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Dutta A, Pattanaik S, Choudhury R, Nanda P, Sahu S, Panigrahi R, Padhi BK, Sahoo KC, Mishra PR, Panigrahi P, Lekharu D, Stevens RH. Impact of involvement of non-formal health providers on TB case notification among migrant slum-dwelling populations in Odisha, India. PLoS One 2018; 13:e0196067. [PMID: 29791449 PMCID: PMC5965830 DOI: 10.1371/journal.pone.0196067] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 04/05/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Migrant labourers living in the slums of urban and industrial patches across India make up a key sub-population so far controlling Tuberculosis (TB) in the country is concerned. This is because many TB patients from these communities- remain under reached by the Revised National Tuberculosis Control Programme (RNTCP) of India. This marginalized community usually seeks early-stage healthcare from "friendly neighbourhood" non-formal health providers (NFHPs). Because, RNTCP has limited capacity to involve the NFHPs, an implementation research project was conceived, whereby an external partner would engage with the NFHPs to enable them to identify early TB symptomatics from this key sub-population who would be then tested using Xpert MTB/RIF technology. Diagnosed TB cases among them would be referred promptly to RNTCP for treatment. This paper aimed to describe the project and its impact. METHODS Adopting a quasi-experimental before-after design, four RNTCP units from two major urban-industrial areas of Odisha were selected for intervention, which spanned five quarters and covered 151,400 people, of which 30% were slum-dwelling migrants. Two similar units comprised the control population. The hypothesis was, reaching the under reached in the intervention area through NFHPs would increase TB notification from these traditionally under-notifying units. RNTCP notification data during intervention was compared with pre-intervention era, adjusted for contemporaneous changes in control population. RESULTS The project detected 488 Xpert+ TB cases, of whom 466 were administered RNTCP treatment. This translated into notification of additional 198 new bacteriologically positive cases to RNTCP, a 30% notification surge, after adjustment for 2% decline in control. This meant an average quarterly increase in notification of 41.20(20.08, 62.31; p<0.001) cases. The increase was immediate, evident from the rise in level in the time series analysis by 50.42(10.28, 90.55; p = 0.02) cases. CONCLUSION Engagement with NFHPs contributed to an increase in TB notification to RNTCP from key under reached, slum-dwelling migrant populations.
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Affiliation(s)
- Ambarish Dutta
- Asian Institute of Public Health, Bhubaneswar, India
- * E-mail:
| | | | | | - Pritish Nanda
- Asian Institute of Public Health, Bhubaneswar, India
| | | | | | | | | | - P. R. Mishra
- Asian Institute of Public Health, Bhubaneswar, India
| | - Pinaki Panigrahi
- University of Nebraska Medical Centre, Omaha, Nebraska, United States of America
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Seki M, Kim CK, Hayakawa S, Mitarai S. Recent advances in tuberculosis diagnostics in resource-limited settings. Eur J Clin Microbiol Infect Dis 2018; 37:1405-1410. [DOI: 10.1007/s10096-018-3258-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
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53
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Kritski A, Andrade KB, Galliez RM, Maciel ELN, Cordeiro-Santos M, Miranda SS, Villa TS, Ruffino Netto A, Arakaki-Sanchéz D, Croda J. Tuberculosis: renewed challenge in Brazil. Rev Soc Bras Med Trop 2018. [PMID: 29513837 DOI: 10.1590/0037-8682-0349-2017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This article reviews tuberculosis control actions performed over the last decade, at a global level. The perspectives for the fulfillment of the goals of the new Global Tuberculosis Elimination Plan are described, where the insertion of social protection (Pillar 2) and research (Pillar 3) will play an innovative and strategic role, especially in high-burden countries, like Brazil.
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Affiliation(s)
- Afranio Kritski
- Rede Brasileira de Pesquisa em Tuberculose, Rede Tuberculose, Rio de Janeiro, RJ, Brasil.,Programa Acadêmico de Tuberculose, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Kleydson Bonfim Andrade
- Programa Nacional de Controle de Tuberculose, Secretaria de Vigilância em Saúde, Ministério da Saúde, Brasília, DF, Brasil
| | - Rafael Mello Galliez
- Rede Brasileira de Pesquisa em Tuberculose, Rede Tuberculose, Rio de Janeiro, RJ, Brasil.,Instituto Estadual São Sebastião, Secretaria Estadual de Saúde do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
| | - Ethel Leonor Noia Maciel
- Rede Brasileira de Pesquisa em Tuberculose, Rede Tuberculose, Rio de Janeiro, RJ, Brasil.,Programa de Pós-Graduação em Saúde Coletiva, Universidade Federal do Espírito Santo, Vitória, ES, Brasil
| | - Marcelo Cordeiro-Santos
- Rede Brasileira de Pesquisa em Tuberculose, Rede Tuberculose, Rio de Janeiro, RJ, Brasil.,Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Secretaria Estadual de Estado da Saúde do Amazonas, Manaus, AM, Brasil
| | - Silvana Spindola Miranda
- Rede Brasileira de Pesquisa em Tuberculose, Rede Tuberculose, Rio de Janeiro, RJ, Brasil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
| | - Teresa Scatena Villa
- Rede Brasileira de Pesquisa em Tuberculose, Rede Tuberculose, Rio de Janeiro, RJ, Brasil.,Escola de Enfermagem de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Antonio Ruffino Netto
- Rede Brasileira de Pesquisa em Tuberculose, Rede Tuberculose, Rio de Janeiro, RJ, Brasil.,Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil
| | - Denise Arakaki-Sanchéz
- Programa Nacional de Controle de Tuberculose, Secretaria de Vigilância em Saúde, Ministério da Saúde, Brasília, DF, Brasil
| | - Julio Croda
- Rede Brasileira de Pesquisa em Tuberculose, Rede Tuberculose, Rio de Janeiro, RJ, Brasil.,Faculdade de Medicina, Universidade Federal de Mato Grosso do Sul/Fundação Oswaldo Cruz, Campo Grande, MS, Brasil
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54
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Nogueira BMF, Rolla VC, Akrami KM, Kiene SM. Factors associated with tuberculosis treatment delay in patients co-infected with HIV in a high prevalence area in Brazil. PLoS One 2018; 13:e0195409. [PMID: 29624603 PMCID: PMC5889181 DOI: 10.1371/journal.pone.0195409] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 03/21/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Worldwide, about 11% of Tuberculosis (TB) cases occur in people living with HIV (PLHIV) and it is the leading cause of death in this population. An important step towards reducing the incidence and mortality of TB in PLHIV is to reduce the time from onset of symptoms to treatment. Factors related to TB treatment delay therefore need to be understood. METHODS Using data from a prospective cohort study of patients diagnosed with TB at the National Institute of Infectious Disease, at the Oswaldo Cruz Foundation, Rio de Janeiro, Brazil we conducted a survival analysis to identify factors associated with patient and health care treatment delay. In our analysis we included patients who were co-infected with TB and HIV (n = 201). Patients were followed during the course of their TB treatment and information regarding duration of symptoms, sociodemographics and clinical characteristics were collected at the baseline visit. RESULTS The median time from onset of initial symptoms to prescription of TB treatment (total delay) was 82 days. From initiation of symptoms to first visit at INI clinic (patient delay), the median was 51 days. From first visit to initiation of treatment (health care delay) the median was 16 days. Illiteracy was associated with greater patient delay [Hazard Ratio (HR) = 2.25, CI 95% 1.29-3.94]. Having had a previous episode of TB (HR = 0.53, CI 95% 0.37-0.74) and being married (HR = 0.71, CI 95% 0.54-0.94) were inversely related to patient delay. Illiteracy was also associated with greater health care delay (HR = 2.83, CI 95% 1.25-5.47) in contrast to high viral load (HR = 0.37, CI 95% 0.24-0.54) and weight loss greater than 10% (HR = 0.54, CI 95% 0.37-0.8), both of which were inversely related to health care delay. CONCLUSIONS This study highlights the existence of factors that lead to greater risk of delayed treatment of TB among patients co-infected with HIV and TB. These include factors that can be assessed through targeted interventions which have implications for improving treatment outcomes and, through reduced duration of infectiousness, reduce the incidence of TB in Brazil.
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Affiliation(s)
- Betânia M. F. Nogueira
- Division of Epidemiology and Biostatistics, San Diego State University, San Diego, California, United States of America
| | - Valéria C. Rolla
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Kevan M. Akrami
- Division of Infectious Diseases, University of California San Diego, La Jolla, California, United States of America
| | - Susan M. Kiene
- Division of Epidemiology and Biostatistics, San Diego State University, San Diego, California, United States of America
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Gidado M, Nwokoye N, Nwadike P, Ajiboye P, Eneogu R, Useni S, Onazi J, Lawanson A, Elom E, Tubi A, Kuye J. Unsuccessful Xpert ® MTB/RIF results: the Nigerian experience. Public Health Action 2018; 8:2-6. [PMID: 29581936 DOI: 10.5588/pha.17.0080] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 01/11/2018] [Indexed: 11/10/2022] Open
Abstract
Setting: Nigeria, a high tuberculosis (TB) burden country. Objective: To study the rate, distribution and causes of unsuccessful Xpert® MTB/RIF test outcomes, with the aim of identifying key areas that need to be strengthened for optimal performance of the assay. Design: This was a retrospective analysis of data uploaded between January and December 2015 from Xpert facilities to the central server using GXAlert. Result: Of 52 219 test results uploaded from 176 Xpert machines, 22.5% were positive for Mycobacterium tuberculosis, 10.8% of which were rifampicin-resistant; 4.7% of the total number of results were invalid, 4.2% had error results and 2.1% no result outcomes. Technical errors were most frequent (69%); these were non-seasonal and occurred in all geopolitical regions and at all health facility levels. Temperature-related errors were more prevalent in the North-West Region, with peaks in April to June. Peak periods for temperature and machine malfunction errors coincided with the periods of low utilisation of the assay. Conclusion: The key challenge affecting performance was poor adherence to standard operating procedures. Periodic refresher training courses, regular supervision, preventive maintenance of Xpert machines and proper storage of cartridges are strategies that could improve Xpert performance.
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Affiliation(s)
- M Gidado
- KNCV Tuberculosis Foundation, Abuja, Nigeria
| | - N Nwokoye
- KNCV Tuberculosis Foundation, Abuja, Nigeria
| | - P Nwadike
- KNCV Tuberculosis Foundation, Abuja, Nigeria
| | - P Ajiboye
- KNCV Tuberculosis Foundation, Abuja, Nigeria
| | - R Eneogu
- KNCV Tuberculosis Foundation, Abuja, Nigeria
| | - S Useni
- KNCV Tuberculosis Foundation, Abuja, Nigeria
| | - J Onazi
- KNCV Tuberculosis Foundation, Abuja, Nigeria
| | - A Lawanson
- National Tuberculosis Leprosy Control Programme, Abuja, Nigeria
| | - E Elom
- National Tuberculosis Leprosy Control Programme, Abuja, Nigeria
| | - A Tubi
- National Tuberculosis Leprosy Control Programme, Abuja, Nigeria
| | - J Kuye
- National Tuberculosis Leprosy Control Programme, Abuja, Nigeria
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56
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Pereira GR, Barbosa MS, Dias NJD, de Almeida CPB, Silva DR. Impact of introduction of Xpert MTB/RIF test on tuberculosis (TB) diagnosis in a city with high TB incidence in Brazil. PLoS One 2018. [PMID: 29518135 PMCID: PMC5843278 DOI: 10.1371/journal.pone.0193988] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Xpert MTB/RIF is increasingly used in many countries as the initial diagnostic test for tuberculosis (TB). Few studies have evaluated the effect of Xpert on TB diagnosis under programmatic conditions in Brazil. The aim of the present study was to evaluate the impact of introduction of Xpert MTB/RIF on TB diagnosis in a city with high TB incidence in Brazil. Methods We included patients evaluated with conventional diagnostic tests during one year before Xpert introduction (pre-Xpert group) and patients evaluated using Xpert during one year after the test introduction (post-Xpert group). Results 620 patients met the inclusion criteria (208 in the pre-Xpert group and 412 in the post-Xpert group) and were included in the analysis. The time until TB diagnosis was shorter in post-Xpert group (0.7 day, IQR: 0.5–1.0 day) than in pre-Xpert group (2.0 days, IQR: 2.0–2.0 days) (p<0.0001). Atypical disease characteristics, such as less weight loss, fever, dyspnea, night sweats, and hemoptysis; a negative sputum smear; a negative culture, and a chest X-ray atypical of TB were more common in post-Xpert group than in pre-Xpert group (p<0.0001 for all). Conclusions We found that the implementation of the Xpert MTB/RIF assay, under programmatic conditions, improve and facilitate TB diagnosis, especially in cases with atypical disease manifestations. These results are likely to be generalizable to settings with a similar high TB incidence.
