Factors associated with a higher risk of LTBI in multivariable logistic regression analysis included being male (odds ratio [OR]:1.32; 95% confidence interval [CI] =:1.01-1.72), smoking (OR: 1.43; 95% CI:1.04-1.97), not opening windows for ventilation at home frequently (OR: 1.88; 95% CI: 1.10-3.22), and abnormal chest radiographs (OR; 1.48; 95% CI; 1.20-1.81). LTBI was prevalent among the elder adults living in high-epidemic rural areas of TB in Zhejiang province. Men, people who smoke, and people without the habit of ventilating at home should be targeted for LTBI screening to accelerate the decline of the TB epidemic in Zhejiang Province.

Analysis of Factors Affecting the Rate of Latent Tuberculosis Infection and Management in Pediatrics.

The incidence of tuberculosis remains high in South Korea; the management of latent tuberculosis infection (LTBI) has become the prime target for reducing the infection rate. The management of pediatric LTBI is especially crucial because children can serve as a long-term source of infection upon developing active tuberculosis. Therefore, it is important to assess pediatric LTBI using contact investigation and follow-up. We conducted a retrospective study on children aged between 0 and 18 years who visited our hospital for tuberculosis contact screening from February 2012 to February 2021. Tuberculosis index cases and their clinical characteristics were also reviewed retrospectively. A total of 350 children were investigated, and 68 of 247 (27.5%) were diagnosed with LTBI. The rate of LTBI (r = 7.98, p < 0.001) and the risk of loss to follow-up (r = 27.038, p < 0.001) were higher in cases with close household contact. Sputum (r = 10.992, p < 0.001) and positive acid-fast bacillus (AFB) stain (r = 4.458, p = 0.001) in tuberculosis index cases were related to the diagnosis of LTBI in pediatric contacts. Active management is needed for tuberculosis screening in pediatric contacts, especially when the contacts are older and the index case is within the family, and when the index case has sputum and has tested positive for AFB smear.

Prevalence of latent tuberculosis infection and incidence of active tuberculosis in school close contacts in Shanghai, China: Baseline and follow-up results of a prospective cohort study.

BackgroundThe management of latent tuberculosis infection (LTBI) is a key action for the realization of the “End tuberculosis (TB) Strategy” worldwide, and it is important to identify priority populations. In this prospective cohort study, we evaluated the prevalence of LTBI and incidence of active TB among close contacts and explored the suitable TB control strategy in schools.MethodsWe designed a cohort with 2 years of follow-up, recruiting freshman/sophomore TB patients’ close contacts from three administrative districts in Shanghai. These were chosen based on different levels of TB incidence reported in 2019. Questionnaires were included and all participants received both tuberculin skin test (TST) and QuantiFERON-TB Gold (QFT) at baseline, then tracked the outcomes of them during the follow-up period.ResultsThe prevalence of LTBI was 4.8% by QFT. Univariate analysis showed that the risk of LTBI was higher in those contacting bacteriologically confirmed patients or did not have BCG scars, including smokers. The risk increased with poor lighting and ventilation conditions at contact sites. Multivariate analysis showed that those contacting with bacteriologically confirmed patients (OR=4.180; 95%CI, 1.164-15.011) or who did not have BCG scars (OR=5.054; 95%CI, 2.278-11.214) had a higher risk of being LTBI, as did the current smokers (OR=3.916; 95%CI, 1.508-10.168) and those who had stopped smoking (OR=7.491; 95%CI, 2.222-25.249). During the 2-year follow-up period, three clinically diagnosed cases of TB were recorded, the 2-year cumulative incidence was 0.4% (95%CI 0.1-1.2), the median duration for TB occurrence was 1 year, the incidence rate of active TB was 2.0 per 1000 person-years with a total of 1497.3 observation person-years. For those LTBI, no one initiated preventive treatment, in the QFT (+) cohort, 1 TB case was observed, 71 person-years with an incidence rate of 14.1 14.1 (95%CI 2.5-75.6) per 1000 person-years, in the TST (+++) cohort, 2 TB cases were observed 91.5 person-years with an incidence rate of 21.9 (95%CI 6.0-76.3) per 1000 person-years.ConclusionsThe results suggest that school close contacts are one of the key populations for LTBI management. Measures should be taken to further reduce the prevalence of LTBI and the incidence of active TB among them.

Strategies to detect and manage latent tuberculosis infection among household contacts of pulmonary TB patients in high TB burden countries - a systematic review and meta-analysis.

