Original Article

Changes in The Trends of Tuberculosis-related Indicators in Hamadan Province Using the Join Point Regression Approach From 2011 to 2022

Please cite this article as follows: Ghasemi F, Poorolajal J, Khazaei S, Zahiri A, Torkaman Asadi F. Changes in the trends of tuberculosis-related indicators in Hamadan province using the join point regression approach from 2011 to 2022. J Res Health Sci. 2025; 25(1):e00641. doi:10.34172/jrhs.2025.176

Background

Tuberculosis (TB) remains one of the primary causes of illness and death in developing countries, especially among individuals with weakened immune systems such as people living with HIV (human immunodeficiency virus), malnutrition, or diabetes, as well as those who use tobacco.¹ It is estimated that TB caused approximately 1.5 million deaths in 2019, with annual TB cases numbering around 10 million. TB remains a public health challenge globally and in developing countries, including Iran, it ranks ninth among the global burden of diseases.² TB ranks thirteenth among the leading causes of death globally, and it is also the leading cause of death from a single infectious agent, posing a considerable concern for public health and a global public health priority.^3,4 The United Nations’ Sustainable Development Goals and the WHO’s End TB Strategy aim to end the global TB epidemic by reducing TB-related deaths by 95% and reducing new cases by 90% by the year 2035.⁵

In Iran, TB is a public health concern and a challenging healthcare issue due to various factors such as migration, poor economic conditions, and comorbidities like diabetes and HIV/AIDS, all contributing to an increasing incidence rate.^6,7 Success in any healthcare program depends on monitoring the epidemiology of diseases and identifying gaps. Despite successful treatment of TB and a low number of multi-drug resistant cases, the incidence of TB in Iran has not significantly decreased.⁸

Trend analysis plays a crucial role in understanding the dynamics of disease patterns over time. By examining the trends of TB-related indicators, we can gain valuable insights into the effectiveness of TB control measures and identify areas for improvement. This information is vital for optimizing resource allocation and achieving the best outcomes in TB reduction and prevention. Despite the importance of TB epidemiology, comprehensive studies estimating its burden are limited, particularly in developing countries such as Iran. Previous studies have often focused on a narrow range of indicators and have seldom utilized advanced analytical methods. Therefore, in this study, we aimed to fill this gap by conducting a detailed trend analysis of a wide range of TB-related indicators using the joinpoint regression model.

Materials and Methods

In the present registry-based cross-sectional study, all TB cases in Hamadan province from 2011 to 2022- were investigated. In this study, the researchers obtained data from the TB registry, which collects information on TB patients from all districts periodically. The TB data are gathered by TB experts at the district health centers, evaluated for accuracy and quality, and then transferred to the provincial Deputy of Health. Therefore, information from different counties is aggregated. Patients with incorrect diagnoses or those who were imported during the treatment were excluded from our analysis. We examined 10 indicators, separately in males and females, including the incidence rate of smear-positive pulmonary TB (SPPT), the incidence rate of extra-pulmonary TB (EPT), the incidence rate of smear-negative pulmonary TB (SNPT), the co-infection of TB and AIDS, the relapse rate, the smear conversion rate two months after the treatment initiation, the mortality rate due to TB, the diagnosis rate of pulmonary TB with a smear grade of 3 + , the treatment success rate, and the TB diagnosis rate by the private sector. We calculated these indicators primarily in this study based on individual-level data. The formulas for estimating the specified indicators are presented in Table S1 (Supplementary file 1).

According to national guidelines, the diagnostic criteria for pulmonary TB were at least two positive sputum smears out of three consecutive sputum samples, a positive smear in one sample along with radiographic evidence of TB disease, or a positive smear in one sample along with a positive sputum culture.

The amount of change in the investigated indicators between time intervals t and t + 1 is estimated using linear regression on the natural logarithm of annual rates and using the calendar year as the predictor variable.

In which ln(r) represents the natural logarithm of the rate in year t. Then, the annual percentage change (APC) from year t to t + 1 is calculated as follows:

To calculate the APC, we only need one b. The average annual percentage change (AAPC) is calculated using the following formula:

Where b_is are the slope coefficients for each segment in the desired range of years, and the w_is are the length of each segment runs in the range of years. A positive APC indicates an increase in the measured variable during the specified period, while a negative APC indicates a decrease in that variable over the same timeframe. The numerical value of APC reflects the annual rate of change. Similarly, a positive AAPC denotes an overall increase in the variable over a specified period of time, whereas a negative AAPC indicates an overall decrease. The numerical value of AAPC serves as a summary measure of the trend over multiple time points, capturing variations in trends throughout the period.

