ABSTRACT
The coronavirus disease (COVID-19) pandemic has had unprecedented negative effects on global health and economies, drawing attention and resources from many other public health services. To minimize negative effects, the parallels, lessons, and resources from existing public health programs need to be identified and used. Often underappreciated synergies relating to COVID-19 are with tuberculosis (TB). COVID-19 and TB share commonalities in transmission and public health response: case finding, contact identification, and evaluation. Data supporting interventions for either disease are, understandably, vastly different, given the diseases' different histories. However, many of the evolving issues affecting these diseases are increasingly similar. As previously done for TB, all aspects of congregate investigations and preventive and therapeutic measures for COVID-19 must be prospectively studied for optimal evidence-based interventions. New attention garnered by the pandemic can ensure that knowledge and investment can benefit both COVID-19 response and traditional public health programs such as TB programs.
Subject(s)
COVID-19 , Communicable Disease Control/organization & administration , Pandemics/prevention & control , Tuberculosis/epidemiology , COVID-19/epidemiology , COVID-19/prevention & control , Global Health , Humans , Preventive Health Services , Strategic PlanningSubject(s)
Global Health/legislation & jurisprudence , Quality of Health Care/trends , Research/economics , Tuberculosis, Pulmonary/economics , Tuberculosis, Pulmonary/prevention & control , Cost of Illness , Disease Eradication , Global Health/statistics & numerical data , Goals , Health Policy , Health Priorities , Humans , Incidence , Leadership , Mortality , Mycobacterium tuberculosis/drug effects , Mycobacterium tuberculosis/pathogenicity , Political Systems , Quality of Health Care/standards , Tuberculosis, Pulmonary/drug therapy , Tuberculosis, Pulmonary/epidemiology , World Health Organization/economicsABSTRACT
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
Subject(s)
Mycobacterium tuberculosis , Tuberculosis , Antitubercular Agents/therapeutic use , HIV Infections/complications , Humans , Public Health , Tuberculosis/diagnosis , Tuberculosis/drug therapy , Tuberculosis/epidemiology , Tuberculosis/microbiologyABSTRACT
The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
Subject(s)
Tuberculosis , Antitubercular Agents/therapeutic use , HIV Infections , Humans , Mycobacterium tuberculosis , Public Health , Tuberculosis/diagnosis , Tuberculosis/drug therapy , Tuberculosis/epidemiology , Tuberculosis/microbiologyABSTRACT
Of all achievements in medicine, the successful treatment of tuberculosis has had one of the greatest impacts on society. Tuberculosis was a leading cause of disease and a mortal enemy of humanity for millennia. The first step in finding a cure was the discovery of the cause of tuberculosis by Robert Koch in 1882. The sanatorium movement that began shortly afterward in Europe, and soon spread to the United States, brought attention to the plight of afflicted persons, and catalyzed public health action. The antituberculosis benefit of streptomycin was announced in 1945, although application was limited by the rapid development of resistance. para-Aminosalicylic acid, also discovered in 1945, when combined with streptomycin was found to greatly reduce the occurrence of drug resistance. In 1952, isoniazid opened the modern era of treatment; it was inexpensive, well tolerated, and safe. In the early 1960s, ethambutol was shown to be effective and better tolerated than para-aminosalicylic acid, which it replaced. In the 1970s, rifampin found its place as a keystone in the therapy of tuberculosis. The use of rifampin enabled the course of treatment to be reduced to nine months. Incorporation of pyrazinamide into the first-line regimen led to a further reduction of treatment duration to six months. Treatment of multiple drug-resistant tuberculosis remains a difficult problem requiring lengthy treatment with toxic drugs. However, shortened regimens show promise, and two new drugs, bedaquiline and delamanid, have demonstrated effectiveness in preliminary studies and are being used for extensively drug-resistant tuberculosis.