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Affiliation(s)
- Giovana Rodrigues Pereira
- Programa de Pós-Graduação em Ciências Pneumológicas da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Setor de Tuberculose, Laboratório Municipal de Alvorada, Alvorada, Brazil
| | | | | | | | - Denise Rossato Silva
- Programa de Pós-Graduação em Ciências Pneumológicas da Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- * E-mail:
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The impact of implementing a Xpert MTB/RIF algorithm on drug-sensitive pulmonary tuberculosis: a retrospective analysis. Epidemiol Infect 2017; 146:246-255. [DOI: 10.1017/s0950268817002746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
SUMMARYXpert MTB/RIF (Xpert) is the preferred first-line test for all persons with tuberculosis (TB) symptoms in South Africa in line with a diagnostic algorithm. This study evaluates pre- and post-implementation trends in diagnostic practices for drug-sensitive, pulmonary TB in adults in an operational setting, following the introduction of the Xpert-based algorithm. We retrospectively analysed data from the national TB database for Greater Tzaneen sub-district, Limpopo Province. Trends in a number of cases, diagnosis and outcome and characteristics associated with death are reported. A total of 8407 cases were treated from 2008 until 2015, with annual cases registered decreasing by 31·7% over that time period (from 1251 to 855 per year). After implementation of Xpert, 69·9% of cases were diagnosed by Xpert, 29·4% clinically, 0·6% by smear microscopy and 0·1% by culture. Cases with a recorded microbiological test increased from 76·2% to 96·4%. Cases started on treatment without confirmation, but with a negative microbiological test increased from 7·1% to 25·7%. Case fatality decreased from 15·0% to 9·8%, remaining consistently higher in empirically treated groups, regardless of HIV status. Implementation of the algorithm coincided with a reduced number of TB cases treated and improved coverage of microbiological testing; however, a substantial proportion of cases continued to start treatment empirically.
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58
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The Good, the Bad and the Ugly of the Next-Generation Xpert Mtb/Rif ® Ultra Test for Tuberculosis Diagnosis. Arch Bronconeumol 2017; 53:665-666. [DOI: 10.1016/j.arbres.2017.05.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/25/2017] [Accepted: 05/26/2017] [Indexed: 11/30/2022]
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Estimated clinical impact of the Xpert MTB/RIF Ultra cartridge for diagnosis of pulmonary tuberculosis: A modeling study. PLoS Med 2017; 14:e1002472. [PMID: 29240766 PMCID: PMC5730108 DOI: 10.1371/journal.pmed.1002472] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 11/14/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Xpert MTB/RIF (Xpert) assay offers rapid and accurate diagnosis of tuberculosis (TB) but still suffers from imperfect sensitivity. The newer Xpert MTB/RIF Ultra cartridge has shown improved sensitivity in recent field trials, but at the expense of reduced specificity. The clinical implications of switching from the existing Xpert cartridge to the Xpert Ultra cartridge in different populations remain uncertain. METHODS AND FINDINGS We developed a Markov microsimulation model of hypothetical cohorts of 100,000 individuals undergoing diagnostic sputum evaluation with Xpert for suspected pulmonary TB, in each of 3 emblematic settings: an HIV clinic in South Africa, a public TB center in India, and an adult primary care setting in China. In each setting, we used existing data to project likely diagnostic results, treatment decisions, and ultimate clinical outcomes, assuming use of the standard Xpert versus Xpert Ultra cartridge. Our primary outcomes were the projected number of additional unnecessary treatments generated, the projected number of TB deaths averted, and the projected number of unnecessary treatments generated per TB death averted, if standard Xpert were switched to Xpert Ultra. We also simulated alternative approaches to interpreting positive results of the Ultra cartridge's semi-quantitative trace call. Extensive sensitivity and uncertainty analyses were performed to evaluate the drivers and generalizability of projected results. In the Indian TB center setting, replacing the standard Xpert cartridge with the Xpert Ultra cartridge was projected to avert 0.5 TB deaths (95% uncertainty range [UR]: 0, 1.3) and generate 18 unnecessary treatments (95% UR: 10, 29) per 1,000 individuals evaluated-resulting in a median ratio of 38 incremental unnecessary treatments added by Ultra per incremental death averted by Ultra compared to outcomes using standard Xpert (95% UR: 12, indefinite upper bound). In the South African HIV care setting-where TB mortality rates are higher and Ultra's improved sensitivity has greater absolute benefit-this ratio improved to 7 unnecessary treatments per TB death averted (95% UR: 2, 43). By contrast, in the Chinese primary care setting, this ratio was much less favorable, at 372 unnecessary treatments per TB death averted (95% UR: 75, indefinite upper bound), although the projected number of unnecessary treatments using Xpert Ultra was lower (with a possibility of no increased overtreatment) when using specificity data only from lower-burden settings. Alternative interpretations of the trace call had little effect on these ratios. Limitations include uncertainty in key parameters (including the clinical implications of false-negative results), the exclusion of transmission effects, and restriction of this analysis to adult pulmonary TB. CONCLUSIONS Switching from the standard Xpert cartridge to the Xpert Ultra cartridge for diagnosis of adult pulmonary TB may have different consequences in different clinical settings. In settings with high TB and HIV prevalence, Xpert Ultra is likely to offer considerable mortality benefit, whereas in lower-prevalence settings, Xpert Ultra will likely result in considerable overtreatment unless the possibility of higher specificity of Ultra in lower-prevalence settings in confirmed. The ideal use of the Ultra cartridge may therefore involve a more nuanced, setting-specific approach to implementation, with priority given to populations in which the anticipated prevalence of TB (and HIV) is the highest.
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Pinto MFT, Steffen R, Entringer A, Costa ACCD, Trajman A. [Budget impact of the incorporation of GeneXpert MTB/RIF for diagnosis of pulmonary tuberculosis from the perspective of the Brazilian Unified National Health System, Brazil, 2013-2017]. CAD SAUDE PUBLICA 2017; 33:e00214515. [PMID: 29019524 DOI: 10.1590/0102-311x00214515] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 12/13/2016] [Indexed: 01/07/2023] Open
Abstract
The study aimed to estimate the budget impact of GeneXpert MTB/RIF for diagnosis of tuberculosis from the perspective of the Brazilian National Program for Tuberculosis Control, drawing on a static model using the epidemiological method, from 2013 to 2017. GeneXpert MTB/RIF was compared with two diagnostic sputum smear tests. The study used epidemiological, population, and cost data, exchange rates, and databases from the Brazilian Unified National Health System. Sensitivity analysis of scenarios was performed. Incorporation of GeneXpert MTB/RIF would cost BRL 147 million (roughly USD 45 million) in five years and would have an impact of 23 to 26% in the first two years and some 11% between 2015 and 2017. The results can support Brazilian and other Latin American health administrators in planning and managing the decision on incorporating the technology.
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Affiliation(s)
- Márcia Ferreira Teixeira Pinto
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Ricardo Steffen
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
| | - Aline Entringer
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Ana Carolina Carioca da Costa
- Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Anete Trajman
- Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil.,Montreal Chest Institute, McGill University, Montréal, Canada
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Verza M, Schmid KB, Barcellos RB, Linck N, Bello GL, Scapin D, Sperhacke RD, Silva MSN, Wollheim C, Rivero MGC, Kritski AL, Rezende L, Oliveira MM, Costa ERD, Rossetti MLR. Performance of a molecular assay to detect Mycobacterium tuberculosis complex DNA in clinical specimens: multicenter study in Brazil. Mem Inst Oswaldo Cruz 2017; 112:94-99. [PMID: 28177043 PMCID: PMC5293118 DOI: 10.1590/0074-02760160196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 10/31/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In high tuberculosis (TB) burden countries, there are few data on the performance of new molecular commercialised assays developed locally. OBJECTIVE To evaluate the performance of a new molecular commercialised assay for TB diagnosis (Detect-TB) in three laboratories. METHODS A total of 302 sputum samples from an equal number of patients with presumptive diagnosis of pulmonary tuberculosis (PTB) were submitted for routine smear microscopy, culture, and Detect-TB assay at three different sites in Brazil (the cities of Caxias do Sul, São Paulo and Canoas). FINDINGS Seventy four (24.7%) TB cases were diagnosed (65 bacteriologically confirmed). When compared to smear microscopy/culture results, the overall sensitivity and specificity of Detect-TB assay was 84.6% (CI 95%; 73.7-91.6) and 93.1% (CI 95%; 89.1-95.8), respectively. When compared to bacteriological and clinical diagnostic criteria, the sensitivity and specificity of Detect-TB assay was 74.3% (CI 95%; 63.3-82.9) and 92.9% (CI 95%; 88.7-95.6), respectively. Among the three sites - Caxias do Sul, São Paulo and Canoas - the sensitivity and specificity were respectively 94.7% and 97.8%; 71.4% and 93.9%, 82.1% and 88.9%. MAIN CONCLUSIONS These findings suggest that the Detect-TB assay could be applied routinely in reference laboratories across different regions in Brazil.