The trend analysis of TB incidence or mortality was conducted using the Joinpoint regression model. This method is utilized to identify short-term changes in the trend. The permutation method was employed to find additional joinpoints in describing the existing trend. Finally, the optimal number of joinpoints for describing the trend was selected. The percentage change in annual rates was calculated using logarithmic linear regression, with the calendar year as the predictor variable. When no joinpoint exists (i.e., no change in the trend), the APC remains constant and equals the AAPC. Otherwise, the entire period is divided by points with changing trends. Then, the AAPC is estimated as the weighted average of the estimated APC in each segment using the segment length as the weight. When the number of joinpoints (k) is determined, different models with k joinpoints were compared using the Bayesian information criterion (BIC). Data analysis was performed using the Joinpoint regression program. A significance level of 0.05 was considered for the statistical tests.

Results

In this study, we analyzed data from the TB registry, which included information on 481 females and 554 males registered in Hamadan Province from 2011 to 2022. The frequency and incidence of investigated indices in both males and females during the mentioned time period are presented in Tables 1 and 2.

In all indicators, except for “the death rate from TB” in males (39.29%) and “the detection rate of SPPT with a smear grade of 3 + ” in females (20%), a decreasing trend was observed in “the incidence of SPPT” in males (-29.41%) and females (-52.57%), “the incidence rate of EPT” in males (-29.41%) and females (-52.57%), “the incidence rate of SNPT” in males (-26.52%) and females (-29.41%), “the negative rate of sputum smear two months after the treatment initiation” in males (-85.64%) and females (-51.16%), “the detection rate of SPPT with a smear grade of 3 + ” in males (-29.93%), “treatment success rate” in males (-48.25%) and females (-54.49%), “TB detection rate by the private sector” in males (-72.23%) and females (-20.30%), and “recurrence rate” in males (-35.29%) (Tables 1 and 2).

A significantly decreasing trend was observed in “the incidence of SPPT” index in females (AAPC: -7.72; 95% CI: -15.63, -1.10; P = 0.008) and overall population (AAPC: -4.8; 95% CI: -9.4, -0.81; P = 0.030) (Table 3). A significantly decreasing trend was observed in “the incidence rate of EPT” (AAPC: -9.30; 95% CI: -18.25, -2.03; P = 0.002) and “the negative rate of sputum smear two months after the treatment initiation” (AAPC: -7.57; 95% CI: -10.62, -5.34; P = 0.00007) in females. Additionally, “the treatment success rate” in both genders had a significantly decreasing trend. The “recurrence rate” in females had a rising trend in the mentioned time period (AAPC: 18.45; 95% CI: 3.23 to 46.47; P = 0.0002). The trend of the “co-infection rate of SPPT and HIV” index in 2011-2015 was increasing (APC: 40.21; 95% CI: 4.29 to 211.13; P = 0.03) and afterwards it was decreasing in both genders (APC: -28.57; 95% CI: -57.8, -18.14; P = 0.010), which was significant in males in 2015-2022 (APC-28.4046; 95% CI: -41.0052, -13.1126; P = 0.004). The changes in these indices are presented graphically in Figures 1 and 2.

Close

Figure 1.

(A) Joinpoint models for co-infection rate of TB and AIDS, (B) Joinpoint models for the detection rate of SPPT with a smear grade of 3 + , (C) Joinpoint models for the incidence rate of EPT, (D) Joinpoint models for the incidence of SPPT, (E) Joinpoint models for the incidence rate of SNPT, (F) Joinpoint models for smear conversion rate two months after the treatment initiation. Abbreviations: SPPT: Smear-positive pulmonary tuberculosis; EPT: Extrapulmonary tuberculosis; SNPT: Smear-negative pulmonary tuberculosis

Figure 1.

(A) Joinpoint models for co-infection rate of TB and AIDS, (B) Joinpoint models for the detection rate of SPPT with a smear grade of 3 + , (C) Joinpoint models for the incidence rate of EPT, (D) Joinpoint models for the incidence of SPPT, (E) Joinpoint models for the incidence rate of SNPT, (F) Joinpoint models for smear conversion rate two months after the treatment initiation. Abbreviations: SPPT: Smear-positive pulmonary tuberculosis; EPT: Extrapulmonary tuberculosis; SNPT: Smear-negative pulmonary tuberculosis

Close

Figure 2.

