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Gaensbauer JT, Dash N, Verma S, Hall DJ, Adler-Shohet FC, Li G, Lee G, Dinnes L, Wendorf K. Multidrug-resistant tuberculosis in children: A practical update on epidemiology, diagnosis, treatment and prevention. J Clin Tuberc Other Mycobact Dis 2024; 36:100449. [PMID: 38757115 PMCID: PMC11096739 DOI: 10.1016/j.jctube.2024.100449] [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] [Indexed: 05/18/2024] Open
Abstract
Pediatric multidrug-resistant tuberculosis (MDR-TB) remains a significant global problem, and there are numerous barriers preventing children with MDR-TB from being identified, confirmed with microbiologic tests, and treated with a safe, practical, and effective regimen. However, several recent advances in diagnostics and treatment regimens have the promise to improve outcomes for children with MDR-TB. We introduce this review with two cases that exemplify both the challenges in management of MDR-TB in children, but also the potential to achieve a positive outcome. More than 30,000 cases of MDR-TB per year are believed to occur in children but less than 5% are confirmed microbiologically, contributing to poorer outcomes and excess mortality. Rapid molecular-based testing that provides information on rifampin susceptibility is increasingly globally available and recommended for all children suspected of TB disease--but remains limited by challenges obtaining appropriate samples and the paucibacillary nature of most pediatric TB. More complex assays allowing better characterization of drug-resistant isolates are emerging. For children diagnosed with MDR-TB, treatment regimens have traditionally been long and utilize multiple drugs associated with significant side effects, particularly injectable agents. Several new or repurposed drugs including bedaquiline, delamanid, clofazimine and linezolid now allow most treatment regimens to be shorter and all-oral. Yet data to support short, all-oral, novel regimens for young children containing pretomanid remain insufficient at present, and there is a compelling need to conduct pediatric trials of promising therapeutics and MDR-TB treatment regimens.
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Affiliation(s)
- James T. Gaensbauer
- Mayo Clinic Center for Tuberculosis, Mayo Clinic, Rochester, MN, USA
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nabaneeta Dash
- Department of Telemedicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Verma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - DJ Hall
- Division of Pediatric Hospital Medicine, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Felice C. Adler-Shohet
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Guyu Li
- Division of Pediatric Infectious Diseases, Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Grace Lee
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Laura Dinnes
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Kristen Wendorf
- Department of Pediatrics, University of California San Francisco Benioff Children’s Hospital, Oakland, CA, USA
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Moretó-Planas L, Mahajan R, Fidelle Nyikayo L, Ajack YBP, Tut Chol B, Osman E, Sangma M, Tobi A, Gallo J, Biague E, Gonçalves R, Rocaspana M, Medina C, Camará M, Flevaud L, Ruby LC, Bélard S, Sagrado MJ, Molina I, Llosa AE. Xpert-Ultra Assay in Stool and Urine Samples to Improve Tuberculosis Diagnosis in Children: The Médecins Sans Frontières Experience in Guinea-Bissau and South Sudan. Open Forum Infect Dis 2024; 11:ofae221. [PMID: 38798893 PMCID: PMC11119760 DOI: 10.1093/ofid/ofae221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/01/2024] [Indexed: 05/29/2024] Open
Abstract
Background More than half of childhood tuberculosis cases remain undiagnosed yearly. The World Health Organization recommends the Xpert-Ultra assay as a first pediatric diagnosis test, but microbiological confirmation remains low. We aimed to determine the diagnostic performance of Xpert-Ultra with stool and urine samples in presumptive pediatric tuberculosis cases in 2 high-tuberculosis-burden settings. Methods This Médecins Sans Frontières cross-sectional multicentric study took place at Simão Mendes Hospital, Guinea-Bissau (July 2019 to April 2020) and in Malakal Hospital, South Sudan (April 2021 to June 2023). Children aged 6 months to 15 years with presumptive tuberculosis underwent clinical and laboratory assessment, with 1 respiratory and/or extrapulmonary sample (reference standard [RS]), 1 stool, and 1 urine specimen analyzed with Xpert-Ultra. Results A total of 563 children were enrolled in the study, 133 from Bissau and 400 from Malakal; 30 were excluded. Confirmation of tuberculosis was achieved in 75 (14.1%), while 248 (46.5%) had unconfirmed tuberculosis. Of 553 with an RS specimen, the overall diagnostic yield was 12.4% (66 of 533). A total of 493 stool and 524 urine samples were used to evaluate the performance of Xpert-Ultra with these samples. Compared with the RS, the sensitivity and specificity of Xpert-Ultra were 62.5% (95% confidence interval, 49.4%-74%) and 98.3% (96.7%-99.2%), respectively, with stool samples, and 13.9% (7.5%-24.3%) and 99.4% (98.1%-99.8%) with urine samples. Nine patients were positive with stool and/or urine samples but negative with the RS. Conclusions Xpert-Ultra in stool samples showed moderate to high sensitivity and high specificity compared with the RS and an added diagnostic yield when RS results were negative. Xpert-Ultra in stool samples was useful in extrapulmonary cases. Xpert-Ultra in urine samples showed low test performance. Clinical Trials Registration NCT06239337.
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Affiliation(s)
- Laura Moretó-Planas
- Medecins Sans Frontières, Medical Department, Barcelona, Spain
- Autonomous University of Barcelona, Faculty of Medicine, Barcelona, Spain
| | | | | | | | - Buai Tut Chol
- Medecins Sans Frontières, Juba, Republic of South Sudan
| | | | | | - Apal Tobi
- National Tuberculosis Program, Ministry of Health, Juba, Republic of South Sudan
| | | | | | | | - Mercè Rocaspana
- Medecins Sans Frontières, Medical Department, Barcelona, Spain
| | | | - Miguel Camará
- National Tuberculosis Program, Ministry of Health, Bissau, Guinea-Bissau
| | | | - Lisa C Ruby
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- German Centre for Infection Research (DZIF), Tübingen, Germany
| | - Sabine Bélard
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
- German Centre for Infection Research (DZIF), Tübingen, Germany
| | | | - Israel Molina
- Infectious Disease Department, Vall d’Hebron Hospital, Barcelona, Spain
| | - Augusto E Llosa
- Medecins Sans Frontières, Medical Department, Barcelona, Spain
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Yenew B, de Haas P, Babo Y, Diriba G, Sherefdin B, Bedru A, Tegegn B, Gudina T, Getahun T, Abdella S, Jerene D, Klinkenberg E, Tiemersma E. Diagnostic accuracy, feasibility and acceptability of stool-based testing for childhood tuberculosis. ERJ Open Res 2024; 10:00710-2023. [PMID: 38770005 PMCID: PMC11103712 DOI: 10.1183/23120541.00710-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/19/2024] [Indexed: 05/22/2024] Open
Abstract
Background Childhood tuberculosis (TB) diagnosis remains challenging, partly because children cannot provide sputum. This study evaluated the diagnostic accuracy of the Simple One-Step (SOS) stool method with Xpert MTB/RIF Ultra (Xpert-Ultra) for childhood TB compared to culture and Xpert-Ultra on a respiratory sample (RS) and clinical diagnosis. It also assessed the feasibility and acceptability of stool testing according to laboratory staff, and caregivers' sample preference. Methods We enrolled children (≤10 years) with presumptive pulmonary tuberculosis in Ethiopia. RS was tested using Xpert-Ultra and culture; stool samples were tested using the SOS stool method with Xpert-Ultra. Laboratory staff and caregivers' opinions were assessed using standardised questionnaires. Results Of the 898 children enrolled, 792, 832 and 794 were included for assessing the diagnostic accuracy of SOS stool with Xpert-Ultra against culture, RS Xpert-Ultra and clinical diagnosis, respectively, yielding sensitivity estimates for SOS stool with Xpert-Ultra of 69.1% (95% confidence interval (CI) 56.0-79.7%), 76.8% (95% CI 64.2-85.9%) and 59.0% (95% CI 47.9-69.2%), respectively. The specificity was ≥98.8% for all comparisons. The rate of non-determinate test results was 2.8% after one repeat test. According to laboratory staff, stool collection was feasible and acceptable and the SOS stool method was easy to perform. Most caregivers (75%) preferred stool for TB diagnosis over RS. Conclusion This study shows that SOS stool Xpert-Ultra testing offers a good alternative to RS testing for TB in children who cannot spontaneously produce a sputum sample and would otherwise need to undergo invasive procedures to obtain RS for diagnosis.
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Affiliation(s)
- Bazezew Yenew
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
- These authors contributed equally
| | - Petra de Haas
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
- These authors contributed equally
| | | | - Getu Diriba
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Ben Tegegn
- Addis Ababa City Health Bureau, Addis Ababa, Ethiopia
| | - Tilaye Gudina
- National Tuberculosis and Leprosy Control Program of Ethiopia, Addis Ababa, Ethiopia
| | | | - Saro Abdella
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Degu Jerene
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Eveline Klinkenberg
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Naidoo K, Perumal R, Cox H, Mathema B, Loveday M, Ismail N, Omar SV, Georghiou SB, Daftary A, O'Donnell M, Ndjeka N. The epidemiology, transmission, diagnosis, and management of drug-resistant tuberculosis-lessons from the South African experience. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00144-0. [PMID: 38527475 DOI: 10.1016/s1473-3099(24)00144-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/29/2024] [Accepted: 02/20/2024] [Indexed: 03/27/2024]
Abstract
Drug-resistant tuberculosis (DR-TB) threatens to derail tuberculosis control efforts, particularly in Africa where the disease remains out of control. The dogma that DR-TB epidemics are fueled by unchecked rates of acquired resistance in inadequately treated or non-adherent individuals is no longer valid in most high DR-TB burden settings, where community transmission is now widespread. A large burden of DR-TB in Africa remains undiagnosed due to inadequate access to diagnostic tools that simultaneously detect tuberculosis and screen for resistance. Furthermore, acquisition of drug resistance to new and repurposed drugs, for which diagnostic solutions are not yet available, presents a major challenge for the implementation of novel, all-oral, shortened (6-9 months) treatment. Structural challenges including poverty, stigma, and social distress disrupt engagement in care, promote poor treatment outcomes, and reduce the quality of life for people with DR-TB. We reflect on the lessons learnt from the South African experience in implementing state-of-the-art advances in diagnostic solutions, deploying recent innovations in pharmacotherapeutic approaches for rapid cure, understanding local transmission dynamics and implementing interventions to curtail DR-TB transmission, and in mitigating the catastrophic socioeconomic costs of DR-TB. We also highlight globally relevant and locally responsive research priorities for achieving DR-TB control in South Africa.
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Affiliation(s)
- Kogieleum Naidoo
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - Rubeshan Perumal
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Helen Cox
- Institute of Infectious Diseases and Molecular Medicine, Wellcome Centre for Infectious Disease Research and Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - Barun Mathema
- Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Marian Loveday
- South African Medical Research Council, Durban, South Africa
| | - Nazir Ismail
- School of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National & WHO Supranational TB Reference Laboratory, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa
| | | | - Amrita Daftary
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; School of Global Health and Dahdaleh Institute of Global Health Research, York University, Toronto, ON, Canada
| | - Max O'Donnell
- SAMRC-CAPRISA HIV/TB Pathogenesis and Treatment Research Unit, Centre for the AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York City, NY, USA; Department of Epidemiology, Columbia University Irving Medical Center, New York City, NY, USA
| | - Norbert Ndjeka
- TB Control and Management, Republic of South Africa National Department of Health, Pretoria, South Africa
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Segala FV, Nigussa W, Guido G, Kenate B, Facci E, Tsegaye A, Gulo B, Manenti F, Bobosha K, Cotugno S, Asmare AB, Cavallin F, Tilahun M, Miccio M, Abdissa A, Putoto G, Saracino A, Di Gennaro F. Active close contact investigation of tuberculosis through computer-aided detection and stool Xpert MTB/RIF among people living in Oromia Region, Ethiopia (CADOOL Study): protocol for a prospective, cross-sectional study. BMJ Open 2023; 13:e074968. [PMID: 38135314 DOI: 10.1136/bmjopen-2023-074968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION Pulmonary tuberculosis (TB) is an infectious disease with high incidence in low-income countries (LICs); it remains one of the infectious diseases with the highest mortality in the world, especially in LICs. It is crucial to recognise and diagnose TB as soon as possible, but microbiological tests on sputum are not always sensitive enough. New methods for an early diagnosis of TB are needed. In this study, we will investigate the role of two different tests to detect TB in Ethiopia (where the prevalence of TB is high): molecular search for TB in stool samples with Xpert assay and detection of pulmonary TB signs on chest X-rays with CAD4TB technology. METHODS AND ANALYSIS A prospective diagnostic test accuracy study during TB active contact investigation will be conducted. In the referral hospital in Southwest Shoa Zone, Oromia Region, Ethiopia, patients with pulmonary TB and a sputum sample positive for Mycobacterium tuberculosis and household contacts of at least 4 years of age will be enrolled, with a target sample size of 231 patients. Trained staff will label household contacts as 'possible TB' cases or not according to their symptoms; when TB is possible, a stool Xpert and computer-aided detection on chest X-ray will be performed, alongside standard diagnostic methods, assessing the diagnostic accuracy of CAD4TB compared with Xpert MTB/RIF during TB contact investigation and the accuracy of stool Xpert compared with sputum Xpert. ETHICS AND DISSEMINATION This study has been approved by the Oromia Health Bureau Research Ethics Committee (ref no BFO/MBTFH/1-16/100023). All information obtained will be kept confidential. Selected investigators will have access to data, while international partners will sign a dedicated data protection agreement. Eligible participants will receive brief information about the study before being asked to participate and they will provide written informed consent. Results will be disseminated through peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05818059.
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Affiliation(s)
- Francesco Vladimiro Segala
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
| | | | | | - Birhanu Kenate
- Health Research Team, Oromia Regional Health Bureau, Addis Ababa, Ethiopia
| | - Enzo Facci
- St Luke Catholic Hospital, Wolisso, Ethiopia
| | - Ademe Tsegaye
- Doctors with Africa CUAMM, Addis Ababa Coordination Office, Addis Ababa, Ethiopia
| | | | | | - Kidist Bobosha
- Mycobacterial Diseases Research, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Sergio Cotugno
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
| | | | | | - Melaku Tilahun
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | | | | | - Annalisa Saracino
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
| | - Francesco Di Gennaro
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Bari, Italy
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Dharmapalan D, Mane SS. Pediatric Drug-Resistant Tuberculosis: The Current and Future Prospects for Management and Prevention. Pathogens 2023; 12:1372. [PMID: 38003836 PMCID: PMC10674844 DOI: 10.3390/pathogens12111372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
In the continued battle against one of the oldest enemies known to mankind, Mycobacterium tuberculosis (MTB), the emergence of drug resistance to antituberculosis drugs among children poses multiple challenges for early detection and treatment. Molecular diagnostics and newer drugs like bedaquiline and delamanid have strengthened the armamentarium and helped design convenient, safe, and child-friendly therapeutic regimens against drug-resistant tuberculosis (TB). Preventive strategies like treatment of TB infection among children living in close contact with patients with drug-resistant TB and effective vaccines against TB are currently in the investigative stages of development and implementation. In addition to the implementation of recent novel diagnostics and treatment modalities, effective psychosocial and nutritional support, as well as dedicated monitoring for compliance and adverse effects, are crucial determinants for successful treatment outcomes in these children.
