Publications by authors named "Natasha Hochberg"

55 Publications

Reasons for refusal among patients with tuberculosis and their household contacts to participate in an observational cohort study.

Perspect Clin Res 2021 Oct-Dec;12(4):234-235. Epub 2021 Sep 20.

Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.

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http://dx.doi.org/10.4103/picr.picr_377_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8525795PMC
September 2021

Prevalence and factors associated with diabetes mellitus among tuberculosis patients in South India-a cross-sectional analytical study.

BMJ Open 2021 10 22;11(10):e050542. Epub 2021 Oct 22.

Department of Preventive and Social Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, Puducherry, India.

Objective: To determine the prevalence and determinants of diabetes mellitus (DM) among tuberculosis (TB) patients and to assess the additional yield and number needed to screen (NNS) to obtain a newly diagnosed DM among TB patients.

Design: We undertook a cross-sectional analysis of the cohort data under Regional Prospective Observational Research for Tuberculosis-India consortium. Newly diagnosed TB patients recruited into the cohort between 2014 and 2018 were included. Pretested standardised questionnaires and tools were used for data collection. Prevalence of DM among TB patients was summarised as proportion with 95% CI. Type II DM was diagnosed if random blood sugar level was >200 mg/dL or if the participant had a documented history of DM. NNS by blood glucose testing to diagnose one new DM case among TB patients was also calculated.

Setting: Three districts of South India: Puducherry, Cuddalore and Villupuram SUBJECTS: Newly diagnosed sputum smear positive pulmonary TB patients aged ≥16 years RESULTS: In total, 1188 TB patients were included. Prevalence of DM among TB patients was 39% (95% CI: 36.2% to 41.8%). In unadjusted analysis, elderly TB, marital status, caste, gender, higher education level, household income and obesity had a significant association with DM. However, in adjusted analysis, only marital status (currently married aPR; 3.77 (95 CI: 2.20 to 6.49), widowed/separated/divorced aPR; 3.66 (95 CI: 1.96 to 6.83)) and body mass index category (normal weight aPR; 3.26 (95 CI: 2.55 to 4.16), overweight aPR; 3.86 (95 CI: 2.69 to 5.52), obesity aPR; 4.08 (95 CI: 2.81 to 5.94)) were found to be significant determinants. The number of TB patients needed to be screened to find a new DM case was 12.

Conclusion: We found that one in three TB patients had coexisting DM. The number of TB patients needed to be screened to obtain a newly diagnosed DM patients was also determined. The study supports and highlights the need of RNTCP's effort in bidirectional screening of TB and DM.
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http://dx.doi.org/10.1136/bmjopen-2021-050542DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8543642PMC
October 2021

'People listen more to what actors say': A qualitative study of tuberculosis-related knowledge, behaviours, stigma, and potential interventions in Puducherry, India.

Glob Public Health 2021 Oct 16:1-13. Epub 2021 Oct 16.

Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.

India has made substantial advancements in reducing the burden of tuberculosis (TB), but persons living with active TB (PLWATB) still face myriad challenges in seeking and receiving care, including TB-related stigma. To meet the END TB targets, it is critical that PLWATB engage in care and are able to adhere to treatment. This qualitative study aimed to understand TB-related stigma (perceived, enacted, and internalised) and possible interventions to reduce stigma in Puducherry and Tamil Nadu, India. We conducted 47 in-depth interviews with PLWATB and household members and eight focus group discussions: two each with PLWATB, their household members, healthcare workers, and key informants. We found varying TB-related knowledge: the vast majority of interview participants reported incorrect modes of transmission, although most were also aware that TB is curable. Participants reported high levels of perceived stigma, with nearly two-thirds of PLWATB choosing to hide their disease to avoid being stigmatised in their community. Participants supported interventions including celebrity advocacy and school-based programming to increase community knowledge and reduce enacted stigma as well as support groups and counselling to reduce internalised stigma in PLWATB. This study has the potential to inform future interventions to reduce TB-related stigma in India.
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http://dx.doi.org/10.1080/17441692.2021.1990372DOI Listing
October 2021

Prevalence and risk factors associated with latent tuberculosis infection among household contacts of smear positive pulmonary tuberculosis patients in South India.

Trop Med Int Health 2021 Dec 26;26(12):1645-1651. Epub 2021 Oct 26.

Department of Preventive & Social Medicine, JIPMER, Puducherry, India.

Objective: We aimed to determine the prevalence and find the risk factors associated with latent tuberculosis infection (LTBI) among the household contacts (HHC) of pulmonary TB patients.

Methods: This cohort study was conducted from 2014 to 2019. Pretested standardised questionnaires and tools were used for data collection. The prevalence of LTBI among HHCs of TB patients was summarised as proportion with 95% confidence interval (CI). Mixed-effects generalised linear modelling function (meglm) in STATA with family Poisson and log link was performed to find the factors associated with LTBI.

Results: In total, 1523 HHC of pulmonary TB patients were included in the study. Almost all HHC shared their residence with the index case (IC) for more than a year; 25% shared the same bed with the IC. The prevalence of LTBI among the HHC of TB patients was 52.6% (95% CI: 50.1-55.1%). In an adjusted model, we found that among HHC belonging to the age group of 19-64 years (aIRR = 1.2; 95% CI: 1.1-1.3; p-value: 0.02), to the age group >65 years (aIRR = 1.4, 95% CI: 1.1-1.9, p-value: 0.02) and sharing the same bed with the IC (aIRR = 1.2, 95% CI: 1.1-1.3, p value: 0.04) were independent determinants of LTBI among the HHC.

Conclusion: One in two household contacts of TB patients have latent tuberculosis infection. This underscores the need of targeted contact screening strategies, effective contact tracing and testing using standardised methods in high TB burden settings.
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http://dx.doi.org/10.1111/tmi.13693DOI Listing
December 2021

Tuberculosis-Learning the Impact of Nutrition (TB LION): protocol for an interventional study to decrease TB risk in household contacts.

BMC Infect Dis 2021 Oct 12;21(1):1058. Epub 2021 Oct 12.

Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA.

Background: Comorbidities such as undernutrition and parasitic infections are widespread in India and other tuberculosis (TB)-endemic countries. This study examines how these conditions as well as food supplementation and parasite treatment might alter immune responses to Mycobacterium tuberculosis (Mtb) infection and risk of progression to TB disease.

Methods: This is a 5-year prospective clinical trial at Jawaharlal Institute of Post Graduate Medical Education and Research in Puducherry, Tamil Nadu, India. We aim to enroll 760 household contacts (HHC) of adults with active TB in order to identify 120 who are followed prospectively for 2 years: Thirty QuantiFERON-TB Gold Plus (QFT-Plus) positive HHCs ≥ 18 years of age in four proposed groups: (1) undernourished (body mass index [BMI] < 18.5 kg/m); (2) participants with a BMI ≥ 18.5 kg/m who have a parasitic infection (3) undernourished participants with a parasitic infection and (4) controls-participants with BMI ≥ 18.5 kg/m and without parasitic infection. We assess immune response at baseline and after food supplementation (for participants with BMI < 18.5 kg/m) and parasite treatment (for participants with parasites). Detailed nutritional assessments, anthropometry, and parasite testing through polymerase chain reaction (PCR) and microscopy are performed. In addition, at serial time points, these samples will be further analyzed using flow cytometry and whole blood transcriptomics to elucidate the immune mechanisms involved in disease progression.

Conclusions: This study will help determine whether undernutrition and parasite infection are associated with gene signatures that predict risk of TB and whether providing nutritional supplementation and/or treating parasitic infections improves immune response towards this infection. This study transcends individual level care and presents the opportunity to benefit the population at large by analyzing factors that affect disease progression potentially reducing the overall burden of people who progress to TB disease. Trial registration ClinicalTrials.gov; NCT03598842; Registered on July 26, 2018; https://clinicaltrials.gov/ct2/show/NCT03598842.
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http://dx.doi.org/10.1186/s12879-021-06734-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8506078PMC
October 2021

Recommendations for Screening and Diagnosis of Chagas Disease in the United States.

J Infect Dis 2021 Oct 8. Epub 2021 Oct 8.

Center of Excellence for Chagas Disease at Olive View-UCLA Medical Center, Sylmar, California, USA.

Background: Chagas disease affects an estimated 326,000-347,000 people in the United States and is severely underdiagnosed. Lack of awareness and clarity regarding screening and diagnosis is a key barrier.

Objective: This document provides straightforward recommendations, with the goal of simplifying identification and testing of people at risk for U.S. healthcare providers.

Methods: A multidisciplinary working group of clinicians and researchers with expertise in Chagas disease agreed on six main questions, and developed recommendations based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, after reviewing the relevant literature on Chagas disease in the United States.

Results: Individuals who were born or resided for prolonged time periods in endemic countries of Mexico, Central and South America should be tested for T. cruzi infection, and family members of people who test positive should be screened. Women of childbearing age with risk factors and infants born to seropositive mothers deserve special consideration due to the risk of vertical transmission. Diagnostic testing for chronic T. cruzi infection should be conducted using two distinct assays.

Conclusions: Increasing provider-directed screening for T. cruzi infection is key to addressing this neglected public health challenge in the United States.
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http://dx.doi.org/10.1093/infdis/jiab513DOI Listing
October 2021

Comparison of profile and treatment outcomes between elderly and non-elderly tuberculosis patients in Puducherry and Tamil Nadu, South India.

PLoS One 2021 27;16(8):e0256773. Epub 2021 Aug 27.

Department of Preventive & Social Medicine, JIPMER, Puducherry, India.

The rising geriatric population and the increased susceptibility of this age group to tuberculosis (TB), the deadliest single infectious agent, is bothersome for India. This study tried to explore the demographic and treatment outcome differences between the elderly (aged 60 years and above) and non-elderly TB (<60 years) patients from South India. This study was part of a large ongoing cohort study under the RePORT India consortium. Newly diagnosed TB patients recruited into the cohort between 2014 and 2018 were included in this study. Pretested and standardized questionnaire and tools were used to collect data and were stored securely for the entire cohort. Required demographic, anthropometric and treatment related variables were extracted from this database and analyzed using Stata version 14.0. Prevalence of elderly TB was summarized as percentage with 95% confidence interval (CI). Generalized linear modelling was attempted to find the factors associated with elderly TB. A total of 1,259 eligible TB patients were included into this present study. Mean (SD) of the participants in the elderly and non-elderly group was 65.8 (6.2) and 40.2 (12.0) respectively. Prevalence of elderly TB was 15.6% (95%CI: 13.6%-17.6%) with nearly 71% belonging to 60-69 age category. Male sex, OBC caste, poor education, unemployment, marriage, alcohol consumption and unable to work as per Karnofsky score were found to be significantly associated with an increased prevalence of elderly TB. Unfavorable outcomes (12% vs 6.5%, p value: 0.018), including death (9.3% vs 3.4%, p value: 0.001) were significantly higher among the elderly group when compared to their non-elderly counterparts. The current TB programme should have strategies to maintain follow up with due attention to adverse effects, social support and outcomes. Additional research should focus on predictors for unfavorable outcomes among the elderly TB group and explore ways to handle the same. Rendering adequate social support from the health system side and family side would be a good start.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0256773PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8396735PMC
August 2021

Chagas Disease in HIV-Infected Patients: It's Time to Consider the Diagnosis.

Am J Trop Med Hyg 2021 08 16;105(3):545-546. Epub 2021 Aug 16.

2School of Medicine, Boston University, Boston, Massachusetts.

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http://dx.doi.org/10.4269/ajtmh.21-0681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8592368PMC
August 2021

Lower serum 25(OH)D levels associated with higher risk of COVID-19 infection in U.S. Black women.

PLoS One 2021 27;16(7):e0255132. Epub 2021 Jul 27.

Slone Epidemiology Center at Boston University, Boston, Massachusetts, United States of America.

