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de Faria MGBF, Andrade RLDP, Leite KFDS, Bonfim RO, Valênça ABM, Ramos ACV, Berra TZ, Arcêncio RA, Rujula MJP, Ballestero JGDA, Chimara E, Ruffino Netto A, Gomes DMDO, Bollela VR, Monroe AA. Operational indicators for pulmonary tuberculosis diagnosis in people living with HIV before and after Xpert MTB/RIF implementation in the state of São Paulo, Brazil. PLoS One 2024; 19:e0305063. [PMID: 38848395 PMCID: PMC11161080 DOI: 10.1371/journal.pone.0305063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 05/22/2024] [Indexed: 06/09/2024] Open
Abstract
Tuberculosis (TB) in people living with HIV (PLHIV) is usually paucibacillary and the smear microscopy has limitations and may lead to high proportions of non-confirmed pulmonary tuberculosis (NC-PTB). Despite culture being the reference method, it usually takes 6 to 8 weeks to produce the results. This study aimed to analyze the effect of a rapid molecular test (Xpert) in the confirmatory rate of PTB among PLHIV, from 2010 to 2020, in São Paulo state, Brazil. This is an ecological study with time series analysis of the trend and the NC-PTB rates before and after Xpert implementation in 21 municipalities. The use of Xpert started and gradually increased after 2014, while the rate of NC-PTB in PLHIV decreased over this time, being more significant between late 2015 and mid-2017. The city of Ribeirão Preto stands out for having the highest percentage (75.0%) of Xpert testing among PLHIV and for showing two reductions in the NC-PTB rate. The cities with low Xpert coverage had a slower and smaller decrease in the NC-PTB rate. Despite being available since 2014, a significant proportion of PLHIV suspected of PTB in the state of São Paulo did not have an Xpert ordered by the doctors. The implementation of Xpert reduced the NC-PTB rates with growing effect as the coverage increased in the municipality.
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Affiliation(s)
| | | | | | - Rafaele Oliveira Bonfim
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | | | - Thais Zamboni Berra
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | | | | | - Erica Chimara
- Adolfo Lutz Institute, Government of the State of São Paulo, São Paulo, Brazil
| | - Antônio Ruffino Netto
- Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Valdes Roberto Bollela
- Ribeirão Preto School of Medicine, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Aline Aparecida Monroe
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Reeve BWP, Ndlangalavu G, Mishra H, Palmer Z, Tshivhula H, Rockman L, Naidoo S, Mbu DL, Naidoo CC, Derendinger B, Walzl G, Malherbe ST, van Helden PD, Semitala FC, Yoon C, Gupta RK, Noursadeghi M, Warren RM, Theron G. Point-of-care C-reactive protein and Xpert MTB/RIF Ultra for tuberculosis screening and diagnosis in unselected antiretroviral therapy initiators: a prospective, cross-sectional, diagnostic accuracy study. Lancet Glob Health 2024; 12:e793-e803. [PMID: 38583458 PMCID: PMC11035478 DOI: 10.1016/s2214-109x(24)00052-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/14/2023] [Accepted: 01/25/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Tuberculosis, a major cause of death in people living with HIV, remains challenging to diagnose. Diagnostic accuracy data are scarce for promising triage and confirmatory tests such as C-reactive protein (CRP), sputum and urine Xpert MTB/RIF Ultra (Xpert Ultra), and urine Determine TB LAM Ag (a lateral flow lipoarabinomannan [LF-LAM] test), without symptom selection. We evaluated novel triage and confirmatory tests in ambulatory people with HIV initiating antiretroviral therapy (ART). METHODS 897 ART-initiators were recruited irrespective of symptoms and sputum induction offered. For triage (n=800), we evaluated point-of-care blood-based CRP testing, compared with the WHO-recommended four-symptom screen (W4SS). For sputum-based confirmatory testing (n=787), we evaluated Xpert Ultra versus Xpert MTB/RIF (Xpert). For urine-based confirmatory testing (n=732), we evaluated Xpert Ultra and LF-LAM. We used a sputum culture reference standard. FINDINGS 463 (52%) of 897 participants were female. The areas under the receiver operator characteristic curves for CRP was 0·78 (95% CI 0·73-0·83) and for number of W4SS symptoms was 0·70 (0·64-0·75). CRP (≥10 mg/L) had similar sensitivity to W4SS (77% [95% CI 68-85; 80/104] vs 77% [68-85; 80/104]; p>0·99] but higher specificity (64% [61-68; 445/696] vs 48% [45-52; 334/696]; p<0·0001]; reducing unnecessary confirmatory testing by 138 (95% CI 117-160) per 1000 people and number-needed-to-test from 6·91 (95% CI 6·25-7·81) to 4·87 (4·41-5·51). Sputum samples with Xpert Ultra, which required induction in 49 (31%) of 158 of people (95% CI 24-39), had higher sensitivity than Xpert (71% [95% CI 61-80; 74/104] vs 56% [46-66; 58/104]; p<0·0001). Of the people with one or more confirmatory sputum or urine test results that were positive, the proportion detected by Xpert Ultra increased from 45% (26-64) to 66% (46-82) with induction. Programmatically done haemoglobin, triage test combinations, and urine tests showed comparatively worse results. INTERPRETATION CRP is a more specific triage test than W4SS in those initiating ART. Sputum induction improves diagnostic yield. Sputum samples with Xpert Ultra is a more accurate confirmatory test than with Xpert. FUNDING South African Medical Research Council, EDCTP2, US National Institutes of Health-National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
- Byron W P Reeve
- 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, South Africa
| | - Gcobisa Ndlangalavu
- 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, South Africa
| | - Hridesh Mishra
- 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, South Africa; Public Health Research Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, USA
| | - Zaida Palmer
- 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, South Africa
| | - Happy Tshivhula
- 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, South Africa
| | - Loren Rockman
- 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, South Africa
| | - Selisha Naidoo
- 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, South Africa
| | - Desiree L Mbu
- 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, South Africa
| | - Charissa C Naidoo
- 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, South Africa
| | - Brigitta Derendinger
- 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, South Africa
| | - Gerhard Walzl
- 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, South Africa
| | - Stephanus T Malherbe
- 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, South Africa
| | - Paul D van Helden
- 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, South Africa
| | - Fred C Semitala
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda; Department of Internal Medicine, Makerere University College of Health Sciences, Makerere, Kampala, Uganda
| | - Christina Yoon
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda; Department of Medicine, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Rishi K Gupta
- Division of Infection and Immunity, University College London, London, UK
| | | | - Robin M Warren
- 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, South Africa
| | - 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, South Africa.
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Reeve BW, Ndlangalavu G, Mishra H, Palmer Z, Tshivhula H, Rockman L, Naidoo S, Mbu DL, Naidoo CC, Derendinger B, Walzl G, Malherbe ST, van Helden PD, Semitala FC, Yoon C, Gupta RK, Noursadeghi M, Warren RM, Theron G. Point-of-care C-reactive protein and Xpert MTB/RIF Ultra for tuberculosis screening and diagnosis in unselected antiretroviral therapy initiators: a prospective diagnostic accuracy study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.30.23290716. [PMID: 37333303 PMCID: PMC10274965 DOI: 10.1101/2023.05.30.23290716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background Tuberculosis (TB), a major cause of death in people living with HIV (PLHIV), remains challenging to diagnose. Diagnostic accuracy data are lacking for promising triage tests, such as C-reactive protein (CRP), and confirmatory tests, such as sputum and urine Xpert MTB/RIF Ultra (Ultra), and urine LAM, without prior symptom selection. Methods 897 PLHIV initiating antiretroviral therapy were consecutively recruited in settings with high TB incidence, irrespective of symptoms. Participants were offered sputum induction, with a liquid culture reference standard. First, we evaluated point-of-care CRP testing on blood, compared to the World Health Organization (WHO)-recommended four-symptom screen (W4SS) for triage (n=800). Second, we evaluated Xpert MTB/RIF Ultra (Ultra) versus Xpert MTB/RIF (Xpert) for sputum-based confirmatory testing (n=787), with or without sputum induction. Third, we evaluated Ultra and Determine LF-LAM for urine-based confirmatory testing (n=732). Findings CRP and number of W4SS symptoms had areas under the receiver operator characteristic curve of 0.78 (95% confidence interval 0.73, 0.83) and 0.70 (0.64, 0.75), respectively. For triage, CRP (≥10 mg/l) has similar sensitivity to W4SS [77% (68, 85) vs. 77% (68, 85); p>0.999] but higher specificity [64% (61, 68) vs. 48% (45, 52); p<0.001]; reducing unnecessary confirmatory testing by 138 per 1000 people and the number-needed-to-test from 6.91 (6.25, 7.81) to 4.87 (4.41, 5.51). Using sputum, which required induction in 31% (24, 39) of people, Ultra had higher sensitivity than Xpert [71% (61, 80) vs. 56% (46, 66); p<0.001] but lower specificity [98% (96, 100) vs. 99% (98, 100); p<0.001]. The proportion of people with ≥1 positive confirmatory result detected by Ultra increased from 45% (26, 64) to 66% (46, 82) when induction was done. Programmatically-done haemoglobin, triage test combinations, and urine tests showed comparatively worse performance. Interpretation Among ART-initiators in a high burden setting, CRP is a more specific triage test than W4SS. Sputum induction improves yield. Sputum Ultra is a more accurate confirmatory test than Xpert. Funding SAMRC (MRC-RFA-IFSP-01-2013), EDCTP2 (SF1401, OPTIMAL DIAGNOSIS), NIH/NIAD (U01AI152087). Research in context Evidence before this study: Novel triage and confirmatory tests are urgently needed for TB, especially in key risk groups like PLHIV. Many TB cases do not meet World Health Organization (WHO)-recommended four-symptom screen (W4SS) criteria despite accounting for significant transmission and morbidity. W4SS also lacks specificity, which makes onward referral of triage-positive people for expensive confirmatory testing inefficient and hampers diagnostic scale-up. Alternative triage approaches like CRP have promise, but have comparatively little data in ART-initiators, especially when done without syndromic preselection and using point-of-care (POC) tools. After triage, confirmatory testing can be challenging due to sputum scarcity and paucibacillary early-stage disease. Next generation WHO-endorsed rapid molecular tests (including Xpert MTB/RIF Ultra; Ultra) are a standard-of-care for confirmatory testing. However, there are no supporting data in ART-initiators, among whom Ultra may offer large sensitivity gains over predecessors like Xpert MTB/RIF (Xpert). The added value of sputum induction to augment diagnostic sampling for confirmatory testing is also unclear. Lastly, the performance of urine tests (Ultra, Determine LF-LAM) in this population requires more data.Added value of this study: We evaluated repurposed and new tests for triage and confirmatory testing using a rigorous microbiological reference standard in a highly vulnerable high-priority patient population (ART-initiators) regardless of symptoms and ability to naturally expectorate sputum. We showed POC CRP triage is feasible, performs better than W4SS, and that combinations of different triage approaches offer no advantages over CRP alone. Sputum Ultra has superior sensitivity to Xpert; often detecting W4SS-negative TB. Furthermore, without induction, confirmatory sputum-based testing would not be possible in a third of people. Urine tests had poor performance. This study contributed unpublished data to systematic reviews and meta-analyses used by the WHO to inform global policy supporting use of CRP triage and Ultra in PLHIV.Implication of all the available evidence: POC CRP triage testing is feasible and superior to W4SS and, together with sputum induction in people who triage CRP-positive should, after appropriate cost and implementation research, be considered for roll-out in ART-initiators in high burden settings. Such people should be offered Ultra, which outperforms Xpert.
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Svadzian A, Daniels B, Sulis G, Das J, Daftary A, Kwan A, Das V, Das R, Pai M. Do private providers initiate anti-tuberculosis therapy on the basis of chest radiographs? A standardised patient study in urban India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2023; 13:100152. [PMID: 37383564 PMCID: PMC10306035 DOI: 10.1016/j.lansea.2023.100152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 06/30/2023]
Abstract
Background The initiation of anti-tuberculosis treatment (ATT) based on results of WHO-approved microbiological diagnostics is an important marker of quality tuberculosis (TB) care. Evidence suggests that other diagnostic processes leading to treatment initiation may be preferred in high TB incidence settings. This study examines whether private providers start anti-TB therapy on the basis of chest radiography (CXR) and clinical examinations. Methods This study uses the standardized patient (SP) methodology to generate accurate and unbiased estimates of private sector, primary care provider practice when a patient presents a standardized TB case scenario with an abnormal CXR. Using multivariate log-binomial and linear regressions with standard errors clustered at the provider level, we analyzed 795 SP visits conducted over three data collection waves from 2014 to 2020 in two Indian cities. Data were inverse-probability-weighted based on the study sampling strategy, resulting in city-wave-representative results. Findings Amongst SPs who presented to a provider with an abnormal CXR, 25% (95% CI: 21-28%) visits resulted in ideal management, defined as the provider prescribing a microbiological test and not offering a concurrent prescription for a corticosteroid or antibiotic (including anti-TB medications). In contrast, 23% (95% CI: 19-26%) of 795 visits were prescribed anti-TB medications. Of 795 visits, 13% (95% CI: 10-16%) resulted in anti-TB treatment prescriptions/dispensation and an order for confirmatory microbiological testing. Interpretation One in five SPs presenting with abnormal CXR were prescribed ATT by private providers. This study contributes novel insights to empiric treatment prevalence based on CXR abnormality. Further work is needed to understand how providers make trade-offs between existing diagnostic practices, new technologies, profits, clinical outcomes, and the market dynamics with laboratories. Funding This study was funded by the Bill & Melinda Gates Foundation (grant OPP1091843), and the Knowledge for Change Program at The World Bank.
