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Jorgensen SCJ, Miljanic S, Tabbara N, Somanader D, Leung F, De Castro C, Tse CLY, Law J, Fernandes V, Lapinsky SE, Malhamé I, Burry L. Inclusion of pregnant and breastfeeding women in nonobstetrical randomized controlled trials. Am J Obstet Gynecol MFM 2022; 4:100700. [PMID: 35914736 DOI: 10.1016/j.ajogmf.2022.100700] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is an urgent need to prioritize and expedite the inclusion of pregnant and breastfeeding women in research. Characterizing trials that have successfully included these populations could inform the design and execution of future studies. In addition, up-to-date data on their inclusion in clinical research could assist in setting benchmarks, establishing targets, and monitoring progress toward more equitable inclusion. OBJECTIVE This study aimed to characterize the eligibility and enrollment of pregnant and breastfeeding women in randomized controlled trials evaluating interventions for nonobstetrical conditions experienced by, but not limited to, these populations. STUDY DESIGN We developed a literature search in collaboration with an information specialist. We included randomized controlled trials published between 2017 and 2019 in the 5 highest-impact general medicine journals and the 3 highest-impact specialty journals in cardiovascular disease, critical care, general infectious diseases, HIV, and psychiatry. We included randomized controlled trials that evaluated screening, diagnosis, prevention, or treatment of nonobstetrical medical conditions. We excluded randomized controlled trials exclusively focused on males, pediatrics, geriatrics, oncology, or postmenopausal women, and publications reporting subgroup, pooled, or follow-up analyses of previously published randomized controlled trials. We screened titles and abstracts independently and in duplicate, with discrepancies resolved by a third reviewer. We entered data into a standardized electronic case report form. We reviewed study protocols, appendices, and trial registries for additional data. RESULTS Of the 1333 randomized controlled trials, pregnant and breastfeeding women were eligible for 13 (1.0%) and 6 (0.5%), respectively. Pregnancy and breastfeeding eligibility criteria were not addressed in 383 of 1333 (28.7%) and 710 of 1333 (53.3%) randomized controlled trials, respectively. In total, 102 of 937 (10.9%) and 33 of 617 (5.3%) randomized controlled trials that explicitly excluded pregnant and breastfeeding women documented the rationale. Most studies excluding pregnant women (542/937; 57.8%) required at least 1 method of contraception and/or pregnancy testing as part of trial participation for women with reproductive capacity. Among the 13 randomized controlled trials that allowed inclusion of pregnant women, 3 restricted eligibility to specific trimesters. Two randomized controlled trials enrolled pregnant women after the first year of the study following interim review of safety results in nonpregnant participants. Four randomized controlled trials reported the number of pregnant women enrolled, which ranged from 0.7% to 3.4% of the study population. None of the studies reported on pregnancy or perinatal outcomes. Compared with randomized controlled trials that excluded pregnant women, those including them more commonly had an infectious disease focus (12/13 [92.3%] vs 270/937 [28.8%]; p<.0001), including HIV (5/13 [38.5%] vs 96/937 [10.2%]; p=.0079), enrolled participants in sub-Saharan Africa (5/13 [38.5%] vs 111/937 [11.8%]; p=.0143), and had exclusively nonindustry sponsorship (13/13 [100%] vs 559/937 [59.7%]; p=.0025); inclusion varied by study phase, randomization level, and intervention type. CONCLUSION This study illustrates a major inequity in research involving pregnant and breastfeeding women. As new health challenges arise, including novel pandemics, and the research community mobilizes to develop therapies and innovate in patient care, it is crucial that pregnant and breastfeeding women not be left behind. Greater regulatory support, in the form of explicit requirements and incentives, will be needed to ensure these populations are integrated into the research agenda.
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Affiliation(s)
- Sarah C J Jorgensen
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Jorgensen and Burry).
| | - Simona Miljanic
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada (Drs Miljanic, Tabbara, Law, Fernandes, and Burry)
| | - Najla Tabbara
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada (Drs Miljanic, Tabbara, Law, Fernandes, and Burry)
| | - Deborah Somanader
- Antimicrobial Stewardship Program, Sinai Health System-University Health Network, Toronto, Ontario, Canada (Ms Somanader)
| | - Felicia Leung
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (Ms Leung and Drs Tse and Burry)
| | - Charmaine De Castro
- Library Services, Mount Sinai Hospital, Toronto, Ontario, Canada (Ms De Castro)
| | - Christopher L Y Tse
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (Ms Leung and Drs Tse and Burry)
| | - Janice Law
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada (Drs Miljanic, Tabbara, Law, Fernandes, and Burry)
| | - Virginia Fernandes
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada (Drs Miljanic, Tabbara, Law, Fernandes, and Burry)
| | - Stephen E Lapinsky
- Division of Respirology, Mount Sinai Hospital, Toronto, Ontario, Canada (Mr Lapinsky); Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada (Mr Lapinsky and Dr Burry)
| | - Isabelle Malhamé
- Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montreal, Canada (Dr Malhamé); Center for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Canada (Dr Malhamé)
| | - Lisa Burry
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Jorgensen and Burry); Department of Pharmacy, Mount Sinai Hospital, Toronto, Ontario, Canada (Drs Miljanic, Tabbara, Law, Fernandes, and Burry); Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (Ms Leung and Drs Tse and Burry); Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada (Mr Lapinsky and Dr Burry)
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Nyirenda-Nyang’wa M, Manthalu G, Arnold M, Nkhoma D, Hosseinipour MC, Chagomerana M, Chibwe P, Mortimer K, Kennedy N, Fairley D, Mwapasa V, Msefula C, Mwandumba HC, Chinkhumba J, Klein N, Alber D, Obasi A. Costing and cost-effectiveness of Cepheid Xpert HIV -1 Qual Assay using whole blood protocol versus PCR by Abbott Systems in Malawi. JOURNAL OF GLOBAL HEALTH ECONOMICS AND POLICY 2022; 2:e2022013. [PMID: 37711180 PMCID: PMC10501532 DOI: 10.52872/001c.37787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Background Timely diagnosis of HIV in infants and children is an urgent priority. In Malawi, 40,000 infants annually are HIV exposed. However, gold standard polymerase-chain-reaction (PCR) based testing requires centralised laboratories, causing turn-around times (TAT) of 2 to 3 months and significant loss to follow-up. If feasible and acceptable, minimising diagnostic delays through HIV Point-of-care-testing (POCT) may be cost-effective. We assessed whether POCT Cepheid Xpert HIV-1 Qual assay whole blood (XpertHIV) was more cost-effective than PCR. Methods From July-August 2018, 700 PCR Abbott tests using dried blood spots (DBS) were performed on 680 participants who enrolled on the feasibility, acceptability and performance of the XpertHIV study. Newly identified HIV-positive We conducted a cost-minimisation and cost-effectiveness analysis of XpertHIV against PCR, as the standard of care. A random sample of 200 caregivers from the 680 participants had semi-structured interviews to explore costs from a societal perspective of XpertHIV at Mulanje District Hospital, Malawi. Analysis used TAT as the primary outcome measure. Results were extrapolated from the study period (29 days) to a year (240 working days). Sensitivity analyses characterised individual and joint parameter uncertainty and estimated patient cost per test. Results During the study period, XpertHIV was cost-minimising at $42.34 per test compared to $66.66 for PCR. Over a year, XpertHIV remained cost-minimising at $16.12 compared to PCR at $27.06. From the patient perspective (travel, food, lost productivity), the cost per test of XpertHIV was $2.45. XpertHIV had a mean TAT of 7.10 hours compared to 153.15 hours for PCR. Extrapolates accounting for equipment costs, lab consumables and losses to follow up estimated annual savings of $2,193,538.88 if XpertHIV is used nationally, as opposed to PCR. Conclusions This preliminary evidence suggests that adopting POCT XpertHIV will save time, allowing HIV-exposed infants to receive prompt care and may improve outcomes. The Malawi government will pay less due to XpertHIV's cost savings and associated benefits.
