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Yates TA, Cebekhulu S, Mthethwa M, Fourie PB, Newell ML, Abubakar I, Tanser F. Tuberculin skin test surveys and the Annual Risk of Tuberculous Infection in school children in Northern KwaZulu-Natal. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003263. [PMID: 38889188 PMCID: PMC11185501 DOI: 10.1371/journal.pgph.0003263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 04/29/2024] [Indexed: 06/20/2024]
Abstract
Tuberculin skin test surveys in primary school children can be used to quantify Mycobacterium tuberculosis transmission at community level. KwaZulu-Natal province, South Africa, is home to 11.5 million people and suffers a burden of tuberculosis disease that is among the highest in the world. The last tuberculin survey in the province was undertaken in 1979. We performed a tuberculin skin test survey nested within a demographic and health household surveillance programme in Northern KwaZulu-Natal. We enrolled children aged between six and eight years of age attending primary schools in this community. Mixture analysis was used to determine tuberculin skin test thresholds and the Annual Risk of Tuberculous Infection derived from age at testing and infection prevalence. The Community Infection Ratio, a measure of the relative importance of within-household and community transmission, was calculated from data on tuberculin positivity disaggregated by household tuberculosis contact. Between June and December 2013, we obtained tuberculin skin test results on 1240 children. Mixture analysis proved unstable, suggesting two potential thresholds for test positivity. Using a threshold of ≥10mm or treating all non zero reactions as positive yielded estimates of the Annual Risk of Tuberculous Infection of 1.7% (1.4-2.1%) or 2.4% (2.0-3.0%). Using the same thresholds and including children reported to be receiving TB treatment as cases, resulted in estimates of 2.0% (1.6-2.5%) or 2.7% (2.2-3.3%). The Community Infection Ratio was 0.58 (0.33-1.01). The force of infection in this community is lower than that observed in Western Cape province, South Africa, but higher than that observed in community settings in most other parts of the world. Children in this community are commonly infected with Mycobacterium tuberculosis outside the home. Interventions to interrupt transmission are urgently needed.
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Affiliation(s)
- Tom A. Yates
- Africa Health Research Institute (AHRI), Congella, South Africa
- Institute of Health Informatics, University College London, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
| | | | - Mumsy Mthethwa
- Africa Health Research Institute (AHRI), Congella, South Africa
| | - P. Bernard Fourie
- Department of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Marie-Louise Newell
- School of Human Development and Health University of Southampton, Southampton, United Kingdom
| | - Ibrahim Abubakar
- Faculty of Population Health Sciences, University College London, London, United Kingdom
- MRC Clinical Trials Unit, University College London, London, United Kingdom
| | - Frank Tanser
- Africa Health Research Institute (AHRI), Congella, South Africa
- Centre for Epidemic Response and Innovation (CERI), Stellenbosch University, Stellenbosch, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of Kwa-Zulu Natal, Congella, South Africa
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2
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Telisinghe L, Floyd S, MacLeod D, Schaap A, Dunbar R, Bwalya J, Bell-Mandla N, Piwowar-Manning E, Donnell D, Shaunaube K, Bock P, Fidler S, Hayes RJ, Ayles HM. Incidence of self-reported tuberculosis treatment with community-wide universal testing and treatment for HIV and tuberculosis screening in Zambia and South Africa: A planned analysis of the HPTN 071 (PopART) cluster-randomised trial. PLoS Med 2024; 21:e1004393. [PMID: 38820246 PMCID: PMC11142425 DOI: 10.1371/journal.pmed.1004393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 03/28/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND HIV is a potent risk factor for tuberculosis (TB). Therefore, community-wide universal testing and treatment for HIV (UTT) could contribute to TB control, but evidence for this is limited. Community-wide TB screening can decrease population-level TB prevalence. Combining UTT with TB screening could therefore significantly impact TB control in sub-Saharan Africa, but to our knowledge there is no evidence for this combined approach. METHODS