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Kontsevaya I, Cabibbe AM, Cirillo DM, DiNardo AR, Frahm N, Gillespie SH, Holtzman D, Meiwes L, Petruccioli E, Reimann M, Ruhwald M, Sabiiti W, Saluzzo F, Tagliani E, Goletti D. Update on the diagnosis of tuberculosis. Clin Microbiol Infect 2024; 30:1115-1122. [PMID: 37490968 DOI: 10.1016/j.cmi.2023.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 07/11/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Tuberculosis (TB) remains a global public health threat, and the development of rapid and precise diagnostic tools is the key to enabling the early start of treatment, monitoring response to treatment, and preventing the spread of the disease. OBJECTIVES An overview of recent progress in host- and pathogen-based TB diagnostics. SOURCES We conducted a PubMed search of recent relevant articles and guidelines on TB screening and diagnosis. CONTENT An overview of currently used methods and perspectives in the following areas of TB diagnostics is provided: immune-based diagnostics, X-ray, clinical symptoms and scores, cough detection, culture of Mycobacterium tuberculosis and identifying its resistance profile using phenotypic and genotypic methods, including next-generation sequencing, sputum- and non-sputum-based molecular diagnosis of TB and monitoring of response to treatment. IMPLICATIONS A brief overview of the most relevant advances and changes in international guidelines regarding screening and diagnosing TB is provided in this review. It aims at reviewing all relevant areas of diagnostics, including both pathogen- and host-based methods.
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Affiliation(s)
- Irina Kontsevaya
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany; Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, United Kingdom.
| | | | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrew R DiNardo
- Global TB Program, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA; Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole Frahm
- Clinical Development, Bill & Melinda Gates Medical Research Institute, Cambridge, MA, USA
| | | | - David Holtzman
- Clinical Development, Bill & Melinda Gates Medical Research Institute, Cambridge, MA, USA; Section of Infectious Diseases, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Lennard Meiwes
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | - Elisa Petruccioli
- Translational Research Unit, National Institute for Infectious Diseases (INMI) "Lazzaro Spallanzani" - IRCCS, Rome, Italy
| | - Maja Reimann
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research (DZIF), Partner Site Hamburg-Lübeck-Borstel-Riems, Borstel, Germany; Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
| | | | - Wilber Sabiiti
- School of Medicine, University of St Andrews, St Andrews, United Kingdom
| | - Francesca Saluzzo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Elisa Tagliani
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Delia Goletti
- Translational Research Unit, National Institute for Infectious Diseases (INMI) "Lazzaro Spallanzani" - IRCCS, Rome, Italy
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Chen J, Liu L, Huang J, Jiang Y, Yin C, Zhang L, Li Z, Lu H. LSTM-Based Prediction Model for Tuberculosis Among HIV-Infected Patients Using Structured Electronic Medical Records: A Retrospective Machine Learning Study. J Multidiscip Healthc 2024; 17:3557-3573. [PMID: 39070689 PMCID: PMC11283178 DOI: 10.2147/jmdh.s467877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 07/17/2024] [Indexed: 07/30/2024] Open
Abstract
Background Both HIV and TB are chronic infectious diseases requiring long-term treatment and follow-up, resulting in extensive electronic medical records. With the exponential growth of health and medical big data, effectively extracting and analyzing these data has become the research hotspot. As a fundamental aspect of artificial intelligence, machine learning has been extensively applied in medical research, encompassing diagnosis, treatment, patient monitoring, drug development, and epidemiological investigations. This significantly enhances medical information systems and facilitates the interoperability of medical data. Methods In our study, we analyzed longitudinal data from the electronic health records of 4540 patients, gathered from the National Clinical Research Center for Infectious Diseases in Shenzhen, China, spanning from 2017 to 2021. Initially, we employed the fine-tuned ChatGLM to structure the electronic medical records. Subsequently, we utilized a multi-layer perceptron to classify each patient and determined the presence of tuberculosis in HIV patients. Using machine learning-based natural language processing, we structured these records to build a specialized database for HIV and TB co-infection. We studied the epidemiological characteristics, focusing on incidence patterns, patient characteristics, and influencing factors, to uncover the transmission characteristics of these diseases in Shenzhen. Additionally, we used Long Short-Term Memory to create a predictive model for TB co-infection among HIV patients, based on their medical records. This model predicted the risk of TB co-infection, providing scientific evidence for clinical decision-making and enabling early detection and precise intervention. Results Based on the refined ChatGLM model tailored for structured electronic health records, the accuracy of symptom extraction consistently surpassed 0.95 precision. Key symptoms such as diarrhea and normal showed precision rates exceeding 0.90. High scores were also achieved in recall and F1 scores. Among 4540 HIV patients, 758 were diagnosed with concurrent tuberculosis, indicating a 16.7% co-infection rate, while syphilis co-infection affected 25.1%, underscoring the prevalence of concurrent infections among HIV patients. Utilizing electronic health records, a Multilayer Perceptron classifier was developed as a benchmark against Long Short-Term Memory to predict high-risk groups for HIV and tuberculosis co-infections. The Multilayer Perceptron classifier demonstrated predictive ability with AUROC values ranging from 0.616 to 0.682 on the test set, suggesting opportunities for further optimization and generalization despite its accuracy in identifying HIV-TB co-infections. In tuberculosis intelligent diagnosis based on laboratory results, the Long Short-Term Memory showed consistent performance across 5-fold cross-validation, with AUROC values ranging from 0.827 to 0.850, indicating reliability and consistency in tuberculosis prediction. Furthermore, by optimizing classification thresholds, the model achieved an overall accuracy of 81.18% in distinguishing HIV co-infected tuberculosis from simple HIV infection. Conclusion Combining the Multilayer Perceptron classifier with Long Short-Term Memory represented an advanced approach for effectively extracting electronic health records and utilizing it for disease prediction. This underscored the superior performance of deep learning techniques in managing both structured and unstructured medical data. Models leveraging laboratory time-series data demonstrated notably better performance compared to those relying solely on electronic health records for predicting tuberculosis incidence. This emphasized the benefits of deep learning in handling intricate medical data and provided valuable insights for healthcare providers exploring the use of deep learning in disease prediction and management.
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Affiliation(s)
- Jingfang Chen
- Faculty of Medicine, Macau University of Science and Technology, Macau, 999078, People’s Republic of China
- Department of Research and Teaching, The Third People’s Hospital of Shenzhen, Shenzhen, 518112, People’s Republic of China
| | - Linlin Liu
- Hengyang Medical School, School of Nursing, University of South China, Hengyang, 421001, People’s Republic of China
| | - Junxiong Huang
- Faculty of Medicine, Macau University of Science and Technology, Macau, 999078, People’s Republic of China
| | - Youli Jiang
- Department of Neurology, The People’s Hospital of Longhua, Shenzhen, 518109, People’s Republic of China
| | - Chengliang Yin
- Faculty of Medicine, Macau University of Science and Technology, Macau, 999078, People’s Republic of China
| | - Lukun Zhang
- Department of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The Third People’s Hospital of Shenzhen, Shenzhen, 518112, People’s Republic of China
| | - Zhihuan Li
- Faculty of Medicine, Macau University of Science and Technology, Macau, 999078, People’s Republic of China
| | - Hongzhou Lu
- Faculty of Medicine, Macau University of Science and Technology, Macau, 999078, People’s Republic of China
- Department of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The Third People’s Hospital of Shenzhen, Shenzhen, 518112, People’s Republic of China
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Dupnik K, Rivera VR, Dorvil N, Duffus Y, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumont E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification Among Patients With Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-income Countries. Open Forum Infect Dis 2024; 11:ofae356. [PMID: 39022393 PMCID: PMC11252845 DOI: 10.1093/ofid/ofae356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 06/27/2024] [Indexed: 07/20/2024] Open
Abstract
Background The World Health Organization recommends initiating same-day antiretroviral therapy (ART) while tuberculosis (TB) testing is under way for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve TB risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with TB symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP as a continuous variable using generalized linear models. Results Eighty-seven (17.5%) participants were diagnosed with baseline TB. The median CRP was 33.0 mg/L (interquartile range: 5.1, 85.5) in those with TB, and 2.6 mg/L (interquartile range: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4% and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3- to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Affiliation(s)
- Kathryn Dupnik
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Vanessa R Rivera
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Nancy Dorvil
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Yanique Duffus
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Yipeng Gao
- The Analysis Group, Boston, Massachusetts, USA
| | - Jingyi Liu
- The Analysis Group, Boston, Massachusetts, USA
| | - Alexandra Apollon
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Emelyne Dumont
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Cynthia Riviere
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Patrice Severe
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Kerlyne Lavoile
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Samuel Pierre
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | - Vanessa Rouzier
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Kathleen F Walsh
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Anthony L Byrne
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Patrice Joseph
- Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), Port-au-Prince, Haiti
| | | | - Jean William Pape
- Center for Global Health, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- St. Vincent's Hospital and Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Serena P Koenig
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Gebregergs GB, Berhe G, Gebrehiwot KG, Mulugeta A. Predictors contributing to the estimation of pulmonary tuberculosis among adults in a resource-limited setting: A systematic review of diagnostic predictions. SAGE Open Med 2024; 12:20503121241243238. [PMID: 38764538 PMCID: PMC11100385 DOI: 10.1177/20503121241243238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 03/14/2024] [Indexed: 05/21/2024] Open
Abstract
Background Although tuberculosis is highly prevalent in low- and middle-income countries, millions of cases remain undetected using current diagnostic methods. To address this problem, researchers have proposed prediction rules. Objective We analyzed existing prediction rules for the diagnosis of pulmonary tuberculosis and identified factors with a moderate to high strength of association with the disease. Methods We conducted a comprehensive search of relevant databases (MEDLINE/PubMed, Cochrane Library, Science Direct, Global Health for Reports, and Google Scholar) up to 14 November 2022. Studies that developed diagnostic algorithms for pulmonary tuberculosis in adults from low and middle-income countries were included. Two reviewers performed study screening, data extraction, and quality assessment. The study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2. We performed a narrative synthesis. Results Of the 26 articles selected, only half included human immune deficiency virus-positive patients. In symptomatic human immune deficiency virus patients, radiographic findings and body mass index were strong predictors of pulmonary tuberculosis, with an odds ratio of >4. However, in human immune deficiency virus-negative individuals, the biomarkers showed a moderate association with the disease. In symptomatic human immune deficiency virus patients, a C-reactive protein level ⩾10 mg/L had a sensitivity and specificity of 93% and 40%, respectively, whereas a trial of antibiotics had a specificity of 86% and a sensitivity of 43%. In smear-negative patients, anti-tuberculosis treatment showed a sensitivity of 52% and a specificity of 63%. Conclusions The performance of predictors and diagnostic algorithms differs among patient subgroups, such as in human immune deficiency virus-positive patients, radiographic findings, and body mass index were strong predictors of pulmonary tuberculosis. However, in human immune deficiency virus-negative individuals, the biomarkers showed a moderate association with the disease. A few models have reached the World Health Organization's recommendation. Therefore, more work should be done to strengthen the predictive models for tuberculosis screening in the future, and they should be developed rigorously, considering the heterogeneity of the population in clinical work.