(A) Joinpoint models for recurrence rate, (B) Joinpoint models for TB detection rate by the private sector, (C) Joinpoint models for treatment success rate, (D) Joinpoint models for death rate from TB

Figure 2.

(A) Joinpoint models for recurrence rate, (B) Joinpoint models for TB detection rate by the private sector, (C) Joinpoint models for treatment success rate, (D) Joinpoint models for death rate from TB

Discussion

In this study, we examined 10 selected TB indices separately in males, females, and the total population from 2011 to 2022. One of the key points emphasized in this study is the remarkable changes in the TB-related indicators over the years under investigation.

Regarding the “co-infection rate of TB and HIV”, the trend in males has shifted from an increasing trend with a steep slope in 2015 to a decreasing trend, while a noticeable upward trend was observed in females. These changes may be due to various factors such as the prevalence of AIDS, differences in lifestyle patterns, and gender disparities in the supply and demand for health services. The reduction in the co-infection rate of TB and HIV may indicate successful efforts in the prevention and treatment of both diseases, demonstrating that continuous programs for controlling both diseases together have been effective. The rate of increase in viral load over time is higher in females than in males and females living with HIV have limited access to care and treatment in several countries.^9,10 Additionally, in the study by Wang et al, the ASR (age-standardized rate) of HIV-XDR-TB (HIV-associated extensively drug-resistant tuberculosis) increased significantly by an average of 14.77% (95% CI: 11.05%, 18.62%) globally during 1990-2019, as indicated by the results of the Global Burden of Disease Study in 2019, while ASRs of HIV-DS-TB (HIV-associated drug-susceptible tuberculosis) and HIV-MDR-TB (HIV-associated multi-drug resistant tuberculosis) decreased after 2005.¹¹ In the study by Osei et al, the prevalence of TB/HIV co-infection did not change significantly from 2013 to 2017.¹² In the study by Wang et al, the age-standardized incidence rate and age-standardized prevalence rate of HIV and DS-TB co-infection exhibited an overall increasing trend from 1990 to 2019, and the prediction indicated a slow downward trend from 2019 to 2040.¹³ In the study by Mehri et al, the percentage of TB patients with known HIV status during 2003-2017 had an increasing trend in all World Health Organization (WHO) regions. The HIV/TB co-infection showed a decreasing tendency in all regions, except for Europe. Furthermore, the trend of HIV/TB co-infection in Europe was increasing during the studied period.¹⁴ The study by Salisu et al reviewed records of patients retrospectively from January 1, 2009, to December 31, 2018, in Suhum Municipal. A sharp increase in the trend of the co-infection was observed from 6 (14.6%) in 2009 to 21 (36.8%) in 2010. The highest co-infection prevalence (40.4%) was recorded in 2011. The study recorded an overall decreasing trend of the co-infection, and case detection rate for HIV among persons living with TB was high.¹⁵

Regarding the “the incidence rate of EPT” index, there was a pattern of initially increasing and then decreasing trends in males, while in females, a consistently decreasing pattern was observed. The reduction in the incidence rate of EPTB may result from increased public awareness about this type of disease, as well as advancements in its diagnosis and treatment.¹⁶ In the study by Ben Ayed et al, the annual incidence rate of TB from 1995 to 2016 was 91.13 per 100 000 population. EPT was present, with an APC of 2.04.¹⁷ In the study by Fallah et al, it was observed that EPT had a decreasing trend from 2015 to 2019 in Iran¹⁸ which is consistent with our results.

