1
|
Cherkos AS, LaCourse SM, Enquobahrie DA, Escudero JN, Mecha J, Matemo D, Kinuthia J, Iribarren SJ, John-Stewart G. Isoniazid preventive therapy during infancy does not adversely affect growth among HIV-exposed uninfected children: Secondary analysis of data from a randomized controlled trial. PLoS One 2024; 19:e0293708. [PMID: 39150949 PMCID: PMC11329125 DOI: 10.1371/journal.pone.0293708] [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: 11/09/2023] [Accepted: 04/08/2024] [Indexed: 08/18/2024] Open
Abstract
BACKGROUND Isoniazid preventive therapy (IPT) decreases risk of tuberculosis (TB) disease; impact on long-term infant growth is unknown. In a recent randomized trial (RCT), we assessed IPT effects on infant growth without known TB exposure. METHODS The infant TB Infection Prevention Study (iTIPS) trial was a non-blinded RCT among HIV-exposed uninfected (HEU) infants in Kenya. Inclusion criteria included age 6-10 weeks, birthweight ≥2.5 kg, and gestation ≥37 weeks. Infants in the IPT arm received 10 mg/kg isoniazid daily for 12 months, while the control trial received no intervention; post-trial observational follow-up continued through 24 months of age. We used intent-to-treat linear mixed-effects models to compare growth rates (weight-for-age z-score [WAZ] and height-for-age z-score [HAZ]) between trial arms. RESULTS Among 298 infants, 150 were randomized to IPT, 47.6% were females, median birthweight was 3.4 kg (interquartile range [IQR] 3.0-3.7), and 98.3% were breastfed. During the 12-month intervention period and 12-month post-RCT follow-up, WAZ and HAZ declined significantly in all children, with more HAZ decline in male infants. There were no growth differences between trial arms, including in sex-stratified analyses. In longitudinal linear analysis, mean WAZ (β = 0.04 [95% CI:-0.14, 0.22]), HAZ (β = 0.14 [95% CI:-0.06, 0.34]), and WHZ [β = -0.07 [95% CI:-0.26, 0.11]) z-scores were similar between arms as were WAZ and HAZ growth trajectories. Infants randomized to IPT had higher monthly WHZ increase (β to 24 months 0.02 [95% CI:0.01, 0.04]) than the no-IPT arm. CONCLUSION IPT administered to HEU infants did not significantly impact growth outcomes in the first two years of life.
Collapse
Affiliation(s)
- Ashenafi Shumey Cherkos
- Department of Population and Community Health, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, United States of America
| | - Sylvia M. LaCourse
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Daniel A. Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Jaclyn N. Escudero
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
| | - Jerphason Mecha
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Daniel Matemo
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Sarah J. Iribarren
- Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, United States of America
| | - Grace John-Stewart
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, United States of America
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| |
Collapse
|
2
|
Kakande E, Ssekyanzi B, Abbott R, Ariho W, Nattabi G, Landsiedel K, Temple J, Chamie G, Havlir DV, Kamya MR, Charlebois ED, Balzer LB, Marquez C. Prevalence and Predictors of Tuberculosis Infection in Children and Adolescents in Rural Uganda: A Cross-sectional Study. Pediatr Infect Dis J 2024:00006454-990000000-00946. [PMID: 39018476 DOI: 10.1097/inf.0000000000004475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/19/2024]
Abstract
BACKGROUND Much of the latent tuberculosis (TB) reservoir is established in childhood and adolescence. Yet, age-specific data on prevalence and predictors of infection in this population are sparse and needed to guide prevention and case finding. METHODS From December 2021 to June 2023, we measured TB infection in children 1-17 years in 25 villages in rural Southwestern Uganda. We defined TB infection as a positive QuantiFERON Gold Plus Test (QFT). We estimated overall and age-stratified population-level prevalence and adjusted risk ratios (aRR) of TB infection for individual, household, and community-based predictors, accounting for age, TB contact, and clustering by household. RESULTS Estimated TB infection prevalence was 9.6% [95% confidence interval (CI): 8.7-10.5%] among the 5789 participants, and prevalence varied slightly with age. Household-level risk factors included crowding (aRR: 1.25, 95% CI: 1.03-1.53), indoor cooking (aRR: 1.62, 95% CI: 1.14-2.30), living with ≥2 persons who drink alcohol (aRR: 1.47, 95% CI: 1.04-2.07). The predominant community-based risk factor was child mobility (aRR: 1.67, 95% CI: 1.24-2.26). In age-stratified analyses, household predictors were important in early childhood but not adolescence, where mobility was predominant (aRR: 1.66, 95% CI: 1.13-2.44). CONCLUSION We detected a high prevalence of TB infection in children and adolescents in rural Uganda. On a population level, TB risk factors change throughout the early life course, with child mobility a key risk factor in adolescence. Age-specific TB case finding and prevention strategies that address both household and extra-household risk factors are needed to address TB transmission.
Collapse
Affiliation(s)
- Elijah Kakande
- From the Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Bob Ssekyanzi
- From the Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Rachel Abbott
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, California
| | - Willington Ariho
- From the Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Gloria Nattabi
- From the Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Kirsten Landsiedel
- Division of Biostatistics, University of California, Berkeley, Berkeley, California
| | - Jennifer Temple
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, California
| | - Gabriel Chamie
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, California
| | - Diane V Havlir
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, California
| | - Moses R Kamya
- From the Infectious Diseases Research Collaboration, Kampala, Uganda
- Department of Medicine, School of Medicine, Makerere University, Kampala, Uganda
| | - Edwin D Charlebois
- Department of Medicine, Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, San Francisco, California
| | - Laura B Balzer
- Division of Biostatistics, University of California, Berkeley, Berkeley, California
| | - Carina Marquez
- Department of Medicine, Division of HIV, ID and Global Medicine, University of California, San Francisco, California
| |
Collapse
|
3
|
Marquez C, Atukunda M, Nugent J, Charlebois ED, Chamie G, Mwangwa F, Ssemmondo E, Kironde J, Kabami J, Owaraganise A, Kakande E, Ssekaynzi B, Abbott R, Ayieko J, Ruel T, Kwariisima D, Kamya M, Petersen M, Havlir DV, Balzer LB. Community-Wide Universal HIV Test and Treat Intervention Reduces Tuberculosis Transmission in Rural Uganda: A Cluster-Randomized Trial. Clin Infect Dis 2024; 78:1601-1607. [PMID: 38226445 PMCID: PMC11175690 DOI: 10.1093/cid/ciad776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) treatment reduces tuberculosis (TB) disease and mortality; however, the population-level impact of universal HIV-test-and-treat interventions on TB infection and transmission remain unclear. METHODS In a sub-study nested in the SEARCH trial, a community cluster-randomized trial (NCT01864603), we assessed whether a universal HIV-test-and-treat intervention reduced population-level incident TB infection in rural Uganda. Intervention communities received annual, population-level HIV testing and patient-centered linkage. Control communities received population-level HIV testing at baseline and endline. We compared estimated incident TB infection by arms, defined by tuberculin skin test conversion in a cohort of persons aged 5 and older, adjusting for participation and predictors of infection, and accounting for clustering. RESULTS Of the 32 trial communities, 9 were included, comprising 90 801 participants (43 127 intervention and 47 674 control). One-year cumulative incidence of TB infection was 16% in the intervention and 22% in the control; SEARCH reduced the population-level risk of incident TB infection by 27% (adjusted risk ratio = 0.73; 95% confidence interval [CI]: .57-.92, P = .005). In pre-specified analyses, the effect was largest among children aged 5-11 years and males. CONCLUSIONS A universal HIV-test-and-treat intervention reduced incident TB infection, a marker of population-level TB transmission. Investments in community-level HIV interventions have broader population-level benefits, including TB reductions.
