ABSTRACT
Epidemiologic data regarding persons with active tuberculosis (TB) and chronic hepatitis B virus (cHBV) infection are limited because of lack of routine surveillance of cHBV in persons with TB. Potential underdiagnosis of cHBV in California among those with TB is concerning. We matched TB and cHBV registries to identify cHBV infections among persons diagnosed with TB during 2016-2020 and described their demographic characteristics. We calculated expected cHBV cases among persons with TB for each demographic characteristic using published cHBV prevalence estimates for the locations of birth for persons with TB. Estimates were from general or emigrant adult and teen populations. Reported cHBV infection among persons with TB were 23% lower than expected, particularly among Asian persons, persons living in the two healthiest Healthy Places Index quartiles, and residents of less populated jurisdictions in California. Results show the possibility exists for underdiagnosis of cHBV in persons with TB in California.
Subject(s)
Hepatitis B, Chronic , Tuberculosis , Humans , California/epidemiology , Male , Female , Adult , Hepatitis B, Chronic/epidemiology , Hepatitis B, Chronic/complications , Middle Aged , Tuberculosis/epidemiology , Adolescent , Prevalence , AgedABSTRACT
BACKGROUND: Improved epidemiologic and treatment data for active tuberculosis (TB) with chronic hepatitis B virus (cHBV) infection might inform and encourage screening and vaccination programs focused on persons at risk of having both conditions. METHODS: We matched the California Department of Public Health TB registry during 2016-2020 to the cHBV registry using probabilistic matching algorithms. We used chi-square analysis to compare the characteristics of persons with TB and cHBV with those with TB only. We compared TB treatment outcomes between these groups using modified Poisson regression models. We calculated the time between reporting of TB and cHBV diagnoses for those with both conditions. RESULTS: We identified 8435 persons with TB, including 316 (3.7%) with cHBV. Among persons with TB and cHBV, 256 (81.0%) were non-US-born Asian versus 4186 (51.6%) with TB only (P < .0001). End-stage renal disease (26 [8.2%] vs 322 [4.0%]; P < .001) and HIV (21 [6.7%] vs 247 [3.0%]; P = .02) were more frequent among those with TB and cHBV compared with those with TB only. Among those with both conditions, 35 (11.1%) had TB diagnosed >60 days before cHBV (median, 363 days) and 220 (69.6%) had TB diagnosed >60 days after cHBV (median, 3411 days). CONCLUSIONS: Persons with TB and cHBV were found more frequently in certain groups compared with TB only, and infrequently had their conditions diagnosed together. This highlights an opportunity to improve screening and treatment of TB and cHBV in those at high risk for coinfection.
Subject(s)
Hepatitis B, Chronic , Tuberculosis , Humans , Male , Female , Hepatitis B, Chronic/complications , Hepatitis B, Chronic/epidemiology , Hepatitis B, Chronic/drug therapy , California/epidemiology , Middle Aged , Adult , Tuberculosis/epidemiology , Tuberculosis/drug therapy , Treatment Outcome , Coinfection/epidemiology , Antitubercular Agents/therapeutic use , Young Adult , Aged , Registries , HIV Infections/complications , HIV Infections/epidemiology , AdolescentABSTRACT
We assessed tuberculosis (TB) diagnostic delays among patients with TB and COVID-19 in California, USA. Among 58 persons, 43% experienced TB diagnostic delays, and a high proportion (83%) required hospitalization for TB. Even when viral respiratory pathogens circulate widely, timely TB diagnostic workup for at-risk persons remains critical for reducing TB-related illness.