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Affiliation(s)
| | - Sushant Satish Mane
- Sir JJ Group of Hospitals, Grant Govt. Medical College, Mumbai 400008, India
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Khambati N, Song R, MacLean ELH, Kohli M, Olbrich L, Bijker EM. The diagnostic yield of nasopharyngeal aspirate for pediatric pulmonary tuberculosis: a systematic review and meta-analysis. BMC GLOBAL AND PUBLIC HEALTH 2023; 1:18. [PMID: 38628460 PMCID: PMC11019899 DOI: 10.1186/s44263-023-00018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/22/2023] [Indexed: 04/19/2024]
Abstract
Background Tuberculosis (TB) is a leading cause of death in children, but many cases are never diagnosed. Microbiological diagnosis of pulmonary TB is challenging in young children who cannot spontaneously expectorate sputum. Nasopharyngeal aspirates (NPA) may be more easily collected than gastric aspirate and induced sputum and can be obtained on demand, unlike stool. However, further information on its diagnostic yield is needed. Methods We systematically reviewed and meta-analyzed the diagnostic yield of one NPA for testing by either culture or nucleic acid amplification testing (NAAT) to detect Mycobacterium tuberculosis from children. We searched three bibliographic databases and two trial registers up to 24th November 2022. Studies that reported the proportion of children diagnosed by NPA compared to a microbiological reference standard (MRS) were eligible. Culture and/or WHO-endorsed NAAT on at least one respiratory specimen served as the MRS. We also estimated the incremental yield of two NPA samples compared to one and summarized operational aspects of NPA collection and processing. Univariate random-effect meta-analyses were performed to calculate pooled diagnostic yield estimates. Results From 1483 citations, 54 were selected for full-text review, and nine were included. Based on six studies including 256 children with microbiologically confirmed TB, the diagnostic yield of NAAT on one NPA ranged from 31 to 60% (summary estimate 44%, 95% CI 36-51%). From seven studies including 242 children with confirmed TB, the diagnostic yield of culture was 17-88% (summary estimate 58%, 95% CI 42-73%). Testing a second NPA increased the yield by 8-19% for NAAT and 4-35% for culture. NPA collection procedures varied between studies, although most children had NPA successfully obtained (96-100%), with a low rate of indeterminate results (< 5%). Data on NPA acceptability and specifically for children under 5 years were limited. Conclusions NPA is a suitable and feasible specimen for diagnosing pediatric TB. The high rates of successful collection across different levels of healthcare improve access to microbiological testing, supporting its inclusion in diagnostic algorithms for TB, especially if sampling is repeated. Future research into the acceptability of NPA and how to standardize collection to optimize diagnostic yield is needed.
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Affiliation(s)
- Nisreen Khambati
- Oxford Vaccine Group, Department of Pediatrics, University of Oxford, Oxford, UK
| | - Rinn Song
- Oxford Vaccine Group, Department of Pediatrics, University of Oxford, Oxford, UK
| | - Emily Lai-Ho MacLean
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, Australia
- Centre of Research Excellence in Tuberculosis, Sydney, NSW, Australia
| | - Mikashmi Kohli
- Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Laura Olbrich
- Oxford Vaccine Group, Department of Pediatrics, University of Oxford, Oxford, UK
- Division of Infectious Diseases and Tropical Medicine, University Hospital, Munich, Germany
- German Centre for Infection Research (DZIF), Partner Site Munich, Munich, Germany
- Fraunhofer Institute ITMP, Immunology, Infection and Pandemic Research, Munich, Germany
| | - Else Margreet Bijker
- Oxford Vaccine Group, Department of Pediatrics, University of Oxford, Oxford, UK
- Department of Pediatrics, Maastricht University Medical Center, MosaKids Children’s Hospital, Maastricht, the Netherlands
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Torane VP, Nataraj G, Kanade S, Deshmukh CT. Comparison of gastric lavage/sputum and stool specimens in the diagnosis of pediatric pulmonary tuberculosis- A pilot study. Indian J Tuberc 2023; 70:445-450. [PMID: 37968050 DOI: 10.1016/j.ijtb.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 10/09/2022] [Accepted: 03/29/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND AND OBJECTIVE Global TB report 2021 mentions 11 % prevalence of pediatric TB, whereas 5.65% of the cases were reported from India in 2020. India features in the list of TB high burden countries, HIV-TB high burden and MDR-TB high burden countries. The diagnosis of pulmonary tuberculosis in children is difficult as they tend to swallow the sputum, invasive techniques of gastric aspirates needs to be followed and the disease itself is paucibacillary. The disease progresses rapidly in young children and hence rapid diagnosis is needed. Obtaining appropriate respiratory samples for diagnosis is difficult especially in primary care settings. Stool sample is easy to obtain and since children swallow sputum, it can be used to diagnose pulmonary tuberculosis. With this background, a pilot study was planned to evaluate the accuracy of the Xpert MTB/RIF assay for the detection of MTB in stool specimens obtained from pediatric pulmonary TB patients confirmed either by gastric lavage(GL) or sputum(SP) Xpert MTB/RIF assay. In addition, the results of microscopy of stool specimen were compared with that of gastric lavage/ sputum (GL/SP) specimen by Ziehl-Neelsen (ZN) and fluorescent light-emitting diode (LED) staining. MATERIAL AND METHODS A prospective study was carried out on 50 GL/SP Xpert MTB/RIF assay positive children (0-14 years). Stool specimens from these children were processed for Xpert MTB/RIF assay. The GL/SP and stool specimens were processed for ZN and Auramine O fluorescent microscopy as well. RESULTS Fluorescent staining detected acid fast bacilli (AFB) in 24 GL/SP and 16 stool specimens as compared to 20 GL/SP and 10 stool specimens by ZN staining. Stool Xpert MTB/ RIF assay was positive in 29 out of 50 children. Rifampicin resistance was detected in 13 of the 50 (26%) GL/SP specimens. Of these 13 children, rifampicin resistance was detected in 7 stool specimens, rifampicin indeterminate resistance was detected in one specimen and in the remaining 5 children, M.tuberculosis was not detected in stool. CONCLUSION Stool is a good non-invasive specimen for the detection of pulmonary TB in children, especially in remote areas, where invasive techniques cannot be performed for sample collection.
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Affiliation(s)
- Vijaya P Torane
- Department of Microbiology, Seth Gordhandas Sunderdas Medical College (GSMC) & King Edward Memorial Hospital (KEMH), Mumbai, Maharashtra, India.
| | - Gita Nataraj
- Department of Microbiology, Seth Gordhandas Sunderdas Medical College (GSMC) & King Edward Memorial Hospital (KEMH), Mumbai, Maharashtra, India
| | - Swapna Kanade
- Department of Microbiology, Seth Gordhandas Sunderdas Medical College (GSMC) & King Edward Memorial Hospital (KEMH), Mumbai, Maharashtra, India
| | - Chandrahas T Deshmukh
- Department of Pediatrics, Seth Gordhandas Sunderdas Medical College (GSMC) & King Edward Memorial Hospital (KEMH), Mumbai, Maharashtra, India
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Shaikh A, Rodrigues C. What's New in the Molecular Diagnosis of Childhood Tuberculosis? Pediatr Infect Dis J 2023; 42:e377-e379. [PMID: 37463349 DOI: 10.1097/inf.0000000000004044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Ambreen Shaikh
- From the Department of Laboratory Medicine, Section Tuberculosis, Foundation Medical Research, Worli, Mumbai, India
| | - Camilla Rodrigues
- Department of Laboratory Medicine, Section Microbiology, Hinduja Hospital, Mahim, Mumbai, India
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Singhal R, Dayal R, Bhatnagar S, Nayak M, Yadav N, Kumar P, Kumar S, Singh H, Singh G. Diagnostic Accuracy of Cartridge Based Nucleic Acid Amplification Test (CBNAAT) in Stool Samples in Pediatric Tuberculosis. Indian J Pediatr 2023:10.1007/s12098-023-04849-6. [PMID: 37747634 DOI: 10.1007/s12098-023-04849-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/17/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES To find out the diagnostic accuracy of stool Cartridge-based nucleic acid amplification test (CBNAAT) as an alternate method as compared to CBNAAT in gastric aspirate (GA) samples in pediatric tuberculosis (TB). METHODS This cross-sectional study was performed at Department of Pediatrics of a tertiary care hospital. Children aged 0-18 y diagnosed as presumptive tuberculosis were consecutively enrolled. Gastric aspirate and corresponding stool sample was subjected to CBNAAT and its performance was compared in both samples using appropriate statistical tests. RESULTS Total 100 patients were enrolled in the study. Diagnostic accuracy of CBNAAT was 81% and 80% in gastric aspirate and stool sample respectively. On comparing gastric aspirate with corresponding stool sample there was 97% agreement, with Cohen's kappa value of 0.94. There was a statistically significant association observed between gastric aspirate CBNAAT and stool CBNAAT p <0.001 using chi square test. Sensitivity of gastric aspirate CBNAAT and stool CBNAAT was 75% and 73% respectively and specificity was 100% for both the samples compared against Composite Reference Standard (CRS). CONCLUSIONS The diagnostic accuracy of stool CBNAAT is comparable to GA CBNAAT in children and can be used as a good alternative to gastric aspirate for diagnosis of pulmonary and disseminated tuberculosis in children.
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Affiliation(s)
- Richa Singhal
- Department of Pediatrics, S.N. Medical College, Agra, 282003, India
| | - Rajeshwar Dayal
- Department of Pediatrics, S.N. Medical College, Agra, 282003, India.
| | - Shailendra Bhatnagar
- Intermediate Reference Laboratory (IRL) State TB Training and Demonstration Center (STDC), Agra, India
| | - Madhu Nayak
- Department of Pediatrics, S.N. Medical College, Agra, 282003, India
| | - Neeraj Yadav
- Department of Pediatrics, S.N. Medical College, Agra, 282003, India
| | - Pankaj Kumar
- Department of Pediatrics, S.N. Medical College, Agra, 282003, India
| | - Santosh Kumar
- Department of Tuberculosis and Chest Diseases, S.N. Medical College, Agra, India
| | - Hari Singh
- Department of Radiodiagnosis, S.N. Medical College, Agra, India
| | - Geetu Singh
- Department of Preventive and Social Medicine, S.N. Medical College, Agra, India
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11
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Jayagandan S, Singh J, Mudliar SR, Shankar P, Maurya AK, Malhotra AG, Malik S, Purwar S, Singh S. Evaluation of Xpert MTB/RIF Assay on Stool Samples for the Diagnosis of Pulmonary Tuberculosis among the Pediatric Population. J Lab Physicians 2023; 15:329-335. [PMID: 37564227 PMCID: PMC10411201 DOI: 10.1055/s-0042-1757721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective Microbiological confirmation of tuberculosis (TB) in pediatric cases is challenging due to its paucibacillary nature and difficulty in specimen collection. This study aimed to validate stool as an alternative sample for the diagnosis of pediatric pulmonary TB via Xpert MTB/RIF (Xpert) assay. Materials and Methods This cross-sectional study included 75 pediatric patients up to 10 years of age with signs and symptoms suggestive of TB. From each recruited patient, pulmonary and stool samples were collected in a sterile container. The collected samples were subjected to Ziehl-Neelsen staining, BACTEC MGIT 960 culture (MGIT), Xpert, and in-house multiplex polymerase chain reaction for TB diagnosis. Results About 13.33% (10/75) of the pulmonary samples and, of them, 50% (5/75) of the stool samples were positive by Xpert assay. The sensitivity and specificity of Xpert assay with stool and pulmonary samples were 50 (95% confidence interval [CI]: 18.71-81.29%) and 100% (95% CI: 94.48-100%), respectively. Conclusion The Xpert assay on stool samples showed limited sensitivity and good specificity in the diagnosis of pulmonary TB. Therefore, it can be proposed as an alternative screening sample to diagnose TB in pediatric cases for which getting a respiratory sample is extremely difficult. However, further studies with greater number of samples and multiple baseline variables are required to support our findings. Strategies to optimize stool Xpert assay should be performed to enhance the sensitivity of this method to detect Mycobacterium tuberculosis in children.
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Affiliation(s)
- Sangitha Jayagandan
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Jitendra Singh
- Department of Translational Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Shivkumar Rashmi Mudliar
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Prem Shankar
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Anand Kumar Maurya
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Anvita Gupta Malhotra
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Shikha Malik
- Department of Paediatrics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Shashank Purwar
- Department of Microbiology, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Sarman Singh
- Former Director, All India Institute of Medical Sciences, Bhopal, India
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12
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Yu X, Wang F, Ren R, Dong L, Xue Y, Zhao L, Jia J, Huang H. Xpert MTB/RIF Ultra Assay Using Stool: an Effective Solution for Bacilli Identification from Adult Pulmonary Tuberculosis Suspects without Expectorated Sputum. Microbiol Spectr 2023; 11:e0126523. [PMID: 37378554 PMCID: PMC10434112 DOI: 10.1128/spectrum.01265-23] [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: 03/23/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
This study evaluated the diagnostic performance of stool-based Xpert MTB/RIF Ultra assay (Xpert-Ultra, Cepheid, USA) against other tests using respiratory tract specimens (RTS) and stool for diagnosing adult pulmonary tuberculosis. A prospective study on patients with presumptive pulmonary tuberculosis was conducted in Beijing Chest Hospital from June to November 2021. The smear test, MGIT960 liquid culture, and Xpert MTB/RIF (Xpert, Cepheid, USA) were performed simultaneously on RTS, and smear, culture Xpert, and Xpert-Ultra were performed simultaneously using stool. Patients were grouped based on the outcomes of RTS examination and other tests. In total, 130 eligible patients were enrolled that included 96 pulmonary tuberculosis and 34 non-TB patients. The sensitivity of smear, culture, Xpert, and Xpert-Ultra using stool was 10.96%, 23.28%, 60.27%, and 79.45%, respectively. The specificities of Xpert and Xpert-Ultra using RTS and stool were all 100% (34/34). Notably, all five confirmed cases detected by bronchoalveolar lavage fluid (BALF) examination yielded Xpert-Ultra positive outcomes with the stool specimens. Xpert-Ultra assay on stool sample harbors comparable sensitivity with Xpert on RTS. Thus, the Xpert-Ultra testing on stool specimens could be a very promising and practical strategy to improve pulmonary tuberculosis (PTB) diagnosis, especially among patients who could not expectorate sputum. IMPORTANCE This study is aimed at assessing the value of Xpert MTB/RIF Ultra (Xpert-Ultra) in PTB on stool in adult in low HIV settings and Xpert-Ultra assay on stool sample harboring comparable sensitivity with Xpert MTB/RIF on respiratory tract specimens. Although the yield in stool samples by Xpert-Ultra is lower than RTS, it may be useful in detecting disease in presumptive TB patients who cannot expectorate sputum and are not open to BALF collection. In addition, Xpert-Ultra with a "trace call" on stool in adult was highly supportive of PTB.