Collapse
Affiliation(s)
- Carina Marquez
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | | | - Joshua Nugent
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Edwin D Charlebois
- Center for AIDS Prevention Studies (CAPS), University of California, San Francisco, California, USA
| | - Gabriel Chamie
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | | | | | - Joel Kironde
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Elijah Kakande
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Bob Ssekaynzi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Rachel Abbott
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - James Ayieko
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Theodore Ruel
- Department of Pediatrics, University of California, San Francisco, California, USA
| | | | - Moses Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- School of Medicine, Makerere University, Kampala, Uganda
| | - Maya Petersen
- Division of Biostatistics, School of Public Health University of California, Berkeley, California, USA
| | - Diane V Havlir
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, California, USA
| | - Laura B Balzer
- Division of Biostatistics, School of Public Health University of California, Berkeley, California, USA
| |
Collapse
|
4
|
Cherkos AS, Cranmer LM, Njuguna I, LaCourse SM, Mugo C, Moraa H, Maleche-Obimbo E, Enquobahrie DA, Richardson BA, Wamalwa D, John-Stewart G. Effect of tuberculosis-HIV co-treatment on clinical and growth outcomes among hospitalized children newly initiating antiretroviral therapy. AIDS 2024; 38:579-588. [PMID: 38016160 PMCID: PMC10922257 DOI: 10.1097/qad.0000000000003797] [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] [Indexed: 11/30/2023]
Abstract
OBJECTIVE Evaluate effects of tuberculosis (TB)-HIV co-treatment on clinical and growth outcomes in children with HIV (CHIV). DESIGN Longitudinal study among Kenyan hospitalized ART-naive CHIV in the PUSH trial (NCT02063880). METHODS CHIV started ART within 2 weeks of enrollment; Anti-TB therapy was initiated based on clinical and TB diagnostics. Children were followed for 6 months with serial viral load, CD4%, and growth assessments [weight-for-age z -score (WAZ), height-for-age z -score (HAZ), and weight-for-height z -score (WHZ)]. TB-ART treated and ART-only groups were compared at 6 months post-ART for undetectable viral load (<40 c/ml), CD4% change, and growth using generalized linear models, linear regression, and linear mixed-effects models, respectively. RESULT Among 152 CHIV, 40.8% (62) were TB-ART treated. Pre-ART, median age was 2.0 years and growth was significantly lower, and viral load significantly higher in the TB-ART versus ART-only group. After 6 months on ART, 37.2% of CHIV had undetectable viral load and median CD4% increased by 7.2% (IQR 2.0-11.6%) with no difference between groups. The TB-ART group had lower WAZ and HAZ over 6 month follow-up [WAZ -0.81 (95% CI: -1.23 to -0.38], P < 0.001; HAZ -0.15 (95% CI: -0.29 to -0.01), P = 0.030] and greater rate of WAZ increase in analyses unadjusted and adjusted for baseline WAZ [unadjusted 0.62 (95% CI: 0.18-1.07, P = 0.006) or adjusted 0.58 (95% CI: 0.12-1.03, P = 0.013)]. CONCLUSION TB-HIV co-treatment did not adversely affect early viral suppression and CD4 + recovery post-ART. TB-ART-treated CHIV had more rapid growth reconstitution, but growth deficits persisted, suggesting need for continued growth monitoring.
Collapse
Affiliation(s)
- Ashenafi S Cherkos
- Department of Population and Community Health, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX
| | - Lisa M Cranmer
- Department of Pediatrics, Emory School of Medicine
- Department of Epidemiology, Emory Rollins School of Public Health
- Children's Healthcare of Atlanta, Atlanta, GA
| | - Irene Njuguna
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Sylvia M LaCourse
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Cyrus Mugo
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Hellen Moraa
- Department of Pediatrics and Child Health, University of Nairobi, Kenya
| | | | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
| | - Barbra A Richardson
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, School of Public Health
| | - Dalton Wamalwa
- Department of Pediatrics and Child Health, University of Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA
- Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| |
Collapse
|
5
|
Mecha J, Escudero JN, Richardson BA, Maleche-Obimbo E, Matemo D, Kinuthia J, John-Stewart G, LaCourse SM. Maternal HIV Status and Risk of Infant Mycobacterium tuberculosis Infection as Measured by Tuberculin Skin Test. Pediatr Infect Dis J 2024; 43:250-256. [PMID: 37991383 PMCID: PMC10922277 DOI: 10.1097/inf.0000000000004190] [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] [Indexed: 11/23/2023]
Abstract
BACKGROUND The effect of maternal HIV on infant Mycobacterium tuberculosis (Mtb) infection risk is not well-characterized. METHODS Pregnant women with/without HIV and their infants were enrolled in a longitudinal cohort in Kenya. Mothers had interferon gamma-release assays (QFT-Plus) and tuberculin skin tests (TST) at enrollment in pregnancy; children underwent TST at 12 and 24 months of age. We estimated the incidence and correlates of infant TST-positivity using Cox proportional hazards regression. RESULTS Among 322 infants, 170 (53%) were HIV-exposed and 152 (47%) were HIV-unexposed. Median enrollment age was 6.6 weeks [interquartile range (IQR): 6.1-10.0]; most received Bacillus Calmette-Guerin (320, 99%). Thirty-nine (12%) mothers were TST-positive; 102 (32%) were QFT-Plus-positive. Among HIV-exposed infants, 154 (95%) received antiretrovirals for HIV prevention and 141 (83%) of their mothers ever received isoniazid preventive therapy (IPT). Cumulative 24-month infant Mtb infection incidence was 3.6/100 person-years (PY) [95% confidence interval (CI): 2.4-5.5/100 PY]; 5.4/100 PY in HIV-exposed infants (10%, 17/170) versus 1.7/100 PY in HIV-unexposed infants (3.3%, 5/152) [hazard ratio (HR): 3.1 (95% CI: 1.2-8.5)]. More TST conversions occurred in the first versus second year of life [5.8 vs. 2.0/100 PY; HR: 2.9 (95% CI: 1.0-10.1)]. Infant TST-positivity was associated with maternal TST-positivity [HR: 2.9 (95% CI: 1.1-7.4)], but not QFT-Plus-positivity. Among HIV-exposed children, Mtb infection incidence was similar regardless of maternal IPT. CONCLUSIONS Mtb infection incidence (by TST) by 24 months of age was ~3-fold higher among HIV-exposed children, despite high maternal IPT uptake. Overall, more TST conversions occurred in the first 12 months compared to 12-24 months of age, similar in both HIV-exposed and HIV-unexposed children.
Collapse
Affiliation(s)
- Jerphason Mecha
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Elizabeth Maleche-Obimbo
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, USA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Reproductive Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Sylvia M. LaCourse
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| |
Collapse
|
6
|
Cherkos AS, LaCourse SM, Enquobahrie DA, Escudero JN, Mecha J, Matemo D, Kinuthia J, John-Stewart G. Isoniazid preventive therapy during infancy does not adversely effect growth among HIV-exposed uninfected children: secondary analysis of data from a randomized controlled trial. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.19.23297259. [PMID: 37905041 PMCID: PMC10614991 DOI: 10.1101/2023.10.19.23297259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Background Isoniazid preventive therapy (IPT) decreases risk of tuberculosis (TB) disease; impact on long-term infant growth is unknown. In a recent randomized trial (RCT), we assessed IPT effects on infant growth without known TB exposure. Methods The infant TB Infection Prevention Study (iTIPS) trial was a non-blinded RCT among HIV-exposed uninfected (HEU) infants in Kenya. Inclusion criteria included age 6-10 weeks, birthweight ≥2.5 kg, and gestation ≥37 weeks. Infants in the IPT arm received 10 mg/kg isoniazid daily for 12 months, while the control trial received no intervention; post-trial observational follow-up continued through 24 months of age. We used intent-to-treat linear mixed-effects models to compare growth rates (weight-for-age z-score [WAZ] and height-for-age z-score [HAZ]) between trial arms. Results Among 298 infants, 150 were randomized to IPT, 47.6% were females, median birthweight was 3.4 kg (interquartile range [IQR] 3.0-3.7), and 98.3% were breastfed. During the 12-month intervention period and 12-month post-RCT follow-up, WAZ and HAZ declined significantly in all children, with more HAZ decline in male infants. There were no growth differences between trial arms, including in sex-stratified analyses. In longitudinal linear analysis, mean WAZ (β=0.04 [95% CI:-0.14, 0.22]), HAZ (β=0.14 [95% CI:-0.06, 0.34]), and WHZ [β=-0.07 [95% CI: -0.26, 0.11]) z-scores were similar between arms as were WAZ and HAZ growth trajectories. Infants randomized to IPT had higher monthly WHZ increase (β to 24 months 0.02 [95% CI:0.01, 0.04]) than the no-IPT arm. Conclusion IPT administered to HEU infants did not significantly impact growth outcomes in the first two years of life.
Collapse
Affiliation(s)
- Ashenafi S Cherkos
- Biostatistics and Epidemiology Department, School of Public Health, University of North Texas Health Science Center, Fort Worth, Texas, USA
| | - Sylvia M LaCourse
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Jaclyn N Escudero
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, USA
| | - Jerphason Mecha
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Daniel Matemo
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace John-Stewart
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, Washington, USA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| |
Collapse
|
7
|
Iwase SC, Edlefsen PT, Bhebhe L, Motsumi K, Moyo S, Happel AU, Shao D, Mmasa N, Schenkel S, Gasper MA, Dubois M, Files MA, Seshadri C, Duffy F, Aitchison J, Netea MG, Jao J, Cameron DW, Gray CM, Jaspan HB, Powis KM. T-SPOT.TB Reactivity in Southern African Children With and Without in Utero Human Immunodeficiency Virus Exposure. Clin Infect Dis 2023; 77:1133-1136. [PMID: 37293702 PMCID: PMC10573724 DOI: 10.1093/cid/ciad356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/29/2023] [Accepted: 06/08/2023] [Indexed: 06/10/2023] Open
Abstract
Infants who are human immunodeficiency virus (HIV)-exposed uninfected (iHEU) experience higher risk of infectious morbidity than infants HIV-unexposed uninfected (iHUU). We compared tuberculosis (TB) infection prevalence in 418 Bacillus Calmette-Guérin vaccinated sub-Saharan African iHEU and iHUU aged 9-18 months using T-SPOT.TB. Prevalence of TB infection was low and did not differ by HIV exposure status.