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Affiliation(s)
- Maggie Nyirenda-Nyang’wa
- University College London, London, UK
- College of Medicine, University of Malawi, Malawi
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Gerald Manthalu
- Department of Planning and Policy, Ministry of Health, Malawi
| | - Matthias Arnold
- Institute for Applied Health Services Research , Berlin, Germany
- Health Economics Policy Unit (HEPU), College of Medicine, Malawi
| | - Dominic Nkhoma
- Health Economics Policy Unit (HEPU), College of Medicine, Malawi
| | - Mina C. Hosseinipour
- University of North Carolina Project–Malawi, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maganizo Chagomerana
- University of North Carolina Project–Malawi, Lilongwe, Malawi
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Precious Chibwe
- Health Economics Policy Unit (HEPU), College of Medicine, Malawi
| | | | | | | | | | | | - Henry C. Mwandumba
- Liverpool School of Tropical Medicine, Liverpool, UK
- Malawi–Liverpool–Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Jobiba Chinkhumba
- College of Medicine, University of Malawi, Malawi
- Malaria Alert Centre, University of Malawi College of Medicine, Blantyre, Malawi
| | | | | | - Angela Obasi
- Liverpool School of Tropical Medicine, Liverpool, UK
- The Royal Liverpool University Hospital NHS Foundation Trust
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Cattamanchi A, Reza TF, Nalugwa T, Adams K, Nantale M, Oyuku D, Nabwire S, Babirye D, Turyahabwe S, Tucker A, Sohn H, Ferguson O, Thompson R, Shete PB, Handley MA, Ackerman S, Joloba M, Moore DAJ, Davis JL, Dowdy DW, Fielding K, Katamba A. Multicomponent Strategy with Decentralized Molecular Testing for Tuberculosis. N Engl J Med 2021; 385:2441-2450. [PMID: 34936740 PMCID: PMC9212879 DOI: 10.1056/nejmoa2105470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Effective strategies are needed to facilitate the prompt diagnosis and treatment of tuberculosis in countries with a high burden of the disease. METHODS We conducted a cluster-randomized trial in which Ugandan community health centers were assigned to a multicomponent diagnostic strategy (on-site molecular testing for tuberculosis, guided restructuring of clinic workflows, and monthly feedback of quality metrics) or routine care (on-site sputum-smear microscopy and referral-based molecular testing). The primary outcome was the number of adults treated for confirmed tuberculosis within 14 days after presenting to the health center for evaluation during the 16-month intervention period. Secondary outcomes included completion of tuberculosis testing, same-day diagnosis, and same-day treatment. Outcomes were also assessed on the basis of proportions. RESULTS A total of 20 health centers underwent randomization, with 10 assigned to each group. Of 10,644 eligible adults (median age, 40 years) whose data were evaluated, 60.1% were women and 43.8% had human immunodeficiency virus infection. The intervention strategy led to a greater number of patients being treated for confirmed tuberculosis within 14 days after presentation (342 patients across 10 intervention health centers vs. 220 across 10 control health centers; adjusted rate ratio, 1.56; 95% confidence interval [CI], 1.21 to 2.01). More patients at intervention centers than at control centers completed tuberculosis testing (adjusted rate ratio, 1.85; 95% CI, 1.21 to 2.82), received a same-day diagnosis (adjusted rate ratio, 1.89; 95% CI, 1.39 to 2.56), and received same-day treatment for confirmed tuberculosis (adjusted rate ratio, 2.38; 95% CI, 1.57 to 3.61). Among 706 patients with confirmed tuberculosis, a higher proportion in the intervention group than in the control group were treated on the same day (adjusted rate ratio, 2.29; 95% CI, 1.23 to 4.25) or within 14 days after presentation (adjusted rate ratio, 1.22; 95% CI, 1.06 to 1.40). CONCLUSIONS A multicomponent diagnostic strategy that included on-site molecular testing plus implementation supports to address barriers to delivery of high-quality tuberculosis evaluation services led to greater numbers of patients being tested, receiving a diagnosis, and being treated for confirmed tuberculosis. (Funded by the National Heart, Lung, and Blood Institute; XPEL-TB ClinicalTrials.gov number, NCT03044158.).
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Affiliation(s)
- Adithya Cattamanchi
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Tania F Reza
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Talemwa Nalugwa
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Katherine Adams
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Mariam Nantale
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Denis Oyuku
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Sarah Nabwire
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Diana Babirye
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Stavia Turyahabwe
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Austin Tucker
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Hojoon Sohn
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Olivia Ferguson
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Ryan Thompson
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Priya B Shete
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Margaret A Handley
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Sara Ackerman
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Moses Joloba
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - David A J Moore
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - J Lucian Davis
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - David W Dowdy
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Katherine Fielding
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
| | - Achilles Katamba
- From the Division of Pulmonary and Critical Care Medicine and the Center for Tuberculosis, San Francisco General Hospital (A.C., T.F.R., P.B.S.), the Partnerships for Research in Implementation Science for Equity Center (A.C., P.B.S., M.A.H.), and the Departments of Epidemiology and Biostatistics (M.A.H.) and Social and Behavioral Sciences (S.A.), University of California, San Francisco, San Francisco; the Uganda Tuberculosis Implementation Research Consortium (A.C., T.N., M.N., D.O., S.N., D.B., S.T., P.B.S., D.A.J.M., J.L.D., D.W.D., A.K.), National Tuberculosis and Leprosy Program, Uganda Ministry of Health (S.T.), and the Schools of Biomedical Sciences (M.J.) and Medicine (A.K.), Makerere University College of Health Sciences - all in Kampala, Uganda; the Implementation Science Program (K.A.) and the Department of Epidemiology (A.T., H.S., O.F., R.T., D.W.D.), Johns Hopkins Bloomberg School of Public Health, Baltimore; the Faculties of Infectious and Tropical Diseases (D.A.J.M.) and Epidemiology and Population Health (K.F.) and the TB Centre (D.A.J.M., K.F.), London School of Hygiene and Tropical Medicine, London; the Department of Epidemiology of Microbial Diseases and the Center for Methods in Implementation and Prevention Sciences, Yale School of Public Health, and the Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine - both in New Haven, CT (J.L.D.)
