Chest

Chest

Volume 146, Issue 3, September 2014, Pages 563-572
Journal home page for Chest

Original Research: Chest Infections
Risk of Mycobacterial Infections Associated With Rheumatoid Arthritis in Ontario, Canada

https://doi.org/10.1378/chest.13-2058Get rights and content

OBJECTIVE

Patients with rheumatoid arthritis (RA) are at increased risk of TB. Little is known about the risk of nontuberculous mycobacteria (NTM) disease in these patients. We sought to ascertain the rate of NTM infection and TB in all residents of Ontario, Canada, with and without RA.

METHODS

In a cohort study, all Ontarians aged ≥ 15 years in January 2001 were followed until December 2010. Individuals with RA were identified using a validated algorithm to search hospitalization and physician billing claims. We linked Public Health Ontario Laboratory data to identify all cases of laboratory-confirmed TB and NTM disease. Analysis was performed using Cox proportional hazards regression.

RESULTS

We identified 113,558 Ontarians with RA and 9,760,075 Ontarians without RA. Relative to the non-RA group, adjusted hazard ratios (HRs) and 95% CIs for TB (1.92, [1.50-2.47]) and NTM disease (2.07, [1.84-2.32]) demonstrated increased risks in the RA group. Among those with RA, per 100,000 person-years, NTM disease (HR, 41.6; 95% CI, 37.1-46.5) was more common than TB (HR, 8.5; 95% CI, 6.5-10.8). After full adjustment, people with RA who developed NTM disease were 1.81 times as likely to die than uninfected people with RA.

CONCLUSIONS

Mycobacterial infections are more common in Ontarians with RA, with NTM disease more likely than TB. NTM disease is associated with an increased risk of death in patients with RA. Given the rising rates of NTM disease worldwide, determining whether this risk is due to the use of immunosuppressive medications vs RA itself is an important objective for future research.

Section snippets

Study Population and Setting

We conducted a population-based cohort study using linked health administrative data and Public Health Ontario Laboratory data from Ontario. We included all people in Ontario's Registered Persons Database aged ≥ 15 years on January 1, 2001, and followed them until the earliest of emigration, death, or December 31, 2010. Ontario residents have universal public health insurance under the Ontario Health Insurance Plan (OHIP), the single payer for medically necessary services. We excluded people

Results

We identified 59,017 individuals with RA as of January 1, 2001, and 54,541 individuals who developed RA during the study period, for a total 113,558 individuals with RA. There were 9,760,075 individuals who never developed RA. Ontarians with RA were more frequently female, older, more likely to have comorbidities (except HIV), and more likely to die during the study period than those in the non-RA group (Table 1).

In the RA group, we identified 64 cases of TB and 298 cases of NTM disease. In the

Discussion

In this population-based study of almost 10 million people, including > 113,000 with RA, we found that the presence of RA was associated with an approximately twofold higher adjusted incidence of TB and NTM. Importantly, among people with RA, the incidence of NTM disease was approximately fivefold higher than that of TB. Also, NTM disease was associated with an increased risk of death in people with RA.

The association between RA and TB has been described previously. Most prior studies

Acknowledgments

Author contributions: T. K. M. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S. K. B. served as principal author. S. K. B. and T. K. M. contributed to the concept and design of the study, drafting and revision of the manuscript, and approval of the final version of the manuscript; F. B. J., J. C. K., J. M. P., and C. B. contributed to the concept and design of the study, revision of the manuscript,

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    Part of this article was presented in abstract form (Brode SK, Jamieson FB, Ng R, et al.Am J Respir Crit Care Med. 2013;187:A3793).

    FUNDING/SUPPORT: The Grant-in-Aid Program of the Ontario Thoracic Society and Ontario Lung Association funded this research. This research was also supported by the Institute for Clinical Evaluative Sciences, a nonprofit research institute funded by the Ontario Ministry of Health and Long-Term Care.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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    Copyright © 2014 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.