Collapse
Affiliation(s)
- Saori C Iwase
- Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Paul T Edlefsen
- Vaccine and Infectious Disease Division, Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Lynnette Bhebhe
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Kesego Motsumi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Anna-Ursula Happel
- Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Danica Shao
- Vaccine and Infectious Disease Division, Statistical Center for HIV/AIDS Research and Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Nicholas Mmasa
- Surgical Department, County Durham and Darlington NHS Trust, Darlington Memorial Hospital, Darlington, United Kingdom
| | - Sara Schenkel
- Division of Pediatric Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Melanie A Gasper
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Melanie Dubois
- Division of Pediatric Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Megan A Files
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Chetan Seshadri
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Fergal Duffy
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - John Aitchison
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Immunology and Metabolism, Life & Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Jennifer Jao
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Pediatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Donald W Cameron
- Divisions of Infectious Diseases and Respirology, University of Ottawa at the Ottawa Hospital, Ottawa, Canada
| | - Clive M Gray
- Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Division of Molecular Biology and Human Genetics, Biomedical Research Institute, Stellenbosch University, Cape Town, South Africa
| | - Heather B Jaspan
- Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Center for Global Infectious Disease Research, Seattle Children’s Research Institute, Seattle, Washington, USA
| | - Kathleen M Powis
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Departments of Internal Medicine and Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
8
|
Gupta A, Singh P, Aaron L, Montepiedra G, Chipato T, Stranix-Chibanda L, Chanaiwa V, Vhembo T, Mutambanengwe M, Masheto G, Raesi M, Bradford S, Golner A, Costello D, Kulkarni V, Shayo A, Kabugho E, Jean-Phillippe P, Chakhtoura N, Sterling TR, Theron G, Weinberg A. Timing of maternal isoniazid preventive therapy on tuberculosis infection among infants exposed to HIV in low-income and middle-income settings: a secondary analysis of the TB APPRISE trial. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:708-717. [PMID: 37634517 PMCID: PMC10883460 DOI: 10.1016/s2352-4642(23)00174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/18/2023] [Accepted: 07/03/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Infants born to women with HIV in settings with a high tuberculosis burden are at risk of tuberculosis infection and rapid progression to active disease. Maternal isoniazid preventive therapy might mitigate this risk, but optimal timing of therapy remains unclear. The TB APPRISE trial showed that initiation of isoniazid during pregnancy resulted in more frequent adverse pregnancy outcomes than when initiated postpartum. We aimed to determine the proportion of infants testing positive for tuberculosis infection born to mothers who initiated isoniazid therapy antepartum compared with postpartum using two commonly used tests, the test agreement, and predictors of test positivity. METHODS TB APPRISE was a randomised, double-blind, placebo-controlled, non-inferiority trial done at 13 study sites across eight countries (Botswana, Haiti, India, South Africa, Tanzania, Thailand, Uganda, and Zimbabwe). Pregnant women with HIV on antiretroviral therapy were randomly assigned to receive immediate isoniazid preventive therapy (28 weeks isoniazid [300 mg daily], then placebo until week 40 after delivery) or deferred treatment (placebo until week 12 after delivery, then isoniazid [300 mg daily] for 28 weeks). Mother-infant pairs were followed up until 48 weeks after delivery. We included all liveborn infants with a tuberculin skin test or interferon-γ release assay (IGRA) at 44 weeks. The outcomes assessed in this secondary analysis were tuberculosis test positivity by study group, test agreement, and predictors of test positivity. This study was registered with ClinicalTrials.gov, NCT01494038. FINDINGS Between Aug 19, 2014, and April 4, 2016, 956 mothers were randomly assigned, and 749 mother-child pairs were included in this secondary analysis. Of 749 infants, 694 (93%) received Bacille Calmette-Guérin (BCG) vaccination, 675 (90%) were born to mothers who had completed isoniazid treatment, 20 (3%) were exposed to tuberculosis, seven (1%) became HIV positive, and one (<1%) developed probable tuberculosis. 43 (6%; 95% CI 4-8]) of 732 infants had a positive IGRA test result and 55 (8%; 6-10) of 727 infants had a positive tuberculin skin test result. Test positivity did not differ by study group (p=0·88 for IGRA; p=0·44 for tuberculin skin test). Test agreement was poor (κ=0·107 [95% CI 0·002-0·212]). Infant tuberculin skin test positivity was associated with breastfeeding (adjusted odds ratio 6·63 [95% CI 1·57-27·9]), BCG vaccination (4·97 [1·50-16·43]), and maternal tuberculin skin test positivity at delivery (3·28 [1·70-6·33]); IGRA positivity was associated with female sex (2·09 [1·06-4·14]). INTERPRETATION Deferral of maternal isoniazid preventive therapy to early postpartum had no effect on infant tuberculosis acquisition in our trial population, regardless of the diagnostic test used; however, tuberculosis test agreement is poor during infancy. FUNDING US National Institutes of Health.
Collapse
Affiliation(s)
- Amita Gupta
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Priya Singh
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lisa Aaron
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Tsungai Chipato
- Faculty of Medicine and Health Sciences, Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Lynda Stranix-Chibanda
- Faculty of Medicine and Health Sciences, Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Vongai Chanaiwa
- Faculty of Medicine and Health Sciences, Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Tichaona Vhembo
- Faculty of Medicine and Health Sciences, Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | - Mercy Mutambanengwe
- Faculty of Medicine and Health Sciences, Clinical Trials Research Centre, University of Zimbabwe, Harare, Zimbabwe
| | | | - Mpho Raesi
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | | | - Vandana Kulkarni
- Byramjee Jeejeebhoy Government College-Johns Hopkins Clinical Research Site, Pune, India
| | - Aisa Shayo
- Kilimanjaro Christian Medical Center, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Enid Kabugho
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Patrick Jean-Phillippe
- Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Nahida Chakhtoura
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | | | - Gerhard Theron
- Department of Obstetrics and Gynecology, Family Centre for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Adriana Weinberg
- University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
9
|
Malhotra A, Nonyane BAS, Shirey E, Mulder C, Hippner P, Mulatu F, Ratshinanga A, Mitiku P, Cohn S, Conradie G, Chihota V, Chaisson RE, Churchyard GJ, Golub J, Dowdy D, Sohn H, Charalambous S, Bedru A, Salazar-Austin N. Pragmatic cluster-randomized trial of home-based preventive treatment for TB in Ethiopia and South Africa (CHIP-TB). Trials 2023; 24:475. [PMID: 37491264 PMCID: PMC10367260 DOI: 10.1186/s13063-023-07514-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/16/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Each year, 1 million children develop TB resulting in over 200,000 child deaths. TB preventive treatment (TPT) is highly effective in preventing TB but remains poorly implemented for household child contacts. Home-based child contact management and TPT services may improve access to care. In this study, we aim to evaluate the effectiveness and cost-effectiveness of home-based contact management with TPT initiation in two TB high-burden African countries, Ethiopia and South Africa. METHODS This pragmatic cluster randomized trial compares home-based versus facility-based care delivery models for contact management. Thirty-six clinics with decentralized TB services (18 in Ethiopia and 18 in South Africa) were randomized in a 1:1 ratio to conduct either home-based or facility-based contact management. The study will attempt to enroll all eligible close child contacts of infectious drug-sensitive TB index patients diagnosed and treated for TB by one of the study clinics. Child TB contact management, including contact tracing, child evaluation, and TPT initiation and follow-up, will take place in the child's home for the intervention arm and at the clinic for the control arm. The primary outcome is the cluster-level ratio of the number of household child contacts less than 15 years of age in Ethiopia and less than 5 years of age in South Africa initiated on TPT per index patient, comparing the intervention to the control arm. Secondary outcomes include child contact identification and the TB prevention continuum of care. Other implementation outcomes include acceptability, feasibility, fidelity, cost, and cost-effectiveness of the intervention. DISCUSSION This implementation research trial will determine whether home-based contact management identifies and initiates more household child contacts on TPT than facility-based contact management. TRIAL REGISTRATION NCT04369326 . Registered on April 30, 2020.
Collapse
Affiliation(s)
- Akash Malhotra
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bareng Aletta Sanny Nonyane
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Evan Shirey
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christiaan Mulder
- Department of TB Elimination and Health System Innovations, KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Piotr Hippner
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | | | | | | | - Silvia Cohn
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Violet Chihota
- The Aurum Institute, Parktown, Johannesburg, South Africa
| | - Richard E Chaisson
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gavin J Churchyard
- The Aurum Institute, Parktown, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Jonathan Golub
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David Dowdy
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hojoon Sohn
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Salome Charalambous
- The Aurum Institute, Parktown, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
- Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Nicole Salazar-Austin
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| |
Collapse
|
10
|
LaCourse SM, Escudero JN, Mecha J, Warr AJ, Richardson BA, Carimo N, Cranmer LM, Maleche-Obimbo E, Matemo D, Kinuthia J, Hawn TR, John-Stewart G. Cumulative Mycobacterium tuberculosis Infection Incidence (Measured Primarily by Tuberculin Skin Test) Among Infants With Human Immunodeficiency Virus Exposure: Observational Follow-up of an Isoniazid Prophylaxis Trial. Clin Infect Dis 2022; 75:2253-2256. [PMID: 35607710 PMCID: PMC10200296 DOI: 10.1093/cid/ciac393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/05/2022] [Accepted: 05/17/2022] [Indexed: 01/19/2023] Open
Abstract
Cumulative 24-month Mycobacterium tuberculosis infection incidence (measured primarily by tuberculin skin test [TST]) was high among human immunodeficiency virus exposed but uninfected infants (8.7 [95% confidence interval, 6.3-11.9] per 100 person-years). Trend for decreased TST positivity among infants at trial end (12 months postenrollment) randomized to isoniazid at 6 weeks of age was not sustained through observational follow-up to 24 months of age. CLINICAL TRIALS REGISTRATION NCT02613169.
