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World TB Day: Current rate of progress not enough to eliminate TB
Although the incidence of tuberculosis is decreasing in the United States, the CDC recently warned that progress toward the elimination of the disease in the country remains slow, and it is unlikely that TB will be eradicated in this century.
According to a recent MMWR, 9,093 new cases of TB were reported in the U.S. last year, representing a 1.8% reduction from 2016 and a 2.5% reduction in overall incidence. Still, the current rate of 2.8 cases per 100,000 persons remains 28 times higher than the elimination threshold of less than one case per million persons, according to Rebekah J. Stewart, MSN, MPH, of the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), and colleagues.
“I had hoped we would eliminate TB in my children’s lifetime, but the goal is elusive,” Jonathan Mermin, MD, director of NCHHSTP, said in a press release. “Nine thousand TB cases in this country is far too many. Each case represents a human and financial burden shouldered by those with TB, their families and the nation’s health care system.”
The CDC estimates that TB treatment costs $18,000 per case but can exceed $500,000 in people with extensively drug-resistant TB. According to the report, more than 80% of TB cases in the U.S. are associated with reactivation of latent infection, and half of all new infections are reported in four states: California, New York, Texas and Florida. People born outside of the country remain disproportionately affected. Their rate of infection was approximately 15 times higher than people born in the U.S., declining only 0.9% vs. 7% since 2016.
To achieve TB elimination by 2100, the annual decline in incidence needs to increase from 2% to 3.9%, Stewart and colleagues reported.
Despite slow progress, the CDC noted that TB control efforts in the U.S. prevented about 300,000 cases and saved up to $14 billion over the past 20 years. Moving forward, the agency said a dual approach that involves diagnosing and treating active cases, as well as identifying and treating latent infections, is needed to eliminate TB.
“While tremendous progress has been made toward eradicating TB, there’s still more we can do to ensure those at risk are accurately tested and treated as their latent TB infection could progress to active, becoming highly contagious and deadly,” Lee Reichman, MD, MPH, senior advisor and founding executive director of the Global Tuberculosis Institute at the Rutgers New Jersey Medical School, told Infectious Disease News. “This year, the CDC is revising their Tuberculosis Technical Instructions requiring U.S. Civil Surgeons to transition from 100-year-old skin tests to far more accurate and objective IGRA blood tests. And WHO recently updated their latent TB guidelines, supporting the use of IGRA blood tests for latent TB detection. These changes are a very important step in the right direction towards eliminating this disease. In today’s globalized society, we know now more than ever that until TB is eradicated everywhere, it’s not eradicated anywhere.”
World TB day is observed annually on March 24 to raise public awareness of the disease. The day commemorates the date in 1882, when German physician and scientist Robert Koch, MD, announced his discovery of the TB-causing bacillus Mycobacterium tuberculosis. To mark the occasion, Infectious Disease News compiled a list of the top 10 articles about TB over the past year. – by Stephanie Viguers
WHO updates latent TB guidelines
WHO released new guidance that aims to expand testing and treatment options for latent TB, as well as the types of patients that are prioritized for care.
The guidance includes 24 existing, updated and new recommendations. They were issued in response to requests from several WHO member states that claimed the agency’s previous recommendations for latent TB were “fragmented” and difficult to implement. Read more.
1 month of TB prophylaxis as effective as 9 months
A 1-month antibiotic regimen to prevent active TB in patients living with HIV was just as effective and caused fewer adverse events than a standard 9-month regimen, according to results of a phase 3 clinical trial presented at CROI.
Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said in a press release that the findings “have the potential to change clinical practice by offering people living with HIV who are at risk of developing active tuberculosis an additional, shorter-duration prevention option that is safe, works well and may be more convenient.” Read more.
Xpert MTB/RIF Ultra: Another advance in TB diagnostics
The development of the Xpert MTB/RIF assay has been the most important breakthrough for the diagnosis of TB in decades.
This molecular-based test provides a rapid and sensitive method for the diagnosis of active TB and detection of organisms that are resistant to rifampin from the sputum of infected patients. It is superior to acid fast bacilli smear microscopy, the relatively insensitive standard method for the initial detection of TB in most parts of the world. Read more.
Higher rifampin doses safe for patients with pulmonary TB
Results of a phase 2 randomized clinical trial show that up to twice the standard daily dose of rifampin was safe in patients with pulmonary TB. The findings suggest that TB therapy can be shortened using higher doses, which could potentially improve outcomes without increasing toxicity. Read more.
WHO: Ending TB will take greater political commitment
Health experts warned that progress to end TB has stalled and that greater political commitment is needed to address the burden of the world’s No. 1 infectious disease killer.
There were 10.4 million new TB infections in 2016, with 10% occurring in patients who also have HIV, according to a new WHO report outlining the burden. Around 1.7 million people died from the disease, including nearly 400,000 patients who were coinfected with HIV. Read more.
Sirturo-delamanid combination safe, effective against MDR-TB
Researchers recommend expanding access to a combination regimen of Sirturo and delamanid for multidrug-resistant TB after preliminary data showed the treatment was safe and associated with high cure rates in patients who previously had “very little treatment success.” Read more.
Urine-based TB testing identifies additional cases
The addition of systematic urine screening to sputum screening identified more cases of TB and was associated with a 50% increase in treatment among hospitalized patients with HIV in sub-Saharan Africa, according to findings from the STAMP trial.
“HIV/TB coinfection causes around one in four admissions to hospitals in sub-Saharan Africa,” Ankur Gupta-Wright, BSc, MBBS, MRCP, MSc, DTM&H, clinical research fellow at the London School of Hygiene & Tropical Medicine, said during a press conference at CROI. “It is a common cause of death and we know that up to half of fatal TB remains undiagnosed, so our current sputum-based TB testing approach is failing this patient population.” Read more.
WHO releases ethics guidance to protect rights of patients with TB
WHO recently issued new TB ethics guidance that outlines key obligations for countries that implement the End TB Strategy to protect patients’ rights.
According to WHO, communities that are most affected by TB include refugees, prisoners, ethnic minorities and other marginalized populations. The new guidance addresses issues such as the isolation of contagious patients, the rights of patients in prison, and discriminatory policies against migrants affected by TB. Read more.
Daily therapy superior to intermittent for TB in patients with HIV
A daily anti-TB regimen prevented rifampicin resistance and was more effective than an intermittent regimen among patients with HIV with pulmonary tuberculosis who were receiving antiretroviral therapy, according to findings published in JAMA Internal Medicine. Read more.
Household screening doubles detection of TB cases
Adding household screening to standard passive case finding more than doubled the detection of TB cases during a nearly 5-year study in Vietnam, where the disease is prevalent but undertreated, according to findings published today in The New England Journal of Medicine.
“These findings are critical,” Greg J. Fox, MB, BS, PhD, associate professor in respiratory medicine at Sydney Medical School in Australia and a co-author of the study, told Infectious Disease News. “WHO guidelines for screening identify a lack of high-quality evidence to support the use of contact investigation. They recommend it but have called for studies to show it is effective.” Read more.
Reference:
Stewart RJ, et al. MMWR Morb Mortal Wkly Rep. 2018;doi:10.15585/mmwr.mm6711a2.
Disclosures: Mermin, Reichman and Stewart report no relevant financial disclosures.