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Dinkele R, Gessner S, Patterson B, McKerry A, Hoosen Z, Vazi A, Seldon R, Koch A, Warner DF, Wood R. Persistent Mycobacterium tuberculosis bioaerosol release in a tuberculosis-endemic setting. iScience 2024; 27:110731. [PMID: 39310776 PMCID: PMC11414687 DOI: 10.1016/j.isci.2024.110731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/22/2024] [Accepted: 08/12/2024] [Indexed: 09/25/2024] Open
Abstract
Pioneering studies linking symptomatic disease and cough-mediated Mycobacterium tuberculosis (Mtb) release established the infectious origin of tuberculosis (TB), simultaneously informing the notion that pathology is a prerequisite for Mtb transmission. Our recent work has challenged this assumption: by sampling TB clinic attendees, we detected equivalent release of Mtb-containing bioaerosols by confirmed TB patients and individuals not receiving a TB diagnosis and observed time-dependent reduction in Mtb bioaerosol positivity during 6-month follow-up of both cohorts, irrespective of anti-TB chemotherapy. Now, we report widespread Mtb release in our TB-endemic setting: of 89 randomly recruited community members, 79.8% (71/89) produced Mtb-containing bioaerosols independently of QuantiFERON status, a standard test for Mtb exposure. Moreover, during 2-month longitudinal sampling, only 2% (1/50) were serially Mtb bioaerosol negative. These results necessitate a reframing of the prevailing paradigm of Mtb transmission and TB etiology, perhaps explaining the historical inability to elucidate Mtb transmission networks in TB-endemic regions.
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Affiliation(s)
- Ryan Dinkele
- UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - Sophia Gessner
- UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - Benjamin Patterson
- Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam 1105, the Netherlands
| | - Andrea McKerry
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town 7925, South Africa
| | - Zeenat Hoosen
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town 7925, South Africa
| | - Andiswa Vazi
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town 7925, South Africa
| | - Ronnett Seldon
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town 7925, South Africa
| | - Anastasia Koch
- UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - Digby F. Warner
- UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
| | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7925, South Africa
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town 7925, South Africa
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Nduba V, Njagi LN, Murithi W, Mwongera Z, Byers J, Logioia G, Peterson G, Segnitz RM, Fennelly K, Hawn TR, Horne DJ. Mycobacterium tuberculosis cough aerosol culture status associates with host characteristics and inflammatory profiles. Nat Commun 2024; 15:7604. [PMID: 39217183 PMCID: PMC11365933 DOI: 10.1038/s41467-024-52122-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 08/27/2024] [Indexed: 09/04/2024] Open
Abstract
Interrupting transmission events is critical to tuberculosis control. Cough-generated aerosol cultures predict tuberculosis transmission better than microbiological or clinical markers. We hypothesize that highly infectious individuals with pulmonary tuberculosis (positive for cough aerosol cultures) have elevated inflammatory markers and unique transcriptional profiles compared to less infectious individuals. We performed a prospective, longitudinal study using cough aerosol sampling system. We enrolled 142 participants with treatment-naïve pulmonary tuberculosis in Kenya and assessed the association of clinical, microbiologic, and immunologic characteristics with Mycobacterium tuberculosis aerosolization and transmission in 129 household members. Contacts of the forty-three aerosol culture-positive participants (30%) are more likely to have a positive interferon-gamma release assay (85% vs 53%, P = 0.006) and higher median IFNγ level (P < 0.001, 4.28 IU/ml (1.77-5.91) vs. 0.71 (0.01-3.56)) compared to aerosol culture-negative individuals. We find that higher bacillary burden, younger age, larger mean upper arm circumference, and host inflammatory profiles, including elevated serum C-reactive protein and lower plasma TNF levels, associate with positive cough aerosol cultures. Notably, we find pre-treatment whole blood transcriptional profiles associate with aerosol culture status, independent of bacillary load. These findings suggest that tuberculosis infectiousness is associated with epidemiologic characteristics and inflammatory signatures and that these features may identify highly infectious persons.
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Affiliation(s)
- Videlis Nduba
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Lilian N Njagi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Wilfred Murithi
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Zipporah Mwongera
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jodi Byers
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Gisella Logioia
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Glenna Peterson
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - R Max Segnitz
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Kevin Fennelly
- Division of Intramural Research, National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health, Bethesda, MD, USA
| | - Thomas R Hawn
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - David J Horne
- Department of Global Health, University of Washington, Seattle, WA, USA.
- Department of Medicine, University of Washington, Seattle, WA, USA.
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Perez-Porcuna TM, Noguera-Julian A, Riera-Bosch MT, Macià-Rieradevall E, Santos-Santiago J, Rifà Pujol MÀ, Eril M, Aulet-Molist L, Padilla-Esteba E, Tórtola MT, Gómez i Prat J, Vilamala Bastarras A, Rebull-Fatsini JS, Papaleo A, Rius-Gordillo N, Gonçalves AQ, Naranjo-Orihuela À, Urgelles M, García-Lerín MG, Jimenez-Lladser G, Lorenzo-Pino B, Giuliano-Cuello MA, Pascual-Sánchez MT, Marco-García M, Abellana R, Espiau M, Altet-Gómez MN, Orcau-Palau A, Caylà JA, Soriano-Arandes A. Tuberculosis among children visiting friends & relatives. J Travel Med 2024; 31:taae037. [PMID: 38438137 PMCID: PMC11298048 DOI: 10.1093/jtm/taae037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 02/15/2024] [Accepted: 02/26/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND Most paediatric tuberculosis (TB) cases in low-TB-incidence countries involve children born to migrant families. This may be partially explained by trips to their countries of origin for visiting friends and relatives (VFR). We aimed to estimate the risk of latent TB infection (LTBI) and TB in children VFR. METHODS We conducted a prospective multicentric observational study in Catalonia (Spain) from June 2017 to December 2019. We enrolled children aged < 15 years with a negative tuberculin skin test (TST) at baseline and at least one parent from a high-TB-incidence country, and who had travelled to their parent's birth country for ≥21 days. TST and QuantiFERON-TB Gold Plus (QFT-Plus) were performed within 8-12 weeks post-return. LTBI was defined as a TST ≥5 mm and/or a positive QFT-Plus. RESULTS Five hundred children completed the study, equivalent to 78.2 person-years of follow-up (PYFU). Thirteen children (2.6%) were diagnosed with LTBI (16.6/per100 PYFU, 95%CI = 8.8-28.5), including two cases (0.4%) of TB (2.5/per100 PYFU, 95%CI = 0.3-9.3). LTBI incidence rates remained high after excluding BCG-vaccinated children (9.7/per100 PYFU, 95%CI = 3.9-20.0). Household tobacco smoke exposure was associated with LTBI (aOR = 3.9, 95%CI = 1.1-13.3). CONCLUSIONS The risk of LTBI in children VFR in high-TB-incidence countries may equal, or perhaps even exceed, the infection risk of the native population. The primary associated risk factor was the presence of smokers in the household. Furthermore, the incidence rate of active TB largely surpassed that of the countries visited. Children VFR in high-TB-incidence countries should be targeted for diagnostic and preventive interventions.