Subject(s)
COVID-19 , Tuberculosis , Humans , Delayed Diagnosis , COVID-19/diagnosis , California/epidemiology , Treatment Outcome , Tuberculosis/diagnosis , Tuberculosis/drug therapy , Tuberculosis/epidemiology , COVID-19 TestingABSTRACT
BACKGROUND: Indicators of extensive disease-acid fast bacilli (AFB) smear positivity and lung cavitation-have been inconsistently associated with clinical rifampin-resistant/multidrug-resistant tuberculosis (RR/MDR-TB) outcomes. We evaluated the association of these indicators with end-of-treatment outcomes. METHODS: We did an individual participant data meta-analysis of people treated for RR/MDR-TB with longer regimens with documented AFB smear and chest radiography findings. We compared people AFB smear-negative without cavities to people: (1) smear-negative with lung cavities; (2) smear-positive without lung cavities and (3) AFB smear-positive with lung cavities. Using multivariable logistic regression accounting for demographic, treatment and clinical factors, we calculated adjusted ORs (aOR) for any unfavourable outcome (death, lost to follow-up, failure/recurrence), and mortality and treatment failure/recurrence alone. RESULTS: We included 5596 participants; included participants significantly differed from excluded participants. Overall, 774 (13.8%) were AFB smear-negative without cavities, 647 (11.6%) only had cavities, 1424 (25.4%) were AFB smear-positive alone and 2751 (49.2%) were AFB smear-positive with cavities. The median age was 37 years (IQR: 28-47), 3580 (64%) were male and 686 (12.5%) had HIV. Compared with participants AFB smear-negative without cavities, aOR (95% CI) for any unfavourable outcome was 1.0 (0.8 to 1.4) for participants smear-negative with lung cavities, 1.2 (0.9 to 1.5) if smear-positive without cavities and 1.6 (1.3 to 2.0) if AFB smear-positive with lung cavities. Odds were only significantly increased for mortality (1.5, 95% CI 1.1 to 2.1) and failure/recurrence (2.2, 95% CI 1.5 to 3.3) among participants AFB smear-positive with lung cavities. CONCLUSION: Only the combination of AFB smear-positivity and lung cavitation was associated with unfavourable outcomes, suggesting they may benefit from stronger regimens.
Subject(s)
Mycobacterium tuberculosis , Tuberculosis, Multidrug-Resistant , Tuberculosis, Pulmonary , Humans , Male , Adult , Female , Rifampin/therapeutic use , Tuberculosis, Pulmonary/drug therapy , Tuberculosis, Multidrug-Resistant/drug therapy , SputumABSTRACT
Using California Tuberculosis (TB) Registry data from 2010-2020, we compared the presentation and outcomes of patients with TB aged >15 years with and without solid organ transplantation (SOT). We matched to the United Network for Organ Sharing registry for 1987-2020 and the estimated time from transplantation to the diagnosis of TB, the incidence of posttransplant TB, and the probability of death and graft failure in SOT recipients with TB, compared to those without TB. From 2010-2020, there were 148 posttransplant TB cases. Patients with posttransplant TB were more likely to have extrapulmonary disease and more than twice as likely to die as TB patients without SOT (relative risk [RR], 2.2; 95% confidence interval [CI], 1.6-2.9). The median time from transplantation to TB diagnosis was 1.2 years, with the shortest time among lung transplant recipients. The incidence of TB disease among Californians with SOT was 56.0 per 100 000 person-years. The risk of death was higher among SOT recipients with posttransplant TB than those without (adjusted hazard ratio, 2.8; 95% CI, 2.0-4.1); the risk of graft failure was higher among kidney transplant recipients with posttransplant TB than those without (adjusted hazard ratio, 3.4; 95% CI, 1.7-6.9). An increased risk of death and graft failure in SOT recipients with posttransplant TB highlights the need for enhanced pretransplant TB prevention.
Subject(s)
Organ Transplantation , Tuberculosis , Humans , Transplant Recipients , Risk Factors , Organ Transplantation/adverse effects , CaliforniaABSTRACT
Rationale: Wildfires are a significant cause of exposure to ambient air pollution in the United States and other settings. Although indoor air pollution is a known contributor to tuberculosis reactivation and progression, it is unclear whether ambient pollution exposures, including wildfire smoke, similarly increase risk. Objectives: To determine whether tuberculosis diagnosis was associated with recent exposure to acute outdoor air pollution events, including those caused by wildfire smoke. Methods: We conducted a case-crossover analysis of 6,238 patients aged ⩾15 years diagnosed with active tuberculosis disease between 2014 and 2019 in 8 California counties. Using geocoded address data, we characterized individuals' daily exposure to <2.5 µm-diameter particulate matter (PM2.5) during counterfactual risk periods 3-6 months before tuberculosis diagnosis (hazard period) and the same time 1 year previously (control period). We compared the frequency of residential PM2.5 exposures exceeding 35 µg/m3 (PM2.5 events) overall and for wildfire-associated and nonwildfire events during individuals' hazard and control periods. Measurements and Main Results: In total, 3,139 patients experienced 1 or more PM2.5 events during the hazard period, including 671 experiencing 1 or more wildfire-associated events. Adjusted odds of tuberculosis diagnosis increased by 5% (95% confidence interval, 3-6%) with each PM2.5 event experienced over the 6-month observation period. Each wildfire-associated PM2.5 event was associated with 23% (19-28%) higher odds of tuberculosis diagnosis in this time window, whereas no association was apparent for nonwildfire-associated events. Conclusions: Residential exposure to wildfire-associated ambient air pollution is associated with an increased risk of active tuberculosis diagnosis.
