Jyoti S. Mathad, MD MSc Assistant Professor Center for Global Health Weill Cornell Medical College North American Regional Meeting of IUTLD March 2, 2018 Diagnosing and Treating TB in Pregnant Women: Current Practices and Research Opportunities Weill Cornell Medicine CENTER FOR GLOBAL HEALTH
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Tuberculosis in Pregnancy and Postpartum - Jyoti Mathad.pdf · IRR 1.95 Postpartum TB Risk of TB in Pregnancy: UK primary care cohort 1996-2008 •192,801 women enrolled with 264,136
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Jyoti S. Mathad, MD MScAssistant Professor
Center for Global HealthWeill Cornell Medical College
North American Regional Meeting of IUTLDMarch 2, 2018
Diagnosing and Treating TB in Pregnant Women: Current Practices
and Research Opportunities
Weill Cornell Medicine
CENTER FOR GLOBAL HEALTH
Objectives
• Epidemiology– What is the burden of TB in pregnancy?
• Immunology and pathophysiology– Does pregnancy impact the course of
TB?– Does pregnancy impact the treatment
or prevention of TB?
• Outcomes– How does maternal TB impact maternal
and infant outcomes?
• Screening and Treatment
Weill Cornell Medical College
CENTER FOR GLOBAL HEALTH
WHAT IS THE BURDEN OF TB IN PREGNANCY?
Weill Cornell Medicine
CENTER FOR GLOBAL HEALTH
~500,000 died
3.5 million
WHO Global TB Report, 2017Weill Cornell Medicine
CENTER FOR GLOBAL HEALTH
TB incidence in US-born vs. foreign-born persons, 1993-2016
0
5,000
10,000
15,000
20,000
U.S.-born Foreign-born
US CDC TB Report, 2016Weill Cornell Medicine
CENTER FOR GLOBAL HEALTH
TB Case Rates by Age and Sex, United States, 2015
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Under 5 5 - 14 15 - 24 25 - 44 45 - 64 ≥65
Cas
es
pe
r 1
00
,00
0
Age, years
Male Female
US CDC TB Report, 2016Weill Cornell Medicine
CENTER FOR GLOBAL HEALTH
TB incidence peaks in women of reproductive age
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
Under 5 5 - 14 15 - 24 25 - 44 45 - 64 ≥65
Cas
es
pe
r 1
00
,00
0
Age, years
Male Female
US CDC TB Report, 2016Weill Cornell Medicine
CENTER FOR GLOBAL HEALTH
Global estimate of TB in pregnancy
Based on total population, crude birth rate, age distribution, TB case notification by age/sex
Sugarman, Lancet Global Health 2014
IRR 1.95 Postpartum TB
Risk of TB in Pregnancy: UK primary care cohort 1996-2008
• 192,801 women enrolled with 264,136 pregnancies
• Mean follow-up 9.1 years, (1,745,834 PY)
• 177 TB events; • Postpartum 15.4 vs. 9.1
per 100,000 PY
Zenner AJRCCM 2011Weill Cornell Medicine
CENTER FOR GLOBAL HEALTH
Postpartum
Immune changes during pregnancy increase risk of disease
Figure adapted from Kourtis NEJM 2014
• Increased risk of malaria, listeria• Increased severity of flu, varicella
TB Treatment and Prevention Trials for Pregnant Women
Goals Study
Immunology
• Impact of pregnancy, stage of pregnancy and HIV on immune response to MTB
PRACHITi study (~85% enrolled)
Treatment
• Opportunistic PK/safety of 1st line TB drugs in pregnancy
TSHEPISO (completed)
• PK/safety of MDR TB drugs in pregnancy IMPAACT P1026s (enrolling)
• Maternal TB treatment registry IMPAACT P1026s (accrual early 2016)
Preventive Therapy
• IPT in HIV-infected pregnant women P1078 (completed)
• INH/Rifapentine x 12 weeks in HIV-infected and HIV-uninfected pregnant women
P2001 Version 1.0-50% enrolled
Summary
• Peak incidence of TB in women during reproductive age
• Immune and physiological changes may be important for diagnosis and treatment
• Best approaches of integrated TB screening and prevention are still needed
• Maternal TB associated with adverse pregnancy outcomes, maternal mortality and infant TB and mortality
• Need to include pregnant women in trials of diagnostics and drugs whenever feasible
• Several ongoing studies will help to fill in the knowledge gaps
Acknowledgements
NIAID: K23AI129854 NICHD: R01HD081929NCATS: KL2 TR00458 of the CTSC at Weill Cornell Medical CollegeFogarty: D43TW000010, CFAR 1P30AI094189 Foundations: Ujala, Wyncote, GileadIndian Dept. of Biotechnology (DBT) and Council of Medical Research (ICMR)