The increase in “the incidence rate of SPPT” in males from 2011 to 2022 may be related to factors such as reduced access to healthcare services, non-adherence to treatment regimens, and the spread of associated infections. This issue requires more precise planning for TB control and prevention. However, this indicator only measures part of the TB situation and does not reflect the frequency of individuals’ exposure to TB. In a study by Tao et al, it was shown that the overall incidence of PTB in children (7.62 to 3.74 per 100­000) decreased during 2005-2017, with a non-significant APC after 2010.¹⁹ In a study by Essien, the incidence of TB was examined and compared in Canada and the United States from 1953 to 2015. The TB rates for both countries were retrieved from 1953 to 2015. The AAPC change in Canada from 1975 to 2015 was -2.9%, compared to -4.1% in the United States.²⁰ In a study performed by Brito et al on TB in Northeast Brazil (2001-2016), the overall incidence rate decreased from 44.84/100 000 persons in 2001 to 30.92/100 000 persons in 2016 (AAPC: -2.3; P < 0.001) ²¹. In a study conducted by Alavi et al in Khuzestan province, the results of evaluating the trend of TB from 2010 to 2019 showed no significant change in the overall TB trend, with an annual increase of 0.84% (95% CI: -5.17, 6.82). Additionally, the findings of regression analysis revealed a breakpoint indicating an annual increase of 18.10% (95% CI: 8.78 to 34.89) in TB incidence between 2010 and 2013, and an annual increase of 5.42% (95% CI: -10.04, -2.22) in incidence between 2013 and 2019. Moreover, from 2010 to 2012, an annual increase of 33.10% (95% CI: 15.77 to 48.06) in TB incidence was observed in males, while an annual decrease of 9.47% (95% CI: -14.02, -6.33) was observed in females.²² In a study by Lima et al on TB cases in Brazil from 2001 to 2016, an increasing trend in TB cases was observed in patients under 20 years old and 20-39 years old, especially in males,²³ which is similar to the results of our study.

The analysis of “The Incidence rate of SNPT” index, highlights the importance of early and accurate diagnosis of TB. The increase in SNPT cases may stem from increased public awareness and the development of advanced diagnostic methods. The rise in the frequency of this indicator could signify an increase in accurate TB testing and improvement in prevention programs. In the study by Tao et al, which investigated the epidemiological characteristics of SNPT in children in Shandong, China, from 2005 to 2017, it was demonstrated that the incidence of SNPT significantly increased.¹⁹ We also observed an increasing trend until 2017.

«The negative rate of smear 2 months after the treatment initiation « may indicate treatment failure or non-adherence to it. This indicator highlights the need for careful monitoring and improvement of the treatment process. An increase in the percentage of negative test results after two months can indicate the effectiveness of treatment and prevent the spread of the disease. The bacilli load usually decreases steadily during treatment and is expected to be negative in most cases by the end of the second month of treatment, when the intensive phase of treatment ends.²⁴

«The detection rate of SPPT with a smear grade of 3 + », defined as the number of individuals diagnosed with TB who have a high smear grading of 3 + , serves as a measure for assessing disease severity and treatment follow-up. This information can help optimize public health programs for TB control and prevention. In the case of males, distinct periods of both decline and increase were observed. Higher sputum smear grade was significantly associated with the number of previous TB treatments, body mass index, and patient’s educational status in the multivariable ordinary logistic regression analysis.²⁵ The probability of having a high grade of sputum smear among patients who had a history of two or more previous TB treatments is almost twice that of their counterparts.²⁶. In females, a milder upward trend was observed, which may be attributed to disparities in access to healthcare services, increased awareness, and diagnostic accuracy.

«The treatment success rate» shows a significant stability and continuous decrease, which is evident in both females and males. However, the limitation of this indicator lies in its failure to account for factors that may affect treatment efficacy, such as drug resistance, malnutrition, and so forth ²⁷. The WHO report of 2020 shows that the global treatment success rate of new cases of TB was 85% and 76% for TB patients living with HIV²⁸ and the TB success rate was found to be 78.9% in Africa and 80.1% globally.²⁹ An epidemiological study conducted by Aketi et al on pediatric TB in SSA reported a treatment success rate of 69.6%.³⁰ In a study by Tao et al in Shandong, China, an overall treatment success rate of 94.2% was achieved among pediatric TB cases from 2005 to 2017.¹⁹ The disparity in treatment outcomes between these studies may be due to differences in the study population’s age, gender, and disease severity, the existence of comorbid conditions, tobacco use, the drug resistance pattern, social determinants of health, and socioeconomic characteristics.³¹