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Affiliation(s)
- Xia Yu
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, Beijing, China
| | - Fen Wang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, Beijing, China
| | - Ruyan Ren
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, Beijing, China
| | - Lingling Dong
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, Beijing, China
| | - Yi Xue
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, Beijing, China
| | - Liping Zhao
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, Beijing, China
| | - Junnan Jia
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, Beijing, China
| | - Hairong Huang
- National Clinical Laboratory on Tuberculosis, Beijing Key Laboratory for Drug Resistant Tuberculosis Research, Beijing Chest Hospital, Capital Medical University, Beijing Tuberculosis and Thoracic Tumor Institute, Beijing, Beijing, China
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13
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Agarwal A, Mathur SB. Stool CBNAAT: Alternative tool in the diagnosis of pulmonary tuberculosis in children. Indian J Tuberc 2023; 70 Suppl 1:S29-S34. [PMID: 38110257 DOI: 10.1016/j.ijtb.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 12/20/2023]
Abstract
Tuberculosis (TB) remains a significant public health concern, especially in children. The World Health Organization now provides estimates on pediatric TB cases and deaths, underscoring the urgency of addressing this issue. In India, childhood TB contributes significantly to the global burden, with a notable gap between reported cases and estimated incidence. Diagnosing pulmonary TB in children presents challenges, primarily due to difficulties in obtaining suitable respiratory specimens. Rapid tests like Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) have shown promise in enhancing diagnostic sensitivity. Recent research suggests that stool samples offer a non-invasive alternative for diagnosing pulmonary TB in children, with good diagnostic accuracy observed for stool CBNAAT. Furthermore, stool CBNAAT results demonstrate high agreement with gastric aspirate CBNAAT in TB diagnosis. Various stool processing methods, such as centrifugation, filtration, and sedimentation, have shown improved results for CBNAAT testing. However, it is crucial to standardize these methods to ensure consistent and comparable outcomes. Integrating stool CBNAAT into existing diagnostic algorithms for pediatric TB can enhance accuracy and efficiency in diagnosis. When implementing these algorithms, local resources, epidemiological context, and healthcare settings should be taken into account. Stool CBNAAT holds promise for microbiological confirmation of pediatric pulmonary TB, especially in resource-limited settings where obtaining representative respiratory specimens is challenging. Further comparative studies and standardization of stool processing methods are necessary to determine the most suitable approach in different contexts. By doing so, we can make significant strides in improving TB diagnosis and management in children.
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Affiliation(s)
- Anurag Agarwal
- Department of Pediatrics, Maulana Azad Medical College & Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi, 110002, India.
| | - Surendra Bahadur Mathur
- Department of Pediatrics, Hamdard Institute of Medical Sciences and Research & HAHC Hospital, Hamdard Nagar, New Delhi, 110062, India
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14
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Huang Z, Zhang G, Lyon CJ, Hu TY, Lu S. Outlook for CRISPR-based tuberculosis assays now in their infancy. Front Immunol 2023; 14:1172035. [PMID: 37600797 PMCID: PMC10436990 DOI: 10.3389/fimmu.2023.1172035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/03/2023] [Indexed: 08/22/2023] Open
Abstract
Tuberculosis (TB) remains a major underdiagnosed public health threat worldwide, being responsible for more than 10 million cases and one million deaths annually. TB diagnosis has become more rapid with the development and adoption of molecular tests, but remains challenging with traditional TB diagnosis, but there has not been a critical review of this area. Here, we systematically review these approaches to assess their diagnostic potential and issues with the development and clinical evaluation of proposed CRISPR-based TB assays. Based on these observations, we propose constructive suggestions to improve sample pretreatment, method development, clinical validation, and accessibility of these assays to streamline future assay development and validation studies.
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Affiliation(s)
- Zhen Huang
- National Clinical Research Center for Infectious Disease, Shenzhen Third People’s Hospital, Shenzhen, Guangdong, China
| | - Guoliang Zhang
- National Clinical Research Center for Infectious Disease, Shenzhen Third People’s Hospital, Shenzhen, Guangdong, China
| | - Christopher J. Lyon
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, United States
| | - Tony Y. Hu
- Center for Cellular and Molecular Diagnostics, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Biochemistry and Molecular Biology, Tulane University School of Medicine, New Orleans, LA, United States
| | - Shuihua Lu
- National Clinical Research Center for Infectious Disease, Shenzhen Third People’s Hospital, Shenzhen, Guangdong, China
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15
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Babo Y, Seremolo B, Bogale M, Bedru A, Wabe Y, Churako H, Bilat A, Degaga T, de Haas P, Tiemersma E, Jerene D. Comparison of Xpert MTB/RIF Ultra Results of Stool and Sputum in Children with Presumptive Tuberculosis in Southern Ethiopia. Trop Med Infect Dis 2023; 8:350. [PMID: 37505646 PMCID: PMC10384425 DOI: 10.3390/tropicalmed8070350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023] Open
Abstract
The introduction of stool as a readily obtainable sample and the recently developed simple one-step (SOS) stool processing method on Xpert MTB/RIF Ultra (Xpert Ultra) offer an opportunity for TB diagnosis in children. We conducted this study in secondary health facilities in Ethiopia, which are the first-level referral facilities for childhood TB diagnosis and treatment, with the aim to determine if stool-based TB diagnosis can be performed with a reasonable level of concordance with sputum tests using Xpert MTB/RIF Ultra. Eligible children 0-14 years old with presumptive pulmonary TB were asked to provide stools in addition to routinely requested sputum samples. We determined the level of agreement between the stool and sputum test results. Of the 373 children included in the study, 61% were <5 years of age and 56% were male. Thirty-six children (9.7%) were diagnosed with TB, and all started treatment. The rate of concordance between stool and sputum was high, with a kappa value of 0.83 (p < 0.001). There were more Xpert Ultra positive results on stool (n = 27 (7.2%)) than on sputum/NGA (n = 23 (6.2%)). Laboratories in secondary hospitals can perform stool-based TB diagnosis in children, with high concordance between stool and sputum test results reaffirming the applicability of the SOS stool method.
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Affiliation(s)
- Yohannes Babo
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Bihil Seremolo
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Mamush Bogale
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Ahmed Bedru
- KNCV Tuberculosis Foundation, P.O. Box 703 Code 1110, Addis Ababa, Ethiopia
| | - Yasin Wabe
- Worabe Comprehensive Specialized Hospital, Worabe, Ethiopia
| | - Haba Churako
- Wolaita Sodo University Hospital, Wolaita, Ethiopia
| | - Alemu Bilat
- Nigist Eleni Memorial Comprehensive Specialized Hospital, Hossana, Ethiopia
| | - Tamiru Degaga
- College of Medicine & Health Sciences, Arba Minch University, Arbaminch, Ethiopia
| | - Petra de Haas
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
| | - Edine Tiemersma
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
| | - Degu Jerene
- KNCV Tuberculosis Foundation, Maanweg 174, 2516 AB The Hague, The Netherlands
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16
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Segala FV, Papagni R, Cotugno S, De Vita E, Susini MC, Filippi V, Tulone O, Facci E, Lattanzio R, Marotta C, Manenti F, Bavaro DF, De Iaco G, Putoto G, Veronese N, Barbagallo M, Saracino A, Di Gennaro F. Stool Xpert MTB/RIF as a possible diagnostic alternative to sputum in Africa: a systematic review and meta-analysis. Front Public Health 2023; 11:1117709. [PMID: 37293615 PMCID: PMC10244509 DOI: 10.3389/fpubh.2023.1117709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
Introduction Worldwide, COVID-19 pandemic lead to a large fall in the number of newly reported TB cases. In sub-Saharan Africa, microbiological diagnosis of TB is generally based on smear microscopy and Xpert MTB/RIF on sputum samples, but good quality sputum samples are often difficult to obtain, leading clinicians to rely on more invasive procedures for diagnosis. Aim of this study was to investigate pooled sensitivity and specificity of Xpert MTB/RIF on stool samples compared to respiratory microbiological reference standards in African countries. Methods Four investigators independently searched PubMed, SCOPUS, and Web of Science until 12th October 2022, then screened titles and abstracts of all potentially eligible articles. The authors applied the eligibility criteria, considered the full texts. All the studies reported the data regarding true positive (TP), true negative (TN), false positive (FP) and false negative (FN). Risk of bias and applicability concerns were assessed with the Quadas-2 tool. Results overall, among 130 papers initially screened, we evaluated 47 works, finally including 13 papers for a total of 2,352 participants, mainly children. The mean percentage of females was 49.6%, whilst the mean percentage of patients reporting HIV was 27.7%. Pooled sensitivity for Xpert MTB/RIF assay for detecting pulmonary tuberculosis was 68.2% (95%CI: 61.1-74.7%) even if characterized by a high heterogeneity (I2=53.7%). Specificity was almost 100% (99%, 95%CI: 97-100%; I2 = 45.7%). When divided for reference standard, in the six studies using sputum and nasogastric aspirate the accuracy was optimal (AUC = 0.99, SE = 0.02), whilst in the studies using only sputum for tuberculosis detection the AUC was 0.85 (with a SE = 0.16). The most common source of bias was exclusion of enrolled patients in the analysis. Conclusions Our study confirms that, in Africa, stool Xpert MTB/RIF may be a useful rule-in test for children above and below 5 years of age under evaluation for pulmonary tuberculosis. Sensitivity increased substantially when using both sputum and nasogastric aspirate as reference samples.
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Affiliation(s)
- Francesco Vladimiro Segala
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
- Operational Research Unit, Doctors With Africa CUAMM, Padua, Italy
| | - Roberta Papagni
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Sergio Cotugno
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Elda De Vita
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | | | | | - Ottavia Tulone
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Enzo Facci
- Doctors With Africa CUAMM, Wolisso, Ethiopia
| | - Rossana Lattanzio
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Claudia Marotta
- Operational Research Unit, Doctors With Africa CUAMM, Padua, Italy
| | | | - Davide Fiore Bavaro
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Giuseppina De Iaco
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Giovanni Putoto
- Operational Research Unit, Doctors With Africa CUAMM, Padua, Italy
| | - Nicola Veronese
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Mario Barbagallo
- Geriatric Unit, Department of Internal Medicine and Geriatrics, University of Palermo, Palermo, Italy
| | - Annalisa Saracino
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
| | - Francesco Di Gennaro
- Department of Precision and Regenerative Medicine and Ionian Area, Clinic of Infectious Diseases, University of Bari, Bari, Italy
- Operational Research Unit, Doctors With Africa CUAMM, Padua, Italy
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17
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Sultana S, Afrin S, Hasan M, Ansar A, Saif-Ur-Rahman KM. Stool specimen for diagnosis of pulmonary tuberculosis in adults: a systematic review. BMJ Open 2023; 13:e062135. [PMID: 37105702 PMCID: PMC10151869 DOI: 10.1136/bmjopen-2022-062135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/18/2023] [Indexed: 04/29/2023] Open
Abstract
OBJECTIVE To assess the diagnostic accuracy of stool specimens to diagnose pulmonary tuberculosis (PTB) in adults. DESIGN Systematic review. DATA SOURCES MEDLINE (Ovid), Embase (Ovid), Web of Science and the Cochrane database were searched from inception to 9 March 2023-10 March 2023 using a comprehensive search strategy; reference lists of selected articles and relevant review articles were manually searched. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies in English reporting diagnostic performance of stool specimens against respiratory specimens using mycobacterial culture or smear microscopy or Xpert assay to diagnose PTB in adults were eligible for this systematic review. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened the retrieved citations and extracted data. The risk of bias and applicability of results were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Narrative data synthesis was performed. RESULTS A total of 1658 citations were screened, and 28 full-text articles were assessed. Nine studies met the inclusion criteria. The reported sensitivity and specificity of stool culture varied between 21.4% and 63.9%, and 61.5% and 100%, respectively. In stool smear microscopy, sensitivities and specificities ranged from 12.1% to 53.9%, and from 79.5% to 100%, respectively. The reported sensitivities of PCR assays, including Xpert assays, ranged from 69.7% to 100%, with specificities ranging from 69.8% to 100%. Most of the studies had a low risk of bias and a low applicability concern in all domains. CONCLUSION This systematic review could not conclude on the diagnostic accuracy of stool specimens for PTB diagnosis in adults. Further studies are required to evaluate the accuracy of stool specimens in adults to enable meta-analyses in updates of this review as well as other systematic reviews. PROSPERO REGISTRATION NUMBER CRD42021245203.
