Risk for Mycobacterial Disease among Patients with Rheumatoid Arthritis, Taiwan, 2001–2011 - Volume 21, Number 8—August 2015 - Emerging Infectious Disease journal - CDC

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Risk for Mycobacterial Disease among Patients with Rheumatoid Arthritis, Taiwan, 2001–2011 - Volume 21, Number 8—August 2015 - Emerging Infectious Disease journal - CDC

Volume 21, Number 8—August 2015

Research

Risk for Mycobacterial Disease among Patients with Rheumatoid Arthritis, Taiwan, 2001–2011

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• Results
• Discussion
• Suggested Citation

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• Figure 1
• Figure 2

Tables

• Table 1
• Table 2
• Table 3
• Table 4

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Tsai-Ling Liao, Ching-Heng Lin, Gwan-Han Shen1, Chia-Li Chang, Chin-Fu Lin, and Der-Yuan Chen 

Author affiliations: Taichung Veterans General Hospital, Taichung, Taiwan (T.-L. Liao, C.-H. Lin, G.-H. Shen, C.-L. Chang, C.-F. Lin, D.-Y. Chen); National Chung Hsing University, Taichung (T.-L. Liao, G.-H. Shen, D.-Y. Chen);National Taipei University of Nursing and Health Science, Taipei, Taiwan (C.-H. Lin); National Yang Ming University, Taipei (D.-Y. Chen); Chung Shan Medical University, Taichung (D.-Y. Chen)

Suggested citation for this article

Abstract

Increasing evidence indicates that the risk of acquiring tuberculosis (TB) and nontuberculous mycobacterial disease is elevated among patients with rheumatoid arthritis (RA). To determine the epidemiology of mycobacterial diseases among RA patients in Asia, we conducted a retrospective cohort study. We used a nationwide database to investigate the association of RA with mycobacterial diseases. The risk for development of TB or nontuberculous mycobacterial disease was 2.28-fold and 6.24-fold higher among RA patients than among the general population, respectively. Among RA patients, risk for development of mycobacterial disease was higher among those who were older, male, or both. Furthermore, among RA patients with mycobacterial infections, the risk for death was increased. Therefore, RA patients, especially those with other risk factors, should be closely monitored for development of mycobacterial disease.

The major clinical spectrum of mycobacterial diseases is caused by tuberculosis (TB) and nontuberculous mycobacteria (NTM). TB remains a major global health problem; in 2012, an estimated 8.6 million persons became infected and 1.3 million died of the disease (1). NTM are ubiquitous environmental microorganisms that cause chronic pulmonary and extrapulmonary infection in patients with inflammatory diseases (2). Several NTM strains are resistant to many antimicrobial drugs, making treatment difficult (3). Because reporting of NTM disease to public health administrations is not required in most countries, epidemiologic data for these countries are not available (4). Pulmonary diseases caused by NTM are being diagnosed with increasing frequency worldwide (5), including in Taiwan (6). In Taiwan, the incidence of TB remains high, despite extensive implementation of well-known TB control measures and use of the Bacillus Calmette-Guérin vaccine (7); between 2000 and 2012, a laboratory-based study indicated a trend of decreasing TB cases but significantly increasing NTM cases in Taiwan (6).

Rheumatoid arthritis (RA), a chronic articular inflammatory disease (8), affects 0.5%–1.0% of the adult population and is a major cause of disability in industrialized countries (9,10). Among RA patients, the risks of acquiring or dying of an infectious disease are increased, possibly because of disease-related immune dysfunction or the immunosuppressive effects of therapeutic agents (11). In Europe and the United States, an increased risk for TB among RA patients has been reported (12), and the risk for active TB is even higher among those receiving anti–tumor necrosis factor α (TNF-α) therapy (13). Previous clinical studies have shown that the prevalence of latent tuberculosis infection was higher among RA patients than among healthy controls (14). A recent study indicated that in the United States, the incidence of NTM disease was significantly higher among RA patients receiving anti–TNF-α therapy than among patients with other inflammatory diseases who were receiving the same treatment (15). The prevalence of mycobacterial diseases is higher among the general population in Asia than in the United States and Europe (1,16). However, few population-based epidemiologic studies have investigated the association of RA with mycobacterial diseases in Asia. In addition, prevalence of concurrent medical conditions is higher among RA patients (17,18), which may affect their risk for TB (19). However, the association of RA with concurrent medical conditions and mycobacterial infection is unclear.

In Taiwan, the National Health Insurance program is a mandatory universal health insurance program that provides comprehensive medical care for >99% of Taiwan’s residents (20–22). The National Health Insurance Research Database (NHIRD) is managed by the National Health Research Institutes, and confidentiality is maintained according to Bureau of National Health Insurance guidelines (23). We used this nationwide database to conduct a retrospective cohort study investigating the association between RA and mycobacterial diseases in Taiwan during 2001–2011.

Dr. Liao is an associate research fellow at Taichung Veterans General Hospital, Taiwan. Her primary research interest is infectious diseases, especially TB and NTM diseases.

Acknowledgments

We thank the Healthcare Service Research Center of Taichung Veterans General Hospital for statistical support.

This study was supported in part by grants from Taichung Veterans General Hospital, Taiwan (TCVGH-NHRI10307). This study is based in part on data from the NHIRD provided by the National Health Insurance Administration, Ministry of Health and Welfare and managed by National Health Research Institutes (registered no. 101095, 102148).

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Figures

• Figure 1. Flowchart of case selection for rheumatoid arthritis (RA) patients and age- and sex-matched controls (without RA) from the National Health Insurance Research Database (NHIRD). LHID 2000, Longitudinal Health Insurance...
• Figure 2. Adjusted hazard ratios (aHRs) and 95% CIs (error bars) for tuberculosis and nontuberculous mycobacteria infection according to age among patients with rheumatoid arthritis and matched controls. Increased risk correlated...

Tables

• Table 1. Baseline characteristics for 144,985 patients with and without RA, Taiwan, 2001–2011
• Table 2. Subgroup analysis for new-onset TB and NTM among 144,985 patients with and without RA, Taiwan, 2001–2011
• Table 3. Multivariable analysis of baseline factors for 28,997 RA patients with new-onset TB and NTM, Taiwan, 2001–2011
• Table 4. Multivariable analysis for risk for death among 28,997 RA patients with and without TB and NTM, Taiwan, 2001–2011

Suggested citation for this article: Liao TL, Lin CH, Shen GH, Chang CL, Lin CF, Chen DY. Risk for mycobacterial disease among patients with rheumatoid arthritis, Taiwan, 2001–2011. Emerg Infect Dis. 2015 Aug [date cited]. http://dx.doi.org/10.3201/eid2108.141846

DOI: 10.3201/eid2108.141846

1Deceased.