«TB detection rate by the private sector» was one of the key findings of this study, showing significant changes in TB incidence over the years. In this indicator, a decreasing trend with a mild slope was observed in females and in males; in other words, three distinct periods with different decreasing, increasing, and again decreasing trends were observed, which may indicate fluctuations in the performance of the private sector and changes in policies or treatment protocols. The private sector plays an important role in TB elimination by providing access to quality TB care services.³² In the study by Khan et al, it was found that novel approaches to TB case-finding involving the private sector can substantially increase case notification. In the intervention area, TB case notification to the private sector increased two times (from 1569 to 3140 cases) from 2010 to 2011, a 2.21 times increase (95% CI 1.93, 2.53).³³ The increase in the detection rate by the private sector can indicate the effective role of this sector in controlling TB incidence. In the study by Kumar et al, the annual new AFB-positive case notification rate increased by 21%, from 27.8/100 000 in 2000 to 33.5/100 000 in 2002. This public-private partnership substantially increased TB case detection and established a sustainable framework for private sector involvement in TB control. In the setting of a strong public sector program, the combination of active surveillance of private laboratories along with physician sensitization is a promising approach to improve TB case detection.³⁴

Regarding «the recurrence rate» index, it was observed that during the study period, males experienced a very slight increase. On the other hand, females showed a clear trend toward an increase, which may be the result of changes in environmental or biological factors. However, the recurrence rate decreased relatively rapidly at the end of the period, which is likely indicative of the implementation of effective prevention and treatment programs or changes in environmental and social factors. In a study by Pascopella et al, out of 23 517 TB patients, 148 individuals (0.63%) had delayed recurrence.³⁵ Furthermore, in a study by Tao et al, the recurrence cases decreased by approximately 80% (from 5.11 to 1.01 per 100 000) from 2005 to 2017.³⁶ In our study, relapse cases decreased by 35.29% (from 7.27 to 11.11 per 1000).

In the indicator of «The death rate from TB», initially, an increase in the rate of mortality from TB was observed in both genders, which could be due to factors such as increased disease distribution or fluctuations in the quality of care and treatment. However, then a decrease in the mortality rate occurred, which could be attributed to improvements in treatment modalities, advancements in prevention, effective public health interventions, and more importantly, the COVID-19 pandemic.³⁷ The risk of death due to TB is higher in males than in females and this can be due to systemic factors.³⁸. In the study conducted by Liaw et al in Sabah on 10 058 TB patients, there were 842 deaths (9.2%) ³⁹. In our study, female patients had a sharper decline than male patients. In the study conducted by Dhamnetiya et al in India over the past three decades (from 1990 to 2019), the standardized incidence and mortality rate of TB in India decreased from 121.72 to 36.11 per 100 000 population. The decreasing trend was more prominent in females (AAPC: -4.35; 95% CI: -5.12, -3.57; P < 0.001) compared to males (AAPC: -3.11; 95% CI: -3.74, -2.48; P < 0.001). For specific age groups, the incidence and mortality rate of TB decreased in both males and females across all ages during this period.⁴⁰. Additionally, in the study by Varshney et al, there was a significant reduction in TB cases and total deaths across India since the emergence of COVID-19, which is consistent with our study.⁴¹

However, it is essential to acknowledge the limitations of this study. In this study, we only considered data from 2011 to 2022. This might overlook long-term changes and trends, with the possibility of significant changes in previous or subsequent years. Additionally, variables such as economic status, education level, history of other diseases, and access to healthcare services, which may influence TB status, were not controlled in this study. Despite these limitations, this study remains valuable as it provides us with information that can aid in improving TB prevention, diagnosis, and treatment strategies and offers crucial insights into the occurrence and other indicators of TB in Hamadan.

Conclusion

The results of this study showed that the state of TB has had a relatively successful trend in some of the studied indicators since 2011, and we have seen a decrease in the co-infection of TB and AIDS, SPPT, and EPT in the region. However, an increase in mortality due to TB was observed, especially in females. Moreover, a decrease in the success rate of treatment was observed in females. It can be concluded that the patterns of changing indicators are different based on gender; therefore, the need for gender-based approaches in the management and prevention of TB is felt. This data analysis provides valuable information about the state of TB in Hamadan city, which can help to improve programs for the prevention, treatment, and control of TB in this community. In general, the results of the study show that despite the progress made in the field of TB control, there is still a need for careful attention and planning to reduce the incidence of TB and improve public health conditions.

Acknowledgments

This study is a part of thesis for the MSc student of Epidemiology. The study was approved by the Research Vice-Chancellor of Hamadan University of Medical Sciences (140302251370). The authors would like to express their thanks to all those who contributed to the study.

Competing Interests

None.