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Affiliation(s)
- Anita Svadzian
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
| | - Benjamin Daniels
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Giorgia Sulis
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jishnu Das
- McCourt School of Public Policy, Georgetown University, Washington, DC, USA
- Centre for Policy Research, New Delhi, India
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, School of Global Health, York University, Toronto, ON, Canada
- Centre for the Aids Programme of Research in South Africa MRC-HIV-TB Pathogenesis and Treatment, Research Unit, Durban, South Africa
| | - Ada Kwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Veena Das
- Department of Anthropology, Johns Hopkins University, Baltimore, USA
| | - Ranendra Das
- Institute for Socio-Economic Research on Development and Democracy, Delhi, India
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- McGill International TB Centre, McGill University, Montreal, QC, Canada
- Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Pagaduan JV, Altawallbeh G. Advances in TB testing. Adv Clin Chem 2023; 115:33-62. [PMID: 37673521 PMCID: PMC10056534 DOI: 10.1016/bs.acc.2023.03.003] [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] [Indexed: 03/31/2023]
Abstract
Globally, tuberculosis (TB) was the leading cause of death from a single infectious agent until the coronavirus (COVID-19) pandemic. In 2020, an estimated 10 million people fell ill with TB and a total of 1.5 million people died from the disease. About one-quarter of the global population, almost two billion people, is estimated to be latently infected with Mycobacterium tuberculosis (MTB). Although latent TB infection (LTBI) is asymptomatic and noncontagious, about 5-10% of LTBI patients have a lifetime risk of progression to active TB. The diagnosis and treatment of active cases are extremely vital for TB control programs. However, achieving the End TB goal of 2035 without the ability to identify and treat the pool of latently infected individuals will be a big challenge. To do so, improved technology to provide more accurate diagnostic tools and accessibility are crucial. Therefore, this chapter covers the current WHO-endorsed tests and advances in diagnostic and screening tests for active and latent TB.
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Affiliation(s)
- Jayson V Pagaduan
- Intermountain Central Laboratory Intermountain Medical Center, Murray, UT, United States
| | - Ghaith Altawallbeh
- Intermountain Central Laboratory Intermountain Medical Center, Murray, UT, United States.
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da Silva KN, Santos PSPD, Barbosa RDS, Lopes MDSV, Pinto AGA, Cavalcante EGR. Educational technologies to guide pulmonary tuberculosis sputum collection: a systematic review. Rev Esc Enferm USP 2022; 56:e20210433. [PMID: 35899816 PMCID: PMC10081603 DOI: 10.1590/1980-220x-reeusp-2021-0433en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/26/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the contributions of educational technologies used during the guidelines for sputum collection from pulmonary tuberculosis. METHOD Systematic review guided by Preferred Reporting items for Systematic Reviews with protocol registered in the database International Prospective Register of Systematic Reviews, with number CRD42020208162. The search was performed in the Cinahl, Scopus, PubMed, Web of Science, Embase, Lilacs, CENTRAL, CAPES, Proquest, OpenGrey databases and manual search in the reference list. The search, selection of studies, data extraction, and methodological evaluation using the Cochrane Risk-of-Bias tool were performed by two independent reviewers. RESULTS A total of 2,488 studies were evidenced, with seven being selected and analyzed, of which four used structured lectures; three, educational booklet; and one, an educational video, used alone or together, impacting the bacteriological confirmation of tuberculosis. The studies had a low risk of bias. CONCLUSION Scientific evidence has shown that educational technologies contribute to increasing the quality, volume, and appearance of the sputum sample, which improves the bacteriological confirmation of the disease.
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Mafirakureva N, Klinkenberg E, Spruijt I, Levy J, Shaweno D, de Haas P, Kaswandani N, Bedru A, Triasih R, Gebremichael M, Dodd PJ, Tiemersma EW. Xpert Ultra stool testing to diagnose tuberculosis in children in Ethiopia and Indonesia: a model-based cost-effectiveness analysis. BMJ Open 2022; 12:e058388. [PMID: 35777870 PMCID: PMC9252203 DOI: 10.1136/bmjopen-2021-058388] [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] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The WHO currently recommends stool testing using GeneXpert MTB/Rif (Xpert) for the diagnosis of paediatric tuberculosis (TB). The simple one-step (SOS) stool method enables processing for Xpert testing at the primary healthcare (PHC) level. We modelled the impact and cost-effectiveness of implementing the SOS stool method at PHC for the diagnosis of paediatric TB in Ethiopia and Indonesia, compared with the standard of care. SETTING All children (age <15 years) presenting with presumptive TB at primary healthcare or hospital level in Ethiopia and Indonesia. PRIMARY OUTCOME Cost-effectiveness estimated as incremental costs compared with incremental disability-adjusted life-years (DALYs) saved. METHODS Decision tree modelling was used to represent pathways of patient care and referral. We based model parameters on ongoing studies and surveillance, systematic literature review, and expert opinion. We estimated costs using data available publicly and obtained through in-country expert consultations. Health outcomes were based on modelled mortality and discounted life-years lost. RESULTS The intervention increased the sensitivity of TB diagnosis by 19-25% in both countries leading to a 14-20% relative reduction in mortality. Under the intervention, fewer children seeking care at PHC were referred (or self-referred) to higher levels of care; the number of children initiating anti-TB treatment (ATT) increased by 18-25%; and more children (85%) initiated ATT at PHC level. Costs increased under the intervention compared with a base case using smear microscopy in the standard of care resulting in incremental cost-effectiveness ratios of US$132 and US$94 per DALY averted in Ethiopia and Indonesia, respectively. At a cost-effectiveness threshold of 0.5×gross domestic product per capita, the projected probability of the intervention being cost-effective in Ethiopia and Indonesia was 87% and 96%, respectively. The intervention remained cost-effective under sensitivity analyses. CONCLUSIONS The addition of the SOS stool method to national algorithms for diagnosing TB in children is likely to be cost-effective in both Ethiopia and Indonesia.
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Affiliation(s)
| | - Eveline Klinkenberg
- Independent consultant, Connect TB, Den Haag, The Netherlands
- Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ineke Spruijt
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Jens Levy
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | | | - Petra de Haas
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Nastiti Kaswandani
- Pediatric Department, RSCM Hospital, University of Indonesia Faculty of Medicine, Jakarta, Indonesia
| | - Ahmed Bedru
- Technical Division, KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Rina Triasih
- Department of Paediatrics, Universitas Gadjah Mada Fakultas Kedokteran, Yogyakarta, Indonesia
| | | | - Peter J Dodd
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Edine W Tiemersma
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
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da Silva KN, Santos PSPD, Barbosa RDS, Lopes MDSV, Pinto AGA, Cavalcante EGR. Tecnologias educativas para orientação da coleta de escarro da tuberculose pulmonar: revisão sistemática. Rev Esc Enferm USP 2022. [DOI: 10.1590/1980-220x-reeusp-2021-0433pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: Avaliar as contribuições das tecnologias educativas utilizadas durante as orientações para coleta de escarro da tuberculose pulmonar. Método: Revisão sistemática guiada pelo Preferred Reporting items for Systematic Reviews com protocolo registrado na base International Prospective Register of Systematic Reviews, sob o número CRD42020208162. A busca foi realizada nas bases de dados Cinahl, Scopus, PubMed, Web of Science, Embase, Lilacs, CENTRAL, CAPES, Proquest, OpenGrey e busca manual na lista de referências. A busca, seleção dos estudos, extração dos dados e avaliação metodológica pela ferramenta do Risco de Viés da Cochrane foram realizadas por dois revisores independentes. Resultados: Evidenciaram-se 2488 estudos, sendo sete selecionados e analisados, dos quais quatro utilizaram palestras estruturadas; três, folder educativo; e um, vídeo educativo. Todos foram utilizados de forma isolada ou em conjunto, impactando na confirmação bacteriológica da tuberculose. Os estudos apresentaram baixo risco de viés. Conclusão: As evidências científicas demonstraram que as tecnologias educativas apresentam como contribuições o aumento da qualidade, volume e aspecto da amostra de escarro, o que proporciona a melhoria da confirmação bacteriológica da doença.
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Zifodya JS, Kreniske JS, Schiller I, Kohli M, Dendukuri N, Schumacher SG, Ochodo EA, Haraka F, Zwerling AA, Pai M, Steingart KR, Horne DJ. Xpert Ultra versus Xpert MTB/RIF for pulmonary tuberculosis and rifampicin resistance in adults with presumptive pulmonary tuberculosis. Cochrane Database Syst Rev 2021; 2:CD009593. [PMID: 33616229 DOI: 10.1002/14651858.cd009593.pub5] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Xpert MTB/RIF and Xpert MTB/RIF Ultra (Xpert Ultra) are World Health Organization (WHO)-recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in people with signs and symptoms of tuberculosis. This review builds on our recent extensive Cochrane Review of Xpert MTB/RIF accuracy. OBJECTIVES To compare the diagnostic accuracy of Xpert Ultra and Xpert MTB/RIF for the detection of pulmonary tuberculosis and detection of rifampicin resistance in adults with presumptive pulmonary tuberculosis. For pulmonary tuberculosis and rifampicin resistance, we also investigated potential sources of heterogeneity. We also summarized the frequency of Xpert Ultra trace-positive results, and estimated the accuracy of Xpert Ultra after repeat testing in those with trace-positive results. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, LILACS, Scopus, the WHO ICTRP, the ISRCTN registry, and ProQuest to 28 January 2020 with no language restriction. SELECTION CRITERIA We included diagnostic accuracy studies using respiratory specimens in adults with presumptive pulmonary tuberculosis that directly compared the index tests. For pulmonary tuberculosis detection, the reference standards were culture and a composite reference standard. For rifampicin resistance, the reference standards were culture-based drug susceptibility testing and line probe assays. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a standardized form, including data by smear and HIV status. We assessed risk of bias using QUADAS-2 and QUADAS-C. We performed meta-analyses comparing pooled sensitivities and specificities, separately for pulmonary tuberculosis detection and rifampicin resistance detection, and separately by reference standard. Most analyses used a bivariate random-effects model. For tuberculosis detection, we estimated accuracy in studies in participants who were not selected based on prior microscopy testing or history of tuberculosis. We performed subgroup analyses by smear status, HIV status, and history of tuberculosis. We summarized Xpert Ultra trace results. MAIN RESULTS We identified nine studies (3500 participants): seven had unselected participants (2834 participants). All compared Xpert Ultra and Xpert MTB/RIF for pulmonary tuberculosis detection; seven studies used a paired comparative accuracy design, and two studies used a randomized design. Five studies compared Xpert Ultra and Xpert MTB/RIF for rifampicin resistance detection; four studies used a paired design, and one study used a randomized design. Of the nine included studies, seven (78%) were mainly or exclusively in high tuberculosis burden countries. For pulmonary tuberculosis detection, most studies had low risk of bias in all domains. Pulmonary tuberculosis detection Xpert Ultra pooled sensitivity and specificity (95% credible interval) against culture were 90.9% (86.2 to 94.7) and 95.6% (93.0 to 97.4) (7 studies, 2834 participants; high-certainty evidence) versus Xpert MTB/RIF pooled sensitivity and specificity of 84.7% (78.6 to 89.9) and 98.4% (97.0 to 99.3) (7 studies, 2835 participants; high-certainty evidence). The difference in the accuracy of Xpert Ultra minus Xpert MTB/RIF was estimated at 6.3% (0.1 to 12.8) for sensitivity and -2.7% (-5.7 to -0.5) for specificity. If the point estimates for Xpert Ultra and Xpert MTB/RIF are applied to a hypothetical cohort of 1000 patients, where 10% of those presenting with symptoms have pulmonary tuberculosis, Xpert Ultra will miss 9 cases, and Xpert MTB/RIF will miss 15 cases. The number of people wrongly diagnosed with pulmonary tuberculosis would be 40 with Xpert Ultra and 14 with Xpert MTB/RIF. In smear-negative, culture-positive participants, pooled sensitivity was 77.5% (67.6 to 85.6) for Xpert Ultra versus 60.6% (48.4 to 71.7) for Xpert MTB/RIF; pooled specificity was 95.8% (92.9 to 97.7) for Xpert Ultra versus 98.8% (97.7 to 99.5) for Xpert MTB/RIF (6 studies). In people living with HIV, pooled sensitivity was 87.6% (75.4 to 94.1) for Xpert Ultra versus 74.9% (58.7 to 86.2) for Xpert MTB/RIF; pooled specificity was 92.8% (82.3 to 97.0) for Xpert Ultra versus 99.7% (98.6 to 100.0) for Xpert MTB/RIF (3 studies). In participants with a history of tuberculosis, pooled sensitivity was 84.2% (72.5 to 91.7) for Xpert Ultra versus 81.8% (68.7 to 90.0) for Xpert MTB/RIF; pooled specificity was 88.2% (70.5 to 96.6) for Xpert Ultra versus 97.4% (91.7 to 99.5) for Xpert MTB/RIF (4 studies). The proportion of Ultra trace-positive results ranged from 3.0% to 30.4%. Data were insufficient to estimate the accuracy of Xpert Ultra repeat testing in individuals with initial trace-positive results. Rifampicin resistance detection Pooled sensitivity and specificity were 94.9% (88.9 to 97.9) and 99.1% (97.7 to 99.8) (5 studies, 921 participants; high-certainty evidence) for Xpert Ultra versus 95.3% (90.0 to 98.1) and 98.8% (97.2 to 99.6) (5 studies, 930 participants; high-certainty evidence) for Xpert MTB/RIF. The difference in the accuracy of Xpert Ultra minus Xpert MTB/RIF was estimated at -0.3% (-6.9 to 5.7) for sensitivity and 0.3% (-1.2 to 2.0) for specificity. If the point estimates for Xpert Ultra and Xpert MTB/RIF are applied to a hypothetical cohort of 1000 patients, where 10% of those presenting with symptoms have rifampicin resistance, Xpert Ultra will miss 5 cases, and Xpert MTB/RIF will miss 5 cases. The number of people wrongly diagnosed with rifampicin resistance would be 8 with Xpert Ultra and 11 with Xpert MTB/RIF. We identified a higher number of rifampicin resistance indeterminate results with Xpert Ultra, pooled proportion 7.6% (2.4 to 21.0) compared to Xpert MTB/RIF pooled proportion 0.8% (0.2 to 2.4). The estimated difference in the pooled proportion of indeterminate rifampicin resistance results for Xpert Ultra versus Xpert MTB/RIF was 6.7% (1.4 to 20.1). AUTHORS' CONCLUSIONS Xpert Ultra has higher sensitivity and lower specificity than Xpert MTB/RIF for pulmonary tuberculosis, especially in smear-negative participants and people living with HIV. Xpert Ultra specificity was lower than that of Xpert MTB/RIF in participants with a history of tuberculosis. The sensitivity and specificity trade-off would be expected to vary by setting. For detection of rifampicin resistance, Xpert Ultra and Xpert MTB/RIF had similar sensitivity and specificity. Ultra trace-positive results were common. Xpert Ultra and Xpert MTB/RIF provide accurate results and can allow rapid initiation of treatment for rifampicin-resistant and multidrug-resistant tuberculosis.