Subject(s)
Air Pollutants , Air Pollution , Tuberculosis , Wildfires , Humans , United States , Aged , Particulate Matter/adverse effects , Particulate Matter/analysis , Smoke/adverse effects , California/epidemiology , Tuberculosis/diagnosis , Tuberculosis/epidemiology , Air Pollutants/adverse effects , Air Pollutants/analysis , Environmental Exposure/adverse effectsABSTRACT
We assessed the association of area-based socio-economic status (SES) measures with tuberculosis (TB) incidence in California. We used TB disease data for 2012-2016 (n = 9901), population estimates, and SES measures to calculate incidence rates, rate ratios, and 95% confidence intervals (95% CI) by SES and birth country. SES was measured by census tract and was categorized by quartiles for education, crowding, and the California Healthy Places Index (HPI)and by specific cutoffs for poverty. The lowest SES areas defined by education, crowding, poverty, and HPI had 39%, 40%, 41%, and 33% of TB cases respectively. SES level was inversely associated with TB incidence across all SES measures and birth countries. TB rates were 3.2 (95% CI 3.0-3.4), 2.1 (95% CI 1.9-2.2), 3.6 (95% CI 3.3-3.8), and 2.0 (95% CI 1.9-2.1) times higher in lowest SES areas vs. highest SES areas as defined by education, crowding, poverty and HPI respectively. Area-based SES measures are associated with TB incidence in California. This information could inform TB prevention efforts in terms of materials, partnerships, and prioritization.
Subject(s)
Tuberculosis , Humans , Incidence , Tuberculosis/epidemiology , Social Class , Poverty , California/epidemiology , Socioeconomic FactorsABSTRACT
BACKGROUND: California tuberculosis (TB) prevention goals include testing more than ten million at-risk Californians and treating two million infected with tuberculosis. Adequate health insurance and robust healthcare utilization are crucial to meeting these goals, but information on these factors for populations that experience risk for TB is limited. METHODS: We used data from the 2014-2017 California Health Interview Survey (n = 82,758), a population-based dual-frame telephone survey to calculate survey proportions and 95% confidence intervals (CI) stratified by country of birth, focusing on persons from countries of birth with the highest number of TB cases in California. Survey proportions for recent doctor's visit, overall health, smoking, and diabetes were age-adjusted. RESULTS: Among 18-64 year-olds, 27% (CI: 25-30) of persons born in Mexico reported being uninsured in contrast with 3% (CI: 1-5) of persons born in India. Report of recent doctor's visit was highest among persons born in the Philippines, 84% (CI: 80-89) and lowest among Chinese-born persons, 70% (CI: 63-76). Persons born in Mexico were more likely to report community clinics as their usual source of care than persons born in China, Vietnam, or the Philippines. Poverty was highest among Mexican-born persons, 56% (CI: 54-58) and lowest among Indian-born persons, 9% (CI: 5-13). Of adults with a medical visit in a non-English language, 96% (CI: 96-97) were non-U.S.-born, but only 42% (CI: 40-44) of non-U.S.-born persons had a visit in a non-English language. DISCUSSION: Many, though not all, of the populations that experience risk for TB had health insurance and used healthcare. We found key differences in usual source of care and language use by country of birth which should be considered when planning outreach to specific providers, clinic systems, insurers and communities for TB prevention and case-finding.
Subject(s)
Language , Tuberculosis , Adult , Ambulatory Care Facilities , California/epidemiology , Delivery of Health Care , Humans , Insurance, Health , Patient Acceptance of Health Care , Tuberculosis/epidemiology , Tuberculosis/therapy , United StatesABSTRACT
BACKGROUND: Recognizing pulmonary involvement in tuberculosis (TB) patients is necessary to prevent TB transmission. We describe frequency and characteristics of patients with extrapulmonary TB (EPTB), normal chest radiographs, and positive sputum culture. METHODS: We analyzed data of patients ≥15 years of age with EPTB reported to the California TB registry during 2011-2017 with cultured sputum and normal chest radiographs using generalized linear modeling to estimate prevalence ratios associated with positive sputum culture. Demographic, behavioral, clinical characteristics, and testing were compared for patients with positive and negative sputum culture. RESULTS: Of 1635 patients with EPTB and normal chest radiographs, 937 (57%) had sputum culture performed, and 127 (13%) patients had positive results for Mycobacterium tuberculosis complex. Patients with positive results were more likely to: be male, experience homelessness, use substances, have HIV, and have >1 disease site. Among 85 patients with HIV co-infection, 54% had positive culture results compared with 9.5% among 852 patients without HIV co-infection. Patients with EPTB in more than 1 site were also more likely to have a positive sputum culture. CONCLUSIONS: Culturing sputum from patients with EPTB identified pulmonary cases not detected by chest radiograph, particularly among patients with HIV or >1 disease site.
