TB Mortality Research Articles

Public health benefits of shifting from hospital-focused to ambulatory TB care in Eastern Europe: Optimising TB investments in Belarus, the Republic of Moldova, and Romania.

High rates of drug-resistant tuberculosis (DR-TB) continue to threaten public health, especially in Eastern Europe. Costs for treating DR-TB are substantially higher than treating drug-susceptible TB, and higher yet if DR-TB services are delivered in hospital. The WHO recommends that multidrug-resistant (MDR) TB be treated using mainly ambulatory care, shown to have non-inferior health outcomes, however, there has been a delay to transition away from hospital-focused MDR-TB care in certain Eastern European countries. Allocative efficiency analyses were conducted for three countries in Eastern Europe, Belarus, the Republic of Moldova, and Romania, to minimise a combination of TB incidence, prevalence, and mortality by 2035. A primary focus of these studies was to determine the health benefits and financial savings that could be realised if DR-TB service delivery shifted from hospital-focused to ambulatory care. Here we provide a comprehensive assessment of findings from these studies to demonstrate the collective benefit of transitioning from hospital-focused to ambulatory TB care, and to address common regional considerations. We highlight that transitioning from hospital-focused to ambulatory TB care could reduce treatment costs by 20% in Romania, 24% in Moldova, and by as much as 40% in Belarus or almost 35 million US dollars across these three countries by 2035 without affecting quality of care. Improved TB outcomes could be achieved, however, without additional spending by reinvesting these savings in higher-impact TB diagnosis and more efficacious DR-TB treatment regimens. We found commonalities in the large portion of TB cases treated in hospital across these three regional countries, and similar obstacles to transitioning to ambulatory care. National governments in the Eastern European region should examine barriers delaying adoption of ambulatory DR-TB care and consider lost opportunities caused by delays in switching to more efficient treatment modes.

Risk factors for disruptions in tuberculosis care in Uganda during the COVID-19 pandemic.

During the COVID-19 pandemic, TB mortality increased while diagnoses decreased, likely due to care disruption. In March, 2020, Uganda-a country with high TB burden, implemented a COVID-19 lockdown with associated decrease in TB diagnoses. This study aims to examine patient level risk factors for disruption in TB care during the COVID-19 pandemic in Uganda. This retrospective cross-sectional cohort study included six TB clinics in Uganda. Clustered sampling included phases of TB care and three time-periods: pre-lockdown, lockdown and post-lockdown. Characteristics of patients with TB care disruption (TBCD), defined as those with > 2 months of symptoms prior to diagnosis or who missed a TB clinic, and those without TB care disruption (non-TBCD) were analyzed between time-periods. 1,624 charts were reviewed; 1322 were contacted, 672 consented and completed phone interview; pre-lockdown (n = 213), lockdown (n = 189) and post-lockdown (n = 270). TBCD occurred in 57% (385/672) of patients. There was an increase in the proportion of urban patients in the TBCD and non-TBCD groups during post-lockdown (p <0.001). There was no difference in demographics, HIV co-infection, socioeconomic status, or distance to TB clinic between TBCD and non-TBCD groups or within TBCD by time-period. There were few differences amongst TBCD and all TB patients by time-period. The increase in urban patients' post-lockdown may represent a portion of urban patients who delayed care until post-lockdown. Insignificant trends suggesting more TBCD amongst those who lived further from clinics and those without HIV-coinfection require more investigation.

Estimating the Burden of Tuberculosis in India: A Modelling Study.