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Affiliation(s)
- Jerry S Zifodya
- Department of Medicine, Section of Pulmonary, Critical Care, & Environmental Medicine , Tulane University, New Orleans, LA, USA
| | - Jonah S Kreniske
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Ian Schiller
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | - Mikashmi Kohli
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Nandini Dendukuri
- Centre for Outcomes Research, McGill University Health Centre - Research Institute, Montreal, Canada
| | | | - Eleanor A Ochodo
- Centre for Evidence-based Health Care, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Frederick Haraka
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
- Ifakara Health Institute, Bagamoyo, Tanzania
| | - Alice A Zwerling
- School of Epidemiology & Public Health, University of Ottawa, Ottawa, Canada
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - David J Horne
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, and Firland Northwest TB Center, University of Washington, Seattle, WA, USA
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10
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Jayamohan H, Lambert CJ, Sant HJ, Jafek A, Patel D, Feng H, Beeman M, Mahmood T, Nze U, Gale BK. SARS-CoV-2 pandemic: a review of molecular diagnostic tools including sample collection and commercial response with associated advantages and limitations. Anal Bioanal Chem 2021; 413:49-71. [PMID: 33073312 PMCID: PMC7568947 DOI: 10.1007/s00216-020-02958-1] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/03/2020] [Accepted: 09/16/2020] [Indexed: 12/18/2022]
Abstract
The unprecedented global pandemic known as SARS-CoV-2 has exercised to its limits nearly all aspects of modern viral diagnostics. In doing so, it has illuminated both the advantages and limitations of current technologies. Tremendous effort has been put forth to expand our capacity to diagnose this deadly virus. In this work, we put forth key observations in the functionality of current methods for SARS-CoV-2 diagnostic testing. These methods include nucleic acid amplification-, CRISPR-, sequencing-, antigen-, and antibody-based detection methods. Additionally, we include analysis of equally critical aspects of COVID-19 diagnostics, including sample collection and preparation, testing models, and commercial response. We emphasize the integrated nature of assays, wherein issues in sample collection and preparation could impact the overall performance in a clinical setting.
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Affiliation(s)
- Harikrishnan Jayamohan
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA.
| | - Christopher J Lambert
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Himanshu J Sant
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Alexander Jafek
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Dhruv Patel
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Haidong Feng
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Michael Beeman
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Tawsif Mahmood
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Ugochukwu Nze
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
| | - Bruce K Gale
- Department of Mechanical Engineering, University of Utah, Salt Lake City, UT, 84112, USA
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11
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Zheng H, Zhong F, Yu G, Shen Y. Comparison of the diagnostic efficacy of the CapitalBio Mycobacterium real-time polymerase chain reaction detection test and Xpert MTB/RIF in smear-negative pulmonary tuberculosis. Eur J Clin Microbiol Infect Dis 2020; 40:969-977. [PMID: 33242168 DOI: 10.1007/s10096-020-04113-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/20/2020] [Indexed: 01/17/2023]
Abstract
To compare the diagnostic efficacy of CapitalBio Mycobacterium real-time polymerase chain reaction (RT-PCR) detection test and the first-generation Xpert MTB/RIF in smear-negative pulmonary tuberculosis (PTB). In this retrospective study of smear-negative PTB, we reviewed patient medical records to determine the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) of Xpert MTB/RIF, CapitalBio Mycobacterium detection test, and the parallel test (positive result for either of the Xpert MTB/RIF and CapitalBio Mycobacterium detection tests) to evaluate their diagnostic accuracy against a composite reference standard. In total, 1553 patients were evaluated. The sensitivity, specificity, PPV, NPV, and AUC of Xpert MTB/RIF, CapitalBio Mycobacterium detection test, and the parallel test were 57.1%, 92.9%, 81.1%, 95.9%, and 0.75; 53.4%, 97.7%, 98.6%, 41.5%, and 0.76; and 66.2%, 90.8%, 95.5%, 47.7%, and 0.79, respectively. For the bronchoalveolar lavage fluid (BALF) specimens, these values for Xpert MTB/RIF, CapitalBio Mycobacterium detection test, and the parallel test were 68.8%, 97.7%, 99.2%, 43.9%, and 0.83; 61.7%, 97.7%, 99.1%, 38.9%, and 0.80; and 77.0%, 95.5%, 98.6%, 50.9%, and 0.86, respectively. CapitalBio Mycobacterium detection test had moderate accuracy for smear-negative PTB, similar to Xpert MTB/RIF. The parallel test improved the sensitivity. BALF significantly improved the sensitivity and diagnostic accuracy of the test. The maximum diagnostic accuracy for smear-negative PTB was obtained with the parallel test and BALF specimens. BALF was the most effective specimen for diagnosing smear-negative PTB.
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Affiliation(s)
- Hong Zheng
- Zhejiang Tuberculosis Diagnosis and Treatment Center, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, Zhejiang, China
| | - Fangming Zhong
- Zhejiang Tuberculosis Diagnosis and Treatment Center, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, Zhejiang, China
| | - Guocan Yu
- Zhejiang Tuberculosis Diagnosis and Treatment Center, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, Zhejiang, China
| | - Yanqin Shen
- Zhejiang Tuberculosis Diagnosis and Treatment Center, Zhejiang Chinese Medicine and Western Medicine Integrated Hospital, Hangzhou, Zhejiang, China.
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12
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Khan FA, Majidulla A, Tavaziva G, Nazish A, Abidi SK, Benedetti A, Menzies D, Johnston JC, Khan AJ, Saeed S. Chest x-ray analysis with deep learning-based software as a triage test for pulmonary tuberculosis: a prospective study of diagnostic accuracy for culture-confirmed disease. LANCET DIGITAL HEALTH 2020; 2:e573-e581. [PMID: 33328086 DOI: 10.1016/s2589-7500(20)30221-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/20/2020] [Accepted: 08/27/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Deep learning-based radiological image analysis could facilitate use of chest x-rays as triage tests for pulmonary tuberculosis in resource-limited settings. We sought to determine whether commercially available chest x-ray analysis software meet WHO recommendations for minimal sensitivity and specificity as pulmonary tuberculosis triage tests. METHODS We recruited symptomatic adults at the Indus Hospital, Karachi, Pakistan. We compared two software, qXR version 2.0 (qXRv2) and CAD4TB version 6.0 (CAD4TBv6), with a reference of mycobacterial culture of two sputa. We assessed qXRv2 using its manufacturer prespecified threshold score for chest x-ray classification as tuberculosis present versus not present. For CAD4TBv6, we used a data-derived threshold, because it does not have a prespecified one. We tested for non-inferiority to preset WHO recommendations (0·90 for sensitivity, 0·70 for specificity) using a non-inferiority limit of 0·05. We identified factors associated with accuracy by stratification and logistic regression. FINDINGS We included 2198 (92·7%) of 2370 enrolled participants. 2187 (99·5%) of 2198 were HIV-negative, and 272 (12·4%) had culture-confirmed pulmonary tuberculosis. For both software, accuracy was non-inferior to WHO-recommended minimum values (qXRv2 sensitivity 0·93 [95% CI 0·89-0·95], non-inferiority p=0·0002; CAD4TBv6 sensitivity 0·93 [0·90-0·96], p<0·0001; qXRv2 specificity 0·75 [0·73-0·77], p<0·0001; CAD4TBv6 specificity 0·69 [0·67-0·71], p=0·0003). Sensitivity was lower in smear-negative pulmonary tuberculosis for both software, and in women for CAD4TBv6. Specificity was lower in men and in those with previous tuberculosis, and reduced with increasing age and decreasing body mass index. Smoking and diabetes did not affect accuracy. INTERPRETATION In an HIV-negative population, these software met WHO-recommended minimal accuracy for pulmonary tuberculosis triage tests. Sensitivity will be lower when smear-negative pulmonary tuberculosis is more prevalent. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Faiz Ahmad Khan
- McGill International TB Centre, Research Institute of the McGill University Health Centre and McGill University, Montreal, QC, Canada; Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada; Department of Medicine and Department of Epidemiology, McGill University, Montreal, Canada.
| | - Arman Majidulla
- Interactive Research and Development Pakistan, Karachi, Pakistan
| | - Gamuchirai Tavaziva
- McGill International TB Centre, Research Institute of the McGill University Health Centre and McGill University, Montreal, QC, Canada; Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | | | - Syed Kumail Abidi
- McGill International TB Centre, Research Institute of the McGill University Health Centre and McGill University, Montreal, QC, Canada
| | - Andrea Benedetti
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada; Department of Medicine and Department of Epidemiology, McGill University, Montreal, Canada
| | - Dick Menzies
- McGill International TB Centre, Research Institute of the McGill University Health Centre and McGill University, Montreal, QC, Canada; Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, QC, Canada; Department of Medicine and Department of Epidemiology, McGill University, Montreal, Canada
| | - James C Johnston
- Ghori TB Clinic, University of British Columbia, Vancouver, BC, Canada
| | | | - Saima Saeed
- Global Health Directorate, Indus Health Network, Karachi, Pakistan
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13
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Cunnama L, Gomez GB, Siapka M, Herzel B, Hill J, Kairu A, Levin C, Okello D, DeCormier Plosky W, Garcia Baena I, Sweeney S, Vassall A, Sinanovic E. A Systematic Review of Methodological Variation in Healthcare Provider Perspective Tuberculosis Costing Papers Conducted in Low- and Middle-Income Settings, Using An Intervention-Standardised Unit Cost Typology. PHARMACOECONOMICS 2020; 38:819-837. [PMID: 32363543 PMCID: PMC7437656 DOI: 10.1007/s40273-020-00910-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND There is a need for easily accessible tuberculosis unit cost data, as well as an understanding of the variability of methods used and reporting standards of that data. OBJECTIVE The aim of this systematic review was to descriptively review papers reporting tuberculosis unit costs from a healthcare provider perspective looking at methodological variation; to assess quality using a study quality rating system and machine learning to investigate the indicators of reporting quality; and to identify the data gaps to inform standardised tuberculosis unit cost collection and consistent principles for reporting going forward. METHODS We searched grey and published literature in five sources and eight databases, respectively, using search terms linked to cost, tuberculosis and tuberculosis health services including tuberculosis treatment and prevention. For inclusion, the papers needed to contain empirical unit cost estimates for tuberculosis interventions from low- and middle-income countries, with reference years between 1990 and 2018. A total of 21,691 papers were found and screened in a phased manner. Data were extracted from the eligible papers into a detailed Microsoft Excel tool, extensively cleaned and analysed with R software (R Project, Vienna, Austria) using the user interface of RStudio. A study quality rating was applied to the reviewed papers based on the inclusion or omission of a selection of variables and their relative importance. Following this, machine learning using a recursive partitioning method was utilised to construct a classification tree to assess the reporting quality. RESULTS This systematic review included 103 provider perspective papers with 627 unit costs (costs not presented here) for tuberculosis interventions among a total of 140 variables. The interventions covered were active, passive and intensified case finding; tuberculosis treatment; above-service costs; and tuberculosis prevention. Passive case finding is the detection of tuberculosis cases where individuals self-identify at health facilities; active case finding is detection of cases of those not in health facilities, such as through outreach; and intensified case finding is detection of cases in high-risk populations. There was heterogeneity in some of the reported methods used such cost allocation, amortisation and the use of top-down, bottom-up or mixed approaches to the costing. Uncertainty checking through sensitivity analysis was only reported on by half of the papers (54%), while purposive and convenience sampling was reported by 72% of papers. Machine learning indicated that reporting on 'Intervention' (in particular), 'Urbanicity' and 'Site Sampling', were the most likely indicators of quality of reporting. The largest data gap identified was for tuberculosis vaccination cost data, the Bacillus Calmette-Guérin (BCG) vaccine in particular. There is a gap in available unit costs for 12 of 30 high tuberculosis burden countries, as well as for the interventions of above-service costs, tuberculosis prevention, and active and intensified case finding. CONCLUSION Variability in the methods and reporting used makes comparison difficult and makes it hard for decision makers to know which unit costs they can trust. The study quality rating system used in this review as well as the classification tree enable focus on specific reporting aspects that should improve variability and increase confidence in unit costs. Researchers should endeavour to be explicit and transparent in how they cost interventions following the principles as laid out in the Global Health Cost Consortium's Reference Case for Estimating the Costs of Global Health Services and Interventions, which in turn will lead to repeatability, comparability and enhanced learning from others.