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Affiliation(s)
| | - Sadia Afrin
- Health Systems and Population Studies Division, ICDDRB, Dhaka, Bangladesh
| | | | - Adnan Ansar
- School of Nursing and Midwifery, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia
| | - K M Saif-Ur-Rahman
- Health Systems and Population Studies Division, ICDDRB, Dhaka, Bangladesh
- Evidence Synthesis Ireland and Cochrane Ireland, University of Galway, Galway, Ireland
- College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
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18
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Kay AW, Ness T, Verkuijl SE, Viney K, Brands A, Masini T, González Fernández L, Eisenhut M, Detjen AK, Mandalakas AM, Steingart KR, Takwoingi Y. Xpert MTB/RIF Ultra assay for tuberculosis disease and rifampicin resistance in children. Cochrane Database Syst Rev 2022; 9:CD013359. [PMID: 36065889 PMCID: PMC9446385 DOI: 10.1002/14651858.cd013359.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Every year, an estimated one million children and young adolescents become ill with tuberculosis, and around 226,000 of those children die. Xpert MTB/RIF Ultra (Xpert Ultra) is a molecular World Health Organization (WHO)-recommended rapid diagnostic test that simultaneously detects Mycobacterium tuberculosis complex and rifampicin resistance. We previously published a Cochrane Review 'Xpert MTB/RIF and Xpert MTB/RIF Ultra assays for tuberculosis disease and rifampicin resistance in children'. The current review updates evidence on the diagnostic accuracy of Xpert Ultra in children presumed to have tuberculosis disease. Parts of this review update informed the 2022 WHO updated guidance on management of tuberculosis in children and adolescents. OBJECTIVES To assess the diagnostic accuracy of Xpert Ultra for detecting: pulmonary tuberculosis, tuberculous meningitis, lymph node tuberculosis, and rifampicin resistance, in children with presumed tuberculosis. Secondary objectives To investigate potential sources of heterogeneity in accuracy estimates. For detection of tuberculosis, we considered age, comorbidity (HIV, severe pneumonia, and severe malnutrition), and specimen type as potential sources. To summarize the frequency of Xpert Ultra trace results. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, MEDLINE, Embase, three other databases, and three trial registers without language restrictions to 9 March 2021. SELECTION CRITERIA Cross-sectional and cohort studies and randomized trials that evaluated Xpert Ultra in HIV-positive and HIV-negative children under 15 years of age. We included ongoing studies that helped us address the review objectives. We included studies evaluating sputum, gastric, stool, or nasopharyngeal specimens (pulmonary tuberculosis), cerebrospinal fluid (tuberculous meningitis), and fine needle aspirate or surgical biopsy tissue (lymph node tuberculosis). For detecting tuberculosis, reference standards were microbiological (culture) or composite reference standard; for stool, we also included Xpert Ultra performed on a routine respiratory specimen. For detecting rifampicin resistance, reference standards were drug susceptibility testing or MTBDRplus. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and, using QUADAS-2, assessed methodological quality judging risk of bias separately for each target condition and reference standard. For each target condition, we used the bivariate model to estimate summary sensitivity and specificity with 95% confidence intervals (CIs). We stratified all analyses by type of reference standard. We summarized the frequency of Xpert Ultra trace results; trace represents detection of a very low quantity of Mycobacterium tuberculosis DNA. We assessed certainty of evidence using GRADE. MAIN RESULTS We identified 14 studies (11 new studies since the previous review). For detection of pulmonary tuberculosis, 335 data sets (25,937 participants) were available for analysis. We did not identify any studies that evaluated Xpert Ultra accuracy for tuberculous meningitis or lymph node tuberculosis. Three studies evaluated Xpert Ultra for detection of rifampicin resistance. Ten studies (71%) took place in countries with a high tuberculosis burden based on WHO classification. Overall, risk of bias was low. Detection of pulmonary tuberculosis Sputum, 5 studies Xpert Ultra summary sensitivity verified by culture was 75.3% (95% CI 64.3 to 83.8; 127 participants; high-certainty evidence), and specificity was 97.1% (95% CI 94.7 to 98.5; 1054 participants; high-certainty evidence). Gastric aspirate, 7 studies Xpert Ultra summary sensitivity verified by culture was 70.4% (95% CI 53.9 to 82.9; 120 participants; moderate-certainty evidence), and specificity was 94.1% (95% CI 84.8 to 97.8; 870 participants; moderate-certainty evidence). Stool, 6 studies Xpert Ultra summary sensitivity verified by culture was 56.1% (95% CI 39.1 to 71.7; 200 participants; moderate-certainty evidence), and specificity was 98.0% (95% CI 93.3 to 99.4; 1232 participants; high certainty-evidence). Nasopharyngeal aspirate, 4 studies Xpert Ultra summary sensitivity verified by culture was 43.7% (95% CI 26.7 to 62.2; 46 participants; very low-certainty evidence), and specificity was 97.5% (95% CI 93.6 to 99.0; 489 participants; high-certainty evidence). Xpert Ultra sensitivity was lower against a composite than a culture reference standard for all specimen types other than nasopharyngeal aspirate, while specificity was similar against both reference standards. Interpretation of results In theory, for a population of 1000 children: • where 100 have pulmonary tuberculosis in sputum (by culture): - 101 would be Xpert Ultra-positive, and of these, 26 (26%) would not have pulmonary tuberculosis (false positive); and - 899 would be Xpert Ultra-negative, and of these, 25 (3%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in gastric aspirate (by culture): - 123 would be Xpert Ultra-positive, and of these, 53 (43%) would not have pulmonary tuberculosis (false positive); and - 877 would be Xpert Ultra-negative, and of these, 30 (3%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in stool (by culture): - 74 would be Xpert Ultra-positive, and of these, 18 (24%) would not have pulmonary tuberculosis (false positive); and - 926 would be Xpert Ultra-negative, and of these, 44 (5%) would have tuberculosis (false negative). • where 100 have pulmonary tuberculosis in nasopharyngeal aspirate (by culture): - 66 would be Xpert Ultra-positive, and of these, 22 (33%) would not have pulmonary tuberculosis (false positive); and - 934 would be Xpert Ultra-negative, and of these, 56 (6%) would have tuberculosis (false negative). Detection of rifampicin resistance Xpert Ultra sensitivity was 100% (3 studies, 3 participants; very low-certainty evidence), and specificity range was 97% to 100% (3 studies, 128 participants; low-certainty evidence). Trace results Xpert Ultra trace results, regarded as positive in children by WHO standards, were common. Xpert Ultra specificity remained high in children, despite the frequency of trace results. AUTHORS' CONCLUSIONS We found Xpert Ultra sensitivity to vary by specimen type, with sputum having the highest sensitivity, followed by gastric aspirate and stool. Nasopharyngeal aspirate had the lowest sensitivity. Xpert Ultra specificity was high against both microbiological and composite reference standards. However, the evidence base is still limited, and findings may be imprecise and vary by study setting. Although we found Xpert Ultra accurate for detection of rifampicin resistance, results were based on a very small number of studies that included only three children with rifampicin resistance. Therefore, findings should be interpreted with caution. Our findings provide support for the use of Xpert Ultra as an initial rapid molecular diagnostic in children being evaluated for tuberculosis.
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Key Words
- adolescent
- child
- humans
- antibiotics, antitubercular
- antibiotics, antitubercular/therapeutic use
- cross-sectional studies
- hiv infections
- hiv infections/drug therapy
- microbial sensitivity tests
- mycobacterium tuberculosis
- mycobacterium tuberculosis/genetics
- rifampin
- rifampin/pharmacology
- sensitivity and specificity
- sputum
- sputum/microbiology
- tuberculosis, lymph node
- tuberculosis, lymph node/diagnosis
- tuberculosis, lymph node/drug therapy
- tuberculosis, meningeal
- tuberculosis, meningeal/cerebrospinal fluid
- tuberculosis, meningeal/diagnosis
- tuberculosis, meningeal/drug therapy
- tuberculosis, pulmonary
- tuberculosis, pulmonary/diagnosis
- tuberculosis, pulmonary/drug therapy
- tuberculosis, pulmonary/microbiology
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Affiliation(s)
- Alexander W Kay
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Tara Ness
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | - Kerri Viney
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Annemieke Brands
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Tiziana Masini
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Lucia González Fernández
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Michael Eisenhut
- Paediatric Department, Luton & Dunstable University Hospital NHS Foundation Trust, Luton, UK
| | | | - Anna M Mandalakas
- The Global Tuberculosis Program, Texas Children's Hospital, Section of Global and Immigrant Health, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Karen R Steingart
- Honorary Research Fellow, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Yemisi Takwoingi
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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19
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Pediatric Tuberculosis Management: A Global Challenge or Breakthrough? CHILDREN 2022; 9:children9081120. [PMID: 36010011 PMCID: PMC9406656 DOI: 10.3390/children9081120] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/19/2022] [Accepted: 07/23/2022] [Indexed: 12/17/2022]
Abstract
Managing pediatric tuberculosis (TB) remains a public health problem requiring urgent and long-lasting solutions as TB is one of the top ten causes of ill health and death in children as well as adolescents universally. Minors are particularly susceptible to this severe illness that can be fatal post-infection or even serve as reservoirs for future disease outbreaks. However, pediatric TB is the least prioritized in most health programs and optimal infection/disease control has been quite neglected for this specialized patient category, as most scientific and clinical research efforts focus on developing novel management strategies for adults. Moreover, the ongoing coronavirus pandemic has meaningfully hindered the gains and progress achieved with TB prophylaxis, therapy, diagnosis, and global eradication goals for all affected persons of varying age bands. Thus, the opening of novel research activities and opportunities that can provide more insight and create new knowledge specifically geared towards managing TB disease in this specialized group will significantly improve their well-being and longevity.
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20
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Mafirakureva N, Klinkenberg E, Spruijt I, Levy J, Shaweno D, de Haas P, Kaswandani N, Bedru A, Triasih R, Gebremichael M, Dodd PJ, Tiemersma EW. Xpert Ultra stool testing to diagnose tuberculosis in children in Ethiopia and Indonesia: a model-based cost-effectiveness analysis. BMJ Open 2022; 12:e058388. [PMID: 35777870 PMCID: PMC9252203 DOI: 10.1136/bmjopen-2021-058388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The WHO currently recommends stool testing using GeneXpert MTB/Rif (Xpert) for the diagnosis of paediatric tuberculosis (TB). The simple one-step (SOS) stool method enables processing for Xpert testing at the primary healthcare (PHC) level. We modelled the impact and cost-effectiveness of implementing the SOS stool method at PHC for the diagnosis of paediatric TB in Ethiopia and Indonesia, compared with the standard of care. SETTING All children (age <15 years) presenting with presumptive TB at primary healthcare or hospital level in Ethiopia and Indonesia. PRIMARY OUTCOME Cost-effectiveness estimated as incremental costs compared with incremental disability-adjusted life-years (DALYs) saved. METHODS Decision tree modelling was used to represent pathways of patient care and referral. We based model parameters on ongoing studies and surveillance, systematic literature review, and expert opinion. We estimated costs using data available publicly and obtained through in-country expert consultations. Health outcomes were based on modelled mortality and discounted life-years lost. RESULTS The intervention increased the sensitivity of TB diagnosis by 19-25% in both countries leading to a 14-20% relative reduction in mortality. Under the intervention, fewer children seeking care at PHC were referred (or self-referred) to higher levels of care; the number of children initiating anti-TB treatment (ATT) increased by 18-25%; and more children (85%) initiated ATT at PHC level. Costs increased under the intervention compared with a base case using smear microscopy in the standard of care resulting in incremental cost-effectiveness ratios of US$132 and US$94 per DALY averted in Ethiopia and Indonesia, respectively. At a cost-effectiveness threshold of 0.5×gross domestic product per capita, the projected probability of the intervention being cost-effective in Ethiopia and Indonesia was 87% and 96%, respectively. The intervention remained cost-effective under sensitivity analyses. CONCLUSIONS The addition of the SOS stool method to national algorithms for diagnosing TB in children is likely to be cost-effective in both Ethiopia and Indonesia.
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Affiliation(s)
| | - Eveline Klinkenberg
- Independent consultant, Connect TB, Den Haag, The Netherlands
- Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ineke Spruijt
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Jens Levy
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | | | - Petra de Haas
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
| | - Nastiti Kaswandani
- Pediatric Department, RSCM Hospital, University of Indonesia Faculty of Medicine, Jakarta, Indonesia
| | - Ahmed Bedru
- Technical Division, KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Rina Triasih
- Department of Paediatrics, Universitas Gadjah Mada Fakultas Kedokteran, Yogyakarta, Indonesia
| | | | - Peter J Dodd
- ScHARR, The University of Sheffield, Sheffield, UK
| | - Edine W Tiemersma
- Technical Division, KNCV Tuberculosis Foundation, Den Haag, The Netherlands
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21
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Sharma V, Singh A, Gaur M, Rawat D, Yadav A, Rajan, Kumar C, Varma-Basil M, Lohiya S, Khanna V, Khanna A, Chaudhry A, Singh Y, Misra R. Evaluating the efficacy of stool sample on Xpert MTB/RIF Ultra and its comparison with other sample types by meta-analysis for TB diagnostics. Eur J Clin Microbiol Infect Dis 2022; 41:893-906. [PMID: 35508741 DOI: 10.1007/s10096-022-04449-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/19/2022] [Indexed: 11/03/2022]
Abstract
Precise and timely detection of tuberculosis (TB) is crucial to reduce transmission. This study aims to assess the accuracy of Xpert MTB/RIF Ultra on stool samples and systematically review the performance of Xpert MTB/RIF Ultra with different sample types by meta-analysis. Stool samples of smear-negative pulmonary TB (PTB), cervical lymph node TB, and abdominal TB patients were tested on the Xpert MTB/RIF Ultra system. Meta-analysis was performed on a set of 44 studies. Data were grouped by sample type, and the pooled sensitivity and specificity of Xpert MTB/RIF Ultra were calculated. The sensitivity of Xpert MTB/RIF Ultra with stool samples was 100% for smear-negative PTB, 27.27% for cervical lymph node TB, and 50% for abdominal TB patients, with 100% specificity for all included TB groups. The summary estimate for all PTB samples showed 84.2% sensitivity and 94.5% specificity, and EPTB samples showed 88.6% sensitivity and 96.4% specificity. Among all sample types included in our meta-analysis, urine showed the best performance for EPTB diagnosis. This pilot study supports the use of stool as an alternative non-invasive sample on Xpert MTB/RIF Ultra for rapid testing, suitable for both PTB and EPTB diagnosis.
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Affiliation(s)
- Vishal Sharma
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Anoop Singh
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Mohita Gaur
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Deepti Rawat
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Anjali Yadav
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Rajan
- Department of Zoology, University of Delhi, Delhi, 110007, India
| | - Chanchal Kumar
- Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India
| | - Mandira Varma-Basil
- Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, 110007, India
| | - Sheelu Lohiya
- Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Vishal Khanna
- Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Ashwani Khanna
- State TB Officer & In-Charge, Chest Clinic, Lok Nayak Hospital, Delhi, 110002, India
| | - Anil Chaudhry
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, Kingsway Camp, Delhi, 110009, India
| | - Yogendra Singh
- Department of Zoology, University of Delhi, Delhi, 110007, India.
| | - Richa Misra
- Department of Zoology, University of Delhi, Delhi, 110007, India. .,Department of Zoology, Sri Venkateswara College, University of Delhi, Delhi, 110021, India.
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22
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Agarwal A, Kodethoor D, Khanna A, Hanif M. Utility of stool CBNAAT in the diagnosis of pediatric pulmonary tuberculosis in India. Indian J Tuberc 2022; 69:178-183. [PMID: 35379399 DOI: 10.1016/j.ijtb.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 06/28/2021] [Accepted: 07/06/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND India houses 27% of the tuberculosis cases worldwide. Pediatric tuberculosis accounts for 11% cases worldwide. Microbiological confirmation of diagnosis is difficult in children. We aimed to study the proportion of Stool CBNAAT (Cartridge Based Nucleic Acid Amplification Test) and GA CBNAAT positive cases among the presumptive cases of tuberculosis in children and assess diagnostic utility of the Stool CBNAAT in comparison to GA CBNAAT and culture. METHODS Ours was a cross sectional study. 75 children, aged 6 months to 12 years who were presumptive cases of pulmonary tuberculosis and who were unable to expectorate, were enrolled. Gastric aspirate and stool samples were obtained and CBNAAT and culture was done. Results of stool CBNAAT were compared with GA CBNAAT and culture. RESULTS Of the 75 children enrolled, 28 were started on antitubercular therapy, 12 of whom were microbiologically confirmed and 16 were started on clinical grounds. Overall, 10 (13.3%) and 11 (14.6%) were positive by Stool CBNAAT and GA CBNAAT respectively. GA CBNAAT and Stool CBNAAT were found to have near perfect agreement (Cohen's kappa 0.834). Stool CBNAAT had sensitivity and specificity of 73% and 97% as compared to culture. CONCLUSIONS Stool CBNAAT may be used for bacteriological confirmation of pediatric pulmonary tuberculosis. It was found to have a high degree of concordance with the conventionally used GA CBNAAT. This test would be helpful in endemic countries where there is a dearth of trained staff, especially in the periphery, to obtain gastric aspirate. Discomfort associated with sampling would be avoided.
