Researchers from the Huzhou Center for Disease Control and Prevention, working alongside colleagues from the Zhejiang Provincial Center for Disease Control and Prevention and several district-level health agencies, conducted a cross-sectional survey among older adults aged 60 and above who had screened positive for latent tuberculosis infection, or LTBI. The study, published in Frontiers in Cellular and Infection Microbiology, set out to answer a deceptively simple question: among older people who carry the dormant bacterium and are medically eligible for preventive treatment, who actually agrees to take it?

Latent tuberculosis infection is a peculiar biological state. The bacterium, Mycobacterium tuberculosis, sits quietly inside the body, held in check by the immune system, causing no symptoms and no active disease. But it can reactivate at any time, particularly when the immune system weakens with age. Older adults are especially vulnerable to this reactivation. Age-related immune senescence—the gradual deterioration of immune function that comes with growing older—combined with a high burden of chronic diseases, delayed healthcare-seeking due to atypical symptoms, and the sheer passage of time since the original infection, makes the elderly population a priority target for tuberculosis prevention. In China, the reported incidence of active pulmonary tuberculosis among people aged 65 and above is substantially higher than the national average, and the prevalence increases with age.

The World Health Organization’s End TB Strategy explicitly identifies tuberculosis preventive treatment, or TPT, for high-risk populations with LTBI as a key intervention to reduce tuberculosis incidence and interrupt transmission. Short-course chemoprophylaxis regimens, such as three months of rifapentine combined with isoniazid, have favorable safety and adherence profiles, providing a feasible technical foundation for scale-up in older populations. But translating effective treatment protocols from theoretically viable to practically implemented faces substantial real-world barriers. Prior studies have largely focused on the efficacy, safety, and cost-effectiveness of TPT regimens, or broadly examined adherence-related factors in the general population. When narrowed to the specific subgroup of adults aged 60 and above, the initial decision-making process regarding whether to accept TPT remains a relatively neglected blind spot in the literature.

The Huzhou study recruited 620 older adults with LTBI through two channels: community-based health examinations for older adults and screening of close contacts of active tuberculosis patients. All participants were clinically evaluated as meeting the medical indications for TPT according to Chinese guidelines, with clear consciousness and basic communication ability. Individuals with confirmed active pulmonary tuberculosis, contraindications to TPT such as severe hepatic dysfunction or allergy to treatment medications, and severe mental illness or cognitive impairment were excluded. The study offered participants two types of preventive treatment: chemoprophylaxis regimens and Mycobacterium vaccae immunotherapy. Most participants chose the short-course chemoprophylaxis regimen due to its convenient dosing, while immunotherapy provided an alternative for those unsuitable for or reluctant to undergo chemotherapy.

The results were striking. Of the 620 participants enrolled, 430—69.35 percent—accepted TPT. Among the participants, 354 were male, 192 were aged over 70 years, 593 were married, 499 resided in rural areas, 577 had an education level of junior high school or below, 135 smoked daily or occasionally, and 152 consumed alcohol occasionally or at least twice weekly. The acceptance rate was relatively high, indicating a reasonable implementation foundation for preventive intervention. Nevertheless, approximately 30 percent of the eligible population did not initiate treatment, suggesting that intervention strategies require further optimization.

To identify the factors driving treatment decisions, the researchers performed univariate and multivariate Logistic regression analyses. Variables with P less than 0.2 in the univariate analysis were entered into a multivariate unconditional Logistic regression model using a forward stepwise procedure. The analysis revealed three independent factors associated with TPT acceptance. Participants from households with three or fewer persons had an 88 percent increase in the odds of accepting TPT, with an adjusted odds ratio of 1.88 and a 95 percent confidence interval of 1.15 to 3.07. Those with an annual household income of 150,000 Chinese yuan or less had a 124 percent increase in the odds, with an adjusted odds ratio of 2.24 and a 95 percent confidence interval of 1.33 to 3.77. And those with a history of underlying diseases had an 86 percent increase in the odds, with an adjusted odds ratio of 1.86 and a 95 percent confidence interval of 1.16 to 2.99.