Objective: Limited evidence suggests that higher levels of serum vitamin D (25(OH)D) protect against SARS-CoV-2 virus (COVID-19) infection. Black women commonly experience 25(OH)D insufficiency and are overrepresented among COVID-19 cases. We conducted a prospective analysis of serum 25(OH)D levels in relation to COVID-19 infection among participants in the Black Women's Health Study.

Methods: Since 1995, the Black Women's Health Study has followed 59,000 U.S. Black women through biennial mailed or online questionnaires. Over 13,000 study participants provided a blood sample in 2013-2017. 25(OH)D assays were performed in a certified national laboratory shortly after collection of the samples. In 2020, participants who had completed the online version of the 2019 biennial health questionnaire were invited to complete a supplemental online questionnaire assessing their experiences related to the COVID-19 pandemic, including whether they had been tested for COVID-19 infection and the result of the test. We used logistic regression analysis to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association of 25(OH)D level with COVID-19 positivity, adjusting for age, number of people living in the household, neighborhood socioeconomic status, and other potential confounders.

Results: Among 5,081 eligible participants whose blood sample had been assayed for 25(OH)D, 1,974 reported having had a COVID-19 test in 2020. Relative to women with 25(OH)D levels of 30 ng/mL (75 nmol/l) or more, multivariable-adjusted ORs for COVID-19 infection in women with levels of 20-29 ng/mL (50-72.5 nmol/l) and <20 ng/mL (<50 nmol/l) were, respectively, 1.48 (95% CI 0.95-2.30) and 1.69 (95% CI 1.04-2.72) (p trend 0.02).

Conclusion: The present results suggest that U.S. Black women with lower levels of 25(OH)D are at increased risk of infection with COVID-19. Further work is needed to confirm these findings and determine the optimal level of 25(OH)D for a beneficial effect.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0255132PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8315514PMC
August 2021

Beyond the new normal: Assessing the feasibility of vaccine-based suppression of SARS-CoV-2.

PLoS One 2021 16;16(7):e0254734. Epub 2021 Jul 16.

Fractal Therapeutics, Cambridge, MA, United States of America.

As the COVID-19 pandemic drags into its second year, there is hope on the horizon, in the form of SARS-CoV-2 vaccines which promise disease suppression and a return to pre-pandemic normalcy. In this study we critically examine the basis for that hope, using an epidemiological modeling framework to establish the link between vaccine characteristics and effectiveness in bringing an end to this unprecedented public health crisis. Our findings suggest that a return to pre-pandemic social and economic conditions without fully suppressing SARS-CoV-2 will lead to extensive viral spread, resulting in a high disease burden even in the presence of vaccines that reduce risk of infection and mortality. Our modeling points to the feasibility of complete SARS-CoV-2 suppression with high population-level compliance and vaccines that are highly effective at reducing SARS-CoV-2 infection. Notably, vaccine-mediated reduction of transmission is critical for viral suppression, and in order for partially-effective vaccines to play a positive role in SARS-CoV-2 suppression, complementary biomedical interventions and public health measures must be deployed simultaneously.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254734PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284637PMC
July 2021

Severe undernutrition in children affects tuberculin skin test performance in Southern India.

PLoS One 2021 16;16(7):e0250304. Epub 2021 Jul 16.

Department of Medicine, Section of Infectious Diseases, Boston University, School of Medicine, Boston, Massachusetts, United States of America.

Background: Undernutrition impairs immunity to Mycobacterium tuberculosis and is a risk factor for tuberculosis disease (TB). We aim to investigate if severe undernutrition affects the tuberculin skin test (TST) response among household contacts (HHCs) of pulmonary TB cases.

Methods: We analyzed data from HHCs (> five years) of pulmonary TB cases in Southern India. Undernutrition was defined as per World Health Organization based on body mass index (BMI) for adults (undernutrition 16-18.4 and severe undernutrition <16 kg/m2) and BMI relative to the mean for children (undernutrition 2SD-3SD and severe undernutrition < 3SDs below mean). Univariate and multivariate models of TST positivity (> five mm) were calculated using logistic regression with generalized estimating equations.

Results: Among 1189 HHCs, 342 were children (age 5-17 years) and 847 were adults. Prevalence of TST positivity in well-nourished, undernourished and severely undernourished children was 135/251 (53.8%), 32/68 (47.1%), and 7/23 (30.4%) respectively; among adults, prevalence of TST positivity was 304/708 (42.9%), 43/112 (38.4%) and 12/26 (46.2%), respectively. Severe undernutrition in children was associated with decreased odds of TST positivity (adjusted odds ratio 0.3; 95%CI 0.1-0.9).

Conclusion: Severe undernutrition in children was associated with decreased odds of TST positivity. False-negative TSTs may result from undernutrition; caution is warranted when interpreting negative results in undernourished populations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0250304PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284816PMC
October 2021

Self-identified Race and COVID-19-Associated Acute Kidney Injury and Inflammation: a Retrospective Cohort Study of Hospitalized Inner-City COVID-19 Patients.

J Gen Intern Med 2021 11 7;36(11):3487-3496. Epub 2021 Jun 7.

Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Background: Black individuals have been disproportionately affected by the coronavirus disease 2019 (COVID-19). However, it remains unclear whether there are any biological factors that predispose Black patients to COVID-19-related morbidity and mortality.

Objective: To compare in-hospital morbidity, mortality, and inflammatory marker levels between Black and White hospitalized COVID-19 patients.

Design And Participants: This single-center retrospective cohort study analyzed data for Black and White patients aged ≥18 years hospitalized with a positive SARS-CoV-2 PCR test between March 1, 2020, and August 4, 2020.

Main Measures: The exposure was self-identified race documented in the medical record. The primary outcome of was in-hospital death. Secondary outcomes included intensive care unit admission, hospital morbidities, and inflammatory marker levels.