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Affiliation(s)
- Tomas M Perez-Porcuna
- TB Pediatric Unit, Research Foundation of Primary Health and Mútua Terassa University Hospital, Mútua Terrassa, Terrassa, Catalunya 08221, Spain
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Servei de Malalties Infeccioses, Institut de Recerca Pediàtrica Sant Joan de Déu, Barcelona 08950, Spain
| | | | | | - José Santos-Santiago
- Salut International i Malalties Transmisibles Drassanes, Institut Català de la Salut, Barcelona 08001, Spain
| | | | - Maria Eril
- EAP La Vall del Ges, Institut Català de la Salut, Barcelona 08007, Spain
| | | | | | - Maria Teresa Tórtola
- Microbiology Department, Hospital Universitari Vall d'Hebron, Barcelona 08035, Barcelona
| | - Jordi Gómez i Prat
- Public Health and Community Team (eSPiC), Unit of Tropical Medicine and International Health Drassanes-Vall d'Hebron (UTMIHD-VH), PROSICS, Barcelona 08028, Spain
| | - Anna Vilamala Bastarras
- Hospital Universitari de Vic, Multidisciplinary Inflammation Research group (MIRG), Barcelona 08500, Spain
| | | | - Andrea Papaleo
- CAP Magoria, Institut Català de la Salut, Barcelona 08014, Spain
| | - Neus Rius-Gordillo
- Servei de Pediatria, Hospital Universitari Sant Joan de Reus, Reus 43204, Spain
| | - Alessandra Q Gonçalves
- Unitat de Suport a la Recerca Terres de l'Ebre, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Tortosa 08007, Spain
| | | | - Marta Urgelles
- CAP Terrassa Sud, Fundació Assistencial Mútua Terrassa, Terrassa 08221, Spain
| | | | | | - Beatriz Lorenzo-Pino
- CAP Rubí Mútua Terrassa, Fundació Assistencial Mútua Terrassa, Terrassa 08221, Spain
| | | | | | | | - Rosa Abellana
- Departament de Fonaments Clínics. Unitat de Bioestadística. Universitat de Barcelona, Barcelona 08007, Spain
| | - Maria Espiau
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Children's Hospital Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia 08035, Spain
| | | | | | - Joan A Caylà
- Barcelona Tuberculosis Research Unit Foundation, Barcelona 08036, Spain
| | - Antoni Soriano-Arandes
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Children's Hospital Vall d'Hebron Barcelona Hospital Campus, Barcelona, Catalonia 08035, Spain
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Martinez L, Seddon JA, Horsburgh CR, Lange C, Mandalakas AM. Effectiveness of preventive treatment among different age groups and Mycobacterium tuberculosis infection status: a systematic review and individual-participant data meta-analysis of contact tracing studies. THE LANCET. RESPIRATORY MEDICINE 2024; 12:633-641. [PMID: 38734022 DOI: 10.1016/s2213-2600(24)00083-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Tuberculosis is a preventable disease. However, there is debate regarding which individuals would benefit most from tuberculosis preventive treatment and whether these benefits vary in settings with a high burden and low burden of tuberculosis. We aimed to compare the effectiveness of tuberculosis preventive treatment in exposed individuals of differing ages and Mycobacterium tuberculosis infection status while considering tuberculosis burden of the settings. METHODS In this systematic review and individual-participant meta-analysis, we investigated the development of incident tuberculosis in people closely exposed to individuals with tuberculosis. We searched for studies published between Jan 1, 1998, and April 6, 2018, in MEDLINE, Web of Science, BIOSIS, and Embase. We restricted our search to cohort studies; case-control studies and outbreak reports were excluded. Two reviewers evaluated titles, abstracts, and full text articles for eligibility. At each stage, two reviewers discussed discrepancies and re-evaluated articles until a consensus was reached. Individual-participant data and a pre-specified list of variables, including characteristics of the exposed contact, the index patient, and environmental characteristics, were requested from authors of all eligible studies; contacts exposed to a drug-resistant tuberculosis index patient were excluded. The primary study outcome was incident tuberculosis. We estimated adjusted hazard ratios (aHRs) for incident tuberculosis with mixed-effects Cox regression models with a study-level random effect. We estimated the number-needed-to-treat (NNT) to prevent one person developing tuberculosis. Propensity score matching procedures were used in all analyses. This study is registered with PROSPERO (CRD42018087022). FINDINGS After screening 25 358 records for eligibility, 439 644 participants from 32 cohort studies were included in the individual-participant data meta-analysis. Participants were followed for 1 396 413 person-years (median of 2·7 years [IQR 1·3-4.4]), during which 2496 people were diagnosed with incident tuberculosis. Overall, effectiveness of preventive treatment was 49% (aHR 0·51 [95% CI 0·44-0·60]). Participants with a positive tuberculin-skin-test (TST) or IFNγ release assay (IGRA) result at baseline benefitted from greater protection, regardless of age (0·09 [0·05-0·17] in children younger than 5 years, 0·20 [0·15-0·28] in individuals aged 5-17 years, and 0·17 [0·13-0·22] in adults aged 18 years and older). The effectiveness of preventive treatment was greater in high-burden (0·31 [0·23-0·40]) versus low-burden (0·58 [0·47-0·72]) settings. The NNT ranged from 9 to 34 depending on age among participants with a positive TST or IGRA in both high-burden and low-burden settings; among all contacts (regardless of TST or IGRA test result), the NNT ranged from 29 to 43 in high-burden settings and 213 to 455 in low-burden settings. INTERPRETATION Our findings suggest that a risk-targeted strategy prioritising contacts with evidence of M tuberculosis infection might be indicated in low-burden settings, and a broad approach including all contacts should be considered in high-burden settings. Preventive treatment was similarly effective among contacts of all ages. FUNDING None.
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Affiliation(s)
- Leonardo Martinez
- Boston University School of Public Health, Department of Epidemiology, Boston, MA, USA.
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa; Department of Infectious Disease, Imperial College London, London, UK
| | - C Robert Horsburgh
- Boston University School of Public Health, Department of Epidemiology, Boston, MA, USA
| | - Christoph Lange
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Global TB and Immigrant Health Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | - Anna M Mandalakas
- German Center for Infection Research, Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Global TB and Immigrant Health Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA; Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
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Asare KK, Azumah DE, Adu-Gyamfi CO, Opoku YK, Adela EM, Afful P, Abotsi GK, Abban EA, Duntu PE, Anyamful A, Moses AB, Botchway E, Mwintige P, Kyei S, Amoah LE, Ekuman EO. Comparison of microscopic and xpert MTB diagnoses of presumptive mycobacteria tuberculosis infection: retrospective analysis of routine diagnosis at Cape Coast Teaching Hospital. BMC Infect Dis 2024; 24:660. [PMID: 38956504 PMCID: PMC11218342 DOI: 10.1186/s12879-024-09566-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/25/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Tuberculosis is a global health problem that causes 1. 4 million deaths every year. It has been estimated that sputum smear-negative diagnosis but culture-positive pulmonary TB diagnosis contribute to 12.6% of pulmonary TB transmission. TB diagnosis by smear microscopy smear has a minimum detection limit (LOD) of 5,000 to 10,000 bacilli per milliliter (CFU/ml) of sputum result in missed cases and false positives. However, GeneXpert technology, with a LOD of 131-250 CFU/ml in sputum samples and its implementation is believe to facilitate early detection TB and drug-resistant TB case. Since 2013, Ghana health Service (GHS) introduce GeneXpert MTB/RIF diagnostic in all regional hospitals in Ghana, however no assessment of performance between microscopy and GeneXpert TB diagnosis cross the health facilities has been reported. The study compared the results of routine diagnoses of TB by microscopy and Xpert MTB from 2016 to 2020 at the Cape Coast Teaching Hospital (CCTH). METHODS The study compared routine microscopic and GeneXpert TB diagnosis results at the Cape Coast Teaching Hospital (CCTH) from 2016 to 2020 retrospectively. Briefly, sputum specimens were collected into 20 mL sterile screw-capped containers for each case of suspected TB infection and processed within 24 h. The samples were decontaminated using the NALC-NaOH method with the final NaOH concentration of 1%. The supernatants were discarded after the centrifuge and the remaining pellets dissolved in 1-1.5 ml of phosphate buffer saline (PBS) and used for diagnosis. A fixed smears were Ziehl-Neelsen acid-fast stain and observed under microscope and the remainings were used for GeneXpert MTB/RIF diagnosis. The data were analyze using GraphPad Prism. RESULTS 50.11% (48.48-51.38%) were females with an odd ratio (95% CI) of 1.004 (0.944-1.069) more likely to report to the TB clinic for suspected TB diagnosis. The smear-positive cases for the first sputum were 6.6% (5.98-7.25%), and the second sputum was 6.07% (5.45-6.73%). The Xpert MTB-RIF diagnosis detected 2.93% (10/341) (1.42-5.33%) in the first and 5.44% (16/294) (3.14-8.69%) in the second smear-negative TB samples. The prevalence of Xpert MTB-RIF across smear positive showed that males had 56.87% (178/313) and 56.15% (137/244) and females had 43.13% (135/313) and 43.85% (107/244) for the first and second sputum. Also, false negative smears were 0.18% (10/5607) for smear 1 and 0.31% (16/5126) for smear 2. CONCLUSION In conclusion, the study highlights the higher sensitivity of the GeneXpert assay compared to traditional smear microscopy for detecting MTB. The GeneXpert assay identified 10 and 16 positive MTB from smear 1 and smear 2 samples which were microscopic negative.
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Affiliation(s)
- Kwame Kumi Asare
- Biomedical and Clinical Research Centre, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana.
- Department of Biomedical Sciences, School of Allied Health Sciences, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana.
| | | | - Czarina Owusua Adu-Gyamfi
- Biomedical and Clinical Research Centre, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Yeboah Kwaku Opoku
- Department of Biology Education, Faculty of Science Education, University of Education, Winneba, Ghana
| | | | - Philip Afful
- Biomedical and Clinical Research Centre, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Godwin Kwami Abotsi
- Biomedical and Clinical Research Centre, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | | | - Paul Ekow Duntu
- Biomedical and Clinical Research Centre, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
- Department of Medical Laboratory Science, School of Allied Health Sciences, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Akwasi Anyamful
- Biomedical and Clinical Research Centre, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
- Department of Medical Biochemistry, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana
| | | | - Emmanuel Botchway
- Laboratory Departments, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Philimon Mwintige
- Laboratory Departments, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Samuel Kyei
- Biomedical and Clinical Research Centre, College of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
- Department of Optometry and Vision Science, University of Cape Coast, Cape Coast, Ghana
| | - Linda Eva Amoah
- Department of Immunology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
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Matteelli A, Churchyard G, Cirillo D, den Boon S, Falzon D, Hamada Y, Houben RMGJ, Kanchar A, Kritski A, Kumar B, Miller C, Menzies D, Masini T. Optimizing the cascade of prevention to protect people from tuberculosis: A potential game changer for reducing global tuberculosis incidence. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003306. [PMID: 38954723 PMCID: PMC11218967 DOI: 10.1371/journal.pgph.0003306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
The provision of tuberculosis preventive treatment is one of the critical interventions to reduce tuberculosis incidence and ultimately eliminate the disease, yet we still miss appropriate tools for an impactful intervention and treatment coverage remains low. We used recent data, epidemiological estimates, and research findings to analyze the challenges of each step of the cascade of tuberculosis prevention that currently delay the strategy implementation. We addressed research gaps and implementation bottlenecks that withhold key actions in tuberculosis case finding, testing for tuberculosis infection, provision of preventive treatment with safer, shorter regimens and supporting people to complete their treatment. Empowering communities to generate demand for preventive therapy and other prevention services in a holistic manner and providing adequate financial support to sustain implementation are essential requirements. The adoption of an effective, universal monitoring and evaluation system is a prerequisite to provide general and granular insight, and to steer progress of the tuberculosis infection strategy at global and local level.