Subject(s)
Antitubercular Agents/history , Tuberculosis/history , Antitubercular Agents/therapeutic use , History, 18th Century , History, 19th Century , History, 20th Century , History, 21st Century , Humans , Tuberculosis/drug therapySubject(s)
Mycobacterium tuberculosis/isolation & purification , Reagent Kits, Diagnostic , Tuberculosis, Multidrug-Resistant/diagnosis , Tuberculosis/diagnosis , Area Under Curve , Communicable Disease Control , False Positive Reactions , Humans , Mass Screening/methods , Mycobacterium tuberculosis/genetics , Reproducibility of Results , Sensitivity and Specificity , Tuberculosis/microbiology , Tuberculosis, Multidrug-Resistant/microbiologyABSTRACT
It is estimated that 85% of the world's population lives in low- and middle-income countries (LMICs). Although economic conditions are improving in these countries, health expenditures have not kept pace with the overall economic growth, and health systems remain weak. These already inadequate systems are being further stressed by the epidemiologic transition that is taking place, characterized by a slow decrease in communicable diseases and an increase in noninfectious chronic diseases, resulting in a "double burden" of infectious and noninfectious diseases. Respiratory diseases comprise the largest category of illness within this combined burden of disease. Although there are chronic respiratory disease programs of proven effectiveness appropriate for LMICs, implementation has been greatly hampered by the lack of physicians who have special knowledge and skills in addressing the full spectrum of lung diseases. Thus, there is an urgent need to create training programs for specialists in respiratory diseases. Such programs should be developed and conducted by institutions in LMICs and tailored to fit the prevailing circumstances of the country. Existing curriculum blueprints may be used to guide training program development with appropriate modifications. Academic institutions and professional societies in high-income countries may be called upon to provide technical assistance in developing and implementing training programs. In order to better define the burden of respiratory diseases and identify effective interventions, research, moved forward by persons committed and specialized in this area of health, will be essential.
Subject(s)
Developing Countries , Fellowships and Scholarships/methods , Health Services Needs and Demand , Pulmonary Medicine/education , Respiratory Tract Diseases/epidemiology , Fellowships and Scholarships/statistics & numerical data , Humans , Program Development , Quality Improvement , Respiratory Tract Diseases/therapy , WorkforceSubject(s)
Antitubercular Agents/therapeutic use , Drug Resistance, Multiple, Bacterial , Mycobacterium tuberculosis/drug effects , Tuberculosis, Multidrug-Resistant/drug therapy , Tuberculosis, Multidrug-Resistant/microbiology , Tuberculosis, Pulmonary/drug therapy , Tuberculosis, Pulmonary/microbiology , Female , Humans , MaleABSTRACT
SETTING: The impact of diabetes on tuberculosis in United States and foreign-born populations in San Francisco has not been studied. OBJECTIVE: To determine the characteristics, prevalence and temporal trends of diabetes in US and foreign-born persons attending the San Francisco Tuberculosis Clinic. DESIGN: We analyzed data from individuals seeking medical attention at the San Francisco Tuberculosis Clinic. We included patients with diagnosis of tuberculosis, latent infection, or not infected with Mycobacterium tuberculosis. We assessed the temporal trend and the characteristics of individuals with and without diabetes. RESULT: Between 2005 and 2012, there were 4371 (19.0%) individuals without evidence of tuberculosis infection, 17,856 (77.6%) with latent tuberculosis, and 791 (3.4%) with tuberculosis. 66% were born in the United States, China, Mexico, and the Philippines. The prevalence of diabetes was the highest among individuals with tuberculosis and increased during the study period. Patients with tuberculosis and diabetes were more likely to be male, older than 45 years and born in the Philippines. There was a disproportionate association of TB and DM relative to LTBI and DM among Filipinos in individuals older than 45 years old. CONCLUSIONS: Our data suggest that Filipinos older than 45 years old are more likely to have tuberculosis probably due to a higher prevalence of diabetes. In San Francisco, tuberculosis-screening programs in individuals with diabetes and latent tuberculosis may be beneficial in patients older than 45 years old especially from the Philippines.