Measurements TB incidence and mortality are crucial for monitoring progress towards SDG goals for TB. Until recently, WHO estimated TB burden in India with applied simple, transparent equilibrium models to data from Gujarat, an Indian state where the first state-level prevalence survey was conducted in 2011. However, since then there has been several interventions in India including national TB prevalence survey, infection survey, sub-national survey & certification which gives opportunity for national and sub-national estimates for TB incidence and mortality. We developed a model is a compartmental, deterministic framework, taking account of TB natural history, as well as India's healthcare system including health care seeking from public and private sector. To address changes in TB burden owing to COVID disruptions, we followed same model that used by WHO in the global TB Report 2022 with additional impact of delta wave in 2021. Major sources of data included National TB Prevalence survey, trends in caseloads in public and private sector including their contribution and mortality information. We estimated total TB incidence of 2.77 million in the year 2022 as against 2.97 in the year 2015 and corresponding TB mortality of 0.32 and 0.36 million respectively. In terms of rate per 1,00,000 TB incidence in 2022 was 196 as compared to 225 in the year 2015 and mortality was 23 and 27 respectively. TB incidence estimates are similar to what was estimated by WHO, while mortality estimates appear different in our estimates due to different calibration targets depending on in-country published data. Even if TB burden is infeasible to measure directly, a range of data can nonetheless offer indirect evidence for its estimation: mathematical modelling can be a helpful tool for bringing together these diverse sources of evidence, and deriving estimates that are consistent with them all. While the RGI reported mortality is an important source of information, its quality and coverage for medically certified cause of deaths requires improvement in India.

Characteristics and mortality of central nervous system TB in the Netherlands: a 15-year comparison with other forms of TB.

Characteristics and mortality of central nervous system TB in the Netherlands: a 15-year comparison with other forms of TB.

Peningkatan Kapasitas Keluarga Dalam Pemenuhan Self Care Pasien Tuberkulosis di Kelurahan Balocci Baru

Tuberculosis is still one of the deadliest infectious diseases and has claimed millions of lives over the years. Several factors such as treatment adherence including length of treatment, drug side effects and access to health services are factors in increasing TB mortality rates. Some people who have family members with a history of tuberculosis do not understand how to care for and increase the independence of TB patients, plus the lack of internet access which makes people less exposed to health information, this is a partner problem so it is important to hold counseling on how to care for family members with TB, as well as assistance in increasing the self-care independence of TB patients. The service method is lecture/counseling, accompanied by simulations and questions and answers. This community service is held in January-February in Balocci Baru Village, Kec. Balocci to be exact in the courtyard area of the Balocci Baru village office. The results of the service are in accordance with the plan where participants are able to understand increasing the independence of self-care for TB patients and are enthusiastic during the counseling and mentoring process.

A systematic review of risk factors for mortality among tuberculosis patients in South Africa

BackgroundTuberculosis (TB)-associated mortality in South Africa remains high. This review aimed to systematically assess risk factors associated with death during TB treatment in South African patients.MethodsWe conducted a systematic review of TB research articles published between 2010 and 2018. We searched BioMed Central (BMC), PubMed®, EBSCOhost, Cochrane, and SCOPUS for publications between January 2010 and December 2018. Searches were conducted between August 2019 and October 2019. We included randomised control trials (RCTs), case control, cross sectional, retrospective, and prospective cohort studies where TB mortality was a primary endpoint and effect measure estimates were provided for risk factors for TB mortality during TB treatment. Due to heterogeneity in effect measures and risk factors evaluated, a formal meta-analysis of risk factors for TB mortality was not appropriate. A random effects meta-analysis was used to estimate case fatality ratios (CFRs) for all studies and for specific subgroups so that these could be compared. Quality assessments were performed using the Newcastle-Ottawa scale or the Cochrane Risk of Bias Tool.ResultsWe identified 1995 titles for screening, 24 publications met our inclusion criteria (one cross-sectional study, 2 RCTs, and 21 cohort studies). Twenty-two studies reported on adults (n = 12561) and two were restricted to children < 15 years of age (n = 696). The CFR estimated for all studies was 26.4% (CI 18.1–34.7, n = 13257 ); 37.5% (CI 24.8-50.3, n = 5149) for drug-resistant (DR) TB; 12.5% (CI 1.1–23.9, n = 1935) for drug-susceptible (DS) TB; 15.6% (CI 8.1–23.2, n = 6173) for studies in which drug susceptibility was mixed or not specified; 21.3% (CI 15.3-27.3, n = 7375) for people living with HIV/AIDS (PLHIV); 19.2% (CI 7.7–30.7, n = 1691) in HIV-negative TB patients; and 6.8% (CI 4.9–8.7, n = 696) in paediatric studies. The main risk factors associated with TB mortality were HIV infection, prior TB treatment, DR-TB, and lower body weight at TB diagnosis.ConclusionsIn South Africa, overall mortality during TB treatment remains high, people with DR-TB have an elevated risk of mortality during TB treatment and interventions to mitigate high mortality are needed. In addition, better prospective data on TB mortality are needed, especially amongst vulnerable sub-populations including young children, adolescents, pregnant women, and people with co-morbidities other than HIV. Limitations included a lack of prospective studies and RCTs and a high degree of heterogeneity in risk factors and comparator variables.Systematic review registrationThe systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42018108622. This study was funded by the Bill and Melinda Gates Foundation (Investment ID OPP1173131) via the South African TB Think Tank.