To summarise latent tuberculosis infection (LTBI) management strategies among household contacts of bacteriologically confirmed pulmonary tuberculosis (TB) patients in high-TB burden countries. PubMed/MEDLINE (NCBI) and Scopus were searched (January 2006 to December 2021) for studies reporting primary data on LTBI management. Study selection, data management and data synthesis were protocol-driven (PROSPERO-CRD42021208715). Primary outcomes were the proportions of LTBI, initiating and completing tuberculosis preventive treatment (TPT). Reported factors influencing the LTBI care cascade were qualitatively synthesised. From 3694unique records retrieved, 58 studies from 23 countries were included. Most identified contacts were screened (median 99%, interquartile range [IQR] 82%-100%; 46 studies). Random-effects meta-analysis yielded pooled proportions for: LTBI 41% (95% confidence interval [CI] 33%-49%; 21,566 tested contacts); TPT initiation 91% (95% CI 79%-97%; 129,573 eligible contacts, 34 studies); TPT completion 65% (95% CI 54%-74%; 108,679 TPT-initiated contacts, 28 studies). Heterogeneity was significant (I2 ≥ 95%-100%) and could not be explained in subgroup analyses. Median proportions (IQR) were: LTBI 44% (28%-59%); TPT initiation 86% (60%-100%); TPT completion 68% (44%-82%). Nine broad themes related to diagnostic testing, health system structure and functions, risk perception, documentation and adherence were considered likely to influence the LTBI care cascade. The proportions of household contacts screened, detected with LTBI and initiated on TPT, though variable was high, but the proportions completing TPT were lower indicating current strategies used for LTBI management in high TB burden countries are not sufficient.

Management of Latent Tuberculosis Infection in Saudi Arabia: Knowledge and Perceptions Among Healthcare Workers.

BackgroundTuberculosis (TB) continues to pose a serious threat to public health despite great efforts. For many years, management and screening for active TB cases have been the main focus of TB control programs. Latent TB is a stage where TB can be prevented and controlled. Therefore, designing a comprehensive TB control program that includes latent tuberculosis infection (LTBI) management diseases is needed to be implemented among the healthcare workers (HCWs) who have been found to be at a higher risk for active TB compared to the general population.The objective of the studyThe objective of the study is to assess the knowledge and perceptions of LTBI among HCWs. In addition to estimating the prevalence of LTBI among HCWs using closed-end questions in a self-administered questionnaire.Subjects and methodsThrough a cross-sectional study and non-random sampling technique, 324 (84%) healthcare workers who met the inclusion criteria completed and submitted the electronic questionnaire.ResultsAmong all participants, the study reported a good knowledge about LTBI; however, a third of HCWs had poor knowledge about the difference between LTBI and active TB. Eighteen percent of participants were diagnosed with LTBI, and two-thirds accepted the treatment. Of all participants who started the treatment, 55% completed the treatment course. The compliance rate was high among young HCWs and physicians who had a short course of LTB treatment regimen. ConclusionThe study reported a low acceptance and completion rate of LTBI therapy among HCWs. Low knowledge about some clinical facts of LTBI, the long duration of treatment, and being the treatment optional in Saudi health institutes were all barriers to accepting and completing the treatment of LTBI. All of these factors need to be addressed to increase the compliance rate to LTBI treatment.

Tuberculosis in pregnancy.

Due to COVID-19 pandemic, the latest progress of the End Tuberculosis (TB) Strategy was far from optimal and services for TB needs to be quickly restored. Pregnancy is a unique opportunity to screen and manage TB, and it is an essential step in TB eradication. Early diagnosis and treatment for active disease can reduce maternal and neonatal morbidities and mortality. The more widespread utilization of newer rapid molecular assays with drug-susceptibility testing has significantly shortened the diagnostic process for active TB disease. First-line anti-TB drugs are proven to be safe in pregnancy. Management of latent TB infection (LTBI) during pregnancy is controversial, but puerperium is a period of increased susceptibility to progress to active disease. Extrapulmonary TB (EPTB), multidrug-resistant TB (MDR-TB) and HIV co-infection remain significant issues surrounding TB management during pregnancy and often require input from a multidisciplinary team including TB experts.

Isoniazid prophylaxis in liver transplant recipient with latent tuberculosis: Is it harmful for transplanted liver?