Subject(s)
Diabetes Mellitus/epidemiology , Emigrants and Immigrants , Tuberculosis/epidemiology , Female , Humans , Male , Middle Aged , Prevalence , San Francisco/epidemiologyABSTRACT
RATIONALE: Guidelines recommend routine nucleic-acid amplification testing in patients with presumed tuberculosis (TB), but these tests have not been widely adopted. GeneXpert MTB/RIF (Xpert), a novel, semiautomated TB nucleic-acid amplification test, has renewed interest in this technology, but data from low-burden countries are limited. OBJECTIVES: We sought to estimate Xpert's potential clinical and public health impact on empiric treatment, contact investigation, and housing in patients undergoing TB evaluation. METHODS: We performed a prospective, cross-sectional study with 2-month follow-up comparing Xpert with standard strategies for evaluating outpatients for active pulmonary TB at the San Francisco Department of Public Health TB Clinic between May 2010 and June 2011. We calculated the diagnostic accuracy of standard algorithms for initial empiric TB treatment, contact investigation, and housing in reference to three Mycobacterium tuberculosis sputum cultures, as compared with that of a single sputum Xpert test. We estimated the incremental diagnostic value of Xpert, and the hypothetical reductions in unnecessary treatment, contact investigation, and housing if Xpert were adopted to guide management decisions. MEASUREMENTS AND MAIN RESULTS: A total of 156 patients underwent Xpert testing. Fifty-nine (38%) received empiric TB treatment. Thirteen (8%) had culture-positive TB. Xpert-guided management would have hypothetically decreased overtreatment by 94%, eliminating a median of 44 overtreatment days (interquartile range, 43-47) per patient and 2,169 total overtreatment days (95% confidence interval, 1,938-2,400) annually, without reducing early detection of TB patients. We projected similar benefits for contact investigation and housing. CONCLUSIONS: Xpert could greatly reduce the frequency and impact of unnecessary empiric treatment, contact investigation, and housing, providing substantial patient and programmatic benefits if used in management decisions.
Subject(s)
Mycobacterium tuberculosis/genetics , Nucleic Acid Amplification Techniques , Tuberculosis, Pulmonary/diagnosis , Adult , Antibiotics, Antitubercular/economics , Antibiotics, Antitubercular/therapeutic use , Contact Tracing , Cost of Illness , Cross-Sectional Studies , False Positive Reactions , Female , Housing/economics , Humans , Male , Middle Aged , Mycobacterium tuberculosis/isolation & purification , Prospective Studies , Risk Assessment , San Francisco , Sensitivity and Specificity , Triage , Tuberculosis, Pulmonary/drug therapy , Tuberculosis, Pulmonary/economics , Tuberculosis, Pulmonary/epidemiology , Unnecessary Procedures/economics , Unnecessary Procedures/statistics & numerical dataABSTRACT
The International Standards for Tuberculosis Care, first published in 2006 (Lancet Infect Dis 2006;6:710-725.) with a second edition in 2009 ( www.currytbcenter.ucsf.edu/international/istc_report ), was produced by an international coalition of organizations funded by the United States Agency for International Development. Development of the document was led jointly by the World Health Organization and the American Thoracic Society, with the aim of promoting engagement of all care providers, especially those in the private sector in low- and middle-income countries, in delivering high-quality services for tuberculosis. In keeping with World Health Organization recommendations regarding rapid molecular testing, as well as other pertinent new recommendations, the third edition of the Standards has been developed. After decades of dormancy, the technology available for tuberculosis care and control is now rapidly evolving. In particular, rapid molecular testing, using devices with excellent performance characteristics for detecting Mycobacterium tuberculosis and rifampin resistance, and that are practical and affordable for use in decentralized facilities in low-resource settings, is being widely deployed globally. Used appropriately, both within tuberculosis control programs and in private laboratories, these devices have the potential to revolutionize tuberculosis care and control, providing a confirmed diagnosis and a determination of rifampin resistance within a few hours, enabling appropriate treatment to be initiated promptly. Major changes have been made in the standards for diagnosis. Additional important changes include: emphasis on the recognition of groups at increased risk of tuberculosis; updating the standard on antiretroviral treatment in persons with tuberculosis and human immunodeficiency virus infection; and revising the standard on treating multiple drug-resistant tuberculosis.