Collapse
Affiliation(s)
- Sylvia M LaCourse
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Jerphason Mecha
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - A J Warr
- Department of Pediatrics and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Naziat Carimo
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Lisa M Cranmer
- Division of Infectious Diseases, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Elizabeth Maleche-Obimbo
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Pediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daniel Matemo
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Medical Research Department, Kenyatta National Hospital, Nairobi, Kenya
- Department of Reproductive Health, Kenyatta National Hospital, Nairobi, Kenya
| | - Thomas R Hawn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| |
Collapse
|
11
|
Cranmer LM, Cotton MF, Day CL, Nemes E. What's Old and New in Tuberculosis Vaccines for Children. J Pediatric Infect Dis Soc 2022; 11:S110-S116. [PMID: 36314550 PMCID: PMC9620432 DOI: 10.1093/jpids/piac078] [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] [Indexed: 11/05/2022]
Abstract
Tuberculosis (TB) is a leading cause of global child mortality. Until the turn of the 21st century, Mycobacterium bovis bacille Calmette-Guerin (BCG) was the only vaccine to prevent TB. The pediatric TB vaccine pipeline has advanced in the past decade to include the evaluation of novel whole cell vaccines to replace infant BCG and investigation of subunit and whole cell vaccines to boost TB immunity during adolescence. We describe the history of BCG, current TB vaccine candidates in clinical trials, and the challenges and opportunities for future TB vaccine research in children. Children are a critical target population for TB vaccines, and expansion of the pediatric TB vaccine pipeline is urgently needed to end the TB pandemic.
Collapse
Affiliation(s)
- Lisa M Cranmer
- Department of Pediatrics, Division of Pediatric Infectious Disease, Emory School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Mark F Cotton
- Department of Pediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - Cheryl L Day
- Department of Microbiology & Immunology, Emory School of Medicine, Atlanta, Georgia, USA
- Emory Vaccine Center, Atlanta, Georgia, USA
| | - Elisa Nemes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
12
|
Teunissen CE, Rohlwink U, Pajkrt D, Naudé PJW. Biomarkers of Tuberculous Meningitis and Pediatric Human Immunodeficiency Virus on the African Continent. Front Neurol 2022; 13:793080. [PMID: 35665032 PMCID: PMC9160376 DOI: 10.3389/fneur.2022.793080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
Biomarkers in body fluids are helpful objective tools in diagnosis, prognosis and monitoring of (therapeutic) responses of many neurological diseases. Cerebrospinal fluid (CSF) biomarkers are part of the diagnostic toolbox for infectious neurological diseases. Tuberculous meningitis (TBM) and Human immunodeficiency virus (HIV), are important burdens of disease in Africa and can negatively affect brain health. Two thirds of the world's population of people living with HIV reside in sub-Saharan Africa and 25% of the global burden of tuberculosis (TB) is carried by the African continent. Neuroinflammation and damage of specific neuronal cell types are key constituents in the pathophysiology of these central nervous system (CNS) diseases, and important potential sources of circulating biomarkers. In this review, we summarize current research in the use of biomarkers in TBM and pediatric HIV as case demonstrations for high prevalence neurological diseases in Africa. Inflammatory molecules, primarily when detected in CSF, appear to have diagnostic value in these diseases, especially when measured as profiles. Brain injury molecules, such as S100, Neuron specific enolase and glial fibrillary acidic protein may have prognostic value in TBM, but more studies are needed. There is a need for more cost-economic and high sensitivity technologies to drive further biomarker discoveries and translate into healthcare improvements for these important healthcare problems in a globally fair way.
Collapse
Affiliation(s)
- Charlotte Elisabeth Teunissen
- Neurochemistry Laboratory, Department of Clinical Chemistry, Amsterdam Neuroscience, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, Netherlands
| | - Ursula Rohlwink
- Division of Neurosurgery, Neuroscience Institute, Department of Surgery, University of Cape Town, Cape Town, South Africa
- The Francis Crick Institute, London, United Kingdom
| | - Dasja Pajkrt
- Department of Pediatric Infectious Diseases, Amsterdam University Medical Centers, Location Academic Medical Center, Amsterdam, Netherlands
| | - Petrus J. W. Naudé
- Department of Psychiatry and Mental Health, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
13
|
Warr AJ, Anterasian C, Shah JA, De Rosa SC, Nguyen FK, Maleche-Obimbo E, Cranmer LM, Matemo D, Mecha J, Kinuthia J, LaCourse SM, John-Stewart GC, Hawn TR. A CD4+ TNF+ monofunctional memory T-cell response to BCG vaccination is associated with Mycobacterium tuberculosis infection in infants exposed to HIV. EBioMedicine 2022; 80:104023. [PMID: 35533496 PMCID: PMC9092381 DOI: 10.1016/j.ebiom.2022.104023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 03/20/2022] [Accepted: 04/09/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The immunologic correlates of risk of Mycobacterium tuberculosis (Mtb) infection after BCG vaccination are unknown. The mechanism by which BCG influences the tuberculin skin test (TST) remains poorly understood. We evaluated CD4+ T-cell responses in infants exposed to HIV and uninfected (HEU) who received BCG at birth and examined their role in susceptibility to Mtb infection and influence on TST induration. METHODS HEU infants were enrolled in a randomised clinical trial of isoniazid (INH) to prevent Mtb infection in Kenya. We measured mycobacterial antigen-specific Th1 and Th17 cytokine responses at 6-10 weeks of age prior to INH randomisation and compared responses between Mtb infected and uninfected infants. Outcomes at 14 months of age included TST, QuantiFERON-Plus (QFT-Plus), and ESAT-6/CFP-10-specific non-IFN-γ cytokines measured in QFT-Plus supernatants. FINDINGS A monofunctional mycobacterial antigen-specific TNF+ CD4+ effector memory (CCR7-CD45RA-) T-cell response at 6-10 weeks of age was associated with Mtb infection at 14 months of age as measured by ESAT-6/CFP-10-specific IFN-γ and non-IFN-γ responses (Odds Ratio 2.26; Confidence Interval 1.27-4.15; P = 0.006). Mycobacterial antigen-specific polyfunctional effector memory Th1 responses at 6-10 weeks positively correlated with TST induration in infants without evidence of Mtb infection at 14 months, an association which was diminished by INH therapy. INTERPRETATION Induction of monofunctional TNF+ CD4+ effector memory T-cell responses may be detrimental in TB vaccine development. This study also provides mechanistic insight into the association of BCG-induced immune responses with TST induration and further evidence that TST-based diagnoses of Mtb infection in infants are imprecise. FUNDING Thrasher Research Fund.
Collapse
Affiliation(s)
- Alex J. Warr
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA,Corresponding author.
| | - Christine Anterasian
- Department of Pediatrics, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Javeed A Shah
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA,Veteran Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA
| | - Stephen C. De Rosa
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave North, E4-200, Seattle, WA 98109, USA,Department of Laboratory Medicine and Pathology, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Felicia K. Nguyen
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA
| | - Elizabeth Maleche-Obimbo
- Department of Paediatrics and Child Health, University of Nairobi, Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya
| | - Lisa M. Cranmer
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, 100 Woodruff Circle, Atlanta, GA 30322, USA
| | - Daniel Matemo
- Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya
| | - Jerphason Mecha
- Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya
| | - John Kinuthia
- Kenyatta National Hospital, PO Box 20723-00202, Nairobi, Kenya
| | - Sylvia M. LaCourse
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA,Department of Global Health, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA
| | - Grace C. John-Stewart
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA,Department of Pediatrics, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, USA,Department of Global Health, University of Washington, 325 9th Ave, Seattle, WA, 98104, USA
| | - Thomas R. Hawn
- Department of Medicine, University of Washington, 750 Republican St, Seattle, WA 98109, USA
| |
Collapse
|
14
|
Immunopathogenesis in HIV-associated pediatric tuberculosis. Pediatr Res 2022; 91:21-26. [PMID: 33731810 PMCID: PMC8446109 DOI: 10.1038/s41390-021-01393-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/25/2020] [Accepted: 01/18/2021] [Indexed: 11/09/2022]
Abstract
Tuberculosis (TB) is an increasing global emergency in human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients, in which host immunity is dysregulated and compromised. However, the pathogenesis and efficacy of therapeutic strategies in HIV-associated TB in developing infants are essentially lacking. Bacillus Calmette-Guerin vaccine, an attenuated live strain of Mycobacterium bovis, is not adequately effective, which confers partial protection against Mycobacterium tuberculosis (Mtb) in infants when administered at birth. However, pediatric HIV infection is most devastating in the disease progression of TB. It remains challenging whether early antiretroviral therapy (ART) could maintain immune development and function, and restore Mtb-specific immune function in HIV-associated TB in children. A better understanding of the immunopathogenesis in HIV-associated pediatric Mtb infection is essential to provide more effective interventions, reducing the risk of morbidity and mortality in HIV-associated Mtb infection in infants. IMPACT: Children living with HIV are more likely prone to opportunistic infection, predisposing high risk of TB diseases. HIV and Mtb coinfection in infants may synergistically accelerate disease progression. Early ART may probably induce immune reconstitution inflammatory syndrome and TB pathology in HIV/Mtb coinfected infants.
