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Nguyen TA, Jing Teo AK, Zhao Y, Quelapio M, Hill J, Morishita F, Marais BJ, Marks GB. Population-wide active case finding as a strategy to end TB. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 46:101047. [PMID: 38827931 PMCID: PMC11143452 DOI: 10.1016/j.lanwpc.2024.101047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 06/05/2024]
Abstract
Tuberculosis (TB) is the leading infectious cause of morbidity and mortality globally. Despite available tools for preventing, finding, and treating TB, many people with TB remain undiagnosed. In high-incidence settings, TB transmission is ubiquitous within the community, affecting both high-risk groups and the general population. In fact, most people who develop TB come from the general population. To disrupt the chain of transmission that sustains the TB epidemic, we need to find and treat everyone with infectious TB as early as possible, including those with minimal symptoms or subclinical TB who are unlikely to present for care. Important elements of an effective active case-finding strategy include effective social mobilisation and community engagement, using sensitive screening tools that can be used at scale, and embracing population-wide screening in high-incidence ('hot spot') areas. We require a better description of feasible delivery models, 'real-life' impact and cost effectiveness to enable wider implementation.
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Affiliation(s)
- Thu-Anh Nguyen
- The University of Sydney Vietnam Institute, Ho Chi Minh City, Vietnam
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW, Australia
| | - Alvin Kuo Jing Teo
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW, Australia
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Yanlin Zhao
- Chinese Centre for Disease Control and Prevention, Beijing, China
| | | | - Jeremy Hill
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW, Australia
| | - Fukushi Morishita
- World Health Organization, Regional Office for the Western Pacific, Manila, Philippines
| | - Ben J. Marais
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- The University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW, Australia
| | - Guy B. Marks
- The University of Sydney Institute for Infectious Diseases (Sydney ID) and the Centre of Research Excellence in Tuberculosis (TB-CRE), Sydney, NSW, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
- Woolcock Institute of Medical Research, Sydney, Australia
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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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Mapingure M, Chingombe I, Dzinamarira T, Moyo B, Samba C, Murigo D, Mugurungi O, Mbunge E, Makota RB, Murewanhema G, Musuka G. Presence of tuberculosis symptoms among HIV-positive men who have sex with men (MSM) in Zimbabwe. AIDS Res Ther 2024; 21:18. [PMID: 38549087 PMCID: PMC10979552 DOI: 10.1186/s12981-024-00605-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/14/2024] [Indexed: 04/01/2024] Open
Abstract
We conducted secondary data analysis using a biobehavioral survey dataset of 1538 MSM from Zimbabwe. Survey participants were screened for the four symptoms suggestive of tuberculosis infection using the WHO TB screening algorithm. Results: All participants experienced at least one symptom suggestive of tuberculosis. 40% of HIV-positive MSM reported having had a cough in the last month and 13% of them experienced unexpected weight loss. The prevalence of experiencing any of the four TB symptoms amongst HIV-positive MSM was 23%. Contribution There is an urgent need for active TB case finding and treatment amongst HIV-positive MSM in Zimbabwe. Clinicians will need to ensure that MSM who need TB testing receive it timeously.
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Affiliation(s)
| | | | | | - Brian Moyo
- AIDS and TB Programmes, Ministry of Health and Child Care, Harare, Zimbabwe
| | | | | | - Owen Mugurungi
- AIDS and TB Programmes, Ministry of Health and Child Care, Harare, Zimbabwe
| | - Elliot Mbunge
- Department of Computer Science, Faculty of Science and Engineering, University of Eswatini, Kwaluseni, Eswatini
| | - Rutendo Birri Makota
- Department of Biological Sciences and Ecology, University of Zimbabwe, Harare, Zimbabwe
| | - Grant Murewanhema
- Unit of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Godfrey Musuka
- International Initiative for Impact Evaluation, Harare, Zimbabwe.
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Schiff HF, Walker NF, Ugarte-Gil C, Tebruegge M, Manousopoulou A, Garbis SD, Mansour S, Wong PH(M, Rockett G, Piazza P, Niranjan M, Vallejo AF, Woelk CH, Wilkinson RJ, Tezera LB, Garay-Baquero D, Elkington P. Integrated plasma proteomics identifies tuberculosis-specific diagnostic biomarkers. JCI Insight 2024; 9:e173273. [PMID: 38512356 PMCID: PMC11141874 DOI: 10.1172/jci.insight.173273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 03/13/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUNDNovel biomarkers to identify infectious patients transmitting Mycobacterium tuberculosis are urgently needed to control the global tuberculosis (TB) pandemic. We hypothesized that proteins released into the plasma in active pulmonary TB are clinically useful biomarkers to distinguish TB cases from healthy individuals and patients with other respiratory infections.METHODSWe applied a highly sensitive non-depletion tandem mass spectrometry discovery approach to investigate plasma protein expression in pulmonary TB cases compared to healthy controls in South African and Peruvian cohorts. Bioinformatic analysis using linear modeling and network correlation analyses identified 118 differentially expressed proteins, significant through 3 complementary analytical pipelines. Candidate biomarkers were subsequently analyzed in 2 validation cohorts of differing ethnicity using antibody-based proximity extension assays.RESULTSTB-specific host biomarkers were confirmed. A 6-protein diagnostic panel, comprising FETUB, FCGR3B, LRG1, SELL, CD14, and ADA2, differentiated patients with pulmonary TB from healthy controls and patients with other respiratory infections with high sensitivity and specificity in both cohorts.CONCLUSIONThis biomarker panel exceeds the World Health Organization Target Product Profile specificity criteria for a triage test for TB. The new biomarkers have potential for further development as near-patient TB screening assays, thereby helping to close the case-detection gap that fuels the global pandemic.FUNDINGMedical Research Council (MRC) (MR/R001065/1, MR/S024220/1, MR/P023754/1, and MR/W025728/1); the MRC and the UK Foreign Commonwealth and Development Office; the UK National Institute for Health Research (NIHR); the Wellcome Trust (094000, 203135, and CC2112); Starter Grant for Clinical Lecturers (Academy of Medical Sciences UK); the British Infection Association; the Program for Advanced Research Capacities for AIDS in Peru at Universidad Peruana Cayetano Heredia (D43TW00976301) from the Fogarty International Center at the US NIH; the UK Technology Strategy Board/Innovate UK (101556); the Francis Crick Institute, which receives funding from UKRI-MRC (CC2112); Cancer Research UK (CC2112); and the NIHR Biomedical Research Centre of Imperial College NHS.