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Affiliation(s)
- Mirela Verza
- Centro de Desenvolvimento Científico e Tecnológico, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil
| | - Karen Barros Schmid
- Centro de Desenvolvimento Científico e Tecnológico, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil
| | - Regina Bones Barcellos
- Centro de Desenvolvimento Científico e Tecnológico, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil.,Rede Brasileira de Pesquisa em Tuberculose, Rio de Janeiro, RJ, Brasil
| | - Natali Linck
- Universidade Luterana do Brasil, Canoas, RS, Brasil
| | | | | | - Rosa Dea Sperhacke
- Universidade de Caxias do Sul, Laboratório de Pesquisa em HIV/AIDS, Caxias do Sul, RS, Brasil
| | | | - Claudia Wollheim
- Universidade de Caxias do Sul, Laboratório de Microbiologia Clínica, Caxias do Sul, RS, Brasil
| | | | - Afrânio Lineu Kritski
- Universidade Federal do Rio de Janeiro, Faculdade de Medicina, Centro de Pesquisa em Tuberculose do Hospital Universitário Clementino Fraga Filho, Laboratório de Genética e Biologia Molecular, Rio de Janeiro, RJ, Brasil.,Rede Brasileira de Pesquisa em Tuberculose, Rio de Janeiro, RJ, Brasil
| | | | - Martha Maria Oliveira
- Universidade Federal do Rio de Janeiro, Faculdade de Medicina, Centro de Pesquisa em Tuberculose do Hospital Universitário Clementino Fraga Filho, Laboratório de Genética e Biologia Molecular, Rio de Janeiro, RJ, Brasil.,Rede Brasileira de Pesquisa em Tuberculose, Rio de Janeiro, RJ, Brasil
| | - Elis Regina Dalla Costa
- Centro de Desenvolvimento Científico e Tecnológico, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil.,Rede Brasileira de Pesquisa em Tuberculose, Rio de Janeiro, RJ, Brasil
| | - Maria Lucia Rosa Rossetti
- Centro de Desenvolvimento Científico e Tecnológico, Fundação Estadual de Produção e Pesquisa em Saúde, Porto Alegre, RS, Brasil.,Universidade Luterana do Brasil, Canoas, RS, Brasil.,Rede Brasileira de Pesquisa em Tuberculose, Rio de Janeiro, RJ, Brasil
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Meyer AJ, Atuheire C, Worodria W, Kizito S, Katamba A, Sanyu I, Andama A, Ayakaka I, Cattamanchi A, Bwanga F, Huang L, Davis JL. Sputum quality and diagnostic performance of GeneXpert MTB/RIF among smear-negative adults with presumed tuberculosis in Uganda. PLoS One 2017; 12:e0180572. [PMID: 28686705 PMCID: PMC5501569 DOI: 10.1371/journal.pone.0180572] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 06/16/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Introduction of GeneXpert MTB/RIF (Xpert) assay has constituted a major breakthrough for tuberculosis (TB) diagnostics. Several patient factors may influence diagnostic performance of Xpert including sputum quality. OBJECTIVE We carried out a prospective, observational, cross-sectional study to determine the effect of sputum quality on diagnostic performance of Xpert among presumed TB patients in Uganda. METHODS We collected clinical and demographic information and two sputum samples from participants. Staff recorded sputum quality and performed LED fluorescence microscopy and mycobacterial culture on each sample. If both smear examinations were negative, Xpert testing was performed. We calculated diagnostic yield, sensitivity, specificity, and other indicators for Xpert for each stratum of sputum quality in reference to a standard of mycobacterial culture. RESULTS Patients with salivary sputum showed a trend towards a substantially higher proportion of samples that were Xpert-positive (54/286, 19%, 95% CI 15-24) compared with those with all other sputum sample types (221/1496, 15%, 95% CI 13-17). Blood-stained sputum produced the lowest sensitivity (28%; 95% CI 12-49) and salivary sputum the highest (66%; 95% CI 53-77). Specificity didn't vary meaningfully by sample types. Salivary sputum was significantly more sensitive than mucoid sputum (+13%, 95% CI +1 to +26), while blood-stained sputum was significantly less sensitive (-24%, 95% CI -42 to -5). CONCLUSIONS Our findings demonstrate the need to exercise caution in collecting sputum for Xpert and in interpreting results because sputum quality may impact test yield and sensitivity. In particular, it may be wise to pursue additional testing should blood-stained sputum test negative while salivary sputum should be readily accepted for Xpert testing given its higher sensitivity and potentially higher yield than other sample types. These findings challenge conventional recommendations against collecting salivary sputum for TB diagnosis and could inform new standards for sputum quality.
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Affiliation(s)
- Amanda J. Meyer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Collins Atuheire
- Department of Health Sciences & Special Education, Africa Renewal University, Kampala, Uganda
| | - William Worodria
- Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda
| | - Samuel Kizito
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - Achilles Katamba
- Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - Ingvar Sanyu
- Infectious Diseases Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Alfred Andama
- Department of Medicine, Mulago Hospital, Makerere University, Kampala, Uganda
- Infectious Diseases Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Irene Ayakaka
- Infectious Diseases Research Collaboration, Mulago Hospital, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Freddie Bwanga
- Department of Microbiology, Makerere University, Kampala, Uganda
| | - Laurence Huang
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, California, United States of America
- Division of HIV, Infectious Diseases, and Global Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - J. Lucian Davis
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, New Haven, Connecticut, United States of America
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Hermans SM, Babirye JA, Mbabazi O, Kakooza F, Colebunders R, Castelnuovo B, Sekaggya-Wiltshire C, Parkes-Ratanshi R, Manabe YC. Treatment decisions and mortality in HIV-positive presumptive smear-negative TB in the Xpert™ MTB/RIF era: a cohort study. BMC Infect Dis 2017; 17:433. [PMID: 28622763 PMCID: PMC5473987 DOI: 10.1186/s12879-017-2534-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 06/07/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The Xpert™ MTB/RIF (XP) has a higher sensitivity than sputum smear microscopy (70% versus 35%) for TB diagnosis and has been endorsed by the WHO for TB high burden countries to increase case finding among HIV co-infected presumptive TB patients. Its impact on the diagnosis of smear-negative TB in a routine care setting is unclear. We determined the change in diagnosis, treatment and mortality of smear-negative presumptive TB with routine use of Xpert MTB/RIF (XP). METHODS Prospective cohort study of HIV-positive smear-negative presumptive TB patients during a 12-month period after XP implementation in a well-staffed and trained integrated TB/HIV clinic in Kampala, Uganda. Prior to testing clinicians were asked to decide whether they would treat empirically prior to Xpert result; actual treatment was decided upon receipt of the XP result. We compared empirical and XP-informed treatment decisions and all-cause mortality in the first year. RESULTS Of 411 smear-negative presumptive TB patients, 175 (43%) received an XP; their baseline characteristics did not differ. XP positivity was similar in patients with a pre-XP empirical diagnosis and those without (9/29 [17%] versus 14/142 [10%], P = 0.23). Despite XP testing high levels of empirical treatment prevailed (18%), although XP results did change who ultimately was treated for TB. When adjusted for CD4 count, empirical treatment was not associated with higher mortality compared to no or microbiologically confirmed treatment. CONCLUSIONS XP usage was lower than expected. The lower sensitivity of XP in smear-negative HIV-positive patients led experienced clinicians to use XP as a "rule-in" rather than "rule-out" test, with the majority of patients still treated empirically.
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Affiliation(s)
- Sabine M Hermans
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda.
- Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
- Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
| | - Juliet A Babirye
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | - Olive Mbabazi
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | - Francis Kakooza
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | - Robert Colebunders
- Institute for Tropical Medicine, University of Antwerp, Antwerp, Belgium
- Global Health Institute, University of Antwerp, Antwerp, Belgium
| | - Barbara Castelnuovo
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
| | | | - Rosalind Parkes-Ratanshi
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
- Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, P.O. Box 22418, Kampala, Uganda
- Department of Internal Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
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Pai M, Furin J. Tuberculosis innovations mean little if they cannot save lives. eLife 2017; 6. [PMID: 28460659 PMCID: PMC5413344 DOI: 10.7554/elife.25956] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 04/10/2017] [Indexed: 12/18/2022] Open
Abstract
The past decade has seen the emergence of new diagnostics and drugs for tuberculosis, a disease that kills over 1.8 million people each year. However, these new tools are yet to reach scale, and access remains a major challenge for patients in low and middle income countries. Urgent action is needed if we are committed to ending the TB epidemic. This means raising the level of ambition, embracing innovation, increasing financial investments, addressing implementation gaps, and ensuring that new technologies reach those who need them to survive. Otherwise, the promise of innovative technologies will never be realized.
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Affiliation(s)
- Madhukar Pai
- McGill Global Health Programs and McGill International Tuberculosis Centre, McGill University, Montreal, Canada.,Manipal McGill Centre for Infectious Diseases, Manipal University, Manipal, India
| | - Jennifer Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, United States
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Hermans S, Caldwell J, Kaplan R, Cobelens F, Wood R. The impact of the roll-out of rapid molecular diagnostic testing for tuberculosis on empirical treatment in Cape Town, South Africa. Bull World Health Organ 2017; 95:554-563. [PMID: 28804167 PMCID: PMC5537747 DOI: 10.2471/blt.16.185314] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 02/01/2017] [Accepted: 03/20/2017] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To investigate the impact of introducing a rapid test as the first-line diagnostic test for drug-sensitive tuberculosis in Cape Town, South Africa. METHODS Xpert® MTB/RIF (Xpert®), an automated polymerase-chain-reaction-based assay, was rolled out between 2011 and 2013. Data were available on 102 007 adults treated for pulmonary tuberculosis between 2010 and 2014. Tuberculosis notification rates per 100 000 population were calculated for each calendar year and for each year relative to the test roll-out locally, overall and by bacteriological confirmation. Empirical treatment was defined as treatment given without bacteriological confirmation by Xpert®, sputum smear microscopy or sputum culture. FINDINGS Between 2010 and 2014, the proportion of human immunodeficiency virus (HIV)-negative patients treated empirically for tuberculosis declined from 23% (2445/10 643) to 11% (1149/10 089); in HIV-positive patients, it declined from 42% (4229/9985) to 27% (2364/8823). The overall tuberculosis notification rate decreased by 12% and 19% among HIV-negative and HIV-positive patients, respectively; the rate of bacteriologically confirmed cases increased by 1% and 3%, respectively; and the rate of empirical treatment decreased by 56% and 49%, respectively. These changes occurred gradually following the test's introduction and stabilized after 3 years. CONCLUSION Roll-out of the rapid test in a setting with a high prevalence of pulmonary tuberculosis and HIV infection was associated with a halving of empirical treatment that occurred gradually after the test's introduction, possibly reflecting the time needed for full implementation. More than a quarter of HIV-positive patients with tuberculosis were still treated empirically, highlighting the diagnostic challenge in these patients.
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Affiliation(s)
- Sabine Hermans
- The Desmond Tutu HIV Centre, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Judy Caldwell
- City of Cape Town Health Directorate, Cape Town, South Africa
| | - Richard Kaplan
- The Desmond Tutu HIV Centre, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925, South Africa
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Robin Wood
- The Desmond Tutu HIV Centre, Institute for Infectious Diseases and Molecular Medicine, University of Cape Town Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925, South Africa
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A comparison of tuberculosis diagnostic systems in a retrospective cohort of HIV-infected children in Rio de Janeiro, Brazil. Int J Infect Dis 2017; 59:150-155. [PMID: 28455104 PMCID: PMC7978502 DOI: 10.1016/j.ijid.2017.01.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/16/2017] [Accepted: 01/27/2017] [Indexed: 11/30/2022] Open
Abstract
Objectives: The diagnosis of pediatric tuberculosis (TB) presents many challenges, and is further complicated in HIV-infected patients. While many diagnostic systems have been proposed, there is no pediatric TB diagnosis gold standard. The outcomes of four TB diagnostic systems in HIV-infected children were compared in this study. Methods: A retrospective cohort study was conducted at a TB/HIV reference hospital in Rio de Janeiro. HIV-infected pediatric patients evaluated for TB from 1998 to 2010 were reassessed using four diagnostic systems: Kenneth Jones, 1969; Tidjani, 1986; Ben Marais, 2006; Brazilian Ministry of Health, 2010. Results were compared to standardized diagnoses made by an expert panel of physicians. Results: Of the 121 patients in the study cohort, the expert panel diagnosed 64 as TB and 57 as not TB cases. The Tidjani system showed the highest diagnostic accuracy, with and without the inclusion of microbiological data. The Tidjani and Kenneth Jones systems produced fewer false-positives, and the Ben Marais and Ministry of Health fewer false-negatives. Across systems, there was little agreement between TB diagnoses. Conclusions: In HIV-infected pediatric patients, the Ben Marais and Ministry of Health systems are useful for TB diagnostic screening, whereas the Tidjani and Kenneth Jones systems are best used in a reference center setting.