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Affiliation(s)
- Alberto Matteelli
- Institute of Infectious and Tropical Diseases, WHO Collaborating Centre for Tuberculosis Prevention, University of Brescia, Brescia, Italy
| | - Gavin Churchyard
- The Aurum Institute, Parktown, South Africa, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | - Saskia den Boon
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Dennis Falzon
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Yohhei Hamada
- Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
- University College London, London, United Kingdom
| | - Rein M. G. J. Houben
- TB Modelling Group, TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Avinash Kanchar
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Afrânio Kritski
- Rede Brasileira de Pesquisa em Tuberculose, REDE TB, Rio de Janeiro, Brasil
- Programa Acadêmico de Tuberculose, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil
| | | | - Cecily Miller
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Dick Menzies
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
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Dale KD, Schwalb A, Coussens AK, Gibney KB, Abboud AJ, Watts K, Denholm JT. Overlooked, dismissed, and downplayed: reversion of Mycobacterium tuberculosis immunoreactivity. Eur Respir Rev 2024; 33:240007. [PMID: 39048129 PMCID: PMC11267292 DOI: 10.1183/16000617.0007-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/16/2024] [Indexed: 07/27/2024] Open
Abstract
Tuberculosis (TB) is caused by Mycobacterium tuberculosis (Mtb). Following infection, immune responses to Mtb antigens can be measured using the tuberculin skin test or an interferon-γ release assay. The gain of Mtb immunoreactivity, a change from a negative to a positive tuberculin skin test or interferon-γ release assay result, is called conversion and has long been used as a measure of Mtb exposure. However, the loss of immunoreactivity (reversion; a positive followed by a negative result) has often been overlooked. Instead, in clinical and epidemiological circles, Mtb immunoreactivity is commonly considered to persist lifelong and confer a lifetime of disease risk. We present a critical review, describing the evidence for reversion from cohort studies, ecological studies and studies of TB progression risk. We outline the inconsistent reasons why reversion has been dismissed from common understanding and present evidence demonstrating that, just as conversion predominantly indicates prior exposure to Mtb antigens, so its opposite, reversion, suggests the reduction or absence of exposure (endogenous or exogenous). Mtb immunoreactivity is dynamic in both individuals and populations and this is why it is useful for stratifying short-term TB progression risk. The neglect of reversion has shaped TB research and policy at all levels, influencing clinical management and skewing Mtb infection risk estimation and transmission modelling, leading to an underestimation of the contribution of re-exposure to the burden of TB, a serious oversight for an infectious disease. More than a century after it was first demonstrated, it is time to incorporate reversion into our understanding of the natural history of TB.
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Affiliation(s)
- Katie D Dale
- Victorian Tuberculosis Program, Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Alvaro Schwalb
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Anna K Coussens
- Infectious Diseases and Immune Defence Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
- Department of Medical Biology, University of Melbourne, Parkville, Australia
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Katherine B Gibney
- Victorian Tuberculosis Program, Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Victorian Infectious Disease Service, Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Alison J Abboud
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Krista Watts
- Victorian Tuberculosis Program, Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Social Work, School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Justin T Denholm
- Victorian Tuberculosis Program, Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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8
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Kiwanuka N, Zalwango S, Kakaire R, Castellanos ME, Quach THT, Whalen CC. M. tuberculosis Infection Attributable to Exposure in Social Networks of Tuberculosis Cases in an Urban African Community. Open Forum Infect Dis 2024; 11:ofae200. [PMID: 38737427 PMCID: PMC11083641 DOI: 10.1093/ofid/ofae200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 04/11/2024] [Indexed: 05/14/2024] Open
Abstract
Background The persistence of tuberculosis today and its global disparity send a powerful message that effective tuberculosis control must respond to its regional epidemiology. Active case finding through contact investigation is a standard protocol used for tuberculosis control, but its effectiveness has not been established, especially in endemic areas. Methods To quantify the potential effectiveness of contact investigation in Kampala, Uganda, we used a cross-sectional design to evaluate the social networks of 123 tuberculosis index cases and 124 controls without tuberculosis. Results Tuberculous infection was present in 515 of 989 tuberculosis case contacts (52.1%) and 396 of 1026 control contacts (38.6%; adjusted prevalence ratio, 1.4; 95% CI, 1.3-1.6). The proportion of infected participants with known exposure within the social network of the tuberculosis case was 35%. The population-attributable fraction was 11.1% for any known exposure, with 7.3% attributable to household exposure and 3.4% attributable to extrahousehold exposure. Conclusions This low population-attributable fraction indicates that contact tracing in the social networks of index cases will have only a modest effect in reducing tuberculous infection in a community. New approaches to community-level active case finding are needed.
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Affiliation(s)
- Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Zalwango
- Department of Public Health and Environment, Kampala Capital City Authority, Kampala, Uganda
| | - Robert Kakaire
- Global Health Institute, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Maria Eugenia Castellanos
- Public Health and Tropical Medicine, College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Trang Ho Thu Quach
- Global Health Institute, College of Public Health, University of Georgia, Athens, Georgia, USA
| | - Christopher C Whalen
- Global Health Institute, College of Public Health, University of Georgia, Athens, Georgia, USA
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van de Water BJ, Brooks MB, Matji R, Ncanywa B, Dikgale F, Abuelezam NN, Mzileni B, Nokwe M, Moko S, Mvusi L, Loveday M, Gimbel S. Systems analysis and improvement approach to optimize tuberculosis (SAIA-TB) screening, treatment, and prevention in South Africa: a stepped-wedge cluster randomized trial. Implement Sci Commun 2024; 5:40. [PMID: 38627799 PMCID: PMC11021007 DOI: 10.1186/s43058-024-00582-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The use of systems engineering tools, including the development and use of care cascades using routinely collected data, process mapping, and continuous quality improvement, is used for frontline healthcare workers to devise systems level change. South Africa experiences high rates of tuberculosis (TB) infection and disease as well as HIV co-infection. The Department of Health has made significant gains in HIV services over the last two decades, reaching their set "90-90-90" targets for HIV. However, TB services, although robust, have lagged in comparison for both disease and infection. The Systems Analysis and Improvement Approach (SAIA) is a five-step implementation science method, drawn from systems engineering, to identify, define, and implement workflow modifications using cascade analysis, process mapping, and repeated quality improvement cycles within healthcare facilities. METHODS This stepped-wedge cluster randomized trial will evaluate the effectiveness of SAIA on TB (SAIA-TB) cascade optimization for patients with TB and high-risk contacts across 16 clinics in four local municipalities in the Sarah Baartman district, Eastern Cape, South Africa. We hypothesize that SAIA-TB implementation will lead to a 20% increase in each of: TB screening, TB preventive treatment initiation, and TB disease treatment initiation during the 18-month intervention period. Focus group discussions and key informant interviews with clinic staff will also be conducted to determine drivers of implementation variability across clinics. DISCUSSION This study has the potential to improve TB screening, treatment initiation, and completion for both active disease and preventive measures among individuals with and without HIV in a high burden setting. SAIA-TB provides frontline health care workers with a systems-level view of their care delivery system with the aim of sustainable systems-level improvements. TRIAL REGISTRATION Clinicaltrials.gov, NCT06314386. Registered 18 March 2024, https://clinicaltrials.gov/study/NCT06314386 . NCT06314386.