Subject(s)
Coinfection , HIV Infections , Mycobacterium tuberculosis , Tuberculosis, Extrapulmonary , Tuberculosis , Humans , Male , Cross-Sectional Studies , Sputum/microbiology , Coinfection/epidemiology , Tuberculosis/epidemiology , HIV Infections/complicationsABSTRACT
Background: Linezolid has been prioritized for treating multidrug-resistant tuberculosis (MDR TB), but toxicity limits its use. We report treatment outcomes for MDR TB patients in California who received standard-dose linezolid vs those who switched to low-dose. Methods: We include culture-positive MDR TB cases treated with linezolid and receiving California MDR TB Service consultation during 2009-2016. Demographic, clinical, and laboratory data are analyzed using univariate analysis to compare patients who received linezolid of different dosing strategies. Analysis end points are linezolid treatment duration (measure of tolerability), treatment success (completion or cure), and adverse events (AEs). Results: Sixty-nine of 194 (36%) MDR TB patients met inclusion criteria. While all patients began linezolid treatment at 600â mg daily, 39 (57%) continued at this dosage (standard-dose), and 30 (43%) switched to 300â mg daily (29%) or intermittent dosing (14%) (low dose). Patients on standard-dose linezolid were treated for 240 days, compared with 535 for those on low-dose (P < .0001). Sixty-three patients (91%) achieved treatment success, 2 (2.9%) died, 1 (1.5%) failed treatment, 1 (1.5%) stopped treatment due to side effects, and 2 (2.9%) were lost or moved. Treatment success was higher (P = .03) in the low-dose group. Sixty-two patients experienced ≥1 hematologic (71%) or neurologic (65%) AE. Those on low-dose linezolid experienced significantly (P = .03) fewer AEs per linezolid-month after switching (0.32 vs 0.10). Conclusions: Patients who switched to low dose tolerated linezolid longer with better treatment outcomes and fewer recurring AEs.
ABSTRACT
Importance: Tuberculosis (TB) and COVID-19 are respiratory diseases that disproportionately occur among medically underserved populations; little is known about their epidemiologic intersection. Objective: To characterize persons diagnosed with TB and COVID-19 in California. Design, Setting, and Participants: This cross-sectional analysis of population-based public health surveillance data assessed the sociodemographic, clinical, and epidemiologic characteristics of California residents who were diagnosed with TB (including cases diagnosed and reported between September 3, 2019, and December 31, 2020) and COVID-19 (including confirmed cases based on positive results on polymerase chain reaction tests and probable cases based on positive results on antigen assays reported through February 2, 2021) in close succession compared with those who were diagnosed with TB before the COVID-19 pandemic (between January 1, 2017, and December 31, 2019) or diagnosed with COVID-19 alone (through February 2, 2021). This analysis included 3â¯402â¯713 California residents with COVID-19 alone, 6280 with TB before the pandemic, and 91 with confirmed or probable COVID-19 diagnosed within 120 days of a TB diagnosis (ie, TB/COVID-19). Exposures: Sociodemographic characteristics, medical risk factors, factors associated with TB severity, and health equity index. Main Outcomes and Measures: Frequency of reported successive TB and COVID-19 (TB/COVID-19) diagnoses within 120 days, frequency of deaths, and age-adjusted mortality rates. Results: Among the 91 persons with TB/COVID-19, the median age was 58.0 years (range, 3.0-95.0 years; IQR, 41.0-73.0 years); 52 persons (57.1%) were male; 81 (89.0%) were born outside the US; and 28 (30.8%) were Asian or Pacific Islander, 4 (4.4%) were Black, 55 (60.4%) were Hispanic or Latino, 4 (4.4%) were White. The frequency of reported COVID-19 among those who received a TB diagnosis between September 3, 2019, and December 31, 2020, was 225 of 2210 persons (10.2%), which was similar to that of the general population (3 402 804 of 39 538 223 persons [8.6%]). Compared with persons with TB before the pandemic, those with TB/COVID-19 were more likely to be Hispanic or Latino (2285 of 6279 persons [36.4%; 95% CI, 35.2%-37.6%] vs 55 of 91 persons [60.4%; 95% CI, 49.6%-70.5%], respectively; P < .001), reside in low health equity census tracts (1984 of 6027 persons [32.9%; 95% CI, 31.7%-34.1%] vs 40 of 89 persons [44.9%; 95% CI, 34.4%-55.9%]; P = .003), live in the US longer before receiving a TB diagnosis (median, 19.7 years [IQR, 7.2-32.3 years] vs 23.1 years [IQR, 15.2-31.5 years]; P = .03), and have diabetes (1734 of 6280 persons [27.6%; 95% CI, 26.5%-28.7%] vs 42 of 91 persons [46.2%; 95% CI, 35.6%-56.9%]; P < .001). The frequency of deaths among those with TB/COVID-19 successively diagnosed within 30 days (8 of 34 persons [23.5%; 95% CI, 10.8%-41.2%]) was more than twice that of persons with TB before the pandemic (631 of 5545 persons [11.4%; 95% CI, 10.6%-12.2%]; P = .05) and 20 times that of persons with COVID-19 alone (42 171 of 3 402 713 persons [1.2%; 95% CI, 1.2%-1.3%]; P < .001). Persons with TB/COVID-19 who died were older (median, 81.0 years; IQR, 75.0-85.0 years) than those who survived (median, 54.0 years; IQR, 37.5-68.5 years; P < .001). The age-adjusted mortality rate remained higher among persons with TB/COVID-19 (74.2 deaths per 1000 persons; 95% CI, 26.2-122.1 deaths per 1000 persons) compared with either disease alone (TB before the pandemic: 56.3 deaths per 1000 persons [95% CI, 51.2-61.4 deaths per 1000 persons]; COVID-19 only: 17.1 deaths per 1000 persons [95% CI, 16.9-17.2 deaths per 1000 persons]). Conclusions and Relevance: In this cross-sectional analysis, TB/COVID-19 was disproportionately diagnosed among California residents who were Hispanic or Latino, had diabetes, or were living in low health equity census tracts. These results suggest that tuberculosis and COVID-19 occurring together may be associated with increases in mortality compared with either disease alone, especially among older adults. Addressing health inequities and integrating prevention efforts could avert the occurrence of concurrent COVID-19 and TB and potentially reduce deaths.
Subject(s)
COVID-19/diagnosis , Comorbidity , Mortality/trends , Sociodemographic Factors , Time Factors , Tuberculosis/diagnosis , Adolescent , Adult , Aged , Aged, 80 and over , COVID-19/epidemiology , COVID-19/mortality , California/epidemiology , Child , Child, Preschool , Cross-Sectional Studies , Humans , Middle Aged , Tuberculosis/epidemiology , Tuberculosis/mortalityABSTRACT
INTRODUCTION: Preventing tuberculosis (TB) disease requires treatment of latent TB infection (LTBI) as well as prevention of person-to-person transmission. We estimated the LTBI prevalence for the entire United States and for each state by medical risk factors, age, and race/ethnicity, both in the total population and stratified by nativity. METHODS: We created a mathematical model using all incident TB disease cases during 2013-2017 reported to the National Tuberculosis Surveillance System that were classified using genotype-based methods or imputation as not attributed to recent TB transmission. Using the annual average number of TB cases among US-born and non-US-born persons by medical risk factor, age group, and race/ethnicity, we applied population-specific reactivation rates (and corresponding 95% confidence intervals [CI]) to back-calculate the estimated prevalence of untreated LTBI in each population for the United States and for each of the 50 states and the District of Columbia in 2015. RESULTS: We estimated that 2.7% (CI: 2.6%-2.8%) of the U.S. population, or 8.6 (CI: 8.3-8.8) million people, were living with LTBI in 2015. Estimated LTBI prevalence among US-born persons was 1.0% (CI: 1.0%-1.1%) and among non-US-born persons was 13.9% (CI: 13.5%-14.3%). Among US-born persons, the highest LTBI prevalence was in persons aged ≥65 years (2.1%) and in persons of non-Hispanic Black race/ethnicity (3.1%). Among non-US-born persons, the highest LTBI prevalence was estimated in persons aged 45-64 years (16.3%) and persons of Asian and other racial/ethnic groups (19.1%). CONCLUSIONS: Our estimations of the prevalence of LTBI by medical risk factors and demographic characteristics for each state could facilitate planning for testing and treatment interventions to eliminate TB in the United States. Our back-calculation method feasibly estimates untreated LTBI prevalence and can be updated using future TB disease case counts at the state or national level.