Collapse
|
15
|
Kaplan SR, Escudero JN, Mecha J, Richardson BA, Maleche-Obimbo E, Matemo D, Kinuthia J, John-Stewart GC, LaCourse SM. Interferon Gamma Release Assay and Tuberculin Skin Test Performance in Pregnant Women Living With and Without HIV. J Acquir Immune Defic Syndr 2022; 89:98-107. [PMID: 34629414 PMCID: PMC8665065 DOI: 10.1097/qai.0000000000002827] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/27/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND HIV and pregnancy may affect latent TB infection (LTBI) diagnostics. Tuberculin skin test (TST) and newer generation QuantiFERON-TB Gold Plus (QFT-Plus) evaluations in pregnant women living with HIV (WLHIV) and without HIV are lacking. METHODS In this cross-sectional study, pregnant women underwent TST and QFT-Plus testing during antenatal care in Kenya. We estimated LTBI prevalence and TST and QFT-Plus performances. Diagnostic agreement was assessed with kappa statistic, participant characteristics associated with LTBI and HIV were assessed with generalized linear models, and QFT-Plus quantitative responses were assessed with Mann-Whitney U test. RESULTS We enrolled 400 pregnant women (200 WLHIV/200 HIV-negative women) at median 28 weeks gestation (interquartile range 24-30). Among WLHIV (all on antiretroviral therapy), the median CD4 count was 464 cells/mm3 (interquartile range 325-654); 62.5% (125) had received isoniazid preventive therapy. LTBI prevalence was 35.8% and similar among WLHIV and HIV-negative women. QFT-Plus testing identified 3-fold more women with LTBI when compared with TST (32% vs. 12%, P < 0.0001). QFT-Plus positivity prevalence was similar regardless of HIV status, although TB-specific antigen responses were lower in WLHIV than in HIV-negative women with LTBI (median QFT-TB1 1.05 vs. 2.65 IU/mL, P = 0.035; QFT-TB2 1.26 vs. 2.56 IU/mL, P = 0.027). TST positivity was more frequent among WLHIV than among HIV-negative women (18.5% vs 4.6%; P < 0.0001). CONCLUSIONS QFT-Plus assay had higher diagnostic yield than TST for LTBI in WLHIV and HIV-negative women despite lower TB-specific antigen responses in WLHIV. Higher TST positivity was observed in WLHIV. LTBI diagnostic performance in the context of pregnancy and HIV has implications for clinical use and prevention studies, which rely on these diagnostics for TB infection entry criteria or outcomes.
Collapse
Affiliation(s)
| | | | - Jerphason Mecha
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, WA
- Department of Biostatistics, University of Washington, Seattle, WA
| | - Elizabeth Maleche-Obimbo
- Department of Global Health, University of Washington, Seattle, WA
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Grace C John-Stewart
- Department of Global Health, University of Washington, Seattle, WA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
- Department of Epidemiology, University of Washington, Seattle, WA; and
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Sylvia M LaCourse
- Department of Global Health, University of Washington, Seattle, WA
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
| |
Collapse
|
16
|
Mellqvist H, Saggers RT, Elfvin A, Hentz E, Ballot DE. The effects of exposure to HIV in neonates at a referral hospital in South Africa. BMC Pediatr 2021; 21:485. [PMID: 34727920 PMCID: PMC8565056 DOI: 10.1186/s12887-021-02969-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/21/2021] [Indexed: 12/30/2022] Open
Abstract
Background Fewer infants are infected with HIV through mother-to-child transmission, making HIV-exposed but uninfected (HEU) infants a growing population. HIV-exposure seems to affect immunology, early growth and development, and is associated with higher morbidity and mortality rates. Currently, there is a lack of information regarding the clinical effects of HIV-exposure during the neonatal period. Objectives To identify a possible difference in mortality and common neonatal morbidities in HEU neonates compared to HIV-unexposed neonates. Methods This was a retrospective, descriptive study of all neonates admitted to the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital between 1 January 2017 and 31 December 2018. HEU neonates were compared to HIV-unexposed neonates. Results There were 3236 neonates included, where 855 neonates were HEU. The HEU neonates had significantly lower birth weight and gestational age. The HEU neonates had higher rates of neonatal sepsis (19.8% vs 14.2%, OR 1.49, p < 0.001), specifically for late onset sepsis, and required more respiratory support. NCPAP and invasive ventilation was more common in the HEU group (36.3% vs 31.3% required NCPAP, p = 0.008, and 20.1% vs 15,0% required invasive ventilation, p < 0.001). Chronic lung disease was more common among HIV-exposed neonates (12.2% vs 8.7%, OR 1.46, p = 0.003). The difference in mortality rates between the study groups was not significant (10.8% of HEU neonates and 13.3% of HIV-unexposed). Conclusions HEU neonates had higher rates of neonatal sepsis, particularly late-onset sepsis, required more respiratory support and had higher rates of chronic lung disease. Mortality of HEU neonates was not different HIV-unexposed neonates.
Collapse
Affiliation(s)
- Helena Mellqvist
- Futurum, County Hospital Ryhov, Jonkoping, Sweden.,Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Robin T Saggers
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa. .,Department of Paediatrics and Child Health, Charlotte Maxeke Johannesburg Academic Hospital, Jubilee Road, Parktown, Johannesburg, South Africa.
| | - Anders Elfvin
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabet Hentz
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Department of Pediatrics, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Daynia E Ballot
- School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
17
|
LaCourse SM, Richardson BA, Kinuthia J, Warr AJ, Maleche-Obimbo E, Matemo D, Cranmer LM, Mecha J, Escudero JN, Hawn TR, John-Stewart G. A Randomized Controlled Trial of Isoniazid to Prevent Mycobacterium tuberculosis Infection in Kenyan Human Immunodeficiency Virus-Exposed Uninfected Infants. Clin Infect Dis 2021; 73:e337-e344. [PMID: 32564076 PMCID: PMC8282257 DOI: 10.1093/cid/ciaa827] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV)-exposed uninfected (HEU) infants in endemic settings are at high risk of tuberculosis (TB). For infants, progression from primary Mycobacterium tuberculosis (Mtb) infection to TB disease can be rapid. We assessed whether isoniazid (INH) prevents primary Mtb infection. METHODS We conducted a randomized nonblinded controlled trial enrolling HEU infants 6 weeks of age without known TB exposure in Kenya. Participants were randomized (1:1) to 12 months of daily INH (10 mg/kg) vs no INH. Primary endpoint was Mtb infection at end of 12 months, assessed by interferon-γ release assay (QuantiFERON-TB Gold Plus) and/or tuberculin skin test (TST, added 6 months after first participant exit). RESULTS Between 15 August 2016 and 6 June 2018, 416 infants were screened, with 300 (72%) randomized to INH or no INH (150 per arm); 2 were excluded due to HIV infection. Among 298 randomized HEU infants, 12-month retention was 96.3% (287/298), and 88.9% (265/298) had primary outcome data. Mtb infection prevalence at 12-month follow-up was 10.6% (28/265); 7.6% (10/132) in the INH arm and 13.5% (18/133) in the no INH arm (7.0 vs 13.4 per 100 person-years; hazard ratio, 0.53 [95% confidence interval {CI}, .24-1.14]; P = .11]), and driven primarily by TST positivity (8.6% [8/93] in INH and 18.1% [17/94] in no INH; relative risk, 0.48 [95% CI, .22-1.05]; P = .07). Frequency of severe adverse events was similar between arms (INH, 14.0% [21/150] vs no INH, 10.7% [16/150]; P = .38), with no INH-related adverse events. CONCLUSIONS Further studies evaluating TB preventive therapy to prevent or delay primary Mtb infection in HEU and other high-risk infants are warranted. CLINICAL TRIALS REGISTRATION NCT02613169.
Collapse
Affiliation(s)
- Sylvia M LaCourse
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Barbra A Richardson
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - A J Warr
- Department of Pediatrics, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jerphason Mecha
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Thomas R Hawn
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| |
Collapse
|
18
|
Dikobe W, Molefi M, Nkomo B, Kgwaadira B, Gasenelwe B, Seloilwe E, Mashalla Y, Mills TA. The utility of a modified WHO TB screening tool among children at a Botswana child welfare clinic. Afr Health Sci 2021; 21:64-71. [PMID: 34447426 PMCID: PMC8367304 DOI: 10.4314/ahs.v21i1.11s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background In high TB/HIV settings, the increased risk for TB amongst children exposed to HIV has been established through biomedical tests. Screening HIV exposed children for TB can improve early childhood TB detection and treatment. Objective This study assessed the utility of a modified World Health Organization (WHO) tool by including HIV variables, to determine TB exposure amongst HIV exposed children presenting to a “Well Child” Clinic (CWC). Methods Clinical data were obtained from medical records and/or from the caregivers of children presenting to CWC. Data was analyzed to explore factors associated with positive screening for TB, including being exposed to HIV and current HIV status. Results Five percent (55/1100) screened reported a close TB contact and 21% (n=231) had positive TB symptom screen. History of close TB contact was a risk factor for positive screening for TB symptoms (OR 1.89 CI 1.05–3.4) while being HIV negative was protective (OR 0.3, Cl 0.19–0.62). HIV exposure was associated with increased risk of TB exposure (OR 2.9 CI 1.61–5.19). Conclusion Integrating HIV variables in the existing WHO screening tool for childhood TB can be useful in early detection and treatment of TB in HIV exposed children in resource limited settings.
