One in five women worldwide carries latent tuberculosis infection (LTBI), and 3 million are diagnosed with active tuberculosis (TB) each year. Women are most likely to convert from latent to active TB during and immediately after pregnancy. The immunologic conditions responsible for this phenomenon are not understood. This knowledge gap impairs our ability to develop effective LTBI screening tests for pregnant women and accurately predict which patients should be targeted for TB prevention. The need is urgent. TB is a leading cause of maternal mortality, especially among HIV-infected women. Maternal TB is also an important children's health issue: Maternal TB more than doubles the risk of mother-to-child HIV transmission and significantly increases the risk of mortality for the newborn and other young children living in the household. Our recent research shows that pregnant women with LTBI have diminished IFN-gamma response to Mycobacterium tuberculosis (MTB)-specific antigens during the 3rd trimester and return to baseline 3-6 months postpartum. We hypothesize that the increase in regulatory T cells (Treg) during pregnancy reduces multi-functional CD4+ T-cell production of Th1 cytokines in response to MTB antigens, which increases the risk of progression to active TB. In partnership with BJ Medical College and the National Institute for Research of Tuberculosis/ intramural NIH-supported ICER program in India, we propose a longitudinal cohort study to describe the timing, extent, and causes of these immune changes. We will also follow women prospectively and identify immunological correlates of TB reactivation. Pregnant women with LTBI will be enrolled from the antenatal clinic in Pune, India, during their 2nd trimester with additional visits at 3rd trimester, delivery 3, 6, and 12 months postpartum. At each visit, we will screen for active TB. We will also collect blood samples for IFN-gamma release assays, cytokine assays, flow cytometry, and gene transcription studies.
Our first aim i s to quantify the extent and timing of the suppression of Th1 cytokine production in response to MTB-specific antigens, a process that likely contributes to the reactivation of LTBI during pregnancy. By including both HIV-infected and HIV-uninfected women, we will further explore how HIV affects this suppression.
Our second aim i s to describe the cellular mechanisms underlying the suppression, which we believe is related to increase Treg frequency in pregnancy.
Our third aim i s to use cytokine and RNA expression profiles to identify a biosignature associated with progression to active TB. These findings will provide a comprehensive picture of the immune changes of pregnancy that compromise a woman's ability to contain MTB in its latent form. The study will also provide a path towards identifying a diagnostic biomarker to enable clinicians to identify and treat pregnant women at highest risk of developing active TB.

Public Health Relevance

Over one-third of India's women carry latent tuberculosis infection, which often progresses to active tuberculosis disease during pregnancy, increasing illness and death for both mothers and their infants. We propose to follow pregnant women with latent tuberculosis to describe how the body's immune response to tuberculosis changes with stage of pregnancy and HIV status. This information will help identify which pregnant women are most likely to develop active TB, improving the diagnosis and prevention of tuberculosis in pregnant women and their infants.

National Institute of Health (NIH)
Eunice Kennedy Shriver National Institute of Child Health & Human Development (NICHD)
Research Project (R01)
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Special Emphasis Panel (ZHD1)
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Worrell, Carol
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Johns Hopkins University
Internal Medicine/Medicine
Schools of Medicine
United States
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LaCourse, Sylvia M; Cranmer, Lisa M; Bekker, Adrie et al. (2018) Symptom screening for active tuberculosis in pregnant women living with HIV. Cochrane Database Syst Rev 2018:
Vaidya, A; Bhosale, R; Sambarey, P et al. (2017) Household food insecurity is associated with low interferon-gamma levels in pregnant Indian women. Int J Tuberc Lung Dis 21:797-803
Mathad, Jyoti S; Gupta, Amita (2017) Pulmonary Infections in Pregnancy. Semin Respir Crit Care Med 38:174-184
Kapoor, S; Gupta, A; Shah, M (2016) Cost-effectiveness of isoniazid preventive therapy for HIV-infected pregnant women in India. Int J Tuberc Lung Dis 20:85-92