AND FINDINGS HPTN 071 (PopART) was a community-randomised trial conducted between November 2013 to July 2018; 21 Zambian and South African communities (with a total population of approximately 1 million individuals) were randomised to arms A (community-wide UTT and TB screening), B (community-wide universal HIV testing with treatment following national guidelines and TB screening), or C (standard-of-care). In a cohort of randomly selected adults (18 to 44 years) enrolled between 2013 and 2015 from all 21 communities (total size 38,474; 27,139 [71%] female; 8,004 [21%] HIV positive) and followed-up annually for 36 months to measure the population-level impact of the interventions, data on self-reported TB treatment in the previous 12 months (self-reported TB) were collected by trained research assistants and recorded using a structured questionnaire at each study visit. In this prespecified analysis of the trial, self-reported TB incidence rates were measured by calendar year between 2014 and 2017/2018. A p-value ≤0.05 on hypothesis testing was defined as reaching statistical significance. Between January 2014 and July 2018, 38,287 individuals were followed-up: 494 self-reported TB during 104,877 person-years. Overall incidence rates were similar across all arms in 2014 and 2015 (0.33 to 0.46/100 person-years). In 2016 incidence rates were lower in arm A compared to C overall (adjusted rate ratio [aRR] 0.48 [95% confidence interval (95% CI) 0.28 to 0.81; p = 0.01]), with statistical significance reached. In 2017/2018, while incidence rates were lower in arm A compared to C, statistical significance was not reached (aRR 0.58 [95% CI 0.27 to 1.22; p = 0.13]). Among people living with HIV (PLHIV) incidence rates were lower in arm A compared to C in 2016 (RR 0.56 [95% CI 0.29 to 1.08; p = 0.08]) and 2017/2018 (RR 0.50 [95% CI 0.26 to 0.95; p = 0.04]); statistical significance was only reached in 2017/2018. Incidence rates in arms B and C were similar, overall and among PLHIV. Among HIV-negative individuals, there were too few events for cross-arm comparisons. Study limitations include the use of self-report which may have been subject to under-reporting, limited covariate adjustment due to the small number of events, and high losses to follow-up over time. CONCLUSIONS In this study, community-wide UTT and TB screening resulted in substantially lower TB incidence among PLHIV at population-level, compared to standard-of-care, with statistical significance reached in the final study year. There was also some evidence this translated to a decrease in self-reported TB incidence overall in the population. Reduction in arm A but not B suggests UTT drove the observed effect. Our data support the role of UTT in TB control, in addition to HIV control, in high TB/HIV burden settings. TRIAL REGISTRATION ClinicalTrials.gov: NCT01900977.
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Affiliation(s)
- L. Telisinghe
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, Lusaka, Zambia
| | - S. Floyd
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - D. MacLeod
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - A. Schaap
- Zambart, Lusaka, Zambia
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - R. Dunbar
- The Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - N. Bell-Mandla
- The Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - E. Piwowar-Manning
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - D. Donnell
- The Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | | | - P. Bock
- The Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - S. Fidler
- Imperial College, London, United Kingdom
- National Institute for Health Research, Imperial Biomedical Research Centre, London, United Kingdom
| | - R. J. Hayes
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - H. M. Ayles
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, Lusaka, Zambia
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3