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Affiliation(s)
- Hannah F. Schiff
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Institute for Life Sciences, Southampton, United Kingdom
| | - Naomi F. Walker
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Cesar Ugarte-Gil
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Epidemiology, School of Public and Population Health, University of Texas Medical Branch, Galveston, Texas, USA
| | - Marc Tebruegge
- Department of Infection, Immunity & Inflammation, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
- Department of Paediatrics, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
- Department of Paediatrics, The University of Melbourne, Parkville, Australia
| | - Antigoni Manousopoulou
- Proteas Bioanalytics, The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Spiros D. Garbis
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Proteas Bioanalytics, The Lundquist Institute for Biomedical Innovation, Harbor-UCLA Medical Center, Torrance, California, USA
| | - Salah Mansour
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Institute for Life Sciences, Southampton, United Kingdom
| | | | - Gabrielle Rockett
- Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Paolo Piazza
- Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Mahesan Niranjan
- Institute for Life Sciences, Southampton, United Kingdom
- Electronics and Computer Sciences, Faculty of Engineering and Physical Sciences, University of Southampton, Southampton, United Kingdom
| | - Andres F. Vallejo
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | | | - Robert J. Wilkinson
- Centre for Infectious Diseases Research in Africa, Institute of Infectious Diseases and Molecular Medicine, and
- Department of Medicine, University of Cape Town, Observatory, Republic of South Africa
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
- The Francis Crick Institute, London, United Kingdom
| | - Liku B. Tezera
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Institute for Life Sciences, Southampton, United Kingdom
| | - Diana Garay-Baquero
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Institute for Life Sciences, Southampton, United Kingdom
| | - Paul Elkington
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Institute for Life Sciences, Southampton, United Kingdom
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Biewer AM, Tzelios C, Tintaya K, Roman B, Hurwitz S, Yuen CM, Mitnick CD, Nardell E, Lecca L, Tierney DB, Nathavitharana RR. Accuracy of digital chest x-ray analysis with artificial intelligence software as a triage and screening tool in hospitalized patients being evaluated for tuberculosis in Lima, Peru. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002031. [PMID: 38324610 PMCID: PMC10849246 DOI: 10.1371/journal.pgph.0002031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy. We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors. In the triage cohort (n = 387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n = 191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort. qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs.
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Affiliation(s)
- Amanda M. Biewer
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christine Tzelios
- Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | - Shelley Hurwitz
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Courtney M. Yuen
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Carole D. Mitnick
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Edward Nardell
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | | | - Dylan B. Tierney
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts Department of Public Health, Boston, Massachusetts, United States of America
| | - Ruvandhi R. Nathavitharana
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, United States of America
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Biewer A, Tzelios C, Tintaya K, Roman B, Hurwitz S, Yuen CM, Mitnick CD, Nardell E, Lecca L, Tierney DB, Nathavitharana RR. Accuracy of digital chest x-ray analysis with artificial intelligence software as a triage and screening tool in hospitalized patients being evaluated for tuberculosis in Lima, Peru. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.17.23290110. [PMID: 37292955 PMCID: PMC10246158 DOI: 10.1101/2023.05.17.23290110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Introduction Tuberculosis (TB) transmission in healthcare facilities is common in high-incidence countries. Yet, the optimal approach for identifying inpatients who may have TB is unclear. We evaluated the diagnostic accuracy of qXR (Qure.ai, India) computer-aided detection (CAD) software versions 3.0 and 4.0 (v3 and v4) as a triage and screening tool within the FAST (Find cases Actively, Separate safely, and Treat effectively) transmission control strategy. Methods We prospectively enrolled two cohorts of patients admitted to a tertiary hospital in Lima, Peru: one group had cough or TB risk factors (triage) and the other did not report cough or TB risk factors (screening). We evaluated the sensitivity and specificity of qXR for the diagnosis of pulmonary TB using culture and Xpert as primary and secondary reference standards, including stratified analyses based on risk factors. Results In the triage cohort (n=387), qXR v4 sensitivity was 0.91 (59/65, 95% CI 0.81-0.97) and specificity was 0.32 (103/322, 95% CI 0.27-0.37) using culture as reference standard. There was no difference in the area under the receiver-operating-characteristic curve (AUC) between qXR v3 and qXR v4 with either a culture or Xpert reference standard. In the screening cohort (n=191), only one patient had a positive Xpert result, but specificity in this cohort was high (>90%). A high prevalence of radiographic lung abnormalities, most notably opacities (81%), consolidation (62%), or nodules (58%), was detected by qXR on digital CXR images from the triage cohort. Conclusions qXR had high sensitivity but low specificity as a triage in hospitalized patients with cough or TB risk factors. Screening patients without cough or risk factors in this setting had a low diagnostic yield. These findings further support the need for population and setting-specific thresholds for CAD programs.
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Affiliation(s)
- Amanda Biewer
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | | | | | | | - Courtney M Yuen
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Carole D Mitnick
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Edward Nardell
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | | | - Dylan B Tierney
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA
- Massachusetts Department of Public Health, Boston, MA
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Htet KKK, Phyu AN, Zayar NN, Chongsuvivatwong V. Active Tuberculosis Screening via a Mobile Health App in Myanmar: Incremental Cost-Effectiveness Evaluation. JMIR Form Res 2023; 7:e51998. [PMID: 37948119 PMCID: PMC10674145 DOI: 10.2196/51998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/10/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND A mobile app that calculates a tuberculosis (TB) risk score based on individual social and pathological characteristics has been shown to be a better predictor of the risk of contracting TB than conventionally used TB signs and symptoms (TBSS) in Myanmar, where the TB burden is high. Its cost-effectiveness, however, has not yet been assessed. OBJECTIVE This study aimed to determine the incremental costs of this mobile app and of chest x-rays (CXRs) in averting disability-adjusted life years (DALYs) among missed cases of active TB in the population being screened. METHODS Elements of incremental costs and effectiveness of 3 initial TB screening strategies were examined, including TBSS followed by CXR, the mobile app followed by CXR, and universal CXR. The incremental cost-effectiveness ratio (ICER; ie, the additional cost for each additional DALY averted) was compared to TBSS screening. Based on the latest 2020 gross domestic product (GDP) per capita of Myanmar (US $1477.50), the ICER was compared to willingness-to-pay (WTP) thresholds of 1, 2, and 3 times the GDP per capita. Probabilistic sensitivity analysis was conducted with a Monte Carlo simulation to compute the levels of probability that the ICER for each strategy was below each WTP threshold. RESULTS For each 100,000 population, the incremental cost compared to TBSS of active TB screening was US $345,942 for the mobile app and US $1,810,712 for universal CXR. The incremental effectiveness was 325 DALYs averted for the mobile app and 576 DALYs averted for universal CXR. For the mobile app, the estimated ICER was US $1064 (72% of GDP per capita) per 1 DALY averted. Furthermore, 100% of the simulated values were below an additional cost of 1 times the GDP per capita for 1 additional DALY averted. The universal CXR strategy has an estimated ICER of US $3143 (2.1 times the GDP per capita) per 1 DALY averted and an additional 77.2% DALYs averted compared to the app (ie, 576 - 325 / 325 DALYs); however, 0.5% of the simulated values were higher than an additional expenditure of 3 times the GDP per capita. CONCLUSIONS Based on the status of the economy in 2020, the mobile app strategy is affordable for Myanmar. The universal CXR strategy, although it could prevent an additional 77% of DALYs, is probably unaffordable. Compared to the TBSS strategy, the mobile app system based on social and pathological characteristics of TB has potential as a TB screening tool to identify missing TB cases and to reduce TB morbidity and mortality, thereby helping to achieve the global goal of "End TB" in resource-limited settings with a high TB burden.