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Characterizing the inclusion of pregnant and breastfeeding people in infectious diseases randomized controlled trials: a targeted literature review. Clin Microbiol Infect 2021; 28:801-811. [PMID: 34768020 DOI: 10.1016/j.cmi.2021.10.024] [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: 07/19/2021] [Revised: 10/04/2021] [Accepted: 10/30/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Severe complications of infectious diseases can occur during pregnancy. Evidence-based prevention and treatment strategies are critical to improve maternal and neonatal health outcomes. Despite this medical need, pregnant and breastfeeding people have been systematically excluded from biomedical research. The objective of this study was to characterize representation of pregnant and breastfeeding people in randomized controlled trials (RCTs) evaluating a broad range of interventions for infectious diseases. METHODS Pregnancy and breastfeeding inclusion criteria were examined in infectious diseases RCTs published between 1 January 2017, and 31 December 2019, in the top five highest impact general medicine and the top three highest impact infectious diseases and HIV journals. RESULTS Of 376 RCTs, 5.3% and 1.9% included pregnant and breastfeeding people, respectively. Justification for exclusion was documented in 36/271 (13.3%) studies that explicitly excluded pregnant people. Most studies excluding pregnant people (177/271, 65.3%) required at least one form of contraception, abstinence and/or negative pregnancy test(s) as part of participation. Only 11/271 (4.1%) studies excluding pregnant people allowed participants to continue the intervention if unintended pregnancy occurred during the study. When both pregnant and non-pregnant people were eligible, pregnant people made up <3% of participants. Only 2/48 (4.2%) vaccine studies included pregnant people; 13/234 (5.5%) drug studies included pregnant people. All studies of procedures, devices, behaviour/education and supplements/vitamins explicitly excluded or did not address pregnancy eligibility criteria. Only 2/20 (10.0%) RCTs including pregnant people collected pharmacokinetic data. DISCUSSION This study demonstrates widespread exclusion of pregnant and breastfeeding people from infectious disease RCTs.
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Nathavitharana RR, Lederer P, Chaplin M, Bjerrum S, Steingart KR, Shah M. Impact of diagnostic strategies for tuberculosis using lateral flow urine lipoarabinomannan assay in people living with HIV. Cochrane Database Syst Rev 2021; 8:CD014641. [PMID: 34416013 PMCID: PMC8407503 DOI: 10.1002/14651858.cd014641] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Tuberculosis is the primary cause of hospital admission in people living with HIV, and the likelihood of death in the hospital is unacceptably high. The Alere Determine TB LAM Ag test (AlereLAM) is a point-of-care test and the only lateral flow lipoarabinomannan assay (LF-LAM) assay currently commercially available and recommended by the World Health Organization (WHO). A 2019 Cochrane Review summarised the diagnostic accuracy of LF-LAM for tuberculosis in people living with HIV. This systematic review assesses the impact of the use of LF-LAM (AlereLAM) on mortality and other patient-important outcomes. OBJECTIVES To assess the impact of the use of LF-LAM (AlereLAM) on mortality in adults living with HIV in inpatient and outpatient settings. To assess the impact of the use of LF-LAM (AlereLAM) on other patient-important outcomes in adults living with HIV, including time to diagnosis of tuberculosis, and time to initiation of tuberculosis treatment. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (Ovid); Science Citation Index Expanded (Web of Science), BIOSIS Previews, Scopus, LILACS; ProQuest Dissertations and Theses; ClinicalTrials.gov; and the WHO ICTRP up to 12 March 2021. SELECTION CRITERIA Randomized controlled trials that compared a diagnostic intervention including LF-LAM with diagnostic strategies that used smear microscopy, mycobacterial culture, a nucleic acid amplification test such as Xpert MTB/RIF, or a combination of these tests. We included adults (≥ 15 years) living with HIV. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility, extracted data, and analysed risk of bias using the Cochrane tool for assessing risk of bias in randomized studies. We contacted study authors for clarification as needed. We used risk ratio (RR) with 95% confidence intervals (CI). We used a fixed-effect model except in the presence of clinical or statistical heterogeneity, in which case we used a random-effects model. We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included three trials, two in inpatient settings and one in outpatient settings. All trials were conducted in sub-Saharan Africa and assessed the impact of diagnostic strategies that included LF-LAM on mortality when the test was used in conjunction with other tuberculosis diagnostic tests or clinical assessment for clinical decision-making in adults living with HIV. Inpatient settings In inpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy likely reduces mortality in people living with HIV at eight weeks compared to routine tuberculosis diagnostic testing without LF-LAM (pooled RR 0.85, 95% CI 0.76 to 0.94; 5102 participants, 2 trials; moderate-certainty evidence). That is, people living with HIV who received LF-LAM had 15% lower risk of mortality. The absolute effect was 34 fewer deaths per 1000 (from 14 fewer to 55 fewer). In inpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy probably results in a slight increase in the proportion of people living with HIV who were started on tuberculosis treatment compared to routine tuberculosis diagnostic testing without LF-LAM (pooled RR 1.26, 95% CI 0.94 to 1.69; 5102 participants, 2 trials; moderate-certainty evidence). Outpatient settings In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may reduce mortality in people living with HIV at six months compared to routine tuberculosis diagnostic testing without LF-LAM (RR 0.89, 95% CI 0.71 to 1.11; 2972 participants, 1 trial; low-certainty evidence). Although this trial did not detect a difference in mortality, the direction of effect was towards a mortality reduction, and the effect size was similar to that in inpatient settings. In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may result in a large increase in the proportion of people living with HIV who were started on tuberculosis treatment compared to routine tuberculosis diagnostic testing without LF-LAM (RR 5.44, 95% CI 4.70 to 6.29, 3022 participants, 1 trial; low-certainty evidence). Other patient-important outcomes Assessment of other patient-important and implementation outcomes in the trials varied. The included trials demonstrated that a higher proportion of people living with HIV were able to produce urine compared to sputum for tuberculosis diagnostic testing; a higher proportion of people living with HIV were diagnosed with tuberculosis in the group that received LF-LAM; and the incremental diagnostic yield was higher for LF-LAM than for urine or sputum Xpert MTB/RIF. AUTHORS' CONCLUSIONS In inpatient settings, the use of LF-LAM as part of a tuberculosis diagnostic testing strategy likely reduces mortality and probably results in a slight increase in tuberculosis treatment initiation in people living with HIV. The reduction in mortality may be due to earlier diagnosis, which facilitates prompt treatment initiation. In outpatient settings, the use of LF-LAM testing as part of a tuberculosis diagnostic strategy may reduce mortality and may result in a large increase in tuberculosis treatment initiation in people living with HIV. Our results support the implementation of LF-LAM to be used in conjunction with other WHO-recommended tuberculosis diagnostic tests to assist in the rapid diagnosis of tuberculosis in people living with HIV.