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Effect of HIV status and antiretroviral treatment on treatment outcomes of tuberculosis patients in a rural primary healthcare clinic in South Africa. PLoS One 2022; 17:e0274549. [PMID: 36223365 PMCID: PMC9555649 DOI: 10.1371/journal.pone.0274549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 08/30/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) remains the leading cause of death among human immunodeficiency virus (HIV) infected individuals in South Africa. Despite the implementation of HIV/TB integration services at primary healthcare facility level, the effect of HIV on TB treatment outcomes has not been well investigated. To provide evidence base for TB treatment outcome improvement to meet End TB Strategy goal, we assessed the effect of HIV status on treatment outcomes of TB patients at a rural clinic in the Ugu Health District, South Africa. METHODS We reviewed medical records involving a cohort of 508 TB patients registered for treatment between 1 January 2013 and 31 December 2015 at rural public sector clinic in KwaZulu-Natal province, South Africa. Data were extracted from National TB Programme clinic cards and the TB case registers routinely maintained at study sites. The effect of HIV status on TB treatment outcomes was determined by using multinomial logistic regression. Estimates used were relative risk ratio (RRR) at 95% confidence intervals (95%CI). RESULTS A total of 506 patients were included in the analysis. Majority of the patients (88%) were new TB cases, 70% had pulmonary TB and 59% were co-infected with HIV. Most of HIV positive patients were on antiretroviral therapy (ART) (90% (n = 268)). About 82% had successful treatment outcome (cured 39.1% (n = 198) and completed treatment (42.9% (n = 217)), 7% (n = 39) died 0.6% (n = 3) failed treatment, 3.9% (n = 20) defaulted treatment and the rest (6.6% (n = 33)) were transferred out of the facility. Furthermore, HIV positive patients had a higher mortality rate (9.67%) than HIV negative patients (2.91%)". Using completed treatment as reference, HIV positive patients not on ART relative to negative patients were more likely to have unsuccessful outcomes [RRR, 5.41; 95%CI, 2.11-13.86]. CONCLUSIONS When compared between HIV status, HIV positive TB patients were more likely to have unsuccessful treatment outcome in rural primary care. Antiretroviral treatment seems to have had no effect on the likelihood of TB treatment success in rural primary care. The TB mortality rate in HIV positive patients, on the other hand, was higher than in HIV negative patients emphasizing the need for enhanced integrated management of HIV/TB in rural South Africa through active screening of TB among HIV positive individuals and early access to ART among HIV positive TB cases.
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4
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Govender I, Karat AS, Olivier S, Baisley K, Beckwith P, Dayi N, Dreyer J, Gareta D, Gunda R, Kielmann K, Koole O, Mhlongo N, Modise T, Moodley S, Mpofana X, Ndung'u T, Pillay D, Siedner MJ, Smit T, Surujdeen A, Wong EB, Grant AD. Prevalence of Mycobacterium tuberculosis in sputum and reported symptoms among clinic attendees compared to a community survey in rural South Africa. Clin Infect Dis 2021; 75:314-322. [PMID: 34864910 PMCID: PMC9410725 DOI: 10.1093/cid/ciab970] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) case finding efforts typically target symptomatic people attending health facilities. We compared the prevalence of Mycobacterium tuberculosis (Mtb) sputum culture-positivity among adult clinic attendees in rural South Africa with a concurrent, community-based estimate from the surrounding demographic surveillance area (DSA). METHODS Clinic: Randomly-selected adults (≥18 years) attending two primary healthcare clinics were interviewed and requested to give sputum for mycobacterial culture. HIV and antiretroviral therapy (ART) status were based on self-report and record review. Community: All adult (≥15 years) DSA residents were invited to a mobile clinic for health screening, including serological HIV testing; those with ≥1 TB symptom (cough, weight loss, night sweats, fever) or abnormal chest radiograph were asked for sputum. RESULTS Clinic: 2,055 patients were enrolled (76.9% female, median age 36 years); 1,479 (72.0%) were classified HIV-positive (98.9% on ART) and 131 (6.4%) reported ≥1 TB symptom. Of 20/2,055 (1.0% [95% CI 0.6-1.5]) with Mtb culture-positive sputum, 14 (70%) reported no symptoms. Community: 10,320 residents were enrolled (68.3% female, median age 38 years); 3,105 (30.3%) tested HIV-positive (87.4% on ART) and 1,091 (10.6%) reported ≥1 TB symptom. Of 58/10,320 (0.6% [95% CI 0.4-0.7]) with Mtb culture-positive sputum, 45 (77.6%) reported no symptoms.In both surveys, sputum culture positivity was associated with male sex and reporting >1 TB symptom. CONCLUSIONS In both clinic and community settings, most participants with Mtb culture-positive sputum were asymptomatic. TB screening based only on symptoms will miss many people with active disease in both settings.
