Undernourished Household Contacts Are at Increased Risk of Tuberculosis (TB) Disease, but not TB Infection- a Multicenter Prospective Cohort Analysis.

Undernutrition is the leading risk factor for tuberculosis (TB) globally and in India. This multicenter prospective cohort analysis from India suggests that undernutrition is associated with increased risk of TB disease but not TB infection among household contacts of persons with TB.

Food Insecurity and Undernutrition Are Associated With Distinct Immunologic Profiles in People With Tuberculosis and Advanced HIV Starting Antiretroviral Therapy.

BACKGROUND: Food insecurity and undernutrition are related but distinct concepts contributing to poor HIV and tuberculosis outcomes. Pathways linking them with immunologic profile, which may relate to clinical outcomes, remain understudied. METHODS: We analyzed data from a cohort study of 165 antiretroviral therapy (ART)-naïve adults with advanced HIV and newly diagnosed tuberculosis in Botswana from 2009 to 2013. Twenty-nine plasma biomarkers were measured pre-ART and 4 weeks post-ART initiation. We used principal components analysis (PCA) and multivariable linear regression models to assess relationships between immunological profiles and food insecurity (based on the Household Food Insecurity Access Scale), undernutrition (body mass index <18.5 kg/m 2 ), and clinical outcomes. RESULTS: PCA identified 5 principal components with eigenvalues >1. After adjustment, food insecurity was associated with PC3 pre-ART (0.19 per increased category of severity, 95% CI: 0.02 to 0.36) and post-ART (0.24, 95% CI: 0.07 to 0.41). PC3 was driven by higher levels of IFN-α, IFN-γ, interleukin (IL)-12p40, vascular endothelial growth factor, IL-1α, and IL-8 and decreased concentrations of IL-3. Undernutrition was associated with PC5 post-ART (0.49, 95% CI: 0.16 to 0.82). PC5 was driven by higher levels of IL-8, MIP-1α, IL-6, and IL-10 and decreased concentrations in IP-10 and IFN-α. Post-ART PC3 (4.3 percentage point increased risk per increased score of 1, 95% CI: 0.3 to 8.9) and post-ART PC5 (4.8, 95% CI: 0.6 to 8.9) were associated with death in adjusted models. DISCUSSION: We identified 2 distinct immunologic profiles associated with food insecurity, undernutrition, and clinical outcomes in patients with advanced HIV and tuberculosis. Different pathophysiologic processes may link food insecurity and undernutrition with poor outcomes in this vulnerable patient population. Future studies should assess the impact of improving food access and intake on immune function and clinical outcomes.

In-kind nutritional supplementation for household contacts of persons with tuberculosis would be cost-effective for reducing tuberculosis incidence and mortality in India: a modeling study.

Background: Undernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost prohibitive. The RATIONS study demonstrated that nutritional support provided to household contacts of persons with TB can reduce TB incidence. However, the long-term cost-effectiveness of this intervention is unclear. Methods: We assessed the cost-effectiveness of a RATIONS-style intervention (daily 750 kcal dietary supplementation and multi-micronutrient tablet). Using a Markov state transition model we simulated TB incidence, treatment, and TB-attributable mortality among household contacts receiving the RATIONS intervention, as compared to no nutritional support. We calculated health outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from government and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis. Findings: Over two years, household contacts receiving the RATIONS intervention would experience 39% (95% uncertainty interval (UI): 23-52) fewer TB cases and 59% (95% UI: 44-69) fewer TB deaths. The intervention was estimated to avert 13,775 (95% UI: 9036-20,199) TB DALYs over the lifetime of the study cohort comprising 100,000 household contacts and was cost-effective from both government (incremental cost-effectiveness ratio: $229 per DALY averted [95% UI: 133-387]) and societal perspectives ($184 per DALY averted [95% UI: 83-344]). The results were most sensitive to the cost of the nutritional supplement. Interpretation: Prompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India. Summary: Undernutrition is the leading cause of tuberculosis in India. Using a Markov state-transition model, we found that food baskets for household contacts of persons with tuberculosis would be cost-effective in reducing tuberculosis incidence and mortality in India. Research in context: Evidence before this study: Undernutrition is the leading risk factor for TB worldwide. Recently, the RATIONS study demonstrated a roughly 40% reduction in incident TB among household contacts who received in-kind macronutrient and micronutrient supplementation. Added value of this study: Although the RATIONS study demonstrated a dramatic reduction in incident TB, it is unclear if nutritional interventions to prevent TB are cost-effective. Previously, only one cost-effectiveness analysis of nutritional interventions for household contacts has been published. Due to lack of published data, that study had to make assumptions regarding the impact of nutritional interventions on TB incidence and mortality. In this study, we conducted an economic evaluation of a RATIONS-style intervention to reduce incident TB and mortality in India using observed data. Implications of all the available evidence: In-kind nutritional supplementation for household contacts of individuals with TB disease would be cost-effective in reducing incident TB and TB mortality, particularly if TB programs leverage economies of scale to bring down the cost of the nutritional intervention.