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Affiliation(s)
- Kyaw Ko Ko Htet
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Aye Nyein Phyu
- Department of Public Health, National Tuberculosis Programme, Ministry of Health and Sports, Mandalay, Myanmar
| | - Nyi Nyi Zayar
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Yates TA, Karat AS, Bozzani F, McCreesh N, MacGregor H, Beckwith PG, Govender I, Colvin CJ, Kielmann K, Grant AD. Time to change the way we think about tuberculosis infection prevention and control in health facilities: insights from recent research. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e117. [PMID: 37502244 PMCID: PMC10369445 DOI: 10.1017/ash.2023.192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 07/29/2023]
Abstract
In clinical settings where airborne pathogens, such as Mycobacterium tuberculosis, are prevalent, they constitute an important threat to health workers and people accessing healthcare. We report key insights from a 3-year project conducted in primary healthcare clinics in South Africa, alongside other recent tuberculosis infection prevention and control (TB-IPC) research. We discuss the fragmentation of TB-IPC policies and budgets; the characteristics of individuals attending clinics with prevalent pulmonary tuberculosis; clinic congestion and patient flow; clinic design and natural ventilation; and the facility-level determinants of the implementation (or not) of TB-IPC interventions. We present modeling studies that describe the contribution of M. tuberculosis transmission in clinics to the community tuberculosis burden and economic evaluations showing that TB-IPC interventions are highly cost-effective. We argue for a set of changes to TB-IPC, including better coordination of policymaking, clinic decongestion, changes to clinic design and building regulations, and budgeting for enablers to sustain implementation of TB-IPC interventions. Additional research is needed to find the most effective means of improving the implementation of TB-IPC interventions; to develop approaches to screening for prevalent pulmonary tuberculosis that do not rely on symptoms; and to identify groups of patients that can be seen in clinic less frequently.
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Affiliation(s)
- Tom A. Yates
- Division of Infection and Immunity, Faculty of Medicine, University College London, London, UK
| | - Aaron S. Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- The Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
| | | | - Nicky McCreesh
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Hayley MacGregor
- The Institute of Development Studies, University of Sussex, Brighton, UK
| | - Peter G. Beckwith
- Department of Medicine, University of Cape Town, Rondebosch, South Africa
| | - Indira Govender
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Christopher J. Colvin
- Division of Social and Behavioural Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Karina Kielmann
- The Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Alison D. Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, DurbanSouth Africa
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9
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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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10
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Abdulgader SM, Okunola AO, Ndlangalavu G, Reeve BWP, Allwood BW, Koegelenberg CFN, Warren RM, Theron G. Diagnosing Tuberculosis: What Do New Technologies Allow Us to (Not) Do? Respiration 2022; 101:797-813. [PMID: 35760050 PMCID: PMC9533455 DOI: 10.1159/000525142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/10/2022] [Indexed: 12/11/2022] Open
Abstract
New tuberculosis (TB) diagnostics are at a crossroads: their development, evaluation, and implementation is severely damaged by resource diversion due to COVID-19. Yet several technologies, especially those with potential for non-invasive non-sputum-based testing, hold promise for efficiently triaging and rapidly confirming TB near point-of-care. Such tests are, however, progressing through the pipeline slowly and will take years to reach patients and health workers. Compellingly, such tests will create new opportunities for difficult-to-diagnose populations, including primary care attendees (all-comers in high burden settings irrespective of reason for presentation) and community members (with early stage disease or risk factors like HIV), many of whom cannot easily produce sputum. Critically, all upcoming technologies have limitations that implementers and health workers need to be cognizant of to ensure optimal deployment without undermining confidence in a technology that still offers improvements over the status quo. In this state-of-the-art review, we critically appraise such technologies for active pulmonary TB diagnosis. We highlight strengths, limitations, outstanding research questions, and how current and future tests could be used in the presence of these limitations and uncertainties. Among triage tests, CRP (for which commercial near point-of-care devices exist) and computer-aided detection software with digital chest X-ray hold promise, together with late-stage blood-based assays that detect host and/or microbial biomarkers; however, aside from a handful of prototypes, the latter category has a shortage of promising late-stage alternatives. Furthermore, positive results from new triage tests may have utility in people without TB; however, their utility for informing diagnostic pathways for other diseases is under-researched (most sick people tested for TB do not have TB). For confirmatory tests, few true point-of-care options will be available soon; however, combining novel approaches like tongue swabs with established tests like Ultra have short-term promise but first require optimizations to specimen collection and processing procedures. Concerningly, no technologies yet have compelling evidence of meeting the World Health Organization optimal target product profile performance criteria, especially for important operational criteria crucial for field deployment. This is alarming as the target product profile criteria are themselves almost a decade old and require urgent revision, especially to cater for technologies made prominent by the COVID-19 diagnostic response (e.g., at-home testing and connectivity solutions). Throughout the review, we underscore the importance of how target populations and settings affect test performance and how the criteria by which these tests should be judged vary by use case, including in active case finding. Lastly, we advocate for health workers and researchers to themselves be vocal proponents of the uptake of both new tests and those − already available tests that remain suboptimally utilized.