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Affiliation(s)
- Lucy Cunnama
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, South Africa.
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mariana Siapka
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ben Herzel
- Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | - Jeremy Hill
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Angela Kairu
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, South Africa
| | - Carol Levin
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Dickson Okello
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, South Africa
| | | | - Inés Garcia Baena
- TB Monitoring and Evaluation (TME), Global TB Programme, The World Health Organization, Geneva, Switzerland
| | - Sedona Sweeney
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Edina Sinanovic
- Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Cape Town, South Africa
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14
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Mathebula U, Emerson C, Agizew T, Pals S, Boyd R, Mathoma A, Basotli J, Rankgoane-Pono G, Serumola C, Date A, Auld AF, Finlay A. Improving sputum collection processes to increase tuberculosis case finding among HIV-positive persons in Botswana. Public Health Action 2020; 10:11-16. [PMID: 32368518 DOI: 10.5588/pha.19.0051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/26/2019] [Indexed: 11/10/2022] Open
Abstract
SETTING Twenty-two human immunodeficiency virus (HIV) clinics in Botswana. OBJECTIVE To compare sputum collection rates, sputum quality and volume, and tuberculosis (TB) diagnosis rates before and after field efforts to improve sputum collection among individuals newly diagnosed with HIV with TB symptoms. DESIGN Newly diagnosed individuals living with HIV attending 22 HIV clinics in Botswana were screened for TB from August 2012 to March 2014. Starting in May 2013, a field intervention composed of the introduction of a tracking log for presumed TB patients, and patient instructions and sputum induction to improve sputum collection rates was implemented. RESULTS Prior to the intervention, sputum collection rates were 44.1% (384/870). Subsequently, sputum collection increased to 58.3% (579/993) (P < 0.001). Sputum quality and volume also improved. Although rates of TB diagnosis increased from 9.7% (84/870) to 12.5% (120/993), this difference was not significant (P = 0.143). CONCLUSION Sputum collection rates among presumptive TB cases, as well as sputum quality and volume improved after implementation of the field intervention. To improve sputum collection rates, efforts at the program level should be ongoing.
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Affiliation(s)
- U Mathebula
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana
| | - C Emerson
- Division of Global HIV and Tuberculosis, CDC, Atlanta, GA, USA
| | - T Agizew
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana
| | - S Pals
- Division of Global HIV and Tuberculosis, CDC, Atlanta, GA, USA
| | - R Boyd
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana.,Division of Tuberculosis Elimination, CDC, Atlanta, GA, USA
| | - A Mathoma
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana
| | - J Basotli
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana
| | | | - C Serumola
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana
| | - A Date
- Division of Global HIV and Tuberculosis, CDC, Atlanta, GA, USA
| | - A F Auld
- Division of Global HIV and Tuberculosis, CDC, Atlanta, GA, USA
| | - A Finlay
- Centers for Disease Control and Prevention (CDC), Gaborone, Botswana.,Division of Tuberculosis Elimination, CDC, Atlanta, GA, USA
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15
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Infection prevention in general medical wards: A call to action. Afr J Thorac Crit Care Med 2019; 25. [PMID: 34286264 PMCID: PMC8278849 DOI: 10.7196/ajtccm.2019.v25i4.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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16
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Griesel R, Stewart A, van der Plas H, Sikhondze W, Rangaka MX, Nicol MP, Kengne AP, Mendelson M, Maartens G. Optimizing Tuberculosis Diagnosis in Human Immunodeficiency Virus-Infected Inpatients Meeting the Criteria of Seriously Ill in the World Health Organization Algorithm. Clin Infect Dis 2019; 66:1419-1426. [PMID: 29126226 DOI: 10.1093/cid/cix988] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 11/03/2017] [Indexed: 11/15/2022] Open
Abstract
Background The World Health Organization (WHO) algorithm for the diagnosis of tuberculosis in seriously ill human immunodeficiency virus (HIV)-infected patients lacks a firm evidence base. We aimed to develop a clinical prediction rule for the diagnosis of tuberculosis and to determine the diagnostic utility of the Xpert MTB/RIF assay in seriously ill HIV-infected patients. Methods We conducted a prospective study among HIV-infected inpatients with any cough duration and WHO-defined danger signs. Culture-positive tuberculosis from any site was the reference standard. A priori selected variables were assessed for univariate associations with tuberculosis. The most predictive variables were assessed in a multivariate logistic regression model and used to establish a clinical prediction rule for diagnosing tuberculosis. Results We enrolled 484 participants. The median age was 36 years, 65.5% were female, the median CD4 count was 89 cells/µL, and 35.3% were on antiretroviral therapy. Tuberculosis was diagnosed in 52.7% of participants. The c-statistic of our clinical prediction rule (variables: cough ≥14 days, unable to walk unaided, temperature >39°C, chest radiograph assessment, hemoglobin, and white cell count) was 0.811 (95% confidence interval, .802-.819). The classic tuberculosis symptoms (fever, night sweats, weight loss) added no discriminatory value in diagnosing tuberculosis. Xpert MTB/RIF assay sensitivity was 86.3% and specificity was 96.1%. Conclusions Our clinical prediction rule had good diagnostic utility for tuberculosis among seriously ill HIV-infected inpatients. Xpert MTB/RIF assay, incorporated into the updated 2016 WHO algorithm, had high sensitivity and specificity in this population. Our findings could facilitate improved diagnosis of tuberculosis among seriously ill HIV-infected inpatients in resource-constrained settings.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, University of Cape Town, South Africa
| | - Annemie Stewart
- Division of Clinical Pharmacology, University of Cape Town, South Africa
| | - Helen van der Plas
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, South Africa
| | - Welile Sikhondze
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, South Africa
| | - Molebogeng X Rangaka
- Department of Medicine, University of Cape Town, South Africa.,Institute of Global Health, Department of Infection and Population Health, University College London, United Kingdom.,Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark P Nicol
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service of South Africa, Cape Town, South Africa
| | - Andre P Kengne
- Department of Medicine, University of Cape Town, South Africa.,Medical Research Council, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, University of Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, University of Cape Town, South Africa
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Armstrong-Hough M, Ggita J, Turimumahoro P, Meyer AJ, Ochom E, Dowdy D, Cattamanchi A, Katamba A, Davis JL. 'Something so hard': a mixed-methods study of home sputum collection for tuberculosis contact investigation in Uganda. Int J Tuberc Lung Dis 2019; 22:1152-1159. [PMID: 30236182 DOI: 10.5588/ijtld.18.0129] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Home sputum collection could facilitate prompt evaluation and diagnosis of tuberculosis (TB) among contacts of patients with active TB. We analyzed barriers to home-based collection as part of an enhanced intervention for household TB contact investigation in Kampala, Uganda. DESIGN We conducted a convergent mixed-methods study to describe the outcomes of home sputum collection in 91 contacts and examine their context through 19 nested contact interviews and two focus group discussions with lay health workers (LHWs). RESULTS LHWs collected sputum from 35 (39%) contacts. Contacts reporting cough were more likely to provide sputum than those with other symptoms or risk factors (53% vs. 15%, RR 3.6, 95%CI 1.5-2.8, P < 0.001). Males were more likely than females to provide sputum (54% vs. 32%, RR 1.7, 95%CI 1.0-2.8, P = 0.05). Contacts said support from the index patient and the convenience of the home visit facilitated collection. Missing containers and difficulty producing sputum spontaneously impeded collection. Women identified stigma as a barrier. LHWs emphasized difficulty in procuring sputum and discomfort pressing contacts to produce sputum. CONCLUSIONS Home sputum collection by LHWs entails different challenges from sputum collection in clinical settings. More research is needed to develop interventions to mitigate stigma and increase success of home-based collection.
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Affiliation(s)
- M Armstrong-Hough
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda, Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - J Ggita
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - P Turimumahoro
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - A J Meyer
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda, Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - E Ochom
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda
| | - D Dowdy
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - A Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, California, USA
| | - A Katamba
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda, Clinical Epidemiology Unit, Makerere University, Kampala, Uganda
| | - J L Davis
- Uganda Tuberculosis Implementation Research Consortium, Makerere University, Kampala, Uganda, Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, Pulmonary, Critical Care, and Sleep Medicine Section, Yale School of Medicine, New Haven, Connecticut, USA
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18
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Kerschberger B, Schomaker M, Telnov A, Vambe D, Kisyeri N, Sikhondze W, Pasipamire L, Ngwenya SM, Rusch B, Ciglenecki I, Boulle A. Decreased risk of HIV-associated TB during antiretroviral therapy expansion in rural Eswatini from 2009 to 2016: a cohort and population-based analysis. Trop Med Int Health 2019; 24:1114-1127. [PMID: 31310029 PMCID: PMC6852273 DOI: 10.1111/tmi.13290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Objectives This paper assesses patient‐ and population‐level trends in TB notifications during rapid expansion of antiretroviral therapy in Eswatini which has an extremely high incidence of both TB and HIV. Methods Patient‐ and population‐level predictors and rates of HIV‐associated TB were examined in the Shiselweni region in Eswatini from 2009 to 2016. Annual population‐level denominators obtained from projected census data and prevalence estimates obtained from population‐based surveys were combined with individual‐level TB treatment data. Patient‐ and population‐level predictors of HIV‐associated TB were assessed with multivariate logistic and multivariate negative binomial regression models. Results Of 11 328 TB cases, 71.4% were HIV co‐infected and 51.8% were women. TB notifications decreased fivefold between 2009 and 2016, from 1341 to 269 cases per 100 000 person‐years. The decline was sixfold in PLHIV vs. threefold in the HIV‐negative population. Main patient‐level predictors of HIV‐associated TB were recurrent TB treatment (adjusted odds ratio [aOR] 1.40, 95% confidence interval [CI]: 1.19–1.65), negative (aOR 1.31, 1.15–1.49) and missing (aOR 1.30, 1.11–1.53) bacteriological status and diagnosis at secondary healthcare level (aOR 1.18, 1.06–1.33). Compared with 2009, the probability of TB decreased for all years from 2011 (aOR 0.69, 0.58–0.83) to 2016 (aOR 0.54, 0.43–0.69). The most pronounced population‐level predictor of TB was HIV‐positive status (adjusted incidence risk ratio 19.47, 14.89–25.46). Conclusions This high HIV‐TB prevalence setting experienced a rapid decline in TB notifications, most pronounced in PLHIV. Achievements in HIV‐TB programming were likely contributing factors.