Key Results: A total of 1,424 Black and White patients were identified. The mean ± SD age was 56.1 ± 17.4 years, and 663 (44.5%) were female. There were 683 (48.0%) Black and 741 (52.0%) White patients. In the univariate analysis, Black patients had longer hospital stays (8.1 ± 10.2 vs. 6.7 ± 8.3 days, p = 0.011) and tended to have higher rates of in-hospital death (11.0% vs. 7.3%), myocardial infarction (6.9% vs. 4.5%), pulmonary embolism (PE; 5.0% vs. 2.3%), and acute kidney injury (AKI; 39.4% vs. 23.1%) than White patients (p <0.05). However, after adjusting for potential confounders, only PE (adjusted odds ratio [aOR] 2.07, 95% CI, 1.13-3.79) and AKI (aOR 2.16, 95% CI, 1.57-2.97) were statistically significantly associated with Black race. In comparison with White patients, Black patients had statistically significantly higher peak plasma D-dimer (standardized β = 0.10), erythrocyte sedimentation rate (standardized β = 0.13), ferritin (standardized β = 0.09), and lactate dehydrogenase (standardized β = 0.11), after adjusting for potential confounders (p<0.05).

Conclusions: Black hospitalized COVID-19 patients had increased risks of developing PE and AKI and higher inflammatory marker levels compared with White patients. This observation may be explained by differences in the prevalence and severity of underlying comorbidities and other unmeasured biologic risk factors between Black and White patients. Future research is needed to investigate the mechanism of these observed differences in outcomes of severe COVID-19 infection in Black versus White patients.
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http://dx.doi.org/10.1007/s11606-021-06931-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8183592PMC
November 2021

Multidrug-resistant tuberculosis imported into low-incidence countries-a GeoSentinel analysis, 2008-2020.

J Travel Med 2021 08;28(6)

Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden.

Background: Early detection of imported multidrug-resistant tuberculosis (MDR-TB) is crucial, but knowledge gaps remain about migration- and travel-associated MDR-TB epidemiology. The aim was to describe epidemiologic characteristics among international travellers and migrants with MDR-TB.

Methods: Clinician-determined and microbiologically confirmed MDR-TB diagnoses deemed to be related to travel or migration were extracted from GeoSentinel, a global surveillance network of travel and tropical medicine clinics, from January 2008 through December 2020. MDR-TB was defined as resistance to both isoniazid and rifampicin. Additional resistance to either a fluoroquinolone or a second-line injectable drug was categorized as pre-extensively drug-resistant (pre-XDR) TB, and as extensively drug-resistant (XDR) TB when resistance was detected for both. Sub-analyses were performed based on degree of resistance and country of origin.

Results: Of 201 patients, 136 had MDR-TB (67.7%), 25 had XDR-TB (12.4%), 23 had pre-XDR TB (11.4%) and 17 had unspecified MDR- or XDR-TB (8.5%); 196 (97.5%) were immigrants, of which 92 (45.8%) originated from the former Soviet Union. The median interval from arrival to presentation was 154 days (interquartile range [IQR]: 10-751 days); 34.3% of patients presented within 1 month after immigration, 30.9% between 1 and 12 months and 34.9% after ≥1 year. Pre-XDR- and XDR-TB patients from the former Soviet Union other than Georgia presented earlier than those with MDR-TB (26 days [IQR: 8-522] vs. 369 days [IQR: 84-827]), while patients from Georgia presented very early, irrespective of the level of resistance (8 days [IQR: 2-18] vs. 2 days [IQR: 1-17]).

Conclusions: MDR-TB is uncommon in traditional travellers. Purposeful medical migration may partly explain differences in time to presentation among different groups. Public health resources are needed to better understand factors contributing to cross-border MDR-TB spread and to develop strategies to optimize care of TB-infected patients in their home countries before migration.
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http://dx.doi.org/10.1093/jtm/taab069DOI Listing
August 2021

Individually optimal choices can be collectively disastrous in COVID-19 disease control.

BMC Public Health 2021 04 30;21(1):832. Epub 2021 Apr 30.

Fractal Therapeutics, Cambridge, MA, USA.

Background: The word 'pandemic' conjures dystopian images of bodies stacked in the streets and societies on the brink of collapse. Despite this frightening picture, denialism and noncompliance with public health measures are common in the historical record, for example during the 1918 Influenza pandemic or the 2015 Ebola epidemic. The unique characteristics of SARS-CoV-2-its high basic reproduction number (R), time-limited natural immunity and considerable potential for asymptomatic spread-exacerbate the public health repercussions of noncompliance with interventions (such as vaccines and masks) to limit disease transmission. Our work explores the rationality and impact of noncompliance with measures aimed at limiting the spread of SARS-CoV-2.

Methods: In this work, we used game theory to explore when noncompliance confers a perceived benefit to individuals. We then used epidemiological modeling to predict the impact of noncompliance on control of SARS-CoV-2, demonstrating that the presence of a noncompliant subpopulation prevents suppression of disease spread.

Results: Our modeling demonstrates that noncompliance is a Nash equilibrium under a broad set of conditions and that the existence of a noncompliant population can result in extensive endemic disease in the long-term after a return to pre-pandemic social and economic activity. Endemic disease poses a threat for both compliant and noncompliant individuals; all community members are protected if complete suppression is achieved, which is only possible with a high degree of compliance. For interventions that are highly effective at preventing disease spread, however, the consequences of noncompliance are borne disproportionately by noncompliant individuals.

Conclusions: In sum, our work demonstrates the limits of free-market approaches to compliance with disease control measures during a pandemic. The act of noncompliance with disease intervention measures creates a negative externality, rendering suppression of SARS-CoV-2 spread ineffective. Our work underscores the importance of developing effective strategies for prophylaxis through public health measures aimed at complete suppression and the need to focus on compliance at a population level.
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http://dx.doi.org/10.1186/s12889-021-10829-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085805PMC
April 2021

Food for thought: addressing undernutrition to end tuberculosis.

Lancet Infect Dis 2021 10 23;21(10):e318-e325. Epub 2021 Mar 23.

Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston University, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston University, MA, USA.

