Tuberculosis in the Elderly

The tuberculosis (TB) epidemic is most prevalent in the elderly, and there is a progressive increase in the notification rate with age. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. The mortality rate from tuberculosis remains higher in elderly patients. Symptoms of active TB are nonspecific and less pronounced in the elderly. Diagnostic difficulties in the elderly are common in many diseases but it is important to use all possible techniques to make a microbiological diagnosis. Recognising frailty to prevent loss of independence is a major challenge in dealing with the therapeutic aspects of elderly patients. Several studies report contrasting data about poorer tolerance of TB drugs in this population. Adherence to antituberculosis treatment is a fundamental issue for the outcome of treatment. Decreased completeness of treatment was shown in older people as well as a higher risk of treatment failure.

Decreased annual risk of tuberculosis infection in South Korean healthcare workers using interferon-gamma release assay between 1986 and 2005

Background Tuberculosis (TB) has been a major public health problem in South Korea. Although TB notification rate in Korea is gradually decreasing, still highest among the member countries of the Organization for Economic Cooperation and Development. To effectively control TB, understanding the TB epidemiology such as prevalence of latent tuberculosis infection (LTBI) and annual risk of TB infection (ARI) are important. This study aimed to identify the prevalence of LTBI and ARI among South Korean health care workers (HCWs) based on their interferon-gamma release assays (IGRA). Methods This was single center, cross-sectional retrospective study in a tertiary hospital in South Korea. We performed IGRA in HCWs between May 2017 and March 2018. We estimated ARI based on IGRA results. Logistic regression model was used to identify factors affecting IGRA positivity. Results A total of 3233 HCWs were analyzed. Median age of participants was 38.0 and female was predominant (72.6%). Overall positive rate of IGRA was 24.1% and IGRA positive rates age-group wise were 6.6%, 14.4%, 34.3%, and around 50% in the age groups 20s, 30s, 40s, and 50s and 60s, respectively. The ARIs was 0.26–1.35% between 1986 and 2005; rate of TB infection has gradually decreased in the last two decades. Multivariable analysis indicated that older age, healed TB lesion in x-ray, and male gender were risk factors for IGRA positivity, whereas working in high-risk TB departments was not. Conclusions Results showed that ARI in South Korean HCWs gradually decreased over two decades, although LTBI remained prevalent. Our results suggest that the LTBI test result of HCWs might be greatly affected by age, rather than occupational exposure, in intermediate TB burden countries. Thus, careful interpretation considering the age structure is required.

Retrospective epidemiological analysis of SARS-CoV-2 wastewater surveillance and case notifications data – New South Wales, Australia, 2020

This epidemiological study analysed SARS-CoV-2 wastewater surveillance and case notifications data to inform evidence-based public health action in NSW. We investigated measures of association between SARS-CoV-2 RNA fragments detected in wastewater samples (n=100) and case notifications (n=1,367, as rates per 100,000 population) within wastewater catchment areas (n=6); and evaluated the performance of wastewater testing as a population-level diagnostic tool. Furthermore, we modelled SARS-CoV-2 RNA fragment detection in wastewater given the case notification rate using logistic regression. The odds of a viral detection in wastewater samples increased by a factor of 5.68 (95% CI: 1.51–32.1, P=0.004) with rates of one or more notified cases within a catchment. The diagnostic specificity of wastewater viral detection results was 0.88 (95% CI: 0.69–0.97); the overall diagnostic sensitivity was 0.44 (95% CI: 0.33–0.56). The probability of a viral detection result in wastewater exceeded 50% (95% CI: 36–64%) once the case rate within a catchment exceeded 10.5. Observed results suggest that in a low prevalence setting, wastewater viral detections are a more reliable indicator of the presence of recent virus shedding cases in a catchment, than non-detect results are of the absence of cases in a catchment.

Combined assessment of tuberculosis case notification rate and infection control at health facilities of Dale districts, Sidama Zone, Southern Ethiopia