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Affiliation(s)
- Anurag Agarwal
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi, India
| | - Dhrithi Kodethoor
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi, India.
| | - Ashwani Khanna
- Chest Clinic(TB), Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi, India
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23
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Nathavitharana RR, Garcia-Basteiro AL, Ruhwald M, Cobelens F, Theron G. Reimagining the status quo: How close are we to rapid sputum-free tuberculosis diagnostics for all? EBioMedicine 2022; 78:103939. [PMID: 35339423 PMCID: PMC9043971 DOI: 10.1016/j.ebiom.2022.103939] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/14/2022] [Accepted: 02/28/2022] [Indexed: 01/26/2023] Open
Abstract
Rapid, accurate, sputum-free tests for tuberculosis (TB) triage and confirmation are urgently needed to close the widening diagnostic gap. We summarise key technologies and review programmatic, systems, and resource issues that could affect the impact of diagnostics. Mid-to-early-stage technologies like artificial intelligence-based automated digital chest X-radiography and capillary blood point-of-care assays are particularly promising. Pitfalls in the diagnostic pipeline, included a lack of community-based tools. We outline how these technologies may complement one another within the context of the TB care cascade, help overturn current paradigms (eg, reducing syndromic triage reliance, permitting subclinical TB to be diagnosed), and expand options for extra-pulmonary TB. We review challenges such as the difficulty of detecting paucibacillary TB and the limitations of current reference standards, and discuss how researchers and developers can better design and evaluate assays to optimise programmatic uptake. Finally, we outline how leveraging the urgency and innovation applied to COVID-19 is critical to improving TB patients' diagnostic quality-of-care.
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Affiliation(s)
- Ruvandhi R. Nathavitharana
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, USA
| | - Alberto L. Garcia-Basteiro
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain,Centro de Investigação em Saude de Manhiça, Maputo, Mozambique
| | - Morten Ruhwald
- FIND, the global alliance for diagnostics, Geneva, Switzerland
| | - Frank Cobelens
- Department of Global Health and Amsterdam Institute for Global Health and Development, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Grant Theron
- DSI-NRF Centre of Excellence for Biomedical Tuberculosis Research, South African Medical Research Council Centre for Tuberculosis Research, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa,Corresponding author.
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24
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Diagnostic Advances in Childhood Tuberculosis—Improving Specimen Collection and Yield of Microbiological Diagnosis for Intrathoracic Tuberculosis. Pathogens 2022; 11:pathogens11040389. [PMID: 35456064 PMCID: PMC9025862 DOI: 10.3390/pathogens11040389] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 01/26/2023] Open
Abstract
There is no microbiological gold standard for childhood tuberculosis (TB) diagnosis. The paucibacillary nature of the disease, challenges in sample collection in young children, and the limitations of currently available microbiological tests restrict microbiological confirmation of intrathoracic TB to the minority of children. Recent WHO guidelines recommend the use of novel rapid molecular assays as initial diagnostic tests for TB and endorse alternative sample collection methods for children. However, the uptake of these tools in high-endemic settings remains low. In this review, we appraise historic and new microbiological tests and sample collection techniques that can be used for the diagnosis of intrathoracic TB in children. We explore challenges and possible ways to improve diagnostic yield despite limitations, and identify research gaps to address in order to improve the microbiological diagnosis of intrathoracic TB in children.
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25
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Vaezipour N, Fritschi N, Brasier N, Bélard S, Domínguez J, Tebruegge M, Portevin D, Ritz N. Towards Accurate Point-of-Care Tests for Tuberculosis in Children. Pathogens 2022; 11:pathogens11030327. [PMID: 35335651 PMCID: PMC8949489 DOI: 10.3390/pathogens11030327] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 12/20/2022] Open
Abstract
In childhood tuberculosis (TB), with an estimated 69% of missed cases in children under 5 years of age, the case detection gap is larger than in other age groups, mainly due to its paucibacillary nature and children’s difficulties in delivering sputum specimens. Accurate and accessible point-of-care tests (POCTs) are needed to detect TB disease in children and, in turn, reduce TB-related morbidity and mortality in this vulnerable population. In recent years, several POCTs for TB have been developed. These include new tools to improve the detection of TB in respiratory and gastric samples, such as molecular detection of Mycobacterium tuberculosis using loop-mediated isothermal amplification (LAMP) and portable polymerase chain reaction (PCR)-based GeneXpert. In addition, the urine-based detection of lipoarabinomannan (LAM), as well as imaging modalities through point-of-care ultrasonography (POCUS), are currently the POCTs in use. Further to this, artificial intelligence-based interpretation of ultrasound imaging and radiography is now integrated into computer-aided detection products. In the future, portable radiography may become more widely available, and robotics-supported ultrasound imaging is currently being trialed. Finally, novel blood-based tests evaluating the immune response using “omic-“techniques are underway. This approach, including transcriptomics, metabolomic, proteomics, lipidomics and genomics, is still distant from being translated into POCT formats, but the digital development may rapidly enhance innovation in this field. Despite these significant advances, TB-POCT development and implementation remains challenged by the lack of standard ways to access non-sputum-based samples, the need to differentiate TB infection from disease and to gain acceptance for novel testing strategies specific to the conditions and settings of use.
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Affiliation(s)
- Nina Vaezipour
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
- Infectious Disease and Vaccinology Unit, University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
| | - Nora Fritschi
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
| | - Noé Brasier
- Department of Health Sciences and Technology, Institute for Translational Medicine, ETH Zurich, 8093 Zurich, Switzerland;
- Department of Digitalization & ICT, University Hospital Basel, 4031 Basel, Switzerland
| | - Sabine Bélard
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany;
- Institute of Tropical Medicine and International Health, Charité–Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - José Domínguez
- Institute for Health Science Research Germans Trias i Pujol. CIBER Enfermedades Respiratorias, Universitat Autònoma de Barcelona, 08916 Barcelona, Spain;
| | - Marc Tebruegge
- Department of Infection, Immunity and Inflammation, UCL Great Ormond Street Institute of Child Health, University College London, London WCN1 1EH, UK;
- Department of Pediatrics, The Royal Children’s Hospital Melbourne, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Damien Portevin
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, 4123 Allschwil, Switzerland;
- University of Basel, 4001 Basel, Switzerland
| | - Nicole Ritz
- Mycobacterial and Migrant Health Research Group, University Children’s Hospital Basel, Department for Clinical Research, University of Basel, 4056 Basel, Switzerland; (N.V.); (N.F.)
- Department of Pediatrics, The Royal Children’s Hospital Melbourne, The University of Melbourne, Parkville, VIC 3052, Australia
- Department of Paediatrics and Paediatric Infectious Diseases, Children’s Hospital, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
- Correspondence: ; Tel.: +41-61-704-1212
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26
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Abstract
Tuberculosis (TB) is one of the leading causes of mortality in children worldwide, but there remain significant challenges in diagnosing and treating TB infection and disease. Treatment of TB infection in children and adolescents is critical to prevent progression to TB disease and to prevent them from becoming the future reservoir for TB transmission. This article reviews the clinical approach to diagnosing and treating latent TB infection and pulmonary and extrapulmonary TB disease in children. Also discussed are emerging diagnostics and therapeutic regimens that aim to improve pediatric TB detection and outcomes.
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Affiliation(s)
- Devan Jaganath
- Division of Pediatric Infectious Diseases, University of California, San Francisco
| | - Jeanette Beaudry
- Division of Pediatric Infectious Diseases, Johns Hopkins University Baltimore, USA
| | - Nicole Salazar-Austin
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, 200 N Wolfe Street, Room 3147, Baltimore, MD 21287, USA.
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27
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Research Questions and Priorities for Pediatric Tuberculosis: A Survey of Published Systematic Reviews and Meta-Analyses. Tuberc Res Treat 2022; 2022:1686047. [PMID: 35178252 PMCID: PMC8844079 DOI: 10.1155/2022/1686047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Advancing a research agenda designed to meet the specific needs of children is critical to ending pediatric TB epidemic. Systematic reviews are increasingly informing policies in pediatric tuberculosis (TB) care and control. However, there is a paucity of information on pediatric TB research priorities. Methodology. We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library for systematic reviews and meta-analyses on any aspect related to pediatric TB published between 2015 and 2021. We used the UK Health Research Classification System (HRCS) to help us classify the research questions and priorities. Findings. In total, 29 systematic reviews, with 84 research questions, were included in this review. The four most common research topics in the area of detection were 43.33% screening and diagnosis of TB, 23.33% evaluation of treatments and therapeutic interventions, 13.34% TB etiology and risk factors, and 13.34% prevention of disease and conditions and promotion of well-being. The research priorities focused mainly on evaluating TB diagnosis by improving yield through enhanced in specimen collection or preparation and evaluating of bacteriological TB diagnostic tests. Other topics of future research were developing a treatment for TB in children, assessing the use of IPT in reducing TB-associated morbidity, evaluating the prioritization of an IPT-friendly healthcare environment, and providing additional guidance for the use of isoniazid in the prevention of TB in HIV-infected children. Conclusion. There is a need for more systematic reviews on pediatric TB. The review identified several key priorities for future pediatric TB research mainly in the domain of (1) “Detection, screening and diagnosis,” “Development of Treatments and Therapeutic Interventions,” and “Prevention of Disease and Conditions, and Promotion of Well-Being.” These domains are very relevant in the research component of the roadmap towards ending TB in children. It also will serve as an additional action in the WHO End TB strategy.
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28
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Zawedde-Muyanja S, Reuter A, Tovar MA, Hussain H, Loando Mboyo A, Detjen AK, Yuen CM. Provision of Decentralized TB Care Services: A Detect-Treat-Prevent Strategy for Children and Adolescents Affected by TB. Pathogens 2021; 10:1568. [PMID: 34959523 PMCID: PMC8705395 DOI: 10.3390/pathogens10121568] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 11/16/2022] Open
Abstract
In this review, we discuss considerations and successful models for providing decentralized diagnosis, treatment, and prevention services for children and adolescents. Key approaches to building decentralized capacity for childhood TB diagnosis in primary care facilities include provider training and increased access to child-focused diagnostic tools and techniques. Treatment of TB disease should be managed close to where patients live; pediatric formulations of both first- and second-line drugs should be widely available; and any hospitalization should be for as brief a period as medically indicated. TB preventive treatment for child and adolescent contacts must be greatly expanded, which will require home visits to identify contacts, building capacity to rule out TB, and adoption of shorter preventive regimens. Decentralization of TB services should involve the private sector, with collaborations outside the TB program in order to reach children and adolescents where they first enter the health care system. The impact of decentralization will be maximized if programs are family-centered and designed around responding to the needs of children and adolescents affected by TB, as well as their families.
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Affiliation(s)
- Stella Zawedde-Muyanja
- The Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala P.O. Box 22418, Uganda
| | - Anja Reuter
- Médecins Sans Frontières, Cape Town 7784, South Africa;
| | - Marco A. Tovar
- Socios En Salud Sucursal Perú, Lima 15001, Peru;
- Faculty of Health Sciences, Universidad Peruana de Ciencias Aplicadas, Lima 15067, Peru
| | - Hamidah Hussain
- Interactive Research and Development Global, Singapore 238884, Singapore;
| | - Aime Loando Mboyo
- Elizabeth Glaser Pediatric AIDS Foundation, Kinshasa B.P. 1002030, Democratic Republic of the Congo;
| | - Anne K. Detjen
- United Nations Children’s Fund, New York, NY 10017, USA;
| | - Courtney M. Yuen
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA;
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29
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Difficulties in the differential diagnosis of intestinal tuberculosis and Crohn‘s disease. ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.5.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The differential diagnosis of intestinal tuberculosis and Crohn’s disease is a difficult task for most specialists due to their high similarity in clinical manifestations, instrumental diagnosis and histological pattern.The aim: to consider the clinical and diagnostic features of intestinal tuberculosis and Crohn’s disease, to show the role of various methods of their diagnosis (CT of the abdominal cavity, CT-enterography, colonoscopy with biopsy).A clinical example shows a case illustrating the difficulties of diagnosing intestinal tuberculosis, initially diagnosed as Crohn’s disease. The features of the course, complex diagnosis and treatment of intestinal tuberculosis and its complications during immunosuppression are demonstrated. At the first stage of treatment, the patient’s data related to CT of the chest organs, colonoscopy and histological examination of biopsy samples were incorrectly interpreted. As a result, a wrong diagnosis of Crohn’s disease was made, and immunosuppressive therapy was prescribed that provoked a generalization of the existing tuberculosis process. Subsequently, repeated surgical interventions were performed for complications of intestinal tuberculosis – perforation of tuberculous ulcers, peritonitis. Based on the analysis of the literature data and our own observation, it is shown that granulomatous inflammation in the study of intestinal biopsies doesn’t always allow us to make a clear diagnosis, first of all, there are intestinal tuberculosis and Crohn’s disease in the differential diagnostic series. The use of histobacterioscopy according to Ziehl – Neelsen, the study of fecal matter by luminescent microscopy, as well as molecular genetic methods for detecting DNA MTB allow us to verify the diagnosis. If Crohn’s disease is misdiagnosed as intestinal tuberculosis, then the prescribed anti-tuberculosis therapy can cause harm and lead to a delay in the underlying disease treatment. The reverse misdiagnosis is potentially more dangerous: if tuberculosis is misdiagnosed as Crohn’s disease, then the appointment of immunosuppressive therapy can lead to the generalization of tuberculosis and the development of fatal complications.
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30
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Sun L, Liu Y, Fang M, Chen Y, Zhu Y, Xia C, Jia J, Quan S, Wang Y, Tian X, Shi Y, Duan L, Shi X, Liao Q, Wan C, Shen A. Use of Xpert MTB/RIF Ultra assay on stool and gastric aspirate samples to diagnose pulmonary tuberculosis in children in a high-tuberculosis burden but resource-limited area of China: Diagnosis of Childhood TB using Stool. Int J Infect Dis 2021; 114:236-243. [PMID: 34774781 DOI: 10.1016/j.ijid.2021.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES We analyzed the performance of Xpert MTB/RIF Ultra (Ultra) on stool and gastric aspirate (GA) samples for the diagnosis of pediatric pulmonary tuberculosis (TB) caused by Mycobacterium tuberculosis in a high burden area in China. METHODS Children with presumptive TB were enrolled in two hospitals in Sichuan Province (July 2019-Oct 2020). Because of the unavailable sputum for etiological tests, GA samples were aspirated and tested by bacterial culture, acid-fast bacillus microscopy and Ultra. Stool samples were tested simultaneously using Ultra and Xpert. RESULTS Finally, 141 children with active TB and 34 with non-TB respiratory tract infections were enrolled. Ultra-stool (60.3%, 85/141) and Ultra-GA (52.5%, 74/141) were similarly sensitive (P=0.187). Among the subset of 48 children with confirmed TB, Ultra testing was equally sensitive on stool and GA samples (85.4%, 41/48). The agreement between Ultra-stool and Ultra-GA was moderate in children with active TB (kappa value = 0.527). After integrating Ultra-GA and Ultra-stool outcomes, 70.9% (100/141) of the children were considered to have confirmed TB. The specificities of Ultra-stool and Ultra-GA were 97.1% (33/34) and 100% (34/34), respectively (P=0.314). CONCLUSIONS In children, stools can be used as alternative samples to GAs for Ultra tests. Stool- and GA-based Ultra are appropriate tests for bacteriological TB confirmation.