National Institutes of Health Funding for Tuberculosis Comorbidities Is Disproportionate to Their Epidemiologic Impact.

Tuberculosis (TB) is a leading infectious killer worldwide. We systematically searched the National Institutes of Health Research, Portfolio Online Reporting Tools Expenditures and Results (RePORTER) website to compare research funding for key TB comorbidities-undernutrition, alcohol use, human immunodeficiency virus, tobacco use, and diabetes-and found a large mismatch between the population attributable fraction of these risk factors and the funding allocated to them.

The Costly Vicious Cycle of Infections and Malnutrition.

Malnutrition, which continues to affect hundreds of millions of people worldwide, is both a cause and consequence of a range of infectious diseases. In this perspective piece, we provide an overview of the bidirectional relationship between malnutrition and infectious diseases. In addition to enteric infections, we use tuberculosis as a case study of this relationship between malnutrition and infectious diseases and to demonstrate the potential of nutritional interventions to mitigate mortality and morbidity from infectious diseases. We conclude with suggestions on advancing our understanding of the vicious cycle of microbes and malnutrition and finding ways to break it.

At Long Last: Short, All-Oral Regimens for Multidrug-Resistant Tuberculosis in the United States.

Multidrug-resistant tuberculosis (MDR-TB) has historically required longer treatment regimens that were associated with higher unfavorable outcomes and side effects rates compared with drug susceptible TB (DS-TB). During the last decade, several studies conducted mostly in high-incidence settings have shown that MDR-TB can be successfully treated using all-oral shorter regimens of 6- to 9-month duration. In this article, we review the evolution of MDR-TB treatment from the early long regimens with injectables agents (IAs), followed by the shorter regimens with IA, to the groundbreaking, all-oral, 6- to 9-month regimens. Finally, we propose a framework for implementation of the shorter all-oral regimens in the United States.

Not business as usual: Engaging the corporate sector in India's TB elimination efforts.

India has the highest global burden of tuberculosis (TB), accounting for a quarter of the worldwide TB disease incidence. Given the magnitude of India's epidemic, TB has enormous economic implications. Indeed, the majority of individuals with TB disease are in their prime years of economic productivity. Absenteeism and employee turnover due to TB have economic ramifications for employers. Furthermore, TB can easily spread in the workplace and compound the economic impact. Employers who fund workplace, community, or national TB initiatives stand to gain directly and also enjoy reputational benefits, which are important in the era of socially conscious investing. Corporate social responsibility laws in India and tax incentives can be leveraged to bring the logistical networks, reach, and innovative spirit of the private sector to bear on India's formidable TB epidemic. In this perspective piece, we explore the economic impacts of TB; opportunities for and benefits from businesses contributing to TB elimination efforts; and strategies to enlist India's corporate sector in the fight against TB.

Comparing COVID-19-related Morbidity and Mortality Between Patients With and Without Substance Use Disorders: A Retrospective Cohort Study.

Objectives: People with substance use disorders (SUD) are suggested to have higher risk of hospitalization, intubation, or death from coronavirus disease 2019 (COVID-19), although data are mixed. Little is known about other COVID-19-related complications in this group. We compared morbidity and mortality among individuals with and without SUD who were admitted to an urban safety net hospital with COVID-19 early in the pandemic, contemporaneous to other published studies on this subject. Methods: We performed a retrospective study of patients ⩾18 years old admitted with COVID-19 from March 16th to April 8th, 2020. SUD included alcohol, opioid, cocaine, amphetamine, and benzodiazepine use disorders and was identified using diagnostic codes, free text clinical documentation, and urine drug screens. The primary outcome was inpatient mortality. Secondary outcomes included clinical complications (eg, secondary infections, venous thromboembolism) and resource utilization (eg, mechanical ventilation, length of stay). We used multivariable regression to assess the relationship between SUD and mortality. Results: Of 409 patients, the mean age was 56 years and 13.7% had SUD. Those with SUD were more likely to be male, have experienced homelessness, have pulmonary disease or hepatitis C, or use tobacco or cannabis. After multivariable analysis, SUD was not associated with mortality (aOR 1.03; 95% CI, 0.31-3.10). Secondary outcomes were also similar between groups. Conclusions: Our findings suggest that persons with and without SUD have similar COVID-19-related outcomes. Previously reported increased COVID-19 complications may be from medical comorbidities.

Addressing the risk of monkeypox exposure during gastrointestinal endoscopy.

