Nicole Salazar-Austin, Maternal and Child Tuberculosis Working Group co-chair, explains why TB notifications for persons during maternal and postpartum must be included in the WHO Global TB Report and UN High Level Meeting targets.
Tuberculosis (TB) is responsible for 6-15% of all maternal deaths and leads to adverse pregnancy outcomes such as pre-eclampsia, eclampsia, vaginal bleeding, hospitalisation and miscarriage (Mathad 2012).
Infants born to mothers with TB have a higher rate of prematurity, low birth weight and stillbirth (WHO Factsheet 2015). Maternal TB more than doubles the risk of mother-to-child transmission of HIV (Gupta 2011), and significantly increases the risk of mortality for the newborn (Gupta 2007, Figueroa-Damian 2001, Cantwell 1994) and other young children living in the household (Gomes 2011).
TB is twice as likely to be diagnosed postpartum (that is, after childbirth) than at any other time in a woman’s life, likely due to a delays in early detection during pregnancy related physiologic and immunologic changes (Zenner 2011).
Yet we do not even know how many pregnant and postpartum persons have TB disease.
In the absence of systematic collection of data on TB in pregnancy, modelling studies have estimated that more than 215,000 TB cases occur annually among pregnant and postpartum persons, with the vast majority of cases occurring in Africa and South East Asia (Sugarman 2014). However, this is likely an under-estimate of actual numbers due to challenges in diagnosing TB during pregnancy.
Current screening and diagnostic algorithms have reduced performance in pregnancy and often miss TB. The physiologic changes of pregnancy often mask TB symptoms. During pregnancy, classic TB symptoms, such as cough, are non-specific or, like weight loss, are less relevant.
More research is needed to define optimal TB treatment and prevention strategies in pregnant and postpartum persons. There are few second line medications known to be safe for use in pregnancy for persons who do not tolerate first-line medications, which is unfortunately common in pregnancy, or who have drug-resistant TB.
Data from TB APPRISE and BRIEF TB suggest isoniazid for TB prevention may cause an increased risk of non-live births, as well as prematurity and low birth weight, both significant risk factors for infant death. Answering these questions will be critical to scaling up TB prevention in persons of childbearing age among household contacts of people with TB and persons living with HIV.
A reliable estimate of the number of TB cases during pregnancy and postpartum would provide a starting point to improve the diagnosis, prevention and management of TB in this population, which would have the beneficial side effect of decreasing TB-related morbidity and mortality in children.
Therefore, we request TB notifications for persons during pregnancy and postpartum (6 months) be included in the WHO Global TB Report and UN High Level Meeting targets.
To help decrease TB-related maternal and infant morbidity and mortality, we need to understand the burden of TB in pregnant and postpartum persons. Improved data on maternal TB notifications are critical.
Early results from a short survey with several high-burden countries (Lesotho, Zimbabwe, Kenya, Brazil and South Africa) indicate a strong willingness to report on TB notifications in pregnant and postpartum persons, but a mixed ability to report on these data using existing systems.
The US Centers for Disease Control has recently added pregnancy to their national TB surveillance.
We anticipate three immediate benefits of TB notification data in pregnant and postpartum persons:
• Improved global estimates of TB burden in pregnant/postpartum persons: TB notification data will assist in refining existing models, thereby improving global estimates of the TB burden in pregnant and postpartum persons. It will allow us to start cautiously estimating the degree of undiagnosed and untreated TB in pregnant persons. Further, these data could be used to estimate the effect of maternal TB on infant morbidity and mortality.
• Advocacy for programmatic implementation funding: TB notification data and TB burden estimates will assist in health services planning and resource allocation. Over time, data can be used to develop and assess targeted interventions to improve TB case detection among pregnant persons and to define best practices for integrating TB screening and prevention into existing maternal and child health programmes, ultimately improving both maternal and infant health.
• Advocacy for increased research funding: Both TB notifications and estimates of TB burden among pregnant and postpartum persons will raise awareness of this high-risk yet understudied population. These data can be used to motivate international agencies, funders, and academic partners to fund and conduct research that will:
- Develop and evaluate improved TB screening and diagnostics for pregnant and postpartum persons
- Define optimal TB treatment regimens for drug-susceptible and drug-resistant TB in pregnancy that consider both maternal and foetal outcomes
- Optimise timing and regimen for TB preventive therapy for pregnant and postpartum persons.
Directed attention and funding to this group of persons and their infants is critical as our knowledge in diagnosis, treatment, and prevention in pregnant and postpartum persons shamefully lags behind.
In summary, the addition of pregnancy and postpartum fields in the Global TB Data Collection Form will help quantify TB disease burden in this hitherto ignored population of at-risk persons and their infants, facilitating appropriate policy, treatment and research programmes.