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Affiliation(s)
- Shima M Abdulgader
- 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
| | - Anna O Okunola
- 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
| | - 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
| | - Brian W Allwood
- Division of Pulmonology, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Tygerberg Hospital, Stellenbosch University, Cape Town, South Africa
| | - Rob 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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11
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Loesch RBR, Ribeiro RM, Conceição C. Tuberculosis contact investigation in African Portuguese-speaking countries at End TB Strategy era: a scoping review. BMJ Open 2022; 12:e056761. [PMID: 35379632 PMCID: PMC8981322 DOI: 10.1136/bmjopen-2021-056761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The contact investigation of tuberculosis (TB) index case is one of the critical elements pointed by the WHO to reach the end of the TB epidemic. The scoping review aimed to map out the recommended and the adopted processes applied to active contact investigation of TB index case in African Portuguese-speaking countries (PALOP). DESIGN Scoping review. DATA SOURCES We searched B-on, Cochrane Library, PubMed, Web of Science, Scopus, WHOLIS, IRIS, OKR, each country's Ministry of Health websites, WHO, Global Fund, World Bank and bibliographic reference lists from February to May 2020. ELIGIBILITY CRITERIA All available literature on TB contact investigation in each country part of PALOP (Angola, Cape Verde, Guinea-Bissau, Mozambique and Sao Tome and Principe) published from 1 January 2010 to 31 January2020. DATA EXTRACTION AND SYNTHESIS A data-charting form was developed to extract data on documents' characteristics and variables pertinent to the TB contact investigation process. Before qualitative analysis, we thematically synthesised findings and converted them into appropriate text units. RESULTS Fifteen documents were included in the scoping review. The recommended processes for TB contact investigation were identified only for Cape Verde and Mozambique. It included clinical evaluation, counselling and testing for HIV, chest radiography, tuberculin skin test, sputum smear microscopy or Xpert MTB/RIF. The adopted processes were detected only in research studies from Angola, Guinea-Bissau and Mozambique. Therefore, they cannot be assumed as adopted within the scope of the national programmes of the respective countries. CONCLUSION This review highlights the scarcity of references on TB contact investigation in PALOP at the End TB Strategy era. Furthermore, it is well clear the importance of an information system that provides actual data for assessing the real impact of such interventions in controlling the disease in African Portuguese-speaking countries.
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Affiliation(s)
| | - Rafaela M Ribeiro
- Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
| | - Cláudia Conceição
- Global Health and Tropical Medicine, GHTM, Instituto de Higiene e Medicina Tropical, IHMT, Universidade Nova de Lisboa, UNL, Lisboa, Portugal
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12
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Oh JY, Lee SS, Kim HW, Min J, Ko Y, Koo HK, Jeong YJ, Kang HH, Kang JY, Kim JS, Park JS, Kwon Y, Yang J, Han J, Jang YJ, Lee MK, Jegal Y, Kim YC, Kim YS. Additional Usefulness of Bronchoscopy in Patients with Initial Microbiologically Negative Pulmonary Tuberculosis: A Retrospective Analysis of a Korean Nationwide Prospective Cohort Study. Infect Drug Resist 2022; 15:1029-1037. [PMID: 35310369 PMCID: PMC8926010 DOI: 10.2147/idr.s354962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/26/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Bronchoscopy is widely used for microbiological diagnosis of patients with minimal sputum production. However, the usefulness of bronchoscopy in patient groups who benefit from subsequent microbiological confirmation has not been established. Patients and Methods We retrospectively analyzed Korean tuberculosis (TB) cohort data from September 2018 to October 2019 to evaluate the usefulness of bronchoscopy in patients with microbiologically negative pulmonary TB (based on initial sputum polymerase chain reaction and culture results). The primary outcome was the proportion of microbiological diagnoses made after bronchoscopy. Secondary outcomes were the predictors of microbiological confirmation and the percentage of additional resistance detection after bronchoscopy. Results A total of 5194 patients were diagnosed with pulmonary TB, 937 of whom were microbiologically negative for pulmonary TB based on the initial sputum findings. Of these, 319 patients underwent bronchoscopy, and further microbiological confirmation was achieved in 157 (49.1%) patients. The predictors of microbiological confirmation after bronchoscopy were age >65 years, female sex, and low body mass index (BMI). The rate of additional resistance detection was 10.5% (multidrug resistant/rifampin-resistant 3.8%; isoniazid-resistant 5.7%). Conclusion Bronchoscopy can be used for the detection of resistant pathogens. Bronchoscopy should be considered for microbiologically negative pulmonary TB in women aged >65 years and with low BMI for subsequent microbiological confirmation.
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Affiliation(s)
- Jee Youn Oh
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sung-Soon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Hyung Woo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jinsoo Min
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Daejeon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yousang Ko
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Hyeon-Kyoung Koo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea
| | - Yun-Jeong Jeong
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Hyeon Hui Kang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Ji Young Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ju Sang Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Seuk Park
- Division of Pulmonary Medicine, Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Yunhyung Kwon
- Division of Tuberculosis Prevention and Control, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Jiyeon Yang
- Division of Tuberculosis Prevention and Control, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Jiyeon Han
- Division of Tuberculosis Prevention and Control, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - You Jin Jang
- Division of Tuberculosis Prevention and Control, Korea Disease Control and Prevention Agency, Cheongju, Republic of Korea
| | - Min Ki Lee
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Pusan, Republic of Korea
| | - Yangjin Jegal
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Republic of Korea
| | - Young-Chul Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Yun Seong Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
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Baluku JB, Nabwana M, Winters M, Bongomin F. Tuberculosis contact tracing yield and associated factors in Uganda. BMC Pulm Med 2022; 22:64. [PMID: 35172788 PMCID: PMC8848908 DOI: 10.1186/s12890-022-01860-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The yield of tuberculosis (TB) contact tracing is historically low in Uganda. We determined factors associated with a positive contact tracing yield at an urban public TB clinic in Kampala, Uganda. METHODS We reviewed contact tracing registers of index TB cases registered between 2015 and 2020 at Kitebi Health Center, a primary level facility. Contacts who had symptoms of TB were designated as having presumptive TB. A contact investigation that yielded a new TB case was designated as a positive yield. We used logistic regression to determine factors associated with a positive yield of contact tracing. RESULTS Of 778 index TB cases, 455 (58.5%) had a contact investigation conducted. Index cases with a telephone contact in the unit TB register (adjusted odds ratio (aOR) 1.66, 95% CI 1.02-1.97, p = 0.036) were more likely to have a contact investigation conducted than those who did not. Of 1350 contacts, 105 (7.8%) had presumptive TB. Of these, 73 (69.5%) were further evaluated for active TB and 29 contacts had active TB. The contact tracing yield for active TB was therefore 2.1% (29/1,350). The odds of a positive yield increased tenfold with each additional presumptive contact evaluated for active TB (aOR 10.1, 95% CI 2.95-34.66, p < 0.001). Also, retreatment index TB cases were more likely to yield a positive contact (aOR 7.69 95% CI 2.08-25.00, p = 0.002) than to new cases. CONCLUSION TB contact tracing should aim to evaluate all contacts with presumptive TB and contacts of retreatment cases to maximise the yield of contact tracing.