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Affiliation(s)
| | - Gebretsadik Berhe
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| | | | - Afework Mulugeta
- School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
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Dupnik K, Rivera VR, Dorvil N, Akbarnejad H, Gao Y, Liu J, Apollon A, Dumond E, Riviere C, Severe P, Lavoile K, Duran Mendicuti MA, Pierre S, Rouzier V, Walsh KF, Byrne AL, Joseph P, Cremieux PY, Pape JW, Koenig SP. Potential Utility of C-reactive Protein for Tuberculosis Risk Stratification among Patients with Non-Meningitic Symptoms at HIV Diagnosis in Low- and Middle-Income Countries. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.19.23300232. [PMID: 38196598 PMCID: PMC10775334 DOI: 10.1101/2023.12.19.23300232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Article Summary We assessed the association between C-reactive protein (CRP) and Mycobacterium tuberculosis (TB) diagnosis in symptomatic patients at HIV diagnosis. We found that CRP concentrations can improve tuberculosis risk stratification, facilitating decision making about whether (specific) tuberculosis testing is indicated before antiretroviral therapy initiation. Background The World Health Organization recommends initiating same-day ART while tuberculosis testing is underway for patients with non-meningitic symptoms at HIV diagnosis, though safety data are limited. C-reactive protein (CRP) testing may improve tuberculosis risk stratification in this population. Methods In this baseline analysis of 498 adults (>18 years) with tuberculosis symptoms at HIV diagnosis who were enrolled in a trial of rapid ART initiation in Haiti, we describe test characteristics of varying CRP thresholds in the diagnosis of TB. We also assessed predictors of high CRP (≥3 mg/dL) using generalized linear models. Results Eighty-seven (17.5%) patients were diagnosed with baseline TB. The median CRP was 33.0 mg/L (IQR: 5.1, 85.5) in those with TB, and 2.6 mg/L (IQR: 0.8, 11.7) in those without TB. As the CRP threshold increased from ≥1 mg/L to ≥10 mg/L, the positive predictive value for TB increased from 22.4% to 35.4%, and negative predictive value decreased from 96.9% to 92.3%. With CRP thresholds varying from <1 to <10 mg/L, a range from 25.5% to 64.9% of the cohort would have been eligible for same-day ART, and 0.8% to 5.0% would have untreated TB at ART initiation. Conclusions CRP concentrations can be used to improve TB risk stratification, facilitating same-day decisions about ART initiation. Depending on the CRP threshold, one-quarter to two-thirds of patients could be eligible for same-day ART, with a reduction of 3-fold to 20-fold in the proportion with untreated TB, compared with a strategy of same-day ART while awaiting TB test results.
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Wolde HF, Clements ACA, Alene KA. Development and validation of a risk prediction model for pulmonary tuberculosis among presumptive tuberculosis cases in Ethiopia. BMJ Open 2023; 13:e076587. [PMID: 38101842 PMCID: PMC10729072 DOI: 10.1136/bmjopen-2023-076587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/22/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Early diagnosis and treatment of tuberculosis (TB) is one of the key strategies to achieve the WHO End TB targets. This study aimed to develop and validate a simple, convenient risk score to diagnose pulmonary TB among presumptive TB cases. METHODS This prediction model used Ethiopian national TB prevalence survey data and included 5459 presumptive TB cases from all regions of Ethiopia. Logistic regression was used to determine which variables are predictive of pulmonary TB. A risk prediction model was developed, incorporating significant variables (p<0.05). The Youden Index method was used to choose the optimal cut-off point to separate the risk score of the patients as high and low. Model performance was assessed using discrimination power and calibration. Internal validation of the model was assessed using Efron's enhanced bootstrap method, and the clinical utility of the risk score was assessed using decision curve analysis. RESULTS Of total participants, 94 (1.7%) were confirmed to have TB. The final prediction model included three factors with different scores: (1) TB contact history, (2) chest X-ray (CXR) abnormality and (3) two or more symptoms of TB. The optimal cut-off point for the risk score was 6 and was found to have a good discrimination accuracy (c-statistic=0.70, 95% CI: 0.65 to 0.75). The risk score has sensitivity of 51.1%, specificity of 79.9%, positive predictive value of 4.3% and negative predictive value of 98.9%. After internal validation, the optimism coefficient was 0.003, which indicates the model is internally valid. CONCLUSION We developed a risk score that combines TB contact, number of TB symptoms and CXR abnormality to estimate individual risk of pulmonary TB among presumptive TB cases. Though the score is easy to calculate and internally validated, it needs external validation before widespread implementation in a new setting.
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Affiliation(s)
- Haileab Fekadu Wolde
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | | | - Kefyalew Addis Alene
- School of Population Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
- Geospatial and Tuberculosis Research Team, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Dhana A, Gupta RK, Hamada Y, Kengne AP, Kerkhoff AD, Yoon C, Cattamanchi A, Reeve BWP, Theron G, Ndlangalavu G, Wood R, Drain PK, Calderwood CJ, Noursadeghi M, Boyles T, Meintjes G, Maartens G, Barr DA. Clinical utility of WHO-recommended screening tools and development and validation of novel clinical prediction models for pulmonary tuberculosis screening among outpatients living with HIV: an individual participant data meta-analysis. Eur Respir Rev 2023; 32:230021. [PMID: 37286216 PMCID: PMC10245131 DOI: 10.1183/16000617.0021-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/15/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND The World Health Organization (WHO) recommends that outpatient people living with HIV (PLHIV) undergo tuberculosis screening with the WHO four-symptom screen (W4SS) or C-reactive protein (CRP) (5 mg·L-1 cut-off) followed by confirmatory testing if screen positive. We conducted an individual participant data meta-analysis to determine the performance of WHO-recommended screening tools and two newly developed clinical prediction models (CPMs). METHODS Following a systematic review, we identified studies that recruited adult outpatient PLHIV irrespective of tuberculosis signs and symptoms or with a positive W4SS, evaluated CRP and collected sputum for culture. We used logistic regression to develop an extended CPM (which included CRP and other predictors) and a CRP-only CPM. We used internal-external cross-validation to evaluate performance. RESULTS We pooled data from eight cohorts (n=4315 participants). The extended CPM had excellent discrimination (C-statistic 0.81); the CRP-only CPM had similar discrimination. The C-statistics for WHO-recommended tools were lower. Both CPMs had equivalent or higher net benefit compared with the WHO-recommended tools. Compared with both CPMs, CRP (5 mg·L-1 cut-off) had equivalent net benefit across a clinically useful range of threshold probabilities, while the W4SS had a lower net benefit. The W4SS would capture 91% of tuberculosis cases and require confirmatory testing for 78% of participants. CRP (5 mg·L-1 cut-off), the extended CPM (4.2% threshold) and the CRP-only CPM (3.6% threshold) would capture similar percentages of cases but reduce confirmatory tests required by 24, 27 and 36%, respectively. CONCLUSIONS CRP sets the standard for tuberculosis screening among outpatient PLHIV. The choice between using CRP at 5 mg·L-1 cut-off or in a CPM depends on available resources.