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Affiliation(s)
- Brittney J van de Water
- Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA, 02467, USA.
| | - Meredith B Brooks
- School of Public Health, Boston University, 715 Albany Street, Boston, MA, 02118, USA
| | - Refiloe Matji
- AQUITY Innovations, 114 Sovereign Drive, Centurion, South Africa
| | - Betty Ncanywa
- AQUITY Innovations, Greenacres Park, Gqeberha, South Africa
| | - Freck Dikgale
- AQUITY Innovations, 114 Sovereign Drive, Centurion, South Africa
| | - Nadia N Abuelezam
- Connell School of Nursing, Boston College, 140 Commonwealth Avenue, Chestnut Hill, MA, 02467, USA
| | - Bulelwa Mzileni
- Department of Health, Sarah Baartman District, 16 Grace Street, Gqeberha, South Africa
| | - Miyakazi Nokwe
- Department of Health, Eastern Cape, Dukumbana Building, Bisho, South Africa
| | - Singilizwe Moko
- Department of Health, Eastern Cape, Dukumbana Building, Bisho, South Africa
- Walter Sisulu University, Mthatha, South Africa
| | - Lindiwe Mvusi
- National Department of Health, 1112 Voortrekker Road, Pretoria, South Africa
| | - Marian Loveday
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Francie Van Zijl Drive, Parow Valley, Cape Town, South Africa
| | - Sarah Gimbel
- Department of Child, University of Washington, Family & Population Health Nursing, Gerberding HallSeattle, WA, 98195, USA
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10
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Dinkele R, Gessner S, Patterson B, McKerry A, Hoosen Z, Vazi A, Seldon R, Koch A, Warner DF, Wood R. Persistent Mycobacterium tuberculosis bioaerosol release in a tuberculosis-endemic setting. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.02.24305196. [PMID: 38633787 PMCID: PMC11023659 DOI: 10.1101/2024.04.02.24305196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pioneering studies linking symptomatic disease and cough-mediated release of Mycobacterium tuberculosis (Mtb) established the infectious origin of tuberculosis (TB), simultaneously informing the pervasive notion that pathology is a prerequisite for Mtb transmission. Our prior work has challenged this assumption: by sampling TB clinic attendees, we detected equivalent release of Mtb-containing bioaerosols by confirmed TB patients and individuals not receiving a TB diagnosis, and we demonstrated a time-dependent reduction in Mtb bioaerosol positivity during six-months' follow-up, irrespective of anti-TB chemotherapy. Now, by extending bioaerosol sampling to a randomly selected community cohort, we show that Mtb release is common in a TB-endemic setting: of 89 participants, 79.8% (71/89) produced Mtb bioaerosols independently of QuantiFERON-TB Gold status, a standard test for Mtb infection; moreover, during two-months' longitudinal sampling, only 2% (1/50) were serially Mtb bioaerosol negative. These results necessitate a reframing of the prevailing paradigm of Mtb transmission and infection, and may explain the current inability to elucidate Mtb transmission networks in TB-endemic regions.
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Affiliation(s)
- Ryan Dinkele
- UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
| | - Sophia Gessner
- UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
| | - Benjamin Patterson
- Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, 1105, The Netherlands
| | - Andrea McKerry
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town, 7925, South Africa
| | - Zeenat Hoosen
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town, 7925, South Africa
| | - Andiswa Vazi
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town, 7925, South Africa
| | - Ronnett Seldon
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town, 7925, South Africa
| | - Anastasia Koch
- UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
| | - Digby F. Warner
- UCT Molecular Mycobacteriology Research Unit, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
| | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa
- Aerobiology and TB Research Unit, Desmond Tutu Health Foundation, Cape Town, 7925, South Africa
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11
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Salindri AD, Auld SC, Gujral UP, Urbina EM, Andrews JR, Huaman MA, Magee MJ. Tuberculosis infection and hypertension: prevalence estimates from the US National Health and Nutrition Examination Survey. BMJ Open 2024; 14:e075176. [PMID: 38479740 PMCID: PMC10936476 DOI: 10.1136/bmjopen-2023-075176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 12/20/2023] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES Tuberculosis infection (TBI) is marked by dynamic host-pathogen interactions with persistent low-grade inflammation and is associated with increased risk of cardiovascular diseases (CVD) including acute coronary syndrome, myocardial infarction and stroke. However, few studies assess the relationship between TBI and hypertension, an intermediate of CVD. We sought to determine the association between TBI and hypertension using data representative of the adult US population. METHODS We performed cross-sectional analyses using data from the 2011-2012 US National Health and Nutrition Examination Survey (NHANES). Eligible participants included adults with valid QuantiFERON-TB Gold In-Tube (QFT-GIT) test results who also had blood pressure measures and no history of TB disease. TBI was defined by a positive QFT-GIT. We defined hypertension by either elevated measured blood pressure levels (ie, systolic ≥130 mm Hg or diastolic ≥80 mm Hg) or known hypertension indications (ie, self-reported previous diagnosis or use of antihypertensive medications). Analyses were performed using robust quasi-Poisson regressions and accounted for the stratified probability sampling design of NHANES. RESULTS The overall prevalence of TBI was 5.7% (95% CI 4.7% to 6.7%) and hypertension was present among 48.9% (95% CI 45.2% to 52.7%) of participants. The prevalence of hypertension was higher among those with TBI (58.5%, 95% CI 52.4% to 64.5%) than those without TBI (48.3%, 95% CI 44.5% to 52.1%) (prevalence ratio (PR) 1.2, 95% CI 1.1 to 1.3). However, after adjusting for confounders, the prevalence of hypertension was similar for those with and without TBI (adjusted PR 1.0, 95% CI 1.0 to 1.1). The unadjusted prevalence of hypertension was higher among those with TBI versus no TBI, especially among individuals without CVD risk factors including those with normal body mass index (PR 1.6, 95% CI 1.2 to 2.0), euglycaemia (PR 1.3, 95% CI 1.1 to 1.5) or non-smokers (PR 1.2, 95% CI 1.1 to 1.4). CONCLUSIONS More than half of adults with TBI in the USA had hypertension. Importantly, we observed a relationship between TBI and hypertension among those without established CVD risk factors. SUMMARY The prevalence of hypertension was high (59%) among adults with TBI in the USA. In addition, we found that the prevalence of hypertension was significantly higher among adults with positive QFT without established hypertension risk factors.
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Affiliation(s)
- Argita D Salindri
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sara C Auld
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Unjali P Gujral
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Elaine M Urbina
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Moises A Huaman
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew J Magee
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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Liu D, Yuan C, Guo C, Huang M, Lin D. Recombinant expression and functional characterization of FadD2 protein in Mycobacterium tuberculosis. Protein Expr Purif 2024; 214:106377. [PMID: 37813293 DOI: 10.1016/j.pep.2023.106377] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
Mycobacterium tuberculosis (Mtb) is a crucial and highly destructive intracellular pathogen responsible for causing tuberculosis (TB). The emergence and dissemination of multi-drug resistant Mtb has further aggravated the TB crisis, leading to high mortality. Mtb FadD2 is a fatty acyl-coenzyme A (CoA) synthetase that modifies the cell envelope and plays an important role in reducing Mtb susceptibility to pyrazinoic acid (POA). However, the functional mechanism of Mtb FadD2 remains poorly understood. Here, we successfully expressed, purified and obtained monomeric FadD2 by using buffer (500 mM NaCl, 20 mM Tris-HCl, pH7.4 and 5 % glycerol). Palmitate was found to be the optimal substrate for FadD2. Fatty acyl-CoA synthetase activity reached maximum at 450 μM palmitate, and the Km value was 318.2 μM for palmitate. The results of mutation experiments indicated the critical role of T370 and K551 in the enzymatic activity of FadD2. Our work provides a guideline and concept for the development of novel drugs against Mtb.
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Affiliation(s)
- Dafeng Liu
- MOE Key Laboratory of Spectrochemical Analysis & Instrumentation, Key Laboratory of Chemical Biology of Fujian Province, College of Chemistry and Chemical Engineering, Xiamen University, Xiamen, 361005, China
| | - Cai Yuan
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian, 350108, China.
| | - Chenyun Guo
- MOE Key Laboratory of Spectrochemical Analysis & Instrumentation, Key Laboratory of Chemical Biology of Fujian Province, College of Chemistry and Chemical Engineering, Xiamen University, Xiamen, 361005, China
| | - Mingdong Huang
- College of Chemistry, Fuzhou University, Fuzhou, 350108, China.
| | - Donghai Lin
- MOE Key Laboratory of Spectrochemical Analysis & Instrumentation, Key Laboratory of Chemical Biology of Fujian Province, College of Chemistry and Chemical Engineering, Xiamen University, Xiamen, 361005, China.
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13
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Banholzer N, Schmutz R, Middelkoop K, Hella J, Egger M, Wood R, Fenner L. Airborne transmission risks of tuberculosis and COVID-19 in schools in South Africa, Switzerland, and Tanzania: Modeling of environmental data. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002800. [PMID: 38236801 PMCID: PMC10796007 DOI: 10.1371/journal.pgph.0002800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024]
Abstract
The COVID-19 pandemic renewed interest in airborne transmission of respiratory infections, particularly in congregate indoor settings, such as schools. We modeled transmission risks of tuberculosis (caused by Mycobacterium tuberculosis, Mtb) and COVID-19 (caused by SARS-CoV-2) in South African, Swiss and Tanzanian secondary schools. We estimated the risks of infection with the Wells-Riley equation, expressed as the median with 2.5% and 97.5% quantiles (credible interval [CrI]), based on the ventilation rate and the duration of exposure to infectious doses (so-called quanta). We computed the air change rate (ventilation) using carbon dioxide (CO2) as a tracer gas and modeled the quanta generation rate based on reported estimates from the literature. The share of infectious students in the classroom is determined by country-specific estimates of pulmonary TB. For SARS-CoV-2, the number of infectious students was estimated based on excess mortality to mitigate the bias from country-specific reporting and testing. Average CO2 concentration (parts per million [ppm]) was 1,610 ppm in South Africa, 1,757 ppm in Switzerland, and 648 ppm in Tanzania. The annual risk of infection for Mtb was 22.1% (interquartile range [IQR] 2.7%-89.5%) in South Africa, 0.7% (IQR 0.1%-6.4%) in Switzerland, and 0.5% (IQR 0.0%-3.9%) in Tanzania. For SARS-CoV-2, the monthly risk of infection was 6.8% (IQR 0.8%-43.8%) in South Africa, 1.2% (IQR 0.1%-8.8%) in Switzerland, and 0.9% (IQR 0.1%-6.6%) in Tanzania. The differences in transmission risks primarily reflect a higher incidence of SARS-CoV-2 and particularly prevalence of TB in South Africa, but also higher air change rates due to better natural ventilation of the classrooms in Tanzania. Global comparisons of the modeled risk of infectious disease transmission in classrooms can provide high-level information for policy-making regarding appropriate infection control strategies.