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Affiliation(s)
- Indira Govender
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Stephen Olivier
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Kathy Baisley
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Peter Beckwith
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Njabulo Dayi
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Jaco Dreyer
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Dickman Gareta
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Resign Gunda
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa.,School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Karina Kielmann
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, United Kingdom
| | - Olivier Koole
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Ngcebo Mhlongo
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Tshwaraganang Modise
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Sashen Moodley
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Xolile Mpofana
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Thumbi Ndung'u
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa.,School of Public Health, Harvard Medical School, Boston, United States of America
| | - Deenan Pillay
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa.,Division of Infection & Immunity, University College London, London, United Kingdom
| | - Mark J Siedner
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, United States of America
| | - Theresa Smit
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Ashmika Surujdeen
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa
| | - Emily B Wong
- Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa.,Division of Infection & Immunity, University College London, London, United Kingdom.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, United States of America.,Division of Infectious Diseases, University of Alabama Birmingham, Birmingham, United States of America.,Division of Infection and Immunity, University College London, London, United Kingdom
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom.,Clinical Research Department, Africa Health Research Institute, Somkhele, South Africa.,School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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5
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Gareta D, Baisley K, Mngomezulu T, Smit T, Khoza T, Nxumalo S, Dreyer J, Dube S, Majozi N, Ording-Jesperson G, Ehlers E, Harling G, Shahmanesh M, Siedner M, Hanekom W, Herbst K. Cohort Profile Update: Africa Centre Demographic Information System (ACDIS) and population-based HIV survey. Int J Epidemiol 2021; 50:33-34. [PMID: 33437994 PMCID: PMC7938501 DOI: 10.1093/ije/dyaa264] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
- Dickman Gareta
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, UK
| | | | - Theresa Smit
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Thandeka Khoza
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | - Jaco Dreyer
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Sweetness Dube
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | | | | | - Eugene Ehlers
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Guy Harling
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK.,MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology & Harvard Centre for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Institute for Global Health, University College London, London, UK
| | - Mark Siedner
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,Harvard Medical School, Boston, MA, USA.,Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Willem Hanekom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, South Africa.,SAPRIN, South African Medical Research Council, Cape Town, South Africa
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Mzembe T, Lessells R, Karat AS, Randera-Rees S, Edwards A, Khan P, Tomita A, Tanser F, Baisley K, Grant AD. Prevalence and Risk Factors for Mycobacterium tuberculosis Infection Among Adolescents in Rural South Africa. Open Forum Infect Dis 2021; 8:ofaa520. [PMID: 33511219 PMCID: PMC7814392 DOI: 10.1093/ofid/ofaa520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/21/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We aimed to estimate the prevalence of and explore risk factors for Mycobacterium tuberculosis infection among adolescents in a high tuberculosis (TB) and human immunodeficiency virus (HIV) prevalence setting. METHODS A cross-sectional study of adolescents (10-19 years) randomly selected from a demographic surveillance area (DSA) in rural KwaZulu-Natal, South Africa. We determined M tuberculosis infection status using the QuantiFERON-TB Gold-plus assay. We used HIV data from the DSA to estimate community-level adult HIV prevalence and random-effects logistic regression to identify risk factors for TB infection. RESULTS We enrolled 1094 adolescents (548 [50.1%] female); M tuberculosis infection prevalence (weighted for nonresponse by age, sex, and urban/rural residence) was 23.0% (95% confidence interval [CI], 20.6-25.6%). Mycobacterium tuberculosis infection was associated with older age (adjusted odds ratio [aOR], 1.37; 95% CI, 1.10-1.71, for increasing age-group [12-14, 15-17, and 18-19 vs 10-11 years]), ever (vs never) having a household TB contact (aOR, 2.13; 95% CI, 1.25-3.64), and increasing community-level HIV prevalence (aOR, 1.43 and 95% CI, 1.07-1.92, for increasing HIV prevalence category [25%-34.9%, 35%-44.9%, ≥45% vs <25%]). CONCLUSIONS Our data support prioritizing TB prevention and care activities in TB-affected households and high HIV prevalence communities.