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Affiliation(s)
- Ashar Dhana
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rishi K Gupta
- Institute for Global Health, University College London, London, UK
| | - Yohhei Hamada
- Institute for Global Health, University College London, London, UK
- Centre for International Cooperation and Global TB Information, The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan
| | - Andre P Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco, CA, USA
| | - Christina Yoon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Adithya Cattamanchi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
| | - Byron W P Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gcobisa Ndlangalavu
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Robin Wood
- Institute of Infectious Disease and Molecular Medicine (IDM), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Paul K Drain
- Departments of Global Health, Medicine, and Epidemiology, University of Washington, Seattle, WA, USA
| | - Claire J Calderwood
- Institute for Global Health, University College London, London, UK
- Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- The Research Unit Zimbabwe, Biomedical Research and Training Institute, Harare, Zimbabwe
| | - Mahdad Noursadeghi
- Division of Infection and Immunity, University College London, London, UK
| | - Tom Boyles
- Helen Joseph Hospital, Johannesburg, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
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Reeve BW, Ndlangalavu G, Mishra H, Palmer Z, Tshivhula H, Rockman L, Naidoo S, Mbu DL, Naidoo CC, Derendinger B, Walzl G, Malherbe ST, van Helden PD, Semitala FC, Yoon C, Gupta RK, Noursadeghi M, Warren RM, Theron G. Point-of-care C-reactive protein and Xpert MTB/RIF Ultra for tuberculosis screening and diagnosis in unselected antiretroviral therapy initiators: a prospective diagnostic accuracy study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.30.23290716. [PMID: 37333303 PMCID: PMC10274965 DOI: 10.1101/2023.05.30.23290716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Background Tuberculosis (TB), a major cause of death in people living with HIV (PLHIV), remains challenging to diagnose. Diagnostic accuracy data are lacking for promising triage tests, such as C-reactive protein (CRP), and confirmatory tests, such as sputum and urine Xpert MTB/RIF Ultra (Ultra), and urine LAM, without prior symptom selection. Methods 897 PLHIV initiating antiretroviral therapy were consecutively recruited in settings with high TB incidence, irrespective of symptoms. Participants were offered sputum induction, with a liquid culture reference standard. First, we evaluated point-of-care CRP testing on blood, compared to the World Health Organization (WHO)-recommended four-symptom screen (W4SS) for triage (n=800). Second, we evaluated Xpert MTB/RIF Ultra (Ultra) versus Xpert MTB/RIF (Xpert) for sputum-based confirmatory testing (n=787), with or without sputum induction. Third, we evaluated Ultra and Determine LF-LAM for urine-based confirmatory testing (n=732). Findings CRP and number of W4SS symptoms had areas under the receiver operator characteristic curve of 0.78 (95% confidence interval 0.73, 0.83) and 0.70 (0.64, 0.75), respectively. For triage, CRP (≥10 mg/l) has similar sensitivity to W4SS [77% (68, 85) vs. 77% (68, 85); p>0.999] but higher specificity [64% (61, 68) vs. 48% (45, 52); p<0.001]; reducing unnecessary confirmatory testing by 138 per 1000 people and the number-needed-to-test from 6.91 (6.25, 7.81) to 4.87 (4.41, 5.51). Using sputum, which required induction in 31% (24, 39) of people, Ultra had higher sensitivity than Xpert [71% (61, 80) vs. 56% (46, 66); p<0.001] but lower specificity [98% (96, 100) vs. 99% (98, 100); p<0.001]. The proportion of people with ≥1 positive confirmatory result detected by Ultra increased from 45% (26, 64) to 66% (46, 82) when induction was done. Programmatically-done haemoglobin, triage test combinations, and urine tests showed comparatively worse performance. Interpretation Among ART-initiators in a high burden setting, CRP is a more specific triage test than W4SS. Sputum induction improves yield. Sputum Ultra is a more accurate confirmatory test than Xpert. Funding SAMRC (MRC-RFA-IFSP-01-2013), EDCTP2 (SF1401, OPTIMAL DIAGNOSIS), NIH/NIAD (U01AI152087). Research in context Evidence before this study: Novel triage and confirmatory tests are urgently needed for TB, especially in key risk groups like PLHIV. Many TB cases do not meet World Health Organization (WHO)-recommended four-symptom screen (W4SS) criteria despite accounting for significant transmission and morbidity. W4SS also lacks specificity, which makes onward referral of triage-positive people for expensive confirmatory testing inefficient and hampers diagnostic scale-up. Alternative triage approaches like CRP have promise, but have comparatively little data in ART-initiators, especially when done without syndromic preselection and using point-of-care (POC) tools. After triage, confirmatory testing can be challenging due to sputum scarcity and paucibacillary early-stage disease. Next generation WHO-endorsed rapid molecular tests (including Xpert MTB/RIF Ultra; Ultra) are a standard-of-care for confirmatory testing. However, there are no supporting data in ART-initiators, among whom Ultra may offer large sensitivity gains over predecessors like Xpert MTB/RIF (Xpert). The added value of sputum induction to augment diagnostic sampling for confirmatory testing is also unclear. Lastly, the performance of urine tests (Ultra, Determine LF-LAM) in this population requires more data.Added value of this study: We evaluated repurposed and new tests for triage and confirmatory testing using a rigorous microbiological reference standard in a highly vulnerable high-priority patient population (ART-initiators) regardless of symptoms and ability to naturally expectorate sputum. We showed POC CRP triage is feasible, performs better than W4SS, and that combinations of different triage approaches offer no advantages over CRP alone. Sputum Ultra has superior sensitivity to Xpert; often detecting W4SS-negative TB. Furthermore, without induction, confirmatory sputum-based testing would not be possible in a third of people. Urine tests had poor performance. This study contributed unpublished data to systematic reviews and meta-analyses used by the WHO to inform global policy supporting use of CRP triage and Ultra in PLHIV.Implication of all the available evidence: POC CRP triage testing is feasible and superior to W4SS and, together with sputum induction in people who triage CRP-positive should, after appropriate cost and implementation research, be considered for roll-out in ART-initiators in high burden settings. Such people should be offered Ultra, which outperforms Xpert.
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Chen J, Li L, Chen T, Yang X, Ru H, Li X, Yang X, Xie Q, Xu L. Predicting the risk of active pulmonary tuberculosis in people living with HIV: development and validation of a nomogram. BMC Infect Dis 2022; 22:388. [PMID: 35439965 PMCID: PMC9019965 DOI: 10.1186/s12879-022-07368-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 04/07/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diagnosis of pulmonary tuberculosis (PTB) among people living with HIV (PLHIV) was challenging. The study aimed to develop and validated a simple, convenient screening model for prioritizing TB among PLHIV. METHODS The study included eligible adult PLHIV participants who attended health care in Yunnan, China, from January 2016 to July 2019. Participants included before June 2018 were in the primary set; others were in the independent validation set. The research applied the least absolute shrinkage and selection operator regression to identify predictors associated with bacteriological confirmed PTB. The TB nomogram was developed by multivariate logistic regression. The C-index, receiver operating characteristic curve (ROC), the Hosmer-Lemeshow goodness of fit test (H-L), and the calibration curves were applied to evaluate and calibrate the nomogram. The developed nomogram was validated in the validation set. The clinical usefulness was assessed by cutoff analysis and decision curve analysis in the primary set. RESULT The study enrolled 766 PLHIV, of which 507 were in the primary set and 259 in the validation set, 21.5% and 14.3% individuals were confirmed PTB in two sets, respectively. The final nomogram included 5 predictors: current CD 4 cell count, the number of WHO screen tool, previous TB history, pulmonary cavity, and smoking status (p < 0.05). The C-statistic was 0.72 (95% CI 0.66-0.77) in primary set and 0.68 (95% CI 0.58-0.75) in validation set, ROC performed better than other models. The nomogram calibration was good (H-L χ2 = 8.14, p = 0.15). The area under the decision curve (0.025) outperformed the existing models. The optimal cutoff for screening TB among PLHIV was the score of 100 (sensitivity = 0.93, specificity = 0.35). CONCLUSION The study developed and validated a discriminative TB nomogram among PLHIV in the moderate prevalence of TB and HIV. The easy-to-use and straightforward nomogram would be beneficial for clinical practice and rapid risk screening in resource-limited settings.
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Affiliation(s)
- Jinou Chen
- Division of Tuberculosis Control and Prevention, Yunnan Center for Disease Control and Prevention, Kunming, China
| | - Ling Li
- Family Health International Office, Kunming, China
| | - Tao Chen
- Division of Tuberculosis Control and Prevention, Yunnan Center for Disease Control and Prevention, Kunming, China
| | - Xing Yang
- Division of Tuberculosis Control and Prevention, Yunnan Center for Disease Control and Prevention, Kunming, China
| | - Haohao Ru
- Division of Tuberculosis Control and Prevention, Yunnan Center for Disease Control and Prevention, Kunming, China
| | - Xia Li
- Yunnan Provincial Hospital of Infectious Disease, Kunming, China
| | - Xinping Yang
- Yunnan Provincial Hospital of Infectious Disease, Kunming, China
| | - Qi Xie
- Yunnan Provincial Hospital of Infectious Disease, Kunming, China
| | - Lin Xu
- Division of Tuberculosis Control and Prevention, Yunnan Center for Disease Control and Prevention, Kunming, China.
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Dhana A, Hamada Y, Kengne AP, Kerkhoff AD, Rangaka MX, Kredo T, Baddeley A, Miller C, Singh S, Hanifa Y, Grant AD, Fielding K, Affolabi D, Merle CS, Wachinou AP, Yoon C, Cattamanchi A, Hoffmann CJ, Martinson N, Mbu ET, Sander MS, Balcha TT, Skogmar S, Reeve BWP, Theron G, Ndlangalavu G, Modi S, Cavanaugh J, Swindells S, Chaisson RE, Ahmad Khan F, Howard AA, Wood R, Thit SS, Kyi MM, Hanson J, Drain PK, Shapiro AE, Kufa T, Churchyard G, Nguyen DT, Graviss EA, Bjerrum S, Johansen IS, Gersh JK, Horne DJ, LaCourse SM, Al-Darraji HAA, Kamarulzaman A, Kempker RR, Tukvadze N, Barr DA, Meintjes G, Maartens G. Tuberculosis screening among ambulatory people living with HIV: a systematic review and individual participant data meta-analysis. THE LANCET. INFECTIOUS DISEASES 2022; 22:507-518. [PMID: 34800394 PMCID: PMC8942858 DOI: 10.1016/s1473-3099(21)00387-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/24/2021] [Accepted: 06/21/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND The WHO-recommended tuberculosis screening and diagnostic algorithm in ambulatory people living with HIV is a four-symptom screen (known as the WHO-recommended four symptom screen [W4SS]) followed by a WHO-recommended molecular rapid diagnostic test (eg Xpert MTB/RIF [hereafter referred to as Xpert]) if W4SS is positive. To inform updated WHO guidelines, we aimed to assess the diagnostic accuracy of alternative screening tests and strategies for tuberculosis in this population. METHODS In this systematic review and individual participant data meta-analysis, we updated a search of PubMed (MEDLINE), Embase, the Cochrane Library, and conference abstracts for publications from Jan 1, 2011, to March 12, 2018, done in a previous systematic review to include the period up to Aug 2, 2019. We screened the reference lists of identified pieces and contacted experts in the field. We included prospective cross-sectional, observational studies and randomised trials among adult and adolescent (age ≥10 years) ambulatory people living with HIV, irrespective of signs and symptoms of tuberculosis. We extracted study-level data using a standardised data extraction form, and we requested individual participant data from study authors. We aimed to compare the W4SS with alternative screening tests and strategies and the WHO-recommended algorithm (ie, W4SS followed by Xpert) with Xpert for all in terms of diagnostic accuracy (sensitivity and specificity), overall and in key subgroups (eg, by antiretroviral therapy [ART] status). The reference standard was culture. This study is registered with PROSPERO, CRD42020155895. FINDINGS We identified 25 studies, and obtained data from 22 studies (including 15 666 participants; 4347 [27·7%] of 15 663 participants with data were on ART). W4SS sensitivity was 82% (95% CI 72-89) and specificity was 42% (29-57). C-reactive protein (≥10 mg/L) had similar sensitivity to (77% [61-88]), but higher specificity (74% [61-83]; n=3571) than, W4SS. Cough (lasting ≥2 weeks), haemoglobin (<10 g/dL), body-mass index (<18·5 kg/m2), and lymphadenopathy had high specificities (80-90%) but low sensitivities (29-43%). The WHO-recommended algorithm had a sensitivity of 58% (50-66) and a specificity of 99% (98-100); Xpert for all had a sensitivity of 68% (57-76) and a specificity of 99% (98-99). In the one study that assessed both, the sensitivity of sputum Xpert Ultra was higher than sputum Xpert (73% [62-81] vs 57% [47-67]) and specificities were similar (98% [96-98] vs 99% [98-100]). Among outpatients on ART (4309 [99·1%] of 4347 people on ART), W4SS sensitivity was 53% (35-71) and specificity was 71% (51-85). In this population, a parallel strategy (two tests done at the same time) of W4SS with any chest x-ray abnormality had higher sensitivity (89% [70-97]) and lower specificity (33% [17-54]; n=2670) than W4SS alone; at a tuberculosis prevalence of 5%, this strategy would require 379 more rapid diagnostic tests per 1000 people living with HIV than W4SS but detect 18 more tuberculosis cases. Among outpatients not on ART (11 160 [71·8%] of 15 541 outpatients), W4SS sensitivity was 85% (76-91) and specificity was 37% (25-51). C-reactive protein (≥10 mg/L) alone had a similar sensitivity to (83% [79-86]), but higher specificity (67% [60-73]; n=3187) than, W4SS and a sequential strategy (both test positive) of W4SS then C-reactive protein (≥5 mg/L) had a similar sensitivity to (84% [75-90]), but higher specificity than (64% [57-71]; n=3187), W4SS alone; at 10% tuberculosis prevalence, these strategies would require 272 and 244 fewer rapid diagnostic tests per 1000 people living with HIV than W4SS but miss two and one more tuberculosis cases, respectively. INTERPRETATION C-reactive protein reduces the need for further rapid diagnostic tests without compromising sensitivity and has been included in the updated WHO tuberculosis screening guidelines. However, C-reactive protein data were scarce for outpatients on ART, necessitating future research regarding the utility of C-reactive protein in this group. Chest x-ray can be useful in outpatients on ART when combined with W4SS. The WHO-recommended algorithm has suboptimal sensitivity; Xpert for all offers slight sensitivity gains and would have major resource implications. FUNDING World Health Organization.