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Affiliation(s)
- Joseph Baruch Baluku
- Makerere University Lung Institute, Kampala, Uganda. .,Kiruddu National Referral Hospital, Kampala, Uganda.
| | - Martin Nabwana
- Makerere University - Johns Hopkins University Research Collaboration, Kampala, Uganda
| | | | - Felix Bongomin
- Department Medical Microbiology and Immunology, Faculty of Medicine, Gulu University, Gulu, Uganda
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14
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MacPherson P, Webb EL, Kamchedzera W, Joekes E, Mjoli G, Lalloo DG, Divala TH, Choko AT, Burke RM, Maheswaran H, Pai M, Squire SB, Nliwasa M, Corbett EL. Computer-aided X-ray screening for tuberculosis and HIV testing among adults with cough in Malawi (the PROSPECT study): A randomised trial and cost-effectiveness analysis. PLoS Med 2021; 18:e1003752. [PMID: 34499665 PMCID: PMC8459969 DOI: 10.1371/journal.pmed.1003752] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 09/23/2021] [Accepted: 08/03/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Suboptimal tuberculosis (TB) diagnostics and HIV contribute to the high global burden of TB. We investigated costs and yield from systematic HIV-TB screening, including computer-aided digital chest X-ray (DCXR-CAD). METHODS AND FINDINGS In this open, three-arm randomised trial, adults (≥18 years) with cough attending acute primary services in Malawi were randomised (1:1:1) to standard of care (SOC); oral HIV testing (HIV screening) and linkage to care; or HIV testing and linkage to care plus DCXR-CAD with sputum Xpert for high CAD4TBv5 scores (HIV-TB screening). Participants and study staff were not blinded to intervention allocation, but investigator blinding was maintained until final analysis. The primary outcome was time to TB treatment. Secondary outcomes included proportion with same-day TB treatment; prevalence of undiagnosed/untreated bacteriologically confirmed TB on day 56; and undiagnosed/untreated HIV. Analysis was done on an intention-to-treat basis. Cost-effectiveness analysis used a health-provider perspective. Between 15 November 2018 and 27 November 2019, 8,236 were screened for eligibility, with 473, 492, and 497 randomly allocated to SOC, HIV, and HIV-TB screening arms; 53 (11%), 52 (9%), and 47 (9%) were lost to follow-up, respectively. At 56 days, TB treatment had been started in 5 (1.1%) SOC, 8 (1.6%) HIV screening, and 15 (3.0%) HIV-TB screening participants. Median (IQR) time to TB treatment was 11 (6.5 to 38), 6 (1 to 22), and 1 (0 to 3) days (hazard ratio for HIV-TB versus SOC: 2.86, 1.04 to 7.87), with same-day treatment of 0/5 (0%) SOC, 1/8 (12.5%) HIV, and 6/15 (40.0%) HIV-TB screening arm TB patients (p = 0.03). At day 56, 2 SOC (0.5%), 4 HIV (1.0%), and 2 HIV-TB (0.5%) participants had undiagnosed microbiologically confirmed TB. HIV screening reduced the proportion with undiagnosed or untreated HIV from 10 (2.7%) in the SOC arm to 2 (0.5%) in the HIV screening arm (risk ratio [RR]: 0.18, 0.04 to 0.83), and 1 (0.2%) in the HIV-TB screening arm (RR: 0.09, 0.01 to 0.71). Incremental costs were US$3.58 and US$19.92 per participant screened for HIV and HIV-TB; the probability of cost-effectiveness at a US$1,200/quality-adjusted life year (QALY) threshold was 83.9% and 0%. Main limitations were the lower than anticipated prevalence of TB and short participant follow-up period; cost and quality of life benefits of this screening approach may accrue over a longer time horizon. CONCLUSIONS DCXR-CAD with universal HIV screening significantly increased the timeliness and completeness of HIV and TB diagnosis. If implemented at scale, this has potential to rapidly and efficiently improve TB and HIV diagnosis and treatment. TRIAL REGISTRATION clinicaltrials.gov NCT03519425.
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Affiliation(s)
- Peter MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Emily L. Webb
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Wala Kamchedzera
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Elizabeth Joekes
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Gugu Mjoli
- Department of Radiology, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | - David G. Lalloo
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Titus H. Divala
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Helse Nord TB Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Augustine T. Choko
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Rachael M. Burke
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Madhukar Pai
- McGill International TB Centre, McGill University, Montreal, Canada
| | - S. Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Marriott Nliwasa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Helse Nord TB Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Saito H, Nishikawa Y, Masuzawa Y, Tsubokura M, Mizuno Y. Helicobacter pylori Infection Mass Screening for Children and Adolescents: a Systematic Review of Observational Studies. J Gastrointest Cancer 2021; 52:489-497. [PMID: 33761050 PMCID: PMC8131279 DOI: 10.1007/s12029-021-00630-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE Population-based Helicobacter pylori (H. pylori) screening and eradication for adults in areas with a high incidence of gastric cancer have been shown to be effective. The current status of H. pylori screening for young people, however, has not been sufficiently evaluated. METHODS A systematic review of population-based H. pylori screening of young people was performed using four databases (MEDLINE, EMBASE, the Cochrane Library, and ICHUSHI) and independently evaluated by two investigators. Studies were evaluated with regard to the country, region, screening method, target age, number of screened people, and rate of positive screening. RESULTS From 3231 studies, 39 studies were included (14 English original studies published in peer-review journals, 6 Japanese original studies, and 19 conference reports). These studies originated from 10 countries, with the largest number stemming from Japan (29 studies) followed by Germany (2 studies). Screening was performed using the urea breath test, blood antibodies, stool antigens, and urine antibodies. Five countries used the breath test as the first screening method, five used blood samples, two used stool antigens, and only Japan used urinary tests. CONCLUSION Screening for H. pylori in young people was reviewed based on reports from several countries, and findings suggest that local authorities considering screening for H. pylori in young people need to scrutinize the age and potential methods. Further research is required to determine the effectiveness of mid- to long-term H. pylori screening for young people.
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Affiliation(s)
- Hiroaki Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Miyagi, Japan.