Subject(s)
Latent Tuberculosis/epidemiology , Models, Theoretical , Tuberculosis/epidemiology , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Ethnicity , Female , Humans , Infant , Latent Tuberculosis/microbiology , Male , Middle Aged , Mycobacterium tuberculosis/pathogenicity , Risk Factors , Tuberculin Test , Tuberculosis/microbiology , United States , Young AdultABSTRACT
BACKGROUND: Bedaquiline (BDQ) is recommended for the treatment of multidrug-resistant tuberculosis (MDR TB), however, it has the potential to prolong QTc interval. We assessed the frequency and severity of QTc prolongation in patients receiving BDQ in California. METHODS: Based on chart review for patients receiving BDQ as part of MDR TB therapy from January 2013-May 2019, we analyzed QTc values at six pre-specified time points during BDQ therapy (baseline, 2, 4, 8, 12, and 24 weeks), as well as peak QTc, time to peak QTc, and the clinical characteristics of patients who had QTc elevation >500 milliseconds (ms) during therapy. RESULTS: A total of 37 patients were treated with BDQ during the analysis period, with a total of 449 QTc measurements available for analysis. Most patients (89%) received at least one QTc-prolonging drug in addition to BDQ. Median QTc values at all pre-specified time points were <450 ms. Median peak QTc was 455 ms (interquartile range [IQR]: 437-486) and median time to peak was 57 days (IQR: 19-156). Four patients (11%) had a non-transient elevation in QTc to >500 ms, including one patient with profound hypokalemia and one receiving concurrent chemotherapy, but none had cardiac arrhythmia. Less than 10% of patient in our cohort had ECGs performed at all six pre-specified time points. DISCUSSION: BDQ was generally well-tolerated in a cohort of patients treated for MDR TB in California, with 11% of patients experiencing a non-transient QTc elevation >500 ms, and no episodes of arrhythmia. Frequent ECG monitoring during BDQ therapy presents a challenge for TB clinicians, even in well-resourced countries.
ABSTRACT
OBJECTIVE: Targeted testing and treatment of persons with latent tuberculosis infection (LTBI) is a critical component of the US tuberculosis (TB) elimination strategy. In January 2016, the California Department of Public Health issued a tool and user guide for TB risk assessment (California tool) and guidance for LTBI testing, and in September 2016, the US Preventive Services Task Force (USPSTF) issued recommendations for LTBI testing in primary care settings. We estimated the epidemiologic effect of adherence to both recommendations in California. METHODS: We used an individual-based Markov micro-simulation model to estimate the number of cases of TB disease expected through 2026 with baseline LTBI strategies compared with implementation of the USPSTF or California tool guidance. We estimated the risk of LTBI by age and country of origin, the probability of being in a targeted population, and the probability of presenting for primary care based on available data. We assumed 100% adherence to testing guidance but imperfect adherence to treatment. RESULTS: Implementation of USPSTF and California tool guidance would result in nearly identical numbers of tests administered and cases of TB disease prevented. Perfect adherence to either recommendation would result in approximately 7000 cases of TB disease averted (40% reduction compared with baseline) by 2026. Almost all of this decline would be driven by a reduction in the number of cases among non-US-born persons. CONCLUSIONS: By focusing on the non-US-born population, adherence to LTBI testing strategies recommended by the USPSTF and the California tool could substantially reduce the burden of TB disease in California in the next decade.
Subject(s)
Latent Tuberculosis/diagnosis , Primary Health Care/organization & administration , Adult , Age Factors , Antitubercular Agents/therapeutic use , California , Emigrants and Immigrants , Guideline Adherence , Humans , Immunocompromised Host , Latent Tuberculosis/drug therapy , Latent Tuberculosis/ethnology , Markov Chains , Mass Screening , Practice Guidelines as Topic , Primary Health Care/standards , Residential Facilities , Risk Assessment , Tuberculosis/ethnologyABSTRACT
BACKGROUND: Although the number of patients with active tuberculosis (TB) has decreased in the last 25 years, anecdotal reports suggest that the complexity of these patients has increased. However, this complexity and its components have never been quantified or defined. We therefore aimed to describe the complexity of patients with active TB in California during 1993-2016. METHODS: We analyzed data on patient comorbidities, clinical features, and demographics from the California Department of Public Health TB Registry. All adult patients who were alive at the time of TB diagnosis in California during 1993-2016 were included in the analyses. Factors deemed by an expert panel to increase complexity (ie, increased resources or expertise requirement for successful management) were analyzed and included the following: age >75 years, HIV infection, multidrug resistance (MDR), and extrapulmonary TB disease. Second, using additional information on other comorbidities available starting in 2010, we performed exploratory factor analysis on 25 variables in order to define the dimensions of complexity. RESULTS: Among the 67â 512 patients analyzed, the proportion of patients with extrapulmonary disease, age >75 years, or MDR-TB each increased over the study period (Pâ <â .001), while the proportion of patients with HIV decreased. Furthermore, the proportion of patients with at least 1 factor of those increased, rising from 38.8% to 45.3% (Pâ <â .001) from 1993 to 2016. Dimensions of complexity identified in the exploratory factor analysis included the following: race/immigration, social features, elderly/institutionalized, advanced TB, comorbidity, and drug resistance risk. CONCLUSIONS: In this first description of complexity in the setting of TB, we found that the complexity of patients with active TB has risen over the last 25 years in California. These findings suggest that despite the overall decline in active TB cases, effective management of more complex patients may require additional attention and resource investment.
