title: Risk of tuberculosis in pregnancy: a national, primary care-based cohort and self-controlled case series study.
abstract: OBJECTIVE
  Tuberculosis (TB) disease adversely affects mother and child, and strategies to control TB in this group are important. The aim of this study was to analyze the epidemiology of TB in pregnancy, and to establish whether pregnancy is an independent risk factor for TB.
  
  
  METHODS
  The United Kingdom-wide cohort study was based on the General Practitioner Research Database (GPRD), enrolling all women with pregnancies between 1996 and 2008. Incidence rates and incidence rate ratios (IRRs) of TB events during pregnancy, 6 months postpartum, and outside pregnancy were calculated and compared by Poisson regression. A nested self-controlled case series compared the risk of TB in these periods, adjusting for individual and time-bound confounders.
  
  
  RESULTS
  The crude TB rate for the combined pregnancy and postpartum period was 15.4 per 100,000 person-years, significantly higher than outside of pregnancy (9.1 per 100,000 person-years; P = 0.02). Adjusting for age, region, and socioeconomic status the postpartum TB risk was significantly higher than outside pregnancy (IRR, 1.95; 95% confidence interval [CI], 1.24-3.07), whereas there was no significant increase during pregnancy (IRR, 1.29; 95% CI, 0.82-2.03). These observations were confirmed in the self-controlled case series (IRR, 1.62; 95% CI, 1.01-2.58 and IRR, 1.03; 95% CI, 0.64-1.65, respectively).
  
  
  CONCLUSIONS
  The incidence of TB diagnosis is significantly increased postpartum. Although we did not find an increase during pregnancy, the postpartum incidence may reflect an increase during pregnancy given diagnostic, immunological and administrative delays. Clinicians' awareness should be improved and the effectiveness of public health policy measures such as targeted screening of pregnant and postpartum women in high-risk groups should be evaluated.
authors.affiliation: Health Protection Agency, Health Protection Services Colindale, London, UK. dominik.zenner@hpa.org.uk
authors.forename: Dominik
authors.initials: D
authors.lastname: Zenner
authors.forename: Michelle E
authors.initials: ME
authors.lastname: Kruijshaar
authors.forename: Nick
authors.initials: N
authors.lastname: Andrews
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Abubakar
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D015331:Cohort Studies; D005260:Female; D006801:Humans; D015994:Incidence; D008875:Middle Aged; D016012:Poisson Distribution; D049590:Postpartum Period; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology / Q000209:etiology / Q000382:microbiology*; D011256:Pregnancy Outcome; D012307:Risk Factors; D014397:Tuberculosis, Pulmonary / Q000453:epidemiology* / Q000209:etiology; D006113:United Kingdom / Q000453:epidemiology; D055815:Young Adult