Community-based referral for tuberculosis preventive therapy is effective for treatment completion.

Expansion of tuberculous preventive therapy (TPT) is essential to curb TB incidence and mortality among people with HIV (PWH), yet implementation has been slow. Innovative strategies to operationalize TPT are urgently needed. Here we present an evaluation of community-based identification and referral of PWH on completion of a six-month course of isoniazid in a highly prevalent region in rural South Africa. Using a community-based TB/HIV intensive case finding strategy, a team of nurses and lay workers identified community members with HIV who were without fever, night sweats, weight loss, or cough and referred them to the government primary care clinics for daily oral isoniazid, the only available TPT regimen. We measured monthly adherence and six-month treatment completion in the community-based identification and referral (CBR) group compared to those already engaged in HIV care. Adherence was measured by self-report and urine isoniazid metabolite testing. A multivariable analysis was performed to identify independent predictors of TPT completion. Among 240 participants, 81.7% were female, median age 35 years (IQR 30-44), and 24.6% had previously been treated for TB. The median CD4 count in the CBR group was 457 (IQR 301-648), significantly higher than the clinic-based comparison group median CD4 of 344 (IQR 186-495, p<0.001). Independent predictors of treatment completion included being a woman (aOR 2.41, 95% 1.02-5.72) and community-based identification and referral for TPT (aOR 2.495, 95% 1.13-5.53). Among the CBR group, treatment completion was 90.0%, an absolute 10.8% higher than the clinic-based comparison group (79.2%, p = 0.02). Adherence was significantly greater in the CBR group than the clinic-based comparison group, as measured by self-report (p = 0.02) and urine isoniazid testing (p = 0.01). Among those not on ART at baseline, 10% of eligible PWH subsequently initiated ART. Community members living with HIV in TB endemic regions identified and referred for TPT demonstrated higher treatment completion and adherence compared to PWH engaged for TPT while receiving clinic-based care. Community-based identification and referral is an innovative adjunctive strategy to facilitate implementation of TB preventive therapy in people living with HIV.

Tuberculosis in Ukraine during the COVID-­19 pandemic

Objective — to study the situation with tuberculosis in Ukraine in 2020—2021 compared to 2019.&#x0D; Materials and methods. Searched and statistically analyzed data from official statistical reports and analytical collections on tuberculosis for 2019—2021 in Ukraine.&#x0D; Results and discussion. The COVID-19 epidemic, to eliminate which the main material and human resources in health care were directed, aggravated the epidemiological situation with tuberculosis in Ukraine; there was a reduction in anti-tuberculosis activities, human resources and infrastructure of anti-tuberculosis institutions. This has led to a decrease in TB incidence, prevalence and mortality, while in other parts of the world, TB incidence and mortality rates and the effectiveness of treatment have increased significantly.&#x0D; Conclusions. During the COVID-19 pandemic, the majority of health resources have been devoted to fighting it. Anti-tuberculosis measures were secondary and were being phased out. This led to a decrease in statistical indicators of the incidence of all clinical forms of tuberculosis and mortality from it, including multi-resistant, and its relapses, as well as co-infection — tuberculosis/HIV/AIDS. The incidence of tuberculosis among medical workers decreased. The prevalence of all forms of active tuberculosis among Ukrainians had the same trend as the incidence.