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Affiliation(s)
- Nicolas Banholzer
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Remo Schmutz
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Keren Middelkoop
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu Health Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jerry Hella
- Ifakara Health Institute, Dar-es-Salaam, Tanzania
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology & Research, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Desmond Tutu Health Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lukas Fenner
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Sinha P, Dauphinais M, Carwile ME, Horsburgh CR, Menzies NA. In-kind nutritional supplementation for household contacts of persons with tuberculosis would be cost-effective for reducing tuberculosis incidence and mortality in India: a modeling study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.12.30.23300673. [PMID: 38260435 PMCID: PMC10802630 DOI: 10.1101/2023.12.30.23300673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background Undernutrition is the leading cause of tuberculosis (TB) globally, but nutritional interventions are often considered cost prohibitive. The RATIONS study demonstrated that nutritional support provided to household contacts of persons with TB can reduce TB incidence. However, the long-term cost-effectiveness of this intervention is unclear. Methods We assessed the cost-effectiveness of a RATIONS-style intervention (daily 750 kcal dietary supplementation and multi-micronutrient tablet). Using a Markov state transition model we simulated TB incidence, treatment, and TB-attributable mortality among household contacts receiving the RATIONS intervention, as compared to no nutritional support. We calculated health outcomes (TB cases, TB deaths, and disability-adjusted life years [DALYs]) over the lifetime of intervention recipients and assessed costs from government and societal perspectives. We tested the robustness of results to parameter changes via deterministic and probabilistic sensitivity analysis. Findings Over two years, household contacts receiving the RATIONS intervention would experience 39% (95% uncertainty interval (UI): 23-52) fewer TB cases and 59% (95% UI: 44-69) fewer TB deaths. The intervention was estimated to avert 13,775 (95% UI: 9036-20,199) TB DALYs over the lifetime of the study cohort comprising 100,000 household contacts and was cost-effective from both government (incremental cost-effectiveness ratio: $229 per DALY averted [95% UI: 133-387]) and societal perspectives ($184 per DALY averted [95% UI: 83-344]). The results were most sensitive to the cost of the nutritional supplement. Interpretation Prompt nutritional support for household contacts of persons with TB disease would be cost-effective in reducing TB incidence and mortality in India. Summary Undernutrition is the leading cause of tuberculosis in India. Using a Markov state-transition model, we found that food baskets for household contacts of persons with tuberculosis would be cost-effective in reducing tuberculosis incidence and mortality in India. Research in context Evidence before this study: Undernutrition is the leading risk factor for TB worldwide. Recently, the RATIONS study demonstrated a roughly 40% reduction in incident TB among household contacts who received in-kind macronutrient and micronutrient supplementation. Added value of this study: Although the RATIONS study demonstrated a dramatic reduction in incident TB, it is unclear if nutritional interventions to prevent TB are cost-effective. Previously, only one cost-effectiveness analysis of nutritional interventions for household contacts has been published. Due to lack of published data, that study had to make assumptions regarding the impact of nutritional interventions on TB incidence and mortality. In this study, we conducted an economic evaluation of a RATIONS-style intervention to reduce incident TB and mortality in India using observed data. Implications of all the available evidence: In-kind nutritional supplementation for household contacts of individuals with TB disease would be cost-effective in reducing incident TB and TB mortality, particularly if TB programs leverage economies of scale to bring down the cost of the nutritional intervention.
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Wang H, Liu D, Zhou X. Effect of Mycolic Acids on Host Immunity and Lipid Metabolism. Int J Mol Sci 2023; 25:396. [PMID: 38203570 PMCID: PMC10778799 DOI: 10.3390/ijms25010396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 01/12/2024] Open
Abstract
Mycolic acids constitute pivotal constituents within the cell wall structure of Mycobacterium tuberculosis. Due to their structural diversity, the composition of mycolic acids exhibits substantial variations among different strains, endowing them with the distinctive label of being the 'signature' feature of mycobacterial species. Within Mycobacterium tuberculosis, the primary classes of mycolic acids include α-, keto-, and methoxy-mycolic acids. While these mycolic acids are predominantly esterified to the cell wall components (such as arabinogalactan, alginate, or glucose) of Mycobacterium tuberculosis, a fraction of free mycolic acids are secreted during in vitro growth of the bacterium. Remarkably, different types of mycolic acids possess varying capabilities to induce foamy macro-phages and trigger immune responses. Additionally, mycolic acids play a regulatory role in the lipid metabolism of host cells, thereby exerting influence over the progression of tuberculosis. Consequently, the multifaceted properties of mycolic acids shape the immune evasion strategy employed by Mycobacterium tuberculosis. A comprehensive understanding of mycolic acids is of paramount significance in the pursuit of developing tuberculosis therapeutics and unraveling the intricacies of its pathogenic mechanisms.
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Affiliation(s)
- Haoran Wang
- College of Veterinary Medicine, China Agricultural University, Beijing 100086, China; (H.W.); (D.L.)
- National Key Laboratory of Veterinary Public Health and Safety, Beijing 100086, China
| | - Dingpu Liu
- College of Veterinary Medicine, China Agricultural University, Beijing 100086, China; (H.W.); (D.L.)
- National Key Laboratory of Veterinary Public Health and Safety, Beijing 100086, China
| | - Xiangmei Zhou
- College of Veterinary Medicine, China Agricultural University, Beijing 100086, China; (H.W.); (D.L.)
- National Key Laboratory of Veterinary Public Health and Safety, Beijing 100086, China
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Wingfield T. Ending Tuberculosis in Older People: New Strategies for an Age-old Disease. Clin Infect Dis 2023; 77:1476-1479. [PMID: 37506252 PMCID: PMC10654857 DOI: 10.1093/cid/ciad439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/27/2023] [Indexed: 07/30/2023] Open
Affiliation(s)
- Tom Wingfield
- Departments of Clinical Sciences and International Public Health, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, United Kingdom
- World Health Organization Collaborating Centre in Tuberculosis and Social Medicine, Department of Global Public Health, Karolinska Institutet, Norrbackagatan 4, 171 76 Stockholm, Sweden
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Horsburgh CR. Invited Commentary: The Winding Road to Identifying the Annual Rate of Tuberculosis Infection. Am J Epidemiol 2023; 192:1944-1946. [PMID: 37222469 DOI: 10.1093/aje/kwad125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 05/25/2023] Open
Abstract
Many persons with immunological tests indicating Mycobacterium tuberculosis infection, such as tuberculin skin tests or interferon-γ release assays, are at risk of progression to tuberculosis disease. Persons whose tests revert to negative may no longer be at such risk. Therefore, identifying the rate of test reversion, potentially indicating cure of M. tuberculosis infection, is an important area of investigation. In their accompanying article (Am J Epidemiol. 2023;192(12):1937-1943), Schwalb et al. extract data on test reversion from prechemotherapy literature and construct a model to predict the rate of reversion, and thus the likely cure of infection. Unfortunately, the incompleteness of the historical data and the use of imprecise definitions of test positivity and reversion lead to substantial misclassification and limit the usefulness of the model. Better definitions and improved tests will be needed in order to develop a clear picture of this aspect of the natural history of tuberculosis.
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Schwalb A, Emery JC, Dale KD, Horton KC, Ugarte-Gil CA, Houben RMGJ. Impact of Reversion of Mycobacterium tuberculosis Immunoreactivity Tests on the Estimated Annual Risk of Tuberculosis Infection. Am J Epidemiol 2023; 192:1937-1943. [PMID: 36749011 PMCID: PMC10691197 DOI: 10.1093/aje/kwad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/26/2022] [Accepted: 02/02/2023] [Indexed: 02/08/2023] Open
Abstract
A key metric in tuberculosis epidemiology is the annual risk of infection (ARI), which is usually derived from tuberculin skin test (TST) and interferon-γ release assay (IGRA) prevalence surveys carried out in children. Derivation of the ARI assumes that immunoreactivity is persistent over time; however, reversion of immunoreactivity has long been documented. We used a deterministic, compartmental model of Mycobacterium tuberculosis (Mtb) infection to explore the impact of reversion on ARI estimation using age-specific reversion probabilities for the TST and IGRA. Using empirical data on TST reversion (22.2%/year for persons aged ≤19 years), the true ARI was 2-5 times higher than that estimated from immunoreactivity studies in children aged 8-12 years. Applying empirical reversion probabilities for the IGRA (9.9%/year for youths aged 12-18 years) showed a 1.5- to 2-fold underestimation. ARIs are increasingly underestimated in older populations, due to the cumulative impact of reversion on population reactivity over time. Declines in annual risk did not largely affect the results. Ignoring reversion leads to a stark underestimation of the true ARI in populations and our interpretation of Mtb transmission intensity. In future surveys, researchers should adjust for the reversion probability and its cumulative effect with increasing age to obtain a more accurate reflection of the burden and dynamics of Mtb infection.