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Affiliation(s)
- Ashar Dhana
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Yohhei Hamada
- Centre for International Cooperation and Global Tuberculosis Information, The Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association, Tokyo, Japan; Institute for Global Health, University College London, London, UK
| | - Andre P Kengne
- Non-communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Andrew D Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, CA, USA
| | - Molebogeng X Rangaka
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Institute for Global Health, University College London, London, UK
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa; Division of Clinical Pharmacology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Annabel Baddeley
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Cecily Miller
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Satvinder Singh
- Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Yasmeen Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Alison D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Africa Health Research Institute, School of Laboratory Medicine and Medical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Corinne S Merle
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland
| | | | - Christina Yoon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Center for Tuberculosis, University of California, San Francisco, CA, USA
| | - Adithya Cattamanchi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Center for Tuberculosis, University of California, San Francisco, CA, USA
| | | | - Neil Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa; Johns Hopkins University Center for Tuberculosis Research, Baltimore, MD, USA
| | | | | | - Taye T Balcha
- Clinical Infection Medicine, Lund University, Malmö, Sweden; Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Sten Skogmar
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Byron W P Reeve
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Gcobisa Ndlangalavu
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, Western Cape, South Africa
| | - Surbhi Modi
- US Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | | | - Richard E Chaisson
- Johns Hopkins University Center for Tuberculosis Research, Baltimore, MD, USA
| | - Faiz Ahmad Khan
- McGill International Tuberculosis Centre, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Andrea A Howard
- ICAP at Columbia University, New York, NY, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Robin Wood
- Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Swe Swe Thit
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Mar Mar Kyi
- Department of Medicine, University of Medicine 2, Yangon, Yangon Division, Myanmar
| | - Josh Hanson
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Paul K Drain
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Adrienne E Shapiro
- Department of Global Health, University of Washington, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Tendesayi Kufa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Gavin Churchyard
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa; The Aurum Institute, Parktown, South Africa
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Stephanie Bjerrum
- Department of Clinical Research, Infectious Diseases, University of Southern Denmark, Odense, Denmark
| | - Isik S Johansen
- Research Unit for Infectious Diseases, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | | | - David J Horne
- Department of Medicine, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Sylvia M LaCourse
- Department of Medicine, Division of Infectious Diseases, University of Washington, Seattle, WA, USA; Department of Global Health, Division of Infectious Diseases, University of Washington, Seattle, WA, USA
| | | | - Adeeba Kamarulzaman
- Centre of Excellence for Research in AIDS, University of Malaya, Kuala Lumpur, Malaysia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - David A Barr
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Department of Medicine, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa.
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Mendelsohn SC, Fiore-Gartland A, Awany D, Mulenga H, Mbandi SK, Tameris M, Walzl G, Naidoo K, Churchyard G, Scriba TJ, Hatherill M. Clinical predictors of pulmonary tuberculosis among South African adults with HIV. EClinicalMedicine 2022; 45:101328. [PMID: 35274090 PMCID: PMC8902614 DOI: 10.1016/j.eclinm.2022.101328] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/04/2022] [Accepted: 02/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Tuberculosis (TB) clinical prediction rules rely on presence of symptoms, however many undiagnosed cases in the community are asymptomatic. This study aimed to explore the utility of clinical factors in predicting TB among people with HIV not seeking care. Methods Baseline data were analysed from an observational cohort of ambulant adults with HIV in South Africa. Participants were tested for Mycobacterium tuberculosis (Mtb) sensitisation (interferon-γ release assay, IGRA) and microbiologically-confirmed prevalent pulmonary TB disease at baseline, and actively surveilled for incident TB through 15 months. Multivariable LASSO regression with post-selection inference was used to test associations with Mtb sensitisation and TB disease. Findings Between March 22, 2017, and May 15, 2018, 861 participants were enrolled; Among 851 participants included in the analysis, 94·5% were asymptomatic and 45·9% sensitised to Mtb. TB prevalence was 2·0% at baseline and incidence 2·3/100 person-years through 15 months follow-up. Study site was associated with baseline Mtb sensitisation (p < 0·001), prevalent (p < 0·001), and incident TB disease (p = 0·037). Independent of site, higher CD4 counts (per 50 cells/mm3, aOR 1·48, 95%CI 1·12-1·77, p = 0·006) were associated with increased IGRA positivity, and participants without TB disease (aOR 0·80, 95%CI 0·69-0·94, p = 0·006) had reduced IGRA positivity; no variables were independently associated with prevalent TB. Mixed ancestry (aHR 1·49, 95%CI 1·30->1000, p = 0·005) and antiretroviral initiation (aHR 1·48, 95%CI 1·01-929·93, p = 0·023) were independently associated with incident TB. Models incorporating clinical features alone performed poorly in diagnosing prevalent (AUC 0·65, 95%CI 0·44-0·85) or predicting progression to incident (0·67, 0·46-0·88) TB. Interpretation CD4 count and antiretroviral initiation, proxies for immune status and HIV stage, were associated with Mtb sensitisation and TB disease. Inadequate performance of clinical prediction models may reflect predominantly subclinical disease diagnosed in this setting and unmeasured local site factors affecting transmission and progression. Funding The CORTIS-HR study was funded by the Bill & Melinda Gates Foundation (OPP1151915) and by the Strategic Health Innovation Partnerships Unit of the South African Medical Research Council with funds received from the South African Department of Science and Technology. The regulatory sponsor was the University of Cape Town.
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Affiliation(s)
- Simon C. Mendelsohn
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Andrew Fiore-Gartland
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Denis Awany
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Humphrey Mulenga
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Stanley Kimbung Mbandi
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Michèle Tameris
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Gerhard Walzl
- DST/NRF Centre of Excellence for Biomedical TB Research, South African Medical Research Council Centre for TB Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban 4001, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban 4001, South Africa
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg 2194, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg 2193, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN 37232, USA
| | - Thomas J. Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
| | - the CORTIS-HR Study Team
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and Division of Immunology, Department of Pathology, University of Cape Town, Anzio Road, Observatory, Cape Town 7925, South Africa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
- DST/NRF Centre of Excellence for Biomedical TB Research, South African Medical Research Council Centre for TB Research, Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban 4001, South Africa
- MRC-CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Doris Duke Medical Research Institute, University of KwaZulu-Natal, Durban 4001, South Africa
- The Aurum Institute, Johannesburg 2194, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg 2193, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN 37232, USA
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Derivation and external validation of a risk score for predicting HIV-associated tuberculosis to support case finding and preventive therapy scale-up: A cohort study. PLoS Med 2021; 18:e1003739. [PMID: 34491987 PMCID: PMC8454974 DOI: 10.1371/journal.pmed.1003739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 09/21/2021] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Among people living with HIV (PLHIV), more flexible and sensitive tuberculosis (TB) screening tools capable of detecting both symptomatic and subclinical active TB are needed to (1) reduce morbidity and mortality from undiagnosed TB; (2) facilitate scale-up of tuberculosis preventive therapy (TPT) while reducing inappropriate prescription of TPT to PLHIV with subclinical active TB; and (3) allow for differentiated HIV-TB care. METHODS AND FINDINGS We used Botswana XPRES trial data for adult HIV clinic enrollees collected during 2012 to 2015 to develop a parsimonious multivariable prognostic model for active prevalent TB using both logistic regression and random forest machine learning approaches. A clinical score was derived by rescaling final model coefficients. The clinical score was developed using southern Botswana XPRES data and its accuracy validated internally, using northern Botswana data, and externally using 3 diverse cohorts of antiretroviral therapy (ART)-naive and ART-experienced PLHIV enrolled in XPHACTOR, TB Fast Track (TBFT), and Gugulethu studies from South Africa (SA). Predictive accuracy of the clinical score was compared with the World Health Organization (WHO) 4-symptom TB screen. Among 5,418 XPRES enrollees, 2,771 were included in the derivation dataset; 67% were female, median age was 34 years, median CD4 was 240 cells/μL, 189 (7%) had undiagnosed prevalent TB, and characteristics were similar between internal derivation and validation datasets. Among XPHACTOR, TBFT, and Gugulethu cohorts, median CD4 was 400, 73, and 167 cells/μL, and prevalence of TB was 5%, 10%, and 18%, respectively. Factors predictive of TB in the derivation dataset and selected for the clinical score included male sex (1 point), ≥1 WHO TB symptom (7 points), smoking history (1 point), temperature >37.5°C (6 points), body mass index (BMI) <18.5kg/m2 (2 points), and severe anemia (hemoglobin <8g/dL) (3 points). Sensitivity using WHO 4-symptom TB screen was 73%, 80%, 94%, and 94% in XPRES, XPHACTOR, TBFT, and Gugulethu cohorts, respectively, but increased to 88%, 87%, 97%, and 97%, when a clinical score of ≥2 was used. Negative predictive value (NPV) also increased 1%, 0.3%, 1.6%, and 1.7% in XPRES, XPHACTOR, TBFT, and Gugulethu cohorts, respectively, when the clinical score of ≥2 replaced WHO 4-symptom TB screen. Categorizing risk scores into low (<2), moderate (2 to 10), and high-risk categories (>10) yielded TB prevalence of 1%, 1%, 2%, and 6% in the lowest risk group and 33%, 22%, 26%, and 32% in the highest risk group for XPRES, XPHACTOR, TBFT, and Gugulethu cohorts, respectively. At clinical score ≥2, the number needed to screen (NNS) ranged from 5.0 in Gugulethu to 11.0 in XPHACTOR. Limitations include that the risk score has not been validated in resource-rich settings and needs further evaluation and validation in contemporary cohorts in Africa and other resource-constrained settings. CONCLUSIONS The simple and feasible clinical score allowed for prioritization of sensitivity and NPV, which could facilitate reductions in mortality from undiagnosed TB and safer administration of TPT during proposed global scale-up efforts. Differentiation of risk by clinical score cutoff allows flexibility in designing differentiated HIV-TB care to maximize impact of available resources.