Why people die of active tuberculosis in the era of effective chemotherapy in Southern Ethiopia: A qualitative study

BackgroundHigh TB mortality is increasingly understood as an indicator of different problems in the health system and community. Limited awareness of TB in the community, restricted accessibility and/or quality of health services can hamper survival. Exploration and analysis of death among TB patients can lead to a clearer and specific understanding of why the deaths happened and where interventions are likely to make a difference in a specific context. ObjectiveThe study aimed to assess why people die of active tuberculosis in the era of effective chemotherapy. MethodsThe study was conducted from October to December 2020 in Arba Minch Health and Demographic Surveillance System (AM-HDSS) by applying phenomenological study design. A total of 27 family members of people who had died of TB, 9 health extension workers (HEW) and 8 health care professionals working in TB clinics were participated in open in-depth interview. A total of 130 individuals participated in 16 focus group discussion which composed of patient survived from TB, religious leader, health development army (HAD) and HEWs. Adequacy of information (saturation) was considered as an adequate sample size to create the intended qualitative product. All the interviews and FGD were tape recorded and recordings were transcribed immediately. ATLAS TI 9 software was used to analyse and process qualitative data. From data set codes were created then by identifying pattern among them themes were created. Then, generated themes were compared and some of them were split, combined, discarded and new ones created after returning to data set. Finally, themes were defined and a concise and easily understandable name was given for each theme. ResultLuck of sufficient knowledge about TB was considered to be a reason for cause of death. Most of the time, TB patients underestimate and ignore when the symptoms first emerge and will not relate it with any diseases. The low level of community awareness about the cause, transmission, treatment and prevention highly contributed to increased transmission rate and death due to TB. The study identified misconceptions in the community; they prefer traditional medicine to the scientific way. First, they try different herbal medicine to get relief from their illness. At the end, if the disease is getting worse, they visit health facilities. Participants mentioned high transportation cost, poor health seeking behaviours, inadequate food consumption and lack of TB awareness as reasons for low treatment adherence. The health facilities were inaccessible for the community. Most of them indicated that health facilities were too far to reach. In some health institution, right amount and combination of medication were not delivery on time and Diagnostic facilities for TB were reported to be inadequate. ConclusionPoor treatment adherence, lack of TB awareness, stigma, inadequate food consumption, poor health care seeking behaviour and inaccessibility of health facility were identified as major reasons for death. To prevent death of TB patients all sectors such as education, health, and agriculture should work to address health education, infrastructures, nutritional supplementation needs of TB patients, caregivers and the community as a whole.

Epidemiology of Tuberculosis in Kazakhstan: Data from National Electronic Healthcare System 2014-2019

Abstract Background Tuberculosis (TB) remains a global public health threat. WHO determined Kazakhstan as one of 18 high-priority countries for TB elimination in Europe, with reported TB incidence &amp;gt;20 cases per 100,000 population. There is a lack of comprehensive reseach of TB epidemiology in the country. This study aims to estimate the prevalence, incidence, mortality rates and survival hazard ratios of TB in Kazakhstan, using large-scale administrative health data records in 2014-2019. Methods This is a population-wide retrospective study assessing 150 thousand TB (ICD10: A15-A19) patients’ incidence, prevalence and mortality. Demographic factors, diagnoses and comorbidities were analyzed. Univariate, bivariate and multivariate statistical analyses were performed. Cox regression and Kaplan-Meier survival analysis have been done. Results Out of 150 thousand all TB patients, 61 percent were male and 94 percent had respiratory TB. During 2014-2019, the TB incidence, prevalence and mortality per 100K population declined (227-15.2), doubled (325.3-746.6) and increased (8.4-15.2), respectively. Age-specific TB incidence was lowest for 0-10 y.o., highest for 20 y.o. Being an old person, male, urban resident, retired, with HIV and diabetes was significantly associated with lower survival compared to a young, female, rural resident, employed, with no comorbidities. Conclusions This was the largest TB study in Kazakhstan, presenting the country’s TB by demographic groups, incidence, prevalence, mortality trends, and risk factors against survival. Key messages • During 2014-2019, the TB incidence, prevalence and mortality per 100K population declined (227-15.2), doubled (325.3-746.6) and increased (8.4-15.2), respectively. • Being an old person, male, urban resident, retired, with HIV and diabetes was significantly associated with lower survival compared to a young, female, rural resident, employed, with no comorbidities.

Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa.

Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV) infected individuals in South Africa. Despite the implementation of HIV/TB integration services at primary healthcare facility level, the effect of HIV on TB treatment outcomes has not been well investigated. To provide evidence base for TB treatment outcome improvement to meet End TB Strategy goal, we assessed the effect of HIV status on treatment outcomes of TB patients at a rural clinic in the Ugu Health District, South Africa. We reviewed medical records involving a cohort of 508 TB patients registered for treatment between 1 January 2013 and 31 December 2015 at rural public sector clinic in KwaZulu-Natal province, South Africa. Data were extracted from National TB Programme clinic cards and the TB case registers routinely maintained at study sites. The effect of HIV status on TB treatment outcomes was determined by using multinomial logistic regression. Estimates used were relative risk ratio (RRR) at 95% confidence intervals (95%CI). A total of 506 patients were included in the analysis. Majority of the patients (88%) were new TB cases, 70% had pulmonary TB and 59% were co-infected with HIV. Most of HIV positive patients were on antiretroviral therapy (ART) (90% (n = 268)). About 82% had successful treatment outcome (cured 39.1% (n = 198) and completed treatment (42.9% (n = 217)), 7% (n = 39) died 0.6% (n = 3) failed treatment, 3.9% (n = 20) defaulted treatment and the rest (6.6% (n = 33)) were transferred out of the facility. Furthermore, HIV positive patients had a higher mortality rate (9.67%) than HIV negative patients (2.91%)". Using completed treatment as reference, HIV positive patients not on ART relative to negative patients were more likely to have unsuccessful outcomes [RRR, 5.41; 95%CI, 2.11-13.86]. When compared between HIV status, HIV positive TB patients were more likely to have unsuccessful treatment outcome in rural primary care. Antiretroviral treatment seems to have had no effect on the likelihood of TB treatment success in rural primary care. The TB mortality rate in HIV positive patients, on the other hand, was higher than in HIV negative patients emphasizing the need for enhanced integrated management of HIV/TB in rural South Africa through active screening of TB among HIV positive individuals and early access to ART among HIV positive TB cases.

Extrapulmonary tuberculosis mortality according to clinical and point of care ultrasound features in Mozambique

In resource-limited settings, point-of-care ultrasound (POCUS) has great potential to support the timely diagnosis of extrapulmonary tuberculosis (EPTB). We aim to determine the in-hospital mortality due to EPTB according to clinical and POCUS features and risk factors in newly diagnosed patients hospitalized for EPTB in Chókwè district, Mozambique. We analyzed routinely collected data from paper medical files and electronic POCUS records of EPTB in infected patients aged 15 years or older and admitted to Carmelo Hospital of Chókwè from 2016 to 2020. Kaplan–Meier survival curves and adjusted Cox regression analyses were used to model predictors of mortality and time to death. The 390 included in-patients with EPTB and POCUS data contributed a total of 6240 in-hospital person-days of observation. The overall mortality rate was 2.16 per 100 person-days. Adjusted Cox regression showed a higher risk of death in those with abdominal tenderness (adjusted hazard ratio [aHR] 1.61, 95% confidence interval [CI] 1.00–2.82, p = 0.050), antiretroviral treatment (ART) for more than 90 days (aHR 4.03, 95% CI 1.50–10.78, p = 0.006), and mixed patterns on kidney POCUS (aHR 2.91, 95% CI 1.38–6.10, p = 0.005). An optimal immunovirological response to ART was a protective factor against death [aHR] 0.12, 95% CI 0.04–0.35, p < 0.001). Variables associated with an increased risk of death were male gender, abdominal pain, ART for more than three months (with immunovirological failure or non-response to ART) and having a mixed pattern of kidney POCUS characteristics. Early detection of these risk factors may have a direct impact on reducing TB mortality, and the POCUS approach as a complementary diagnostic method for EPTB provides a simple, feasible and affordable intervention in resource-limited settings like Mozambique.