- Department of Radiation Health Management, Fukushima Medical University School of Medicine, Fukushima, Fukushima, Japan.
| | - Yoshitaka Nishikawa
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Kyoto, Japan
| | - Yuko Masuzawa
- Chiba Faculty of Nursing, Tokyo Healthcare University, Funabashi, Chiba, Japan
| | - Masaharu Tsubokura
- Department of Radiation Health Management, Fukushima Medical University School of Medicine, Fukushima, Fukushima, Japan
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Mendelsohn SC, Fiore-Gartland A, Penn-Nicholson A, Mulenga H, Mbandi SK, Borate B, Hadley K, Hikuam C, Musvosvi M, Bilek N, Erasmus M, Jaxa L, Raphela R, Nombida O, Kaskar M, Sumner T, White RG, Innes C, Brumskine W, Hiemstra A, Malherbe ST, Hassan-Moosa R, Tameris M, Walzl G, Naidoo K, Churchyard G, Scriba TJ, Hatherill M. Validation of a host blood transcriptomic biomarker for pulmonary tuberculosis in people living with HIV: a prospective diagnostic and prognostic accuracy study. LANCET GLOBAL HEALTH 2021; 9:e841-e853. [PMID: 33862012 PMCID: PMC8131200 DOI: 10.1016/s2214-109x(21)00045-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 01/18/2021] [Accepted: 01/27/2021] [Indexed: 12/21/2022]
Abstract
Background A rapid, blood-based triage test that allows targeted investigation for tuberculosis at the point of care could shorten the time to tuberculosis treatment and reduce mortality. We aimed to test the performance of a host blood transcriptomic signature (RISK11) in diagnosing tuberculosis and predicting progression to active pulmonary disease (prognosis) in people with HIV in a community setting. Methods In this prospective diagnostic and prognostic accuracy study, adults (aged 18–59 years) with HIV were recruited from five communities in South Africa. Individuals with a history of tuberculosis or household exposure to multidrug-resistant tuberculosis within the past 3 years, comorbid risk factors for tuberculosis, or any condition that would interfere with the study were excluded. RISK11 status was assessed at baseline by real-time PCR; participants and study staff were masked to the result. Participants underwent active surveillance for microbiologically confirmed tuberculosis by providing spontaneously expectorated sputum samples at baseline, if symptomatic during 15 months of follow-up, and at 15 months (the end of the study). The coprimary outcomes were the prevalence and cumulative incidence of tuberculosis disease confirmed by a positive Xpert MTB/RIF, Xpert Ultra, or Mycobacteria Growth Indicator Tube culture, or a combination of such, on at least two separate sputum samples collected within any 30-day period. Findings Between March 22, 2017, and May 15, 2018, 963 participants were assessed for eligibility and 861 were enrolled. Among 820 participants with valid RISK11 results, eight (1%) had prevalent tuberculosis at baseline: seven (2·5%; 95% CI 1·2–5·0) of 285 RISK11-positive participants and one (0·2%; 0·0–1·1) of 535 RISK11-negative participants. The relative risk (RR) of prevalent tuberculosis was 13·1 times (95% CI 2·1–81·6) greater in RISK11-positive participants than in RISK11-negative participants. RISK11 had a diagnostic area under the receiver operating characteristic curve (AUC) of 88·2% (95% CI 77·6–96·7), and a sensitivity of 87·5% (58·3–100·0) and specificity of 65·8% (62·5–69·0) at a predefined score threshold (60%). Of those with RISK11 results, eight had primary endpoint incident tuberculosis during 15 months of follow-up. Tuberculosis incidence was 2·5 per 100 person-years (95% CI 0·7–4·4) in the RISK11-positive group and 0·2 per 100 person-years (0·0–0·5) in the RISK11-negative group. The probability of primary endpoint incident tuberculosis was greater in the RISK11-positive group than in the RISK11-negative group (cumulative incidence ratio 16·0 [95% CI 2·0–129·5]). RISK11 had a prognostic AUC of 80·0% (95% CI 70·6–86·9), and a sensitivity of 88·6% (43·5–98·7) and a specificity of 68·9% (65·3–72·3) for incident tuberculosis at the 60% threshold. Interpretation RISK11 identified prevalent tuberculosis and predicted risk of progression to incident tuberculosis within 15 months in ambulant people living with HIV. RISK11's performance approached, but did not meet, WHO's target product profile benchmarks for screening and prognostic tests for tuberculosis. Funding Bill & Melinda Gates Foundation and the South African Medical Research Council.
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Affiliation(s)
- Simon C Mendelsohn
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Andrew Fiore-Gartland
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Adam Penn-Nicholson
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Humphrey Mulenga
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Stanley Kimbung Mbandi
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Bhavesh Borate
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Katie Hadley
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Chris Hikuam
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Munyaradzi Musvosvi
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Nicole Bilek
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Mzwandile Erasmus
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Lungisa Jaxa
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Rodney Raphela
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Onke Nombida
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Masooda Kaskar
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Tom Sumner
- TB Modelling Group, TB Centre, Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard G White
- TB Modelling Group, TB Centre, Centre for Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Craig Innes
- The Aurum Institute, Johannesburg, South Africa
| | | | - Andriëtte Hiemstra
- DST/NRF Centre of Excellence for Biomedical TB Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa; SAMRC Centre for TB Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephanus T Malherbe
- DST/NRF Centre of Excellence for Biomedical TB Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa; SAMRC Centre for TB Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa
| | - Razia Hassan-Moosa
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa; MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Michèle Tameris
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Gerhard Walzl
- DST/NRF Centre of Excellence for Biomedical TB Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa; SAMRC Centre for TB Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, Durban, South Africa; MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban, South Africa
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa.
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Sohn H, Sweeney S, Mudzengi D, Creswell J, Menzies NA, Fox GJ, MacPherson P, Dowdy DW. Determining the value of TB active case-finding: current evidence and methodological considerations. Int J Tuberc Lung Dis 2021; 25:171-181. [PMID: 33688805 PMCID: PMC8647907 DOI: 10.5588/ijtld.20.0565] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Active case-finding (ACF) is an important component of the End TB Strategy. However, ACF is resource-intensive, and the economics of ACF are not well-understood. Data on the costs of ACF are limited, with little consistency in the units and methods used to estimate and report costs. Mathematical models to forecast the long-term effects of ACF require empirical measurements of the yield, timing and costs of case detection. Pragmatic trials offer an opportunity to assess the cost-effectiveness of ACF interventions within a 'real-world´ context. However, such analyses generally require early introduction of economic evaluations to enable prospective data collection on resource requirements. Closing the global case-detection gap will require substantial additional resources, including continued investment in innovative technologies. Research is essential to the optimal implementation, cost-effectiveness, and affordability of ACF in high-burden settings. To assess the value of ACF, we must prioritize the collection of high-quality data regarding costs and effectiveness, and link those data to analytical models that are adapted to local settings.