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67
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Lyons VH, Li L, Hughes JP, Rowhani-Rahbar A. Proposed variations of the stepped-wedge design can be used to accommodate multiple interventions. J Clin Epidemiol 2017; 86:160-167. [PMID: 28412466 DOI: 10.1016/j.jclinepi.2017.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 03/14/2017] [Accepted: 04/04/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Stepped-wedge design (SWD) cluster-randomized trials have traditionally been used for evaluating a single intervention. We aimed to explore design variants suitable for evaluating multiple interventions in an SWD trial. STUDY DESIGN AND SETTING We identified four specific variants of the traditional SWD that would allow two interventions to be conducted within a single cluster-randomized trial: concurrent, replacement, supplementation, and factorial SWDs. These variants were chosen to flexibly accommodate study characteristics that limit a one-size-fits-all approach for multiple interventions. RESULTS In the concurrent SWD, each cluster receives only one intervention, unlike the other variants. The replacement SWD supports two interventions that will not or cannot be used at the same time. The supplementation SWD is appropriate when the second intervention requires the presence of the first intervention, and the factorial SWD supports the evaluation of intervention interactions. The precision for estimating intervention effects varies across the four variants. CONCLUSION Selection of the appropriate design variant should be driven by the research question while considering the trade-off between the number of steps, number of clusters, restrictions for concurrent implementation of the interventions, lingering effects of each intervention, and precision of the intervention effect estimates.
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Affiliation(s)
- Vivian H Lyons
- Department of Epidemiology, School of Public Health, University of Washington, Box 357236, Seattle, WA 98195-7236, USA; Harborview Injury Prevention & Research Center, 401 Broadway Avenue, 4th Floor, Seattle, WA 98122, USA.
| | - Lingyu Li
- Department of Biostatistics, School of Public Health, University of Washington, Box 357232, Seattle, WA 98195-7232, USA
| | - James P Hughes
- Department of Biostatistics, School of Public Health, University of Washington, Box 357232, Seattle, WA 98195-7232, USA
| | - Ali Rowhani-Rahbar
- Department of Epidemiology, School of Public Health, University of Washington, Box 357236, Seattle, WA 98195-7236, USA; Harborview Injury Prevention & Research Center, 401 Broadway Avenue, 4th Floor, Seattle, WA 98122, USA
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Pathmanathan I, Date A, Coggin WL, Nkengasong J, Piatek AS, Alexander H. Rolling Out Xpert ® MTB/RIF for TB Detection in HIV-Infected Populations:An Opportunity for Systems Strengthening. Afr J Lab Med 2017; 6. [PMID: 28785533 PMCID: PMC5523912 DOI: 10.4102/ajlm.v6i2.460] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background To eliminate preventable deaths, disease and suffering due to tuberculosis, improved diagnostic capacity is critical. The Cepheid Xpert MTB/RIF® assay is recommended by the World Health Organization as the initial diagnostic test for people with suspected HIV-associated tuberculosis. However, despite high expectations, its scale-up in real-world settings has faced challenges, often due to the systems that support it. Opportunities for System Strengthening In this commentary, we discuss needs and opportunities for systems strengthening to support widespread scale-up of Xpert MTB/RIF as they relate to each step within the tuberculosis diagnostic cascade, from finding presumptive patients, to collecting, transporting and testing sputum specimens, to reporting and receiving results, to initiating and monitoring treatment and, ultimately, to ensuring successful and timely treatment and cure. Investments in evidence-based interventions at each step along the cascade and within the system as a whole will augment not only the utility of Xpert MTB/RIF, but also the successful implementation of future diagnostic tests. Conclusion Xpert MTB/RIF will only improve patient outcomes if optimally implemented within the context of strong tuberculosis programmes and systems. Roll-out of this technology to people living with HIV and others in resource-limited settings offers the opportunity to leverage current tuberculosis and HIV laboratory, diagnostic and programmatic investments, while also addressing challenges and strengthening coordination between laboratory systems, laboratory-programme interfaces, and tuberculosis-HIV programme interfaces. If successful, the benefits of this tool could extend beyond progress toward global End TB Strategy goals, to improve system-wide capacity for global disease detection and control.
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Affiliation(s)
- Ishani Pathmanathan
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA.,Epidemic Intelligence Service, U.S. Centers for Disease Control & Prevention, Atlanta, USA
| | - Anand Date
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA
| | - William L Coggin
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA
| | - John Nkengasong
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA
| | - Amy S Piatek
- Global Health Bureau, United States Agency for International Development, Washington DC, USA
| | - Heather Alexander
- Division of Global HIV and TB, U.S. Centers for Disease Control & Prevention, Atlanta, USA
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Scott L, da Silva P, Boehme CC, Stevens W, Gilpin CM. Diagnosis of opportunistic infections: HIV co-infections - tuberculosis. Curr Opin HIV AIDS 2017; 12:129-138. [PMID: 28059955 PMCID: PMC6024079 DOI: 10.1097/coh.0000000000000345] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Tuberculosis (TB) incidence has declined ∼1.5% annually since 2000, but continued to affect 10.4 million individuals in 2015, with 1/3 remaining undiagnosed or underreported. The diagnosis of TB among those co-infected with HIV is challenging as TB remains the leading cause of death in such individuals. Accurate and rapid diagnosis of active TB will avert mortality in both adults and children, reduce transmission, and assist in timeous decisions for antiretroviral therapy initiation. This review describes advances in diagnosing TB, especially among HIV co-infected individuals, highlights national program's uptake, and impact on patient care. RECENT FINDINGS The TB diagnostic landscape has been transformed over the last 5 years. Molecular diagnostics such as Xpert MTB/RIF, which simultaneously detects Mycobacterium tuberculosis (MTB) resistance to rifampicin, has revolutionized TB control programs. WHO endorsed the use of Xpert MTB/RIF in 2010 for use in HIV/TB co-infected patients, and later in 2013 for use as the initial diagnostic test for all adults and children with signs and symptoms of pulmonary TB. Line probe assays (LPAs) are recommended for the detection of rifampicin and isoniazid resistance in sputum smear-positive specimens and mycobacterial cultures. A second-line line probe assay has been recommended for the diagnosis of extensively drug-resistant (XDR)-TB Assays such as the urine lateral flow (LF)-lipoarabinomannan (LAM), can be used at the point of care (POC) and have a niche role to supplement the diagnosis of TB in seriously ill HIV-infected, hospitalized patients with low CD4 cell counts of less than 100 cells/μl. Polyvalent platforms such as the m2000 (Abbott Molecular) and GeneXpert (Cepheid) offer potential for integration of HIV and TB testing services. While the Research and Development (R&D) pipeline appears to be rich at first glance, there are actually few leads for true POC tests that would allow for earlier TB diagnosis or rapid, comprehensive drug susceptibility testing, especially when considering the very high attrition rates observed between biomarker discovery and product market entry. SUMMARY In this review, we describe diagnostic strategies specifically for HIV and TB co-infected individuals. Molecular diagnostics in particular within the past 5 years have revolutionized and 'disrupted' this field. They lend themselves to integration of services with platforms capable of polyvalent testing. Impact on patient care is, however, still debatable. What has been highlighted is the need for health system strengthening and for true POC testing that can be used in active case finding.
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Affiliation(s)
- Lesley Scott
- aDepartment of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa bNational Priority Programs, National Health Laboratory Service, Johannesburg, Gauteng, South Africa cFoundation for Innovative New Diagnostics, Geneva dGlobal TB Program, WHO, Geneva, Switzerland
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Mwansa-Kambafwile J, Maitshotlo B, Black A. Microbiologically Confirmed Tuberculosis: Factors Associated with Pre-Treatment Loss to Follow-Up, and Time to Treatment Initiation. PLoS One 2017; 12:e0168659. [PMID: 28068347 PMCID: PMC5222612 DOI: 10.1371/journal.pone.0168659] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 12/05/2016] [Indexed: 11/19/2022] Open
Abstract
Background The impact of new diagnostics on pre-treatment loss to follow up (Pre-treatment LTFU) has not been widely investigated. The reported rate of pre-treatment LTFU is however lower in studies where Xpert MTB/Rif (Xpert) has been used onsite as opposed to centrally. The use of the Xpert at point of care (POC) could have a role in reducing the pre-treatment LTFU rate among TB patients. We aimed to determine the pre-treatment LTFU rate and the time to treatment initiation as well as to describe associated factors in patients diagnosed with TB using POC Xpert or smear microscopy. Method Xpert machines were installed at 7 primary healthcare facilities in inner-city Johannesburg. POC Xpert TB testing was the primary diagnostic method for all patients although there were some patients who were tested using only laboratory-based smear microscopy (during power outages or machine operator off-sick). Data on patients’ demographics, TB diagnostic test (Xpert or smear microscopy), test result, and time to treatment initiation were collected. Associations and predictors of pre-treatment LTFU and time to treatment initiation were explored. Findings A total of 1981 people with presumptive TB were tested (1743 using Xpert and 238 using smear). A bacteriological diagnosis of TB was made in 271 patients (90% Xpert; 10% smear). The median time to treatment initiation in the smear group was 9 days (IQR: 4–20) while those tested using Xpert had a median time of 0 days (IQR: 0–0). Pre-treatment LTFU was 22.5% with no difference between diagnostic groups (p = 0.8). Conclusion The Pre-treatment LTFU rate of 22.5% found in this study is much higher than the 5% target of the South African National TB Control Program. POC Xpert resulted in a significantly greater proportion of bacteriologically proven TB patients being started on treatment within 30 days of presentation. No risk factors associated with pre-treatment LTFU were identified.
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Affiliation(s)
- Judith Mwansa-Kambafwile
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
- Department of Clinical Medicine, University of Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | | | - Andrew Black
- Wits Reproductive Health and HIV Institute, Johannesburg, South Africa
- Department of Clinical Medicine, University of Witwatersrand, Johannesburg, South Africa
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Trajman A, Cobelens F. It takes more than a sensitive test to find more tuberculosis cases. THE LANCET. INFECTIOUS DISEASES 2017; 17:357-358. [PMID: 28063794 DOI: 10.1016/s1473-3099(16)30458-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Anete Trajman
- Social Medicine Institute, State University of Rio de Janeiro, Brazil; McGill University, Montréal, QC, Canada.
| | - Frank Cobelens
- Amsterdam Institute for Global Health and development, Academic Medical Center, Amsterdam, Netherlands; KNCV Tuberculosis Foundation, The Hague, Netherlands
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Stevens WS, Scott L, Noble L, Gous N, Dheda K. Impact of the GeneXpert MTB/RIF Technology on Tuberculosis Control. Microbiol Spectr 2017; 5. [PMID: 28155817 DOI: 10.1128/microbiolspec.tbtb2-0040-2016] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Indexed: 11/20/2022] Open
Abstract
Molecular technology revolutionized the diagnosis of tuberculosis (TB) with a paradigm shift to faster, more sensitive, clinically relevant patient care. The most recent molecular leader is the GeneXpert MTB/RIF assay (Xpert) (Cepheid, Sunnyvale, CA), which was endorsed by the World Health Organization with unprecedented speed in December 2010 as the initial diagnostic for detection of HIV-associated TB and for where high rates of drug resistance are suspected. South Africa elected to take an aggressive smear replacement approach to facilitate earlier diagnosis and treatment through the decision to implement the Xpert assay nationally in March 2011, against the backdrop of approximately 6.3 million HIV-infected individuals, one of highest global TB and HIV coinfection rates, no available implementation models, uncertainties around field performance and program costs, and lack of guidance on how to operationalize the assay into existing complex clinical algorithms. South Africa's national implementation was conducted as a phased, forecasted, and managed approach (March 2011 to September 2013), through political will and both treasury-funded and donor-funded support. Today there are 314 GeneXperts across 207 microscopy centers; over 8 million assays have been conducted, and South Africa accounts for over half the global test cartridge usage. As with any implementation of new technology, challenges were encountered, both predicted and unexpected. This chapter discusses the challenges and consequences of such large-scale implementation efforts, the opportunities for new innovations, and the need to strengthen health systems, as well as the impact of the Xpert assay on rifampin-sensitive and multidrug-resistant TB patient care that translated into global TB control as we move toward the sustainable development goals.
