tb and hiv care :: Article CreatorSurvivors Of Tuberculosis May Benefit From Better Linkage To Post-Treatment Care
Efforts to improve linkage to primary and HIV comprehensive care may reduce the risk of post-treatment mortality among survivors of tuberculosis (TB) infection in the United States, according to results of a study published in Emerging Infectious Diseases.
Researchers conducted an observational cohort study of adults in Georgia who were diagnosed with TB infection and completed treatment between January 2008 and December 2019. The researchers performed survival analyses among the cohort to determine risk factors for post-treatment mortality. Eligible study patients included those aged 18 years and older who had a bacteriologic or clinical diagnosis of pulmonary or extrapulmonary TB disease. Patients who died before or during TB treatment were excluded. Kaplan-Meier curves and Cox proportional hazard models were employed for statistical analysis.
The final analysis comprised 3182 patients, of whom the median age was 44 (IQR, 32-57) years, 66% were men, 51% were born outside the US, and 13% were non-Hispanic White. At the study mid-point (2014), patients in the cohort exhibited higher prevalence of coexisting illnesses or TB risk factors than that of the overall state population, including HIV coinfection (10% vs 0.5%), homelessness (10% vs 0.12%), excess alcohol use (15% vs 5.3%), and diabetes (12% vs 11%). Overall, 75% of TB diagnoses in the population were confirmed via culture analysis; 80% of the cohort had pulmonary disease, 20% had extrapulmonary disease, and 8% had both.
A total of 233 (7%) patients died following TB treatment, with higher mortality rates observed between those who were US-born vs born outside the US (13% vs 2%) and between those with vs without HIV coinfection (12% vs 7%). The researchers noted similar post-treatment mortality rates between patients who completed treatment and those who did not (both 7%). The median treatment duration was 224 (IQR, 189-289) days, and 7% of the overall cohort did not complete treatment.
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[C]omprehensive care during and after treatment should also consider social determinants of health and co-existing illnesses, which might be more prevalent among US-Born person.
Overall, US-born persons accounted for the highest percentage of patients with HIV coinfection (66%), injection drug-use history (92%), excess alcohol use history (79%), prior homelessness (84%), or end-stage kidney disease (70%). Approximately one-fifth (21%) of those who did not complete treatment were US-born patients.
In the adjusted analysis, post-treatment mortality was associated with older age at TB diagnosis (hazard ratio [HR], 1.06 per 1-year increase; 95% CI, 1.05-1.07), US-born status (HR, 2.42; 95% CI, 2.25-5.19), HIV coinfection (HR, 1.87; 95% CI, 1.20-2.90), excess alcohol use (HR, 1.64; 95% CI, 1.17-2.30), unknown homelessness history (HR, 17.3; 95% CI, 2.0-150.0), diabetes (HR, 2.05; 95% CI, 1.44-2.91), and end-stage kidney disease (HR, 2.24; 95% CI, 1.05-4.80).
The crude mortality rate of the population 12.69 (95% CI, 11.12-14.3) per 1000 person-years, with post-treatment mortality occurring earlier in study cohort vs the overall state population (median age, 64.0 vs 70.2 years). Patients who died of HIV coinfection were younger overall (mean age, 49.6 years) at the time of post-treatment mortality. Mortality among the cohort was primarily attributed to cardiovascular disease (24.0%), malignancy (24%), and HIV coinfection (9.9%).
Study limitations include the lack of individual-level data for the overall population of Georgia, insufficient data on tobacco and alcohol use, and the inability to use the TB outcomes classification system from the World Health Organization.
According to the researchers, "[C]omprehensive care during and after treatment should also consider social determinants of health and co-existing illnesses, which might be more prevalent among US-Born person."
Extrapulmonary Tuberculosis Among US Veterans: What Are The Risk Factors?
Independent factors associated with extrapulmonary tuberculosis (TB) among United States veterans include Non-Hispanic Black race, diabetes, and HIV infection, according to study findings published in Open Forum Infectious Diseases.
Investigators conducted a retrospective cohort study to identify risk factors for extrapulmonary vs pulmonary TB among US veterans with active TB. Data were sourced from the Veterans Health Administration electronic health record system, Veterans Information Systems and Technology Architecture, and Oracle Cerner.
Veterans with laboratory-confirmed TB between January 1990 and December 2022 were eligible for inclusion. Patients with extrapulmonary TB were categorized as either those with exclusive extrapulmonary TB infection or those with concurrent extrapulmonary and pulmonary TB infection.
Outcome data included 30-day hospital admissions, hospital length of stay, and date of death within 30, 90, and 365 days of TB confirmation. To assess the relationship between demographic and clinical risk factors and extrapulmonary TB, multivariable logistic regression was used.
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Healthcare providers should be educated regarding patient populations at risk for EPTB, especially given the challenges in diagnosing this disease and the importance of instituting early treatment to prevent severe illness and death.
A total of 7493 participants (median age at time of TB confirmation, 58; men, 99%) with laboratory-confirmed TB were included in the study, of whom 6096 (81%) had exclusively pulmonary TB infection, 796 (11%) had exclusively extrapulmonary TB infection, and 601 (8%) had concurrent pulmonary and extrapulmonary TB infection. A total of 1397 (19%; median age, 55; men, 98.4%) patients had any extrapulmonary TB.
Among patients with extrapulmonary TB, the most common sites of infection were pleural (31.6%) and lymphadenitis (14.8%). Meningitis was associated with the highest risk for 90-day morality. Those with gastrointestinal or blood or bone marrow TB were also at an increased risk for death at 90 days. In contrast, patients with lymphadenitis, musculoskeletal, or spinal abscess had a decreased risk for 90-day mortality.
According to all 4 logistic regression models, non-Hispanic Black race and the presence of all-cause mortality within 90 days of TB diagnosis were both associated with extrapulmonary TB. Clinical morbidities such as diabetes, HIV infection, and severe kidney disease were also significantly associated with extrapulmonary TB. In contrast, homelessness and nicotine dependency were found to be negatively related to extrapulmonary TB.
Study limitations include the inability to capture TB diagnosed solely via pathology findings or clinical criteria, lack of clinical records for patients who were treated at facilities outside of the Veterans Health Administration network, unavailability of susceptibility testing results, and reduced generalizability of results to the larger US population.
"Healthcare providers should be educated regarding patient populations at risk for EPTB [extrapulmonary TB], especially given the challenges in diagnosing this disease and the importance of instituting early treatment to prevent severe illness and death," the investigators concluded.
TB Burden: Survivors Recount Experiences
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