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Affiliation(s)
- Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Philip Lederer
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA
| | - Marty Chaplin
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Bjerrum
- Department of Clinical Research, Research Unit of Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maunank Shah
- Department of Medicine, Division of Infectious Diseases, John Hopkins University School of Medicine, Baltimore, Maryland, USA
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Haraka F, Kakolwa M, Schumacher SG, Nathavitharana RR, Denkinger CM, Gagneux S, Reither K, Ross A. Impact of the diagnostic test Xpert MTB/RIF on patient outcomes for tuberculosis. Cochrane Database Syst Rev 2021; 5:CD012972. [PMID: 34097769 PMCID: PMC8208889 DOI: 10.1002/14651858.cd012972.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND The World Health Organization (WHO) recommends Xpert MTB/RIF in place of smear microscopy to diagnose tuberculosis (TB), and many countries have adopted it into their diagnostic algorithms. However, it is not clear whether the greater accuracy of the test translates into improved health outcomes. OBJECTIVES To assess the impact of Xpert MTB/RIF on patient outcomes in people being investigated for tuberculosis. SEARCH METHODS We searched the following databases, without language restriction, from 2007 to 24 July 2020: Cochrane Infectious Disease Group (CIDG) Specialized Register; CENTRAL; MEDLINE OVID; Embase OVID; CINAHL EBSCO; LILACS BIREME; Science Citation Index Expanded (Web of Science), Social Sciences citation index (Web of Science), and Conference Proceedings Citation Index - Social Science & Humanities (Web of Science). We also searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, and the Pan African Clinical Trials Registry for ongoing trials. SELECTION CRITERIA We included individual- and cluster-randomized trials, and before-after studies, in participants being investigated for tuberculosis. We analysed the randomized and non-randomized studies separately. DATA COLLECTION AND ANALYSIS: For each study, two review authors independently extracted data, using a piloted data extraction tool. We assessed the risk of bias using Cochrane and Effective Practice and Organisation of Care (EPOC) tools. We used random effects meta-analysis to allow for heterogeneity between studies in setting and design. The certainty of the evidence in the randomized trials was assessed by GRADE. MAIN RESULTS We included 12 studies: eight were randomized controlled trials (RCTs), and four were before-and-after studies. Most included RCTs had a low risk of bias in most domains of the Cochrane 'Risk of bias' tool. There was inconclusive evidence of an effect of Xpert MTB/RIF on all-cause mortality, both overall (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.75 to 1.05; 5 RCTs, 9932 participants, moderate-certainty evidence), and restricted to studies with six-month follow-up (RR 0.98, 95% CI 0.78 to 1.22; 3 RCTs, 8143 participants; moderate-certainty evidence). There was probably a reduction in mortality in participants known to be infected with HIV (odds ratio (OR) 0.80, 95% CI 0.67 to 0.96; 5 RCTs, 5855 participants; moderate-certainty evidence). It is uncertain whether Xpert MTB/RIF has no or a modest effect on the proportion of participants starting tuberculosis treatment who had a successful treatment outcome (OR) 1.10, 95% CI 0.96 to 1.26; 3RCTs, 4802 participants; moderate-certainty evidence). There was also inconclusive evidence of an effect on the proportion of participants who were treated for tuberculosis (RR 1.10, 95% CI 0.98 to 1.23; 5 RCTs, 8793 participants; moderate-certainty evidence). The proportion of participants treated for tuberculosis who had bacteriological confirmation was probably higher in the Xpert MTB/RIF group (RR 1.44, 95% CI 1.29 to 1.61; 6 RCTs, 2068 participants; moderate-certainty evidence). The proportion of participants with bacteriological confirmation who were lost to follow-up pre-treatment was probably reduced (RR 0.59, 95% CI 0.41 to 0.85; 3 RCTs, 1217 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We were unable to confidently rule in or rule out the effect on all-cause mortality of using Xpert MTB/RIF rather than smear microscopy. Xpert MTB/RIF probably reduces mortality among participants known to be infected with HIV. We are uncertain whether Xpert MTB/RIF has a modest effect or not on the proportion treated or, among those treated, on the proportion with a successful outcome. It probably does not have a substantial effect on these outcomes. Xpert MTB/RIF probably increases both the proportion of treated participants who had bacteriological confirmation, and the proportion with a laboratory-confirmed diagnosis who were treated. These findings may inform decisions about uptake alongside evidence on cost-effectiveness and implementation.
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Affiliation(s)
- Frederick Haraka
- Elizabeth Glaser Pediatric AIDS Foundation, Dar es Salaam, Tanzania
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | - Ruvandhi R Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA
| | - Claudia M Denkinger
- FIND, Geneva, Switzerland
- Division of Tropical Medicine, Centre for Infectious Diseases, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastien Gagneux
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Klaus Reither
- Ifakara Health Institute, Bagamoyo, Tanzania
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Amanda Ross
- University of Basel, Basel, Switzerland
- Swiss Tropical and Public Health Institute, Basel, Switzerland
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7
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Jo Y, Gomes I, Shin H, Tucker A, Ngwira LG, Chaisson RE, Corbett EL, Dowdy DW. Health-related quality of life of inpatients and outpatients with TB in rural Malawi. Int J Tuberc Lung Dis 2020; 24:1165-1171. [PMID: 33172524 PMCID: PMC7847550 DOI: 10.5588/ijtld.20.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION: Patients being treated for TB may suffer reductions in health-related quality of life (HRQoL). This study aims to assess the extent of such reductions and the trajectory of HRQoL over the course of treatment in rural Malawi.METHODS: We collected patient demographic and socioeconomic status, TB-related characteristics, and HRQoL data (i.e., EQ-5D and a visual analogue scale VAS) from adults (age ≥18 years) being treated for TB in 12 primary health centers and one hospital in rural Thyolo District, Malawi, from 2014 to 2016. Associations between HRQoL and patient characteristics were estimated using multivariable linear regression.RESULTS: Inpatients (n = 197) consistently showed lower median HRQoL scores and suffered more severe health impairments during hospitalization than outpatients (n = 156) (EQ5D and VAS: 0.79, 55 vs. 0.84, 70). Longer treatment duration was associated with higher HRQoL among outpatients (EQ5D: 0.034 increase per 2 months, 95%CI 0.012-0.057). We found no substantial associations between patients´ demographic and socioeconomic characteristics and HRQoL in this setting.CONCLUSION: HRQoL scores among patients receiving treatment for TB in rural Malawi differ by clinical setting and duration of treatment, with greater impairment among inpatients and those early in their treatment course.
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Affiliation(s)
- Y Jo
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - I Gomes
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - H Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - L G Ngwira
- Malawi-Liverpool-Wellcome Trust Clinical Research Center, Blantyre, Malawi
| | - R E Chaisson
- Center for Tuberculosis Research, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - E L Corbett
- Malawi-Liverpool-Wellcome Trust Clinical Research Center, Blantyre, Malawi, Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK
| | - D W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, Center for Tuberculosis Research, Johns Hopkins School of Medicine, Baltimore, MD, USA
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8
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Schmit KM, Shah N, Kammerer S, Bamrah Morris S, Marks SM. Tuberculosis Transmission or Mortality Among Persons Living with HIV, USA, 2011-2016. J Racial Ethn Health Disparities 2020; 7:865-873. [PMID: 32060748 PMCID: PMC7918278 DOI: 10.1007/s40615-020-00709-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 12/30/2019] [Accepted: 01/21/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Persons living with HIV are more likely to have tuberculosis (TB) disease attributed to recent transmission (RT) and to die during TB treatment than persons without HIV. We examined factors associated with RT or mortality among TB/HIV patients. METHODS Using National TB Surveillance System data from 2011 to 2016, we calculated multivariable adjusted odds ratios (aOR) with 99% confidence intervals (CI) to estimate associations between patient characteristics and RT or mortality. Mortality analyses were restricted to 2011-2014 to allow sufficient time for reporting outcomes. RESULTS TB disease was attributed to RT in 491 (20%) of 2415 TB/HIV patients. RT was more likely among those reporting homelessness (aOR, 2.6; CI, 2.0, 3.5) or substance use (aOR,1.6; CI, 1.2, 2.1) and among blacks (aOR,1.8; CI, 1.2, 2.8) and Hispanics (aOR, 1.8; CI, 1.1, 2.9); RT was less likely among non-US-born persons (aOR, 0.2; CI, 0.2, 0.3). The proportion who died during TB treatment was higher among persons with HIV than without (8.6% versus 5.2%; p < 0.0001). Among 2273 TB/HIV patients, 195 died during TB treatment. Age ≥ 65 years (aOR, 5.3; CI, 2.4, 11.6), 45-64 years (aOR, 2.2; CI, 1.4, 3.4), and having another medical risk factor for TB (aOR, 3.3; CI, 1.8, 6.2) were associated with death; directly observed treatment (DOT) for TB was protective (aOR, 0.5; CI, 0.2, 1.0). CONCLUSIONS Among TB/HIV patients, blacks, Hispanics, and those reporting homelessness or substance use should be prioritized for interventions that decrease TB transmission. Improved adherence to treatment through DOT was associated with decreased mortality, but additional interventions are needed to reduce mortality among older patients and those TB/HIV patients with another medical risk factor for TB.