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A clinical score for identifying active tuberculosis while awaiting microbiological results: Development and validation of a multivariable prediction model in sub-Saharan Africa. PLoS Med 2020; 17:e1003420. [PMID: 33170838 PMCID: PMC7654801 DOI: 10.1371/journal.pmed.1003420] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 10/14/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In highly resource-limited settings, many clinics lack same-day microbiological testing for active tuberculosis (TB). In these contexts, risk of pretreatment loss to follow-up is high, and a simple, easy-to-use clinical risk score could be useful. METHODS AND FINDINGS We analyzed data from adults tested for TB with Xpert MTB/RIF across 28 primary health clinics in rural South Africa (between July 2016 and January 2018). We used least absolute shrinkage and selection operator regression to identify characteristics associated with Xpert-confirmed TB and converted coefficients into a simple score. We assessed discrimination using receiver operating characteristic (ROC) curves, calibration using Cox linear logistic regression, and clinical utility using decision curves. We validated the score externally in a population of adults tested for TB across 4 primary health clinics in urban Uganda (between May 2018 and December 2019). Model development was repeated de novo with the Ugandan population to compare clinical scores. The South African and Ugandan cohorts included 701 and 106 individuals who tested positive for TB, respectively, and 686 and 281 randomly selected individuals who tested negative. Compared to the Ugandan cohort, the South African cohort was older (41% versus 19% aged 45 years or older), had similar breakdown of biological sex (48% versus 50% female), and had higher HIV prevalence (45% versus 34%). The final prediction model, scored from 0 to 10, included 6 characteristics: age, sex, HIV (2 points), diabetes, number of classical TB symptoms (cough, fever, weight loss, and night sweats; 1 point each), and >14-day symptom duration. Discrimination was moderate in the derivation (c-statistic = 0.82, 95% CI = 0.81 to 0.82) and validation (c-statistic = 0.75, 95% CI = 0.69 to 0.80) populations. A patient with 10% pretest probability of TB would have a posttest probability of 4% with a score of 3/10 versus 43% with a score of 7/10. The de novo Ugandan model contained similar characteristics and performed equally well. Our study may be subject to spectrum bias as we only included a random sample of people without TB from each cohort. This score is only meant to guide management while awaiting microbiological results, not intended as a community-based triage test (i.e., to identify individuals who should receive further testing). CONCLUSIONS In this study, we observed that a simple clinical risk score reasonably distinguished individuals with and without TB among those submitting sputum for diagnosis. Subject to prospective validation, this score might be useful in settings with constrained diagnostic resources where concern for pretreatment loss to follow-up is high.
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Kiyasseh D, Zhu T, Clifton D. The Promise of Clinical Decision Support Systems Targetting Low-Resource Settings. IEEE Rev Biomed Eng 2020; 15:354-371. [PMID: 32813662 DOI: 10.1109/rbme.2020.3017868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Low-resource clinical settings are plagued by low physician-to-patient ratios and a shortage of high-quality medical expertise and infrastructure. Together, these phenomena lead to over-burdened healthcare systems that under-serve the needs of the community. Alleviating this burden can be undertaken by the introduction of clinical decision support systems (CDSSs); systems that support stakeholders (ranging from physicians to patients) within the clinical setting in their day-to-day activities. Such systems, which have proven to be effective in the developed world, remain to be under-explored in low-resource settings. This review attempts to summarize the research focused on clinical decision support systems that either target stakeholders within low-resource clinical settings or diseases commonly found in such environments. When categorizing our findings according to disease applications, we find that CDSSs are predominantly focused on dealing with bacterial infections and maternal care, do not leverage deep learning, and have not been evaluated prospectively. Together, these highlight the need for increased research in this domain in order to impact a diverse set of medical conditions and ultimately improve patient outcomes.
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Nayak SS, Shetty MV, Pai CG, Guruprasad KP, Satyamoorthy K. Apoptosis in peripheral blood lymphocytes in intestinal tuberculosis and Crohn's disease: Implications to diagnostic differentiation. Indian J Gastroenterol 2020; 39:338-345. [PMID: 32803718 DOI: 10.1007/s12664-019-01011-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 12/24/2019] [Indexed: 02/04/2023]
Abstract
AIM Intestinal tuberculosis (ITb) and Crohn's disease (CD) mimic each other often leading to misdiagnosis. We evaluated the difference between ITb and CD using the extent of apoptosis in peripheral blood lymphocytes. METHODS CD4+ cells as a percentage of the lymphocytes and viable, dead, total apoptotic, early apoptotic, and late apoptotic CD4+ cells were assessed in the peripheral blood by flow cytometry in healthy controls and patients with confirmed active ITb and CD prior to initiating therapy. Early apoptotic and total apoptotic cells were further expressed as a proportion of the percentage of CD4+ cells. RESULTS The percentages of CD4+ cells (6.5 [3.0, 8.7] vs. 13.40 [10.15, 13.40]; p < 0.001), total apoptotic cells (0.13 [0.0, 0.22] vs. 0.08 [0.0, 0.21]; p = 0.045), early apoptotic (1.24 [0.55, 2.54] vs. 0.71 [0.40, 1.30]; p = 0.037), and the proportion of the latter two parameters (17.18 [5.61, 57.33] vs. 4.84 [2.71, 9.83]; p-value 0.039) and (17.18 [7.4, 67.50] vs. 5.51 [3.10, 11.03]; p-value 0.036) were significantly different between patients with ITb and CD. The best sensitivity, specificity, and positive and negative predictive values for the diagnosis of ITb were seen with the CD4+ cell percentage (82.6%, 82.4%, 86.4%, 77.8%, respectively) and the proportion of early apoptotic cells (73.9%, 70.6%, 77.3%, 66.7%, respectively). CONCLUSION CD4+ cells as a percentage of peripheral blood lymphocytes and the proportion of early apoptotic CD4+ cells show promise to diagnostic differentiation between ITb and CD.
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Affiliation(s)
- Suprabha Suresh Nayak
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576 104, India
| | - Mamatha Vishwanatha Shetty
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576 104, India
| | - Cannanore Ganesh Pai
- Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576 104, India.
| | - Kanive Parashiva Guruprasad
- School of Life Sciences, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576 104, India
| | - Kapaettu Satyamoorthy
- School of Life Sciences, Kasturba Medical College, Manipal Academy of Higher Education, Manipal 576 104, India
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Kerkhoff AD, Longley N, Kelly N, Cross A, Vogt M, Wood R, Hermans S, Lawn SD, Harrison TS. Determine TB-LAM point-of-care tuberculosis assay predicts poor outcomes in outpatients during their first year of antiretroviral therapy in South Africa. BMC Infect Dis 2020; 20:555. [PMID: 32736601 PMCID: PMC7393716 DOI: 10.1186/s12879-020-05227-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Determine TB-LAM is the first point-of-care test (POC) for HIV-associated tuberculosis (TB) and rapidly identifies TB in those at high-risk for short-term mortality. While the relationship between urine-LAM and mortality has been previously described, the outcomes of those undergoing urine-LAM testing have largely been assessed during short follow-up periods within diagnostic accuracy studies. We therefore sought to assess the relationship between baseline urine-LAM results and subsequent hospitalization and mortality under real-world conditions among outpatients in the first year of ART. METHODS Consecutive, HIV-positive adults with a CD4 count < 100 cells/uL presenting for ART initiation were enrolled. TB diagnoses and outcomes (hospitalization, loss-to-follow and mortality) were recorded during the first year following enrolment. Baseline urine samples were retrospectively tested using the urine-LAM POC assay. Kaplan Meier survival curves were used to assess the cumulative probability of hospitalization or mortality in the first year of follow-up, according to urine-LAM status. Cox regression analyses were performed to determine independent predictors of hospitalization and mortality at three months and one year of follow-up. RESULTS 468 patients with a median CD4 count of 59 cells/uL were enrolled. There were 140 patients (29.9%) with newly diagnosed TB in the first year of follow-up of which 79 (56.4%) were microbiologically-confirmed. A total of 18% (n = 84) required hospital admission and 12.2% (n = 57) died within a year of study entry. 38 out of 468 (8.1%) patients retrospectively tested urine-LAM positive - including 19.0% of those with microbiologically-proven TB diagnoses (n = 15/79) and 23.0% (n = 14/61) of those with clinical-only TB diagnoses; 9 of 38 (23.7%) of patients retrospectively testing LAM positive were never diagnosed with TB under routine program conditions. Among all patients (n = 468) in the first year of follow-up, a positive urine-LAM result was strongly associated with all-cause hospitalization and mortality with a corresponding adjusted hazard ratio (aHR) of 3.7 (95%CI, 1.9-7.1) and 2.6 (95%, 1.2-5.7), respectively. CONCLUSIONS Systematic urine-LAM testing among ART-naïve HIV-positive outpatients with CD4 counts < 100 cells/uL detected TB cases that were missed under routine programme conditions and was highly predictive for subsequent hospitalization and mortality in the first year of ART.