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Affiliation(s)
- Lin Sun
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yang Liu
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Min Fang
- The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, Sichuan, China
| | - Yu Chen
- Shenyang Tenth People's Hospital (Shenyang Chest Hospital), Shenyang, Liaoning, China
| | - Yu Zhu
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Cheng Xia
- Ganzi Tibetan Autonomous Prefecture People's Hospital, Ganzi, Sichuan, China
| | - Jihang Jia
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Shuting Quan
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yacui Wang
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xue Tian
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Yan Shi
- The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, Sichuan, China
| | - Li Duan
- The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, Sichuan, China
| | - Xiaomei Shi
- The No. 1 People's Hospital of Liangshan Yizu Autonomous Prefecture, Liangshan, Sichuan, China
| | - Qiong Liao
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chaomin Wan
- West China Second Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Adong Shen
- Beijing Key Laboratory of Pediatric Respiratory Infection Diseases, Key Laboratory of Major Diseases in Children, Ministry of Education, National Clinical Research Center for Respiratory Diseases, National Key Discipline of Pediatrics (Capital Medical University), Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China; Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, Henan, China.
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31
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Sultana S, Ansar A, Saif-Ur-Rahman KM. Stool specimen for diagnosis of pulmonary tuberculosis in adults: protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e052212. [PMID: 34408058 PMCID: PMC8375732 DOI: 10.1136/bmjopen-2021-052212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Tuberculosis (TB) continues to be a significant health burden, most commonly affecting the lungs and referred to as pulmonary TB (PTB). Diagnostic techniques of PTB primarily rely on expectorated sputum samples. However, the diagnostic yields are often hindered due to insufficient volume and quality of the sputum specimens. Moreover, some individuals are unable to provide sputum samples due to scanty sputum production or difficulty in coughing up and require an invasive procedure to obtain a respiratory sample, such as bronchoscopic or gastric aspiration. Thus, challenges in the acquisition of respiratory specimens warrant an alternate specimen. Therefore, this systematic review aims to evaluate the diagnostic accuracy of a stool specimen for the diagnosis of PTB in adults. METHODS AND ANALYSIS We will search MEDLINE (Ovid), Embase (Ovid), Web of Science and Cochrane database from inception to April 2021 using a comprehensive search strategy. Two reviewers will independently perform screening, data extraction and quality assessment. The risk of bias assessment and applicability of results of eligible studies will be performed using the Quality of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects models will be performed to calculate pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio and diagnostic odds ratio along with 95% CI of stool specimen for each reported diagnostic method against any of the reference standard test (ie, mycobacterial culture or smear microscopy or Xpert assay using respiratory specimens). Heterogeneity between studies will be assessed by I2 statistics and Q statistic of the χ2 test. ETHICS AND DISSEMINATION The results will be disseminated through publishing in a peer-reviewed medical journal and public presentations in relevant national and international conferences. As this is a systematic review of publicly available data, ethics approval is not required. PROSPERO REGISTRATION NUMBER CRD42021245203.
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Affiliation(s)
| | - Adnan Ansar
- School of Nursing and Midwifery, College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia
| | - K M Saif-Ur-Rahman
- Public Health and Health Systems, Nagoya University Graduate School of Medicine Faculty of Medicine, Nagoya, Aichi, Japan
- Health Systems and Population Studies Division (HSPSD), icddr,b, Dhaka, Bangladesh
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32
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Kabir S, Rahman SMM, Ahmed S, Islam MS, Banu RS, Shewade HD, Thekkur P, Anwar S, Banu NA, Nasrin R, Uddin MKM, Choudhury S, Ahmed S, Paul KK, Khatun R, Chisti MJ, Banu S. Xpert Ultra Assay on Stool to Diagnose Pulmonary Tuberculosis in Children. Clin Infect Dis 2021; 73:226-234. [PMID: 32421765 PMCID: PMC8521743 DOI: 10.1093/cid/ciaa583] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 05/12/2020] [Indexed: 12/20/2022] Open
Abstract
Background The World Health Organization recommends the Xpert MTB/RIF Ultra assay for diagnosing pulmonary tuberculosis (PTB) in children. Though stool is a potential alternative to respiratory specimens among children, the diagnostic performance of Xpert Ultra on stool is unknown. Thus, we assessed the diagnostic performance of Xpert Ultra on stool to diagnose PTB in children. Methods We conducted a cross-sectional study among consecutively recruited children (< 15 years of age) with presumptive PTB admitted in 4 tertiary care hospitals in Dhaka, Bangladesh, between January 2018 and April 2019. Single induced sputum and stool specimens were subjected to culture, Xpert, and Xpert Ultra. We considered children as bacteriologically confirmed on induced sputum if any test performed on induced sputum was positive for Mycobacterium tuberculosis and bacteriologically confirmed if M. tuberculosis was detected on either induced sputum or stool. Results Of 447 children, 29 (6.5%) were bacteriologically confirmed on induced sputum and 72 (16.1%) were bacteriologically confirmed. With “bacteriologically confirmed on induced sputum” as a reference, the sensitivity and specificity of Xpert Ultra on stool were 58.6% and 88.1%, respectively. Xpert on stool had sensitivity and specificity of 37.9% and 100.0%, respectively. Among bacteriologically confirmed children, Xpert Ultra on stool was positive in 60 (83.3%), of whom 48 (80.0%) had “trace call.” Conclusions In children, Xpert Ultra on stool has better sensitivity but lesser specificity than Xpert. A high proportion of Xpert Ultra assays positive on stool had trace call. Future longitudinal studies on clinical evolution are required to provide insight on the management of children with trace call.
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Affiliation(s)
- Senjuti Kabir
- Programme on Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - S M Mazidur Rahman
- Programme on Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Shakil Ahmed
- Department of Paediatrics, Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh
| | - Md Shamiul Islam
- Mycobacterium Disease Control, TB-Leprosy & ASP (AIDS STD Program), Directorate General of Health Services, Dhaka, Bangladesh.,National Tuberculosis Control Program, Dhaka, Bangladesh
| | | | - Hemant Deepak Shewade
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,The Union South East Asia Office, New Delhi, India
| | - Pruthu Thekkur
- International Union Against Tuberculosis and Lung Disease (The Union), Paris, France.,The Union South East Asia Office, New Delhi, India
| | - Sayeeda Anwar
- Department of Paediatrics, Dhaka Medical College Hospital, Dhaka, Bangladesh
| | - Nazneen Akhter Banu
- Department of Paediatrics, Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh
| | - Rumana Nasrin
- Programme on Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | | | - Sabrina Choudhury
- Programme on Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Shahriar Ahmed
- Programme on Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Kishor Kumar Paul
- Programme on Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh.,Kirby Institute, University of New South Wales, Kensington, Australia
| | - Razia Khatun
- Programme on Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | | | - Sayera Banu
- Programme on Emerging Infections, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
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Gebre M, Cameron LH, Tadesse G, Woldeamanuel Y, Wassie L. Variable Diagnostic Performance of Stool Xpert in Pediatric Tuberculosis: A Systematic Review and Meta-analysis. Open Forum Infect Dis 2021; 8:ofaa627. [PMID: 34430668 PMCID: PMC8378590 DOI: 10.1093/ofid/ofaa627] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 12/21/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Difficult specimen collection and low bacillary load make microbiological confirmation of tuberculosis (TB) in children challenging. In this study, we conducted a systematic review and meta-analysis to assess the diagnostic accuracy of Xpert on stool for pediatric tuberculosis. METHODS Our search included studies from 2011 through 2019, and specific search terms were used to retrieve articles from Pubmed, EMBASE, BIOSIS, ClinicalTrials.gov, and Google Scholar. Risk of bias was assessed using the QUADAS 2 tool. The protocol was registered in PROSPERO (CRD42018083637). Summary estimates of sensitivity and specificity were conducted using meta-disc Software assuming a random-effects model. RESULTS We identified 12 eligible studies, which included data from 2177 children, of whom 295 (13.6%) had bacteriologically confirmed TB on respiratory specimens. The pooled sensitivity of Xpert MTB/RIF on stool specimens compared with bacteriologically confirmed tuberculosis with respiratory specimens was 0.50 (95% CI, 0.44-0.56) with an I 2 of 86%, which was statistically significant (P < .001). The pooled specificity was 0.99 (95% CI, 0.98-0.99; I 2 = 0.0%; P = .44). CONCLUSIONS Despite the observed heterogeneity, stool may be considered an additional specimen to support diagnosis of pulmonary TB in children, especially in settings where it is impossible to get respiratory samples. Further studies should evaluate its optimization as a diagnostic tool.
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Affiliation(s)
- Meseret Gebre
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
| | | | | | - Yohannes Woldeamanuel
- Stanford University, Palo Alto, California, USA
- Propria Health Solutions, Addis Ababa, Ethiopia
| | - Liya Wassie
- Armauer Hansen Research Institute (AHRI), Addis Ababa, Ethiopia
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34
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The Simple One-Step (SOS) Stool Processing Method for Use with the Xpert MTB/RIF Assay for a Child-Friendly Diagnosis of Tuberculosis Closer to the Point of Care. J Clin Microbiol 2021; 59:e0040621. [PMID: 34076469 PMCID: PMC8373220 DOI: 10.1128/jcm.00406-21] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Young children cannot easily produce sputum for diagnosis of pulmonary tuberculosis (TB). Alternatively, Mycobacterium tuberculosis complex bacilli can be detected in stool by using the Xpert MTB/RIF (Ultra) assay (Xpert). Published stool processing methods contain somewhat complex procedures and require additional supplies. The aim of this study was to develop a simple one-step (SOS) stool processing method based on gravity sedimentation only, similar to Xpert testing of sputum samples, for the detection of M. tuberculosis in stool samples. We first assessed whether the SOS stool method could provide valid Xpert results without the need for bead-beating, dilution, and filtration steps. We concluded that this was the case, and we then validated the SOS stool method by testing spiked stool samples. By using the SOS stool method, 27 of the 29 spiked samples gave valid Xpert results, and M. tuberculosis was recovered from all 27 samples. The proof of principle of the SOS stool method was demonstrated in routine settings in Addis Ababa, Ethiopia. Nine of 123 children with presumptive TB had M. tuberculosis-positive results for nasogastric aspiration (NGA) samples, and 7 (77.8%) of those children also had M. tuberculosis-positive Xpert results for stool samples. Additionally, M. tuberculosis was detected in the stool samples but not the NGA samples from 2 children. The SOS stool processing method makes use of the standard Xpert assay kit, without the need for additional supplies or equipment. The method can potentially be rolled out to any Xpert site, bringing a bacteriologically confirmed diagnosis of TB in children closer to the point of care.
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35
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Gaensbauer J. Xpert Ultra, Pediatric Pulmonary Tuberculosis and Stool: Forward Progress Raises New Questions. Clin Infect Dis 2021; 73:235-236. [PMID: 32449508 DOI: 10.1093/cid/ciaa589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/21/2020] [Indexed: 12/29/2022] Open
Affiliation(s)
- James Gaensbauer
- Denver Metro Tuberculosis Clinic, Denver Public Health, Denver, Colorado, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA.,Center for Global Health, Colorado School of Public Health, Aurora, Colorado, USA.,Denver Health Medical Center, Denver, Colorado, USA
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36
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Jasumback CL, Dlamini Q, Kahari J, Maphalala G, Dlamini MG, Dube GS, DiNardo A, Kirchner HL, Mandalakas A, Kay AW. Laboratory comparison of stool processing methods for Xpert ® Ultra. Public Health Action 2021; 11:55-57. [PMID: 34159062 DOI: 10.5588/pha.20.0079] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 04/02/2021] [Indexed: 11/10/2022] Open
Abstract
TB disease diagnosis in children is difficult due to non-specific symptoms, paucibacillary disease and the need for invasive procedures to obtain diagnostic specimens. In many settings, these specimens are simply not collected and therefore stool, easily obtained, has emerged as a promising specimen for the diagnosis of child TB. In this study, stool from a healthy adult was spiked with known concentrations of bacille Calmette-Guérin vaccine and tested using the Xpert® Ultra assay to determine the relative detection and error rate associated with four different published stool processing methods.
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Affiliation(s)
- C L Jasumback
- United States Peace Corps, Mbabane, Eswatini.,Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | - Q Dlamini
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | - J Kahari
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini
| | - G Maphalala
- Eswatini National Health Services Laboratory, Mbabane, Eswatini
| | - M G Dlamini
- Eswatini National Health Services Laboratory, Mbabane, Eswatini
| | - G S Dube
- Eswatini National Tuberculosis Control Program, Manzini, Eswatini
| | - A DiNardo
- Baylor College of Medicine, Houston, TX, USA
| | - H L Kirchner
- Department of Population Health Sciences, Geisinger, Danville, VA, USA
| | | | - A W Kay
- Baylor College of Medicine Children's Foundation-Eswatini, Mbabane, Eswatini.,Baylor College of Medicine, Houston, TX, USA
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37
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Ainan S, Furia FF, Mhimbira F, Mnyambwa NP, Mgina N, Zumla A, Mfinanga SG, Ngadaya E. Xpert® MTB/RIF assay testing on stool for the diagnosis of paediatric pulmonary TB in Tanzania. Public Health Action 2021; 11:75-79. [PMID: 34159066 DOI: 10.5588/pha.20.0062] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/03/2021] [Indexed: 11/10/2022] Open
Abstract
SETTING Six health facilities in Dar es Salaam, Tanzania. OBJECTIVE To evaluate the use of stool specimens in the diagnostic workup of paediatric TB using the Xpert® MTB/RIF assay. DESIGN Between December 2018 and May 2019, we performed a cross-sectional diagnostic study of children aged between 1 month and 14 years with presumptive TB. A single stool specimen was tested using Xpert. The result was compared with the reference microbiological standard for respiratory or gastric specimens tested using Xpert and/or solid culture. The sensitivity, specificity and predictive values of stool Xpert assay were assessed. RESULTS A total of 225 children with a median age of 2.17 years (IQR 1.16-5.19) were enrolled; 165/225 (73.3%) were aged <5 years. Of 225 children, 8 (3.6%) were diagnosed with TB as they were culture- or Xpert-positive on sputum/gastric aspirate. The stool Xpert assay showed a sensitivity of 62.5% (95% CI 25-92) and specificity of 100% (95% CI 98-100) against the reference standard. CONCLUSION Use of the Xpert assay on stool specimens had a moderate sensitivity and high specificity in the diagnosis of pulmonary TB in children. Our data adds to the body of evidence for the use of Xpert assay on stool as a non-respiratory specimen to complement conventional methods used to diagnose the disease.
