| Individual biological and/or clinical determinant |
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Immune senescence, “inflammaging” Lack of BCG efficacy Underweight/undernutrition Comorbidities including diabetes, CLD, and chronic kidney disease Reduced sensitivity of tuberculin skin testing among older people
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As per TB infection plus delayed diagnosis due to:
Asymptomatic, pauci-symptomatic Atypical or masked symptoms Unable to produce sputum Lack of microbiological confirmation Distinct chest radiographic findings (eg, less cavitation, more pleural involvement) Low specificity of human-read chest radiographs Alternative or dual diagnoses (ie, lung cancer or CLD)
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Adverse effects of medications Polypharmacy and drug-drug interactions Altered absorption and pharmacokinetic/pharmacodynamic drug properties, including due to changes in muscle mass and gastrointestinal disorders Pre-existing lung disease, decreased lung function secondary to aging, potential altered risk of post-TB lung disease or disability compared to younger people
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| Individual social determinant |
|
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Smoking history, and smoke and air pollution exposure indoors, outdoors, and through occupation Food insecurity or reduced dietary intake Reduced health knowledge and awareness Lack of access to social protection or pension schemes
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Variations in social networks and availability of treatment support to facilitate treatment adherence and accompany to clinic or for directly-observed therapy where needed Difficulties with adherence due to memory, visual, or hearing impairment
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| Health system factors |
More frequent and/or prolonged contact with health system at all levels, including in the community and during home visits Nosocomial TB transmission
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Limited access to healthcare Difficulties navigating healthcare due to disabilities including visual and hearing impairment Lack of health insurance or only basic health insurance Lack of specific TB infection screening and TB preventive therapy guidance for elderly Inconsistent implementation of TB preventive therapy
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Limited access to healthcare Difficulties navigating healthcare due to disabilities including visual and hearing impairment Lack of health insurance or only basic insurance Lack of specific TB disease and symptom screening for elderly
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Lack of specific guidance on TB treatment and care for elderly Limited guidance on integrated management of TB and comorbidities or multimorbidity, or palliative care options where appropriate Lack of health insurance or only basic insurance
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| Potential solutions |
Awareness and knowledge raising campaigns through outreach and/or media suitable for elderly people and/or through involvement of social care staff or relatives/friends TB surveillance data disaggregated by age Modelling of intersecting age, social determinants, and comorbidities to predict and respond to TB epidemic in older people both nationally and subnationally
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Implementation and evaluation of interferon gamma release assays and newer TB infection screening tools (ie, C-Tb) among older people Implementation and evaluation of safe and effective shorter TB preventive therapy regimens among older people, including consideration of mitigation and management of side effects and drug-drug interactions Improved access to health insurance and simplified processes for use of health insurance, taking into account visual or hearing impairment Evaluation of newer TB vaccines among older people
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Mass TB disease screening including through outreach and/or integrated with existing screening and health checks for older people and/or those with comorbidities or multimorbidity Active case finding strategies tailored to reach underserved older people including in the community and social care settings Improvement in CAD AI algorithms to identify TB and other diagnoses among older people with and without symptoms
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Improve access to health insurance, social protection, and pension schemes Integrated care pathways for older people with TB and comorbidities or multimorbidity, with consideration of assessment and management of frailty and disability, and involvement of gerontologist or other healthcare professional with expertise in medicine for the elderly where possible Adherence support mechanisms adapted to older people with due consideration of memory, visual and hearing impairment, and use of appropriate media/tools (i.e mobile phone interventions may not be appropriate vs setting alarms or landline prompts)
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