Ethical Approval

This study was approved by the Ethics Committee of Hamadan University of Medical Sciences (IR.UMSHA.REC.1403.123).

Funding

None.

Supplementary files

References

1. Natarajan A, Beena PM, Devnikar AV, Mali S. A systemic review on tuberculosis. Indian J Tuberc 2020; 67(3):295-311. doi: 10.1016/j.ijtb.2020.02.005 [Crossref] [ Google Scholar]
2. Fukunaga R, Glaziou P, Harris JB, Date A, Floyd K, Kasaeva T. Epidemiology of tuberculosis and progress toward meeting global targets - worldwide, 2019. MMWR Morb Mortal Wkly Rep 2021; 70(12):427-30. doi: 10.15585/mmwr.mm7012a4 [Crossref] [ Google Scholar]
3. Gebretsadik D, Ahmed N, Kebede E, Mohammed M, Belete MA. Prevalence of tuberculosis by automated GeneXpert rifampicin assay and associated risk factors among presumptive pulmonary tuberculosis patients at Ataye District Hospital, North East Ethiopia. Infect Drug Resist 2020; 13:1507-16. doi: 10.2147/idr.s248059 [Crossref] [ Google Scholar]
4. Schrager LK, Vekemens J, Drager N, Lewinsohn DM, Olesen OF. The status of tuberculosis vaccine development. Lancet Infect Dis 2020; 20(3):e28-37. doi: 10.1016/s1473-3099(19)30625-5 [Crossref] [ Google Scholar]
5. Villa S, Kasaeva T, Raviglione MC. A multisectoral approach to tuberculosis control and elimination in the era of the United Nations Sustainable Development Goals. In: Migliori GB, Raviglione MC, eds. Essential Tuberculosis. Cham: Springer; 2021. p. 349-58. 10.1007/978-3-030-66703-0_38.
6. Pourhossein B, Doosti-Irani A, Mostafavi E. Major infectious diseases affecting the Afghan immigrant population of Iran: a systematic review and meta-analysis. Epidemiol Health 2015; 37:e2015002. doi: 10.4178/epih/e2015002 [Crossref] [ Google Scholar]
7. Sadeghi K, Poorolajal J, Doosti-Irani A. Prevalence of modifiable risk factors of tuberculosis and their population attributable fraction in Iran: a cross-sectional study. PLoS One 2022; 17(8):e0271511. doi: 10.1371/journal.pone.0271511 [Crossref] [ Google Scholar]
8. Doosti A, Nasehi M, Moradi G, Roshani D, Sharafi S, Ghaderi E. The pattern of tuberculosis in Iran: a national cross-sectional study. Iran J Public Health 2023; 52(1):193-200. doi: 10.18502/ijph.v52i1.11682 [Crossref] [ Google Scholar]
9. Druyts E, Dybul M, Kanters S, Nachega J, Birungi J, Ford N. Male sex and the risk of mortality among individuals enrolled in antiretroviral therapy programs in Africa: a systematic review and meta-analysis. AIDS 2013; 27(3):417-25. doi: 10.1097/QAD.0b013e328359b89b [Crossref] [ Google Scholar]
10. Gandhi M, Bacchetti P, Miotti P, Quinn TC, Veronese F, Greenblatt RM. Does patient sex affect human immunodeficiency virus levels?. Clin Infect Dis 2002; 35(3):313-22. doi: 10.1086/341249 [Crossref] [ Google Scholar]
11. Wang Y, Jing W, Liu J, Liu M. Global trends, regional differences and age distribution for the incidence of HIV and tuberculosis co-infection from 1990 to 2019: results from the Global Burden of Disease Study 2019. Infect Dis (Lond) 2022; 54(11):773-83. doi: 10.1080/23744235.2022.2092647 [Crossref] [ Google Scholar]
12. Osei E, Oppong S, Der J. Trends of tuberculosis case detection, mortality and co-infection with HIV in Ghana: a retrospective cohort study. PLoS One 2020; 15(6):e0234878. doi: 10.1371/journal.pone.0234878 [Crossref] [ Google Scholar]
13. Wang L, Lv H, Zhang X, Zhang X, Bai J, You S. Global prevalence, burden and trend in HIV and drug-susceptible tuberculosis co-infection from 1990 to 2019 and prediction to 2040. Heliyon 2024; 10(1):e23479. doi: 10.1016/j.heliyon.2023.e23479 [Crossref] [ Google Scholar]