Background Mycobacterium tuberculosis (TB) is the deadliest disease that claims millions of deaths globally. Ethiopia is among the countries heavily hit by the disaster. Despite the effective directly observed treatment and TB infection control (TBIC) measures provided by the world health organization (WHO), the rate of new cases increased daily throughout the country. Healthcare workers (HCWs) are at highest risk serving without having the necessary facility in place while overcrowding of patients exacerbated TB transmission. The study aimed to assess TBIC implementation and analyze case notification rate (CNR) of smear-positive pulmonary TB in the selected health facilities at Dale district, Sidama Zone, Southern Ethiopia. Methods Seven health care facilities have been visited in the study area and smear-positive pulmonary TB notification rate was determined retrospectively during the years 2012 to 2014. Data on smear positive test results and demographic characteristics were collected from the TB unit registries. A structured questionnaire, facility survey, and observation checklists were used to assess the presence of TBIC plans at the health care facilities. Results The overall case notification rate of smear-positive pulmonary tuberculosis was 5.3% among all 7696 TB suspected patients. The odds of being diagnosed with smear-positive TB were 24% more in males than in females (adj OR = 1.24, 95% CI: (1.22, 1.55). Moreover, in the study area, only 28% of the facilities have been practiced TB infection control and 71% of the facilities assigned a focal person for the TBIC plan. The implementation of environmental control measures in the facilities was ranged between 16–83%. N95 particulate respirators were found only in 14% of the facilities. Conclusion TB CNR in Dale district was low. Moreover, implementations of TBIC in Dale district health facilities were poor when the survey was done. Hence, urgent measures should be taken to reverse the burden of TB.

Impact of COVID-19 Pandemic on Refugees, Migrants and Asylum Seekers Living in Camps and Reception and Identification Centers in Greece in the Pre-Vaccination Period, February 2020 to May 2021. Summary of Epidemiological Findings

Background: Protection of refugees, migrants, and asylum seekers living in open hosting camps (HCs) and reception and identification centers (RICs) has been a priority since the beginning of the COVID-19 pandemic. We present the epidemiological data of COVID-19 infection in HCs/RICs in Greece from February 2020 to May 2021, before the initiation of the onsite vaccinations.Methods: Case confirmation was performed by rapid antigenic test and/or RT-PCR. Data were retrieved from the National COVID-19 registry. The notification rate by type of accommodation facility, by sex and ethnicity and the mean age of cases, were calculated for HCs, RICs and general population. Data on clinical manifestations, and disease severity (admissions to intensive care unit (ICU) / case fatality rate) were analysed.Results: Of the 397,497 recorded domestic COVID-19 infection cases, 2,609 (0.7%) regarded HCs/RICs; of them 1,566 (60%) were identified in 27 HCs and 1,043 (40%) in six RICs. The notification rate was 542 and 380 cases per 10,000 population in HCs/RICs and the general population, respectively (p-value<0.001).Up to February 2021 the occurrence of cases in HCs/RICs did not follow the occurrence of cases in the general population. After March 2021 the course of the outbreak in HCs/RICs and the general population was similar.The median age of cases in HCs/RICs and the general population was 27 (range:0-81) and 44 (range:0-106), respectively (p<0.001). Twenty-four different ethnicities were reported among migrant cases; 51% were from Afghanistan, 13% from Syria, 6% from Kongo and 5% from Somalia.Overall, 48% and 80% of cases, respectively in HCs/RICs and the general population were symptomatic (p<0.001). Five (0.2%) cases in HCs/RICs were admitted to the ICU compared to 10,426 cases (3.0%) in the general population (p-value <0.001). Case fatality rate was 3% in the general population and 0.08% in HCs/RICs (p-value <0.001).Conclusion: Recorded COVID-19 infections were less severe in migrants living at HCs/RICs than the general population, however, the number of identified cases was high and measures for the prevention of transmission should be strengthened.

Tuberculosis Death Epidemiology and Its Associated Risk Factors in Sabah, Malaysia

Tuberculosis (TB) is a leading killer from a single infectious agent globally. In 2019, Malaysia’s TB incidence rate was 92 per 100,000 population, and the TB mortality rate was estimated at 4 cases per 100,000 population per year. However, the state of Sabah had a higher burden of TB with a notification rate of 128 per 100,000 population and a TB case fatality rate of 8% compared to the national figure. This study aims to provide a comprehensive report on TB deaths epidemiology and its associated factors at a sub-national level. This nested case-control study used Sabah State Health Department TB surveillance data from the Malaysia national case-based TB registry (MyTB) between 2014 and 2018. Cases were defined as all-cause TB deaths that occurred before anti-TB treatment completion from the time of TB diagnosis. Controls were randomly selected from TB patients who completed anti-TB treatment. The TB mortality rate had increased significantly from 9.0/100,000 population in 2014 to 11.4/100,000 population in 2018. The majority of TB deaths occurred in the first two months of treatment. TB-related deaths were primarily due to advanced disease or disseminated TB, whereas non-TB-related deaths were primarily due to existing comorbidities. Many important independent risk factors for TB deaths were identified which are useful to address the increasing TB mortality rate.