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Affiliation(s)
- Themba Mzembe
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Richard Lessells
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- KwaZulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), UKZN, Durban, South Africa
| | - Aaron S Karat
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Anita Edwards
- Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Palwasha Khan
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Interactive Research and Development, Karachi, Pakistan
| | - Andrew Tomita
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- KwaZulu-Natal Research Innovation and Sequencing Platform, University of KwaZulu-Natal, Durban, South Africa
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Frank Tanser
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), UKZN, Durban, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Lincoln Institute for Health, University of Lincoln, Lincoln, United Kingdom
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Kathy Baisley
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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7
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Tomita A, Cuadros DF, Burns JK, Tanser F, Slotow R. Exposure to waste sites and their impact on health: a panel and geospatial analysis of nationally representative data from South Africa, 2008-2015. Lancet Planet Health 2020; 4:e223-e234. [PMID: 32559439 PMCID: PMC7302423 DOI: 10.1016/s2542-5196(20)30101-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Rapid population growth, urbanisation, and economic development have led to an unprecedented number of waste sites in developing countries. This challenge has become a contentious international relations issue, with an unsustainable amount of waste and its health consequences often being borne by developing countries. However, little national-level evidence is available in sub-Saharan Africa to quantify the association between exposure to waste sites and health. METHODS We used panel data from the South African National Income Dynamics Study (SA-NIDS) to investigate the association between exposure to waste sites and asthma, tuberculosis, diabetes, and depression. The SA-NIDS is a panel survey of a nationally representative sample in South Africa, which includes data reporting the health status of 32 255 individuals between 2008 and 2015. The study exposure was distance of households, in km, to the nearest waste site, derived from waste site geospatial locations from the South Africa Waste Information System. FINDINGS We observed a substantial increase in exposure of households to waste sites between 2008 and 2015. The median distance between study households and waste sites decreased from 68·3 km (IQR 31·1-111·7) to 8·5 km (3·0-23·7). Residing within 5 km of a waste site was significantly associated with asthma (adjusted relative risk 1·41; 95% CI 1·20-1·64), tuberculosis (1·18; 1·02-1·36), diabetes (1·25; 1·05-1·49), and depression (1·08; 1·03-1·14). The association persisted even after controlling for multiple socioeconomic factors. INTERPRETATION We identified multiple adverse health outcomes in individuals living close to waste sites at a national level in South Africa, suggesting the need to reduce the number and size of waste sites to diminish harmful effects on health and wellbeing for communities living in close proximity to such sites. FUNDING South African Medical Research Council, South African National Treasury, and Wellcome Trust.
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Affiliation(s)
- Andrew Tomita
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; KwaZulu-Natal Research Innovation and Sequencing Platform, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Diego F Cuadros
- Department of Geography and Geographic Information Science, and Health Geography and Disease Modeling Laboratory, University of Cincinnati, Cincinnati, OH, USA
| | - Jonathan K Burns
- Department of Psychiatry, University of KwaZulu-Natal, Durban, South Africa; Institute of Health Research, University of Exeter, Exeter, UK
| | - Frank Tanser
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa; Lincoln International Institute for Rural Health, University of Lincoln, Lincoln, UK; Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Rob Slotow
- Centre for Functional Biodiversity, School of Life Sciences, University of KwaZulu-Natal, Durban, South Africa; Department of Genetics, Evolution & Environment, University College London, London, UK
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8