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Affiliation(s)
- H Sohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - S Sweeney
- London School of Hygiene & Tropical Medicine, London, UK
| | - D Mudzengi
- The Aurum Institute, Johannesburg, South Africa
| | - J Creswell
- The Stop TB Partnership, UNOPS, Geneva, Switzerland
| | - N A Menzies
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - G J Fox
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Woolcock Institute of Medical Research, Glebe, NSW, Australia
| | - P MacPherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Malawi, Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - D W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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18
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Feasey HRA, Corbett EL, Nliwasa M, Mair L, Divala TH, Kamchedzera W, Khundi ME, Burchett HED, Webb EL, Maheswaran H, Squire SB, MacPherson P. Tuberculosis diagnosis cascade in Blantyre, Malawi: a prospective cohort study. BMC Infect Dis 2021; 21:178. [PMID: 33588804 PMCID: PMC7883960 DOI: 10.1186/s12879-021-05860-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/31/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) control relies on early diagnosis and treatment. International guidelines recommend systematic TB screening at health facilities, but implementation is challenging. We investigated completion of recommended TB screening steps in Blantyre, Malawi. METHODS A prospective cohort recruited adult outpatients attending Bangwe primary clinic. Entry interviews were linked to exit interviews. The proportion of participants progressing through each step of the diagnostic pathway were estimated. Factors associated with request for sputum were investigated using multivariable logistic regression. RESULTS Of 5442 clinic attendances 2397 (44%) had exit interviews. In clinically indicated participants (n = 445) 256 (57.5%) were asked about cough, 36 (8.1%) were asked for sputum, 21 (4.7%) gave sputum and 1 (0.2%) received same-day results. Significant associations with request for sputum were: any TB symptom (aOR:3.20, 95%CI:2.02-5.06), increasing age (aOR:1.02, 95%CI:1.01-1.04 per year) and for HIV-negative participants only, a history of previous TB (aOR:3.37, 95%CI:1.45-7.81). Numbers requiring sputum tests (26/day) outnumbered diagnostic capacity (8-12/day). CONCLUSIONS Patients were lost at every stage of the TB care cascade, with same day sputum submission following all steps of the diagnosis cascade achieved in only 4.7% if clinically indicated. Infection control strategies should be implemented, with reporting on early steps of the TB care cascade formalised. High-throughput screening interventions, such as digital CXR, that can achieve same-day TB diagnosis are urgently needed to meet WHO End TB goals.
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Affiliation(s)
- Helena R. A. Feasey
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Elizabeth L. Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Luke Mair
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Titus H. Divala
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
- Helse Nord Tuberculosis Initiative, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Wala Kamchedzera
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Mc Ewen Khundi
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Helen E. D. Burchett
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | - Emily L. Webb
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
| | | | | | - Peter MacPherson
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- London School of Hygiene & Tropical Medicine, Keppel Street, Bloomsbury, London, UK
- Liverpool School of Tropical Medicine, Liverpool, UK
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19
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Vonasek B, Kay A, Devezin T, Bacha JM, Kazembe P, Dhillon D, Dlamini S, Haq H, Thahane L, Simon K, Matshaba M, Sanders J, Minde M, Wanless S, Nyasulu P, Mandalakas A. Tuberculosis symptom screening for children and adolescents living with HIV in six high HIV/TB burden countries in Africa. AIDS 2021; 35:73-79. [PMID: 33048868 PMCID: PMC7752241 DOI: 10.1097/qad.0000000000002715] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 08/31/2020] [Accepted: 09/15/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The WHO recommends that children and adolescents living with HIV (CALHIV) complete TB symptom screening at every clinical encounter but evidence supporting this recommendation is limited. We evaluated the performance of the recommended TB symptom screening in six high-burden TB/HIV countries. DESIGN Retrospective longitudinal cohort. METHODS We extracted data from electronic medical records of CALHIV receiving care from clinics in Botswana, Eswatini, Lesotho, Malawi, Tanzania, and Uganda from January 2014 to June 2017. We defined incident TB cases as those prescribed TB treatment within 30 days of TB diagnosis. We analyzed the most recent symptom screen preceding a TB diagnosis. In accordance with WHO guidelines, positive screens were defined as current fever, cough, poor weight gain, or recent TB contact. Odds of TB disease was modeled by screen result and age at which screening was conducted. RESULTS Twenty thousand seven hundred and six patients collectively had 316 740 clinic visits, of which 240 161 (75.8%) had documented TB symptom screens. There were 35 701 (14.9%) positive TB symptom screens, and 1212 incident TB diagnoses. Sensitivity and specificity of the TB symptom screen to diagnose TB were 61.2% (95% CI 58.4--64.0) and 88.8% (95% CI 88.7--88.9), respectively. Log odds of documented TB for positive or negative screens was statistically different only for screens conducted at ages 7--17. CONCLUSION Although specificity was high, the sensitivity of the TB symptom screen to detect TB in CALHIV was low. More accurate screening approaches are needed to optimally identify TB disease in CALHIV.
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Affiliation(s)
- Bryan Vonasek
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Alexander Kay
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation-Swaziland, Mbabane, Eswatini
| | - Tara Devezin
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M. Bacha
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation-Tanzania, Mbeya, Tanzania
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kazembe
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Dilsher Dhillon
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Sandile Dlamini
- Baylor College of Medicine Children's Foundation-Swaziland, Mbabane, Eswatini
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Heather Haq
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Lineo Thahane
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho
| | - Katie Simon
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Mogomotsi Matshaba
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Botswana-Baylor Children's Clinical Center of Excellence, Gaborone, Botswana
| | - Jill Sanders
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
- Baylor College of Medicine Children's Foundation-Lesotho, Maseru, Lesotho
| | - Mercy Minde
- Baylor College of Medicine Children's Foundation-Tanzania, Mwanza, Tanzania
| | - Sebastian Wanless
- The Baylor International Pediatric AIDS Initiative (BIPAI) at Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Phoebe Nyasulu
- Baylor College of Medicine Children's Foundation Malawi, Lilongwe, Malawi
| | - Anna Mandalakas
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- The Global Tuberculosis Program, Texas Children's Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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20
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Mwebe SZ, Yoon C, Asege L, Nakaye M, Katende J, Andama A, Cattamanchi A, Semitala FC. Impact of hematocrit on point-of-care C-reactive protein-based tuberculosis screening among people living with HIV initiating antiretroviral therapy in Uganda. Diagn Microbiol Infect Dis 2020; 99:115281. [PMID: 33453673 DOI: 10.1016/j.diagmicrobio.2020.115281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 11/16/2020] [Accepted: 11/22/2020] [Indexed: 11/28/2022]
Abstract
Point-of-care C-reactive protein (POC CRP) testing is a potential tuberculosis (TB) screening tool for people living with HIV (PLHIV). Unlike lab-based assays, POC assays do not routinely adjust CRP levels for hematocrit, potentially resulting in TB screening status misclassification. We compared the diagnostic accuracy of unadjusted and hematocrit-adjusted POC CRP for culture-confirmed TB among PLHIV with CD4 cell-count ≤350 cells/uL initiating antiretroviral therapy (ART) in Uganda. We prospectively enrolled consecutive adults, measured POC CRP (Boditech; normal <8 mg/L), collected two spot sputum specimens for comprehensive TB testing, and extracted pre-ART hematocrit from clinic records. Of the 605 PLHIV included, hematocrit-adjusted POC CRP had similar sensitivity (80% vs 81%, difference +1% [95% CI -3 to +5], P= 0.56) and specificity (71% vs 71%, difference 0% [95% CI -1 to +1], P= 0.56) for culture-confirmed TB, relative to unadjusted POC CRP. When used for TB screening, POC CRP may not require adjustment for hematocrit. However, larger studies may be required if differences close to the clinically meaningful threshold are to be detected.