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Affiliation(s)
- K M Schmit
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention (CDC), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Mailstop US12-4, 1600 Clifton Road, Atlanta, GA, 30329, USA.
| | - N Shah
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention (CDC), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Mailstop US12-4, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - S Kammerer
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention (CDC), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Mailstop US12-4, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - S Bamrah Morris
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention (CDC), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Mailstop US12-4, 1600 Clifton Road, Atlanta, GA, 30329, USA
| | - S M Marks
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention (CDC), National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Mailstop US12-4, 1600 Clifton Road, Atlanta, GA, 30329, USA
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9
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Ochodo EA, Kalema N, Schumacher S, Steingart K, Young T, Mallett S, Deeks J, Cobelens F, Bossuyt PM, Nicol MP, Cattamanchi A. Variation in the observed effect of Xpert MTB/RIF testing for tuberculosis on mortality: A systematic review and analysis of trial design considerations. Wellcome Open Res 2020; 4:173. [PMID: 32851196 PMCID: PMC7438967 DOI: 10.12688/wellcomeopenres.15412.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Most studies evaluating the effect of Xpert MTB/RIF testing for tuberculosis (TB) concluded that it did not reduce overall mortality compared to usual care. We conducted a systematic review to assess whether key study design and execution features contributed to earlier identification of patients with TB and decreased pre-treatment loss to follow-up, thereby reducing the potential impact of Xpert MTB/RIF testing. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Scopus for literature published from 1 st January 2009 to February 2019. We included all primary intervention studies that had evaluated the effect of Xpert MTB/RIF on mortality compared to usual care in participants with presumptive pulmonary TB. We critically reviewed features of included studies across: Study setting and context, Study population, Participant recruitment and enrolment, Study procedures, and Study follow-up. Results: We included seven randomised and one non-randomised study. All included studies demonstrated relative reductions in overall mortality in the Xpert MTB/RIF arm ranging from 6% to 40%. However, mortality reduction was reported to be statistically significant in two studies. Study features that could explain the lack of observed effect on mortality included: the higher quality of care at study sites; inclusion of patients with a higher pre-test probability of TB leading to higher than expected empirical rates; performance of additional diagnostic testing not done in usual care leading to increased TB diagnosis or empiric treatment initiation; the recruitment of participants likely to return for follow-up; and involvement of study staff in ensuring adherence with care and follow-up. Conclusion: Most studies of Xpert MTB/RIF were designed and conducted in a manner that resulted in more patients being diagnosed and treated for TB, minimising the potential difference in mortality Xpert MTB/RIF testing could have achieved compared to usual care.
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Affiliation(s)
- Eleanor A. Ochodo
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Nelson Kalema
- Infectious Diseases Institute, Makerere University, Kampala, 22418, Uganda
| | - Samuel Schumacher
- Tuberculosis Department, Foundation for Innovative New Diagnostics, Geneva, 1202, Switzerland
| | - Karen Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Taryn Young
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Susan Mallett
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jon Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, 1105 BP, The Netherlands
| | - Patrick M. Bossuyt
- Deapartment of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, 1105 AZ, The Netherlands
| | - Mark P. Nicol
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, 6009, Australia
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, California, 94110, USA
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10
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Shin H, Ngwira LG, Tucker A, Chaisson RE, Corbett EL, Dowdy D. Patient-incurred cost of inpatient treatment for Tuberculosis in rural Malawi. Trop Med Int Health 2020; 25:624-634. [PMID: 32034984 PMCID: PMC7658961 DOI: 10.1111/tmi.13381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To mitigate the economic burden of tuberculosis (TB), it is important to fully understand the costs of TB treatment from the patient perspective. We therefore sought to quantify the patient-incurred cost of TB treatment in rural Malawi, with specific focus on costs borne by patients requiring inpatient hospitalisation. METHODS We conducted a cross-sectional survey of 197 inpatients and 156 outpatients being treated for TB in rural Malawi. We collected data on out-of-pocket costs and lost wages, including costs to guardians. Costs for inpatient TB treatment were estimated and compared to costs for outpatient TB treatment. We then explored the equity distribution of inpatient TB treatment cost using concentration curves. RESULTS Despite free government services, inpatients were estimated to incur a mean of $137 (standard deviation: $147) per initial TB episode, corresponding to >50% of annual household spending among patients in the lowest expenditure quintile. Non-medical hospitalisation costs accounted for 88% of this total. Patients treated entirely as outpatients incurred estimated costs of $25 (standard deviation: $15) per episode. The concentration curves showed that, among individuals hospitalised for an initial TB episode, poorer patients shouldered a much greater proportion of inpatient TB treatment costs than wealthier ones (concentration index: -0.279). CONCLUSION Patients hospitalised for TB in resource-limited rural Malawi experience devastating costs of TB treatment. Earlier diagnosis and treatment must be prioritised if we are to meet goals of effective TB control, avoidance of catastrophic costs and provision of appropriate patient-centred care in such settings.
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Affiliation(s)
- Hyejeong Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lucky G. Ngwira
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Sciences Department, Liverpool School of Tropical Medicine, UK
| | - Austin Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Richard E Chaisson
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth L Corbett
- HIV and TB Group, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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11
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Sun HY, Wang JY, Chen YC, Hsueh PR, Chen YH, Chuang YC, Fang CT, Chang SC, Wang JD. Impact of introducing fluorescent microscopy on hospital tuberculosis control: A before-after study at a high caseload medical center in Taiwan. PLoS One 2020; 15:e0230067. [PMID: 32243434 PMCID: PMC7122812 DOI: 10.1371/journal.pone.0230067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 02/20/2020] [Indexed: 11/23/2022] Open
Abstract
Background Undiagnosed tuberculosis (TB) patients hospitalized because of comorbidities constitute a challenge to TB control in hospitals. We aimed to assess the impact of introducing highly sensitive fluorescent microscopy for examining sputum smear to replace conventional microscopy under a high TB risk setting. Methods We measured the impact of switch to fluorescent microscopy on the smear detection rate of culture-confirmed pulmonary TB, timing of respiratory isolation, and total non-isolated infectious person-days in hospital at a high-caseload medical center (approximately 400 TB cases annually) in Taipei. Multivariable Cox regression was applied to adjust for effects of covariates. The effect attributable to the improved smear detection rate was determined using causal mediation analysis. Results After switch to fluorescence microscopy, median non-isolated infectious duration decreased from 12.5 days to 3 days (P<0.001). Compared with conventional microscopy, fluorescence microscopy increased sputum smear detection rate by two-fold (for all patients: from 22.8% to 48.1%, P<0.001; for patients with cavitary lung lesion: from 43% to 82%, P = 0.029) and was associated with a 2-fold higher likelihood of prompt respiratory isolation (odds ratio mediated by the increase in sputum smear detection rate: 1.8, 95% CI 1.3–2.5). Total non-isolated infectious patient-days in hospital decreased by 69% (from 4,778 patient-days per year to 1,502 patient-days per year). Conclusions In a high TB caseload setting, highly sensitive rapid diagnostic tools could substantially improve timing of respiratory isolation and reduce the risk of nosocomial TB transmission.