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Tanser F, Kim HY, Vandormael A, Iwuji C, Bärnighausen T. Opportunities and Challenges in HIV Treatment as Prevention Research: Results from the ANRS 12249 Cluster-Randomized Trial and Associated Population Cohort. Curr HIV/AIDS Rep 2020; 17:97-108. [PMID: 32072468 PMCID: PMC7072051 DOI: 10.1007/s11904-020-00487-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The ANRS 12249 treatment as prevention (TasP) trial investigated the impact of a universal test and treat (UTT) approach on reducing HIV incidence in one of the regions of the world most severely affected by the HIV epidemic-KwaZulu-Natal, South Africa. We summarize key findings from this trial as well as recent findings from controlled studies conducted in the linked population cohort quantifying the long-term effects of expanding ART on directly measured HIV incidence (2004-2017). RECENT FINDINGS The ANRS TasP trial did not-and could not-demonstrate a reduction in HIV incidence, because the offer of UTT in the intervention communities did not increase ART coverage and population viral suppression compared to the standard of care in the control communities. Ten controlled studies from the linked population cohort-including several quasi-experimental study designs-exploit heterogeneity in ART exposure to show a consistent and substantial impact of expanding provision of ART and population viral suppression on reduction in HIV incidence at the couple, household, community, and population levels. In this setting, all of the evidence from large, population-based studies (inclusive of the ANRS TasP trial) is remarkably coherent and consistent-i.e., higher ART coverage and population viral suppression were repeatedly associated with clear, measurable decreases in HIV incidence. Thus, the expanded provision of ART has plausibly contributed in a major way toward the dramatic 43% decline in population-level HIV incidence in this typical rural African population. The outcome of the ANRS TasP trial constitutes a powerful null finding with important insights for overcoming implementation challenges in the population delivery of ART. This finding does not imply lack of ART effectiveness in blocking onward transmission of HIV nor its inability to reduce HIV incidence. Rather, it demonstrates that large increases in ART coverage over current levels will require health systems innovations to attract people living with HIV in early stages of the disease to participate in HIV treatment. Such innovations and new approaches are required for the true potential of UTT to be realized.
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Affiliation(s)
- Frank Tanser
- Lincoln Institute for Health, University of Lincoln, Lincoln, LN6 7TS, UK.
- Africa Health Research Institute, KwaZulu-Natal, South Africa.
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban, South Africa.
| | - Hae-Young Kim
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Department of Population Health, New York University School of Medicine, New York, USA
- KwaZulu-Natal Innovation and Sequencing Platform, Durban, KwaZulu-Natal, South Africa
| | - Alain Vandormael
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- KwaZulu-Natal Innovation and Sequencing Platform, Durban, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Collins Iwuji
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Till Bärnighausen
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, University of Heidelberg, Heidelberg, Germany
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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McLean MR, Lu LL, Kent SJ, Chung AW. An Inflammatory Story: Antibodies in Tuberculosis Comorbidities. Front Immunol 2019; 10:2846. [PMID: 31921122 PMCID: PMC6913197 DOI: 10.3389/fimmu.2019.02846] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/19/2019] [Indexed: 12/20/2022] Open
Abstract
Mycobacterium tuberculosis (Mtb) resides in a quarter of the world's population and is the causative agent for tuberculosis (TB), the most common infectious reason of death in humans today. Although cellular immunity has been firmly established in the control of Mtb, there is growing evidence that antibodies may also modulate the infection. More specifically, certain antibody features are associated with inflammation and are divergent in different states of human infection and disease. Importantly, TB impacts not just the healthy but also those with chronic conditions. While HIV represents the quintessential comorbid condition for TB, recent epidemiological evidence shows that additional chronic conditions such as diabetes and kidney disease are rising. In fact, the prevalence of diabetes as a comorbid TB condition is now higher than that of HIV. These chronic diseases are themselves independently associated with pro-inflammatory immune states that encompass antibody profiles. This review discusses isotypes, subclasses, post-translational modifications and Fc-mediated functions of antibodies in TB infection and in the comorbid chronic conditions of HIV, diabetes, and kidney diseases. We propose that inflammatory antibody profiles, which are a marker of active TB, may be an important biomarker for detection of TB disease progression within comorbid individuals. We highlight the need for future studies to determine which inflammatory antibody profiles are the consequences of comorbidities and which may potentially contribute to TB reactivation.
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Affiliation(s)
- Milla R McLean
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Lenette L Lu
- Division of Infectious Disease and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Stephen J Kent
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.,Infectious Diseases Department, Melbourne Sexual Health Centre, Alfred Health, Central Clinical School, Monash University, Brisbane, VIC, Australia.,ARC Centre of Excellence in Convergent Bio-Nano Science and Technology, University of Melbourne, Melbourne, SA, Australia
| | - Amy W Chung
- Department of Microbiology and Immunology, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
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