Subject(s)
Communicable Disease Control/standards , International Agencies , Pathology, Molecular , Standard of Care , Tuberculosis/diagnosis , Tuberculosis/therapy , Adult , Antitubercular Agents/therapeutic use , Child , Early Diagnosis , HumansSubject(s)
Antitubercular Agents/therapeutic use , Bacteriological Techniques/standards , International Cooperation , Standard of Care/standards , Tuberculosis/diagnosis , Tuberculosis/therapy , Cooperative Behavior , Directly Observed Therapy/standards , Humans , Predictive Value of Tests , Risk Factors , Tuberculosis/epidemiology , Tuberculosis/microbiologyABSTRACT
To estimate prevalence of multidrug-resistant tuberculosis (MDR TB) in Harare, Zimbabwe, in 2012, we performed microbiologic testing on acid-fast bacilli smear-positive sputum samples from patients previously treated for TB. Twenty (24%) of 84 specimens were consistent with MDR TB. A national drug-resistance survey is needed to determine MDR TB prevalence in Zimbabwe.
Subject(s)
Drug Resistance, Multiple, Bacterial , Mycobacterium tuberculosis/drug effects , Tuberculosis, Multidrug-Resistant/epidemiology , Humans , Microbial Sensitivity Tests , Prevalence , Prospective Studies , Zimbabwe/epidemiologyABSTRACT
OBJECTIVE: Poverty is both a cause and consequence of tuberculosis. The objective of this study is to quantify patient/household costs for an episode of tuberculosis (TB), its relationships with household impoverishment, and the strategies used to cope with the costs by TB patients in a resource-limited high TB/HIV setting. METHODS: A cross-sectional study was conducted in three rural hospitals in southeast Nigeria. Consecutive adults with newly diagnosed pulmonary TB were interviewed to determine the costs each incurred in their care-seeking pathway using a standardised questionnaire. We defined direct costs as out-of-pocket payments, and indirect costs as lost income. RESULTS: Of 452 patients enrolled, majority were male 55% (249), and rural residents 79% (356), with a mean age of 34 (± 11.6) years. Median direct pre-diagnosis/diagnosis cost was $49 per patient. Median direct treatment cost was $36 per patient. Indirect pre-diagnostic and treatment costs were $416, or 79% of total patient costs, $528. The median total cost of TB care per household was $592; corresponding to 37% of median annual household income pre-TB. Most patients reported having to borrow money 212(47%), sell assets 42(9%), or both 144(32%) to cope with the cost of care. Following an episode of TB, household income reduced increasing the proportion of households classified as poor from 54% to 79%. Before TB illness, independent predictors of household poverty were; rural residence (adjusted odds ratio [aOR] 2.8), HIV-positive status (aOR 4.8), and care-seeking at a private facility (aOR 5.1). After TB care, independent determinants of household poverty were; younger age (≤ 35 years; aOR 2.4), male gender (aOR 2.1), and HIV-positive status (aOR 2.5). CONCLUSION: Patient and household costs for TB care are potentially catastrophic even where services are provided free-of-charge. There is an urgent need to implement strategies for TB care that are affordable for the poor.
Subject(s)
Delivery of Health Care/economics , Rural Health Services/economics , Rural Population , Tuberculosis, Pulmonary/economics , Adolescent , Adult , Aged , Costs and Cost Analysis , Family Characteristics , Female , Humans , Male , Middle Aged , Nigeria/epidemiology , Tuberculosis, Pulmonary/diagnosis , Tuberculosis, Pulmonary/epidemiology , Tuberculosis, Pulmonary/therapyABSTRACT
OBJECTIVE: Rifampin monoresistant tuberculosis (RMR-TB) is increasingly identified because of scale-up of rapid molecular tests. The longitudinal association of RMR-TB, multidrug-resistant TB (MDR-TB), and HIV/AIDS is incompletely described. METHODS: We examined clinical characteristics and treatment outcomes of patients with RMR-TB, isoniazid monoresistant TB (IMR-TB), MDR-TB, and drug-susceptible TB during a 16-year period (1993-2008) in California. TB cases were cross-matched with the state HIV/AIDS registry, and HIV prevalence denominators modeled using nonparametric backcalculation. RESULTS: Of 42,582 TB cases, 178 (0.4%), 3469 (8.1%), and 635 (1.5%) were RMR-TB, IMR-TB, and MDR-TB, respectively. From the pre-HAART (1993-1996) to HAART (2005-2008) era, RMR-TB rates declined rapidly (12.0 vs. 0.5 per 100,000) among patients with HIV infection. The proportion of patients for whom rifampin resistance indicated RMR-TB (rather than MDR-TB) decreased from 31% [95% confidence interval (CI) 26-38%] to 11% (95% CI 5-19%). In multivariate analysis controlling for HIV coinfection and other covariates, patients with RMR-TB were twice as likely to die as patients with drug-sensitive TB (relative risk 1.94, 95% CI 1.40-2.69). CONCLUSION: RMR-TB/HIV rates declined substantially over time in association with improved TB control and HIV control in California. Mortality among patients with RMR-TB was high, even after adjusting for HIV status.