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Affiliation(s)
- Hsin-Yun Sun
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Po-Ren Hsueh
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Laboratory Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Hsuan Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Tai Fang
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail:
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jung-Der Wang
- Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
- Departments of Internal Medicine and Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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12
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Auld AF, Agizew T, Mathoma A, Boyd R, Date A, Pals SL, Serumola C, Mathebula U, Alexander H, Ellerbrock TV, Rankgoane-Pono G, Pono P, Shepherd JC, Fielding K, Grant AD, Finlay A. Effect of tuberculosis screening and retention interventions on early antiretroviral therapy mortality in Botswana: a stepped-wedge cluster randomized trial. BMC Med 2020; 18:19. [PMID: 32041583 PMCID: PMC7011529 DOI: 10.1186/s12916-019-1489-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 12/24/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Undiagnosed tuberculosis (TB) remains the most common cause of HIV-related mortality. Xpert MTB/RIF (Xpert) is being rolled out globally to improve TB diagnostic capacity. However, previous Xpert impact trials have reported that health system weaknesses blunted impact of this improved diagnostic tool. During phased Xpert rollout in Botswana, we evaluated the impact of a package of interventions comprising (1) additional support for intensified TB case finding (ICF), (2) active tracing for patients missing clinic appointments to support retention, and (3) Xpert replacing sputum-smear microscopy, on early (6-month) antiretroviral therapy (ART) mortality. METHODS At 22 clinics, ART enrollees > 12 years old were eligible for inclusion in three phases: a retrospective standard of care (SOC), prospective enhanced care (EC), and prospective EC plus Xpert (EC+X) phase. EC and EC+X phases were implemented as a stepped-wedge trial. Participants in the EC phase received SOC plus components 1 (strengthened ICF) and 2 (active tracing) of the intervention package, and participants in the EC+X phase received SOC plus all three intervention package components. Primary and secondary objectives were to compare all-cause 6-month ART mortality between SOC and EC+X and between EC and EC+X phases, respectively. We used adjusted analyses, appropriate for study design, to control for baseline differences in individual-level factors and intra-facility correlation. RESULTS We enrolled 14,963 eligible patients: 8980 in SOC, 1768 in EC, and 4215 in EC+X phases. Median age of ART enrollees was 35 and 64% were female. Median CD4 cell count was lower in SOC than subsequent phases (184/μL in SOC, 246/μL in EC, and 241/μL in EC+X). By 6 months of ART, 461 (5.3%) of SOC, 54 (3.2%) of EC, and 121 (3.0%) of EC+X enrollees had died. Compared with SOC, 6-month mortality was lower in the EC+X phase (adjusted hazard ratio, 0.77; 95% confidence interval, 0.61-0.97, p = 0.029). Compared with EC enrollees, 6-month mortality was similar among EC+X enrollees. CONCLUSIONS Interventions to strengthen ICF and retention were associated with lower early ART mortality. This new evidence highlights the need to strengthen ICF and retention in many similar settings. Similar to other trials, no additional mortality benefit of replacing sputum-smear microscopy with Xpert was observed. TRIAL REGISTRATION Retrospectively registered: ClinicalTrials.gov (NCT02538952).
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Affiliation(s)
- Andrew F Auld
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, USA. .,Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC), Lilongwe, Malawi.
| | - Tefera Agizew
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Anikie Mathoma
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Rosanna Boyd
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Anand Date
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, USA
| | - Sherri L Pals
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, USA
| | - Christopher Serumola
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Unami Mathebula
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
| | - Heather Alexander
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, USA
| | - Tedd V Ellerbrock
- Division of Global HIV & TB, Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - James C Shepherd
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana.,Yale University School of Medicine, New Haven, CT, USA
| | - Katherine Fielding
- TB Centre, London Sch. of Hygiene & Tropical Med, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Alison D Grant
- TB Centre, London Sch. of Hygiene & Tropical Med, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.,Africa Health Research Institute, School of Nursing and Public Heath, University of KwaZulu-Natal, Durban, South Africa
| | - Alyssa Finlay
- Division of TB Elimination, Centers for Disease Control and Prevention, Gaborone, Botswana
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13
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Ochodo EA, Kalema N, Schumacher S, Steingart K, Young T, Mallett S, Deeks J, Cobelens F, Bossuyt PM, Nicol MP, Cattamanchi A. Variation in the observed effect of Xpert MTB/RIF testing for tuberculosis on mortality: A systematic review and analysis of trial design considerations. Wellcome Open Res 2019; 4:173. [PMID: 32851196 PMCID: PMC7438967 DOI: 10.12688/wellcomeopenres.15412.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 02/15/2024] Open
Abstract
Background: Most studies evaluating the effect of Xpert MTB/RIF testing for tuberculosis (TB) concluded that it did not reduce overall mortality compared to usual care. We conducted a systematic review to assess whether key study design and execution features contributed to earlier identification of patients with TB and decreased pre-treatment loss to follow-up, thereby reducing the potential impact of Xpert MTB/RIF testing. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Scopus for literature published from 1 st January 2009 to February 2019. We included all primary intervention studies that had evaluated the effect of Xpert MTB/RIF on mortality compared to usual care in participants with presumptive pulmonary TB. We critically reviewed features of included studies across: Study setting and context, Study population, Participant recruitment and enrolment, Study procedures, and Study follow-up. Results: We included seven randomised and one non-randomised study. All included studies demonstrated relative reductions in overall mortality in the Xpert MTB/RIF arm ranging from 6% to 40%. However, mortality reduction was reported to be statistically significant in two studies. Study features that could explain the lack of observed effect on mortality included: the higher quality of care at study sites; inclusion of patients with a higher pre-test probability of TB leading to higher than expected empirical rates; performance of additional diagnostic testing not done in usual care leading to increased TB diagnosis or empiric treatment initiation; the recruitment of participants likely to return for follow-up; and involvement of study staff in ensuring adherence with care and follow-up. Conclusion: Most studies of Xpert MTB/RIF were designed and conducted in a manner that resulted in more patients being diagnosed and treated for TB, minimising the potential difference in mortality Xpert MTB/RIF testing could have achieved compared to usual care.