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Affiliation(s)
- Andrew D. Kerkhoff
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California, San Francisco, San Francisco, California USA
| | - Nicky Longley
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Institute of Infection and Immunity, St George’s University of London, London, UK
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicola Kelly
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Anna Cross
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Monica Vogt
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Robin Wood
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Sabine Hermans
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Global Health, Academic Medical Centre, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands
| | - Stephen D. Lawn
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Thomas S. Harrison
- Institute of Infection and Immunity, St George’s University of London, London, UK
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Maokola W, Ngowi B, Lawson L, Mahande M, Todd J, Msuya SE. Performance of and Factors Associated With Tuberculosis Screening and Diagnosis Among People Living With HIV: Analysis of 2012-2016 Routine HIV Data in Tanzania. Front Public Health 2020; 7:404. [PMID: 32117844 PMCID: PMC7015871 DOI: 10.3389/fpubh.2019.00404] [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] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 12/18/2019] [Indexed: 12/15/2022] Open
Abstract
People Living with HIV (PLHIV) should be screened for tuberculosis (TB) at every visit to the HIV care and treatment clinic (CTC), and those with positive results on screening should undergo further diagnostic investigations. We evaluated the performance of the TB diagnosis cascade among PLHIV attending CTC between January 2012 and December 2016 in three regions of Tanzania: Dar es Salaam, Iringa, and Njombe. We used descriptive epidemiology to evaluate performance and logistic regression to determine odds ratios (OR) for factors associated with TB screening and further TB diagnosis after positive TB screening. We analyzed 169,741 PLHIV who made 2,638,876 visits to CTC between January 2012 and December 2016. We excluded 2,074 (0.80%) visits as these involved PLHIV enrolled in CTC with a prior TB disease diagnosis. Of the 2,636,802 visits, 2,524,494 (95.67%) had TB screening according to national guidelines, of which 88,028 (3.49%) had TB screening positive results. Of the 88,028 visits with a positive TB screening, 27,810 (31.59%) had no records for further TB diagnosis following positive TB screening. Of all visits with positive TB screening, 32,986 (37.50%) had a TB disease diagnosis. On multivariate logistic regression, those who visited with World Health Organization (WHO) clinical stage four (aOR = 3.61, 95% CI 3.48–3.75, P < 0.001), enrolled in health center (aOR = 1.26, 95% CI 1.24–1.29, P < 0.001), enrolled in Iringa region (aOR = 1.54, 95% CI 1.50–1.57, P < 0.001), and enrolled in 2015 (aOR = 1.20, 95% CI 1.18–1.24, P < 0.001) were more likely to have no TB screening. Visits involving those who were of the female sex (aOR = 1.14, 95% CI 1.11–1.18, P < 0.001), enrolled in Njombe region (aOR = 4.36, 95% CI 4.09–4.65, P < 0.001), and enrolled in 2016 (aOR = 2.62, 95% CI 2.49–2.77, P < 0.001) were more likely to have no further TB diagnosis after positive TB screening. The study documented high performance of TB screening for PLHIV in HIV CTCs but a low transition of presumptive TB case undergoing further investigations. Better systems are needed for ensuring presumptive TB cases are diagnosed including using more efficient diagnostic methods like Gene pert.
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Affiliation(s)
- Werner Maokola
- National AIDS Control Program/Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania.,Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi Urban, Tanzania
| | - Bernard Ngowi
- National Institute of Medical Research, Dar es Salaam, Tanzania
| | | | - Michael Mahande
- Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi Urban, Tanzania
| | - Jim Todd
- Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi Urban, Tanzania.,London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sia E Msuya
- Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi Urban, Tanzania
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Boyles TH, Nduna M, Pitsi T, Scott L, Fox MP, Maartens G. A Clinical Prediction Score Including Trial of Antibiotics and C-Reactive Protein to Improve the Diagnosis of Tuberculosis in Ambulatory People With HIV. Open Forum Infect Dis 2020; 7:ofz543. [PMID: 32042850 PMCID: PMC7000838 DOI: 10.1093/ofid/ofz543] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/02/2020] [Indexed: 11/15/2022] Open
Abstract
Background The use of a “trial of antibiotics” as empiric therapy for bacterial pneumonia as a diagnostic tool for tuberculosis in people with HIV (PWH) was removed from World Health Organization (WHO) recommendations in 2007, based on expert opinion. Current guidelines recommend antibiotics only after 2 Xpert MTB/RIF tests (if available), chest x-ray, and clinical assessment have suggested that tuberculosis is unlikely. Despite this, a “trial of antibiotics” remains common in algorithms in low-resource settings, but its value is uncertain. C-reactive protein (CRP), which has been proposed as a “rule-out” test for tuberculosis, may be an objective marker of response to antibiotics. Methods We performed a passive case-finding cohort study of adult PWH with a positive WHO symptom screen. All participants received antibiotics at first visit according to the local protocol and were reviewed to ascertain clinical response. Point-of-care CRP was measured at both visits. All patients had sputum tested with Xpert MTB/RIF Ultra (Ultra), and the reference standard was based on 2 sputum mycobacterial cultures. We explored multivariable prediction models (MPM) for tuberculosis based on 1 or 2 visits. Results Seventy-five of 207 patients (36%) had confirmed tuberculosis. Clinical response to antibiotics after 2 days was a good predictor of disease. An MPM based on 2 visits, without CRP, had acceptable discrimination (c-statistic, 0.75) and calibration (goodness-of-fit P = .07). Addition of CRP after antibiotics improved the model moderately (c-statistic, 0.78). CRP at first visit was not an independent predictor of tuberculosis. Conclusions In adult PWH seeking care for symptoms suggestive of tuberculosis, lack of response to antibiotics is a strong predictor of disease and is likely to be useful, particularly when access to Ultra is limited. CRP adds value when measured after antibiotics but is of limited value at first visit.
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Affiliation(s)
- Tom H Boyles
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Matilda Nduna
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Thalitha Pitsi
- Hillbrow Community Healthcare Clinic, Johannesburg, South Africa
| | - Lesley Scott
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA.,Department of Internal Medicine, Health Economics and Epidemiology Research Office, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Jensen SB, Rudolf F, Wejse C. Utility of a clinical scoring system in prioritizing TB investigations - a systematic review. Expert Rev Anti Infect Ther 2019; 17:475-488. [PMID: 31159621 DOI: 10.1080/14787210.2019.1625770] [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: 10/26/2022]
Abstract
Introduction: Tuberculosis (TB) is among the 10 most common causes of death worldwide and it is the leading cause of mortality in people with human immunodeficiency virus (HIV). Clinical scoring systems have the potential to improve case finding and to prioritize patients for TB testing. Areas covered: This systematic review investigated the utility of prediction models to improve pulmonary tuberculosis (pTB) case finding. Studies were searched through PubMed until 15th of August 2018 and 20 studies were eligible according to the inclusion criteria. Data on study population, outcome measurements, predictors, and performance were extracted. Many studies showed promising results but lacked external validation. Furthermore, head-to-head studies are needed to compare the different prediction models. Sensitivities of the prediction models ranged from 26% to 96% and specificities from 18% to 92%, negative likelihood ratios (LR-) from 0.22 to 0.8 and positive likelihood ratios(LR+) 1.07 to 7.32. Composite scores including paraclinical measures added to sensitivity. Expert opinion: TB case finding is of utmost importance to advance the quest for global TB elimination, and simple measures to identify high-risk populations or persons to undergo further diagnostic evaluation are highly needed. A number of clinical scores are available and could be implemented in practice to improve case finding.
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Affiliation(s)
- Signe Bernth Jensen
- a GloHAU, Center for Global Health, Department of Public Health , Aarhus University , Aarhus , Denmark
| | - Frauke Rudolf
- b Department of Infectious Diseases , Aarhus University Hospital , Aarhus , Denmark.,c Bandim Health Project , Statens Serum Institute , Bissau , Guinea Bissau
| | - Christian Wejse
- a GloHAU, Center for Global Health, Department of Public Health , Aarhus University , Aarhus , Denmark.,b Department of Infectious Diseases , Aarhus University Hospital , Aarhus , Denmark.,c Bandim Health Project , Statens Serum Institute , Bissau , Guinea Bissau
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20
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Olsson O, Björkman P, Jansson M, Balcha TT, Mulleta D, Yeba H, Valfridsson C, Carlsson F, Skogmar S. Plasma Profiles of Inflammatory Markers Associated With Active Tuberculosis in Antiretroviral Therapy-Naive Human Immunodeficiency Virus-Positive Individuals. Open Forum Infect Dis 2019; 6:ofz015. [PMID: 30800697 PMCID: PMC6379652 DOI: 10.1093/ofid/ofz015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 01/21/2019] [Indexed: 01/29/2023] Open
Abstract
Background Diagnosis of tuberculosis (TB) in human immunodeficiency virus (HIV)-coinfected individuals is challenging. We hypothesized that combinations of inflammatory markers could facilitate identification of active TB in HIV-positive individuals. Methods Participants were HIV-positive, treatment-naive adults systematically investigated for TB at Ethiopian health centers. Plasma samples from 130 subjects with TB (HIV+/TB+) and 130 subjects without TB (HIV+/TB−) were tested for concentration of the following markers: CCL5, C-reactive protein (CRP), interleukin (IL)-6, IL12-p70, IL-18, IL-27, interferon-γ-induced protein-10 (IP-10), procalcitonin (PCT), and soluble urokinase-type plasminogen activator receptor (suPAR). Analyzed markers were then assessed, either individually or in combination, with regard to infection status, CD4 cell count, and HIV ribonucleic acid (RNA) levels. Results The HIV+/TB+ subjects had higher levels of all markers, except IL12p70, compared with HIV+/TB− subjects. The CRP showed the best performance for TB identification (median 27.9 vs 1.8 mg/L for HIV+/TB+ and HIV+/TB−, respectively; area under the curve [AUC]: 0.80). Performance was increased when CRP was combined with suPAR analysis (AUC, 0.83 [0.93 for subjects with CD4 cell count <200 cells/mm3]). Irrespective of TB status, IP-10 concentrations correlated with HIV RNA levels, and both IP-10 and IL-18 were inversely correlated to CD4 cell counts. Conclusions Although CRP showed the best single marker discriminatory potential, combining CRP and suPAR analyses increased performance for TB identification.