The current monkeypox virus (MPV) outbreak is now a global health concern. MPV, a zoonotic double-stranded DNA virus, may be transmitted from human to human or by contaminated surfaces. Understanding the clinical characteristics and risks of MPV transmission are important, especially for health care workers, who may unknowingly encounter the virus while fulfilling their clinical responsibilities. The World Health Organization has recognized this orthopoxvirus outbreak as a public health emergency and the knowledge gaps regarding MPV's transmission are likely to have contributed to its spread. Instituting proper infection controls in all settings, including the endoscopy suite, is critical to stemming this developing epidemic. Direct contact with skin lesions is the primary mode of transmission, and anorectal lesions are the most common skin manifestation. Hence, gastroenterologists and endoscopists are very likely to see patients with MPV infection. In this context, patients may present with symptoms of proctitis, or lesions may be encountered unexpectedly during anoscopy, sigmoidoscopy, or colonoscopy. In consequence, preprocedural exams and endoscopic procedures may increase exposure risk, especially if characteristic lesions go unrecognized. In this review, we provide background epidemiological and virological information, but focus on the potential risk of MPV exposure during gastrointestinal endoscopy and evaluate current practices regarding personal protective equipment and post-procedure instrument and endoscopy suite decontamination.

Cost-effectiveness of second-line therapies in adults with chronic immune thrombocytopenia.

Major options for second-line therapy in adults with chronic immune thrombocytopenia (ITP) include splenectomy, rituximab, and thrombopoietin receptor agonists (TRAs). The American Society of Hematology guidelines recommend rituximab over splenectomy, TRAs over rituximab, and splenectomy or TRAs while noting a lack of evidence on the cost-effectiveness of these therapies. Using prospective, observational, and meta-analytic data, we performed the first cost-effectiveness analysis of second-line therapies in chronic ITP, from the perspective of the U.S. health system. Over a 20-year time-horizon, our six-strategy Markov model shows that a strategy incorporating early splenectomy, an approach at odds with current guidelines and clinical practice, is the cost-effective strategy. All four strategies utilizing TRAs in the first or second position cost over $1 million per quality-adjusted life-year, as compared to strategies involving early use of splenectomy and rituximab. In a probabilistic sensitivity analysis, early use of splenectomy and rituximab in either order was favored in 100% of 10 000 iterations. The annual cost of TRAs would have to decrease over 80% to begin to become cost-effective in any early TRA strategy. Our data indicate that effectiveness of early TRA and late TRA strategies is similar with the cost significantly greater with early TRA strategies. Contrary to current practice trends and guidelines, early use of splenectomy and rituximab, rather than TRAs, constitutes cost-effective treatment in adults with chronic ITP.

Effect of treatment adherence on the association between sex and unfavourable treatment outcomes among tuberculosis patients in Puducherry, India: a mediation analysis.

BACKGROUND: A better understanding of the complex interplay between risk factors of tuberculosis (TB) is essential. This study was part of the Regional Prospective Observational Research for Tuberculosis (RePORT) India consortium and includes newly diagnosed TB patients in Puducherry between 2014 and 2018. We employed mediation analysis to identify the effect of treatment adherence on association between sex and unfavourable TB treatment outcomes. METHODS: Required demographic and treatment-related variables were extracted from the RePORT India consortium database and causal mediation analysis using parametric regression models was done. RESULTS: Of the 712 TB patients, ~87 (12.2%) had unfavourable TB treatment outcomes. Total effect of male sex was significantly associated with the unfavourable TB treatment outcomes [adjusted odds ratio (aOR) = 2.48; 95% confidence interval (CI): 1.11-5.55]. However, the overall association between male sex and TB treatment outcomes was dominated by the indirect pathway, as the direct pathway does not show significant association (aOR = 1.67; 95% CI: 0.75-3.75), while the indirect pathway shows significantly higher odds of TB treatment outcomes (aOR = 1.48; 95% CI:1.27-1.73), indicating complete mediation by the treatment adherence. CONCLUSIONS: The study has shown a complete mediation of sexes through TB treatment adherence for unfavourable treatment outcomes. Developing of treatment strategies require better understanding between the biological and social factors related to TB.

Impact of Undernutrition on Tuberculosis Treatment Outcomes in India: A Multicenter, Prospective, Cohort Analysis.