ABSTRACT
Trees can sequester air pollutants, and air pollution is associated with poor tuberculosis outcomes. However, the health impacts of urban trees on tuberculosis patients are unknown. To elucidate the effects of urban tree canopy on mortality during tuberculosis treatment, we evaluated patients diagnosed with active tuberculosis in California from 2000 through 2012, obtaining patient data from the California tuberculosis registry. Our primary outcome was all-cause mortality during tuberculosis treatment. We determined percent tree cover using 1 mresolution color infrared orthoimagery categorized into land cover classes, then linked tree cover to four circular buffer zones of 50-300 m radii around patient residential addresses. We used the Kaplan-Meier method to estimate survival probabilities and Cox regression models to determine mortality hazard ratios, adjusting for demographic, socioeconomic, and clinical covariates. Our cohort included 33,962 tuberculosis patients of median age 47, 59% male, 51% unemployed, and 4.9% HIV positive. Tuberculosis was microbiologically confirmed in 79%, and 1.17% were multi-drug resistant (MDR). Median tree cover was 7.9% (50 m buffer). Patients were followed for 23,280 person-years with 2370 deaths during tuberculosis treatment resulting in a crude mortality rate of 1018 deaths per 10,000 person-years. Increasing tree cover quintiles were associated with decreasing mortality risk during tuberculosis treatment in all buffers, and the magnitude of association decreased incrementally with increasing buffer radius: In the 50 m buffer, patients living in neighborhoods with the highest quintile tree cover experienced a 22% reduction in mortality (HR 0.78, 95%CI 0.68-0.90) compared to those living in lowest quintile tree cover; whereas for 100, 200, and 300 m buffers, a 21%, 13%, and 11% mortality risk reduction was evident. In conclusion, urban tree canopy was associated with decreased mortality during tuberculosis treatment even after adjusting for multiple demographic, socioeconomic, and clinical factors, suggesting that trees might play a role in improving tuberculosis outcomes.
Subject(s)
Tuberculosis , Adult , Aged , Air Pollutants , Air Pollution , California/epidemiology , Female , Humans , Male , Middle Aged , Residence Characteristics , Trees , Tuberculosis/mortality , Urban Health ServicesABSTRACT
BACKGROUND: In 2012, the Food and Drug Administration approved use of bedaquiline fumarate as part of combination therapy for multidrug-resistant tuberculosis (MDR TB). We describe treatment outcomes, safety, and tolerability of bedaquiline in our case series. METHODS: Data on patients started on bedaquiline for MDR TB between September 2012 and August 2016 were collected retrospectively through 4 TB programs using a standardized abstraction tool. Data were analyzed using univariate methods. Adverse events were graded using the Common Terminology Criteria for Adverse Events. RESULTS: Of 14 patients, 7 (50%) had MDR, 4 (29%) had pre-extensively drug-resistant (XDR), and 3 (21%) had XDR TB. All had pulmonary TB, 5 (36%) had pulmonary and extrapulmonary TB, and 9/13 (69%) were smear positive. One patient (7%) had HIV coinfection, 5 (36%) had diabetes mellitus, and 5/14 (36%) had previous treatment TB. All patients were non-US-born and 5/14 (36%) had private insurance. All patients achieved sputum culture conversion within a mean of 71 days (26-116); 5 after starting bedaquiline. Twelve (86%) completed treatment and 1 (7%) moved out of the country. One patient (7%) had QTc prolongation >500 milliseconds and died 20 months after discontinuing bedaquiline of a cause not attributable to the drug. Common adverse events were peripheral neuropathy 7/14 (50%), not customarily associated with bedaquiline use, and QTc prolongation 6/14 (43%). CONCLUSIONS: Of 14 patients, 1 (7%) had an adverse event necessitating bedaquiline discontinuation. Safety, culture conversion, and treatment completion in this series (7%) support use of bedaquiline for the treatment of MDR/XDR TB.