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Affiliation(s)
- Bernhard Kerschberger
- Médecins Sans Frontières (Operational Centre Geneva), Mbabane, Eswatini.,Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Michael Schomaker
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Institute of Public Health, Medical Decision Making and HealthTechnology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Alex Telnov
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Debrah Vambe
- National TB Control Program, Ministry of Health, Manzini, Eswatini
| | - Nicholas Kisyeri
- Eswatini National AIDS Programme, Ministry of Health, Mbabane, Eswatini
| | - Welile Sikhondze
- National TB Control Program, Ministry of Health, Manzini, Eswatini
| | | | | | - Barbara Rusch
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Iza Ciglenecki
- Médecins Sans Frontières (Operational Centre Geneva), Geneva, Switzerland
| | - Andrew Boulle
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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19
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Horne DJ, Kohli M, Zifodya JS, Schiller I, Dendukuri N, Tollefson D, Schumacher SG, Ochodo EA, Pai M, Steingart KR. Xpert MTB/RIF and Xpert MTB/RIF Ultra for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev 2019; 6:CD009593. [PMID: 31173647 PMCID: PMC6555588 DOI: 10.1002/14651858.cd009593.pub4] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Xpert MTB/RIF (Xpert MTB/RIF) and Xpert MTB/RIF Ultra (Xpert Ultra), the newest version, are the only World Health Organization (WHO)-recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in persons with signs and symptoms of tuberculosis, at lower health system levels. A previous Cochrane Review found Xpert MTB/RIF sensitive and specific for tuberculosis (Steingart 2014). Since the previous review, new studies have been published. We performed a review update for an upcoming WHO policy review. OBJECTIVES To determine diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for tuberculosis in adults with presumptive pulmonary tuberculosis (PTB) and for rifampicin resistance in adults with presumptive rifampicin-resistant tuberculosis. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, to 11 October 2018, without language restriction. SELECTION CRITERIA Randomized trials, cross-sectional, and cohort studies using respiratory specimens that evaluated Xpert MTB/RIF, Xpert Ultra, or both against the reference standard, culture for tuberculosis and culture-based drug susceptibility testing or MTBDRplus for rifampicin resistance. DATA COLLECTION AND ANALYSIS Four review authors independently extracted data using a standardized form. When possible, we also extracted data by smear and HIV status. We assessed study quality using QUADAS-2 and performed meta-analyses to estimate pooled sensitivity and specificity separately for tuberculosis and rifampicin resistance. We investigated potential sources of heterogeneity. Most analyses used a bivariate random-effects model. For tuberculosis detection, we first estimated accuracy using all included studies and then only the subset of studies where participants were unselected, i.e. not selected based on prior microscopy testing. MAIN RESULTS We identified in total 95 studies (77 new studies since the previous review): 86 studies (42,091 participants) evaluated Xpert MTB/RIF for tuberculosis and 57 studies (8287 participants) for rifampicin resistance. One study compared Xpert MTB/RIF and Xpert Ultra on the same participant specimen.Tuberculosis detectionOf the total 86 studies, 45 took place in high tuberculosis burden and 50 in high TB/HIV burden countries. Most studies had low risk of bias.Xpert MTB/RIF pooled sensitivity and specificity (95% credible Interval (CrI)) were 85% (82% to 88%) and 98% (97% to 98%), (70 studies, 37,237 unselected participants; high-certainty evidence). We found similar accuracy when we included all studies.For a population of 1000 people where 100 have tuberculosis on culture, 103 would be Xpert MTB/RIF-positive and 18 (17%) would not have tuberculosis (false-positives); 897 would be Xpert MTB/RIF-negative and 15 (2%) would have tuberculosis (false-negatives).Xpert Ultra sensitivity (95% confidence interval (CI)) was 88% (85% to 91%) versus Xpert MTB/RIF 83% (79% to 86%); Xpert Ultra specificity was 96% (94% to 97%) versus Xpert MTB/RIF 98% (97% to 99%), (1 study, 1439 participants; moderate-certainty evidence).Xpert MTB/RIF pooled sensitivity was 98% (97% to 98%) in smear-positive and 67% (62% to 72%) in smear-negative, culture-positive participants, (45 studies). Xpert MTB/RIF pooled sensitivity was 88% (83% to 92%) in HIV-negative and 81% (75% to 86%) in HIV-positive participants; specificities were similar 98% (97% to 99%), (14 studies).Rifampicin resistance detectionXpert MTB/RIF pooled sensitivity and specificity (95% Crl) were 96% (94% to 97%) and 98% (98% to 99%), (48 studies, 8020 participants; high-certainty evidence).For a population of 1000 people where 100 have rifampicin-resistant tuberculosis, 114 would be positive for rifampicin-resistant tuberculosis and 18 (16%) would not have rifampicin resistance (false-positives); 886 would be would be negative for rifampicin-resistant tuberculosis and four (0.4%) would have rifampicin resistance (false-negatives).Xpert Ultra sensitivity (95% CI) was 95% (90% to 98%) versus Xpert MTB/RIF 95% (91% to 98%); Xpert Ultra specificity was 98% (97% to 99%) versus Xpert MTB/RIF 98% (96% to 99%), (1 study, 551 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF to be sensitive and specific for diagnosing PTB and rifampicin resistance, consistent with findings reported previously. Xpert MTB/RIF was more sensitive for tuberculosis in smear-positive than smear-negative participants and HIV-negative than HIV-positive participants. Compared with Xpert MTB/RIF, Xpert Ultra had higher sensitivity and lower specificity for tuberculosis and similar sensitivity and specificity for rifampicin resistance (1 study). Xpert MTB/RIF and Xpert Ultra provide accurate results and can allow rapid initiation of treatment for multidrug-resistant tuberculosis.
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Affiliation(s)
- David J Horne
- University of WashingtonDepartment of Medicine, Division of Pulmonary and Critical Care Medicine, and Firland Northwest TB CenterSeattleUSA
| | - Mikashmi Kohli
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Jerry S Zifodya
- University of WashingtonPulmonary and Critical Care Medicine325 9th Avenue – Campus Box 359762SeattleUSA98104
| | - Ian Schiller
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | - Nandini Dendukuri
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | | | | | - Eleanor A Ochodo
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesPO Box 241Cape TownSouth Africa8000
| | - Madhukar Pai
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Karen R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical MedicineHonorary Research FellowPembroke PlaceLiverpoolUK
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20
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Abstract
Introduction Early diagnosis and treatment of pulmonary tuberculosis (PTB) remains fundamental in reducing transmissions and death. Sputum induction is recommended for the diagnosis of pulmonary tuberculosis (PTB) in patients who are unable to expectorate or smear negative. Objective The aim of this study was to evaluate the diagnostic accuracy of pooling two induced sputum specimens into one microbiological test over a single day for the diagnosis of PTB. Methods We prospectively enrolled consecutive hospitalized adults with suspected PTB from 2009–2016. Two induced sputum specimens were obtained on the same day and pooled together for AFB smear, culture and Xpert MTB/RIF testing. The final diagnosis of PTB was based on a positive culture from any respiratory specimen. All patients were followed up for 3 months. Results Of 420 patients, 86(20.5%) were diagnosed with PTB based on a positive respiratory culture. The sensitivity, specificity, positive and negative predictive values for pooled induced sputum were 98.8% (CI 93.7–100%), 100% (CI 98.9–100%) and 100% (94.6–100%) and 99.7% (CI 98.1–100%) respectively. Xpert MTB/RIF in pooled induced sputum was positive in 88.4% of the PTB patients. Conclusion In the diagnosis of PTB, testing two induced sputum specimens which were pooled together for one microbiological testing process may be comparable to repeat testing.
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Affiliation(s)
- Mei Ying Chew
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Corresponding author at: Division of Respiratory and Critical Care Medicine, National University Hospital, Level 10, Tower Block, National University Health System, 1E Kent Ridge Road, Singapore 119228, Singapore.
| | - Jeffrey Ng
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tow Keang Lim
- Division of Respiratory and Critical Care Medicine, University Medicine Cluster, National University Hospital, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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21
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22
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False-Positive Xpert MTB/RIF Results in Retested Patients with Previous Tuberculosis: Frequency, Profile, and Prospective Clinical Outcomes. J Clin Microbiol 2018; 56:JCM.01696-17. [PMID: 29305538 DOI: 10.1128/jcm.01696-17] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 12/14/2017] [Indexed: 11/20/2022] Open
Abstract
Globally, Xpert MTB/RIF (Xpert) is the most widely used PCR test for the diagnosis of tuberculosis (TB). Positive results in previously treated patients, which are due to old DNA or active disease, are a diagnostic dilemma. We prospectively retested sputum from 238 patients, irrespective of current symptoms, who were previously diagnosed to be Xpert positive and treated successfully. Patients who retested as Xpert positive and culture negative were exhaustively investigated (repeat culture, chest radiography, bronchoscopy with bronchoalveolar lavage, long-term clinical follow-up). We evaluated whether the duration since previous treatment completion, mycobacterial burden (the Xpert cycle threshold [CT ] value), and reclassification of Xpert-positive results with a very low semiquantitation level to Xpert-negative results reduced the rate of false positivity. A total of 229/238 (96%) of patients were culture negative. Sixteen of 229 (7%) were Xpert positive a median of 11 months (interquartile range, 5 to 19 months) after treatment completion. The specificity was 93% (95% confidence interval [CI], 89 to 96%). Nine of 15 (40%) Xpert-positive, culture-negative patients reverted to Xpert negative after 2 to 3 months (1 patient declined further participation). Patients with false-positive Xpert results had a lower mycobacterial burden than patients with true-positive Xpert results (CT , 28.7 [95% CI, 27.2 to 30.4] versus 17.6 [95% CI, 16.9 to 18.2]; P < 0.001), an increased likelihood of a chest radiograph not compatible with active TB (5/15 patients versus 0/5 patients; P = 0.026), and less-viscous sputum (15/16 patients versus 2/5 patients whose sputum was graded as mucoid or less; P = 0.038). All patients who initially retested as Xpert positive and culture negative ("Xpert false positive") were clinically well without treatment after follow-up. The duration since the previous treatment poorly predicted false-positive results (a duration of ≤2 years identified only 66% of patients with false-positive results). Reclassifying Xpert-positive results with a very low semiquantitation level to Xpert negative improved the specificity (+3% [95% CI, +2 to +5%]) but reduced the sensitivity (-10% [95% CI, -4 to -15%]). Patients with previous TB retested with Xpert can have false-positive results and thus not require treatment. These data inform clinical practice by highlighting the challenges in interpreting Xpert-positive results, underscore the need for culture, and have implications for next-generation ultrasensitive tests.
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23
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Chawla KS, Kanyama C, Mbewe A, Matoga M, Hoffman I, Ngoma J, Hosseinipour MC. Policy to practice: impact of GeneXpert MTB/RIF implementation on the TB spectrum of care in Lilongwe, Malawi. Trans R Soc Trop Med Hyg 2017; 110:305-11. [PMID: 27198215 DOI: 10.1093/trstmh/trw030] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 04/05/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND While previous research has provided evidence of the diagnostic accuracy of the GeneXpert MTB/RIF (GeneXpert), further information is needed about implementation in the real-world. This study evaluated the impact of the introduction of GeneXpert testing in a tertiary medical center according to the testing algorithm proposed by the National TB Control Program (NTP) guidelines. METHODS All adult medicine inpatient persons with presumptive TB admitted between November 2013 and March 2014 were eligible for GeneXpert sputum testing and followed to TB treatment initiation status. RESULTS We identified 932 persons with presumptive TB, of which 307 (32.9%) were GeneXpert tested. Those tested had an average age of 40 years, 49.2% (151) were male, 34.5% (106) were HIV positive, and 84.1% (249) presented with a cough. Of those GeneXpert tested, 28/307 (9.1%) tested positive, a 55.5% increase in detection compared to smear microscopy. However, the majority (44/72, 61%) of TB diagnoses were made by other modalities and not confirmed microbiologically. Of the 58 patients recommended to start treatment and discharged from the hospital, only 23 (40%) were documented to have started treatment at regional directly observed treatment short (DOTS) centers. CONCLUSIONS GeneXpert contributed minimally to overall TB diagnosis and the cascade of care due to implementation challenges of sputum collection, empiric treatment, and weak linkage to care between inpatient and outpatient settings.
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Affiliation(s)
| | | | | | | | - Irving Hoffman
- UNC Project Malawi, Lilongwe, Malawi Division of Infectious Diseases, Department of Medicine, University of North Carolina Chapel Hill, NC USA
| | - Jonathan Ngoma
- Department of Medicine, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Mina C Hosseinipour
- UNC Project Malawi, Lilongwe, Malawi Division of Infectious Diseases, Department of Medicine, University of North Carolina Chapel Hill, NC USA
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24
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Fan J, Zhang H, Nguyen DT, Lyon CJ, Mitchell CD, Zhao Z, Graviss EA, Hu Y. Rapid diagnosis of new and relapse tuberculosis by quantification of a circulating antigen in HIV-infected adults in the Greater Houston metropolitan area. BMC Med 2017; 15:188. [PMID: 29089034 PMCID: PMC5664577 DOI: 10.1186/s12916-017-0952-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 10/04/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND HIV-associated immune defects inhibit tuberculosis (TB) diagnosis, promote development of extrapulmonary TB and paucibacillary pulmonary TB cases with atypical radiographic features, and increase TB relapse rates. We therefore assessed the diagnostic performance of a novel assay that directly quantitates serum levels of the Mycobacterium tuberculosis (Mtb) virulence factor 10-kDa culture filtrate protein (CFP-10) to overcome limitations associated with detecting Mtb bacilli in sputum or tissue biopsies. METHODS This study analyzed HIV-positive adults enrolled in a large, population-based TB screening and surveillance project, the Houston Tuberculosis Initiative, between October 1995 and September 2004, and assigned case designations using standardized criteria. Serum samples were trypsin-digested and immunoprecipitated for an Mtb-specific peptide of CFP-10 that was quantified by liquid chromatography-mass spectrometry for rapid and sensitive TB diagnosis. RESULTS Among the 1053 enrolled patients, 110 met all inclusion criteria; they included 60 tuberculosis cases (12 culture-negative TB), including 9 relapse TB cases, and 50 non-TB controls, including 15 cases with history of TB. Serum CFP-10 levels diagnosed 89.6% (77.3-96.5) and 66.7% (34.9-90.1) of culture-positive and culture-negative TB cases, respectively, and exhibited 88% (75.7-95.5) diagnostic specificity in all non-TB controls. Serum antigen detection and culture, respectively, identified 85% (73.4-92.9) and 80.0% (67.3-88.8) of all 60 TB cases. CONCLUSIONS Quantitation of the Mtb virulence factor CFP-10 in serum samples of HIV-infected subjects diagnosed active TB cases with high sensitivity and specificity and detected cases missed by the gold standard of Mtb culture. These results suggest that serum CFP-10 quantitation holds great promise for the rapid diagnosis of suspected TB cases in patients who are HIV-infected.
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Affiliation(s)
- Jia Fan
- School of Biological and Health Systems Engineering, Virginia G. Piper Biodesign Center for Personalized Diagnostics, The Biodesign Institute, Arizona State University, Tempe, AZ, 85287, USA
| | - Hedong Zhang
- Department of Nanomedicine, Houston Methodist Research Institute, Houston, TX, 77030, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, 77030, USA
| | - Christopher J Lyon
- School of Biological and Health Systems Engineering, Virginia G. Piper Biodesign Center for Personalized Diagnostics, The Biodesign Institute, Arizona State University, Tempe, AZ, 85287, USA
| | - Charles D Mitchell
- University of Miami, Leonard M. Miller School of Medicine, Miami, FL, 33136, USA
| | - Zhen Zhao
- Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, 77030, USA
| | - Ye Hu
- School of Biological and Health Systems Engineering, Virginia G. Piper Biodesign Center for Personalized Diagnostics, The Biodesign Institute, Arizona State University, Tempe, AZ, 85287, USA.