843Hepatitis C in South Australia and Northern Territory: a population-based linkage study

Background In Australia, the notification rate for hepatitis C is five times greater among Aboriginal and Torres Strait Islander peoples than nonIndigenous populations. Infection with Hepatitis C virus is associated with increased morbidity, mortality and health-related costs. However simple, tolerable and short-duration HCV therapies with extremely high efficacy are available. Methods Overall, this project aims to identify inequities in hepatitis C healthcare for Aboriginal and Torres Strait Islander peoples across South Australia (SA) and Northern Territory (NT). By using 19 routinely collected health administration datasets, we will evaluate hepatitis C diagnoses, treatment uptake, and treatment outcomes, with focus on identifying patterns in healthcare access among Aboriginal and Torres Strait Islander people in SA since 1992 or in NT since 1999 using probabilistic data linkage methodology in a secured online environment. Results The study population includes all hepatitis C notifications recorded in SA and NT, totaling more than 25,000 cases. Preliminary findings will be reported including incidence of hospitalisation, mortality, and morbidity by Aboriginal and Torres Strait Islander status. Conclusions Now that highly effective direct acting anti-viral treatments are available, it is crucial to ensure key affected populations, including Aboriginal and Torres Strait Islander people, have access to these novel biomedical approaches. Key messages This project is of national importance to address hepatitis C related morbidity and mortality in Australia, particularly among Aboriginal and Torres Strait Islander peoples. Findings will underpin future policy to reduce the burden of hepatitis C across SA and NT populations.

The Evaluation of Preventive and Control Measures on Congenital Syphilis in South China: A Time Series Modelling Study

Background: The re-emergence of congenital syphilis (CS) was witnessed since the 1990s over the globe, including China. The country, therefore, carried out the prevention and control measures in an all-around way in 2010, including large-scale syphilis screening for pregnant women, providing standard treatment and follow-up management for both infected mothers and their infants, as well as the supportive strategies from the government as the response. However, there is a lack of the published evaluation for these measures when the deadline of the final goal (CS notification rate < 15/100,000 livebirths by 2025) is approaching. This study evaluates the effectiveness of CS control measures based on the change of the notification rate from 2005 to 2020 and predicts the CS case number in the following year in Guangdong, one of the provinces which used to have the highest CS notification rate in China. Methods: The interrupted time series analysis was conducted to compare changes in slope and level of CS notification rate from 2005 to 2020 in Guangdong Province and its three regions with different economic development levels. The year 2012 was identified as the intervention point, the time when Guangdong Province officially launched a bunch of measures. The autoregressive integrated moving average model was established to predict the CS case number of Guangdong Province in 2021. Results: A total of 12,687 CS cases were reported from 2005 to 2020. The notification rate of CS had been increasing in Guangdong Province until 2012 (128.55/ 100,000 livebirths), followed by a constant downward trend. It hit the lowest point in 2020 (5.76/ 100,000 livebirths), which was lower than the national goal set for 2025 (15/100,000 livebirths). The effectiveness of preventive and control measures was proved by the significant change in slope of the notification rate which was found in both of the whole province and two less-developed regions (-18.18, 95%CI: -25.63 to -10.75, -10.49, 95%CI: -13.13 to -7.86 and − 32.89, 95%CI: -41.67 to -24.10, respectively). In the developed region where the notification rate had already been decreasing in the pre-program period, implementing these measures also aided in hastening the rate of descent. The CS case number in 2021 was predicted to be 48, which remains a low-level epidemic. Conclusions: The comprehensive preventive and control measures have assisted Guangdong Province to control CS and exceed the goal that China set for 2025 ahead of schedule. As these measures worked effectively in places with varying levels of development and produced satisfying outcomes in regions with limited resources, it could be feasible to be generalized in other Low-and-Middle-Income countries where CS is still a public health concern.

Epidemiology of childhood tuberculosis after ceasing universal Bacillus Calmette–Guérin vaccination

Universal Bacillus Calmette–Guérin (BCG) vaccination is recommended in countries with high tuberculosis (TB) burden. Nevertheless, several countries have ceased universal BCG vaccination over the past 40 years, with scarce comparative epidemiological analyses regarding childhood TB after the policy change. We analysed data on childhood TB in countries that ceased universal BCG vaccination. Data sources included national/international databases, published papers, annual TB reports, and public health authority websites. Childhood TB notification rate increased in one of seven countries with available data. Pulmonary TB and TB lymphadenitis were the main causes of increasing childhood cases, while changes in severe forms of TB cases were minor. Maintaining high vaccine coverage for the target group was a common challenge after shifting selective vaccination. In some countries showing no increase in childhood TB after a BCG policy change, the majority of childhood TB cases were patients from abroad or those with overseas parents; these countries had changed immigration policies during the same period. Heterogeneity in childhood TB epidemiology was observed after ceasing universal BCG vaccination; several factors might obscure the influence of vaccination policy change. Lessons learned from these countries may aid in the development of better BCG vaccination strategies.