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Affiliation(s)
- Wendy Susan Stevens
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, and National Health Laboratory Service and National Priority Program of the National Health Laboratory Service, Johannesburg, South Africa
| | - Lesley Scott
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Lara Noble
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Natasha Gous
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of the Witwatersrand, and National Health Laboratory Service and National Priority Program of the National Health Laboratory Service, Johannesburg, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Kendall EA, Cohen T, Mitnick CD, Dowdy DW. Second line drug susceptibility testing to inform the treatment of rifampin-resistant tuberculosis: a quantitative perspective. Int J Infect Dis 2016; 56:185-189. [PMID: 28007660 DOI: 10.1016/j.ijid.2016.12.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 11/28/2022] Open
Abstract
Treatment failure and resistance amplification are common among patients with rifampin-resistant tuberculosis (TB). Drug susceptibility testing (DST) for second-line drugs is recommended for these patients, but logistical difficulties have impeded widespread implementation of second-line DST in many settings. To provide a quantitative perspective on the decision to scale up second-line DST, we synthesize literature on the prevalence of second-line drug resistance, the expected clinical and epidemiologic benefits of using second-line DST to ensure that patients with rifampin-resistant TB receive effective regimens, and the costs of implementing (or not implementing) second-line DST for all individuals diagnosed with rifampin-resistant TB. We conclude that, in most settings, second-line DST could substantially improve treatment outcomes for patients with rifampin-resistant TB, reduce transmission of drug-resistant TB, prevent amplification of drug resistance, and be affordable or even cost-saving. Given the large investment made in each patient treated for rifampin-resistant TB, these payoffs would come at relatively small incremental cost. These anticipated benefits likely justify addressing the real challenges faced in implementing second-line DST in most high-burden settings.
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Affiliation(s)
- Emily A Kendall
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, PCTB Suite 211, 725 N. Wolfe St, Baltimore, MD 21205, USA.
| | - Ted Cohen
- Department of Epidemiology, Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA.
| | - Carole D Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntin, gton Ave., Boston, MA, USA.
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615N. Wolfe St., Baltimore, MD 21205, USA.
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Stagg HR, White PJ, Riekstiņa V, Cīrule A, Šķenders Ģ, Leimane V, Kuksa L, Dravniece G, Brown J, Jackson C. Decreased Time to Treatment Initiation for Multidrug-Resistant Tuberculosis Patients after Use of Xpert MTB/RIF Test, Latvia. Emerg Infect Dis 2016; 22:482-90. [PMID: 26889608 PMCID: PMC4766893 DOI: 10.3201/eid2203.151227] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This test decreased time to treatment initiation by 66%–84%. Few studies have examined whether the Xpert MTB/RIF test improves time to treatment initiation for persons with multidrug-resistant tuberculosis (MDR TB). We determined the impact of this test in Latvia, where it was introduced in 2010. After descriptive analyses of pulmonary MDR TB patients in Latvia during 2009–2012, time to treatment initiation was calculated, and univariate and multivariable accelerated failure time models were constructed. Univariate results showed strong evidence of an association between having rifampin-resistant TB detected by Xpert MTB/RIF and reduced time to treatment initiation versus the test not being used. A multivariable model stratifying by previous TB showed similar results. Our finding that in Latvia, time to treatment initiation was decreased for MDR TB cases that were rifampin-resistant TB by XpertMTB/RIF has implications for the use of this test in other settings with a high burden of MDR TB in which rifampin resistance is highly predictive of MDR TB.
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75
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Auld AF, Agizew T, Pals S, Finlay A, Ndwapi N, Boyd R, Alexander H, Mathoma A, Basotli J, Gwebe-Nyirenda S, Shepherd J, Ellerbrock TV, Date A. Implementation of a pragmatic, stepped-wedge cluster randomized trial to evaluate impact of Botswana's Xpert MTB/RIF diagnostic algorithm on TB diagnostic sensitivity and early antiretroviral therapy mortality. BMC Infect Dis 2016; 16:606. [PMID: 27782821 PMCID: PMC5080709 DOI: 10.1186/s12879-016-1905-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/08/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In 2012, as a pilot for Botswana's national Xpert MTB/RIF (Xpert) rollout plans, intensified tuberculosis (TB) case finding (ICF) activities were strengthened at 22 HIV treatment clinics prior to phased activation of 13 Xpert instruments. Together, the strengthened ICF intervention and Xpert activation are referred to as the "Xpert package". METHODS The evaluation, called the Xpert Package Rollout Evaluation using a Stepped-wedge design (XPRES), has two key objectives: (1) to compare sensitivity of microscopy-based and Xpert-based pulmonary TB diagnostic algorithms in diagnosing sputum culture-positive TB; and (2) to evaluate impact of the "Xpert package" on all-cause, 6-month, adult antiretroviral therapy (ART) mortality. A pragmatic, stepped-wedge cluster-randomized trial design was chosen. The design involves enrollment of three cohorts: (1) cohort R, a retrospective cohort of all study clinic ART enrollees in the 24 months before study initiation (July 31, 2012); (2) cohort A, a prospective cohort of all consenting patients presenting to study clinics after study initiation, who received the ICF intervention and the microscopy-based TB diagnostic algorithm; and (3) cohort B, a prospective cohort of all consenting patients presenting to study clinics after Xpert activation, who received the ICF intervention and the Xpert-based TB diagnostic algorithm. TB diagnostic sensitivity will be compared between TB culture-positive enrollees in cohorts A and B. All-cause, 6-month ART-mortality will be compared between cohorts R and B. With anticipated cohort R, A, and B sample sizes of about 10,131, 1,878, and 4,258, respectively, the study is estimated to have >80 % power to detect differences in pre-versus post-Xpert TB diagnostic sensitivity if pre-Xpert sensitivity is ≤52.5 % and post-Xpert sensitivity ≥82.5 %, and >80 % power to detect a 40 % reduction in all-cause, 6-month, ART mortality between cohorts R and B if cohort R mortality is ≥13/100 person-years. DISCUSSION Only one small previous trial (N = 424) among ART enrolees in Zimbabwe evaluated, in a secondary analysis, Xpert impact on all-cause 6-month ART mortality. No mortality impact was observed. This Botswana trial, with its larger sample size and powered specifically to detect differences in all-cause 6-month ART mortality, remains well-positioned to contribute understanding of Xpert impact. TRIAL REGISTRATION Retrospectively registered at ClinicalTrials.gov: NCT02538952 .
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA.
| | - Tefera Agizew
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Sherri Pals
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Alyssa Finlay
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Division of TB Elimination, National Center for HIV, Hepatitis and STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Ndwapi Ndwapi
- Ministerial Strategy Office, Ministry of Health, 24 Amos Street, Gaborone, Botswana
| | - Rosanna Boyd
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Division of TB Elimination, National Center for HIV, Hepatitis and STD Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Heather Alexander
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Anikie Mathoma
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Joyce Basotli
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - Sambayawo Gwebe-Nyirenda
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana
| | - James Shepherd
- Centers for Disease Control and Prevention Botswana, Plot 14818 Lebatlane Road, Gaborone, Botswana.,Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Tedd V Ellerbrock
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
| | - Anand Date
- Division of Global HIV & TB, Center for Global Health, United States Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA, 30333, USA
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76
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Xpert MTB/RIF Assay Shows Faster Clearance of Mycobacterium tuberculosis DNA with Higher Levels of Rifapentine Exposure. J Clin Microbiol 2016; 54:3028-3033. [PMID: 27733634 PMCID: PMC5121396 DOI: 10.1128/jcm.01313-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 09/15/2016] [Indexed: 12/15/2022] Open
Abstract
The Xpert MTB/RIF assay is both sensitive and specific as a diagnostic test. Xpert also reports quantitative output in cycle threshold (CT) values, which may provide a dynamic measure of sputum bacillary burden when used longitudinally. We evaluated the relationship between Xpert CT trajectory and drug exposure during tuberculosis (TB) treatment to assess the potential utility of Xpert CT for treatment monitoring. We obtained serial sputum samples from patients with smear-positive pulmonary TB who were consecutively enrolled at 10 international clinical trial sites participating in study 29X, a CDC-sponsored Tuberculosis Trials Consortium study evaluating the tolerability, safety, and antimicrobial activity of rifapentine at daily doses of up to 20 mg/kg of body weight. Xpert was performed at weeks 0, 2, 4, 6, 8, and 12. Longitudinal CT data were modeled using a nonlinear mixed effects model in relation to rifapentine exposure (area under the concentration-time curve [AUC]). The rate of change of CT was higher in subjects receiving rifapentine than in subjects receiving standard-dose rifampin. Moreover, rifapentine exposure, but not assigned dose, was significantly associated with rate of change in CT (P = 0.02). The estimated increase in CT slope for every additional 100 μg · h/ml of rifapentine drug exposure (as measured by AUC) was 0.11 CT/week (95% confidence interval [CI], 0.05 to 0.17). Increasing rifapentine exposure is associated with a higher rate of change of Xpert CT, indicating faster clearance of Mycobacterium tuberculosis DNA. These data suggest that the quantitative outputs of the Xpert MTB/RIF assay may be useful as a dynamic measure of TB treatment response.
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77
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Sanaie A, Mergenthaler C, Nasrat A, Seddiq MK, Mahmoodi SD, Stevens RH, Creswell J. An Evaluation of Passive and Active Approaches to Improve Tuberculosis Notifications in Afghanistan. PLoS One 2016; 11:e0163813. [PMID: 27701446 PMCID: PMC5049786 DOI: 10.1371/journal.pone.0163813] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 09/14/2016] [Indexed: 11/19/2022] Open
Abstract
Background In Afghanistan, improving TB case detection remains challenging. In 2014, only half of the estimated incident TB cases were notified, and notifications have decreased since peaking in 2007. Active case finding has been increasingly considered to improve TB case notifications. While access to health services has improved in Afghanistan, it remains poor and many people seeking health services won’t receive proper care. Methods From October 2011 through December 2012 we conducted three separate case finding strategies in six provinces of Afghanistan and measured impact on TB case notification. Systematically screening cough among attendees at 47 health facilities, active household contact investigation of smear-positive index TB patients, and active screening at 15 camps for internally displaced people were conducted. We collected both intervention yield and official quarterly notification data. Additional TB notifications were calculated by comparing numbers of cases notified during the intervention with those notified before the intervention, then adjusting for secular trends in notification. Results We screened 2,022,127 people for TB symptoms during the intervention, tested 59,838 with smear microscopy and detected 5,046 people with smear-positive TB. Most cases (81.7%, 4,125) were identified in health facilities while nearly 20% were found through active case finding. A 56% increase in smear-positive TB notifications was observed between the baseline and intervention periods among the 47 health facilities, where cases detected by all three strategies were notified. Discussion While most people with TB are likely to be identified through health facility screening, there are many people who remain without a proper diagnosis if outreach is not attempted. This is especially true in places like Afghanistan where access to general services is poor. Targeted active case finding can improve the number of people who are detected and treated for TB and can push towards the targets of the Stop TB Global Plan and End TB Strategy.