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25
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Venter R, Derendinger B, de Vos M, Pillay S, Dolby T, Simpson J, Kitchin N, Ruiters A, van Helden PD, Warren RM, Theron G. Mycobacterial genomic DNA from used Xpert MTB/RIF cartridges can be utilised for accurate second-line genotypic drug susceptibility testing and spoligotyping. Sci Rep 2017; 7:14854. [PMID: 29093504 PMCID: PMC5666021 DOI: 10.1038/s41598-017-14385-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/09/2017] [Indexed: 01/18/2023] Open
Abstract
Xpert MTB/RIF (Xpert) is a widely-used test for tuberculosis (TB) and rifampicin-resistance. Second-line drug susceptibility testing (DST), which is recommended by policymakers, typically requires additional specimen collection that delays effective treatment initiation. We examined whether cartridge extract (CE) from used Xpert TB-positive cartridges was, without downstream DNA extraction or purification, suitable for both genotypic DST (MTBDRplus, MTBDRsl), which may permit patients to rapidly receive a XDR-TB diagnosis from a single specimen, and spoligotyping, which could facilitate routine genotyping. To determine the limit-of-detection and diagnostic accuracy, CEs from dilution series of drug-susceptible and -resistant bacilli were tested (MTBDRplus, MTBDRsl). Xpert TB-positive patient sputa CEs (n = 85) were tested (56 Xpert-rifampicin-susceptible, MTBDRplus and MTBDRsl; 29 Xpert-rifampicin-resistant, MTBDRsl). Spoligotyping was done on CEs from dilution series and patient sputa (n = 10). MTBDRplus had high non-valid result rates. MTBDRsl on CEs from dilutions ≥103CFU/ml (CT ≤ 24, >“low” Xpert semiquantitation category) was accurate, had low indeterminate rates and, on CE from sputa, highly concordant with MTBDRsl isolate results. CE spoligotyping results from dilutions ≥103CFU/ml and sputa were correct. MTBDRsl and spoligotyping on CE are thus highly feasible. These findings reduce the need for additional specimen collection and culture, for which capacity is limited in high-burden countries, and have implications for diagnostic laboratories and TB molecular epidemiology.
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Affiliation(s)
- Rouxjeane Venter
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Brigitta Derendinger
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Margaretha de Vos
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Samantha Pillay
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,National Health Laboratory Services, Cape Town, South Africa
| | - Tanya Dolby
- National Health Laboratory Services, Cape Town, South Africa
| | - John Simpson
- National Health Laboratory Services, Cape Town, South Africa
| | - Natasha Kitchin
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Ashley Ruiters
- National Health Laboratory Services, Cape Town, South Africa
| | - Paul D van Helden
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Robin M Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Grant Theron
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SA MRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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26
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Boyles TH, Brink A, Calligaro GL, Cohen C, Dheda K, Maartens G, Richards GA, van Zyl Smit R, Smith C, Wasserman S, Whitelaw AC, Feldman C. South African guideline for the management of community-acquired pneumonia in adults. J Thorac Dis 2017; 9:1469-1502. [PMID: 28740661 DOI: 10.21037/jtd.2017.05.31] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tom H Boyles
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrian Brink
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa
| | - Greg L Calligaro
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Disease and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Guy A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Richard van Zyl Smit
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | | | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Andrew C Whitelaw
- Division of Medical Microbiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Charles Feldman
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Fisher M, Dolby T, Surtie S, Omar G, Hapeela N, Basu D, DeWalt A, Kelso D, Nicol M, McFall S. Improved method for collection of sputum for tuberculosis testing to ensure adequate sample volumes for molecular diagnostic testing. J Microbiol Methods 2017; 135:35-40. [PMID: 28159630 DOI: 10.1016/j.mimet.2017.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/12/2017] [Accepted: 01/23/2017] [Indexed: 11/29/2022]
Abstract
The quality and quantity of sputum collected has an important impact on the laboratory diagnosis of pulmonary TB. We conducted a pilot study to assess a new collection cups for the collection of sputum for the diagnosis of pulmonary tuberculosis. The pilot study utilized the standard collection cup in South Africa demonstrating a mean collection volume of 2.86±2.36SDml for 198 samples; 19% of the specimens contained <1ml and 12% contained >5ml. We designed and tested two novel sputum cups with a narrow bottom section and clear minimum and maximum markings to allow patients and clinicians to know whether sufficient sputum volume has been produced. The cups differed in their shape and manufacturing approach. The two options also support different mixing approaches being considered for a highly sensitive companion TB-screening assay being developed at Northwestern University (XtracTB assay). Sputum was collected from 102 patients at Nolungile Youth Centre, Khayelitsha, Cape Town, South Africa for a total of 204 samples. The mean volumes collected from the two cups were 2.70±0.88SDml and 2.88±0.89SDml. While the mean volumes of current and novel cups are similar, the volume ranges collected with the novel cups were narrower, and 98% of the specimen volumes were within the target range. Only 4 samples contained >5ml, but none were >6ml, and none of the specimens contained <1ml. The number of coughs that produced the samples, patient HIV and TB status plus qualitative descriptions of the sputum specimens were also evaluated.
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Affiliation(s)
| | - Tania Dolby
- University of Cape Town, Cape Town, South Africa
| | | | | | | | - Debby Basu
- Northwestern University, Evanston, IL, USA
| | | | | | - Mark Nicol
- University of Cape Town, Cape Town, South Africa
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Dharan NJ, Blakemore R, Sloutsky A, Kaur D, Alexander RC, Ghajar M, Musser KA, Escuyer VE, Rowlinson MC, Crowe S, Laniado-Laborin R, Valli E, Nabeta P, Johnson P, Alland D. Performance of the G4 Xpert ® MTB/RIF assay for the detection of Mycobacterium tuberculosis and rifampin resistance: a retrospective case-control study of analytical and clinical samples from high- and low-tuberculosis prevalence settings. BMC Infect Dis 2016; 16:764. [PMID: 27993132 PMCID: PMC5168809 DOI: 10.1186/s12879-016-2039-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 11/15/2016] [Indexed: 11/10/2022] Open
Abstract
Background The Xpert® MTB/RIF (Xpert) assay is a rapid PCR-based assay for the detection of Mycobacterium tuberculosis complex DNA (MTBc) and mutations associated with rifampin resistance (RIF). An updated version introduced in 2011, the G4 Xpert, included modifications to probe B and updated analytic software. Methods An analytical study was performed to assess Xpert detection of mutations associated with rifampin resistance in rifampin-susceptible and -resistant isolates. A clinical study was performed in which specimens from US and non-US persons suspected of tuberculosis (TB) were tested to determine Xpert performance characteristics. All specimens underwent smear microscopy, mycobacterial culture, conventional drug-susceptibility testing and Xpert testing; DNA from isolates with discordant rifampin resistance results was sequenced. Results Among 191 laboratory-prepared isolates in the analytical study, Xpert sensitivity for detection of rifampin resistance associated mutations was 97.7% and specificity was 90.8%, which increased to 99.0% after DNA sequencing analysis of the discordant samples. Of the 1,096 subjects in the four clinical studies, 49% were from the US. Overall, Xpert detected MTBc in 439 of 468 culture-positive specimens for a sensitivity of 93.8% (95% confidence interval [CI]: 91.2%–95.7%) and did not detect MTBc in 620 of 628 culture-negative specimens for a specificity of 98.7% (95% CI: 97.5%–99.4%). Sensitivity was 99.7% among smear-positive cases, and 76.1% among smear-negative cases. Non-determinate MTBc detection and false-positive RIF resistance results were low (1.2 and 0.9%, respectively). Conclusions The updated Xpert assay retained the high sensitivity and specificity of the previous assay versions and demonstrated low rates of non-determinate and RIF resistance false positive results. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2039-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nila J Dharan
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, MSB I-689, Newark, NJ, 07103, USA.
| | - Robert Blakemore
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, MSB I-689, Newark, NJ, 07103, USA.,Current address: Sackler School of Graduate Biomedical Science - Tufts University, Boston, MA, USA
| | - Alex Sloutsky
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Devinder Kaur
- University of Massachusetts Medical School, Worcester, MA, USA
| | | | - Minoo Ghajar
- Orange County Health Care Agency, Santa Ana, CA, USA
| | | | - Vincent E Escuyer
- Wadsworth Center, New York State Department of Health, Albany, NY, USA
| | | | | | | | - Eloise Valli
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Pamela Nabeta
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | | | - David Alland
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, MSB I-689, Newark, NJ, 07103, USA.
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Yu Y, Wang Z, Wu L, Zhang Y, Wang F. A precise and objective tool for tuberculosis detection. THE LANCET. INFECTIOUS DISEASES 2016; 16:1327-1328. [PMID: 27998588 DOI: 10.1016/s1473-3099(16)30464-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/07/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Yang Yu
- Laboratory Medicine Unit, Nanjing Clinical Nuclear Medicine Center and Department of Infectious Diseases, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Zizheng Wang
- Laboratory Medicine Unit, Nanjing Clinical Nuclear Medicine Center and Department of Infectious Diseases, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Lan Wu
- Laboratory Medicine Unit, Nanjing Clinical Nuclear Medicine Center and Department of Infectious Diseases, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Yanliang Zhang
- Laboratory Medicine Unit, Nanjing Clinical Nuclear Medicine Center and Department of Infectious Diseases, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China
| | - Feng Wang
- Laboratory Medicine Unit, Nanjing Clinical Nuclear Medicine Center and Department of Infectious Diseases, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing 210006, China.
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Abstract
Although the worldwide incidence of tuberculosis has been slowly decreasing, the global disease burden remains substantial (∼9 million cases and ∼1·5 million deaths in 2013), and tuberculosis incidence and drug resistance are rising in some parts of the world such as Africa. The modest gains achieved thus far are threatened by high prevalence of HIV, persisting global poverty, and emergence of highly drug-resistant forms of tuberculosis. Tuberculosis is also a major problem in health-care workers in both low-burden and high-burden settings. Although the ideal preventive agent, an effective vaccine, is still some time away, several new diagnostic technologies have emerged, and two new tuberculosis drugs have been licensed after almost 50 years of no tuberculosis drugs being registered. Efforts towards an effective vaccine have been thwarted by poor understanding of what constitutes protective immunity. Although new interventions and investment in control programmes will enable control, eradication will only be possible through substantial reductions in poverty and overcrowding, political will and stability, and containing co-drivers of tuberculosis, such as HIV, smoking, and diabetes.
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, University of Cape Town, Cape Town, South Africa; Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA.
| | - Clifton E Barry
- Department of Medicine, and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa; Tuberculosis Research Section, Laboratory of Clinical Infectious Diseases, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, USA
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Automated chest-radiography as a triage for Xpert testing in resource-constrained settings: a prospective study of diagnostic accuracy and costs. Sci Rep 2015. [PMID: 26212560 PMCID: PMC4515744 DOI: 10.1038/srep12215] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Molecular tests hold great potential for tuberculosis (TB) diagnosis, but are costly, time consuming, and HIV-infected patients are often sputum scarce. Therefore, alternative approaches are needed. We evaluated automated digital chest radiography (ACR) as a rapid and cheap pre-screen test prior to Xpert MTB/RIF (Xpert). 388 suspected TB subjects underwent chest radiography, Xpert and sputum culture testing. Radiographs were analysed by computer software (CAD4TB) and specialist readers, and abnormality scores were allocated. A triage algorithm was simulated in which subjects with a score above a threshold underwent Xpert. We computed sensitivity, specificity, cost per screened subject (CSS), cost per notified TB case (CNTBC) and throughput for different diagnostic thresholds. 18.3% of subjects had culture positive TB. For Xpert alone, sensitivity was 78.9%, specificity 98.1%, CSS $13.09 and CNTBC $90.70. In a pre-screening setting where 40% of subjects would undergo Xpert, CSS decreased to $6.72 and CNTBC to $54.34, with eight TB cases missed and throughput increased from 45 to 113 patients/day. Specialists, on average, read 57% of radiographs as abnormal, reducing CSS ($8.95) and CNTBC ($64.84). ACR pre-screening could substantially reduce costs, and increase daily throughput with few TB cases missed. These data inform public health policy in resource-constrained settings.