Tuberculosis screening among children and adolescents in China: insights from a mathematical model

BackgroundTuberculosis (TB) continues to be prevalent in China also among children and adolescents in China. We built a dynamic mathematical model for TB transmission in China, and applied it to compare the epidemic trends 2021–2030 under a range of screening interventions focusing on children and adolescents. MethodsWe developed a dynamic mathematical model with a flexible structure. The model can be applied either stochastically or deterministically, and can encompass arbitrary age structure and resistance levels. In the present version, we used the deterministic version excluding resistance but including age structure with six groups: 0–5, 6–11, 12–14, 15–17, 18–64, and 65 years and above. We parameterized the model by literature data and fitting it to case and death estimates provided by the World Health Organization. We compared the new TB cases and TB-related deaths in each age group over the period 2021–2030 in 10 scenarios that involved intensified screening of particular age groups of children, adolescents, or young adults, or decreased or increased diagnostic accuracy of the screening. ResultsScreening the entire age class of 18-year-old persons would prevent 517,000 TB cases and 14,600 TB-related deaths between years 2021 and 2030, corresponding to 6.6% and 5.5% decrease from the standard of care projection, respectively. Annual screening of children aged 6–11 and, to a lesser extent, 0–5 years, also reduced TB incidence and mortality, particularly among children of the respective ages but also in other age groups. In contrast, intensified screening of adolescents did not have a major impact. Screening with a simpler and less accurate method resulted in worsened outcomes, which could not be offset by more intensive screening. More accurate screening and better sensitivity to detect latent TB could prevent 2.3 million TB cases and 68,500 TB deaths in the coming 10 years. ConclusionRoutine screening in schools can efficiently reduce the burden of TB in China. Screening should be intensified particularly among children in primary school age.

Utility of the lateral flow urine lipoarabinomannan tuberculosis assay in patients with advanced HIV disease at antiretroviral therapy centres in Mumbai, India.

BackgroundPeople with Advanced HIV Disease (AHD) are at higher risk of TB coinfection and mortality. However, there are challenges in TB diagnosis with the currently recommended diagnostic tools. WHO recommends lateral flow urine lipoarabinomannan (LF-LAM) assay to assist TB diagnosis among AHD patients. We assessed the utility and acceptability of using urine LF-LAM assay for TB diagnosis among patients at public Antiretroviral Therapy (ART) Centres in Mumbai.MethodsThe cross-sectional study was conducted among adult AHD patients accessing care from 17 ART centres during November,2020-June, 2021. Urine LF-LAM was offered as routine care for eligible patients in combination with standard diagnostic tests. We calculated the proportion of positive LF-LAM results by CD4 categories and TB symptoms and performed multivariable logistic regression to determine the factors associated with LF-LAM positivity.ResultsAmong 2,390 patients, the majority (74.5%) had CD4 between 101–200 cells/mm3. The mean age was 43.7 years (SD:10.6), 68.6% were male, 8.4% had TB symptoms and 88.0% were on ART. The overall proportion of patients with urine LF-LAM positive results was 6.4%. Among PLHIV with CD4≤100 cells/mm3, the positivity was 43.0% and 7.7% in symptomatic and asymptomatic patients, respectively. Among PLHIV with a CD4>100 cells/mm3, the positivity was 26.7% and 2.7% in symptomatic and asymptomatic patients respectively. Urine LF-LAM positivity was higher among inpatients, ART naïve, patients on treatment for <6 months, symptomatic and in WHO clinical stage III/IV of HIV disease as compared to the reference categories. We detected an additional 131 TB cases with urine LF-LAM in combination with the standard diagnostic tests.ConclusionThe study demonstrated the utility of urine LF-LAM for TB diagnosis among AHD patients and the simple, user-friendly test was acceptable as part of routine care. Inclusion of urine LF-LAM test in the current diagnostic algorithm may facilitate early TB diagnosis among AHD patients.