The finding that lower household income was associated with higher TPT acceptance appears to contradict the conventional assumption that lower socioeconomic status is generally associated with unfavorable health behaviors. But the researchers propose three plausible, mutually non-exclusive pathways that may explain this observation in the context of Huzhou. First, the financial barriers that typically link poverty to poor treatment uptake were largely absent in this setting: under national guidelines and Huzhou’s tuberculosis control program, TPT—including medications, baseline examinations, and follow-up monitoring—was delivered free of charge through the local CDC system at primary healthcare facilities. Second, the opportunity costs of accepting TPT likely differed by income. The sample was predominantly rural older adults, most of whom had exited the labor market, whereas higher-income participants were more likely to remain economically active; for these individuals, the repeated follow-up visits and laboratory monitoring required by TPT may have imposed substantial time and opportunity costs, thereby discouraging acceptance. Third, lower-income participants may have perceived greater vulnerability to disease and therefore regarded the freely offered preventive intervention as a worthwhile health investment.

The association between smaller household size and TPT acceptance suggests that family structure plays a pivotal role in health-related decision-making among older adults. Smaller households may facilitate more direct communication and concentrated caregiving responsibilities, with family members’ attention to and encouragement of the older adult’s health being more effective, thereby promoting TPT acceptance. Meanwhile, the finding that older adults with underlying diseases were more likely to accept TPT strongly supports the applicability of the perceived susceptibility construct of the health belief model in older populations. Those with comorbidities such as diabetes and chronic respiratory diseases may more acutely perceive their health vulnerability and hold stronger perceptions of tuberculosis as an infectious threat, thereby showing greater propensity to adopt preventive measures.

Several variables that were significant in the univariate analysis lost significance in the multivariate model, highlighting the complex interplay among influencing factors. Age of 70 years or younger, close contact status, alcohol consumption, and higher body mass index were associated with TPT acceptance in the univariate analysis, but their independent effects were attenuated after controlling for household, economic, and health-related factors. This suggests that the influence of these variables on treatment decisions may be mediated through, or contingent upon, deeper socioeconomic and health-perception factors. The researchers caution that the cross-sectional design precludes determination of temporal ordering, and reverse causation cannot be excluded. Future longitudinal studies incorporating data on time availability, occupational status, and out-of-pocket costs are needed to disentangle these competing explanations. The study also relied on structured questionnaires without qualitative data on the deeper motivations, concerns, and family interaction processes underlying older adults’ treatment decisions, and was conducted in Huzhou, an economically developed city in eastern China with a well-established primary tuberculosis control network, so the findings may not be directly generalizable to less developed regions.

Despite these limitations, the study provides an evidence base for developing precision-targeted intervention strategies. The researchers suggest that future efforts should transcend simple information dissemination models and instead adopt integrated approaches: for individuals from larger households, incorporate family mobilization components into health education; for those with better economic conditions and without underlying diseases, strengthen personal risk perception; and leverage the intrinsic motivation of those with comorbidities, transforming them into active advocates for community-based prevention. Through such precision-targeted, multi-level interventions, TPT coverage among this critical older population may be further improved, thereby solidifying the foundation for achieving the goal of ending tuberculosis.

Subject of Research: Infectious Diseases

Article Title: Factors associated with acceptance of preventive treatment among older adults with latent tuberculosis infection in Huzhou, Zhejiang province: a cross-sectional study

Article References: Yang, Z., Zu, Z., Sun, X., Chen, X., Wang, W., Zheng, P., Wen, D., Ren, F., Ding, Z., Gan, M., Wang, H., Zhang, S., Kong, Y., Jiang, G., Fan, J., Qin, J., You, J., Jin, M., Chen, B., … Shen, J. (2026). Factors associated with acceptance of preventive treatment among older adults with latent tuberculosis infection in Huzhou, Zhejiang province: a cross-sectional study. Frontiers in Cellular and Infection Microbiology, 16, Article 1967858. https://doi.org/10.3389/fcimb.2026.1967858

Image Credits: AI Generated

DOI: 10.3389/fcimb.2026.1967858

Keywords: tuberculosis, latent tuberculosis infection, tuberculosis preventive treatment, older adults, public health, China, epidemiology, preventive medicine, Factors, associated, acceptance, preventive