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Tuberculosis in biologic users for rheumatic diseases: results from the South African Biologics Registry (SABIO)
  1. Clive Pettipher1,
  2. Romela Benitha2
  1. 1 Department of Rheumatology, Busamed Paardevlei Hospital, Western Province, South Africa
  2. 2 Department of Rheumatology, Wilgeheuwel Hospital, Johannesburg, Gauteng, South Africa
  1. Correspondence to Dr Clive Pettipher, Rheumatology, South African Rheumatism and Arthritis Association, Stellenbosch 7600, Western Province, South Africa; cpetti{at}


Objectives To evaluate the rate of tuberculosis (TB) in biologic users for rheumatic diseases in South Africa, the effectiveness of our latent TB infection (LTBI) programme, risk factors and outcome.

Methods TB cases were collected from the South African Biologics Registry (SABIO), rheumatologists and pharmaceutical companies. Demographics, LTBI screening and treatment, biological and disease modifying antirheumatic drug (DMARD) therapies, TB diagnosis and outcomes were recorded.

Results 96 TB cases were collected from 1999 to June 2017: rheumatoid arthritis 55, ankylosing spondylitis 27, psoriatic arthritis 4, and juvenile inflammatory arthritis 10. The TB rate was 1240/100 000 person years for biologic users (n=96) versus the biologic naive cohort of 0/100 000 years with an incidence rate difference of 0.0124 (p<0.0001). 60/96 had pulmonary and 36/96 had extra-pulmonary TB. Reactivation TB occurred in 45/96 cases. TB occurred in all biologics licenced in South Africa, the majority in monoclonal inhibitors (1683/100 000 person years) compared with etanercept (861/100 000 person years) and non-tumour necrosis factor (TNF) inhibitors (681/100 000 person years). The incidence rate ratio for monoclonal inhibitors compared with etanercept was 1.96 (p=0.005) and 2.47 (p=0.002) compared with non-TNF inhibitors with no significant difference between non-TNF inhibitors and etanercept (p=0.336). From those (12.9%) who screened LTBI positive, 14 developed TB, while the majority (77) screened LTBI negative. Black race, male sex, younger age and residence in the Western Cape were statistical risk factors. Two drug resistant TB cases and six deaths occurred.

Conclusion Reactivation and new onset TB is a significant risk for all biologics users in SA. Screening for LTBI is an imperative preventative strategy.

  • tuberculosis
  • DMARDs (biologic)
  • anti-TNF

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  • Handling editor Josef S Smolen

  • Contributors Both authors contributed meaningfully to this article.

  • Funding The statistical analysis of this project was funded by AbbVie, who had no influence on the study design, analyses, interpretation or the decision to publish the results.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethical approval Pharma Ethics approval has been obtained for both the South African Biologics Registry and this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon resonable request subject to SARAA approval.