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Affiliation(s)
- S Ainan
- Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - F F Furia
- Department of Paediatrics and Child Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - F Mhimbira
- Department of Intervention and Clinical Trials, Ifakara Health Institute, Dar es Salaam, Tanzania.,Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - N P Mnyambwa
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - N Mgina
- Central Tuberculosis Reference Laboratory, Dar es salaam, Tanzania
| | - A Zumla
- Department of Infection, Division of Infection and Immunity, University College London, and NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - S G Mfinanga
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania.,Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - E Ngadaya
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
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Orikiriza P, Smith J, Ssekyanzi B, Nyehangane D, Mugisha Taremwa I, Turyashemererwa E, Byamukama O, Tusabe T, Ardizzoni E, Marais BJ, Wobudeya E, Kemigisha E, Mwanga-Amumpaire J, Nampijja D, Bonnet M. Tuberculosis diagnostic accuracy of stool Xpert MTB/RIF and urine AlereLAM in vulnerable children. Eur Respir J 2021; 59:13993003.01116-2021. [PMID: 34140291 DOI: 10.1183/13993003.01116-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/16/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Non-sputum based diagnostic approaches are crucial in children at high risk of disseminated tuberculosis [TB] who cannot expectorate sputum. We evaluated the diagnostic accuracy of Xpert MTB/RIF from stool and urine AlereLipoarabinomannan [LAM] test in this group of children. METHODS Hospitalised children with presumptive TB and either age <2 years, HIV-positive or severe malnutrition were enrolled in a diagnostic cohort. At enrolment, we attempted to collect two urine, two stool and two respiratory samples. Urine and stool were tested with AlereLAM and Xpert MTB/RIF, respectively. Respiratory samples were tested with Xpert MTB/RIF and mycobacterial culture. Both a microbiological and a composite clinical reference standard were used. RESULTS The study enrolled 219 children; median age 16.4 months, 72 (32.9%) HIV-positive and 184 (84.4%) severely malnourished. Twelve (5.5%) and 58 (28.5%) children had confirmed and unconfirmed TB respectively. Stool and urine were collected in 219 (100%) and 216 (98.6%) children. Against the microbiological reference standard the sensitivity and specificity (n/N, 95% confidence intervals) of stool Xpert MTB/RIF was 50.0% (6/12, 21.1-78.9) and 99.1% (198/200 96.4-99.9), while that of urine AlereLAM was 50.0% (6/12, 21.1-78.9) and 74.6% (147/197, 67.9-80.5) respectively. Against the composite reference standard sensitivity was reduced to 11.4% (8/70) for stool and 26.2% (17/68) for urine, with no major difference by age group (<2 and >2 years) or HIV status. CONCLUSION The Xpert MTB/RIF assay has excellent specificity on stool, but sensitivity is suboptimal. Urine AlereLAM is compromised by poor sensitivity and specificity in children.
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Affiliation(s)
- Patrick Orikiriza
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda.,Université de Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France
| | | | | | | | | | | | - Onesmas Byamukama
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Tobias Tusabe
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Elisa Ardizzoni
- Mycobacteriology department, Institute of Tropical Medicine, Antwerp, Belgium.,Médecins Sans Frontières, Paris, France
| | - Ben J Marais
- The Children's Hospital at Westmead and WHO Collaborating Centre for Tuberculosis, University of Sydney, Sydney, Australia
| | - Eric Wobudeya
- MUJHU Care Ltd, MUJHU Research Collaboration, Kampala, Uganda
| | - Elizabeth Kemigisha
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Juliet Mwanga-Amumpaire
- Epicentre Mbarara Research Centre, Mbarara, Uganda.,Mbarara University of Science and Technology, Mbarara, Uganda
| | - Dora Nampijja
- Mbarara University of Science and Technology, Mbarara, Uganda.,Pediatric department, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Maryline Bonnet
- Epicentre Mbarara Research Centre, Mbarara, Uganda .,Université de Montpellier, IRD, INSERM, TransVIHMI, Montpellier, France
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Fei B, Zhou L, Zhang Y, Luo L, Chen Y. Application value of tissue tuberculosis antigen combined with Xpert MTB/RIF detection in differential diagnoses of intestinal tuberculosis and Crohn's disease. BMC Infect Dis 2021; 21:498. [PMID: 34049506 PMCID: PMC8161674 DOI: 10.1186/s12879-021-06210-8] [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] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 05/19/2021] [Indexed: 01/28/2023] Open
Abstract
Background The purpose of this study was to examine the value of Xpert MTB/RIF assay and detection of additional Mycobacterium tuberculosis complex (MTBC) species antigens from intestinal tissue samples in differentiating intestinal tuberculosis (ITB) from Crohn’s disease (CD). Methods Several clinical specimens of intestinal tissue obtained by either endoscopic biopsy or surgical excision were used for mycobacteriologic solid cultures,Xpert MTB/RIF assays, immunohistochemistry, and histological examinations. Four antigens (38KDa, ESAT-6, MPT64, and Ag85 complex) of MTBC in the intestinal tissue were detected by immunohistochemical analysis. Results The study included 42 patients with ITB and 46 with CD. Perianal lesions and longitudinal ulcers were more common in patients with CD, while caseating granuloma and annular ulcers were more common in patients with ITB. The positive rate of MTBC detected by Xpert MTB/RIF in intestinal tissues of patients with ITB was 33.33%, which was significantly higher than that in patients with CD and that detected using acid-fast staining smears. It was also higher than that detected by tissue MTBC culture, but the difference was not statistically significant. The positive MPT64 expression rate in patients with ITB was 40.48%, which was significantly higher than that observed in patients with CD. The sensitivity of parallelly combined detection of tuberculosis protein MPT64 and Xpert MTB/RIF in diagnosing ITB was 50.0%. Conclusions The detection of Xpert MTB/RIF in intestinal tissue is a rapid and useful method for establishing an early diagnosis of ITB. The detection of MTBC using Xpert MTB/RIF and MPT64 antigen in intestinal tissues has a definitive value in the differential diagnosis ofITB and CD. The combination of these two methods can improve the detection sensitivity.
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Affiliation(s)
- Baoying Fei
- Department of Gastroenterology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, Zhejiang, China.
| | - Lin Zhou
- Departments of Minimally Invasive Surgery, Tuberculous Experimental Center, Hangzhou Red Cross Hospital, Hangzhou, 310003, Zhejiang, China
| | - Yu Zhang
- Department of Gastroenterology, Zhejiang Province People's Hospital, Hangzhou, 310014, Zhejiang, China
| | - Linhe Luo
- Department of Gastroenterology, Tongde Hospital of Zhejiang Province, 234 Gucui Road, Hangzhou, 310012, Zhejiang, China
| | - Yuanyuan Chen
- Tuberculosis Diagnosis and Treatment Center, Hangzhou Red Cross Hospital, Hangzhou, 310003, Zhejiang, China
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Song R, Click ES, McCarthy KD, Heilig CM, Mchembere W, Smith JP, Fajans M, Musau SK, Okeyo E, Okumu A, Orwa J, Gethi D, Odeny L, Lee SH, Perez-Velez CM, Wright CA, Cain KP. Sensitive and Feasible Specimen Collection and Testing Strategies for Diagnosing Tuberculosis in Young Children. JAMA Pediatr 2021; 175:e206069. [PMID: 33616611 PMCID: PMC7900937 DOI: 10.1001/jamapediatrics.2020.6069] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Criterion-standard specimens for tuberculosis diagnosis in young children, gastric aspirate (GA) and induced sputum, are invasive and rarely collected in resource-limited settings. A far less invasive approach to tuberculosis diagnostic testing in children younger than 5 years as sensitive as current reference standards is important to identify. OBJECTIVE To characterize the sensitivity of preferably minimally invasive specimen and assay combinations relative to maximum observed yield from all specimens and assays combined. DESIGN, SETTING, AND PARTICIPANTS In this prospective cross-sectional diagnostic study, the reference standard was a panel of up to 2 samples of each of 6 specimen types tested for Mycobacterium tuberculosis complex by Xpert MTB/RIF assay and mycobacteria growth indicator tube culture. Multiple different combinations of specimens and tests were evaluated as index tests. A consecutive series of children was recruited from inpatient and outpatient settings in Kisumu County, Kenya, between October 2013 and August 2015. Participants were children younger than 5 years who had symptoms of tuberculosis (unexplained cough, fever, malnutrition) and parenchymal abnormality on chest radiography or who had cervical lymphadenopathy. Children with 1 or more evaluable specimen for 4 or more primary study specimen types were included in the analysis. Data were analyzed from February 2015 to October 2020. MAIN OUTCOMES AND MEASURES Cumulative and incremental diagnostic yield of combinations of specimen types and tests relative to the maximum observed yield. RESULTS Of the 300 enrolled children, the median (interquartile range) age was 2.0 (1.0-3.6) years, and 151 (50.3%) were female. A total of 294 met criteria for analysis. Of 31 participants with confirmed tuberculosis (maximum observed yield), 24 (sensitivity, 77%; interdecile range, 68%-87%) had positive results on up to 2 GA samples and 20 (sensitivity, 64%; interdecile range, 53%-76%) had positive test results on up to 2 induced sputum samples. The yields of 2 nasopharyngeal aspirate (NPA) samples (23 of 31 [sensitivity, 74%; interdecile range, 64%-84%]), of 1 NPA sample and 1 stool sample (22 of 31 [sensitivity, 71%; interdecile range, 60%-81%]), or of 1 NPA sample and 1 urine sample (21.5 of 31 [sensitivity, 69%; interdecile range, 58%-80%]) were similar to reference-standard specimens. Combining up to 2 each of GA and NPA samples had an average yield of 90% (28 of 31). CONCLUSIONS AND RELEVANCE NPA, in duplicate or in combination with stool or urine specimens, was readily obtainable and had diagnostic yield comparable with reference-standard specimens. This combination could improve tuberculosis diagnosis among children in resource-limited settings. Combining GA and NPA had greater yield than that of the current reference standards and may be useful in certain clinical and research settings.
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Affiliation(s)
- Rinn Song
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | | | | | | | - Walter Mchembere
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Jonathan P. Smith
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia,Northrop Grumman, Atlanta, Georgia
| | - Mark Fajans
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan K. Musau
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Elisha Okeyo
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Albert Okumu
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - James Orwa
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Dickson Gethi
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Lazarus Odeny
- Kenya Medical Research Institute, Center for Global Health Research, Kisumu, Kenya
| | - Scott H. Lee
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carlos M. Perez-Velez
- Tuberculosis Clinic, Pima County Health Department, Tucson, Arizona,Infectious Diseases, University of Arizona College of Medicine, Tucson
| | - Colleen A. Wright
- Division of Anatomical Pathology, University of Stellenbosch, Cape Town, South Africa
| | - Kevin P. Cain
- US Centers for Disease Control and Prevention, Kisumu, Kenya
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Saktiawati AMI, Triyana K, Wahyuningtias SD, Dwihardiani B, Julian T, Hidayat SN, Ahmad RA, Probandari A, Mahendradhata Y. eNose-TB: A trial study protocol of electronic nose for tuberculosis screening in Indonesia. PLoS One 2021; 16:e0249689. [PMID: 33882070 PMCID: PMC8059810 DOI: 10.1371/journal.pone.0249689] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/16/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Even though conceptually, Tuberculosis (TB) is almost always curable, it is currently the world's leading infectious killer. Patients with pulmonary TB are the source of transmission. Approximately 23% of the world's population is believed to be latently infected with TB bacteria, and 5-15% of them will progress at any point in time to develop the disease. There was a global diagnostic gap of 2.9 million between notifications of new cases and the estimated number of incident cases, and Indonesia carries the third-highest of this gap. Therefore, screening TB among the community is of great importance to prevent further transmission and infection. The electronic nose for screening TB (eNose-TB) project is initiated in Yogyakarta, Indonesia, to screen TB by breath test with an electronic-nose that is easy-to-use, point-of-care, does not expose patients to radiation, and can be produced at low cost. METHODS/DESIGN The objectives of the two-phase planned project are to: 1) investigate the potential of an eNose-TB as a screening tool in Indonesia, in comparison with screening with clinical symptoms and chest radiology, which are currently used as a standard, and 2) analyze the time and cost of a screening algorithm with eNose-TB to obtain additional case detection. A cross-sectional study will be conducted in the first phase to validate the eNose-TB. The validation phase will involve 395 presumptive TB patients in the Surakarta General Hospital, Central Java. In the second phase, a cross-sectional research will be conducted, involving 1,383 adults and children in the municipality of Yogyakarta and Kulon Progo district of Yogyakarta Province. DISCUSSION The findings will provide data concerning the sensitivity and specificity of the eNose-TB as a screening tool for tuberculosis, and the time and cost analysis of a screening algorithm with the eNose. TRIAL REGISTRATION NCT04567498; https://clinicaltrials.gov/.
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Affiliation(s)
| | - Kuwat Triyana
- Faculty of Mathematics and Natural Sciences, Department of Physics, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Siska Dian Wahyuningtias
- Faculty of Medicine, Public Health and Nursing, Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Bintari Dwihardiani
- Faculty of Medicine, Public Health and Nursing, Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Trisna Julian
- Faculty of Mathematics and Natural Sciences, Department of Physics, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Shidiq Nur Hidayat
- Faculty of Mathematics and Natural Sciences, Department of Physics, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Riris Andono Ahmad
- Faculty of Medicine, Public Health and Nursing, Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Public Health and Nursing, Department of Biostatistics, Epidemiology, and Population Health, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Ari Probandari
- Faculty of Medicine, Public Health and Nursing, Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Department of Public Health, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Yodi Mahendradhata
- Faculty of Medicine, Public Health and Nursing, Center for Tropical Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Faculty of Medicine, Public Health and Nursing, Department of Health Policy and Management, Universitas Gadjah Mada, Yogyakarta, Indonesia
- * E-mail:
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Gutiérrez-González LH, Juárez E, Carranza C, Carreto-Binaghi LE, Alejandre A, Cabello-Gutiérrrez C, Gonzalez Y. Immunological Aspects of Diagnosis and Management of Childhood Tuberculosis. Infect Drug Resist 2021; 14:929-946. [PMID: 33727834 PMCID: PMC7955028 DOI: 10.2147/idr.s295798] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/11/2021] [Indexed: 12/24/2022] Open
Abstract
The diagnosis of tuberculosis (TB) in children is difficult because of the low sensitivity and specificity of traditional microbiology techniques in this age group. Whereas in adults the culture of Mycobacterium tuberculosis (M. tuberculosis), the gold standard test, detects 80% of positive cases, it only detects around 30-40% of cases in children. The new methods based on the immune response to M. tuberculosis infection could be affected by many factors. It is necessary to evaluate the medical record, clinical features, presence of drug-resistant M. tuberculosis strains, comorbidities, and BCG vaccination history for the diagnosis in children. There is no ideal biomarker for all TB cases in children. A new strategy based on personalized diagnosis could be used to evaluate specific molecules produced by the host immune response and make therapeutic decisions in each child, thereby changing standard immunological signatures to personalized signatures in TB. In this way, immune diagnosis, prognosis, and the use of potential immunomodulators as adjunct TB treatments will meet personalized treatment.