Collapse
Affiliation(s)
- Wame Dikobe
- Ministry of Health, Department of Public Health, TB Program, Gaborone, Botswana
| | - Mooketsi Molefi
- University of Botswana, Department of Family Medicine & Public Health, Gaborone, Botswana
| | - Bornapate Nkomo
- Ministry of Health, Department of Public Health, TB Program, Gaborone, Botswana
| | - Botshelo Kgwaadira
- Ministry of Health, Department of Public Health, TB Program, Gaborone, Botswana
| | | | - Esther Seloilwe
- University of Botswana, Faculty Health Sciences, Gaborone, Botswana
| | - Yohanna Mashalla
- University of Botswana, Faculty Health Sciences, Gaborone, Botswana
| | - Tonya-Ascortt Mills
- Botswana-University of Pennsylvania Partnership, TB Program, Gaborone, Botswana
| |
Collapse
|
19
|
Marquez C, Atukunda M, Balzer LB, Chamie G, Kironde J, Ssemmondo E, Ruel TD, Mwangwa F, Tram KH, Clark TD, Kwarisiima D, Petersen M, Kamya MR, Charlebois ED, Havlir DV. The age-specific burden and household and school-based predictors of child and adolescent tuberculosis infection in rural Uganda. PLoS One 2020; 15:e0228102. [PMID: 31995631 PMCID: PMC6988961 DOI: 10.1371/journal.pone.0228102] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/07/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The age-specific epidemiology of child and adolescent tuberculosis (TB) is poorly understood, especially in rural areas of East Africa. We sought to characterize the age-specific prevalence and predictors of TB infection among children and adolescents living in rural Uganda, and to explore the contribution of household TB exposure on TB infection. METHODS From 2015-2016 we placed and read 3,121 tuberculin skin tests (TST) in children (5-11 years old) and adolescents (12-19 years old) participating in a nested household survey in 9 rural Eastern Ugandan communities. TB infection was defined as a positive TST (induration ≥10mm or ≥5mm if living with HIV). Age-specific prevalence was estimated using inverse probability weighting to adjust for incomplete measurement. Generalized estimating equations were used to assess the association between TB infection and multi-level predictors. RESULTS The adjusted prevalence of TB infection was 8.5% (95%CI: 6.9-10.4) in children and 16.7% (95% CI:14.0-19.7) in adolescents. Nine percent of children and adolescents with a prevalent TB infection had a household TB contact. Among children, having a household TB contact was strongly associated with TB infection (aOR 5.5, 95% CI: 1.7-16.9), but the strength of this association declined among adolescents and did not meet significance (aOR 2.3, 95% CI: 0.8-7.0). The population attributable faction of TB infection due to a household TB contact was 8% for children and 4% among adolescents. Mobile children and adolescents who travel outside of their community for school had a 1.7 (95% CI 1.0-2.9) fold higher odds of TB infection than those who attended school in the community. CONCLUSION Children and adolescents in this area of rural eastern Uganda suffer a significant burden of TB. The majority of TB infections are not explained by a known household TB contact. Our findings underscore the need for community-based TB prevention interventions, especially among mobile youth.
Collapse
Affiliation(s)
- Carina Marquez
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, California, United States of America
| | | | - Laura B. Balzer
- University of Massachusetts, Amherst, Department of Biostatistics and Epidemiology, Amherst, Massachusetts, United States of America
| | - Gabriel Chamie
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, California, United States of America
| | - Joel Kironde
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Theodore D. Ruel
- University of California, San Francisco, Department of Pediatrics, San Francisco, California, United States of America
| | | | - Khai Hoan Tram
- Stanford University School of Medicine, Palo Alto, California, United States of America
| | - Tamara D. Clark
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, California, United States of America
| | - Dalsone Kwarisiima
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Maya Petersen
- University of California, Berkeley School of Public Health, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Edwin D. Charlebois
- Center for AIDS Prevention (CAPS), University of California, San Francisco, San Francisco, California United States of America
| | - Diane V. Havlir
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, San Francisco, California, United States of America
| |
Collapse
|
20
|
LaCourse SM, Richardson BA, Kinuthia J, Warr AJ, Maleche-Obimbo E, Matemo D, Cranmer LM, Escudero JN, Hawn TR, John-Stewart GC. Infant TB Infection Prevention Study (iTIPS): a randomised trial protocol evaluating isoniazid to prevent M. tuberculosis infection in HIV-exposed uninfected children. BMJ Open 2020; 10:e034308. [PMID: 31969368 PMCID: PMC7045242 DOI: 10.1136/bmjopen-2019-034308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 12/05/2019] [Accepted: 01/07/2020] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION HIV-exposed uninfected (HEU) infants in tuberculosis (TB) endemic settings are at high risk of Mycobacterium tuberculosis (Mtb) infection and TB disease, even in the absence of known Mtb exposure. Because infancy is a time of rapid progression from primary infection to active TB disease, it is important to define when and how TB preventive interventions exert their effect in order to develop effective prevention strategies in this high-risk population. METHODS AND ANALYSIS We designed a non-blinded randomised controlled trial to determine efficacy of isoniazid (INH) to prevent primary Mtb infection among HEU children. Target sample size is 300 (150 infants in each arm). Children are enrolled at 6 weeks of age from maternal and child health clinics in Kenya and are randomised to receive 12 months of daily INH ~10 mg/kg plus pyridoxine or no INH. The primary endpoint is Mtb infection, assessed by interferon-gamma release assay QuantiFERON-TB Gold Plus (QFT-Plus) or tuberculin skin test after 12 months post-enrolment. Secondary outcomes include severe adverse events, expanded Mtb infection definition using additional QFT-Plus supernatant markers and determining correlates of Mtb infection. Exploratory analyses include a combined outcome of TB infection, disease and mortality, and sensitivity analyses excluding infants with baseline TB-specific responses on flow cytometry. ETHICS AND DISSEMINATION An external and independent Data and Safety Monitoring Board monitors adverse events. Results will be disseminated through peer-reviewed journals, presentations at local and international conferences to national and global policy-makers, the local community and participants. TRIAL REGISTRATION NUMBER NCT02613169; Pre-results.
Collapse
Affiliation(s)
- Sylvia M LaCourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - John Kinuthia
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Reproductive Health, Kenyatta National Hospital, Nairobi, Kenya
| | - A J Warr
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Daniel Matemo
- Research and Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - Lisa M Cranmer
- Department of Pediatrics, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta Inc, Atlanta, Georgia, USA
| | - Jaclyn N Escudero
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Thomas R Hawn
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Grace C John-Stewart
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| |
Collapse
|
21
|
Fry SHL, Barnabas SL, Cotton MF. Tuberculosis and HIV-An Update on the "Cursed Duet" in Children. Front Pediatr 2019; 7:159. [PMID: 32211351 PMCID: PMC7073470 DOI: 10.3389/fped.2019.00159] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/04/2019] [Indexed: 11/13/2022] Open
Abstract
HIV and tuberculosis (TB) often occur together with each exacerbating the other. Improvements in vertical transmission prevention has reduced the number of HIV-infected children being born and early antiretroviral therapy (ART) protects against tuberculosis. However, with delayed HIV diagnosis, HIV-infected infants often present with tuberculosis co-infection. The number of HIV exposed uninfected children has increased and these infants have high exposure to TB and may be more immunologically vulnerable due to HIV exposure in utero. Bacillus Calmette-Guérin (BCG) immunization shortly after birth is essential for preventing severe TB in infancy. With early infant HIV diagnosis and ART, disseminated BCG is no longer an issue. TB prevention therapy should be implemented for contacts of a source case and for all HIV-infected individuals over a year of age. Although infection can be identified through skin tests or interferon gamma release assays, the non-availability of these tests should not preclude prevention therapy, once active TB has been excluded. Therapeutic options have moved from isoniazid only for 6-9 months to shorter regimens. Prevention therapy after exposure to a source case with resistant TB should also be implemented, but should not prevent pivotal prevention trials already under way. A microbiological diagnosis for TB remains the gold standard because of increasing drug resistance. Antiretroviral therapy for rifampicin co-treatment requires adaptation for those on lopinavir-ritonavir, which requires super-boosting with additional ritonavir. For those with drug resistant TB, the main problems are identification and overlapping toxicity between antiretroviral and anti-TB therapy. In spite of renewed focus and improved interventions, infants are still vulnerable to TB.