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Affiliation(s)
- A. Sanaie
- Anti-TB Association Afghanistan, Kabul, Afghanistan
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78
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Auld AF, Fielding KL, Gupta-Wright A, Lawn SD. Xpert MTB/RIF - why the lack of morbidity and mortality impact in intervention trials? Trans R Soc Trop Med Hyg 2016; 110:432-44. [PMID: 27638038 DOI: 10.1093/trstmh/trw056] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 08/10/2016] [Indexed: 11/13/2022] Open
Abstract
Compared with smear microscopy, the Xpert MTB/RIF assay (Xpert), with superior accuracy and capacity to diagnose rifampicin resistance, has advanced TB diagnostic capability. However, recent trials of Xpert impact have not demonstrated reductions in patient morbidity and mortality. We conducted a narrative review of Xpert impact trials to summarize which patient-relevant outcomes Xpert has improved and explore reasons for no observed morbidity or mortality reductions. We searched PubMed, Google Scholar, Cochrane Library and Embase and identified eight trials meeting inclusion criteria: three individually randomized, three cluster-randomized, and two pre-post trials. In six trials Xpert increased diagnostic yield of bacteriologically-confirmed TB from sputa and in four trials Xpert shortened time to TB treatment. However, all-cause mortality was similar between arms in all six trials reporting this outcome, and the only trial to assess Xpert impact on morbidity reported no impact. Trial characteristics that might explain lack of observed impact on morbidity and mortality include: higher rates of empiric TB treatment in microscopy compared with Xpert arms, enrollment of study populations not comprised exclusively of populations most likely to benefit from Xpert, and health system weaknesses. So far as equipoise exists, future trials that address past limitations are needed to inform Xpert use in resource-limited settings.
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & Tuberculosis, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, 30333, USA
| | - Katherine L Fielding
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E7HT, UK
| | - Ankur Gupta-Wright
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E7HT, UK
| | - Stephen D Lawn
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E7HT, UK The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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79
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Trajman A, Menzies D. Active tuberculosis case finding-do we have the right tool? THE LANCET. INFECTIOUS DISEASES 2016; 16:986-987. [PMID: 27289388 DOI: 10.1016/s1473-3099(16)30133-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 05/18/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Anete Trajman
- Instituto de Medicina Social, Rio de Janeiro State University, Rua São Francisco Xavier 524, Rio de Janeiro 20550-013, Brazil; McGill University, Montreal, QC, Canada.
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80
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Albert H, Nathavitharana RR, Isaacs C, Pai M, Denkinger CM, Boehme CC. Development, roll-out and impact of Xpert MTB/RIF for tuberculosis: what lessons have we learnt and how can we do better? Eur Respir J 2016; 48:516-25. [PMID: 27418550 PMCID: PMC4967565 DOI: 10.1183/13993003.00543-2016] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/14/2016] [Indexed: 12/03/2022]
Abstract
The global roll-out of Xpert MTB/RIF (Cepheid Inc., Sunnyvale, CA, USA) has changed the diagnostic landscape of tuberculosis (TB). More than 16 million tests have been performed in 122 countries since 2011, and detection of multidrug-resistant TB has increased three- to eight-fold compared to conventional testing. The roll-out has galvanised stakeholders, from donors to civil society, and paved the way for universal drug susceptibility testing. It has attracted new product developers to TB, resulting in a robust molecular diagnostics pipeline. However, the roll-out has also highlighted gaps that have constrained scale-up and limited impact on patient outcomes. The roll-out has been hampered by high costs for under-funded programmes, unavailability of a complete solution package (notably comprehensive training, quality assurance, implementation plans, inadequate service and maintenance support) and lack of impact assessment. Insufficient focus has been afforded to effective linkage to care of diagnosed patients, and clinical impact has been blunted by weak health systems. In many countries the private sector plays a dominant role in TB control, yet this sector has limited access to subsidised pricing. In light of these lessons, we advocate for a comprehensive diagnostics implementation approach, including increased engagement of in-country stakeholders for product launch and roll-out, broader systems strengthening in preparation for new technologies, as well as quality impact data from programmatic settings. A comprehensive diagnostic solution approach including systems strengthening is essential for TB diagnostics impacthttp://ow.ly/uWSy300CfJT
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Affiliation(s)
| | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Madhukar Pai
- Dept of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Claudia M Denkinger
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA FIND, Geneva, Switzerland
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81
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Schito M, Migliori GB, Fletcher HA, McNerney R, Centis R, D'Ambrosio L, Bates M, Kibiki G, Kapata N, Corrah T, Bomanji J, Vilaplana C, Johnson D, Mwaba P, Maeurer M, Zumla A. Perspectives on Advances in Tuberculosis Diagnostics, Drugs, and Vaccines. Clin Infect Dis 2016; 61Suppl 3:S102-18. [PMID: 26409271 DOI: 10.1093/cid/civ609] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite concerted efforts over the past 2 decades at developing new diagnostics, drugs, and vaccines with expanding pipelines, tuberculosis remains a global emergency. Several novel diagnostic technologies show promise of better point-of-care rapid tests for tuberculosis including nucleic acid-based amplification tests, imaging, and breath analysis of volatile organic compounds. Advances in new and repurposed drugs for use in multidrug-resistant (MDR) or extensively drug-resistant (XDR) tuberculosis have focused on development of several new drug regimens and their evaluation in clinical trials and now influence World Health Organization guidelines. Since the failure of the MVA85A vaccine 2 years ago, there have been no new tuberculosis vaccine candidates entering clinical testing. The current status quo of the lengthy treatment duration and poor treatment outcomes associated with MDR/XDR tuberculosis and with comorbidity of tuberculosis with human immunodeficiency virus and noncommunicable diseases is unacceptable. New innovations and political and funder commitment for early rapid diagnosis, shortening duration of therapy, improving treatment outcomes, and prevention are urgently required.
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Affiliation(s)
- Marco Schito
- Critical Path to TB Drug Regimens, Critical Path Institute, Tucson, Arizona
| | - Giovanni Battista Migliori
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Helen A Fletcher
- Department of Immunology and Infection, London School of Hygiene and Tropical Medicine
| | | | - Rosella Centis
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Lia D'Ambrosio
- World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | - Matthew Bates
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Gibson Kibiki
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Nathan Kapata
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Tumena Corrah
- Department of Infectious Diseases and Tropical Medicine, Northwick Park Hospital
| | - Jamshed Bomanji
- Department of Nuclear Imaging, University College London Hospitals NHS Foundation Trust, United Kingdom
| | - Cris Vilaplana
- Unitat de Tuberculosi Experimental, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Ctra. de Can Ruti, Camí de les Escoles, Barcelona, Spain
| | - Daniel Johnson
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Peter Mwaba
- University of Zambia-University College London Medical School Research and Training Project, University Teaching Hospital, Lusaka, Zambia
| | - Markus Maeurer
- Therapeutic Immunology, Departments of Laboratory Medicine and Microbiology, Tumour and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London and National Institute for Health Research Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, United Kingdom
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82
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Langley I, Squire SB, Dacombe R, Madan J, Lapa e Silva JR, Barreira D, Galliez R, Oliveira MM, Fujiwara PI, Kritski A. Developments in Impact Assessment of New Diagnostic Algorithms for Tuberculosis Control. Clin Infect Dis 2016; 61Suppl 3:S126-34. [PMID: 26409273 DOI: 10.1093/cid/civ580] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A modified presentation of the impact assessment framework is proposed that improves accessibility while continuing to provide a checklist of the evidence needed to support policy decisions on the implementation of new tools for the diagnosis of tuberculosis.
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Affiliation(s)
- Ivor Langley
- Clinical Sciences and Centre for Applied Health Research and Delivery
| | - S Bertel Squire
- Clinical Sciences and Centre for Applied Health Research and Delivery
| | | | - Jason Madan
- Warwick Medical School and Centre for Applied Health Research and Delivery, University of Warwick, United Kingdom
| | | | | | | | - Martha Maria Oliveira
- Rede-TB, Center for Technological Development in Health-Fiocruz, Rio de Janeiro, Brazil
| | - Paula I Fujiwara
- International Union Against Tuberculosis and Lung Disease, Paris, France
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83
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Auld SC, Moore BK, Kyle RP, Eng B, Nong K, Pevzner ES, Eam KK, Eang MT, Killam WP. Mixed impact of Xpert(®) MTB/RIF on tuberculosis diagnosis in Cambodia. Public Health Action 2016; 6:129-35. [PMID: 27358807 DOI: 10.5588/pha.16.0001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/01/2016] [Indexed: 01/04/2023] Open
Abstract
SETTING National Tuberculosis (TB) Program sites in northwest Cambodia. OBJECTIVE To evaluate the impact of Xpert(®) MTB/RIF at point of care (POC) as compared to non-POC sites on the diagnostic evaluation of people living with the human immunodeficiency virus (PLHIV) with TB symptoms and patients with possible multidrug-resistant (MDR) TB. DESIGN Observational cohort of patients undergoing routine diagnostic evaluation for TB following the rollout of Xpert. RESULTS Between October 2011 and June 2013, 431 of 822 (52%) PLHIV with TB symptoms and 240/493 (49%) patients with possible MDR-TB underwent Xpert. Xpert was more likely to be performed when available as POC. A smaller proportion of PLHIV at POC sites were diagnosed with TB than at non-POC sites; however, at POC sites, a higher proportion of those diagnosed with TB were bacteriologically positive. There was poor agreement between Xpert and other tests such as smear microscopy and culture. Overall, the evaluation of patients with possible MDR-TB increased following Xpert rollout, yet for patients confirmed as having drug resistance on drug susceptibility testing, only 46% had rifampin resistance that would be identified with Xpert. CONCLUSION Although utilization of Xpert was low, it may have contributed to an increase in evaluations for possible MDR-TB and a decline in empiric treatment for PLHIV when available as POC.
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Affiliation(s)
- S C Auld
- Division of Global HIV/TB, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA ; Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - B K Moore
- Division of Global HIV/TB, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - R P Kyle
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - B Eng
- Division of Global HIV/TB, CDC, Phnom Penh, Cambodia
| | - K Nong
- Division of Global HIV/TB, CDC, Phnom Penh, Cambodia
| | - E S Pevzner
- Division of Global HIV/TB, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia, USA
| | - K K Eam
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - M T Eang
- National Center for Tuberculosis and Leprosy Control, Phnom Penh, Cambodia
| | - W P Killam
- Division of Global HIV/TB, CDC, Phnom Penh, Cambodia
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84
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Barker D, McElduff P, D'Este C, Campbell MJ. Stepped wedge cluster randomised trials: a review of the statistical methodology used and available. BMC Med Res Methodol 2016; 16:69. [PMID: 27267471 PMCID: PMC4895892 DOI: 10.1186/s12874-016-0176-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous reviews have focussed on the rationale for employing the stepped wedge design (SWD), the areas of research to which the design has been applied and the general characteristics of the design. However these did not focus on the statistical methods nor addressed the appropriateness of sample size methods used.This was a review of the literature of the statistical methodology used in stepped wedge cluster randomised trials. METHODS Literature Review. The Medline, Embase, PsycINFO, CINAHL and Cochrane databases were searched for methodological guides and RCTs which employed the stepped wedge design. RESULTS This review identified 102 trials which employed the stepped wedge design compared to 37 from the most recent review by Beard et al. 2015. Forty six trials were cohort designs and 45 % (n = 46) had fewer than 10 clusters. Of the 42 articles discussing the design methodology 10 covered analysis and seven covered sample size. For cohort stepped wedge designs there was only one paper considering analysis and one considering sample size methods. Most trials employed either a GEE or mixed model approach to analysis (n = 77) but only 22 trials (22 %) estimated sample size in a way which accounted for the stepped wedge design that was subsequently used. CONCLUSIONS Many studies which employ the stepped wedge design have few clusters but use methods of analysis which may require more clusters for unbiased and efficient intervention effect estimates. There is the need for research on the minimum number of clusters required for both types of stepped wedge design. Researchers should distinguish in the sample size calculation between cohort and cross sectional stepped wedge designs. Further research is needed on the effect of adjusting for the potential confounding of time on the study power.