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Affiliation(s)
- Oskar Olsson
- Department of Translational Medicine, Clinical Infection Medicine, Lund University, Malmö, Sweden
| | - Per Björkman
- Department of Translational Medicine, Clinical Infection Medicine, Lund University, Malmö, Sweden
| | - Marianne Jansson
- Department of Laboratory Medicine, Division of Medical Microbiology, Lund University, Sweden
| | - Taye Tolera Balcha
- Department of Translational Medicine, Clinical Infection Medicine, Lund University, Malmö, Sweden.,Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | | | - Christine Valfridsson
- Department of Experimental Medical Science, Section for Immunology, Lund University, Sweden
| | - Fredric Carlsson
- Department of Experimental Medical Science, Section for Immunology, Lund University, Sweden.,Department of Biology, Section for Molecular Cell Biology, Lund University, Sweden
| | - Sten Skogmar
- Department of Translational Medicine, Clinical Infection Medicine, Lund University, Malmö, Sweden
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Hanifa Y, Toro Silva S, Karstaedt A, Sahid F, Charalambous S, Chihota VN, Churchyard GJ, von Gottberg A, McCarthy K, Nicol MP, Ndlovu NT, Stevens W, Fielding KL, Grant AD. What causes symptoms suggestive of tuberculosis in HIV-positive people with negative initial investigations? Int J Tuberc Lung Dis 2019; 23:157-165. [PMID: 30678747 PMCID: PMC6394279 DOI: 10.5588/ijtld.18.0251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE: To identify the causes of symptoms suggestive of tuberculosis (TB) among people living with the human immunodeficiency virus (PLHIV) in South Africa. METHODS: A consecutive sample of HIV clinic attendees with symptoms suggestive of TB (⩾1 of cough, weight loss, fever or night sweats) at enrolment and at 3 months, and negative initial TB investigations, were systematically evaluated with standard protocols and diagnoses assigned using standard criteria. TB was ‘confirmed’ if Mycobacterium tuberculosis was identified within 6 months of enrolment, and ‘clinical’ if treatment started without microbiological confirmation. RESULTS: Among 103 participants, 50/103 were preantiretroviral therapy (ART) and 53/103 were on ART; respectively 68% vs. 79% were female; the median age was 35 vs. 45 years; the median CD4 count was 311 vs. 508 cells/mm3. Seventy-two (70%) had ⩾5% measured weight loss and 50 (49%) had cough. The most common final diagnoses were weight loss due to severe food insecurity (n = 20, 19%), TB (n = 14, 14%: confirmed n = 7; clinical n = 7), other respiratory tract infection (n = 14, 14%) and post-TB lung disease (n = 9, 9%). The basis for TB diagnosis was imaging (n = 7), bacteriological confirmation from sputum (n = 4), histology, lumbar puncture and other (n = 1 each). CONCLUSION: PLHIV with persistent TB symptoms require further evaluation for TB using all available modalities, and for food insecurity in those with weight loss.
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Affiliation(s)
- Y Hanifa
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - S Toro Silva
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, University of the Witwatersrand, Johannesburg
| | - F Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, University of the Witwatersrand, Johannesburg
| | - S Charalambous
- The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - V N Chihota
- The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - G J Churchyard
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK, The Aurum Institute, Johannesburg, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Advancing Care and Treatment for TB-HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Tygerberg
| | - A von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | | | - M P Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, National Health Laboratory Service, Johannesburg
| | | | - W Stevens
- National Health Laboratory Service, Johannesburg, Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg
| | - K L Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A D Grant
- TB Centre, London School of Hygiene & Tropical Medicine, London, UK, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, Africa Health Research Institute, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
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22
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Thorman J, Björkman P, Tesfaye F, Jeylan A, Balcha TT, Reepalu A. Validation of the Viral Load Testing Criteria - an algorithm for targeted viral load testing in HIV-positive adults receiving antiretroviral therapy. Trop Med Int Health 2019; 24:356-362. [PMID: 30624826 DOI: 10.1111/tmi.13201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Restricted capacity for viral load (VL) testing is a major obstacle for antiretroviral therapy (ART) programmes in high-burden regions. Algorithms for targeted VL testing could help allocate laboratory resources rationally. We validated the performance of the Viral Load Testing Criteria (VLTC), an algorithm with satisfactory performance in derivation (sensitivity 91%, specificity 43%). METHODS HIV-positive adults who had been receiving first-line ART for ≥12 months at three Ethiopian public ART clinics were included. Healthcare providers collected data on variables of the VLTC: current CD4 count, mid-upper arm circumference (MUAC) and self-reported treatment interruption. VL testing was performed in parallel. Performance of the algorithm for identification of patients with VL ≥ 1000 copies/ml was evaluated. RESULTS Of 562 patients (female 62%, median ART duration 92 months), 33 (6%) had VL ≥ 1000 copies/ml. Sensitivity for the VLTC was 85% (95% CI, 68-95), specificity 60% (95% CI, 55-64), positive predictive value 12% (95% CI, 10-14) and negative predictive value 98% (95% CI, 97-99). Use of the algorithm would reduce the number of VL tests required by 57%. Misclassification occurred in 5/33 (15%) of subjects with VL ≥ 1000 copies/ml. CONCLUSION In validation, the VLTC performed similarly well as derivation. Use of the VLTC may be considered for targeted VL testing for ART monitoring in high-burden regions.
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Affiliation(s)
- Johannes Thorman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Per Björkman
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Fregenet Tesfaye
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
| | | | - Taye Tolera Balcha
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden.,Armauer Hansen Research Institute, Addis Abeba, Ethiopia
| | - Anton Reepalu
- Clinical Infection Medicine, Department of Translational Medicine, Lund University, Malmö, Sweden
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23
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Reepalu A, Balcha TT, Skogmar S, Isberg PE, Medstrand P, Björkman P. Development of an algorithm for determination of the likelihood of virological failure in HIV-positive adults receiving antiretroviral therapy in decentralized care. Glob Health Action 2018; 10:1371961. [PMID: 28914169 PMCID: PMC5645660 DOI: 10.1080/16549716.2017.1371961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Early identification of virological failure (VF) limits occurrence and spread of drug-resistant viruses in patients receiving antiretroviral treatment (ART). Viral load (VL) monitoring is therefore recommended, but capacities to comply with this are insufficient in many low-income countries. Clinical algorithms might identify persons at higher likelihood of VF to allocate VL resources. Objectives: We aimed to construct a VF algorithm (the Viral Load Testing Criteria; VLTC) and compare its performance to the 2013 WHO treatment failure criteria. Methods: Subjects with VL results available 1 year after ART start (n = 494) were identified from a cohort of ART-naïve adults (n = 812), prospectively recruited and followed 2011–2015 at Ethiopian health centres. VF was defined as VL≥1000 copies/mL. Variables recorded at the time of sampling, with potential association with VF, were used to construct the algorithm based on multivariate logistic regression. Results: Fifty-seven individuals (12%) had VF, which was independently associated with CD4 count <350 cells/mm3, previous ART interruption, and short mid-upper arm circumference (<24cm and <23cm, for men and women, respectively). These variables were included in the VLTC. In derivation, the VLTC identified 52/57 with VF; sensitivity 91%, specificity 43%, positive predictive value (PPV) 17%, negative predictive value (NPV) 97%. In comparison, the WHO criteria identified 38/57 with VF (sensitivity 67%, specificity 74%, PPV 25%, NPV 94%). Conclusions: The VLTC identified subjects at greater likelihood of VF, with higher sensitivity and NPV than the WHO criteria. If external validation confirms this performance, these criteria could be used to allocate limited VL resources. Due to its limited specificity, it cannot be used to determine treatment failure in the absence of a confirmatory viral load.
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Affiliation(s)
- Anton Reepalu
- a Clinical Infection Medicine, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Taye Tolera Balcha
- a Clinical Infection Medicine, Department of Translational Medicine , Lund University , Malmö , Sweden.,b Armauer Hansen Research Institute , Addis Ababa , Ethiopia
| | - Sten Skogmar
- a Clinical Infection Medicine, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Per-Erik Isberg
- c Department of Statistics , Lund University , Lund , Sweden
| | - Patrik Medstrand
- d Clinical Virology, Department of Translational Medicine , Lund University , Malmö , Sweden
| | - Per Björkman
- a Clinical Infection Medicine, Department of Translational Medicine , Lund University , Malmö , Sweden
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24
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Hamada Y, Lujan J, Schenkel K, Ford N, Getahun H. Sensitivity and specificity of WHO's recommended four-symptom screening rule for tuberculosis in people living with HIV: a systematic review and meta-analysis. THE LANCET HIV 2018; 5:e515-e523. [DOI: 10.1016/s2352-3018(18)30137-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 04/09/2023]
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25
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Hanifa Y, Fielding KL, Chihota VN, Adonis L, Charalambous S, Foster N, Karstaedt A, McCarthy K, Nicol MP, Ndlovu NT, Sinanovic E, Sahid F, Stevens W, Vassall A, Churchyard GJ, Grant AD. A clinical scoring system to prioritise investigation for tuberculosis among adults attending HIV clinics in South Africa. PLoS One 2017; 12:e0181519. [PMID: 28771504 PMCID: PMC5542442 DOI: 10.1371/journal.pone.0181519] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 06/21/2017] [Indexed: 12/23/2022] Open
Abstract
Background The World Health Organization (WHO) recommendation for regular tuberculosis (TB) screening of HIV-positive individuals with Xpert MTB/RIF as the first diagnostic test has major resource implications. Objective To develop a diagnostic prediction model for TB, for symptomatic adults attending for routine HIV care, to prioritise TB investigation. Design Cohort study exploring a TB testing algorithm. Setting HIV clinics, South Africa. Participants Representative sample of adult HIV clinic attendees; data from participants reporting ≥1 symptom on the WHO screening tool were split 50:50 to derive, then internally validate, a prediction model. Outcome TB, defined as “confirmed” if Xpert MTB/RIF, line probe assay or M. tuberculosis culture were positive; and “clinical” if TB treatment started without microbiological confirmation, within six months of enrolment. Results Overall, 79/2602 (3.0%) participants on ART fulfilled TB case definitions, compared to 65/906 (7.2%) pre-ART. Among 1133/3508 (32.3%) participants screening positive on the WHO tool, 1048 met inclusion criteria for this analysis: 52/515 (10.1%) in the derivation and 58/533 (10.9%) in the validation dataset had TB. Our final model comprised ART status (on ART > 3 months vs. pre-ART or ART < 3 months); body mass index (continuous); CD4 (continuous); number of WHO symptoms (1 vs. >1 symptom). We converted this to a clinical score, using clinically-relevant CD4 and BMI categories. A cut-off score of ≥3 identified those with TB with sensitivity and specificity of 91.8% and 34.3% respectively. If investigation was prioritised for individuals with score of ≥3, 68% (717/1048) symptomatic individuals would be tested, among whom the prevalence of TB would be 14.1% (101/717); 32% (331/1048) of tests would be avoided, but 3% (9/331) with TB would be missed amongst those not tested. Conclusion Our clinical score may help prioritise TB investigation among symptomatic individuals.