Tuberculosis is the leading cause of deaths from an infectious disease worldwide. WHO's End TB Strategy is falling short of several 2020 targets. Undernutrition is the leading population-level risk factor for tuberculosis. Studies have consistently found that undernutrition is associated with increased tuberculosis incidence, increased severity, worse treatment outcomes, and increased mortality. Modelling studies support implementing nutritional interventions for people living with tuberculosis and those at risk of tuberculosis disease to ensure the success of the End TB Strategy. In this Personal View, we highlight nutrition-related immunocompromisation, implications of undernutrition for tuberculosis treatment and prevention, the role of nutritional supplementation, pharmacokinetics and pharmacodynamics of antimycobacterial medications in undernourished people with tuberculosis, and the role of social protection interventions in addressing undernutrition as a tuberculosis risk factor. To catalyse action on this insufficiently addressed accelerant of the global tuberculosis epidemic, research should be prioritised to understand the immunological pathways that are impaired by nutrient deficiencies, develop tools to diagnose clinical and subclinical tuberculosis in people who are undernourished, and understand how nutritional status affects the efficacy of tuberculosis vaccine and therapy. Through primary research, modelling, and implementation research, policy change should also be accelerated, particularly in countries with a high burden of tuberculosis.
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http://dx.doi.org/10.1016/S1473-3099(20)30792-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8458477PMC
October 2021

In the long shadow of our best intentions: Model-based assessment of the consequences of school reopening during the COVID-19 pandemic.

PLoS One 2021 25;16(3):e0248509. Epub 2021 Mar 25.

Fractal Therapeutics, Cambridge, MA, United States of America.

As the world grapples with the ongoing COVID-19 pandemic, a particularly thorny set of questions surrounds the reopening of primary and secondary (K-12) schools. The benefits of in-person learning are numerous, in terms of education quality, mental health, emotional well-being, equity and access to food and shelter. Early reports suggested that children might have reduced susceptibility to COVID-19, and children have been shown to experience fewer complications than older adults. Over the past few months, our understanding of COVID-19 has been further shaped by emerging data, and it is now understood that children are as susceptible to infection as adults and have a similar viral load during infection, even if asymptomatic. Based on this updated understanding of the disease, we have used epidemiological modeling to explore the feasibility and consequences of school reopening in the face of differing rates of COVID-19 prevalence and transmission. We focused our analysis on the United States, but the results are applicable to other countries as well. We demonstrate the potential for a large discrepancy between detected cases and true infections in schools due to the combination of high asymptomatic rates in children coupled with delays in seeking testing and receiving results from diagnostic tests. Our findings indicate that, regardless of the initial prevalence of the disease, and in the absence of robust surveillance testing and contact-tracing, most schools in the United States can expect to remain open for 20-60 days without the emergence of sizeable disease clusters. At this point, even if schools choose to close after outbreaks occur, COVID-19 cases will be seeded from these school clusters and amplified into the community. Thus, our findings suggest that the debate between the risks to student safety and benefits of in-person learning frames a false dual choice. Reopening schools without surveillance testing and contact tracing measures in place will lead to spread within the schools and within the communities that eventually forces a return to remote learning and leaves a trail of infection in its wake.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248509PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993767PMC
April 2021

Risk factors for death during treatment in pulmonary tuberculosis patients in South India: A cohort study.

Indian J Tuberc 2021 Jan 1;68(1):32-39. Epub 2020 Oct 1.

Department of Preventive & Social Medicine, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India.

Objective: Identifying the risk factors for deaths during tuberculosis (TB) treatment is important for achieving the vision of India's National Strategic Plan of 'Zero Deaths' by 2025. We aimed to determine the proportion of deaths during TB treatment and its risk factors among smear positive pulmonary TB patients aged more than 15 years.

Study Design: We performed a cohort study using data collected for RePORT India Consortium (Regional Prospective Observational Research in Tuberculosis).

Setting: Revised TB Control Program (RNTCP) in three districts of South India.

Participants: The cohort consisted of newly diagnosed drug sensitive patients enrolled under the Revised National TB Control Program during 2014-2018 in three districts of southern India. Information on death was collected at homes by trained project staff.

Primary Outcome Measures: We calculated 'all-cause mortality' during TB treatment and expressed this as a proportion with 95% confidence interval (CI). Risk factors for death were assessed by calculating unadjusted and adjusted relative risks with 95% CI.

Results: The mean (SD) age was of the 1167 participants was 45 (14.5) years and 79% of them were males. Five participants (0.4%) were HIV infected. Among the males, 560 (61%) were tobacco users and 688 (75%) reported consuming alcohol. There were 47 deaths (4%; 95% CI 3.0-5.3) of which 28 deaths (60%) occurred during first two months of treatment. In a bi-variable analysis, age of more than 60 years (RR 2.27; 95%CI: 1.24-4.15), male gender (RR 3.98; 95% CI: 1.25-12.70), alcohol use in last 12 months (RR 2.03; 95%CI: 1.07-3.87), tobacco use (RR 1.87; 95%CI: 1.05-3.36) and severe anaemia (RR 3.53: 95%CI: 1.34-9.30) were associated with a higher risk of death. In adjusted analysis, participants with severe anaemia (<7gm/dl) had 2.4 times higher risk of death compared to their counterparts.

Conclusion: Though deaths during TB treatment was not very high, early recognition of risk groups and targeted interventions are required to achieve zero TB deaths.
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http://dx.doi.org/10.1016/j.ijtb.2020.09.022DOI Listing
January 2021

Chagas Disease in the United States: A Perspective on Diagnostic Testing Limitations and Next Steps.

Am J Trop Med Hyg 2021 Feb 1. Epub 2021 Feb 1.

9Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Chagas disease is a neglected tropical disease that affects an estimated 300,000 people in the United States. This perspective piece reviews diagnostic challenges and proposes next steps to address these shortfalls.
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http://dx.doi.org/10.4269/ajtmh.19-0871DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941835PMC
February 2021

Comparing tuberculosis gene signatures in malnourished individuals using the TBSignatureProfiler.

BMC Infect Dis 2021 Jan 22;21(1):106. Epub 2021 Jan 22.

Boston Medical Center, Boston, MA, USA.