Tuberculosis Epidemiology in South Konawe Regency, Southeast Sulawesi, Indonesia

One of the deadliest infectious diseases in the world is Tuberculosis. The disease is caused by Mycobacterium tuberculosis and causes health problems around the world. Tuberculosis has spread globally. This study used various sources of information from Indonesia Government Agencies. Tuberculosis data was obtained from South Konawe Public Health Office in the period from 2018 to 2020. The data is an annual report published by the South Konawe Public Health Office. Cases tend to increase in men other than women. Men are mostly susceptible to pulmonary TB risk factors. The cure rates percentage for TB patients in South Konawe Regency varies every year, such as in the year 2020 it became very low. The high number of TB patients is in Ranomeeto and Benua sub-districts. Cases show that prevention improvement is needed in these sub-districts. The number of TB patients and mortality rate in South Konawe Regency tend to increase every year. Real actions are needed from the government, health workers and the community itself to reduce the number of sufferers and mortality.&#x0D; Keywords: TB, South Konawe Regency, Indonesia

TB in the elderly: clinical features and outcomes.

BACKGROUND: TB in low-incidence countries is characterised by changes in age distribution towards larger numbers of cases among the elderly.OBJECTIVES: To investigate clinical features and outcomes of TB treatment in older patients and identify predictors of poor outcome.METHODS: Multicentre retrospective study of new TB cases from 53 hospitals included in the registry of the Integrated Tuberculosis Research Programme of the Spanish Society of Pulmonology and Thoracic Surgery (Sociedad Española de Neumología y Cirugía Torácica) between 2006 and 2020.RESULTS: We identified 731 patients aged ≥75 years from a cohort of 7,505 patients with TB. In the elderly, weight loss, disseminated disease and normal X-rays or infiltrates without cavitation were more common. All-cause mortality was 16% (5% of deaths due to TB). The elderly had higher rates of toxicity (6.7%) and hospital admissions (36%). In the multivariate analysis of predictors of TB mortality in ≥75-year-olds, only weight, age and treatment with non-standard regimens remained significant.CONCLUSIONS: TB in older patients needs more attention and remains a challenge because of a lack of specific clinical and radiological features. Standard treatment is effective, although mortality is higher than in young patients. Low weight, non-standard regimens and age are significant predictors of TB mortality.

High burden of childhood tuberculosis in migrants: a retrospective cohort study from the Thailand–Myanmar border

BackgroundTuberculosis (TB) is a leading cause of morbidity and mortality in children but epidemiological data are scarce, particularly for hard-to-reach populations. We aimed to identify the risk factors for unsuccessful outcome and TB mortality in migrant children at a supportive residential TB programme on the Thailand–Myanmar border.MethodsWe conducted retrospective analysis of routine programmatic data for children (aged ≤ 15 years old) with TB diagnosed either clinically or bacteriologically between 2013 and 2018. Treatment outcomes were described and risk factors for unsuccessful outcome and death were identified using multivariable logistic regression.ResultsChildhood TB accounted for a high proportion of all TB diagnoses at this TB programme (398/2304; 17.3%). Bacteriological testing was done on a quarter (24.9%) of the cohort and most children were diagnosed on clinical grounds (94.0%). Among those enrolled on treatment (n = 367), 90.5% completed treatment successfully. Unsuccessful treatment outcomes occurred in 42/398 (10.6%) children, comprising 26 (6.5%) lost to follow-up, one (0.3%) treatment failure and 15 (3.8%) deaths. In multivariable analysis, extra-pulmonary TB [adjusted OR (aOR) 3.56 (95% CI 1.12–10.98)], bacteriologically confirmed TB [aOR 6.07 (1.68–21.92)] and unknown HIV status [aOR 42.29 (10.00–178.78)] were independent risk factors for unsuccessful outcome. HIV-positive status [aOR 5.95 (1.67–21.22)] and bacteriological confirmation [aOR 9.31 (1.97–44.03)] were risk factors for death in the secondary analysis.ConclusionsChildren bear a substantial burden of TB disease within this migrant population. Treatment success rate exceeded the WHO End TB target of 90%, suggesting that similar vulnerable populations could benefit from the enhanced social support offered by this TB programme, but better child-friendly diagnostics are needed to improve the quality of diagnoses.

Trends in TB and HIV care and treatment cascade, Kenya, 2008-2018.