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Affiliation(s)
- Alvaro Schwalb
- Correspondence to Dr. Alvaro Schwalb, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom (e-mail: )
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Krishnan S, Wu X, Kim S, McIntire K, Naini L, Hughes MD, Dawson R, Mave V, Gaikwad S, Sanchez J, Mendoza-Ticona A, Gonzales P, Comins K, Shenje J, Fontain SN, Omozoarhe A, Mohapi L, Lalloo UG, Garcia Ferreira AC, Mugah C, Harrington M, Shah NS, Hesseling AC, Churchyard G, Swindells S, Gupta A. 1-Year Incidence of Tuberculosis Infection and Disease Among Household Contacts of Rifampin- and Multidrug-Resistant Tuberculosis. Clin Infect Dis 2023; 77:892-900. [PMID: 37227925 PMCID: PMC10681643 DOI: 10.1093/cid/ciad301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/24/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Tuberculosis infection (TBI) and TB disease (TBD) incidence remains poorly described following household contact (HHC) rifampin-/multidrug-resistant TB exposure. We sought to characterize TBI and TBD incidence at 1 year in HHCs and to evaluate TB preventive treatment (TPT) use in high-risk groups. METHODS We previously conducted a cross-sectional study of HHCs with rifampin-/multidrug-resistant TB in 8 high-burden countries and reassessed TBI (interferon-gamma release assay, HHCs aged ≥5 years) and TBD (HHCs all ages) at 1 year. Incidence was estimated across age and risk groups (<5 years; ≥5 years, diagnosed with human immunodeficiency virus [HIV]; ≥5 years, not diagnosed with HIV/unknown, baseline TBI-positive) by logistic or log-binomial regression fitted using generalized estimating equations. RESULTS Of 1016 HHCs, 850 (83.7%) from 247 households were assessed (median, 51.4 weeks). Among 242 HHCs, 52 tested interferon-gamma release assay-positive, yielding a 1-year 21.6% (95% confidence interval [CI], 16.7-27.4) TBI cumulative incidence. Sixteen of 742 HHCs developed confirmed (n = 5), probable (n = 3), or possible (n = 8) TBD, yielding a 2.3% (95% CI, 1.4-3.8) 1-year cumulative incidence (1.1%; 95% CI, .5-2.2 for confirmed/probable TBD). TBD relative risk was 11.5-fold (95% CI, 1.7-78.7), 10.4-fold (95% CI, 2.4-45.6), and 2.9-fold (95% CI, .5-17.8) higher in age <5 years, diagnosed with HIV, and baseline TBI high-risk groups, respectively, vs the not high-risk group (P = .0015). By 1 year, 4% (21 of 553) of high-risk HHCs had received TPT. CONCLUSIONS TBI and TBD incidence continued through 1 year in rifampin-/multidrug-resistant TB HHCs. Low TPT coverage emphasizes the need for evidence-based prevention and scale-up, particularly among high-risk groups.
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Affiliation(s)
- Sonya Krishnan
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xingye Wu
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Soyeon Kim
- Frontier Science Foundation, Brookline, Massachusetts, USA
| | - Katie McIntire
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Linda Naini
- Social & Scientific Systems, Silver Spring, Maryland, USA
| | - Michael D Hughes
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Rodney Dawson
- University of Cape Town Lung Institute and Department of Medicine, Cape Town, South Africa
| | - Vidya Mave
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Sanjay Gaikwad
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Jorge Sanchez
- Centro de Investigaciones Biomedicas y Medioambientales (CITBM), Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Pedro Gonzales
- Asociació n Civil Impacta Salud y Educació n, Lima, Peru
| | - Kyla Comins
- TASK Applied Science Clinical Research Site, Bellville, South Africa
| | - Justin Shenje
- South African Tuberculosis Vaccine Initiative, Cape Town, South Africa
| | - Sandy Nerette Fontain
- GHESKIO Centers Institute of Infectious Diseases and Reproductive Health, Port-au-Prince, Haiti
| | - Ayotunde Omozoarhe
- Botswana Harvard AIDS Institute Partnership CTU, Gaborone Clinical Research Site, Gaborone, Botswana
| | - Lerato Mohapi
- Soweto Clinical Research Site, University of the Witwatersrand, Johannesburg, South Africa
| | - Umesh G Lalloo
- Durban International Clinical Research Site, Durban University of Technology, Durban, South Africa
| | | | | | | | - N Sarita Shah
- Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Gavin Churchyard
- Aurum Institute, Parktown, South Africa
- University of the Witwatersrand, School of Public Health, Johannesburg, South Africa
- Advancing Care and Treatment, South African Medical Research Council, Johannesburg, South Africa
| | - Susan Swindells
- Department of Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Amita Gupta
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Byramjee Jeejeebhoy Government Medical College, Pune, India
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Tovar M, Moreno Y, Sanz J. Addressing mechanism bias in model-based impact forecasts of new tuberculosis vaccines. Nat Commun 2023; 14:5312. [PMID: 37658078 PMCID: PMC10474143 DOI: 10.1038/s41467-023-40976-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 08/15/2023] [Indexed: 09/03/2023] Open
Abstract
In tuberculosis (TB) vaccine development, multiple factors hinder the design and interpretation of the clinical trials used to estimate vaccine efficacy. The complex transmission chain of TB includes multiple routes to disease, making it hard to link the vaccine efficacy observed in a trial to specific protective mechanisms. Here, we present a Bayesian framework to evaluate the compatibility of different vaccine descriptions with clinical trial outcomes, unlocking impact forecasting from vaccines whose specific mechanisms of action are unknown. Applying our method to the analysis of the M72/AS01E vaccine trial -conducted on IGRA+ individuals- as a case study, we found that most plausible models for this vaccine needed to include protection against, at least, two over the three possible routes to active TB classically considered in the literature: namely, primary TB, latent TB reactivation and TB upon re-infection. Gathering new data regarding the impact of TB vaccines in various epidemiological settings would be instrumental to improve our model estimates of the underlying mechanisms.
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Affiliation(s)
- M Tovar
- Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, Zaragoza, 50009, Spain
- Department of Theoretical Physics, University of Zaragoza, Zaragoza, 50009, Spain
| | - Y Moreno
- Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, Zaragoza, 50009, Spain
- Department of Theoretical Physics, University of Zaragoza, Zaragoza, 50009, Spain
- Centai Institute S.p.A, 10138, Torino, Italy
| | - J Sanz
- Institute for Biocomputation and Physics of Complex Systems (BIFI), University of Zaragoza, Zaragoza, 50009, Spain.
- Department of Theoretical Physics, University of Zaragoza, Zaragoza, 50009, Spain.
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21
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Stein CM. Genetic epidemiology of resistance to M. tuberculosis Infection: importance of study design and recent findings. Genes Immun 2023; 24:117-123. [PMID: 37085579 PMCID: PMC10121418 DOI: 10.1038/s41435-023-00204-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 04/23/2023]
Abstract
Resistance to M. tuberculosis, often referred to as "RSTR" in the literature, is being increasingly studied because of its potential relevance as a clinical outcome in vaccine studies. This review starts by addressing the importance of epidemiological characterization of this phenotype, and ongoing challenges in that characterization. Then, this review summarizes the extant genetic and genomic studies of this phenotype, including heritability studies, candidate gene studies, and genome-wide association studies, as well as whole transcriptome studies. Findings from recent studies that used longitudinal characterization of the RSTR phenotype are compared to those using a cross-sectional definition, and the challenges of using tuberculin skin test and interferon-gamma release assay are discussed. Finally, future directions are proposed. Since this is a rapidly evolving area of public health significance, this review will help frame future research questions and study designs.
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Affiliation(s)
- Catherine M Stein
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA.
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University, Cleveland, OH, USA.
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22
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Salindri AD, Auld SC, Gujral UP, Urbina EM, Andrews JR, Huaman MA, Magee MJ. Tuberculosis infection and hypertension: Prevalence estimates from the US National Health and Nutrition Examination Survey. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.12.23289899. [PMID: 37325781 PMCID: PMC10262262 DOI: 10.1101/2023.05.12.23289899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Objectives Latent Tuberculosis infection (LTBI) is marked by dynamic host-pathogen interactions with persistent low-grade inflammation and is associated with increased risk of cardiovascular diseases (CVD) including acute coronary syndrome, myocardial infarction, and stroke. However, few studies assess the relationship between LTBI and hypertension, an intermediate of CVD. We sought to determine the association between LTBI and hypertension using data representative of the adult US population. Methods We performed cross-sectional analyses using data from the 2011-2012 US National Health and Nutrition Examination Survey (NHANES). Eligible participants included adults with valid QuantiFERON-TB Gold In-Tube (QFT-GIT) test results who also had blood pressure measures and no history of TB disease. LTBI was defined by a positive QFT-GIT. We defined hypertension by either elevated measured blood pressure levels (i.e., systolic ≥130mmHg or diastolic ≥80mmHg) or known hypertension indications (i.e., self-reported previous diagnosis or use of antihypertensive medications). Analyses were performed using robust quasi-Poisson regressions and accounted for the stratified probability sampling design of NHANES. Results The overall prevalence of LTBI was 5.7% (95%CI 4.7-6.7) and hypertension was present among 48.9% (95%CI 45.2-52.7) of participants. The prevalence of hypertension was higher among those with LTBI (58.5%, 95%CI 52.4-64.5) than those without LTBI (48.3%, 95%CI 44.5-52.1) (prevalence ratio [PR]=1.2, 95%CI 1.1-1.3). However, after adjusting for confounders, the prevalence of hypertension was similar for those with and without LTBI (adjusted PR=1.0, 95%CI 0.9 -1.1). Among individuals without CVD risk factors of elevated BMI (PRnormal BMI=1.6, 95%CI 1.2-2.0), hyperglycemia (PReuglycemia=1.3, 95%CI 1.1-1.5), or cigarette smoking (PRnon-smokers=1.2, 95%CI 1.1-1.4), the unadjusted prevalence of hypertension was higher among those with LTBI vs. no LTBI. Conclusions More than half of adults with LTBI in the US had hypertension. Importantly, we observed a relationship between LTBI and hypertension among those without established CVD risk factors.