BACKGROUND: Undernutrition is the leading risk factor for tuberculosis (TB) globally. Its impact on treatment outcomes is poorly defined. METHODS: We conducted a prospective cohort analysis of adults with drug-sensitive pulmonary TB at 5 sites from 2015-2019. Using multivariable Poisson regression, we assessed associations between unfavorable outcomes and nutritional status based on body mass index (BMI) nutritional status at treatment initiation, BMI prior to TB disease, stunting, and stagnant or declining BMI after 2 months of TB treatment. Unfavorable outcome was defined as a composite of treatment failure, death, or relapse within 6 months of treatment completion. RESULTS: Severe undernutrition (BMI <16 kg/m2) at treatment initiation and severe undernutrition before the onset of TB disease were both associated with unfavorable outcomes (adjusted incidence rate ratio [aIRR], 2.05; 95% confidence interval [CI], 1.42-2.91 and aIRR, 2.20; 95% CI, 1.16-3.94, respectively). Additionally, lack of BMI increase after treatment initiation was associated with increased unfavorable outcomes (aIRR, 1.81; 95% CI, 1.27-2.61). Severe stunting (height-for-age z score <-3) was associated with unfavorable outcomes (aIRR, 1.52; 95% CI, 1.00-2.24). Severe undernutrition at treatment initiation and lack of BMI increase during treatment were associated with a 4- and 5-fold higher rate of death, respectively. CONCLUSIONS: Premorbid undernutrition, undernutrition at treatment initiation, lack of BMI increase after intensive therapy, and severe stunting are associated with unfavorable TB treatment outcomes. These data highlight the need to address this widely prevalent TB comorbidity. Nutritional assessment should be integrated into standard TB care.

Corrigendum: Malnutrition leads to increased inflammation and expression of tuberculosis risk signatures in recently exposed household contacts of pulmonary tuberculosis.

[This corrects the article DOI: 10.3389/fimmu.2022.1011166.].

Malnutrition leads to increased inflammation and expression of tuberculosis risk signatures in recently exposed household contacts of pulmonary tuberculosis.

Background: Most individuals exposed to Mycobacterium tuberculosis (Mtb) develop latent tuberculosis infection (LTBI) and remain at risk for progressing to active tuberculosis disease (TB). Malnutrition is an important risk factor driving progression from LTBI to TB. However, the performance of blood-based TB risk signatures in malnourished individuals with LTBI remains unexplored. The aim of this study was to determine if malnourished and control individuals had differences in gene expression, immune pathways and TB risk signatures. Methods: We utilized data from 50 tuberculin skin test positive household contacts of persons with TB - 18 malnourished participants (body mass index [BMI] < 18.5 kg/m2) and 32 controls (individuals with BMI ≥ 18.5 kg/m2). Whole blood RNA-sequencing was conducted to identify differentially expressed genes (DEGs). Ingenuity Pathway Analysis was applied to the DEGs to identify top canonical pathways and gene regulators. Gene enrichment methods were then employed to score the performance of published gene signatures associated with progression from LTBI to TB. Results: Malnourished individuals had increased activation of inflammatory pathways, including pathways involved in neutrophil activation, T-cell activation and proinflammatory IL-1 and IL-6 cytokine signaling. Consistent with known association of inflammatory pathway activation with progression to TB disease, we found significantly increased expression of the RISK4 (area under the curve [AUC] = 0.734) and PREDICT29 (AUC = 0.736) progression signatures in malnourished individuals. Conclusion: Malnourished individuals display a peripheral immune response profile reflective of increased inflammation and a concomitant increased expression of risk signatures predicting progression to TB. With validation in prospective clinical cohorts, TB risk biomarkers have the potential to identify malnourished LTBI for targeted therapy.

Case Report: Tuberculosis Autoregression after Minimal Treatment and Review of the Literature.

Mycobacterium tuberculosis (Mtb) is a complex pathogen causing multiple possible disease states in its host including latency, active disease, and elimination. While there is reasonable indirect evidence of elimination of tuberculosis (TB) in the absence of treatment, direct reports of autoregression are rare. We report a case of smear-negative, polymerase chain reaction (PCR)-positive TB disease regression in the absence of therapy due to severe adverse effects from antimycobacterial drugs. Indirect reports of TB autoregression, or self-cure, in the literature are reviewed, and an updated framework for conceptualizing Mtb infection is discussed.

Undernutrition is feeding the tuberculosis pandemic: A perspective.

Tuberculosis (TB) is a major cause of death worldwide, with 1.5 million deaths in 2020. While TB incidence and mortality had previously been on a downwards trend, in 2020, TB mortality actually rose for the first time in a decade, largely due to the COVID-19 pandemic. Undernutrition is the leading risk factor for TB, with a population attributable fraction (PAF) of 15%, compared to 7.6% for HIV. Individuals who are undernourished are more likely to develop active TB compared to those with a healthy bodyweight. They are also more likely to have greater severity of TB, and less likely to have successful TB treatment outcomes. The likelihood of TB mortality significantly increases as weight decreases. Nutritional interventions are likely to improve both nutritional status and TB treatment success, thereby decreasing TB mortality. However, many previous studies focusing on nutritional interventions have provided insufficient calories or been underpowered. Nutritional supplementation will be particularly important as factors such as the COVID-19 pandemic, climate change, and political conflict further threaten food security. The global TB elimination effort can no longer afford to ignore undernutrition.