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Affiliation(s)
- Sandra Z Mwebe
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Christina Yoon
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Lucy Asege
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Martha Nakaye
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jane Katende
- Makerere University Joint AIDS Program (MJAP), Kampala, Uganda
| | - Alfred Andama
- Infectious Diseases Research Collaboration, Kampala, Uganda; Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Fred C Semitala
- Infectious Diseases Research Collaboration, Kampala, Uganda; Makerere University Joint AIDS Program (MJAP), Kampala, Uganda; Department of Internal Medicine, Makerere University College of Health Sciences, Kampala, Uganda.
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Deep learning-based automated detection algorithm for active pulmonary tuberculosis on chest radiographs: diagnostic performance in systematic screening of asymptomatic individuals. Eur Radiol 2020; 31:1069-1080. [PMID: 32857202 DOI: 10.1007/s00330-020-07219-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/17/2020] [Accepted: 08/21/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Performance of deep learning-based automated detection (DLAD) algorithms in systematic screening for active pulmonary tuberculosis is unknown. We aimed to validate DLAD algorithm for detection of active pulmonary tuberculosis and any radiologically identifiable relevant abnormality on chest radiographs (CRs) in this setting. METHODS We performed out-of-sample testing of a pre-trained DLAD algorithm, using CRs from 19.686 asymptomatic individuals (ages, 21.3 ± 1.9 years) as part of systematic screening for tuberculosis between January 2013 and July 2018. Area under the receiver operating characteristic curves (AUC) for diagnosis of tuberculosis and any relevant abnormalities were measured. Accuracy measures including sensitivities, specificities, positive predictive values (PPVs), and negative predictive values (NPVs) were calculated at pre-defined operating thresholds (high sensitivity threshold, 0.16; high specificity threshold, 0.46). RESULTS All five CRs from four individuals with active pulmonary tuberculosis were correctly classified as having abnormal findings by DLAD with specificities of 0.959 and 0.997, PPVs of 0.006 and 0.068, and NPVs of both 1.000 at high sensitivity and high specificity thresholds, respectively. With high specificity thresholds, DLAD showed comparable diagnostic measures with the pooled radiologists (p values > 0.05). For the radiologically identifiable relevant abnormality (n = 28), DLAD showed an AUC value of 0.967 (95% confidence interval, 0.938-0.996) with sensitivities of 0.821 and 0.679, specificities of 0.960 and 0.997, PPVs of 0.028 and 0.257, and NPVs of both 0.999 at high sensitivity and high specificity thresholds, respectively. CONCLUSIONS In systematic screening for tuberculosis in a low-prevalence setting, DLAD algorithm demonstrated excellent diagnostic performance, comparable with the radiologists in the detection of active pulmonary tuberculosis. KEY POINTS • Deep learning-based automated detection algorithm detected all chest radiographs with active pulmonary tuberculosis with high specificities and negative predictive values in systematic screening. • Deep learning-based automated detection algorithm had comparable diagnostic measures with the radiologists for detection of active pulmonary tuberculosis on chest radiographs. • For the detection of radiologically identifiable relevant abnormalities on chest radiographs, deep learning-based automated detection algorithm showed excellent diagnostic performance in systematic screening.
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Nathavitharana RR, Yoon C, Macpherson P, Dowdy DW, Cattamanchi A, Somoskovi A, Broger T, Ottenhoff THM, Arinaminpathy N, Lonnroth K, Reither K, Cobelens F, Gilpin C, Denkinger CM, Schumacher SG. Guidance for Studies Evaluating the Accuracy of Tuberculosis Triage Tests. J Infect Dis 2019; 220:S116-S125. [PMID: 31593600 PMCID: PMC6782021 DOI: 10.1093/infdis/jiz243] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Approximately 3.6 million cases of active tuberculosis (TB) go potentially undiagnosed annually, partly due to limited access to confirmatory diagnostic tests, such as molecular assays or mycobacterial culture, in community and primary healthcare settings. This article provides guidance for TB triage test evaluations. A TB triage test is designed for use in people with TB symptoms and/or significant risk factors for TB. Triage tests are simple and low-cost tests aiming to improve ease of access and implementation (compared with confirmatory tests) and decrease the proportion of patients requiring more expensive confirmatory testing. Evaluation of triage tests should occur in settings of intended use, such as community and primary healthcare centers. Important considerations for triage test evaluation include study design, population, sample type, test throughput, use of thresholds, reference standard (ideally culture), and specimen flow. The impact of a triage test will depend heavily on issues beyond accuracy, primarily centered on implementation.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Department of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston,Correspondence: R. Nathavitharana, MBBS, MPH, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Lowry Building, Suite GB, 110 Francis Street, Boston MA 02215
| | - Christina Yoon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco
| | - Peter Macpherson
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, United Kingdom,Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Malawi
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco,Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, University of California San Francisco
| | - Akos Somoskovi
- Intellectual Ventures Laboratory, Global Good Fund, Bellevue, Washington
| | - Tobias Broger
- Foundation for Innovative Diagnostics (FIND), Geneva, Switzerland
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, The Netherlands
| | - Nimalan Arinaminpathy
- MRC Centre for Global Infectious Disease Analysis, Department of Infectious Disease Epidemiology, Faculty of Medicine, Imperial College London, Stockholm, Sweden
| | - Knut Lonnroth
- Department of Public Health Sciences, Karolinska Instituet, Stockholm, Sweden
| | - Klaus Reither
- University of Basel, Switzerland,Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Frank Cobelens
- Department of Global Health, Amsterdam UMC, University of Amsterdam, The Netherlands
| | | | - Claudia M Denkinger
- Foundation for Innovative Diagnostics (FIND), Geneva, Switzerland,University Hospital Heidelberg, Division of Tropical Medicine, Centre of Infectious Diseases, Germany
| | - Samuel G Schumacher
- University Hospital Heidelberg, Division of Tropical Medicine, Centre of Infectious Diseases, Germany
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