14. Mehri A, Alimohamadi Y, Mohammadi M, Sepandi M, Khodamoradi F, Eesmaeilzadeh F. Trend of HIV and tuberculosis co-epidemics in different regions of World Health Organization during 2003-2017. HIV AIDS Rev 2020; 19(3):167-71. doi: 10.5114/hivar.2020.99688 [Crossref] [ Google Scholar]
15. Salisu HM, Ojule IN, Adeniji FO, Kwakye GK. Prevalence and trend of TB/HIV co-infection in Suhum municipality, Ghana. PLOS Glob Public Health 2022; 2(7):e0000378. doi: 10.1371/journal.pgph.0000378 [Crossref] [ Google Scholar]
16. Sharma SK, Mohan A, Kohli M. Extrapulmonary tuberculosis. Expert Rev Respir Med 2021; 15(7):931-48. doi: 10.1080/17476348.2021.1927718 [Crossref] [ Google Scholar]
17. Ben Ayed H, Koubaa M, Gargouri L, Ben Jemaa M, Trigui M, Hammemi F. Epidemiology and disease burden of tuberculosis in south of Tunisia over a 22-year period: current trends and future projections. PLoS One 2019; 14(7):e0212853. doi: 10.1371/journal.pone.0212853 [Crossref] [ Google Scholar]
18. Fallah S, Nasehi M, Etemadinezhad S, Fallah S, Yazdani Charati J. A five-year epidemiological study of extra-pulmonary tuberculosis and its related risk factors in Iran. Tanaffos 2022; 21(2):221-9. [ Google Scholar]
19. Tao NN, Li YF, Liu YX, Liu JY, Song WM, Liu Y. Epidemiological characteristics of pulmonary tuberculosis among children in Shandong, China, 2005-2017. BMC Infect Dis 2019; 19(1):408. doi: 10.1186/s12879-019-4060-x [Crossref] [ Google Scholar]
20. Essien SK. Comparative Incidence of Tuberculosis in Canada: The Past, Present and Future [dissertation]. University of Saskatchewan; 2019.
21. Brito AB, de Magalhães WB, de Paiva JP, Leal TC, da Silva LF, Santos LG. Tuberculosis in Northeastern Brasil (2001-2016): trend, clinical profile, and prevalence of risk factors and associated comorbidities. Rev Assoc Med Bras (1992) 2020; 66(9):1196-202. doi: 10.1590/1806-9282.66.9.1196 [Crossref] [ Google Scholar]
22. Alavi SM, Enayatrad M, Cheraghian B, Amoori N. Incidence trend analysis of tuberculosis in Khuzestan province, southwest of Iran: 2010-2019. Glob Epidemiol 2023; 6:100118. doi: 10.1016/j.gloepi.2023.100118 [Crossref] [ Google Scholar]
23. Lima S, Dos Santos AD, Duque AM, de Oliveira Goes MA, da Silva Peixoto MV, da Conceição Araújo D. Spatial and temporal analysis of tuberculosis in an area of social inequality in Northeast Brazil. BMC Public Health 2019; 19(1):873. doi: 10.1186/s12889-019-7224-0 [Crossref] [ Google Scholar]
24. Djouma FN, Noubom M, Ateudjieu J, Donfack H. Delay in sputum smear conversion and outcomes of smear-positive tuberculosis patients: a retrospective cohort study in Bafoussam, Cameroon. BMC Infect Dis 2015; 15:139. doi: 10.1186/s12879-015-0876-1 [Crossref] [ Google Scholar]
25. Kassa GM, Merid MW, Muluneh AG, Fentie DT. Sputum smear grading and associated factors among bacteriologically confirmed pulmonary drug-resistant tuberculosis patients in Ethiopia. BMC Infect Dis 2021; 21(1):238. doi: 10.1186/s12879-021-05933-y [Crossref] [ Google Scholar]
26. Hesseling AC, Walzl G, Enarson DA, Carroll NM, Duncan K, Lukey PT. Baseline sputum time to detection predicts month two culture conversion and relapse in non-HIV-infected patients. Int J Tuberc Lung Dis 2010; 14(5):560-70. [ Google Scholar]