Background: Gene expression signatures have been used as biomarkers of tuberculosis (TB) risk and outcomes. Platforms are needed to simplify access to these signatures and determine their validity in the setting of comorbidities. We developed a computational profiling platform of TB signature gene sets and characterized the diagnostic ability of existing signature gene sets to differentiate active TB from LTBI in the setting of malnutrition.

Methods: We curated 45 existing TB-related signature gene sets and developed our TBSignatureProfiler software toolkit that estimates gene set activity using multiple enrichment methods and allows visualization of single- and multi-pathway results. The TBSignatureProfiler software is available through Bioconductor and on GitHub. For evaluation in malnutrition, we used whole blood gene expression profiling from 23 severely malnourished Indian individuals with TB and 15 severely malnourished household contacts with latent TB infection (LTBI). Severe malnutrition was defined as body mass index (BMI) < 16 kg/m2 in adults and based on weight-for-height Z scores in children < 18 years. Gene expression was measured using RNA-sequencing.

Results: The comparison and visualization functions from the TBSignatureProfiler showed that TB gene sets performed well in malnourished individuals; 40 gene sets had statistically significant discriminative power for differentiating TB from LTBI, with area under the curve ranging from 0.662-0.989. Three gene sets were not significantly predictive.

Conclusion: Our TBSignatureProfiler is a highly effective and user-friendly platform for applying and comparing published TB signature gene sets. Using this platform, we found that existing gene sets for TB function effectively in the setting of malnutrition, although differences in gene set applicability exist. RNA-sequencing gene sets should consider comorbidities and potential effects on diagnostic performance.
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http://dx.doi.org/10.1186/s12879-020-05598-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821401PMC
January 2021

Alcohol use and tuberculosis clinical presentation at the time of diagnosis in Puducherry and Tamil Nadu, India.

PLoS One 2020 17;15(12):e0240595. Epub 2020 Dec 17.

Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, United States of America.

Setting: Alcohol use increases the risk of tuberculosis (TB) disease and is associated with worse outcomes.

Objective: To determine whether alcohol use affects TB severity at diagnosis in a high-burden setting.

Design: Participants were smear-positive people living with TB (PLWTB) in India. Disease severity was assessed as 1) high versus low smear grade, 2) time to positivity (TTP) on liquid culture, 3) chest radiograph cavitation, and 4) percent lung affected. Alcohol use and being at-risk for alcohol use disorders (AUD) were assessed using the AUDIT-C. Univariable and multivariable analyses were conducted.

Results: Of 1166 PLWTB, 691 (59.3%) were drinkers; of those, 518/691 (75.0%) were at-risk for AUD. Drinkers had more lung affected than non-drinkers (adjusted mean difference 10.8%, p<0.0001); this was not significant for those at-risk for AUD (adjusted mean difference 3.7%, p = 0.11). High smear grade (aOR 1.0, 95%CI: 0.7-1.4), cavitation (aOR 0.8, 95%CI 0.4-1.8), and TTP (mean difference 5.2 hours, p = 0.51) did not differ between drinkers and non-drinkers, nor between those at-risk and not at-risk for AUD.

Conclusions: A large proportion of PLWTB were drinkers and were at-risk for AUD. Alcohol drinkers had more lung affected than non-drinkers. Studies are needed to explore mechanisms of this association.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240595PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746146PMC
January 2021

Clinical outcomes and inflammatory marker levels in patients with Covid-19 and obesity at an inner-city safety net hospital.

PLoS One 2020 16;15(12):e0243888. Epub 2020 Dec 16.

Section of Infectious Diseases, Department of Internal Medicine, School of Medicine, Boston University, Boston, Massachusetts, United States of America.

Objectives: Patients with Covid-19 and obesity have worse clinical outcomes which may be driven by increased inflammation. This study aimed to characterize the association between clinical outcomes in patients with obesity and inflammatory markers.

Methods: We analyzed data for patients aged ≥18 years admitted with a positive SARS-CoV-2 PCR test. We used multivariate logistic regression to determine the association between BMI and intensive care unit (ICU) transfer and all-cause mortality. Inflammatory markers (C-reactive protein [CRP], lactate dehydrogenase [LDH], ferritin, and D-dimer) were compared between patients with and without obesity (body mass index [BMI] ≥30 kg/m2).

Results: Of 791 patients with Covid-19, 361 (45.6%) had obesity. In multivariate analyses, BMI ≥35 was associated with a higher odds of ICU transfer (adjusted odds ratio [aOR] 2.388 (95% confidence interval [CI]: 1.074-5.310) and hospital mortality (aOR = 4.3, 95% CI: 1.69-10.82). Compared to those with BMI<30, patients with obesity had lower ferritin (444 vs 637 ng/mL; p<0.001) and lower D-dimer (293 vs 350 mcg/mL; p = 0.009), non-significant differences in CRP (72.8 vs 84.1 mg/L, p = 0.099), and higher LDH (375 vs 340, p = 0.009) on the first hospital day.

Conclusions: Patients with obesity were more likely to have poor outcomes even without increased inflammation.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243888PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744045PMC
December 2020

Evaluation of factors influencing Mycobacterium tuberculosis complex recovery and contamination rates in MGIT960.

Indian J Tuberc 2020 Oct 19;67(4):466-471. Epub 2020 Jul 19.

Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, India. Electronic address:

Background: Tuberculosis (TB) is a major public health problem worldwide. Contamination rate and poor recovery of Mycobacterium tuberculosis complex (MTBC) in MGIT960 culture may affect the early diagnosis of TB. Evidence is needed to determine the factors associated with contamination rates and MTBC recovery in MGIT960. Hence, we undertook this study to compare the factors influencing MTBC culture positivity and contamination rates in MGIT960 in patients with Pulmonary tuberculosis (PTB).

Methods: A total of 849 sputum samples from newly diagnosed smear-positive TB cases enrolled into the Regional Prospective Observational Research for Tuberculosis India cohort between May 2014 to March 2017 were analyzed. Samples were inoculated into MGIT960 and positive cultures were examined for the presence of MTBC by immunochromatographic test for detection of MPT64 antigen.