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Affiliation(s)
- D Barker
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - P McElduff
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - C D'Este
- School of Medicine and Public Health, Faculty of Health, CCEB, HMRI Building, Level 4 West, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.,National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, ACT, 0200, Australia
| | - M J Campbell
- Medical Statistics Group, ScHARR, University of Sheffield, Sheffield, UK
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Programmatic Management of Drug-Resistant Tuberculosis: An Updated Research Agenda. PLoS One 2016; 11:e0155968. [PMID: 27223622 PMCID: PMC4880345 DOI: 10.1371/journal.pone.0155968] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/07/2016] [Indexed: 12/03/2022] Open
Abstract
Introduction There are numerous challenges in delivering appropriate treatment for multidrug-resistant tuberculosis (MDR-TB) and the evidence base to guide those practices remains limited. We present the third updated Research Agenda for the programmatic management of drug-resistant TB (PMDT), assembled through a literature review and survey. Methods Publications citing the 2008 research agenda and normative documents were reviewed for evidence gaps. Gaps were formulated into questions and grouped as in the 2008 research agenda: Laboratory Support, Treatment Strategy, Programmatically Relevant Research, Epidemiology, and Management of Contacts. A survey was distributed through snowball sampling to identify research priorities. Respondent priority rankings were scored and summarized by mean. Sensitivity analyses explored weighting and handling of missing rankings. Results Thirty normative documents and publications were reviewed for stated research needs; these were collapsed into 56 research questions across 5 categories. Of more than 500 survey recipients, 133 ranked priorities within at least one category. Priorities within categories included new diagnostics and their effect on improving treatment outcomes, improved diagnosis of paucibacillary and extra pulmonary TB, and development of shorter, effective regimens. Interruption of nosocomial transmission and treatment for latent TB infection in contacts of known MDR−TB patients were also top priorities in their respective categories. Results were internally consistent and robust. Discussion Priorities retained from the 2008 research agenda include shorter MDR-TB regimens and averting transmission. Limitations of recent advances were implied in the continued quest for: shorter regimens containing new drugs, rapid diagnostics that improve treatment outcomes, and improved methods of estimating burden without representative data. Conclusion There is continuity around the priorities for research in PMDT. Coordinated efforts to address questions regarding shorter treatment regimens, knowledge of disease burden without representative data, and treatment for LTBI in contacts of known DR-TB patients are essential to stem the epidemic of TB, including DR-TB.
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86
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Schumacher SG, Sohn H, Qin ZZ, Gore G, Davis JL, Denkinger CM, Pai M. Impact of Molecular Diagnostics for Tuberculosis on Patient-Important Outcomes: A Systematic Review of Study Methodologies. PLoS One 2016; 11:e0151073. [PMID: 26954678 PMCID: PMC4783056 DOI: 10.1371/journal.pone.0151073] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/23/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Several reviews on the accuracy of Tuberculosis (TB) Nucleic Acid Amplification Tests (NAATs) have been performed but the evidence on their impact on patient-important outcomes has not been systematically reviewed. Given the recent increase in research evaluating such outcomes and the growing list of TB NAATs that will reach the market over the coming years, there is a need to bring together the existing evidence on impact, rather than accuracy. We aimed to assess the approaches that have been employed to measure the impact of TB NAATs on patient-important outcomes in adults with possible pulmonary TB and/or drug-resistant TB. METHODS We first develop a conceptual framework to clarify through which mechanisms the improved technical performance of a novel TB test may lead to improved patient outcomes and outline which designs may be used to measure them. We then systematically review the literature on studies attempting to assess the impact of molecular TB diagnostics on such outcomes and provide a narrative synthesis of designs used, outcomes assessed and risk of bias across different study designs. RESULTS We found 25 eligible studies that assessed a wide range of outcomes and utilized a variety of experimental and observational study designs. Many potentially strong design options have never been used. We found that much of the available evidence on patient-important outcomes comes from a small number of settings with particular epidemiological and operational context and that confounding, time trends and incomplete outcome data receive insufficient attention. CONCLUSIONS A broader range of designs should be considered when designing studies to assess the impact of TB diagnostics on patient outcomes and more attention needs to be paid to the analysis as concerns about confounding and selection bias become relevant in addition to those on measurement that are of greatest concern in accuracy studies.
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Affiliation(s)
- Samuel G. Schumacher
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Hojoon Sohn
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Zhi Zhen Qin
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
| | - Genevieve Gore
- McGill University, Schulich Library of Science and Engineering, Montreal, Canada
| | - J. Lucian Davis
- UCSF Pulmonary & Critical Care Medicine, San Francisco, United States of America
| | - Claudia M. Denkinger
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
- Beth Israel Deaconess Medical Centre, Division of Infectious Disease, Boston, MA, United States of America
| | - Madhukar Pai
- McGill University Department of Epidemiology & Biostatistics, Montreal, Canada
- McGill International TB Centre, Montreal, Canada
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87
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Naidoo P, Dunbar R, Lombard C, du Toit E, Caldwell J, Detjen A, Squire SB, Enarson DA, Beyers N. Comparing Tuberculosis Diagnostic Yield in Smear/Culture and Xpert® MTB/RIF-Based Algorithms Using a Non-Randomised Stepped-Wedge Design. PLoS One 2016; 11:e0150487. [PMID: 26930400 PMCID: PMC4773132 DOI: 10.1371/journal.pone.0150487] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 02/15/2016] [Indexed: 11/21/2022] Open
Abstract
Setting Primary health services in Cape Town, South Africa. Study Aim To compare tuberculosis (TB) diagnostic yield in an existing smear/culture-based and a newly introduced Xpert® MTB/RIF-based algorithm. Methods TB diagnostic yield (the proportion of presumptive TB cases with a laboratory diagnosis of TB) was assessed using a non-randomised stepped-wedge design as sites transitioned to the Xpert® based algorithm. We identified the full sequence of sputum tests recorded in the electronic laboratory database for presumptive TB cases from 60 primary health sites during seven one-month time-points, six months apart. Differences in TB yield and temporal trends were estimated using a binomial regression model. Results TB yield was 20.9% (95% CI 19.9% to 22.0%) in the smear/culture-based algorithm compared to 17.9% (95%CI 16.4% to 19.5%) in the Xpert® based algorithm. There was a decline in TB yield over time with a mean risk difference of -0.9% (95% CI -1.2% to -0.6%) (p<0.001) per time-point. When estimates were adjusted for the temporal trend, TB yield was 19.1% (95% CI 17.6% to 20.5%) in the smear/culture-based algorithm compared to 19.3% (95% CI 17.7% to 20.9%) in the Xpert® based algorithm with a risk difference of 0.3% (95% CI -1.8% to 2.3%) (p = 0.796). Culture tests were undertaken for 35.5% of smear-negative compared to 17.9% of Xpert® negative low MDR-TB risk cases and for 82.6% of smear-negative compared to 40.5% of Xpert® negative high MDR-TB risk cases in respective algorithms. Conclusion Introduction of an Xpert® based algorithm did not produce the expected increase in TB diagnostic yield. Studies are required to assess whether improving adherence to the Xpert® negative algorithm for HIV-infected individuals will increase yield. In light of the high cost of Xpert®, a review of its role as a screening test for all presumptive TB cases may be warranted.
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Affiliation(s)
- Pren Naidoo
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- * E-mail:
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Elizabeth du Toit
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Judy Caldwell
- City of Cape Town Health Directorate, Cape Town, South Africa
| | - Anne Detjen
- The International Union against TB and Lung Disease, Paris, France
| | - S. Bertel Squire
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Nulda Beyers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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88
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Trajman A, Bastos ML, Belo M, Calaça J, Gaspar J, Dos Santos AM, Dos Santos CM, Brito RT, Wells WA, Cobelens FG, Vassall A, Gomez GB. Shortened first-line TB treatment in Brazil: potential cost savings for patients and health services. BMC Health Serv Res 2016; 16:27. [PMID: 26800677 PMCID: PMC4722708 DOI: 10.1186/s12913-016-1269-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 01/12/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Shortened treatment regimens for tuberculosis are under development to improve treatment outcomes and reduce costs. We estimated potential savings from a societal perspective in Brazil following the introduction of a hypothetical four-month regimen for tuberculosis treatment. METHODS Data were gathered in ten randomly selected health facilities in Rio de Janeiro. Health service costs were estimated using an ingredient approach. Patient costs were estimated from a questionnaire administered to 126 patients. Costs per visits and per case treated were analysed according to the type of therapy: self-administered treatment (SAT), community- and facility-directly observed treatment (community-DOT, facility-DOT). RESULTS During the last 2 months of treatment, the largest savings could be expected for community-DOT; on average USD 17,351-18,203 and USD 43,660-45,856 (bottom-up and top-down estimates) per clinic. Savings to patients could also be expected as the median (interquartile range) patient-related costs during the two last months were USD 108 (13-291), USD 93 (36-239) and USD 11 (7-126), respectively for SAT, facility-DOT and community-DOT. CONCLUSION Introducing a four-month regimen may result in significant cost savings for both the health service and patients, especially the poorest. In particular, a community-DOT strategy, including treatment at home, could maximise health services savings while limiting patient costs. Our cost estimates are likely to be conservative because a 4-month regimen could hypothetically increase the proportion of patients cured by reducing the number of patients defaulting and we did not include the possible cost benefits from the subsequent prevention of costs due to downstream transmission averted and rapid clinical improvement with less side effects in the last two months.
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Affiliation(s)
- Anete Trajman
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil. .,McGill University, Montreal, Canada. .,Tuberculosis Scientific League, Rio de Janeiro, Brazil.
| | - Mayara Lisboa Bastos
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Tuberculosis Scientific League, Rio de Janeiro, Brazil
| | - Marcia Belo
- Tuberculosis Scientific League, Rio de Janeiro, Brazil.,Souza Marques Foundation, Rio de Janeiro, Brazil
| | | | - Júlia Gaspar
- Tuberculosis Scientific League, Rio de Janeiro, Brazil
| | | | | | | | - William A Wells
- Global Alliance for TB Drug Development, New York, USA.,Current address: United States Agency for International Development, Washington, DC, USA
| | - Frank G Cobelens
- Amsterdam Institute for Global Health and Development and Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Gabriela B Gomez
- Amsterdam Institute for Global Health and Development and Department of Global Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
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89
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Theron G, Jenkins HE, Cobelens F, Abubakar I, Khan AJ, Cohen T, Dowdy DW. Data for action: collection and use of local data to end tuberculosis. Lancet 2015; 386:2324-33. [PMID: 26515676 PMCID: PMC4708262 DOI: 10.1016/s0140-6736(15)00321-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Accelerating progress in the fight against tuberculosis will require a drastic shift from a strategy focused on control to one focused on elimination. Successful disease elimination campaigns are characterised by locally tailored responses that are informed by appropriate data. To develop such a response to tuberculosis, we suggest a three-step process that includes improved collection and use of existing programmatic data, collection of additional data (eg, geographic information, drug resistance, and risk factors) to inform tailored responses, and targeted collection of novel data (eg, sequencing data, targeted surveys, and contact investigations) to improve understanding of tuberculosis transmission dynamics. Development of a locally targeted response for tuberculosis will require substantial investment to reconfigure existing systems, coupled with additional empirical data to evaluate the effectiveness of specific approaches. Without adoption of an elimination strategy that uses local data to target hotspots of transmission, ambitious targets to end tuberculosis will almost certainly remain unmet.