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Affiliation(s)
| | - Esmeralda Juárez
- Microbiology Department, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City, Mexico
| | - Claudia Carranza
- Microbiology Department, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City, Mexico
| | - Laura E Carreto-Binaghi
- Microbiology Department, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City, Mexico
| | - Alejandro Alejandre
- Pediatric Clinic, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City, Mexico
| | - Carlos Cabello-Gutiérrrez
- Virology and Mycology Department, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City, Mexico
| | - Yolanda Gonzalez
- Microbiology Department, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City, Mexico
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Githinji L, Zar HJ. Respiratory Complications in Children and Adolescents with Human Immunodeficiency Virus. Pediatr Clin North Am 2021; 68:131-145. [PMID: 33228928 DOI: 10.1016/j.pcl.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Respiratory complications comprise a large proportion of the burden of mortality and morbidity in children with human immunodeficiency virus (HIV). HIV-associated lower respiratory tract infection (LRTI) has declined in incidence with early diagnosis and use of antiretroviral therapy (ART) but is widespread in areas with limited access to ART. HIV-exposed uninfected infants have a higher risk of LRTI early in life than unexposed infants. Pulmonary tuberculosis (PTB) presenting as acute or chronic disease is common in highly TB endemic areas. Chronic lung disease is common; preceding LRTI, PTB or late initiation of ART are risk factors.
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Affiliation(s)
- Leah Githinji
- Department of Paediatrics and Child Health, South Africa MRC Unit on Child & Adolescent Health, University of Cape Town, Red Cross War Memorial Children's Hospital, ICH Building, Klipfontein Road, Rondebosch 7700, South Africa
| | - Heather J Zar
- Department of Paediatrics and Child Health, South Africa MRC Unit on Child & Adolescent Health, University of Cape Town, Red Cross War Memorial Children's Hospital, ICH Building, Klipfontein Road, Rondebosch 7700, South Africa.
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Chen X, Hu TY. Strategies for advanced personalized tuberculosis diagnosis: Current technologies and clinical approaches. PRECISION CLINICAL MEDICINE 2021; 4:35-44. [PMID: 33842836 PMCID: PMC8023014 DOI: 10.1093/pcmedi/pbaa041] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 02/05/2023] Open
Abstract
Diagnosis of tuberculosis can be difficult as advances in molecular diagnosis approaches (especially nanoparticles combined with high-throughput mass spectrometry for detecting mycobacteria peptide) and personalized medicine result in many changes to the diagnostic framework. This review will address issues concerning novel technologies from bench to bed and new strategies for personalized tuberculosis diagnosis.
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Affiliation(s)
- Xuerong Chen
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Tony Y Hu
- Center for Cellular and Molecular Diagnostics, School of Medicine, Tulane University, New Orleans, LA 70112, USA
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How do private practitioners in Pakistan manage children suspected having tuberculosis? A cross sectional study. BMC Public Health 2021; 21:71. [PMID: 33413206 PMCID: PMC7791821 DOI: 10.1186/s12889-020-10053-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 12/10/2020] [Indexed: 11/15/2022] Open
Abstract
Background In Pakistan, private providers provide a large portion of health care, including for tuberculosis (TB). All TB patients are supposed to be reported to the National Tuberculosis Program (NTP), which provides drugs free of charge in addition to monitoring, supervision, and support. However, diagnosis of TB in children is difficult. We aimed to assess the private health care providers’ investigation practices and management of childhood TB. Methods We used a cross-sectional study, which was based on a national survey measuring under-reporting of children with TB in 12 selected districts in Pakistan from April–June, 2016. We explored the practices of the private health care providers, including the health care workers i.e. general practitioners, pediatricians, pulmonologists and chest specialists, who were involved in the diagnosis of TB in children under 15 years for investigating and managing children suspected having TB. Results Among 6519 presumptive child TB cases, a total of 5193(79.7%) children under 15 years were diagnosed as TB by private health care providers during second quarter, 2016. Only 187(2.9%) were notified to NTP. The majority of presumptive child TB cases reported cough, fever, and failure to thrive; few had TB contacts with pulmonary TB patients. Failure to thrive, loss of body weight and absence of BCG (Bacillus Calmette–Guérin) scar was more common in female children. Private providers relied on chest X-ray in 46.1%, while tuberculin skin test and Gene-Xpert MTB/RIF testing was little utilized. Bacteriological confirmation was present in 7.6%, and clinical assessment was the only basis for diagnosis in 39.3%. Of children with presumptive TB, only 955(14.6%) children were treated by private provider, while 3121(47.9%) cases were referred for diagnosis and 2443(37.5%) were referred after diagnosis for treatment; among all the referred, 3812(68.5%) were sent for investigations to District TB Centre (NTP). Conclusion This study showed that many private providers referred children suspected having TB to laboratories for further diagnosis, but the cases identified in these investigations were often not notified to the NTP. This problem could be resolved by strengthening the referral linkages between private health providers, NTP laboratories and treatment centres through capacity building and training of their staff.
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Ketema L, Dememew ZG, Assefa D, Gudina T, Kassa A, Letta T, Ayele B, Tadesse Y, Tegegn B, Datiko DG, Negeri C, Bedru A, Klinkenberg E. Evaluating the integration of tuberculosis screening and contact investigation in tuberculosis clinics in Ethiopia: A mixed method study. PLoS One 2020; 15:e0241977. [PMID: 33211710 PMCID: PMC7676707 DOI: 10.1371/journal.pone.0241977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 10/24/2020] [Indexed: 11/21/2022] Open
Abstract
Background Aligned with global childhood tuberculosis (TB) road map, Ethiopia developed its own in 2015. The key strategies outlined in the Ethiopian roadmap are incorporating TB screening in Integrated Maternal, Neonatal and Child Illnesses (IMNCI) clinic for children under five years (U5) and intensifying contact investigations at TB clinic. However, these strategies have never been evaluated. Objective To evaluate the integration of tuberculosis (TB) screening and contact investigation into Integrated Maternal, Neonatal and Child Illnesses (IMNCI) and TB clinics in Addis Ababa, Ethiopia. Methods The study used mixed methods with stepped-wedge design where 30 randomly selected health care facilities were randomized into three groups of 10 during August 2016-November 2017. The integration of TB screening into IMNCI clinic and contact investigation in TB clinic were introduced by a three-day childhood TB training for health providers. An in-depth interview was used to explore the challenges of the interventions and supplemented data on TB screening and contact investigation. Results Overall, 180896 children attended 30 IMNCI clinics and145444 (80.4%) were screened for TB. A total of 688 (0.4%) children had presumptive TB and 47(0.03%) had TB. During the pre-intervention period, 51873 of the 85278 children (60.8%) were screened for TB as compared to 93570 of the 95618 children (97.9%) in the intervention (p<0.001). This had resulted in 149 (0.30%) and 539 (0.6%) presumptive TB cases in pre-intervention and intervention periods (p<0.001), respectively. Also, nine TB cases (6.0%) in pre-intervention and 38 (7.1%) after intervention were identified (p = 0.72). In TB clinics, 559 under-five (U5) contacts were identified and 419 (80.1%) were screened. In all, 51(9.1%) presumed TB cases and 12 (2.1%) active TB cases were identified from the traced contacts. TB screening was done for 182 of the 275 traced contacts (66.2%) before intervention and for 237 of the 284 of the traced (83.5%) under intervention (p<0.001). Isoniazid prevention therapy (IPT) was initiated for 69 of 163 eligible contacts (42.3%) before intervention and for 159 of 194 eligible children (82.0%) under intervention (p<0.001). Over 95% of health providers indicated that the integration of TB screening into IMNCI and contact investigation in TB clinic is acceptable and practical. Gastric aspiration to collect sputum using nasogastric tube was reported to be difficult. Conclusions Integrating TB screening into IMNCI clinics and intensifying contact investigation in TB clinics is feasible improving TB screening, presumed TB cases, TB cases, contact screening and IPT coverage during the intervention period. Stool specimen could be non-invasive to address the challenge of sputum collection.
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Affiliation(s)
- L. Ketema
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - Z. G. Dememew
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
- * E-mail:
| | - D. Assefa
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - T. Gudina
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - A. Kassa
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - T. Letta
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - B. Ayele
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - Y. Tadesse
- Federal Ministry of Health of Ethiopia, National TB Program and Child Health Unit, Addis Ababa, Ethiopia
| | - B. Tegegn
- Addis Ababa City Administration Health Bureau, Addis Ababa, Ethiopia
| | - D. G. Datiko
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - C. Negeri
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - A. Bedru
- KNVC Tuberculosis Foundation/Management Sciences for Health USAID/Challenge TB Project, Addis Ababa, Ethiopia
| | - E. Klinkenberg
- KNCV Tuberculosis Foundation, The Hague, Netherlands
- Department of Global Health and Amsterdam Institute for Global Health and Development, Location Academic Medical Center, Amsterdam University Medical Centers, Amsterdam, Netherlands
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Abstract
We examined Mycobacterium tuberculosis DNA detection from buccal swab samples collected from children in Lima, Peru. DNA was extracted and amplified via real-time polymerase chain reaction. Sensitivity was 21% (95% confidence interval [CI]: 7%-42%) in 24 culture-confirmed tuberculosis cases and 4.6% (95% CI: 1%-13%) in 65 clinically diagnosed unconfirmed cases. Sensitivity was highest for smear-positive tuberculosis. Specificity was 99% in the 199 controls (95% CI: 96%-100%).
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48
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Nicol MP, Zar HJ. Advances in the diagnosis of pulmonary tuberculosis in children. Paediatr Respir Rev 2020; 36:52-56. [PMID: 32624357 PMCID: PMC7686111 DOI: 10.1016/j.prrv.2020.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
Major challenges still exist in the accurate diagnosis of tuberculosis in children. Algorithms based on clinical and radiological features remain in widespread use despite poor performance. Newer molecular diagnostics allow for rapid identification of TB and detection of drug-resistance in a subset of children, but lack sensitivity. Molecular testing of multiple specimens, including non-traditional specimen types, such as nasopharyngeal aspirates and stool and urine, may improve sensitivity, but the optimal combination of specimens requires further research. Novel tests under development or evaluation include a urine lipoarabinomannan test with improved sensitivity and a range of biomarkers measured from stimulated or unstimulated peripheral blood.
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Affiliation(s)
- Mark P Nicol
- Division of Infection and Immunity, School of Biomedical Sciences, University of Western Australia, Perth, Australia.
| | - Heather J Zar
- Department of Paediatrics and Child Health, and SA-MRC Unit on Child & Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
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Evaluation of stool GeneXpert MTB/RIF for the diagnosis of pulmonary tuberculosis among presumptive patients in Tanzania. J Clin Tuberc Other Mycobact Dis 2020; 21:100195. [PMID: 33204852 PMCID: PMC7653276 DOI: 10.1016/j.jctube.2020.100195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Diagnosis of pulmonary tuberculosis remains grim, especially in resource-limited settings. Low quality of sputum, particularly among seriously ill, HIV/AIDS, and pediatric patients might result in missing the diagnosis. This study evaluated the performance of GeneXpert MTB/RIF for the detection of pulmonary tuberculosis on stool specimens as an alternative to respiratory specimens. Methods A cross-sectional study design was used to evaluate the performance of GeneXpert MTB/RIF to detect TB in stool specimens from presumptive TB patients. Sputum culture on Lowenstein-Jensen media was used as the gold standard. Recruitment of patients into the study was conducted in 12 selected health facilities in Tanzania. Two sputa and a stool specimen were collected from each study participant. Both sputa and stool samples were tested at their respective study sites of collection using GeneXpert, and their respective portions shipped to the Central Tuberculosis Reference Laboratory for testing by stool GeneXpert and sputum culture in the LJ media. Statistical analysis was performed using STATA software version 14.1. Results A total of 590 presumptive tuberculosis patients were enrolled in this study. Their median age was 35 years (IQR = 21–47 years). More than half (57.5%, n = 339) of the study participants, were males. Children aged below 15 years constituted 17.6% (n = 104) of the study participants. A total of 75 tuberculosis cases were detected by sputum culture. The sensitivity and specificity of Stool GeneXpert conducted at CTRL was 84% (95% CI: 81.0–87.0%), and 93.4% (CI: 98.5–99.9%) respectively. The overall sensitivity and specificity of stool GeneXpert at the peripheral laboratories was 63.0% (95% CI: 47.8–76.1) and 76.7% (95% CI: 72.1–81.4), respectively. Conclusion Findings from this study suggest that stool is a potential alternative to respiratory specimen for use in routine diagnosis of tuberculosis, especially when obtaining a respiratory specimen is challenging.
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50
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Lounnas M, Diack A, Nicol MP, Eyangoh S, Wobudeya E, Marcy O, Godreuil S, Bonnet M. Laboratory development of a simple stool sample processing method diagnosis of pediatric tuberculosis using Xpert Ultra. Tuberculosis (Edinb) 2020; 125:102002. [PMID: 33049437 DOI: 10.1016/j.tube.2020.102002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
Stool samples are alternatives to respiratory samples for bacteriological confirmation of childhood tuberculosis but require intensive laboratory processing before molecular testing to remove PCR inhibitors and debris. We aimed to develop a centrifuge-free processing method for use in resource-limited settings based on a sucrose-flotation method that showed good sensitivity for childhood tuberculosis diagnosis. In an in vitro study using Xpert MTB/RIF Ultra on stool samples spiked with defined bacterial concentrations of Mycobacterium tuberculosis (MTB), we compared different simplification parameters to the reference sucrose-flotation method. Best methods were selected based on the rate of invalid/error results and on sensitivity, compared to the reference method on stools spiked at 103 colony forming units (CFU)/g MTB. For final selection, we tested the best parameter combinations at 102 CFU/g. Out of 13 different parameter combinations, three were tested at 102 CFU/g. The best combination used 0.5 g stool, manual shaking, no filtration, 30-min sedimentation, and a 1:3.6 dilution ratio. This method gave 10% invalid/error results and a sensitivity of 70% vs 63% at 103 CFU/g and 53% vs 58% at 102 CFU/g compared to the reference method. This pre-clinical study was able to develop a centrifuge-free processing method to facilitate stool Xpert Ultra testing.
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Affiliation(s)
- Manon Lounnas
- UMR MIVEGEC Univ Montpellier-IRD-CNRS, IRD, Montpellier, France; Département de Bactériologie, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, Montpellier, France.
| | - Abibatou Diack
- UMR MIVEGEC Univ Montpellier-IRD-CNRS, IRD, Montpellier, France; Département de Bactériologie, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Mark P Nicol
- Division of Medical Microbiology and Institute for Infectious Diseases and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; School of Biomedical Sciences, University of Western Australia, Perth, Australia
| | - Sara Eyangoh
- Service de Mycobactériologie, Centre Pasteur du Cameroun, Réseau International des Instituts Pasteur, Yaounde, Cameroon
| | - Eric Wobudeya
- Mulago National Referral Hospital, Directorate of Paediatrics & Child Health, Kampala, Uganda
| | - Olivier Marcy
- University of Bordeaux, Inserm, French National Research Institute for Sustainable Development (IRD), UMR, 1219, Bordeaux, France
| | - Sylvain Godreuil
- UMR MIVEGEC Univ Montpellier-IRD-CNRS, IRD, Montpellier, France; Département de Bactériologie, Centre Hospitalier Universitaire de Montpellier, Université de Montpellier, Montpellier, France
| | - Maryline Bonnet
- IRD UMI 233 TransVIHMI- UM-INSERM U1175, Montpellier, France.
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