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Affiliation(s)
- Yasmeen Hanifa
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Violet N Chihota
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Nicola Foster
- Health Economics Unit, School of public health and family medicine, University of Cape Town, Cape Town, South Africa
| | - Alan Karstaedt
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | | | - Mark P Nicol
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,National Health Laboratory Service, Johannesburg, South Africa
| | | | - Edina Sinanovic
- Health Economics Unit, School of public health and family medicine, University of Cape Town, Cape Town, South Africa
| | - Faieza Sahid
- Department of Medicine, Chris Hani Baragwanath Hospital, Johannesburg, South Africa.,University of the Witwatersrand, Johannesburg, South Africa
| | - Wendy Stevens
- National Health Laboratory Service, Johannesburg, South Africa.,Department of Molecular Medicine and Haematology, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anna Vassall
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Gavin J Churchyard
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,The Aurum Institute, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Advancing Treatment and Care for TB/HIV, South African Medical Research Council Collaborating Centre for HIV and TB, Johannesburg, South Africa
| | - Alison D Grant
- London School of Hygiene & Tropical Medicine, London, United Kingdom.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,School of Nursing and Public Health, Africa Health Research Institute, University of KwaZulu-Natal, Durban, South Africa
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26
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Bjerrum S, Bonsu F, Hanson-Nortey NN, Kenu E, Johansen IS, Andersen AB, Bjerrum L, Jarbøl D, Munck A. Tuberculosis screening in patients with HIV: use of audit and feedback to improve quality of care in Ghana. Glob Health Action 2016; 9:32390. [PMID: 27569593 PMCID: PMC5002398 DOI: 10.3402/gha.v9.32390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Tuberculosis screening of people living with HIV (PLHIV) can contribute to early tuberculosis diagnosis and improved patient outcomes. Evidence-based guidelines for tuberculosis screening are available, but literature assessing their implementation and the quality of clinical practice is scarce. OBJECTIVES To assess tuberculosis screening practices and the effectiveness of audit and performance feedback to improve quality of tuberculosis screening at HIV care clinics in Ghana. DESIGN Healthcare providers at 10 large HIV care clinics prospectively registered patient consultations during May and October 2014, before and after a performance feedback intervention in August 2014. The outcomes of interest were overall tuberculosis suspicion rate during consultations and provider adherence to the International Standards for Tuberculosis Care and the World Health Organizations' guidelines for symptom-based tuberculosis screening among PLHIV. RESULTS Twenty-one healthcare providers registered a total of 2,666 consultations; 1,368 consultations before and 1,298 consultations after the feedback intervention. Tuberculosis suspicion rate during consultation increased from 12.6 to 20.9% after feedback (odds ratio, OR 1.83; 95% confidence interval, CI: 1.09-3.09). Before feedback, sputum smear microscopy was requested for 58.7% of patients with suspected tuberculosis, for 47.2% of patients with cough ≥2 weeks, and for 27.5% of patients with a positive World Health Organization (WHO) symptom screen (any of current cough, fever, weight loss or night sweats). After feedback, patients with a positive WHO symptom screen were more likely to be suspected of tuberculosis (OR 2.21; 95% CI: 1.19-4.09) and referred for microscopy (OR 2.71; 95% CI: 1.25-5.86). CONCLUSIONS A simple prospective audit tool identified flaws in clinical practices for tuberculosis screening of PLHIV. There was no systematic identification of people with suspected active tuberculosis. We found low initial tuberculosis suspicion rate compounded by low referral rates of relevant patients for sputum smear microscopy. Adherence to recommended standards and guidelines for tuberculosis screening improved after performance feedback.
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Affiliation(s)
- Stephanie Bjerrum
- Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark;
| | - Frank Bonsu
- National Tuberculosis Control Programme, Disease Control and Prevention Department, Ghana Health Services, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Nii Nortey Hanson-Nortey
- National Tuberculosis Control Programme, Disease Control and Prevention Department, Ghana Health Services, Korle-Bu Teaching Hospital, Accra, Ghana
| | - Ernest Kenu
- Department of Medicine-Fevers Unit, Korle-Bu Teaching Hospital, Accra, Ghana
- School of Public Health, University of Ghana, Legon, Accra, Ghana
| | | | - Aase Bengaard Andersen
- Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Bjerrum
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Dorte Jarbøl
- Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Anders Munck
- Department of Public Health, University of Southern Denmark, Odense, Denmark
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Reepalu A, Balcha TT, Skogmar S, Güner N, Sturegård E, Björkman P. Factors Associated with Early Mortality in HIV-Positive Men and Women Investigated for Tuberculosis at Ethiopian Health Centers. PLoS One 2016; 11:e0156602. [PMID: 27272622 PMCID: PMC4896420 DOI: 10.1371/journal.pone.0156602] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/17/2016] [Indexed: 11/19/2022] Open
Abstract
Introduction Despite increasing access to antiretroviral treatment (ART) in low-income countries, HIV-related mortality is high, especially in the first months following ART initiation. We aimed to evaluate the impact of TB coinfection on early mortality and to assess gender-specific predictors of mortality in a cohort of Ethiopian adults subjected to intensified casefinding for active TB before starting ART. Material and Methods Prospectively recruited ART-eligible adults (n = 812, 58.6% female) at five Ethiopian health centers were followed for 6 months. At inclusion sputum culture, Xpert MTB/RIF, and smear microscopy were performed (158/812 [19.5%] had TB). Primary outcome was all-cause mortality. We used multivariate Cox models to identify predictors of mortality. Results In total, 37/812 (4.6%) participants died, 12 (32.4%) of whom had TB. Karnofsky performance score (KPS) and mid-upper arm circumference (MUAC) were associated with mortality in the whole population. However, the associations were different in men and women. In men, only MUAC remained associated with mortality (adjusted hazard ratio [aHR] 0.71 [95% CI 0.57–0.88]). In women, KPS <80% was associated with mortality (aHR 10.95 [95% CI 2.33–51.49]), as well as presence of cough (aHR 3.98 [95% CI 1.10–14.36]). Cough was also associated with mortality for TB cases (aHR 8.30 [95% CI 1.06–65.14]), but not for non-TB cases. Conclusions In HIV-positive Ethiopian adults managed at health centers, mortality was associated with reduced performance score and malnutrition, with different distribution with regard to gender and TB coinfection. These robust variables could be used at clinic registration to identify persons at increased risk of early mortality.
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Affiliation(s)
- Anton Reepalu
- Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
- * E-mail:
| | - Taye Tolera Balcha
- Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
- Ministry of Health, Addis Ababa, Ethiopia
| | - Sten Skogmar
- Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
| | - Nuray Güner
- Region Skåne Competence Center, Skåne University Hospital, Lund, Sweden
| | - Erik Sturegård
- Medical Microbiology, Department of Laboratory Medicine, Malmö, Lund University, Lund, Sweden
| | - Per Björkman
- Infectious Diseases Research Unit, Department of Clinical Sciences, Faculty of Medicine, Lund University, Malmö, Sweden
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28
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Balcha TT, Skogmar S, Sturegård E, Björkman P, Winqvist N. Outcome of tuberculosis treatment in HIV-positive adults diagnosed through active versus passive case-finding. Glob Health Action 2015; 8:27048. [PMID: 25819037 PMCID: PMC4377322 DOI: 10.3402/gha.v8.27048] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 02/25/2015] [Accepted: 02/27/2015] [Indexed: 11/14/2022] Open
Abstract
Background The World Health Organization strongly recommends regular screening for tuberculosis (TB) in HIV-positive individuals. Objective To compare the outcome of anti-tuberculosis treatment (ATT) in HIV-positive adults diagnosed with TB through active case-finding (ACF) or passive case-finding (PCF). Design Antiretroviral therapy (ART)-naïve adults diagnosed with TB were included from two prospective cohort studies conducted in Ethiopia between September 2010 and March 2013. The PCF cohort was based at out-patient TB clinics, whereas participants in the ACF cohort were actively screened for TB by bacteriological sputum testing (smear microscopy, Xpert MTB/RIF assay, and liquid culture) without pre-selection on the basis of symptoms and signs. Outcomes of ATT were compared between participants in the two cohorts; characteristics at diagnosis and predictors of adverse outcomes were analysed. Results Among 439 TB/HIV co-infected participants, 307 and 132 belonged to PCF and ACF cohorts, respectively. Compared with the ACF participants, hemoptysis, conjunctival pallor, bedridden status, and low mid upper-arm circumference (MUAC) were significantly more common in participants identified through PCF. Sputum smear-positivity rates among pulmonary TB cases were 44.2% and 21.1% in the PCF and ACF cohorts, respectively (p<0.001). Treatment success was ascertained in 247 (80.5%) of the participants in the PCF cohort and 102 (77.2%) of the participants in the ACF cohorts (p=0.223). Low MUAC (p=0.001) independently predicted mortality in the participants in both cohorts. Conclusion Although patients identified through ACF had less advanced TB disease, ATT outcome was similar to the patients identified through PCF. To achieve a better outcome, case management in ACF strategy should be strengthened through enhanced patient-centred counselling and adherence support.
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Affiliation(s)
- Taye T Balcha
- Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Ministry of Health, Addis Ababa, Ethiopia;
| | - Sten Skogmar
- Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Erik Sturegård
- Clinical Microbiology, Regional and University Laboratories, Region Skåne, Sweden
| | - Per Björkman
- Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Niclas Winqvist
- Infectious Disease Research Unit, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Regional Department of Infectious Disease Control and Prevention, Malmö, Sweden
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