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Affiliation(s)
- Grant Theron
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, and South African Medical Research Council Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa; Lung Infection and Immunity Unit, Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Helen E Jenkins
- Department of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Frank Cobelens
- KNCV Tuberculosis Foundation, The Hague, Netherlands; Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, Netherlands
| | | | - Aamir J Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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91
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Durovni B, Saraceni V, van den Hof S, Trajman A, Cordeiro-Santos M, Cavalcante S, Menezes A, Cobelens F. Correction: Impact of Replacing Smear Microscopy with Xpert MTB/RIF for Diagnosing Tuberculosis in Brazil: A Stepped-Wedge Cluster-Randomized Trial. PLoS Med 2015; 12:e1001928. [PMID: 26632815 PMCID: PMC4669082 DOI: 10.1371/journal.pmed.1001928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
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Pinto M, Entringer AP, Steffen R, Trajman A. Cost analysis of nucleic acid amplification for diagnosing pulmonary tuberculosis, within the context of the Brazilian Unified Health Care System. J Bras Pneumol 2015; 41:536-8. [PMID: 26785963 PMCID: PMC4722795 DOI: 10.1590/s1806-37562015000004524] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 07/14/2015] [Indexed: 11/22/2022] Open
Abstract
We estimated the costs of a molecular test for Mycobacterium tuberculosis and resistance to rifampin (Xpert MTB/RIF) and of smear microscopy, within the Brazilian Sistema Único de Saúde (SUS, Unified Health Care System). In SUS laboratories in the cities of Rio de Janeiro and Manaus, we performed activity-based costing and micro-costing. The mean unit costs for Xpert MTB/RIF and smear microscopy were R$35.57 and R$14.16, respectively. The major cost drivers for Xpert MTB/RIF and smear microscopy were consumables/reagents and staff, respectively. These results might facilitate future cost-effectiveness studies and inform the decision-making process regarding the expansion of Xpert MTB/RIF use in Brazil.
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Affiliation(s)
- Márcia Pinto
- . Instituto de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro (RJ) Brasil
| | - Aline Piovezan Entringer
- . Instituto de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro (RJ) Brasil
| | - Ricardo Steffen
- . Programa de Pós-Graduação em Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro (RJ) Brasil
| | - Anete Trajman
- . Programa de Pós-Graduação em Clínica Médica, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro (RJ) Brasil
- . Montreal Chest Institute, McGill University, Montreal (QC) Canada
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93
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Should countries implement Xpert MTB/RIF when empirical treatment precludes a clinical effect? THE LANCET RESPIRATORY MEDICINE 2015. [PMID: 26208997 DOI: 10.1016/s2213-2600(15)00231-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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94
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Calligaro GL, Theron G, Khalfey H, Peter J, Meldau R, Matinyenya B, Davids M, Smith L, Pooran A, Lesosky M, Esmail A, Miller MG, Piercy J, Michell L, Dawson R, Raine RI, Joubert I, Dheda K. Burden of tuberculosis in intensive care units in Cape Town, South Africa, and assessment of the accuracy and effect on patient outcomes of the Xpert MTB/RIF test on tracheal aspirate samples for diagnosis of pulmonary tuberculosis: a prospective burden of disease study with a nested randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2015. [PMID: 26208996 DOI: 10.1016/s2213-2600(15)00198-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND There are few prospective data about the incidence and mortality associated with pulmonary tuberculosis in intensive care units (ICUs), and none on the accuracy and clinical effect of the Xpert-MTB/RIF assay in this setting. We aimed to measure the frequency of culture-positive tuberculosis in ICUs in Cape Town, South Africa and to assess the performance and effect on patient outcomes of Xpert MTB/RIF versus smear microscopy for diagnosis of tuberculosis. METHODS We did a prospective burden of disease study with a randomised controlled substudy at the ICUs of four hospitals in Cape Town. Mechanically ventilated adults (≥18 years) with suspected pulmonary tuberculosis admitted between Aug 1, 2010, and July 31, 2013 (irrespective of the reason for admission), were prospectively investigated by culture, and by Xpert-MTB/RIF testing or smear microscopy, of tracheal aspirate samples. In the substudy, patients were randomly assigned (1:1), via a computer-generated allocation list, to smear microscopy or Xpert MTB/RIF. Participants, caregivers, and outcome assessors were not masked to group assignment. Only the laboratory staff were blinded to the clinical details of the participants. In November, 2012, Xpert MTB/RIF was adopted as the initial diagnostic test for respiratory samples in Western Cape province. Thereafter, patients received Xpert MTB/MIF and culture as standard of care. For the whole study cohort, the primary outcome was the frequency of bacteriologically confirmed tuberculosis. The primary endpoint of the randomised substudy was the proportion of culture-positive patients on treatment at 48 h after enrolment. The randomised substudy is registered with ClinicalTrials.gov, number NCT01530568. FINDINGS We investigated 341 patients for suspected pulmonary tuberculosis out of a total of 2309 ICU admissions. 46 (15%) of 317 patients included in the final analysis had a positive test for tuberculosis (Xpert MTB/RIF or culture). Culture-positive patients who failed to initiate treatment (adjusted HR 4·49, 95% CI 1·45-13·89) or who received inotropes (4·33, 1·49-12·60) were more likely to die. However, tuberculosis status was not associated with 28-day or 90-day mortality. In the substudy, we randomly assigned 115 patients to smear microscopy and 111 to Xpert MTB/RIF. Smear microscopy detected six (43%) of 14 culture-positive patients, and Xpert MTB/RIF detected 11 (100%) of 11 culture-positive patients (p=0·002). The proportion of culture-positive patients on treatment at 48 h was higher in the Xpert MTB/RIF group than in the smear microscopy group (11 [92%] of 12 vs nine [53%] of 17; p=0·043), although use of Xpert MTB/RIF had no effect on mortality or other patient outcomes. INTERPRETATION Tuberculosis is fairly common in ICUs in high-burden settings, and clinicians should screen and test patients for tuberculosis with Xpert MTB/RIF where available. This test improves diagnostic yield and rates of treatment initiation, and reduces unnecessary treatment, but might not increase the total number of patients on treatment when empirical treatment is widely used. A suspected diagnosis of pulmonary tuberculosis should not exclude patients from ICU care in resource-limited settings because mortality is unaffected by the presence of this disease. FUNDING European and Developing Countries Clinical Trials Partnership, South African Medical Research Council, and the Discovery Foundation.
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Affiliation(s)
- Gregory L Calligaro
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Grant Theron
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Hoosain Khalfey
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Jonathan Peter
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Richard Meldau
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Brian Matinyenya
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Malika Davids
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Liezel Smith
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Anil Pooran
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Maia Lesosky
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aliasgar Esmail
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Malcolm G Miller
- Division of Critical Care, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Jenna Piercy
- Division of Critical Care, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Lancelot Michell
- Division of Critical Care, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Rodney Dawson
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Richard I Raine
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Ivan Joubert
- Division of Critical Care, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.
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Abstract
The challenge of diagnosing childhood tuberculosis (TB) results from its paucibacillary nature and the difficulties of sputum collection in children. Mycobacterial culture, the diagnostic gold standard, provides microbiological confirmation in only 30% to 40% of childhood pulmonary TB cases and takes up to 6 weeks to result. Conventional drug susceptibility testing requires an additional 2 to 4 weeks after culture confirmation. In response to the low sensitivity and long wait time of the traditional diagnostic approach, many new assays have been developed. These new tools have shortened time to result; however, none of them offer greater sensitivity than culture.
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Affiliation(s)
- Silvia S Chiang
- Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, 1102 Bates Street, Suite 1150, Houston, TX 77030, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Douglas S Swanson
- Division of Infectious Diseases, Department of Pediatrics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Jeffrey R Starke
- Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine, 1102 Bates Street, Suite 1150, Houston, TX 77030, USA.
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Impact of the Xpert MTB/RIF diagnostic test for tuberculosis in countries with a high burden of disease. Curr Opin Pulm Med 2015; 21:304-8. [DOI: 10.1097/mcp.0000000000000161] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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97
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Trajman A, Durovni B, Saraceni V, Menezes A, Cordeiro-Santos M, Cobelens F, Van den Hof S. Impact on Patients' Treatment Outcomes of XpertMTB/RIF Implementation for the Diagnosis of Tuberculosis: Follow-Up of a Stepped-Wedge Randomized Clinical Trial. PLoS One 2015; 10:e0123252. [PMID: 25915745 PMCID: PMC4411054 DOI: 10.1371/journal.pone.0123252] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 02/27/2015] [Indexed: 11/19/2022] Open
Abstract
Introduction The impact on treatment outcomes of XpertMTB/RIF, a molecular-based test that provides rapid diagnosis of tuberculosis (TB) and rifampicin resistance with high accuracy, has not been reported despite its adoption in a few countries. We here report treatment outcomes in a step-wedged cluster randomized trial for patients diagnosed with XpertMTB/RIF compared to patients diagnosed with sputum smear examination in public health facilities in Brazil. Methods Treatment outcome data were added to the trial database of patients diagnosed from 4 February to 4 October 2012, and crosschecked with data from the national mortality and the drug-resistant TB registers. Treatment outcomes in the intervention (n=2232) and baseline (n=1856) arms were compared using a multilevel regression model. Results Unfavourable outcomes were frequent in both arms, mainly due to loss to follow-up (16%). Overall unfavourable outcomes were not reduced in the intervention arm (29.6% versus 31.7%, OR=0.93; 95%CI=0.79-1.08). However, the overall TB-attributed death rate was lower in the intervention arm (2.3% vs. 3.8%). Adjusted for HIV status, age group and city, the intervention resulted in a 35% decrease in TB-attributed deaths (OR=0.65, 95%CI=0.44-0.97). Conclusions The proportion of patients successfully treated did not increase with Xpert MTB/RIF implementation, with high loss to follow-up rates in both arms. We did observe a 35% reduction in TB-related mortality, which we hypothesize may be explained by less advanced disease among the smear-negative patients diagnosed by Xpert. In conclusion, XpertMTB/RIF introduction did not improve TB treatment outcomes in Brazil. Trial Registration clinicaltrials.gov NCT01363765
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Affiliation(s)
- Anete Trajman
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- McGill University, Montreal, Canada
- * E-mail:
| | - Betina Durovni
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Rio de Janeiro City Health Secretariat, Rio de Janeiro, Brazil
| | - Valeria Saraceni
- Rio de Janeiro City Health Secretariat, Rio de Janeiro, Brazil
- Dr. Heitor Dourado Vieira Foundation of Tropical Medicine, Manaus, Brazil
| | | | - Marcelo Cordeiro-Santos
- Dr. Heitor Dourado Vieira Foundation of Tropical Medicine, Manaus, Brazil
- Amazonas State University, Manaus, Brazil
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, Netherlands
- KNCV Foundation, The Hague, Netherlands
| | - Susan Van den Hof
- Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, Netherlands
- KNCV Foundation, The Hague, Netherlands
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Mycobacterium tuberculosis: 2014 Clinical trials in review. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2015; 26:11-4. [PMID: 25798148 PMCID: PMC4353263 DOI: 10.1155/2015/984635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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