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Affiliation(s)
- Eleanor A. Ochodo
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Nelson Kalema
- Infectious Diseases Institute, Makerere University, Kampala, 22418, Uganda
| | - Samuel Schumacher
- Tuberculosis Department, Foundation for Innovative New Diagnostics, Geneva, 1202, Switzerland
| | - Karen Steingart
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Taryn Young
- Department of Global Health, Stellenbosch University, Cape Town, Western Cape, 8000, South Africa
| | - Susan Mallett
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Jon Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Trust, University of Birmingham, Edgbaston, Birmingham, UK
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Frank Cobelens
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, 1105 BP, The Netherlands
| | - Patrick M. Bossuyt
- Deapartment of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, 1105 AZ, The Netherlands
| | - Mark P. Nicol
- School of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, 6009, Australia
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco Medical Center, San Francisco, California, 94110, USA
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14
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Horne DJ, Kohli M, Zifodya JS, Schiller I, Dendukuri N, Tollefson D, Schumacher SG, Ochodo EA, Pai M, Steingart KR. Xpert MTB/RIF and Xpert MTB/RIF Ultra for pulmonary tuberculosis and rifampicin resistance in adults. Cochrane Database Syst Rev 2019; 6:CD009593. [PMID: 31173647 PMCID: PMC6555588 DOI: 10.1002/14651858.cd009593.pub4] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Xpert MTB/RIF (Xpert MTB/RIF) and Xpert MTB/RIF Ultra (Xpert Ultra), the newest version, are the only World Health Organization (WHO)-recommended rapid tests that simultaneously detect tuberculosis and rifampicin resistance in persons with signs and symptoms of tuberculosis, at lower health system levels. A previous Cochrane Review found Xpert MTB/RIF sensitive and specific for tuberculosis (Steingart 2014). Since the previous review, new studies have been published. We performed a review update for an upcoming WHO policy review. OBJECTIVES To determine diagnostic accuracy of Xpert MTB/RIF and Xpert Ultra for tuberculosis in adults with presumptive pulmonary tuberculosis (PTB) and for rifampicin resistance in adults with presumptive rifampicin-resistant tuberculosis. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, Science Citation Index, Web of Science, Latin American Caribbean Health Sciences Literature, Scopus, the WHO International Clinical Trials Registry Platform, the International Standard Randomized Controlled Trial Number Registry, and ProQuest, to 11 October 2018, without language restriction. SELECTION CRITERIA Randomized trials, cross-sectional, and cohort studies using respiratory specimens that evaluated Xpert MTB/RIF, Xpert Ultra, or both against the reference standard, culture for tuberculosis and culture-based drug susceptibility testing or MTBDRplus for rifampicin resistance. DATA COLLECTION AND ANALYSIS Four review authors independently extracted data using a standardized form. When possible, we also extracted data by smear and HIV status. We assessed study quality using QUADAS-2 and performed meta-analyses to estimate pooled sensitivity and specificity separately for tuberculosis and rifampicin resistance. We investigated potential sources of heterogeneity. Most analyses used a bivariate random-effects model. For tuberculosis detection, we first estimated accuracy using all included studies and then only the subset of studies where participants were unselected, i.e. not selected based on prior microscopy testing. MAIN RESULTS We identified in total 95 studies (77 new studies since the previous review): 86 studies (42,091 participants) evaluated Xpert MTB/RIF for tuberculosis and 57 studies (8287 participants) for rifampicin resistance. One study compared Xpert MTB/RIF and Xpert Ultra on the same participant specimen.Tuberculosis detectionOf the total 86 studies, 45 took place in high tuberculosis burden and 50 in high TB/HIV burden countries. Most studies had low risk of bias.Xpert MTB/RIF pooled sensitivity and specificity (95% credible Interval (CrI)) were 85% (82% to 88%) and 98% (97% to 98%), (70 studies, 37,237 unselected participants; high-certainty evidence). We found similar accuracy when we included all studies.For a population of 1000 people where 100 have tuberculosis on culture, 103 would be Xpert MTB/RIF-positive and 18 (17%) would not have tuberculosis (false-positives); 897 would be Xpert MTB/RIF-negative and 15 (2%) would have tuberculosis (false-negatives).Xpert Ultra sensitivity (95% confidence interval (CI)) was 88% (85% to 91%) versus Xpert MTB/RIF 83% (79% to 86%); Xpert Ultra specificity was 96% (94% to 97%) versus Xpert MTB/RIF 98% (97% to 99%), (1 study, 1439 participants; moderate-certainty evidence).Xpert MTB/RIF pooled sensitivity was 98% (97% to 98%) in smear-positive and 67% (62% to 72%) in smear-negative, culture-positive participants, (45 studies). Xpert MTB/RIF pooled sensitivity was 88% (83% to 92%) in HIV-negative and 81% (75% to 86%) in HIV-positive participants; specificities were similar 98% (97% to 99%), (14 studies).Rifampicin resistance detectionXpert MTB/RIF pooled sensitivity and specificity (95% Crl) were 96% (94% to 97%) and 98% (98% to 99%), (48 studies, 8020 participants; high-certainty evidence).For a population of 1000 people where 100 have rifampicin-resistant tuberculosis, 114 would be positive for rifampicin-resistant tuberculosis and 18 (16%) would not have rifampicin resistance (false-positives); 886 would be would be negative for rifampicin-resistant tuberculosis and four (0.4%) would have rifampicin resistance (false-negatives).Xpert Ultra sensitivity (95% CI) was 95% (90% to 98%) versus Xpert MTB/RIF 95% (91% to 98%); Xpert Ultra specificity was 98% (97% to 99%) versus Xpert MTB/RIF 98% (96% to 99%), (1 study, 551 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS We found Xpert MTB/RIF to be sensitive and specific for diagnosing PTB and rifampicin resistance, consistent with findings reported previously. Xpert MTB/RIF was more sensitive for tuberculosis in smear-positive than smear-negative participants and HIV-negative than HIV-positive participants. Compared with Xpert MTB/RIF, Xpert Ultra had higher sensitivity and lower specificity for tuberculosis and similar sensitivity and specificity for rifampicin resistance (1 study). Xpert MTB/RIF and Xpert Ultra provide accurate results and can allow rapid initiation of treatment for multidrug-resistant tuberculosis.
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Affiliation(s)
- David J Horne
- University of WashingtonDepartment of Medicine, Division of Pulmonary and Critical Care Medicine, and Firland Northwest TB CenterSeattleUSA
| | - Mikashmi Kohli
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Jerry S Zifodya
- University of WashingtonPulmonary and Critical Care Medicine325 9th Avenue – Campus Box 359762SeattleUSA98104
| | - Ian Schiller
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | - Nandini Dendukuri
- McGill University Health Centre ‐ Research InstituteDivision of Clinical EpidemiologyMontrealCanada
| | | | | | - Eleanor A Ochodo
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesPO Box 241Cape TownSouth Africa8000
| | - Madhukar Pai
- McGill UniversityDepartment of Epidemiology, Biostatistics and Occupational HealthMontrealCanada
| | - Karen R Steingart
- Department of Clinical Sciences, Liverpool School of Tropical MedicineHonorary Research FellowPembroke PlaceLiverpoolUK
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15
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Di Tanna GL, Khaki AR, Theron G, McCarthy K, Cox H, Mupfumi L, Trajman A, Zijenah LS, Mason P, Bandason T, Durovni B, Bara W, Hoelscher M, Clowes P, Mangu C, Chanda D, Pym A, Mwaba P, Cobelens F, Nicol MP, Dheda K, Churchyard G, Fielding K, Metcalfe JZ. Effect of Xpert MTB/RIF on clinical outcomes in routine care settings: individual patient data meta-analysis. Lancet Glob Health 2019; 7:e191-e199. [PMID: 30683238 PMCID: PMC6366854 DOI: 10.1016/s2214-109x(18)30458-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 07/20/2018] [Accepted: 09/27/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Xpert MTB/RIF, the most widely used automated nucleic acid amplification test for tuberculosis, is available in more than 130 countries. Although diagnostic accuracy is well documented, anticipated improvements in patient outcomes have not been clearly identified. We performed an individual patient data meta-analysis to examine improvements in patient outcomes associated with Xpert MTB/RIF. METHODS We searched PubMed, Embase, ClinicalTrials.gov, and the Pan African Clinical Trials Registry from inception to Feb 1, 2018, for randomised controlled trials (RCTs) comparing the use of Xpert MTB/RIF with sputum smear microscopy as tests for tuberculosis diagnosis in adults (aged 18 years or older). We excluded studies of patients with extrapulmonary tuberculosis, and studies in which mortality was not assessed. We used a two-stage approach for our primary analysis and a one-stage approach for the sensitivity analysis. To assess the primary outcome of cumulative 6-month all-cause mortality, we first performed logistic regression models (random effects for cluster randomised trials, with robust SEs for multicentre studies) for each trial, and then pooled the odds ratio (OR) estimates by a fixed-effects (inverse variance) or random-effects (Der Simonian Laird) meta-analysis. We adjusted for age and gender, and stratified by HIV status and previous tuberculosis-treatment history. The study protocol has been registered with PROSPERO, number CRD42014013394. FINDINGS Our search identified 387 studies, of which five RCTs were eligible for analysis. 8567 adult clinic attendees (4490 [63·5%] of 7074 participants for whom data were available were HIV-positive) were tested for tuberculosis with Xpert MTB/RIF (Xpert group) versus sputum smear microscopy (sputum smear group), across five low-income and middle-income countries (South Africa, Brazil, Zimbabwe, Zambia, and Tanzania). The primary outcome (reported in three studies) occurred in 182 (4·5%) of 4050 patients in the Xpert group and 217 (5·3%) of 4093 patients in the smear group (pooled adjusted OR 0·88, 95% CI 0·68-1·14 [p=0·34]; for HIV-positive individuals OR 0·83, 0·65-1·05 [p=0·12]). Kaplan-Meier estimates showed a lower rate of death (12·73 per 100 person-years in the Xpert group vs 16·38 per 100 person-years in the sputum smear group) for HIV-positive patients (hazard ratio 0·76, 95% CI 0·60-0·97; p=0·03). The risk of bias was assessed as reasonable and the statistical heterogeneity across studies was low (I2<20% for the primary outcome). INTERPRETATION Despite individual patient data analysis from five RCTs, we were unable to confidently rule in nor rule out an Xpert MTB/RIF-associated reduction in mortality among outpatients tested for tuberculosis. Reduction in mortality among HIV-positive patients in a secondary analysis suggests the possibility of population-level impact. FUNDING US National Institutes of Health.