Results: Of the 849 cases, 811 (95.5%) were culture positive for MTBC, 23 (2.7%) were culture negative and 15 (1.8%) were contaminated. Salivary sputum showed significantly less culture yield compared to mucopurulent/blood stained samples (p = 0.021). Sputum from individuals <20 or ≥60 years showed lower culture yield of 93.9%, compared to those aged 20-59years (98.2%) (p = 0.002). Based on smear grading, culture isolation of MTBC by MGIT960 was 86.1%, 93.6% and 99.5% for negative, scanty and positive (1+/2+/3+) samples, respectively (p ≤ 0.0001). Sputum from HIV negative patients showed higher culture yield, compared to HIV positive patients (p ≤ 0.0001). Chest X-Ray revealed that patient with cavity showed higher culture isolation of MTBC compared to patients without cavity (p = 0.035). Contamination rates were higher in smear negatives (6.0%), compared to scanty (2.1%) and smear positives (1.1%) (p = 0.007). However, delay in transport of the specimen to the laboratory was the only independent factor significantly associated with increase in culture contamination.

Conclusion: Our results highlight that extremes of age, smear negativity, HIV infection, sputum quality and cavitation significantly influence the culture yield of MTBC, whereas transport duration and smear grading affected the contamination rates in MGIT960. Hence, addressing these factors may improve the diagnostic performance of MGIT960.
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http://dx.doi.org/10.1016/j.ijtb.2020.07.016DOI Listing
October 2020

Testing for Chagas disease in an at-risk population.

J Card Fail 2021 01 6;27(1):109-111. Epub 2020 Sep 6.

Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA.

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http://dx.doi.org/10.1016/j.cardfail.2020.09.002DOI Listing
January 2021

Predictors of Loss to Follow-Up among Men with Tuberculosis in Puducherry and Tamil Nadu, India.

Am J Trop Med Hyg 2020 09;103(3):1050-1056

Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts.

Identifying predictors of loss to follow-up (LTFU; treatment lapse ≥ 2 months) among people with tuberculosis (TB) may assist programmatic efforts in controlling the spread of TB. Newly diagnosed smear-positive TB patients were enrolled in the Regional Prospective Observational Research for TB study in Puducherry and Tamil Nadu, India. Treatment records were used to identify LTFU of those who were enrolled from May 2014 through December 2017. This nested case-control study evaluated male TB patients. Predictors were assessed using multivariable logistic regression. Of 425 men with TB, 82 (19%) were LTFU. In the adjusted analyses of males, divorced/separated marital status (adjusted odds ratio [aOR] 3.80; 95% CI: 1.39-10.38) and at-risk alcohol use (aOR 1.92; 95% CI: 1.12-3.27) were significant predictors for increased risk of LTFU, and diabetes was a significant predictor for decreased risk of LTFU (aOR 0.52; 95% CI: 0.29-0.92). Of 53 men with recorded date of last treatment visit, 23 (43%) and 43 (81%) had LTFU within the first 2 and first 4 months of treatment, respectively. Addressing at-risk alcohol use and providing more intensive follow-up could lead to improved treatment completion.
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http://dx.doi.org/10.4269/ajtmh.19-0415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7470548PMC
September 2020

Controlling for undernutrition in epidemiological studies of tuberculosis.

Lancet Infect Dis 2020 05;20(5):540-541

Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, MA 02119, USA; Department of Epidemiology, Boston University School of Public Health, MA, USA.

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http://dx.doi.org/10.1016/S1473-3099(20)30267-XDOI Listing
May 2020

Zika among international travellers presenting to GeoSentinel sites, 2012-2019: implications for clinical practice.

J Travel Med 2020 Jul;27(4)

Department of Epidemiology and Global Health, University of Umea, Petrus Laestadius Väg, 901 87, Umeå, Sweden.

Introduction: International travellers contribute to the rapid spread of Zika virus (ZIKV) and its sentinel identification globally. We describe ZIKV infections among international travellers seen at GeoSentinel sites with a focus on ZIKV acquired in the Americas and the Caribbean, describe countries of exposure and traveller characteristics, and assess ZIKV diagnostic testing by site.

Methods: Records with an international travel-related diagnosis of confirmed or probable ZIKV from January 2012 through December 2019 reported to GeoSentinel with a recorded illness onset date were included to show reported cases over time. Records from March 2016 through December 2019 with an exposure region of the Americas or the Caribbean were included in the descriptive analysis. A survey was conducted to assess the availability, accessibility and utilization of ZIKV diagnostic tests at GeoSentinel sites.

Results: GeoSentinel sites reported 525 ZIKV cases from 2012 through 2019. Between 2012 and 2014, eight cases were reported, and all were acquired in Asia or Oceania. After 2014, most cases were acquired in the Americas or the Caribbean, a large decline in ZIKV cases occurred in 2018-19.Between March 2016 and December 2019, 423 patients acquired ZIKV in the Americas or the Caribbean, peak reporting to these regions occurred in 2016 [330 cases (78%)]. The median age was 36 years (range: 3-92); 63% were female. The most frequent region of exposure was the Caribbean (60%). Thirteen travellers were pregnant during or after travel; one had a sexually acquired ZIKV infection. There was one case of fetal anomaly and two travellers with Guillain-Barré syndrome. GeoSentinel sites reported various challenges to diagnose ZIKV effectively.

Conclusion: ZIKV should remain a consideration for travellers returning from areas with risk of ZIKV transmission. Travellers should discuss their travel plans with their healthcare providers to ensure ZIKV prevention measures are taken.
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http://dx.doi.org/10.1093/jtm/taaa061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604850PMC
July 2020

Household food insecurity among patients with pulmonary tuberculosis and its associated factors in South India: a cross-sectional analysis.

BMJ Open 2020 02 28;10(2):e033798. Epub 2020 Feb 28.

Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India.