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Fløe A, Hilberg O, Thomsen VØ, Lillebaek T, Wejse C. Shortening Isolation of Patients With Suspected Tuberculosis by Using Polymerase Chain Reaction Analysis: A Nationwide Cross-sectional Study. Clin Infect Dis 2015; 61:1365-73. [PMID: 26175524 DOI: 10.1093/cid/civ563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 07/02/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Isolation of patients suspected for pulmonary tuberculosis is guided by serial sputum smears. This can result in isolation for days for patients with noncontagious tuberculosis. To determine whether a single sample negative for Mycobacterium tuberculosis complex at polymerase chain reaction (PCR) can guide isolation. METHODS We retrospectively evaluated sputum samples analyzed for M. tuberculosis complex at the International Reference Laboratory of Mycobacteriology, Copenhagen, Denmark in 2002-2011. We selected culture-confirmed tuberculosis cases with ≥3 samples within 14 days before or after the initial culture-positive sample. We repeated the process for those with ≥2 samples within 28 days. The primary outcome was PCR-negative, smear-positive patients. RESULTS We included 53 533 sputum samples from 20 928 individuals; 1636 had culture-confirmed tuberculosis. Of these, 856 had ≥3 sputum samples analyzed within the 28 days, and 482 had ≥1 PCR result. Nine patients (2.5% of smear-positive patients) were smear positive/PCR negative; 8 of the 9 had a smear-positive result in only 1 of 3 samples, and 5 had a low smear grade. Of 722 patients with 2 samples, 7 (1.3% of smear-positive patients) were smear positive/PCR negative. Overall, none were smear positive for the sample that produced the negative PCR result. CONCLUSIONS Primary PCR identified >97% of serial smear-positive cases. The majority of the missed cases had low-grade smears. Nevertheless, the occurrence of smear-positive/PCR-negative cases underlines the importance of increasing the quantity and quality of samples. Moreover, it is important that samples analyzed with PCR are cultured, owing to higher-sensitivity drug susceptibility testing, differential diagnosis, and surveillance.
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Affiliation(s)
| | - Ole Hilberg
- Departments of Respiratory Diseases and Allergy
| | | | - Troels Lillebaek
- International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark
| | - Christian Wejse
- Infectious Diseases, Aarhus University Hospital GloHAU Center for Global Health, Department of Public Health, Aarhus University
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Lora MH, Reimer-McAtee MJ, Gilman RH, Lozano D, Saravia R, Pajuelo M, Bern C, Castro R, Espinoza M, Vallejo M, Solano M, Challapa R, Torrico F. Evaluation of Microscopic Observation Drug Susceptibility (MODS) and the string test for rapid diagnosis of pulmonary tuberculosis in HIV/AIDS patients in Bolivia. BMC Infect Dis 2015; 15:222. [PMID: 26047953 PMCID: PMC4458042 DOI: 10.1186/s12879-015-0966-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/28/2015] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is the most common opportunistic infection and the leading cause of death in HIV-positive people worldwide. Diagnosing TB is difficult, and is more challenging in resource-scarce settings where culture-based diagnostic methods rely on poorly sensitive smear microscopy by Ziehl-Neelsen stain (ZN). METHODS We performed a cross-sectional study examining the diagnostic utility of Microscopic Observation Drug Susceptibility liquid culture (MODS) versus traditional Ziehl-Neelsen staining (ZN) and Lowenstein Jensen culture (LJ) of pulmonary tuberculosis (TB) and multidrug-resistant tuberculosis (MDRTB) in HIV-infected patients in Bolivia. For sputum scarce individuals we assessed the value of the string test and induced sputum for TB diagnosis. The presence of Mycobacterium tuberculosis (Mtb) in the sputum of 107 HIV-positive patients was evaluated by ZN, LJ, and MODS. Gastric secretion samples obtained by the string test were evaluated by MODS in 102 patients. RESULTS The TB-HIV co-infection rate of HIV patients with respiratory symptoms by sputum sample was 45 % (48/107); 46/48 (96 %) were positive by MODS, 38/48 (79 %) by LJ, and 30/48 (63 %) by ZN. The rate of MDRTB was 9 % (4/48). Median time to positive culture was 10 days by MODS versus 34 days by LJ (p < 0.0001). In smear-negative patients, MODS detected TB in 17/18 patients, compared to 11/18 by LJ (94.4 % vs 61.0 %, p = 0.03 %). In patients unable to produce a sputum sample without induction, the string test cultured by MODS yielded Mtb in of 9/11 (82 %) TB positive patients compared to 11/11 (100 %) with induced sputum. Of the 10 patients unable to produce a sputum sample, 4 were TB-positive by string test. CONCLUSION MODS was faster and had a higher Mtb detection yield compared to LJ, with a greater difference in yield between the two in smear-negative patients. The string test is a valuable diagnostic technique for HIV sputum-scarce or sputum-absent patients, and should be considered as an alternative test to induced sputum to obtain sample for Mtb in resource-limited settings. Nine percent of our TB+ patients had MDRTB, which reinforces the need for rapid detection with direct drug susceptibility testing in HIV patients in Bolivia.
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Affiliation(s)
- Meredith H Lora
- Department of Medicine, University of California in San Francisco, 505 Parnassus Ave, Rm 987, San Francisco, CA, 94143-0119, USA.
| | | | - Robert H Gilman
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
| | - Daniel Lozano
- Facultad de Medicina, Universidad Mayor de San Simón, Cochabamba, Bolivia.
| | - Ruth Saravia
- Colectivo de Estudios Aplicados y Desarrollo Salud y Medio Ambiente, Cochabamba, Bolivia.
| | | | - Caryn Bern
- University of California in San Francisco, San Francisco, USA.
| | - Rosario Castro
- Facultad de Medicina, Universidad Mayor de San Simón, Cochabamba, Bolivia.
| | | | - Maya Vallejo
- La Escuela Técnica de Salud, Cochabamba, Bolivia.
| | - Marco Solano
- Facultad de Medicina, Universidad Mayor de San Simón, Cochabamba, Bolivia.
| | - Roxana Challapa
- Colectivo de Estudios Aplicados y Desarrollo Salud y Medio Ambiente, Cochabamba, Bolivia.
| | - Faustino Torrico
- Facultad de Medicina, Universidad Mayor de San Simón, Cochabamba, Bolivia.
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Male Gender is independently associated with pulmonary tuberculosis among sputum and non-sputum producers people with presumptive tuberculosis in Southwestern Uganda. BMC Infect Dis 2014; 14:638. [PMID: 25492725 PMCID: PMC4265338 DOI: 10.1186/s12879-014-0638-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 11/18/2014] [Indexed: 02/05/2023] Open
Abstract
Background Little is known about the association between gender and risk of TB infection. We sought to assess the impact of gender on TB prevalence among people with presumptive tuberculosis at a regional referral hospital in a high TB and HIV prevalence setting. Methods We analyzed data from two diagnostic TB studies conducted in rural, southwestern Uganda. People with presumptive tuberculosis were evaluated by chest X-ray, fluorescence microscopy, TB culture, and HIV testing. Our primary outcome of interest was TB infection, as defined by a positive TB culture. Our primary explanatory variable of interest was gender. We fit univariable and multivariable logistic regression models to investigate associations between TB infection and gender, before and after adjusting or possible confounding factors, including ability to produce sputum, age and residence. Results Between April 2010 and September 2012, 863 people with presumptive tuberculosis (PWPTB) were enrolled in the two studies at Mbarara Regional Referral Hospital (MRRH) in Uganda. Among them 664 (76.9%) were able to produce sputum. X-ray was suggestive of TB for 258 (66.5%) of males and 175 (44.8%) of female (p < 0.001). using microscopy 84 (20%) of males and 48 (10.9%) of females were diagnosed with TB (p < 0.001) while 122 (30.3%) of males and 76 (18.4%) of females were diagnosed with TB (p < 0.001) using TB culture. In multivariable logistic regression models, the odds of having TB was higher in males than females (AOR 2.2 (1.56-3.18 95% CI°, P < 0.001), after adjustment for age, HIV status, ability to produce sputum, and residence. Conclusion In Southwestern Uganda, TB prevalence is higher among male than female people with presumptive TB. The increased risk of TB among males is independent of other TB risk factors. These findings emphasize the need for gender-focused interventions aimed at reducing TB transmission. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0638-5) contains supplementary material, which is available to authorized users.
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Hu X, Shang M, Chen X, Xie Y, Ye Y, Zhou J, Song X, Lu X, Ying B, Wang L. Evaluation of three rapid assays for Mycobacterium tuberculosis complex detection in a comprehensive hospital from West China. Clin Biochem 2014; 48:79-84. [PMID: 25444951 DOI: 10.1016/j.clinbiochem.2014.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/26/2014] [Accepted: 10/01/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To assess the capacity of rapid and accurate confirmation of the Mycobacterium tuberculosis complex (MTBC) in a Chinese clinical laboratory. DESIGN AND METHODS This prospective study investigated three rapid assays, the Amplified Mycobacterium Tuberculosis Direct (MTD) test, real-time PCR, and acid-fast bacilli (AFB) smear, for direct detection of MTBC in a large consecutive series of different clinical specimens. Performance parameters were estimated and compared overall and for separate specimen categories using a combined reference gold standard. RESULTS The overall sensitivities were similar for MTD and real-time PCR (62.26% vs. 58.49%), significantly higher than those of AFB smear (31.13%). Among three assays, MTD had a satisfactory sensitivity in respiratory specimen (73.33%) and a nearly perfect detection for smear-positive samples (96.97%). Real-time PCR showed a high positive rate (58.97%) in regard to nonrespiratory specimen. A combination of molecular assays with conventional methods reached marked additive diagnostic values (sensitivity up to 76.42%), higher than each method individually. All detection systems showed excellent specificities (>96.00%). CONCLUSIONS The present study indicated that our lab had a moderate diagnostic performance for tuberculosis. Quality guarantee for specimen pretreatment, as well as combination analysis, will enable these assays to better incorporate into the routine laboratory workflow in China.
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Affiliation(s)
- Xuejiao Hu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Mengqiao Shang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Xuerong Chen
- Division of Pulmonary Disease, Department of Respiratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Yi Xie
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Yuanxin Ye
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Juan Zhou
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Xingbo Song
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Xiaojun Lu
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China
| | - Binwu Ying
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China.
| | - Lanlan Wang
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu 610041, PR China.
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El Sahly HM. Performance of Xpert MTB/RIF in Induced Sputum Samples at Detecting Mycobacterium Tuberculosis. Clin Infect Dis 2014; 59:911-2. [DOI: 10.1093/cid/ciu375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Denkinger CM, Pai M. Reply to El Sahly. Clin Infect Dis 2014; 59:912. [PMID: 24855148 DOI: 10.1093/cid/ciu376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Claudia M Denkinger
- McGill International Tuberculosis Centre and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada Division of Infectious Disease, Beth Israel Deaconess Medical Centre, Boston, Massachusetts
| | - Madhukar Pai
- McGill International Tuberculosis Centre and Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Canada Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute, Montreal, Canada
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Geldenhuys HD, Whitelaw A, Tameris MD, Van As D, Luabeya KKA, Mahomed H, Hussey G, Hanekom WA, Hatherill M. A controlled trial of sputum induction and routine collection methods for TB diagnosis in a South African community. Eur J Clin Microbiol Infect Dis 2014; 33:2259-66. [PMID: 25022447 DOI: 10.1007/s10096-014-2198-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 06/27/2014] [Indexed: 01/26/2023]
Abstract
The diagnostic yield of pulmonary tuberculosis (TB) by sputum induction (SI) at the first point of contact with health services, conducted in all patients with suspected TB regardless of the ability to expectorate spontaneously, has not been evaluated. We compared the diagnostic yield of SI to routine sputum collection in a South African community setting. Ambulatory patients with suspected TB provided a 'spot' expectorated sputum sample, an SI sample by hypertonic (5 %) saline nebulization, and early morning expectorated sputum sample. The diagnostic yield of sputum smear microscopy and liquid culture (denominator all subjects with any positive Mycobacterium tuberculosis culture), and time-to-positivity of culture were compared between SI and expectorated samples. A total of 555 subjects completed the SI procedure, of whom 132 (24 %) were human immunodeficiency virus (HIV)-infected. One hundred and twenty-nine samples (129, 23 %) were M. tuberculosis culture-positive. The time-to-positivity of Mycobacteria Growth Indicator Tube (MGIT) culture was shorter for SI (median difference 2 days, p = 0.63) and for early morning expectorated sputum (median difference 2 days, p = 0.02) compared to spot expectorated sputum. However, there was no difference in the culture-positive diagnostic yield between SI and spot expectorated sputum [difference +0.7 %; confidence interval (CI) -7.0 to +8.5 %, p = 0.82] or SI and early morning expectorated sputum (difference +4.7 %; CI -3.2 to +12.5 %, p = 0.20) for all subjects or for HIV-infected subjects. SI reduces the time to positive M. tuberculosis culture, but does not increase the rate of positive culture compared to routine expectorated sputum collection. SI cannot be recommended as the routine collection method at first contact among ambulatory patients with suspected TB in high-burden communities.
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Affiliation(s)
- H D Geldenhuys
- South African Tuberculosis Vaccine Initiative (SATVI), Institute of Infectious Disease and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa,
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Theron G, Peter J, Calligaro G, Meldau R, Hanrahan C, Khalfey H, Matinyenya B, Muchinga T, Smith L, Pandie S, Lenders L, Patel V, Mayosi BM, Dheda K. Determinants of PCR performance (Xpert MTB/RIF), including bacterial load and inhibition, for TB diagnosis using specimens from different body compartments. Sci Rep 2014; 4:5658. [PMID: 25014250 PMCID: PMC5375978 DOI: 10.1038/srep05658] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/16/2014] [Indexed: 11/09/2022] Open
Abstract
The determinants of Xpert MTB/RIF sensitivity, a widely used PCR test for the diagnosis of tuberculosis (TB) are poorly understood. We compared culture time-to-positivity (TTP; a surrogate of bacterial load), MTB/RIF TB-specific and internal positive control (IPC)-specific C(T) values, and clinical characteristics in patients with suspected TB who provided expectorated (n = 438) or induced sputum (n = 128), tracheal aspirates (n = 71), bronchoalveolar lavage fluid (n = 152), pleural fluid (n = 76), cerebral spinal fluid (CSF; n = 152), pericardial fluid (n = 131), or urine (n = 173) specimens. Median bacterial load (TTP in days) was the strongest associate of MTB/RIF positivity in each fluid. TTP correlated with C(T) values in pulmonary specimens but not extrapulmonary specimens (Spearman's coefficient 0.5043 versus 0.1437; p = 0.030). Inhibition affected a greater proportion of pulmonary specimens than extrapulmonary specimens (IPC C(T) > 34: 6% (47/731) versus 1% (4/381; p < 0.0001). Pulmonary specimens had greater load than extrapulmonary specimens [TTPs (interquartile range) of 11 (7-16) versus 22 (18-33.5) days; p < 0.0001]. HIV-infection was associated with a decreased likelihood of MTB/RIF-positivity in pulmonary specimens but an increased likelihood in extrapulmonary specimens. Mycobacterial load, which displays significant variation across different body compartments, is the main determinant of MTB/RIF-positivity rather than PCR inhibition. MTB/RIF C(T) is a poor surrogate of load in extrapulmonary specimens.