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Affiliation(s)
- Argita D Salindri
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara C Auld
- Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Unjali P Gujral
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Elaine M Urbina
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Moises A Huaman
- Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew J Magee
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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23
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Dodd PJ, Shaweno D, Ku CC, Glaziou P, Pretorius C, Hayes RJ, MacPherson P, Cohen T, Ayles H. Transmission modeling to infer tuberculosis incidence prevalence and mortality in settings with generalized HIV epidemics. Nat Commun 2023; 14:1639. [PMID: 36964130 PMCID: PMC10037365 DOI: 10.1038/s41467-023-37314-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 03/13/2023] [Indexed: 03/26/2023] Open
Abstract
Tuberculosis (TB) killed more people globally than any other single pathogen over the past decade. Where surveillance is weak, estimating TB burden estimates uses modeling. In many African countries, increases in HIV prevalence and antiretroviral therapy have driven dynamic TB epidemics, complicating estimation of burden, trends, and potential intervention impact. We therefore develop a novel age-structured TB transmission model incorporating evolving demographic, HIV and antiretroviral therapy effects, and calibrate to TB prevalence and notification data from 12 African countries. We use Bayesian methods to include uncertainty for all TB model parameters, and estimate age-specific annual risks of TB infection, finding up to 16.0%/year in adults, and the proportion of TB incidence from recent (re)infection, finding a mean across countries of 34%. Rapid reduction of the unacceptably high burden of TB in high HIV prevalence settings will require interventions addressing progression as well as transmission.
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Affiliation(s)
- Peter J Dodd
- School of Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Debebe Shaweno
- School of Public Health, Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Chu-Chang Ku
- School of Public Health, Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Philippe Glaziou
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | - Richard J Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter MacPherson
- School of Health & Wellbeing, University of Glasgow, Glasgow, UK
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Helen Ayles
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- ZAMBART Project, Ridgeway Campus, University of Zambia, Lusaka, Zambia
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24
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A cost-effectiveness evaluation of latent tuberculosis infection screening of a migrant population in Malaysia. Sci Rep 2023; 13:2390. [PMID: 36765258 PMCID: PMC9918505 DOI: 10.1038/s41598-023-29648-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/08/2023] [Indexed: 02/12/2023] Open
Abstract
To estimate the costs and benefits of screening for latent tuberculosis infection (LTBI) in a migrant population in Malaysia. An economic model was developed from a Malaysian healthcare perspective to compare QuantiFERON-TB Gold Plus (QuantiFERON) with the tuberculin skin test (TST). A decision tree was used to capture outcomes relating to LTBI screening followed by a Markov model that simulated the lifetime costs and benefits of the patient cohort. The Markov model did not capture the impact of secondary infections. The model included an R shiny interactive interface to allow adaptation to other scenarios and settings. QuantiFERON is both more effective and less costly than TST (dominant). Compared with QuantiFERON, the lifetime risk of developing active TB increases by approximately 40% for TST due to missed LTBI cases during screening (i.e. a higher number of false negative cases for TST). For a migrant population in Malaysia, QuantiFERON is cost-effective when compared with TST. Further research should consider targeted LTBI screening for migrants in Malaysia based on common risk factors.
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25
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Horsburgh CR, Jo Y, Nichols B, Jenkins HE, Russell CA, White LF. Contribution of Reinfection to Annual Rate of Tuberculosis Infection (ARI) and Incidence of Tuberculosis Disease. Clin Infect Dis 2023; 76:e965-e972. [PMID: 35666515 PMCID: PMC10169390 DOI: 10.1093/cid/ciac451] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/24/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Modeling studies have concluded that 60-80% of tuberculosis (TB) infections result from reinfection of previously infected persons. The annual rate of infection (ARI), a standard measure of the risk of TB infection in a community, may not accurately reflect the true risk of infection among previously infected persons. We constructed a model of infection and reinfection with Mycobacterium tuberculosis to explore the predictive accuracy of ARI and its effect on disease incidence. METHODS We created a deterministic simulation of the progression from TB infection to disease and simulated the prevalence of TB infection at the beginning and end of a theoretical year of infection. We considered 10 disease prevalence scenarios ranging from 100/100 000 to 1000/100 000 in simulations where TB exposure probability was homogeneous across the whole simulated population or heterogeneously stratified into high-risk and low-risk groups. ARI values, rates of progression from infection to disease, and the effect of multiple reinfections were obtained from published studies. RESULTS With homogeneous exposure risk, observed ARI values produced expected numbers of infections. However, when heterogeneous risk was introduced, observed ARI was seen to underestimate true ARI by 25-58%. Of the cases of TB disease that occurred, 36% were among previously infected persons when prevalence was 100/100 000, increasing to 79% of cases when prevalence was 1000/100 000. CONCLUSIONS Measured ARI underestimates true ARI as a result of heterogeneous population mixing. The true force of infection in a community may be greater than previously appreciated. Hyperendemic communities likely contribute disproportionally to the global TB disease burden.
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Affiliation(s)
- C Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Youngji Jo
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Brooke Nichols
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Helen E Jenkins
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Colin A Russell
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Department of Medical Microbiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, USA
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26
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Chin KL, Anibarro L, Sarmiento ME, Acosta A. Challenges and the Way forward in Diagnosis and Treatment of Tuberculosis Infection. Trop Med Infect Dis 2023; 8:tropicalmed8020089. [PMID: 36828505 PMCID: PMC9960903 DOI: 10.3390/tropicalmed8020089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/20/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023] Open
Abstract
Globally, it is estimated that one-quarter of the world's population is latently infected with Mycobacterium tuberculosis (Mtb), also known as latent tuberculosis infection (LTBI). Recently, this condition has been referred to as tuberculosis infection (TBI), considering the dynamic spectrum of the infection, as 5-10% of the latently infected population will develop active TB (ATB). The chances of TBI development increase due to close contact with index TB patients. The emergence of multidrug-resistant TB (MDR-TB) and the risk of development of latent MDR-TB has further complicated the situation. Detection of TBI is challenging as the infected individual does not present symptoms. Currently, there is no gold standard for TBI diagnosis, and the only screening tests are tuberculin skin test (TST) and interferon gamma release assays (IGRAs). However, these tests have several limitations, including the inability to differentiate between ATB and TBI, false-positive results in BCG-vaccinated individuals (only for TST), false-negative results in children, elderly, and immunocompromised patients, and the inability to predict the progression to ATB, among others. Thus, new host markers and Mtb-specific antigens are being tested to develop new diagnostic methods. Besides screening, TBI therapy is a key intervention for TB control. However, the long-course treatment and associated side effects result in non-adherence to the treatment. Additionally, the latent MDR strains are not susceptible to the current TBI treatments, which add an additional challenge. This review discusses the current situation of TBI, as well as the challenges and efforts involved in its control.
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Affiliation(s)
- Kai Ling Chin
- Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia
- Borneo Medical and Health Research Centre, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu 88400, Malaysia
- Correspondence: (K.L.C.); (L.A.); (A.A.)
| | - Luis Anibarro
- Tuberculosis Unit, Infectious Diseases and Internal Medicine Department, Complexo Hospitalario Universitario de Pontevedra, 36071 Pontevedra, Spain
- Immunology Research Group, Galicia Sur Health Research Institute (IIS-GS), 36312 Vigo, Spain
- Correspondence: (K.L.C.); (L.A.); (A.A.)
| | - Maria E. Sarmiento
- School of Health Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
| | - Armando Acosta
- School of Health Sciences, Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
- Correspondence: (K.L.C.); (L.A.); (A.A.)
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Mukhida S, Mirza S, Kannuri S, Das NK. Are the Diagnosed Cases of Tuberculosis Just the Tip of Iceberg? Comments on "Syndemic of Tuberculosis and COVID-19 in Bangladesh". Asia Pac J Public Health 2022; 34:875-876. [PMID: 36004397 PMCID: PMC9679206 DOI: 10.1177/10105395221121049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sahjid Mukhida
- Department of Microbiology, Dr. D. Y.
Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth,
Pune, Pune, India
| | - Shahzad Mirza
- Department of Microbiology, Dr. D. Y.
Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth,
Pune, Pune, India
| | - Sriram Kannuri
- Department of Microbiology, Dr. D. Y.
Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth,
Pune, Pune, India
| | - Nikunja Kumar Das
- Department of Microbiology, Dr. D. Y.
Patil Medical College, Hospital & Research Centre, Dr. D. Y. Patil Vidyapeeth,
Pune, Pune, India,Nikunja Kumar Das, Department of
Microbiology, Dr. D. Y. Patil Medical College, Hospital & Research Centre,
Dr. D. Y. Patil Vidyapeeth, Pune, Pimpri, Pune 411018, Maharashtra, India.
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28
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Coleman M, Martinez L, Theron G, Wood R, Marais B. Mycobacterium tuberculosis Transmission in High-Incidence Settings-New Paradigms and Insights. Pathogens 2022; 11:1228. [PMID: 36364978 PMCID: PMC9695830 DOI: 10.3390/pathogens11111228] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 12/01/2023] Open
Abstract
Tuberculosis has affected humankind for thousands of years, but a deeper understanding of its cause and transmission only arose after Robert Koch discovered Mycobacterium tuberculosis in 1882. Valuable insight has been gained since, but the accumulation of knowledge has been frustratingly slow and incomplete for a pathogen that remains the number one infectious disease killer on the planet. Contrast that to the rapid progress that has been made in our understanding SARS-CoV-2 (the cause of COVID-19) aerobiology and transmission. In this Review, we discuss important historical and contemporary insights into M. tuberculosis transmission. Historical insights describing the principles of aerosol transmission, as well as relevant pathogen, host and environment factors are described. Furthermore, novel insights into asymptomatic and subclinical tuberculosis, and the potential role this may play in population-level transmission is discussed. Progress towards understanding the full spectrum of M. tuberculosis transmission in high-burden settings has been hampered by sub-optimal diagnostic tools, limited basic science exploration and inadequate study designs. We propose that, as a tuberculosis field, we must learn from and capitalize on the novel insights and methods that have been developed to investigate SARS-CoV-2 transmission to limit ongoing tuberculosis transmission, which sustains the global pandemic.
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Affiliation(s)
- Mikaela Coleman
- WHO Collaborating Centre for Tuberculosis and the Sydney Institute for Infectious Diseases, The University of Sydney, Sydney 2006, Australia
- Tuberculosis Research Program, Centenary Institute, The University of Sydney, Sydney 2050, Australia
| | - Leonardo Martinez
- Department of Epidemiology, Boston University School of Public Health, Boston, MA 02118, USA
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7602, South Africa
| | - Robin Wood
- Desmond Tutu Health Foundation and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town 7700, South Africa
| | - Ben Marais
- WHO Collaborating Centre for Tuberculosis and the Sydney Institute for Infectious Diseases, The University of Sydney, Sydney 2006, Australia
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29
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Dowdy DW, Behr MA. Estimating annual risk of infection with Mycobacterium tuberculosis - Authors' reply. THE LANCET. INFECTIOUS DISEASES 2022; 22:1277-1278. [PMID: 36029782 DOI: 10.1016/s1473-3099(22)00448-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Affiliation(s)
- David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Marcel A Behr
- McGill International Tuberculosis Centre and Department of Medicine, McGill University, Montreal, QC, Canada
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30
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Yates TA, Khan PY. Estimating annual risk of infection with Mycobacterium tuberculosis. THE LANCET. INFECTIOUS DISEASES 2022; 22:1276-1277. [PMID: 36029781 DOI: 10.1016/s1473-3099(22)00454-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Tom A Yates
- Division of Infection and Immunity, Faculty of Medicine, University College London, London, UK.
| | - Palwasha Y Khan
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Africa Health Research Institute, KwaZulu-Natal, South Africa
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Dale KD, Schwalb A, Houben RMGJ. Estimating annual risk of infection with Mycobacterium tuberculosis. THE LANCET. INFECTIOUS DISEASES 2022; 22:1275-1276. [PMID: 36029780 DOI: 10.1016/s1473-3099(22)00452-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/23/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Katie D Dale
- Victorian Tuberculosis Program, Peter Doherty Institute for Infection and Immunity, The Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - Alvaro Schwalb
- TB Modelling Group, TB Centre, and Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Rein M G J Houben
- TB Modelling Group, TB Centre, and Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Cancino-Muñoz I, López MG, Torres-Puente M, Villamayor LM, Borrás R, Borrás-Máñez M, Bosque M, Camarena JJ, Colijn C, Colomer-Roig E, Colomina J, Escribano I, Esparcia-Rodríguez O, García-García F, Gil-Brusola A, Gimeno C, Gimeno-Gascón A, Gomila-Sard B, Gónzales-Granda D, Gonzalo-Jiménez N, Guna-Serrano MR, López-Hontangas JL, Martín-González C, Moreno-Muñoz R, Navarro D, Navarro M, Orta N, Pérez E, Prat J, Rodríguez JC, Ruiz-García MM, Vanaclocha H, Comas I. Population-based sequencing of Mycobacterium tuberculosis reveals how current population dynamics are shaped by past epidemics. eLife 2022; 11:76605. [PMID: 35880398 PMCID: PMC9323001 DOI: 10.7554/elife.76605] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Transmission is a driver of tuberculosis (TB) epidemics in high-burden regions, with assumed negligible impact in low-burden areas. However, we still lack a full characterization of transmission dynamics in settings with similar and different burdens. Genomic epidemiology can greatly help to quantify transmission, but the lack of whole genome sequencing population-based studies has hampered its application. Here, we generate a population-based dataset from Valencia region and compare it with available datasets from different TB-burden settings to reveal transmission dynamics heterogeneity and its public health implications. We sequenced the whole genome of 785 Mycobacterium tuberculosis strains and linked genomes to patient epidemiological data. We use a pairwise distance clustering approach and phylodynamic methods to characterize transmission events over the last 150 years, in different TB-burden regions. Our results underscore significant differences in transmission between low-burden TB settings, i.e., clustering in Valencia region is higher (47.4%) than in Oxfordshire (27%), and similar to a high-burden area as Malawi (49.8%). By modeling times of the transmission links, we observed that settings with high transmission rate are associated with decades of uninterrupted transmission, irrespective of burden. Together, our results reveal that burden and transmission are not necessarily linked due to the role of past epidemics in the ongoing TB incidence, and highlight the need for in-depth characterization of transmission dynamics and specifically tailored TB control strategies.
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Affiliation(s)
- Irving Cancino-Muñoz
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia (IBV-CSIC), Valencia, Spain
| | - Mariana G López
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia (IBV-CSIC), Valencia, Spain
| | - Manuela Torres-Puente
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia (IBV-CSIC), Valencia, Spain
| | - Luis M Villamayor
- Unidad Mixta "Infección y Salud Pública" (FISABIO-CSISP), Valencia, Spain
| | - Rafael Borrás
- Microbiology Service, Hospital Clínico Universitario, Valencia, Spain
| | - María Borrás-Máñez
- Microbiology and Parasitology Service, Hospital Universitario de La Ribera, Alzira, Spain
| | | | - Juan J Camarena
- Microbiology Service, Hospital Universitario Dr Peset, Valencia, Spain
| | - Caroline Colijn
- Department of Mathematics, Faculty of Science, Simon Fraser University, Burnaby, Canada
| | - Ester Colomer-Roig
- Unidad Mixta "Infección y Salud Pública" (FISABIO-CSISP), Valencia, Spain.,Microbiology Service, Hospital Universitario Dr Peset, Valencia, Spain
| | - Javier Colomina
- Microbiology Service, Hospital Clínico Universitario, Valencia, Spain
| | - Isabel Escribano
- Microbiology Laboratory, Hospital Virgen de los Lirios, Alcoy, Spain
| | | | | | - Ana Gil-Brusola
- Microbiology Service, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Concepción Gimeno
- Microbiology Service, Hospital General Universitario de Valencia, Valencia, Spain
| | | | - Bárbara Gomila-Sard
- Microbiology Service, Hospital General Universitario de Castellón, Castellón, Spain
| | | | | | | | | | - Coral Martín-González
- Microbiology Service, Hospital Universitario de San Juan de Alicante, Alicantes, Spain
| | - Rosario Moreno-Muñoz
- Microbiology Service, Hospital General Universitario de Castellón, Castellón, Spain
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, Valencia, Spain
| | - María Navarro
- Microbiology Service, Hospital de la Vega Baixa, Orihuela, Spain
| | - Nieves Orta
- Microbiology Service, Hospital Universitario de San Juan de Alicante, Alicantes, Spain
| | - Elvira Pérez
- Subdirección General de Epidemiología y Vigilancia de la Salud y Sanidad Ambiental de Valencia (DGSP), Valencia, Spain
| | - Josep Prat
- Microbiology Service, Hospital de Sagunto, Sagunto, Spain
| | | | | | - Hermelinda Vanaclocha
- Subdirección General de Epidemiología y Vigilancia de la Salud y Sanidad Ambiental de Valencia (DGSP), Valencia, Spain
| | | | - Iñaki Comas
- Tuberculosis Genomics Unit, Instituto de Biomedicina de Valencia (IBV-CSIC), Valencia, Spain.,CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
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