Liver transplantation (LT) is considered the only treatment for patients with end-stage liver disease and, despite its incredible impacts on the patients' health status, places them in an immunocompromised state in which opportunistic infection would find a way to present. Latent tuberculosis infection (LTBI) is the most common form of TB and can be diagnosed through tuberculin skin test (TST) or Interferon-Gamma Release Assays (IGRA). LT recipients are at significant risk of TB activation. There is no strict guideline to approaching these cases though, in most centers, Isoniazid (INH) would be prescribed prophylactically. INH is a hepatotoxic medication and can have adverse effects on the transplanted liver. There is no consensus on this issue; therefore, we aimed to survey the potential hepatotoxic effects of INH among LT recipients in Shiraz, Iran. A retrospective cohort study was conducted among LT candidates and recipients at Abu Ali Sina Organ Transplantation Center between 1993 and 2019. All the cases underwent TST and chest X-ray to detect LTBI. All the LTBI were treated with INH from 6-9 months and followed by the level of liver enzymes for quick detection of hepatotoxicity. A control group was selected among LT recipients and matched for age, gender, MELD score, and donor age. Among 4895 medical records reviewed, 55 (1.12%) cases had LTBI. Neither INH-related hepatotoxicity, nor signs and symptoms that were suspicious to TB reactivation were reported. Overall, three deaths were reported, two because of myocardial infarction and one due to pneumonia. Ten patients (18.2%) experienced acute rejection as confirmed with pathology and responded to methylprednisolone. Aspartate aminotransferase (AST) was diminished from pre-LT time to the first time after transplantation; after that, it showed a steady pattern. Meanwhile, Alanine transaminase (ALT) was constant before and one stage later and decreased after that. Statistical analyses only showed significant changes in the total bilirubin titer between the case and control groups. This survey showed prophylactic management of LTBI with INH in LT candidates and recipients was associated with no hepatotoxicity or related death. It seems that INH prophylaxis is safe in LT settings and can efficiently prevent TB activation; however, careful monitoring for adverse effects and liver enzymes elevation is highly recommended.

Review article: latent tuberculosis in patients with inflammatory bowel diseases receiving immunosuppression-risks, screening, diagnosis and management.

SummaryBackgroundOne quarter of the world's population has latent tuberculosis infection (LTBI). Systemic immunosuppression is a risk factor for LTBI reactivation and the development of active tuberculosis. Such reactivation carries a risk of significant morbidity and mortality. Despite the increasing global incidence of inflammatory bowel disease (IBD) and the use of immune‐based therapies, current guidelines on the testing and treatment of LTBI in patients with IBD are haphazard with a paucity of evidence.AimTo review the screening, diagnostic practices and medical management of LTBI in patients with IBD.MethodsPublished literature was reviewed, and recommendations for testing and treatment were synthesised by experts in both infectious diseases and IBD.ResultsScreening for LTBI should be performed proactively and includes assessment of risk factors, an interferon‐gamma releasing assay or tuberculin skin test and chest X‐ray. LTBI treatment in patients with IBD is scenario‐dependent, related to geographical endemicity, travel and other factors. Ideally, LTBI therapy should be used prior to immune suppression but can be applied concurrently where urgent IBD medical treatment is required. Management is best directed by a multidisciplinary team involving gastroenterologists, infectious diseases specialists and pharmacists. Ongoing surveillance is recommended during therapy. Newer LTBI therapies show promise, but medication interactions need to be considered. There are major gaps in evidence, particularly with specific newer therapeutic approaches to IBD.ConclusionsProactive screening for LTBI is essential in patients with IBD undergoing immune‐suppressing therapy and several therapeutic strategies are available. Reporting of real‐world experience is essential to refining current management recommendations.

Impact and benefit-cost ratio of a program for the management of latent tuberculosis infection among refugees in a region of Canada.

The identification and treatment of latent tuberculosis infection (LTBI) among immigrants from high-incidence regions who move to low-incidence countries is generally considered an ineffective strategy because only ≈14% of them comply with the multiple steps of the 'cascade of care' and complete treatment. In the Estrie region of Canada, a refugee clinic was opened in 2009. One of its goals is LTBI management. Key components of this intervention included: close collaboration with community organizations, integration within a comprehensive package of medical care for the whole family, timely delivery following arrival, shorter treatment through preferential use of rifampin, and risk-based selection of patients to be treated. Between 2009-2020, 5131 refugees were evaluated. To determine the efficacy and benefit-cost ratio of this intervention, records of refugees seen in 2010-14 (n = 1906) and 2018-19 (n = 1638) were reviewed. Cases of tuberculosis (TB) among our foreign-born population occurring before (1997-2008) and after (2009-2020) setting up the clinic were identified. All costs associated with TB or LTBI were measured. Out of 441 patients offered LTBI treatment, 374 (85%) were compliant. Adding other losses, overall compliance was 69%. To prevent one case of TB, 95.1 individuals had to be screened and 11.9 treated, at a cost of $16,056. After discounting, each case of TB averted represented $32,631, for a benefit-cost ratio of 2.03. Among nationals of the 20 countries where refugees came from, incidence of TB decreased from 68.2 (1997-2008) to 26.3 per 100,000 person-years (2009-2020). Incidence among foreign-born persons from all other countries not targeted by the intervention did not change. Among refugees settling in our region, 69% completed the LTBI cascade of care, leading to a 61% reduction in TB incidence. This intervention was cost-beneficial. Current defeatism towards LTBI management among immigrants and refugees is misguided. Compliance can be enhanced through simple measures.