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Affiliation(s)
- Gian Luca Di Tanna
- TB Centre, Riskcenter-IREA, Department of Econometrics, Statistics and Applied Economics, University of Barcelona, Barcelona, Spain
| | - Ali Raza Khaki
- Division of Oncology, University of Washington, Seattle, WA, USA
| | - Grant Theron
- DST-NRF Centre of Excellence for Biomedical Tuberculosis Research and SAMRC Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Kerrigan McCarthy
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa
| | - Helen Cox
- Division of Medical Microbiology, and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lucy Mupfumi
- Botswana Harvard AIDS Institute, Gaborone, Botswana
| | - Anete Trajman
- Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, McGill University, Montreal, QC, Canada
| | - Lynn Sodai Zijenah
- Department of Immunology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | | | - Tsitsi Bandason
- Biomedical Research and Training Institute, Harare, Zimbabwe
| | | | - Wilbert Bara
- Zimbabwe Ministry of Health and Child Welfare, Harare, Zimbabwe
| | - Michael Hoelscher
- Mbeya Medical Research Center, Mbeya, Tanzania, Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany
| | - Petra Clowes
- Mbeya Medical Research Center, Mbeya, Tanzania, Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich, Munich, Germany
| | | | - Duncan Chanda
- University Teaching Hospital and University of Zambia School of Medicine, Lusaka, Zambia
| | - Alexander Pym
- Africa Health Research Institute, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Peter Mwaba
- University Teaching Hospital and University of Zambia School of Medicine, Lusaka, Zambia
| | - Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, Netherlands
| | - Mark P Nicol
- National Institute for Communicable Diseases, National Health Laboratory Service, Johannesburg, South Africa, Division of Medical Microbiology, and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Keertan Dheda
- London School of Hygiene and Tropical Medicine, London, UK, Lung Infection and Immunity Unit, Division of Pulmonology, University of Cape Town, Cape Town, South Africa
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa, Advancing Care and Treatment for TB/HIV, South African Medical Research Council, Johannesburg, South Africa
| | | | - John Z Metcalfe
- Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General Hospital, University of California, San Francisco, CA, USA
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16
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Dowdy DW. Xpert at 8 years: where are we now, and what should we do next? Int J Tuberc Lung Dis 2019; 23:3-4. [PMID: 30674373 DOI: 10.5588/ijtld.18.0717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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17
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Gupta-Wright A, Corbett EL, van Oosterhout JJ, Wilson D, Grint D, Alufandika-Moyo M, Peters JA, Chiume L, Flach C, Lawn SD, Fielding K. Rapid urine-based screening for tuberculosis in HIV-positive patients admitted to hospital in Africa (STAMP): a pragmatic, multicentre, parallel-group, double-blind, randomised controlled trial. Lancet 2018; 392:292-301. [PMID: 30032978 PMCID: PMC6078909 DOI: 10.1016/s0140-6736(18)31267-4] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Current diagnostics for HIV-associated tuberculosis are suboptimal, with missed diagnoses contributing to high hospital mortality and approximately 374 000 annual HIV-positive deaths globally. Urine-based assays have a good diagnostic yield; therefore, we aimed to assess whether urine-based screening in HIV-positive inpatients for tuberculosis improved outcomes. METHODS We did a pragmatic, multicentre, double-blind, randomised controlled trial in two hospitals in Malawi and South Africa. We included HIV-positive medical inpatients aged 18 years or more who were not taking tuberculosis treatment. We randomly assigned patients (1:1), using a computer-generated list of random block size stratified by site, to either the standard-of-care or the intervention screening group, irrespective of symptoms or clinical presentation. Attending clinicians made decisions about care; and patients, clinicians, and the study team were masked to the group allocation. In both groups, sputum was tested using the Xpert MTB/RIF assay (Xpert; Cepheid, Sunnyvale, CA, USA). In the standard-of-care group, urine samples were not tested for tuberculosis. In the intervention group, urine was tested with the Alere Determine TB-LAM Ag (TB-LAM; Alere, Waltham, MA, USA), and Xpert assays. The primary outcome was all-cause 56-day mortality. Subgroup analyses for the primary outcome were prespecified based on baseline CD4 count, haemoglobin, clinical suspicion for tuberculosis; and by study site and calendar time. We used an intention-to-treat principle for our analyses. This trial is registered with the ISRCTN registry, number ISRCTN71603869. FINDINGS Between Oct 26, 2015, and Sept 19, 2017, we screened 4788 HIV-positive adults, of which 2600 (54%) were randomly assigned to the study groups (n=1300 for each group). 13 patients were excluded after randomisation from analysis in each group, leaving 2574 in the final intention-to-treat analysis (n=1287 in each group). At admission, 1861 patients were taking antiretroviral therapy and median CD4 count was 227 cells per μL (IQR 79-436). Mortality at 56 days was reported for 272 (21%) of 1287 patients in the standard-of-care group and 235 (18%) of 1287 in the intervention group (adjusted risk reduction [aRD] -2·8%, 95% CI -5·8 to 0·3; p=0·074). In three of the 12 prespecified, but underpowered subgroups, mortality was lower in the intervention group than in the standard-of-care group for CD4 counts less than 100 cells per μL (aRD -7·1%, 95% CI -13·7 to -0·4; p=0.036), severe anaemia (-9·0%, -16·6 to -1·3; p=0·021), and patients with clinically suspected tuberculosis (-5·7%, -10·9 to -0·5; p=0·033); with no difference by site or calendar period. Adverse events were similar in both groups. INTERPRETATION Urine-based tuberculosis screening did not reduce overall mortality in all HIV-positive inpatients, but might benefit some high-risk subgroups. Implementation could contribute towards global targets to reduce tuberculosis mortality. FUNDING Joint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, and the Wellcome Trust.
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Affiliation(s)
- Ankur Gupta-Wright
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi.
| | - Elizabeth L Corbett
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi
| | - Joep J van Oosterhout
- Dignitas International, Zomba, Malawi; College of Medicine, University of Malawi, Blantyre, Malawi
| | - Douglas Wilson
- Department of Medicine, Edendale Hospital, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Daniel Grint
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Jurgens A Peters
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Lingstone Chiume
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi
| | - Clare Flach
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Division of Health and Social Care Research, Faculty of Life Sciences and Medicine, Kings College London, London, UK
| | - Stephen D Lawn
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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