Collapse
Affiliation(s)
| | | | - Mark F. Cotton
- Family Centre for Research with Ubuntu (FAM-CRU), Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| |
Collapse
|
22
|
Said K, Hella J, Ruzegea M, Solanki R, Chiryamkubi M, Mhimbira F, Ritz N, Schindler C, Mandalakas AM, Manji K, Tanner M, Utzinger J, Fenner L. Immunologic-based Diagnosis of Latent Tuberculosis Among Children Younger Than 5 Years of Age Exposed and Unexposed to Tuberculosis in Tanzania. Pediatr Infect Dis J 2019; 38:333-339. [PMID: 30882720 DOI: 10.1097/inf.0000000000002131] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Childhood tuberculosis (TB) is acquired after exposure to an infectious TB case, often within the household. We prospectively screened children 6-59 months of age, exposed and unexposed to an infectious TB case within the same household, for latent tuberculosis infection (LTBI), in Dar es Salaam, Tanzania. METHODS We collected medical data and clinical specimens (to evaluate for helminths, TB and HIV coinfections) and performed physical examinations at enrollment and at 3-month and 6-month follow-up surveys. LTBI was assessed using QuantiFERON-TB Gold (QFT) at enrollment and at 3 months. RESULTS In total, 301 children had complete data records (186 with TB exposure and 115 without known TB exposure). The median age of children was 26 months (range: 6-58); 52% were females, and 4 were HIV positive. Eight children (3%) developed TB during the 6-month follow-up. We found equal proportions of children with LTBI among those with and without exposure: 20% (38/186) versus 20% (23/115) QFT-positive, and 2% (4/186) versus 4% (5/115) indeterminate QFT. QFT conversion rate was 7% (22 children) and reversion 8% (25 children). Of the TB-exposed children, 72% initiated isoniazid preventive therapy, but 61% of parents/caregivers of children with unknown TB exposure and positive QFT refused isoniazid preventive therapy. CONCLUSIONS In this high burden TB setting, TB exposure from sources other than the household was equally important as household exposure. Nearly one third of eligible children did not receive isoniazid preventive therapy. Evaluation for LTBI in children remains an important strategy for controlling TB but should not be limited to children with documented TB exposure.
Collapse
Affiliation(s)
- Khadija Said
- From the Ifakara Health Institute, Bagamoyo Research and Training Centre, Bagamoyo, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Jerry Hella
- From the Ifakara Health Institute, Bagamoyo Research and Training Centre, Bagamoyo, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Mwajabu Ruzegea
- From the Ifakara Health Institute, Bagamoyo Research and Training Centre, Bagamoyo, Tanzania
| | - Rajesh Solanki
- Temeke Municipal Council Hospital, Dar es Salaam, Tanzania
| | | | - Francis Mhimbira
- From the Ifakara Health Institute, Bagamoyo Research and Training Centre, Bagamoyo, Tanzania
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Nicole Ritz
- University of Basel, Basel, Switzerland
- Basel University Children's Hospital, Basel, Switzerland
| | - Christian Schindler
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Karim Manji
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Marcel Tanner
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Jürg Utzinger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Lukas Fenner
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| |
Collapse
|
23
|
Basu Roy R, Whittaker E, Seddon JA, Kampmann B. Tuberculosis susceptibility and protection in children. THE LANCET. INFECTIOUS DISEASES 2019; 19:e96-e108. [PMID: 30322790 PMCID: PMC6464092 DOI: 10.1016/s1473-3099(18)30157-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 01/27/2018] [Accepted: 02/09/2018] [Indexed: 12/14/2022]
Abstract
Children represent both a clinically important population susceptible to tuberculosis and a key group in whom to study intrinsic and vaccine-induced mechanisms of protection. After exposure to Mycobacterium tuberculosis, children aged under 5 years are at high risk of progressing first to tuberculosis infection, then to tuberculosis disease and possibly disseminated forms of tuberculosis, with accompanying high risks of morbidity and mortality. Children aged 5-10 years are somewhat protected, until risk increases again in adolescence. Furthermore, neonatal BCG programmes show the clearest proven benefit of vaccination against tuberculosis. Case-control comparisons from key cohorts, which recruited more than 15 000 children and adolescents in total, have identified that the ratio of monocytes to lymphocytes, activated CD4 T cell count, and a blood RNA signature could be correlates of risk for developing tuberculosis. Further studies of protected and susceptible populations are necessary to guide development of novel tuberculosis vaccines that could facilitate the achievement of WHO's goal to eliminate deaths from tuberculosis in childhood.
Collapse
Affiliation(s)
- Robindra Basu Roy
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK; Vaccines and Immunity Theme MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Elizabeth Whittaker
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
| | - James A Seddon
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK
| | - Beate Kampmann
- Centre for International Child Health, Department of Paediatrics, Imperial College London, London, UK; Vaccines and Immunity Theme MRC Unit The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia.
| |
Collapse
|
24
|
Abstract
Mycobacterium tuberculosis is the leading cause of death worldwide from a single bacterial pathogen. The World Health Organization estimates that annually 1 million children have tuberculosis (TB) disease and many more harbor a latent form. Accurate estimates are hindered by under-recognition and challenges in diagnosis. To date, an accurate diagnostic test to confirm TB in children does not exist. Treatment is lengthy but outcomes are generally favorable with timely initiation. With the End TB Strategy, there is an urgent need for improved diagnostics and treatment to prevent the unnecessary morbidity and mortality from TB in children.
Collapse
Affiliation(s)
- Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801340, Charlottesville, VA 22908-1340, USA.
| |
Collapse
|
25
|
High Incidence of Tuberculosis Infection in HIV-exposed Children Exiting an Isoniazid Preventive Therapy Trial. Pediatr Infect Dis J 2018; 37:e254-e256. [PMID: 29462104 PMCID: PMC6095832 DOI: 10.1097/inf.0000000000001946] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Young HIV-exposed children are at high risk for TB infection. We performed QuantiFERON-TB Gold among HIV-exposed children in South Africa at enrolment and 1-year follow-up. The incidence of TB infection was high for HIV+ (11 cases per 100 child-years) and HIV-exposed uninfected children (15 cases per 100 child-years). QuantiFERON-TB Gold may identify HIV-exposed children at risk for TB disease progression.
Collapse
|
26
|
Abstract
BACKGROUND Tuberculosis (TB) is the major cause of mortality in HIV-infected children globally. Current guidelines about the management of antiretroviral therapy in children with TB are based on a limited number of nonrandomized studies involving small numbers of participants. The aim of the study was to systematically retrieve and critically appraise available evidence on the efficacy and safety of different antiretroviral regimens in children with HIV infection who are receiving treatment for active TB. METHODS We conducted a systematic review of the literature according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Records were retrieved through March 2016 from Medline, Embase and manual screening of key conference proceedings. Four specific research questions assessing available treatment options were defined. RESULTS Although 4 independent searches were conducted (1 for each Population, Intervention, Comparator, Outcomes question), results were elaborated and interpreted together because of significant overlap among the retrieved records. Six observational studies were selected for qualitative synthesis while meta-analysis could not be performed. CONCLUSION Evidence for optimal treatment options for HIV/TB coinfected children is limited. As the global community strives to reach the fast-track HIV treatment targets and eliminate childhood TB deaths, it must ensure that coinfected children are included in key treatment studies and expand this neglected but crucial area of research.
Collapse
|
27
|
Mwangwa F, Chamie G, Kwarisiima D, Ayieko J, Owaraganise A, Ruel TD, Plenty A, Tram KH, Clark TD, Cohen CR, Bukusi EA, Petersen M, Kamya MR, Charlebois ED, Havlir DV, Marquez C. Gaps in the Child Tuberculosis Care Cascade in 32 Rural Communities in Uganda and Kenya. J Clin Tuberc Other Mycobact Dis 2017; 9:24-29. [PMID: 29291251 PMCID: PMC5743212 DOI: 10.1016/j.jctube.2017.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 10/11/2017] [Accepted: 10/24/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Reducing tuberculosis (TB) deaths among children requires a better understanding of the gaps in the care cascade from TB diagnosis to treatment completion. We sought to assess the child TB care cascade in 32 rural communities in Uganda and Kenya using programmatic data. METHODS This is a retrospective cohort study of 160,851 children (ages <15 years) living in 12 rural communities in Kenya and 22 in Uganda. We reviewed national TB registries from health centers in and adjacent to the 32 communities, and we included all child TB cases recorded from January 1, 2013 to June 30, 2016. To calculate the first step of the child TB care cascade, the number of children with active TB, we divided the number of reported child TB diagnoses by the 2015 World Health Organization (WHO) child TB case detection ratio for Africa of 27%. The remaining components of the Child TB Care Cascade were ascertained directly from the TB registries and included: diagnosed with TB, started on TB treatment, and completed TB treatment. RESULTS In two and a half years, a total of 42 TB cases were reported among children living in 32 rural communities in Uganda and Kenya. 40% of the children were co-infected with HIV. Using the WHO child TB case detection ratio, we calculated that 155 children in this cohort had TB during the study period. Of those 155 children, 42 were diagnosed and linked to TB care, 42 were started on treatment, and 31 completed treatment. Among the 42 children who started TB treatment, reasons for treatment non-completion were loss to follow up (7%), death (5%), and un-recorded reasons (5%). Overall, 20% (31/155) of children completed the child TB care cascade. CONCLUSION In 32 rural communities in Uganda and Kenya, we estimate that 80% of children with TB fell off the care cascade. Reducing morbidity and mortality from child TB requires strengthening of the child TB care cascade from diagnosis through treatment completion.