BACKGROUND: HIV infection is associated with high mortality among people with TB. Antiretroviral therapy (ART) reduces TB incidence and mortality among people living with HIV (PLHIV). Since 2005, Kenya has scaled up TB and HIV prevention, diagnosis and treatment. We evaluated the impact of these services on trends and TB treatment outcomes.METHODS: Using Microsoft Excel (2016) and Epi-Info 7, we analysed Kenya Ministry of Health TB surveillance data from 2008 to 2018 to determine trends in TB notifications, TB classification, HIV and ART status, and TB treatment outcomes.RESULTS: Among the 1,047,406 people reported with TB, 93% knew their HIV status, and 37% of these were HIV-positive. Among persons with TB and HIV, 69% received ART. Between 2008 and 2018, annual TB notifications declined from 110,252 to 96,562, and HIV-coinfection declined from 45% to 27%. HIV testing and ART uptake increased from 83% to 98% and from 30% to 97%, respectively. TB case fatality rose from 3.5% to 3.9% (P <0.018) among HIV-negative people and from 5.1% to 11.2% (P <0.001) among PLHIV on ART.CONCLUSION: TB notifications decreased in settings with suboptimal case detection. Although HIV-TB services were scaled-up, HIV-TB case fatality rose significantly. Concerted efforts are needed to address case detection and gaps in quality of TB care.

Impact of on-site Xpert on TB diagnosis and mortality trends in Uganda.

Since 2012, Uganda expanded the Xpert® MTB/RIF network for diagnosis of TB. We compared TB care cascades at health facilities with on-site Xpert vs. facilities that accessed the assay through specimen referral. We analysed secondary aggregate data of the National TB and Leprosy Program (NTLP) from 2016 to 2019. We computed the proportions of notified TB cases and mortality ratios in relation to the estimated TB burden. TB case notifications per annum increased from 24,287 in 2016 to 30,739 in 2019, and the proportion of cases diagnosed at facilities with on-site Xpert testing increased from 62% (15,070/24,287) to 81% (24,829/30,739) (P < 0.001). TB mortality at facilities with on-site Xpert decreased from 8.6% (1,302/15,070) to 7.8% (1,938/24,829) (P = 0.41), while it increased at facilities without on-site Xpert from 6.9% (638/9,217) to 8.8% (521/5,910) (P = 0.23). Furthermore, mortality among TB-HIV co-infected patients at facilities with on-site Xpert dropped from 5.0% (760/15,070) in 2016 to 4.8% (1,187/24,826) in 2019 (P = 0.84) compared to 4.4% (407/9,217) in 2016 to 5.3% (315/5,910) in 2019 (P = 0.57). Wider installation and decentralisation of Xpert leads to increased case-finding. However, the impact on reduction in mortality remains limited. Interventions to address TB-related mortality in addition to Xpert roll-out are required.

Number needed to screen for TB in clinical, structural or occupational risk groups.

BACKGROUND: Screening for active TB using active case-finding (ACF) may reduce TB incidence, prevalence, and mortality; however, yield of ACF interventions varies substantially across populations. We systematically reviewed studies reporting on ACF to calculate the number needed to screen (NNS) for groups at high risk for TB.METHODS: We conducted a literature search for studies reporting ACF for adults published between November 2010 and February 2020. We determined active TB prevalence detected through various screening strategies and calculated crude NNS for - TB confirmed using culture or Xpert® MTB/RIF, and weighted mean NNS stratified by screening strategy, risk group, and country-level TB incidence.RESULTS: We screened 27,223 abstracts; 90 studies were included (41 in low/moderate and 49 in medium/high TB incidence settings). High-risk groups included inpatients, outpatients, people living with diabetes (PLWD), migrants, prison inmates, persons experiencing homelessness (PEH), healthcare workers, and miners. Screening strategies included symptom-based screening, chest X-ray and Xpert testing. NNS varied widely across and within incidence settings based on risk groups and screening methods. Screening tools with higher sensitivity (e.g., Xpert, CXR) were associated with lower NNS estimates.CONCLUSIONS: NNS for ACF strategies varies substantially between adult risk groups. Specific interventions should be tailored based on local epidemiology and costs.