The Western Pacific Region, with 1.9 billion people across 37 countries, has one of the world’s largest and fastest-growing older populations, boasting an average life expectancy of 77.7 years in 2019, above the global average. This diverse region varies in population structure, cultural norms, economic resources, and healthcare systems, leading to differences in tuberculosis (TB) transmission risk.
TB Transmission Dynamics:
- Both reactivation and reinfection pathways contribute to TB burden, especially in high-risk settings like households, aged-care facilities, and hospitals.
- Institutional transmission among residents and staff in care and health facilities poses significant infection control challenges, particularly with delayed disease detection.
Vulnerability of Older Adults:
- Ageing, diabetes, and undernutrition weaken immunity, increasing susceptibility to TB, including drug-resistant strains.
- Older adults living with HIV face similar risks due to age-related comorbidities.
Diagnostic Challenges in Older Adults:
- Typical TB symptoms (e.g., cough, haemoptysis, night sweats) are often less pronounced in older adults and can be masked by other comorbidities.
- Radiological features differ, with older adults less likely to show classic TB signs (e.g., lung nodules or apical cavities) but more likely to present with malignancy indicators, complicating diagnosis.
Barriers to TB Preventive Therapy (TPT):
- A survey of national TB programs in high-burden, lower-middle-income countries (e.g., Philippines, Papua New Guinea, Cambodia, and Vietnam) revealed insufficient time and funding for adopting safer, shorter TPT regimens, hindering policy implementation.
The unique challenges of TB in the Western Pacific's ageing population highlight the need for tailored strategies in prevention, diagnosis, and treatment.
Older adults face heightened risks and unique challenges in TB management due to physiological, social, and systemic factors.
Drug-Related Risks:
- Older adults are more prone to adverse drug events, including hepatotoxicity from isoniazid and rifampicin.
- Concurrent use of traditional and herbal medicines, often seen as "liver protectors" (notably in China), is discouraged due to the risk of drug-induced liver injury, despite a lack of supporting evidence.
Social and Economic Support:
- Social protection measures like income replacement and financial grants can help reduce TB incidence and mortality in older adults.
Screening and Diagnosis:
- Active TB case-finding, particularly through targeted screening (e.g., for those with diabetes or a history of TB), is more effective than passive methods.
- Chest radiography is a useful tool for detecting undiagnosed TB cases among older adults.
Age-Friendly Healthcare:
- The WHO’s age-friendly healthcare principles aim to improve healthcare quality through geriatric training, enhanced physical environments, reduced waiting times, and efficient appointment systems.
- Decentralizing TB services to primary care increases accessibility.
Person-Centered Care:
- Comprehensive, tailored interventions are vital, including support beyond directly observed therapy (DOT), such as education, social and psychological support for patients and families.
- Facility-based treatment, requiring daily visits, poses challenges for older adults and may need alternative models.
Technology Barriers:
- Older adults are less likely to adopt technology-dependent approaches due to varying regional access and acceptability, emphasizing the need for context-sensitive solutions.
Improving TB outcomes for older adults requires integrating tailored medical, social, and systemic interventions while addressing their unique vulnerabilities.
Source: Teo, A.K.J., Morishita, F., Islam, T., Viney, K., Ong, C.W., Kato, S., Kim, H., Liu, Y., Oh, K.H., Yoshiyama, T. and Ohkado, A., 2023. Tuberculosis in older adults: challenges and best practices in the Western Pacific Region. The Lancet Regional Health-Western Pacific, 36, p.100770.
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