Collapse
Affiliation(s)
| | - Gabriel Chamie
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Dalsone Kwarisiima
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University Joint AIDS Program, Kampala, Uganda
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Theodore D. Ruel
- University of California, San Francisco, Division Pediatric Infectious Diseases and Global Medicine, Department of Pediatrics, San Francisco, USA
| | - Albert Plenty
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Khai Hoan Tram
- Stanford University, School of Medicine, Palo Alto, CA, USA
| | - Tamara D. Clark
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Craig R. Cohen
- University of California, San Francisco, Department of Obstetrics and Gynecology, San Francisco, USA
| | | | - Maya Petersen
- University of California, Berkeley School of Public Health, Berkeley, United States
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, School of Medicine, Kampala, Uganda
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, United States
| | - Diane V. Havlir
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, San Francisco, USA
| | - Carina Marquez
- University of California, San Francisco, Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General Hospital, San Francisco, USA
| |
Collapse
|
28
|
Doan TN, Eisen DP, Rose MT, Slack A, Stearnes G, McBryde ES. Interferon-gamma release assay for the diagnosis of latent tuberculosis infection: A latent-class analysis. PLoS One 2017; 12:e0188631. [PMID: 29182688 PMCID: PMC5705142 DOI: 10.1371/journal.pone.0188631] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 11/11/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Accurate diagnosis and subsequent treatment of latent tuberculosis infection (LTBI) is essential for TB elimination. However, the absence of a gold standard test for diagnosing LTBI makes assessment of the true prevalence of LTBI and the accuracy of diagnostic tests challenging. Bayesian latent class models can be used to make inferences about disease prevalence and the sensitivity and specificity of diagnostic tests using data on the concordance between tests. We performed the largest meta-analysis to date aiming to evaluate the performance of tuberculin skin test (TST) and interferon-gamma release assays (IGRAs) for LTBI diagnosis in various patient populations using Bayesian latent class modelling. METHODS Systematic search of PubMeb, Embase and African Index Medicus was conducted without date and language restrictions on September 11, 2017 to identify studies that compared the performance of TST and IGRAs for LTBI diagnosis. Two IGRA methods were considered: QuantiFERON-TB Gold In Tube (QFT-GIT) and T-SPOT.TB. Studies were included if they reported 2x2 agreement data between TST and QFT-GIT or T-SPOT.TB. A Bayesian latent class model was developed to estimate the sensitivity and specificity of TST and IGRAs in various populations, including immune-competent adults, immune-compromised adults and children. A TST cut-off value of 10 mm was used for immune-competent subjects and 5 mm for immune-compromised individuals. FINDINGS A total of 157 studies were included in the analysis. In immune-competent adults, the sensitivity of TST and QFT-GIT were estimated to be 84% (95% credible interval [CrI] 82-85%) and 52% (50-53%), respectively. The specificity of QFT-GIT was 97% (96-97%) in non-BCG-vaccinated and 93% (92-94%) in BCG-vaccinated immune-competent adults. The estimated figures for TST were 100% (99-100%) and 79% (76-82%), respectively. T-SPOT.TB has comparable specificity (97% for both tests) and better sensitivity (68% versus 52%) than QFT-GIT in immune-competent adults. In immune-compromised adults, both TST and QFT-GIT display low sensitivity but high specificity. QFT-GIT and TST are equally specific (98% for both tests) in non-BCG-vaccinated children; however, QFT-GIT is more specific than TST (98% versus 82%) in BCG-vaccinated group. TST is more sensitive than QFT-GIT (82% versus 73%) in children. CONCLUSIONS This study is the first to assess the utility of TST and IGRAs for LTBI diagnosis in different population groups using all available data with Bayesian latent class modelling. Our results challenge the current beliefs about the performance of LTBI screening tests, and have important implications for LTBI screening policy and practice. We estimated that the performance of IGRAs is not as reliable as previously measured in the general population. However, IGRAs are not or minimally affected by BCG and should be the preferred tests in this setting. Adoption of IGRAs in settings where BCG is widely administered will allow for a more accurate identification and treatment of LTBI.
Collapse
Affiliation(s)
- Tan N. Doan
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- * E-mail:
| | - Damon P. Eisen
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Morgan T. Rose
- Department of Infectious Diseases, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Slack
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Grace Stearnes
- Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Emma S. McBryde
- Department of Medicine at The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| |
Collapse
|
29
|
Goldberg RE, Short SE. What do we know about children living with HIV-infected or AIDS-ill adults in Sub-Saharan Africa? A systematic review of the literature. AIDS Care 2017; 28 Suppl 2:130-41. [PMID: 27392008 PMCID: PMC4991228 DOI: 10.1080/09540121.2016.1176684] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Millions of children in Sub-Saharan Africa live with adults, often parents, who are HIV-infected or ill due to AIDS. These children experience social, emotional, and health vulnerabilities that overlap with, but are not necessarily the same as, those of orphans or other vulnerable children. Despite their distinctive vulnerabilities, research aimed at understanding the situation of these children has been limited until very recently. This review summarizes the state of knowledge based on a systematic search of PubMed and Web of Science that identified 47 empirical research articles that examined either the population prevalence of children living with HIV-infected or AIDS-sick adults, or the consequences of adult HIV infection or AIDS illness for child well-being. This review confirms that this population of children is substantial in size, and that the vulnerabilities they experience are multi-faceted, spanning physical and emotional health and schooling. Mechanisms were examined empirically in only a small number of studies, but encompass poverty, transmission of opportunistic infections, care for unwell adults, adult distress, AIDS stigma, lack of social support, maternal breastfeeding issues, and vertical HIV transmission. Some evidence is provided that infants, adolescents, children with infected or ill mothers, and children living with severely ill adults are particularly vulnerable. Future research would benefit from more attention to causal inference and further characterization of processes and circumstances related to vulnerability and resilience. It would also benefit from further study of variation in observed associations between adult HIV/AIDS and child well-being based on characteristics such as age, sex, kinship, severity of illness, TB co-infection, disclosure, and serostatus awareness. Almost one-quarter of the studies reviewed did not investigate variation based on any of these factors. More nuanced understanding of the short- and long-term effects of adult HIV on children's needs and circumstances will be important to ongoing discussions about equity in policies and interventions.
Collapse
Affiliation(s)
- Rachel E Goldberg
- a Department of Sociology , University of California Irvine , Irvine , CA , USA
| | - Susan E Short
- b Department of Sociology and Population Studies and Training Center , Brown University , Providence , RI , USA
| |
Collapse
|
30
|
Abstract
Mycobacterium tuberculosis is the leading cause of death worldwide from a single bacterial pathogen. The World Health Organization estimates that annually 1 million children have tuberculosis (TB) disease and many more harbor a latent form. Accurate estimates are hindered by under-recognition and challenges in diagnosis. To date, an accurate diagnostic test to confirm TB in children does not exist. Treatment is lengthy but outcomes are generally favorable with timely initiation. With the End TB Strategy, there is an urgent need for improved diagnostics and treatment to prevent the unnecessary morbidity and mortality from TB in children.
Collapse
Affiliation(s)
- Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, PO Box 801340, Charlottesville, VA 22908-1340, USA.
| |
Collapse
|
31
|
Rezai MS, Abedi S, Afshari M, Moosazadeh M. Estimating Tuberculin Skin Test Reactions among Children and Teenagers Who Received the Bacillus Calmette-Guerin Vaccination at Birth: A Meta-analysis. Osong Public Health Res Perspect 2017; 8:3-10. [PMID: 28443219 PMCID: PMC5402850 DOI: 10.24171/j.phrp.2017.8.1.02] [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: 11/05/2022] Open
Abstract
OBJECTIVES Tuberculin skin reaction size is one indicator of bacillus Calmette-Guérin (BCG) vaccine efficacy and a way to diagnose latent infection. Several primary studies have examined this issue. Combining the results of these studies using a meta-analysis will provide reliable evidence regarding this indicator for policymakers. This study aimed to estimate the total frequency of different tuberculin skin test reactions among Iranian children and teenagers who received the BCG vaccination at birth. METHODS National and international databanks were searched using relevant keywords. After the search strategy was restricted and duplicates were excluded, the titles and abstracts of the remaining papers were screened. All included studies included healthy children who received the BCG vaccine without confirmed tuberculosis exposure. Heterogeneity of the results was assessed using the Cochrane test and I2 index showed the random effects model as the best model for estimating the pooled results. RESULTS We combined the results of 14 primary studies including purified protein derivative reaction test measures of 26,281 Iranian children. The frequencies (95% confidence intervals) of the reactions were 8.5% (6.2-10.8) for patients with a reaction size ≥ 10 mm, 29.9% (22.3-37.4) for a reaction size of 5-9 mm, and 60% (48.9-71.1) for a reaction size < 5 mm. CONCLUSION Our study showed that large numbers of Iranian children and teens have no positive BCG vaccine reaction and a considerable number of children have been exposed to Mycobacterium tuberculosis.
Collapse
Affiliation(s)
- Mohammad Sadegh Rezai
- Infectious Diseases Research Center with Focus on Nosocomial Infection, Mazandaran University of Medical Sciences, Sari, Iran
| | - Siavosh Abedi
- Department of Internal Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Afshari
- Department of Community Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | - Mahmood Moosazadeh
- Health Science Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
| |
Collapse
|