Subject(s)
Antitubercular Agents , Tuberculosis, Multidrug-Resistant , Antitubercular Agents/adverse effects , Diarylquinolines/adverse effects , Humans , Retrospective Studies , Treatment Outcome , Tuberculosis, Multidrug-Resistant/drug therapy , United States/epidemiologyABSTRACT
Rationale: Mathematical modeling is used to understand disease dynamics, forecast trends, and inform public health prioritization. We conducted a comparative analysis of tuberculosis (TB) epidemiology and potential intervention effects in California, using three previously developed epidemiologic models of TB.Objectives: To compare the influence of various modeling methods and assumptions on epidemiologic projections of domestic latent TB infection (LTBI) control interventions in California.Methods: We compared model results between 2005 and 2050 under a base-case scenario representing current TB services and alternative scenarios including: 1) sustained interruption of Mycobacterium tuberculosis (Mtb) transmission, 2) sustained resolution of LTBI and TB prior to entry of new residents, and 3) one-time targeted testing and treatment of LTBI among 25% of non-U.S.-born individuals residing in California.Measurements and Main Results: Model estimates of TB cases and deaths in California were in close agreement over the historical period but diverged for LTBI prevalence and new Mtb infections-outcomes for which definitive data are unavailable. Between 2018 and 2050, models projected average annual declines of 0.58-1.42% in TB cases, without additional interventions. A one-time LTBI testing and treatment intervention among non-U.S.-born residents was projected to produce sustained reductions in TB incidence. Models found prevalent Mtb infection and migration to be more significant drivers of future TB incidence than local transmission.Conclusions: All models projected a stagnation in the decline of TB incidence, highlighting the need for additional interventions including greater access to LTBI diagnosis and treatment for non-U.S.-born individuals. Differences in model results reflect gaps in historical data and uncertainty in the trends of key parameters, demonstrating the need for high-quality, up-to-date data on TB determinants and outcomes.
Subject(s)
Models, Theoretical , Tuberculosis/epidemiology , Tuberculosis/prevention & control , Adolescent , Adult , Aged , California/epidemiology , Child , Child, Preschool , Health Policy , Humans , Incidence , Infant , Latent Tuberculosis/epidemiology , Latent Tuberculosis/prevention & control , Middle Aged , Prevalence , Young AdultABSTRACT
The current tuberculosis (TB) case reporting system for the United States, the Report of Verified Case of TB (RVCT), has minimal capture of multidrug-resistant (MDR) TB treatment and adverse events. Data were abstracted in five states using the form for 13 MDR TB patients during 2012-2015. The Centers for Disease Control and Prevention Guidelines for Evaluating Public Health Surveillance Systems were used to evaluate attributes of the form. Unstructured interviews with pilot sites and stakeholders provided qualitative feedback. The form was acceptable, simple, stable, representative, and provided high-quality data but was not flexible or timely. For the 13 patients on whom data were collected, the median duration of treatment with an injectable medication was 216 days (IQR 203-252). Six (46%) patients reported a side effect requiring a medication change and eight (62%) had a side effect present at treatment completion. A standardized MDR TB supplemental surveillance form was well received by stakeholders whose feedback was critical to making modifications. The finalized form will be implemented nationally in 2020 and will provide MDR TB treatment and morbidity data in the United States to help ensure patients with MDR TB receive the most effective treatment regimens with the least toxic drugs.
ABSTRACT
The incidence of tuberculosis (TB) in the United States has stabilized, and additional interventions are needed to make progress toward TB elimination. However, the impact of such interventions depends on local demography and the heterogeneity of populations at risk. Using state-level individual-based TB transmission models calibrated to California, Florida, New York, and Texas, we modeled 2 TB interventions: 1) increased targeted testing and treatment (TTT) of high-risk populations, including people who are non-US-born, diabetic, human immunodeficiency virus (HIV)-positive, homeless, or incarcerated; and 2) enhanced contact investigation (ECI) for contacts of TB patients, including higher completion of preventive therapy. For each intervention, we projected reductions in active TB incidence over 10 years (2016-2026) and numbers needed to screen and treat in order to avert 1 case. We estimated that TTT delivered to half of the non-US-born adult population could lower TB incidence by 19.8%-26.7% over a 10-year period. TTT delivered to smaller populations with higher TB risk (e.g., HIV-positive persons, homeless persons) and ECI were generally more efficient but had less overall impact on incidence. TTT targeted to smaller, highest-risk populations and ECI can be highly efficient; however, major reductions in incidence will only be achieved by also targeting larger, moderate-risk populations. Ultimately, to eliminate TB in the United States, a combination of these approaches will be necessary.