Subject(s)
Antitubercular Agents/pharmacology , Drug Resistance, Bacterial , HIV Infections/complications , HIV Infections/epidemiology , Rifampin/pharmacology , Tuberculosis, Multidrug-Resistant/complications , Tuberculosis, Multidrug-Resistant/epidemiology , Adult , Aged , California/epidemiology , Cohort Studies , Comorbidity , Female , Humans , Incidence , Isoniazid/pharmacology , Male , Middle Aged , Mycobacterium tuberculosis/drug effects , Mycobacterium tuberculosis/isolation & purification , Prevalence , Retrospective Studies , Survival AnalysisABSTRACT
To understand the epidemiology of tuberculosis (TB) and HIV co-infection in California, we cross-matched incident TB cases reported to state surveillance systems during 19932008 with cases in the state HIV/AIDS registry. Of 57,527 TB case-patients, 3,904 (7%) had known HIV infection. TB rates for persons with HIV declined from 437 to 126 cases/100,000 persons during 19932008; rates were highest for Hispanics (225/100,000) and Blacks (148/100,000). Patients co-infected with TBHIV during 20012008 were significantly more likely than those infected before highly active antiretroviral therapy became available to be foreign born, Hispanic, or Asian/Pacific Islander and to have pyrazinamide-monoresistant TB. Death rates decreased after highly active antiretroviral therapy became available but remained twice that for TB patients without HIV infection and higher for women. In California, HIV-associated TB has concentrated among persons from low- and middle-income countries who often acquire HIV infection in the peri-immigration period.
Subject(s)
Coinfection/epidemiology , HIV Infections/epidemiology , Tuberculosis, Pulmonary/epidemiology , Adolescent , Adult , Age Distribution , Antiretroviral Therapy, Highly Active , California/epidemiology , Coinfection/drug therapy , Epidemiological Monitoring , Female , HIV Infections/drug therapy , Humans , Incidence , Male , Middle Aged , Prevalence , Retrospective Studies , Young AdultABSTRACT
RATIONALE: Current tools available to study the molecular epidemiology of tuberculosis do not provide information about the directionality and sequence of transmission for tuberculosis cases occurring over a short period of time, such as during an outbreak. Recently, whole genome sequencing has been used to study molecular epidemiology of Mycobacterium tuberculosis over short time periods. OBJECTIVE: To describe the microevolution of M. tuberculosis during an outbreak caused by one drug-susceptible strain. METHOD AND MEASUREMENTS: We included 9 patients with tuberculosis diagnosed during a period of 22 months, from a population-based study of the molecular epidemiology in San Francisco. Whole genome sequencing was performed using Illumina's sequencing by synthesis technology. A custom program written in Python was used to determine single nucleotide polymorphisms which were confirmed by PCR product Sanger sequencing. MAIN RESULTS: We obtained an average of 95.7% (94.1-96.9%) coverage for each isolate and an average fold read depth of 73 (1 to 250). We found 7 single nucleotide polymorphisms among the 9 isolates. The single nucleotide polymorphisms data confirmed all except one known epidemiological link. The outbreak strain resulted in 5 bacterial variants originating from the index case A1 with 0-2 mutations per transmission event that resulted in a secondary case. CONCLUSIONS: Whole genome sequencing analysis from a recent outbreak of tuberculosis enabled us to identify microevolutionary events observable during transmission, to determine 0-2 single nucleotide polymorphisms per transmission event that resulted in a secondary case, and to identify new epidemiologic links in the chain of transmission.