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Affiliation(s)
- Grant Theron
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Jonny Peter
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Greg Calligaro
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Richard Meldau
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Colleen Hanrahan
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Hoosain Khalfey
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Brian Matinyenya
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Tapuwa Muchinga
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Liezel Smith
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shaheen Pandie
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa
| | - Laura Lenders
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Vinod Patel
- Department of Neurology, University of KwaZulu Natal, South Africa
| | - Bongani M. Mayosi
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology & UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Pandie S, Peter JG, Kerbelker ZS, Meldau R, Theron G, Govender U, Ntsekhe M, Dheda K, Mayosi BM. Diagnostic accuracy of quantitative PCR (Xpert MTB/RIF) for tuberculous pericarditis compared to adenosine deaminase and unstimulated interferon-γ in a high burden setting: a prospective study. BMC Med 2014; 12:101. [PMID: 24942470 PMCID: PMC4073812 DOI: 10.1186/1741-7015-12-101] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 05/28/2014] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Tuberculous pericarditis (TBP) is associated with high morbidity and mortality, and is an important treatable cause of heart failure in developing countries. Tuberculous aetiology of pericarditis is difficult to diagnose promptly. The utility of the new quantitative PCR test (Xpert MTB/RIF) for the diagnosis of TBP is unknown. This study sought to evaluate the diagnostic accuracy of the Xpert MTB/RIF test compared to pericardial adenosine deaminase (ADA) and unstimulated interferon-gamma (uIFNγ) in suspected TBP. METHODS From October 2009 through September 2012, 151 consecutive patients with suspected TBP were enrolled at a single centre in Cape Town, South Africa. Mycobacterium tuberculosis culture and/or pericardial histology served as the reference standard for definite TBP. Receiver-operating-characteristic curve analysis was used for selection of ADA and uIFNγ cut-points. RESULTS Of the participants, 49% (74/151) were classified as definite TBP, 33% (50/151) as probable TBP and 18% (27/151) as non TBP. A total of 105 (74%) participants were human immunodeficiency virus (HIV) positive. Xpert-MTB/RIF had a sensitivity and specificity (95% confidence interval (CI)) of 63.8% (52.4% to 75.1%) and 100% (85.6% to 100%), respectively. Concentration of pericardial fluid by centrifugation and using standard sample processing did not improve Xpert MTB/RIF accuracy. ADA (≥35 IU/L) and uIFNγ (≥44 pg/ml) both had a sensitivity of 95.7% (88.1% to 98.5%) and a negative likelihood ratio of 0.05 (0.02 to 0.10). However, the specificity and positive likelihood ratio of uIFNγ was higher than ADA (96.3% (81.7% to 99.3%) and 25.8 (3.6 to 183.4) versus 84% (65.4% to 93.6%) and 6.0 (3.7 to 9.8); P = 0.03) at an estimated background prevalence of TB of 30%. The sensitivity and negative predictive value of both uIFNγ and ADA were higher than Xpert-MT/RIF (P < 0.001). CONCLUSIONS uIFNγ offers superior accuracy for the diagnosis of microbiologically confirmed TBP compared to the ADA assay and the Xpert MTB/RIF test.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Bongani M Mayosi
- The Cardiac Clinic, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Groote Schuur Drive, Observatory, Cape Town 7925, South Africa.
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Seong GM, Lee J, Lee JH, Kim JH, Kim M. Usefulness of sputum induction with hypertonic saline in a real clinical practice for bacteriological yields of active pulmonary tuberculosis. Tuberc Respir Dis (Seoul) 2014; 76:163-8. [PMID: 24851129 PMCID: PMC4021263 DOI: 10.4046/trd.2014.76.4.163] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 01/07/2014] [Accepted: 02/19/2014] [Indexed: 11/24/2022] Open
Abstract
Background Mycobacterial identification in active pulmonary tuberculosis (APTB) is confirmative, even though successful rates using self-expectorated sputum are limited. Sputum specimens collected by hypertonic saline nebulization showed higher bacteriologic diagnostic sensitivities over those of self-expectoration, mostly studied in smear-negative or sputum-scarce patients. The efficacy of induced sputum was rarely assessed in real clinical settings. Methods A prospective randomized case-control study was performed in one hospital. The subjects highly suspicious of APTB were asked to provide 3 pairs of sputum specimens in 3 consecutive days. The first pairs of the specimens were obtained either by self-expectoration (ES) from the next day of the visit or sputum induction with 7% saline nebulization in clinic (SI), and the other specimens were collected in the same way. The samples were tested in microscopy, culture, and polymerase chain reaction (PCR). The outcomes of the bacteriological diagnosis were compared. Results Seventy six patients were assigned to either ES (38 subjects, median age of 51, 65.8% male) or SI (38 subjects, median age of 55, 52.6% male). APTB was clinically confirmed in 51 patients (70.8%), 27 in ES and 24 in SI. Among the APTB, more adequate specimens were collected from SI (41/65, 63.1%) than ES (34/80, 42.5%) (p=0.01). Bacteriological confirmation was achieved in 14 (58.3%) patients in SI, and 13 (48.1%) in ES (p=0.46). In the same-day bacteriological diagnosis with microscopy and PCR, there were positive results for 9 patients (37.5%) in SI and 7 patients (25.9%) in ES (p=0.37). Conclusion Sputum induction improves sputum specimen adequacy. It may be useful for the same-day bacteriological diagnosis with microscopic examination and PCR.
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Affiliation(s)
- Gil Myeong Seong
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jong Hoo Lee
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | - Jeong Hong Kim
- Department of Otorhinolaryngology, Jeju National University School of Medicine, Jeju, Korea
| | - Miok Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
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Theron G, Zijenah L, Chanda D, Clowes P, Rachow A, Lesosky M, Bara W, Mungofa S, Pai M, Hoelscher M, Dowdy D, Pym A, Mwaba P, Mason P, Peter J, Dheda K. Feasibility, accuracy, and clinical effect of point-of-care Xpert MTB/RIF testing for tuberculosis in primary-care settings in Africa: a multicentre, randomised, controlled trial. Lancet 2014; 383:424-35. [PMID: 24176144 DOI: 10.1016/s0140-6736(13)62073-5] [Citation(s) in RCA: 322] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Xpert MTB/RIF test for tuberculosis is being rolled out in many countries, but evidence is lacking regarding its implementation outside laboratories, ability to inform same-day treatment decisions at the point of care, and clinical effect on tuberculosis-related morbidity. We aimed to assess the feasibility, accuracy, and clinical effect of point-of-care Xpert MTB/RIF testing at primary-care health-care facilities in southern Africa. METHODS In this pragmatic, randomised, parallel-group, multicentre trial, we recruited adults with symptoms suggestive of active tuberculosis from five primary-care health-care facilities in South Africa, Zimbabwe, Zambia, and Tanzania. Eligible patients were randomly assigned using pregenerated tables to nurse-performed Xpert MTB/RIF at the clinic or sputum smear microscopy. Participants with a negative test result were empirically managed according to local WHO-compliant guidelines. Our primary outcome was tuberculosis-related morbidity (measured with the TBscore and Karnofsky performance score [KPS]) in culture-positive patients who had begun anti-tuberculosis treatment, measured at 2 months and 6 months after randomisation, analysed by intention to treat. This trial is registered with Clinicaltrials.gov, number NCT01554384. FINDINGS Between April 12, 2011, and March 30, 2012, we randomly assigned 758 patients to smear microscopy (182 culture positive) and 744 to Xpert MTB/RIF (185 culture positive). Median TBscore in culture-positive patients did not differ between groups at 2 months (2 [IQR 0-3] in the smear microscopy group vs 2 [0·25-3] in the MTB/RIF group; p=0·85) or 6 months (1 [0-3] vs 1 [0-3]; p=0·35), nor did median KPS at 2 months (80 [70-90] vs 90 [80-90]; p=0·23) or 6 months (100 [90-100] vs 100 [90-100]; p=0·85). Point-of-care MTB/RIF had higher sensitivity than microscopy (154 [83%] of 185 vs 91 [50%] of 182; p=0·0001) but similar specificity (517 [95%] 544 vs 540 [96%] of 560; p=0·25), and had similar sensitivity to laboratory-based MTB/RIF (292 [83%] of 351; p=0·99) but higher specificity (952 [92%] of 1037; p=0·0173). 34 (5%) of 744 tests with point-of-care MTB/RIF and 82 (6%) of 1411 with laboratory-based MTB/RIF failed (p=0·22). Compared with the microscopy group, more patients in the MTB/RIF group had a same-day diagnosis (178 [24%] of 744 vs 99 [13%] of 758; p<0·0001) and same-day treatment initiation (168 [23%] of 744 vs 115 [15%] of 758; p=0·0002). Although, by end of the study, more culture-positive patients in the MTB/RIF group were on treatment due to reduced dropout (15 [8%] of 185 in the MTB/RIF group did not receive treatment vs 28 [15%] of 182 in the microscopy group; p=0·0302), the proportions of all patients on treatment in each group by day 56 were similar (320 [43%] of 744 in the MTB/RIF group vs 317 [42%] of 758 in the microscopy group; p=0·6408). INTERPRETATION Xpert MTB/RIF can be accurately administered by a nurse in primary-care clinics, resulting in more patients starting same-day treatment, more culture-positive patients starting therapy, and a shorter time to treatment. However, the benefits did not translate into lower tuberculosis-related morbidity, partly because of high levels of empirical-evidence-based treatment in smear-negative patients. FUNDING European and Developing Countries Clinical Trials Partnership, National Research Foundation, and Claude Leon Foundation.
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Affiliation(s)
- Grant Theron
- Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lynn Zijenah
- Department of Immunology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Petra Clowes
- National Institute of Medical Research, Mbeya Medical Research Centre, Mbeya, Tanzania; Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany
| | - Andrea Rachow
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany; German Centre for Infection Research (DZIF), Munich, Germany
| | - Maia Lesosky
- Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Wilbert Bara
- City of Harare Health Services, Rowan Martin Building, Harare, Zimbabwe
| | - Stanley Mungofa
- City of Harare Health Services, Rowan Martin Building, Harare, Zimbabwe
| | - Madhukar Pai
- McGill International TB Centre and Department of Epidemiology and Biostatistics, McGill University, Montreal, QC, Canada
| | - Michael Hoelscher
- Division of Infectious Diseases and Tropical Medicine, Medical Centre of the University of Munich (LMU), Munich, Germany; German Centre for Infection Research (DZIF), Munich, Germany
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alex Pym
- South African Medical Research Council, Durban, South Africa; KwaZulu Research Institute for Tuberculosis and HIV (K-RITH), Durban, South Africa
| | - Peter Mwaba
- University Teaching Hospital, Lusaka, Zambia
| | - Peter Mason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Jonny Peter
- Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa; University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa; Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Do high rates of empirical treatment undermine the potential effect of new diagnostic tests for tuberculosis in high-burden settings? THE LANCET. INFECTIOUS DISEASES 2014; 14:527-32. [PMID: 24438820 DOI: 10.1016/s1473-3099(13)70360-8] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In tuberculosis-endemic settings, patients are often treated empirically, meaning that they are placed on treatment based on clinical symptoms or tests that do not provide a microbiological diagnosis (eg, chest radiography). New tests for tuberculosis, such as the Xpert MTB/RIF assay (Cepheid, Sunnyvale, CA, USA), are being implemented at substantial cost. To inform policy and rationally drive implementation, data are needed for how these tests affect morbidity, mortality, transmission, and population-level tuberculosis burden. If people diagnosed by use of new diagnostics would have received empirical treatment a few days later anyway, then the incremental benefit might be small. Will new diagnostics substantially improve outcomes and disease burden, or simply displace empirical treatment? Will the extent and accuracy of empirical treatment change with the introduction of a new test? In this Personal View, we review emerging data for how empirical treatment is frequently same-day, and might still be the predominant form of treatment in high-burden settings, even after Xpert implementation; and how Xpert might displace so-called true-positive, rather than false-positive, empirical treatment. We suggest types of studies needed to accurately assess the effect of new tuberculosis tests and the role of empirical treatment in real-world settings. Until such questions can be addressed, and empirical treatment is appropriately characterised, we postulate that the estimated population-level effect of new tests such as Xpert might be substantially overestimated.
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Cuevas LE, Datiko DG. Inducing sputum or advice from a trained worker: does it make a difference? THE LANCET. RESPIRATORY MEDICINE 2013; 1:428-429. [PMID: 24429229 DOI: 10.1016/s2213-2600(13)70144-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Luis E Cuevas
- Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
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