27. Teferi MY, El-Khatib Z, Boltena MT, Andualem AT, Asamoah BO, Biru M. Tuberculosis treatment outcome and predictors in Africa: a systematic review and meta-analysis. Int J Environ Res Public Health 2021; 18(20):10678. doi: 10.3390/ijerph182010678 [Crossref] [ Google Scholar]
28. World Health Organization (WHO). Global Tuberculosis Report 2013. WHO; 2013.
29. Murray CJ, Ortblad KF, Guinovart C, Lim SS, Wolock TM, Roberts DA. Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384(9947):1005-70. doi: 10.1016/s0140-6736(14)60844-8 [Crossref] [ Google Scholar]
30. Aketi L, Kashongwe Z, Kinsiona C, Fueza SB, Kokolomami J, Bolie G. Childhood tuberculosis in a sub-Saharan tertiary facility: epidemiology and factors associated with treatment outcome. PLoS One 2016; 11(4):e0153914. doi: 10.1371/journal.pone.0153914 [Crossref] [ Google Scholar]
31. Khan AH, Syed Sulaiman SA, Hassali MA, Khan KU, Ming LC, Mateen O. Effect of smoking on treatment outcome among tuberculosis patients in Malaysia; a multicenter study. BMC Public Health 2020; 20(1):854. doi: 10.1186/s12889-020-08856-6 [Crossref] [ Google Scholar]
32. Shah HD, Chaudhary S, Desai B, Patel J, Yasobant S, Bhavsar P. Exploring private sector perspectives on barriers and facilitators in availing tuberculosis care cascade services: a qualitative study from the Indian state. BMC Prim Care 2024; 25(1):5. doi: 10.1186/s12875-023-02244-w [Crossref] [ Google Scholar]
33. Khan AJ, Khowaja S, Khan FS, Qazi F, Lotia I, Habib A. Engaging the private sector to increase tuberculosis case detection: an impact evaluation study. Lancet Infect Dis 2012; 12(8):608-16. doi: 10.1016/s1473-3099(12)70116-0 [Crossref] [ Google Scholar]
34. Kumar MK, Dewan PK, Nair PK, Frieden TR, Sahu S, Wares F. Improved tuberculosis case detection through public-private partnership and laboratory-based surveillance, Kannur district, Kerala, India, 2001-2002. Int J Tuberc Lung Dis 2005; 9(8):870-6. [ Google Scholar]
35. Pascopella L, Deriemer K, Watt JP, Flood JM. When tuberculosis comes back: who develops recurrent tuberculosis in California?. PLoS One 2011; 6(11):e26541. doi: 10.1371/journal.pone.0026541 [Crossref] [ Google Scholar]
36. Tao NN, Li YF, Wang SS, Liu YX, Liu JY, Song WM. Epidemiological characteristics of pulmonary tuberculosis in Shandong, China, 2005-2017: a retrospective study. Medicine (Baltimore) 2019; 98(21):e15778. doi: 10.1097/md.0000000000015778 [Crossref] [ Google Scholar]
37. World Health Organization (WHO). WHO Applauds Indian Leadership on Ending TB. WHO; 2024. Available from: https://www.who.int/news/item/30-03-2023-who-applauds-indian-leadership-on-ending-tb. Accessed June 20, 2024.
38. Uchimura K, Ngamvithayapong-Yanai J, Kawatsu L, Ohkado A, Yoshiyama T, Shimouchi A. Characteristics and treatment outcomes of tuberculosis cases by risk groups, Japan, 2007-2010. Western Pac Surveill Response J 2013; 4(1):11-8. doi: 10.5365/wpsar.2012.3.4.016 [Crossref] [ Google Scholar]
39. Liaw YC, Avoi R. Adult Tuberculosis Patients in Sabah: Influencing Factors for Mortality. Malays J Med Health Sci 2023; 19(Suppl 20):30-7. [ Google Scholar]
40. Dhamnetiya D, Patel P, Jha RP, Shri N, Singh M, Bhattacharyya K. Trends in incidence and mortality of tuberculosis in India over past three decades: a joinpoint and age-period-cohort analysis. BMC Pulm Med 2021; 21(1):375. doi: 10.1186/s12890-021-01740-y [Crossref] [ Google Scholar]
41. Varshney K, Patel H, Kamal S. Trends in tuberculosis mortality across India: improvements despite the COVID-19 pandemic. Cureus 2023; 15(4):e38313. doi: 10.7759/cureus.38313 [Crossref] [ Google Scholar]