Objectives: Food insecurity is 'the limited or uncertain availability of nutritionally adequate, safe foods or inability to acquire foods in socially acceptable ways'. Majority of tuberculosis (TB) cases of resource-poor settings experience food insecurity, which impacts treatment adherence and outcomes. We aimed to determine level of household food insecurity (HFI) and its associated factors in patients with pulmonary TB.

Design: This is a cross-sectional analysis of data from an ongoing cohort study.

Setting: National Tuberculosis Programme (NTP) in three districts of South India.

Participants: All newly diagnosed pulmonary TB cases of the cohort enrolled in the NTP at the Designated Microscopy Centres (DMCs) and Primary Health Centres (PHCs) from October 2015 to October 2018.

Primary Outcome Measures: The proportion of baseline HFI assessed using a validated HFI Access Scale was summarised as percentage with 95% CI. Possible association of sociodemographic, morbidity and behavioural characteristics with HFI was assessed using χ test, and unadjusted prevalence ratios with 95% CI were calculated. The characteristics with values of p<0.2 in the univariate model were included in the multivariable generalised linear model (binomial function, log link) to derive adjusted prevalence ratios (aPRs) with 95% CI.

Result: Of a total of 765 patients, 261 had HFI and the proportion was 34.1% (95% CI 30.8% to 37.6%). Mild, moderate and severe food insecurity was found in 17 (2.2%), 67 (8.8%) and 177 (23.1%) TB cases, respectively. Patients with TB who had monthly family income less than rupees 3000 (aPR 2.0; 95% CI 1.3 to 3.0), Karnofsky Score of 60 or less (aPR 1.5; 95% CI 1.1 to 1.9) and those who were employed (aPR 1.4; 95% CI 1.0 to 2.0) were independently associated with HFI.

Conclusions: A high level of food insecurity was seen in households with TB cases. Additional food or cash assistance for this subgroup might improve food insecurity and thereby nutritional status.
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http://dx.doi.org/10.1136/bmjopen-2019-033798DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050349PMC
February 2020

Interaction of nutritional status and diabetes on active and latent tuberculosis: a cross-sectional analysis.

BMC Infect Dis 2019 Jul 16;19(1):627. Epub 2019 Jul 16.

Department of Epidemiology, Boston University School of Public Health, Boston, USA.

Background: Malnutrition and diabetes are risk factors for active tuberculosis (TB), possible risk factors for latent TB infection (LTBI), and may interact to alter their effect on these outcomes. Studies to date have not investigated this interaction.

Methods: We enrolled 919 newly diagnosed active TB patients and 1113 household contacts at Primary Health Centres in Puducherry and Tamil Nadu, India from 2014 to 2018. In cross-sectional analyses, we used generalized estimating equations to measure additive and multiplicative interaction of body mass index (BMI) and diabetes on two outcomes, active TB and LTBI.

Results: Among overweight or obese adults, active TB prevalence was 12-times higher in diabetic compared to non-diabetic participants, 2.5-times higher among normal weight adults, and no different among underweight adults (P for interaction < 0.0001). Diabetes was associated with 50 additional active TB cases per 100 overweight or obese participants, 56 per 100 normal weight participants, and 17 per 100 underweight participants (P for interaction < 0.0001). Across BMI categories, screening 2.3-3.8 active TB patients yielded one hyperglycemic patient. LTBI prevalence did not differ by diabetes and BMI*diabetes interaction was not significant.

Conclusions: BMI and diabetes are associated with newly diagnosed active TB, but not LTBI. Diabetes conferred the greatest risk of active TB in overweight and obese adults whereas the burden of active TB associated with diabetes was similar for normal and overweight or obese adults. Hyperglycemia was common among all active TB patients. These findings highlight the importance of bi-directional diabetes-active TB screening in India.
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http://dx.doi.org/10.1186/s12879-019-4244-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6636094PMC
July 2019

Effect of malnutrition on radiographic findings and mycobacterial burden in pulmonary tuberculosis.

PLoS One 2019 27;14(3):e0214011. Epub 2019 Mar 27.

Department of Epidemiology, Boston University, Boston, MA, United States of America.

Background: The relationship between malnutrition and tuberculosis (TB) severity is understudied. We investigated the effect of malnutrition on radiographic findings and mycobacterial burden.

Methods: Subjects included newly diagnosed, smear-positive, culture-confirmed, pulmonary TB cases enrolled in the Regional Prospective Observational Research for TB (RePORT) cohort. Multivariate regression models were used to evaluate the relationship at start of treatment between body mass index (BMI) and chest radiograph (CXR) findings of cavitation and percentage of lung affected and mycobacterial growth indicator tube (MGIT) time to positive (TTP). Severe malnutrition was defined as BMI<16 kg/m2, moderate malnutrition as 16-18.4kg/m2, and "normal"/overweight as ≥18.5 kg/m2.

Results: Of 173 TB cases with chest x-ray data, 131 (76%) were male. The median age was 45 years (range 16-82); 42 (24%) had severe malnutrition and 58 (34%) moderate malnutrition. Median percentage of lung affected was 32% (range 0-95), and 132 (76%) had cavitation. Individuals with severe malnutrition had, on average, 11.1% [95% CI: 4.0-13.3] more lung affected, compared to those with normal BMI, controlling for diabetes and cavitation. In multivariable analyses, cases with severe malnutrition had a 4.6-fold [95% CI, 1.5-14.1] increased odds of cavitation compared to those with normal BMI, controlling for smoking. Median MGIT TTP was 194.5 hours. Neither severe (aRR 0.99; 95% CI, 0.9-1.2) nor moderate (aRR 0.97; 95% CI, 0.8-1.1) malnutrition was associated with MGIT TTP.

Conclusion: We found that malnutrition was associated with increased extent of disease and cavitation on CXR. These findings may reflect the immunomodulatory effect of malnutrition on pulmonary pathology.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0214011PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436704PMC
December 2019

Crystal ball: the yesterday and tomorrow of tuberculosis.

Environ Microbiol Rep 2019 02 25;11(1):41-44. Epub 2018 Dec 25.

Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA.

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http://dx.doi.org/10.1111/1758-2229.12726DOI Listing
February 2019
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